Integrated Capecitabine-Temozolomide with Radioembolization for Liver-Dominant G2 NETs: Long-Term Outcomes of a Single-Institution Retrospective Study.

PURPOSE: Capecitabine-Temozolomide (CapTem) is an oral chemotherapy regimen for NETs. Both drugs are radiosensitizers. Integrating CapTem and Y90 transarterial radioembolization (TARE) in patients with grade 2 neuroendocrine tumor (NET) liver metastases achieved an encouraging objective response rate (ORR) and progression-free survival (PFS) in a feasibility study. This study expands that report to a larger cohort with longer follow-up. METHODS: Therapy consisted of monthly cycles of capecitabine 600 mg/m2 twice daily for 14 days and temozolomide 150-200 mg/m2 on day 10-14. Simulation angiography was performed during the initial cycle. The dominant lobe was treated with 90Y-resin microspheres using BSA dosimetry on day 7 of the second cycle of CapTem. Patients with bilobar disease had the other lobe treated on day 7 of the third or fourth cycle. CapTem was continued until progression or intolerance. Clinical and laboratory assessment was done monthly and imaging every 3 months. RESULTS: 35/37 patients completed the prescribed regimen. Primary sites of disease were pancreas (16), lung (10), gut (7) and unknown (4). Mean duration of CapTem was 12 months (range, 4-32 months). ORR in the liver was 72% with a disease control rate of 100%. Median PFS was 36 months (95% CI, 25-45 months). Median overall survival was 41 months (95% CI, 24-87 months) from initiation of CapTemY90 therapy and 130 months (95% CI, 56-172 months) from initial diagnosis. CONCLUSION: Chemoradiation with CapTem and TARE provided durable control of G2 NET liver metastases for substantially longer than expectations for embolotherapy or chemotherapy alone.

Impact of PTFE-covered stent position and extension on TIPS patency.

PURPOSE: The objectives of this study were to determine the effects of expanded polytetrafluoroethylene (PTFE)-covered stent location and TIPS extension on primary patency. METHODS: This retrospective cohort study examined patients with PTFE-covered TIPS creation between 07/2002 and 06/2016. Clinical information and patency outcomes at 24 months were extracted. At TIPS creation, extension was performed at the discretion of the operator. Kaplan-Meier curves of primary patency were generated with conditional variables of HVO-HCJ distance, extension status, and covered versus uncovered extensions. Additional logistic regression analyses of distances were performed. RESULTS: Of 393 patients, 115 patients (29%) underwent stent extension, 79 (20% of total cohort) of which were at the HVO end alone. Primary patency for all TIPS was 75%, 68%, and 54% at 3, 6, and 12 months. The data endpoint were transplant or death in 92 (23%) and 116 (30%). Kaplan-Meier curves showed no statistically significant difference between the variables and primary patency at 12 and 24 months: distance up to versus greater than 10 mm (p = 0.32, 0.81); extension versus no extension (p = 0.83, 0.85); uncovered versus covered extensions (p = 0.58, 0.70). Logistic regression analyses showed a trend toward statistical significance. CONCLUSION: In the setting of PTFE-covered TIPS creation, extended TIPSs and unextended well-positioned TIPSs have no difference in primary patency rates. Stent position and extension length may have an effect on primary patency, but were likely obscured by "user recognition" effects.

Giant Iliac Artery Pseudoaneurysm Mimicking Postoperative Fluid Collection and Diskitis.

BACKGROUND: In this report, we describe an extremely rare case of a giant pseudoaneurysm of the internal iliac artery causing marked destructive changes at a disk space and mimicking diskitis-osteomyelitis. Only 2 other cases of pseudoaneurysms extending into the disk space have been reported, and those arose from the aorta and were relatively straightforward to diagnose. CASE DESCRIPTION: Our case is unique because the pseudoaneurysm arose from the internal iliac artery, an artery that is not usually included in the field of view of lumbar magnetic resonance imaging or computed tomography. However, the pseudoaneurysm was so large that it extended to the lumbosacral junction, where it eroded a disk space and caused findings of diskitis-osteomyelitis. CONCLUSIONS: Complex paraspinal fluid collections causing osseous erosions should raise the possibility of an aneurysm/pseudoaneurysm. Computed tomography or conventional angiography should be considered if the question of a vascular mass/collection cannot be answered on conventional cross-sectional imaging, as inadvertent biopsy of a pseudoaneurysm can cause catastrophic bleeding.

