Michael Ginsburg

Comparison of Combination Therapies in the Management of Hepatocellular Carcinoma: Transarterial Chemoembolization with Radiofrequency Ablation versus Microwave Ablation

PURPOSE To compare retrospectively the outcomes and complications of transcatheter arterial chemoembolization with drug-eluting embolic agents combined with radiofrequency (RF) ablation or microwave (MW) ablation in treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS From 2003-2011, 89 patients with HCC received a combination therapy-transcatheter arterial chemoembolization plus RF ablation in 38 patients and transcatheter arterial chemoembolization plus MW ablation in 51 patients. Local tumor response, tumor progression-free survival (PFS), overall PFS, overall survival (OS), and complications were compared. Overall PFS and OS were compared between the two treatment groups in multivariate analysis controlling for Child-Pugh class, Barcelona Clinic Liver Classification stage, and index tumor size. RESULTS Complete local tumor response was achieved in 37 (80.4%) of the tumors treated with transcatheter arterial chemoembolization plus RF ablation and 49 (76.6%) of the tumors treated with transcatheter arterial chemoembolization plus MW ablation (P = .67). The median tumor PFS and overall PFS were 20.8 months and 9.3 months (P = .72) for transarterial chemoembolization plus RF ablation and 21.8 months and 9.2 months for transarterial chemoembolization plus MW ablation (P = .32). The median OS of the transcatheter arterial chemoembolization plus RF ablation group was 23.3 months, and the median OS of the transcatheter arterial chemoembolization plus MW ablation group was 42.6 months, with no significant difference in the survival experience between the two groups (log-rank test, P = .10). In the multivariate analysis, Barcelona Clinic Liver Classification stage was the only factor associated with overall PFS and OS. One patient in the transcatheter arterial chemoembolization plus RF ablation cohort (3%) and two patients in the transcatheter arterial chemoembolization plus MW ablation cohort (4%) required prolonged hospitalization (< 48 h) for pain management after the procedure (P = 1.00). CONCLUSIONS Based on similar safety and efficacy outcomes, both combination therapies, transcatheter arterial chemoembolization plus RF ablation and transcatheter arterial chemoembolization plus MW ablation, are effective treatments for HCC.

Adenoma Localization for Recurrent or Persistent Primary Hyperparathyroidism Using Dynamic Four-Dimensional CT and Venous Sampling

PURPOSE To determine if parathyroid venous sampling (PVS) combined with four-dimensional (4D) computed tomography (CT) improves sensitivity and accuracy of identification of parathyroid adenoma in patients with recurrent or persistent primary hyperparathyroidism (pHPT) and negative technetium-99m methoxyisobutyl isonitrile ((99m)Tc-MIBI) and ultrasound (US) scans. MATERIALS AND METHODS Both PVS and 4D CT were performed in 28 patients with recurrent or persistent pHPT and negative (99m)Tc-MIBI and US examinations. Localization by 4D CT alone and in combination with PVS and lateralization by PVS alone were retrospectively assessed for correlation with surgical results. Suspected adenomas on 4D CT were said to correlate with PVS if venous drainage identified on CT corresponded to sites of elevated parathyroid hormone concentration on PVS. Lesions difficult to identify on 4D CT were lesions < 1 cm in longest dimension. Results of 4D CT were classified as positive, negative, or equivocal. RESULTS Surgery was performed in 22 of 28 patients. Surgery identified 23 parathyroid adenomas, 1 carcinoma, and 2 hyperplastic glands in 20 patients. 4D-CT alone localized 11 lesions in 10 patients. PVS helped localize 13 additional lesions in nine more patients and clarified two lesions that were equivocal on 4D CT. Comparing 4D CT alone with 4D CT plus PVS, the sensitivity increased from 50% to 95% (P = .004), and accuracy increased from 55% to 91% (P = .022). PVS lateralization had a sensitivity of 93.3%, positive predictive value of 66.7%, and accuracy of 63.6%. CONCLUSIONS PVS significantly improves 4D CT localization of parathyroid adenomas in patients undergoing repeat surgery for pHPT with negative (99m)Tc-MIBI and US.

