R. Beecroft

Effectiveness of Stent-graft Placement for Salvage of Dysfunctional Arteriovenous Hemodialysis Fistulas

PURPOSE To determine the clinical effectiveness of stent-graft placement in dysfunctional autogenous hemodialysis fistulas. MATERIALS AND METHODS Between September 2006 and June 2008, 24 Fluency Plus stent-grafts were inserted in 17 patients with failing autogenous hemodialysis fistulas (two radiocephalic, 12 brachiocephalic, and three brachiobasilic). Six fistulas were thrombosed at presentation. Indications for stent-graft insertion included 10 residual stenoses, six pseudoaneurysms, and one fistuloplasty-induced rupture. Fistula function before and after intervention was assessed with ultrasound dilution technique. RESULTS The technical success rate was 100%, as were the anatomic and clinical success rates. Via Kaplan-Meier method, the primary access patency rates were 94.1% at 3 months (95% CI, 0.461-0.995) and 88.2% at 6 and 12 months (95% CI, 0.468-0.980). The primary lesion patency rate was 94.1% (95% CI, 0.650-0.992) at 3, 6, and 12 months. The secondary access patency rate had a point estimate of 100% at 3 months, and was 93.8% (95% CI, 0.632-0.991) at 6 and 12 months. Univariate analysis suggested that male sex and left-sided accesses were associated with a longer primary access patency rate (P = .02). The binary restenosis rate at 6 months was 5.9%. Mean transonic flow rates were 667.5 mL/min before intervention and 2,076.0 mL/min after intervention (P = .03, Wilcoxon signed-rank test). No patients were lost to follow-up. CONCLUSIONS Stent-graft placement in dysfunctional autogenous hemodialysis fistulas is technically feasible and effective in preserving function and preventing access abandonment, with patency rates that exceed historical patency rates with angioplasty and/or uncovered stents.

Stereotactic body radiotherapy vs. TACE or RFA as a bridge to transplant in patients with hepatocellular carcinoma. An intention-to-treat analysis

BACKGROUND & AIMS There is limited information on the use of stereotactic body radiotherapy (SBRT) as a bridge to liver transplantation for hepatocellular carcinoma and no study comparing its efficacy to transarterial chemoembolization (TACE) and radiofrequency ablation (RFA). We aimed to ascertain the safety and efficacy of SBRT on an intention-to-treat basis compared with TACE and RFA as a bridge to liver transplantation in a large cohort of patients with hepatocellular carcinoma. METHODS Outcomes between groups were compared from the time of listing and from the time of transplant. Between July 2004 and December 2014, 379 patients were treated with either SBRT (n=36, SBRT group), TACE (n=99, TACE group) or RFA (n=244, RFA group). RESULTS The drop-out rate was similar between groups (16.7% SBRT group vs. 20.2% TACE group and 16.8% RFA group, p=0.7); 30 patients were transplanted in the SBRT group, 79 in the TACE group and 203 in the RFA group. Postoperative complications were similar between groups. Patients in the RFA group had more tumor necrosis in the explant. The 1-, 3- and 5-year actuarial patient survival from the time of listing was 83%, 61% and 61% in the SBRT group vs. 86%, 61% and 56% in the TACE group, and 86%, 72% and 61% in the RFA group, p=0.4. The 1-, 3- and 5-year survival from the time of transplant was 83%, 75% and 75% in the SBRT group vs. 96%, 75% and 69% in the TACE group, and 95%, 81% and 73% in the RFA group, p=0.7. CONCLUSIONS In conclusion, SBRT can be safely utilized as a bridge to LT in patients with HCC, as an alternative to conventional bridging therapies. LAY SUMMARY Patients with liver cancer included in the waiting list for liver transplantation are at risk of tumor progression and death. Stereotactic body radiotherapy may be a good alternative to conventional therapies to reduce this risk.

Wait Time for Curative Intent Radio Frequency Ablation is Associated with Increased Mortality in Patients with Early Stage Hepatocellular Carcinoma

