Do Yun Lee

The dissected aorta: Percutaneous treatment of ischemic complications - Principles and results

PURPOSE Describe the principles and results of percutaneous treatment of ischemic complications of aortic dissection. MATERIALS AND METHODS Twenty-four patients with aortic dissection complicated by ischemic compromise of the liver or bowel (n = 15), kidney (n = 18), or lower extremity (n = 13) were evaluated by means of aortography, intravascular ultrasound, and manometry, and were treated percutaneously. Visceral arteries were classified as obstructed or nonobstructed. Obstruction was classified as static, in which the dissecting hematoma extended into and narrowed the lumen of a branch artery, or dynamic, in which the dissection flap prolapsed into the vessel origin or narrowed the true lumen (TL) above it. Treatment consisted of vascular stents alone (n = 4), or balloon fenestration (n = 20) without (n = 8) or with (n = 12) vascular stents. RESULTS Obstruction was present in 77 arteries and was static in 12 arteries, dynamic in 45 arteries, static and dynamic in 17 arteries, and indeterminate in three arteries. Percutaneous treatment did not alter false lumen (FL) pressure, but reduced the peak systolic interluminal pressure gradient from 28 mm Hg to 2 mm Hg and restored flow in 71 of 77 arteries (92%). Six patients died within 30 days (25% operative mortality), none as a result of the procedure. Two additional patients died in follow-up from complications of an expanding FL. Technical complications in two patients due to altered hemodynamics after initial intervention were recognized and corrected percutaneously during the same procedure. CONCLUSIONS Percutaneous fenestration and endovascular stent deployment are indicated to restore blood flow to arteries compromised by aortic dissection. The prognosis of patients is related to the ischemic injury sustained prior to the percutaneous interventional procedure and, in patients with acute type I dissection who have not undergone surgery, to the preoperative stability of the FL.

Combined transcatheter arterial chemoembolization and local radiotherapy of unresectable hepatocellular carcinoma.

PURPOSE The best prognosis in hepatocellular carcinoma (HCC) can be achieved with surgical resection; however, the number of resected cases are limited due to advanced lesions or associated liver disease. The purpose of this study was to investigate the efficacy and toxicity of a prospective trial of combined transcatheter arterial chemoembolization (TACE) and local radiotherapy (RT) in unresectable HCC. METHODS AND MATERIALS Patients with histologically proven unresectable HCC due to either advanced lesions or associated cirrhosis were eligible. From March 1992 to August 1994, 30 patients were entered into this study. TACE was performed with Lipiodol (5 ml) and doxorubicin (Adriamycin ; 50 mg), followed by gelatin sponge particle (Gelfoam) embolization. Local RT was started within 7-10 days following TACE. Mean tumor dose was 44.0+/-9.3 Gy in daily 1.8 Gy fractions. Response was assessed by computerized tomography (CT) scan 4-6 weeks following completion of the treatment and then at 1-3-month intervals. Survival was calculated from the start of TACE using the Kaplan-Meier method. RESULTS An objective response was observed in 19 patients, giving a response rate of 63.3%. Distant metastasis occurred in 10 patients, with 8 in the lung only and 2 in both lung and bone. Survival rates at 1, 2, and 3 years were 67%, 33.3%, and 22.2%, respectively. Median survival was 17 months. There were 6 patients surviving more than 3 years. Toxicity included transient elevation of liver function tests in all patients, fever in 20, thrombocytopenia in 4, and nausea and vomiting in 1. There was no treatment-related death. CONCLUSION Combined TACE and local RT is feasible and tolerable. It gives a 63.3% response rate with median survival of 17 months. We feel that this regimen would be a new promising modality in unresectable HCC. Further study is required to compare the therapeutic efficacy of this regimen to TACE alone.

