Francisco Leonardo Galastri

Evaluation and management of symptomatic isolated spontaneous celiac trunk dissection

The purpose of this study is to describe 10 cases of symptomatic isolated spontaneous celiac trunk dissection (ISCTD) in order to evaluate the initial clinical presentation, diagnosis, treatment modalities and outcomes. A retrospective search was performed from 2009 to 2014 and 10 patients with ISCTD were included in the study. Patients with associated aortic and/or other visceral artery dissection were excluded. The following information was collected from each case: sex, age, associated risk factors, symptoms, diagnostic method, anatomic dissection pattern, treatment modality and outcome. Most patients were male (90%), with an average age of 44.8 years, and the most common symptom was abdominal pain (100%). Hypertension and vasculitis (polyarteritis nodosa) were the most frequent risk factors (40% and 30%, respectively). Diagnosis was made in all patients with computed tomography. Dissection was limited to the celiac trunk in three patients and extended to celiac branches in the other seven. Initial conservative treatment was attempted in every case and was successful in nine patients. In one case, initial conservative treatment was unsuccessful and arterial stenting with coil embolization of the false lumen was performed. After successful initial treatment, late progression of the dissection to aneurysmal dilatation was observed in two patients and it was decided to perform endovascular treatment. Mean follow-up was 19 months, ranging from 2 to 59 months. In conclusion, initial conservative treatment seems adequate for most patients with ISCTD. Long-term follow-up is mandatory, owing to the risk of later progression to aneurysm.

Safety and Feasibility of Same-Day Discharge of Patients with Hepatocellular Carcinoma Treated with Transarterial Chemoembolization with Drug-Eluting Beads in a Liver Transplantation Program

PURPOSE To evaluate the safety and feasibility of same-day discharge of patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization with the use of drug-eluting beads (DEBs) and elucidate the prognostic factors for hospital admission. MATERIALS AND METHODS A total of 266 DEB chemoembolization procedures in 154 consecutive patients listed for liver transplantation or identified for potential HCC downstaging were performed with the outpatient treatment protocol. Endpoints evaluated were admission to the hospital after the procedure for clinical reasons, readmission to the hospital within 1 month of the procedure, and procedure-related morbidity and mortality. In the evaluation of prognostic factors for admission, parameters of patients discharged the same day were compared with those of patients admitted overnight. RESULTS Same-day discharge was feasible in 238 cases (89.5%), and 28 (10.5%) needed overnight admission. The main reason for overnight admission was postprocedural abdominal pain (n = 23; 67.8%). The procedure-related complication rate was 2.6%, and there were no readmissions or deaths during the first 30 days after chemoembolization. Chemoembolization performed for downstaging and the use of more than one vial of embolic agent were associated with an increased need for overnight admission (P = .012 and P = .007, respectively). CONCLUSIONS Same-day discharge of patients with HCC treated with DEB chemoembolization in a liver transplantation program is safe and feasible, with low complication and admission rates. Treatment for HCC downstaging and the use of more than one vial of embolic agent were associated with an increased need for hospital admission.

Endovascular Stenting of Brachial Artery Occlusion in Critical Hand Ischemia

Critical upper limb ischemia caused by atherosclerosis is uncommon. Endovascular treatment, with angioplasty or stenting, has been successfully performed for subclavian and below the elbow diseases; however, theres a lack of report regarding the treatment of brachial artery disease causing critical hand ischemia. In this article, we describe the treatment of a brachial artery occlusion with endovascular stenting in a patient with chronic upper limb ischemia.

Minimally invasive treatment of hepatic adenoma in special cases

ABSTRACT Hepatocellular adenoma is a rare benign tumor that was increasingly diagnosed in the 1980s and 1990s. This increase has been attributed to the widespread use of oral hormonal contraceptives and the broader availability and advances of radiological tests. We report two cases of patients with large hepatic adenomas who were subjected to minimally invasive treatment using arterial embolization. One case underwent elective embolization due to the presence of multiple adenomas and recent bleeding in one of the nodules. The second case was a victim of blunt abdominal trauma with rupture of a hepatic adenoma and clinical signs of hemodynamic shock secondary to intra-abdominal hemorrhage, which required urgent treatment. The development of minimally invasive locoregional treatments, such as arterial embolization, introduced novel approaches for the treatment of individuals with hepatic adenoma. The mortality rate of emergency resection of ruptured hepatic adenomas varies from 5 to 10%, but this rate decreases to 1% when resection is elective. Arterial embolization of hepatic adenomas in the presence of bleeding is a subject of debate. This observation suggests a role for transarterial embolization in the treatment of ruptured and non-ruptured adenomas, which might reduce the indication for surgery in selected cases and decrease morbidity and mortality. Magnetic resonance imaging showed a reduction of the embolized lesions and significant avascular component 30 days after treatment in the two cases in this report. No novel lesions were observed, and a reduction in the embolized lesions was demonstrated upon radiological assessment at a 12-month follow-up examination.

Dissecção espontânea do tronco celíaco: qual a melhor abordagem terapêutica?

