Catheter-retaining balloon-occluded retrograde transvenous obliteration for gastric varices.

PURPOSE: We evaluated the effectiveness of catheter-retaining balloon-occluded retrograde transvenous obliteration (BRTO). PATIENTS AND METHODS: Patients were divided into 2 groups based on concurrent contrast imaging findings. The primary endpoint was effectiveness, the secondary endpoint was complications, and the tertiary endpoint was recurrence of esophageal varices in all cases. RESULTS: The mean volume of EO administered was 16.43 ± 4.37 overall and was significantly lower in group 1 (40.61 ± 14.95 mL; 15 patients, 32.6%) than in group 2 (31 patients, 67.4%). The number of injections was 1.60 ± 0.63 in group 1 and 2.97 ± 0.60 in group 2, and the volume of EO used in 1 day did not differ significantly between group 1 (12.28 ± 6.48 mL) and group 2 (13.54 ± 3.12 mL). The disappearance rate of varices was significantly greater in group 1 (100%) than in group 2 (90.3%). Fever developed in 33.3% of patients in group 1 and 87.1% of patients in group 2. The rates of recurrence of esophageal varices 2, 4, and 9 years after the procedure were 34%, 48%, and 57%, respectively. CONCLUSION: These results show that catheter-retaining BRTO is a simple and highly effective procedure for difficult cases with minor complications. Furthermore, catheter-retaining BRTO does not require a large daily dose of EO and is, therefore, an effective treatment for solitary gastric varices.

Gene transduction into aortic wall using plasmid-loaded cationized gelatin hydrogel-coated polyester stent graft.

OBJECTIVE: Stent grafts are increasingly recognized as useful devices for endovascular repair of aortic aneurysms and other vascular diseases. Stent graft-mediated gene delivery into the vascular wall is expected to improve their therapeutic effects. This study evaluated the efficacy of genetically engineered cationized gelatin (CG) hydrogel-coated partially-covered polyester stent grafts that facilitate delivery of an expression plasmid DNA in rabbit aortic wall. METHODS: Partially covered polyester stent grafts coated with CG hydrogel impregnated with 10.0 mg/mL of beta-galactosidase (LacZ)-expression plasmid vector (pCAGGS-LacZ) or empty vector (pCAGGS) solutions were implanted via the femoral artery in rabbit balloon-injured aortas. The aortic segments were removed at 1, 3, or 7 days (4 rabbits/each group) after implantation and evaluated for the transgene (LacZ) delivery and expression by real-time reverse transcriptase polymerase chain reaction (RT-PCR) and X-gal (5-bromo-4-chloro-3-indolyl-beta-D-galactoside) staining. Partially-covered polyester stent grafts coated with CG hydrogel impregnated with various amounts (0.1 mg/mL, 1.0 mg/mL, and 10.0 mg/mL) of pCAGGS-LacZ or pCAGGS were also implanted in rabbits' balloon-injured aortas (4 rabbits/each group) to evaluate transgene delivery and expression in the aortic wall 3 days after implantation. The difference of transgene efficiency among each group was compared using one-way analysis of variance (ANOVA) and Newman-Keuls' test according to the result of quantitative RT-PCR. RESULTS: In all animals, LacZ gene transduction into the aortic wall was detected at the implantation site of pCAGGS-LacZ-loaded, but not pCAGGS-loaded, stent grafts. LacZ expression was not detected in aortic segments immediately proximal or distal to the implanted pCAGGS-LacZ-loaded stent graft or remote organs including the brain, heart, liver, and kidney by either RT-PCR or X-gal staining. The X-gal staining-positive cells were observed at or near the luminal surface in the aortic segments only in contact with the stent graft and the ingrowth tissues within stent grafts. Immunohistochemical studies suggested that the LacZ-positive cells were mainly the neointimal alpha-smooth-muscle actin-positive cells and macrophages. The extent of the transgene expression was dependent on the quantity of the plasmid DNA loaded onto the stent graft (10.0 mg/mL plasmid vs 1.0 mg/mL plasmid, P < .01 and 10.0 mg/mL plasmid vs 0.1 mg/mL plasmid, P < .05). LacZ mRNA expression was maximal at day 1 and declined at day 7 (P < .05) but was still detectable. CONCLUSION: Plasmid-loaded CG hydrogel-coated stent graft is a promising vehicle for local transgene delivery to the aortic wall and offers the possibility of transduction of therapeutic genes into the vascular wall.

Partially covered stent-graft implantation in rabbit aorta: a new model to investigate bioactive stent-grafts in small animals.

