M. Doshi

Long-term oncologic outcomes following radiofrequency ablation with real-time temperature monitoring for T1a renal cell cancer

OBJECTIVE Few studies report long-term follow-up of renal cancer treated by radiofrequency ablation (RFA), thus limiting the comparison of this modality to well-established long-term follow-up series of surgically resected renal masses. Herein, we report long-term oncologic outcomes of renal cancer treated with RFA in a single institution. METHODS AND MATERIALS We retrospectively reviewed patients treated between November 2001 and October 2012 with laparoscopic-guided or computed tomography-guided RFA. All treatments were performed with real-time thermometry ensuring target ablation temperature (>60°C) was adequately reached. Only patients with biopsy-confirmed T1a-category cancer and a follow-up period>48 months were included in our analysis. Follow-up included office visits, laboratory work, and periodic contrast-enhanced imaging. Survival was calculated using the Kaplan-Meier analysis. Overall complications were reported using the Clavien-Dindo scale. RESULTS Of 434 RFA cases, 53 treatments in 50 patients met the inclusion criteria. Of these, 29 were treated with computed tomography-guided RFA and 24 with laparoscopic-guided RFA. The mean follow-up interval was 65.6 months (48.5-120.2), and the mean renal mass size was 2.3 cm (0.3-4.0). There were 4 (7.5%) local recurrences and 1 case of distant metastases with no local recurrence. The 5-year overall survival was 98%, cancer-specific survival was 100%, and recurrence-free survival was 92.5%. The complication rate was 26.4%, which included 71% of Clavien-Dindo grade I and 29% of grade II. Mean estimated glomerular filtration rate preoperatively and at the most recent follow-up visit was 77 and 66 ml/min, respectively. CONCLUSIONS When performed on selected patients, while monitoring real-time temperatures to ensure adequate treatment end points, RFA offers favorable long-term oncologic outcomes approaching those reported for partial nephrectomy.

Irreversible Electroporation (IRE) in Renal Tumors

Small renal masses (SRMs) have been traditionally managed with surgical resection. Minimally invasive nephron-sparing treatment methods are preferred to avoid harmful consequences of renal insufficiency, with partial nephrectomy (PN) considered the gold standard. With increase in the incidence of the SRMs and evolution of ablative technologies, percutaneous ablation is now considered a viable treatment alternative to surgical resection with comparable oncologic outcomes and better nephron-sparing property. Traditional thermal ablative techniques suffer from unique set of challenges in treating tumors near vessels or critical structures. Irreversible electroporation (IRE), with its non-thermal nature and connective tissue-sparing properties, has shown utility where traditional ablative techniques face challenges. This review presents the role of IRE in renal tumors based on the most relevant published literature on the IRE technology, animal studies, and human experience.

Late endovascular removal of Günther-Tulip inferior vena cava filter and stent reconstruction of chronic post-thrombotic iliocaval obstruction after 4753 days of filter dwell time: a case report with review of literature

Chronic post-thrombotic obstruction of the inferior vena cava (IVC) or iliocaval junction is an uncommon complication of long indwelling IVC filter. When such an obstruction is symptomatic, endovascular treatment options include stent placement with or without filter retrieval. Filter retrieval becomes increasingly difficult with longer dwell times. We present a case of symptomatic post-thrombotic obstruction of the iliocaval junction related to Günther-Tulip IVC filter (Cook Medical Inc, Bloomington, IN) with dwell time of 4753 days, treated successfully with endovascular filter removal and stent reconstruction. Filter retrieval and stent reconstruction may be a treatment option in symptomatic patients with filter-related chronic IVC or iliocaval junction obstruction, even after prolonged dwell time.

Proximal Splenic Artery Embolization in Chemotherapy-Induced Thrombocytopenia: A Retrospective Analysis of 13 Patients.