Impact of a Monthly Compliance Review on Interventional Radiology Adverse Event Reporting.

PURPOSE: Our aims were to analyze the change in interventional radiology physician major adverse event (AE) reporting after initiation of a monthly morbidity and mortality (M&M) conference compliance review and to describe the association of procedure class and potentially preventable errors with major AE occurrence. METHODS: In late 2010, to motivate timely reporting, we instituted a structured monthly M&M conference review confirming whether each complication warranted institutional AE reporting and whether timely reporting had occurred. In this study, we retrospectively analyzed the M&M conference minutes over the subsequent 5 years. Logistic regression was used to model the change of AE reporting over time as well as the association of procedure class with the risk of an AE. Each AE was classified as to whether it seemed potentially preventable. RESULTS: There were 46,660 patient encounters, 1,160 (2.5%) major and minor complications, and 462 (1.0%) reportable AEs. From 2011 to 2015, the percentage of reportable AEs reported increased from 67% to 98%. The number of months from initiation of the M&M conference review was a significant predictor of the likelihood of AE reporting (odds ratio 1.06, 95% confidence interval 1.04, 1.08, P < .0001). Procedure class was strongly associated with the risk of a reportable AE (P < .0001). At least 111 (24%) reportable AEs were potentially preventable. CONCLUSIONS: Increasing AE reporting occurred after initiation of a monthly M&M conference compliance review. The incidence of reportable AEs was strongly associated with procedure class, and a significant percentage of these events were potentially preventable.

Perspectives from Human Interventional Radiology.

Interventional radiology is a subspecialty of diagnostic radiology that uses minimally invasive techniques performed under imaging guidance. Interventional radiology has its roots in angiography, which is the radiologic examination of blood vessels after the introduction of a contrast medium that allows them to be imaged. Going forward, the collaboration between human and veterinary interventional radiologists will persist as a two-way street and will continue to innovate together and learn from each other and from the patients.

Combined chemoembolization and thermal ablation for the treatment of metastases to the liver.

PURPOSE: The purpose of the study was to evaluate safety, time to recurrence, and overall survival (OS) in patients with liver metastases (LM), treated with transarterial chemoembolization (TACE) followed by ablation. MATERIALS AND METHODS: This retrospective study included all patients with LM treated with combined TACE and ablation from August 1998 to September 2015. Forty-two patients (12 women, 30 men; age 62.9 ± 11.9 years) were treated for 44 LMs. Tumor characteristics, imaging response to treatment, recurrence, and OS data were reviewed. Statistical analysis included Kaplan-Meier estimation, Cox regression and Fisher's exact, Wilcoxon rank sum, or log rank tests. RESULTS: Median follow-up was 10.3 months. Eighteen patients had 1 hepatic lesion, 16 had 2-5, and 8 had > 5. Median index lesion size was 4.7 cm (range 1.5-8 .0 cm). Tumor response (mRECIST) was available for 41/44 treated lesions, with CR in 32 (78.0%), PR in 8 (19.5%), and PD in 1 (2.4%). Long-term imaging follow-up was available for 38 patients. Freedom from local recurrence was 61% at 1 year and 50% at 2 years. OS was 55% at 1 year and 30% at 2 years (median OS, 14.5 months). Tumor size and histology were not predictors of time to progression or OS. Complications occurred in 19 patients (45%). Major complications occurred in 19% of patients and included hospitalization for fever (n = 2), hepatic abscess (n = 3) and fall requiring transfusion, portal vein thrombus causing lobar infarct, biliary fistula, and retroperitoneal hematoma (n = 1 each). CONCLUSIONS: Combined TACE and ablation is effective for local tumor control of liver metastases up to 8 cm when part of a multidisciplinary treatment strategy. Major complications occurred in 19% of patients.

