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1.
Brachytherapy ; 20(3): 497-511, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33824051

RESUMO

PURPOSE: The American College of Radiology (ACR), American Brachytherapy Society (ABS), American College of Nuclear Medicine (ACNM), American Society for Radiation Oncology (ASTRO), Society of Interventional Radiology (SIR), and Society of Nuclear Medicine and Molecular Imaging (SNMMI) have jointly developed a practice parameter on selective internal radiation therapy (SIRT) or radioembolization for treatment of liver malignancies. Radioembolization is the embolization of the hepatic arterial supply of hepatic primary tumors or metastases with a microsphere yttrium-90 brachytherapy device. MATERIALS AND METHODS: The ACR -ABS -ACNM -ASTRO -SIR -SNMMI practice parameter for SIRT or radioembolization for treatment of liver malignancies was revised in accordance with the process described on the ACR website (https://www.acr.org/ClinicalResources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters-Interventional and Cardiovascular Radiology of the ACR Commission on Interventional and Cardiovascular, Committee on Practice Parameters and Technical Standards-Nuclear Medicine and Molecular Imaging of the ACR Commission on Nuclear Medicine and Molecular Imaging and the Committee on Practice Parameters-Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with ABS, ACNM, ASTRO, SIR, and SNMMI. RESULTS: This practice parameter is developed to serve as a tool in the appropriate application of radioembolization in the care of patients with conditions where indicated. It addresses clinical implementation of radioembolization including personnel qualifications, quality assurance standards, indications, and suggested documentation. CONCLUSIONS: This practice parameter is a tool to guide clinical use of radioembolization. It focuses on the best practices and principles to consider when using radioemboliozation effectively. The clinical benefit and medical necessity of the treatment should be tailored to each individual patient.


Assuntos
Braquiterapia , Neoplasias Hepáticas , Medicina Nuclear , Radioterapia (Especialidade) , Braquiterapia/métodos , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/radioterapia , Imagem Molecular , Radioisótopos de Ítrio/uso terapêutico
2.
Proc (Bayl Univ Med Cent) ; 33(2): 227-228, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32313466

RESUMO

As of October 2019, 1299 cases of "e-cigarette, or vaping, product use associated lung injury" (EVALI) have been reported in the USA, with 26 deaths. Multiple patterns of lung injury have been reported, including lipoid pneumonia, organizing pneumonia, and acute eosinophilic pneumonia, with radiographic findings including diffuse pulmonary infiltrates. We report a case of lipoid pneumonia secondary to EVALI. Physicians should be alert to recognizing these patterns of lung injury, as well as emphasizing to patients the importance of e-cigarette cessation.

3.
Proc (Bayl Univ Med Cent) ; 34(2): 286-288, 2020 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-33678965

RESUMO

The management of spontaneous hemoperitoneum centers on clinical suspicion, fluid resuscitation, appropriate early imaging, and therapeutic intervention. Traditionally, explorative laparotomy has been the treatment of choice for idiopathic spontaneous intraabdominal hemorrhage, but as less invasive percutaneous techniques have matured, superselective arterial embolization may play a critical role in emergent treatment. This case report describes a 65-year-old woman with large-volume hemoperitoneum. At angiography, a single pseudoaneurysm of the middle colic artery was identified and treated with superselective endovascular methods.

4.
Proc (Bayl Univ Med Cent) ; 34(1): 109-110, 2020 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-33456164

RESUMO

Giant cell arteritis (GCA) is a systemic vasculitis that classically affects large- and medium-sized vessels in the head and neck but can also manifest extracranially. We report the case of an elderly man who presented with sharp substernal pain, dizziness, and visual changes. He was initially hypotensive and anemic, and imaging showed hemoperitoneum with possible extravasation. Celiac and gastric angiography demonstrated findings consistent with vasculitis and focal extravasation from a left gastric branch. Subsequent embolization was performed. After the procedure, the patient informed the care team that he had biopsy-proven GCA. Extracranial, celiac/mesenteric arteriopathy is a less common manifestation of GCA, and few reported cases include hemoperitoneum or involvement of second-order branches.

