Neutrophil:lymphocyte ratios and serum cytokine changes after hepatic artery chimeric antigen receptor-modified T-cell infusions for liver metastases.

Our phase I Hepatic Immunotherapy for Metastases (HITM) trial tested the safety of chimeric antigen receptor-modified T-cell (CAR-T) hepatic artery infusions (HAI) for unresectable carcinoembryonic antigen (CEA)+ liver metastases (LM). High neutrophil:lymphocyte ratios (NLR) predict poor outcome in cancer patients and we hypothesized that NLR changes would correlate with early responses to CAR-T HAI. Six patients completed the protocol. Three patients received CAR-T HAI in dose escalation (1 × 10(8), 1 × 10(9) and 1 × 10(10) cells) and the remainder received three doses (1 × 10(10) cells) with interleukin (IL)2 support. Serum cytokines and NLR were measured at multiple time points. The mean NLR for all patients was 13.9 (range 4.8-38.1). NLR increased in four patients following treatment with a mean fold change of 1.9. Serum IL6 levels and NLR fold changes demonstrated a trend towards a positive correlation (r=0.77, P=0.10). Patients with poor CEA responses were significantly more likely to have higher NLR level increases (P=0.048). Increased NLR levels were associated with poor responses following CAR-T HAI. NLR variations and associated cytokine changes may be useful surrogates of response to CAR-T HAI.

Activated clotting time as a screening test prior to catheter-based cardiovascular procedures.

The activated clotting time (ACT) was investigated as a rapid, inexpensive, point-of-service screening test for coagulation abnormalities prior to catheter-based procedures. A total of 963 patients were screened by obtaining a history, standard coagulation profile, and activated coagulation time. The prevalence of normal patients (normal ACT and coagulation profile) was 94% (sensitivity = 91%; specificity = 27%). A normal ACT had a positive predictive value of 95%. The ACT was an acceptable screening test due to its ability to predict positively a low rate of bleeding complication and normal coagulation studies. Patients with ACT > 150 sec should be further evaluated with a screening coagulation panel. Additionally, given its low specificity, coagulation studies should be obtained in high-risk patients since an abnormal ACT does not effectively correlate with abnormal coagulation studies.

Uterine artery embolization for the treatment of adenomyosis: clinical response and evaluation with MR imaging.

OBJECTIVE: This study was performed to evaluate the MR imaging appearance and clinical response of patients undergoing uterine artery embolization for the treatment of menorrhagia due to adenomyosis. MATERIALS AND METHODS: A retrospective review of 15 patients with adenomyosis and menorrhagia who underwent uterine artery embolization was performed. The diagnosis of adenomyosis was based on established MR imaging criteria. Clinical response was assessed at a minimum of 3 months after embolization. Follow-up MR imaging was performed 6 months after embolization. RESULTS: Of the 15 patients in this study, five had diffuse adenomyosis without evidence of uterine fibroids, one had focal adenomyosis without evidence of uterine fibroids, and the remaining nine had adenomyosis with one or more fibroids. At follow-up, 12 (92.3%) of the 13 patients reported significant improvement in presenting symptoms and quality of life. One patient continued experiencing menorrhagia, and one patient experienced amenorrhea during the 5 months of follow-up after embolization. MR imaging in nine patients, performed at a mean of 5.9 months after embolization, revealed significant reductions in median uterine volume (42%), median fibroid volume (71%), and mean-junctional-zone thickness (11 mm; 33%; p < 0.5). Six of the nine patients had subendometrial regions of decreased T2 signal intensity after embolization. CONCLUSION: Uterine artery embolization is a promising nonsurgical alternative for patients with menorrhagia and adenomyosis. Significant improvement in presenting symptoms and in quality of life is associated with decreases in uterine size and junctional zone thickness. Larger prospective studies are needed to establish the safety and efficacy of this procedure for patients with adenomyosis.

The multidisciplinary approach to prevention and treatment of cardiovascular disease: creation of a vascular care network.

Vascular care, diagnosis, and intervention can be very complex. Multiple specialists commonly are involved in dealing with patients with systemic atherosclerotic disease. Although each specialist may provide state-of-the-art care with good result, it would be advantageous to minimize duplication of effort and thereby improve cost efficiency. Patients still could reap the benefit of all these disciplines if evaluated for their vascular complaint in a coordinated system. In doing so, atherosclerosis prevention with risk factor modification, as well as diagnosis and therapy for the presenting problem all can be simultaneously managed. This is the concept that has motivated groups such as our own to form a comprehensive vascular center. We describe our experience with establishing a vascular center and outline its benefits and limitations.

