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1.
Value Health Reg Issues ; 31: 155-162, 2022 Jun 27.
Article in English | MEDLINE | ID: mdl-35772197

ABSTRACT

OBJECTIVES: This study aimed to determine the cost-effectiveness of drug-coated balloon (DCB) angioplasty compared with conventional balloon angioplasty (cPTA) in patients with arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) dysfunction from a Singapore healthcare perspective. METHODS: Existing cost-effectiveness studies comparing DCB and cPTA have not incorporated AVF/AVG abandonment costs. This Markov model-based economic evaluation incorporated AVF/AVG creation and maturation costs on top of routine intervention costs to model a hypothetical cohort of 60-year-old AVF/AVG flow dysfunction patients. Effectiveness was measured in quality-adjusted life-years. Cost-effectiveness was assessed using incremental net monetary benefit (NMB) at a Singapore willingness-to-pay threshold of Singapore dollar (S$)87 000. Deterministic and probabilistic sensitivity analyses were performed to examine parameter uncertainty. To test hypotheses regarding cost-effectiveness, intervention counts per patient, cumulative incidence functions of AVF/AVG abandonment, and survival curves of death were compared between DCB and cPTA. RESULTS: DCB was not cost-effective at 3-year horizon (NMB = -S$1424), but was cost-effective at 1- and 6-year horizons (NMB = S$356 and S$3738, respectively). At 3 years, there was a 34.5% probability of DCB being cost-effective, but at 1- and 6-year horizons there was, respectively, 58.6% and 59.9% probability of DCB being cost-effective. DCB had graphically less AVF/AVG-abandonments, but this was not statistically significant (P = .21). Differences in other parameters were neither graphically nor statistically significant. CONCLUSIONS: With AVF/AVG abandonment considered, DCB may be weakly cost-effective compared with cPTA in treating AVF/AVG flow dysfunction. AV access creation and maturation costs could have important explanatory value in assessing DCB cost-effectiveness.

2.
Cardiovasc Intervent Radiol ; 2022 Mar 02.
Article in English | MEDLINE | ID: mdl-35237860

ABSTRACT

PURPOSE: Drug-coated balloon angioplasty (DCBA) has been studied as a potentially superior option compared to conventional percutaneous transluminal angioplasty (PTA) in treating below-the-knee (BTK) arteries in chronic limb-threatening ischemia (CLTI). The aim of this study is to examine the cost-effectiveness of DCBA versus PTA in BTK arteries based on a randomized controlled trial. MATERIAL AND METHODS: A prospective economic study was embedded in a randomized controlled trial of 138 patients with CLTI. Resource use and health outcomes were assessed at baseline, and at 3, 6 and 12 months post-intervention. Costs were calculated from a societal perspective and health outcomes measured using quality-adjusted life years with probabilistic sensitivity analysis performed to account for subject heterogeneity. RESULTS: Compared with participants randomized to receive PTA, participants randomized to DCBA gained an average baseline-adjusted quality-adjusted life years (QALYs) of .012 while average total costs were USD$1854 higher; this translates to an incremental cost-effectiveness ratio (ICER) of US$154,500 additional cost per QALY gained. However, the estimate of ICER had substantial variance with only 48% of bootstrap ICERs meeting a benchmark threshold of US$57,705 (the average gross domestic product (GDP) per capita of Singapore). CONCLUSION: The use of DCBA in BTK arteries in CLTI patients was not cost-effective compared with PTA. LEVEL OF EVIDENCE: 2, Randomized trial.

4.
Cardiovasc Intervent Radiol ; 45(5): 646-653, 2022 May.
Article in English | MEDLINE | ID: mdl-35059796

ABSTRACT

PURPOSE: To study the safety and efficacy of cutting balloon angioplasty (CBA) followed by paclitaxel drug-coated balloon (PCB) angioplasty for recurrent venous lesions in arteriovenous fistulas (AVFs). MATERIALS AND METHODS: We conducted a prospective single-arm cohort study of CBA followed by PCB angioplasty for recurrent AVF stenoses between September 2017 and April 2019. In total, 44 participants were recruited. Target lesions were included if they had recurred within 12 months post-angioplasty, were > = 0.5 cm upstream from the arteriovenous anastomosis, and did not involve the central veins. Up to two non-target lesions per circuit/participant with the same definition were allowed. Lesions were considered separate when there was an intervening 2-cm segment of normal vessel. Technical success was defined as complete lesion effacement on angioplasty. End-points of target and circuit patency were evaluated clinically at 3, 6, and 12 months post-procedure. RESULT: Technical success was 96% (42/44): Two participants were excluded from analysis due to the need for high-pressure balloon angioplasty as the target lesions did not efface with CBA. The median follow-up duration was 337.5 days. Mean stenosis pre- and post-angioplasty was 69.0% (51.6-84.8) and 20.8% (0-44.8), respectively. The target lesion primary, primary assisted and circuit patency for the entire study population (n = 42) were 61.6 ± 7.8%, 92.7 ± 4.0%, and 54.7 ± 7.9%, respectively, at 12 months. For participants without non-target lesions (n = 22), the rates were 77.3 ± 8.9%, 90.9 ± 6.1%, and 60.7 ± 11.0%, respectively, at 12 months. CONCLUSION: CBA followed by PCB angioplasty appears safe and feasible for treatment of recurrent venous lesions in dysfunctional AVFs.


