Heparin-bonded stent graft placement for treatment of massive epistaxis from ruptured radiation-induced internal carotid artery pseudoaneurysm: A case report.

Rupture of an internal carotid artery (ICA) pseudoaneurysm is a rare but life-threatening complication of irradiation therapy for a nasopharyngeal carcinoma (NPC). A 36-year-old man had a history of NPC treated with radiotherapy 8 years previously. He was admitted to the hospital because of severe repetitive epistaxis with hemodynamically instablility. An emergent angiography showed the left ICA pseudoaneurysm at the petrous portion (C2 segment). The patient was successfully treated by a new-generation heparin-bonded stent graft without any complication. Emergent stent graft placement is effective in stopping hemorrhage and is therefore a life-saving intervention. Long-term follow-up is necessary to look out for delayed post-treatment complications.

Effectiveness of Contrast-enhanced MR Angiography for Visualization of the Prostatic Artery prior to Prostatic Arterial Embolization.

Background A major technical challenge of prostatic arterial embolization (PAE) is the identification and catheterization of the prostatic arteries (PAs). Recently, MR angiography has been shown to help visualize PAs, but the clinical utility of MR angiography for this purpose is not known. Purpose To determine the efficacy of contrast material-enhanced MR angiography in identifying the PA and to evaluate its role in PAE for benign prostatic hyperplasia (BPH). Materials and Methods In this prospective study, 100 consecutive men who were scheduled to undergo PAE for BPH from January 2015 to May 2017 were assigned by using a randomized block design to either group A (n = 50; mean age, 71.7 years ± 11.9 [standard deviation]) without MR angiography or group B (n = 50; mean age, 72.3 years ± 12.2) with MR angiography prior to PAE. MR angiography findings of the PA anatomy were compared with those of digital subtraction angiography (DSA). The Student t test and Wilcoxon rank-sum test were used to compare the differences between the parameters indicating the performance of PAE. Results The mean age of the 100 men in the study was 72.0 years ± 11.8 (range, 51-88 years). Compared with DSA as the reference standard, MR angiography identified PAs with a sensitivity of 91.5% (97 of 106) and a positive predictive value of 100% (97 of 97). With the knowledge of tube obliquity and anatomy, group B had lower procedure times than group A (82.3 minutes ± 5.4 vs 123.9 minutes ± 12.4, P < .001) and shorter fluoroscopy times (13.8 minutes ± 2.7 vs 28.5 minutes ± 8.0, P < .001). Additionally, radiation dose was reduced for group A versus group B, from a median of 920 to 339 mGy (P = .004). Conclusion Contrast-enhanced MR angiography can accurately show anatomy for the prostate arteries, leading to shorter prostatic artery embolization times and lower radiation dose than when preprocedural prostate MR angiography is not performed. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Prince in this issue.

Comparison of Clinical Outcomes of Prostatic Artery Embolization with 50-µm Plus 100-µm Polyvinyl Alcohol (PVA) Particles versus 100-µm PVA Particles Alone: A Prospective Randomized Trial.

PURPOSE: To evaluate the safety and efficacy of prostatic artery embolization (PAE) using the combination of 50-µm and 100-µm polyvinyl alcohol (PVA) particles versus 100-µm PVA particles alone in the treatment of patients with symptomatic benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Over a 5-year period, 120 patients treated with PAE for lower urinary tract symptoms (LUTS) secondary to BPH were randomized to undergo embolization with 50-µm plus 100-µm PVA particles (group A) or 100-µm PVA particles alone (group B). Mean follow-up time was 34 months (range, 12-57 mo). There were no differences between groups regarding baseline data. Primary outcome measurements included change in International Prostate Symptom Score (IPSS) and incidence of adverse events. Secondary outcome measurements included procedure-associated pain, prostate ischemia measured on magnetic resonance (MR) imaging 1 week after PAE, and changes over time in quality of life (QOL) questionnaire, peak urinary flow rate (Qmax), postvoid residual (PVR) volume, prostate volume (PV), prostate-specific antigen (PSA) level, and International Index of Erectile Function (IIEF) were evaluated. Recurrence of LUTS following PAE was defined as relief of LUTS temporally but increased IPSS ≥ 8 or QOL score ≥ 3 or decrease in Qmax to < 7 mL/s. RESULTS: Mean follow-up periods were 35 months ± 22 in group A and 33 months ± 25 in group B (P = .629). No differences between groups regarding procedural details, pain scores, or adverse events were noted (P > .05). At 24 month of follow-up, patients in group A had a greater decrease in mean IPSS (18.7 ± 12.5 vs 14.8 ± 13.5), QOL score (3.7 ± 1.5 vs 2.4 ± 1.8), Qmax (10.5 mL ± 9.5 vs 6.8 mL ± 5.0), PVR (92.0 mL ± 75.0 vs 60.0 mL ± 55.0), and PV (37.0 mL ± 19.5 vs 25.5 mL ± 15.0) compared with patients in group B (P < .05 for all). Mean ratios of prostate ischemic volume at 1 week after PAE were 70% ± 20 in group A and 41% ± 25 in group B (P = .021); mean PSA levels at 24 hour after PAE were 92.5 ng/mL ± 55.0 in group A and 77.5 ng/mL ± 45.0 in group B (P = .031); LUTS recurrence rates were 3.6% in group A and 14.6% in group B (P = .024). The mean IIEF-5 was not significantly different from baseline in either group. CONCLUSIONS: PAE with 50-µm plus 100-µm PVA particles resulted in greater improvement in clinical and imaging outcomes and no significant differences in adverse events compared with 100-µm PVA particles alone.

