James Spain

Comparative Analysis of the Safety and Efficacy of Transcatheter Arterial Chemoembolization and Yttrium-90 Radioembolization in Patients with Unresectable Hepatocellular Carcinoma

PURPOSE To compare retrospectively the safety and efficacy of yttrium-90 ((90)Y) radioembolization with the safety and efficacy of chemoembolization in patients with unresectable hepatocellular carcinoma (HCC). MATERIALS AND METHODS Survival and complication rates were evaluated for patients with HCC who underwent chemoembolization or radioembolization at a single institution between August 2007 and April 2010. Complications were graded according to a standardized grading system for embolization procedures. Survival was determined via the Kaplan-Meier method, and multivariable analysis for factors affecting survival was performed. RESULTS This study included 73 patients with HCC who underwent index embolization with radioembolization (n = 38; 52.1%) or chemoembolization (n = 35; 47.9%). The two patient populations were similar in terms of demographics, etiology of cirrhosis, functional status, tumor characteristics, Child-Pugh class, previous liver-directed therapy, and number of patients with bilirubin > 2.0 mg/dL. There was no significant difference in survival between the radioembolization (median 8.0 months) and chemoembolization (median 10.3 months) cohorts (P = .33). Postembolization syndrome was significantly more severe in patients who underwent chemoembolization, which led to increased total hospitalization rates in these patients. The rates of other complications and rehospitalization were similar between groups. Increased age, Child-Pugh class B, hepatitis seropositivity, bilobar tumor distribution, tumor vascular invasion, and presence of extrahepatic metastases were associated with reduced patient survival. CONCLUSIONS Patients treated with radioembolization did not show a survival advantage over patients treated with chemoembolization. However, patients who underwent chemoembolization had significantly higher rates of hospitalization as a result of postembolization syndrome.

The amplatzer vascular plug: a review of the device and its clinical applications.

The Amplatzer Vascular Plug (AVP) is an established embolic device that can be an excellent alternative to coils or detachable balloons to embolize medium to large vessels with high flow. The device is easy to use and can be precisely deployed in the target vessel with high resistance to migration and a low recanalization rate. The technical success of this device is high, indications for use are expanding, and no absolute contraindications have been reported. Since its introduction, the AVP has grown from a single device to a group of 4 models (AVP, AVP II, AVP III, and AVP 4). Each model has a unique design and features that fit different vascular anatomies, hemodynamic situations, and clinical scenarios. Therefore, the new models cannot simply be treated as replacements for older ones. Unpredictable occlusion time remains a major shortcoming for the new models of the AVP. Large vessel size, high flow status, and coagulopathy can prolong the occlusion time, which can offset the cost benefit, reduced procedure time, and reduced radiation dose typically seen with use of the AVP alone. Coils or multiple AVPs can be used to expedite the occlusion process, and large Gelfoam particles also can be used as an adjunct to achieve rapid and reliable occlusion with minimal cost.

Retrospective Review of 120 Celect Inferior Vena Cava Filter Retrievals: Experience at a Single Institution

PURPOSE To evaluate retrospectively the safety and retrievability of the Celect IVC filter. MATERIALS AND METHODS All patients undergoing Celect filter placement and retrieval during the period 2007-2012 were assessed for complications and retrievability. RESULTS Of 620 patients who underwent Celect filter placement, 120 presented for removal. The indwelling time in these patients was 158.1 days±103.0 (range, 2-518 d). There were 106 filters (88.3%) removed; 14 filters were left in situ for the following reasons: filter embedment (n=6), caval occlusion (n=3), retained thrombus (n=2), large floating thrombus in IVC (n=2), or tilt >15° (n=1). With filters in place, five patients developed new pulmonary embolism (PE), and two others presented with severe abdominal pain. The available 115 pairs of placement and removal cavagrams suggested limb penetration in 99 cases (86.1%), intracaval migration >2 cm in 5, secondary tilt >15° in 8, filter deformity in 10, retained thrombus within filters in 12, and IVC occlusion in 3. Among 38 available computed tomography (CT) scans, 9 scans (24%) showed asymptomatic limb penetration to the duodenum (n=6), aortic wall (n=2), or kidney (n=1). No filter fracture was found. CONCLUSIONS This study showed a high penetration rate for Celect IVC filters, including penetrations that were symptomatic or involved adjacent structures. Penetration appears to correlate with indwelling time, suggesting that the filter should be removed as soon as PE protection is no longer indicated. Although most of the filters were removed, 5.8% of retrievals were unsuccessful because of technical failure.