Subject(s)
Angioplasty, Balloon , Arteriovenous Fistula , Arteriovenous Shunt, Surgical , Angioplasty, Balloon/methods , Coated Materials, Biocompatible , Cohort Studies , Constriction, Pathologic/therapy , Humans , Paclitaxel , Prospective Studies , Renal Dialysis , Treatment Outcome , Vascular Patency
5.
Trials ; 22(1): 945, 2021 Dec 20.
Article in English | MEDLINE | ID: mdl-34930401

ABSTRACT

BACKGROUND: Percutaneous transluminal angioplasty is the current standard treatment for arteriovenous fistula (AVF) stenosis. The mid- and long-term patency with plain balloon angioplasty (PBA) is however far from satisfactory. While paclitaxel-coated balloon angioplasty has been shown to be superior to PBA, concern over its safety profile has recently arisen after a reported possible increased mortality risk with a meta-analysis of large lower limb studies. An angioplasty balloon with a new type of drug coating, the sirolimus-coated balloon (SCB), has been proven to improve patency in the coronary arteries. However, its effect on AV access has yet to be studied. METHODS/DESIGN: This is an investigator-initiated, prospective, multicenter, double-blinded, randomized controlled clinical trial to assess the effectiveness of SCB compared to PBA in improving the patency of AVF after angioplasty. A total of 170 patients with mature AVF that requires PTA due to AVF dysfunction will be randomly assigned to treatment with a SCB or PBA at a 1:1 ratio, stratified by location of AVF and followed up for up to 1 year. The inclusion criteria include [1] adult patient aged 21 to 85 years who requires balloon angioplasty for dysfunctional arteriovenous fistula [2]; matured AVF, defined as being in use for at least 1 month prior to the angioplasty; and [3] successful angioplasty of the underlying stenosis with PBA, defined as less than 30% residual stenosis on digital subtraction angiography (DSA) and restoration of thrill in the AVF on clinical examination. The exclusion criteria include thrombosed or partially thrombosed access circuit at the time of treatment, presence of symptomatic or angiographically significant central vein stenosis that requires treatment with more than 30% residual stenosis post angioplasty, and existing stent placement within the AVF circuit. The primary endpoint of the study is access circuit primary patency at 6 months. The secondary endpoints are target lesion primary patency; access circuit-assisted primary patency; access circuit secondary patency at 3, 6, and 12 months; target lesion restenosis rate at 6 months; total number of interventions; complication rate; and cost-effectiveness. The trial is supported by Concept Medical. DISCUSSION: This study will evaluate the clinical efficacy and safety of SCB compared to PBA in the treatment of AVF stenosis in hemodialysis patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT04409912 . Registered on 1 June 2020.


Subject(s)
Angioplasty, Balloon , Sirolimus , Angioplasty, Balloon/adverse effects , Humans , Multicenter Studies as Topic , Paclitaxel , Prospective Studies , Randomized Controlled Trials as Topic , Renal Dialysis/adverse effects , Sirolimus/adverse effects
6.
Lancet Gastroenterol Hepatol ; 6(12): 1025-1035, 2021 12.
Article in English | MEDLINE | ID: mdl-34695377

ABSTRACT

BACKGROUND: Therapeutic synergism between radiotherapy and immune checkpoint blockade has been observed in preclinical models of hepatocellular carcinoma. We aimed to study the safety and efficacy of sequential radioembolisation with yttrium-90-resin microspheres (Y90-radioembolisation) followed by nivolumab in patients with advanced hepatocellular carcinoma. METHODS: Patients with Child-Pugh A cirrhosis and advanced hepatocellular carcinoma not suitable for curative surgery were treated with Y90-radioembolisation followed by intravenous nivolumab 240 mg 21 days after Y90-radioembolisation and every 2 weeks thereafter. The primary endpoint, assessed in the per-protocol population, was the objective response rate, determined by RECIST version 1.1, defined as the proportion of patients with a confirmed complete or partial response observed for lesions both within and outside the Y90-radioembolisation field. This study is registered with ClinicalTrials.gov, NCT03033446 and has been completed. FINDINGS: 40 patients were enrolled, of whom 36 received Y90-radioembolisation followed by nivolumab. One (3%) patient had a complete response and ten (28%) had a partial response; the objective response rate was 30·6% (95% CI 16·4-48·1). The most common treatment-related adverse events of any grade were pruritus (18 [50%] of 36 patients) and maculopapular rash (13 [36%]). Two (6%) patients experienced grade 3-4 treatment-related adverse events: one patient had a grade 3 increase in alanine aminotransferase levels, grade 3 bilirubin increase, and grade 4 increase in aspartate aminotransferase levels, while the other had a grade 3 maculopapular rash. Five (14%) patients had a treatment-related serious adverse event (Steven-Johnson syndrome, hepatitis E infection, fever, liver abscesses, and ascites). INTERPRETATION: Y90-radioembolisation followed by nivolumab resulted in an encouraging objective response rate in patients with advanced hepatocellular carcinoma, although the activity observed was not as high as the study was powered for. This strategy should be further evaluated in patients with Barcelona Clinic Liver Clinic (BCLC) stage B hepatocellular carcinoma that is ineligible or refractory to transarterial chemoembolisation and patients with BCLC C disease without extrahepatic spread. FUNDING: National Medical Research Council Singapore, Bristol-Myers Squibb, Sirtex.


