Adrenal Vein Sampling in the Management of Primary Aldosteronism: The Added Value of Intraprocedural Cortisol Assessment.

Introduction: Primary aldosteronism is the most common cause of secondary hypertension. Adrenal vein sampling is the gold standard for subtyping primary aldosteronism. However, this procedure is technically challenging and often has a low success rate. Our center is one of the very few performing this technique in our country with an increasing experience. Objective: The aim of this study was to evaluate the role of the cortisol intraprocedural assay in improving the performance of adrenal vein sampling. Design: We enrolled all of the patients with primary aldosteronism that underwent adrenal vein sampling from February 2016 to April 2023. The cortisol intraprocedural assay was introduced in October 2021. Methods: We enrolled a total of 50 adrenal vein samplings performed on 43 patients with the diagnosis of primary aldosteronism. In this sample, 19 patients and 24 patients underwent adrenal vein sampling before and after intraprocedural cortisol measurement, respectively. The procedure was repeated in seven patients (one before and six after intraprocedural cortisol measurement), given the unsuccess of the first exam. Selectivity of the adrenal vein sampling was assumed if the serum cortisol concentration from the adrenal vein was at least five times higher than that of the inferior vena cava. Lateralization was assumed if the aldosterone to cortisol ratio of one adrenal vein was at least four times the aldosterone to cortisol ratio of the contralateral side. Results: The mean age of the patients that underwent adrenal vein sampling (N = 43) was 55.2 ± 8.9 years, and 53.5% (n = 23) were female. The mean interval between the diagnosis of hypertension and the diagnosis of primary aldosteronism was 9.8 years (±9.9). At diagnosis, 62.8% of the patients (n = 27) had hypokalemia (mean value of 3 mmol/L (±0.34)), 88.4% (n = 38) had adrenal abnormalities on preprocedural CT scan, and 67.4% (n = 29) described as unilateral nodules. There were no statistically significant differences in the patients' baseline characteristics between the two groups (before and after intraprocedural cortisol measurement). Before intraprocedural cortisol measurement, adrenal vein sampling selectivity was achieved in 35% (n = 7) patients. Selectivity increased to 100% (30/30) after intraprocedural cortisol measurement (p < 0.001). With the exception of one patient who refused it, all patients with lateralized disease underwent unilateral adrenalectomy with normalization of the aldosterone to renin ratio postoperatively. Conclusions: The lack of effective alternatives in subtyping primary aldosteronism highlights the need to improve the success rate of adrenal vein sampling. In this study, intraprocedural cortisol measurement allowed a selectivity of 100%. Its addition to this procedure protocol should be considered, especially in centers with a low success rate.

Transarterial Chemoembolization with Anthracyclines-Loaded Polyethylene Glycol Drug Eluting Microspheres for the Treatment of Hepatocellular Carcinoma: A Pooled Multicentric Analysis of Survival in 580 Patients.

PURPOSE: To evaluate survival, efficacy and safety of transarterial chemoembolization (TACE) in the treatment of patients with hepatocellular carcinoma (HCC), through a pooled analysis of patients with BCLC 0, A and B HCC stages, treated with polyethylene glycol drug eluting microspheres (PEG-DEM) TACE. MATERIALS AND METHODS: Patients from 3 retrospective and 2 prospective registries were included. Overall survival (OS), progression-free survival (PFS), tumour response and safety were evaluated. Multivariate Cox regression analysis was performed to evaluate predictors of OS. RESULTS: A total of 580 patients (72.1% males, mean age 66.9 ± 10.3 years) were included. 43.5% had BCLC A, and 41.0% BCLC B disease stage, and 85.8% were Child-Pugh class A. Complete and partial response (mRECIST or RECIST1.1) were achieved in 60.14% and 27.11% of patients, with overall response and disease control rates of 87.30% and 94.60%, respectively. Median OS was 50.8 months for the total population, and 61.2 and 38.1 months for BCLC 0 + A and BCLC B patients, respectively. Median PFS for the total population, BCLC 0 + A and BCLC B groups was 15.6, 21.6 and 12.7 months, respectively. CONCLUSIONS: This multicentric pooled analysis confirmed efficacy and safety of PEG-DEM TACE, with a median OS of 50.8 months.

