Naoshi Tanaka

Transcatheter arterial embolization of ruptured pseudoaneurysms with coils and n-butyl cyanoacrylate.

PURPOSE To evaluate the clinical efficacy of transcatheter arterial embolization with n-butyl cyanoacrylate (NBCA) for ruptured pseudoaneurysms, which are difficult to control by coil embolization alone. MATERIALS AND METHODS Ruptured pseudoaneurysms developed at the celiac trunk (n = 1), gastroduodenal artery (n = 2), pancreatic arcade (n = 1), hepatic artery (n = 3), renal artery (n = 1), and intercostal artery (n = 1) in nine patients. NBCA was mixed with iodized-oil (1:2) and injected via the 3-F microcatheter under fluoroscopic guidance, after the catheter was advanced close to the pseudoaneurysm. Coil embolization was performed to control blood flow before administration of NBCA in seven patients. NBCA was injected immediately after coil embolization in four patients. Embolization with NBCA was performed for recurrent bleeding that occurred within 1-21 days (mean, 10.7 days) after initial coil embolization in three patients. Two patients with peripheral pseudoaneurysms underwent embolization with NBCA alone. RESULTS The NBCA mixture was visible under fluoroscopy, and was useful in monitoring the embolization process and deciding the endpoint. Embolization was technically successful without major complications in all patients. Pseudoaneurysms and afferent and efferent arteries were eliminated immediately after embolization. Bleeding was stopped after embolization in all cases. Rebleeding did not occur in any patient during their follow-up periods of 0.7-69.5 months (mean, 17.9 months). CONCLUSION Embolization with NBCA is a feasible and useful treatment for ruptured pseudoaneurysms, which are difficult to control by coil embolization alone.

Superselective Bronchial Artery Embolization for Hemoptysis with a Coaxial Microcatheter System

PURPOSE To compare the effectiveness and safety of superselective bronchial artery embolization with that of nonsuperselective embolization in the control of hemoptysis. MATERIALS AND METHODS Retrospective case analysis was done for 47 patients with hemoptysis originating from a variety of causes. In 22 patients, embolization was performed superselectively using a microcatheter inserted into the bronchial artery beyond the spinal or mediastinal branches (superselective group). In the remaining 25 patients, embolization was performed at the opening of the bronchial artery with a 5-F catheter (nonsuperselective group). RESULTS Initial hemoptysis control rates were 96% (21 of 22) in the superselective group and 88% (22 of 25) in the nonsuperselective group. Cumulative hemoptysis control rates of the superselective and nonsuperselective groups were 80% and 67% at 6 months, 79% and 56% at 1 and 2 years, and 79% and 48% at 3 years, respectively (not significant; generalized Wilcoxon test). One major complication (spinal infarction) occurred in the nonsuperselective group. CONCLUSIONS Superselective embolization is safer and more effective way to control hemoptysis than the ordinary (nonsuperselective) method.

Arterial chemoinfusion therapy through an implanted port system for patients with unresectable intrahepatic cholangiocarcinoma—initial experience

Arterial chemoinfusion therapy through an implanted port system was performed for patients with unresectable intrahepatic cholangiocarcinoma (ICC). Eleven patients with unresectable ICC were studied. Seven patients had stage-IV disease, two had stage-III disease, and two had stage-II disease. The mean tumor size was 7.0+/-2.6 cm (range 3.8-13.5 cm). A catheter and port system was percutaneously implanted, and anticancer drugs featuring fluorouracil were administered via the infusion system every 1-2 weeks on the outpatient basis in all patients except 2. Arterial chemoinfusion therapy was repeated 12-84 times per patient (mean 51 times). Partial and minor responses were achieved in sevenents (64%). Disease was stable in two patients (18%), and progressed in the other two patients (18%). Tumor growth was controlled during a mean period of 14.5 months in seven responders and two patients with stable disease. The survival rates were 91% at 1 year, 51% at 2 years, 20% at 3 years, and 10% at 4 years, respectively. The mean survival period was 26 months. Toxicity such as cholangitis and pancytopenia was found in three patients (27%). This treatment seems to improve the prognosis of patients with unresectable ICC and deserves further studies.

