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Percutaneous Endovascular Radiofrequency Ablation for Malignant Portal Obstruction: An Initial Clinical Experience
PurposeThe Habib™ VesOpen Catheter is a new endovascular radiofrequency ablation (RFA) device used to treat malignant portal obstruction. The purpose of this study was to evaluate the clinical feasibility and safety of RFA with this device.MethodsWe collected the clinical records and follow-up data of patients with malignant portal obstruction treated with percutaneous endovascular portal RFA using the Habib™ VesOpen Catheter. Procedure-related complications, improvement of symptoms, portal patency, survival, and postoperative biochemical tests were investigated.ResultsThe 31 patients enrolled in the study underwent 41 successful endovascular portal RFA procedures. Patients were divided into a portal-stenting (PS) group (n = 13), which underwent subsequent portal stenting with self-expandable metallic stents, and a non-stenting (NS) group (n = 18), which did not undergo stenting. No procedure-related abdominal hemorrhage or portal rupture occurred. Postablation complications included abdominal pain (n = 26), fever (n = 13), and pleural effusion (n = 15). Improvements in clinical manifestations were observed in 27 of the 31 patients. Of the 17 patients experiencing portal restenosis, 10 underwent successful repeat RFA. The rate of successful repeat RFA was significantly higher in the NS group than in the PS group. Median portal patency was shorter in the PS group than in the NS group. No mortality occurred during the 4 weeks after percutaneous endovascular portal RFA.ConclusionsPercutaneous endovascular portal RFA is a feasible and safe therapeutic option for malignant portal obstruction. Prospective investigations should be performed to evaluate clinical efficacy, in particular, the need to evaluate the necessity for subsequent portal stenting.
Portals Reference Implementation v. 1.0
The Portals reference implementation is based on the Portals 4.X API, published by Sandia National Laboratories as a freely available public document. It is designed to be an implementation of the Portals Networking Application Programming Interface and is used by several other upper layer protocols like SHMEM, GASNet and MPI. It is implemented over existing networks, specifically Ethernet and InfiniBand networks. This implementation provides Portals networks functionality and serves as a software emulation of Portals compliant networking hardware. It can be used to develop software using the Portals API prior to the debut of Portals networking hardware, such as Bull’s BXI interconnect, as well as a substitute for portals hardware on development platforms that do not have Portals compliant hardware. The reference implementation provides new capabilities beyond that of a typical network, namely the ability to have messages matched in hardware in a way compatible with upper layer software such as MPI or SHMEM. It also offers methods of offloading network operations via triggered operations, which can be used to create offloaded collective operations. Specific details on the Portals API can be found at http://portals4.org.
Portals Reference Implementation v. 1.0
The Portals reference implementation is based on the Portals 4.X API, published by Sandia National Laboratories as a freely available public document. It is designed to be an implementation of the Portals Networking Application Programming Interface and is used by several other upper layer protocols like SHMEM, GASNet and MPI. It is implemented over existing networks, specifically Ethernet and InfiniBand networks. This implementation provides Portals networks functionality and serves as a software emulation of Portals compliant networking hardware. It can be used to develop software using the Portals API prior to the debut of Portals networking hardware, such as Bull’s BXI interconnect, as well as a substitute for portals hardware on development platforms that do not have Portals compliant hardware. The reference implementation provides new capabilities beyond that of a typical network, namely the ability to have messages matched in hardware in a way compatible with upper layer software such as MPI or SHMEM. It also offers methods of offloading network operations via triggered operations, which can be used to create offloaded collective operations. Specific details on the Portals API can be found at http://portals4.org.
Staged Transcatheter Treatment of Portal Hypoplasia and Congenital Portosystemic Shunts in Children
Purpose: Congenital portosystemic shunts (CPSS) with portal venous hypoplasia cause hyperammonemia. Acute shunt closure results in portal hypertension. A transcatheter method of staged shunt reduction to afford growth of portal vessels followed by shunt closure is reported. Methods: Pressure measurements and angiography in the CPSS or superior mesenteric artery (SMA) during temporary occlusion of the shunt were performed. If vessels were diminutive and the pressure was above 18 mmHg, a staged approach was performed, which included implantation of a tailored reducing stent to reduce shunt diameter by {approx}50 %. Recatheterization was performed approximately 3 months later. If the portal pressure was below 18 mmHg and vessels had developed, the shunt was closed with a device. Results: Six patients (5 boys, 1 girl) with a median age of 3.3 (range 0.5-13) years had CPSS portal venous hypoplasia and hyperammonemia. Five patients underwent staged closure. One patient tolerated acute closure. One patient required surgical shunt banding because a reducing stent could not be positioned. At median follow-up of 3.8 (range 2.2-8.4) years, a total of 21 procedures (20 transcatheter, 1 surgical) were performed. In all patients, the shunt was closed with a significant reduction in portal pressure (27.7 {+-} 11.3 to 10.8 {+-} 1.8 mmHg; p = 0.016), significant growth of the portal vessels (0.8 {+-} 0.5 to 4.0 {+-} 2.4 mm; p = 0.037), and normalization of ammonia levels (202.1 {+-} 53.6 to 65.7 {+-} 9.6 {mu}mol/L; p = 0.002) with no complications. Conclusion: Staged CPSS closure is effective in causing portal vessel growth and treating hyperammonemia.
