Hicham Kobeiter

Influence of a new prophylactic antibiotic therapy on the incidence of liver abscesses after chemoembolization treatment of liver tumors

Intrahepatic abscess is a complication of transcatheter arterial chemoembolization (TACE) treatment in patients who have a history of biliary reconstructive surgery. This study followed eight patients who underwent chemoembolization after biliary surgery. These patients were divided into two groups. Patients in group one (n = 4) were administered intravenous cephalexin for prophylaxis. Patients in group two (n = 4) were administered bowel preparation and tazobactam/piperacillin. All patients in group one developed hepatic abscesses, which were treated with percutaneous catheter drainage and antibiotics. None of the patients in group two developed abscesses. Aggressive antibiotic prophylaxis with bowel preparation may provide protection against intrahepatic abscesses after chemoembolization in patients who have a history of biliary reconstructive surgery.

Transcatheter arterial chemoembolization of liver tumors: effects of embolization protocol on injectable volume of chemotherapy and subsequent arterial patency.

AbstractThe purpose of this study was to determine whetherntranscatheter arterial chemoembolization (TACE) protocol affects thentotal volume of chemotherapy injected into the liver as well asnsubsequent arterial patency. A total of 160 patients with primary ornsecondary liver cancer were treated with 3 different chemoembolizationnprotocols at a single institution. Data were analyzed retrospectively.nGroup 1 (n = 36) consisted of slurry of chemotherapy,noil and polyvinyl alcohol particles (PVA), group 2 (n =n91), chemotherapy and oil followed by PVA, and group 3n(n = 33), chemotherapy and oil followed by Gelfoamnpledgets. The total volume of chemotherapy injected into the liver wasnrecorded. Arterial patency was determined during subsequentnchemoembolizations. The mean percentage of total intended chemotherapyndose administered was 54.6% for group 1, 75.3% for group 2, andn80.6% for group 3. Arterial patency at follow-up angiography was 56%nfor group 1, 74% for group 2, and 81% for group 3. The slurrynprotocol (group 1) significantly reduced arterial patency andninjectable volume of chemotherapy during TACE.

Feasibility of Three-Dimensional MR Angiography Image Fusion Guidance for Endovascular Abdominal Aortic Aneurysm Repair

Magnetic resonance (MR) angiography image fusion (IF) with live fluoroscopy guidance was used while performing endovascular repair of abdominal aortic aneurysm (EVAR) in five patients with a history of chronic renal disease or severe contrast allergy. Intraprocedural technical success was 100%. Median procedure time was 120 minutes (range, 60-180 min), fluoroscopy time was 40 minutes (range, 17-65 min), dose-area product was 245,867 mGy × cm(2) (range, 68,435-690,053 mGy × cm(2)), and iodinated contrast volume injected was 15 mL (range, 0-40 mL). Technical success was achieved in four of five patients (80%); one case was complicated by a type 1 endoleak on follow-up MR angiography, which was successfully treated. EVAR with MR angiography IF guidance was technically feasible and safe in five patients and reduced or eliminated the use of iodinated contrast media.

Triple In Situ Antegrade Laser Fenestration of Aortic Stent-Graft Extension Using Fusion Imaging for Urgent Treatment of Symptomatic Abdominal Aneurysm with Type 1 Endoleak

AbstractThe present report describes the management of massive proximal type 1 endoleak with an enlarged symptomatic aneurysmal sac. Urgent treatment was performed using in situ laser fenestration of an aortic proximal extension facing renovisceral ostia. Image fusion was obtained intraoperatively. For each target vessel (superior mesenteric and two renal arteries), an Aptus HeliFX steerable sheath (Medtronic) inserted through femoral access was curved to face the vessel’s ostium marker. A laser catheter (Spectranetics) was used to traverse the stent-graft and insert a 0.014” guidewire in the vessel. The fenestration was enlarged using a 2.5-mm-diameter cutting balloon, followed by a 4-mm-diameter balloon angioplasty and a V12 I Cast/Advanta covered stent implantation. Final angiogram demonstrated aneurysm exclusion and patent target vessels. The postoperative course and 7xa0months follow-up were uneventful.n Level of evidence Level 4.

