Nikhil B. Amesur

Embolotherapy of Persistent Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysm with the Ancure-Endovascular Technologies Endograft System☆

PURPOSE Endoleak is a potential complication after endovascular repair of abdominal aortic aneurysm (AAA). It may result in continued growth of the aneurysm and potentially result in aneurysm rupture. The authors present their experience with embolotherapy in patients with persistent perigraft flow treated with the Ancure-Endovascular Technologies endograft system. MATERIALS AND METHODS Between February 1996 and August 1998, 54 patients underwent successful repair of AAA with use of the Ancure system. All underwent operative angiography and discharge computed tomography (CT). Follow-up included CT at 6, 12, and 24 months, and CT was also performed at 3 months if an endoleak was present on the discharge CT. Persistent endoleak was defined as perigraft flow still present on the 6-month CT. Seven of 21 initial endoleaks persisted at 6 months. Six patients returned for embolization of the perigraft space and outflow vessels including lumbar arteries and the inferior mesenteric artery (IMA). RESULTS Five of the six patients had leaks from the proximal (n = 1) or distal attachment sites (n = 4) of the Ancure system with outflow into lumbar arteries and/or the IMA; one leak was caused by retrograde IMA flow. The six patients underwent nine embolization procedures with only one minor complication. Follow-up CT showed complete resolution of endoleak and decrease in size of the aneurysm sac in all patients. CONCLUSIONS Although endoleak is commonly seen initially with the Ancure system, persistent leak occurred in 13% of the patients in the study. Persistent flow in most patients arises from a graft attachment site combined with patent outflow vessels such as the IMA or lumbar arteries. Persistent endoleaks can be effectively and safely embolized with use of a combination of coil embolization of the perigraft space and embolization of outflow vessels. Such intervention resulted in a decrease in size of the aneurysm sac.

Interventional radiology in liver transplantation.

Improvements in surgical technique, advances in the field of immunosuppresion and the early diagnosis and treatment of complications related to liver transplantation have all led to prolonged survival after liver transplantation. In particular, advances in diagnostic and interventional radiology have allowed the Interventional Radiologist, as part of the transplant team, to intervene early in patients presenting with complications related to organ transplant with resultant increase in graft and patient survival. Such interventions are often achieved using minimally invasive percutaneous endovascular techniques. Herein we present an overview of some of these diagnostic and therapeutic approaches in the treatment and management of patients before and after liver transplantation. Liver Transpl 12:330–351, 2006.

Balloon Dilation and Endobronchial Stent Placement for Bronchial Strictures after Lung Transplantation

PURPOSE To evaluate the effect of balloon dilation and endobronchial stent placement for bronchial fibrous stenoses and bronchomalacia after lung transplantation. MATERIALS AND METHODS Bronchial dilation and/or stent placement was performed on 25 lung transplant recipients. Indications included severe dyspnea with postobstructive pneumonia (n = 24) and respiratory failure (n = 1). All patients underwent pulmonary function testing (PFT) before and after bronchial dilation, the results of which were evaluated for changes. A total of 63 procedures were performed between February 1996 and December 1998. Thirty-five lesions were treated (18 were due to bronchomalacia, 17 were due to fibrosis). Areas treated included the left mainstem bronchus (n = 11), bronchus intermedius (n = 10), right mainstem bronchus (n = 7), left upper lobe bronchus (n = 4), right lower lobe bronchus (n = 2), and right middle lobe bronchus (n = 1). Bronchoscopic and/or bronchographic follow-up ranged from 1 to 34 months (mean, 15 months). RESULTS Six-month primary patency of stents placed for bronchomalacia was 71% (10 of 14), with three of the four occlusions caused by mechanical failure of Palmaz stents in the mainstem bronchi. Six-month primary patency for treatment of fibrous strictures was 29%. Secondary patency at 1 year was 100% for both bronchomalacia and fibrous strictures. After treatment, there was a significant improvement in mean PFT results (P = .01-.0001). There was one acute complication, obstruction of the left lower lobe bronchus by a Wallstent treated by dilating a hole in the side of the stent. CONCLUSIONS Balloon dilation and stent placement are safe and effective for bronchial strictures and bronchomalacia after lung transplantation, resulting in significant improvement in PFT results. However, there is almost universal restenosis in patients treated for fibrous strictures necessitating reintervention for prolonged patency.

