The use of mechanical thrombectomy devices in the management of acute peripheral arterial occlusive disease.

A number of percutaneous mechanical thrombectomy devices are currently being used or undergoing clinical evaluation for the treatment of acute and chronic limb-threatening ischemia. Preliminary studies on the safety, efficacy, and device limitations have spurred an interest in percutaneous techniques for thrombus debulking as stand-alone therapy or an adjunct to pharmacologic thrombolysis. The devices have various mechanisms or combinations of mechanisms to optimize thrombus removal. Efficacy of thrombus removal is balanced by the propensity for vessel wall damage and distal embolization, especially for wall-contact devices (Arrow-Trerotola device and Cragg and Castañeda brushes). Initial experience in hemodialysis graft occlusion has subsequently moved on to peripheral arterial occlusions. Although the U.S. Food and Drug Administration has approved eight mechanical thrombectomy devices (MTDs) for use in thrombosed hemodialysis grafts, only the AngioJet LF140 is currently approved for use in peripheral arterial occlusive disease. Nevertheless, numerous clinical articles and abstracts have reported the "off-label" use of MTDs in the management of limb-threatening ischemia. A description of the eight MTDs and a review of the current literature on use of MTDs for acute peripheral arterial occlusive disease are provided.

Sarcomas metastatic to the liver: response and survival after cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol chemoembolization.

PURPOSE: To evaluate the response to and survival after chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol for patients with sarcomas metastatic to the liver that are surgically unresectable. MATERIALS AND METHODS: Sixteen patients were treated. Primary tumors included 11 gastrointestinal leiomyosarcomas, two splenic angiosarcomas, one leiomyosarcoma of the broad ligament, one leiomyosarcoma of the inferior vena cava, and one malignant fibrous histiocytoma of the colon. Chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol particles was performed 1-5 times at approximately monthly intervals (mean, 2.8). Pre- and posttreatment cross-sectional imaging was performed 1 month after completion of treatment and then every 3 months. Thirty-day response was graded according to World Health Organization/Eastern Cooperative Oncology Group criteria. Survival was calculated with use of Kaplan-Meier analysis. RESULTS: Two patients (13%) exhibited partial morphologic response, 11 patients (69%) were morphologically stable, and three (19%) demonstrated progression of disease 30 days after completion of treatment. Among the 13 responders, two underwent partial hepatectomy after initial treatment. Seven developed intrahepatic progression at a mean of 10 months and a median time of 8 months. The remaining four patients had no documented intrahepatic progression at the time of last imaging follow-up. Nine patients developed extrahepatic progression at a mean time of 6.3 months and a median time of 6 months, of whom four underwent additional surgical resection. Response to therapy was based on time of first intervention. Cumulative survival from time of diagnosis with use of Kaplan-Meier analysis was 81% at 1 year, 54% at 2 years, and 40% at 3 years. Median survival time was 20 months. Cumulative survival from initial chemoembolization was 67% at 1 year, 50% at 2 years, and 40% at 3 years, with a median survival time of 13 months. The thirty-day mortality rate was zero. CONCLUSION: Durable tumor response with chemoembolization is possible in this form of metastatic disease, which is highly resistant to systemic chemotherapy.

Upper gastrointestinal hemorrhage secondary to erosion of a biliary Wallstent in a woman with pancreatic cancer.

A 77-year-old patient with unresectable pancreatic adenocarcinoma sustained a life-threatening, upper gastrointestinal hemorrhage 1 month after placement of a biliary Wallstent. Radiographic and endoscopic studies revealed a choledocho-arterio-enteric fistula caused by erosion of the stent through the posterior duodenal wall. The patient was treated successfully with arterial embolization. This represents an unusual case of arterial bleeding with choledocho-arterio-enteric fistulization into the duodenum subsequent to biliary stent erosion.

Cutaneous complications of hepatic chemoembolization via extrahepatic collaterals.

PURPOSE: To report cutaneous complications occurring after chemoembolization of hepatic tumors via extrahepatic collaterals. METHODS: Five patients underwent chemoembolization via the internal mammary (n = 3), intercostal (n = 1), or multiple extrahepatic collateral vessels supplying liver metastases. RESULTS: Painful induration and discoloration of the skin in the distribution of the superior epigastric or intercostal arteries occurred in four patients, with transmural necrosis in two. One required surgical excision. One patient developed a radiation burn after 12 procedures and eventually developed a squamous cell carcinoma at the site, which required resection and skin grafting. CONCLUSION: Cutaneous injury can occur after chemoembolization of extrahepatic collaterals. Scrupulous technique is required to avoid nontarget embolization of chemotherapeutic drugs. High cumulative radiation doses to localized areas of skin can occur in patients undergoing multiple procedures.

