Endovascular Treatment of Peripheral Arteriovenous Malformations (AVMs): Do Angiographic Outcomes Relate to the Quality of Life?

PURPOSE: Patients with arteriovenous malformations (AVMs) have a lower health-related quality of life (QoL) than the general population. QoL assessment of patients with peripheral AVMs after endovascular treatment is scarce in the literature. Radiologic and clinical outcomes are not always correlated in vascular malformation treatment. This study aimed to investigate the relationship between clinical outcomes, QoL, and angiographic outcomes. MATERIALS AND METHODS: Patients with peripheral AVM that underwent endovascular treatment between January 2009 and December 2021 in a single center were retrospectively evaluated. Patients' characteristics (age, sex), AVM characteristics (Schobinger classification, location, angiographic architecture), previous treatment, treatment characteristics (type of endovascular approach, embolizing agent and number of sessions), percentages of angiographic response, complications, and recurrence were evaluated. The angiographic architecture was evaluated according to the Yakes classification. The questionnaire was applied for evaluation of clinical response and QoL. Patients older than 12 years and those who can be contacted were included in clinical and QoL analysis. Clinical response was defined as improvement in the patient's most important pretreatment symptom. Treatment response was defined as clinical response plus >50% angiographic response. RESULTS: Eighty-six patients (41 males [47.7%], 45 females [52.3%]) were included in angiographic analysis. The mean age was 28.44±12.99 years (range=5-61). Forty-three patients (50%) had previous treatment. The median number of sessions was 2 (range 1-15, InterQuartile Range [IOR]=2). Sixty-one patients (30 males [49.2%], 31 females [50.8%]) were included in clinical analysis. The clinical response rate was 73.8%, 95% confidence interval (CI) [0.60, 0.84]. The treatment response rate was 45.9%, 95% CI [0.33, 0.59]. The complication rate was 8.2%. Before treatment, 48 patients (78.7%) reported a negative impact on their QoL. Thirty-three of 48 patients (68.8%) reported improvement on their QoL after treatment. Higher Schobinger stages were related to a negative impact on QoL before treatment (p<0.01). Yakes types were not related to QoL (p=0.065). Clinical response was related to improvement on QoL after treatment (p<0.01). Angiographic and treatment responses were not related to improved QoL after treatment (p=0.52 and p=0.055, respectively). CONCLUSION: Angiographic architecture and outcomes were not always reflected in QoL after endovascular treatment. CLINICAL IMPACT: This study's findings will help clinicians with what to focus on in AVM treatment and how to monitor patients with peripheral AVM after endovascular treatment. Rather than relying too much on the angiographic response, patients should be checked for symptoms and quality of life improvement. No clear data in the literature regarding the applicability of the Yakes Classification in patients with previous treatment. This study questioned the applicability of the Yakes Classification in patients with previous treatments. In this study, type 4 AVMs were more common in patients with previous treatment.

Clinical results of polidocanol sclerotherapy in venous malformation treatment: Patient-perceived improvement and satisfaction.

PURPOSE: This study evaluated the results of polidocanol sclerotherapy in the treatment of venous malformations (VM) including patient satisfaction, perceived improvement, and predictors of satisfaction. MATERIAL AND METHOD: Patients with VM that underwent polidocanol foam sclerotherapy between June 2013 and July 2021 in a single center were retrospectively evaluated. Patient demographics, VM, and treatment characteristics were analyzed. Patient-reported outcomes and satisfaction were analyzed with a questionnaire. RESULTS: This study included 232 (136, 58.6%, female) patients. The mean age was 24.49 ± 12.45 years (range 3-72). The clinical response rate was 82.3%. The rate of satisfaction was 82.3%, and 116 (50%) patients were significantly satisfied. There were no major complications. Clinical response and VM margin were related to satisfaction (p < 0.01, p = 0.012, respectively). Clinical response to pretreatment swelling was related to significant satisfaction (p = 0.02). CONCLUSION: Polidocanol sclerotherapy was safe and effective in VM treatment with high satisfaction and low complication rates.