A disseccao espontânea das arterias viscerais e um evento relativamente raro. Dor abdominal subita no epigastrio e o sintoma mais frequentemente manifestado pelos pacientes. O avanco das tecnicas de exames de imagem possibilitou o diagnostico deste evento com maior facilidade, aumentando a incidencia das disseccoes das arterias viscerais. O tratamento clinico conservador, a revascularizacao cirurgica, e a terapia endovascular sao as tres possiveis opcoes terapeuticas. Neste artigo, relatamos os casos de dois pacientes com disseccao espontânea do tronco celiaco conduzidos de formas diversas, de acordo com a apresentacao clinica e exames de imagem, alem de realizar uma revisao bibliografica sobre esta doenca.

Liver Metastases in Pancreatic Acinar Cell Carcinoma Treated with Selective Internal Radiation Therapy with Y-90 Resin Microspheres

Background Pancreatic acinar cell carcinoma (PACC) is a rare tumor. Surgical resection is the treatment of choice when feasible, but there are no clear recommendations for patients with advanced disease. Liver-directed therapy with Y-90 selective internal radiation therapy (SIRT) has been used to treat hepatic metastases from pancreatic tumors. We describe a case of PACC liver metastases treated with SIRT. Case Report 59-year-old man was admitted with an infiltrative, solid lesion in pancreatic tail diagnosed as PACC. Lymph nodes in the hepatic hilum were enlarged, and many metastatic liver nodules were observed. After partial pancreatectomy, the left and right lobes of the liver were separately treated with Y-90 resin microspheres. Follow-up imaging revealed that all hepatic nodules shrank by at least 50%, and 3 nodules disappeared completely. Lipase concentration was 8407 U/L at baseline, rose to 12,705 U/L after pancreatectomy, and declined to 344 U/L after SIRT. Multiple rounds of chemotherapy in the subsequent year shrank the hepatic tumors further; disease then progressed, but a third line of chemotherapy shrank the tumors again, 16 months after SIRT treatment. Conclusion SIRT had a positive effect on liver metastases from PACC. In conjunction with systemic therapy, SIRT can achieve sustained disease control.

Percutaneous Treatment of Intrahepatic Biliary Leak: A Modified Occlusion Balloon Technique

PurposeTo report a novel modified occlusion balloon technique to treat biliary leaks.MethodsA 22-year-old female patient underwent liver transplantation with biliary-enteric anastomosis. She developed thrombosis of the common hepatic artery and extensive ischemia in the left hepatic lobe. Resection of segments II and III was performed and a biliary-cutaneous leak originating at the resection plane was identified in the early postoperative period. Initial treatment with percutaneous transhepatic drainage was unsuccessful. Therefore, an angioplasty balloon was coaxially inserted within the biliary drain and positioned close to the leak.ResultsThe fistula output abruptly decreased after the procedure and stopped on the 7th day. At the 3-week follow-up, cholangiography revealed complete resolution of the leakage.ConclusionThis novel modified occlusion balloon technique was effective and safe. However, greater experience and more cases are necessary to validate the technique.

Percutaneous treatment of complex biliary stone disease using endourological technique and literature review

Most biliary stone diseases need to be treated surgically. However, in special cases that traditional biliary tract endoscopic access is not allowed, a multidisciplinary approach using hybrid technique with urologic instrumental constitute a treatment option. We report a case of a patient with complex intrahepatic stones who previously underwent unsuccessful conventional approaches, and who symptoms resolved after treatment with hybrid technique using an endourologic technology. We conducted an extensive literature review until October 2012 of manuscripts indexed in PubMed on the treatment of complex gallstones with hybrid technique. The multidisciplinary approach with hybrid technique using endourologic instrumental represents a safe and effective treatment option for patients with complex biliary stone who cannot conduct treatment with conventional methods.

Endovascular treatment of chronic occluded renal artery

A 66-year-old man with hypertension, non-dialytic chronic renal failure and hepatic cirrhosis was admitted for liver transplantation. After surgery, he presented with worsening renal failure and need for dialysis. Abdominal duplex ultrasound was performed and subsequent contrast-enhanced computed tomographic angiography confirmed right renal artery occlusion, left renal artery stenosis and asymmetrical kidney size (right kidney 9.5 cm, left kidney 11.4 cm) (Panel A1 and A2; arrows). Three weeks after surgery, he underwent renal arteriography, which confirmed ostial occlusion of the right renal artery (Panel B1), with late filling of the artery in its middle third (black arrow) by a large intercostal branch (white arrow), as well as subocclusive (> 90%) left renal artery stenosis (Panel B2; arrow). The left renal artery ostium was cannulated, the stenosis was crossed with a 0.014” guidewire and a balloonexpandable 6 × 19 mm stent was deployed. The procedure was repeated on the right side after pre-dilatation with a 2.5 × 20 mm balloon. A final angiogram demonstrated well-positioned stents and no residual stenosis (Panel C). A gradual

Percutaneous Transhepatic Mitral Valve Repair With the MitraClip System

The femoral venous approach for percutaneous edge-to-edge repair of the mitral valve with the MitraClip system (Abbott Vascular, Santa Clara, California) may not be possible in patients with occlusion or congenital anomalies of the inferior vena cava (IVC) or limited by the presence of an IVC filter