Subject(s)
Carcinoma, Hepatocellular/drug therapy , Carcinoma, Hepatocellular/therapy , Chemoembolization, Therapeutic/methods , Nivolumab/therapeutic use , Yttrium Radioisotopes/therapeutic use , Administration, Intravenous , Adult , Aged , Carcinoma, Hepatocellular/diagnosis , Combined Modality Therapy/adverse effects , Combined Modality Therapy/methods , Embolization, Therapeutic/adverse effects , Embolization, Therapeutic/methods , Female , Humans , Immune Checkpoint Inhibitors/administration & dosage , Immune Checkpoint Inhibitors/adverse effects , Immune Checkpoint Inhibitors/therapeutic use , Liver Neoplasms/pathology , Male , Microspheres , Middle Aged , Nivolumab/administration & dosage , Nivolumab/adverse effects , Progression-Free Survival , Safety , Severity of Illness Index , Singapore/epidemiology , Treatment Outcome , Yttrium Radioisotopes/administration & dosage , Yttrium Radioisotopes/metabolism
7.
Eur J Vasc Endovasc Surg ; 62(4): 610-621, 2021 Oct.
Article in English | MEDLINE | ID: mdl-34362627

ABSTRACT

OBJECTIVE: To perform an individual patient data level meta-analysis of randomised controlled trials comparing drug coated balloon angioplasty (DCB) against conventional percutaneous transluminal angioplasty (PTA) in the treatment of dysfunctional haemodialysis venous access. METHODS: A search was conducted from inception to 13 November 2020. Kaplan-Meier curves comparing DCB with PTA by target lesion primary patency (TLPP) and access circuit primary patency (ACPP) were graphically reconstructed to retrieve patient level data. One stage meta-analyses with Cox models with random effects shared frailties were conducted to determine hazard ratios (HRs). Dynamic restricted mean survival times (RMST) were conducted in view of violation of the proportional hazards assumption. Conventional two stage meta-analyses and network meta-analyses under random effects Frequentist models were conducted to determine overall and comparative outcomes of paclitaxel concentrations used. Where outliers were consistently detected through outlier and influence analyses, sensitivity analyses excluding those studies were conducted. RESULTS: Among 10 RCTs (1 207 patients), HRs across all models favoured DCB (one stage shared frailty HR 0.62, 95% CI 0.53 - 0.73, p < .001; two stage random effects HR 0.60, 95% CI 0.42 - 0.86, p = .018, I2 = 65%) for TLPP. Evidence of time varying effects (p = .005) was found. TLPP RMST was + 3.54 months (25.0%) longer in DCB treated patients compared with PTA (p = .001) at three years. TLPP at six months, one year, and two years was 75.3% vs. 58.1%, 51.1% vs. 37.1%, and 31.4% vs. 26.0% for DCB and PTA, respectively. The P-Scores within the Frequentist network meta-analysis suggest that higher concentrations of paclitaxel were associated with better TLPP and ACPP. Among six RCTs (854 patients), the one stage model favoured DCB (shared frailty HR 0.72, 95% CI 0.60 - 0.87, p < .001) for ACPP. Conversely, the two stage random effects model demonstrated no significant difference (HR 0.76, 95% CI 0.35 - 1.67, p = .41, I2 = 81%). Sensitivity analysis excluding outliers significantly favoured DCB (HR 0.61, 95% CI 0.41 - 0.91, p = .027, I2 = 62%). CONCLUSION: Overall evidence suggests that DCB is favoured over PTA in TLPP and ACPP.


