Use of dose-volume histograms for metabolic response prediction in hepatocellular carcinoma patients undergoing transarterial radioembolization with Y-90 resin microspheres.

INTRODUCTION: Voxel-based dosimetry offers improved outcomes in the treatment of hepatocellular carcinoma (HCC) with transarterial radioembolization (TARE) using glass microspheres. However, the adaptation of voxel-based dosimetry to resin-based microspheres has been poorly studied, and the prognostic relevance of heterogeneous dose distribution remains unclear. This study aims to explore the use of dose-volume histograms for resin microspheres and to determine thresholds for objective metabolic response in HCC patients treated with resin-based TARE. METHODS: We retrospectively reviewed HCC patients who underwent TARE with Y-90-loaded resin microspheres in our institution between January 2021 and December 2022. Voxel-based dosimetry was performed on post-treatment Y-90 PET/CT images to extract parameters including mean dose absorbed by the tumor (mTD), the percentage of the targeted tumor volume (pTV), and the minimum doses absorbed by consecutive percentages within the tumor volume (D10, D25, D50, D75, D90). Assessment of metabolic response was done according to PERCIST criteria with F-18 FDG PET/CT imaging at 8-12 weeks after the treatment. RESULTS: This study included 35 lesions targeted with 22 TARE sessions in 19 patients (15 males, 4 females, mean age 60 ± 13 years). Objective metabolic response was achieved in 43% of the lesions (n = 15). Responsive lesions had significantly higher mTD, pTV, and D25-D90 values (all p < 0.05). Optimal cut-off values for mTD, pTV, and D50 were 94.6 Gy (sensitivity 73%, specificity 70%, AUC 0.72), 94% (sensitivity 73%, specificity 55%, AUC 0.64), and 91 Gy (sensitivity 80%, specificity 80%, AUC 0.80), respectively. CONCLUSION: Parameters derived from dose-volume histograms could offer valuable insights for predicting objective metabolic response in HCC patients treated with resin-based TARE. If verified with larger prospective cohorts, these parameters could enhance the precision of dose distribution and potentially optimize treatment outcomes.

The Radiation Dose Absorbed by Healthy Parenchyma Is a Predictor for the Rate of Contralateral Hypertrophy After Unilobar Radioembolization of the Right Liver.

Purpose: To investigate the predictors of contralateral hypertrophy in patients treated with unilobar transarterial radioembolization (TARE) with yttrium-90-loaded resin microspheres due to unresectable right-liver tumors. Methods: Patients who underwent right unilobar TARE with resin microspheres between May 2019 and September 2021 were screened retrospectively. Contralateral hypertrophy was evaluated by calculating the kinetic growth rate (KGR) in 8-10 weeks after TARE. The predictors of increased KGR were determined with linear regression analysis. Results: A total of 24 patients (16 with primary and 8 with metastatic liver tumors) were included in the study. After right unilobar TARE, mean volume of the left lobe increased from 368.26 to 436.16 mL, while the mean volume of the right lobe decreased from 1576.22 to 1477.89 mL. The median KGR of the left lobe was 0.28% per week. The radiation dose absorbed by the healthy parenchyma of the right lobe was significantly higher in patients with increased KGR (31.62 vs. 18.78 Gy, p = 0.037). Linear regression analysis showed that the dose absorbed by healthy parenchyma was significantly associated with increased KGR (b = 0.014, p = 0.043). Conclusion: Patients who received right unilobar TARE for liver malignancies could develop a substantial contralateral hypertrophy, and the radiation dose absorbed by the healthy parenchyma of the right lobe was significantly associated with increased KGR in the left lobe. TARE could have a role for inducing contralateral hypertrophy as it offers the advantage of concurrent local tumor control along with its hypertrophic effect.

Endovascular repair of a distal thoracic aortic transection in association with traumatic burst fracture.

We present an endovascular repair of aortic transection at distal thoracic level due to traumatic burst fracture. The association of blunt aortic transections and thoracic burst fractures is very rare. Contemporary preferred treatment approach is endovascular aortic repair, because of low mortality rates. The aortic repair procedure should be performed before spinal stabilization surgery. In this case report, we present a 49-year-old male patient with blunt traumatic descending thoracic aortic transection, treated by endovascular aortic repair. In conclusion, the emergent endovascular repair is a preferable method to treat the traumatic distal thoracic aortic transection.