The Impact of Bridging LRT on Survival in Patients Listed for Liver Transplantation.

PURPOSE: Locoregional therapy (LRT) is recommended for certain groups of patients with hepatocellular carcinoma (HCC) listed for orthotopic liver transplantation (OLT) with expected wait times greater than 6 months. A retrospective single-center study was performed to evaluate the effect of LRT on the outcomes of patients with HCC listed for OLT. METHODS: Institutional database was reviewed to identify the patients listed for OLT with HCC (March 1998-December 2010). Patient and tumor characteristics were recorded with a follow-up period of 6.5 years from diagnosis. RESULTS: Out of 359 listed patients, 72 patients were delisted (delisted group) and 287 underwent orthotopic liver transplantation (OLT group). One hundred fifty-five and 45 patients from the OLT and delisted groups underwent locoregional therapy (LRT), respectively. Median wait time and sum of largest tumor diameter were significantly higher for patients receiving LRT. LRT was associated with significantly better survival among delisted patients at the end of follow-up (1249.6 ± 137.4 vs. 742.1 ± 155.4 days, p = 0.028). In the OLT group, survival was similar between LRT and no LRT group, but survival was significantly better in patients with largest tumor diameter ≥30 mm (1949.4 ± 95.1 vs. 1694.8 ± 135.5, p = 0.02). CONCLUSION: Patients with HCC and the largest tumor greater than 30 mm treated with LRT prior to OLT have improved survival compared to patients not receiving LRT. Additionally, for patients who did not undergo transplant survival is significantly longer for those receiving LRT.

Effect of Substituting 50% Isovue for Sterile Water as the Delivery Medium for SIR-Spheres: Improved Dose Delivery and Decreased Incidence of Stasis.

PURPOSE: The objective of this study was to evaluate the effect of substituting 50% Isovue (Bracco Diagnostics Inc, Monroe Township, NJ) for sterile water on the delivery of Y resin microspheres (SIR-Spheres [Sirtex Medical Limited, Sydney, Australia]). MATERIALS AND METHODS: The authors retrospectively reviewed all SIR-Spheres radioembolizations at the authors' institution from January 1, 2011, to February 10, 2014. From January 1, 2011, to April 30, 2013, all users performed SIR-Spheres radioembolization per the manufacturer's original instructions using sterile water in the B and D lines and intermittently checking the progress of the embolization by injecting contrast via the B line. Beginning May 1, 2013, a modified technique using Isovue diluted 50% with saline in place of sterile water in both the B and D lines of the infusion set. The authors compared the prepared versus administered activity of Y SIR-Spheres, fluoroscopy time, administration time, and frequency of radioembolizations terminated for stasis when using water versus dilute contrast in the B and D lines. RESULTS: One hundred seventy-five radioembolizations were performed, 132 (75%) with water as the delivery medium and 43 (25%) with 50% contrast as delivery medium. The mean percentage of the Y activity administered was 98% with contrast versus 87% with water (P < 0.01). More than 95% of cases using contrast resulted in 90% or more delivery of the prepared Y activity versus 59% of cases with water (P < 0.01). For cases using water, 17% were terminated for stasis, whereas 2% (1 case) using contrast was terminated for stasis. The mean Y administration time was 7 minutes with contrast versus 22 minutes with water (P = 0.015). Excluding the 37 cases involving coil embolization, the mean fluoroscopy time was 8.3 minutes with contrast versus 11.5 minutes with water (P < 0.05). No complications occurred with the contrast method; however, there were 4 complications with water, including 1 nontarget gastric ulceration. CONCLUSIONS: Using dilute contrast as the delivery medium for SIR-Spheres resulted in a significantly greater percentage of the prepared activity administered to the patient with substantially shorter administration time. Termination for stasis occurred less often with dilute contrast. No complications were observed when using dilute contrast, which allowed continuous real-time monitoring of the Y microsphere administration.

A 16-F Sheath with Endobronchial Forceps Improves Reported Retrieval Success of Long-Dwelling "Closed Cell" Inferior Vena Cava Filter Designs.

