Comparison of Complications in Patients with Ductal Cholangiocarcinoma (CCC) and Patients with Colorectal Liver Metastases (CRLMs) After Portal Vein Embolization (PVE): A Matched Cohort Study.

PURPOSE: To compare complications in patients with cholangiocarcinoma (CCC) and patients with colorectal liver metastases (CRLMs) after portal vein embolization (PVE) and to identify possible predictive factors. MATERIAL AND METHODS: Retrospective analysis of consecutive patients, who underwent PVE between July 2011 and March 2020. The study groups were matched for sex and age. Multivariable analysis was performed for the endpoints of complications categorized according for their respective effect on surgical treatment: "Minor" complications had no effect on subsequent surgical treatment, while "intermediate" and "severe" complications delayed or prevented surgery. RESULTS: A total of 160 patients with either CCC (n = 80) or CRLMs (n = 80) were included: 34/160 experienced complications: 27 (CCC: 21; CRLMs: 6) "minor", 4 (CCC: 3; CRLMs: 1) "intermediate", and 3 (CCC: 2; CRLMs: 1) "severe" complications respectively (p = .01). Patients with CCC received a biliary drainage 5 days on average before PVE. Baseline bilirubin levels were 1.1 mg/dl in CCC patients and 0.55 mg/dl in CRLMs patients (p < .01). Postinterventional infections were more common in CCC patients. The preintervention future liver remnant volume (odds ratio (OR) 0.93; 95% confidence interval (CI) 0.88-0.99; p = .02), body mass index (OR 1.19; 95% CI 1.04-1.36; p = .01), age (OR 0,91; 95% CI 0.84-0.99; p = .01), chemotherapy before PVE (OR 0.03; 95% CI 0.01-0.23; p < .01) and severe liver steatosis (OR 29.52; 95% CI 1.87-467,13; p = .02) were the only significant predictive factors for the occurrence of (minor) complications. CONCLUSION: PVE can be performed in CCC patients with prior biliary drainage, with similar procedural safety as in patients with CRLMs.

Contrast-enhanced breast imaging: Current status and future challenges.

BACKGROUND: Contrast-enhanced breast MRI and recently also contrast-enhanced mammography (CEM) are available for breast imaging. The aim of the current overview is to explore existing evidence and ongoing challenges of contrast-enhanced breast imaging. METHODS: This narrative provides an introduction to the contrast-enhanced breast imaging modalities breast MRI and CEM. Underlying principle, techniques and BI-RADS reporting of both techniques are described and compared, and the following indications and ongoing challenges are discussed: problem-solving, high-risk screening, supplemental screening in women with extremely dense breast tissue, breast implants, neoadjuvant systemic therapy (NST) response monitoring, MRI-guided and CEM- guided biopsy. RESULTS: Technique and reporting for breast MRI are standardised, for the newer CEM standardisation is in progress. Similarly, compared to other modalities, breast MRI is well established as superior for problem-solving, screening women at high risk, screening women with extremely dense breast tissue or with implants; and for monitoring response to NST. Furthermore, MRI-guided biopsy is a reliable technique with low long-term false negative rates. For CEM, data is as yet either absent or limited, but existing results in these settings are promising. CONCLUSION: Contrast-enhanced breast imaging achieves highest diagnostic performance and should be considered essential. Of the two contrast-enhanced modalities, evidence of breast MRI superiority is ample, and preliminary results on CEM are promising, yet CEM warrants further study.

Stent Graft Placement by Pseudoaneurysm of the Hepatic Arteries: Efficacy and Patency Rate in Follow-up.

