Ricardo Paz-Fumagalli

Percutaneous image-guided cryoablation of painful metastases involving bone: multicenter trial.

This study sought to describe the results of a single‐arm multicenter clinical trial using image‐guided percutaneous cryoablation for the palliation of painful metastatic tumors involving bone.

Risk of Deep Venous Thrombosis Associated with Chest versus Arm Central Venous Subcutaneous Port Catheters: A 5-Year Single-Institution Retrospective Study

PURPOSE To determine the risk of deep venous thrombosis (DVT) in patients undergoing placement of central (chest) versus peripheral (arm) ports. MATERIALS AND METHODS Between January 1996 and December 2000, a total of 440 implantable chest or arm ports were placed in 422 patients. Data pertaining to the first port placed for each patient was analyzed. Ports were placed for chemotherapy (n = 415) or blood transfusion (n = 7). Subset analysis was performed, taking into consideration whether patients received prophylactic or therapeutic doses of warfarin sodium (Coumadin), to determine if there was any difference in the incidence of DVT between patients undergoing some form of anticoagulation versus those undergoing none. The medical records of these patients were reviewed to determine outcome with reference to development of DVT. RESULTS In 273 chest ports placed, there were 13 (4.8%) instances of DVT; in 149 peripheral ports, there were 17 (11.4%). Censoring data on patients receiving some form of anticoagulation, the respective incidences were eight of 245 (3.3%) and 14 of 129 (10.9%). With use of Kaplan-Meier analysis and log-rank tests to examine comparisons of interest, the probability of thrombosis occurring over a period of 180 days was higher with peripheral ports irrespective of Coumadin use (P =.007 for all patients considered, P =.002 when analyzed only for those not receiving Coumadin). The difference in incidence of thrombosis for all ports between patients receiving Coumadin versus those not receiving Coumadin was not significant. CONCLUSIONS Compared to chest ports, peripheral ports are associated with a significantly higher incidence of DVT.

Effect of suprarenal versus infrarenal aortic endograft fixation on renal function and renal artery patency: a comparative study with intermediate follow-up ☆

PURPOSE Suprarenal fixation of aortic endografts appears to be a safe option in patients with a short or conical proximal aortic neck. However, concern persists regarding the long-term effect on renal function when renal artery ostia are crossed by the uncovered stent. We investigated the effect of suprarenal versus infrarenal endograft fixation on renal function and renal artery patency after endovascular aortic aneurysm repair. METHODS Records of 91 patients who underwent endovascular aortic aneurysm repair with a modular bifurcated stent graft between November 1999 and January 2002 were reviewed retrospectively. Two patients receiving dialysis because of chronic renal failure were excluded. Infrarenal fixation was used in 57 patients (group 1), and suprarenal fixation was used in 32 patients (group 2). In two patients in group 1 a Gianturco Z stent was inserted transrenally because of intraoperative proximal type I endoleak, and data for these patients were excluded from analysis. Follow-up evaluation was performed at 1, 6, and 12 months, and yearly thereafter, and included clinical assessment, measurement of serum creatinine concentration (SCr), and computed tomography angiography, per standard protocol. Median follow-up was 12 months (range, 1-36 months). RESULTS There was no statistically significant difference in patient demographic data, aneurysm size, or preoperative risk factors. Median SCr was significantly higher in group 2 (suprarenal fixation) than in group 1 (infrarenal fixation) preoperatively (1.2 mg/dL [range, 0.6-2.3 mg/dL] vs 0.9 mg/dL [range, 0.6-1.9 mg/dL], P =.008) and at 1 month postoperatively (1.1 mg/dL [range, 0.8-5.6 mg/dL] vs 1.0 mg/dL [range, 0.6-2.1 mg/dL], P =.045). There was a significant increase in median SCr in both groups at 1 month postoperatively (group 1, 1.0 mg/dL [range, 0.6-2.1 mg/dL], P =.05; group 2, 1.1 mg/dL [range, 0.8-5.6 mg/dL] [mean SCr, 1.35 mg/dL vs 1.15 mg/dL, respectively], P <.05). In group 1 SCr was increased significantly at 6 and 12 months (P <.001), whereas in group 2 SCr also increased at 6 and 12 months, but not significantly. The change in SCr over time was not significantly different between the two groups. In two of 32 patients in group 2, renal artery occlusion developed, associated with perfusion defects in renal parenchyma and persistently elevated SCr. Analysis of renal artery patency did not demonstrate any association between patency and treatment. No patient developed hypertension during follow-up. CONCLUSIONS Suprarenal endograft fixation does not lead to significant renal dysfunction, and renal artery occlusion is uncommon within 12 months. A larger study with longer follow-up is essential to determine overall effects on renal function and renal artery patency.

