A comparative analysis of transarterial downstaging for hepatocellular carcinoma: chemoembolization versus radioembolization.

Chemoembolization and other ablative therapies are routinely utilized in downstaging from United Network for Organ Sharing (UNOS) T3 to T2, thus potentially making patients transplant candidates under the UNOS model for end-stage liver disease (MELD) upgrade for hepatocellular carcinoma (HCC). This study was undertaken to compare the downstaging efficacy of transarterial chemoembolization (TACE) versus transarterial radioembolization. Eighty-six patients were treated with either TACE (n = 43) or transarterial radioembolization with Yttrium-90 microspheres (TARE-Y90; n = 43). Median tumor size was similar (TACE: 5.7 cm, TARE-Y90: 5.6 cm). Partial response rates favored TARE-Y90 versus TACE (61% vs. 37%). Downstaging to UNOS T2 was achieved in 31% of TACE and 58% of TARE-Y90 patients. Time to progression according to UNOS criteria was similar for both groups (18.2 months for TACE vs. 33.3 months for TARE-Y90, p = 0.098). Event-free survival was significantly greater for TARE-Y90 than TACE (17.7 vs. 7.1 months, p = 0.0017). Overall survival favored TARE-Y90 compared to TACE (censored 35.7/18.7 months; p = 0.18; uncensored 41.6/19.2 months; p = 0.008). In conclusion, TARE-Y90 appears to outperform TACE for downstaging HCC from UNOS T3 to T2.

Fibrosis, portal hypertension, and hepatic volume changes induced by intra-arterial radiotherapy with 90yttrium microspheres.

PURPOSE: To identify changes in hepatic parenchymal volume, fibrosis, and induction of portal hypertension following radioembolization with glass microspheres for patients with metastatic disease to the liver. RESULTS: In our series of sequential bilobar (n = 17) treatments, a mean decrease in liver volume of 11.8% was noted. In this group, a mean splenic volume increase of 27.9% and portal vein diameter increase of 4.8% were noted. For patients receiving unilobar treatments (n = 15), mean ipsilateral lobar volume decrease of 8.9%, contralateral lobar hypertrophy of 21.2%, and a 5.4% increase in portal vein diameter were also noted. These findings were not associated with clinical toxicities. CONCLUSION: (90)Yttrium radioembolization utilizing glass microspheres in patients with liver metastases results in changes of hepatic parenchymal volume and also induced findings suggestive of fibrosis and portal hypertension. Further studies assessing the long-term effects are warranted.

The vascular impact of uterine artery embolization: prospective sonographic assessment of ovarian arterial circulation.

PURPOSE: The etiology of premature ovarian failure after uterine artery embolization (UAE) is unknown. The authors prospectively assessed ovarian arterial circulation before and after UAE with use of ultrasonography (US). The authors hypothesize that nontarget embolization of the ovary occurs during routine UAE. MATERIALS AND METHODS: Twenty-three women (mean age of 42.6 years; range, 35-51 y) participated in the study. Grayscale, color, and pulsed-wave Doppler US studies were performed immediately before and after UAE. Resistive index (RI) and pulsatility index (PI) were calculated. The proportion of women who developed increased vascular impedance after UAE was statistically assessed with use of the Yates-corrected chi(2) test. RESULTS: Seventeen of 23 patients (74%) completed the study. Nine of 17 (54%) showed complete loss of ovarian arterial perfusion after UAE. Six of 17 (35%) had increases in RI and PI, whereas two of 17 (11%) had decreases in RI and PI. The increase in vascular impedance after UAE in 15 of 17 patients was significant (P <.0001). CONCLUSION: Loss of detectable ovarian arterial perfusion occurs in the majority of patients undergoing UAE. Ovarian vascular impedance increases in nearly all patients as a result of UAE. The authors conclude that inadvertent nontarget embolization of the ovarian arterial bed occurs during routine UAE.

Identification and implications of transgraft microleaks after endovascular repair of aortic aneurysms.