PURPOSE: To report results of a 16-F sheath/endobronchial forceps combination in retrieval of "closed cell" inferior vena cava (IVC) filter designs with prolonged dwell times of ≥ 60 days. MATERIALS AND METHODS: Forceps retrieval of selected IVC filters using a 16-F 45-cm sheath was performed in 35 patients (25 women and 10 men). Patients presented with filters that were no longer needed without (n = 10) or with (n = 21) prior failed retrieval, caval thrombosis before lysis (n = 3), and back pain (n = 1). Filter designs included 19 Günther Tulip (54%), 10 Option (29%), and six OptEase (17%). Mean dwell time was 977 days. Imaging characteristics, technical success, fluoroscopy time, and complications were recorded. RESULTS: Filters included 20 tip-embedded, 6 tip-adherent, 4 fractured, and 6 containing thrombus. All were strut and wall-embedded. Initial snare failures occurred in 8 filters because of hook straightening (n = 4), adherent material (n = 2), snare breakage (n = 1), and filter tilt (n = 1). The 16-F sheath/forceps combination was 100% successful in removing filters. In 1 patient, 2 extravascular fragments could not be retrieved. Median fluoroscopy time, excluding 3 extended lysis procedures, was 8 minutes. Minor caval abnormalities, including caval spasm and caval defects, were noted in 17 patients, and filter fracture occurred in 2 patients. No major complications occurred. CONCLUSIONS: A high rate of retrieval for closed cell long-dwelling strut and wall-embedded filters may be achieved using a 16-F sheath/endobronchial forceps combination.

Percutaneous biliary drainage effectively lowers serum bilirubin to permit chemotherapy treatment.

PURPOSE: For digestive tract cancers, the bilirubin threshold for administration of systemic chemotherapy can be 5 or 2 mg/dL (85.5 or 34.2 µmol/L) depending upon the regimen. We examined the ability of percutaneous biliary drainage (PBD) in patients with malignant biliary obstruction to achieve these clinically relevant endpoints. METHODS: 106 consecutive patients with malignant biliary obstruction and a baseline serum bilirubin >2 mg/dL underwent PBD. Time to achieve a bilirubin of 5 mg/dL (85.5 µmol/L), 2 mg/dL (34.2 µmol/L), and survival was estimated by Kaplan-Meier analysis. Potential technical and clinical prognostic factors were subjected to univariate and multivariate analysis. Categorical variables were analyzed by the log rank test. Hazard ratios were calculated for continuous variables. RESULTS: Median survival was 100 days (range 1-3771 days). Among 88 patients with a pre-drainage bilirubin >5 mg/dL, 62% achieved a serum bilirubin ≤5 mg/dL within 30 days and 84% within 60 days, median 21 days. Among 106 patients with a pre-drainage bilirubin >2 mg/dL, 37% achieved a serum bilirubin ≤2 mg/dL by 30 days and 70% within 60 days, median 43 days. None of the technical or clinical factors evaluated, including pre-drainage bilirubin, were significant predictors of time to achieve a bilirubin ≤2 mg/dL (p = 0.51). Size and type of biliary device were the only technical variables found to affect time to bilirubin of 5 mg/dL (p = 0.016). CONCLUSION: PBD of malignant obstruction achieves clinically relevant reduction in serum bilirubin in the majority of patients within 1-2 months, irrespective of the pre-drainage serum bilirubin, sufficient to allow administration of systemic chemotherapy. However, the decision to undergo this procedure for this indication alone must be considered in the context of patients' prognosis and treatment goals.

Recurrent Bleeding, Survival, and Longitudinal Pulmonary Function following Bronchial Artery Embolization for Hemoptysis in a U.S. Adult Population.