Pilot clinical trial of localized concurrent chemoradiation therapy for locally advanced hepatocellular carcinoma with portal vein thrombosis

Patients with advanced hepatocellular carcinoma (HCC) with portal vein thrombosis (PVT) have a particularly grave prognosis. In the current study, an attempt was made to localize chemoradiation therapy (CCRT) followed by hepatic arterial infusion chemotherapy (HAIC) in patients with locally advanced HCC with PVT and good reserve liver function. The objective of the current study was to evaluate the therapeutic effect of localized CCRT followed by HAIC as a new treatment modality for these patients.

Local radiotherapy for unresectable hepatocellular carcinoma patients who failed with transcatheter arterial chemoembolization

PURPOSE The purpose of this study was to investigate the efficacy of local radiotherapy (RT) as a salvage treatment for unresectable hepatocellular carcinoma (HCC) patients who failed with transcatheter arterial chemoembolization (TACE). METHODS AND MATERIALS Patients with unresectable HCC who had been treated with and eventually failed with TACE were eligible. The judgment of TACE failure was based on incomplete tumor filling of lipiodol-adriamycin mixture on either angiography or computed tomography (CT) scan. From January 1993 to December 1997, 27 patients were entered into this study. They had UICC Stage III (17) or IVA (10) disease, with a mean tumor size of 7.2 +/- 2.9 cm. Local RT was done, with a mean tumor dose of 51.8 +/- 7.9 Gy, in daily 1.8-Gy fractions using a 10- or 6-MV linear accelerator. Survival was calculated from both the diagnosis and the start of RT using the Kaplan-Meier method. RESULTS An objective response was observed in 16 of 24 patients (66.7%) including 1 CR. Intrahepatic metastasis was noted outside the RT field in 10 patients (37.0%). Extrahepatic distant metastasis occurred in 4 patients. Survival rates at 1, 2, and 3 years were 85. 2%, 58.1%, and 33.2%, respectively, from the diagnosis and 55.9%, 35. 7%, and 21.4%, respectively, from the start of RT. The median survivals were 26 months from the diagnosis and 14 months from the start of RT. Acute toxicity involved alteration in liver function test (13 patients) and thrombocytopenia (2 patients). Subacute and chronic toxicity involved gastroduodenal ulcer (3 patients) and duodenitis (2 patients). There was no treatment-related death. CONCLUSION In unresectable HCC patients who failed with TACE, local RT induced a substantial tumor response of 66.7%, with a 3-year survival rate of 21.4% and a median survival time of 14 months. Toxicity was significant but manageable. Although we do not know if there is survival benefit through this treatment, local RT in these patients seems to be valuable as a salvage for TACE-failed HCC.

Elective endovascular treatment of descending thoracic aortic aneurysms and chronic dissections with stent-grafts.

PURPOSE To report our experience of endovascular stent-graft placement in patients with descending thoracic aortic dissections and aneurysms and to evaluate the feasibility, safety, and clinical outcomes of the treatment. MATERIALS AND METHODS Stent-grafts were placed in the descending thoracic aortas of 23 patients with saccular aneurysms (n = 11) and Stanford type B chronic aortic dissections of the descending thoracic and abdominal aorta (n = 12). All stent-grafts were individually constructed of self-expandable stainless steel stents covered with polytetrafluoroethylene. Vascular access was achieved through the femoral artery in all patients. Clinical status of each patient was monitored and postoperative CT was performed within 1 month of the procedure and at 3-12-month intervals after the procedures. RESULTS Successful exclusion of the primary entry tears of dissections and the inlets of saccular aneurysms was achieved in all but two patients with aortic dissection. The overall technical success rate was 91.3% (dissection: 10 of 12 = 83%; aneurysm: 11 of 11 = 100%). All patients in whom technical success was achieved showed complete thrombosis and significant decrease in diameter of the thoracic false lumen (preoperative: 5.3 cm +/- 0.9; postoperative: 4.3 cm +/- 0.9; P = .004) or aneurysm sac (preoperative: 5.3 cm +/- 1.7; postoperative: 2.8 cm +/- 2.5; P = .001). In addition, five patients demonstrated complete resolution of the dissected thoracic false lumen (n = 2) and aneurysm sac (n = 3). However, in all patients with aortic dissection, the abdominal aorta was not significantly changed in size (P = .302) and shape and their false lumen flows remained persistent. Immediate postoperative complications were detected in 12 patients (52%); 10 had fever, leukocytosis, and elevation of C-reactive protein, another had wound infection, and another had transient abdominal pain. Three patients died 2, 3, and 12 months after the procedure: one from septic shock, another from underlying mediastinitis, and the other from an unexplained cause. The remaining 20 patients were well after the procedure (1-9 days; mean, 3 days), without any stent-graft-related complications or discomfort (follow up period: 10-65 mo; mean: 25.1 mo +/- 15.6). The cumulative survival rate after the stent graft was 100% at 30 days and 91% at 12 months. CONCLUSIONS For treatment of aortic dissection and saccular aneurysm of the descending thoracic aorta, endovascular stent-graft repair may be a technically feasible and effective treatment modality.

