Erratum to: Percutaneous Transluminal Angioplasty of Hepatic Artery Stenosis in Patients After Orthotopic Liver Transplantation: Mid-term Results
No abstract prepared.
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Combined Treatment of Large Hepatocellular Carcinoma with Transcatheter Arterial Chemoembolization and Percutaneous Ethanol Injection with a Multipronged Needle: Experimental and Clinical Investigation
Purpose: This study was designed to evaluate the usefulness of percutaneous ethanol injection (PEI) with a multipronged needle for the treatment of large hepatocellular carcinoma (HCC). An experimental animal study and a clinical investigation were performed. Methods: In the experimental study, 20 ml of 99.5% ethanol was injected into porcine liver in vivo with a multipronged needle (n = 5) or a straight needle (n = 5), and the volumes of coagulation necrosis were compared. In the clinical investigation, PEI was performed in 17 patients (10 men, 7 women; mean age 73.4 {+-} 6.7 years) with single, large HCC (mean tumor diameter, 47.2 {+-} 11.5 mm; range, 32-70 mm) by using a multipronged needle. Fifteen of 17 patients received transarterial chemoembolization (TACE) before PEI. Results: The volume of coagulation in porcine liver in vivo was significantly increased with the multipronged needle compared with the straight needle (longest perpendicular diameters, 34.2 {+-} 3.6 mm Multiplication-Sign 30.2 {+-} 3.6 mm vs. 22.6 {+-} 2.5 mm Multiplication-Sign 19 {+-} 2.2 mm, respectively; P < 0.05). In the clinical trial, initial complete response (CR) of the tumor was achieved in 17 of 17 patients, 7 of whom required two PEI sessions. During the follow-up, local recurrence was detected in 4 of 17 patients at 3-19 months after the procedure, for a rate of sustained local CR of 76%. No major complication occurred. Conclusions: Use of a multipronged needle substantially increases the volume of coagulation in vivo with respect to the conventional PEI technique. Combined TACE and PEI with multipronged needles is a safe and effective option for percutaneous treatment of single, large HCC.
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Microwave Ablation with Percutaneous Approach for the Treatment of Pancreatic Adenocarcinoma
No abstract prepared.
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Transjugular Intrahepatic Porto-Systemic Shunt Placement in a Patient with Left-Lateral Split-Liver Transplant and Mesenterico-Left Portal Vein by Pass Placement
This is a report of a successful placement of a transjugular intrahepatic porto-systemic shunt in a young patient with previous left-lateral, split-liver transplant and mesenterico-left portal vein by pass placement after posttransplant extrahepatic portal vein thrombosis.
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Stereotactic Radiofrequency Ablation (SRFA) of Liver Lesions: Technique Effectiveness, Safety, and Interoperator Performance
Purpose: To evaluate technique effectiveness, safety, and interoperator performance of stereotactic radiofrequency ablation (SRFA) of liver lesions. Methods: Retrospective review including 90 consecutive patients from January 2008 to January 2010 with 106 computed tomography-guided SRFA sessions using both single and multiple electrodes for the treatment of 177 lesions: 72 hepatocellular carcinoma (HCC) and 105 metastases with a mean size of 2.9 cm (range 0.5-11 cm). Technique effectiveness and 1-year local recurrence were evaluated by computed tomographic scans. Complications, mortality, and hospital days were recorded. The performance between an experienced and inexperienced interventional radiologist was compared. Results: The overall technique effectiveness after a single SRFA was 95.5% (93.1% for HCC and 97.1% for metastases). Four of the eight unsuccessfully treated lesions could be retreated (secondary technique effectiveness of 97.7%). Local recurrence at 1 year was 2.9%. Technique effectiveness was significantly different for lesions <5 cm (96.7%) and >5 cm (87.5%) (P = 0.044) but not for lesions <3 cm (95.9%) and 3-5 cm (100%). Compared to clear parenchymal property (97.3%), vessel vicinity (93.3%) (P = 0.349) and subcapsular (95.2%) (P = 0.532) had no, but hollow viscera vicinity (83.3%) had a significantly lower technique effectiveness (P = 0.020). Mortality rate was 0.9%. Major complications and hospital days were higher for cirrhosis Child-Pugh B (20%, 7.2 days) than Child-Pugh A (3.1%, 4.7 days) patients and for metastases (5.1%, 4.3 days). There was no significant difference in interoperator performance. Conclusions: RFA allowed for efficient, reliable, and safe ablation of large-volume liver disease.
