Olaguoke Akinwande

Clinical Safety of Bariatric Arterial Embolization: Preliminary Results of the BEAT Obesity Trial

Purpose To conduct a pilot prospective clinical trial to evaluate the feasibility, safety, and short-term efficacy of bariatric embolization, a recently developed endovascular procedure for the treatment of obesity, in patients with severe obesity. Materials and Methods This is an institutional review board- and U.S. Food and Drug Administration-approved prospective physician-initiated investigational device exemption study. This phase of the study ran from June 2, 2014, to August 4, 2015. Five severely obese patients (four women, one man) who were 31-49 years of age and who had a mean body mass index of 43.8 kg/m2 ± 2.9 with no clinically important comorbidities were enrolled in this study. Transarterial embolization of the gastric fundus with fluoroscopic guidance was performed with 300-500-μm Embosphere microspheres. The primary end point was 30-day adverse events (AEs). The secondary end points included short-term weight loss, serum obesity-related hormone levels, hunger and satiety assessments, and quality of life (QOL) surveys, reported up to 3 months. Simple statistics of central tendencies and variability were calculated. No hypothesis testing was performed. Results The left gastric artery, with or without the gastroepiploic artery, was embolized in five patients, with a technical success rate of 100%. There were no major AEs. There were two minor AEs-subclinical pancreatitis and a mucosal ulcer that had healed by the time of 3-month endoscopy. A hospital stay of less than 48 hours for routine supportive care was provided for three patients. Mean excess weight loss of 5.9% ± 2.4 and 9.0% ± 4.1 was noted at 1 month and at 3 months, respectively. Mean change in serum ghrelin was 8.7% ± 34.7 and -17.5% ± 29 at 1 month and 3 months, respectively. Mean changes in serum glucagon-like peptide 1 and peptide YY were 106.6% ± 208.5 and 17.8% ± 54.8 at 1 month. There was a trend toward improvement in QOL parameters. Hunger/appetite scores decreased in the first 2 weeks after the procedure and then rose without reaching preprocedure levels. Conclusion Bariatric embolization is feasible and appears to be well tolerated in severely obese patients. In this small patient cohort, it appears to induce appetite suppression and may induce weight loss. Further expansion of this study will provide more insight into the long-term safety and efficacy of bariatric embolization.

Modified Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) Techniques for the Treatment of Gastric Varices: Vascular Plug-Assisted Retrograde Transvenous Obliteration (PARTO)/Coil-Assisted Retrograde Transvenous Obliteration (CARTO)/Balloon-Occluded Antegrade Transvenous Obliteration (BATO)

Gastric varices in the setting of portal hypertension occur less frequently than esophageal varices but occur at lower portal pressures and are associated with more massive bleeding events and higher mortality rate. Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices has been well documented as an effective therapy for portal hypertensive gastric varices. However, BRTO requires lengthy, higher-level post-procedural monitoring and can have complications related to balloon rupture and adverse effects of sclerosing agents. Several modified BRTO techniques have been developed including vascular plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, and balloon-occluded antegrade transvenous obliteration. This article provides an overview of various modified BRTO techniques.

Hepatic intra-arterial injection of irinotecan drug eluting beads (DEBIRI) for patients with unresectable colorectal liver metastases: A systematic review

PURPOSE To systematically review the safety and efficacy of transarterial drug-eluting beads, irinotecan (DEBIRI) for the treatment of pretreated patients with unresectable colorectal liver metastases (CRLM). METHODS A systematic search of the current literature was conducted to extract publications reporting on the use of DEBIRI for CRLM. Data on the safety and efficacy was extracted and tabulated. Weighted average values (WAV) were calculated for each variable to provide a single value representing the pooled safety and efficacy data. RESULTS 13 studies (15 treatment arms) were evaluated, comprising a total of 850 patients. There were 6 prospective phase I/II trials, 5 retrospective trials and 2 randomized control trials. All papers involved patients previously treated with systemic chemotherapy. The weighted average all-grade toxicity rate was 35.2% (range; 6-100%). The high-grade WAV toxicity rate was 10.1% (range; 0-32%). Weighted average response rates were 56.2% and 51.1% according to RECIST (Response Evaluation Criteria in Solid Tumors) and modified RECIST/EASL (European Association for the Study of the Liver) response criteria respectively. The weighted average progression-free survival and overall survival were 8.1 months and 16.8 months, respectively. CONCLUSION Transarterial DEBIRI is safe and effective in the treatment of unresectable CRLM to the liver. Further studies are warranted to better define its role in the treatment algorithm of this patient subset.

Endovascular Management of SVC Syndrome due to Fibrosing Mediastinitis—A Feasibility and Safety Analysis

Purpose: To assess the outcomes of endovascular management for superior vena cava (SVC) syndrome secondary to fibrosing mediastinitis (FM). Methods: Between January 2004 and December 2016, 10 consecutive patients with endovascularly managed SVC syndrome secondary to FM were identified in an institutional database. Venograms were performed to assess the severity and location of the lesion and allow measurement for stent selection. Standard stenting and angioplasty techniques were utilized to establish luminal patency. The safety, feasibility, clinical success, and the primary and secondary patency were evaluated. Kaplan-Meier survival analysis was used to determine median duration of stent patency. A log-rank test was used to test differences in prior stent use. Results: Our cohort was predominantly female (7/10) with an average age of 42.2 years. Of the 10 patients, 3 had undergone endovascular stenting at an outside institution prior to referral to our institution due to new, recurrent, or worsening symptoms. All patients underwent venography demonstrating stenosis (8/10) or occlusion (2/10) at initial presentation. Stenting or angioplasty was technically successful in 9 (90.0%) patients. Eight of 10 patients had primary stenting, while 1 achieved vascular patency and symptom resolution with angioplasty alone. Median duration of primary patency was 31.3 months (95% confidence interval: 5.9-103). Six (54.5%) patients required secondary revision procedures. Median duration of secondary patency was 6.1 months, with 25% of revisions occurring by 4 months and 75% occurring by 20.9 months. All treated patients (9/9) reported symptomatic relief at 1-month follow-up, establishing a clinical success rate of 100%. There were no 30-day adverse effects related to the procedure. Conclusion: This study demonstrates that endovascular therapy is a safe and feasible approach for managing FM-related SVC syndrome.

