Endovascular management of aortic aneurysm with severe neck angulation and/or iliac artery tortuosity using multiple stiff wire technique: a case series.

Background: Suitable aortic neck is one of the essential components for thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR). Advanced techniques were developed to adjust and compromise the aneurysm neck angulation but with adding additional devices and complexity to the procedure. We proposed a simple technique to modify severe neck angulation and/or iliac artery tortuosity by using the multiple stiff wire (MSW) technique. Method: Two femoral accesses were required for the MSW technique. A guidewire with a support catheter was inserted through the right and left femoral arteries and positioned in the abdominal or thoracic aorta. Wire exchanges were done with extra stiff wire in both femoral accesses. It can be considered to add multiple stiff wires to align the torturous neck / iliac artery. Delivery of the stent graft main body can be done via one of the accesses. Result: Six patients with different aortic pathology were admitted to our hospital. Four patients undergo EVAR procedure and two patients undergo TEVAR procedure. All patients had aortic neck angulation problems with one patient having iliac artery tortuosity. MSW technique was performed on the patients with good results. Follow-up CTA after 3 months revealed a good stent position without stent migration and no endoleak was found in all but one patient. Conclusion: MSW technique is a simple and effective technique to modify aortic neck/iliac artery angulation in TEVAR or EVAR procedure.

Innovation of EUS-guided transmural gallbladder drainage using a novel self-expanding metal stent.

Endoscopic ultrasonography (EUS)-guided transmural drainage has been accepted as a modality of choice in peripancreatic fluid collection and acute cholecystitis. Each type of stent, including double-pigtail plastic stents, tubular self-expandable metal stents (SEMS), and lumen-apposing metal stents, for these procedure has its own advantages and disadvantages. To overcome their disadvantages, this animal study evaluated the feasibility of a newly designed twisted fully covered SEMS with spiral coiled ends. We performed the EUS-guided cholecystogastrostomy with a newly developed metal stent in eight mini pigs with surgically induced gallbladder distension. This novel stent is a twisted fully covered SEMS with spiral coiled ends, a diameter of 8 mm, and a length of 6 cm. The stent has been maintained for four to seven weeks after EUS-guided cholecystogastrostomy. The primary outcome was the technical success rate, and the secondary outcomes were adverse events, stent dysfunction, stent removability, and fistula formation. The stent was placed successfully between the gallbladder and the stomach in all cases without any adverse event. We observed neither stent migration nor dysfunction during the study period, and all the stents were removed easily as scheduled. We confirmed successful cholecysto-gastric fistula formation at endoscopic and histologic level in all cases. EUS-guided transmural drainage and fistula formation using a new twisted fully covered metal stent with spiral coiled ends was technically feasible without any adverse event in this animal study. Further clinical studies are needed to evaluate its efficacy and safety in real practice.

Two Wire System and Modified Olive Tip to Facilitate Implantation of Fenestrated TEVAR in Patient with Proximal Descending Aortic Pathology: First Two Cases.

INTRODUCTION: Although Fenestrated TEVAR (F-TEVAR) has been considered to be a more physiologic approach to treat proximal descending aortic pathology, its application is still limited due to availability, cost and technical difficulties. We introduce a new design of fenestrated stent graft with a new delivery system and successfully performed first in human implantation in two patients, one with an aortic aneurysm and one with an acute aortic dissection. MATERIALS AND METHODS: The design of these two wires fenestrated stent graft include creation of an additional lumen at the side of the olive tip during manufacture, from which an additional wire can be introduced for a side branch passing into the fenestration, running inside the stent graft and exit the delivery sheath through additional hub. The two wires will facilitate delivery and deployment of the stent graft. One patient with descending aortic aneurysm and another with Stanford B aortic dissection is included in this first in human study. RESULTS: The aneurysm and dissection were completely excluded immediately after the TEVAR. Six month follow up CT showed good position of the stent graft and patent LSA in both patients. In the patient with aortic dissection, expansion of the true lumen and partial thrombosis of the false lumen was seen. CONCLUSIONS: This is a report of a two wire system in 2 patients with distal aortic arch pathology demonstrating a good technical and clinical success using pre-cannulated fenestrations through a modified nose cone olive. LEVEL OF EVIDENCE: Level 4, report of two cases.

