Louis Estivalet

Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage

Acute variceal hemorrhage, a life-threatening condition that requires a multidisciplinary approach for effective therapy, is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy, the presence of large esophageal varices with recent stigmata of bleeding, or fresh blood visible in the stomach with no other source of bleeding identified. Transfusion of blood products, pharmacological treatments and early endoscopic therapy are often effective; however, if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs, transjugular intrahepatic portosystemic shunt (TIPS) is recommended as rescue treatment. The TIPS represents a major advance in the treatment of complications of portal hypertension. Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS, which has a 90% to 100% success rate. However, TIPS is associated with a mortality of 30% to 50% in such a setting. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage, particularly as a rescue therapy following failure of endoscopic approaches.

Endovascular management of visceral artery aneurysms: When to watch, when to intervene?

Visceral artery aneurysms (VAA) include splanchnic and renal artery aneurysms. They represent a rare clinical entity, although their detection is rising due to an increased use of cross-sectional imaging. Rupture is the most devastating complication, and is associated with a high morbidity and mortality. In addition, increased percutaneous endovascular interventions have raised the incidence of iatrogenic visceral artery pseudoaneurysms (VAPAs). For this reason, elective repair is preferable in the appropriately chosen patient. Controversy still exists regarding their treatment. Over the past decade, there has been steady increase in the utilization of minimally invasive, non-operative interventions, for vascular aneurysmal disease. All VAAs and VAPAs can technically be fixed by endovascular techniques but that does not mean they should. These catheter-based techniques constitute an excellent approach in the elective setting. However, in the emergent setting it may carry a higher morbidity and mortality. The decision for intervention has to take into account the size and the natural history of the lesion, the risk of rupture, which is high during pregnancy, and the relative risk of surgical or radiological intervention. For splanchnic artery aneurysms, we should recognize that we are not, in reality, well informed about their natural history. For most asymptomatic aneurysms, expectant treatment is acceptable. For large, symptomatic or aneurysms with a high risk of rupture, endovascular treatment has become the first-line therapy. Treatment of VAPAs is always mandatory because of the high risk of rupture. We present our point of view on interventional radiology in the splanchnic arteries, focusing on what has been achieved and the remaining challenges.

Transcatheter embolization as the new reference standard for endoscopically unmanageable upper gastrointestinal bleeding

Acute nonvariceal upper gastrointestinal bleeding (UGIB) is a major medical emergency problem associated with significant morbidity and mortality. Endoscopy is considered the first method of choice to detect and treat UGIB. Endoscopic therapy usually achieves primary hemostasis, but 10%-30% of these patients have repeat bleeding. In patients in whom hemostasis is not achieved with endoscopic techniques, treatment with transcatheter angiographic embolization (TAE) or surgery is needed. Surgical intervention is usually an expeditious and gratifying endeavor, but it can be associated with high operative mortality rates. A large number of studies support the use of TAE as salvage therapy as an alternative to surgery. However, few studies have compared the results of TAE with that of emergency surgery in terms of efficiency, the frequency of repeat bleeding, and complications. Recently, Ang et al retrospectively compared the outcome of TAE and surgery as salvage therapy of UGIB after failed endoscopic treatment. There were no significant differences in 30 d mortality, complication rates and length of stay although higher rebleeding rates were observed after TAE compared with surgery. In this commentary, we discuss the advantages and drawbacks of these two therapeutic strategies for UGIB. We also attempt to define the exact role of TAE for acute nonvariceal UGIB.

C-arm dual-phase cone-beam CT: a revolutionary real-time imaging modality to assess drug-eluting beads TACE success in liver cancer patients

The advent of cone-beam computed tomography (CBCT) in the angiography suite has been revolutionary in interventional radiology. CBCT offers 3 dimensions (3D) diagnostic imaging in the interventional suite and can enhance minimally-invasive therapy beyond the limitations of 2D angiography alone. The role of CBCT has been recognized in transcatheter arterial chemoembolization (TACE) treatment of liver cancer especially with the recent introduction of dual-phase CBCT (DP-CBCT) for unresectable hepatocellular carcinoma (HCC) treatment. Loffroy and colleagues proposed the use of intraprocedural C-arm DP-CBCT immediately after TACE with doxorubicin-eluting beads to predict HCC tumor response at 1-month magnetic resonance (MR) imaging follow-up. They reported a significant relationship between tumor enhancement seen at DP-CBCT after TACE and objective MR imaging response at 1-month follow-up, suggesting that DP-CBCT can be used to predict tumor response after TACE. If confirmed in larger studies, this imaging modality may play a key role in the improvement of treatment planning, especially with regard to the need for repeat treatment. More important, a potential clinical implication of using intraprocedural DP-CBCT in these patients might be elimination of 1-month follow-up MR imaging.