PURPOSE: To report outcomes of bronchial artery embolization (BAE) for hemoptysis, including recurrent bleeding, survival, and longitudinal pulmonary function. MATERIALS AND METHODS: A prospective database identified 69 patients who underwent 97 BAE procedures (n = 1-7 per patient) at a tertiary academic medical center over a period of 11 years. Technical and clinical success were determined. Recurrent bleeding and survival were compared by etiology of lung disease. Rates of change in pulmonary function (forced expiratory volume in 1 s [FEV1] and forced vital capacity [FVC]) were measured and compared before and after index BAE by linear regression in 17 patients. RESULTS: The technical success rate of BAE was 90%. Clinical success rates at 24 hours and 30 days were 82% and 68%, respectively. Thirty percent of patients had recurrent bleeding that required bronchoscopy (7%) or additional embolization (23%). Median time to recurrent bleeding was 29 days among the 13 patients with sarcoidosis, compared with 293 days among patients without sarcoidosis (P = .0013). The hazard ratio for death in patients with sarcoidosis compared with those without sarcoidosis was 4 (95% confidence interval, 2.6-14.6). Analyzing all instances of pulmonary function tests, slopes of decline in FEV1 and FVC were significantly different (FEV1, P = .0048; FVC, P < .0001) before and after index BAE, with an improvement after BAE (FEV1, 0.8%/y; FVC, 1%/y) and a decrease before BAE (FEV1, -1.6%/y; FVC, -1.4%/y). CONCLUSIONS: BAE is an effective therapy for hemoptysis, but patients with sarcoidosis are at significant risk of recurrent bleeding and death compared with patients with other lung diseases. BAE does not accelerate deterioration in lung function.

Initial Clinical Experience: Symmetric-Tip Dialysis Catheter with Helical Flow Characteristics Improves Patient Outcomes.

PURPOSE: To report preliminary clinical experience with a new symmetric-tip dialysis catheter compared with a conventional split-tip catheter. MATERIALS AND METHODS: Over a 5-month period, patients requiring a tunneled catheter for hemodialysis or undergoing exchange of a dysfunctional dialysis catheter at a tertiary academic medical center were retrospectively analyzed. Patients underwent placement of a VectorFlow or Ash Split Cath catheter at the discretion of the inserting interventional radiologist. Patient demographics, catheter patency, mean blood flow rate, and arterial and venous pressures were compared according to catheter type. Catheter failure was analyzed based on clinical and anatomic variables by using a multivariate Cox proportional-hazards model. RESULTS: A total of 33 VectorFlow and 46 Ash Split Cath catheters were placed. Patients in the VectorFlow group had significantly higher body mass index (P = .013) and Charlson Comorbidity Index (P = .049), as well as more non-internal jugular vein placements. At 120 days, 89% of VectorFlow catheters remained functional, compared with 45% of Ash Split Cath catheters (P = .046). The VectorFlow catheter was associated with 16% lower arterial pressures during dialysis (P = .009); mean blood flow rate was equivalent. On multivariate analysis, the risk of catheter failure was 13.3 times higher in the Ash Split Cath group compared with the VectorFlow group (P = .004). Left-sided catheters were also predictive of catheter failure (relative risk = 5.5; P = .02). CONCLUSIONS: The VectorFlow catheter was associated with a significant increase in intervention-free catheter patency compared with the Ash Split Cath catheter, with equivalent flow at lower arterial pressures during dialysis.

Long-Term Patency and Clinical Analysis of Expanded Polytetrafluoroethylene-Covered Transjugular Intrahepatic Portosystemic Shunt Stent Grafts.

PURPOSE: To evaluate long-term patency and symptomatic recurrence rates following transjugular intrahepatic portosystemic shunt (TIPS) creation with expanded polytetrafluoroethylene (ePTFE)-covered stent grafts and to determine the necessity of extended clinical follow-up beyond 2 years after TIPS creation. MATERIALS AND METHODS: A retrospective review including 262 TIPSs created with ePTFE-covered stent grafts between July 2002 and October 2012 was performed. Primary, primary assisted, and secondary patency rates were calculated. Assessment of clinical data included technical, hemodynamic, and clinical success rates, as well as mortality after TIPS creation. RESULTS: Primary patency rates at 2, 4, and 6 years were 74%, 62%, and 50%, respectively. Primary assisted patency rates at 2, 4, and 6 years were 93%, 85%, and 78%, respectively. Secondary patency rates at 2, 4, and 6 years were 99%, 91%, and 84%, respectively. Technical and hemodynamic success rates were 99% and 93%, respectively. Clinical success rates for refractory ascites were 66% (complete response) and 90% (partial response); clinical success rate for bleeding/varices was 90%. Mortality rates at 2, 4, and 6 years after TIPS creation were 27%, 38%, and 46%, respectively. At the median wait time until transplantation, patients had an 84% chance of being alive. TIPS dysfunction developed in 21% of patients; 30% of revisions occurred later than 2 years during follow-up. CONCLUSIONS: Beyond 2 years after TIPS creation, patency rates gradually decrease, mortality rates continue to increase, and the chance of recurrent ascites or bleeding remains present. Together, these findings suggest that continued clinical follow-up beyond 2 years is necessary in patients with a TIPS created with an ePTFE-covered stent graft.

