Wojciech Cwikiel

Selective palliative transcatheter embolization of bony metastases from renal cell carcinoma

To examine whether transcatheter embolization of bone metastases is an effective palliative option for patients with renal cell carcinoma (RCCa). A retrospective review of 21 patients presenting for palliative embolization of painful RCCa skeletal metastases was performed. Details regarding anatomic sites, procedural details, and embolization materials were collected. The clinical response of the patient was assessed from clinic visits and analgesic use. Thirty separate embolization procedures were used to treat 39 metastatic lesions (18 pelvic, 8 lower extremity, 3 upper extremity, 5 rib/chest wall, and 5 vertebral lesions). Five patients underwent more than one embolization. Polyvinyl alcohol was used in all 30 embolization procedures. Additional embolic materials were used in 16 of 30 procedures. A clinical response was achieved at 36 treated sites; the mean duration of the response was 5.5 months. Selective embolization of bony renal cell carcinoma metastases can provide effective palliation in a patient population which has limited therapeutic options.

Interventional Radiological Management of Prehepatic Obstruction the Splanchnic Venous System

PurposeThe purpose of this study was to retrospectively evaluate interventional radiological management of patients with symptomatic portal hypertension secondary to obstruction of splanchnic veins.Material and MethodsTwenty-four patients, 15 males and 9 females, 0.75 to 79 years old (mean, 36.4 years), with symptomatic portal hypertension, secondary to splanchnic venous obstruction, were treated by percutaneous methods. Causes and extent of splanchnic venous obstruction and methods are summarized following a retrospective evaluation.ResultsObstructions were localized to the main portal vein (n = 22), intrahepatic portal veins (n = 8), splenic vein (n = 4), and/or mesenteric veins (n = 4). Interventional treatment of 22 (92%) patients included recanalization (n = 19), pharmacological thrombolysis (n = 1), and mechanical thrombectomy (n = 5). Partial embolization of the spleen was done in five patients, in two of them as the only possible treatment. TIPS placement was necessary in 10 patients, while an existing occluded TIPS was revised in two patients. Transhepatic embolization of varices was performed in one patient, and transfemoral embolization of splenorenal shunt was performed in another. Thirty-day mortality was 13.6% (n=3). During the follow-up, ranging between 2 days and 58 months, revision was necessary in five patients. An immediate improvement of presenting symptoms was achieved in 20 patients (83%).ConclusionWe conclude that interventional procedures can be successfully performed in the majority of patients with obstruction of splanchnic veins, with subsequent improvement of symptoms. Treatment should be customized according to the site and nature of obstruction.

Palliation of Dysphagia in Patients with Malignant Esophageal Strictures: Comparison of results of radiotherapy, chemotherapy and esophageal stent treatment

Dysphagia is the earliest and the most common symptom of malignant disease in the esophagus. The palliative effects on dysphagia of radiotherapy (RT) and chemotherapy (CT) were evaluated retrospectively and compared with the effect of the self-expanding stent, evaluated in the prospective study. After completion of treatment, 78 (56%) of 140 patients treated with RT; 31 (49%) of 63 patients treated with CT; and 53 (81%) of 66 patients treated with stent insertion were free from dysphagia. Stent treatment has a good and prompt effect on dysphagia and can be recommended for palliation of patients with malignant esophageal strictures.

Deposition of platelets and neutrophils in porcine iliac arteries after angioplasty and Wallstent placement compared with angioplasty alone.

PurposeThis study was designed to compare deposition of111In-labeled platelets and neutrophils after balloon angioplasty (PTA) alone and PTA plus Wallstents.MethodsHistological investigation was performed with scanning electron microscopy (SEM). Fifty percent stenoses of both iliac arteries was created by resorbable ligature in 13 pigs. After 30 days, PTA was performed bilaterally with an additional stenting procedure done on one side. Autologous platelets were labeled and reinfused before the interventional procedure in six pigs, and labeled neutrophils were used in seven pigs. The deposition of the labeled cells was recorded itin vivo over 270 min using a scintillation camera. The results were correlated within vitro measurements.ResultsScanning revealed significant increase in platelet and neutrophil deposition at the site of the stent compared with the site where PTA alone was undertaken.In vitro measurements confirmed these differences. SEM demonstrated a fibrin lining on the stent surface and numerous adherent platelets. The adjacent arterial lumen was almost completely covered by fibrinous material. The PTA-alone site demonstrated denudation of endothelial cells and less fibrinous material, as well as platelets and leukocytes.ConclusionThe complex interaction in the response of the vessel wall and flowing blood involves both platelet and neutrophil adhesion. The self-expandable vascular endoprosthesis contributes to increased deposition of platelets and neutrophils as seen in this experimental model of nonatheromatous stenosis.

