Prospective Phase II trial of drug-eluting bead chemoembolization for liver transplant candidates with hepatocellular carcinoma and marginal hepatic reserve.

Purpose: To determine whether chemoembolization using drug-eluting beads (DEB-TACE) is safe and effective for liver transplantation candidates with liver-limited hepatocellular carcinoma (HCC) without vascular invasion and baseline hepatic dysfunction. Materials and methods: Seventeen adult liver transplantation candidates (median age 66 years, range 58-73 years; 13 men) with HCC were treated with DEB-TACE as a part of Stage 1 of a prospective single-institution Phase II trial. All patients had marginal hepatic reserve based on at least one of the following criteria: ascites (n=14), bilirubin between 3 and 6 mg/dL (n=5), AST 5-10 times upper normal limit (n=1), INR between 1.6 and 2.5 (n=4), portal vein thrombosis (n=2), and/or portosystemic shunt (n=2). Primary study objectives were safety and best observed radiographic response. Results: Thirty-seven DEB-TACE procedures were performed. Objective response rate and disease control rate were 63% and 88%, respectively. HCC progression was observed in 12 patients. Median time to progression was 5.6 months (range 0.9-13.6 months). Within 1 month following DEB-TACE, 13 patients (76%) developed grade 3 or 4 AE attributable to the procedure. Four patients (all within Milan Criteria) were transplanted (2.7-6.9 months after DEB-TACE), and 12 patients died (1.8-32 months after DEB-TACE). All deaths were due to liver failure that was either unrelated to HCC (n=5), in the setting of metastatic HCC (n=5), or in the setting of locally advanced HCC (n=2). Mortality rate at 1 month was 0%. Conclusions: DEB-TACE achieves tumor responses but carries a high risk of hepatotoxicity for liver transplant candidates with HCC and marginal hepatic reserve

Abdominal aortic aneurysm repair with the Zenith stent graft: Short to midterm results

AbstractPurpose: The purpose of this study was to assess the short-term and mid-term results of endovascular aneurysm repair with the Zenith stent graft in a single-center prospective study. Method: Between October 1998 and July 2001, we used the Zenith stent graft for elective endovascular aneurysm repair in 116 patients, six of whom were women. The mean age was 75 years, and the mean aneurysm diameter was 60.3 ± 8.8 mm. Stent grafts were oversized 10% to 20% relative to computed tomographic (CT) scan-based diameter measurements. All repairs were performed in the operating room through surgically exposed femoral arteries. The results were assessed before discharge with three-phase, contrast-enhanced CT scan and plain abdominal radiograph. These studies were repeated at 1, 6, 12, and 24 months after operation. Follow-up periods ranged from 1 to 34 months. Results: No failed insertions and no conversions to open surgery occurred. The diameter of the main body of the stent graft was 28 mm or more in 73 patients (63%). Additional stents were inserted during surgery to treat kinking in eight patients (6.9%) and renal artery encroachment in two patients (1.7%). Mean fluoroscopy time was 35.1 ± 18.3 minutes, contrast load was 146 ± 53 mL (350 mg/mL), and estimated blood loss was 249 ± 407 mL. The major complication rate was 9.5%, and the minor complication rate was 10.3%. The perioperative complications were myocardial infarction in four patients, arrythmia in four patients, and pulmonary embolism, renal failure, stroke, small bowel obstruction, femoral stenosis, digital embolism, and graft limb thrombosis in one patient each. All 116 patients went home from the hospital, but one patient died 2 weeks later of a combination of pulmonary embolism and myocardial infarction. Endoleak was seen on the first CT scan in 16 patients (15%); 15 were type II, and one was type III. No endoleaks of type I or IV were seen. Additional interventions were performed for each of the following conditions: type II endoleak (n = 4), type III endoleak (n = 1), femoral clamp injury (n = 1), renal artery stenosis (n = 1), and graft limb occlusion (n = 1). One patient had acute aneurysm dilatation and rupture caused by a type II endoleak through the inferior mesenteric artery 6 months after stent graft implantation. No cases were seen of late graft occlusion, stent graft migration, stent fracture, barb fracture, or secondary endoleak. Conclusion: The Zenith device is safe, versatile, and effective in the short to medium term. Most patients need wide stent grafts (≥28 mm proximally and ≥16 mm distally) to achieve 10% to 20% oversizing to prevent type I endoleak. (J Vasc Surg 2002;36:217-25.

