Xavier Montañá

Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial

BACKGROUND There is no standard treatment for unresectable hepatocellular carcinoma. Arterial embolisation is widely used, but evidence of survival benefits is lacking. METHODS We did a randomised controlled trial in patients with unresectable hepatocellular carcinoma not suitable for curative treatment, of Child-Pugh class A or B and Okuda stage I or II, to assess the survival benefits of regularly repeated arterial embolisation (gelatin sponge) or chemoembolisation (gelatin sponge plus doxorubicin) compared with conservative treatment. 903 patients were assessed, and 112 (12%) patients were finally included in the study. The primary endpoint was survival. Analyses were by intention to treat. FINDINGS The trial was stopped when the ninth sequential inspection showed that chemoembolisation had survival benefits compared with conservative treatment (hazard ratio of death 0.47 [95% CI 0.25-0.91], p=0.025). 25 of 37 patients assigned embolisation, 21 of 40 assigned chemoembolisation, and 25 of 35 assigned conservative treatment died. Survival probabilities at 1 year and 2 years were 75% and 50% for embolisation; 82% and 63% for chemoembolisation, and 63% and 27% for control (chemoembolisation vs control p=0.009). Chemoembolisation induced objective responses sustained for at least 6 months in 35% (14)of cases, and was associated with a significantly lower rate of portal-vein invasion than conservative treatment. Treatment allocation was the only variable independently related to survival (odds ratio 0.45 [95% CI 0.25-0.81], p=0.02). INTERPRETATION Chemoembolisation improved survival of stringently selected patients with unresectable hepatocellular carcinoma.

Embolization of bronchial arteries of anomalous origin

AbstractPurpose: To highlight the importance of detecting bronchial arteries of anomalous origin in patients with massive or recurrent hemoptysis. Methods: In a series of 300 patients submitted to bronchial embolization in our hospital since 1986, we found 25 (8.3%) with 27 anomalous bronchial arteries. Eighteen patients presented with recurrent hemoptysis (10 massive) and seven with their first episode of massive hemoptysis. Results: Of the 27 anomalous bronchial arteries demonstrated, 24 originated from the aortic arch, one from the left thyrocervical trunk, one from the right subclavian artery, and one from the lower descending thoracic aorta; two of the arteries demonstrated showed no pathological findings. Hemoptysis resolved following the first embolization in 14 patients (56%). In nine patients (36%) more than one procedure was necessary to arrest hemorrhage. In two patients surgical intervention was required. One patient died from bleeding. Conclusions: In cases of hemorrhage when the cause is not easily identified, or in cases of recurrence in spite of accurate embolization of pathological arteries, the presence of bronchial arteries of anomalous origin should be considered. Embolization is more difficult in these cases and there is an increased risk of complications.

MRA is useful as a follow-up technique after endovascular repair of aortic aneurysms with nitinol endoprostheses

To evaluate whether MR angiography (MRA) is a useful tool for the follow‐up of aortic aneurysms treated with nitinol endoluminal grafts.

Effects of contrast media on renal function in patients with cirrhosis: A prospective study

Patients with cirrhosis are frequently submitted to radiological procedures that require the administration of contrast media. Contrast media is a well‐known cause of renal failure, particularly in the presence of some predisposing conditions. However, it is not known whether cirrhosis constitutes a risk factor for contrast media–induced renal failure. The aim of this study was to assess the possible nephrotoxicity of contrast media in patients with cirrhosis. In a first protocol, renal function was evaluated with sensitive methods (glomerular filtration rate using iothalamate I 125 clearance and renal plasma flow using iodohippurate I 131 clearance) before and 48 hours after the administration of contrast media in 31 patients with cirrhosis (20 with ascites, 5 with renal failure). Solute‐free water clearance, urine sodium, prostaglandins, and markers of tubular damage were also measured. The administration of contrast media was not associated with significant changes in renal function tests, neither in the whole group of patients nor in patients with ascites or renal failure. Urinary prostaglandin E2 and N‐acetyl‐β‐D‐glucosaminidase increased significantly, but sodium and solute‐free water excretion remained unchanged. In a second protocol, a different series of 60 patients with cirrhosis and renal failure were examined prospectively. No patient had renal failure due to contrast media. Only in 1 patient with septic shock was contrast media a possible contributing factor. In conclusion, the administration of contrast media is not associated with adverse effects on renal function in patients with cirrhosis. Cirrhosis does not appear to be a risk factor for the development of contrast media–induced nephrotoxicity. (HEPATOLOGY 2004;40:646–651.)

Endovascular Treatment of a Giant Intracranial Aneurysm with a Stent-Graft

This report describes a giant intracavernous carotid aneurysm successfully treated by the placement of a single covered stent. A 40-year-old woman was admitted with a progressive diplopia in relation with palsy of the IV and VI cranial nerves. Magnetic resonance imaging revealed an intracavernous giant aneurysm located at the bifurcation between the origin of a trigeminal artery and the intracavernous portion of the right internal carotid artery. A covered stent was successfully placed, and complete exclusion of the aneurysm was confirmed at 11-month follow-up angiography. The use of covered stents in intracranial vascular structures can now be a feasible way of treating selected cases of wide-necked intracranial aneurysms.