Long-term outcomes of a benign biliary stricture protocol.

PURPOSE: To evaluate long-term outcomes of a structured protocol for percutaneous treatment of benign biliary stricture. MATERIALS AND METHODS: Seventy-one patients (37 men, 34 women; mean age, 54 y; age range, 23-84 y) entered the protocol, which consisted of staged upsizing of internal/external biliary catheters, balloon dilation (nominally 8 mm), and prolonged stent treatment (6 mo) at maximal catheter size (nominally 18 F). It concluded with a capping trial and catheter removal if the stricture remained patent. Fifty-three patients completed the protocol and 18 did not (6 died, 6 underwent alternative treatment, 4 were lost to follow-up, and 2 underwent repeat transplantation). Stricture features, treatment parameters, complications, and outcomes were reviewed, and Kaplan-Meier analysis was conducted. RESULTS: Strictures were anastomotic in 45 patients (64%), intrahepatic in 14 (20%), extrahepatic in 7 (10%), and multiple (intra- and extrahepatic) in 5 (7%). A right-sided approach was used in 47 patients (66%) patients, a left-sided approach in 18 (25%), and a bilateral approach in 6 (9%). Forty-six patients who entered the protocol (65%) and 46 patients who completed the protocol (87%) showed stricture patency. Four of 7 patients in whom a capping trial failed underwent surgical revision, 2 required chronic biliary drainage, and 1 received a metal stent. Follow-up (range, 0-12 y; mean, 4.7 y) was obtained for 42 of 53 patients who completed the protocol (79%). Kaplan-Meier analysis showed stricture patency probabilities of 84% at 1 year after treatment, 78% at 2 years, 74% at 5 years, and 67% at 10 years. CONCLUSIONS: Use of a structured protocol for the percutaneous treatment of benign biliary strictures yields durable long-term results, suggesting that percutaneous treatment is an effective therapy.

Effect of central venous angioplasty on hemodialysis access circuit flow: prospective study of 25 symptomatic patients.

PURPOSE: To quantify the effect of central venous percutaneous transluminal angioplasty (PTA) on blood flow within hemodialysis access circuits in patients with symptomatic central venous stenosis (CVS). MATERIALS AND METHODS: This prospective study enrolled 30 adults with symptoms attributable to CVS ipsilateral to their access. Five subjects were deregistered because of a lack of CVS (n = 1), untreatable lesion (n = 1), or improper flow measurement timing (n = 3); 25 completed the study (15 men and 10 women; mean age, 62 y; age range, 33-87 y). There were 7 fistulae, 15 grafts, and 3 hybrid access circuits. Mean access age was 675 days (range, 16-3,039 d). Mean CVS symptom duration was 37 days (range, 3-120 d). Peripheral stenoses, if present, were treated first. Intraaccess flow was measured immediately before and immediately after CVS treatment (PTA, stent). RESULTS: Eleven patients had only CVS, whereas 14 had at least 1 peripheral lesion in addition to CVS. All stenoses underwent PTA. Mean flow rates were 1,424 mL/min (range, 565-2,765 mL/min) before PTA and 1,535 mL/min (range, 598-2,545 mL/min) afterward, yielding a mean increase of 111 mL/min ± 456 or 15% ± 34 (range, -70% to +100%; 95% confidence interval, 1%-29%). Flow was decreased in 9 patients (36%). CVS symptoms were reduced in 24 patients (96%) and recurred in 14 (58%) within a mean of 110 days (range, 7-459 d) after initial PTA. Mean follow-up was 371 days (range, 17-592 d). CONCLUSIONS: CVS symptoms were observed to occur over a wide range of blood flow rates. On average, central venous PTA only mildly increased flow yet reduced symptoms regardless of flow change.