Extrahepatic Portal Biliopathy: Proposed Etiology on the Basis of Anatomic and Clinical Features

PURPOSE To compare the anatomic and clinical features in patients with chronic portal vein thrombosis (PVT) to determine why some patients develop portal biliopathy (PB) while most do not and propose an etiology for PB. MATERIALS AND METHODS This project satisfied HIPAA regulations and received institutional review board approval for a retrospective review without the need for consent. From 100 patients with PVT, 60 were extracted who had chronic, nonmalignant PVT, after exclusion of those with sclerosing cholangitis, liver transplants, choledocholithiasis, or portosystemic shunts. Clinical and imaging data from 19 patients with biliary dilatation (PB group) were compared with data from 41 patients without biliary dilatation (no-PB group). Statistical analysis was performed with the Fisher exact test for categorical variables or the Wilcoxon rank-sum test for numerical and ordered categorical variables. P values of .05 or less were considered to indicate a significant difference. RESULTS The etiology of PVT differed between the groups (P < .001); cirrhosis was infrequently seen in the PB group (two of 19, 11%) but was common in the no-PB group (31 of 41, 76%). Only two of 33 (6%) patients with cirrhosis and PVT had PB. Extension of PVT into the mesenteric veins was significantly more common in the PB group (18 of 19, 95%) than in the no-PB group (one of 41, 2%) (P < .001). Compared with the no-PB group, patients in the PB group had more acute angulation of the bile duct (median, 110° vs 128°; P = .008), less frequent gastroesophageal varices (three of 19 [16%] vs 20 of 41 [49%], P = .021), and a smaller mean coronary vein diameter (median, 5 vs 6 mm; P = .014). CONCLUSION Noncirrhotic patients with hypercoagulable states tend to develop PB when PVT extends to the splenomesenteric veins. A possible etiology is the formation of specific peribiliary venous pathways responsible for bile duct compression and tethering.

Femoral incision morbidity following endovascular aortic aneurysm repair

Currently available aortic stent-grafts require bilateral femoral incisions for device deployment. The incidence of morbidity (infection, lymphatic complications, breakdown) of vertical, infrainguinal incisions used in endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) was assessed, and the natural history of asymptomatic groin fluid collections following such procedures was determined. Between June 1999 and February 2001, 77 consecutive patients underwent EVAR for AAAs utilizing bilateral vertical femoral incisions. Fifty-nine (77%) bifurcated stent-grafts (BSGs), and 18 (23%) aortouniiliac (AUI) devices, with femorofemoral bypass were performed. Patients returned at 2 weeks, 1 month, and 6 months for physical examination, and 1 month and 6 months for abdominal and pelvic computed tomography (CT) scans. The presence of fluid collections was determined from the dictation report of the attending radiologist. Data are reported as (n) mean ± SE. Patient characteristics were compared using Fishers exact test; p <0.05 considered significant. There were 72 males and 5 females, age 75 ±6.4 years and aneurysm size (77) 5.6 ±0.8 cm. There were no cases of wound breakdown or lymph fistula. Wound infections occurred in 3/150 incisions (2%), 2/34 AUI incisions (6%), and 1/1 16 BSG incisions (0.86%). There was no statistical difference (p =0.13) between graft types (BSG vs AUI). All infections were diagnosed clinically before the 1-month CT scan, treated without operative intervention or hospitalization, and resolved. There was a significant decrease in the BSG group and overall in asymptomatic wound fluid collections from 1 to 6 months postoperatively. At 1 and 6 months, respectively, the BSG group had 17 (14.6%) and 3 (2.6%) fluid collections out of 116 incisions (p = 0.003); the AUI group had 6 (17.6%) and 1 (2.9%) fluid collection(s) out of 34 incisions (p = 0. 13); and overall 23 (15.3%) and 4 (2.6%) out of 150 incisions (p = 0.004). The present study demonstrates that bilateral vertical femoral incisions used in EVAR have a wound infection rate of 2.0%. Infections are usually detected and treated clinically and empirically without the need for hospitalization or surgery. Asymptomatic groin wound fluid collections resolve significantly within 6 months without intervention. Therefore, surgical femoral artery exposure adds little morbidity to the endovascular repair of abdominal aortic aneurysms.

Natural History of the Iliac Arteries after Endovascular Abdominal Aortic Aneurysm Repair and Suitability of Ectatic Iliac Arteries as a Distal Sealing Zone

PURPOSE To investigate the natural history of dilated common iliac arteries (CIA) exposed to pulsatile blood flow after endovascular abdominal aortic aneurysm repair (EVAR) and the suitability of ectatic iliac arteries as sealing zones using flared iliac limbs. METHODS Follow-up computed tomograms of 102 CIAs in 60 EVAR patients were investigated. Diameter changes in CIAs < or =16 mm (group 1) were compared with changes in vessels where a dilated segment >16 mm in diameter continued to be exposed to pulsatile blood flow (group 2). Within group 2, cases in which the stent terminated proximal to the dilated artery segment (2a) were compared with those that had been treated with a flared limb (2b). RESULTS The mean CIA diameter increased by 1.0+/-1.0 mm in group 1 (p<0.001 versus immediately after EVAR) and by 1.5+/-1.7 mm in group 2 (p<0.001 versus immediately after EVAR) within an average follow-up of 43.6+/-18.0 months. Diameter increase was more pronounced in dilated CIAs (p=0.048), and it was not significantly different between groups 2a and 2b (p=0.188). No late distal type I endoleak or stent-graft migration associated with CIA ectasia was observed. CONCLUSION Dilatation of the CIA is significant after EVAR, and it is more pronounced in ectatic iliac arteries. Although ectatic iliac arteries appear to be suitable sealing zones in the short term, continued follow-up is mandatory.