Intrahepatic Left to Right Portoportal Venous Collateral Vascular Formation in Patients Undergoing Right Portal Vein Ligation
Purpose: We investigated intrahepatic vascular changes in patients undergoing right portal vein ligation (PVL) or portal vein embolization (PVE) in conjunction with the ensuing hypertrophic response and function of the left liver lobe. Methods: Between December 2008 and October 2011, 7 patients underwent right PVL and 14 patients PVE. Computed tomographic (CT) volumetry to assess future remnant liver (FRL) and functional hepatobiliary scintigraphy were performed in all patients before and 3 weeks after portal vein occlusion. In 18 patients an intraoperative portography was performed to assess perfusion through the occluded portal branches. Results: In all patients after initially successful PVL, reperfused portal veins were observed on CT scan 3 weeks after portal occlusion. This was confirmed in all cases during intraoperative portography. Intrahepatic portoportal collaterals were identified in all patients in the PVL group and in one patient in the PVE group. In all other PVE patients, complete occlusion of the embolized portal branches was observed on CT scan and on intraoperative portography. The median increase of FRL volume after PVE was 41.6 % (range 10-305 %), and after PVL was only 8.1 % (range 0-102 %) (p = 0.179). There were no differences in FRL function between both groups. Conclusion: Preoperative PVE and PVL are both methods to induce hypertrophy of the FRL in anticipation of major liver resection. Compared to PVE, PVL seems less efficient in inducing hypertrophy of the nonoccluded left lobe. This could be caused by the formation of intrahepatic portoportal neocollateral vessels, through which the ligated portal branches are reperfused within 3 weeks.
SU-F-T-283: A Novel Device to Enable Portal Dosimetry for Flattening Filter Free Beams
Purpose: Varian’s electronic portal imaging device (EPID) based portal dosimetry tool is a popular and effective means of performing IMRT QA. EPIDs for older models of the TrueBeam accelerator utilize a 40cmx30cm Image Detection Unit (IDU) that saturates at the center for standard source to imager distances with high dose rate flattening filter free (FFF) beams. This makes portal dosimetry not possible and an alternative means of IMRT QA necessary. We developed a filter that would attenuate the beam to a dose rate measureable by the IDU for portal dosimetry IMRT QA. Methods: Multipurpose 304 stainless steel plates were placed on an accessory tray to attenuate the beam. Profiles of an open field measured on the IDU were acquired with varying number of plates to assess the thickness needed to reduce the maximum dose rates of 6XFFF and 10XFFF beams to measurable levels. A new portal dose image prediction (PDIP) model was commissioned based on open field measurements with plates in position, and a modified beam profile was input to portal dosimetry calibration at the console to empirically correct for attenuation and scatter. The portal dosimetry tool was used to assess agreement between predicted and measured doses for open 25×25cm{sup 2} fields and intensity modulated fields using 6XFFF and 10XFFF beams. Results: Thicknesses of 2.5cm and 3.8cm of steel were required to reduce the highest dose rates to a measureable level for 6XFFF and 10XFFF, respectively. Gamma analysis using a 3%/3mm relative criterion with the filter in place and using the new PDIP model resulted in 98.2% and 93.6% of pixels passing while intensity modulated fields showed passing rates of 98.2% and 99.0%. Conclusion: Use of the filter allows for portal dosimetry to be used for IMRT QA of FFF plans in place of purchasing a second option for IMRT QA.
