Mitchell T. Smith

Metaanalysis of survival, complications, and imaging response following chemotherapy-based transarterial therapy in patients with unresectable intrahepatic cholangiocarcinoma.

PURPOSE Unresectable intrahepatic cholangiocarcinoma represents a devastating illness with poor outcomes when treated with standard systemic therapies. Several smaller nonrandomized outcomes studies have been reported for such patients undergoing transarterial therapies. A metaanalysis was performed to assess primary clinical and imaging outcomes, as well as complication rates, following transarterial interventions in this patient population. MATERIALS AND METHODS By using standard search techniques and metaanalysis methodology, published reports (published in 2012 and before) evaluating survival, complications, and imaging response following transarterial treatments for patients with unresectable intrahepatic cholangiocarcinoma were identified and evaluated. RESULTS A total of 16 articles (N = 542 subjects) met the inclusion criteria and are included. Overall survival times were 15.7 months ± 5.8 and 13.4 months ± 6.7 from the time of diagnosis and time of first treatment, respectively. The overall weighted 1-year survival rate was 58.0% ± 14.5. More than three fourths of all subjects (76.8%) exhibited a response or stable disease on postprocedure imaging; 18.9% of all subjects experienced severe toxicities (National Cancer Institute/World Health Organization grade ≥ 3), and most experienced some form of postembolization syndrome. Overall 30-day mortality rate was 0.7%. CONCLUSIONS As demonstrated by this metaanalysis, transarterial chemotherapy-based treatments for cholangiocarcinoma appears to confer a survival benefit of 2-7 months compared with systemic therapies, demonstrate a favorable response by imaging criteria, and have an acceptable postprocedural complication profile. Such therapies should be strongly considered in the treatment of patients with this devastating illness.

Splenic Artery Embolization as an Adjunctive Procedure for Portal Hypertension

Splenic embolization is a technique that can be used alone or in conjunction with other treatments for the mitigation of portal hypertension and associated physiological effects of portal hypertension. This technique can be used safely when total embolization volume is ~50% and the procedural and periprocedural time periods are covered with antibiotics. In this patient population, partial splenic embolization can decrease the incidence of variceal bleeding, and protection can persist for at least a year. Additionally, liver function tests and serum cell counts can be expected to improve. Although not frequently used as primary therapy for patients with portal hypertension, splenic embolization can often be helpful as an alternative or adjunctive procedure.

Overview of classification systems in peripheral artery disease.

Peripheral artery disease (PAD), secondary to atherosclerotic disease, is currently the leading cause of morbidity and mortality in the western world. While PAD is common, it is estimated that the majority of patients with PAD are undiagnosed and undertreated. The challenge to the treatment of PAD is to accurately diagnose the symptoms and determine treatment for each patient. The varied presentations of peripheral vascular disease have led to numerous classification schemes throughout the literature. Consistent grading of patients leads to both objective criteria for treating patients and a baseline for clinical follow-up. Reproducible classification systems are also important in clinical trials and when comparing medical, surgical, and endovascular treatment paradigms. This article reviews the various classification systems for PAD and advantages to each system.

Endovascular Therapies for Primary Postpartum Hemorrhage: Techniques and Outcomes

Interventional radiologists are often consulted for acute management of hemorrhagic complications in obstetric and gynecologic patients. The aim of this article is to review the common indications for vascular embolization in obstetric and gynecologic emergencies, specifically in the setting of primary postpartum hemorrhage, and to discuss the technique and outcomes of endovascular treatment.

Intravascular US–Guided Portal Vein Access: Improved Procedural Metrics during TIPS Creation

PURPOSE To evaluate transjugular intrahepatic portosystemic shunt (TIPS) outcomes and procedure metrics with the use of three different image guidance techniques for portal vein (PV) access during TIPS creation. MATERIALS AND METHODS A retrospective review of consecutive patients who underwent TIPS procedures for a range of indications during a 28-month study period identified a population of 68 patients. This was stratified by PV access techniques: fluoroscopic guidance with or without portography (n = 26), PV marker wire guidance (n = 18), or intravascular ultrasound (US) guidance (n = 24). Procedural outcomes and procedural metrics, including radiation exposure, contrast agent volume used, procedure duration, and PV access time, were analyzed. RESULTS No differences in demographic or procedural characteristics were found among the three groups. Technical success, technical success of the primary planned approach, hemodynamic success, portosystemic gradient, and procedure-related complications were not significantly different among groups. Fluoroscopy time (P = .003), air kerma (P = .01), contrast agent volume (P = .003), and total procedural time (P = .02) were reduced with intravascular US guidance compared with fluoroscopic guidance. Fluoroscopy time (P = .01) and contrast agent volume (P = .02) were reduced with intravascular US guidance compared with marker wire guidance. CONCLUSIONS Intravascular US guidance of PV access during TIPS creation not only facilitates successful TIPS creation in patients with challenging anatomy, as suggested by previous investigations, but also reduces important procedure metrics including radiation exposure, contrast agent volume, and overall procedure duration compared with fluoroscopically guided TIPS creation.