Sirolimus-eluting Biodegradable Poly-l-Lactic Acid Stent to Suppress Granulation Tissue Formation in the Rat Urethra.

Purpose To investigate the use of sirolimus-eluting biodegradable stents (SEBSs) to suppress granulation tissue formation after stent placement in a rat urethral model. Materials and Methods All experiments were approved by the animal research committee. A total of 36 male Sprague-Dawley rats were randomized into three equal groups after biodegradable stent placement. Group A received control biodegradable stents. Groups B and C received stents coated with 90 µg/cm2 and 450 µg/cm2 sirolimus, respectively. Six rats in each group were sacrificed after 4 weeks; the remaining rats were sacrificed after 12 weeks. The therapeutic effectiveness of SEBSs was assessed by comparing the results of retrograde urethrography and histologic examination. Analysis of variance with post hoc comparisons was used to evaluate statistical differences. Results SEBS placement was technically successful in all rats. Urethrographic and histologic examinations revealed significantly less granulation tissue formation at both time points in the rats receiving SEBSs (groups B and C) compared with those that received control stents (group A) (P < .05 for all). There were no significant differences in urethrographic and histologic findings between groups B and C (P > .05 for all). However, the mean number of epithelial layers in group B was higher than that in group C at 4 weeks after stent placement (P < .001). Apoptosis increased in group C compared with groups A and B (P < .05 for all). Conclusion The use of SEBSs suppressed granulation tissue formation secondary to stent placement in a rat urethral model; local therapy with SEBSs may be used to decrease stent-related granulation tissue formation. © RSNA, 2017.

A novel measurement technique for the design of fenestrated stent grafts: Comparison with three-dimensional aorta models.

BACKGROUND: Stent graft placement is an acceptable treatment option for aortic disease, particularly for abdominal aortic aneurysm. At present, the use of stent grafts is expanding beyond current indications for use. Fenestrated stent grafts are used in patients with abdominal aortic aneurysms whose aortic anatomy is unsuitable for repair using standard devices. The success of fenestrated stent graft placement is largely dependent on planning, including obtaining measurements and designing the stent. OBJECTIVE: To demonstrate a measurement technique that may be used for the design of fenestrated stent grafts to repair endovascular aneurysms, and to compare these measurements, obtained using archived two-dimensional patient data, with measurements obtained using a three-dimensional (3-D) computer-assisted design model. METHODS: Fenestrated stent grafts were designed and fabricated based on computed tomographic angiography images. 3-D models were constructed using modelling software and rapid prototyping technology incorporated with fused deposition modelling. The stent grafts were trunk-type, with four holes for the visceral branches (celiac axis, superior mesenteric artery, right renal artery and left renal artery). Computed tomography scans of 10 patients with abdominal aortic aneurysms were reviewed. Axial, multiplanar reconstruction and curved multiplanar reconstruction images were used to measure 11 parameters. Sizing of the fenestrated aortic stent grafts was performed independently by an experienced interventional radiologist, and the results were compared with the same measurements calculated using the 3-D aorta model (generated using Materialise Interactive Medical Image Control System software [Materialise NV, Belgium]). Data were reported as the mean of the measurements. Measurements were evaluated using Bland-Altman analysis and concordance correlation coefficients (CCCs). RESULTS: A total of 10 fenestrated stent grafts were fabricated. The proximal landing section above the celiac axis (one point of the wall being defined as the standard point) was 3 cm, and the distal flared section was 3 cm below the lowest renal artery. Ten computer-assisted design aorta models were successfully constructed. Measurements of the aortic diameter showed high agreement between those obtained using the archived patient computer system stent graft and those obtained using the 3-D aorta model. The CCC for variability was 0.9974. The distance from the standard point to the branch vessels also demonstrated good agreement. The CCC for variability was 0.9999. DISCUSSION: A direct measurement technique using a standard point was simple to perform and was easily applied to the fabrication process. Preparation time will likely be shortened and the versatility of stent grafts will be improved using this method. It will be possible to produce standardized fenestrated stent grafts once patients' measurements are recorded and analyzed. CONCLUSION: A fenestrated stent graft design technique using measurements of distance from a standard point generally showed a high level of agreement with a 3-D aorta model.

