Sergio Savastano

Transcatheter arterial chemoembolization for hepatocellular carcinoma in patients with Child's grade A or B cirrhosis : A multivariate analysis of prognostic factors

We evaluated factors affecting long-term survival after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) complicating cirrhosis. One hundred eighty-two patients with Childs class A or B cirrhosis and an HCC, not amenable to surgery or percutaneous ethanol injection, underwent 346 TACEs (mean 1.9) with epirubicin, iodized oil, and gelatin sponge. Many prognostic factors were subjected to univariate analysis and thereafter, when significant, to the Coxs hazard proportional model. Finally, the significant indices in the Coxs model were used to estimate the accuracy of the probability of death with computation of the area under the receiving operative characteristic (ROC) curve. The cumulative survival rates at 1, 2, 3, and 5 years were 0.83, 0.52, 0.40, and 0.16, respectively. According to Coxs model, the factors associated with significantly worse survival were the presence of ascites (p = 0.0027), elevated bilirubin levels (p = 0.0163), elevated alpha-fetoprotein (alphaFP) values (p = 0.0067), a tumor greater than 5 cm in diameter (p = 0.0001), and the absence of a tumor capsule-like rim (p = 0.0278). According to these parameters, the accuracy of the probability of death estimated with ROC analysis was 0.63. Minor and major complications occurred in 82 patients (45%) and caused death in 2 patients. Long-term prognosis after TACE for HCCs in patients with Childs class A or B cirrhosis depends on the presence of ascites, the bilirubin level, the alphaFP value, the diameter of the tumor, and the presence of a tumor capsule-like rim. However, when considered altogether, these variables are poor predictors to evaluate survival, and other factors should be investigated to identify subjects more responsive to TACE. Complications occur in a high percentage of patients, but they do not affect long-term prognosis.

Arterial complications of pancreatitis : diagnostic and therapeutic role of radiology

Hemorrhage from pseudoaneurysm complicating pancreatitis is an infrequent but very severe condition. In most cases, acute, massive gastrointestinal bleeding is typical at onset, and prognosis of these cases is usually poor. Nine cases of arterial lesions secondary to pancreatic inflammation are presented, eight related to chronic pancreatitis and one to acute postoperative pancreatitis. Five patients were evaluated during emergency episodes because of acutely gastrointestinal bleeding (four cases), and pseudocyst acute bleeding (one case). Four patients were selectively evaluated: three had a history of self-limiting gastrointestinal hemorrhage, whereas one had experienced no episodes of gastrointestinal hemorrhage. Angiography was performed in all cases and was always diagnostic, even in the two cases of very small pseudoaneurysms. Transcatheter arterial blockade was attempted in five patients and failed to control the hemorrhage in one acutely bleeding patient because of irreversible shock. Two cases of pancreatic hemorrhage not related to a pseudocyst were effectively and permanently treated by embolization. A case of a pseudoaneurysm associated with a pseudocyst required surgery in addition to embolization for a definitive treatment. Nevertheless, when a pseudoaneurysm or a pseudocyst hemorrhages acutely, transcatheter arterial blockade can control the hemorrhage and improve the hemodynamic status of the patient before surgery.

Renal Aneurysm and Arteriovenous Fistula: Management with Transcatheter Embolization

Embolization was performed in six patients with renal artery aneurysms (n = 2) and arteriovenous fistulas (AVF) (n = 5). The aneurysms were observed in one patient with fibromuscular dysplasia and in another with Ehlers-Danlos syndrome. All the AVFs were intraparenchymal and secondary to iatrogenic trauma. Elective embolization was performed in five patients with good clinical results at follow-up between 1 and 9 years. Because of rupture of the aneurysm emergency embolization was attempted without success in the patient with Ehlers-Danlos syndrome, and nephrectomy was carried out. A postembolization syndrome complicated three procedures in which Gelfoam and polyvinyl alcohol were used; in two of these cases unexpected reflux of the particulate material occurred, resulting in limited undesired ablation of the ipsilateral renal parenchyma. Embolization is the most reliable and effective treatment for intrarenal vascular abnormalities since it minimizes the parenchymal damage.