Stent-graft treatment of infected aortic and arterial aneurysms.

Purpose: To evaluate the feasibility and effectiveness of endovascular stent-graft repair of infected aortic and arterial aneurysms. Methods: Eight patients (5 men; mean age 56.6 years, range 30–85) with infected saccular aneurysms in the brachiocephalic artery (n=1), proximal descending thoracic aorta (n=1), infrarenal abdominal aorta (n=3), common iliac artery (n=1), and common femoral artery (n=2) were treated with stent-graft placement and intravenous antibiotic treatment for at least 6 weeks followed by case-specific administration of oral suppressive antibiotics. All patients were considered to be in the high-surgical-risk group. Results: Exclusion of the infected aneurysm was successful in all patients. However, 2 patients died within 30 days of uncontrolled sepsis, and 1 patient died at 6 months after rupture of a persistently infected aneurysm (37% mortality rate). Over a follow-up that ranged to 8 years, the 5 survivors showed complete resolution of the infected aneurysms; no stent-graft infection was observed during follow-up. Conclusion: The acceptable technical and clinical success of endovascular aneurysm repair makes this a promising treatment for infected aortic and arterial aneurysms. However, it is crucial that the infection is treated adequately prior to stent-graft placement.

Successful Treatment of Isolated Spontaneous Superior Mesenteric Artery Dissection with Stent Placement

Isolated dissection of superior mesenteric artery is a rare condition and is usually treated surgically. We treated a patient with severe abdominal pain who was angiographically confirmed to have superior mesenteric artery thrombosis associated with isolated spontaneous dissection. He was treated initially by thrombolysis and oral anticoagulation, but recurrent symptoms developed with radiologic evidence of disease progression. We performed superior mesenteric artery stenting and recovery was uneventful.

Problems Encountered during and after Stent-Graft Treatment of Aortic Dissection

PURPOSE The authors report their experiences with the problems encountered during and after stent-graft placement in patients with aortic dissections. MATERIALS AND METHODS Between July 1994 and December 2003, stent-graft placement was performed in 60 patients with aortic dissections, 9 patients with Stanford type A dissection and 51 patients with type B. Ten patients had acute dissection and 50 patients had chronic dissection. Each patient was followed for 12 to 107 months (mean, 33 mo). All cases were retrospectively reviewed for any problem that occurred during and after the procedure. RESULTS During the procedure, there were two cases (3%) of stent-graft migration, one case (2%) of stent-graft torsion, two cases (3%) of stent-graft folding due to oversizing, three cases (5%) of persistent thoracic false lumen flow by the appearance of a hidden intimal tear, one case (2%) of new intimal tear that resulted in retrograde type A dissection, and 12 cases (20%) of type I endoleaks on aortograms taken immediately after the procedure. During the follow-up period, one case (2%) of transient cerebral ischemia, six cases (10%) of persistent type I endoleaks, two cases (3%) of type II endoleaks through the intercostal artery, four cases (7%) with progressive dilatation of abdominal false lumen, six cases (10%) of new intimal tears which resulted in saccular aneurysms (n=4) or new dissections (n=2) on either or both ends of the stent-graft, and two cases (3%) of mechanical failure were observed. Overall, five patients (8%) required surgical conversion, and there were no cases of procedure-related mortality. CONCLUSION Various problems can occur during and after stent-graft placement in aortic dissection. The thorough evaluation of preoperative imaging and close follow-up are mandatory to optimize the management of such problems.

