Outcomes of Intravascular Lithotripsy in the Treatment of Chronic Limb-Threatening Ischemia: A Single-Center Retrospective Study.

PURPOSE: Vascular calcification is an important risk factor for endovascular treatment failure and complications in patients with chronic limb-threatening ischemia (CLTI). Intravascular lithotripsy (IVL) is a pulsatile balloon-based device that has emerged as a tool in the treatment of calcified vessels. The purpose of this study is to evaluate the efficacy and safety of IVL in the treatment of peripheral calcified lesions in CLTI patients. MATERIALS AND METHODS: A retrospective study was performed within a single institution. Thirty-six CLTI patients treated with IVL for peripheral calcified lesions from 2018 to 2022 were identified. Data on pre- and post-IVL luminal stenosis measured by digital subtraction angiography, lesion location, adjunctive therapies, ankle-brachial index (ABI), and intra-procedural complications were obtained. A total of 41 target lesions in twenty-eight patients were included, with ABI data available in 20 treated lower extremities. RESULTS: Across all 41 target lesions, IVL produced clinically significant luminal gain of 75.5% ± 23.0. Luminal gain by vessel location was 87.3% ± 15.8, 57% ± 25.7, and 78.5% ± 20.6 in the aortoiliac (n = 8), common femoral (n = 9), and femoropopliteal (n = 24) segments, respectively. Lesions treated with IVL alone yielded a luminal gain of 71.4% ± 25.6 (n = 10), while IVL alongside adjunctive therapy produced a luminal gain of 76.8% ± 22.4. In 20 treated lower extremities, ABI improvement of 0.20 ± 0.26 (p = 0.002) was recorded. Intra-procedural complications occurred in 1/36 patients, which was one instance of thrombus occurring prior to IVL. CONCLUSION: IVL may be an effective option for creating safe luminal gain and vessel preparation in patients with CLTI. Level of Evidence 2: Retrospective Cohort Study.

Techniques for Successful Vessel Crossing.

Chronic total occlusions are a common cause of both claudication and critical limb ischemia. Currently, 40%-50% of all individuals undergoing lower extremity interventions will have a chronic total occlusion. Endovascular specialist should be familiar with the different treatment algorithms and classifications systems. Many different techniques have been shown to be successful in crossing the lesion and for re-entry when needed. The vascular access obtained to cross the lesion is frequently dictated by lesion location, lesion length, and the distal runoff in the affected limb.

Stent Graft Outcomes in Dialysis Circuits: A Review of Clinical Trials and Literature.

End-stage renal disease is a prevalent medical condition causing significant problems as the majority of patients are being treated with dialysis. While dialysis provides a means to compensate for the renal impairment, arteriovenous grafts and fistulas are often complicated by neointimal hyperplasia, loss of primary patency, and graft failure. Over the last decade, stent grafts have emerged as an alternative to balloon angioplasty and bare metal stents for revascularization in the event of arteriovenous graft occlusion or stenosis. Several randomized controlled trials have investigated the efficacy of stent grafts compared with balloon angioplasty for improving the function and durability of dialysis circuits. In this review, we present a comprehensive review of clinical trials. Stent grafts appear to offer increased primary patency over balloon angioplasty in the treatment of dialysis circuit stenosis. However, there is generally no significant difference between the two treatment modalities on other clinically relevant measures like complication rates and overall survival.

Radioembolization of Secondary Hepatic Malignancies.

Cancer has become the leading cause of mortality in America, and the majority of patients eventually develop hepatic metastasis. As liver metastases are frequently unresectable, the value of liver-directed therapies, such as transarterial radioembolization (TARE), has become increasingly recognized as an integral component of patient management. Outcomes after radioembolization of hepatic malignancies vary not only by location of primary malignancy but also by tumor histopathology. This article reviews the outcomes of TARE for the treatment of metastatic colorectal cancer, metastatic breast cancer, and metastatic neuroendocrine tumors, as well as special considerations when treating metastatic disease with TARE.

Transjugular Intrahepatic Portosystemic Shunts Reduce Variceal Bleeding and Improve Survival in Patients with Cirrhosis: A Population-Based Analysis.