Fracture and Distant Migration of the Bard Recovery Filter: A Retrospective Review of 363 Implantations for Potentially Life-Threatening Complications

PURPOSE To report the occurrence of fracture of the Recovery filter and incidence of potentially life-threatening complications associated with fractured fragment migration. MATERIALS AND METHODS A retrospective study of images obtained after placement of Recovery inferior vena cava (IVC) filters from 2003 to 2006 was conducted at a single tertiary-care center. Images were reevaluated for fracture and migration; complications related to filter fracture were investigated. Kaplan-Meier survival analysis was performed to investigate the relationship between time in situ and fracture. RESULTS A total of 363 Recovery filters were placed; 97 were retrieved, leaving 266 filters in situ (135 patients subsequently died of other causes). The following images were evaluated: 130 chest computed tomography (CT) scans, 153 abdominal CT scans, 254 chest radiographs, 148 radiographs of the abdomen/pelvis, and 106 cavagrams. Mean imaging follow-up interval was 18.4 months (maximum, 81.3 mo). No en bloc migration occurred outside the IVC. Twenty-six limb fractures (all short limbs) were identified in 20 patients; the earliest occurred at 4.1 months. Eight fragment migrations occurred into pulmonary arteries, seven into iliac/femoral veins, one into the right ventricle, and one into the renal vein. Seven fragments were intracaval near the filter, one was extracaval, and one could not be located. Kaplan-Meier survival estimates predicted a fracture rate of 40% at 5.5 years. Of the 20 patients with filter fractures, three died of unrelated causes and 17 remain asymptomatic. CONCLUSIONS Recovery filter fractures occurred at the short limb only, with a suggested 5.5-year fracture risk of 40%. No life-threatening events occurred in patients with filter fracture.

Fracture and migration of Celect inferior vena cava filters: a retrospective review of 741 consecutive implantations.

PURPOSE To determine the incidence of fracture and migration of the Celect inferior vena cava (IVC) filter at a single tertiary-care center. MATERIALS AND METHODS Images obtained after placement of Celect IVC filters between August 2007 and January 2013 were retrospectively reviewed for evidence of device fracture and migration. The probability of filter fracture at 6 and 12 months after filter placement was estimated, and a 95% upper confidence bound was constructed. RESULTS A total of 741 consecutive Celect filters were placed, and the following studies were subsequently evaluated: 301 abdominal radiographs, 282 abdominal computed tomography (CT) scans, 154 cavagrams, 19 lumbar spine radiographs, 462 chest radiographs, 108 chest CT scans, and 31 pelvic radiographs. The mean imaging follow-up interval was 5.78 months ± 8.80 (range, 0.01-56.03 mo). There was no filter fracture or en-bloc migration outside the IVC. Upper 95% confidence bounds for the probability of fracture were 1.8% at 6 months and 4.3% at 12 months. Intracaval filter migration of more than 2 cm (mean, 2.43 ± 0.12 cm; range, -2.54 to 2.99 cm) was seen in 3.9% of patients (21 of 534; 12 cranial and nine caudal). CONCLUSIONS No fracture of a Celect filter was observed in this large cohort over a relatively short follow-up interval. The results also suggest that the Celect filter has an adequate securing mechanism to prevent distant en-bloc or significant intracaval migration.

Lung Dose Calculation With SPECT/CT for 90Yittrium Radioembolization of Liver Cancer