M&V Tool Testing Portal v1
Software is an online self-service portal for testing M&V methods/tools using buildings' interval meter data. After registering as a user in the portal, that user can download test data files, run those test data files through their own M&V software, and then upload software modeling results to the online portal as a csv file. After the user has uploaded their modeling results the portal will develop statistical accuracy metrics for that M&V tool. The online portal will summarize test results for some or all of the submitted tests. This online portal has been developed by LBNL, and we have been collaborating with the Efficiency Valuation Organization (EVO) with the objective of EVO managing the portal as an ongoing service. Portal is currently posted at http://mvportal.evo-world.org/
Novel Percutaneous Radiofrequency Ablation of Portal Vein Tumor Thrombus: Safety and Feasibility
We report our experience of the safety of partial recanalization of the portal vein using a novel endovascular radiofrequency (RF) catheter for portal vein tumor thrombosis. Six patients with liver cancer and tumor thrombus in the portal vein underwent percutaneous intravascular radiofrequency ablation (RFA) using an endovascular bipolar RF device. A 0.035-inch guidewire was introduced into a tributary of the portal vein and through which a 5G guide catheter was introduced into the main portal vein. After manipulation of the guide catheter over the thrombus under digital subtraction angiography, the endovascular RF device was inserted and activated around the thrombus. There were no observed technique specific complications, such as hemorrhage, vessel perforation, or infection. Post-RFA portography showed partial recanalization of portal vein. RFA of portal vein tumor thrombus in patients with hepatocellular carcinoma is technically feasible and warrants further investigation to assess efficacy compared with current recanalization techniques.
Feasibility of Helical I-125 Seed Implant in the Portal Vein
Purpose: To evaluate the feasibility of helical iodine-125 (I-125) seed portal vein implantation. Materials and Methods: Helical I-125 seed implants were placed into the portal vein of healthy pigs through the transjugular (n = 3) or percutaneous transhepatic (n = 3) route. Six pigs received follow-up at 9 weeks after implantation. Blood tests were performed preimplantation, and at 1 and 9 weeks after implantation. Contrast-enhanced computed tomography (CT) and single-photon emission computed tomography combined with CT (SPECT-CT) were acquired after implantation. Post-implantation CT was imported to the treatment planning system (TPS) for dose verification. At 9 weeks after implantation, another CT was performed before histopathological examination. Results: All implantations were successful, and the helical implants were fixed to the portal vein. CT showed no implant migration or portal vein thrombosis. The average dose to 90% of the target volume calculated from TPS was 68.4 Gy. SPECT-CT revealed an irregular isodose around the implant, in which the hottest spot was near the central portal vein lumen. All pigs were in good condition at the 9-week follow-up. Histopathology studies confirmed no portal vein thrombosis. Pigs showed no signs of bleeding, necrosis, or perforation of the peripheral tissue or organs. Intimal hyperplasia was observed at the two ends of the implant. A mild inflammatory response was detected in the bile duct and adjacent liver tissues, yet there was no apparent inflammation of the hepatic arteries. Conclusion: The helical I-125 seed implants can be inserted into the portal veins of healthy pigs.
Portal protein functions akin to a DNA-sensor that couples genome-packaging to icosahedral capsid maturation
Tailed bacteriophages and herpesviruses assemble infectious particles via an empty precursor capsid (or ‘procapsid’) built by multiple copies of coat and scaffolding protein and by one dodecameric portal protein. Genome packaging triggers rearrangement of the coat protein and release of scaffolding protein, resulting in dramatic procapsid lattice expansion. Here, we provide structural evidence that the portal protein of the bacteriophage P22 exists in two distinct dodecameric conformations: an asymmetric assembly in the procapsid (PC-portal) that is competent for high affinity binding to the large terminase packaging protein, and a symmetric ring in the mature virion (MV-portal) that has negligible affinity for the packaging motor. Modelling studies indicate the structure of PC-portal is incompatible with DNA coaxially spooled around the portal vertex, suggesting that newly packaged DNA triggers the switch from PC- to MV-conformation. Thus, we propose the signal for termination of ‘Headful Packaging’ is a DNA-dependent symmetrization of portal protein.
