Transarterial embolization of gastrointestinal hemorrhages: retrospective study in Siriraj Hospital.

Objective: To determine the technical and clinical results of transarterial embolization of nonvariceal gastrointestinal hemorrhages (GIH) which cannot be managed endoscopically. Methods: A retrospective review of 21 embolizations in 77 patients who underwent arteriography for acute nonvariceal GIH was performed. Gastrointestinal hemorrhage was classified by the site of bleeding as upper, lower, or transpapillar including hemobilia and pancreatic duct bleeding. Clinical parameters and embolized data were assessed for clinical success. In-hospital mortality was also reported. Results: Technical success (bleeding target devascularization) was achieved in all 21 patients (100%). The complete technical success rate was 71.4% (15 out of 21 patients) while the partial technical success rate was 28.6% (6 out of 21 patients). The complication rate was very low (9.5%) including only 2 cases of bowel ischemia. No other complications were found. Eight out of 21 patients (38.1%) had rebleeding within 3 days. Upper GIH seemed to recur more frequently (4 out of 7 patients representing 57.1%) within the first 3 days than did lower (4 out of 11 patients at 36.4%) and transpapillar (0 of 3) GIH. Clinical success (no rebleeding after 30 days) was achieved in 11 of 21 patients (52.4%) including 3 out of 7 patients (42.9%) with UGIH, 7 of 11 patients (63.3%) with LGIH, and all patients with transpapillar hemorrhage. The overall mortality rate was 42.9% (9 out of 21 patients), with 42.9% (3 of 7 patients) for UGIH, 27.3% (3 of 11 patients) for LGIH and none for transpapillar hemorrhage. GIH was the cause of death in 6 of 9 patients (66.7%) while 3 out of 9 patients (33.3%) died from the other causes. Conclusion: Transarterial embolization is an effective treatment modality for lower GIH and transpapillar hemorrhage but less effective in upper GIH.

Endovascular abdominal aortic aneurysm repair in high risk patients: outcomes of management.

BACKGROUND: The concomitant cardiopulmonary disease precluded the elective repair for abdominal aortic aneurysm (AAA) with acceptable risk. The endovascular abdominal aortic aneurysm repair (EVAR) has become an alternative method for the treatment of AAA with high-risk comorbidities. OBJECTIVE: Evaluate the results of EVAR in high-risk patients with large AAA. MATERIAL AND METHOD: A prospective study of high-risk patients with large AAA and suitable morphology who underwent EVAR between August 2003 and August 2005 was conducted. The long-term outcomes were observed up to December 2006. The comorbidities, size of aneurysm, types of procedures, operative time, amount of blood loss and transfusion, length of postoperative stay in intensive care unit and hospital, postoperative complications and mortality were analyzed. RESULTS: Eight patients (7 males and 1 female) with the mean age of 71.4 years (range 66-83 years) were included in the present study. The comorbidities were six of compromised cardiac status, one of severe pulmonary disease and one of morbid obesity. The average size of aneurysm was 6.2 +/- 0.64 centimetres. One patient also had large bilateral iliac artery aneurysms. Seven patients underwent EVAR with bifurcated aortic stent graft and one proceeded with aorto uni-iliac stent graft. Three patients underwent preoperative coil embolisation into internal iliac arteries when the distal landing zones at the external iliac arteries were considered. The mean estimated blood loss was 369cc and the mean blood transfusion was 0.88 units. There were no perioperative mortality, early graft occlusion, AAA rupture and open conversion in the present study. One patient had cardiac arrest due to upper airway obstruction but with successful treatment. Type II endoleak was observed in one patient and successfully treated by expectant management. One limb of bifurcated stent graft was occluded at the 5th month post EVAR and was successfully treated by artery bypass surgery at both groins. The 3-year primary graft limb patency was 87.5% (7/8). The survivals of patients at 1, 2 and 3 years were 100%, 100% and 87.5% respectively. The cause of death in one patient was not related to EVAR. CONCLUSION: EVAR may be a safe and effective alternative to open AAA repair especially in high-risk patients.

Treatment of hepatocellular carcinoma by injection of iodine*131-labelled lipiodol into the hepatic artery.

The therapeutic efficacy iodine*131-labelled Lipiodol was studies in the treatment of hepatocellular carcinoma (HCC). The results of the treatment were evaluated for four aspects: size of the tumour; serum alphafetoprotein level ; the quality of the patient’s life;and the survival rate. The hepatocellular carcinoma was diagnosed by evidence of mass in the liver using either computed tomography or ultrasonography with tissue biopsy and/or a high level of alphafetoprotein of more than 500 U. Twenty patients were randomized into two groups for comparison. The patients in group A were treated by intrahepatic injection of iodine*131-labelled Lipiodol 60 miliCuries(mCi). The patients in group B were treated by intra-hepatic injection of a mixture of Lipiodol and chemotherapeutic agents, mitomicin c 20 mg. and 5-fluoracil 500 mg., followed by selective hepatic artery embolisation of small pieces of gelatin sponge (gelfoam). Both groups were evaluated by computed tomography (CT) and the possible repeat of treatment protocol after two months. There were no serious side-effects or major complications in either group of patients. The patients’ conditions worsened by 40 percent in both groups. The tomours’ sizes remained unchanged by 50 percent in both groups. The serum alphafetoprotein levels had increased by 40 percent in group A, and remained unchanged by 50 percent in group B. The survival rates at one and two years in group A were 20 and 20 percent, and in group B there were 30 and 0 percent, respectively. Satisfactory results were obtained in the treatment of small HCC, size less than 5 cm. with intra-hepatic artery injection of iodine*131-labelled Lipiodol. In large HCC (>10cm) no response by the tumour was seen in either group. This was the first study of this type performed in Thailand.