Yttrium-90 Radioembolization for Colorectal Cancer Liver Metastases: A Single Institution Experience

Purpose. We sought to evaluate our experience using yttrium-90 (90Y) resin microsphere hepatic radioembolization as salvage therapy for liver-dominant metastatic colorectal cancer (mCRC). Methods. A retrospective review of consecutive patients with unresectable mCRC who were treated with 90Y after failing first and second line systemic chemotherapy. Demographics, treatment dose, biochemical and radiographic response, toxicities, and survival were examined. Results. Fifty-one patients underwent 90Y treatments of which 69% were male. All patients had previously undergone extensive chemotherapy, 31% had undergone previous liver-directed therapy and 24% had a prior liver resection. Using RECIST criteria, either stable disease or a partial response was seen in 77% of patients. Overall median survival from the time of first 90Y treatment was 10.2 months (95% CI = 7.5–13.0). The absence of extrahepatic disease at the time of treatment with 90Y was associated with an improved survival, median survival of 17.0 months (95% CI = 6.4–27.6), compared to those with extrahepatic disease at the time of treatment with 90Y, 6.7 months (95% CI = 2.7–10.6 Conclusion: 90Y therapy is a safe locoregional therapy that provides an important therapeutic option to patients who have failed first and second line chemotherapy and have adequate liver function and performance status.

Transjugular Intrahepatic Portosystemic Shunt in Patients Who Have Undergone Liver Transplantation

PURPOSE Transjugular intrahepatic portosystemic shunt (TIPS) placement is an accepted treatment for refractory variceal bleeding and/or ascites in end-stage liver disease and is an effective bridge to liver transplantation. The authors present their experience with TIPS in patients with a liver transplant, who subsequently developed portal hypertension. MATERIALS AND METHODS Thirteen TIPS were placed in 12 adult patients from 6 months to 13 years after liver transplantation for variceal bleeding that failed endoscopic treatment (n = 6) and intractable ascites (n = 6). All patients were followed to either time of retransplantation or death. RESULTS No technical difficulties were encountered in TIPS placement in any of the patients. Four of six patients treated for bleeding stopped bleeding and did not experience re-bleeding, two had functional TIPS at 3 and 36 months and two underwent retransplantation at 3 and 7 months. Two patients had recurrent bleeding within 1 week and required reintervention. In the ascites group, one is 32 months since TIPS placement with control of his ascites, two patients underwent retransplantation at 2 and 6 weeks with interval improvement in ascites. Two patients died within a week of TIPS of fulminant hepatic failure. The last patient died 1 month after TIPS subsequent to a splenectomy. CONCLUSION In conclusion, the placement of a TIPS in a transplanted liver, in general, requires no special technical considerations compared to placement in native livers. Although this series is small, the authors believe that TIPS should be considered a treatment option in liver transplant recipients who present with refractory variceal bleeding. TIPS may have a role in the management of intractable ascites.

Management of Unresectable Symptomatic Focal Nodular Hyperplasia with Arterial Embolization

Symptomatic focal nodular hyperplasia (FNH) of the liver can usually be treated safely with liver resection. However, in those patients in whom resection is not possible because of the location or size of the tumor or other patient factors, selective arterial embolization should be considered. Herein, the authors describe the use of arterial embolization to treat three women with symptomatic FNH and provide a review of the literature.

Sequential FDG PET/CT in 90Y microsphere treatment of unresectable colorectal liver metastases.