Computer-assisted study of the axial orientation and distances between renovisceral arteries ostia

PurposeEndovascular navigation in aortic, renal and visceral procedures are based on precise knowledge of arterial anatomy. Our aim was to define the anatomical localization of the ostia of renovisceral arteries and their distribution to establish anatomical landmarks for endovascular catheterization.MethodsComputer-assisted measurements performed on 55 CT scans and patients features (age, sex, aortic diameter) were analyzed. p valuesxa0<0.05 were considered statistically significant.ResultsThe mean axial angulation of CeT and the SMA origin was 21.8°xa0±xa010.1° and 9.9°xa0±xa010.5°, respectively. The ostia were located on the left anterior edge of the aorta in 96xa0% of cases for the CeT and 73xa0% for the SMA. CeT and SMA angles followed Gaussian distribution. Left renal artery (LRA) rose atxa096°xa0±xa015° and in 67xa0% of cases on the left posterior edge. The right renal artery (RRA) rose at −62°xa0±xa016.5° and in 98xa0% of cases on the right anterior edge of the aorta. RRA angle measurements and cranio-caudal RRA-LRA distance measurements did not follow Gaussian distribution. The mean distances between the CeT and the SMA, LRA, and RRA were 16.7xa0±xa05.0, 30.7xa0±xa07.9 and 30.5xa0±xa07.7xa0mm, respectively. CeT-SMA distance showed correlation with age and aortic diameter (pxa0=xa00.03). CeT-LRA distance showed correlation with age (pxa0=xa00.04). The mean distance between the renal ostia was 3.75xa0±xa00.21xa0mm. The RRA ostium was higher than the LRA ostium in 52xa0% of cases. RRA and LRA origins were located at the same level in 7xa0% of cases.ConclusionOur results illustrate aortic elongation with ageing and high anatomical variability of renal arteries. Our findings are complementary to anatomical features previously published and might contribute to enhance endovascular procedures safety and efficacy for vascular surgeons and interventional radiologists.

Impact of Stent-Graft Oversizing on Gutter Areas after Chimney Graft Repair for Complex Abdominal Aortic Aneurysms

BACKGROUNDnThe aim of this retrospective study was to examine the impact of graft oversizing on gutter area and stent compression in chimney graft (CG) for complex abdominal aortic aneurysm (CAAA) repair. The influence of stent-graft oversizing on type Ia endoleaks and bridging stent occlusion rates was also examined.nnnMETHODSnPreoperative and postoperative computed tomographic angiography scans of patients requiring CGs for CAAA between June 2009 and April 2013 in our institution were analyzed. Two groups were identified: proximal oversizing of the stent-graft component < 25% (group 1) and >25% (group 2). Relative gutter areas were calculated and compared between both groups. Incidence of target vessel stent compression, target vessel occlusions, and type Ia endoleaks was also analyzed.nnnRESULTSnOf 39 patients treated with CG during the study period, 23 fulfilled the selection criteria for analysis. Group 1 included 10 patients and group 2 included 13 patients (mean oversizing: 18.4xa0±xa04.9% and 34.5xa0±xa06% respectively). Relative gutter areas were significantly higher in group 1 when compared with group 2 (6.1xa0±xa02.1% vs. 4.2xa0±xa03.2%, Pxa0=xa00.03). No stent compression and no target vessel occlusion occurred in either groups. There was no statistical difference in type Ia endoleak in both groups (group 1 nxa0=xa00, group 2 nxa0=xa02; Pxa0=xa00.48).nnnCONCLUSIONSnIn our study, a >25% stent-graft oversizing reduced the gutter area without modifying the bridging stent patency. However, no benefit in terms of type Ia endoleak was observed.