Retrieval of Tip-embedded Inferior Vena Cava Filters by Using the Endobronchial Forceps Technique: Experience at a Single Institution.

PURPOSE: To evaluate the use of endobronchial forceps to retrieve tip-embedded inferior vena cava (IVC) filters. MATERIALS AND METHODS: This institutional review board-approved, HIPAA-compliant retrospective study included 114 patients who presented with tip-embedded IVC filters for removal from January 2005 to April 2014. The included patients consisted of 77 women and 37 men with a mean age of 43 years (range, 18-79 years). Filters were identified as tip embedded by using rotational venography. Rigid bronchoscopy forceps were used to dissect the tip or hook of the filter from the wall of the IVC. The filter was then removed through the sheath by using the endobronchial forceps. Statistical analysis entailed calculating percentages, ranges, and means. RESULTS: The endobronchial forceps technique was used to successfully retrieve 109 of 114 (96%) tip-embedded IVC filters on an intention-to-treat basis. Five failures occurred in four patients in whom the technique was attempted but failed and one patient in whom retrieval was not attempted. Filters were in place for a mean of 465 days (range, 31-2976 days). The filters in this study included 10 Recovery, 33 G2, eight G2X, 11 Eclipse, one OptEase, six Option, 13 Günther Tulip, one ALN, and 31 Celect filters. Three minor complications and one major complication occurred, with no permanent sequelae. CONCLUSION: The endobronchial forceps technique can be safely used to remove tip-embedded IVC filters.

Risk of liver abscess formation in patients with prior biliary intervention following yttrium-90 radioembolization.

PURPOSE: Patients without a competent sphincter of Oddi due to prior surgical or endoscopic therapy are at high risk for liver abscess following chemoembolization despite aggressive antimicrobial prophylaxis. We examined a cohort of such patients undergoing Y-90 resin radioembolization and compared them to a cohort of chemoembolized patients. METHODS: Review of our quality-assurance database identified 24 radioembolizations performed in 16 patients with prior biliary intervention. An aggressive prophylactic regimen of oral levofloxacin and metronidazole 2 days pre-procedure continuing for 14 days after, oral neomycin/erythromycin bowel prep the day before, and IV levofloxacin/metronidazole the day of treatment was prescribed. Patients underwent resin microsphere radioembolization dosed according to the BSA method. Patients had clinical, imaging, and laboratory assessment 1 month after each treatment, and then every 3 months. The chemoembolization cohort consisted of 13 patients with prior biliary intervention who had undergone 24 chemoembolization procedures. RESULTS: No radioembolization patient developed an abscess. In the cohort of chemoembolized patients who received the same prophylaxis, liver abscess occurred following 3 of 24 (12.5 %) procedures in 3 of 13 (23 %) patients, one fatal. CONCLUSIONS: This preliminary experience suggests that the risk of liver abscess among patients with prior biliary intervention may be lower following radioembolization than chemoembolization, which could potentially expand treatment options in this high-risk population.

Comparison of polyvinyl alcohol microspheres and tris-acryl gelatin microspheres for uterine fibroid embolization: results of a single-center randomized study.

