P Petruzzi

Conventional versus Doxorubicin-eluting Bead Transarterial Chemoembolization for Hepatocellular Carcinoma

PURPOSE To compare short- and long-term clinical outcomes after conventional transarterial chemoembolization and drug-eluting bead (DEB) transarterial chemoembolization in hepatocellular carcinoma (HCC). MATERIALS AND METHODS Patients with unresectable HCC unsuitable for ablative therapies were randomly assigned to undergo conventional or DEB chemoembolization. The primary endpoints of the study were safety, toxicity, and tumor response at 1 month. Secondary endpoints were number of repeated chemoembolization cycles, time to recurrence and local recurrence, time to radiologic progression, and survival. RESULTS In total, 67 patients (mean age, 70 y ± 7.7) were evaluated. Mean follow-up was 816 days ± 361. Two periprocedural major complications occurred (2.9%) that were treated by medical therapy without the need for other interventions. A significant increase in alanine aminotransferase levels 24 hours after treatment was reported, which was significantly greater after conventional chemoembolization (n = 34) than after DEB chemoembolization (n = 33; preprocedure, 60 IU ± 44 vs 74 IU ± 62, respectively; at 24 h, 216 IU ± 201 vs 101 IU ± 89, respectively; P = 0.007). No other differences were observed in liver toxicity between groups. At 1 month, complete and partial tumor response rates were 70.6% and 29.4%, respectively, in the conventional chemoembolization group and 51.5% and 48.5%, respectively, in the DEB chemoembolization group. No differences were observed between groups in time to recurrence and local recurrence, radiologic progression, and survival. CONCLUSIONS Conventional chemoembolization and DEB chemoembolization have a limited impact on liver function on short- and long-term follow-up and are associated with favorable clinical outcomes.

Doxorubicin-eluting bead-enhanced radiofrequency ablation of hepatocellular carcinoma: a pilot clinical study

BACKGROUND/AIMS Experimental studies have shown synergy between radiofrequency (RF) ablation and adjuvant chemotherapy in animal tumour models. We aimed to assess safety and efficacy of doxorubicin-eluting bead (DEB)-enhanced RF ablation in the treatment of human hepatocellular carcinoma (HCC). METHODS Twenty patients with single HCC ranging 3.3-7.0 cm (mean, 5.0 cm+/-1.4) showing evidence of residual viable tumour after standard RF ablation underwent intraarterial DEB administration (50-125 mg doxorubicin; mean, 60.2 mg+/-21.8). Follow-up period ranged 6-20 months (mean, 12 months+/-5). RESULTS No major complication occurred. No deterioration of liver function was observed. The volume of treatment-induced necrosis--as measured on imaging--increased from 48.1 cm3+/-35.7 after RF ablation to 75.5 cm3+/-52.4 after DEB administration, with an increase of 60.9%+/-39.0. The enhanced effect resulted in confirmed complete response (CR) of the target lesion in 12 (60%) of 20 patients. Incomplete response with persistence of <10% of initial tumour volume was observed in 6 (30%) of 20 patients, and local tumour progression in 2 (10%) of 20. CONCLUSIONS Intraarterial DEB administration substantially enhances the effect of RF ablation. DEB-enhanced RF ablation is safe and results in a high rate of CR in patients refractory to standard RF treatment.

Chemoembolization of Hepatocellular Carcinoma

Transarterial chemoembolization (TACE) is the current standard of care for patients with intermediate-stage hepatocellular carcinoma (HCC) and relatively preserved liver function. In a meta-analysis of randomized controlled trials comparing conventional TACE regimens-including the administration of an anticancer-in-oil emulsion followed by embolic agents-versus best supportive care, TACE was shown to improve median survival from 16 to 20 months. Various strategies to improve outcomes for this patient group have become the subject of much ongoing clinical research. The introduction of an embolic drug-eluting bead (DEB) has been shown to substantially improve the pharmacokinetic profile of TACE, providing levels of consistency and repeatability not available with conventional regimens while concomitantly significantly diminishing systemic drug exposure. In randomized trials, DEB-TACE significantly reduced liver toxicity and drug-related adverse events compared with conventional TACE. In this article, technique, indications and contraindications, and clinical outcomes of conventional and DEB-TACE in the management of HCC are reviewed. In addition, scientific background and early clinical experience with the use of combination regimens including TACE and systemically active molecular-targeted agents with antiangiogenic properties are discussed. The combination of DEB-TACE and antiangiogenic therapy represents a potentially powerful approach that is currently undergoing clinical investigation in a phase 3 setting.