Embolization of ruptured aneurysm of the pancreaticoduodenal artery secondary to long-standing stenosis of the celiac axis

Long-standing stenosis of the celiac axis is a rare cause of aneurysm of the inferior pancreaticoduodenal artery, which serves as a collateral pathway; the etiology is believed to be due to turbulence from increased blood flow. The authors describe 2 cases of such aneurysm, which ruptured in the retroperitoneum and were treated with transcatheter embolization.

A Renin-Secreting Tumour with Severe Hypertension and Cardiova-Scular Disease: A Diagnostic and Therapeutic Challenge

A case of renin-secreting juxtaglomerular cell tumour which presented with a severe hypertensive crisis and did not respond to angiotensin converting enzyme inhibitors but was promptly controlled by intravenous labetalol is reported. The diagnostic difficulties which can be encountered in such cases and the usefulness of the different diagnostic tests, including renal vein renin measurement, are discussed.

Cerebral Ischemia Due to Congenital Malformations of Brachiocephalic Arteries—Case Reports

Seven cases of congenital anomalies of brachiocephalic arteries are presented ; malformations include unilateral absence of the internal carotid artery (ICA) (n = 3), unilateral hypoplasia of the ICA (n = 2), agenesis of the innominate artery (n =1), and atresia of the subclavian artery (n =1). All patients but 1 exhibited symptoms of cerebrovascular insufficiency at the time of radiologic investigation; they were not affected by other cardiovascular malformations, except right aortic arch in 2 cases and left cervical arch in another case. Two patients suffering from congenital subclavian steal syndrome underwent surgery to correct the vascular malformations. Embryogenesis and natural history of such malformations are briefly discussed.

A right common iliac artery pseudoaneurysm with an iliac-caval arteriovenous fistula: a rare complication of the Recovery vena cava filter.

On September 2008 a 49-year-old man complaining ofback pain was admitted to our hospital. The patient wasnormotensive and suffered from an inoperable glioblas-toma of the right temporal lobe diagnosed by stereotaxicbiopsy on July 2007 and treated with radiochemotherapy.On June 2008 he complained of proximal deep veinthrombosis, and as anticoagulation was contraindicated, aninferior vena cava (IVC) filter was percutaneouslyimplanted at another hospital; no other clinical or radio-logical data on this procedure were available to us.At the time of the present hospitalization, a diagnosis ofspondylodiscitis of the lower dorsal spine complicated byperivertebral abscesses was made with a contrast-enhancedMRI of the spine and a contrast-enhanced whole-body CT.For both diagnostic imaging procedures contrast agentswere injected through a surgically isolated dorsal vein ofthe left foot, no other superficial veins being accessible.Abdominal CT scans identified a Recovery filter locatedin the lower tract of the IVC and a saccular aneurysmdeveloping along the lateral aspect of the aortic bifurcation;the aneurysmal neck was located at the origin of the rightcommon iliac artery. The filter penetrated the IVC wall andone of its legs was located within the aneurysm (Fig. 1A, B).The IVC was compressed and narrowed by the aneurysm;more proximally, at the level of the left renal vein, the longaxis and the short axis of the IVC measured 21 and 10 mm,respectively. Diagnosis of an iatrogenic pseudoaneurysm atthe origin of the right common iliac artery was made on thebasis of CT scans.AnabdominalaortographyconfirmedtheCTfindingsandalso demonstrated a high-flow arteriovenous fistula (Fig. 2).Endovascular repair with bilateral kissing aorto-iliac cov-eredstentswasattempted.Graftingoftherightcommoniliacartery required two stents, as the first one was inadvertentlyadvanced into the lumbar aorta; the left common iliac arterystent was deployed toforce the contralateral stentagainst theaneurysmal neck. Since endovascular stent-grafting failed,embolizationofthepseudoaneurysmwasperformedbothviathe right femoral artery and with a venous retrogradeapproach. Unfortunately the postprocedural abdominal aor-tography demonstrated persistent patency of both the pseu-doaneurysm and the arteriovenous fistula (Fig. 3).Spondylodiscitis was successfully treated with antibioticsand with percutaneous drainage. After the patient’s dis-charge serial sonographic investigations did not show anyincrease in size of the pseudoaneurysm. The patient died onApril 2009 from progression of the cerebral disease.Percutaneous implantation of an IVC filter is an effec-tive treatment for preventing pulmonary embolisms, butalthough the complication rate is low, long-term sideeffects remain an open question [1, 2]. Retrievable filtersare nowadays thoroughly preferred, as they can beremoved, even long after implantation, or can be alterna-tively left in situ as a permanent device [1, 3].Some types of filters anchor to the IVC wall withhooked legs. In up to 25% of cases these filters penetratethe vena cava wall and legs are found in the pericavalretroperitoneal tissue [1]; the small diameter of the IVCseems to facilitate filter penetration [1, 4]. This occurrenceis not considered clinically relevant in most cases [1, 5, 6],but it can theoretically preclude the retrieval of the filteritself. The legs of the filter can also penetrate contiguous