Endovascular management of renal angiomyolipomas: Do coils have a benefit in terms of clinical success rates?

PURPOSE This study evaluated single center results of endovascular treatment in renal angiomyolipoma (AML) to determine whether there is clinical relevance of adding proximal coil embolization to distal particle embolization in terms of safety, efficacy and retreatment rates. METHODS A retrospective analysis was performed to evaluate patients undergoing transarterial embolization for renal AMLs from January 2007 to October 2020. Parameters regarding patient and tumor characteristics, embolization technique, treatment outcome and complications were recorded. Patients were divided into two groups as A (only particle group) and B (particle + coil group) based on the type of embolic agent used for treatment. Comparative analysis was performed between the two groups in terms of tumor size reduction, retreatment and complication rates. RESULT Forty-two patients (37 (88.1%) female, 5 (11.9%) male) harboring 48 AMLs were included in the study. The mean age was 43.46 (range 20 to 78). The technical success rate was 95.8% (46 of 48 procedures). The mean size reduction was 1.94±1 cm (p < 0.001) after treatments however, no significant difference was seen between groups in terms of tumor size reduction. Retreatment rates were 3.1% (1 of 32 cases) in group A and 14.3% (2 of 14 cases) in group B (p = 0.21). No significant difference was found between groups in terms of bleeding and complication rates during the perioperative period. Mean follow-up duration was 26.48±25.71 (range from 2 to 102) months. CONCLUSION In this study, no clear supplementary benefit was observed in terms of safety, and efficacy with the adjunction of coils to distal particle embolization in the management of AMLs.

Initiation of Chemosaturation With Percutaneous Hepatic Perfusion Program in Interventional Radiology Department.

Objectives Chemosaturation with percutaneous hepatic perfusion (PHP) is a relatively new minimally-invasive liver-directed therapy, which aims to deliver high-dose chemotherapy into the liver with low systemic side effects. Initial studies showed promising results, especially in the treatment of metastatic uveal melanoma. But unfamiliarity of the interventional radiologists prevents its widespread implantation in clinical routine. This study aimed to outline how to initiate a PHP program and report initial results. Methods We retrospectively reviewed all patients who underwent chemosaturation with PHP in our institution between March 2016 and February 2017 and their follow-up results till October 2018. Patient demographics, procedural characteristics, clinical and imaging results, and complications were evaluated. Additionally, modifications regarding infrastructure and procedure techniques were described. Results A total of three patients (two females and one male) with a mean age of 59 underwent six PHP procedures. The primary disease was colorectal carcinoma in one patient and uveal melanoma in two patients. The technical success rate was 100% and the mean melphalan dose was 190.8 mg. No procedural death was observed. Patients were hospitalized for a mean of 3.3 days after procedures. Grade 3 and 4 complications were seen after 50% and 33.3% of procedures, respectively. Two patients showed partial response and the other patient showed stable disease after procedures. Mean hepatic progression-free survival was 10.8 months. Overall survival from the first procedure was 14.8 months in our cohort. Conclusion Our results show that chemosaturation with PHP offers a promising minimally invasive treatment option in patients with unresectable liver metastases. The technical challenges of PHP can be easily handled by an experienced interventional radiology (IR) team. It is a relatively safe procedure and its toxicities are usually hematological and can be manageable with close surveillance and appropriate medical therapies.

A New Approach to Tertiary Hyperparathyroidism: Percutaneous Embolization: Two Case Reports.

Secondary hyperparathyroidism is one of the most common complications of chronic kidney failure. If prolonged, parathyroid hormone release gains autonomy and tertiary hyperparathyroidism with parathyroid adenoma or hyperplasia can be develop. Tertiary hyperparathyroidism is associated with increased risk of mortality and morbidity; thus, treatment is recommended. Medical treatment includes phosphate binders, vitamin D analogues, and calcimimetic agents. Most cases of tertiary hyperparathyroidism can be controlled with medical treatment. When medical treatment options prove insufficient, parathyroidectomy is recommended. However, recurrence after parathyroidectomy is possible, which requires an alternative treatment. We present our percutaneous embolization experience, which has not been tried in the treatment of tertiary hyperparathyroidism in renal transplantation patients diagnosed with tertiary hyperparathyroidism.