Do acute lesions of Wernicke's encephalopathy show contrast enhancement? Report of three cases and review of the literature

Abstract Contrast medium was given intravenously to three nonalcoholic patients who underwent MRI or CT in the acute stage of Wernickes encephalopathy. Pathological enhancement was not seen in one patient examined within 4 days of clinical onset, was mild in a another 3 days after clinical deterioration and marked in a patient examined 12 days after admission. Contrast enhancement of lesions was present in half of 12 cases of acute disease reported previously. There was a substantial overlap in the time interval between clinical onset and contrast-enhanced CT or MRI in the groups of enhancing and nonenhancing lesions. Since contrast enhancement may be absent in acute WE, proton-density and T 2-weighted images are more useful for diagnosis of this reversible but potentially fatal condition.

Endovascular Repair of Abdominal Aortic Aneurysms: Analysis of Aneurysm Volumetric Changes at Mid-Term Follow-Up

PurposeTo evaluate the volumetric changes in abdominal aortic aneurysms (AAA) after endovascular AAA repair (EVAR) in 24 months of follow-up.MethodsWe evaluated the volume modifications in 63 consecutive patients after EVAR. All patients underwent strict duplex ultrasound and computed tomography angiography (CTA) follow-up; when complications were suspected, digital subtraction angiography was also performed. CTA datasets at 1, 6, 12, and 24 months were post-processed through semiautomatic segmentation, to isolate the aneurysmal sac and calculate its volume. Maximum transverse diameters (Dmax) were also obtained in the true axial plane, Presence and type of endoleak (EL) were recorded. A statistical analysis was performed to assess the degree of volume change, correlation with diameter modifications, and significance of the volume increase with respect to ELs.ResultsMean reconstruction time was 7 min. Mean volume reduction rates were 6.5%, 8%, and 9.6% at 6, 12, and 24 months follow-up, respectively. Mean Dmax reduction rates were 4.2%, 6.7%, and 12%; correlation with volumes was poor (r = 0.73–0.81). ELs were found in 19 patients and were more frequent (p = 0.04) in patients with higher preprocedural Dmax, The accuracies of volume changes in predicting ELs ranged between 74.6% and 84.1% and were higher than those of Dmax modifications. The strongest independent predictor of EL was a volume change at 6 months ≤0.3% (p = 0.005), although 6 of 19 (32%) patients with EL showed no significant AAA enlargement, whereas in 6 of 44 (14%) patients without EL the aneurysm enlarged.ConclusionThe lack of volume decrease in the aneurysm of at least 0.3% at 6 months follow-up indicates the need for closer surveillance, and has a higher predictive accuracy for an endoleak than Dmax.

MRI of cerebellar white matter damage due to carbon monoxide poisoning: Case report

Extensive bilateral cerebellar white matter signal change, with sparing of the overlying cortex, consistent with demyelination was seen in a 12-year-old boy who had suffered carbon monoxide poisoning 6 years previously. His youth at the time of exposure and the long delay between exposure and examination might account for this unusual finding.

Predictive Factors of In-Stent Restenosis in Renal Artery Stenting: A Retrospective Analysis

PurposeTo retrospectively evaluate the role of clinical and procedural factors in predicting in-stent restenosis in patients with renovascular disease treated by renal artery stenting.MethodsFrom 1995 to 2002, 147 patients underwent renal artery stenting for the treatment of significant ostial atherosclerotic stenosis. Patients underwent strict clinical and color-coded duplex ultrasound follow-up. Ninety-nine patients (111 stents), with over 6 months of continuous follow-up (mean 22±12 months, range 6–60 months), were selected and classified according to the presence (group A, 30 patients, 32 lesions) or absence (group B, 69 patients, 79 lesions) of significant in-stent restenosis. A statistical analysis was performed to identify possible preprocedural and procedural predictors of restenosis considering the following data: sex, age, smoking habit, diabetes mellitus, hypertension, serum creatinine, cholesterol and triglyceride levels, renal artery stenosis grade, and stent type, length and diameter.ResultsComparing group A and B patients (χ2 test), a statistically significant relation was demonstrated between stent diameter and length and restenosis: the risk of in-stent restenosis decreased when the stent was ≥6 mm in diameter and between 15 and 20 mm in length. This finding was confirmed by multiple logistic regression analysis. Stent diameter and length were proved to be significantly related to in-stent restenosis also when evaluating only patients treated by Palmaz stent (71 stents).ConclusionAlthough it is based on a retrospective analysis, the present study confirms the importance of correct stent selection in increasing long-term patency, using stents of at least 6 mm in diameter and with a length of approximately 15–20 mm.