PURPOSE: To present a new endovascular technique for placing handmade partially covered stent-grafts in rabbit aortas that is promising for experimental study of direct gene delivery to the aortic wall. METHODS: A 7-mm-diameter Z-stent made from the inner core of a guidewire was covered with a 7-mm-diameter, 10-mm-long polyester fabric tube (2268 mL porosity). To decrease stent profile and make delivery possible through a 6-F introducer, one third of the fabric was cut away to form a partially covered polyester stent-graft. Two stent-grafts were delivered sequentially into the descending thoracic aorta of 12 male Japanese White rabbits; a third device was positioned in each aorta so that the orifices of the celiac trunk and superior mesenteric artery were not occluded. RESULTS: The implantation was successful in 10 animals. One rabbit died during the procedure due to sheath laceration of the infrarenal abdominal aorta. Another animal died within 2 days after the procedure owing to occlusion of the celiac trunk by graft fabric. At 2 weeks, the stent-grafts in the 10 surviving rabbits remained patent, and there was no migration. Gross examination of the lumens showed that both the metal stent and the polyester graft material were completely covered with thin transparent tissue, without massive thrombosis. Histological staining revealed incomplete neointima formation between the stent-graft and the aorta. Incomplete linear endothelial cells on the luminal side of the tissue ingrowth into the stent-graft were also observed. Foreign body giant cells and macrophages represented inflammatory reactions related to the graft material. CONCLUSION: Partially covered stent-grafts can be safely placed in relatively small animals and potentially used in research.

Concurrent intra-arterial chemotherapy and radiotherapy for advanced laryngeal cancer.

OBJECTIVES: An intra-arterial chemoradiotherapy regimen (RADPLAT) provides remarkable local control for head and neck cancer. This study evaluates the efficacy of a reduced RADPLAT protocol in patients who are candidates for total laryngectomy. METHODS: Forty-three patients with advanced laryngeal cancer were treated with 2 courses of intra-arterial cisplatin infusion (100 mg per body) during 40-Gy irradiation. The patients who showed a greatly diminished tumor received sequential irradiation. The patients with obvious residual disease received chemotherapy during the sequential irradiation. Poor responders, with less than 50% tumor reduction, underwent total laryngectomy. RESULTS: Forty-two patients completed the protocol. All surviving patients were followed for at least 3 years. Thirty-four patients were alive (80% of the supraglottic cases and 87.5% of the glottic cases). Local control was achieved in 27 patients (67.5% of the 11 glottic cases and 64.0% of the supraglottic cases). The glottic cohort showed better progression-free survival rates than did the supraglottic cohort (68.8% and 45.0%, respectively; p = 0.019). There were 2 cases of grade 3 neutropenia and 3 cases of grade 3 mucositis. No patients required tube feeding. One patient required tracheostomy 3 months after the completion of the treatment protocol. CONCLUSIONS: Concurrent chemoradiotherapy with a reduced dose of intra-arterial cisplatin is feasible for patients with advanced glottic cancer.

Intra-arterial chemotherapy less intensive than RADPLAT with concurrent radiotherapy for resectable advanced head and neck squamous cell carcinoma: a prospective study.

OBJECTIVES: This study was designed to evaluate the efficacy and feasibility of our intra-arterial chemotherapy protocol with a lower amount and frequency of cisplatin delivery than in RADPLAT for the treatment of resectable advanced head and neck cancer. METHODS: Fifty-one patients with advanced squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx were included in this prospective study. The patients were treated with 3 courses of cisplatin (100 mg at 1 treatment, intra-arterial) and sodium thiosulfate (28 g at 1 treatment, intravenous) once every 2 weeks during concurrent radiotherapy (66 to 70 Gy, 2 Gy per fraction, daily for 5 days over 7 weeks). Nodal metastases larger than 3 cm in diameter were treated with an additional 50 mg of cisplatin. The patients with less than 50% tumor reduction after 40 Gy and 2 courses of chemotherapy were treated with surgery. RESULTS: The protocol was completed for 49 patients. All living patients had a minimum follow-up period of 2 years. Including the 3 patients with salvage surgery, local disease-free control was achieved in 39 patients (80%). For 36 patients (73.5%), disease-free primary organs were preserved at 2 years after treatment. Locoregional disease-free control for 2 years was obtained for 38 patients (77.6%), in 30 of them without salvage surgery. The patients treated with surgery had an overall survival rate similar to that of the patients with a complete response (80% and 84.6%, respectively). The patients with a partial response had a worse prognosis (40%; p = .0069). CONCLUSIONS: This treatment regimen is feasible and effective for advanced resectable head and neck cancer.

Cervical radiculopathy due to intra-arterial infusion of cisplatin.

A 55-year-old man with cervical radiculopathy (C5-C8) was referred to us following intra-arterial infusion of cisplatin (CDDP) because of a recurrent neck mass of laryngeal cancer. Three hours after the CDDP infusion, he had noticed general weakness of the left upper extremity and hypoaesthesia of the lateral side of the upper and lower arm. The next day he was diagnosed with left cervical radiculopathy of C5 to C8, which improved gradually and had resolved completely six months after the infusion. Even with proper positioning of the infusion catheter to minimize potential complications, for anatomical reasons there are always some risks of neural injury with intra-arterial infusion from branches of the subclavian artery. This procedure should be carefully indicated in the case of a large neck tumour that is perfused from the major branches of the subclavian artery.