Palliative treatment of unresectable hepatocellular carcinoma with obstructive jaundice using biliary drainage with subsequent transarterial chemoembolization.

BACKGROUND: Nonsurgical biliary drainage is considered as a priority for obstructive jaundice associated with unresectable hepatocellular carcinoma (HCC). Successful drainage allows the patient to receive antitumor therapy, such as transarterial chemoembolization (TACE). However, only limited data are available on clinical outcomes in patients who treated biliary drainage with subsequent TACE. OBJECTIVE: This study evaluated the clinical outcome of biliary drainage with subsequent TACE in unresectable HCC patients with obstructive jaundice. DESIGN: This was a retrospective study. SETTING/SUBJECTS: A total of 60 patients received endoscopic biliary drainage (ERBD) or percutaneous transhepatic biliary drainage (PTBD) in two tertiary care referral centers. MEASUREMENTS: Successful drainage and survival were measured. RESULTS: Successful drainage was achieved in 39 (65%) patients. The median survival of 39 patients in whom successful drainage was achieved, regardless of which procedure was performed, was much longer than that of 21 patients without successful drainage (147 days versus 38 days, respectively, P<.001). In particular, the median survival was longer in 17 patients who underwent TACE after achieving successful drainage than in 22 patients who were treated conservatively after achieving successful drainage (410 days versus 77 days, respectively, P<.001). Multivariable analysis in 39 patients in the successful drainage group showed that TACE (hazard ratio 0.15; 95% confidence interval 0.05-0.45, P=.001) was an independent predictive factor of a favorable outcome. CONCLUSIONS: Effective palliation by successful biliary drainage with subsequent TACE might prolong the survival in patients with obstructive jaundice caused by unresectable HCC.

Bronchial artery embolization to control hemoptysis: comparison of N-butyl-2-cyanoacrylate and polyvinyl alcohol particles.

PURPOSE: To retrospectively compare safety and effectiveness of embolic agents polyvinyl alcohol (PVA) particles versus n-butyl-2-cyanoacrylate (NBCA) for bronchial artery embolization (BAE) for control of hemoptysis. MATERIALS AND METHODS: Institutional review board approved this retrospective study; informed consent was waived. From January 2005 to December 2008, 406 patients (242 men, 164 women; age range, 6-92 years) with major hemoptysis underwent BAE by using PVA particles (n = 293) or NBCA (n = 113). Technical and clinical success, complications, hemoptysis-free survival rates, and causes of recurrent hemoptysis were compared between PVA and NBCA groups. The differences in hemoptysis-free survival rates were assessed between subgroups stratified to underlying diseases. The predictive factor for recurrent hemoptysis was identified with Cox proportional hazard regression model. RESULTS: Technical success was achieved in 93.9% (275 of 293) and 96.5% (109 of 113) of patients for PVA and NBCA, respectively (P = .463); clinical success was achieved in 92.2% (270 of 293) and 96.5% (109 of 113) of patients for PVA and NBCA, respectively (P = .180). Overall and major complication rates were not statistically different (overall complication rates: 34.1% for PVA, 31.0% for NBCA; P = .56; major complication rates: 0.3% for PVA, 0% for NBCA; P > .999). The 1-, 3-, and 5-year hemoptysis-free survival rates were, respectively, 77%, 68%, and 66% for PVA and 88%, 85%, and 83% for NBCA (P = .01). Recanalization of previously embolized vessels was more frequent in PVA group (21.5%) than in NBCA group (1.8%; P < .001). NBCA group showed hemoptysis-free survival rates superior to PVA group in patients with bronchiectasis (P = .016). PVA (P = .050) and aspergilloma (P < .001) were predictive factors for recurrent hemoptysis. CONCLUSION: BAE with NBCA provided higher hemoptysis-free survival rates compared with PVA particles without increasing complication rates. This improvement was evident in patients with bronchiectasis and was caused by more durable embolic effect than PVA particles. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13130046/-/DC1.