Ultrasonographic Surveillance with Selective CTA after Endovascular Repair of Abdominal Aortic Aneurysm

Purpose: To evaluate the agreement between color-coded duplex ultrasound (US) and computed tomographic angiography (CTA) in monitoring aneurysm diameter and detecting endoleaks after endovascular aneurysm repair (EVAR). Methods: From November 1998 to January 2007, 196 patients (191 men; mean age 72.4 years, range 52–88) underwent EVAR and were followed by CTA and US over a mean 3.9±2.4 years (range 0––8.9, median 3.4). Annual paired CTA and US examinations were reviewed to assess agreement in measuring maximum aneurysm transverse diameter and to evaluate diagnostic accuracy of US in detecting endoleak. Results: The 5-year cumulative endoleak incidence was 43.8% (72 patients). At first diagnosis, US detected 55/72 (76.4%) endoleaks; of the remaining 17, only 3 (4.3%) were clinically significant in terms of aneurysm enlargement. Pairing 709 annual CTA and US examinations from 184 patients showed a high agreement (k=0.96) between examinations in measuring maximum transverse diameter, with a mean difference between US and CTA of −2.5 mm. Conclusion: After the first year of follow-up, EVAR surveillance costs can be reduced by performing annual US examinations only. Keeping in mind that US underestimates diameter measurements, CTA can be reserved for patients with increasing or persistently stable aneurysm diameters.

Renal Artery Stenting in Patients with a Solitary Functioning Kidney

AbstractPurpose: To retrospectively evaluate the results of renal artery stenting in patients with renovascular disease and a solitary functioning kidney. Methods: Palmaz stents were placed in 16 patients with a solitary functioning kidney, renal artery stenosis, hypertension and renal failure. Stenoses were evaluated with color Doppler ultrasound, MR angiography and digital subtraction angiography (DSA). Indications for stenting were: recoil after percutaneous transluminal renal angioplasty (PTRA) (63%), arterial dissection after PTRA (13%) and primary stenting (25%). Immediate results were evaluated by DSA. On follow-up (6-36 months), patients underwent periodical evaluation of clinical conditions (blood pressure and serum creatinine level) and stent patency, by means of color Doppler ultrasound. Results: Stent placement was successful in all patients (100%). Cumulative primary patency rate was: 100% at 1 day, 93.75% at 6 months, 81.25% at 12 months and 75% at 24 months. A significant reduction in diastolic blood pressure occurred (mean ± SD 104 ± 6 vs 92 ± 3; p < 0.05); renal function improved or stabilized in over 80% of patients. However, there was no significant difference in the creatinine values before and after treatment (mean ± SD 200 ± 142 mmol/l vs 197 ± 182 mmol/l; p > 0.05). Conclusion: Renal artery stenting, both after PTRA and as primary stenting, represents a safe procedure, able to preserve renal function in patients with a solitary functioning kidney.

Outcomes of three years of teamwork on critical limb ischemia in patients with diabetes and foot lesions

To evaluate the outcomes of a multidisciplinary team working on diabetic foot (DF) patients with critical limb ischemia (CLI) in a specialized center, the authors retrospectively traced all the patients admitted in their department in 3 consecutive years with a diagnosis of CLI. From January 2006 to December 2008, 245 consecutive DF patients with CLI according the TransAtlantic interSociety Consensus II criteria were included in the study. Treatment strategy was decided by a team of diabetologists, inteventional radiologists, and vascular surgeons. Technical and clinical success, mortality, and ulcer recurrence were evaluated at 6 months and at a mean follow-up of 19.5 ± 13.4 months. Percutaneous transluminal angioplasty (PTA) was performed in 189 (77%) patients, whereas medical treatment, open surgical revascularization (OSR), and primary amputation were performed in 44 (18.3%), 11 (4.3%), and 1 (0.5%) patients, respectively. Revascularization was successful in 227/233 (97.4%) patients. At follow-up, the overall clinical success rate was 60.4%; it was significantly (P = .001) higher after revascularization (75.9%) compared with medical treatment (48.3%). During follow-up, surgical interventions in the foot were 1.5 ± 0.4 in those treated with PTA, 1.6 ± 0.5 in those treated with OSR, and 0.3 ± 0.8 in those receiving medical therapy (P < .05 compared with the others). Ulcer recurrence occurred in 29 (11.8%) patients: 4 (1.6%) in PTA, 2 (0.8%) in OSR, and 23 (9.4%) in the medical therapy group (P < .05). Major amputation rate was 9.3%, being significantly (P = .04) lower after revascularization (5.2%) compared with medical therapy alone (13.8%). Cumulative mortality rate was 10.6%. In conclusion, this study confirms the positive role of a PTA-first approach for revascularizing the complex cases of DF with CLI in a teamwork management strategy.