Kevin McCluskey

Covered Stents and Coil Embolization for Treatment of Postpancreatectomy Arterial Hemorrhage

PURPOSE To evaluate the efficacy and clinical outcomes associated with stent-graft placement and coil embolization for postpancreatectomy arterial hemorrhage (PPAH). MATERIALS AND METHODS Retrospective review of 38 stent-graft and/or embolization procedures in 28 patients (23 men; mean age, 65.1 y) for PPAH between 2007 and 2014 was performed. Time of bleeding, source of hemorrhage, intervention and devices used, repeat intervention rate, time to recurrent bleeding, complications, and 30-day mortality were assessed. Independent risk factors for recurrent bleeding and 30-day mortality were identified. RESULTS Median onset of hemorrhage was at 39 days (mean, 27.9 d; range, 5-182 d). Covered stents were used in 65.7% of interventions, coil embolization in 23.6%, stent-assisted embolization in 5.2%, and stent-graft angioplasty in 2.6%. A total of 28 stent-grafts were placed, of which 19 were self-expandable and nine were balloon-mounted. Mean stent-graft diameter was 6.6 mm (range, 5-10 mm). Recurrent bleeding occurred following 26.3% of interventions in seven patients at a mean interval of 22 days. The site of recurrent bleeding was new in 80% of cases. There was no significant difference in recurrent bleeding rate in early-onset (< 30 d; n = 22) versus late-onset PPAH (> 30 d; n = 6; P > .05). No ischemic hepatic or bowel complications were identified. The 30-day mortality rate was 7.1% (n = 2) and was significantly higher in patients with initial PPAH at ≥ 39 days (n = 5; P = .007). CONCLUSIONS Covered stents and coil embolization are effective for managing PPAH and maintaining distal organ perfusion to minimize morbidity and mortality. Recurrent bleeding is common and most often occurs from new sites of vascular injury rather than previously treated ones.

Comparative Analysis of Intranodal Lymphangiography with Percutaneous Intervention for Postsurgical Chylous Effusions

PURPOSE To evaluate clinical success and time to resolution of intranodal lymphangiography (INL) alone or with thoracic duct embolization (TDE) or thoracic duct disruption (TDD) based on initial effusion volume for postsurgical chylothorax. MATERIALS AND METHODS Retrospective review was performed of 57 patients (mean age 63 y; 65% male) undergoing INL alone or in conjunction with other percutaneous techniques for postsurgical chylous effusions. INL alone was performed when chylothorax output was ≤ 500 mL/d and no leak was identified during fluoroscopy. RESULTS INL was technically successful in all patients. There was 1 major and 2 minor complications. Clinical success rate was 71% (40/56). Clinical success rate meeting algorithmic inclusion criteria was 71.4% (5/7) for INL only, 41.7% (5/12) in INL with TDD, and 90.5% (19/21) in INL with TDE. Hazard ratio (HR) of clinical success of INL with TDE versus INL only was not statistically significant (HR 2.3, 95% confidence interval [CI], 0.70-5.87, P = .19). Median time to resolution was 14 days for INL only (95% CI, 0 days to not reached), 7 days for INL with TDD (95% CI, 4 days to not reached), and 3 days for INL with TDE (95% CI, 2 to 5 days) (P = .007). No statistically significant difference in median time to resolution existed between INL with TDE and INL only (P = .04). CONCLUSION In patients with postsurgical chylothorax, INL alone had similar rates of clinical success and time to resolution compared with INL with TDE when initial effusion volume was ≤ 500 mL/d and no leak was visualized during fluoroscopy.

Incidentally Discovered Uterine Sarcoma in a Premenopausal Patient after Hysterectomy for Postembolization Endometritis

Uterine leiomyomas (fibroids) are the most common benign tumor of the female reproductive system. Fibroids can become symptomatic with symptoms such as menorrhagia and menometrorrhagia, pelvic pain, and reproductive dysfunction. Hysterectomy, myomectomy, and the less invasive uterine artery embolization are now commonly performed if conservative management of symptomatic fibroids fails. Moreover, uterine artery embolization (UAE) is the preferred minimally invasive procedure for the treatment of symptomatic fibroids. Major complications of UAE are extremely rare but well known. Additionally, there is a risk of undiagnosed uterine sarcoma found post embolization, which has been reported in literature during the past 12 years. Herein, we describe a case of an incidentally discovered uterine sarcoma in a premenopausal female after hysterectomy for post uterine artery embolization endometritis and sepsis.