Differentiation of benign and malignant superficial soft tissue lesions using real-time strain elastography

Background/aim: To evaluate benign and malignant cutaneous-subcutaneous lesions using real-time strain elastography (RTSE) and to compare the findings with histopathologic results. Materials and methods: Over a period of 10 months, 72 patients (38 with benign and 34 with malignant cutaneous and subcutaneous lesions) were prospectively included in this study. Elasticity patterns and strain ratios were examined for each lesion. Lesions were evaluated in 4 groups as yellow-red (soft; pattern-1), green-yellow (moderate; pattern-2), blue-green (hard; pattern-3) and blue (hardest; pattern-4). The stiffness of the lesions was displayed with strain ratios by comparing of a nearby reference tissue. The recorded images were compared with histopathologic findings. Results: On sonoelastograms, considering patterns 1-2 as benign and patterns 3-4 as malignant, the sensitivity, specificity, and positive and negative predictive values for the differentiation of malignant from benign lesions were 100%, 68.5%, 74%, and 100%, respectively. Considering a cut-off value of the strain ratio as > 3.05, the sensitivity, specificity, and positive and negative predictive values were 91%, 89%, 88%, and 92%, respectively. The area under the curve (AUC: 0.972) showed the excellent ability of strain elastography to differentiate benign and malignant lesions. Conclusion: RTSE is an important imaging tool to differentiate benign and malignant superficial soft tissue lesions. Our results suggest that RTSE can be used to predict malignancy since malignant lesions are more confidentially diagnosed than benign superficial soft tissue lesions on elastograms.

Primary retrograde transpedal approach for revascularization of chronic total occlusions of the superficial femoral artery and re-route technique using percutaneous puncture for re-entry.

PURPOSE: We aimed to demonstrate the safety and feasibility of revascularization of chronic total occlusion of the superficial femoral artery (SFA) using the transpedal approach and describe a new technique called "re-route". METHODS: The study included all consecutive patients who had chronic total occlusions at the level of SFA and underwent retrograde treatment through a pedal artery intervention between September 2017 and October 2019. Balloon angioplasty was applied as the first treatment option. After angioplasty, bailout stenting was performed when necessary in patients with indications. If the common femoral artery lumen could not be reached from the SFA ostium, the re-route technique was used. Technical success was defined as revascularization with residual stenosis of less than 30%. RESULTS: Twenty-five SFAs were revascularized in 23 patients (17 males; mean age, 66±7.3 years) by angioplasty in 5 SFAs and angioplasty and stents in 20 SFAs. While the transpedal approach was applied after the failure of antegrade recanalization in three patients, it was used as the first treatment route in the remaining cases. The re-route technique was applied in 7 patients, with a 100% technical success rate. The mean follow-up was 15.3 months (range, 12-18 months). The primary patency rate was 78% at one year. CONCLUSION: The retrograde transpedal approach is a safe and successful technique for chronic total occlusion recanalization and carries a low risk of complications. In order to increase technical success, the re-route technique can be used as an alternative re-entry method.

Is radiofrequency ablation safe and effective in treating osteoid osteomas? A prospective single-center study with atypical cases.

PURPOSE: Osteoid osteomas are benign and nonprogressive lesions. The clinical presentation of osteoid osteoma is typical with night pain responsive to nonsteroidal anti-inflammatory agents. The typical radiological appearance is lucent nidus and adjacent reactive sclerosis. The most traditional management of osteoid osteoma is surgical removal which is associated with significant morbidity. This article aims to demonstrate our single-center experience of 55 patients with osteoid osteoma treated with percutaneous radiofrequency ablation (RFA). METHODS: Fifty-five symptomatic patients who were seen at our orthopedics outpatient clinics, diagnosed with osteoid osteoma, and referred to interventional radiology department between May 2015 and April 2019 were enrolled. The nidus size, pain numeric rating scale score, and intramedullary edema diameter before and after RFA were compared. Clinical and technical success, intervention-related complications, and need for subsequent ablation were recorded. RESULTS: Of the 55 patients, including 12 pediatric cases, 6 had atypical locations such as metatarsal, vertebra, and scapula, while 1 case had osteoid osteoma with multiple nidus. The mean age was 18.5 ± 9.6 years. Preintervention maximum nidus diameter, pain score, and edema diameter were significantly lower in postintervention measurements (p < 0.001). Technical success rate was 98.1%, and clinical success was 96.36%. Severe complication occurred in one patient with soft tissue burn and osteomyelitis. CONCLUSION: This is one of the largest series of osteoid osteoma treated with RFA done in a single center with atypical cases. In conclusion, RFA is safe and effective in both pediatric and adult patients with rare complications even in challenging cases with atypical locations.