Malignant Portal Venous Obstructions Treated by Stent Placement: Significant Factors Affecting Patency

PURPOSE To identify factors affecting stent occlusion after stent placement in the portal vein in patients with malignant portal vein invasion. MATERIALS AND METHODS Forty patients were studied. Twenty-three patients had hepatocellular carcinoma, nine patients had pancreatic cancer, and eight patients had bile duct cancer. Stents were placed in the portal venous system across stenotic (n = 28) or obstructive (n = 12) lesions after percutaneous transhepatic portography. Bare stents were used in 33 patients and covered stents were used in seven patients. Twenty-two variables were analyzed with use of univariate and multivariate analyses to identify significant factors affecting stent occlusion. RESULTS Stents remained patent during a mean follow-up period of 11.9 months (range, 2-61 mo) in 60% of the patients. Stent occlusion was found in 40% of the patients, with a mean period until occlusion of 3.7 months (range, 0.2-16 mo). In the univariate analysis, the following five factors were significantly associated with a higher probability of stent occlusion: (i) splanchnic vein involvement, (ii) Child-Pugh class C, (iii) obstruction of the portal venous system, (iv) pancreatic cancer, and (v) lack of anticancer treatment after stent placement. In the multivariate analysis, the first three factors were found to have independent value for stent occlusion. CONCLUSIONS Splanchnic vein involvement, severe hepatic dysfunction, and obstruction of the portal venous system are the most important factors affecting stent occlusion in patients with malignant portal vein invasion.

Clinical efficacy of portal vein stent placement in patients with hepatocellular carcinoma invading the main portal vein

BACKGROUND/AIMS Hepatocellular carcinoma frequently invades the portal veins, and when it invades the main portal vein, the patients prognosis is extremely poor. This study was undertaken to evaluate the clinical efficacy of stent placement into the portal vein in these patients. METHODS Twenty-one patients with hepatocellular carcinoma invading the main portal vein were studied. Stents were placed in the portal veins to compress tumor thrombi after percutaneous transhepatic portography. RESULTS Stents were successfully placed in the portal veins in all patients. Portal venous pressure significantly decreased from 25.3 +/- 7.4 mmHg to 22.4 +/- 6.6 mmHg (p < 0.0001) immediately after stent placement, leading to improvement in gastroesophageal varices, melena and ascites. Although a pseudoaneurysm of the hepatic artery related to portal vein puncture developed in one patient, there were no major complications in the other 20 patients. Blood flow through the stent was maintained during the survival period in 15 patients. The mean stent patency period was 12.4 months. Fifteen patients underwent transcatheter arterial chemoembolization without major complications after stent placement. The survival rate was 64.2% at 6 months and 29.2% at 1 and 2 years, respectively. The mean survival period was 13.7 months. CONCLUSION Stent placement into the portal vein is a relatively safe and feasible procedure. It improves portal hypertension, expands treatment options, and helps to prolong the survival period in patients with hepatocellular carcinoma invading the main portal vein.

LONG-TERM FOLLOW-UP ARTERIAL CHEMOEMBOLIZATION COMBINED WITH TRANSPORTAL ETHANOL INJECTION USED TO TREAT HEPATOCELLULAR CARCINOMA

PURPOSE This study was undertaken to evaluate the long-term efficacy of transcatheter hepatic arterial chemoembolization (TACE) combined with transportal ethanol injection (TPEI) in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS Twenty-six patients with unresectable HCC underwent TPEI 2-6 weeks after TACE. The size of the main tumor ranged from 2.0 to 9.0 cm (mean, 4.5 cm). Ethanol (10-65 mL) was injected via a percutaneous transhepatic approach into the portal vein, perfusing the segment to be treated. TACE was repeated after TPEI in 18 patients. RESULTS The combined therapy was technically successfully in all 26 cases; however, irreversible hepatic failure developed in two (8%) patients. Recurrent disease occurred either from the treated lesion (four patients) or apart from the treated liver segment (five patients) in nine of 21 patients (43%) followed up for a mean of 34 months. The survival rates were 87%, 72%, 72%, 63%, 51, and 51% at 1, 2, 3, 4, 5, and 6 years, respectively. Resected and autopsied specimens showed complete necrosis in seven of nine main lesions and severe parenchymal damage in the treated liver segment. CONCLUSION In selected patients, combined treatment with TACE and TPEI is safe and effective, decreasing recurrence rate in the treated segment, and resulting in a 51% 6-year survival.