PURPOSE: To investigate from a population health perspective the effects of transjugular intrahepatic portosystemic shunt (TIPS) creation on recurrent variceal bleeding and survival in patients with cirrhosis. MATERIALS AND METHODS: Patients with cirrhosis who presented to outpatient and acute-care hospitals in California (2005-2011) and Florida (2005-2014) with variceal bleeding comprised the study cohort. Patients entered the study cohort at their first presentation for variceal bleeding; all subsequent hospital encounters were then evaluated to determine subsequent interventions, complications, and mortality data. RESULTS: A total of 655,577 patients with cirrhosis were identified, of whom 42,708 (6.5%) had at least 1 episode of variceal bleeding and comprised the study cohort. The median follow-up time was 2.61 years. A TIPS was created in 4,201 (9.8%) of these patients. There were significantly greater incidences of coagulopathy (83.9% vs 72.8%; P < .001), diabetes (45.5% vs 38.8%; P < .001), and hepatorenal syndrome (15.3% vs 12.5%; P < .001) in TIPS recipients vs those without a TIPS. Following propensity-score matching, TIPS recipients were found to have improved overall survival (82% vs 77% at 12 mo; P < .001) and a lower rate of recurrent variceal bleeding (88% vs 83% recurrent bleeding-free survival at 12 months,; P < .001) than patients without a TIPS. Patients with a TIPS had a significant increase in encounters for hepatic encephalopathy vs those without (1.01 vs 0.49 per year; P < .001). CONCLUSIONS: TIPS improves recurrent variceal bleeding rates and survival in patients with cirrhosis complicated by variceal bleeding. However, TIPS creation is also associated with a significant increase in hepatic encephalopathy.

Hepatic vein embolization after portal vein embolization to induce additional liver hypertrophy in patients with metastatic colorectal carcinoma.

OBJECTIVES: To assess the effect of salvage hepatic vein embolization (HVE) on the volume of the future liver remnant (FLR) for patients with metastatic colorectal cancer (mCRC) and inadequate hypertrophy following initial portal vein embolization (PVE). METHODS: From April 2011 to October 2018, 9 patients with mCRC underwent HVE following PVE. The right or middle hepatic vein was embolized with coils and/or vascular plugs. Liver volumes were calculated at baseline, following PVE, and following HVE, in order to assess the hypertrophic effect of PVE and HVE on the FLR. RESULTS: Nine patients underwent HVE (n = 3, right HVE; n = 6, middle HVE) because of inadequate FLR hypertrophy following PVE. The standardized FLR increased from 0.16 (median, range 0.08-0.24) at baseline to 0.22 (median, range 0.13-0.29) following PVE (p = 0.0005) to 0.26 (median, range 0.19-0.37) following HVE (p = 0.0050). HVE was performed 40 days (median, range 19-128 days) following PVE, and assessment of FLR hypertrophy was performed 41 days (median, range 19-92 days) following HVE. Four of nine patients underwent hepatectomy; 5 patients failed to undergo hepatectomy (n = 3, inadequate hypertrophy; n = 1, disease progression; n = 1, portal hypertension). One patient required repeat HVE due to a patent accessory vein. CONCLUSIONS: Salvage HVE is an effective technique to induce additional FLR hypertrophy in patients with mCRC and inadequate FLR after initial PVE. KEY POINTS: • Hepatic vein embolization is effective to induce additional liver hypertrophy in surgical patients with metastatic colorectal carcinoma and inadequate hypertrophy after portal vein embolization. • Increases in future liver remnant volume are feasible in patients who receive hepatotoxic neoadjuvant systemic therapy for metastatic colorectal carcinoma. • Sequential portal vein embolization and hepatic vein embolization can be a viable technique to induce liver hypertrophy in patients with small baseline future liver remnant volumes (< 20%).

Baseline Apparent Diffusion Coefficient as a Predictor of Response to Liver-Directed Therapies in Hepatocellular Carcinoma.

Predicting outcomes in patients with hepatocellular carcinoma (HCC) who undergo locoregional therapies remains a substantial clinical challenge. The purpose of this study was to investigate pre-procedure diffusion weighted magnetic resonance imaging (DW-MRI) as an imaging biomarker for tumoral response to therapy for patients with HCC undergoing drug eluting embolic (DEE) chemoembolization and radioembolization. A retrospective review of HCC patients who underwent DEE chemoembolization or radioembolization was performed. Of the 58 patients who comprised the study population, 32 underwent DEE chemoembolization and 26 underwent radioembolization. There was no significant difference in median apparent diffusion coefficient (ADC) values across the two treatment groups (1.01 × 10-3 mm²/s, P = 0.25). The immediate objective response (OR) rate was 71% (40/56). Tumors with high ADC values were found to have a higher probability of OR within 90 days (odds ratio 4.4, P = 0.03). Moreover, index lesion specific progression free survival (PFS) was greater for high ADC tumors, independent of conventional predictors of treatment response (hazard ratio 0.44, P = 0.01). Low ADC was associated with poorer PFS (P = 0.02). Pre-procedure ADC < 1.01 × 10-3 mm²/s is an independent predictor of poorer immediate OR and index lesion specific PFS in patients with HCC undergoing DEE chemoembolization or radioembolization.

Palliative Embolization for Refractory Bleeding.

