Shaoqin Li

Initial and Middle-term Results of Treatment for Symptomatic Spontaneous Isolated Dissection of Superior Mesenteric Artery

OBJECTIVE Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is extremely rare. Various treatment options are currently available, including conservative treatment, endovascular stenting (ES) and surgical repair. Herein, we present our experience in the treatment of symptomatic SIDSMA. METHODS A retrospective study was conducted on 17 consecutive patients with symptomatic SIDSMA from May 2002 to May 2012. Conservative treatment consisted of strict blood-pressure control, bowel rest, nasogastric suction, intravenous fluid therapy and nutritional support as required; fasting was released on resolution of abdominal pain, and fluid food was given first; then, diet was resumed after complete resolution of abdominal pain. The decision to intervene was based on patient symptoms and signs, as well as the morphological characteristics of SMA dissection on computed tomography (CT) angiography. Self-expandable stents were placed via the common femoral artery approach. ES was indicated in patients with severe compression of the true lumen or dissecting aneurysm likely to rupture. RESULTS All patients had acute-onset abdominal pain. Treatment included conservative treatment with the use of anticoagulation in five and without in nine patients, respectively. Three patients with severe compression of the true lumen or large dissecting aneurysm underwent ES as a primary treatment. ES was performed in two patients in whom initial conservative treatment failed. Patients who underwent ES were maintained on anti-platelet therapy for 3 months postoperatively. The median follow-up time was 24 months (range, 2-72 months). No complications were associated with the SIDSMA or ES. The patency of stents was demonstrated on follow-up CT scans up to 8.5 months (range, 4-38 months). CONCLUSIONS Conservative treatment without anticoagulation can be applied successfully to the patients with symptomatic SIDSMA. Our strategy of restricting ES for these patients who have compression of the true lumen or dissecting aneurysm likely to rupture (and for those with failed conservative treatment) was successful.

Early Endovascular Treatment of Superior Mesenteric Occlusion Secondary to Thromboemboli

OBJECTIVE To evaluate our early experience with endovascular revascularization in patients with acute thromboembolic occlusion of the superior mesenteric artery (SMA). METHODS A retrospective review was conducted of all patients who underwent endovascular revascularization for acute thromboembolic SMA occlusion from May 2005 to May 2012. Endovascular revascularization was performed using aspiration, intra-arterial thrombolysis, and adjunctive stent-placement techniques. Laparotomy was performed if the patient developed clinical signs of advanced bowel ischemia after endovascular procedure. RESULTS Twenty-one patients underwent endovascular revascularization for acute thromboembolic SMA occlusion. All presented with acute-onset abdominal pain. Three patients had rebound tenderness before the procedure. Computed tomography angiography revealed complete occlusion in seven cases and incomplete occlusion in 14 cases, with no evidence of free gas or bowel necrosis. The median duration from onset of symptoms to revascularization was 8.7 ± 4.1 hours (range, 2-18 hours). Completely successful endovascular revascularization occurred in six cases (aspiration alone, 3 cases; combined aspiration and urokinase, 3 cases); partial success was achieved in 15 cases (aspiration alone, 4 cases; combined aspiration and urokinase, 10 cases; and combined aspiration, urokinase, and stent placement, 1 case). Laparotomy was required in five patients, all of whom had SMA main trunk complete occlusion and required small bowel resection. The 30-day mortality for all patients was 9.5%. During a median follow-up of 26 months, 15 patients remained asymptomatic, three patients reported occasional abdominal pain, and one patient had temporary short-bowel syndrome. CONCLUSIONS Percutaneous revascularization is a promising alternative to surgery for acute SMA occlusion in selected patients who have no signs of advanced bowel ischemia. Early diagnosis followed by prompt endovascular intervention with close postprocedural monitoring is key. Laparotomy is indicated in patients who develop new or worsening signs of peritonism after endovascular procedure, particularly in those who had complete occlusion of the main trunk of the SMA.