Thyroid arterial embolization in a patient with congenital heart disease and refractory amiodarone-induced thyrotoxicosis.

Introduction: Amiodarone-induced thyrotoxicosis (AIT) can sometimes lead to life-threatening complications, especially in patients with congenital heart disease (CHD). We report the case of a patient with refractory AIT that was successfully treated with thyroid arterial embolization (TAE). Case report: A 34-year-old man with complex cyanotic CHD complicated with heart failure (HF), pulmonary hypertension, and supraventricular tachyarrhythmias, was treated with amiodarone since 2013. In March 2019, he presented worsening of his cardiac condition and symptoms of thyrotoxicosis that were confirmed by laboratory assessment. Thiamazole 30 mg/day and prednisolone 40 mg/day were prescribed, but the patient experienced worsening of his cardiac condition with several hospital admissions in the next 5 months, albeit increasing dosages of thionamide and glucocorticoid and introduction of cholestyramine and lithium. Thyroidectomy was excluded due to the severity of thyrotoxicosis, and plasmapheresis was contraindicated due to the cardiac condition. TAE of the four thyroid arteries was then performed with no immediate complications. Progressive clinical and analytical improvement ensued with gradual reduction and suspension of medication with the patient returning to euthyroid state and his usual cardiac condition previous to the AIT. Conclusion: For patients with medication refractoriness and whose condition precludes thyroidectomy, embolization of thyroid arteries may be an effective and safe option. Established facts: Amiodarone-induced thyrotoxicosis (AIT) can be refractory to a combination therapy of thionamides and glucocorticoids. Restoration of euthyroidism is of paramount importance in heart failure (HF) patients. Emergency thyroidectomy for AIT unresponsive to medical therapy is recommended in patients with severe underlying cardiac disease or deteriorating cardiac function. Novel insights: Thyroid arterial embolization (TAE) appeared as a salvage therapy in this patient. To the best of our knowledge, few case reports in the literature have described the embolization of the four thyroid arteries in AIT context. Endovascular embolization techniques are a valuable therapeutic option and can be considered in cases where standard forms of treatment are ineffective or involve unacceptable risks.

BestFLR Trial: Liver Regeneration at CT before Major Hepatectomies for Liver Cancer-A Randomized Controlled Trial Comparing Portal Vein Embolization with N-Butyl-Cyanoacrylate Plus Iodized Oil versus Polyvinyl Alcohol Particles Plus Coils.

Background In patients with liver cancer, portal vein embolization (PVE) is recommended to promote liver growth before major hepatectomies. However, the optimal embolization strategy has not been established. Purpose To compare liver regeneration as seen at CT in participants with liver cancer, before major hepatectomies, with N-butyl-cyanoacrylate (NBCA) plus iodized oil versus standard polyvinyl alcohol (PVA) particles plus coils, for PVE. Materials and Methods In this single-center, prospective, randomized controlled trial (Best Future Liver Remnant, or BestFLR, trial; International Standard Randomized Controlled Trial Number 16062796), PVE with NBCA plus iodized oil was compared with standard PVE with PVA particles plus coils in participants with liver cancer. Participant recruitment started in November 2017 and ended in March 2020. Participants were randomly assigned to undergo PVE with PVA particles plus coils or PVE with NBCA plus iodized oil. The primary end point was liver growth assessed with CT 14 days and 28 days after PVE. Secondary outcomes included posthepatectomy liver failure, surgical complications, and length of intensive care treatment and hospital stay. The Mann-Whitney U test was used to compare continuous outcomes according to PVE material, whereas the Χ2 test or Fisher exact test was used for categoric variables. Results Sixty participants (mean age, 61 years ± 11 [standard deviation]; 32 men) were assigned to the PVA particles plus coils group (n = 30) or to the NBCA plus iodized oil group (n = 30). Interim analysis revealed faster and superior liver hypertrophy for the NBCA plus iodized oil group versus the PVA particles plus coils group 14 days and 28 days after PVE (absolute hypertrophy of 46% vs 30% [P < .001] and 57% vs 37% [P < .001], respectively). Liver growth for the proposed hepatectomy was achieved in 87% of participants (26 of 30) in the NBCA plus iodized oil group versus 53% of participants (16 of 30) in the PVA particles plus coils group (P = .008) 14 days after PVE. Liver failure occurred in 13% of participants (three of 24) in the NBCA plus iodized oil group and in 27% of participants (six of 22) in the PVA particles plus coils group (P = .27). Conclusion Portal vein embolization with N-butyl-cyanoacrylate plus iodized oil produced greater and faster liver growth as seen at CT in participants with liver cancer, compared with portal vein embolization with polyvinyl alcohol particles plus coils, allowing for earlier surgical intervention. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Arellano in this issue.