A two-dimensional matrix correction for off-axis portal dose prediction errors
Purpose: This study presents a follow-up to a modified calibration procedure for portal dosimetry published by Bailey et al. ['An effective correction algorithm for off-axis portal dosimetry errors,' Med. Phys. 36, 4089-4094 (2009)]. A commercial portal dose prediction system exhibits disagreement of up to 15% (calibrated units) between measured and predicted images as off-axis distance increases. The previous modified calibration procedure accounts for these off-axis effects in most regions of the detecting surface, but is limited by the simplistic assumption of radial symmetry. Methods: We find that a two-dimensional (2D) matrix correction, applied to each calibrated image, accounts for off-axis prediction errors in all regions of the detecting surface, including those still problematic after the radial correction is performed. The correction matrix is calculated by quantitative comparison of predicted and measured images that span the entire detecting surface. The correction matrix was verified for dose-linearity, and its effectiveness was verified on a number of test fields. The 2D correction was employed to retrospectively examine 22 off-axis, asymmetric electronic-compensation breast fields, five intensity-modulated brain fields (moderate-high modulation) manipulated for far off-axis delivery, and 29 intensity-modulated clinical fields of varying complexity in the central portion of the detecting surface. Results: Employing the matrix correction to the off-axis test fields and clinical fields, predicted vs measured portal dose agreement improves by up to 15%, producing up to 10% better agreement than the radial correction in some areas of the detecting surface. Gamma evaluation analyses (3 mm, 3% global, 10% dose threshold) of predicted vs measured portal dose images demonstrate pass rate improvement of up to 75% with the matrix correction, producing pass rates that are up to 30% higher than those resulting from the radial correction technique alone. As in the 1D correction case, the 2D algorithm leaves the portal dosimetry process virtually unchanged in the central portion of the detector, and thus these correction algorithms are not needed for centrally located fields of moderate size (at least, in the case of 6 MV beam energy).Conclusion: The 2D correction improves the portal dosimetry results for those fields for which the 1D correction proves insufficient, especially in the inplane, off-axis regions of the detector. This 2D correction neglects the relatively smaller discrepancies that may be caused by backscatter from nonuniform machine components downstream from the detecting layer.
SU-E-J-15: Automatically Detect Patient Treatment Position and Orientation in KV Portal Images
Purpose: In the course of radiation therapy, the complex information processing workflow will Result in potential errors, such as incorrect or inaccurate patient setups. With automatic image check and patient identification, such errors could be effectively reduced. For this purpose, we developed a simple and rapid image processing method, to automatically detect the patient position and orientation in 2D portal images, so to allow automatic check of positions and orientations for patient daily RT treatments. Methods: Based on the principle of portal image formation, a set of whole body DRR images were reconstructed from multiple whole body CT volume datasets, and fused together to be used as the matching template. To identify the patient setup position and orientation shown in a 2D portal image, the 2D portal image was preprocessed (contrast enhancement, down-sampling and couch table detection), then matched to the template image so to identify the laterality (left or right), position, orientation and treatment site. Results: Five day’s clinical qualified portal images were gathered randomly, then were processed by the automatic detection and matching method without any additional information. The detection results were visually checked by physicists. 182 images were correct detection in a total of 200kV portal images. The correct rate was 91%. Conclusion: The proposed method can detect patient setup and orientation quickly and automatically. It only requires the image intensity information in KV portal images. This method can be useful in the framework of Electronic Chart Check (ECCK) to reduce the potential errors in workflow of radiation therapy and so to improve patient safety. In addition, the auto-detection results, as the patient treatment site position and patient orientation, could be useful to guide the sequential image processing procedures, e.g. verification of patient daily setup accuracy. This work was partially supported by research grant from Varian Medical System.
BSD Portals for LINUX 2.0
Portals, an experimental feature of 4.4BSD, extend the file system name space by exporting certain open () requests to a user-space daemon. A portal daemon is mounted into the file name space as if it were a standard file system. When the kernel resolves a pathname and encounters a portal mount point, the remainder of the path is passed to the portal daemon. Depending on the portal "pathname" and the daemon's configuration, some type of open (2) is performed. The resulting file descriptor is passed back to the kernel which eventually returns it to the user, to whom it appears that a "normal" open has occurred. A proxy portalfs file system is responsible for kernel interaction with the daemon. The overall effect is that the portal daemon performs an open (2) on behalf of the kernel, possibly hiding substantial complexity from the calling process. One particularly useful application is implementing a connection service that allows simple scripts to open network sockets. This paper describes the implementation of portals for LINUX 2.0.
