Ranko Smiljanić

Fluorouracil, leucovorin and irinotecan combined with intra-arterial hepatic infusion of drug-eluting beads preloaded with irinotecan in unresectable colorectal liver metastases: side effects and results of a concomitant treatment schedule. Clinical investigation

Aim Safety evaluation of concomitant systemic chemotherapy and liver chemoembolization in patients with colorectal cancer. Patients and Methods Seven patients with metastases confined to the liver were included and stratified into two groups, depending of dosage of systemic chemotherapy. The first group received systemic chemotherapy (FOLFIRI) with 20% dose reduction, and the second group received the full dose of the same chemotherapy. In both groups, chemoembolization of liver metastases with drug-eluting bead irinotecan (DEBIRI) was performed following the application of systemic chemotherapy. The toxicity profiles of the two groups were compared. Results Of the 7 patients included, 4 received the reduced systemic chemotherapy dose and 3 received the full chemotherapy dose. DEBIRI was performed in all 7 patients. The main toxicities observed in the reduced chemotherapy dose group were leukopenia (25%), anorexia (75%), diarrhea (25%), vomiting (25%), right upper abdominal quadrant pain (100%) and elevated serum amylase level (25%). Main toxicities observed in the full chemotherapy dose group were anorexia (66.6%), vomiting (33.3%), right upper abdominal quadrant pain (100%), and elevated serum amylase level (66.6%). There were no significant differences between the two groups (P = 0.78541). Conclusions Patients with isolated liver metastases from a colorectal primary can safely be treated with DEBIRI chemoembolization and a full dose of systemic chemotherapy (FOLFIRI).

Complications of Permanent Hemodialysis Catheter Placement; Need for Better Pre-Implantation Algorithm?

There is a correlation between central venous cannulation and the development of central venous stenosis. Minor retrosternal vein lesions can be easily missed. Computerized tomographic (CT) venography is the diagnostic procedure of choice. The aim of this study was to examine the complications after catheter implantation in patients with prior permanent catheter placement and to evaluate present diagnostic procedures performed prior to choosing permanent access site in order to reduce possible complications after catheter placement. Complications of permanent CVC insertion in our department were analyzed between October 2011 and February 2015. We have implanted the Tesio twin catheter system and the Hickman Bard dual lumen catheter. All patients with prior permanent dialysis catheter were evaluated with color doppler, while patients with suspected central venous stenosis (CVS) or thrombosis were evaluated with phlebography or CT venography prior to catheter placement. One hundred and ninety‐eight permanent dialysis catheters were placed (173 Tesio [87.4%] and 25 Hickman [12.6%]) in 163 patients. There were 125 patients (76.7%) with prior temporary catheter and 61 (48.8%) of them had more than one prior permanent catheter (1.92 catheter per person).There were 4/61 (6.5%) patients with catheter‐related complications without prior phlebography and CT venography. Phlebography and CT venography were performed in 30 (24.0%) patients with suspected CVS/thrombosis and with dialysis vintage of 76.23 months (52.78–98.28). Phlebography and CT venography were more sensitive than color doppler in the detection of CVS/thrombosis in patients with prior permanent catheter placements (P < 0.001). Since this diagnostic algorithm was introduced prior to catheter placement there were no catheter insertion‐related complications or dysfunctions (P < 0.001). All our procedures on patients with prior permanent catheters followed preliminary color doppler diagnostics. Nevertheless, in four cases, the vessel obstruction and abnormality led to catheter insertion‐related complications. When phlebography and CT venography was performed before the procedure in patients with prior permanent catheters and one or more CVS or thrombosis, early and late catheter‐related complications were avoided by careful selection of the least injured vein and planning of procedure. When planning a permanent dialysis catheter placement in patients with prior multiple CVC, phlebography and CT venography may be diagnostic procedures of choice for avoidance of early catheter dysfunction and CVC placement complications.

Traumatic mesenteric bleeding: early diagnosis and interventional management

We report a rare case of mesenteric bleeding following blunt abdominal trauma successfully treated with transcatheter arterial embolization (TAE) of the ileal artery branch. A 27-year-old man presented with mesenteric bleeding after motorcycle accident. Computed tomography (CT) demonstrated mesenteric hematoma with extravasation of contrast material, and no associated major injuries to other organs. A superior mesenteric angiogram revealed pseudoaneurysm of the ileal branch. After TAE with a single microcoil, control angiography showed cessation of bleeding. There was no need for repeat embolization or additional surgery due to mesenteric bleeding nor ischemic gastrointestinal complications during the 5 months following TAE. In isolated mesenteric injuries, TAE may be a reasonable minimally invasive alternative to emergency laparotomy.