Bleeding is a common and often challenging complication of malignancy. Etiologies of hemorrhage in this patient population vary, and bleeding may present as an acute, life-threatening emergency or a chronic, low-volume blood loss. For patients with advanced malignancies, interventions to manage bleeding must be balanced by the patient's life expectancy and quality of life. As such, minimally invasive procedures such as transarterial embolization are useful therapeutic options in appropriately selected patients. There is a rich history of palliative transarterial embolization for refractory bleeding in cancer patients. This technique was first applied in the 1970s and has since become an established treatment tool for malignancy-related bleeding throughout the body. While the preponderance of published data comprised case reports and small retrospective studies, the use of embolization continues to expand as experience grows and techniques are refined. In this review, we summarize the literature and provide our perspective on embolization for refractory bleeding in cancer patients.

Development of a predictive model for 6 month survival in patients with venous thromboembolism and solid malignancy requiring IVC filter placement.

PURPOSE: Our purpose was to develop a predictive model for short-term survival (i.e. <6 months) following inferior vena cava filter placement in patients with venous thromboembolism (VTE) and solid malignancy. METHODS: Clinical and laboratory parameters were retrospectively reviewed for patients with solid malignancy who received a filter between January 2009 and December 2011 at a tertiary care cancer center. Multivariate Cox proportional hazards modeling was used to assess variables associated with 6 month survival following filter placement in patients with VTE and solid malignancy. Significant variables were used to generate a predictive model. RESULTS: 397 patients with solid malignancy received a filter during the study period. Three variables were associated with 6 month survival: (1) serum albumin [hazard ratio (HR) 0.496, P < 0.0001], (2) recent or planned surgery (<30 days) (HR 0.409, P < 0.0001), (3) TNM staging (stage 1 or 2 vs. stage 4, HR 0.177, P = 0.0001; stage 3 vs. stage 4, HR 0.367, P = 0.0002). These variables were used to develop a predictive model to estimate 6 month survival with an area under the receiver operating characteristic curve of 0.815, sensitivity of 0.782, and specificity of 0.715. CONCLUSIONS: Six month survival in patients with VTE and solid malignancy requiring filter placement can be predicted from three patient variables. Our predictive model could be used to help physicians decide whether a permanent or retrievable filter may be more appropriate as well as to assess the risks and benefits for filter retrieval within the context of survival longevity in patients with cancer.

Thrombosis in cancer patients: etiology, incidence, and management.

Venous thromboembolism (VTE) is the second most common cause of mortality in cancer patients. The mechanisms of cancer-associated thrombosis (CAT), much like cancer itself, are multi-factorial and incompletely understood. Cancer type, stage, tumor-derived factors and genetics all affect CAT risk. Furthermore, cancer therapies as well as the indwelling vascular devices through which these therapies are delivered can increase the risk for CAT. In this review, we summarize mechanisms of hypercoagulability in cancer patients, patterns of thrombosis associated with cancer, current guidelines for the diagnosis and management of CAT, and important considerations regarding the placement of implantable vascular devices in the care of cancer patients with VTE.

Comprehensive Complication Index Predicts Cancer-specific Survival After Resection of Colorectal Metastases Independent of RAS Mutational Status.

OBJECTIVE: To investigate prognostic impact of postoperative complications for colorectal liver metastases (CLM) in the era of RAS mutation analysis. BACKGROUND: Postoperative complications have been associated with cancer-specific outcomes in multiple malignancies. METHODS: We identified 575 patients with known RAS mutation status who underwent hepatic resection for CLM during 2008 to 2014. Postoperative complications were scored with the comprehensive complication index (CCI), and the neutrophil-to-lymphocyte ratio (NLR) was used as an indicator of systemic inflammation before and after surgery. Survival after resection of CLM was stratified by CCI (high, ≥26.2; low, <26.2). RESULTS: Eighty-eight patients had high and 487 low CCI. Recurrence-free survival (RFS) and cancer-specific survival (CSS) after hepatic resection were worse in patients with high CCI than in patients with low CCI (RFS at 3 yrs 26% vs. 41%, P = 0.003; CSS at 5 yrs 46% vs. 64%, P = 0.003). High CCI (odds ratio 3.99, P <0.001) was associated with high NLR (>5) 3 months after hepatic resection. Five factors were associated with worse CSS: high CCI [hazard ratio (HR) 1.61, P = 0.022], primary positive node (HR 1.70, P = 0.003), multiple CLM (HR 1.72, P = 0.001), CLM ≥3 cm (HR 1.73, P <0.001), and mutant RAS (HR 2.04, P <0.001). Receiver operating characteristic and area under receiver operating characteristic curves revealed CCI to be a more sensitive, specific, and accurate predictor of RFS and CSS than NLR. CONCLUSIONS: High CCI is a potent predictor of worse RFS and CSS after resection of CLM. The ramifications of postsurgical complications extend beyond direct influence on patient outcomes to impact cancer-related survival.