N. Tabori

Transcatheter occlusion of pulmonary arteriovenous malformations using the Amplatzer Vascular Plug II.

Pulmonary arteriovenous malformations (PAVMs) are a relatively uncommon but potentially life‐threatening condition manifested by cyanosis, paradoxical embolization, brain abscess, and rupture. A variety of transcatheter closure devices have been used to occlude PAVMs however risks of device embolization, incomplete closure, or large delivery systems have made each of these methods sub‐optimal. The Amplatzer Vascular Plug II (AVP II) is a new multisegmented, woven nitinol cylinder that can be deployed through a small delivery catheter. The AVP II differs from the original AVP in having a finer, more tightly woven nitinol frame and three, rather than one occlusive segment. The authors report the first use of the AVP II for occlusion of bilateral large arteriovenous malformations in a patient with hereditary hemorrhagic telangiectasia.

Transulnar approach as an alternative to transradial approach in non-coronary intervention: safety, feasibility and technical factors

Purpose Transulnar access (TUA) has been shown to be an effective alternative to transradial access (TRA) for coronary intervention. This study evaluates the safety and efficacy of TUA in patients undergoing visceral interventions in the setting of contraindication to TRA. Materials and Methods Patients who underwent visceral interventions via ulnar approach were included in the study. Outcome variables include technical success, access site and bleeding complications. Results From May 2014 to September 2016, TUA was attempted 17 times in 14 patients (mean age: 60 years; range: 27 to 81 years) for whom TRA was planned for visceral intervention, but contraindicated. Contraindication to TRA included Barbeau D waveform (n = 3), radial artery diameter <2 mm (n = 8), known radial loop (n = 2), high takeoff of the radial artery (n = 2), prior radial artery occlusion (RAO) (n = 1), and radiocephalic arteriovenous fistula (n = 1). Interventions included selective internal radiation therapy (SIRT) (n = 4), SIRT mapping (n = 2), chemoembolization (n = 6), renal embolization (n = 1) and bland liver embolization (n = 4). Technical success was achieved in 94.1% (16/17 cases) with the single failure attributed to an inability to cannulate the target vessel due to vessel tortuosity, requiring ipsilateral femoral crossover. There were no major access site or bleeding complications. Minor adverse events include two access site hematomas, which were successfully treated with conservative management. Conclusions TUA for visceral interventions is a safe and effective alternative to femoral approach when TRA is contraindicated.

Transarterial Chemoembolization Outcomes in Downstaging Hepatocellular Carcinoma Patients beyond the Milan Criteria

Purpose In this study, we evaluated outcomes of transarterial chemoembolization (TACE) for tumor downstaging in patients with hepatocellular carcinoma (HCC) beyond Milan criteria. Material and Methods From 1 January 2008 to 1 January 2013, a total of 564 patients with a diagnosis of HCC were listed for liver transplantation. Patients included in the study were determined to be outside of the Milan criteria but within the University of California-San Fransisco (UCSF) downstaging criteria at the time of diagnosis and subsequently underwent either conventional transarterial chemoembolization (c-TACE) or drug-eluting bead TACE (DEB-TACE). Patients who underwent previous therapies at the time of intervention were excluded. The primary outcome variable was overall survival. Secondary outcome variables included effectiveness of TACE at tumor downstaging, progression-free survival prior to transplant, and disease recurrence after transplant. Results Seventeen patients (median age 58 years; 5 female, 12 male) met the criteria for inclusion in this study. Patients underwent a median (range) of 3 (1-6) TACE procedures (c-TACE 17; DEB-TACE 20). Downstaging to within the Milan criteria was successful in 13 patients (76%). Of the 13 patients who were successfully downstaged, 9 underwent liver transplantation (orthotopic 7; living donor 2), 1 remained on the transplant list within Milan criteria, 2 re-progressed beyond Milan criteria (79, 624 days), and 1 died without disease progression of septicemia after a complicated post-operative course following colectomy for pancolitis. Univarate analysis of survival (log-rank test) showed a survival benefit in downstaged vs. non-downstaged patients when censored for transplant (p = 0.004) and when uncensored (p = 0.001). There was disease-free survival in the 9 patients who underwent transplantation. There was one HCC recurrence observed 3.8 years post-transplant. Conclusions In our experience, transarterial chemoembolization is effective at downstaging patients with T3 disease to within the Milan criteria with favorable post-transplant disease free survival.