PURPOSE: The purpose of this report is to describe an interesting cause of endoleak and detail-specific techniques for identifying small transgraft defects, which we have termed microleaks. METHODS: Four patients underwent endovascular repair of abdominal aortic aneurysms with modular nitinol/polyester endoprostheses and were studied after 6 to 30 months. All patients were enrolled in standard follow-up radiographic surveillance protocols. RESULTS: Three of the four abdominal aortic aneurysms continued to expand after endograft repair. Standard computed tomography imaging with precontrast, dynamic contrast, and delayed imaging frequently identifies endoleak, although it fails to precisely identify microleaks as the source. Color flow duplex ultrasound scan was performed on three patients and perigraft "jets," small areas of color flow adjacent to the endograft, were identified in all. Microleaks were identified in one patient who underwent digital subtraction arteriography with directed efforts to completely opacify the prosthesis lumen and multiple oblique projections. In another patient, contrast arteriography with balloon occlusion of the distal endograft clearly depicted midgraft microleaks that might otherwise be mistaken for graft porosity or cuff junction endoleaks. No microleaks were diagnosed on angiograms when these directed efforts were not performed. Aneurysm exploration before aortic clamping provided conclusive determination of the presence of blood flow through the wall of the endoprosthesis in two patients. CONCLUSIONS: Microleaks occur up to 2.5 years after endovascular repair of aortic aneurysms. Although computed tomography demonstrates the presence of an endoleak in these patients, the exact site of origin usually remains obscure. Doppler ultrasound scan and directed arteriography appear to be of greater utility for identifying the presence and location of microleaks. Balloon occlusion arteriography and aneurysm exploration without arterial clamping provide definitive evidence of microleaks. Although the clinical significance of microleaks remains unclear, long-term monitoring of patients is imperative to diagnose and treat these and other modes of endograft failure before they progress to aneurysm rupture.

Treatment of stomal variceal hemorrhage with TIPS: case report and review of the literature.

We report a case in which recurrent hemorrhage from stomal varices was successfully treated by placement of a TIPS in a patient with prior colectomy for inflammatory bowel disease. Although several treatment options have been reported for this entity we believe that TIPS offers minimally invasive and definitive treatment.

The impact of uterine fibroid embolization on resumption of menses and ovarian function.

PURPOSE: To evaluate the effect of uterine fibroid embolization (UFE) on menstruation and ovarian function. METHODS: The authors performed an observational study of UFE for the treatment of symptomatic fibroids. All patients had regular predictable menses before intervention and none had clinical or laboratory findings of menopause. UFE was performed with use of standard methods with 355-700-microm-diameter polyvinyl alcohol (PVA) foam particles. The incidence of ovarian failure was calculated for women younger than 45 years and for those 45 years or older, based on retrospective stratification by age. The authors assessed statistical differences in ovarian failure between the two age groups with use of the X2 test. RESULTS: Sixty-six premenopausal women (age range, 30-55 years) underwent bilateral UFE and were followed for an average of 21 weeks (range, 12-77 weeks). In 56 of 66 (85%) patients, regular menses resumed after an average of 3.5 (range, 1-8) weeks. In 10 of 66 (15%) patients, regular menses did not resume. Clinical and biochemical findings consistent with ovarian failure and presumed menopause were seen in nine of 10 patients without resumption of menses (14% of total patients). Ovarian failure occurred in nine of 21 (43%) women older than 45 years and in none of the 45 women younger than 45 years (P < .05). There were no differences in presenting symptoms, amount of PVA used, or fibroid size between patients who did and did not resume menses. CONCLUSION: The majority of patients undergoing UFE will have resumption of menses, but the incidence of postprocedure ovarian failure is considerably higher than reported to date. Loss of menses induced by UFE is significantly more likely to occur in women older than 45 years.

Treatment of posttraumatic internal carotid arterial pseudoaneurysms with endovascular stents.

BACKGROUND: The sequelae of blunt injury to the carotid arteries are unusual, but pseudoaneurysms causing subsequent strokes are devastating. The utility of treatment of these pseudoaneurysms was examined. METHODS: All patients at a Level I trauma center with previously documented traumatic risk factors were assessed for blunt injury to the carotid arteries and, when a pseudoaneurysm was present, a self-expanding metallic stent was placed across the lesion and the patient placed on anticoagulation. Follow-up arteriograms were obtained in 2 months and every 6 months thereafter. RESULTS: Fourteen patients (7 men, 7 women) with an average age of 27 years, an Injury Severity Score of 38, had formed pseudoaneurysms in 16 extracranial internal carotid arteries. These were stented with metallic endoprostheses. No strokes occurred after the placement of the stents. Mean follow-up period has been 2.5 years. CONCLUSIONS: Use of metallic endoprostheses is an effective method to treat this potentially devastating injury. However, longer follow-up and more patients studied are needed to further examine this promising treatment.