Subject(s)
Angioplasty, Balloon/instrumentation , Arteriovenous Shunt, Surgical/adverse effects , Cardiovascular Agents/administration & dosage , Coated Materials, Biocompatible , Graft Occlusion, Vascular/therapy , Renal Dialysis , Vascular Access Devices , Adult , Aged , Aged, 80 and over , Angioplasty, Balloon/adverse effects , Cardiovascular Agents/adverse effects , Female , Graft Occlusion, Vascular/etiology , Graft Occlusion, Vascular/physiopathology , Humans , Male , Middle Aged , Randomized Controlled Trials as Topic , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , Vascular Patency
8.
Liver Cancer ; 10(3): 224-239, 2021 Jun.
Article in English | MEDLINE | ID: mdl-34239809

ABSTRACT

INTRODUCTION: Real-world management of patients with hepatocellular carcinoma (HCC) is crucially challenging in the current rapidly evolving clinical environment which includes the need for respecting patient preferences and autonomy. In this context, regional/national treatment guidelines nuanced to local demographics have increasing importance in guiding disease management. We report here real-world data on clinical outcomes in HCC from a validation of the Consensus Guidelines for HCC at the National Cancer Centre Singapore (NCCS). METHOD: We evaluated the NCCS guidelines using prospectively collected real-world data, comparing the efficacy of treatment received using overall survival (OS) and progression-free survival (PFS). Treatment outcomes were also independently evaluated against 2 external sets of guidelines, the Barcelona Clinic Liver Cancer (BCLC) and Hong Kong Liver Cancer (HKLC). RESULTS: Overall treatment compliance to the NCCS guidelines was 79.2%. Superior median OS was observed in patients receiving treatment compliant with NCCS guidelines for early (nonestimable vs. 23.5 months p < 0.0001), locally advanced (28.1 vs. 22.2 months p = 0.0216) and locally advanced with macrovascular invasion (10.3 vs. 3.3 months p = 0.0013) but not for metastatic HCC (8.1 vs. 6.8 months p = 0.6300), but PFS was similar. Better clinical outcomes were seen in BCLC C patients who received treatment compliant with NCCS guidelines than in patients with treatment only allowed by BCLC guidelines (median OS 14.2 vs. 7.4 months p = 0.0002; median PFS 6.1 vs. 4.0 months p = 0.0286). Clinical outcomes were, however, similar for patients across all HKLC stages receiving NCCS-recommended treatment regardless of whether their treatment was allowed by HKLC. CONCLUSION: The high overall compliance rate and satisfactory clinical outcomes of patients managed according to the NCCS guidelines confirm its validity. This validation using real-world data considers patient and treating clinician preferences, thus providing a realistic analysis of the usefulness of the NCCS guidelines when applied in the clinics.

9.
Radiology ; 300(3): 715-724, 2021 09.
Article in English | MEDLINE | ID: mdl-34227886

ABSTRACT

Background There is a paucity of randomized trials demonstrating superior efficacy of drug-coated balloon angioplasty (DCBA) compared with conventional percutaneous transluminal angioplasty (PTA) for below-the-knee arterial disease in patients with -critical limb ischemia. Purpose To compare DCBA versus PTA for below-the-knee lesions in participants with critical limb ischemia through 12 months. Materials and Methods In this prospective, randomized, two-center, double-blind superiority study, participants with critical limb ischemia with rest pain or tissue loss with atherosclerotic disease in the native below-the-knee arteries were randomly assigned (in a one-to-one ratio) to DCBA or PTA after stratification for diabetes and renal failure between November 2013 and October 2017. The primary efficacy end point was angiographic primary patency at 6 months analyzed on an intention-to-treat basis. Secondary end points through 12 months were composed of major adverse events including death and major amputations, wound healing, limb salvage, clinically driven target-lesion revascularization, and amputation-free survival. Primary and binary secondary end points, analyzed by using generalized-linear model and time-to-event analyses, were estimated with Kaplan-Meier survival curves and hazard ratios (Cox regression). Results Seventy participants (mean age, 61 years ± 10 [standard deviation]; 43 men) in the DCBA group and 68 (mean age, 64 years ± 10; 50 men) in the PTA group were evaluated. The percentage of patients with angiographic primary patency at 6 months was 43% (30 of 70) in the DCBA group and 38% (26 of 68) in the PTA group (P = .48). Through 12 months, the percentage of deaths was similar: 21% in the DCBA group and 16% in the PTA group (P = .43). Amputation-free survival rate assessed with Kaplan-Meier curves differed through 12 months: 59% (41 of 70) in the DCBA group compared with 78% (53 of 68) in the PTA group (P = .01). Conclusion In participants with critical limb ischemia, the drug-coated balloon angioplasty group and the conventional percutaneous transluminal angioplasty group had similar primary patency rates at 6 months after treatment of below-the-knee arteries. Amputation-free survival rates through 12 months were higher in the percutaneous transluminal angioplasty group. © RSNA, 2021 Online supplemental material is available for this article.