5.
Ann Vasc Surg ; 45: 106-111, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28602899

RESUMO

BACKGROUND: The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) Trial cast doubt on the benefits of renal artery stenting (RAS). However, the outcomes for patients with chronic kidney disease (CKD) were not analyzed separately in the CORAL Trial. We hypothesized that patients who experienced a significant improvement in renal function after RAS would have improved long-term survival, compared with patients whose renal function was not improved by stenting. METHODS: This single-center retrospective study included 60 patients with stage 3 or worse CKD and renal artery occlusive disease who were treated with RAS for renal salvage. Patients were categorized as "responders" or "nonresponders" based on postoperative changes in estimated glomerular filtration rate (eGFR) after RAS. "Responders" were those patients with an improvement of at least 20% in eGFR over baseline; all others were categorized as "nonresponders." Survival was analyzed using the Kaplan-Meier method. Cox proportional hazards regression was used to identify predictors of long-term survival. RESULTS: The median age of the cohort was 66 years (interquartile range [IQR], 60-73). Median preoperative eGFR was 34 mL/min/1.73 m2 (IQR, 24-45). At late follow-up (median 35 months, IQR, 22-97 months), 16 of 60 patients (26.7%) were categorized as "responders" with a median increase in postoperative eGFR of 40% (IQR, 21-67). Long-term survival was superior for responders, compared with nonresponders (P = 0.046 by log-rank test). Cox proportional hazards regression identified improved renal function after RAS as the only significant predictor of increased long-term survival (hazard ratio = 0.235, 95% confidence interval = 0.075-0.733; P = 0.0126 for improved versus worsened renal function after RAS). CONCLUSIONS: Successful salvage of renal function by RAS is associated with improved long-term survival. These data provide an important counter argument to the prior negative clinical trials that found no benefit to RAS.


Assuntos
Procedimentos Endovasculares/instrumentação , Taxa de Filtração Glomerular , Rim/fisiopatologia , Obstrução da Artéria Renal/terapia , Insuficiência Renal Crônica/fisiopatologia , Stents , Idoso , Distribuição de Qui-Quadrado , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Recuperação de Função Fisiológica , Obstrução da Artéria Renal/diagnóstico por imagem , Obstrução da Artéria Renal/mortalidade , Obstrução da Artéria Renal/fisiopatologia , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/mortalidade , Estudos Retrospectivos , Fatores de Risco , Texas , Fatores de Tempo , Resultado do Tratamento
6.
World J Urol ; 35(10): 1549-1555, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28255621

RESUMO

PURPOSE: To report on the first short-term oncologic outcomes of percutaneous irreversible electroporation for small renal masses. METHODS: Patients with cT1a renal masses treated with irreversible electroporation from April 2013 through December 2016 were reviewed. Small, low complexity tumors were generally selected for irreversible electroporation using the NanoKnife® System (Angiodynamics, Latham, NY, USA). Surveillance imaging was performed post-operatively, and survival analysis was completed using the Kaplan-Meier method. RESULTS: A total of 42 tumors in 41 patients underwent irreversible electroporation. Mean tumor size was 2.0 cm with a median R.E.N.A.L nephrometry score of 5. Twenty-nine patients (71%) were discharged the same day of the procedure and no major (Clavien grade II or higher) intraoperative or post-operative complications occurred. Initial treatment success rate was 93%; our three failures (7%) underwent salvage radiofrequency ablation. With a mean follow-up of 22 months, 2-year local recurrence-free survival was 83% for patients with biopsy confirmed renal cell carcinoma, 87% with biopsy confirmed or a history of renal cell carcinoma, and 92% for the intent-to-treat cohort. CONCLUSIONS: Although with low morbidity, in comparison to extirpation and conventional thermal ablation technologies, irreversible electroporation has suboptimal short-term local disease control results in this series of small, low complexity tumors. Larger series and longer follow-up will determine the durability of this modality.


Assuntos
Carcinoma de Células Renais , Ablação por Cateter/métodos , Eletroquimioterapia , Neoplasias Renais , Complicações Pós-Operatórias/diagnóstico , Idoso , Biópsia/métodos , Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/terapia , Eletroquimioterapia/efeitos adversos , Eletroquimioterapia/métodos , Feminino , Humanos , Estimativa de Kaplan-Meier , Neoplasias Renais/patologia , Neoplasias Renais/terapia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Retratamento/métodos , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Carga Tumoral
7.
Vasc Endovascular Surg ; 50(6): 385-90, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27581228

RESUMO

PURPOSE: The purpose of the study is to evaluate the clinical safety and effectiveness of the Denali (Bard, Tempe, Arizona) retrievable inferior vena cava (IVC) filter. MATERIALS AND METHODS: In this retrospective study, authors reviewed the data of Denali IVC filters placed at their institution between 2013 and 2015. The clinical presentation, indications, and procedure-related complications during placement and retrieval were evaluated. The frequency of post filter pulmonary embolism (PE) and filter-related complications was assessed. RESULTS: Denali filters were placed in 87 patients (47 males; mean age: 56 years). Twenty patients presented with PE, 45 with deep vein thrombosis (DVT), and 21 with both PE and DVT, 1 filter was placed prophylactically before surgery. Indications for filter placement included contraindications to anticoagulation (AC; n = 80), failure of AC (n = 4), and complications of AC (n = 3). No patients had PE on follow-up imaging after filter placement. Retrieval was attempted in 31 patients after a mean period of 125 days (range: 34-324 days). The filter was successfully removed in 31 (100%) patients. Follow-up imaging, available in 71 (82%) patients (range: 2-538 days), demonstrated penetration of 15 legs in 5 patients, caval thrombus in 3, 1 resulting in caval occlusion, <15° filter tilt in 5, and no leg fractures or crossed legs. CONCLUSION: The Denali filter is safe during deployment and readily retrievable. The overall safety following deployment is similar to those reported in the literature, and the incidence of filter fractures and migration appears to be less than the previous generation of Bard devices.