Role of TIPS as a bridge to hepatic transplantation in Budd-Chiari syndrome.

PURPOSE: To investigate the role of transjugular intrahepatic portosystemic shunt (TIPS) as a bridge to transplantation for patients with Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: Eight patients (five women, three men) with a mean age of 49.8 years (range, 20-61 years) were diagnosed with BCS by means of computed tomography, hepatic venography, and liver biopsy. One patient had acute liver failure, with subacute or chronic failure in seven. TIPS placement was attempted in all eight patients. Clinical follow-up and portograms were obtained in all patients until death or transplantation. RESULTS: TIPS placement was completed in seven of eight patients (87.5%). During the follow-up period, TIPS occlusion occurred in four patients. TIPS revision in this patient, although successful, was complicated by hemorrhage and multiorgan failure, and the patient died. Assisted patency rate, excluding the technical failure, was 100%. Mean follow-up in the six survivors with TIPS was 342 days (range, 19-660 days). All six survivors had complete resolution of their ascites. Albumin levels improved an average of 0.43 g/dL (range, 0.3-1.4 g/dL). Bilirubin levels improved in five of six patients (83%), decreasing by an average of 5.6 mg/dL (range, 3.0-15.2 mg/dL). Of the six survivors, three underwent elective liver transplantation, one is awaiting transplantation, and one has been removed from the transplantation list because of clinical improvement. One patient was a candidate for transplantation but declined to be put on the list. CONCLUSION: Hepatic synthetic dysfunction improves markedly after TIPS placement in patients with BCS. Significant improvement in ascites can also occur. TIPS can be an effective bridge to transplantation for patients with BCS.

Peripherally inserted central catheters: guidance with use of US versus venography in 2,650 patients.

PURPOSE: To compare technical success and initial complication rates of peripherally inserted central catheters (PICCs) by interventional radiologists using ultrasound (US) or venographic guidance. MATERIALS AND METHODS: With use of a computer database, the authors retrospectively reviewed 2,650 procedures, 2,126 of which were performed with US and 524 with venography. Technical success was defined as placement of a PICC. Initial complications were defined as development of a hematoma, inadvertent arterial puncture, or neuropathy. Statistical significance was assessed using the chi2 test. RESULTS: During 33 consecutive months, 2,650 procedures were performed with a complication rate of 1.0%. The technical success rate was 95.8% for venography and 99.6% for US. The initial complication rate was 0.75% for venography and 1.08% for US. There was no statistically significant difference in immediate complication rates (P = .50); however, there is statistical significance in regard to technical success (P < .001). CONCLUSION: There is no difference in initial complication rates when comparing US and venographic guidance for PICC insertion. The decision to use either method can be based on clinical grounds and/or physician preference, although US has a higher initial success rate.

The treatment of symptomatic os acromiale.

Os acromiale is an uncommon condition of the shoulder. When symptomatic, os acromiale may cause impingement pain, rotator cuff tears, or pain through abnormal motion at the unfused apophysis. Treatment of symptomatic os acromiale is controversial. This article reports on four patients with symptomatic meso-acromions who were treated with open reduction and internal fixation. All four patients recovered full function postoperatively with UCLA shoulder rating scores improving from 19 preoperatively to 35 postoperatively. Open reduction and internal fixation of a symptomatic meso-acromion is a reliable and reproducible technique in which the deltoid attachment and lever arm are minimally affected.

The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome.

OBJECTIVE: To determine the benefit of screening for blunt carotid arterial injuries (BCI) in patients who are asymptomatic. SUMMARY BACKGROUND DATA: Blunt carotid arterial injuries have the potential for devastating complications. Published studies report 23% to 28% mortality rates, with 48% to 58% of survivors having permanent severe neurologic deficits. Most patients have neurologic deficits when the injury is diagnosed. The authors hypothesized that screening patients who are asymptomatic and instituting early therapy would improve neurologic outcome. METHODS: The Trauma Registry of the author's Level I Trauma Center identified patients with BCI from 1990 through 1997. Beginning in August 1996, the authors implemented a screening for BCI. Arteriography was used for diagnosis. Patients without specific contraindications were anticoagulated. Endovascular stents were deployed in the setting of pseudoaneurysms. RESULTS: Thirty-seven patients with BCI were identified among 15,331 blunt-trauma victims (0.24%). During the screening period, 25 patients were diagnosed with BCI among 2902 admissions (0.86%); 13 (52%) were asymptomatic. Overall, eight patients died, and seven of the survivors had permanent severe neurologic deficits. Excluding those dying of massive brain injury and patients admitted with coma and brain injury, mortality associated with BCI was 15%, with severe neurologic morbidity in 16% of survivors. The patients who were asymptomatic at diagnosis had a better neurologic outcome than those who were symptomatic. Symptomatic patients who were anticoagulated showed a trend toward greater neurologic improvement at the time of discharge than those who were not anticoagulated. CONCLUSIONS: Screening allows the identification of asymptomatic BCI and thereby facilitates early systemic anticoagulation, which is associated with improved neurologic outcome. The role of endovascular stents in the treatment of blunt traumatic pseudoaneurysms remains to be defined.