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Radiation Exposure in Nonvascular Fluoroscopy-Guided Interventional Procedures
Purpose: To investigate the radiation exposure in non-vascular fluoroscopy guided interventions and to search strategies for dose reduction. Materials and Methods: Dose area product (DAP) of 638 consecutive non-vascular interventional procedures of one year were analyzed with respect to different types of interventions; gastrointestinal tract, biliary interventions, embolizations of tumors and hemorrhage. Data was analyzed with special focus on the fluoroscopy doses and frame doses. The third quartiles (Q3) of fluoroscopy dose values were defined in order to set a reference value for our in-hospital practice. Results: Mean fluoroscopy times of gastrostomy, jejunostomy, right and left sided percutaneous biliary drainage, chemoembolization of the liver and embolization due to various hemorrhages were 5.9, 8.6, 13.5, 16.6, 17.4 and 25.2 min, respectively. The respective Q3 total DAP were 52.9, 73.3, 155.1, 308.4, 428.6 and 529.3 Gy*cm{sup 2}. Overall, around 66% of the total DAP originated from the radiographic frames with only 34% of the total DAP applied by fluoroscopy (P < 0.001). The investigators experience had no significant impact on the total DAP applied, most likely since there was no stratification to intervention-complexity. Conclusion: To establish Diagnostic Reference Levels (DRLs), there is a need to establish a registry of radiation dose data for the most commonly performed procedures. Documentation of interventional procedures by fluoroscopy 'grabbing' has the potential to considerably reduce radiation dose applied and should be used instead of radiographic frames whenever possible.
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Embolisation of the Gastroduodenal Artery is Not Necessary in the Presence of Reversed Flow Before Yttrium-90 Radioembolisation
Introduction: The gastroduodenal artery (GDA) is usually embolised to avoid nontarget dispersal before yttrium-90 (Y{sup 90}) radioembolisation to treat liver metastases. In a minority of patients, there is retrograde flow in the GDA. The purpose of this study was to determine if there is any increased risk from maintaining a patent GDA in patients with reversed flow. Materials and Methods: A retrospective review was performed of all patients undergoing Y{sup 90} radioembolisation at our institution. The incidence of toxicities arising from nontarget radioembolisation by way of the GDA (gastric/duodenal ulceration, gastric/duodenal bleeding, and pancreatitis) and death occurring within 2 months of treatment were compared between the reversed and the antegrade GDA groups. Results: Ninety-two patients underwent preliminary angiography. Reversed GDA flow was found on angiography in 14.1% of cases; the GDA was not embolised in these patients. The GDA was coiled in 55.7% of patients with antegrade GDA flow to prevent inadvertent dispersal of radioembolic material. There was no increased toxicity related to nontarget dispersal by way of the GDA, or increased early mortality, in patients with reversed GDA flow (P > 0.05). Conclusion: In patients with reversed GDA flow, maintenance of a patent GDA before administration of Y{sup 90} radioembolisation does not increase the risk of toxicity from nontarget dispersal. Therapeutic injection, with careful monitoring to identify early vascular stasis, may be safely performed beyond the origin of the patent GDA. A patent GDA with reversed flow provides forward drive for infused particles and may allow alternative access to the hepatic circulation.
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Newly Designed Y-configured Single-Catheter Stenting for the Treatment of Hilar-Type Nonanastomotic Biliary Strictures After Orthotopic Liver Transplantation
Purpose: This study was designed to introduce our novel technique of percutaneous single catheter placement into the hilar bile ducts strictures while fulfilling the purpose of bilateral biliary drainage and stenting. We investigated the efficacy and safety of the technique for the treatment of hilar nonanastomotic biliary strictures. Methods: Ten patients who were post-orthotopic liver transplantation between July 2000 and July 2010 were enrolled in this study. Percutaneous Y-configured single-catheter stenting for bilateral bile ducts combined with balloon dilation was designed as the main treatment approach. Technical success rate, clinical indicators, complications, and recurrent rate were analyzed. Results: Technical success rate was 100%. Nine of the ten patients had biochemical normalization, cholangiographic improvement, and clinical symptoms relief. None of them experienced recurrence in a median follow-up of 26 months after completion of therapy and removal of all catheters. Complications were minor and limited to two patients. The one treatment failure underwent a second liver transplantation but died of multiple system organ failure. Conclusions: Percutaneous transhepatic Y-configured single-catheter stenting into the hilar bile ducts is technically feasible. The preliminary trial of this technique combined with traditional PTCD or choledochoscopy for the treatment of hilar biliary strictures after orthotopic liver transplantation appeared to be effective and safe. Yet, further investigation is needed.