The Different Impacts on the Long-Term Survival of Tunneled Internal Jugular Hemodialysis Catheters Based on Tip Position and Laterality

Background/Aims: The aim of this study was to examine the impact of different catheter tip positions on the life of the catheter, dysfunction, infection, and quality of hemodialysis and possible differences between the access site laterality in jugular-tunneled hemodialysis catheters. Methods: Catheters were evaluated for the following parameters: place of insertion, time of insertion, duration of use, and reason for removal. In all patients, the catheter tip position was checked using an X-ray. Results: The mean duration of implanted catheters with the tip placed in the cavo-atrial junction and right atrium was significantly longer. There were no differences in catheter functionality at follow-up or complications based on catheter laterality for each catheter tip position. Conclusion: According to our results, the localization of the catheter tip in superior vena cava still remains the least preferable method. Our results showed that the main factor responsible for better catheter functionality was not laterality but the depth to which the catheter tip is inserted into the body.

Localization of Pancreatic Insulinomas with Arterial Stimulation by Calcium and Hepatic Venous Sampling - Presentation of a Single Centre Experience

Context Arterial stimulation and venous sampling (ASVS) is the most sensitive diagnostic method for occult insulinoma localization. We present our experience with this method and modifications used that proved to ensure greater safety and sensitivity with this rare pathology. Relationship between tumour size and changes in peak insulin values and release curves were also tested. Subjects and methods Six consecutive patients with biochemically established diagnosis of endogenous hyperinsulinism underwent preoperative non-invasive diagnostic tests with sensitivities calculated and compared for all methods. Certain modifications were used in ASVS procedure that included hepatic vein catheterization, order of arterial stimulation, time intervals between each stimulation, diagnostic insulin gradient level and the time frame for diagnostic rise of insulin. Peak insulin values and insulin gradients were compared with tumour size in each patient. Results In all patients, calcium stimulation accurately localized the insulinoma, with higher sensitivity than any other method. A more than 4-fold increase in insulin level was observed in all patients, after injection into the tumour feeding artery, while 2 to 4-fold increase was observed in the tumour neighbouring areas. Tumour size showed an inversely proportional correlation to peak insulin values in each artery that correctly located the tumour. Conclusion ASVS presents the most accurate and safe method for localization of occult insulinomas. A four-fold insulin gradient can be used as a limit for positive preoperative localization in order to secure a higher specificity.

Catheter directed thrombolysis for acute limb ischemia: eight cases in two years

Cardiologia CROATICA Introduction: Acute limb ischemia (ALI) is a challenging problem in angiology. It can be associated with significant morbidity or death even after successful limb revascularization. Management of ALI depends on the clinical status of the affected limb and patient comorbidities. We assessed the efficacy and complication of catheter directed thrombolysis for ALI in our institution during 2012 and 2013. Patients and Methods: During the period of 24 months, eight ALI patients were treated by catheter directed infusion with recombinant tissue plasminogen activator (r-tPA). Standard endovascular access and catheter techniques were involved starting with 5 mg bolus of r-TPA, followed by continuous infusion of 0.5-2 mg/h. Concomitant heparin at low dose was applied to prevent catheter-associated thrombus development. During r-TPA, infusion angiography was repeated to determine success of thrombus dissolution. Results: There were 5 males and 3 females, mean age of 74.8 years (range, 54-90 years). One patient had upper extremity ischemia, others had lower ALI. The average duration of symptoms was 3.6 days (1-10 days). Mean duration of r-TPA infusion was 24.2 hours (16 to 4 hours), with mean dosage of 36.6 mg (range 17 to 60 mg).Three patients (38%) had complete reestablishment of blood flow with catheter thrombolysis and mean ankle — brachial index (ABI) improved from 0.22 to 0.85. The other 4 patients (50%) had partial restoration of flow and needed additional endovascular or surgical intervention with final mean ABI improvement from 0.39 to 0.98. In one case catheter directed thrombolysis failed to reestablish blood flow and the patient underwent the bypass surgery. Only one patient had severe periprocedural complication (gastrointestinal bleeding) requiring a blood transfusion. Small access site hematoma was noticed in all of the treated patients. In the follow-up period (7 to 20 months) one patient had unfavorable course of affected limb which ended with an amputation 15 months after thrombolysis. The other seven patients were stabile, without significant impairment of the treated limb. Conclusion: Selective thrombolysis should be considered for ALI patients with the symptom onset less than 14 days and without motor deficit of the affected limb. It is a timeconsuming procedure with potential severe hemorrhagic complications. With the proper patient selection and coordinated multidisciplinary team, it could result in the reestablishment of flow and an acceptable bleeding complication rate.