S. Herber

Response to transarterial chemoembolization as a biological selection criterion for liver transplantation in hepatocellular carcinoma

Criteria to select patients with hepatocellular carcinoma (HCC) for liver transplantation (LT) are based on tumor size and number of nodules rather than on tumor biology. The present study was undertaken to assess the role of transarterial chemoembolization (TACE) in selecting patients with tumors suitable for LT. Ninety‐six consecutive patients with HCC were treated by repeatedly performed TACE, 62 of them exceeding the Milan criteria. Patients meeting the Milan criteria were immediately listed, and patients beyond the listing criteria were listed upon downstaging of the tumor following successful TACE. Fifty patients were finally transplanted. Of these 50 patients, 34 exceeded the Milan criteria. In these 96 patients, overall 5‐year survival was 51.9%. However, it was 80.9% for patients undergoing LT and 0% for patients without transplantation (P < 0.0001). Tumor recurrence was primarily influenced by the control of the disease through continued TACE during the waiting time. Freedom from recurrence after 5 years was 94.5% in patients (n = 39) with progress‐free TACE during the waiting time. Tumor recurrence was significantly higher in patients (n = 11) who after initial response to TACE progressed again before LT (freedom from recurrence 35.4%; P = 0.0017). Progress‐free course of TACE during the waiting time (P = 0.006; risk ratio, 8.95), and a limited number of tumor nodules as assessed in the surgical specimen (P = 0.025; risk ratio, 0.116) proved to be significant predictors for freedom from recurrence in the multivariate analysis. Milan criteria were without impact on recurrence. Our data suggest that sustained response to TACE is a better selection criterion for LT than the initial assessment of tumor size or number. Liver Transpl 12:1260‐1267, 2006.

MRI Versus Helical CT for Endoleak Detection After Endovascular Aneurysm Repair

OBJECTIVE The objective of our study was to investigate the diagnostic accuracy of MRI and helical CT for endoleak detection. SUBJECTS AND METHODS Fifty-two patients underwent endovascular aneurysm repair with nitinol stent-grafts. Follow-up data sets included contrast-enhanced biphasic CT and MRI within 48 hr after the intervention; at 3, 6, and 12 months; and yearly thereafter. The endoleak size was categorized as < or = 3%, > 3% < or = 10%, > 10% < or = 30%, or > 30% of the maximum cross-sectional aneurysm area. A consensus interpretation of CT and MRI was defined as the standard of reference. RESULTS Of 252 data sets, 141 showed evidence for endoleaks. The incidence of types I, II, and III endoleaks and complex endoleaks was 3.2%, 40.1%, 8.7%, and 4.0%, respectively. The sensitivity for endoleak detection was 92.9%, 44.0%, 34.8%, and 38.3% for MRI, biphasic CT, uniphasic arterial CT, and uniphasic late CT, respectively. The corresponding negative predictive values were 91.7%, 58.4%, 54.7%, and 56.1%, respectively. The overall accuracy of endoleak detection and correct sizing was 95.2%, 58.3%, 55.6%, and 57.1% for MRI, biphasic CT, uniphasic arterial CT, and uniphasic late CT, respectively. CONCLUSION MRI is significantly superior to biphasic CT for endoleak detection and rating of endoleak size, followed by uniphasic late and uniphasic arterial CT scans. MRI shows a significant number of endoleaks in cases with negative CT findings and may help illuminate the phenomenon of endotension. Endoleak rates reported after endovascular aneurysm repair substantially depend on the imaging techniques used.