Successful Revascularization has a Significant Impact on Limb Salvage Rate and Wound Healing for Patients with Diabetic Foot Ulcers: Single-Centre Retrospective Analysis with a Multidisciplinary Approach.

PURPOSE: Analyze the impact of endovascular revascularization on major amputation rates and wound healing for patients with diabetic foot ulcers (DFUs). MATERIALS AND METHODS: Single-center retrospective study from 2014-2018 including 314 patients with DFUs submitted to endovascular revascularizations. Group A-patients with a successful endovascular revascularization (n = 285; 90.8%); Group B-patients submitted to a failed attempt of endovascular revascularization (n = 29; 9.2%). Baseline data were not significantly different between the 2 groups (p > 0.05). Both groups were compared regarding: major amputation rates; wound healing, mortality and adverse events. Survival and regression analyses were used. RESULTS: Mean follow-up time was 734.1 ± 610.2 days. Major amputation rates were 3.9% versus 24.1% (p < 0.0001) and complete wound healing was 53.7% versus 20.7% (p < 0.0001) for patients from Group A versus Group B, respectively. Major adverse events were registered in 2 patients (one from each group); minor adverse events included 10 patients from Group A and 2 patients from Group B (p = 0.3654). Major amputation rates were: 3.9% versus 27.5% at 1 year; 4.6% versus 27.5% at 2-5 years for Group A versus Group B, respectively (p < 0.0001). Survival rates were: 87.8% at 1 year; 84.4% at 2 years; and 77.9% at 5 years with no significant differences between groups. Predictors for major amputation included failed revascularization (p < 0.0001), older age (p = 0.0394), prior stroke (0.0018), dialysis (0.0476). Predictors for mortality included older age (p < 0.0001) and coronary artery disease (p = 0.0388). CONCLUSION: Endovascular revascularization for patients with DFUs is safe and has a significant impact on limb salvage and wound healing.

Transarterial Embolization of Iatrogenic Cystic Artery Pseudoaneurysm.

Cystic artery pseudoaneurysm (CAP) is a rare entity most often resulting from inflammatory conditions (acute cholecystitis or pancreatitis) or iatrogenic trauma (cholecystectomy). We report the case of a 73-year-old female who presented with abdominal pain and gastrointestinal bleeding after an episode of acute cholecystitis and endoscopic retrograde cholangiopancreatography for choledocolithiasis removal. Computed tomography and angiography revealed a CAP measuring 5 cm. A right hepatic artery transcatheter embolization was performed with glue, excluding the pseudoaneurysm. The next day, the patient underwent open cholecystectomy with ligation of the cystic artery. Later, ischemic hepatitis and abscess developed.