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Long-Term Outcome of Transcatheter Subsegmental and Segmental Arterial Chemoemobolization Using Lipiodol for Hepatocellular Carcinoma
Purpose: To clarify the efficacy of transcatheter hepatic sub-subsegmental, subsegmental, and segmental arterial chemoembolization using lipiodol (subseg/seg lip-TACE) for hepatocellular carcinoma (HCC), long-term outcomes of patients who had been treated using subseg/seg lip-TACE alone were retrospectively examined. Materials and Methods: Subjects comprised 199 patients with HCC (T1/2/{>=}3 = 30/108/61; Child-Pugh A/B/C = 115/52/32; Japan Integrated Staging [JIS] score {<=}1/2/{>=}3 = 88/64/47) who underwent subseg/seg lip-TACE using lipiodol mixed with an anticancer drug followed by injection of gelatin sponge particles. Each patient was followed-up every 3 months, and repeat subseg/seg lip-TACE and/or conventional lip-TACE was performed in cases showing recurrence. One-, 3-, 5-, 7-, and 10-year cumulative survival rates were calculated. Subgroup analyses were performed by stratifying the population according to T-factor, Child-Pugh classification, and JIS score. Results: Median duration of follow-up was 3.8 years (range 0.2 to 16.4). Median overall survival was 3.8 years. One-, 3-, 5-, 7- and 10-year survival rates were 91.5, 66.1, 38.8, 20.3, and 9.4% for all patients, and 95.5, 76.9, 51.9, 27.9 and 20.4% for patients with JIS {<=}1, respectively. Significant survival differences were found across two subgroups of staging systems (T2 vs. T3{<=} [P = 0.0012] and JIS score {<=}1 vs. 2 [P = 0.0036]). Conclusion: This study demonstrated that subseg/seg lip-TACE is a feasible treatment for obtaining prolonged survival in patients with localized HCC showing rich vasculature. Outcomes are influenced by both tumor stage and liver function, as seen in the best prolonged survival in patients with JIS score {<=}1.
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Superselective Internal Radiation With Yttrium-90 Microspheres in the Management of a Chemorefractory Testicular Liver Metastasis
We treated a patient with biopsy-proven, chemotherapy-resistant testicular cancer liver metastasis using Y-90 selective internal radiation treatment. We chose yttrium-90 rather than surgery and ablation due to tumor location and size as well as the patient's clinical history. The result was marked tumor response by positron emission tomography and computed tomography as well as significant improvement of the patient's quality of life accompanied by a substantial decrease of his tumor markers.
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Successful Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varix Mainly Draining into the Pericardiophrenic Vein
Two cases of gastric varices were treated by balloon-occluded retrograde transvenous obliteration via the pericardiophrenic vein at our hospital, and both were successful. One case developed left hydrothorax. Gastric varices did not bled and esophageal varices were not aggravated in both cases for 24-30 months thereafter. These outcomes indicate the feasibility of balloon-occluded retrograde transvenous obliteration via the pericardiophrenic vein.