Management of a Large Intraoperative Type IIIb Endoleak in a Bifurcated Endograft A Case Report

The purpose of this paper is to describe the intraoperative management of a type IIIb endoleak after deployment of a bifurcated endograft in a patient with narrow iliac access vessels. A 62-year-old man underwent elective endovascular repair (EVAR) of a 53 mm abdominal aortic aneurysm. After device deployment, a large IIIb endoleak, arising from the main body of the device, was visualized. Narrow iliac vessels precluded deployment of a second bifurcated graft, and the endoleak was successfully excluded with an aortomonoiliac device, followed by contralateral iliac occlusion and subsequent creation of a femorofemoral bypass. At 1-year follow-up, the aneurysm remains excluded and is decreasing in size. Type III endoleaks are a known complication of EVAR, requiring immediate treatment through their association with aneurysm enlargement and rupture. If an additional bifurcated graft cannot be used, aortomonoiliac conversion represents a feasible endovascular alternative treatment for type III endoleaks, other than conversion to open surgical repair. Therefore, aortomonoiliac converters with appropriate occluder devices should be readily available during deployment of bifurcated devices.

Does chronic oral anticoagulation with warfarin affect durability of endovascular aortic aneurysm exclusion in a midterm follow-up?

Purpose: To evaluate the effect of oral anticoagulation on durability of endovascular aortic aneurysm repair (EVAR). Methods: Retrospective review was conducted of 182 consecutive EVAR patients (169 men; mean age 75.3 years, range 53–89) between 1999 and 2003. Patients on warfarin anticoagulation (WA, n=21; International Normalized Ratio of 2 to 3) were compared against a control group (CG) with no postoperative anticoagulation (n=161). Death, aneurysm rupture, and reintervention were considered primary endpoints; endoleaks, endograft migration, and aneurysm remodeling were secondary endpoints. Results: Mean follow-up was 16.3±12.6 months. One-year mortality was 6.6% (9.5% WA versus 6.2% CG); overall mortality was 14.3% (p=0.414). No aneurysm rupture occurred. At 1, 2, and 3 years, respectively, cumulative reinterventions (20%/20%/20% WA versus 12%/15%/20% CG; p=0.633) and endoleak rates (25%/25%/25% WA versus 17%/22%/34% CG; p=0.649) were comparable. In both groups, most completion endoleaks resolved (42.9% WA versus 74.4% CG; p=0.474), but few de novo endoleaks did (0% WA versus 12.8% CG; p=0.538). Anticoagulation did not affect mean time to aneurysm sac shrinkage (1.3±0.3 WA versus 1.4±0.1 years CG; p=0.769). Conclusions: After EVAR, anticoagulation appears safe and does not significantly alter mortality, risk for rupture, or the incidence of reintervention. Early endoleaks appear more common in anticoagulated patients, but anticoagulation does not preclude spontaneous endoleak resolution nor does it increase late endoleak rates. Irrespective of the anticoagulation status, early but not late endoleaks usually sealed spontaneously. Observing type II endoleaks appears safe in the absence of aneurysm enlargement.

Single-institution experience of radioembolization with yttrium-90 microspheres for unresectable metastatic neuroendocrine liver tumors: Y-90 treat liver neuroendocrine tumor

The aim of this study was to assess the effectiveness of yttrium‐90 (90Y) microspheres for the treatment of unresectable metastatic liver neuroendocrine tumors (NET).

Segmental Arterial Mediolysis: A Case of Mistaken Hemorrhagic Pancreatitis and Review of the Literature

CONTEXT Segmental arterial mediolysis is an uncommon, non-atherosclerotic, non-inflammatory arteriopathy that involves areas of dissecting aneurysms and strictures that are caused by outer media lysis of the arterial wall from areas of medial necrosis of uncertain pathogenesis. It has a predilection for splanchnic arteries and often presents as abdominal pain or hemorrhage in late middle-aged and elderly patients. Diagnosis can be established by computed tomography angiography, magnetic resonance angiography, or angiogram by visualizing typical abnormalities, in addition to excluding other vasculitides. Histological confirmation is the gold standard but is not easily accessible and, as such, is not frequently performed. CASE REPORT Here we present an updated review of the literature and a case of segmental arterial mediolysis that presented with spontaneous intra-abdominal bleeding near the pancreas that was originally misdiagnosed as hemorrhagic pancreatitis. CONCLUSION Diagnosis is important because immunosuppressants for vasculitis can worsen the arteriopathy. Segmental arterial mediolysis can be self-limiting without treatment or may require urgent surgical or endovascular therapy for bleeding and carries a 50% mortality rate. Therefore, it should be included in the differential of causes of abdominal pain as well as in cases of unexplained abdominal hemorrhage.