BMI-based radiation dose reduction in CT colonography.

RATIONALE AND OBJECTIVES There is potential for x-ray dose reduction in computed tomography colonography (CTC) relative to body mass index (BMI). We evaluated the association between BMI and three-dimensional (3D) CTC image quality to assess the potential utility of BMI as the basis for radiation dose reduction in CTC. MATERIALS AND METHODS Ninety-six consecutive patients underwent CTC and were randomized for scanning at 15 or 30 mAs. Extremely obese patients (BMI > 50) were excluded. Each patient was scanned supine and prone on a multidetector CT scanner. Postprocessing CTC visualization was performed on a dedicated workstation. Three independent observers assessed 3D image quality using a four-point scale. Image noise was measured in both the abdomen and pelvis. The association between BMI and image noise was examined using random-effects linear regression models. Logistic regression was used to examine the relationship between BMI, mAs, and conspicuity scores. RESULTS Statistically significant differences in image noise were observed between 15 and 30 mAs in both the abdomen and pelvis, and the difference was greater with increasing BMI. A positive relationship was detected between BMI and noise in the abdomen (P < .001) and pelvis (P < .001). Inverse correlation was identified between BMI and conspicuity scores in the abdomen (P = .01) and pelvis (P < .001). Overall conspicuity scores were reduced for both 15 and 30 mAs groups as BMI increased. CONCLUSION The radiation dose for CTC can be reduced by 40% and 70% below commonly employed doses for overweight and normal BMI patients, respectively, by using a BMI-adjusted dose reduction approach. Conspicuity scores dropped in obese patients with reduced dose suggesting that standard accepted doses should be utilized in that group.

Strut Penetration: Local Complications, Breakthrough Pulmonary Embolism, and Retrieval Failure in Patients with Celect Vena Cava Filters

PURPOSE To investigate strut penetration in patients with Celect filters, specifically local complications and association with breakthrough pulmonary embolism (PE) or retrieval failure. MATERIALS AND METHODS A retrospective single-center study was conducted to evaluate patients who received Celect filters between January 2007 and May 2013. A total of 595 filters were placed during the study period. Primary indications included thromboembolic disease (93%) and primary surgical prophylaxis (7%). Complications and retrieval data were assessed by computed tomography (CT) and electronic medical records. RESULTS A total of 193 patients underwent follow-up abdominal CT at a mean follow-up interval of 176.2 days (range, 0-1,739 d). The rate of strut penetration more than 3 mm outside the caval wall was 28.5% (n = 55). One patient had CT evidence of clinically major strut penetration (1.8%) with strut compression of the right ureter causing hydronephrosis. Indwelling filter time longer than 100 days was associated with strut penetration (P < .001). Age, sex, and history of thromboembolic disease were not associated with strut penetration (P = .51, P = .81, and P = .89). Sixty-three patients presented for follow-up CT pulmonary angiography at a mean of 128.1 days (range, 1-895 d). The rate of breakthrough PE was 12.7%. The overall retrieval success rate was 96.7% (n = 150). Strut penetration was not associated with breakthrough PE or retrieval failure (P = .49 and P = .22). CONCLUSIONS Although strut penetration is a common complication with Celect filters, there is no association with breakthrough PE or retrieval failure. CT evidence of local complications associated with strut penetration is rare.

Effectiveness of Collateral Vein Embolization for Salvage of Immature Native Arteriovenous Fistulas