Long-term results in patients treated with thrombolysis, thoracic inlet decompression, and subclavian vein stenting for Paget-Schroetter syndrome.

PURPOSE: In an effort to minimize long-term disability related to effort thrombosis of the subclavian vein, selected patients were treated with thrombolysis, thoracic inlet decompression, percutaneous transluminal angioplasty (PTA), and subclavian vein stenting. We evaluated the long-term outcomes of patients treated with this algorithm. METHODS: Between 1994 and 2000, 23 patients were evaluated with effort thrombosis of the subclavian vein. Thrombolysis was instituted on an average of 9.4 days (range, 1-30 days) after initial onset of symptoms. Average time to clot lysis was 34 hours (range, 12-72 hours). After immediate supraclavicular thoracic inlet decompression, all patients underwent PTA. Fourteen patients with residual vein stenosis (>50%) after PTA underwent stenting of the subclavian vein. Complications in this series included three wound hematomas that required drainage in two patients and one subpleural hematoma that required thoracotomy for decompression. RESULTS: All patients who underwent PTA are patent, with a mean follow-up of 4 years (range, 2-6 years). In the veins treated with stents, 9 of 14 veins are patent, with a mean follow-up of 3.5 years (range, 1-6 years). Two veins had early occlusions (2 days); two veins occluded at 1 year; and seven veins occluded at 3 years. Three of the patients (including those patients who experienced the early failed procedures) were later identified with factor V Leiden. Early failures also had clot extending into the brachial vein. CONCLUSION: Patients with short-segment venous strictures after successful lysis and thoracic outlet decompression may safely be treated with subclavian venous stents and can expect long-term patency.

Outpatient uterine artery embolization for symptomatic uterine fibroids: experience in 49 patients.

PURPOSE: To assess the feasibility of performing uterine artery embolization as an outpatient treatment for symptomatic uterine fibroids. MATERIALS AND METHODS: Forty-nine consecutive patients (mean age, 44.5 years; range, 28-54 years) underwent uterine artery embolization during a 12-month period. Embolization was performed with 350-500 microm polyvinyl alcohol particles (44 of 49) or Gelfoam pledgets (five of 49). At discharge, patients were given instructions regarding the constitutional symptoms to expect after embolization. A specific medication regimen consisting of prochlorperazine, ketorolac, meperidine, and hydrocodone was prescribed for relief of these symptoms. All patients were telephoned within 24 hours of discharge. During long-term follow-up, a questionnaire was administered to all patients to evaluate the periprocedural experience. Three-month clinical follow-up was available in 26 patients and 6-month imaging follow-up was available in 16 patients. RESULTS: Fourteen patients presented with menorrhagia, six had bulk-related symptoms (abdominal distension, stress incontinence, pelvic pain), and 29 had both. Technical success for bilateral embolization was 98%. Forty-seven of 49 patients were discharged to home 6-8 hours after the procedure; two patients required overnight observation in an ambulatory unit (one because of postprocedure hypertension and one because of a late procedure completion time). At the first follow-up phone call, reported symptoms included pelvic pain/cramping in 83.7% (41 of 49), fatigue in 75.5% (37 of 49), nausea/vomiting in 46.9% (23 of 49), and a nonpurulent vaginal discharge in 18.4% (nine of 49). These symptoms were satisfactorily controlled with discharge medications in 48 of 49 patients. No patients returned to the hospital or visited an emergency room during the first 48 hours after discharge. Forty-six of 49 patients were satisfied with the decision for home discharge. The average uterine volume reduction in 16 patients with 6-month imaging follow-up was 47.5%; 88.5%, of patients (23 of 26) with 3-month clinical follow-up reported improvement or elimination of symptoms. CONCLUSION: With defined telephone follow-up, staff availability, and a protocol designed to alleviate the postprocedure constitutional symptoms, uterine artery embolization is both safe and effective when performed as an outpatient procedure.

Comparison of the angiojet rheolytic catheter to surgical thrombectomy for the treatment of thrombosed hemodialysis grafts. Peripheral AngioJet Clinical Trial.