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Radioembolization of Symptomatic, Unresectable Neuroendocrine Hepatic Metastases Using Yttrium-90 Microspheres
Purpose: To evaluate safety, efficacy, and symptom-control of radioembolization in patients with unresectable liver metastases from neuroendocrine tumors (NETLMs). Materials and Methods: Forty-two patients (mean age of 62 years) with treatment-refractory NETLMs underwent radioembolization using yttrium-90 ({sup 90}Y) resin microspheres. Posttreatment tumor response was assessed by cross-sectional imaging using the Response Evaluation Criteria in Solid Tumors (RECIST) and tumor-marker levels. Laboratory and clinical toxicities and clinical symptoms were monitored. Results: The median activity delivered was 1.63 GBq (range 0.63-2.36). Imaging follow-up using RECIST at 3-month follow-up demonstrated partial response, stable disease, and progressive disease in 22.5, 75.0, and 2.5% of patients, respectively. In 97.5% of patients, the liver lesions appeared hypovascular or partially necrotic. The mean follow-up was 16.2 months with 40 patients (95.2%) remaining alive. The median decrease in tumor-marker levels at 3 months was 54.8% (chromogranin A) and 37.3% (serotonin), respectively. There were no acute or delayed toxicities greater than grade 2 according to Common Terminology Criteria for Adverse Events [CTCAE (v3.0)]. No radiation-induced liver disease was noted. Improvement of clinical symptoms 3 months after treatment was observed in 36 of 38 symptomatic patients. Conclusion: Radioembolization with {sup 90}Y-microspheres is a safe and effective treatment option in patients with otherwise treatment-refractory NETLMs. Antitumoral effect is supported by good local tumor control, decreased tumor-marker levels, and improved clinical symptoms. Further investigation is warranted to define the role of radioembolization in the treatment paradigm for NETLMs.
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Computed Tomography-Guided Interstitial HDR Brachytherapy (CT-HDRBT) of the Liver in Patients with Irresectable Intrahepatic Cholangiocarcinoma
Purpose: This study was designed to investigate the clinical outcome of patients with irresectable, intrahepatic cholangiocarcinoma (IHC) treated with computed tomography (CT)-guided HDR-brachytherapy (CT-HDRBT) for local tumor ablation.MethodFifteen consecutive patients with histologically proven cholangiocarcinoma were selected for this retrospective study. Patients were treated by high-dose-rate internal brachytherapy (HDRBT) using an Iridium-192 source in afterloading technique through CT-guided percutaneous placed catheters. A total of 27 brachytherapy treatments were performed in these patients between 2006 and 2009. Median tumor enclosing target dose was 20 Gy, and mean target volume of the radiated tumors was 131 ({+-} 90) ml (range, 10-257 ml). Follow-up consisted of clinical visits and magnetic resonance imaging of the liver every third month. Statistical evaluation included survival analysis using the Kaplan-Meier method. Results: After a median follow-up of 18 (range, 1-27) months after local ablation, 6 of the 15 patients are still alive; 4 of them did not get further chemotherapy and are regarded as disease-free. The reached median local tumor control was 10 months; median local tumor control, including repetitive local ablation, was 11 months. Median survival after local ablation was 14 months and after primary diagnosis 21 months. Conclusion: In view of current clinical data on the clinical outcome of cholangiocarcinoma, locally ablative treatment with CT-HDRBT represents a promising and safe technique for patients who are not eligible for tumor resection.
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Erratum to: Combination Therapy of Transcatheter Arterial Chemoembolization and Arterial Administration of Antiangiogenesis on VX2 Liver Tumor
No abstract prepared.
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Erratum to: Computed Tomography-Guided Interstitial HDR Brachytherapy (CT-HDRBT) of the Liver in Patients with Irresectable Intrahepatic Cholangiocarcinoma
No abstract prepared.
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A New Flow Control Technique Using Diluted Epinephrine in the N-butyl-2-cyanoacrylate Embolization of Visceral Artery Pseudoaneurysms Secondary to Chronic Pancreatitis
Although n-butyl-2-cyanoacrylate (NBCA) has been used as an effective liquid embolization material, its indication for pseudoaneurysms has seemingly been limited because of the technical difficulties of using NBCA, such as reflux to the parent artery and causing significant infarction. Thus, considerable skill in using NBCA or a device to control blood flow during its polymerization is required to achieve embolization without severe complications. We report our new technique for controlling blood flow using diluted epinephrine in transcatheter arterial NBCA embolization of five pseudoaneurysms in four cases secondary to hemosuccus pancreaticus.
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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.
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Use of a Multilayered Stent for the Treatment of Hepatic Artery Pseudoaneurysm After Liver Transplantation
No abstract prepared.
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