Sylvain Favelier

Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage

Acute variceal hemorrhage, a life-threatening condition that requires a multidisciplinary approach for effective therapy, is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy, the presence of large esophageal varices with recent stigmata of bleeding, or fresh blood visible in the stomach with no other source of bleeding identified. Transfusion of blood products, pharmacological treatments and early endoscopic therapy are often effective; however, if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs, transjugular intrahepatic portosystemic shunt (TIPS) is recommended as rescue treatment. The TIPS represents a major advance in the treatment of complications of portal hypertension. Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS, which has a 90% to 100% success rate. However, TIPS is associated with a mortality of 30% to 50% in such a setting. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage, particularly as a rescue therapy following failure of endoscopic approaches.

Endovascular management of visceral artery aneurysms: When to watch, when to intervene?

Visceral artery aneurysms (VAA) include splanchnic and renal artery aneurysms. They represent a rare clinical entity, although their detection is rising due to an increased use of cross-sectional imaging. Rupture is the most devastating complication, and is associated with a high morbidity and mortality. In addition, increased percutaneous endovascular interventions have raised the incidence of iatrogenic visceral artery pseudoaneurysms (VAPAs). For this reason, elective repair is preferable in the appropriately chosen patient. Controversy still exists regarding their treatment. Over the past decade, there has been steady increase in the utilization of minimally invasive, non-operative interventions, for vascular aneurysmal disease. All VAAs and VAPAs can technically be fixed by endovascular techniques but that does not mean they should. These catheter-based techniques constitute an excellent approach in the elective setting. However, in the emergent setting it may carry a higher morbidity and mortality. The decision for intervention has to take into account the size and the natural history of the lesion, the risk of rupture, which is high during pregnancy, and the relative risk of surgical or radiological intervention. For splanchnic artery aneurysms, we should recognize that we are not, in reality, well informed about their natural history. For most asymptomatic aneurysms, expectant treatment is acceptable. For large, symptomatic or aneurysms with a high risk of rupture, endovascular treatment has become the first-line therapy. Treatment of VAPAs is always mandatory because of the high risk of rupture. We present our point of view on interventional radiology in the splanchnic arteries, focusing on what has been achieved and the remaining challenges.

Current role of multiparametric magnetic resonance imaging for prostate cancer.

Multiparametric magnetic resonance imaging (mp-MRI) has shown promising results in diagnosis, localization, risk stratification and staging of clinically significant prostate cancer, and targeting or guiding prostate biopsy. mp-MRI consists of T2-weighted imaging (T2WI) combined with several functional sequences including diffusion-weighted imaging (DWI), perfusion or dynamic contrast-enhanced imaging (DCEI) and spectroscopic imaging. Recently, mp-MRI has been used to assess prostate cancer aggressiveness and to identify anteriorly located tumors before and during active surveillance. Moreover, recent studies have reported that mp-MRI is a reliable imaging modality for detecting local recurrence after radical prostatectomy or external beam radiation therapy. Because assessment on mp-MRI can be subjective, use of the newly developed standardized reporting Prostate Imaging and Reporting Archiving Data System (PI-RADS) scoring system and education of specialist radiologists are essential for accurate interpretation. This review focuses on the current place of mp-MRI in prostate cancer and its evolving role in the management of prostate cancer.

C-arm dual-phase cone-beam CT: a revolutionary real-time imaging modality to assess drug-eluting beads TACE success in liver cancer patients

The advent of cone-beam computed tomography (CBCT) in the angiography suite has been revolutionary in interventional radiology. CBCT offers 3 dimensions (3D) diagnostic imaging in the interventional suite and can enhance minimally-invasive therapy beyond the limitations of 2D angiography alone. The role of CBCT has been recognized in transcatheter arterial chemoembolization (TACE) treatment of liver cancer especially with the recent introduction of dual-phase CBCT (DP-CBCT) for unresectable hepatocellular carcinoma (HCC) treatment. Loffroy and colleagues proposed the use of intraprocedural C-arm DP-CBCT immediately after TACE with doxorubicin-eluting beads to predict HCC tumor response at 1-month magnetic resonance (MR) imaging follow-up. They reported a significant relationship between tumor enhancement seen at DP-CBCT after TACE and objective MR imaging response at 1-month follow-up, suggesting that DP-CBCT can be used to predict tumor response after TACE. If confirmed in larger studies, this imaging modality may play a key role in the improvement of treatment planning, especially with regard to the need for repeat treatment. More important, a potential clinical implication of using intraprocedural DP-CBCT in these patients might be elimination of 1-month follow-up MR imaging.