The incidence and outcome of major complication following conventional TAE/TACE for hepatocellular carcinoma

Abstract To investigate the incidence and outcome of major complication following conventional transarterial embolization/chemoembolization (TAE/TACE) therapy for hepatocellular carcinoma (HCC). From May 2010 to May 2016, all patients with major complication following conventional TAE/TACE for HCC were included. Major complication was defined as admission to a hospital for therapy, an unplanned increase in the level of care, prolonged hospitalization, permanent adverse sequelae, or death after conventional TAE/TACE therapy by Society of Interventional Radiology. During the study period, a total of 2863 TAE/TACE procedures were performed among 1120 patients, and a total of 24 patients (21 male and 3 female) developed major complication with the incidence of 2.1% (24/1120) per patient and 0.84% (24/2863) per TAE/TACE procedure. The major complications were liver rupture (n = 6), liver abscess (n = 5), femoral artery pseudoaneurysm (n = 3), cholecystitis (n = 2), biloma (n = 2), pulmonary embolism (n = 2), and 1 each of the following: cerebral lipiodol embolism, tumor lysis syndrome, partial intestinal obstruction, gallbladder perforation. The mean interval from last TAE/TACE procedure to the diagnosis of major complication was 11.1 ± 7.7 days. The treatments of the complications were conservative treatment (n = 12), conservative treatment plus percutaneous drainage (n = 3), ultrasound-guided thrombin injection (n = 3), conservative treatment plus TAE (n = 2), and conservative treatment plus surgery (n = 2). Of the 24 patients, 20 patients were recovered, and remaining 4 patients were died of major complications; therefore, the mortality rate of major complication was 16.7% (4/24). Major complication following conventional TAE/TACE therapy is uncommon; the outcomes are benign of most major complications, but some are mortality.

A systematic review of yttrium-90 radioembolization for unresectable liver metastases of melanoma

PURPOSE To assess the effectiveness of yttrium-90 (90Y) radioembolization in the treatment of unresectable liver metastases of melanoma. METHODS PubMed and EMBASE were systemically searched for all English language studies related to 90Y radioembolization for unresectable liver metastases of melanoma, including clinical trials, observational studies, and abstracts from conferences, published between January 1991 and March 2016. RESULTS A total of 12 reports (7 observational studies and 5 abstracts from conferences) involving 255 patients were included in the analysis. The primary sites of melanoma were cutaneous (n=22; 8.6%), ocular (n=197; 77.3%), rectal (n=3; 1.2%), and unknown (n=33; 12.9%). The median disease control rate at 3 months was 73.6% (range, 58.3%-88.9%). Among the 207 patients for whom tumor response at 3 months was reported, complete response was seen in 1.0% (2/207), partial response was seen in 19.3% (40/207), stable disease was seen in 46.9% (97/207), and progressive disease was seen in 32.9% (68/207). The median survival was 10 months (range, 7-13.4 months), and the median 1-year survival rate was 34.6% (range, 23%-80%). Complications of 90Y radioembolization were reported in 13 cases. The most common side effects were fatigue (median, 36.1%), abdominal pain (median, 17.8%), and nausea (median, 15.0%). CONCLUSIONS 90Y radioembolization is a promising alternative therapy for the treatment of unresectable liver metastases of melanoma, with encouraging effects on disease control and survival. Some complications can occur, and side effects are frequent but mild.

Aspiration thrombectomy using a large-size catheter for acute lower extremity deep vein thrombosis.

OBJECTIVE This study retrospectively evaluated the safety and efficacy of aspiration thrombectomy using a large-size catheter for acute lower extremity deep vein thrombosis (DVT). METHODS All patients who underwent aspiration thrombectomy using 9F or 10F catheters for acute lower extremity DVT were included and analyzed. Aspiration thrombectomy was performed in all patients. Additional intravenous thrombolysis was performed in patients with residual thrombus, and stent placement was performed in patients with iliac vein compression syndrome. RESULTS From October 2010 to September 2013, the study enrolled 68 patients (37 women, 31 men) with a mean age of 61.7 ± 7.8 years (range, 24-86 years). All patients presented with lower extremity swelling and pain, and the duration of symptoms ranged from 1 to 14 days. The DVTs involved popliteal-iliofemoral veins in 29 patients, iliofemoral veins in 31, and iliac veins in 8. Endovascular procedures were performed in all patients with a technical success rate of 100%. Aspiration alone was effective in 47 patients, and additional thrombolysis was required in the remaining 21. An additional stent was required in 32 patients. Significant improvement in presenting symptoms was achieved in all patients after the procedures, with a clinical success rate of 100%. There were no procedure-related or thrombolysis-related complications. The Villalta scores were <5 in 60 patients and from 5 to 9 in four patients. Primary and secondary patency rates were 89.1% (57 of 64) and 96.9% (62 of 64) at 1 year of follow-up. CONCLUSIONS Aspiration thrombectomy using a large-size catheter is safe and effective for acute lower extremity DVT.