Improved patency of transjugular intrahepatic portosystemic shunts in humans: creation and revision with PTFE stent-grafts.

PURPOSE: To determine whether polytetrafluoroethylene (PTFE) stent-grafts yield longer patency for creation or revision of transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS: Fourteen PTFE-covered Wallstents were placed in 13 patients with TIPS: seven at shunt creation and seven during revision of TIPS with one to five prior thromboses at 1 day to 1 year after initial TIPS formation. In six cases, prior to stent-graft placement persistent biliary-TIPS fistulas were demonstrated despite repeated shunt revisions with additional metallic stents. RESULTS: All but one graft-lined TIPS were widely patent at a mean duration of venographic follow-up of 19 months (median, 17 months; range, 5-32 months). The limiting percentage of stenosis within the grafted shunts was 0%-10%. One patient developed stent-graft thrombosis; the prior biliary-TIPS fistula was seen despite the graft. A second, parallel PTFE-lined transcaval shunt was created in this patient; it was widely patent at 11-month follow-up. In two asymptomatic patients, stenoses developed in the short, nongrafted portions of the outflow hepatic veins. CONCLUSION: PTFE stent-grafts can markedly prolong TIPS patency, potentially reducing the need for shunt follow-up and revision and the risk of recurrent symptoms associated with shunt stenosis or occlusion.

Transjugular intrahepatic portosystemic shunts formed with polyethylene terephthalate-covered stents: experimental evaluation in pigs.

PURPOSE: To evaluate the safety, efficacy, and tissue response associated with Wallstents covered with polyethylene terephthalate (PETP) compared with those associated with uncovered Wallstents for creation of transjugular intrahepatic portosystemic shunts (TIPS) in a porcine model. MATERIALS AND METHODS: Thirteen TIPS were created in 13 minipigs: eight with PETP-covered Wallstents, five with standard Wallstents. Shunt venography was performed at 5-8 weeks, and necropsy was performed at 7-8 weeks. Histopathologic, immunohistochemical, and scanning electron microscopic examinations were performed. RESULTS: Mean shunt stenoses of the control and graft groups were 45% and 53%, respectively. Graft stenoses involved the entire graft-bearing segment, whereas bare stent stenoses were localized within the liver tract. Myofibroblast and extracellular collagen matrix proliferation encompassed both control and graft-covered stents. There was one graft TIPS occlusion. One control TIPS stenosis was due to transstent proliferation of normal porcine hepatic tissue. A small focus of bile staining was seen on the abluminal surface of one TIPS, which was a patent PETP-lined shunt. CONCLUSION: PETP graft TIPS provided equal, but not superior, patency to that of bare stent TIPS. The pattern of PETP TIPS graft healing differed from that of bare stents but was similar to that reported with other polyester graft vascular implants and consisted of diffuse transmural penetration and paving of the graft surface by extracellular collagen matrix and myofibroblasts.

Caudal vena cava obstruction and ascites in a cat treated by balloon dilation and endovascular stent placement.

OBJECTIVE: To present details of an unusual case of caudal vena caval obstruction and its management in a cat. STUDY DESIGN: Clinical case report. STUDY POPULATION: A 15 month old male castrated domestic shorthaired cat. RESULTS: The diagnostic evaluation included the use of digital subtraction angiography and ultrasonography to locate the caudal vena caval obstruction. Treatment initially involved puncture and balloon dilation of the obstructed area of the cava. After reobstruction, the stenotic area was redilated and stented. The cat was euthanatized 4 weeks later because of vomiting, anorexia, and abnormal behavior, presumed to be associated with liver disease. CONCLUSION AND CLINICAL RELEVANCE: Interventional radiography provided a minimally invasive way to manage this unusual vascular anomaly.

Porous and nonporous polycarbonate urethane stent-grafts for TIPS formation: biologic responses.