The treatment of primary and metastatic hepatic neoplasms using percutaneous cryotherapy

Cryotherapy has been used clinically in the treatment of metastatic liver malignancies since the 1980s. Rapid freezing to sub-zero temperatures promotes ice formation in the extracellular space and the exit of intracellular water. Cellular death is the result of dehydration, protein denaturation, and microcirculatory failure. Cryotherapy probes use nitrogen or argon gas as a coolant and the development of the ice ball can be monitored using ultrasound, computed tomography, or magnetic resonance imaging. Traditionally, cryotherapy has been performed during laparoscopy or laparotomy, using intraoperative ultrasound for image guidance. A decrease in cryoprobe size (from ~24 Fr to ~15 gauge) in conjunction with experience gained in open cryosurgical treatment has allowed the development of minimally invasive percutaneous approaches. In this review, we describe the use of cryotherapy for treatment of primary or secondary liver neoplasms using a percutaneous approach.

Evolving Indications for Tips.

Transjugular intrahepatic portosystemic shunt creation is a well-established therapy for refractory variceal bleeding and refractory ascites in patients who do not tolerate repeated large volume paracentesis. Experience and technical improvements including covered stents have led to improved TIPS outcomes that have encouraged an expanded application. Evidence for other less frequent indications continues to accumulate, including the indications of primary prophylaxis in patients with high-risk acute variceal bleeding, gastric and ectopic variceal bleeding, primary treatment of medically refractory ascites, recurrent refractory ascites following liver transplantation, hepatic hydrothorax, hepatorenal syndrome, Budd-Chiari syndrome, and portal vein thrombosis. Treatment of patients with high-risk acute variceal bleeding with early TIPS and using transjugular intrahepatic portosystemic shunts as a primary therapy rather than large volume paracentesis for refractory ascites would likely be the 2 circumstances that permit expansion in the frequency of TIPS procedures. The remaining populations discussed above are relatively rare.

Pelvic Vascular Malformations

Vascular malformations (VMs) comprise a wide spectrum of lesions that are classified by content and flow characteristics. These lesions, occurring in both focal and diffuse forms, can involve any organ and tissue plane and can cause significant morbidity in both children and adults. Since treatment strategy depends on the type of malformation, correct diagnosis and classification of a vascular lesion are crucial. Slow-flow VMs (venous and lymphatic malformations) are often treated by sclerotherapy, whereas fast-flow lesions (arteriovenous malformations) are generally managed with embolization. In addition, some cases of VMs are best treated surgically. This review will present an overview of VMs in the female pelvis as well as a discussion of endovascular therapeutic techniques.

Preservation of Internal Iliac Arterial Flow during Endovascular Aortic Aneurysm Repair Using the “Sandwich” Technique

Conventional endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm (AAA) requires adequate graft seal proximally in the infrarenal aorta and distally in the common or external iliac arteries. When possible, sealing in the common iliac artery is performed to maintain perfusion to the internal iliac artery. Approximately 40% of AAAs have associated common iliac artery aneurysms that would require an external iliac seal zone and ipsilateral internal iliac artery embolization to prevent a type II endoleak. Concurrent or staged internal iliac artery occlusion may result in pelvic ischemia, which commonly manifests as buttock claudication or, in men, impotence. Uncommon but more serious consequences include colonic and spinal artery ischemia. Coverage or embolization of a single internal iliac artery is generally well tolerated. There is a varied incidence (20 to 50%) of clinically significant buttock claudication that tends to improve over time resulting in ∼10% incidence of buttock claudication at 1 year with single hypogastric artery embolization. Published case series and individual reports of bilateral internal iliac artery embolization demonstrate that bilateral hypogastric occlusion appears safe, although there is an increased risk of serious complications that may be life threatening. Most physicians attempt to preserve flow to a single internal iliac artery whenever possible. Various methods have been described to preserve internal iliac artery flow during EVAR. Investigational iliac branched devices (not currently approved by the Food and Drug Administration [FDA]), hybrid surgical revascularization of the internal iliac artery, physician modification of existing endografts, and, more recently, parallel endografting with the “sandwich” technique are some of the ways flow can be preserved to the hypogastric artery. The sandwich endograft technique involves placing two endografts side by side into an existing iliac limb to create an off-the-shelf bifurcated component to preserve flow to both the internal iliac and external iliac arteries. This technique has been gaining acceptance as a viable method for preservation of flow to at least a single internal iliac artery allowing for expansion of anatomy suitable for EVAR with the use of commercially available endograft components, albeit in an off-label manner. The sandwich technique is applicable to a variety of endograft designs, although the steep bifurcation of most endografts requires axillary or brachial artery access to deliver a stent into the preserved internal iliac artery. The bifurcation-sparing nature of the Endologix AFX (Endologix, Irvine, CA) endograft allows for this technique to be performed from an entirely femoral approach and has become our preferred approach for internal iliac preservation during EVAR when the anatomy is appropriate.

Digital Ischemia during Sclerotherapy of an Arteriovenous Malformation.

Vascular malformations (VMs) are usually treated conservatively until patients become symptomatic (i.e., pain, complications secondary to venous hypertension, neuropathy, and high-output cardiac failure). They are classified by either low-flow or high-flow characteristics (Table 1). Minimally invasive treatment methods are utilized to manage these lesions. The authors share a case utilizing a referenced method and noting an incidental risk/complication of a high-flow VM. Table 1 Vascular malformation classification