Safety and efficacy of radiological percutaneous jejunostomy for decompression of malignant small bowel obstruction.

OBJECTIVES: This study aimed to evaluate the safety and efficacy of percutaneous radiological jejunostomy (PRJ) and stent placement in patients with malignant small bowel obstructions (MSBO). METHODS: A total of 21 patients (mean age 60 years) with single (n = 4) or multiple (n = 17) MSBO underwent PRJ following jejunopexy. The medical records and imaging studies were retrospectively reviewed to evaluate the technical/clinical success and complications. Clinical success was determined by symptomatic relief and radiologic bowel decompression. RESULTS: PRJ using a 12- or 14-F drainage catheter was technically successful in all patients. Eleven patients required placement of an 18-F nasogastric tube across one (n = 3), two (n = 6) and three (n = 2) obstructions to achieve clinical success. Subsequently, self-expandable stents were placed through the PRJ tracts to recanalise MSBO in four patients. Clinical success was achieved in 18 patients (85.7 %). The median food intake capacity score improved from 4.0 to 2.0 (P = 0.001). There were one major (peritonitis, 4.8 %) and six minor complications (28.6 %) CONCLUSIONS: PRJ using a nasogastric tube across the obstructions is an effective palliative treatment for MSBO. The PRJ tract can be used as an approach route for stent placement to recanalise MSBO. However, dedicated devices should be developed to reduce frequent procedure-related complications. KEY POINTS: • Bowel decompression provides palliative treatment in malignant small bowel obstruction • Percutaneous radiological jejunostomy (PRJ) is a safe and effective palliative treatment. • Long tube placement across obstructions facilitates adequate drainage of multiple bowel obstructions. • PRJ tract can be used for stent placement to approach MSBO recanalisation.

Postpartum haemorrhage from ruptured pseudoaneurysm: efficacy of transcatheter arterial embolisation using N-butyl-2-cyanoacrylate.

OBJECTIVES: To evaluate the efficacy of transcatheter arterial embolisation (TAE) using N-butyl-2-cyanoacrylate (NBCA) in the treatment of postpartum haemorrhage (PPH) due to ruptured pseudoaneurysm. METHODS: From March 2004 to December 2010, 33 patients underwent TAE using NBCA for massive PPH. Twenty-one patients (63.6 %) were in coagulopathic condition. Angiograms and medical records were retrospectively reviewed to determine technical/clinical success, complications and recurrent haemorrhage after TAE. Telephone interviews were conducted to obtain fertility-related data. RESULTS: Emergent angiograms revealed ruptured pseudoaneurysms at the uterine (n = 17), vaginal (n = 14), internal pudendal (n = 3) and obturator (n = 1) arteries, which were successfully embolised with NBCA. Four patients required additional embolisation of the uterine (n = 3) or ovarian artery (n = 1) with an absorbable gelatine sponge. Adequate haemostasis was achieved in 31 patients (93.9 %) after TAE. Two patients experienced persistent (n = 1) or recurrent (n = 1) haemorrhage, which required hysterectomy. There were no major embolisation-related complications. All 29 patients who were interviewed reported regaining of their regular menstruation. Nine patients had normal pregnancies and delivered healthy babies at full term. CONCLUSIONS: TAE using NBCA is an effective treatment of PPH from ruptured pseudoaneurysms. In particular, NBCA is a potent embolic material in patients with coagulopathy. It does not seem to adversely affect future fertility. KEY POINTS: • Transcatheter arterial embolisation is a safe and effective treatment for postpartum haemorrhage. • NBCA is potent embolic material to treat bleeding patients with severe coagulopathy. • NBCA does not seem to adversely affect future fertility.

Failed pelvic arterial embolization for postpartum hemorrhage: clinical outcomes and predictive factors.