Long-Term Follow-Up After Endovascular Treatment of Acute Aortic Emergencies

PurposeTo investigate the long-term outcome and efficacy of emergency treatment of acute aortic diseases with endovascular stent-grafts.MethodsFrom September 1995 to April 2007, 37 patients (21 men, 16 women; age 53.9 ± 19.2 years, range 18–85 years) with acute complications of diseases of the descending thoracic aorta were treated by endovascular stent-grafts: traumatic aortic ruptures (n = 9), aortobronchial fistulas due to penetrating ulcer or hematothorax (n = 6), acute type B dissections with aortic wall hematoma, penetration, or ischemia (n = 13), and symptomatic aneurysm of the thoracic aorta (n = 9) with pain, penetration, or rupture. Diagnosis was confirmed by contrast-enhanced CT. Multiplanar reformations were used for measurement of the landing zones of the stent-grafts. Stent-grafts were inserted via femoral or iliac cut-down. Two procedures required aortofemoral bypass grafting prior to stent-grafting due to extensive arteriosclerotic stenosis of the iliac arteries. In this case the bypass graft was used for introduction of the stent-graft.ResultsA total of 46 stent-grafts were implanted: Vanguard/Stentor (n = 4), Talent (n = 31), and Valiant (n = 11). Stent-graft extension was necessary in 7 cases. In 3 cases primary graft extension was done during the initial procedure (in 1 case due to distal migration of the graft during stent release, in 2 cases due to the total length of the aortic aneurysm). In 4 cases secondary graft extensions were performed—for new aortic ulcers at the proximal stent struts (after 5 days) and distal to the graft (after 8 months) and recurrent aortobronchial fistulas 5 months and 9 years after the initial procedure—resulting in a total of 41 endovascular procedures. The 30-day mortality rate was 8% (3 of 37) and the overall follow-up was 29.9 ± 36.6 months (range 0–139 months). All patients with traumatic ruptures demonstrated an immediate sealing of bleeding. Patients with aortobronchial fistulas also demonstrated a satisfactory follow-up despite the necessity for reintervention and graft extension in 3 of 6 cases (50%). Two patients with type B dissection died due to mesenteric ischemia despite sufficient mesenteric blood flow being restored (but too late). Two suffered from neurologic complications, 1 from paraplegia and 1 from cerebral ischemia (probably embolic), 1 from penetrating ulcer, and 1 from persistent ischemia of the kidney. Five of 9 (56%) patients with symptomatic thoracic aneurysm demonstrated endoleaks during follow-up and there was an increase in the aneurysm in 1.ConclusionEndovascular treatment is safe and effective for emergency treatment of life-threatening acute thoracic aortic syndromes. Results are encouraging, particularly for traumatic aortic ruptures. However, regular follow-up is mandatory, particularly in the other pathologies, to identify late complications of the stent-graft and to perform appropriate additional corrections as required.

MR angiography of the pedal arteries with gadobenate dimeglumine, a contrast agent with increased relaxivity, and comparison with selective intraarterial DSA

To compare gadobenate dimeglumine (Gd‐BOPTA)–enhanced MR angiography (i.e., contrast‐enhanced MRA [CE‐MRA]) of the pedal vasculature with selective digital subtraction angiography (DSA) in patients with peripheral arterial occlusive disease (PAOD).

Transarterial Chemoembolization in Patients Not Eligible for Liver Transplantation: Single-Center Results

OBJECTIVE The purpose of this study was to evaluate the effectiveness of transarterial chemoembolization in the care of patients not eligible for liver transplantation. CONCLUSIONS Prognosis depends on local response, Okuda score, alpha-fetoprotein level, and tumor size and is independent of the presence of portal venous thrombosis.

Hemodynamic effects of monomeric nonionic contrast media in pulmonary angiography in chronic thromboembolic pulmonary hypertension.