Complex Endovascular Abdominal Aneurysm Repair with Fenestrated Endograft Insertion under Hypnosis and Local Anesthesia

emergency CAS placement and intracranial stent retriever use (7), which found the chances of being alive and independent with angiographic recanalization to be 44% (95% confidence interval, 33%–55%; 10 studies) and 83% (95% confidence interval, 73%–91%), respectively. One of the reasons for the discrepancies observed could be the more conservative use of CAS placement in the study of Sallustio et al (6), especially as reperfusion was found to be a significant predictor of favorable outcome. Key concerns with carotid stent placement are embolization of soft atheroma and uncertainty over the use of dual antiplatelet therapy, as there is a high risk of intracerebral hemorrhage (ICH). The reasons for ICH are not clear, but antiplatelet and heparin therapy and rapid reperfusion into damaged capillaries has been suggested (8). Reported incidences of symptomatic ICH, derived mostly from small retrospective case series, vary from 0% to 22% (8,9). Sallustio et al (6) found that symptomatic ICH developed in 12.5% of patients, but CAS placement was not found to be significantly associated with symptomatic ICH on univariate analysis. Of note, only 34% of patients who received a carotid stent received dual antiplatelet therapy. In an elective setting, CAS placement would rarely be performed without dual antiplatelet therapy as a result of the risk of embolization (5%) and stent occlusion (< 1%). Despite these encouraging results, many clinicians remain apprehensive about placing a CAS in the setting of acute stroke. Evidence regarding the safety of CAS placement in this context is derived from small retrospective case series. We are aware of no trial that has compared CAS placement versus alternative approaches. In addition, concern exists that CAS placement may be associated with longer reperfusion times (10). The factors outlined here highlight many unanswered questions. The heterogeneity of the patient population, treatment options, and antiplatelet regimens contribute to the complexity of the matter; therefore, a randomized controlled trial is needed to resolve these issues. Before more robust evidence becomes available, the added time and risks of CAS placement should perhaps be reserved for cases in which carotid occlusion prevents recanalization and subsequently compromises cerebral reperfusion, which is ultimately the target of these acute interventions.

Decision to Interrupt Second-Stage Side-Branch Completion in Thoracoabdominal Branched Aortic Stent Grafting to Prevent Spinal Cord Ischemia

BACKGROUNDnSpinal cord ischemia (SCI) is a severe complication of extended endovascular repair of thoracoabdominal aneurysms. We describe voluntary interruption of side-branch completion in staged branched endovascular aneurysm treatment due to uncertainty regarding SCI possible onset, based on intraoperative angiography findings.nnnMETHODSnWe report a case of a staged endovascular treatment of thoracoabdominal aortic aneurysm in a 64-year-old patient using a branched endograft with an additional side branch that allows temporary sac perfusion to prevent SCI. The third operative step was intended to occlude the side branch. Intraoperative angiography through the side branch demonstrated circulating aneurysm sac, with patent inferior intercostal and superior lumbar arteries giving direct blood supply to a clearly visible anterior spinal artery. The procedure was stopped.nnnRESULTSnOne month later, sac thrombosis occurred spontaneously and was clinically responsible for neurogenic claudication that resolved during follow-up.nnnCONCLUSIONnInterrupting side-branch completion seems to have allowed additional ischemic conditioning of the spinal cord as the spontaneous sac thrombosis induced mild neurological event.

Virtual parenchymal perfusion for selective intra-arterial therapy of liver cancer

Intra-arterial injection of therapeutic agents is among the most common options for unresectable liver cancer. Such procedures rely on an in-depth assessment of the vessels leading to the tumor(s) to select the optimal catheter location maximizing therapy selectivity and potency while limiting healthy liver toxicity. In this paper, we propose a Virtual parenchymal Perfusion (VP) algorithm to approximate distal liver vascular territories given prospective virtual injection points, with all predictive data derived from a single 3D arterial Cone Beam Computed Tomography (CBCT) scan. Vascular territories are extracted from a vessel-driven geodesic distance map computed from the user-selected injection position, without the need for explicit vessel segmentation. In order to evaluate our approach, we compared liver sub-territories segmented from actual CBCT scans after selective injection of contrast agent or lipiodol, with the vascular territories computed with the VP algorithm using the non-selective arterial CBCT scans. Results on 11 pairs of arterial and selective injection CBCT scans showed a non-significant difference between virtual and real segmented volumes (p=0.73), an average mean distance of 4.75 mm, an average volume error of 16% and an average Dice coefficient of 0.75, supporting a high correlation. This study demonstrates the potential of our VP algorithm in planning intra-arterial therapy of liver cancer and provides the basis for clinical translation in a live interventional context.