O pseudoaneurisma da artéria cística é uma entidade rara, que pode resultar de patologia inflamatória (colecistite aguda ou pancreatite) ou trauma iatrogénico (colecistectomia). Apresentamos o caso de uma mulher de 73 anos que se apresentou com dor abdominal e hemorragia digestiva após um episódio de colecistite aguda e CPRE para remoção de coledocolitíase. A TC e a angiografia revelaram um pseudoaneurisma da artéria cística com 5 cm. Foi realizada embolização da artéria hepática direita com cola, com exclusão do pseudoaneurisma. No dia seguinte a paciente foi submetida a colecistectomia com ligação da artéria cística. Posteriormente, desenvolveu-se hepatite isquémica e abcesso hepático.

Preoperative Portal Vein Embolization in Hepatic Surgery: A Review about the Embolic Materials and Their Effects on Liver Regeneration and Outcome.

Liver volume and function after hepatectomies are directly correlated to postoperative complications and mortality. Consequently contemporary liver surgery has focused on reaching an adequate future liver remnant so as to diminish postoperative morbidity and mortality. Portal vein embolization has evolved and is the standard of care as a liver regenerative strategy in many surgery departments worldwide before major liver resections. Different embolic materials have been used for portal vein embolization including gelfoam, ethanol, polyvinyl-alcohol particles, calibrated microspheres, central vascular plugs, coils, n-butyl-cyanoacrylate glue, fibrin glue, polidocanol-foam, alcoholic prolamin solution, and ethylene vinyl alcohol copolymer, as sole occluders or in varied combinations. While to date there has been no prospective controlled trial comparing the efficacy of different embolic materials in portal vein embolization, retrospective data insinuates that the use of n-butyl-cyanoacrylate and absolute ethanol produces higher contralateral liver hypertrophies. In this review, we evaluated publications up to August 2019 to assess the technical and regenerative results of portal vein embolization accomplished with different embolic materials. Special attention was given to specific aspects, advantages, and drawbacks of each embolic agent used for portal vein embolization, its liver regenerative performance, and its influence on patient outcome.

Retrospective Study of Transjugular Intrahepatic Portosystemic Shunt Placement for Cirrhotic Portal Hypertension.

BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) is used for decompressing clinically significant portal hypertension. The aims of this study were to evaluate clinical outcomes and adverse events associated with this procedure. METHODS: Retrospective single-center study including 78 patients submitted to TIPS placement between January 2015 and November 2018. Follow-up data were missing in 27 patients, and finally 51 patients were included in the study sample. Data collected from individual registries included demographics, comorbidities, laboratory results, complications, and clinical results according to the indication. RESULTS: Average pre-TIPS portosystemic pressure gradient decreased from 18.1 ± 5 to 6 ± 3 mm Hg after TIPS placement. Indications for TIPS were refractory ascites (63%, n = 49), recurrent or uncontrolled variceal bleeding (36%, n = 28), and Budd-Chiari syndrome (1.3%, n = 1). TIPS-related adverse events occurred in 29/51 (56.8%) patients, with hepatic encephalopathy (HE) in 21 (41%) patients, sepsis in 3, liver failure in 2, hemolytic anemia in 1, acute pulmonary edema in 1, and capsular perforation in 1 patient. Mean follow-up was 15.7 ± 15 months. First-month mortality was 11.7% (n = 6) (sepsis, n = 3; acute liver failure, n = 2; and recurrence of variceal bleeding, n = 1) and was significantly higher for patients with Child-Pugh >9 points (p = 0.01), model of end-stage liver disease (MELD) scores >19 (p = 0.02), and for patients with a history of HE before the procedure (p = 0.001). Older age (p = 0.006) and higher levels of creatinine (p = 0.008) were significantly higher in patients developing HE after TIPS. Ascites persisted in 21.2% (7/33 patients) and was more frequent in patients with lower baseline albumin levels (p = 0.003). Recurrent variceal bleeding occurred in 22% (n = 4/18 patients) and was more frequent in patients with lower baseline hemoglobin levels (p = 0.03). CONCLUSION: TIPS is effective in up to 80% of patients presenting with variceal bleeding or refractory ascites. Careful patient selection based on age and HE history may reduce adverse events after TIPS.