Ultrasound guided percutaneous radiofrequency thermal ablation of symptomatic uterine fibroids - results from a single center and 52 weeks of follow up.

OBJECTIVES: Uterine fibroids are one of the most common female disorder of the reproductive age and may cause abnormal uterine bleeding (UAB), pain or infertility. Our aim was to evaluate the safety and efficacy of percutaneous radio frequency ablation (RFA) in reducing clinical symptoms, fibroid volume and improving laboratory parameters. MATERIAL AND METHODS: Thirty-five symptomatic patients with 54 uterine fibroids were enrolled. Preintervention evaluation was made for each participant and included ultrasonography to assess the volume, largest diameter and location of the fibroid and Visual Analogue Scale (VAS) for quantifying the degree of menstrual pain. The magnitude of menstrual bleeding was scored for each patient by using pictogram. Preprocedural laboratory assessment included hemoglobulin and hematocrit. Treatment efficacy was evaluated at 3, 6 and 12 months after the intervention with ultrasound (US) measurements, symptom scores and laboratory parameters. RESULTS: Pretreatment mean Hb was significantly lower than those at 3, 6 and 12 month post treatment visits (p < 0.001). The pretreatment median volume was significantly higher than the median volumes measured at 3, 6 and 12 months after RFA (p < 0.001). Visual Analogue Score (VAS) for pain was significantly lower than baseline values at 6 and 12 month visits (p < 0.01). Pretreatment bleeding scores and the number of patients in the predefined severe bleeding category were significantly decreased. CONCLUSIONS: US guided RF ablation of uterine fibroids is relatively safe and effective procedure. It can be applied to the fibroids with varying localizations and sizes. It reduces the fibroid volume and obviate a need for more invasive treatment.

ABLATION OF CYSTIC THYROID NODULES WITH N-BUTYL CYANOACRYLATE: A PRELIMINARY STUDY.

Objective: Generally recommended treatment options for cystic nodules with compressive symptoms are simple aspiration, percutaneous ethanol injection, or surgery. N-butyl cyanoacrylate (NBCA) is a glue-like substance widely used in neurointerventions, mainly for treating arteriovenous malformations. It obstructs and attaches to the vessel walls, preventing recanalization. Our purpose was to investigate the efficacy and safety of NBCA in volume reduction of benign cystic thyroid nodules with compressive symptoms. Methods: Twenty patients with 21 benign pure or partially cystic nodules were enrolled. After simple cyst aspiration, NBCA/lipiodol mixture was injected within the cyst cavity. Success was defined as at least 50% volume reduction after the intervention. Pre- and postintervention longest diameter and volume (calculated with ultrasonography after measuring three dimensions) of the nodules were compared. Posttreatment measurements were made at the 9-month final visit. Results: Median largest diameter of the nodules measured before and after NBCA treatment was 4.8 cm (min-max, 3.1 and 6.3 cm) and 3.4 cm (min-max, 2.4 and 5.6 cm), respectively. Pre-NBCA treatment median volume was 24.8 mL (min-max, 10.9 and 46.1 mL), whereas post-treatment median volume was 5.5 mL (min-max, 2.1 and 29.6 mL). Median volume reduction was 72.6% (min-max, 21.0 and 95.4%). Intervention was successful in 20 of 21 nodules according to the predefined criteria. The changes in pre- and postintervention median longest diameter and volume were statistically significant. Conclusion: For large cystic thyroid nodules, ablation with NBCA may be an effective treatment choice, as it significantly reduces the cyst volume and prevents fluid re-accumulation. There is need for further studies with a larger number of patients and longer follow-up. Abbreviations: NBCA = N-butyl cyanoacrylate; PEI = percutaneous ethanol injection; US = ultrasonography.