Insertion of Self-Expandable Nitinol Stents Without Previous Balloon Angioplasty Reduces Restenosis Compared with PTA Prior to Stenting

Purpose: To compare the development of intimal hyperplasia after deployment of a self-expanding nitinol stent with and without previous percutaneous transluminal balloon angioplasty (PTA), with the results after PTA alone. Methods: In nine healthy pigs, the iliac arteries were divided into three groups: group 1 (n = 6 arteries) was treated with PTA; group 2 n = 6) with insertion of self-expanding stents after PTA; and group 3 (n = 6) with stent insertion without previous PTA. After 8 weeks the vessels were examined with intravascular ultrasonography, histologic examination and morphometric analysis. Results: Although the injury index in group 1 (0.17 ± 0.57) was lower (p <0.05) than in group 2 (0.26 ± 0.06) and group 3 (0.26 ± 0.08), PTA-treated arteries showed significantly (p <0.05) reduced mean luminal gain (0.53 ± 2.84) compared with arteries treated with PTA prior to stenting (2.58 ± 1.38) and compared with stenting alone (4.65 ± 5.34). Stenting after PTA resulted in a higher (p <0.05) restenosis index (2.63 ± 1.06) compared with stenting without PTA (1.35 ± 0.59). Group 2 also had a significantly thicker intima p <0.05) and 83% and 74% higher intima/media ratio (p <0.05) compared with groups 1 and 3, respectively. Conclusion: Insertion of a self-expandable nitinol stent without previous PTA results in less intimal hyperplasia than if PTA is performed prior to stenting, suggesting that direct stenting can be used in angioplasty sessions with a favorable outcome.

Differences in Endothelial Injury After Balloon Angioplasty, Insertion of Balloon-Expanded Stents or Release of Self-Expanding Stents: An Electron Microscopic Experimental Study

AbstractPurpose: To evaluate which of six different commonly available stents inserted into an artery without percutaneous transluminal angioplasty (PTA) causes the least endothelial damage. To compare the degree of endothelial injury after insertion of such a stent with injury caused by PTA. Methods: Twelve healthy pigs were used in the experiments. In the first part of the study six different types of stents were inserted into the common iliac arteries. In the second part of the study self-expanding stents with large spaces between the wires were used. PTA was performed in the contralateral iliac artery. The pigs were killed immediately after the procedure and resected specimens examined after fixation, using scanning electron microscopy. Results: All procedures but two were accomplished successfully. More endothelium was preserved after insertion of self-expanding stents with large spaces between the wires, compared with stents with small spaces and balloon-expanded stents. After insertion of self-expanding stents with large spaces, 50.1% ± 16.4% of the endothelium remained intact, compared with only 5.6% ± 7.7% after PTA. The difference was statistically significant (p < 0.001). Conclusion: Self-expanding stents with large spaces between the wires, inserted without PTA, cause less damage to the endothelium than other stents and significantly less damage than PTA.

Stent-Graft Treatment of Patients with Acute Bleeding from Hepatic Artery Branches

PurposeTo present a new treatment option in patients with acute bleeding from the hepatic artery branches.MethodsFour male patients, 23–49 years old (mean 36.3 years), were treated for acute bleeding and subsequent transient hypotension. Bleeding episodes were secondary to hepatic artery pseudoaneurysms in two patients and surgical suture insufficiency in one patient. In the remaining patient, anastomotic leakage occurred following thrombolysis for hepatic artery thrombosis. Patients were treated by endovascular placement of one or two balloon-expandable stent-grafts, ranging from 17 to 28 mm in length.ResultsAll procedures were carried out without serious complications. All stent-grafts were deployed in the intended position with immediate cessation of bleeding and initial preservation of satisfactory blood flow.ConclusionsBleeding from the hepatic artery can be treated by insertion of balloon-expandable stent-grafts in the acute setting.

Percutaneous drainage of abscess in psoas compartment and epidural space. Case report and review of the literature.

The history of a patient with neurological deficit symptoms secondary to a spinal epidural abscess connected with psoas abscess and several fistulas on the buttocks is described. Etiology, diagnosis, and treatment are discussed. Percutaneous drainage of the spinal epidural abscess is suggested as an alternative to surgery.

Retrievability of Optional Inferior Vena Cava Filters with Caudal Migration and Caval Penetration: Report of Three Cases

The present report describes the safe retrieval of caudally migrated optional inferior vena cava (IVC) filters with significant IVC penetration. Three patients had optional IVC filters placed for deep vein thrombosis/pulmonary emboli and contraindications for anticoagulation. Subsequent imaging showed caudal migration and penetration of the filter legs through the IVC wall. All filters were removed without major complications. One patient experienced abdominal pain after filter removal, which required no treatment. Caudal migration of optional filters with IVC wall penetration by the filter legs may be more common with new filter designs in which the secondary and primary struts are separated.

Proliferative response in smooth muscle cells after angioplasty or insertion of self-expanding stents : An experimental study in pigs

Purpose: Evaluation of the early proliferative reaction of smooth muscle cells (SMC) in the media of the artery following percutaneous transluminal angioplasty (PTA), compared with the reaction on insertion of self-expandable stents. Material and Methods: In 6 healthy pigs, one iliac artery was overdilated with an 8-mm diameter angioplasty balloon. A self-expanding Nitinol stent, OD 8 mm, was inserted into the contralateral iliac artery without previous dilatation. The nuclei of the proliferating SMC in the media of the artery were labelled by intravenous administration of 5-bromo-2-deoxy-uridine and cells in S-phase counted 24 h after the procedure. Results: The mean number of proliferating nuclei of the SMC increased significantly more after PTA (p<0.05) than after the insertion of a stent. Conclusion: Early proliferative reaction of the SMC is more pronounced after PTA than after insertion of the self-expanding stent.