INTRODUÇÃO E OBJECTIVOS: O shunt portossistémico transjugular intra-hepático (TIPS) é usado para descompressão de hipertensão portal hepática clinicamente significativa. Os objetivos deste estudo foram avaliar os resultados clínicos e efeitos adversos associados a este procedimento. MÉTODOS: Estudo retrospectivo de centro único, incluindo 78 pacientes submetidos ao procedimento entre Janeiro de 2015 e Novembro de 2018. Os dados de seguimento estavam ausentes em 27 doentes, tendo sido incluidos 51 doentes na análise. Os dados colhidos de registos individuais incluíram dados demográficos, comorbilidades, resultados laboratoriais, complicações e resultados clínicos, de acordo com a indicação. RESULTADOS: O gradiente médio de pressão portossistémica pré-TIPS foi de 18.1 ± 5 mm Hg, quediminuiu para 6 ± 3 mm Hg. Indicações para TIPS foram ascite refratária (65%, n = 33) e hemorragia varicosa recorrente/refratária (35%, n = 18). As complicações relacionadas ao TIPS ocorreram em 29 doentes (56.8%): encefalopatia hepática (EH) em 21 doentes, sépsis (n = 3), insuficiencia hepática (n = 2), anemia hemolítica (n = 1), edema pulmonar agudo (n = 1) e perfuração capsular (n = 1). O seguimento médio foi de 15.7 ± 15 meses. A mortalidade no primeiro mes foi de 11.7% (n = 6) (sépsis, n = 3; insuficiencia hepática aguda, n = 2; recorrência de hemorragia varicosa, n = 1), e foi significativamente mais frequente em doentes com Child-Pugh >9 pontos (p = 0.01), pontuação de MELD >19 pontos (p = 0.02) e história de EH prévia ao procedimento (p = 0.001). Doentes que desenvolveram EH tinha mais frequentemente idade avançada (p = 0.006) e níveis mais elevados de creatinina (p = 0.008). A ascite persistiu em 21.2% (7/33 doentes), mais habitualmente em doentes com níveis mais baixos de albumina basai (p = 0.003). Hemorragia varicosa recorrente ocorreu em 22% (n = 4/18 doentes), em associação com níveis mais baixos de hemoglobina (p = 0.03). CONCLUSÃO: O TIPS é eficaz em 80% dos doentes que apresentam hemorragia varicosa ou ascite refratária. Eventos adversos podem ser reduzidos através da seleção de doentes, com base na idade e história de EH.

A Rare Cause of Abdominal Pain in a Patient with Acute Necrotizing Pancreatitis.

INTRODUCTION: Walled-off necrosis (WON) is a potentially lethal late complication of acute pancreatitis (AP) and occurs in less than 10% of AP cases. It can be located in or outside the pancreas. When infected, the mortality rate increases and can reach 100% if the collection is not drained. Its treatment is complex and includes, at the beginning, intravenous antibiotics, which permit sepsis control and a delay in the therapeutic intervention, like drainage. Nowadays, a minimally invasive approach is advised. Depending on the location of the collection, computed tomography (CT)-guided drainage or endoscopic necrosectomy are the primary options, then complemented by surgical necrosectomy if needed. Infected WON of the abdominal wall has been rarely described in the literature and there is no report of any infection with Citrobacter freundii. CASE: We present the case of a 61-year-old man with necrotizing AP complicated by WON of the left abdominal wall, infected with Citrobacter freundii that was successfully treated with CT-guided percutaneous drainage and intravenous antibiotics. CONCLUSION: Infected WON accounts for considerable mortality and its location in the abdominal wall is rare; it can be treated with antibiotics and CT-guided drainage with no need for further intervention.