Preoperative portal vein embolization in liver cancer: indications, techniques and outcomes

Postoperative liver failure is a severe complication of major hepatectomies, in particular in patients with a chronic underlying liver disease. Portal vein embolization (PVE) is an approach that is gaining increasing acceptance in the preoperative treatment of selected patients prior to major hepatic resection. Induction of selective hypertrophy of the non-diseased portion of the liver with PVE in patients with either primary or secondary hepatobiliary, malignancy with small estimated future liver remnants (FLR) may result in fewer complications and shorter hospital stays following resection. Additionally, PVE performed in patients initially considered unsuitable for resection due to lack of sufficient remaining normal parenchyma may add to the pool of candidates for surgical treatment. A thorough knowledge of hepatic segmentation and portal venous anatomy is essential before performing PVE. In addition, the indications and contraindications for PVE, the methods for assessing hepatic lobar hypertrophy, the means of determining optimal timing of resection, and the possible complications of PVE need to be fully understood before undertaking the procedure. Technique may vary among operators, but cyanoacrylate glue seems to be the best embolic agent with the highest expected rate of liver regeneration for PVE. The procedure is usually indicated when the remnant liver accounts for less than 25-40% of the total liver volume. Compensatory hypertrophy of the non-embolized segments is maximal during the first 2 weeks and persists, although to a lesser extent during approximately 6 weeks. Liver resection is performed 2 to 6 weeks after embolization. The goal of this article is to discuss the rationale, indications, techniques and outcomes of PVE before major hepatectomy.

Onyx for Embolization of Life-Threatening Hemoptysis: A Promising but Luxury Embolic Agent!

To the Editor,We read with great interest the article by Bommart et al.recently published in Cardiovascular and InterventionalRadiology, which reported the effectiveness of selectivearterial embolization using Onyx in patients with life-threateninghemoptysis [1]. We have several comments. Sinceits marketing, Onyx has been used for the endovasculartreatmentofintracranialaneurysmsandcerebralarteriovenousmalformations [2]. Until now, few studies have examined itsuse for peripheral applications. Onyx is a biocompatiblepolymer, which is an ethylene vinyl alcohol copolymer(EVOH) that is dissolved in an organic solvent—dimethyl-sulfoxide (DMSO). It becomes radiopaque by mixing withmicronizedtantalumpowder.WhenOnyx isinjectedintothevessels, the DMSO rapidly diffuses, and EVOH solidifies atthe tip of the catheter in a shape that conforms to the targetarea. The main advantageof Onyx is that, unlike other liquidembolic agents, such as cyanoacrylates, it does not adhere tothe endothelial wall and catheter tip, allowing better control ofdelivery over the embolization procedure [ 3].However, Onyx has some limitations that should beemphasized for use in interventional radiology, as previ-ously reported [4]. First, DMSO can cause severe vaso-spasm, which is most likely to occur in the early phase of theprocedure. This limitation may be avoided by using no morethan 0.2 ml of DMSO in the first minute of injection. Sec-ond, we find the duration of injection often time-consuming,depending of the amount of Onyx needed. This propensityis confirmed by the authors who used up to 3 ml of EVOHper patient and reported a total injection time of DMSO andOnyx up to45 minutesfor their procedure. Procedural timeoftenisofessencewhenusedonanemergencybasis,andtheuse of Onyx may lead to a loss of precious time comparedwith other faster embolic agents, such as glue, in such asetting. Third, DMSO is volatile and is excreted via respi-ration and sweat. This has a typical smell, which may last afew days. The patient should be warned to expect this. Last,Onyx is very expensive compared with other commonlyused embolic materials, and its cost increases with higherconcentrations of copolymer. Its high cost explains itsrestricted use in neuroradiology in most of the institutionsaroundtheworldandneedstobeborne inmindwhenusedinother organs. In conclusion, we think that Onyx is a verypromising, but too luxurious, embolic agent at this time forits use in peripheral indications.

Comparison of three different embolic materials for varicocele embolization: retrospective study of tolerance, radiation and recurrence rate