Peroneal Arteriovenous Fistula and Pseudoaneurysm: An Unusual Presentation

Peroneal artery arteriovenous fistulas and pseudoaneurysms are extremely rare with the majority of reported cases due to penetrating, orthopedic, or iatrogenic trauma. Failure to diagnose this unusual vascular pathology may lead to massive hemorrhage or limb threatening ischemia. We report an interesting case of a 14-year-old male who presented with acute musculoskeletal pain of his lower extremity. Initial radiographs were negative. Further imaging workup revealed a peroneal arteriovenous fistula with a large pseudoaneurysm. After initial endovascular intervention was unsuccessful, the vessels were surgically ligated in the operating room. Pathology revealed papillary endothelial hyperplasia consistent with an aneurysm and later genetic testing was consistent with Ehlers-Danlos syndrome Type IV. This case illustrates an unusual cause of acute atraumatic musculoskeletal pain and uncommon presentation of Ehlers-Danlos syndrome.

Tu1042 Post Pancreatectomy Hemorrage Endovascular Management: Single Instution Experience Using Covered Stents

Background: There is limited data on the utility of the percentage of lens culinaris agglutininreactive α-fetoprotein (AFP-L3%) measured on the new μTASWako i30 Immunoanalyzer for the diagnosis of early stage HCC in the U.S. population. The utility of AFP, AFP-L3% or des-γ-carboxy prothrombin (DCP) for predictingHCC recurrence after liver transplantation is also unknown. Aims: To 1) determine the sensitivity and specificity of AFP, AFP-L3%, and DCP for the diagnosis of early stage HCC; and 2) evaluate the utility of AFP, AFP-L3% and DCP in predicting HCC recurrence after orthotopic liver transplantation (OLT). Methods: Three hundred and thirteen HCC patients and 307 non-HCC controls with end-stage liver disease who were transplanted at Mayo Clinic, Rochester, MN and Jacksonville, FL between 2000 2008 and had serum samples available for biomarker testing were included in the study. Demographic and clinical information were abstracted from the medical record. AFP, AFP-L3% and des-γ-carboxy prothrombin (DCP) assays were performed on the μTASWako i30 Immunoanalyzer. Receiver operating characteristic (ROC) curves were generated to determine the sensitivity and specificity of the biomarkers for diagnosis of HCC. Predictors of HCC development and HCC recurrence were analyzed using the Logistic regression model. Results: AFP had the best area under the ROC curve (0.75, 95%CI 0.72-0.78) for diagnosis of early stage HCC, followed by AFP-L3% (0.63, 95% CI 0.60-0.66) and DCP (0.46, 95%CI 0.43-0.49). The optimum cut-off value of AFP was 9.4 ng/ml with the sensitivity of 62.6% and specificity of 80% and of AFP-L3% was 15.8% with a sensitivity of 30.1% and specificity of 85.1%. AFP and AFP-L3% were independently associated with early stage HCC. Every 10 ng/mL increase in AFP value and every 10% increase in AFP-L3% value were associated with a 36.6% and 43.0% increased risk for HCC diagnosis (OR=1.37, 95%CI 1.20-1.56 for AFP, p,0.0001,and OR 1.43, 95% CI 1.18-1.58 for AFP-L3%, p,0.0001). Of the 313 HCC patients, 301 (96.2%) patients were treated with transarterial chemoembolization (TACE) prior to transplantation. Forty-seven (15%) patients had HCC recurrence after transplant (median time for recurrence was 18.4 months). The post-TACE pre-OLT AFP-L3% was significantly associated with HCC recurrence after OLT. Every 10% increase in post-TACE AFP-L3 was associated with a 48.2% increased risk of HCC recurrence after OLT (OR=1.48, 95% CI 1.11 to 1.97, p=0.007). AFP, AFP-L3% and DCP at the time of HCC diagnosis were not associated with HCC recurrence after OLT. Conclusions: AFP-L3% is potentially useful in predicting HCC recurrence after liver transplantation in US patients. Validation of these results in additional cohorts is needed.