Subject(s)
Angioplasty, Balloon/instrumentation , Ischemia/surgery , Lower Extremity/blood supply , Paclitaxel/administration & dosage , Peripheral Arterial Disease/surgery , Tubulin Modulators/administration & dosage , Angiography , Contrast Media , Double-Blind Method , Drug Delivery Systems , Female , Humans , Iohexol , Ischemia/diagnostic imaging , Limb Salvage , Lower Extremity/diagnostic imaging , Male , Middle Aged , Peripheral Arterial Disease/diagnostic imaging , Prospective Studies
10.
Br J Radiol ; 94(1124): 20210061, 2021 Aug 01.
Article in English | MEDLINE | ID: mdl-34106779

ABSTRACT

Hepatic venous pressure gradient (HVPG) is the gold-standard for measurement of portal hypertension, a common cause for life-threatening conditions such as variceal bleeding and hepatic encephalopathy. HVPG also plays a crucial role in risk stratification, treatment selection and assessment of treatment response. Thus recognition of common pitfalls and unusual hepatic venous conditions is crucial. This article aims to provide a radiographical and clinical guide to HVPG with representative clinical cases.


Subject(s)
Hypertension, Portal/diagnostic imaging , Hypertension, Portal/physiopathology , Portal Pressure , Adult , Female , Humans , Male , Middle Aged
12.
J Vasc Interv Radiol ; 31(12): 1969-1977.e1, 2020 12.
Article in English | MEDLINE | ID: mdl-33139186

ABSTRACT

PURPOSE: To review outcomes of patients with critical limb ischemia (CLI) who underwent conventional percutaneous transluminal angioplasty (PTA) as first-line treatment for revascularization. MATERIALS AND METHODS: Retrospective review of 3,303 angioplasty procedures on 2,402 limbs in 1,968 patients with CLI was conducted. Mean patient age was 68 years ± 11, and 1,057 patients (54%) were male. Diabetes mellitus (DM) was present in 1,736 patients (88%), and end-stage renal disease (ESRD) in 579 (29%). A majority of patients (90%) had tissue loss. Limb salvage rates were generated by Kaplan-Meier plot. Univariate and multivariate Cox regression analysis was conducted to investigate associations between clinical predictors and time-to-event outcome. RESULTS: Limb salvage rates at 1, 3, 5, and 10 years were 75%, 73%, 72%, and 62%, respectively, and overall survival rates were 79%, 64%, 56%, and 34%, respectively. In multivariable Cox regression analysis with the outcome of major amputation, significant predictors included age < 69 years (P = .032), Malay race (P = .029), DM (P < .001), history of cerebral vascular disease (P = .003), ESRD (P < .001), Rutherford classification (P = .042), repeat intervention (P = .034), and number of straight-line flows (P < .001) and plantar arch integrity (P < .001) on completion angiography. Significant associations with mortality were age < 69 years (P < .001), male sex (P = .030), Malay race (P = .027), history of ischemic heart disease (P < .001), ESRD (P < .001), and repeat intervention (P < .001). CONCLUSIONS: PTA as first-line revascularization for patients with CLI is safe and effective. Further studies are suggested to validate the outcome predictive model.


Subject(s)
Angioplasty, Balloon , Ischemia/therapy , Limb Salvage , Peripheral Arterial Disease/therapy , Aged , Amputation , Angioplasty, Balloon/adverse effects , Angioplasty, Balloon/instrumentation , Angioplasty, Balloon/mortality , Comorbidity , Critical Illness , Databases, Factual , Female , Humans , Ischemia/diagnostic imaging , Ischemia/mortality , Limb Salvage/adverse effects , Limb Salvage/mortality , Male , Middle Aged , Peripheral Arterial Disease/diagnostic imaging , Peripheral Arterial Disease/mortality , Retrospective Studies , Risk Assessment , Risk Factors , Singapore , Stents , Tertiary Care Centers , Time Factors , Treatment Outcome
13.
Abdom Radiol (NY) ; 46(4): 1737-1745, 2021 04.
Article in English | MEDLINE | ID: mdl-33052468

ABSTRACT

OBJECTIVE: To describe rates and management strategies of arterial dissections in transarterial chemoembolization (TACE) and Yttrium-90 selective internal radiotherapy (90Y SIRT) for primary and secondary liver tumours. MATERIALS AND METHODS: This retrospective review included 1377 hepatic angiographies between May 2010 and June 2015 in a single centre for TACE and 90Y SIRT of liver tumours. The angiogram results, management, treatment outcomes and follow-up angiography/imaging findings were recorded. RESULTS AND DISCUSSION: Twelve cases of arterial dissections (12/1377, 0.87%) were documented. Three dissections (3/633, 0.47%) occurred during TACE, seven (7/449, 1.56%) during pre-treatment planning angiographies (PTPA) for 90Y SIRT, and two (2/249, 0.80%) during the treatment procedure of 90Y SIRT. The preferred management strategy was to manoeuvre past the dissection and complete the procedure, which was achieved in six patients (50%). Angioplasty with stenting was performed in one patient. In three patients, the procedure was held off for up to 3 months to allow the dissection to heal before repeating the procedure. A dissection that occurred during PTPA was detected only when the patient returned for 90Y SIRT. PTPA was immediately repeated for this patient. The last patient opted for sorafenib. Residual 50% stenosis was seen in one patient on follow-up hepatic angiography, but he was otherwise asymptomatic. In the remaining patients, no residual dissection or clinical sequelae was observed on follow-up. CONCLUSION: Arterial dissection is a rare but important complication of transarterial locoregional therapy. Where possible, attempts should be made at completing the therapy. Deferring treatment can be considered as dissections usually heal within 3 months. LEVEL OF EVIDENCE: Level 4, case series.