PURPOSE: To compare the clinical effectiveness of the AngioJet F105 rheolytic catheter to that of surgical thrombectomy for the treatment of thrombosed hemodialysis grafts. MATERIALS AND METHODS: This was a multicenter, prospective, randomized trial comparing technical success, primary patency, and complication rates. A total of 153 patients were enrolled: 82 patients in the AngioJet group and 71 patients in the surgical thrombectomy group. Patient follow-up was performed 24-48 hours, 1 month, and 6 months after the procedures. RESULTS: Technical success, as defined by the patient's ability to undergo hemodialysis treatment, was 73.2% for the AngioJet group and 78.8% for the surgical thrombectomy group (P = .41). The primary patency rates of the AngioJet group were 32%, 21%, and 15% at 1, 2, and 3 months, respectively. The primary patency rates for the surgical group were 41%, 32%, and 26% at 1, 2, and 3 months, respectively. This difference approached statistical significance (P = .053). The groups had similar complication rates-14.6% in the AngioJet group and 14.1% in the surgery group-although the surgery group had more major complications (11.3%). In the AngioJet group, there was a transient increase in plasma-free hemoglobin, which normalized within 24-48 hours. CONCLUSIONS: The AngioJet F105 catheter provides similar clinical results when compared to surgical thrombectomy for the treatment of thrombosed hemodialysis grafts. The difference in patency rates between these two techniques approached statistical significance. In addition, results of both thrombectomy methods were inferior to those suggested by the Dialysis Outcomes Quality Initiative guidelines.

Management of failing prosthetic bypass grafts with metallic stent placement.

PURPOSE: To evaluate the role of metallic stents in treating stenoses involving prosthetic arterial bypass grafts. METHODS: Patients undergoing stent placement within a failing prosthetic bypass graft, during a 41-month period, were reviewed for treatment outcome and complications. The indications for stent placement in 15 patients included severe claudication (n = 3), rest pain (n = 9), and minor or major tissue loss (n = 3). Lesions were at the proximal anastomosis (n = 6), the distal anastomosis (n = 3), or within the graft (n = 6). RESULTS: Treatment with metallic stents was successful in all patients. There was one acute stent thrombosis, successfully treated with thrombolytic therapy. Follow-up data are available for a mean duration of 12.3 months. The mean duration of primary patency was 9.4 months with 6- and 12-month primary patency rates of 51.9% and 37.0%, respectively. The mean duration of secondary patency was 12.1 months with 6- and 12-month secondary patency rates of 80.0% and 72.7%, respectively. Two patients with discontinuous runoff and preexisting gangrene required a below-knee amputation. Six patients were revised surgically after stent placement (at a mean of 10.8 months). Three late deaths occurred during follow-up. CONCLUSION: Given the mortality risks of surgical revision and the reduced life expectancy of this patient population, metallic stent placement represents a viable, short-term treatment option for stenoses within or at the anastomoses of prosthetic grafts. Further evaluation is warranted to compare intragraft stent placement with surgical graft revision.

Combined use of iliac artery angioplasty and infrainguinal revascularization for treatment of multilevel atherosclerotic disease.

The purpose of this report is to review our recent experience with the combined use of iliac artery angioplasty and infrainguinal surgical revascularization for the treatment of multilevel atherosclerotic disease. A retrospective review of all patients with multilevel atherosclerotic disease who were treated with both iliac artery angioplasty and infrainguinal bypass surgery during a 4-year period was performed. The medical records and preoperative arteriograms of all patients were reviewed for demographic information, radiologic findings, and postoperative follow-up data. Ninety-three limbs in 87 patients were studied. There were 57 male and 30 female patients with an average age of 67.2 years (range: 38-90). We concluded that the combined use of iliac artery angioplasty and infrainguinal surgical revascularization is an effective and durable means of treating multilevel atherosclerotic disease.

Rheolytic thrombectomy in the treatment of acute limb-threatening ischemia: immediate results and six-month follow-up of the multicenter AngioJet registry. Possis Peripheral AngioJet Study AngioJet Investigators.

We tested the efficacy of rheolytic thrombectomy in treating 21 patients (mean age 68+/-12 years; 66% male) and 22 vessels (limbs) who presented to the hospital within 2 weeks of the development of limb-threatening ischemia. Fifty-two percent had contraindications to use thrombolytics, and 57% had severe comorbidities. All of the vessels were occluded with thrombus on the initial angiogram. Procedural success was achieved in 20 limbs (91%). Three patients expired in the hospital, and one expired at follow-up due to nonvascular causes. Acute limb salvage was achieved in 18 of 19 limbs (95%) in the 18 survivors, and 6-month limb salvage was achieved in 16 of 18 limbs (89%) in the 17 survivors. Rheolytic thrombectomy is effective in restoring immediate blood flow in acute limb-threatening ischemia, especially in high-risk surgical patients or patients with contraindications to thrombolytic therapy.

Prevention of hemobilia during percutaneous biliary drainage: long-term follow-up.