PURPOSE: To investigate efficacy and patency status of stent graft implantation in the treatment of hepatic artery pseudoaneurysm. MATERIALS AND METHODS: A retrospective analysis of patients who had undergone endovascular treatment of hepatic artery pseudoaneurysms between 2011 and 2020 was performed. Medical records were examined to obtain patients' surgical histories and to screen for active bleeding. Angiographic data on vascular access, target vessel, material used and technical success, defined as the exclusion of the pseudoaneurysm by means of a stent graft with sufficient control of bleeding, were collected. Vessel patency at follow-up CT was analyzed and classified as short-term (< 6 weeks), mid-term (between 6 weeks and 1 year), and long-term patency (> 1 year). In case of stent occlusion, collateralization and signs of hepatic hypoperfusion were examined. RESULTS: In total, 30 patients were included and of these, 25 and 5 had undergone stent graft implantation and coiling, respectively. In patients with implanted stent grafts, technical success was achieved in 23/25 patients (92%). Follow-up CT scans were available in 16 patients, showing stent graft patency in 9/16 patients (56%). Short-term, mid-term, and long-term short-term stent patency was found in 81% (13/16), 40% (4/10), and 50% (2/4). In patients with stent graft occlusion, 86% (6/7) exhibited maintenance of arterial liver perfusion via collaterals and 14% (1/7) exhibited liver abscess during follow-up. CONCLUSION: Stent graft provides an effective treatment for hepatic artery pseudoaneurysms. Even though patency rates decreased as a function of time, stent occlusion was mainly asymptomatic due to sufficient collateralization.

Machine learning-augmented and microspectroscopy-informed multiparametric MRI for the non-invasive prediction of articular cartilage composition.

BACKGROUND: Articular cartilage degeneration is the hallmark change of osteoarthritis, a severely disabling disease with high prevalence and considerable socioeconomic and individual burden. Early, potentially reversible cartilage degeneration is characterized by distinct changes in cartilage composition and ultrastructure, while the tissue's morphology remains largely unaltered. Hence, early degenerative changes may not be diagnosed by clinical standard diagnostic tools. METHODS: Against this background, this study introduces a novel method to determine the tissue composition non-invasively. Our method involves quantitative MRI parameters (i.e., T1, T1ρ, T2 and [Formula: see text] maps), compositional reference measurements (i.e., microspectroscopically determined local proteoglycan [PG] and collagen [CO] contents) and machine learning techniques (i.e., artificial neural networks [ANNs] and multivariate linear models [MLMs]) on 17 histologically grossly intact human cartilage samples. RESULTS: Accuracy and precision were higher in ANN-based predictions than in MLM-based predictions and moderate-to-strong correlations were found between measured and predicted compositional parameters. CONCLUSION: Once trained for the clinical setting, advanced machine learning techniques, in particular ANNs, may be used to non-invasively determine compositional features of cartilage based on quantitative MRI parameters with potential implications for the diagnosis of (early) degeneration and for the monitoring of therapeutic outcomes.

Correlation Between Sarcopenia and Growth Rate of the Future Liver Remnant After Portal Vein Embolization in Patients with Colorectal Liver Metastases.

PURPOSE: To investigate whether sarcopenia and myosteatosis correlate with the degree of hypertrophy (DH) and kinetic growth rate (KiGR) of the future liver remnant (FLR) in patients with colorectal liver metastases undergoing portal vein embolization (PVE) in preparation for right hepatectomy. MATERIALS AND METHODS: Forty-two patients were included. Total liver volume and FLR volume were measured before and 2-4 weeks after PVE. KiGR of the FLR was calculated. Sarcopenia was assessed using the total psoas muscle volume (PMV), the psoas muscle cross-sectional area (PMCS) and the total skeletal muscle index (L3SMI) at the level of 3rd lumbar vertebra. Degree of myosteatosis was assessed by mean muscle attenuation at L3 (L3MA). Correlations between muscle indices and DH and KiGR were assessed using simple linear regression analyses. RESULTS: Mean DH was 8.9 ± 5.7%, and mean KiGR was 3.6 ± 2.3. Mean PMV was 55.56 ± 14.19 cm3/m3, mean PMCS was 8.76 ± 2.3 cm2/m2, mean L3SMI was 45.6 ± 9.89 cm2/m2, and mean L3MA was 27.9 ± 18.6 HU. There was a strong positive correlation between PMV and DH (R = 0.503, p = 0.001) and PMV and KiGR (R = 0.545, p < 0.001). Furthermore, there was a moderate correlation between PMCS and KiGR (R = 0.389, p = 0.014). L3SMI and L3MA were neither associated with DH (p = 0.390 and p = 0.768, respectively) nor with KiGR (p = 0.188 and p = 0.929, respectively). CONCLUSION: We identified a positive correlation between PMV and PMCS, as markers for sarcopenia, and the KiGR of the FLR after PVE. PMV and PMCS might therefore aid to identify patients who are poor candidates for FLR augmentation using PVE alone.