INTRODUCTION Radiofrequency ablation (RFA) is a recommended curative intent treatment option for patients with early stage hepatocellular carcinoma (HCC). We investigated if wait times for RFA were associated with residual tumor, tumor recurrence, need for liver transplantation, or death. MATERIAL AND METHODS We conducted a retrospective study of patients diagnosed with HCC between January 2010 and December 2013 presenting to University Health Network (UHN) in Toronto, Canada. All patients receiving curative intent RFA for HCC were included. Multivariable Cox regression was used to determine if wait times were associated with clinical outcomes. RESULTS 219 patients were included in the study. 72.6% were male and the median age was 62.7 years (IQR 55.6-71). Median tumor size at diagnosis was 21.5 mm (IQR 17-26); median MELD was 8.7 (IQR 7.2-11.4) and 57.1% were Barcelona stage 0. The cause of liver disease was viral hepatitis in 73.5% (Hepatitis B and C). The median time from HCC diagnosis to RFA treatment was 96 days (IQR 75-139). In multivariate analysis, wait time was not associated with requiring liver transplant or tumor recurrence, however, each incremental 30-day wait time was associated with an increased risk of residual tumor (HR = 1.09; 95% CI 1.01-1.19; p = 0.033) as well as death (HR = 1.23; 95% CI 1.11-1.36; p ≤ 0.001). CONCLUSION Incremental 30-day wait times are associated with a 9% increased risk of residual tumor and a 23% increased risk of death. We have identified system gaps where quality improvement measures can be implemented to reduce wait times and allocate resources for future RFA treatment, which may improve both quality and efficiency of HCC care.INTRODUCTION Radiofrequency ablation (RFA) is a recommended curative intent treatment option for patients with early stage hepa-tocellular carcinoma (HCC). We investigated if wait times for RFA were associated with residual tumor, tumor recurrence, need for liver transplantation, or death. MATERIAL AND METHODS We conducted a retrospective study of patients diagnosed with HCC between January 2010 and December 2013 presenting to University Health Network (UHN) in Toronto, Canada. All patients receiving curative intent RFA for HCC were included. Multivariable Cox regression was used to determine if wait times were associated with clinical outcomes. RESULTS 219 patients were included in the study. 72.6% were male and the median age was 62.7 years (IQR 55.6-71). Median tumor size at diagnosis was 21.5 mm (IQR 17-26); median MELD was 8.7 (IQR 7.2-11.4) and 57.1% were Barcelona stage 0. The cause of liver disease was viral hepatitis in 73.5% (Hepatitis B and C). The median time from HCC diagnosis to RFA treatment was 96 days (IQR 75-139). In multivariate analysis, wait time was not associated with requiring liver transplant or tumor recurrence, however, each incremental 30-day wait time was associated with an increased risk of residual tumor (HR = 1.09; 95% CI 1.01-1.19; p = 0.033) as well as death (HR = 1.23; 95% CI 1.11-1.36; p ≤ 0.001). CONCLUSION Incremental 30-day wait times are associated with a 9% increased risk of residual tumor and a 23% increased risk of death. We have identified system gaps where quality improvement measures can be implemented to reduce wait times and allocate resources for future RFA treatment, which may improve both quality and efficiency of HCC care.

Clinical Case Panel: Treatment Alternatives for Inoperable Hepatocellular Carcinoma

Surgical resection or liver transplantation offers the best chance of cure for patients with hepatocellular carcinoma (HCC). Unfortunately, most patients are not good candidates for liver resection due to locally advanced disease or compromised liver function. Moreover, liver transplantation waiting lists are long. For those cases not amenable for resection, a variety of local treatment modalities are available, such as image-guided ablative procedures, transarterial chemoembolization, and radioembolization, as well as external beam radiation. HCC presentation can vary considerably in size, number, and location of lesions. The management of inoperable HCC is, therefore, quite complex, and there is a lack of consensus on the best local treatment modality for each type tumor presentation. Here, we present 4 clinical case scenarios representative of commonly seen cases in the clinical setting, with different therapeutic perspectives from institutions with high expertise in the management of HCC.

Determination of the Best Parameter for Defining the Hemodynamic Significance of an Iliac Artery Stenosis Detected on Computed Tomography Angiography

Purpose The purpose of this study was to determine the best parameter, derived from computed tomography angiography (CTA) for accurate prediction of a hemodynamically significant stenosis of the common or external iliac artery. Methods A retrospective keyword search was performed on the Radiology Information System at our tertiary academic medical centre. Reports from January 2008 to September 2013 were searched using the keywords iliac, stenosis, and pressure. Patients who had both and CTA and a pelvic angiogram with pressure measurements obtained across a potential stenosis were selected. Using 3D postprocessing software (TeraRecon, Foster City, CA), the CTAs were analysed for the following parameters of each lesion: minimum diameter of stenosis, minimum cross-sectional area of stenosis, percent narrowing of vessel diameter, and percent reduction in vessel area. The percent stenosis was calculated in reference to the outer diameter at the point of maximal narrowing and also in reference to a normal segment of vessel more distal to the stenosis. These parameters were then compared with the measured pressure gradient using receiver-operating characteristic analysis and the Mann-Whitney U test to determine which best predicted a significant stenosis, defined as a greater than 10% drop in systolic pressure across a lesion. Results One hundred and two stenoses in 83 patients (26 women, 57 men; 47-88 years old) were identified. Mean diameter of the stenosis was 2.8 mm for significant stenosis compared to 3.8 mm in nonsignificant stenoses (P = .005). Mean minimum area for significant stenoses was 11.8 mm2 compared to 17.22 mm2 for nonsignificant stenoses (P = .032) No other variables showed a significant difference between significant and nonsignificant stenoses. A minimum diameter of ≤4.0 mm at the level of a stenosis is 92% sensitive and 48% specific for predicting a hemodynamically significant iliac artery stenosis, with a positive predictive value of 88%. Conclusions A simple measurement of the minimum diameter of an iliac artery at the level of stenosis is the best predictor of the hemodynamic significance of a stenosis in the common or external iliac artery.

Endoscopic or percutaneous biliary drainage for Klatskin tumors? A large retrospective study.

277 Background: Controversy exists over the preferred technique of biliary drainage in patients with Klatskin tumors as few comparative studies exist. This study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD). Methods: 129 patients with Klatskin tumors with an initial EBD or PTBD were identified from 01/01/1991 to 31/05/2011 and their clinical histories were retrospectively reviewed. The primary end point was the time to therapeutic success (TTS: time between the first drainage and a total bilirubin<40µmol/L), estimated by Kaplan-Meier analysis. Results: The first biliary decompression procedure was EBD in 87 patients and PTBD in 42 patients. The technical (98% vs 78%, p=0.004) and therapeutic (79% vs 49%, p=0.002) successes were significantly higher in the PTBD group than EBD group, respectively; Forty four patients (51%) in the EBD group subsequently underwent a PTBD before achieving therapeutic success or starting their antitumoral treatment...