Factors affecting the response to Y-90 microsphere therapy in the cholangiocarcinoma patients.

OBJECTIVE: The aim of this study was to assess the early therapy response in patients with unresectable CCA who received Y-90 microsphere therapy for CCA and define the factors related to therapy response. MATERIALS AND METHODS: Data of 19 patients [extrahepatic (n: 6) and intrahepatic (n: 13)] who received 24 sessions of Y-90 microsphere therapy [glass (n: 13) and resin (n: 11)] were retrospectively evaluated. Tumor load, tumor size, therapy response evaluation by RECIST1.1 criteria (n: 13), tumor lesion glycolysis (TLG), metabolic tumor volume (MTV), and metabolic therapy responses were evaluated (n: 8) using PERCIST1.0 criteria. RESULTS: No significant relation was found between therapy response and tumor localization, treated liver lobe, type of Y90 microspheres, the presence of previous therapies, perfusion pattern on hepatic artery perfusion scintigraphy, or patient demographics. The mean overall survival (OS) was 11.9 ± 2.3 months and was similar after both resin and glass Y90 microspheres; however, it was longer RECIST responders (p: 0.005). MTV and TLG values significantly decreased after therapy, and ΔMTV (- 45.4% ± 12.1) was found to be positively correlated with OS. No statistical difference was found between iCCA and eCCA, in terms of OS and response to therapy. Although not quantitatively displayed, better-perfused areas on HAPS images had a better metabolic response and less perfused areas were prone to local recurrences. CONCLUSIONS: Both resin and glass microsphere therapy can be applied safely to iCCA and eCCA patients. Early therapy response can be evaluated with both RECIST and PERCIST criteria. Both anatomical and metabolic therapy response evaluations give complementary information.

Outcomes of Radioembolization in Patients with Chemorefractory Colorectal Cancer Liver Metastasis: a Single-Center Experience.

PURPOSE: We aimed to evaluate the efficacy and outcomes of radioembolization with Yttrium-90 (Y-90) microspheres in patients with unresectable and chemorefractory colorectal cancer liver metastasis (CRCLM). METHODS: This single-center study included 43 patients (34 male, 9 female) who underwent radioembolization with Y-90 for unresectable, chemorefractory CRCLM between September 2008 and July 2014. Overall survival (OS), liver progression-free survival (LPFS), overall response rate (ORR), local disease control rate (LDCR), and relations of these parameters with patient disease characteristics were evaluated. OS and LPFS rates were compared according to microspheres. Survival rates were calculated with Kaplan-Meier method, and potential prognostic variables were evaluated on univariate analyses. RESULTS: Post-procedural median OS was 12.8 months. LPFS was 5.6 months. ORR was 33%, LDCR was 67% on 3rd month follow-up. Low tumor burden (< 25%) was associated with higher median OS after radioembolization (< 25 vs > 25-50% p < 0.0001 and < 25 vs > 50% p = 0.005). Patients with left colon tumors exhibited significantly longer median OS after metastasis than right colon tumors (p = 0.046). Extrahepatic disease and synchronicity showed poorer survival parameters; however, the difference was not significant (p = 0.1 and p = 0.3, respectively). In subgroup analyses, the distribution of patient number and characteristics showed heterogeneity as number of patients with low tumor burden was higher in resin Y-90 group. Resin Y-90 group exhibited significantly higher median OS and LPFS compared to glass Y-90 group (16.5 vs. 7 months, p = 0.001; 6.73 vs. 3.38 months, p = 0.023, respectively). CONCLUSION: Radioembolization is a safe local-regional treatment option in chemorefractory, inoperable CRCLM. Radioembolization at earlier stages may lead to more favorable results especially with lower tumor burden patients.