The intra-arterial administration of Ymicrospheres (SIRSpheres, Sirtex Medical Ltd., Sydney, Australia) is a new palliative treatment option for unresectable colorectal liver metastases [1–4]. The Y-imprinted resin-based microspheres inducemicroembolisation of the hepatic and neovascular arterioles, thus delivering selective internal radiation. The figure shows transaxial PET/CT images of the upper abdomen with multiple liver metastases on CT and PET in both lobes of the liver (a: prior to treatment with Y microspheres). The right lobe was treated with 930 MBq (25.1 mCi) Y microspheres, resulting in a radiation dose of approximately 47 Gy. Two months after the treatment (b), the liver metastases in segment VI/VII demonstrated a marked reduction of FDG uptake to background level. The response on CT was less apparent, with partial improvement of the hypodense right lobe lesions. The dominant hypodense lesion in segment VI, which appears to have less response, is centrally hypometabolic on FDG-PET, likely secondary to tumour necrosis. The untreated metastases in the left lobe increased inmetabolic activity and tumour size. PET appears to reflect treatment response more accurately than does CT. References

A Case-Based Approach to Common Embolization Agents Used in Vascular Interventional Radiology

OBJECTIVE The objective of this article is to familiarize the reader with the most commonly used embolic agents in interventional radiology and discuss an approach for selecting among the different embolic agents. This article reviews their properties and uses a case-based approach to explain how to select one. CONCLUSION A wide variety of embolic agents are available. Familiarity with the available embolic agents and selection of the most appropriate embolic agent is critical in interventional radiology to achieve optimum therapeutic response and avoid undesired, potentially disastrous complications such as nontarget embolization.

Peripherally inserted central catheter placement with the sonic flashlight: initial clinical trial by nurses.

Objective. We describe a case series constituting the first clinical trial by intravenous (IV) team nurses using the sonic flashlight (SF) for ultrasound guidance of peripherally inserted central catheter (PICC) placement. Methods. Two IV team nurses with more than 10 years of experience with placing PICCs and 3 to 6 years of experience with ultrasound attempted to place PICCs under ultrasound guidance in patients requiring long‐term IV access. One of two methods of ultrasound guidance was used: conventional ultrasound (CUS; 60 patients) or a new device called the SF (44 patients). The number of needle punctures required to gain IV access was recorded for each patient. Results. In both methods, 87% of the cases resulted in successful venous access on the first attempt. The average number of needle sticks per patient was 1.18 for SF‐guided procedures compared with 1.20 for CUS‐guided procedures. No significant difference was found in the distribution of the number of attempts between the two methods. Anecdotal comments by the nurses indicated the comparative ease of use of the SF display, although the relatively small scale of the SF image compared with the CUS image was also noted. Conclusions. We have shown that the SF is a safe and effective device for guidance of PICC placement in the hands of experienced IV team nurses. The advantage of placing the ultrasound image at its actual location must be balanced against the relatively small scale of the SF image.

The Prognostic Role of Neutrophil-to-Lymphocyte Ratio in Patients with Unresectable Hepatocellular Carcinoma Treated with Radioembolization

PURPOSE To assess the prognostic value of neutrophil-to-lymphocyte ratio (NLR) in patients with unresectable intermediate- or advanced-stage hepatocellular carcinoma (HCC) treated with yttrium-90 radioembolization (RE). MATERIALS AND METHODS Retrospective chart review was performed for 176 patients with intermediate- or advanced-stage HCC treated with RE between August 2000 and November 2012. The appropriate NLR cutoff was determined by receiver operating characteristic curves. Demographic, clinical, radiographic, and pathologic parameters were compared between patients with a normal NLR (< 5) and those with an elevated NLR (≥ 5) before RE. Barcelona Clinic Liver Cancer (BCLC) stage-stratified univariate and multivariate analyses were conducted to determine variables associated with overall survival. RESULTS Under univariate analyses, patients with a normal NLR were found to have longer survival than individuals with a high NLR in intermediate/advanced-disease and advanced-disease cohorts. A multivariate Cox proportional-hazards model in the advanced-disease group confirmed that elevated NLR, high α-fetoprotein level, and low albumin level were independent predictors of worse survival. CONCLUSIONS This study provides stage-dependent evidence for the prognostic role of NLR in the radioembolized HCC cohort. Patients with BCLC stage C disease with elevated NLR may not derive benefit from RE, and other intervening modalities should be explored in this subpopulation.