Subject(s)
Carcinoma, Hepatocellular , Chemoembolization, Therapeutic , Liver Neoplasms , Carcinoma, Hepatocellular/diagnostic imaging , Carcinoma, Hepatocellular/radiotherapy , Dissection , Humans , Liver Neoplasms/diagnostic imaging , Liver Neoplasms/radiotherapy , Male , Retrospective Studies , Treatment Outcome , Yttrium Radioisotopes/therapeutic use
14.
Ann Acad Med Singap ; 49(6): 360-366, 2020 Jun.
Article in English | MEDLINE | ID: mdl-32712633

ABSTRACT

INTRODUCTION: To evaluate the mid-term outcomes of regular surveillance venography with or without percutaneous transluminal angioplasty (PTA) in haemodialysis patients presenting with central venous occlusive disease. MATERIALS AND METHODS: A single-centre retrospective analysis of haemodialysis patients who presented with central vein occlusion (CVO) and central vein stenosis (CVS) between January 2008 and December 2011 was performed. CVO and significant CVS were defined as 100% and >50% luminal narrowing, respectively. Upon successful angioplasty on first presentation, patients were followed up with regular surveillance venography within 3-6 months of the intervention and were re-treated when a significant stenosis or occlusion was demonstrated. Data on patient's demographics, comorbidities, presenting symptoms, type of upper limb dialysis access, lesion characteristics and complications were collected. Technical success, primary patency and primary assisted patency were analysed. RESULTS: Thirty-five patients with CVO and 77 patients with CVS were enrolled. The technical success of initial PTA was 77% and 73% for the CVO and CVS groups, respectively. The primary patency at 3 months was 65% and 55% for the CVO group and CVS group, respectively (P = 0.32). The primary assisted patency at 1 year was 88% and 99% for the CVO group and CVS group, respectively (P = 0.009). At 2 years, the primary assisted patency were 77% and 90%, respectively (P = 0.07). There was significant difference in the overall primary assisted patency (P = 0.048) between the CVO and CVS groups. CONCLUSION: CVOs are more difficult to treat than CVS. High primary assisted patency rates can be achieved with surveillance venography, albeit at the expense of increased number of interventions. Further cost effectiveness studies need to be performed to study the true benefit of our surveillance programme.


Subject(s)
Angioplasty, Balloon , Catheterization, Central Venous , Humans , Phlebography , Renal Dialysis , Retrospective Studies , Stents , Treatment Outcome , Vascular Patency
15.
Cardiovasc Intervent Radiol ; 43(7): 963-970, 2020 Jul.
Article in English | MEDLINE | ID: mdl-32409998

ABSTRACT

PURPOSE: The exact significance of type 2 endoleaks (T2ELs) and the indication and efficacy of treatment are widely debated. We report our experience with managing T2ELs in a tertiary Asian centre. MATERIALS AND METHODS: This was a retrospective study of patients who underwent endovascular abdominal aortic aneurysm repair (EVAR) between February 2006 and December 2016. Patients with T2ELs were identified, and their data were analysed. RESULTS: A total of 156 patients underwent EVAR, of which 67 (42.9%) developed T2ELs. Seven were lost to follow-up. The remaining 60 patients had a mean follow-up period of 50.3 ± 33.9 months-34 (56.7%) experienced T2ELs early and the rest (43.3%) had late T2ELs. Forty-one patients had isolated T2EL, whilst 19 had concomitant T1EL and/or T3EL. Spontaneous resolution occurred in 25 patients (41.7%). All T2ELs with stable sac size were on continued surveillance. Amongst those with persistent T2ELs associated with sac growth (n = 17), 14 underwent intervention, of which 7 (50%) received > 1 embolisation procedure. A total of 16 transarterial embolisation and 8 translumbar embolisation procedures were performed. Technical success rate was 75%. In the intervention group, 5 (35.7%) had complete and sustained resolution, 7 had persistent/recurrent T2ELs but stable sac size, and 2 had progressive sac expansion. Overall mortality due to sac rupture occurred in 2 patients with concomitant T2EL and T1EL/T3EL. CONCLUSION: T2ELs are common, albeit mostly benign if occurring in isolation and not in association with sac growth. Achieving complete T2EL resolution with embolisation is difficult even with reinterventions. LEVEL OF EVIDENCE: Level 2B, retrospective study.