PURPOSE: To assess the efficacy of two embolic agents in the treatment of symptomatic uterine leiomyomas. MATERIALS AND METHODS: A randomized, prospective, single-center study enrolled 60 women with symptomatic uterine leiomyomas. Uterine artery embolization (UAE) with spherical polyvinyl alcohol (SPVA) microspheres (n = 30; 700-900 µm and 900-1,200 µm; near-stasis or stasis endpoint) and tris-acryl gelatin (TAG) microspheres (n = 30; 500-700 µm; "pruned-tree" endpoint) was performed. Infarction rates were calculated for the dominant tumor and for small (< 2 cm) and large (> 2 cm) nondominant tumors. The primary endpoint was tumor infarction at 24 hours measured by contrast-enhanced magnetic resonance imaging assessed by a blinded reviewer. RESULTS: Baseline characteristics were similar between groups. The primary endpoint was similar in both treatments (≥ 91% dominant tumor infarction; SPVA. 86.2%; TAG, 93.3%, P = .35). Complete infarction (100%) was also similar between arms at 24 hours and 3 months. Symptom severity was reduced and quality of life improved equally at 3 and 12 months in each treatment group. Complications were minor in both groups. CONCLUSIONS: Uterine leiomyoma infarction at 24 hours and 3 months after treatment with SPVA or TAG microspheres was comparable when using near-stasis as a procedural endpoint with SPVA microspheres. Symptom relief was maintained for as long as 12 months for both embolic agents.

Should all inflow stenoses be treated in failing autogenous hemodialysis fistulae?

PURPOSE: To determine whether angioplasty of inflow stenosis in malfunctioning but patent autogenous hemodialysis fistulae has an impact on postintervention primary patency in patients without a clinical indicator of inflow-related access malfunction. MATERIALS AND METHODS: Medical records for 76 procedures in 62 patients with inflow stenoses undergoing fistulography in nonthrombosed mature autogenous fistulae without an inflow-related indication of access malfunction over a 5-year period were reviewed retrospectively. Control and treatment arms were defined as patients with untreated (26 procedures in 23 patients) and treated (50 procedures in 39 patients) inflow stenoses, respectively. All patients in both arms of the study had concurrent intrafistula and/or venous outflow stenosis, which were treated successfully with angioplasty. The clinical endpoint was defined as return for a failing or thrombosed access (ie, primary patency). A two-tailed unpaired Student t test was performed to compare primary patency and percent inflow stenosis in treatment (angioplasty) and control (untreated inflow stenoses) groups, with significance defined at P < .05. Kaplan-Meier analysis was performed. RESULTS: There was no significant difference in percent inflow stenosis between control and treatment arms (P = .95). There was no significant difference in access patency between the two groups (139 and 124 d for control and treated groups, respectively; P = .95). No procedural complications occurred in either arm of the study. CONCLUSIONS: Angioplasty of inflow stenosis in failing autogenous fistulae without an appropriate clinical indicator of an inflow pathologic process does not improve postintervention primary patency.

Diagnostic yield of transjugular liver biopsy samples to evaluate for infectious etiology of liver dysfunction in bone marrow transplant recipients.

PURPOSE: To determine the diagnostic yield of transjugular liver biopsy (TJLBx) samples to evaluate for infectious etiology (immunosuppressed protocol [ISP] of TJLBx) in bone marrow transplant (BMT) recipients. METHODS: A retrospective review of 78 TJLBx in 61 patients who had undergone BMT was undertaken. Biopsy was performed with an automated 19-gauge needle set. The primary indication was suspected graft-versus-host disease in all; a subset also sought to detect infectious liver pathology. In these (n = 31 biopsy samples, 22 patients), an ISP was used with tissue sent for bacterial, viral, fungal, and mycobacterial analysis in addition to histology. In the remainder (n = 47 biopsy samples, 41 patients), tissue was sent for histology only (H). Sample adequacy, histological diagnosis, microorganism assay results (ISP), and complications were reviewed. To assess sample adequacy in BMT compared to non-BMT patients, random control sample of 77 biopsy samples in 75 inpatients during the same period was reviewed (C). RESULTS: All but 1 TJLBx (C group) were technically successful (99%). One major (ISP) and 5 minor complications occurred (H = 3, ISP = 1, C = 1). There were 3 inadequate specimens (6.4%) in the H group, 4 in the ISP group (12.9%), and 4 in the C group (5.2%) (p = NS). No organisms were isolated in any ISP biopsy samples (yield 0%). CONCLUSION: When ISP is requested in BMT recipients, biopsy yields were lower, for unclear reasons possibly relating to degree of liver injury. ISP adds no useful positive information over histology alone. The value of negative cultures in this population is unclear.