Adolescent and pediatric sports injuries.

With the ever increasing number of boys and girls participating in organized sports, specific injury patterns, often dependent upon sport and gender, have been identified. This article identifies the most common sports injuries, focusing on mechanisms of injury, pathoanatomy, the history and physical findings, as well as recommendations, for the primary care physician, for initial diagnostic studies and treatment.

Treatment of blunt injury to the carotid artery by using endovascular stents: an early experience.

Identification of blunt carotid injury prior to the development of ischemic symptoms requires aggressive screening of patients at risk. The treatment of these lesions has centered around long-term anticoagulation therapy. However, studies have revealed that many of these lesions persist despite medical treatment, as does the risk of distal embolization. The authors present a series of six patients who were successfully treated by means of endovascular stent placement for nonpenetrating carotid injuries. In the authors' experience this treatment requires only temporary anticoagulation therapy, results in immediate reconstruction of the injured vessel, obliterates pseudoaneurysms, and prevents distal embolization.

Traumatic bilateral jugular vein thrombosis: case report and review of the literature.

OBJECTIVE AND IMPORTANCE: Thrombosis of the internal jugular vein (IJV) with associated elevated intracranial pressure (ICP) is a rare complication of central venous catheterization but has not been reported as a result of blunt trauma. CLINICAL PRESENTATION: An 18-year-old male patient was observed to be obtunded after an assault. The initial examination was remarkable for somnolence, bruising of the anterior neck, and diffuse, edematous swelling of the face and scalp. The results of computed tomography of the brain were normal. An angiogram obtained on the 2nd hospital day to rule out carotid injury revealed bilateral IJV thromboses to the cranial base. An ICP monitor was placed with an opening pressure of 33 mm Hg. The central venous pressure was measured to be 9 mm Hg. A catheter was passed through the left IJV thrombus and into the sigmoid sinus, where the pressure was 17 mm Hg. INTERVENTION: An intravascular stent was deployed in the left IJV. ICP rapidly normalized. A regimen of coumadin was administered to the patient for 6 weeks, at which time the stent remained patent. CONCLUSION: We conclude that traumatic jugular vein thrombosis can be associated with significant elevation in ICP and that treatment with an endovascular stent can affect the rapid correction of intracranial hypertension in patients who are candidates for anticoagulation.

MRI appearance of meniscal cysts.

PURPOSE: The purpose of this study was to review the MRI criteria for the distinction of meniscal cysts from other cystic lesions in the knee so that appropriate treatment may be planned. DESIGN: A retrospective review of 62 knee MRI scans possibly showing meniscal cysts was performed. The type of meniscal tear, the appearance of the connection between the cyst and the meniscal tear, and the location, size, morphology, and signal characteristics of the meniscal cysts were recorded. Other types of fluid collections that had been mistaken for meniscal cysts were described. PATIENTS: Sixty-two patients were studied, ages 16-79 years, 61% male, 39% female. RESULTS AND CONCLUSIONS: Most of the meniscal cysts (91%) occurred immediately adjacent to the meniscal tear (98% horizontal cleavage tears, 49% anterolateral), with the tear leading directly into the cysts. In two cases, the cyst had dissected into the soft tissues distant from the meniscus and a connecting stalk was visualized. Fluid collections in normal bursae and recesses that had been mistaken for meniscal cysts had no direct connection to a meniscal tear. MRI can be used to distinguish meniscal cysts from other fluid collections that may mimic meniscal cysts. Pitfalls can be avoided by familiarity with the normal bursal and capsular anatomy, and by the application of specific diagnostic criteria.