Percutaneous Treatment of Deep Vein Thrombosis in May-Thurner Syndrome

Background/PurposeMay-Thurner syndrome is an uncommon disease entity in which the left common iliac vein is compressed by the right common iliac artery with subsequent development of deep vein thrombosis and chronic venous insufficiency. We report our experience on the treatment of extensive iliofemoral deep venous thrombosis due to May-Thurner syndrome using endovascular techniques.MethodsThe study group comprised 21 patients (8 men, 13 women; mean age 51 years) diagnosed with May-Thurner syndrome by venogram. Eighteen patients were treated with catheter-guided thrombolysis; 3 patients with short segment involvement did not require thrombolysis. After completion of the thrombolytic therapy, the residual venous narrowing was treated by balloon angioplasty and/or placement of a self-expandable stent.ResultsThe mean total dose of urokinase was 4.28 ± 1.89 million units, and the mean duration of infusion was 72 ± 35 hr. Eighteen of the 21 patients received stent deployment. The mean diameter of the stents was 12.9 ± 2.0 mm. Initial technical successes with immediate symptom resolution were achieved in 20 of the 21 patients (95%). We performed a follow-up venogram 6 months after procedure and checked clinical symptoms at outpatient clinics (mean follow-up duration 10.8 months). Among the patients who received stent implantation, 2 had recurrent thrombotic occlusion during the follow-up period. Three patients, who did not receive stent implantation, all had recurrent thrombosis. There were no major bleeding complications except in 1 patient who developed retroperitoneal hematoma.ConclusionCatheter-guided thrombolysis and angioplasty with stent implantation is a safe and effective method for the treatment of May-Thurner syndrome.

Intermediate to long-term outcomes of endoluminal stent-graft repair in patients with chronic type B aortic dissection.

Purpose: To assess mid- to long-term clinical results of stent-graft repair in patients with type B aortic dissection. Methods: Retrospective analysis was done on 72 patients (47 men; mean age 55±12 years) who were diagnosed with chronic type B aortic dissection and underwent stent-graft repair from June 1994 to December 2007. Two types of stent-grafts were employed. Prior to 2000, a custom-designed stent-graft composed of self-expanding Z-type stainless steel stents covered with woven polytetrafluoroethylene material was used. Thereafter, a separate-type (modular) manufactured stent-graft was used, consisting of proximal and distal nitinol stents with an unsupported Dacron tube graft in between; the unsupported graft was stented after deployment. Results: Procedural success (completion of the stent-graft deployment at the target area without device failure) was obtained in 97% (70/72). The 2 failures were due to stent migration and tortuous anatomy, respectively. There were persistent type I endoleaks in 6 cases for a clinical success (entry tear exclusion) of 88% (64/72). There was no immediate postprocedural mortality or paraplegia. There was unintended partial left subclavian artery occlusion in 1 case, as well as postprocedural transient renal failure in 1 patient and 2 access-site pseudoaneurysms. Median follow-up was 43 months (range 5–97, mean 64.4±38.8) in 61 patients (3 patients lost to follow-up). Five patients died, 1 of probable aortic rupture in the setting of residual type I endoleak. Overall clinical success (no death, conversion, or endoleak) was achieved in 84% (47/56); of these, 35 (74%) showed complete resolution of the thoracic false lumen, while the other 12 (26%) had a decrease in false lumen diameter. Conclusions: Intermediate to long-term results of stent-graft implantation in patients with chronic type B aortic dissection seem acceptable and may justify the use of this minimally invasive approach as first line therapy in these patients.