Acute Lower Extremity Deep Venous Thrombosis: The Data, Where We Are, and How It Is Done

The incidence of venous thromboembolism, including both deep vein thrombosis and pulmonary embolism, is estimated at 300,000-600,000 per year. Although thrombosis may occur anywhere, it is thrombosis of the deep veins of the lower extremities that is of interest as this is where thrombosis occurs most often within the venous system. This article discusses the evaluation and interventions, including endovascular catheter-direct treatments, for patients with acute deep venous thrombosis.

Thermal ablation versus surgical resection for localized hepatocellular carcinoma: a population study using the SEER database

AIM To compare overall survival (OS) and liver cancer-specific survival (LCSS) in patients with localized hepatocellular carcinoma treated with surgical resection (SR) or thermal ablation (TA) using the Surveillance, Epidemiology and End Results database. MATERIALS & METHODS Kaplan-Meier, competing risk and Cox regression analyses were performed after identifying patients. Propensity score matching was then applied. RESULTS There was significantly better OS in the SR group and significantly lower probability of LCSS in the TA group. After matching, there was significantly longer OS in the SR group and a lower probability of LCSS in the TA group. CONCLUSION SR offered a significant survival benefit over TA for localized hepatocellular carcinoma.

Analysis of weight changes after left gastric artery embolization in a cancer-naive population

PURPOSE We aimed to evaluate weight changes after left gastric artery (LGA) embolization in a retrospective cancer-naive cohort. METHODS A retrospective study was conducted to identify patients who underwent LGA embolization for gastrointestinal bleeding (GI). Patients with known cancer diagnoses at the time of LGA embolization were excluded. Pre- and postprocedure weights were assessed. Statistical analysis was performed using paired t-test and Wilcoxon signed-rank test. RESULTS A total of 39 patients were identified. In 21 patients who had documented pre- and postprocedural weights, a median of 16.3 kg weight loss (P = 0.045) was observed over a median time of 12 months (range, 2-72). In patients who had pre- and postprocedure endoscopies (n=6), 2 had worsening ulcers following LGA embolization and 4 had stable or no abnormal findings. CONCLUSION Our preliminary observation suggests that LGA embolization is well tolerated and results in unintended weight loss. Larger studies are needed to confirm these preliminary findings.

Renal Embolization: Current Recommendations and Rationale for Clinical Practice

Purpose of ReviewRenal embolization (RE) is a minimally invasive endovascular procedure performed primarily by interventional radiology that can be used to treat a variety of urologic conditions including malignant renal tumors, angiomyolipomas, renal trauma, and complications following biopsy. The following review examines renal embolization indications, technique, and potential complications.Recent FindingsRenal embolization is a versatile therapeutic and adjunctive tool for many acute and chronic urologic conditions. RE has become a first-line therapy for renal trauma in lower grade injuries and increasing in prevalence for higher grade injuries. Additionally, the safety and efficacy of chemoembolization for primary treatment of renal cell carcinoma is under evaluation.SummaryA multidisciplinary approach between urology and interventional radiology should be pursued for all patients undergoing renal embolization regardless of indication. Preprocedural planning and careful monitoring of complications should be performed to optimize clinical outcomes.

Hepatic Arterial Therapy for First-Line Treatment of Unresectable Colorectal Liver Metastases: What We Know in the Wake of Two Recent Randomized Control Trials

The most common site of metastatic disease from colorectal cancer is the liver, and liver disease frequently dictates the prognosis. Therefore, it is sensible to be aggressive in treating colorectal liver metastases (CRLM). Surgical resection is the only chance of long-term disease control (5-year survival 25 to 58 %), but only about 25 % of the cases are deemed resectable at the time of presentation. For unresectable cases, systemic therapy is the standard-of-care for the initial first-line therapy. Unfortunately, those treated with systemic therapy will invariably develop dose-limiting toxicities or will progress leaving less responsive 2nd line and 3rd line options for disease control. HAT (chemoembolization or radioembolization) is commonly used in this clinical setting, and it has been shown to provide benefit in that regard [1]. HAT consists of the placement of a catheter into the hepatic artery through a femoral artery access site. Through the catheter, drugeluting beads loaded with irinotecan (DEBIRI) or beads loaded with the radioactive yttrium 90 (Y) isotope are delivered to the target liver lesions by taking advantage of differential perfusion (CRLMs and most liver tumors are preferentially perfused by the hepatic artery). As a result, HAT aggressively treats liver tumor burden with minimal collateral damage and systemic toxicity. If HAT works in a salvage setting [1], why not introduce it in the earlier treatment stages where it can be of greater benefit? Given that standard-of-care first-line systemic chemotherapy is very effective, it is more appropriate to investigate HAT as a complimentary rather than competitive treatment, with the goal of establishing safety and synergy. Herein, we discuss two landmark randomized control trials (RCTs) that may influence the current treatment paradigm or at least potentiate further investigations on this topic.