Assuntos
Implantação de Prótese/instrumentação , Embolia Pulmonar/prevenção & controle , Filtros de Veia Cava , Veia Cava Inferior , Trombose Venosa/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia por Tomografia Computadorizada , Remoção de Dispositivo , Feminino , Migração de Corpo Estranho/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Flebografia/métodos , Desenho de Prótese , Falha de Prótese , Implantação de Prótese/efeitos adversos , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/etiologia , Estudos Retrospectivos , Fatores de Risco , Texas , Fatores de Tempo , Resultado do Tratamento , Veia Cava Inferior/diagnóstico por imagem , Trombose Venosa/complicações , Trombose Venosa/diagnóstico por imagem , Adulto Jovem
8.
J Vasc Interv Radiol ; 26(10): 1465-71, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26250855

RESUMO

PURPOSE: To evaluate whether irreversible electroporation (IRE) can be used as an ablation technique for small renal tumors (T1a cancers or small benign tumors) and to describe features after ablation on computed tomography (CT) or magnetic resonance (MR) imaging. MATERIALS AND METHODS: In this retrospective study, 20 patients (mean age, 65 y ± 12.8 y) underwent CT-guided IRE of T1a renal carcinoma (n = 13) or small benign or indeterminate renal masses < 4 cm in size (n = 7). Mean tumor size was 2.2 cm ± 0.7. The ablation area was verified with contrast-enhanced imaging performed immediately after the procedure to determine technical success. Imaging was performed 6 weeks (20 of 20 patients), 6 months (15 of 20), and 12 months (6 of 20) after ablation. Medical records and CT/MR imaging features of all patients were reviewed for recurrence, symptoms, and complications after treatment. RESULTS: Technical success was achieved in all patients (100%); there were no major procedure-related complications. Minor complications occurred in 7 patients, including self-limiting perinephric hematomas, pain difficult to control, and urinary retention. Mean procedure time was 2.0 hours ± 0.7. At 6 weeks, 2 patients required salvage therapy because of incomplete ablation. At 6 months, all 15 patients with imaging studies available had no evidence of recurrence. At 1 year, 1 patient (1 of 6) was noted to have experienced recurrence. CT/MR imaging after IRE ablation demonstrated an area of nonenhancement in the treatment zone that involuted over ~6 months. CONCLUSIONS: Renal IRE appears to be a safe treatment for small renal tumors. Tumors treated with IRE demonstrated nonenhancement in the treatment zone with involution on follow-up CT/MR imaging.


Assuntos
Carcinoma de Células Renais/cirurgia , Ablação por Cateter/métodos , Eletroquimioterapia/métodos , Neoplasias Renais/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Cirurgia Assistida por Computador/métodos , Idoso , Carcinoma de Células Renais/diagnóstico por imagem , Ablação por Cateter/instrumentação , Eletroquimioterapia/instrumentação , Feminino , Humanos , Neoplasias Renais/diagnóstico por imagem , Masculino , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
9.
J Urol ; 194(3): 653-7, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25846416

RESUMO

PURPOSE: Current radio frequency ablation series do not distinguish renal cell carcinoma subtypes when reporting oncologic efficacy. Papillary neoplasms may be more amenable to radio frequency ablation than clear cell carcinoma because they are less vascular, which may limit heat energy loss. We report the long-term outcomes of patients treated with radio frequency ablation for small renal masses by renal cell carcinoma subtype. MATERIALS AND METHODS: The records of patients undergoing radio frequency ablation for small renal masses (cT1a) at 2 institutions from March 2007 to July 2012 were retrospectively reviewed. Patients were included in analysis if they had biopsy confirmed clear cell or papillary renal cell carcinoma histology. Patients had at least 1 contrast enhanced cross-sectional image following radio frequency ablation. Demographic data between tumor subtypes were compared using the paired t-test. Oncologic outcomes were determined by Kaplan-Meier survival analysis and survivor curves were compared with the log rank test. RESULTS: A total of 229 patients met study inclusion criteria. There were 181 clear cell tumors and 48 papillary tumors. Median followup was 33.2 months. There was no difference between tumor groups based on patient age, tumor size or grade, or months of followup. Five-year disease-free survival was 89.7% for clear cell tumors and 100% for papillary tumors (p = 0.041). There was no significant difference in overall survival (88.4% vs 89.6%, p = 0.764). CONCLUSIONS: Radio frequency ablation outcomes seem to be determined in part by renal cell carcinoma subtype with clear cell renal tumors having less favorable outcomes. We hypothesize that this is due to differences in tumor vascularity. Our experience suggests that future tumor ablation studies should consider reporting outcomes based on tumor cell types.


