Extravascular endoconduit for compromised access route in patients with ruptured thoracic aortic aneurysm

Some patients who undergo thoracic endovascular repair (TEVAR) for a thoracic aortic aneurysm have a compromised or unfavorable access route that requires additional intervention or another access route approach. We experienced a case involving an 80-year-old woman who developed a ruptured thoracic aortic aneurysm with an unfavorable access route characterized by a narrow external artery and severe atherosclerosis. She was severely frail due to a history of fractures and extensive intestinal resection for necrosis of the intestine. Although we planned to perform TEVAR following establishment of an internal endoconduit (IEC) of the common and external iliac arteries, the stent graft sheath did not pass IEC. We resolved the issue of the unfavorable access route with extravascular deployment of a stent graft following establishment of IEC (so-called extravascular endoconduit technique)

TACE for treatment-naive HCC has different treatment effects depending on central or peripheral tumor-location

Introduction: The purpose of this study was to evaluate the treatment efficacy of transcatheter arterial chemo-embolization (TACE) for treatment-naive hepatocellular carcinoma (HCC) according to tumor location and burden. Methods: Between 2010 and 2019, consecutive patients who underwent TACE as the first treatment were enrolled. Tumors were classified into two categories based on their location, as central or peripheral tumors. Tumors in the central zone, which is within 1 cm of the main trunk or the first branch of the portal vein, were classified as central tumors, while those located in the peripheral zone were classified as peripheral tumors. Patients were grouped according to the HCC location and up-to-7 criteria. Patients with central tumors were classified into the central arm and those with only peripheral tumors were classified into the peripheral arm. Patients within and beyond the up-to-7 criteria were classified into the up-to-7 in and up-to-7 out groups, respectively. Local recurrence-free survival (LRFS) and progression-free survival (PFS) were compared per-nodule (central tumor vs. peripheral tumor) and per-patient (central arm vs. peripheral arm), respectively. The prognostic factors of LRFS and PFS were analyzed by univariate and multivariate analyses. Results: A total of 174 treatment-naive patients with 352 HCCs were retrospectively enrolled. Ninety-six patients and 130 lesions were selected by propensity score matching. Median LRFS was longer for peripheral tumors than central tumors (not reached vs. 3.3 months, p<0.001). Median PFS was: 17.1 months (8.3-24.9) in the peripheral arm & up-to-7 in, 7.0 months (3.3-12.7) in the peripheral arm & up-to-7 out, 8.4 months (4.0-12.6) in the central arm & up-to-7 in, and 3.0 months (1.2-4.9) in the central arm & up-to-7 out groups. The peripheral arm & up-to-7 in group had significantly longer PFS than the other three groups (p=0.013, p=0.015, p<0.001, respectively). Multivariate analysis confirmed that the central zone and central arm were associated with high adjusted hazard ratios for tumor recurrence or death (2.87, p<0.001; 2.89, p<0.001, respectively). Conclusion: Treatment-naive HCCs in the peripheral zone had a longer LRFS and PFS following TACE compared to those in the central zone

Atezolizumab plus bevacizumab-induced intratumoral hemorrhage in a patient with rib metastasis from unresectable hepatocellular carcinoma

Recently, combination therapy with atezolizumab, a humanized monoclonal antiprogrammed death ligand-1 antibody, and bevacizumab, has become available for treatment of unresectable hepatocellular carcinoma (HCC). We herein report a 73-year-old man with advanced stage HCC who developed fatigue during treatment with atezolizumab–bevacizumab combination therapy. Computed tomography identified intratumoral hemorrhage within the HCC metastasis to the right fifth rib metastasis of HCC, which was confirmed on emergency angiography of the right 4th and 5th intercostal arteries and some branches of the subclavian artery confirmed intratumoral hemorrhage, following which transcatheter arterial embolization (TAE) was performed to achieve hemostasis. He continued to receive atezolizumab-bevacizumab combination therapy after TAE, and no rebleeding was seen. Although uncommon, rupture and intratumoral hemorrhage in the HCC metastasis to the ribs can cause life-threatening hemothorax. However, to our knowledge, no previous cases of intratumoral hemorrhage in HCC during atezolizumab–bevacizumab combination therapy have been reported. This is the first report of intratumoral hemorrhage with the combination therapy of atezolizumab and bevacizumab, which was successfully controlled by TAE. Patients receiving this combination therapy should be observed for intratumoral hemorrhage, which can be managed by TAE if it does occur