Total endovascular aortic arch repair using chimney and periscope grafts for treatment of ruptured aortic arch pseudoaneurysm.

Aortic arch pseudoaneurysms are rare but quite fatal when ruptured. Owing to its less morbidity and mortality compared with the surgical approach, endovascular and hybrid treatment methods are increasingly preferred. In this report, we present a 58-year-old male patient who has a ruptured saccular aortic arch pseudoaneurysm treated by endovascular approach using parallel grafts.

Successful treatment of unexpected complication during aortic stent-grafting: retrieval of broken stent-graft tip by coaxial technique.

Thoracic aortic endovascular repair (TEVAR) is increasingly preferred as a treatment of choice in thoracic aortic diseases. Intravascular foreign body is one of the TEVAR-related complications similar to the other endovascular operations. Here, to the our best knowledge for the first time in the English literature, this report presents an extremely rare complication of a broken and stuck tip part of aortic stent-graft in the intravascular space and successful removal by using the coaxial technique. Thoracic aortic endovascular repair (TEVAR) has been increasingly preferred as the treatment of choice in thoracic aortic diseases (1). Endovascular treatment has been gaining popularity compared with open surgery due to its less invasive approach and rapid application, and allows the patient to easily return to daily life (2). However, TEVAR is associated with several specific complications including paraplegia, stroke, vascular injuries and local complications. These complications depend on vascular or nonvascular comorbidities, vascular anatomy, equipment, and experience of the provider (3-6). Intravascular foreign body could be among TEVAR-related complications similar to other endovascular operations (7). Several types of equipment, including guidewire, vascular sheath, or suboptimally uncoiled stents may get stuck in the intravascular space, causing complications (8). Herein, to the best of our knowledge, we present the first report in the English literature of broken and stuck tip part of an aortic stent-graft in the intravascular space and its successful removal using the coaxial technique.

Clearlumen-II thrombectomy system for treatment of acute lower limb ischemia with underlying chronic occlusive disease.

We aimed to present a case of effective and successful endovascular treatment of acute lower limb thromboembolism with Clearlumen-II, a new aspiration thrombectomy device. Also, we emphasize the superiority of endovascular treatment compared with surgery, especially together with acute and chronic occlusive diseases, as in our case.

Endovascular approach in isolated abdominal aortic dissections.

Background Here, we report the mid-term results of endovascular treatment of isolated dissection of the abdominal aorta, which is a very rare pathology. Materials and methods A total of 11 patients (4 males (36.3%) and 7 females (63.6%)) aged 42-72 (mean, 60.3 ± 10.45) years with isolated dissection of the abdominal aorta underwent endovascular stent-graft treatment at our institution between August 2010 and September 2015. Eight patients were symptomatic, and the remaining three were asymptomatic. The asymptomatic patients had aortic aneurysms coexisting with dissection. Eight patients without aneurysm had spontaneous dissections, and the most common symptom was unresponsive abdominal pain. Results The mean abdominal aorta diameter was 46.7 ± 20.6 (range, 31.2-100.9) mm and the mean dissection length was 71.1 ± 47.3 (range, 17-162) mm. Aorto-bi-iliac stent grafts were used in all patients, and were placed successfully under spinal anesthesia in all but one (90.9%) patient. Occlusion developed in one patient due to compression of the aorto-bi-iliac graft. Right-left femoral-femoral bypass was performed in this patient, who could not be placed on the opposite side. In addition, the graft was placed in one patient using the left renal artery chimney technique. No intraoperative mortality occurred, and open surgery was not required. In addition, no death occurred and no additional intervention was required during the mean follow-up period of 25.5 ± 17.1 (range, 6-60) months. Conclusion Limited data regarding endovascular treatment of isolated dissection of the abdominal aorta are available in the literature. Based on data obtained in a limited number of patients, we consider endovascular aortic repair to be a good alternative to surgery due to its low morbidity and mortality rates.

Predictability and Outcome of Vascular Complications after Transfemoral Transcatheter Aortic Valve Implantation.