Short-Term Oral Sorafenib for Therapy of Intratumoral Shunts of Hepatocellular Carcinoma to Enable Intraarterial Treatment.

INTRODUCTION: Significant intratumoral shunts between tumor-supplying arteries and portal or liver veins are a contraindication for transarterial therapy of HCC because interventional treatment of these shunts is frequently insufficient. Sorafenib has anti-angiogenic effects and is indicated for palliative treatment of patients with HCC. Here, we report our experience with the use of sorafenib for the closure of intratumoral shunts in patients scheduled for transarterial therapy of HCC. MATERIALS AND METHODS: Three patients with HCC, aged 65, 82 and 79 years, exhibited a significant intratumoral shunting from tumor artery to portal (n = 1) or liver veins (n = 2). In all cases, intratumoral shunting had already been suspected based on pre-interventional CT angiography, and DSA confirmed the shunt. Oral sorafenib (800 mg/day) was administered for at least four weeks, only and specifically to occlude the shunt. Hereafter, patients were re-evaluated by CT and DSA. RESULTS: All patients tolerated the full prescribed dose for at least 4 weeks. In one case, therapy was prolonged with an adapted dose (400 mg/day) due to sorafenib-related hand-foot syndrome. After sorafenib treatment, CT and DSA confirmed a complete closure of intratumoral shunts for all patients. No tumor progression was observed. All three patients hereafter underwent successful transarterial treatment by TACE (n = 2) or TARE (n = 1) without complications. Progression-free survival according to mRECIST was 501, 397 and 599 days, respectively. CONCLUSION: Even short-term oral sorafenib seems to effectively close intratumoral shunts in patients with HCC and thus might enable transarterial treatment of these patients.

Human articular cartilage mechanosensitivity is related to histological degeneration - a functional MRI study.

OBJECTIVE: To investigate changes in response to sequential pressure-controlled loading and unloading in human articular cartilage of variable histological degeneration using serial T1ρ mapping. METHOD: We obtained 42 cartilage samples of variable degeneration from the medial femoral condyles of 42 patients undergoing total knee replacement. Samples were placed in a standardized artificial knee joint within an MRI-compatible whole knee-joint compressive loading device and imaged before (δ0), during (δld1, δld2, δld3, δld4, δld5) and after (δrl1, δrl2, δrl3, δrl4, δrl5) pressure-controlled loading to 0.663 ± 0.021 kN (94% body weight) using serial T1ρ mapping (spin-lock multigradient echo sequence; 3.0T MRI system [Achieva, Philips]). Reference assessment included histology (Mankin scoring) and conventional biomechanics (Tangent stiffness). We dichotomized sample into intact (n = 21) and degenerative (n = 21) based on histology and analyzed data using Mann Whitney, Kruskal Wallis, one-way ANOVA tests and Spearman's correlation, respectively. RESULTS: At δ0, we found no significant differences between intact and degenerative samples, while the response-to-loading patterns were distinctly different. In intact samples, T1ρ increases were consistent and non-significant, while in degenerative samples, T1ρ increases were significantly higher (P = 0.004, δ0 vs δld1, δ0 vs δld3), yet undulating and variable. With unloading, T1ρ increases subsided, yet were persistently elevated beyond δ0. CONCLUSION: Cartilage mechanosensitivity is related to histological degeneration and assessable by serial T1ρ mapping. Unloaded, T1ρ characteristics are not significantly different in intact vs degenerative cartilage, while load bearing is organized in intact cartilage and disorganized in degenerative cartilage.

[Current CO2 angiography]. / Aktuelle CO2-Angiographie.