Assuntos
Carcinoma de Células Renais/cirurgia , Ablação por Cateter , Neoplasias Renais/cirurgia , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Carga Tumoral
10.
J Reprod Med ; 60(1-2): 90-2, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25745760

RESUMO

BACKGROUND: Postoperative bleeding is a known complication after laparoscopic supracervical hysterectomy (LASH), and trachelectomy is the traditional management of significant bleeding. CASE: We present the case of a patient with significant postoperative bleeding 1 month after LASH, resulting in symptomatic anemia requiring blood transfusion. Gelfoam embolization of the bilateral cervical arteries was successful in stopping the bleeding. The patient had no further bleeding and had resolution of anemia at 6 months postprocedure. CONCLUSION: Our case demonstrates a successful multidisciplinary and minimally invasive approach to management of postoperative bleeding with bilateral cervical artery embolization and should be considered as a potential treatment option.


Assuntos
Colo do Útero , Histerectomia/efeitos adversos , Hemorragia Pós-Operatória/cirurgia , Embolização da Artéria Uterina/métodos , Artéria Uterina/cirurgia , Adulto , Colo do Útero/irrigação sanguínea , Colo do Útero/cirurgia , Feminino , Humanos
11.
Urology ; 85(1): 125-9, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25440815

RESUMO

OBJECTIVE: To assess the predictive performance of a modified RENAL nephrometry score for renal tumors undergoing radiofrequency ablation (RFA). METHODS: Patients who underwent RFA were identified from 2002 to 2011, and RENAL nephrometry scoring was performed for each. A modified RENAL (m-RENAL) nephrometry score was created to account for the small sizes of tumors ablated for which the size variable, R, was adjusted. A size of 3 cm was calculated as the optimal cutoff for the R component of the m-RENAL nephrometry score, and tumors were given an R score of 1 if <3 cm, 2 if 3-4 cm, or 3 if >4 cm. Other RENAL variables were unchanged. Oncologic outcomes were stratified by complexity tertiles defined as low (4-6), medium (7-9), and high (10-12). Outcomes were reported as initial ablation success (IAS), recurrence-free survival (RFS), and metastatic-free survival (MFS). The Kaplan-Meir method was used to estimate survival based on complexity tertile. RESULTS: Two hundred forty patients were identified who underwent RFA, of which 192 patients were eligible for analysis. Median follow-up was 32.2 months, and median tumor size was 2.4 cm. IAS was achieved in 185 of 192 patients (96.4%). Overall, the estimated 3-year RFS was 95.1% and MFS was 97.3%. There was no statistical difference between complexity tertiles using the standard RENAL nephrometry score; however, the m-RENAL nephrometry score was significantly associated with IAS and RFS (P = .027 and P = .003, respectively). There were too few events (n = 3) to perform statistical analysis for MFS. CONCLUSION: A modification to the size variable increases the performance of the RENAL nephrometry score when used to stratify RFA ablation success.


Assuntos
Ablação por Cateter , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Idoso , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Resultado do Tratamento , Carga Tumoral
12.
Ann Surg Oncol ; 21(4): 1287-95, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24318095

RESUMO

PURPOSE: To evaluate differences in overall survival in patients with hepatocellular carcinoma (HCC) after the establishment of a multidisciplinary clinic (MDC) for HCC. METHODS: Patient demographic and tumor characteristics of 355 patients diagnosed with HCC were collected between October 2006 and September 2011. Patients diagnosed after the initiation of the HCC MDC on October 1, 2010, were compared to patients diagnosed in the 4 years before. Patient demographics, tumor characteristics, treatment regimens, and overall survival were analyzed between the groups. RESULTS: A total of 105 patients were diagnosed in the time period after HCC MDC initiation compared to 250 patients in the previous 4 years. Patients diagnosed with HCC after the HCC MDC had fewer symptoms at presentation (64 vs. 78 %, p = 0.01) and earlier stage of tumor presentation [Barcelona Clinic for Liver Cancer (BCLC) A stage, 44 vs. 26 %, p = 0.0003; tumor, node, metastasis classification system stage 1, 44 vs. 30 %, p = 0.003) compared with patients diagnosed before MDC formation. The median time to treatment after diagnosis in the later period was significantly shorter than in the earlier time period (2.3 vs. 5.3 months, p = 0.002). On multivariate analysis, being seen in the HCC MDC remained independently associated with better overall survival (hazard ratio 2.5, 95 % confidence interval 2-3), after adjusting for BCLC stage and recipient of curative treatment. Patients diagnosed after HCC MDC initiation had a median survival of 13.2 months compared to the 4.8 months observed in patients diagnosed before MDC formation (p = 0.005). CONCLUSIONS: The implementation of a MDC for the evaluation and treatment of patients with HCC is associated with improved overall survival.