PURPOSE: To evaluate the biologic response to transjugular intrahepatic portosystemic shunts (TIPS) lined with polycarbonate urethane endografts and the effects of different porosity formulations. MATERIALS AND METHODS: Seventeen TIPS were created in non-modified portal hypertensive miniswine with use of porous (n = 6), nonporous (n = 7) polycarbonate urethane stent-grafts, and control Wallstents TIPS (n = 4). Eight-week venography, histology, scanning electron microscopy, and immunohistochemical analyses were performed. RESULTS: The mean 8-week percent parenchymal tract shunt stenosis was 75%, 46%, and 26% in the control, porous, and nonporous groups, respectively. Occlusions developed in one control, one porous, and two nonporous shunts. The biologic response to porous grafts included marked inflammation and encapsulation and permeation of the grafts by a thick fibrous pseudointima. Nonporous grafts evoked little inflammation or pseudointima. Mature thrombus lined the occluded shunts (under which little luminal pseudointima or endothelium was present). The control group showed typical pseudointimal hyperplasia enveloping the intraparenchymal portions of the stents. CONCLUSIONS: The healing response of the porous and nonporous grafts markedly differed. Unlike the porous grafts and control stents, the nonporous endografts elicited little inflammation or luminal pseudointimal hyperplasia, although sporadic thrombosis was problematic in this normotensive model. Graft use in high-flow situations (ie, human TIPS, possibly in concert with antiplatelet agents) may allow desired shunt patency prolongation.

Chemoembolization of hepatocellular carcinoma with cisplatin, doxorubicin, mitomycin-C, ethiodol, and polyvinyl alcohol: prospective evaluation of response and survival in a U.S. population.

PURPOSE: To evaluate response and survival after hepatic chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol in a U.S. population of patients with hepatocellular carcinoma. MATERIALS AND METHODS: Thirty-eight consecutive patients were treated: 35% stage I, 62% stage II, 3% stage III. Fifty-one percent had cirrhosis. Chemoembolization was performed at approximately monthly intervals for one to seven sessions (mean, 2.2). Pretreatment and posttreatment cross-sectional imaging and alpha-fetoprotein (AFP) levels were obtained prospectively 1 month after treatment and then every 3 months. Thirty-day response was calculated by means of the the World Health Organization/Eastern Cooperative Oncology Group criteria. RESULTS: One patient was lost to follow-up. In seven patients, lesions became resectable after chemoembolization. Among 13 evaluable patients with initially elevated AFP level, 70% had a partial biologic response (>50% decrease in AFP), 15% had a minor response (25-50% decrease), and the remaining 15% remained stable. Among 25 patients evaluable for morphologic response, 36% had a partial response, 32% had a minor response, and 32% remained stable. No patients had progression of disease while receiving therapy. The cumulative survival was 60% at 1 year, 41% at 2 years, and 16% at 3 years. Two patients developed progressive hepatic failure. Thirty-day mortality was 3% (one patient). CONCLUSION: These results compare favorably to published response and survival data for chemoembolization of advanced hepatocellular carcinoma from Asia and Europe.

Direct percutaneous jejunostomy: techniques and applications--ten years experience.

PURPOSE: To present 10 years experience with direct fluoroscopically guided percutaneous jejunostomy. MATERIALS AND METHODS: Percutaneous jejunostomy was performed in 62 patients, most of whom had undergone major abdominal surgery. A new or replacement jejunostomy was created for alimentation in 20 and 21 patients, respectively. Jejunostomy was performed for interventional procedures of the bile ducts or intestine in 13 patients and for retrograde gastroesophageal drainage in eight. The distended jejunum was accessed with a 21-gauge needle, immobilized with a gastric anchor, and catheterized with a 10-14-F locking loop drain. RESULTS: The technical success rate was 19 of 20 (95%) for new feeding jejunostomy and 17 of 21 (81%) for replacement feeding jejunostomy. Jejunostomy facilitated drainage, dilation, stone extraction, and recanalization in the bile ducts or intestine in all 13 patients. Retrograde jejunoesophagogastrostomy suction effectively replaced painful nasogastric suction in all eight patients. Two patients who underwent replacement jejunostomy required laparotomy for possible leakage; there was no important procedure-related morbidity and no procedure-related mortality. CONCLUSION: The technical success and complication rates of feeding percutaneous jejunostomy compare favorably with those of surgery or endoscopy. Percutaneous jejunostomy is a useful and underused approach to managing bowel and biliary obstruction.