BACKGROUND To evaluate pain, radiation and recurrence rates in patients undergoing varicocele embolization with three different embolic materials. METHODS Retrospective study of 182 consecutive patients who underwent transcatheter retrograde varicocele embolization from July 2011 to May 2015 with glue (Glubran(®)2) (group 1, n=63), mechanical agents (coils and/or plugs) (group 2, n=53) or a sclerosing agent (polidocanol) (group 3, n=66). Patients were asked by telephone interview to evaluate pain during embolization and at 1, 7 and 30 days using a quantitative pain scale ranging from 0 to 10. Duration of scopy, kinetic energy released per unit mass (kerma) and dose area product (DAP) were assessed as radiation parameters during embolization procedures. Recurrence rates after treatment were also evaluated. Statistical analyses were performed using parametric and non-parametric tests. RESULTS Patients in the three study groups were comparable for age, clinical indication and embolization side. No difference was noted for significant pain (pain score ≥3) during embolization and at 1, 7 and 30 days after treatment. Discomfort (pain score <3) was more frequent in group 1 than in groups 2 and 3 at 7 days after the procedure (P=0.049). No difference in discomfort was noted during embolization or at 1 and 30 days. Duration of scopy was shorter (P<0.0001) and kerma was lower (P=0.0087) in group 1 than in groups 2 and 3. DAP was lower in group 1 than in group 2 (P=0.04) but no difference was noted between groups 1 and 3, and groups 2 and 3. The recurrence rate at a mean follow-up of 24.4 months (range, 2-53 months) was significantly lower in group 1 than in the two other groups (P=0.032). CONCLUSIONS The use of Glubran(®)2 acrylic glue for varicocele embolization is safe and leads to less radiation and lower recurrence rates than is the case for other embolic materials without any more significant pain.

Stent-assisted detachable coil embolization of a late-onset wide-necked anastomotic renal allograft artery pseudoaneurysm.

A 56-year-old woman presented with bearing down. She had received a renal allograft 3 years before admission, without any renal complaints after transplantation. There was no fever. The physical examination findings were unremarkable. Her blood pressure was 143/102 mm Hg with a pulse rate of 68 beats/min. Laboratory tests revealed a white blood cell count of 5 10/mm, hemoglobin was 12.8 g/dL, and the serum creatinine level was 1.3 mg/dL. A contrast-enhanced multislice helical computed tomography scan of the abdomen was performed. On the axial images (A), an ovoid mass with contrast filling at the arterial phase was seen in the right part of the pelvis (arrows). A selective iliac arteriogram (B) with three-dimensional reconstruction (C) confirmed the diagnosis of a large-necked pseudoaneurysm at the anastomotic site of the renal allograft artery. An uncovered, flexible, self-expanding endovascular stent was placed at the base of the pseudoaneurysm in the renal allograft and external iliac arteries. Superselective coil embolization of the pseudoaneurysm cavity was then performed through the stent meshes using the packing technique: detachable microcoils of various lengths and diameters (DCS, Standart or Soft Detach-18 Embolization Coil System, Cook, Bjaeverskov, Denmark) were deployed across the neck into the pseudoaneurysmal sac. A control angiography showed total exclusion of the pseudoaneurysm perfusion, with preserved patency of the renal allograft artery and unchanged delineation of the external iliac artery (D). The patient’s postprocedural course was uneventful, without flow into the aneurysm cavity by duplex ultrasound imaging.

Ethylene-vinyl alcohol copolymer (Onyx®) transarterial embolization for post-traumatic high-flow priapism

We report a case of high-flow priapism treated successfully with superselective embolization of the cavernous artery. A 16-year-old male developed post-traumatic priapism subsequent to a fall causing blunt perineal trauma. He presented to our hospital four days after trauma. Immediately after the injury, he suffered painless sustained incomplete erection. High-flow priapism was diagnosed on the basis of color doppler ultrasonography findings. Computed tomography scan showed a high-flow arterio-venous fistula with feeders from branches of the right internal iliac artery. Selective arteriography of the right internal pudendal artery demonstrated an arterio-cavernous fistula. The fistula was superselectively embolized with ethylene-vinyl alcohol copolymer (Onyx(®)) liquid agent and disappeared completely. Improvement was noted, with significant detumescence on table. This was later confirmed on repeat color Doppler imaging. At follow-up 3 months later, he had normal erectile function. To our knowledge, transarterial embolization of high-flow priapism with Onyx(®) has never been reported and appears to be a safe and effective treatment for managing patients with such a condition.

Successful Endovascular Treatment of a Large Azygos Vein Aneurysm With Stent-Graft Implantation

Fig 2. Fig 3. FE A T U R E 78-year-old woman came to our institution with A R T IC L E S Achest pain and received a diagnosis of pulmonary embolus and mediastinal mass of 6 5 cm by computed tomography of the chest. The result of magnetic resonance imaging was consistent with an azygos vein aneurysm (Fig 1). Anticoagulant therapy was given in the hope of preventing thrombus formation and additional pulmonary embolization. Phlebographic studies through a transfemoral approach were undertaken to confirm the diagnosis and, if feasible, to attempt endovascular treatment of the azygos vein aneurysm (Fig 2). Because of the favorable curvature of the azygos vein, exclusion of the