BACKGROUND: Although the efficacy and safety of transfemoral transcatheter aortic valve implantation (TAVI) have been improved with new devices, careful patient selection is essential and awkward complications associated with the procedure persist. Despite a gradual reduction in the delivery system size and the development of access site arterial closure devices, vascular complications remain one of the main challenges of TAVI. The aim of this single-center study was to prospectively evaluate the incidence and predictors of vascular complications in transfemoral TAVI. METHODS: A total of 211 patients (mean age 77.98 ± 8.20 years) who underwent transfemoral TAVI between 2011 and 2014 at the authors' institution, using two different commercially available devices, was included in the study. Technical success, vascular complications, predictors of vascular complications and mortality were each assessed. Vascular complications were defined by the current Valve Academic Research Consortium-2 (VARC-2) criteria. RESULTS: The mean logistic EuroSCORE of the patients was 21.04 ± 7.51. An Edwards SAPIEN XT valve was used in 69.7% of cases, and a Medtronic CoreValve in 30.3%. Completely percutaneous transfemoral TAVI was successful in 81.6% of patients. Procedural and 30-day mortalities were 1.4% and 8.5%, respectively. Vascular complications occurred in 16.1% of patients (minor 10.4%, major 5.7%), and necessitated surgical repair in 25 cases (11.8%). Major vascular complications were predictive of 30-day mortality (58.3% versus 5.6% (p = 0.000). Predicted major vascular complications (by multivariate analysis) were female gender (hazard ratio (HR) 5.45; 95% confidence interval (CI) 0.91-32.5, p = 0.063), arterial calcification (HR 2,88; 95% CI 1.14-7.30, p = 0.025) and sheath to iliofemoral artery ratio (SIFAR) (HR 1.91, 95% CI 1.27-2.87, p = 0.001). CONCLUSIONS: Although vascular preclosure devices have revolutionized transfemoral TAVI, and offer a simple but effective percutaneous procedure, vascular complications are still observed in a considerable number of patients. The major vascular complications were predictive of 30-day mortality, and included female gender, iliofemoral calcification and SIFAR. Further technological and procedural developments are required to reduce vascular complication rates and related mortality.

Treatment of acute thoracic aortic syndromes using endovascular techniques.

PURPOSE: Acute thoracic aortic syndrome (ATAS) is a novel term to define emergency aortic conditions with common clinical features and challenges. Traditional management of ATAS includes surgical replacement of the aorta and is correlated with high perioperative mortality and morbidity. We aimed to evaluate our experience and outcomes in patients presenting with ATAS, managed by endovascular techniques. METHODS: This cohort consisted of 31 consecutive patients (24 males; mean age, 57.5±13.81 years; range, 19-84 years) with acute thoracic aortic pathologies who underwent endovascular repair between January 2011 and January 2015. The study was designed as a retrospective analysis of prospectively maintained data. RESULTS: Complicated acute type-B aortic dissection was the most common pathology (35.5%). All aortic stent-grafts (n=37) and dissection stents (n=9) were implanted with 100% procedural success. The overall in-hospital mortality was 9.7%. The mean follow-up duration of patients who were alive at 30 days was 25.9±11.49 months (3-53 months). So far, there have been no late deaths after 30 days. CONCLUSION: In the high-risk setting of ATAS, endovascular procedures come forward as novel therapeutic strategies with promising results. Endovascular repair of ATAS can be considered as a first-line treatment alternative under emergency conditions with encouraging results, particularly when conventional surgical repair cannot be implemented due to prohibitive comorbidities.

Endovascular treatment for acute traumatic thoracic aortic transection.