Palliative Treatment of Hepatocellular Carcinoma with Transcatheter Arterial Embolization

Thirty-three consecutive patients with previously untreated hepatocellular carcinoma (HCC) and 6 patients with recurrent HCC were treated with transcatheter arterial embolization (TAE). The patients were not eligible for surgical resection or percutaneous ethanol injection. TAE was performed with Lipiodol Ultra-Fluid, epidoxorubicin and Gelfoam, with a mean of 1.7 treatments per patient. CT was performed 15 days after TAE. The mean cumulative survival was 14.2 months in patients with previously untreated HCC. The survival of patients stages Okuda I and II did not differ significantly (p > 0.05); tumor size did not affect survival (p > 0.05). Two patients with recurrent HCC died 7.0 and 9.3 months after the diagnosis of tumor recurrence; the remaining 4 patients are still alive with a maximum follow-up of 22.5 months from the diagnosis of HCC recurrence. Ten complications occurred in 8 patients, and were controlled by medical therapy. Eleven patients died during the study; no death was related to TAE. The series was not randomized, but comparison with the natural history of HCC suggests that TAE is effective as palliative treatment of advanced or recurrent HCC.

Vascular Parenchymal Sources of Upper Gastrointestinal Bleeding

Fourteen cases of upper gastrointestinal bleeding (UGIB) were reviewed: 6 (group A) were caused by pancreatitis, 3 (group B) by hemobilia, and 5 (group C) by rupture of esophageal varices due to arterioportal shunts. Elective endoscopy carried out in 7 patients in groups A and B was negative; in 2 actively bleeding patients in group A emergency endoscopy could not detect the source of hemorrhage. Endoscopy was carried out in 4 patients in group C for diagnosis and sclerosis, but severe hemorrhage recurred in spite of treatment. Ultrasonography (US) and computed tomography (CT) were carried out prior to angiography in 5 and 4 patients, respectively, and always suggested a parenchymal lesion. All patients underwent angiography. Transcatheter control of the hemorrhage was attempted as an emergency in 2 patients (as a presurgical step in one); elective embolization was the treatment of choice for 8 patients, with good results in 6. This study suggests the usefulness of US and CT both in the detection of parenchymal lesions causing UGIB not clarified by endoscopy, and in the selection of patients for angiographic treatment.

Transcatheter arterial embolisation versus no treatment in cirrhotic patients with hepatocellular carcinoma: a retrospective comparative study

To evaluate the effectiveness of transcatheter arterial embolisation (TAE) as a treatment of hepatocellular carcinoma (HCC) complicating cirrhosis, the survival of 27 untreated patients and 57 TAE-treated patients was compared. Clinical features, laboratory findings and tumour stage were comparable in the two groups of patients. TAE was undertaken with epirubicin, iodised oil and gelatine esponge. Cumulative survival rates at 6, 12, 24 and 36 months were 0.59, 0.47, 0.17 and 0.08 in the untreated group, and 0.87, 0.75, 0.40 and 0.19 in the TAE-treated group (P = 0.01). Patients with Childs grade B cirrhosis and patients with tumour smaller than 25% of the liver volume responded better to TAE. Twenty-four untreated patients and 25 TAE-treated patients died during the follow-up. The complication rate and mortality rate of TAE were 28% and 1.7% respectively. TAE prolongs the survival of patients with HCC complicating cirrhosis; prognosis depends on tumour stage and the degree of hepatic function impairment.