BACKGROUND: Carbon dioxide (CO2) is a very good and validated alternative to iodine-containing contrast media in diagnostic and interventional angiography. Nevertheless, its routinely use is still limited to specialized centers. OBJECTIVE: The presentation of the current role and limitations of CO2 in diagnostic and interventional angiography (venous and arterial). MATERIAL AND METHODS: A comprehensive review of the literature regarding CO2 angiography (physical features, indications, contraindications, applications) was carried out. RESULTS: The results show that CO2 can be used as a reliable alternative for diagnostic angiography and to support interventions in many arterial and venous vascular territories. An exception is the intra-arterial use of CO2 above the diaphragm due to the risk of severe myocardial and cerebral complications, which represents the most important contraindication. Moreover, due to its very low viscosity, CO2 is more effective than iodine-containing contrast media in detecting bleeding arising from small vessels. CONCLUSION: The CO2 angiography is a safe and effective technique and can be used as valid alternative. In several clinical cases it even offers some advantages compared to iodine-containing contrast media.

Toward Transpulmonary Chemoembolization with Degradable Starch Microspheres: Systematic Analysis of Local and Systemic Effects in a Porcine Model.

PURPOSE: To investigate local and systemic effects of transpulmonary chemoembolization (TPCE) with degradable starch microspheres (DSM) and doxorubicin. The long-term goal is to establish DSM-TPCE as a treatment option for pulmonary malignancies. MATERIALS AND METHODS: Nine pigs underwent TPCE of either the right or left lower lobe pulmonary artery (LLPA) and bland embolization (TPE) of the contralateral LLPA. Before the procedures, macroaggregated albumin (MAA) particles were injected into both LLPAs, to exclude systemic shunting. Pulmonary arterial pressure, heart rate and oxygenation were recorded immediately before and at 1, 3, 5 and 10 min after treatment. To investigate possible nontarget embolization, animals underwent cerebral MRI (cMRI). We killed the animals after a contrast-enhanced chest computed tomography (CT) and performed a pathologic examination at 12 h (3), 24 h (3) and 72 h (3) after treatment. RESULTS: All experiments were technically successful. Mean injected DSM dose until stasis was similar in TPCE and TPE (4.3 ± 1.4 vs. 4.0 ± 1.4 mL). Pulmonary arterial pressure increased significantly 3 min after treatment (TPE: 17 ± 5 vs. 27 ± 7 mmHg; TPCE: 22 ± 6 vs. 36 ± 8 mmHg). No significant changes in heart rate or peripheral oxygenation levels occurred. We observed no evidence of structural lung damage or permanent perfusion disruption on CT. MAA test injection and cMRI revealed no shunting or nontarget embolization. The pathologic assessment revealed nonspecific local inflammation of the lung parenchyma. CONCLUSION: In this large-animal model, TPCE and TPE appear feasible and safe. We observed a mild increase in pulmonary arterial pressure. Nontarget embolization did not occur. TPCE, as well as TPE, did not cause structural damage to the normal lung parenchyma.

Multiparametric MRI and Computational Modelling in the Assessment of Human Articular Cartilage Properties: A Comprehensive Approach.

Quantitative magnetic resonance imaging (qMRI) is a promising approach to detect early cartilage degeneration. However, there is no consensus on which cartilage component contributes to the tissue's qMRI signal properties. T1, T1ρ, and T2⁎ maps of cartilage samples (n = 8) were generated on a clinical 3.0-T MRI system. All samples underwent histological assessment to ensure structural integrity. For cross-referencing, a discretized numerical model capturing distinct compositional and structural tissue properties, that is, fluid fraction (FF), proteoglycan (PG) and collagen (CO) content and collagen fiber orientation (CFO), was implemented. In a pixel-wise and region-specific manner (central versus peripheral region), qMRI parameter values and modelled tissue parameters were correlated and quantified in terms of Spearman's correlation coefficient ρs. Significant correlations were found between modelled compositional parameters and T1 and T2⁎, in particular in the central region (T1: ρs ≥ 0.7 [FF, CFO], ρs ≤ -0.8 [CO, PG]; T2⁎: ρs ≥ 0.67 [FF, CFO], ρs ≤ -0.71 [CO, PG]). For T1ρ, correlations were considerably weaker and fewer (0.16 ≤ ρs ≤ -0.15). QMRI parameters are characterized in their biophysical properties and their sensitivity and specificity profiles in a basic scientific context. Although none of these is specific towards any particular cartilage constituent, T1 and T2⁎ reflect actual tissue compositional features more closely than T1ρ.

