Mikołaj Wojtaszek

Transarterial Chemoembolization Prior to Liver Transplantation in Patients with Hepatocellular Carcinoma

BACKGROUND Transarterial chemoembolization (TACE) induces ischemic tumor necrosis, which is intensified by regional chemotherapy. By reducing the active tumor tissue, it can be assumed that patients on the waiting list for liver transplantation may benefit from this locoregional treatment. The aim of this study was to assess the relevance of TACE in hepatocellular carcinoma (HCC) patients before liver transplantation. MATERIAL AND METHODS A retrospective analysis was performed on data of 229 patients who were transplanted for HCC. A group of 75 patients were treated with TACE prior to liver transplantation. Tumor necrosis related to pretransplantation locoregional treatment was assessed in an explanted liver and classified into extensive (51-100%), moderate (26-50%) and limited (<25%) grades. Five-year recurrence-free survival was estimated using the Kaplan-Meier method and compared using the log-rank test. RESULTS In total, 143 HCC lesions were treated with TACE. Extensive necrosis was found in 63 (44.0%) tumors. Moderate and limited necrosis were observed in 42 (29.4%) and 38 (26.6%) tumors, respectively. In 36 (58.1%) explanted livers, every tumor was classified as extensively necrotic. The 5-year recurrence-free survival was estimated as 81.6% in the group not treated with TACE prior to liver transplantation (TACE-) and as 73.1% in the TACE+ group (p=0.169). Among patients not fulfilling the Milan criteria, 5-year recurrence-free survival was 63.1% in TACE- and 65.1% in TACE+ (p=0.656). CONCLUSIONS In conclusion, TACE prior to liver transplantation is effective in inducing tumor necrosis. However, evidence of benefits in long-term results after liver transplantation requires further confirmation.

Do high levels of serum triglycerides in pancreas graft recipients before transplantation promote graft pancreatitis

OBJECTIVE Graft pancreatitis is a serious complication following pancreas transplantation. The aim of this study was to evaluate the influence of pretransplant serum lipid levels on the development of graft pancreatitis among patients undergoing simultaneous pancreas and kidney transplantation (spkTx). METHODS We reviewed data from spkTx patients engrafted between 1999 and 2002. Group 1 consisted of 10 recipients with well-established pancreas and kidney graft function without postoperative pancreatitis; group 2 5 spkTx recipients who developed fatal graft pancreatitis in the first posttransplant month. The lipid parameters evaluated within 1 hour before transplantation and after hemodialysis included total cholesterol, HDL, LDL, VLDL, triglicerides and apoproteins A and B. RESULTS Triglycerides, apoprotein B and VLDL were significantly increased just before transplantation among patients who developed fatal pancreatitis compared to those patients with good graft function. CONCLUSION Recipient hypertriglyceridemia promotes graft pancreatitis in previously injured pancreatic graft.

Promoting False-Lumen Thrombosis after Thoracic Endovascular Aneurysm Repair in Type B Aortic Dissection by Selectively Excluding False-Lumen Distal Entry Tears

PURPOSE To evaluate the efficacy and clinical outcomes of ancillary endovascular procedures in promoting false-lumen (FL) thrombosis (FLT) and preventing aortic expansion in patients after thoracic endografting for type B dissections. MATERIALS AND METHODS This retrospective review included 15 patients (12 men and 3 women; mean age, 59.6 y). Mean aortic diameter at the time of ancillary treatment was 47.4 mm. Different techniques were used as single procedures or sequentially: covered stent occlusion of detached visceral artery entry tears, occlusion of single entry tears with vascular plugs, or aortic endograft occlusion of multiple FL entry tears. FL embolization with ethylene vinyl alcohol copolymer was performed when selective occlusion was considered insufficient to close distal entry tears. Apart from endovascular aneurysm repair, all procedures were performed percutaneously under local anesthesia. If FL diameter increase persisted after 6-month follow-up computed tomographic (CT) angiography, another intervention was planned; otherwise, yearly follow-up was performed. RESULTS Mean clinical follow-up duration was 43.8 months (range, 8 d to 86.8 mo), with no in-hospital mortality. Estimated overall survival rates were 93.3%, 86.6%, and 77% at 12, 24, and 48 months, respectively. Three late deaths occurred, one of which was dissection-related at 40 months. Eight surviving patients (53%) had total FLT and 3 had partial FLT with stable aortic diameter on follow-up CT angiography. FL diameter increased in one patient, requiring further intervention. CONCLUSIONS Selective exclusion of new distal entry tears remaining after thoracic endovascular aneurysm repair can stabilize abdominal aortic expansion and promote FLT.