PURPOSE: To evaluate clinical outcomes of failed pelvic arterial embolization (PAE) and determine predictive factors associated with this failure in the treatment of postpartum hemorrhage (PPH). MATERIALS AND METHODS: This retrospective study included all consecutive patients who underwent PAE for life-threatening PPH between March 2004 and January 2011 at a tertiary-care center. Medical records and imaging studies were reviewed to identify cases of failed PAE and their clinical outcomes. Multiple parameters were compared between the failed and successful PAE groups, and multivariate analysis was performed to determine the predictive factors associated with failed PAE. RESULTS: PAE was performed in 257 patients (mean age, 32 y; range, 20-40 y). A total of 24 cases of PAE involved a failure to achieve hemostasis (9.3%). Patients in the failed PAE group experienced more major complications than those in the successful PAE group (37.5% [nine of 24] vs 9.4% [22 of 233]). Factors more frequently found in failed PAE included hemodynamic instability, hemoglobin level lower than 8g/dL, disseminated intravascular coagulation (DIC), and extravasation detected on angiography. After multivariate analysis, DIC emerged as the only significant predictive factor (odds ratio, 6.569; 95% confidence interval, 1.602-26.932; P = .009). CONCLUSIONS: PAE is an effective treatment for medically intractable PPH. However, PAE failed in a high percentage of patients and was commonly associated with major complications. DIC was the only significant predictor of failed PAE.

Inaccessible postoperative abdominal abscess: percutaneous drainage technique with puncture of a sinus tract.

The present report describes percutaneous drainage involving puncture of a sinus tract in 14 patients with inaccessible postoperative abdominal abscesses. In eight patients, a sinus tract formed by a previously placed surgical drain was percutaneously punctured under ultrasound guidance. In six patients, a sinus tract was accessed under fluoroscopic guidance, aiming at an indwelling surgical drain. A drainage catheter was successfully placed into the abscesses in 13 patients (92.9%). Complete resolution of abscesses was documented on follow-up computed tomography. Percutaneous drainage with puncture of a sinus tract may be a feasible and effective treatment for inaccessible postoperative abdominal abscesses.

Effects of arsenic trioxide on radiofrequency ablation of VX2 liver tumor: intraarterial versus intravenous administration.

OBJECTIVE: Arsenic trioxide (As(2)O(3)) can be used as a possible pharmaceutical alternative that augments radiofrequency (RF) ablation by reducing tumor blood flow. The aim of this study was to assess the effect of intraarterial and intravenous administration of As(2)O(3) on RF-induced ablation in an experimentally induced liver tumor. MATERIALS AND METHODS: VX2 carcinoma was grown in the livers of 30 rabbits. As(2)O(3) (1 mg/kg) was administered through the hepatic artery (n = 10, group A) or ear vein (n = 10, group B), 30 minutes before RF ablation (125 mA ± 35; 90 ± 5℃). As a control group, 10 rabbits were treated with RF ablation alone (group C). RF was intentionally applied to the peripheral margin of the tumor so that ablation can cover the tumor and adjacent hepatic parenchyma. Ablation areas of the tumor and adjacent parenchymal changes among three groups were compared by the Kruskal-Wallis and Mann-Whitney U test. RESULTS: The overall ablation areas were 156 ± 28.9 mm(2) (group A), 119 ± 31.7 (group B), and 92 ± 17.4 (group C, p < 0.04). The ablation area of the tumor was significantly larger in group A (73 ± 19.7 mm(2)) than both group B (50 ± 19.4, p = 0.02) and group C (28 ± 2.2, p < 0.01). The ratios of the tumoral ablation area to the overall ablation area were larger in group A (47 ± 10.5%) than that of the other groups (42 ± 7.3% in group B and 32 ± 5.6% in group C) (p < 0.03). CONCLUSION: Radiofrequency-induced ablation area can be increased with intraarterial or intravenous administration of As(2)O(3). The intraarterial administration of As(2)O(3) seems to be helpful for the selective ablation of the tumor.

The biodurability of covering materials for metallic stents in a bile flow phantom.