Non-invasive T1ρ mapping of the human cartilage response to loading and unloading.

OBJECTIVE: To define the physiological response to sequential loading and unloading in histologically intact human articular cartilage using serial T1ρ mapping, as T1ρ is considered to indicate the tissue's macromolecular content. METHOD: 18 macroscopically intact cartilage-bone samples were obtained from the central lateral femoral condyles of 18 patients undergoing total knee replacement. Serial T1ρ mapping was performed on a clinical 3.0-T MRI system using a modified prostate coil. Spin-lock multiple gradient-echo sequences prior to, during and after standardized indentation loading (displacement controlled, strain 20%) were used to obtain seven serial T1ρ maps: unloaded (δ0), quasi-statically loaded (indentation1-indentation3) and under subsequent relaxation (relaxation1-relaxation3). After manual segmentation, zonal and regional regions-of-interest were defined. ROI-specific relative changes were calculated and statistically assessed using paired t-tests. Histological (Mankin classification) and biomechanical (unconfined compression) evaluations served as references. RESULTS: All samples were histologically and biomechanically grossly intact (Mankin sum: 1.8 ± 1.2; Young's Modulus: 0.7 ± 0.4 MPa). Upon loading, T1ρ consistently increased throughout the entire sample thickness, primarily subpistonally (indentation1 [M ± SD]: 9.5 ± 7.8% [sub-pistonal area, SPA] vs 4.2 ± 5.8% [peri-pistonal area, PPA]; P < 0.001). T1ρ further increased with ongoing loading (indentation3: 14.1 ± 8.1 [SPA] vs 7.7 ± 5.9% [PPA]; P < 0.001). Even upon unloading (i.e., relaxation), T1ρ persistently increased in time. CONCLUSION: Serial T1ρ-mapping reveals distinct and complex zonal and regional changes in articular cartilage as a function of loading and unloading. Thereby, longitudinal adaptive processes in hyaline cartilage become evident, which may be used for the tissue's non-invasive functional characterization by T1ρ.

Impact of Preoperative Three-Dimensional Computed Tomography Cholangiography on Postoperative Resection Margin Status in Patients Operated due to Hilar Cholangiocarcinoma.

INTRODUCTION: The purpose of this study was to analyse the value of 3-dimensional computed tomography cholangiography (3D-ERC) compared to conventional retrograde cholangiography in the preoperative diagnosis of hilar cholangiocarcinoma (HC) with special regard to the resection margin status (R0/R1). PATIENTS AND METHODS: All hepatic resections performed between January 2011 and November 2013 in patients with HC at the Department of General, Visceral and Transplant Surgery of the RWTH Aachen University Hospital were analysed. All patients underwent an ERC and contrast-enhanced multiphase CT scan or a 3D-ERC. RESULTS: The patient collective was divided into two groups (group ERC: n = 17 and group 3D-ERC: n = 16). There were no statistically significant differences between the two groups with regard to patient characteristics or intraoperative data. Curative liver resection with R0 status was reached in 88% of patients in group ERC and 87% of patients in group 3D-ERC (p = 1.00). We could not observe any differences with regard to postoperative complications, hospital stay, and mortality rate between both groups. CONCLUSION: Based on our findings, preoperative imaging with 3D-ERC has no benefit for operative planning and R0 resection status. It cannot replace the exploration by an experienced surgeon in a centre for hepatobiliary surgery.

[Chondral and osteochondral defects : Representation by imaging methods]. / Chondrale und osteochondrale Defekte : Darstellung mittels bildgebender Verfahren.

Morphological imaging of cartilage at high resolution allows the differentiation of chondral and osteochondral lesions. Nowadays, magnetic resonance imaging is the principal diagnostic tool in the assessment of cartilage structure and composition. Conventional radiography, computed tomography, ultrasound or optical coherence tomography are adjunct diagnostic modalities in the assessment of cartilage pathologies. The present article discusses the up-to-date diagnostic practice of cartilage imaging in terms of its scientific basis and current clinical status, requirements, techniques and image interpretation. Innovations in the field such as functional MRI are discussed as well due to their mid- to long-term clinical perspective.