BACKGROUND: This study aimed to present our experience in patients with acute traumatic thoracic aortic transection treated by endovascular stent-graft. METHODS: From October 2011 to October 2014, eleven patients were brought to our hospitals after suffering motor vehicle accident or fall from height. Computed tomography revealed acute traumatic transection of the thoracic aorta at the aortic isthmus just distal to the left subclavian artery in nine patients, at the middle or distal thoracic aorta in two, and both aortic isthmus and middle thoracic aorta in one. Endovascular technique was preferred as the treatment modality. All patients, except one, were treated within twelve hours of diagnosis. RESULTS: Deployment of stent-grafts was successful in all cases. The stent-grafts were oversized between 10% and 20%. The origin of left subclavian artery was covered with stent-graft in six patients to achieve adequate proximal landing zone. In two of them, carotico-subclavian bypass and periscope graft placement were applied to maintain subclavian artery blood flow. There were no procedure related deaths, paraplegia or ischemic complications. A patient with cardiac arrest, on whom cardiopulmonary resuscitation and transient aortic balloon occlusion within the aorta were applied in the angiography suit died at the postoperative twelve hours. Mean hospital stay after procedures was 14.8 days (range, 4-60 days). Mean follow-up time of ten patients was 16.6 months (range, 1-36 months). CONCLUSION: Our study supports that thoracic endovascular aortic stenting for acute transection is promising in terms of short- and mid-term results similar to other studies in the literature.

Iliorenal periscope graft to maintain blood flow to accessory renal artery.

Parallel endografts such as "chimney" and "periscope" are being increasingly used to maintain blood flow to visceral and supra-aortic branches in patients with different aortic disorders. We present a new technique, "iliorenal periscope graft", in a patient with abdominal aortic aneurysm undergoing endovascular aortic repair. In this case, left accessory renal artery flows were provided by an iliorenal periscope graft that extends from the left accessory renal artery to the right common iliac artery in a retrograde fashion.

An Unusual Reason for Gastric Variceal Hemorrhage: Wandering Spleen.

Wandering spleen is the displacement of the spleen due to the loss or weakening of the ligaments of the spleen and is seen very rarely with an incidence of less than 0.5 %. It can cause portal hypertension, but gastric variceal hemorrhage is a quite rare condition within the spectrum of this uncommon disease. We report a 22-year-old woman with wandering spleen presenting with life-threatening gastric variceal hemorrhage. Her diagnosis was made by computerized tomography. Endoscopic therapy was not adequate to stop the bleeding, and urgent splenectomy was performed. After surgery she has been well with no symptoms until now.

Covered stent-graft treatment of a postoperative common carotid artery pseudoaneurysm.

BACKGROUND: Extracranial carotid artery pseudoaneurysms are rare cases resulting from trauma, mycotic infection, head and neck carcinomas or complications related to their treatment. Trauma is the most common cause of carotid artery pseudoaneurysms. They can also present after surgery, most commonly following endarterectomy, which is a rare cause with an estimated incidence of 0.3-0.6%. CASE REPORT: A 26-year-old male patient was admitted with swelling in his left neck after left carotid endarterectomy. Angiography confirmed pseudoaneursym in the left carotid bulb and it was treated successfully with two heparin-bonded covered stent grafts. CONCLUSIONS: Endovascular treatment of carotid pseudoaneurysms with covered stent-grafts is a safe and efficient method providing definitive arterial reconstruction. But series with longer follow-up periods are needed to evaluate patient compatibility to lifelong antiplatelet theraphy.

Simultaneously successful transfemoral aortic valve implantation and endovascular repair of thoracic aortic saccular aneurysm.

The prevalence of aortic stenosis (AS) increases in the elderly. They present high surgical risk due to comorbid factors that increase with age. Transcatheter aortic valve implantation (TAVI) is an effective method in patients who present with severe aortic stenosis with a higher surgical risk or who cannot undergo surgical aortic valve replacement (s-AVR). In our case, the presence of saccular thoracic aortic aneurysm with severe AS, which is a vital co-morbidity, requires the treatment of both. The rise in systolic pressure following the TAVI procedure increases the saccular thoracic aneurysm rupture risk and this is why the timing and method of the two treatments become crucial. In this case, which is as far as we know the fi rst and only report in the literature, both TAVI and endovascular thoracic aortic saccular aneurysm repair were applied simultaneously and successfully to the patient via the same transfemoral route. After 1 month, the patient had good functional capacity and there were no complications in control tomography and echocardiography. In this way, we attempted to emphasize with a multidisciplinary study that the patients be assessed carefully before the procedure, and found that even in patients with common peripheral vascular diseases, a transfemoral route could be used together with the proper methods, and that both procedures could be performed simultaneously.