BACKGROUND: Covered biliary metal stents have been introduced for the purpose of overcoming tumor ingrowth and treatment of benign biliary stricture. The aim of this study was to evaluate the biodurability of three commercially available biliary metal stent covering materials [e-PTFE (expanded polytetrafluoroethylene), silicone, and polyurethane] in a bile flow phantom. MATERIALS AND METHODS: By operation of a peristaltic pump, human bile was circulated continuously in an experimental perfusion system containing covered metal stents. Each stent was removed, respectively, 1, 2, 4, and 6 months after bile exposure. We performed a gross inspection of the covered stents. The covering membrane was detached from the stent and observed by scanning electron microscopy (SEM). Finally, we measured tensile and tear strength of the membranes. RESULTS: Bile-staining of the membrane showed gradual progression after bile exposure; however, progress was the fastest in e-PTFE. SEM examination showed that the polyurethane surface was smooth, and the silicone surface was relatively smooth. However, e-PTFE had a rough and uneven surface. After bile exposure, there were no significant changes in polyurethane and silicone; however, biofilms and microcracks were observed in e-PTFE. In contrast to a gradual decrease of tensile/tear strength of polyurethane and silicone, those of e-PTFE showed a rapid reduction despite of the strongest baseline tensile and tear strength. CONCLUSION: e-PTFE tended to form biofilms more frequently than polyurethane and silicone during bile exposure. e-PTFE seemed to be less durable than silicone and polyurethane, however, as clinically applicable material because of strong absolute tensile/tear strengths.

Use of covered stents in the central vein: a feasibility study in a canine model.

PURPOSE: To evaluate the feasibility of using covered stents vs. bare stents in a model of central vein stenosis with an arteriovenous graft created to mimic the conditions in hemodialysis patients. METHODS: In 7 mongrel dogs, an expanded polytetrafluoroethylene-covered nitinol stent was placed in one common iliac vein and a bare stent was placed in the contralateral vein. Arteriovenous grafts were created bilaterally between the common femoral artery and vein to induce endothelial damage. Neointima formation in the covered stents was compared to the bare stents at 12 weeks using microscopy and histochemical staining. RESULTS: Two dogs were excluded due to thrombosis and infection of the arteriovenous grafts, but all stents in the remaining 5 dogs were patent. Smooth, complete neointimal coverage was observed on the inner surface of all the covered stents without intraluminal thrombus. In contrast, incomplete neointimal coverage was seen in all bare stents, with small focal thrombi adhering to the neointima on 3 bare stents. Focal nodular neointimal hyperplasia with denudation of the endothelium was observed in only 2 bare stents. Mean neointimal thickening was significantly greater in the covered stents. Eccentric neointimal thickening was observed at the inflow and outflow segments of both types of stents. CONCLUSION: Covered stents are technically feasible for the treatment of central vein stenosis, and they demonstrate complete, smooth neointimal coverage in normal central veins, but they also display greater neointimal thickening than bare stents.

Transcatheter arterial embolization of gastroduodenal artery stump pseudoaneurysms after pancreaticoduodenectomy: safety and efficacy of two embolization techniques.

PURPOSE: To evaluate the safety and efficacy of two transcatheter arterial embolization (TAE) techniques used to treat pseudoaneurysms of the gastroduodenal artery (GDA) stump after pancreaticoduodenectomy. MATERIALS AND METHODS: Between March 2003 and March 2008, 16 patients were treated with TAE for pseudoaneurysms of the GDA stump after pancreaticoduodenectomy. Two embolization techniques were employed: endovascular trapping of the hepatic artery (embolization of the hepatic artery proximal and distal to GDA stump; group A; n = 13) and selective embolization of the GDA stump and/or pseudoaneurysm sparing hepatic arterial flow (group B; n = 3). Technical success, initial hemostasis, recurrence of bleeding, and complications were compared between the two groups retrospectively. RESULTS: All TAE procedures were technically successful and immediate hemostasis was achieved in all patients. There was no recurrent bleeding in group A; however, all three patients in group B experienced recurrent bleeding after initial hemostasis (P = .002), and these patients required subsequent embolization with the endovascular trapping technique. Two patients died of multiple organ failure (one patient in each group) despite successful hemostasis. Three patients experienced subsegmental (n = 1, group A) and multisegmental (n = 2, group B) liver infarction, which were successfully managed with conservative treatment. There was a higher incidence of major complications in group B (15.4% vs 100%; P = .018). CONCLUSIONS: Endovascular trapping of the hepatic artery is a safe and effective treatment of pseudoaneurysms of the GDA stump after pancreaticoduodenectomy. Hepatic ischemic complications are not rare, but can be conservatively managed. Selective embolization of the GDA stump and/or pseudoaneurysm is frequently associated with recurrence of bleeding, which eventually leads to major complications.