Endovascular treatment of true renal artery aneurysms: a single center experience.

PURPOSE: We aimed to report a single center's experience on endovascular treatment of true renal artery aneurysms (TRAAs), including treatment techniques and outcomes. METHODS: This retrospective study was designed to evaluate the treatment and follow-up of TRAAs treated by a variety of endovascular interventional techniques over a period of 6 years. Six patients with nine TRAAs were identified; seven of the TRAAs were treated using different combinations of coil embolization and flow diverter stents. The clinical findings, aneurysm characteristics, endovascular methods and treatment outcomes were reported. RESULTS: Seven TRAAs of six patients were treated, with a median aneurysm size of 20 mm. Three TRAAs were treated with primary sac occlusion (one with primary coil embolization, one with balloon and stent assisted coil and glue embolization, and one with amplatzer vascular occlusion device and coil embolization). The remaining four TRAAs of three patients were treated with flow diverter stents (Cardiatis, Silk, Pipeline, and Surpass). Immediate clinical success was achieved in patients treated with primary sac embolization (95% CI, 29.2%-100%). Among patients treated with flow diverter stents, one patient required an additional flow diverter at 6-month follow-up. The occlusion time in flow diverters ranged from 1 month to 12 months (median, 3.5 months) taking the repeat procedure into account. In patients treated with flow diverters, the clinical success rate was 100% (95% CI, 29.2%-100%) at one-year follow-up. Long-term follow-up ranged from 3 to 52 months. One intraprocedural complication was encountered with a flow diverter during deployment, which required additional stenting and tirofiban infusion. No other major complication was seen. CONCLUSION: Endovascular treatment is an effective and safe method offering high success rates and low morbidity in the treatment of TRAAs and may supplant surgery as the primary therapy. Current experience in the use of flow diverter stents in TRAAs is limited to individual case reports with one brand of flow diverter device. Our small numbered series of four TRAAs shows our experience regarding endovascular treatment with different flow diverter brands.

Iliac arteriovenous fistulas after lumbar spinal surgery.

Iatrogenic arteriovenous fistula (AVF) is an unusual and potentially fatal complication of lumbar spinal surgery. The presentation of these injuries is usually late, with symptoms such as leg swelling or cardiac failure. It is crucial to suspect AVF in the patient which presents to emergency with lumbar spinal surgery history. The diagnosis is often based on imaging studies such as computed tomography (CT) or magnetic resonance (MR) angiography. Surgery was the first choice of treatment, but with recent advances in stent technology endovascular approach has become widely popular. We present two cases of AVF secondary to lumbar spinal surgery, one of them presenting with overt heart failure and the other one with leg swelling.

HFE gene mutation is a risk factor for tissue iron accumulation in hemodialysis patients.

INTRODUCTION: HFE gene mutations are responsible from iron overload in general population. Studies in hemodialysis patients investigated the effect of presence of HFE gene mutations on serum ferritin and transferrin saturation (TSAT) with conflicting results. However effect of HFE mutations on iron overload in hemodialysis patients was not previously extensively studied. METHODS: 36 hemodialysis patients (age 51.3 ± 15.6, (18/18) male/female) and 44 healthy control subjects included in this cross sectional study. Hemoglobin, ferritin, TSAT in the preceding 2 years were recorded. Iron and erythropoietin (EPO) administered during this period were calculated. Iron accumulation in heart and liver was detected by MRI. Relationship between HFE gene mutation, hemoglobin, iron parameters and EPO doses, and tissue iron accumulation were determined. FINDINGS: Iron overload was detected in nine (25%) patients. Hemoglobin, iron parameters, weekly EPO doses, and monthly iron doses of patients with and without iron overload were similar. There was no difference between control group and hemodialysis patients with respect to the prevalence of HFE gene mutations. Iron overload was detected in five of eight patients who had HFE gene mutations, but iron overload was present in 4 of 28 patients who had no mutations (P = 0.01). Hemoglobin, iron parameters, erythropoietin, and iron doses were similar in patients with and without gene mutations. HFE gene mutations remained the main determinant of iron overload after multivariate logistic regression analysis (P = 0.02; OR, 11.6). DISCUSSION: Serum iron parameters were not adequate to detect iron overload and HFE gene mutation was found to be an important risk factor for iron accumulation.