Assuntos
Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/terapia , Comunicação Interdisciplinar , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/terapia , Avaliação de Resultados em Cuidados de Saúde , Carcinoma Hepatocelular/patologia , Terapia Combinada , Feminino , Seguimentos , Humanos , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Prospectivos , Taxa de Sobrevida
13.
J Endourol ; 27(12): 1516-9, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24199730

RESUMO

PURPOSE: To report one of the largest series of clinical and renal function outcomes of treated iatrogenic vascular lesions (IVL) after partial nephrectomy (PN). Angioembolization (AE) is the treatment of choice for patients with these lesions, but the additional renal injury conferred by this treatment has not been well described. PATIENTS AND METHODS: Patients who underwent open, laparoscopic, or robot-assisted PN from 2002 to 2012 were identified and those with AE were selected. Patients' charts were reviewed, and renal function was analyzed using estimated glomerular filtration rate (eGFR) and progression of chronic kidney disease (CKD) classification before and after PN and AE. RESULTS: There were 849 patients who underwent PN and an IVL developed in 28 (3.3%). Twenty (71%) presented with gross hematuria at a mean of 10.2 ± 7.7 days after PN and 8 (28%) needed transfusion. All patients had identifiable IVL at the time of selective AE, and technical success was achieved in 24/28 (86%), although 4 needed subsequent additional AE. The paired decrease in eGFR after PN was significant (P<0.01), while the paired change in eGFR after AE was not with either short-term (2.8 days) or intermediate-term (362 days) follow-up (P=0.50). Four patients experienced transient worsening in CKD classification after AE, although three experienced CKD stage improvement. CONCLUSION: Selective AE for IVL after PN is safe, efficacious, and does not lead to a significant impairment of renal function. It remains the preferred approach for the evaluation and management of post-PN hemorrhage.


Assuntos
Embolização Terapêutica/métodos , Neoplasias Renais/cirurgia , Rim/fisiopatologia , Laparoscopia/efeitos adversos , Nefrectomia/efeitos adversos , Hemorragia Pós-Operatória/terapia , Adulto , Idoso , Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/fisiopatologia , Carcinoma de Células Renais/cirurgia , Progressão da Doença , Feminino , Taxa de Filtração Glomerular , Humanos , Doença Iatrogênica , Rim/irrigação sanguínea , Neoplasias Renais/fisiopatologia , Masculino , Pessoa de Meia-Idade , Nefrectomia/métodos , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/fisiopatologia , Artéria Renal/lesões , Resultado do Tratamento
14.
J Vasc Interv Radiol ; 23(4): 479-87, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22464712

RESUMO

PURPOSE: To review technical and 180-day clinical outcomes when stent grafts were used to treat dysfunctional arteriovenous (AV) hemodialysis access circuits. MATERIALS AND METHODS: The FLUENCY Plus Stent Graft (Bard Peripheral Vascular, Tempe, Arizona) was used to salvage percutaneous transluminal angioplasty (PTA) technical failures and complications in AV access circuits over 2 years. There were 106 patients treated with 138 stent grafts. Indications for stent graft use included residual stenosis after PTA (n = 81), extravasation after PTA (n = 22), early recurrent stenosis (n = 14), pseudoaneurysms (n = 4), and "other" (n = 4). Data were retrospectively analyzed for complications and outcomes. RESULTS: Technical success was achieved in all patients, and clinical success was achieved in 104 (98%) of 106 patients. At 180 days, postintervention primary patency (PIPP) was 47%, and postintervention secondary patency (PISP) was 79%. PIPP was 62% for autogenous fistulas (AVFs) and 35% for prosthetic grafts (AVGs) (P = .010). The 180-day PIPP for stent grafts 9-10 mm in diameter was 63% versus 38% for stent grafts 6-8 mm in diameter (P = .012). Implants that did not cross the elbow had a 180-day PIPP of 47% compared with 25% for implants across the elbow (P = .032). Technical complications were periprocedure AVG thromboses (n = 2), intraprocedural stent graft dislodgment (n = 1), venospasm (n = 2), and contrast agent-related hives (n = 1). One patient returned at 2 months with an infected AVG and stent graft in the outflow vein. CONCLUSIONS: The FLUENCY Plus Stent Graft was effective for maintenance of hemodialysis access circuit patency and was comparable or better than historical outcomes for PTA and bare stents. Factors that favored improved patency included larger diameter devices, use in AVFs, and avoiding placement across the elbow joint.