INTRODUÇÃO: A necrose pancreática coletada (NPC) é uma complicação potencialmente fatal da pancreatite aguda (PA) e ocorre em menos de 10% dos casos. Pode estar localizada dentro ou fora do pâncreas. Quando infetada, a mortalidade aumenta, podendo atingir os 100% se a coleção não for drenada. O seu tratamento é complexo e inclui, de início, antibioterapia intravenosa que permite o controlo da sepsis e um atraso na terapêutica de intervenção, como a drenagem. Atualmente é aconselhada uma abordagem minimamente invasiva. Dependendo da localização da coleção, a drenagem guiada por tomografia computorizada (TC) ou a necrosectomia endoscópica são as opções de primeira linha, posteriormente complementadas por necrosectomia cirúrgica, caso seja necessário. A NPC infetada na parede abdominal foi raramente descrita na literatura e não existe até ao momento nenhum caso de uma NPC infetada por Citrobacter freundii. CASO: Apresentamos o caso de um doente do sexo masculino de 61 anos com uma PA necrotizante complicada por NPC da parede abdominal esquerda, infetada por Citrobacter freundii, que foi tratada com sucesso através de drenagem percutânea guiada por TC e antibioterapia intravenosa. CONCLUSÃO: A NPC infetada condiciona mortalidade considerável e a sua localização na parede abdominal é rara; pode ser tratada através de antibioterapia e drenagem percutânea guiada por TC, sem necessidade de intervenção posterior.

Chemoembolization of Hepatocellular Carcinoma with Drug-Eluting Polyethylene Glycol Embolic Agents: Single-Center Retrospective Analysis in 302 Patients.

PURPOSE: To evaluate the efficacy and safety of transarterial chemoembolization with polyethylene glycol (PEG) drug-eluting embolic agents in the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A single-center retrospective study of 302 patients (258 men; 85.4%) with HCC treated during a 20-month period was conducted. The mean patient age was 66 years ± 10; 142 (47%) had Barcelona Clinic Liver Cancer stage A disease and 134 had (44.4%) stage B disease; 174 (57.6%) had a single HCC tumor, 65 (21.5%) had 2, and 62 (20.9%) had 3 or more. Mean index tumor size was 36.6 mm ± 24.8. One-month follow-up computed tomography (CT) response per modified Response Evaluation Criteria In Solid Tumors and clinical and biochemical safety were analyzed. Progression-free and overall survival were calculated by Kaplan-Meier method. RESULTS: Median follow-up time was 11.9 months (95% confidence interval, 11.0-13.0 mo). One-month follow-up CT revealed complete response in 179 patients (63.2%), partial response in 63 (22.3%), stable disease in 16 (5.7%), and progressive disease in 25 (8.8%). The most frequent complications were postembolization syndrome in 18 patients (6%), liver abscess in 5 (1.7%), and puncture-site hematoma in 3 (1%). Biochemical toxicities occurred in 57 patients (11.6%). Survival analysis at 12 months showed a progression-free survival rate of 65.9% and overall survival rate of 93.5%. Patients who received transplants showed a 57.7% rate of complete pathologic response. CONCLUSIONS: Chemoembolization with PEG embolic agents for HCC is safe and effective, achieving an objective response rate of 85.5%.

Embolization with Onyx® of an arterial pseudoaneurysm with an arteriovenous fistula complicating a percutaneous nephrolithotomy: A case report and review of literature.

Percutaneous nephrolithotomy (PCNL) has proven very effective in the management of renal stones. However, complications are not so rare, and bleeding is one of the most worrisome; it has a reported incidence of 1%-3% and may happen during track dilatation. In addition, arterial pseudoaneurysms and/or arteriovenous fistulas (AVF) may occur. We report the case of a patient with an intrarenal pseudoaneurysm associated with an AVF, after PCNL. Superselective endovascular embolization with Onyx® was successfully performed, achieving exclusion of the pseudoaneurysm and AVF with preservation of the remaining vascularization of the kidney. We review the literature regarding endovascular management of kidney vascular lesions after PCNL. Selective renal embolization is a minimally invasive procedure, highly effective with a low incidence of complications. Currently, it is considered the most appropriate technique in the treatment of arterial iatrogenic complications following percutaneous renal procedures. Onyx® is an effective, easy to handle, and safe alternative embolic agent for these procedures.