Subject(s)
Aortic Aneurysm, Abdominal/surgery , Embolization, Therapeutic/methods , Endoleak/therapy , Aged , Angiography, Digital Subtraction/methods , Endoleak/diagnostic imaging , Female , Humans , Male , Retrospective Studies , Treatment Outcome
16.
J Vasc Interv Radiol ; 31(6): 869-875, 2020 06.
Article in English | MEDLINE | ID: mdl-32331919

ABSTRACT

This paper describes country-wide special measures undertaken for interventional radiology staff during the current coronavirus disease 2019 (COVID-19) pandemic. Although each interventional radiology service around the world faces unique challenges, the principles outlined in this article will be useful when designing or strengthening individual practices and integrating them within wider hospital and national measures. Moving beyond the current outbreak, these measures will be useful for any future infectious diseases which are likely to arise.


Subject(s)
Coronavirus Infections/complications , Coronavirus Infections/prevention & control , Pandemics/prevention & control , Pneumonia, Viral/complications , Pneumonia, Viral/prevention & control , Radiology, Interventional/methods , COVID-19 , Humans , Singapore
17.
Singapore Med J ; 62(10): 546-553, 2021 10.
Article in English | MEDLINE | ID: mdl-32299186

ABSTRACT

INTRODUCTION: Image-guided thermal ablation, preferably with ultrasonography (US), is increasingly used for treatment of small liver tumours. Perfluorobutane-contrast-enhanced US (pCEUS) is a promising tool that may allow for targeting of tumours that are otherwise imperceptible on greyscale US. Although pCEUS has been reported to be effective, the literature has been limited outside of Japan and South Korea. We aimed to provide data that supports the use of pCEUS in the thermal ablation of sonographically occult liver tumours. METHODS: We conducted a retrospective single-centre study of 35 consecutive patients who underwent pCEUS-guided ablation of 48 liver tumours with a median size of 1.2 cm. Periprocedural, one-month post-treatment and relevant follow-up imaging studies were reviewed. Electronic records were also obtained, with long-term follow-up data of 12-28 months being available for 32 patients. RESULTS: 36 (75%) tumours that were imperceptible on greyscale US became visible with pCEUS. Overall, complete tumour ablation at one month was 89%. 1 (3%) patient developed a major complication following treatment, while 6 (17%) had minor post-treatment complaints. The local tumour progression rate was 17%, with a median time of 14 months. CONCLUSION: pCEUS has a role in US-guided thermal ablation of liver tumours, offering a high technical success rate that is comparable to reported data. Additional benefits may include improved procedural time and freedom from ionising radiation.


Subject(s)
Carcinoma, Hepatocellular , Catheter Ablation , Liver Neoplasms , Carcinoma, Hepatocellular/diagnostic imaging , Carcinoma, Hepatocellular/pathology , Carcinoma, Hepatocellular/surgery , Catheter Ablation/methods , Fluorocarbons , Humans , Liver Neoplasms/diagnostic imaging , Liver Neoplasms/pathology , Liver Neoplasms/surgery , Retrospective Studies , Treatment Outcome , Ultrasonography
18.
J Vasc Interv Radiol ; 31(4): 601-606, 2020 Apr.
Article in English | MEDLINE | ID: mdl-32127314

ABSTRACT

PURPOSE: To report the outcome and distal access patency of the Subintimal Arterial Flossing with Antegrade-Retrograde Intervention (SAFARI) technique for chronic total occlusion (CTO) in critical limb ischemia (CLI). MATERIALS AND METHODS: From January 2009 to June 2015, 220 SAFARI procedures were performed for 200 limbs in 191 patients (108 males [56.5%]; median age, 70 years old; range, 36 to 97 years old) with CLI (9.4% were Fontaine classification 3; and 90.6% were Fontaine classification 4). Distal access was obtained from the distal superficial femoral artery (n = 6), popliteal artery (n = 49), anterior tibial artery (n = 56), dorsalis pedis (n = 51), peroneal artery (n = 12), posterior tibial artery (n = 45), and lateral plantar artery (n = 1). Distal access hemostasis was obtained with internal balloon tamponade in 71.4% (n = 157). Outcome measurements were technical success, freedom from major amputation and complications. Preprocedural angiograms of clinically driven repeat interventions were reviewed in 73 cases for distal access patency. RESULTS: Technical success was achieved in 80.5% (n = 177). Reasons for technical failure include inability to obtain distal access (n = 3), cross the occlusion retrogradely (n = 16), re-enter the true lumen (n = 9), and achieve antegrade blood flow after the procedure (n = 15). Freedom from major amputation for technically successful procedures was 84.7%, 82.9%, and 81.9% at 6, 12, and 24 months, respectively. There were 3 cases of distal access bleeding with 1case that required coil embolization. The distal access remained patent in 80.8% of observable cases with repeated endovascular intervention. CONCLUSIONS: Distal retrograde arterial access (SAFARI) technique is safe and effective in the treatment of CTOs in the context of CLI, after failure of antegrade revascularization.