Assuntos
Angioplastia/estatística & dados numéricos , Prótese Vascular/estatística & dados numéricos , Cateteres de Demora/estatística & dados numéricos , Rejeição de Enxerto/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Diálise Renal/estatística & dados numéricos , Stents/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Análise de Falha de Equipamento , Feminino , Sobrevivência de Enxerto , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Terapia de Salvação , Resultado do Tratamento , Estados Unidos/epidemiologia
15.
J Urol ; 187(4): 1183-9, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22335865

RESUMO

PURPOSE: Renal tumor size influences the efficacy of radio frequency ablation but identification of confident size cutoffs has been limited by small numbers and short followup. We evaluated tumor size related outcomes after radio frequency ablation for patients with adequate (greater than 3 years) followup. MATERIALS AND METHODS: We identified 159 tumors treated with radio frequency ablation as primary treatment. Disease-free survival was defined as the time from definitive treatment to local recurrence, detection of metastasis or the most recent imaging showing no evidence of disease. Patients were evaluated with contrast enhancing imaging preoperatively, and at 6 weeks, 6 months and at least annually thereafter. RESULTS: Median tumor size was 2.4 cm (range 0.9 to 5.4) with a median followup of 54 months (range 1.5 to 120). Renal cell carcinoma was confirmed in 72% of the 150 tumors that had pre-ablation biopsy (94%). The 3 and 5-year disease-free survival was comparable at 92% and 91% overall, and was dependent on tumor size, being 96% and 95% for tumors smaller than 3.0 cm and 79% and 79%, respectively, for tumors 3 cm or larger (p=0.001). Most failures (14 of 18) were local, either incomplete ablations or local recurrences. This is an intent to treat analysis and, therefore, includes patients ultimately found to have benign tumors, although outcomes were comparable in patients with cancer. CONCLUSIONS: Radio frequency ablation treatment success of the small renal mass is strongly correlated with tumor size. Radio frequency ablation provides excellent and durable outcomes, particularly in tumors smaller than 3 cm. Of tumors 3 cm or larger, approximately 20% will recur such that alternative treatment techniques should be considered. However, most treatment failures are local and are often successfully treated with another ablation session.


Assuntos
Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/cirurgia , Ablação por Cateter , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Carga Tumoral , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
16.
Urology ; 79(4): 827-30, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22309782

RESUMO

OBJECTIVE: To review our 10-year experience with radiofrequency ablation, focusing on the outcomes for the incidental benign renal tumor. Tumor ablation is an alternative minimally invasive approach for the treatment of small renal masses (SRMs), with published series appropriately emphasizing the outcomes for the renal cell carcinoma subset of treated tumors. However, just as with partial nephrectomy, approximately 20% of SRMs are benign. The intermediate- to long-term outcome of the incidentally ablated benign tumor and its appropriate follow-up protocol is unknown. METHODS: All SRMs treated with temperature-based radiofrequency ablation from 2001 to 2011 were reviewed. Of a total of 280 enhancing SRMs biopsied at radiofrequency ablation, 47 were confirmed as benign tumors. Ablation success was defined as the lack of enhancement on the initial postablation axial imaging. Recurrence was defined as tumor growth and enhancement on follow-up axial imaging. RESULTS: Of the 47 benign tumors, 32 were treated percutaneously and 15 laparoscopically. The histologic biopsy finding was angiomyolipoma in 10 and oncocytoma in 37. The median tumor size was 2 cm (range 1-3.6), and the mean follow-up was 45 months. No recurrences developed, and all lesions required only 1 treatment session. The median pre- and postoperative glomerular filtration rate was 77 mL/min/1.73 m(2) (range 39-137) and 68 mL/min/1.73 m(2) (range 36-137). The present study was limited by its retrospective nature and small sample population. CONCLUSION: Radiofrequency ablation of SRMs <3.5 cm found to be benign on concurrent biopsy can be efficaciously treated with a single treatment session. Long-term follow-up imaging might not be required if successful ablation is determined at the initial post-treatment cross-sectional imaging study.