Evaluation of Abdominal Aortic Aneurysm after Endovascular Repair: Prospective Validation of Contrast-enhanced US with a Second-Generation US Contrast Agent

PURPOSE To prospectively assess the accuracy of contrast agent-enhanced (CE) ultrasonography (US) with a second-generation US contrast agent in the detection and classification of endoleaks after endovascular repair of abdominal aortic aneurysms (EVAR), with computed tomographic (CT) angiography as the reference standard. MATERIALS AND METHODS Institutional review board and written informed consent were obtained. Thirty-five patients who underwent EVAR were enrolled in a prospective study that consisted of CT angiography and CE US studies performed at 1- and 6-month follow-up and performed yearly thereafter. CE US was performed after bolus injection of 2.4 mL of sulfur hexafluoride by using equipment with specific software for contrast studies. Angiography was performed in patients who had type II endoleaks with an increase in aneurysm sac size and in patients with type I or III endoleaks. CE US sensitivity, specificity, positive and negative predictive values, and accuracy were determined for endoleak detection, and Cohen κ statistic was used to assess agreement of CE US and CT angiographic findings for endoleak classification. RESULTS A total of 126 CT angiographic and CE US studies were performed. CT angiography depicted 34 endoleaks in 16 patients (type IA, n=1; type IB, n=1; type II inferior mesenteric artery, n=2; type II lumbar artery, n=28; type II complex, inferior mesenteric, and lumbar arteries, n=2). CE US depicted 33 endoleaks. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CE US in endoleak detection were 97%, 100%, 100%, 98%, and 99%, respectively. CE US enabled correct classification of 26 of 33 endoleaks. No clinically important endoleak was missed at CE US. CONCLUSION CE US yields good sensitivity, specificity, and accuracy in endoleak detection, and it might represent a noninvasive tool that can be used in the follow-up of patients who undergo EVAR.

Tratamiento endovascular de las úlceras penetrantes de aorta torácica: seguimiento a medio plazo

INTRODUCTION AND OBJECTIVES The aim of this work is to describe the short- and mid-term results of endovascular treatment of penetrating ulcers in the thoracic aorta. METHODS Between 1998 and 2010, 22 patients with penetrating ulcers in the thoracic aorta received endografts (mean age 69.8 years, 91% male); 50% were indicated for acute aortic syndrome (8 chest pain, 1 aortic rupture, 1 aortobronchial fistula, 1 distal embolization) and 50% for aortic or ulcer diameter. All preoperative, operative and follow-up data were recorded prospectively and met EUROSTAR criteria. RESULTS Technical success was 100% with no intraoperative deaths or open conversions; 6 (27.3%) required preoperative supraaortic trunk debranching and 1.3 endografts were used per patient; 27.3% developed complications in-hospital and 9.1% required reintervention prior to discharge. Mortality at 30 days was 4.5%. After a mean 52.3 month follow-up (range 0.1-122), cumulative survival free from complications and reinterventions at 100 months was 61.7% and 79.5% respectively, with 95.5% cumulative survival free from aorta- or procedure-related death. We identified no factors significantly related to poor intra- or postoperative clinical course. CONCLUSIONS Endovascular treatment of penetrating aortic ulcers is both possible and effective despite high patient comorbidity. Although a substantial rate of complications and reinterventions can be expected-especially in-hospital-(38.3% and 20.5% respectively at 100 months), long-term mortality is low (4.5%).

Aneurisma de aorta abdominal y enfermedad vascular renal

Recent technological advances in the diagnosis and therapy of abdominal aortic aneurysm and renovascular disease are continuing to bring about changes in the way patients suffering from these conditions are treated. The prevalence of both these conditions is increasing. This is due to greater life-expectancy in patients with arteriosclerosis, a pathogenetic factor underlying both conditions. The application of diagnostic imaging techniques to non-vascular conditions has led to the early diagnosis of abdominal aortic aneurysm. Clinical suspicion of reno-vascular disease can be confirmed easily using high-resolution diagnostic imaging modalities such as CT angiography and magnetic resonance angiography. Endovascular intervention is successfully replacing conventional surgical repair techniques, with the result that it may be possible to improve outcome in both conditions using effective and minimally invasive approaches. Future technological developments will enable these endovascular techniques to be applied in the large majority of patients with abdominal aortic aneurysm or renovascular disease.

Stent Grafting–Related Acute Type B Redissection

The purpose of this article is to report two distal dissections resulting as a complication of endovascular aneurysm repair (EVAR) in two cases of type B aortic dissection (TBAD) and its relationship with prosthetic alignment at the distal landing zone. Two patients affected by aneurysm formation of a chronic type B dissection underwent EVAR. During postoperative follow-up, at 48 and 39 months, respectively, a new chest pain episode recommended a new computed tomographic angiography examination. New false lumen reperfusion and increased aortic diameter distally to the prosthesis were demonstrated. The distal end of each stent graft showed an angulated alignment to the proximal descending aorta at the point of the secondary entry site. Both patients were successfully treated after deployment of a distal endograft. Prosthetic alignment with the aortic axis is important to avoid wall stress and secondary perforation in patients treated for TBAD. The distal landing point at the descending aortic straight segment is recommended.

Pulmonary Artery Pseudoaneurysm after Swan-Ganz Catheter Placement: Embolization with Vascular Plugs

Three patients who presented with massive hemoptysis after the insertion of a Swan-Ganz catheter for cardiac surgery are reported. Pulmonary artery pseudoaneurysms were diagnosed and successfully treated by embolization with a vascular plug. Follow-up at 15 months showed no recurrence of hemoptysis, and computed tomography helped confirm complete occlusion of the pseudoaneurysms.