New approach for predictive measurement of knee cartilage defects with three-dimensional printing based on CT-arthrography: A feasibility study.

PURPOSE: The aim was to prove the possibility of creating an exact module of knee cartilage defects using 3D printing. METHODS: Defects were created in cadaver knees. CT-arthrography and 3-Tesla MRI were performed. Based on CTA images a model of the cartilage was created using 3D printing. Defect-sizes in the imaging modalities were compared. RESULTS: Estimated lesion area in 3D model differed approximately 5% comparing to the defect sizes in knees. MRI underestimated the defect on average of 12%, whereas the CTA overestimated the defect about 3%. CONCLUSIONS: We proved the feasibility of creating an accurate module of knee cartilage.

Transarterial Alcohol-Lipiodol Therapy in Patients with Hepatocellular Carcinoma Using Low Alcohol Concentrations.

PURPOSE: To evaluate transarterial alcohol-lipiodol therapy (TAL) with low concentrations of alcohol for the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: 17 patients (69.3 ±â€Š10.7a, 13 male, 4 female) with previously untreated HCC (tumor diameter: 7.7 ±â€Š5.8 cm), who underwent 20 transarterial alcohol-lipiodol injections, were evaluated retrospectively. 14 patients had HCC with coexistent cirrhosis (Child-A n = 9, Child-B n = 4, Child-C n = 1). 9 patients presented an Okuda stage I, 7 patients an Okuda stage II and 1 patient an Okuda stage III. Infiltration of the portal vein was seen in 3 patients. RESULTS: 15 patients underwent TAL with an alcohol:lipiodol ratio of 1:2, another one with a ratio of 1:3 and yet another one with a ratio of 1:5. The median survival was 23 months, and the 1-year and 2-year survival rates were 62.7 % and 31.4 %, respectively. The median survival of patients with HCC < 7.5 cm (n = 10) was 25 months and significantly (p = 0.009) higher than for patients with HCC ≥ 7.5 cm (n = 7; 3 months). Tumor diameters ≥ 7.5 cm were associated with worse lipiodol-contrasting of HCC. Intrainterventional side effects were only feelings of slight abdominal pressure in 2 of 20 interventions. Postinterventional, mild side effects were observed after 3 interventions (abdominal pain n = 1, thoracic pain n = 1, fever n = 1). Serious complications were not observed, in particular there was no decompensation of liver cirrhosis. CONCLUSION: TAL with low concentrations of alcohol was a safe and effective treatment in our cohort in spite of extensive tumors and impaired liver function. TAL could be a treatment option for patients who cannot receive other therapies (e. g. TACE, RFA) because of their advanced tumor disease, liver cirrhosis or other contraindications. KEY POINTS: • TAL can be performed safely in advanced tumor disease and liver cirrhosis Citation Format: • Mohné F, Meyer C, Kuhl CK et al. Transarterial Alcohol-Lipiodol Therapy in Patients with Hepatocellular Carcinoma Using Low Alcohol Concentrations. Fortschr Röntgenstr 2016; 188: 676 - 683.

[Oligometastasized stage IV colorectal cancer : Surgical resection and local ablative procedures]. / Oligometastasierung beim kolorektalen Karzinom im Stadium IV : Chirurgie und lokal ablative Verfahren.

BACKGROUND: By the intensified combination of systemic, surgical and local ablative therapies a significant improvement in therapy results for metastasized colorectal cancer has been achieved in the last decade. Downstaging with subsequent resection is nowadays a standard for oligometastasized primarily unresectable colorectal cancer. MATERIAL AND METHODS: The value of combining resection and local ablation is unclear; therefore, this article gives an overview of the available literature dealing with the combination of surgery and local ablative methods for oligometastasized stage IV colorectal cancer. RESULTS: The best results were obtained following surgical resection alone. Whereas nowadays cryoablation is of minor importance, the most successful results are achieved following local ablative methods by radiofrequency and microwave ablation. In the future irreversible electroporation will be the most promising local ablative method. A combination of surgical resection and local ablation appears to be rational in patients if an R0 resection can be achieved. CONCLUSION: Surgical resection of colorectal liver metastases is the gold standard for oncological therapy whenever possible. The rational combination of non-curative surgical resection and local ablation should be considered in the context of a multimodal therapeutic strategy, particularly in patients with primarily resectable disease.