Next Gen One Portal Usability Evaluation
Each exercise device on the International Space Station (ISS) has a unique, customized software system interface with unique layouts / hierarchy, and operational principles that require significant crew training. Furthermore, the software programs are not adaptable and provide no real-time feedback or motivation to enhance the exercise experience and/or prevent injuries. Additionally, the graphical user interfaces (GUI) of these systems present information through multiple layers resulting in difficulty navigating to the desired screens and functions. These limitations of current exercise device GUI's lead to increased crew time spent on initiating, loading, performing exercises, logging data and exiting the system. To address these limitations a Next Generation One Portal (NextGen One Portal) Crew Countermeasure System (CMS) was developed, which utilizes the latest industry guidelines in GUI designs to provide an intuitive ease of use approach (i.e., 80% of the functionality gained within 5-10 minutes of initial use without/limited formal training required). This is accomplished by providing a consistent interface using common software to reduce crew training, increase efficiency & user satisfaction while also reducing development & maintenance costs. Results from the usability evaluations showed the NextGen One Portal UI having greater efficiency, learnability, memorability, usability and overall user experience than the current Advanced Resistive Exercise Device (ARED) UI used by astronauts on ISS. Specifically, the design of the One-Portal UI as an app interface similar to those found on the Apple and Google's App Store, assisted many of the participants in grasping the concepts of the interface with minimum training. Although the NextGen One-Portal UI was shown to be an overall better interface, observations by the test facilitators noted specific exercise tasks appeared to have a significant impact on the NextGen One-Portal UI efficiency. Future updates to the NextGen One Portal UI will address these inefficiencies.
Radionuclide identification algorithm for organic scintillator-based radiation portal monitor
We have developed an algorithm for on-the-fly radionuclide identification for radiation portal monitors using organic scintillation detectors. The algorithm was demonstrated on experimental data acquired with our pedestrian portal monitor on moving special nuclear material and industrial sources at a purpose-built radiation portal monitor testing facility. The experimental data also included common medical isotopes. The algorithm takes the power spectral density of the cumulative distribution function of the measured pulse height distributions and matches these to reference spectra using a spectral angle mapper. F-score analysis showed that the new algorithm exhibited significant performance improvements over previously implemented radionuclide identification algorithms for organic scintillators. Reliable on-the-fly radionuclide identification would help portal monitor operators more effectively screen out the hundreds of thousands of nuisance alarms they encounter annually due to recent nuclear-medicine patients and cargo containing naturally occurring radioactive material. Lastly, portal monitor operators could instead focus on the rare but potentially high impact incidents of nuclear and radiological material smuggling detection for which portal monitors are intended.
Percutaneous Transsplenic Access to the Portal Vein for Management of Vascular Complication in Patients with Chronic Liver Disease
Purpose: To evaluate the safety and feasibility of percutaneous transsplenic access to the portal vein for management of vascular complication in patients with chronic liver diseases. Methods: Between Sept 2009 and April 2011, percutaneous transsplenic access to the portal vein was attempted in nine patients with chronic liver disease. Splenic vein puncture was performed under ultrasonographic guidance with a Chiba needle, followed by introduction of a 4 to 9F sheath. Four patients with hematemesis or hematochezia underwent variceal embolization. Another two patients underwent portosystemic shunt embolization in order to improve portal venous blood flow. Portal vein recanalization was attempted in three patients with a transplanted liver. The percutaneous transsplenic access site was closed using coils and glue. Results: Percutaneous transsplenic splenic vein catheterization was performed successfully in all patients. Gastric or jejunal varix embolization with glue and lipiodol mixture was performed successfully in four patients. In two patients with a massive portosystemic shunt, embolization of the shunting vessel with a vascular plug, microcoils, glue, and lipiodol mixture was achieved successfully. Portal vein recanalization was attempted in three patients with a transplanted liver; however, only one patient was treated successfully. Complete closure of the percutaneous transsplenic tract was achieved using coils and glue without bleeding complication in all patients. Conclusion: Percutaneous transsplenic access to the portal vein can be an alternative route for portography and further endovascular management in patients for whom conventional approaches are difficult or impossible.
Disastrous Portal Vein Embolization Turned into a Successful Intervention
Portal vein embolization (PVE) may be performed before hemihepatectomy to increase the volume of future liver remnant (FLR) and to reduce the risk of postoperative liver insufficiency. We report the case of a 71-year-old patient with hilar cholangiocarcinoma undergoing PVE with access from the right portal vein using a mixture of n-butyl-2-cyanoacrylate and ethiodized oil. During the procedure, nontarget embolization of the left portal vein occurred. An aspiration maneuver of the polymerized plug failed; however, the embolus obstructing portal venous flow in the FLR was successfully relocated into the right portal vein while carefully bypassing the plug with a balloon catheter, inflating the balloon, and pulling the plug into the main right portal vein.