Abdominal Vascular Evaluation.

The vascular lab (VL) is instrumental in diagnosing vascular diseases such as renal artery stenosis and mesenteric ischemia or following a patient after transjugular intrahepatic portal systemic shunt (TIPS) creation. This article discusses indications, protocol, and diagnostic criteria for abdominal vascular ultrasound. The vascular lab can be used to investigate pathology in the abdomen either as a preliminary screening tool to evaluate for a pathology such as mesenteric artery stenosis in a patient with food fear and weight loss, renal artery stenosis in a patient with refractory hypertension or renal failure, or as a diagnostic tool in follow up after a patient has undergone a transjugular intrahepatic portal systemic shunt (TIPS) for portal hypertension. The technical success of duplex ultrasonography of the abdomen can be compromised by respiratory motion, obesity, and intestinal gas. Therefore, duplex scanning is performed in the fasting state particularly in elective outpatient cases. In emergent cases when pathology such as acute mesenteric ischemia is suspected evaluation with CT angiography may be best.

Endovascular Treatment of Infrainguinal Peripheral Arterial Disease (PAD): Update on Stent Technology.

Peripheral artery disease (PAD) is a progressive vascular disease affecting millions of individuals and is a considerable cause of morbidity and mortality worldwide. While balloon angioplasty remains the cornerstone option for endovascular management of arterial stenosis, advances in percutaneous endovascular stent technology have broadened the toolbox of therapeutic options for PAD and have significantly improved function and quality of life. Indeed, covered stents, bioabsorbable stents and drug eluting stents are several of the innovations in stent technology made since the advent of nitinol bare metal stents in the 1980s. The indications for use, technical considerations, treatment outcomes, and current concerns regarding current stent devices will herein be discussed in this review.

Adrenal vein sampling with and without cosyntropin stimulation for detection of surgically remediable aldosteronism.

CONTEXT AND OBJECTIVE: Bilateral adrenal vein sampling (AVS), the diagnostic standard for identifying surgically remediable aldosteronism (SRA), is commonly performed after cosyntropin stimulation (post-ACTHstim). The role of AVS without cosyntropin stimulation (pre-ACTHstim) has not been established. The selectivity index (SI), the adrenal vein (av) serum cortisol concentration divided by that in a peripheral vein, confirms av sampling. The minimally acceptable SI is controversial. The objectives of this study were to determine the role of pre-ACTHstim AVS and a predetermined SI. DESIGN: Using biochemical cure as the endpoint, we performed a retrospective head-to-head comparison of pre-ACTHstim AVS to post-ACTHstim AVS. The specificity of a predetermined minimum SI of 1.5 in pre-ACTHstim AVS was determined. PATIENTS: At a regional AVS referral centre, we analysed 32 patients who had undergone simultaneous bilateral AVS both pre- and post-ACTHstim and had returned for postadrenalectomy evaluation. MEASUREMENTS: Simultaneous bilateral AVS was performed with measurements of venous concentrations of aldosterone and cortisol. End points were postadrenalectomy plasma renin activity, serum aldosterone concentration, and number of antihypertensive medications. RESULTS: All 32 patients achieved a biochemical cure following adrenalectomy. The two AVS protocols were complementary. Notably, seven patients (22%; CI = 11-38) were found to have SRA by a lateralization index (LI) > 4 on the pre-ACTHstim AVS, but not on the post-ACTHstim AVS. SI pre-ACTHstim was divided into tertiles. Specificity was 100% in all. CONCLUSIONS: Simultaneous bilateral AVS performed both pre-ACTHstim and post-ACTHstim maximizes SRA identification. A SI of 1.5 pre-ACTHstim does not reduce specificity.

18F-FDG PET/CT Is an Immediate Imaging Biomarker of Treatment Success After Liver Metastasis Ablation.