Assuntos
Adenoma Oxífilo/cirurgia , Angiomiolipoma/cirurgia , Neoplasias Renais/cirurgia , Adenoma Oxífilo/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiomiolipoma/fisiopatologia , Biópsia por Agulha , Ablação por Cateter , Feminino , Taxa de Filtração Glomerular , Humanos , Neoplasias Renais/patologia , Neoplasias Renais/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
17.
Eur Urol ; 61(6): 1156-61, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22257424

RESUMO

BACKGROUND: Long-term comparative outcomes for radiofrequency ablation (RFA) versus partial nephrectomy (PN) for the primary treatment of clinical T1a renal cell carcinoma (RCC) have not previously been reported. OBJECTIVE: Report comparative 5-yr oncologic outcomes for RFA versus PN in patients with clinical T1a RCC. DESIGN, SETTING, AND PARTICIPANTS: Observational single-institution cohort study, involving consecutive patients with a solitary histologically confirmed T1a RCC treated by RFA or PN and followed for a minimum of 5 yr. Those presenting with synchronous multiple, metachronous, bilateral, and/or metastatic disease, a history of hereditary RCC syndromes, a family history of RCC, and with post-treatment follow-up <5 yr were excluded from analysis. MEASUREMENTS: The Kaplan-Meier method was used to determine 5-yr overall survival (OS), cancer-specific survival (CSS), local recurrence-free survival (local RFS), overall disease-free survival (DFS), and metastasis-free survival (MFS) for RFA versus PN. Survival curves were compared using the log-rank test. A p value ≤ 0.05 was considered statistically significant. RESULTS AND LIMITATIONS: A total of 37 patients in each group met the selection criteria. The RFA cohort was significantly older and had more advanced comorbidities, but other patient characteristics were similar. For RFA versus PN, median follow-up was 6.5 yr (interquartile range [IQR]: 5.8-7.1) versus 6.1 yr (IQR: 5.4-7.3) (p = 0.68), respectively. The 5-yr OS was 97.2% versus 100% (p = 0.31), CSS was 97.2% versus 100% (p = 0.31), DFS was 89.2% versus 89.2% (p = 0.78), local RFS was 91.7% versus 94.6% (p = 0.96), and MFS was 97.2% versus 91.8% (p = 0.35), respectively. Study limitations are retrospective data analysis, loss to follow-up, limited statistical power, and limited generalizability of our data. CONCLUSIONS: In appropriately selected patients, RFA is an effective minimally invasive therapy for the treatment of cT1a RCC, yielding comparable long-term oncologic outcomes to nephron-sparing surgery.


Assuntos
Carcinoma de Células Renais/cirurgia , Ablação por Cateter , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Idoso , Biópsia , Carcinoma de Células Renais/mortalidade , Carcinoma de Células Renais/secundário , Ablação por Cateter/efeitos adversos , Ablação por Cateter/mortalidade , Distribuição de Qui-Quadrado , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Neoplasias Renais/mortalidade , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Gradação de Tumores , Recidiva Local de Neoplasia , Nefrectomia/efeitos adversos , Nefrectomia/mortalidade , Seleção de Pacientes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Texas , Fatores de Tempo , Resultado do Tratamento
18.
J Vasc Surg ; 55(3): 774-80; discussion 780, 2012 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22264697

RESUMO

OBJECTIVE: This study assessed the longitudinal changes in renal volume after renal artery stenting (RAS) to determine if renal mass is preserved by stenting. METHODS: The study cohort consisted of 38 patients with longitudinal imaging available for renal volume quantification before and after RAS. Renal volume was estimated as (kidney length) × (width) × (depth/2) based on preoperative renal imaging. For each patient, the clinical response of blood pressure (BP) and renal function to RAS was categorized according to modified American Heart Association guidelines. Changes in renal volume were assessed using paired nonparametric analyses. RESULTS: The cohort was a median age of 69 years (interquartile range [IQR], 60-74 years). A favorable BP response was observed in 11 of 38 patients (28.9%). At a median interval between imaging studies of 21 months (IQR, 13-32 months), ipsilateral renal volume was significantly increased from baseline (146.8 vs 133.8 cm(3);P = .02). This represents a 6.9% relative increase in ipsilateral kidney volume from baseline. A significant negative correlation between preoperative renal volume and the relative change in renal volume postoperatively (r = -0.42; P = .0055) suggests that smaller kidneys experienced the greatest gains in renal volume after stenting. It is noteworthy that the 25 patients with no change in BP or renal function-clinical failures using traditional definitions-experienced a 12% relative increase in ipsilateral renal volume after RAS. Multivariate analysis determined that stable or improved renal volume after stenting was an independent predictor of stable or improved long-term renal function (odds ratio, 0.008; 95% confidence interval, 0.000-0.206; P = .004). CONCLUSIONS: These data lend credence to the belief that RAS preserves renal mass in some patients. This benefit of RAS even extends to those patients who would be considered treatment failures by traditional definitions. Patients with stable or increased renal volume after RAS had more stable renal function during long-term follow-up, whereas patients with renal volume loss after stenting were prone to deterioration of renal function.