PURPOSE To investigate the value of collateral vein embolization (CVE) as a salvage treatment for nonmaturing native arteriovenous fistulae (AVFs) in patients requiring hemodialysis. MATERIALS AND METHODS A total of 49 patients undergoing CVE (N = 65) for immature native AVFs at a single institution were reviewed. The study included 42 patients treated by 56 embolizations. Average fistula age at time of intervention was 18.2 weeks. Each patient underwent angiographic evaluation for fistula immaturity, with clinical success defined by initiation of single-session hemodialysis through the native fistula. RESULTS Fistula maturity was achieved in 32 of 42 patients (76.2%). No major complications occurred. Average time from CVE to fistula maturity was 38.4 days. Angioplasty done with CVE was found in a statistically higher percentage of patients with fistula success versus failure (31.3% vs 8.3%; P = .039). Radiocephalic fistulae were seen in a higher percentage of fistula failures compared with successes, but the results were not statistically significant (83.3% vs 59.4%; P = .054). Thirty-four patients underwent CVE without angioplasty, which resulted in successful fistula maturation in 22 cases (64.7%). Radiocephalic fistulae were again seen in a higher percentage of fistula failures compared with successes, but the findings did not meet statistical significance (81.8% vs 54.5%; P = .052). CONCLUSIONS Coil embolization of competing collateral vessels as a salvage treatment for nonfunctioning autologous AVFs is a viable treatment option in the majority of patients. Patients with radiocephalic fistulae may be at higher risk for primary fistula failure, but the present data are inconclusive.

Radiofrequency and microwave ablation in combination with transarterial chemoembolization induce equivalent histopathologic coagulation necrosis in hepatocellular carcinoma patients bridged to liver transplantation.

BACKGROUND Bridging therapy plays an increasingly important role in the management of patients with hepatocellular carcinoma (HCC) awaiting liver transplantation (LT). Combination therapy with drug-eluting bead transarterial chemoembolization (DEB-TACE) and percutaneous thermal ablation, such as radiofrequency ablation (RFA) or microwave ablation (MWA), has shown success at prolonging survival and bridging patients to LT. However, few studies have evaluated the two combination therapy regimens head-to-head at a single institution, and fewer have compared histopathology. This retrospective study compares tumor coagulation on explanted livers in patients with HCC treated with DEB-TACE sequentially combined with RFA versus MWA. METHODS From 2005 to 2015, 42 sequential patients underwent combination therapy prior to LT by Milan criteria, with 11 patients (11 tumors; mean, 2.9 cm; range, 1.8-4.3 cm) in the DEB-TACE/RFA cohort and 31 patients (40 tumors; mean, 2.4 cm; range, 1.1-5.4 cm) in the DEB-TACE/MWA cohort. The mean TACE procedures in the RFA and MWA cohorts were 1.3 (range, 1-2) and 1.3 (range, 1-3), respectively. The mean thermal ablations in the RFA and MWA cohorts were 1.2 (range, 1-2) and 1.3 (range, 1-3), respectively. Tumor coagulation was evaluated on explanted livers. RESULTS Mean tumor coagulation in the RFA and MWA cohorts were 88.9% (range, 0-100%) and 90.5% (range, 30-100%), respectively (P=0.82). Rates of complete tumor coagulation in the RFA and MWA cohorts were 45% and 53%, respectively (P=0.74). No difference in tumor coagulation was found between the cohorts when separating tumors <3 cm (P=0.21) and >3 cm (P=0.09). Among all 51 tumors, the 36 in complete response (CR) on imaging at LT demonstrated mean tumor coagulation of 95.8%. No correlation was found between tumor coagulation and initial tumor size or time interval to LT. No tumor seeding was seen along the ablation tracts. CONCLUSIONS RFA and MWA in sequential combination with DEB-TACE, used as a bridge to LT, are equally efficacious at inducing HCC tumor coagulation.

Ectopic pancreas presenting with pancreatitis and a mesenteric mass

Ectopic pancreas is defined by the presence of abnormally situated pancreatic tissue that lacks contact with normal pancreas and possesses its own duct system and vascular supply. Ectopic pancreas in the gastrointestinal tract is not uncommon. Moreover, there are several reported cases of adult ectopic pancreatitis in the literature, but to date, only two cases of pediatric ectopic pancreatitis have been reported. We describe a 15-year-old female with acute right upper quadrant pain and elevated serum lipase and amylase, in whom the radiological diagnosis was mesenteric soft tissue mass with adjacent inflammatory changes. The surgical pathology diagnosis, however, was mesenteric ectopic pancreas complicated by pancreatitis. We advocate for ectopic pancreatitis to be considered in a pediatric patient with acute abdominal pain, laboratory findings consistent with pancreatitis, and imaging findings of a mesenteric mass and normal orthotopic pancreas.