PURPOSE To propose a new method to estimate lung mean dose (LMD) using technetium-99m labeled macroaggregated albumin ((99m)Tc-MAA) single photon emission CT (SPECT)/CT for (90)Yttrium radioembolization of liver tumors and to compare the LMD estimated using SPECT/CT with clinical estimates of LMD using planar gamma scintigraphy (PS). METHODS AND MATERIALS Images of 71 patients who had SPECT/CT and PS images of (99m)Tc-MAA acquired before TheraSphere radioembolization of liver cancer were analyzed retrospectively. LMD was calculated from the PS-based lung shunt assuming a lung mass of 1 kg and 50 Gy per GBq of injected activity shunted to the lung. For the SPECT/CT-based estimate, the LMD was calculated with the activity concentration and lung volume derived from SPECT/CT. The effect of attenuation correction and the patients breathing on the calculated LMD was studied with the SPECT/CT. With these effects correctly taken into account in a more rigorous fashion, we compared the LMD calculated with SPECT/CT with the LMD calculated with PS. RESULTS The mean dose to the central region of the lung leads to a more accurate estimate of LMD. Inclusion of the lung region around the diaphragm in the calculation leads to an overestimate of LMD due to the misregistration of the liver activity to the lung from the patients breathing. LMD calculated based on PS is a poor predictor of the actual LMD. For the subpopulation with large lung shunt, the mean overestimation from the PS method for the lung shunt was 170%. CONCLUSIONS A new method of calculating the LMD for TheraSphere and SIR-Spheres radioembolization of liver cancer based on (99m)Tc-MAA SPECT/CT is presented. The new method provides a more accurate estimate of radiation risk to the lungs. For patients with a large lung shunt calculated from PS, a recalculation of LMD based on SPECT/CT is recommended.

Acute Abdominal Pain After Retrievable Inferior Vena Cava Filter Insertion: Case Report of Caval Perforation by an Option Filter

Symptomatic caval injury is rare after inferior vena cava (IVC) filter insertion. A 39-year-old woman developed acute abdominal pain after uneventful placement of a retrievable Option IVC Filter (Angiotech Pharmaceuticals, Vancouver, British Columbia, Canada). Two days after placement, computed tomography showed a right-sided retroperitoneal hematoma, and three-dimensional C-arm rotational venography confirmed limb penetration beyond the caval wall. This is the first report of this complication despite two recent studies highlighting the safety profile of this relatively new filter.

Gelfoam-Assisted Amplatzer Vascular Plug Technique for Rapid Occlusion in Proximal Splenic Artery Embolization

OBJECTIVE The objective of this study was to prospectively investigate the role of rapid Gelfoam-assisted occlusion of the splenic artery with an Amplatzer Vascular Plug (AVP). Ten consecutive proximal splenic artery embolizations were performed with AVP as the primary embolic agent and Gelfoam slurry as an adjunct. These cases were then compared with 10 retrospective cases of splenic artery embolization performed with AVP and augmented with coils or additional AVPs, or both, in patients with similar indications. CONCLUSION Successful proximal splenic artery embolization using a single Amplatzer Vascular Plug and Gelfoam slurry occurred in all cases. No recanalization was identified on imaging follow-up at an average interval of 5.1 months. Gelfoam can be used as an adjunct to AVP in proximal splenic artery embolization. Using adjunctive Gelfoam is a simple, safe, and cost-saving method of improving the occlusion efficiency of the Amplatzer Vascular Plug.

Iatrogenic migration of VenaTech LP IVC filter to superior vena cava secondary to guidewire entrapment: case report and review of literature.

Modern inferior vena cava (IVC) filters are generally safe devices for preventing pulmonary embolus, with fewer complications compared to earlier techniques of caval interruption. Despite continuing improvement in filter designs and insertion methods, complications still occur. The IVC filter complications resulting from iatrogenic causes are rare and include but are not limited to misplacement, filter tilting, incomplete deployment, and filter migration. We recently experienced a problem in which the Vena Tech LP filter (B. Braun, Bethlehem, Pennsylvania) migrated to the superior vena cava (SVC) immediately after successful deployment of the filter in the infrarenal venacava. The root cause analysis of this case revealed that the complication was related to blind pullout of the J-tipped guidewire following deployment of the filter in the IVC. This report highlights the potential risks of using a wire while an IVC filter is in place.

Balloon-Assisted N-Butyl-2-Cyanoacrylate Closure of an Iatrogenic Femoral Arteriovenous Fistula

Femoral arteriovenous fistula (AVF) is an abnormal communication between femoral artery and vein, which is frequently caused by an iatrogenic or traumatic event. Surgery and endovascular approach with coil and stent graft placement are the most frequent choices of treatment. Herein, we present 2 cases of iatrogenic superficial femoral AVF, which were treated with percutaneous balloon-assisted N-butyl-2-cyanoacrylate glue (N-BCA). Both fistulae had a short tract, and 1 of the patients had previously undergone a failed coil embolization. The occlusions with N-BCA were achieved immediately, and both fistulae remained obliterated at 1 and 12 months of follow-up.