Outcomes of partial splenic embolization in patients with massive splenomegaly due to idiopathic portal hypertension.

AIM: To determine the outcomes of partial splenic embolization (PSE) for massive splenomegaly due to idiopathic portal hypertension (IPH). METHODS: In this prospective study, we evaluated the characteristics and prognosis of consecutive patients with IPH who underwent PSE for all indications at a single medical center between June 2009 and January 2015. The inclusion criteria were: presence of hypersplenism, massive splenomegaly, and resultant pancytopenia. The exclusion criteria were: presence of other diseases causing portal hypertension. During the post-PSE period, the patients were hospitalized. All patients underwent abdominal computed tomography imaging 4 wk post-PSE to determine total splenic and non-infarcted splenic volumes. RESULTS: A total of 11 patients, with median age of 33.27 ± 4.8 years, were included in the study. Mean spleen size was 22.9 cm (21-28 cm), and severe hypersplenism was diagnosed in all patients before PSE. Post-PSE, leukocyte and platelet counts increased significantly, reaching peak levels in the second week with gradual decreases thereafter. Liver function tests did not exhibit significant changes during post-intervention follow-up. All patients developed post-embolization syndrome, and one patient experienced serious complications; all complications were successfully treated with conservative therapy and no death occurred. CONCLUSION: Our findings showed that PSE has a lower complication rate than previously-reported surgical complication rates, which supports this intervention as a viable alternative for high-risk operable patients with severe hypersplenism.

Local recurrence of renal cell carcinoma that simulated multiple renal arteriovenous fistulas after laparoscopic partial nephrectomy: Report of a rare case.

Herein we report a patient who was initially thought to have renal arteriovenous fistulas 3 months after laparoscopic partial nephrectomy for a small renal mass. After timely intervention using selective renal artery embolization, computed tomography 9 months post-surgery showed persistent renal arteriovenous fistulas and nodular lesions in the perirenal fat. The patient then underwent radical nephrectomy, and histopathological examination showed underlying recurrent clear cell renal cell carcinoma invading the intraparenchymal arteries and veins, which was simulating multiple high-flow renal arteriovenous fistulas.

Omental vascular pedicle sign: multidetector CT finding useful for diagnosis of an omental mass.

OBJECTIVE: To describe multidetector CT findings of "omental vascular pedicle" sign. MATERIALS AND METHODS: "Omental vascular pedicle" sign was defined as dilated omental vein associated with a mass located in omentum and was observed in 7 patients (5 women, 2 men). Mean age was 45 years. CT examinations and patient records were retrospectively reviewed. CT images were obtained by 16-MDCT (n = 1) and 64-dual source MDCT (n = 6). Curved planar and volume rendered images were reconstructed from axial images. Diameter of omental vein and drainage site were recorded. Images were evaluated by 2 radiologists in consensus. RESULTS: Pathologic diagnosis of patients with "omental vascular pedicle sign" was omental angiosarcoma (n = 1), endometrial adenocarcinoma (n = 2), ovarian serous adenocarcinoma (n = 2), mixed gonadal tumor (n = 1), malignant peripheral sheath tumor (n = 1). In 5 patients, omental vein drained into splenic vein and in 2 patients it drained into right gastroepiploic vein. Mean size of omental masses associated with omental vascular pedicle was 7.1 × 4.5 cm (range 15 × 11 cm to 2.7 × 1.6 cm). Mean diameter of omental vein was 3.1mm (range 6-1.5mm). Diameter of the omental vein increased with the increasing size of omental masses and Pearson's correlation coefficient was 0.99. CONCLUSION: "Omental vascular pedicle sign" can be helpful to objectively diagnose omental masses in patients with primary and metastatic omental tumors.