PURPOSE To determine if proximal splenic artery embolization (PSAE) provides a safe and effective alternative to alleviate chemotherapy-induced thrombocytopenia (CIT), allowing patients with cancer to resume chemotherapy regimens. MATERIALS AND METHODS Thirteen patients (9 men, 4 women; mean age, 63 y) with underlying malignancy (pancreatic adenocarcinoma, n = 6; cholangiocarcinoma, n = 5; other, n = 2) complicated by CIT underwent PSAE. Mean platelet counts were calculated before the initiation of chemotherapy, at the nadir that resulted in discontinuation of chemotherapy before the PSAE procedure, at peak values after the procedure, and at a mean follow-up of 9.2 months. The time to reinitiation of chemotherapy after PSAE was calculated. RESULTS Baseline platelet count before initiation of chemotherapy was 162 × 10(9)/L (range, 90-272 × 10(9)/L). The platelet count nadir resulting in cessation of chemotherapy was 45 × 10(9)/L (range, 23-67 × 10(9)/L), and the pre-PSAE platelet count was 88 × 10(9)/L (range, 49-131 × 10(9)/L). The post-PSAE peak platelet count improved significantly (to 209 × 10(9)/L; range, 83-363 × 10(9)/L) compared with the nadir counts and the pre-PSAE counts (P < .01) at a mean short-term follow-up of 35 days (range, 7-91 d). The counts at follow-up to 9.2 months (range, 3-15 mo) were 152 × 10(9)/L (range, 91-241 × 10(9)/L). All patients became eligible to resume chemotherapy. The time to initiation of chemotherapy after PSAE averaged 22 days (range, 4-58 d) in 12 patients; one patient declined chemotherapy. CONCLUSIONS Proximal splenic artery embolization appears to be safe and effective in alleviating CIT, allowing resumption of systemic chemotherapy. Further studies may help guide patient selection by identifying characteristics that allow a sustained improvement in thrombocytopenia.

Transsplenic portal vein reconstruction–transjugular intrahepatic portosystemic shunt in a patient with portal and splenic vein thrombosis

Portal vein thrombosis (PVT) is a potential complication of cirrhosis and can worsen outcomes after liver transplant (LT). Portal vein reconstruction–transjugular intrahepatic portosystemic shunt (PVR-TIPS) can restore flow through the portal vein (PV) and facilitate LT by avoiding complex vascular conduits. We present a case of transsplenic PVR-TIPS in the setting of complete PVT and splenic vein (SV) thrombosis. The patient had a 3-year history of PVT complicated by abdominal pain, ascites, and paraesophageal varices. A SV tributary provided access to the main SV and was punctured percutaneously under ultrasound scan guidance. PV access, PV and SV venoplasty, and TIPS placement were successfully performed without complex techniques. The patient underwent LT with successful end-to-end anastomosis of the PVs. Our case suggests transsplenic PVR-TIPS to be a safe and effective alternative to conventional PVR-TIPS in patients with PVT and SV thrombosis.

Ultrasound-Assisted Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism:

Purpose: Catheter-directed thrombolysis (CDT) is a relatively new therapy for pulmonary embolism that achieves the superior clot resolution compared to systemic thrombolysis while avoiding the high bleeding risk intrinsically associated with that therapy. In order to examine the efficacy and safety of CDT, we conducted a retrospective cohort study of patients undergoing ultrasound-assisted CDT at our institution. Methods: The charts of 30 consecutive patients who underwent CDT as a treatment of pulmonary embolism at our institution were reviewed. Risk factors for bleeding during thrombolysis were noted. Indicators of the right heart strain on computed tomography and echocardiogram, as well as the degree of pulmonary vascular obstruction, were recorded before and after CDT. Thirty-day mortality and occurrence of bleeding events were recorded. Results: Nine (30%) patients had 3 or more minor contraindications to thrombolysis and 14 (47%) had major surgery in the month prior to CDT. Right ventricular systolic pressure and vascular obstruction decreased significantly after CDT. There was a significant decrease in the proportion of patients with right ventricular dilation or hypokinesis. Decrease in pulmonary vascular obstruction was associated with nadir of fibrinogen level. No patients experienced major or moderate bleeding attributed to CDT. Conclusion: Catheter-directed thrombolysis is an effective therapy in rapidly alleviating the right heart strain that is associated with increased mortality and long-term morbidity in patients with pulmonary embolism with minimal bleeding risk. Catheter-directed thrombolysis is a safe alternative to systemic thrombolysis in patients with risk factors for bleeding such as prior surgery. Future studies should examine the safety of CDT in patients with contraindications to systemic thrombolysis.