Assuntos
Angioplastia com Balão/instrumentação , Rim/irrigação sanguínea , Rim/patologia , Obstrução da Artéria Renal/terapia , Stents , Idoso , Angioplastia com Balão/efeitos adversos , Biomarcadores/sangue , Distribuição de Qui-Quadrado , Creatinina/sangue , Feminino , Taxa de Filtração Glomerular , Humanos , Estimativa de Kaplan-Meier , Rim/diagnóstico por imagem , Rim/fisiopatologia , Modelos Logísticos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Tamanho do Órgão , Valor Preditivo dos Testes , Obstrução da Artéria Renal/diagnóstico , Terapia de Substituição Renal , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Texas , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento
19.
J Vasc Surg ; 55(2): 413-9; discussion 419-20, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22133456

RESUMO

OBJECTIVE: The goal of the study was to determine the blood pressure (BP) response to renal artery stenting (RAS) for patients with hypertension urgency, hypertension emergency, and angina with congestive heart failure (angina/congestive heart failure [CHF]). METHODS: Patients who underwent RAS for hypertension emergencies (n = 13), hypertension urgencies (n = 25), and angina/CHF (n = 14) were included in the analysis. By convention, hypertension urgency was defined by a sustained systolic BP ≥ 180 mm Hg or diastolic BP ≥ 120 mm Hg, while the definition of hypertension emergency required the same BP parameters plus hypertension-related symptoms prompting hospitalization. Patient-specific response to RAS was defined according to modified American Heart Association reporting guidelines. RESULTS: The study cohort of 52 patients had a median age of 66 years (interquartile range 58-72). The BP response to RAS varied significantly according to the indication for RAS. Hypertension emergency provided the highest BP response rate (85%), while the response rate was significantly lower for hypertension urgency (52%) and angina/CHF (7%; P = .03). Only 1 of 14 patients with angina/CHF was a BP responder. Multivariate analysis showed that hypertension urgency or emergency were not independent predictors of BP response to RAS. Instead, the only independent predictor of a favorable BP response was the number of preoperative antihypertensive medications (odds ratio 7.5; 95% confidence interval 2.5-22.9; P = .0004), which is another indicator of the severity of hypertension. Angina/CHF was an independent predictor of failure to respond to RAS (odds ratio 118.6; 95% confidence interval 2.8-999.9; P = .013). CONCLUSIONS: Hypertension urgency and emergency are clinical manifestations of severe hypertension, but the number of preoperative antihypertensive medications proved to be a better predictor of a favorable BP response to RAS. In contrast, angina/CHF was a predictor of failure to respond to stenting, providing further evidence against the practice of incidental stenting during coronary interventions.


Assuntos
Angioplastia com Balão/instrumentação , Pressão Sanguínea , Hipertensão Renovascular/terapia , Hipertensão/terapia , Stents , Idoso , Angina Pectoris/etiologia , Angina Pectoris/terapia , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/mortalidade , Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Distribuição de Qui-Quadrado , Emergências , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Humanos , Hipertensão/complicações , Hipertensão/diagnóstico , Hipertensão/mortalidade , Hipertensão/fisiopatologia , Hipertensão Renovascular/complicações , Hipertensão Renovascular/diagnóstico , Hipertensão Renovascular/mortalidade , Hipertensão Renovascular/fisiopatologia , Estimativa de Kaplan-Meier , Modelos Logísticos , Pessoa de Meia-Idade , Razão de Chances , Seleção de Pacientes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Texas/epidemiologia , Fatores de Tempo , Resultado do Tratamento
20.
AJR Am J Roentgenol ; 197(3): W519-24, 2011 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-21862782

RESUMO

OBJECTIVE: The development of collateral pathways for arterial blood flow is common in the presence of atherosclerotic occlusive disease of the abdominal aorta and iliac arteries. The collateral pathways are divided into systemic-systemic and systemic-visceral pathways. MDCT is commonly used to evaluate aortic stenosis and the resulting collateral pathways. CONCLUSION: Common and rare arterial collateral pathways are reviewed by 3D volume-rendered CT images. Visceral and lower extremity arterial embryology is reviewed.


Assuntos
Angiografia/métodos , Aorta Abdominal/diagnóstico por imagem , Doenças da Aorta/diagnóstico por imagem , Arteriopatias Oclusivas/diagnóstico por imagem , Aterosclerose/diagnóstico por imagem , Circulação Colateral , Artéria Ilíaca/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Humanos , Interpretação de Imagem Radiográfica Assistida por Computador
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