Subject(s)
Endovascular Procedures , Ischemia/therapy , Lower Extremity/blood supply , Peripheral Arterial Disease/therapy , Vascular Patency , Adult , Aged , Aged, 80 and over , Amputation , Chronic Disease , Critical Illness , Endovascular Procedures/adverse effects , Female , Humans , Ischemia/diagnostic imaging , Ischemia/physiopathology , Limb Salvage , Male , Middle Aged , Peripheral Arterial Disease/diagnostic imaging , Peripheral Arterial Disease/physiopathology , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome
19.
Cardiovasc Intervent Radiol ; 43(3): 478-487, 2020 Mar.
Article in English | MEDLINE | ID: mdl-31705243

ABSTRACT

OBJECTIVES: To determine the rate of prophylactic embolization of extrahepatic vessels in patients undergoing yttrium-90 selective internal radiotherapy (90Y SIRT) for hepatocellular carcinoma (HCC) with the use of catheter-directed computed tomography hepatic angiography (CD-CTHA). MATERIALS AND METHODS: This retrospective study included 186 HCC patients who received 90Y SIRT from May 2010 to June 2015 in a single institution. All procedures were performed in a hybrid angiography-CT suite equipped with digital subtraction angiography (DSA) and CD-CTHA capabilities. CD-CTHA was performed during pre-treatment hepatic angiography. 90Y SIRT was administered approximately 2 weeks later. Selective prophylactic embolization of extrahepatic vessels was performed if extrahepatic enhancement was seen on CD-CTHA or if an extrahepatic vessel opacified on DSA/CD-CTHA despite the final microcatheter position for 90Y microsphere delivery being beyond the origin of this vessel. RESULTS: Thirty-five patients (18.8%) required selective embolization of extrahepatic vessels. Technical success of 90Y SIRT was 99.5%. Two patients (1.1%) developed radiation-induced gastrointestinal ulceration, and one (0.54%) developed radiation-induced pneumonitis. Extrahepatic uptake of 90Y microspheres was seen in the gallbladder of one patient without significant complications. CONCLUSION: The use of CD-CTHA in 90Y SIRT of HCC was associated with a low rate of prophylactic embolization of extrahepatic vessels while maintaining a high technical success rate of treatment and low rate of complications. LEVEL OF EVIDENCE: Level 4, case series.


Subject(s)
Brachytherapy/methods , Carcinoma, Hepatocellular/radiotherapy , Computed Tomography Angiography/instrumentation , Computed Tomography Angiography/methods , Liver Neoplasms/radiotherapy , Radiography, Interventional/methods , Yttrium Radioisotopes , Carcinoma, Hepatocellular/diagnostic imaging , Catheters , Female , Hepatic Artery/diagnostic imaging , Humans , Liver/diagnostic imaging , Liver Neoplasms/diagnostic imaging , Male , Middle Aged , Radiography, Interventional/instrumentation , Retrospective Studies
20.
J Endovasc Ther ; 26(5): 732-735, 2019 10.
Article in English | MEDLINE | ID: mdl-31257993

ABSTRACT

Purpose: To report a candy-plug technique using a Zenith Alpha stent-graft to occlude the distal false lumen in a patient with a complicated chronic type B aortic dissection. Case Report: A 50-year-old male smoker presented with chest pain due to rapidly growing complicated chronic type B aortic dissection. Computed tomography angiography (CTA) showed the dissection extending from distal to the origin of the left subclavian artery (LSA) down to the left femoral artery. There was fusiform aneurysmal dilatation of the proximal descending aorta measuring up to 5.8 cm in diameter. He underwent left carotid-subclavian artery bypass, thoracic endovascular aortic repair with a Zenith Alpha stent-graft, a left common carotid artery chimney, and embolization of the proximal LSA. Serial CTA showed persistent false lumen flow. A decision was made to occlude the distal large false lumen using the candy-plug technique. A 44×125-mm Zenith Alpha stent-graft was used to prepare the candy plug. A gutter leak and a type Ia endoleak were embolized via a left brachial artery approach. At 2.5 years, imaging showed the candy plug in position, no endoleak, and the thrombosed false lumen in the thoracic aorta reduced in size. Conclusion: The candy-plug technique is useful in facilitating complete occlusion of the false lumen in chronic aortic dissection, which avoids an open procedure and the risk of higher morbidity.


Subject(s)
Aneurysm, Dissecting/surgery , Aortic Aneurysm/surgery , Blood Vessel Prosthesis Implantation/instrumentation , Blood Vessel Prosthesis , Endovascular Procedures/instrumentation , Prosthesis Design , Stents , Acute Disease , Aneurysm, Dissecting/diagnostic imaging , Aneurysm, Dissecting/physiopathology , Aortic Aneurysm/diagnostic imaging , Aortic Aneurysm/physiopathology , Chronic Disease , Humans , Male , Middle Aged , Treatment Outcome
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