Combined transcatheter arterial chemoembolization and radiofrequency ablation in single-session for solitary hepatocellular carcinoma larger than 7 cm.

AIMS: To evaluate technical feasibility and treatment results of combined transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) in single-session for solitary hepatocellular carcinoma (HCC) larger than 7 cm in diameter. METHODS: Institutional review board approved this retrospective study. Written informed consent was obtained from all patients. Between June 2007 and July 2013, 87 patients (75 men, 12 women; mean age, 55.5 years ± 15.0) with solitary HCC with a mean maximum diameter of 9.5 cm ± 2.4 (range, 7.1-13.5 cm) not feasible for surgical resection underwent combined TACE and RFA in a single-session. Immediately following TACE, RFA was performed under fluoroscopy and CB-CT guidance. The primary endpoint was overall survival (OS). The secondary endpoints were technical safety and local tumor progression (LTP) rates. OS and time to progression (TTP) were analyzed with the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify prognostic factors affecting OS and TTP. RESULTS: Technical success of combined TACE and RFA in a single-session was achieved in all patients (100%). On 1-month follow-up MRI, complete response (CR) was observed in 76 of 87 patients (87.4 %), partial response (PR) in 8 and stable disease (SD) in 3 patients. The median follow-up period was 49.5 months (interquartile range, 30.0-70.0 months). The median OS was 39 months (range, 15-86 months). The cumulative OS rates at 1, 3 and 5 years were 100%, 65.5% and 47.5%, respectively. The estimated 1, 3 and 5 year LTP rates were 0 %, 29.9% and 55.2 %, respectively. Univariate and multivariate analyses showed a tumor larger than 10.0 cm (P < 0.05) and presence of portal vein branch invasion (P < 0.05) led to the worst prognosis. No major complications were noted. CONCLUSIONS: Combined use of TACE and RFA in single-session is a safe and effective option in the treatment of patients with solitary large HCC (> 7 cm) not amenable to surgery.

Transarterial Embolization for Treatment of Symptomatic Polycystic Liver Disease: More than 2-year Follow-up.

BACKGROUND: Currently, treatment of symptomatic polycystic liver disease (PLD) is still a challenging problem, especially for these patients who are not feasible for surgery. Minimally invasive options such as laparoscopic fenestration and percutaneous cyst aspiration with sclerotherapy demonstrated disappointing results due to multiple lesions. Because the cysts in PLD are mostly supplied from hepatic arteries but not from portal veins, transcatheter arterial embolization (TAE) of the hepatic artery branches that supply the major hepatic cysts can lead to shrinkage of the cyst and liver size, relieve symptoms, and improve nutritional status. This study aimed to evaluate the effectiveness of TAE with a mixture of N-butyl-2-cyanoacrylate (NBCA) and iodized oil for patients with severe symptomatic PLD during a more than 2-year follow-up. METHODS: Institutional review board had approved this study. Written informed consent was obtained from all patients. From February 2007 to December 2014, twenty-three patients (20 women and 3 men; mean age, 49.0 ± 14.5 years) infeasible for surgical treatments underwent TAE. Changes in the abdominal circumferences, volumes of intrahepatic cysts, hepatic parenchyma volume, and whole liver, clinical symptoms, laboratory data, and complications were evaluated after TAE. RESULTS: Technical success was achieved in all cases. No procedure-related major complications occurred. The median follow-up period after TAE was 48.5 months (interquartile range, 30.0-72.0 months). PLD-related severe symptoms were improved remarkably in 86% of the treated patients; TAE failed to benefit in four patients (four patients did not benefit from TAE). The mean maximum abdominal circumference decreased significantly from 106.0 ± 8.0 cm to 87.0 ± 15.0 cm (P = 0.021). The mean intrahepatic cystic volume reduction rates compared with pre-TAE were 36% at 12 months, 37% at 24 months, and 38% at 36 months after TAE (P < 0.05). The mean liver volume reduction rates were 32% at 12 months, 31% at 24 months, and 33% at 36 months (P < 0.05). CONCLUSIONS: TAE with the mixture of NBCA and iodized oil appears to be a safe and effective treatment method for patients with symptomatic PLD, especially for those who are not good candidates for surgical treatments, to improve both hepatic volume and hepatic cysts volume.