Preoperative portal vein embolization in liver cancer: indications, techniques and outcomes

Postoperative liver failure is a severe complication of major hepatectomies, in particular in patients with a chronic underlying liver disease. Portal vein embolization (PVE) is an approach that is gaining increasing acceptance in the preoperative treatment of selected patients prior to major hepatic resection. Induction of selective hypertrophy of the non-diseased portion of the liver with PVE in patients with either primary or secondary hepatobiliary, malignancy with small estimated future liver remnants (FLR) may result in fewer complications and shorter hospital stays following resection. Additionally, PVE performed in patients initially considered unsuitable for resection due to lack of sufficient remaining normal parenchyma may add to the pool of candidates for surgical treatment. A thorough knowledge of hepatic segmentation and portal venous anatomy is essential before performing PVE. In addition, the indications and contraindications for PVE, the methods for assessing hepatic lobar hypertrophy, the means of determining optimal timing of resection, and the possible complications of PVE need to be fully understood before undertaking the procedure. Technique may vary among operators, but cyanoacrylate glue seems to be the best embolic agent with the highest expected rate of liver regeneration for PVE. The procedure is usually indicated when the remnant liver accounts for less than 25-40% of the total liver volume. Compensatory hypertrophy of the non-embolized segments is maximal during the first 2 weeks and persists, although to a lesser extent during approximately 6 weeks. Liver resection is performed 2 to 6 weeks after embolization. The goal of this article is to discuss the rationale, indications, techniques and outcomes of PVE before major hepatectomy.

Comparison of three different embolic materials for varicocele embolization: retrospective study of tolerance, radiation and recurrence rate

BACKGROUND To evaluate pain, radiation and recurrence rates in patients undergoing varicocele embolization with three different embolic materials. METHODS Retrospective study of 182 consecutive patients who underwent transcatheter retrograde varicocele embolization from July 2011 to May 2015 with glue (Glubran(®)2) (group 1, n=63), mechanical agents (coils and/or plugs) (group 2, n=53) or a sclerosing agent (polidocanol) (group 3, n=66). Patients were asked by telephone interview to evaluate pain during embolization and at 1, 7 and 30 days using a quantitative pain scale ranging from 0 to 10. Duration of scopy, kinetic energy released per unit mass (kerma) and dose area product (DAP) were assessed as radiation parameters during embolization procedures. Recurrence rates after treatment were also evaluated. Statistical analyses were performed using parametric and non-parametric tests. RESULTS Patients in the three study groups were comparable for age, clinical indication and embolization side. No difference was noted for significant pain (pain score ≥3) during embolization and at 1, 7 and 30 days after treatment. Discomfort (pain score <3) was more frequent in group 1 than in groups 2 and 3 at 7 days after the procedure (P=0.049). No difference in discomfort was noted during embolization or at 1 and 30 days. Duration of scopy was shorter (P<0.0001) and kerma was lower (P=0.0087) in group 1 than in groups 2 and 3. DAP was lower in group 1 than in group 2 (P=0.04) but no difference was noted between groups 1 and 3, and groups 2 and 3. The recurrence rate at a mean follow-up of 24.4 months (range, 2-53 months) was significantly lower in group 1 than in the two other groups (P=0.032). CONCLUSIONS The use of Glubran(®)2 acrylic glue for varicocele embolization is safe and leads to less radiation and lower recurrence rates than is the case for other embolic materials without any more significant pain.

Successful Endovascular Treatment of a Large Azygos Vein Aneurysm With Stent-Graft Implantation

Fig 2. Fig 3. FE A T U R E 78-year-old woman came to our institution with A R T IC L E S Achest pain and received a diagnosis of pulmonary embolus and mediastinal mass of 6 5 cm by computed tomography of the chest. The result of magnetic resonance imaging was consistent with an azygos vein aneurysm (Fig 1). Anticoagulant therapy was given in the hope of preventing thrombus formation and additional pulmonary embolization. Phlebographic studies through a transfemoral approach were undertaken to confirm the diagnosis and, if feasible, to attempt endovascular treatment of the azygos vein aneurysm (Fig 2). Because of the favorable curvature of the azygos vein, exclusion of the

Interventional radiology therapies for liver cancer

Hepatocellular carcinoma (HCC) is the fifth most frequently found primary malignant tumor in the world. Hepatic surgery and liver transplantation are considered optimal for the curative treatment of HCC. However, only 15-20% of HCCs may be surgically treated. Most of the surgically-non-eligible patients have to receive locoregional imageguided interventional treatments including intra-arterial and percutaneous ablative therapies. The goal of this paper is to review these interventional oncology approaches. Ablative therapeutic approaches include chemical therapies (such as ethanol or acetic acid injection), and thermal therapies (such as radiofrequency ablation, laser-induced thermotherapy, microwave ablation, cryoablation, and high-intensity focused ultrasound ablation). Catheter-based therapies include embolotherapy/chemotherapy-based treatments (such as transcatheter arterial chemoembolization, bland embolization, transcatheter arterial chemoinfusion, and chemoembolization with drug-eluting beads), and radiotherapy-based treatments (such as radioembolization with yttrium-90 and injection of iodine-131-labeled lipiodol). As a result of the technical development of locoregional approaches for HCC during the recent decades, the range of combined interventional therapies has been continuously extended. In this article, an evidence-based approach will be used to review the current role of interventional radiology therapies in the management of unresectable HCC.