Efficacy and safety of hepatic arterial infusion of fluorouracil with leucovorin as salvage treatment for refractory liver metastases from colorectal cancer.

BACKGROUND/AIMS: Limited options remain for patients with metastatic colorectal cancer (CRC) after failure of standard systemic chemotherapy. Readministration of chemotherapeutic agents by hepatic arterial infusion (HAI) has the rationale of providing higher concentrations of chemotherapeutic agents to hepatic metastases. The present study was conducted to evaluate the efficacy and safety of HAI of fluorouracil with leucovorin (HAI 5-FU/LV) for patients with liver metastases from CRC. METHODS: Fourteen patients with liver metastases from CRC who received HAI 5-FU/LV after failure of systemic chemotherapy containing fluorouracil and leucovorin were identified and their medical records were reviewed. RESULTS: Of 10 patients evaluable for response, one partial response, six stable disease, and three progressive disease were reported. Additionally, the overall response and disease control rates were 7% and 50%, respectively. The median time to progression was 4.3 months (range, 2.9 to 5.6), to hepatic progression was 5.8 months (range, 4.7 to 6.9), and to extrahepatic progression was 5.8 months (range, 2.3 to 9.2). No grade 3/4 hematologic toxicities occurred and one case of abdominal pain and two cases of oral mucositis were the only grade 3 nonhematologic toxicities. Catheter-related complications occurred in three patients: one thrombosis, one infection, and one displacement. CONCLUSIONS: HAI 5-FU/LV was well tolerated and showed modest efficacy for patients with liver metastases from refractory CRC. Readministration of previously used chemotherapeutic agents via the hepatic artery could be an effective salvage option and warrants further investigation in a prospective trial.

Hepatocellular carcinoma in older adults: clinical features, treatments, and survival.

OBJECTIVES: To evaluate the clinical features, treatments, stages, and survival in older adults with hepatocellular carcinoma (HCC). DESIGN: A consecutive case study with retrospective medical record review. SETTING: University hospital (tertiary referral center) in Korea. PARTICIPANTS: Two hundred sixty-two participants with HCC diagnosed between May 1, 2003, and December 31, 2006. MEASUREMENTS: Clinical characteristics, treatments, four staging systems for HCC, and survival in older (≥65, n=113) and younger (<65, n=149) people with HCC. RESULTS: The older HCC group were less likely to have hepatitis B virus infection and diffuse tumors and had more comorbidities, poorer performance status, smaller tumor area, and multinodular disease. There were no significant differences between the two groups with regard to Child-Pugh-Turcotte score, Model for End Stage Liver Disease (MELD) score, Child class, alpha-fetoprotein levels, and tumor stage at diagnosis. Approximately 88% of subjects were treated regardless of age, but resection was performed less frequently in the older participants. Older participants with HCC had overall survival and liver-related mortality similar to those of the younger participants, although they had poorer performance, greater comorbidity, and less likelihood of receiving surgery than the younger patients. CONCLUSION: This study supports the effectiveness and safety of nonsurgical treatment for older adults with HCC. Further study is needed to elucidate the reasons for similar prognoses in the older adults in spite of the greater burdens of comorbidities and poorer performance status.

Bronchial and nonbronchial systemic artery embolization in patients with major hemoptysis: safety and efficacy of N-butyl cyanoacrylate.

OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of N-butyl cyanoacrylate for bronchial and nonbronchial systemic artery embolization in the management of major hemoptysis. MATERIALS AND METHODS: From March 2004 through March 2006, 108 patients with major hemoptysis underwent embolization with N-butyl cyanoacrylate. The common conditions causing hemoptysis were bronchiectasis (n = 34), sequelae of tuberculosis (n = 31), active tuberculosis (n = 18), lung cancer (n = 8), and aspergilloma (n = 6). A retrospective analysis of postprocedure outcomes, including immediate success, recurrence of hemoptysis, cause of recurrence, and complications, was performed. RESULTS: Immediate success was achieved in 105 patients (97.2%). During the follow-up period (range, 5 days-63 months; median, 28.5 months), recurrent hemoptysis was found in 21 of the 105 patients (20%). Repeat angiograms (n = 14) revealed incomplete embolization during the initial procedure in seven patients with early recurrence (< 3 months) and revascularization of nonbronchial systemic collateral arteries in seven patients with late recurrence (> 3 months). No recanalization of embolized arteries was found on repeat angiograms or at follow-up CT. The cumulative nonrecurrence rates were 91.4% 1 month, 83.4% 1 year, 76.7% 3 years, and 56.8% 5 years after the initial procedure. The procedure-related complications included transient chest pain (n = 21) and denudation of the bronchial mucosa (n = 3), which was clinically silent but found at bronchoscopy. CONCLUSION: N-butyl cyanoacrylate is a safe and effective agent for embolization in patients with major hemoptysis.

Gastrointestinal stent update.

The use of self-expanding metallic stents in the upper gastrointestinal tract, placed under radiologic imaging or endoscopic guidance, is the current treatment of choice for the palliation of malignant gastrointestinal outlet obstructions. Advances in metallic stent design and delivery systems have progressed to the stage where this treatment is now considered a minimally invasive therapy. Metallic stent placement will broaden further into the field of nonsurgical therapy for the gastrointestinal tract. To date, metallic stents placed in the esophagus, gastric outlet, colorectum, and bile ducts are not intended to be curative, but rather to provide a palliative treatment for obstructions. The evolution of metallic stent technology will render such procedures not only palliative but also therapeutic, by enabling local drug delivery, and the use of biodegradable materials will reduce procedure-related complications.

Single-session combined therapy with chemoembolization and radiofrequency ablation in hepatocellular carcinoma less than or equal to 5 cm: a preliminary study.

PURPOSE: To evaluate the efficacy and safety of a single-session combined chemoembolization and radiofrequency (RF) ablation for hepatocellular carcinomas (HCCs) less than or equal to 5 cm. MATERIALS AND METHODS: Between June 1, 2004, and January 1, 2006, 50 patients (41 men, nine women; age range, 35-77 years; mean age, 61.5 years) with 57 HCCs (1.5-4.5 cm; mean, 2.4 cm) underwent single-session combined therapy. Chemoembolization was performed by using a doxorubicin hydrochloride/iodized oil emulsion with or without gelatin sponge particles. Immediately following chemoembolization, RF ablation was performed under fluoroscopy or ultrasonographic guidance. Initial tumor response and local tumor progression were determined with follow-up computed tomography or magnetic resonance imaging. The recurrence-free and overall survival rates as well as procedure-related complications were evaluated. RESULTS: At 1-month follow up, complete necrosis was achieved in all index tumors; however, nonindex intrahepatic recurrences were found in two patients (complete response in 48 patients and progressive disease in two patients). The estimated 1- and 3-year local tumor progression rates during the follow-up period (range, 13.1-51.6 months; mean, 29.0 months) were 1.8% and 9.4%, respectively. The 1- and 3-year recurrence-free and overall survival rates were 64.6% and 30.5% and 100% and 79.7%, respectively. Three of the 50 patients (6%) had major complications, including segmental hepatic infarction (n = 2) and hepatic arterial bleeding (n = 1). CONCLUSIONS: Single-session combined therapy is an effective and safe treatment for HCCs less than or equal to 5 cm.