OBJECTIVE The purpose of this study was to investigate the hemodynamic safety of the monomeric nonionic contrast agent iomeprol for selective pulmonary angiography in chronic thromboembolic pulmonary hypertension (CTPH), and to investigate the effect of periinterventional oxygen administration. SUBJECTS AND METHODS Selective pulmonary digital subtraction angiography was performed in 94 patients with CTPH using six bolus injections of iomeprol (posteroanterior, oblique, and lateral projections; both pulmonary arteries; iomeprol, 25 mL at 13 mL/s). Hemodynamics were obtained with Swan-Ganz catheters, and systolic pulmonary artery pressure (PAsyst) was classified into one of three groups: 30 mm Hg or less (control group), greater than 30 but less than or equal to 60 mm Hg (group 1, moderate pulmonary hypertension), and greater than 60 mm Hg (group 2, severe pulmonary hypertension). RESULTS At baseline, values for PAsyst were 21.4 +/- 2.3 (control group, n = 8), 49.8+/- 8.5 (group 1, n = 18), and 86.5 +/- 18.9 (group 2, n = 68) mm Hg (p < 0.001). Pulmonary vascular resistance indexes (PVRI) were 222 +/- 105 (control), 703 +/- 364 (group 1), and 1,582 +/- 562 (group 2) dyne x s x cm(-5) x m2 (p < 0.001). The mean cardiac indexes were 3.1 (control), 2.8 (group 1), and 2.3 (group 2) L/min/m2 (p < 0.05). Pulmonary capillary wedge pressure (PCw) indicated healthy left heart function. Periinterventional oxygen inhalation improved oxygen saturation in all groups and slightly reduced pulmonary artery pressure and heart rate. Online measurement of pulmonary artery pressure during contrast bolus injection for angiography showed only a minor increase, predominantly in severe pulmonary hypertension (triangle up [difference] PAsyst: 1.3 +/- 1.9 [control], 2.9 +/- 3.4 [group 1], and 3.8 +/- 4.5 [group 2] mm Hg [p < 0.001]). After completion of angiography, right atrial pressure (RAP) and PAsyst were moderately increased: triangle up RAP: 1.4 (control), 2.6 (group 1, p < 0.001), and 3.0 (group 2, p < 0.001) mm Hg; triangle up PAsyst: 3.2 (control), 7.7 (group 1, p < 0.01), and 8.5 (group 2) mm Hg (p < 0.001). PVRI was significantly higher in group 2 (triangle up PVRI: 188 dyne x s x cm(-5) x m2, p < 0.001). CONCLUSION Selective pulmonary angiography using iomeprol is safe without critical pressure peaks during selective contrast bolus injection or significant hemodynamic derangement in severe CTPH. Periinterventional oxygen inhalation improved pulmonary circulation.

Fluoroscopy-Guided Removal of Pull-Type Gastrostomy Tubes

These case reports demonstrate a radiologic interventional technique for removal of pull-type gastrostomy tubes. This approach proved to be a safe and efficient procedure in two patients. The procedure may be applicable in situations where endoscopic attempts fail.

MRT versus 64-Zeilen MDCT zur Diagnose des hepatozellulären Karzinoms

Ziele: Vergleich der diagnostischen Sensitivitat von kontrastverstarktem MDCT und MRT zur Diagnose des hepatozellularen Karzinoms. Methode: Im Rahmen einer prospektiven Studie wurden 28 Patienten (25Manner, 3 Frauen, Alter 67±10,79) mit bioptisch gesichertem HCC jeweils mit einem triphasischen, kontrastverstarkten CT-Protokoll (64-Zeilen MDCT, Kollimation 0,6mm, Schichtdicke 1mm, native, arterielle und portal-venose Phase, 120ml Imeron, 4ml/s, bolus trigger) sowie einem kontrastverstarkten, dynamischen MRT-Protokoll (T1fs fl2d TE/TR2,72/129ms, T2tse TE/TR102/4000ms, 4 dynamische, kontrastmittelverstarkte Phasen 20s, 45s, 90s und 5min nach Kontrastmittelgabe, T1fs fl3d TE/TR1,56/4,6, 0,1mmol/kgKG Gadolinium-DTPA, Schichtdicke 4mm) untersucht. Die Ergebnisse beider Untersuchungen wurden unabhangig voneinander im Hinblick auf Anzahl, Grose und Lage der Tumorknoten ausgewertet. Als Referenz diente die Synopsis der Ergebnisse beider Untersuchungen, wobei jeder Herd als positiv bewertet wurde, der mit wenigstens einer der beiden Methoden als hypervaskularisiert darstellbar war. Ergebnis: Die Befundsynopsis zeigte insgesamt 162 Tumore. Die MRT entdeckte signifikant mehr Tumorknoten als die MDCT (159 versus 123, p20mm. Die MRT verfehlte 2 Knoten ≤10mm und 1 Knoten ≤15mm. Im Vergleich zur MDCT stellten sich die Tumore mittels MRT signifikant groser dar (29,2±25,1mm (5–140mm) versus 24,1±22,7mm (4–129mm), p<0,01). Bei 2 Patienten, bei denen die CT-Darstellung einen unauffalligen Leberlappen zeigte, konnte die MRT hier zusatzliche Tumormanifestationen (n=6) diagnostizieren, welche die Stratifizierung zur Resektion, Transplantation oder interventionellen Therapie beeinflusst hatten. Schlussfolgerung: Die MRT ist der MDCT bei Diagnose und Staging des HCC uberlegen. Die Stratifizierung von HCC Patienten zur operativen oder interventionellen Behandlung sollte auf einer dedizierten MRT Bildgebung beruhen. Korrespondierender Autor: Kloeckner R Universitatsklinik Mainz, Abteilung fur Diagnostische und Interventionelle Radiologie, Langenbeckstr. 1, 55131 Mainz E-Mail: Roman.Kloeckner@web.de