Comparison of Barbed versus Conventional Sutures for Wound Closure of Radiologically Implanted Chest Ports

PURPOSE To retrospectively compare the incidences of complications with barbed suture versus conventional interrupted suture for incision closure in implantable chest ports. MATERIALS AND METHODS A total of 715 power-injectable dual-lumen chest ports placed between 2011 and 2013 were studied. Primary outcomes included wound dehiscence, local port infection, local infections treated by wound packing, early infections within 30 days, and total infections. A multivariate analysis of independent risk factors for port infection was also performed. RESULTS A total of 442 ports were closed with nonbarbed suture, versus 273 closed with barbed suture. Mean catheter-days in the traditional and barbed groups were 257.9 (range, 3-722) and 189.1 (range, 13-747), respectively (P < .01). The rate of dehiscence with traditional suture (1.6%; seven of 442) was significantly higher than that with barbed suture (zero of 273; P = .04). Percentage of total infections was also significantly higher with traditional suture (9.5% vs 5.1%; P = .03). No difference in rate of infection per 1,000 catheter-days was seen between traditional and barbed suture groups (0.0035 vs 0.0026; P = .17). The rate of local infection with traditional suture was significantly higher (2.7% vs 0.4%; P = .02). Additionally, multivariate analysis identified the use of traditional suture as the only independent risk factor for infection (39% vs 25%; P = .03). CONCLUSIONS Barbed suture for incision closure in implantable dual-lumen chest ports was associated with lower rates of dehiscence and potentially lower rates of local infectious complications compared with traditional nonbarbed suture.

A Practical Review of the Use of Stents for the Maintenance of Hemodialysis Access

At the end of 2012, more than 402,000 end-stage renal disease (ESRD) patients in the United States were receiving hemodialysis (HD) therapy.1 By current estimates, more than 700,000 Americans will have ESRD by 2015.2 HD vascular access dysfunction is a major cause of morbidity and mortality in this population, and results in a significant component of the overall health care cost in the United States.3 4 Arteriovenous (AV) fistula use in HD patients has surpassed alternative access options during the past decade as a result of the National Vascular Access Improvement Initiative, or Fistula First program.5 6 Fistulas are associated with better clinical outcomes and decreased morbidity, including lower infection rates and shorter lengths of hospitalization, compared with AV grafts. However, both AV fistulas and grafts are prone to dysfunction and eventual failure.7 8 Neointimal hyperplasia associated with HD access causes significant morbidity such as disruption of adequate flow rates for HD, suboptimal HD, arm swelling, prolonged bleeding after the removal of dialysis sheaths, extremity swelling caused by diversion of flow, pseudoaneurysms, and frank thrombosis.9 Percutaneous transluminal angioplasty (PTA) is a standard, first-line treatment for venous stenosis and is known to prolong the lifespan of HD access, but indications such as occlusions, frequent or early restenosis, and PTA-induced rupture have resulted in the frequent use of stents to supplement or replace PTA. Several retrospective series and multicenter, randomized, prospective trials10 11 12 have examined the effectiveness of PTA, bare metal stents (BMS), and stent grafts (SGs) for a variety of indications related to the maintenance of HD access. This article provides guidance on the use of stents to preserve HD access from the perspective of our busy academic practice, as well as an updated review of the relevant published literature.

Percutaneous transhepatic placement of a stent-graft to treat a delayed mesoportal hemorrhage after pancreaticoduodenectomy

Postoperative hemorrhage is one of the most severe complications after pancreaticoduodenectomy. While detection of bleeding from adjacent arteries via conventional angiography and treatment with endovascular arterial coil embolization has been well established, to date no reports of percutaneous therapy for mesoportal hemorrhage have been published. This article describes an unusual case of delayed post-pancreaticoduodenectomy hemorrhage detected on a fluoroscopic drain check and treated with percutaneous transhepatic covered stent placement.