Risk Factors for the Development of Postembolization Syndrome after Transarterial Chemoembolization for Hepatocellular Carcinoma Treatment.

INTRODUCTION: Hepatic transarterial chemoembolization is a widely used technique for the treatment of hepatocellular carcinoma. The most common complication of this procedure is postembolization syndrome. The main objective of this study was to assess risk factors for the development of postembolization syndrome. MATERIAL AND METHODS: Single-centre retrospective analysis of 563 hepatic transarterial chemoembolization procedures from January 1st, 2014 - December 31st, 2015. Hepatic transarterial chemoembolization was performed with ½ - 2 vials of 100 - 300 µm microspheres loaded with doxorubicin. Patients who experienced postembolization syndrome were identified based on prolongation of hospitalization due to pain, fever, nausea and/or vomiting. A control group with the patients who did not have postembolization syndrome was randomly created (three controls for one case). Descriptive analysis and multivariate logistic regression were performed. RESULTS: The overall prevalence of postembolization syndrome was 6.2%. Hepatic transarterial chemoembolization with doxorubicin dosage above 75 mg (more than one vial), the size of the largest nodule and female gender had statistically significant relation with development of postembolization syndrome (p = 0.030, p = 0.046 and p = 0.037, respectively). DISCUSSION: Doxorrubicin dosage above 75 mg is associated with a higher risk of postembolization syndrome. This result can be helpful for decision-making in clinical practice, whenever it is possible to avoid a higher dose without compromising the efficacy of the treatment. The size of the largest nodule and female gender also constitute risk factors for postembolization syndrome. The other variables studied were not related to the development of postembolization syndrome. CONCLUSION: The dose of doxorrubicin, the size of the largest nodule treated and female gender are potential risk factors for the development of postembolization syndrome after hepatic transarterial chemoembolization for hepatocellular carcinoma.

Introdução: A quimioembolização hepática é uma técnica amplamente usada para o tratamento do carcinoma hepatocelular. A principal complicação deste procedimento é a síndrome pós-quimioembolização. O principal objetivo deste estudo foi determinar fatores de risco para síndrome pós-quimioembolização. Material e Métodos: Análise retrospetiva unicêntrica de 563 procedimentos de quimioembolização hepática efetuados entre 1/1/2014-31/12/2015. A quimioembolização hepática foi efetuada com ½ - 2 ampolas de microesferas 100 - 300 µm carregadas com doxorrubicina. Os pacientes que desenvolveram síndrome pós-quimioembolização foram identificados pelo prolongamento do internamento por dor, febre, náuseas e/ou vómitos. Um grupo controlo com os pacientes que não desenvolveram síndrome pós-quimioembolização foi criado de forma randomizada (três controlos para um caso). Foi realizada análise descritiva e regressão logística multivariada. Resultados: A prevalência global de síndrome pós-quimioembolização foi 6,2%. Quimioembolização hepática com dose de doxorrubicina superior a 75 mg (mais de uma ampola), o tamanho do nódulo maior e o género feminino demonstraram relação estatisticamente significativa com o desenvolvimento de síndrome pós-quimioembolização (p = 0,030, p = 0,046 e p = 0,037, respetivamente). Discussão: Doses de doxorrubicina superiores a 75 mg estão associadas a maior risco de síndrome pós-quimioembolização. Este resultado pode ter impacto na prática clínica, sempre que for possível evitar doses maiores sem comprometer a eficácia do tratamento. O tamanho do maior nódulo tratado e o género feminino também constituem fatores de risco para síndrome pós-quimioembolização. As outras variáveis estudadas não demonstraram relação com síndrome pós-quimioembolização. Conclusão: A dose de doxorrubicina, o tamanho do maior nódulo tratado e o género feminino são potenciais fatores de risco para o desenvolvimento de síndrome pós-quimioembolização após quimioembolização hepática para o tratamento de carcinoma hepatocelular.