PURPOSE: The authors evaluated a technique for the prevention of hemobilia when placing transhepatic biliary drainage catheters (THBDCs). MATERIALS AND METHODS: Initially, 20 patients were randomized into two groups. In the control group, a THBDC was placed after blind needle passage without contrast material opacification of the needle tract. In the experimental group, the tract was studied and then abandoned if a major vascular structure was encountered. Once a tract was found that did not traverse a major vascular structure, a THBDC was placed. An additional 35 patients undergoing 40 procedures were studied with use of the technique as outlined for the original experimental group. The original experimental group patients and the additional 35 patients were followed for up to 3 years. RESULTS: There were three cases of hemobilia in the initial control group. None of the patients in the initial experimental group experienced hemobilia. In the additional 35 patients, there were three cases of bloody drainage from the THBDC; however, the etiology of hemobilia was not secondary to transgression of a vascular structure. CONCLUSION: Visualization of the tract prevents the usage of tracts that communicate with large vascular structures. This technique reduces the incidence of hemobilia when placing THBDCs.

Transrectal ultrasound-guided transperineal cryoablation in the treatment of prostate carcinoma: preliminary results.

PURPOSE: We studied ultrasound-guided percutaneous cryoablation for treatment of prostate carcinoma. MATERIALS AND METHODS: Our series includes 83 individuals who underwent transrectal ultrasound-guided transperineal percutaneous cryoablation of the prostate. Prostate specific antigen levels, biopsy results and complications were assessed at 3 months. RESULTS: Of 61 biopsies 8 (13.1%) were positive for carcinoma (half showed stage D disease). Of patients with stages T1 to T3 cancer 92.6% were free of disease at 3 months. Prostate specific antigen levels were significantly decreased by an average of 1.90 ng./ml. (p < 0.05). Major complications were infrequent, including bladder perforation in 1 patient, urethral strictures in 3, bladder outlet obstruction in 2 and partial incontinence in 2. Impotence was frequent but transient. CONCLUSIONS: Transrectal ultrasound-guided transperineal percutaneous cryoablation of the prostate produces few major complications and appears at 3 months to be effective in eradicating local prostate tumors. Longer followup is required to test the original hypothesis.

Prevention of significant hemobilia during placement of transhepatic biliary drainage catheters: technique modification and initial results.

PURPOSE: The authors evaluated a technique for the prevention of significant hemobilia during placement of transhepatic biliary drainage catheters (TBDCs). PATIENTS AND METHODS: Twenty patients with strictures were randomized to two groups. In the control group, the biliary tree was accessed with an Accustick system and a TBDC was placed routinely. In the experimental group, following initial access, a rotating hemostatic valve was attached and the outer sheath was pulled back over the wire while contrast material was injected. If a major vascular structure was encountered, the tract was not used for TBDC placement. However, the outer sheath was re-advanced and used to opacify the ducts. This facilitated separate access. Once access was achieved without traversing a major vascular structure, a TBDC was placed, and the Accustick system was removed. If a portal vein or hepatic vein branch was traversed, no additional maneuvers were performed. However, if a branch of the hepatic artery had been traversed, the tract and biliary-arterial fistula were embolized with gelatin sponge pledgets. Both groups were evaluated for hemobilia for 6 weeks. RESULTS: In the control group, there were three cases of significant hemobilia; two were mild, one was severe. In the experimental group, the tract communicated with a major vascular structure in three patients. In these patients, a second access was used for TBDC placement. None of the patients in the experimental group experienced significant hemobilia. CONCLUSION: Visualization prevents the usage of tracts that communicate with large vascular structures. Initial results indicate that this reduces the frequency of significant hemobilia when TBDCs are placed.

Uterine inner myometrial echogenic foci. Relationship to prior dilatation and curettage and endocervical biopsy.

The frequent presence of small echogenic foci within the inner myometrium in women who have had prior uterine instrumentation is reported. Bright foci were observed in 35 of 80 patients who had had prior dilatation and curettage or endocervical biopsy and in only 2 of 174 patients who gave no history of either procedure (P less than 0.005). These foci tend to be small (3 to 6 mm), linear, usually nonshadowing, single or multiple, and located immediately adjacent to the endometrium anywhere along the length of the endometrial cavity; they can be seen many years after the procedure was performed. The histopathologic features of these foci are unconfirmed, but we suspect they represent calcification or fibrosis at sites of mechanical injury to myometrium. The presence of these foci serves as a marker of prior instrumentation and probably has no clinical significance. However, sonographers who are aware of their possible occurrence, can avoid mistaking them for leiomyoma calcifications or for air in the endometrium or myometrium in patients with suspected endometritis.

MR image of localized giant cell tumor of the tendon sheath involving the knee.

A case of giant cell tumor of the tendon sheath is presented. The CT and magnetic resonance appearances are described, correlated with pathologic findings, and compared with those of villonodular synovitis.