SELECTIVE TRANSCATHETER HEPATIC ARTERIAL CHEMOEMBOLIZATION FOR HEMOBILIA FROM HEPATOCELLULAR CARCINOMA : REPORT OF THREE CASES

0 SCVIR, 1999 WE present the clinical and radiological features in three cases of advanced hepatocellular carcinoma (HCC) that ruptured into the biliary system and caused hemobilia. Abrupt epigastric pain, melena, and jaundice were the symptoms, and the liver profile deteriorated after the onset of hemobilia. Computed tomography (CT) and endoscopic retrograde cholangiography (ERC) were useful in diagnosing hemobilia and localizing the bleeding sites. Transcatheter hepatic arterial chemoembolization (TACE) was selectively performed in the arteries feeding the ruptured HCCs. Hemobilia was well controlled and liver function improved after TACE. All patients were discharged within 25 days :fter the procedure. Although hemob;lia recurred a t 2 and 3 months after TACE in two patients, selective TACE again succeeded in controlling the bleeding in one patient. The patients died a t 2, 3, and 25 months after TACE. Bile duct invasion has been reported to be rare in patients with HCC (1). When HCC invades the biliary tree, the clinical features are characterized by obstructive jaundice and hemobilia due to rupture of the tumor into the biliary system. Hemobilia secondary to ruptured HCC is considered to be a terminal event, leading to the rapid death of the patient (2). However, effective treatments for hemobilia have not been established. Although hepatectomy seems to be the effective treatment, most patients are not candidates for surgery because they have advanced HCC (2-4). TACE is a useful treatment for intraperitoneal hemorrhage secondary to ruptured HCC (5). However, the appearance of hyperbilirubinemia that is frequently seen in patients with hemobilia is a significant poor prognostic factor. In this report, we present the clinical and radiologic features in three cases of HCC that ruptured into the biliary system and evaluate the clinical usefulness of selective TACE in controlling hemobilia.

Preoperative transcatheter arterial infusion chemotherapy for locally advanced breast cancer (stage IIIb) for down-staging and increase of resectability

OBJECTIVES To evaluate the clinical usefulness of preoperative transcatheter arterial infusion chemotherapy (TAIC) for locally advanced breast cancer. METHODS Seven patients with unresectable locally advanced breast cancer (stage IIIb) underwent TAIC percutaneously 1-3 times (mean, 1.7 times) until tumors became resectable. Anticancer drugs were injected into both the internal mammary and the distal subclavian arteries. RESULTS There was no major complication related to the procedure. The mean tumor size was significantly decreased from 10.0+/-3.9 to 5.1+/-2.5 cm (P=0.0086). Skin and muscle invasions were improved in two patients (28%) and lymph nodes disappeared in one patient (14%). In two patients (28%), down-staging was achieved from stage IIIb to stage IIIa. All tumors turned into resectable, and mastectomy was performed with a mean period of 35 days (range 9-60 days) after TAIC. Marked decrease in tumor size allowed one patient to receive breast-conserving surgery. There was no local recurrence in any patient. However, five patients (71%) experienced distant metastases. The 3-year disease free and overall survival were 0 and 71.4%, respectively. CONCLUSIONS TAIC for locally advanced breast cancer is useful in reducing tumor size and achieving down-staging in a relatively short period, leading to an expanded surgical indication.

Letter to the Editor Re: Transjugular Intrahepatic Portosystemic Shunt for Intractable Esophageal-Gastric Variceal Hemorrhage in a Patient with Idiopathic Myelofibrosis

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