Rex Shunt Preoperative Imaging: Diagnostic Capability of Imaging Modalities

The purpose of this study was to evaluate the diagnostic capability of imaging modalities used for preoperative mesenteric-left portal bypass (“Rex shunt”) planning. Twenty patients with extrahepatic portal vein thrombosis underwent 57 preoperative planning abdominal imaging studies. Two readers retrospectively reviewed these studies for an ability to confidently determine left portal vein (PV) patency, superior mesenteric vein (SMV) patency, and intrahepatic left and right PV contiguity. In this study, computed tomographic arterial portography allowed for confident characterization of left PV patency, SMV patency and left and right PV continuity in 100% of the examinations. Single phase contrast-enhanced CT, multi-phase contrast-enhanced CT, multiphase contrast-enhanced MRI, and transarterial portography answered all key diagnostic questions in 33%, 30%, 0% and 8% of the examinations, respectively. In conclusion, of the variety of imaging modalities that have been employed for Rex shunt preoperative planning, computed tomographic arterial portography most reliably allows for assessment of left PV patency, SMV patency, and left and right PV contiguity in a single study

Complications Associated with the Percutaneous Insertion of Fiducial Markers in the Thorax

Radiosurgery requires precise lesion localization. Fiducial markers enable lesion tracking, but complications from insertion may occur. The purpose of this study was to describe complications of fiducial marker insertion into pulmonary lesions. Clinical and imaging records of 28 consecutive patients with 32 lung nodules or masses who underwent insertion of a total of 59 fiducial markers before radiosurgery were retrospectively reviewed. Eighteen patients (67%) developed a pneumothorax, and six patients (22%) required a chest tube. The rates of pneumothorax were 82% and 40%, respectively, when 18-gauge and 19-gauge needles were used for marker insertion (P = 0.01). Increased rate of pneumothorax was also associated with targeting smaller lesions (P = 0.03) and tumors not in contact with the pleural surface (P = 0.04). A total of 11 fiducials (19%) migrated after insertion into the pleural space (10 markers) or into the airway (1 marker). Migration was associated with shorter distances from pleura to the marker deposition site (P = 0.04) and with fiducial placement outside of the target lesion (P = 0.03). Fiducial marker placement into lung lesions is associated with a high risk of pneumothorax and a risk of fiducial migration

90Y Radioembolization for Hepatic Malignancy in Patients with Previous Biliary Intervention: Multicenter Analysis of Hepatobiliary Infections

PurposeTo determine the frequency of hepatobiliary infections after transarterial radioembolization (TARE) with yttrium 90 (90Y) in patients with liver malignancy and a history of biliary intervention.Materials and MethodsFor this retrospective study, records of all consecutive patients with liver malignancy and history of biliary intervention treated with TARE at 14 centers between 2005 and 2015 were reviewed. Data regarding liver function, 90Y dosimetry, antibiotic prophylaxis, and bowel preparation prophylaxis were collected. Primary outcome was development of hepatobiliary infection.ResultsOne hundred twenty-six patients (84 men, 42 women; mean age, 68.8 years) with primary (n = 39) or metastatic (n = 87) liver malignancy and history of biliary intervention underwent 180 procedures with glass (92 procedures) or resin (88 procedures) microspheres. Hepatobiliary infections (liver abscesses in nine patients, cholangitis in five patients) developed in 10 of the 126 patients (7.9%) after 11 of the 180 procedures (6.1%; nine of those procedures were performed with glass microspheres). All patients required hospitalization (median stay, 12 days; range, 2–113 days). Ten patients required percutaneous abscess drainage, three patients underwent endoscopic stent placement and stone removal, and one patient needed insertion of percutaneous biliary drains. Infections resolved in five patients, four patients died (two from infection and two from cancer progression while infection was being treated), and one patient continued to receive suppressive antibiotics. Use of glass microspheres (P = .02), previous liver resection or ablation (P = .02), and younger age (P = .003) were independently predictive of higher infection risk.ConclusionInfectious complications such as liver abscess and cholangitis are uncommon but serious complications of transarterial radioembolization with 90Y in patients with liver malignancy and a history of biliary intervention.© RSNA, 2018Online supplemental material is available for this article