Treatment of Spontaneous Isolated Superior Mesenteric Artery Dissection

1. Tomita K, Obara H, Sekimoto Y, Matsubara K, Watada S, Fujimura N, et al. Evolution of computed tomographic characteristics of spontaneous isolated superior mesenteric artery dissection during conservative management. Circ J 2016; 80: 1452 – 1459. 2. Clair DG, Beach JM. Mesenteric ischemia. N Engl J Med 2016; 374: 959 – 968. 3. Garrett HE Jr. Options for treatment of spontaneous mesenteric artery dissection. J Vasc Surg 2014; 59: 1433 – 1439. 4. Han Y, Cho YP, Ko GY, Seo DW, Kim MJ, Kwon H, et al. Clinical outcomes of anticoagulation therapy in patients with symptomatic spontaneous isolated dissection of the superior mesenteric artery. Medicine (Baltimore) 2016; 95: e3480, doi:10.1097/MD.0000000000003480. 5. Jia ZZ, Zhao JW, Tian F, Li SQ, Wang K, Wang Y, et al. Initial and middle-term results of treatment for symptomatic spontaneous isolated dissection of superior mesenteric artery. Eur J Vasc Endovasc Surg 2013; 45: 502 – 508.

Regarding “Amplatzer Vascular Plugs Versus Coils for Embolization of Pulmonary Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia”

To the Editor, We read with great interest the recent article by Tau et al. [1]. The authors concluded that the use of Amplatzer plugs for the embolization of pulmonary arteriovenous malformations (PAVMs) in patients with hemorrhagic telangiectasia is associated with a significantly lower rate of recanalization of feeding vessels than coils. However, we would like to elaborate on the patient selection of this study. Firstly, there were a total of 36 patients who received embolization of PAVMs; however, only 16 patients were available for imaging scans and were included in this study. The authors did not clarify why the other 20 patients were not available for imaging scans and how many of them used coils or Amplatzer plugs for the embolization of PAVMs. Secondly, 93.4 % (15/16) patients were proved recanalization of feeding vessels by intrapulmonary angiograms; however, the authors did not explain why those patients underwent intrapulmonary angiograms. We are interested in knowing why those patients underwent intrapulmonary angiograms but CT arteriography. All of which may bias the results.

Regarding ''The Value of Rotational Venography Versus Anterior-Posterior Venography in 100 Consecutive IVC Filter Retrievals''

To the Editor, We read with great interest the recent article by Kiefer et al. [1]. They raised an important issue on the value of rotational venography versus anterior–posterior (AP) venography. The authors concluded rotational venograms allow for more accurate detection of tip-embedded IVC filters compared to AP views alone. However, the authors did not define the IVC filter tip-embedded, and we would like to elaborate on the IVC filter tip-embedded. It is known that the tilt was defined as the angulation between the long axes of the filter and the vena cava [2], and the tip-embedded was defined as filter tip adherent to the vessel wall as a result of endothelialization and fibrin formation [3], and there is a close relationship between of them. The diagnosis of tip-embedded dependent on CT scan, and the venography cannot accurate diagnosis of tipembedded. The tip-embedded was dependent on filter tilt and filter dwell time (usually more than 15 days). However, the shortest dwell time of IVC filter in this study was 11 days, and we do not think this short dwelling time will made the tip-embedded. Although most of the patients in this study were proved with tip-embedded, we believe the conclusion will be more appropriately be ‘‘rotational venograms allow for more accurate detection of IVC filters tilt compared to AP views alone’’ for many option filters’ dwell time are less than half month, such as OptEase filter and Aegisy filter, and most patients in such condition will be filter tilt other than tip-embedded.

Comment on Management of Spontaneous Isolated Visceral Artery Dissection

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