Endovaskuläre Aneurysmatherapie – Langzeitergebnisse nach 7 Jahren

ZusammenfassungHintergrund: Seit der Entwicklung von Stentprothesen und deren kommerzieller Verfügbarkeit 1994 gibt es eine neue, sich zunehmend verbreitende endovaskuläre Methode der Aneurysmatherapie. Patienten und Methodik: In 7 Jahren, von 1994–2001, erhielten 115 Patienten mit Bauchaortenaneurysma (AAA) an unserer Institution gemeinsam durch Radiologen und Gefäßchirurgen eine endovaskuläre Aneurysmaausschaltung mit Stentor®-, Vanguard®- und Talent®-Stentprothesen. Es wurden überwiegend modulare Bifurkationsprothesen in Lokalanästhesie und nach präoperativer Embolisierung der Arteria mesenterica inferior und der Lumbalarterien eingesetzt. Ergebnisse: Stentprothesen der ersten und zweiten Generation weisen eine sehr hohe Spätkomplikationsrate von insgesamt 52% auf. Bei 30% mussten radiologisch-interventionelle oder chirurgische Maßnahmen zur Erhaltung des Ziels, der Aneurysmaausschaltung getroffen werden. In weiteren 22% besteht in der Nachbeobachtung ein Endoleak oder eine Migration von Prothesen, durch die ein Endoleak droht. Stentprothesen der dritten Generation haben eine niedrigere Spätkomplikationsrate mit Interventionen in 12,2% und Endoleaks sowie Konfigurationsänderungen der Stentprothesen in 18,3%, entsprechend einer Gesamtkomplikationsrate von 30,5%. Schlussfolgerung: Angesichts der hohen Kosten, der ständigen Kontrollbedürftigkeit wegen der ungewissen Lebensdauer der Implantate und der damit verbundenen hohen Spätkomplikationsrate ist die endovaskuläre Methode der konventionellen Operation noch nicht als ebenbürtig anzusehen und sollte individuell indiziert werden.AbstractBackground: Stentgrafts for endovascular treatment of abdominal aortic aneurysms (AAA) have been commercially available since 1994, with now large numbers of implantations all over the world. Patients and Methods: From 1994–2001, 115 patients were treated with Stentor®, Vanguard® and Talent® stentgrafts in our institution. Results: Late complications of the first- and second-generation stentgrafts as radiologic or surgical interventions to maintain complete exclusion of the aneurysm amounted to 30% with an additional 22% for observed endoleaks and configuration changes of the stentgraft. Third-generation stentgrafts had a lower complication rate of 12.2% for interventions and 18.3% for late endoleaks and graft changes. Conclusion: High costs of the devices, a pretty high late complication rate, and the uncertain maintenance of stentgraft function to prevent aneurysm rupture currently limit the widespread application of this new technology, leaving conventional aneurysmectomy the standard for aneurysm treatment and reserving the endovascular method for selected patients.