The effects of deferasirox on renal, cardiac and hepatic iron load in patients with ß-thalassemia major: preliminary results.

The iron loading related to erythrocyte transfusions is the major cause of morbidities and mortalities in patients with ß-thalassemia major (ß-TM). Deferasirox, an orally active iron chelator, has been reported to cause serum creatinine increases in addition to acute renal failures in elderly patients with comorbidities. The nefrotoxicities in patients using deferasirox, despite the facts that the drug is minimally excreted from kidneys and its effective chelation of iron from liver and heart, may rise the question of decomparmentalization of iron from these organs to kidneys. Thirteen patients with ß-TM were included in the study (mean age 18.5 ± 7.5 years [9-33 years]). The patients received deferasirox in a dose of 34.3 ± 6.5 mg/kg [17-37 mg/kg]. Four patients (31%) exhibited consecutive increases in serum creatinine greater than 33% above baseline twice during the follow-up period. The results indicated that the earliest iron chelation starts in liver in patients receiving deferasirox. Additionally, by the 6th month of deferasirox, the status of cardiac and renal iron in chronically transfused patients with ß-TM were preserved. This may indicate that the serum creatinine increases may not be attributed to iron decompartmantalization from other organs to kidneys.

Deferasirox use after hematopoietic stem cell transplantation in pediatric patients with beta-thalassemia major: preliminary results.

There are limited data on the posttransplantation pharmacological treatment of iron overload in ex-thalassemic patients and the current approach is phlebotomy. The authors chelated 2 ex-thalassemic patients after hematopoietic stem cell transplantation with deferasirox for 6 and 24 months. Although serum ferritin levels decreased, cardiac and hepatic iron load, measured by T2* magnetic resonance imaging (MRI), showed decrease in iron overload in these organs. The drug was tolerated well by both patients and no adverse effect on donor hematopoiesis was observed. This preliminary study demonstrates that deferasirox is well tolerated in these patients and will be a good potential therapy when more data have been obtained from larger studies.

Dual-echo TFE MRI for the assessment of myocardial iron overload in beta-thalassemia major patients.

PURPOSE: Cardiac failure due to myocardial iron overload is the most common cause of death in beta-thalassemia patients. Multi/ two echo times-turbo field echo (TE-TFE) magnetic resonance imaging (MRI) is considered the gold standard technique in the evaluation of myocardial iron accumulation. However, multi TE-TFE technique is not available in all scanners. The aim of our study was to show the role of black blood dualecho cardiac triggered TFE in the assessment of myocardial iron overload. MATERIALS AND METHODS: Sixteen beta-thalassemia major patients (10 males) with a mean age of 19 years who were receiving parenteral deferoxamine and oral deferiprone treatment were included in this study. Baseline measurement of myocardial T2* values were < 20 ms in all patients. Cardiac MRI was performed after 6 months, 12 months, and 18 months with the same technique. RESULTS: The average baseline value of T2* was 8.2 +/- 3.6 ms. After treatment of combined deferoxamine and deferiprone, the average measurements of myocardial T2* at 6, 12, and 18 months were 11.3 +/- 6.0, 13.6 +/- 7.5, and 15.7 +/- 7.4 ms, respectively (P < 0.05). The basal ejection fraction (EF) value was 49 +/- 8.7%. The EFs were 54.4 +/- 11% at 6 months, 54.8 +/- 6.9% at 12 months, and 58.6 +/- 3.6% at 18 months of followup (P > 0.05). CONCLUSION: Cardiac MRI with dual TE-TFE technique can be used to determine myocardial iron accumulation and response to the chelation treatment.

When do we need contrast-enhanced CT in patients with vague urinary system findings on unenhanced CT?

Determination of renal neoplasms, hematoma, infarct, urinoma, cysts, and pyelonephritis may require contrast material administration following unenhanced CT in patients with flank pain. In this pictorial review, we aimed to clarify when contrast material administration is needed following vague urinary system findings on unenhanced CT.