Novel imaging biomarkers of response to transcatheter arterial chemoembolization in hepatocellular carcinoma patients

Hepatocellular carcinoma (HCC) is the third most common cause of cancer death worldwide (1). Most patients present with intermediate or advanced disease that is not amenable to curative treatment, and the median survival in this group is 6-8 months (2). Several studies and well-designed randomized trials have shown a positive effect of transcatheter arterial chemoembolization (TACE) on patient outcome and survival (3-8). As nicely described in the present article from Wang et al. , assessment of tumor response is of extreme importance in patients undergoing locoregional treatments of liver cancer (9). Early assessment of the effectiveness of TACE and monitoring of tumor response are paramount to the identification of treatment failure, guidance of future therapy, and determination of the interval for repeat treatment. Wang et al. confirm in this article that imaging evaluation of HCC response to therapy is generally and widely performed with cross-sectional imaging [computed tomography (CT) and magnetic resonance imaging (MRI)] by using the modified Response Evaluation Criteria in Solid Tumors (RECIST) criteria and the European Association for the Study of the Liver (EASL) criteria which have been introduced in the past decade (9). It is interesting to note that these criteria are not based on experimental or observational studies, but are proposed as revised versions of World Health Organization (WHO) and RECIST criteria (10-13). Initial reports showed that they were better than the latter for assessment of response, and both have been shown to be independent prognostic factors (14-19). Nevertheless, these criteria have been shown to have several limitations, mainly the lack of standardization, and there are concerns about applicability and reproducibility that have been raised. Indeed, they may be difficult to use, especially in heterogeneous lesions, and their use is dependent on operator experience. Although recent guidelines have acknowledged the potential value of these new criteria, they are not considered robust enough to replace older morphological criteria in trials (18). As a result, since they were first introduced, numerous studies have been published to better define the type and optimal number of target lesions, the ideal imaging technique, and the follow-up schedule. At present most teams perform one-dimensional mRECIST or two-dimensional EASL measurement of the enhanced portion of a maximum of two target lesions (18,19). Nevertheless, very recent data have suggested that three-dimensional (3D) evaluation of the whole tumor burden using specific software, functional imaging or cone-beam CT (CBCT) imaging may be of interest as novel imaging biomarkers to predict future tumor response to TACE in HCC patients (10,20-27).

Reply: Which is the Best Chemotherapeutic Agent for Transarterial Chemoembolization of Hepatocellular Carcinoma?

To the Editor, We would like to thank the authors for giving us the opportunity to make some comments on the use of transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) from an evidence-based medicine point of view. TACE is an accepted therapy for intermediatestage HCC [1]. A meta-analysis revealed highly variable objective response rates between 16 and 61 %, which did not always lead to improved survival [2]. An important limitation of conventional TACE is that the technique and treatment schedules can be heterogeneous from one unit to another and this makes the results reported in the literature very inconsistent [3]. For these reasons, TACE with drugeluting beads (DEBs) (commonly doxorubicin, cisplatin, epirubicin and more recently idarubicin) has increasingly been performed interchangeably with conventional TACE in many institutions throughout the world, as a novel technique capable of ensuring more sustained and tumorselective drug delivery and permanent embolization [4, 5]. However, previous comparisons between TACE with DEBs and conventional TACE with lipiodol in intermediate-stage HCC demonstrated only slightly conflicting results. A recent meta-analysis based on seven studies even demonstrated that the two procedures showed equivalent results, strongly suggesting the lack of difference in tumor responses between the two procedures, whatever the chemotherapeutic agent used [6]. Based on preclinical in vitro studies that demonstrated superior cytotoxicity of idarubicin on HCC cells [7], two first-in-human studies of lipiodol-TACE using idarubicin and of idarubicin-loaded DEBs were performed in unresectable HCC patients [5, 8]. Unfortunately, despite encouraging safety profile, these studies failed to demonstrate any superiority of idarubicin on time to progression and overall survival in comparison with the previous published data on TACE using doxorubicin. It is well known that discrepancy in the results may be observed between in vitro, animal and human studies. We can even wonder whether the use of any specific chemotherapeutic agent for TACE of HCC is absolutely mandatory. Indeed, no randomized trial has demonstrated the superiority of chemoembolization over embolization, and thus the role of chemotherapy remains unclear. A recent randomized trial in 101 patients comparing the outcomes of embolization using microspheres alone with chemoembolization using doxorubicin-eluting microspheres showed no apparent difference in RECIST response and overall survival between the treatment arms, challenging the use of doxorubicin-eluting beads for chemoembolization of HCC [9]. Consequently, many preclinical studies are essential to determine the best chemotherapeutic agent for TACE, and despite potential superior cytotoxicity of idarubicin on HCC cells, it remains to be demonstrated whether idarubicin DEB is superior over doxorubicin DEB or conventional TACE in intermediate-stage HCC therapy, through a randomized controlled clinical trial.