UNLABELLED: The rationale of this study was to examine whether (18)F-FDG PET/CT and contrast-enhanced CT performed immediately after percutaneous ablation of liver metastases are predictors of local treatment failure at 1 y. METHODS: This Health Insurance Portability and Accountability Act-compliant, Institutional Review Board-approved retrospective study reviewed 25 PET/CT-guided thermal ablations performed from September 2011 to March 2013 on 21 patients (11 women and 10 men; mean age, 56.8 y; range, 35-79 y) for the treatment of liver metastases (colorectal, n = 23; breast, n = 1; and sarcoma, n = 1). One to 3 tumors (mean size, 2.3 cm; range, 0.7-4.6 cm; mean SUVmax, 22.7; range, 9.5-77.1) were ablated using radiofrequency (n = 16) or microwave (n = 9) energy in a single session. Immediate-postablation enhanced CT and PET/CT scans were qualitatively evaluated by 2 reviewers independently, and the results were compared with clinical and imaging outcome at 1 y. The PET/CT scans were also analyzed to determine tissue radioactivity concentration (TRC) from 3-dimensional regions of interest in the ablation zone, the margin, and the surrounding normal liver to calculate a TRC ratio, which was then compared with outcome at 1 y. Receiver operating characteristics (ROC) were used, and the maximal-accuracy threshold in predicting recurrence was calculated. RESULTS: Eleven (44%) of the 25 tumors recurred within 1 y. Enhanced CT did not significantly correlate with recurrence (P = 0.288). Accuracy was 64% (16/25), and the area under the ROC curve was 0.601 (95% confidence interval [95% CI], 0.387-0.789). The accuracy of the qualitative analysis of (18)F-FDG PET was 92% (23/25) (P < 0.001), and the area under the ROC curve was 0.929 (95% CI, 0.740-0.990). The mean TRC ratio was 40.6 in the recurrence group (SD, 9.2; range, 29.3-53.9) and 15.9 in the group without recurrence (SD, 7.3; range, 3-27.3). A TRC ratio of 28.3 predicted recurrence at 1 y with 100% accuracy (25/25) (P < 0.001), and the area under the ROC curve was 1 (95% CI, 0.863-1). CONCLUSION: Immediate PET/CT accurately predicts the success of liver metastasis ablation at 1 y and is superior to immediate enhanced CT.

Radioembolization as a Salvage Therapy for Heavily Pretreated Patients With Colorectal Cancer Liver Metastases: Factors That Affect Outcomes.

BACKGROUND: In this study we assessed the efficacy and factors that affect outcomes of radioembolization (RE) using yttrium-90 resin microspheres in patients with unresectable and chemorefractory colorectal cancer liver metastases (CLM). PATIENTS AND METHODS: After an institutional review board waiver of approval, a review of a Health Insurance Portability and Accountability Act-registered, prospectively created and maintained database was performed. Data on patient demographic and disease characteristics, RE treatment parameters, and additional treatments were evaluated for significance in predicting overall survival (OS) and liver progression-free survival (LPFS). Complications were evaluated according to the National Cancer Institute Common Terminology Criteria for adverse events. RESULTS: From September 2009 to September 2013, 53 patients underwent RE at a median of 35 months after CLM diagnosis. Median OS was 12.7 months. Multivariate analysis showed that carcinoembryonic antigen levels at the time of RE ≥ 90 ng/mL (P = .004) and microscopic lymphovascular invasion of the primary (P = .002) were independent predictors of decreased OS. Median LPFS was 4.7 months. At 4 to 8 and 12 to 16 weeks after RE, most patients (80% and 61%, respectively) according to Response Evaluation Criteria in Solid Tumors (RECIST) had stable disease; additional evaluation using PET Response Criteria in Solid Tumors (PERCIST) led to reclassification in 77% of these cases (response or progression). No deaths were noted within the first 30 days. Within the first 90 days after RE, 4 patients (8%) developed liver failure and 5 patients (9%) died, all with evidence of disease progression. CONCLUSION: RE in the salvage setting was well-tolerated, and permitted the administration of additional therapies and led to a median OS of 12.7 months. Evaluation using PERCIST was more likely than RECIST to document response or progression compared with the baseline assessment before RE.

Successful control of liver metastases from pancreatic solid-pseudopapillary neoplasm (SPN) using hepatic arterial embolization.

No systemic agents that are known to be effective for the treatment of solid-pseudopapillary neoplasm (SPN) are available. We report the prolonged and sustained control of metastatic pancreatic SPN to the liver using hepatic arterial embolization (HAE), where a total of 13 HAE sessions were performed over a 6-year period.

Microwave ablation (MWA) for the treatment of a solitary, chemorefractory testicular cancer liver metastasis.

We present a case of a patient with stage IIIC metastatic seminoma with a persistent chemorefractory liver lesion. The patient was deemed a poor surgical candidate due to the tumor's aggressive biology with numerous other liver lesions treated with chemotherapy and a relatively high probability for additional recurrences. Further chemotherapy with curative intent was not a feasible option due to the fact that the patient had already received second-line high-dose chemotherapy and four cycles of third-line treatment complicated by renal failure, refractory thrombocytopenia, and debilitating neuropathy. After initial failure of laser, microwave ablation of the chemorefractory liver metastasis resulted in prolonged local tumor control and rendered the patient disease-free for more than 35 months, allowing him to regain an improved quality of life.