Recent Developments and Controversies in the Treatment of Resistant Hypertension.

Resistant hypertension is defined as elevated blood pressure despite the appropriate use of 3 or more antihypertensive drugs, including a diuretic, and constitutes a frequent and important clinical problem with significant disease morbidity and mortality. Several sources of evidence point to the sympathetic nervous system as a major protagonist in this disease entity. The catheter-based, radiofrequency ablation of renal sympathetic nerves (renal denervation) to treat resistant hypertension has sparked great enthusiasm. However, failure of this interventional approach in the randomized, sham-controlled Symplicity HTN-3 trial to reach its efficacy endpoint of attaining a significant blood pressure reduction has called this intervention into substantial question and fueled an ongoing scientific debate. Electrical stimulation of the carotid baroreceptors (baroreflex activation therapy) represents another technique to modulate sympathetic activity currently being studied in several clinical trials. This review summarizes and comments the current literature focusing on the invasive treatment of resistant hypertension.

Stentgraft Implantation for the Treatment of Postoperative Hepatic Artery Pseudoaneurysm.

PURPOSE: Hepatic artery pseudoaneurysms are a rare but potentially life-threatening complication of major pancreaticobiliary surgery. We evaluated the safety and efficacy of endovascular stentgraft implantation for the management of such vascular lesions. MATERIALS AND METHODS: Between May 2013 and October 2015, ten patients with postoperative hepatic artery pseudoaneurysm, of which eight presented with active hemorrhage, were treated with endovascular stentgraft implantation. All patients had undergone major pancreatic or hepatic surgery before (pylorus-preserving pancreaticoduodenectomy, pancreatectomy, hemihepatectomy, extended hemihepatectomy). The pseudoaneurysms were diagnosed 13-202 days after surgery and were associated with postsurgical complications (e.g., leakage of pancreaticojejunal anastomosis). RESULTS: In 9/10 patients, the pseudoaneurysm was completely excluded via stentgraft implantation. In 1/10 patient, the pseudoaneurysm ruptured during the procedure and was successfully treated by immediate open surgery. In 1/10 patient, a second intervention was performed after 6 days because of rebleeding; this was successfully treated by implantation of a second overlapping stentgraft. Mean follow-up time is 51 days. None of the patients died due to stentgraft- or aneurysm-related complications. Further episodes of hemorrhage were not observed. In one patient, clinically asymptomatic complete occlusion of the stentgraft was discovered at follow-up imaging. CONCLUSION: Stentgraft implantation is a safe and effective technique to treat hepatic artery pseudoaneurysms related to major pancreatic or hepatic surgery, especially in the setting of acute hemorrhage.

Lymphatic Interventions for Treatment of Chylothorax.

PURPOSE: To determine effectiveness of lymphatic interventional procedures for treatment of chylothorax. MATERIAL AND METHODS: Analysis of interventions performed from 2001 to 2014. RESULTS: In 21 patients with therapy resistant chylothorax a lymphatic radiological intervention was attempted, which could be performed in 19 cases: 17 thoracic duct embolizations (15 transabdominal, one transzervical and one retrograde transvenous procedure), 2 percutaneous destructions of lymphatic vessels, one CT-guided injection of ethanol next to a duplicated thoracic duct. Fourteen of seventeen (82.3 %) of the technically successful embolizations lead to clinical cure. This encluded three patients with prior unsuccessful surgical thoracic duct ligation. Also the injection of ethanol was clinically effective. Complications were a bile peritonitis requiring operation, and one clinical deterioration of unknown cause. CONCLUSION: Interventional lymphatic procedures allow for effective treatment in many cases of chylothorax, and should be considered early during treatment. KEY POINTS: • Thoracic duct embolization is an effective treatment method for chylothorax. • If embolization is impossible, percutaneous lymphatic destruction or injection of sclerosants/tissue adhesive next to the thoracic duct may be tried.