Improving the results of transarterial embolization of type 2 endoleaks with the embolic polymer Onyx

Introduction Type 2 endoleaks (T2E) occur in 10 to 20% of patients after endovascular abdominal aortic aneurysm repair (EVAR) and remain a significant clinical issue. Aim To evaluate the efficacy and clinical outcomes of transarterial treatment of persistent type II endoleaks after EVAR using the liquid embolic Onyx. Material and methods From February 2012 to August 2015 transarterial T2E embolization was attempted in 22 patients (21 men, median age: 73, range: 62–88 years). Indications for treatment included an increase in the diameter of the aneurysm sac above 5 mm and a persistent endoleak observed for more than 6 months. Mean time from EVAR to endoleak treatment was 43 months (range: 2–125 months). Results Primary technical success was achieved in 17 (77.3%) patients and secondary technical success in 81.8%, with 0% in-hospital mortality. The mean procedure time was 95 ±48 min, with an average fluoroscopy time of 54 ±25 min. The mean amount of Onyx used was 7.5 ±6.6 ml. Clinical success was seen in 17/21 patients with follow-up imaging (80.9%). Mean follow-up time was 17 months (range: 3–38 months). Conclusions Onyx has been shown to effectively stabilize previous aneurysm growth as a result of the T2E in the majority of our patients. Transarterial embolization of T2E can be significantly improved as compared to previously reported results by using liquid embolic polymers such as Onyx.

Bridging therapy: coil and polymer embolisation of a ruptured penetrating aortic ulceration of the visceral aorta.

A 74-year-old woman complaining of fatigue and abdominal pain that increased during physical examination was referred to our hospital. She was conscious but hypotensive with a haemoglobin level of 8.8 g/dL. Creatinine level of 2.2 mg/dL suggested concomitant acute renal insufficiency. Abdominal contrast-enhanced computer tomography (CECT) revealed a large haematoma (132 × 118 × 80 mm) with active extravasation of contrast medium at the level between the celiac trunk and superior mesenteric artery, filling the retroperitoneal space directly adjacent to the right kidney (Fig. 1). A penetrating aortic ulceration was considered the most probable underlying cause of rupture. Comorbidities disqualified the patient from surgical open repair and she was referred to the radiology suite for a non-standard emergency endovascular procedure. The procedure was performed under local anaesthesia using bilateral femoral access (10 F and 6 F sheaths). Aortography confirmed CECT findings (Fig. 2). Through the perforation, the retroperitoneal space was catheterised using a 5 F Cobra 1 catheter (Cook Medical Europe) and “jailed” with a SINUS XL 30 × 62 mm self-expandable stent (OptiMed) at the rupture level. This enabled safe filling of the retroperitoneal space with 18 pushable Nester coils (Cook Medical Europe) and 13 detachable Concerto coils (Covidien) of various sizes. Coil embolisation was followed by a 3-ampule injection of the liquid embolic agent Onyx 34 (Covidien) while protecting the potential polymer reflux with a 33-mm occlusion balloon (Equalizer, Boston Scientific). Control angiography revealed no sign of extravasation and preserved blood flow to the visceral arteries (Fig. 3). The patient was transferred to the intensive care unit for 4 days of observation. During her stay she regained kidney function and was transferred for further observation to an internal medicine ward to leave the hospital 12 days after the initial procedure. Bearing in mind that the performed procedure was only a bridging therapy, a branched endoprosthesis was ordered and a secondary aortic intervention was scheduled. Unfortunately, the patient was never readmitted for the procedure because she died 5 weeks after the primary procedure and just 1 week before the scheduled reintervention, with symptoms strongly suggesting another rupture at the sealing level. In conclusion, for patients with a ruptured aorta and with no means of traditional open or endovascular repair, sealing of the rupture site with embolisation polymers and coils can provide a bridging therapy before a prompt and definitive treatment can be established.

Heart failure as an independent prognostic factor for endovascular method of abdominal aortic aneurysm treatment

Endovascular aneurysm repair (EVAR) has been accepted as an alternative to traditional open surgery in selected patients. Now it is a widely accepted standard. In case of contraindications for open repair, after accomplishing including criteria for EVAR, the patient can be treated by this method. Despite the minimally invasiveness of this treatment, several complications may occur during or after EVAR. Complications arise from the limitations of the method and improper patient selection. We report a case of patient with heart failure and complications after EVAR.

Emergency endovascular treatment for ruptured type B dissection in the abdominal aorta.

Despite successful endograft placement in the thoracic aorta, dissections remain problematic in the abdominal aorta. Herein, the authors describe two successful cases of endovascular treatment of ruptured abdominal aortic dissections. One patient, despite previously undergoing successful thoracic endograft placement, presented with a ruptured false channel and was treated by excluding major re-entries with a covered renal stent and stent-graft limb. A second patient, with a ruptured dissection superimposed on a preexisting abdominal aortic aneurysm, was treated with thoracic and abdominal stent-grafts. In both patients, progressive healing of the aorta occurred, with patients presenting no symptoms at an average follow-up of 20 months.