[Endovascular Treatment of a Gastroduodenal Artery Pseudoaneurysm Rupture after a Car Accident]. / Tratamento Endovascular de Rotura de Pseudoaneurisma da Artéria Gastroduodenal após Acidente de Viação.

The authors present a case of a 39-year-old man with alcoholic chronic pancreatitis that was admitted in the emergency department after a car accident, complaining of abdominal pain and looking pale. The patient was hemodinamically unstable, requiring blood transfusions. He underwent computed tomography angiogram of the abdomen and pelvis, showing a pseudoaneurysm of the gastroduodenal artery and a hemoperitoneum. He was referred to our interventional radiology unit and submitted to endovascular treatment, consisting of 'backdoor' and 'frontdoor' embolization of the gastroduodenal artery and pseudoaneurysm neck with coils, with total exclusion in control angiography. With this case description we intend to highlight the rarity of the pseudoaneurysm rupture of the gastroduodenal artery and to emphasize the importance of an interventional radiology response that had a fundamental role in the endovascular treatment, in an emergency context.

Os autores apresentam o caso de um homem de 39 anos de idade, com antecedentes de pancreatite crónica alcoólica, que foi admitido no serviço de Urgência na sequência de um acidente de viação. À entrada apresentava-se pálido, com dor abdominal, e hemodinamicamente instável, com necessidade de transfusões de sangue. Realizou angio-tomografia computorizada abdomino-pélvica, que mostrou um pseudoaneurisma da artéria gastroduodenal e hemoperitoneu. Foi referenciado à unidade de Radiologia de Intervenção do nosso centro hospitalar e submetido a tratamento endovascular, que consistiu na embolização 'backdoor' e 'frontdoor' da artéria gastroduodenal e do colo do pseudoaneurisma com coils, obtendo-se exclusão total nas angiografias de controlo. Com a descrição deste caso pretende-se destacar a raridade das roturas de pseudoaneurismas da artéria gastroduodenal e enfatizar a importância da radiologia de intervenção, que desempenhou um papel fundamental no tratamento endovascular, em contexto de urgência, permitindo o controlo da lesão.

Portal vein embolization with n-butyl-cyanoacrylate through an ipsilateral approach before major hepatectomy: single center analysis of 50 consecutive patients.

PURPOSE: To evaluate the efficacy of portal vein embolization (PVE) with n-Butyl-cyanoacrylate (NBCA) through an ipsilateral approach before major hepatectomy. Secondary end-points were PVE safety, liver resection and patient outcome. METHODS: Over a 5-year period 50 non-cirrhotic consecutive patients were included with primary or secondary liver cancer treatable by hepatectomy with a liver remnant (FLR) volume less than 25% or less than 40% in diseased livers. RESULTS: There were 37 men and 13 women with a mean age of 57 years. Colorectal liver metastases were the most frequent tumor and patients were previously exposed to chemotherapy. FLR increased from 422 ml to 629 ml (P < 0.001) after PVE, corresponding to anincrease of 52%. The FLR ratio increased from 29.6% to 42.3% (P < 0.001). Kinetic growth rate was 2.98%/week. A negative association was observed between increase in the FLR and FLR ratio and FLR volume before PVE (P = 0.002). In 31 patients hepatectomy was accomplished and only one patient presented with liver insufficiency within 30 days after surgery. CONCLUSIONS: PVE with NBCA through an ipsilateral puncture is effective before major hepatectomy. Meticulous attention is needed especially near the end of the embolization procedure to avoid complications. TRIAL REGISTRATION: Clinical Study ISRCTN registration number: ISRCTN39855523 . Registered March 13th 2017.