Portal venous stenosis following liver transplant: Role of transsplenic intervention

Portal vein stenosis (PVS) is uncommon, complicating approximately 5% of liver transplantations (LTs). It is more likely to occur with split grafts in pediatric recipients where smaller graft size, mismatch of donorrecipient vein diameters, interposition grafts, and complex reconstructions potentiate scarring and neointimal hyperplasia at the site of anastomosis. Severity varies from asymptomatic mild narrowing to complete thrombotic occlusion. Intervention is indicated to alleviate portal hypertension and prevent graft failure. Percutaneous transhepatic (TH) intervention has become the mainstay of treatment for posttransplant portal vein (PV) anastomotic stenosis with several reports of TH treatment of PVS, most notably by Funaki et al. and Shibata et al. 3 with technical success rates of 19/25 and 35/45 and reintervention rates of 7/19 and 10/35, respectively. Funaki et al. had 4 complications: 2 patients developed portal vein thrombosis (PVT), 1 during and 1 after the procedure, both successfully treated with catheter-directed thrombolysis (CDT). There were no bleeding complications. Shibata et al. had 2 complications: 1 had an intrahepatic pseudoaneurysm successfully treated with coil embolization and 1 had an intraprocedural PVT successfully treated with CDT. In this issue of Liver Transplantation, Ohm et al. describe their experience of transsplenic (TS) and TH PV interventions after LT. Their experience differs from earlier authors because they used the TS approach to avoid graft injury. Criteria for attempting the TS approach included preprocedural imaging demonstrating and having an enlarged spleen in the normal location with patent splenic vein (SpV) and unaffected SpV–superior mesenteric vein (SMV) junction. Of 18 LT recipients, 10 met these criteria and were treated via the TS approach. The other 8 patients were treated via the TH approach due to prior splenectomy (n5 3), involvement of SpV-SMV junction (n5 3), and chronic SpV thrombosis (n5 2). Technical success was achieved in all patients. One patient with a tortuous SpV in the TS group had a tear of this vessel. Although TH access is a more commonly used route for PV catheterization, TS access has steadily gained traction over the last decade. Injury to the graft during TH PV intervention is a concern, particularly in the first month after transplantation. The first large series on TS catheterization of the PV in patients with cirrhosis was published in 1997 by Liang et al. with a success rate of 16/17 and included the use of gelfoam to plug the TS tract. Complications included intrasplenic hematoma (n5 2), hemoperitoneum (n5 1), and left pleural effusion (n5 1). Since then, several studies have been published reporting TS PV catheterization for various indications such as embolization of the varices or portosystemic shunts, PV venoplasty or stent placement following LT, PV recanalization along with transjugular intrahepatic portosystemic shunt (TIPS) to improve transplant candidacy and outcome, and for lobar PV embolization to induce hypertrophy of the future liver remnant. Bleeding complication from splenic puncture still remains a concern, however, with a growing body of evidence and experience. Several technical aspects have been recognized to help reduce bleeding complications such as correlation with preprocedural imaging; ultrasound guidance; targeting perihilar SpV branch that is in straight line with the vector of Abbreviations: CDT, catheter-directed thrombolysis; LT, liver transplantation; PV, portal vein; PVS, portal vein stenosis; PVT, portal vein thrombosis; SMV, superior mesenteric vein; SpV, splenic vein; TH, transhepatic; TIPS, transjugular intrahepatic portosystemic shunt; TS, transsplenic.

Acute tumor lysis syndrome after proximal splenic artery embolization

Preoperative splenic artery embolization for massive splenomegaly has been shown to reduce intraoperative hemorrhage during splenectomy. We describe a case of tumor lysis syndrome after proximal splenic artery embolization in a patient with advanced mantle cell lymphoma and splenic involvement. The patient presented initially with hyperkalemia two days after embolization that worsened during splenectomy. He was stabilized, but developed laboratory tumor lysis syndrome with renal failure and expired. High clinical suspicion of tumor lysis syndrome in this setting is advised. Treatment must be started early to avoid serious renal injury and death. Lastly, same day splenectomy and embolization should be considered to decrease the likelihood of developing tumor lysis syndrome.