Clinical course of patients with hepatocellular carcinoma who experienced radiologic complete response after radioembolization.

Purpose: The purpose of this study is to elucidate the patterns of recurrence of hepatocellular carcinoma and to analyze factors that can predict recurrence after complete response to radioembolization. Materials and methods: A total of 289 consecutive patients who underwent radioembolization for the treatment of hepatocellular carcinoma at a single tertiary center were retrospectively reviewed. Baseline characteristics were collected and compared between the group showing complete response and the group showing noncomplete response. Data on recurrence status, time to recurrence, and the patterns of recurrence among the patients who showed radiologic complete response were collected. The group that maintained complete response and the group that experienced recurrence were compared, and the risk factors affecting recurrence were evaluated by logistic regression analysis. Results: The complete response rate was 24.9% (73/289). Age, sex, tumor markers, maximum tumor diameter, multiplicity, presence of vascular invasion, and target radiation dose were significantly different between the complete response and noncomplete response groups. The recurrence rate after complete response was 38.4% (28/73), and 67.9% (19/28) of recurrences occurred by 8 months after complete response. Eight patients who underwent resection/transplantation after complete response experienced no recurrence. Multiple tumors and a lower target radiation dose were independent risk factors of recurrence after complete response in the multivariate logistic regression. Conclusion: Hepatocellular carcinoma recurrence following complete response after radioembolization is not uncommon and frequently occurs within 1 year after complete response. Multiple tumors and a lower target radiation dose may be risk factors for recurrence.

Thoracic Duct Embolization for Treatment of Chyle Leakage After Thyroidectomy and Neck Dissection.

OBJECTIVE: This study aimed to evaluate the safety and efficacy of intranodal lymphangiography and thoracic duct embolization (TDE) for chyle leakage (CL) after thyroid surgery. MATERIALS AND METHODS: Fourteen patients who underwent intranodal lymphangiography and TDE for CL after thyroid surgery were included in this retrospective study. Among the 14 patients, 13 underwent bilateral total thyroidectomy with neck dissection (central compartment neck dissection [CCND], n = 13; left modified radical neck dissection (MRND), n = 11; bilateral MRND, n = 2), and one patient underwent left hemithyroidectomy with CCND. Ten patients (76.9%) had high-output CL (> 500 mL/d). Before the procedure, surgical intervention was attempted in three patients (thoracic duct ligation, n = 1; lymphatic leakage site ligation, n = 2). Lymphangiographic findings, technical and clinical successes, and complications were analyzed. Technical success was defined as the successful embolization of the thoracic duct after access to the lymphatic duct via the transabdominal route. Clinical success was defined as the resolution of CL or surgical drain removal. RESULTS: On lymphangiography, ethiodized oil leakage near the surgical bed was identified in 12 of 14 patients (85.7%). The technical success rate of TDE was 78.6% (11/14). Transabdominal antegrade access was not feasible due to the inability to visualize the identifiable cisterna chyli or a prominent lumbar lymphatic duct. Among patients who underwent a technically successful TDE, the clinical success rate was 90.1% (10/11). The median time from the procedure to drain removal was 3 days (with a range of 1-13 days) for the 13 patients who underwent surgical drainage. No CL recurrence was observed during the follow-up period (ranging from 2-44 months; median, 8 months). There were no complications, except for one case of chylothorax that developed after TDE. CONCLUSION: TDE appears to be a safe and effective minimally invasive treatment option for CL after thyroid surgery, with acceptable technical and clinical success rates.

Efficacy of intra-arterial lidocaine administration on pain and inflammatory response after uterine artery embolization for symptomatic fibroids.

BACKGROUND: There have been conflicting outcomes regarding the use of lidocaine to reduce pain after uterine artery embolization (UAE). PURPOSE: To investigate the efficacy of intra-arterial lidocaine injection for pain and inflammatory response control within 24 h of UAE for symptomatic uterine fibroids. MATERIAL AND METHODS: Of 1530 patients who underwent UAE for uterine fibroids in 2007-2021, 5 mL of 1% lidocaine was injected into each uterine artery immediately after UAE in 23 patients. A disease-matched control group (n = 23) who did not receive intra-arterial lidocaine was generated from the same registry. The pain score, white blood cell (WBC) count, C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), and fentanyl consumption were compared before and after UAE. Complete infarction of the dominant fibroid was assessed using magnetic resonance imaging. RESULTS: Significantly lower WBC count, CRP level, and NLR were noted 24 h after UAE in the lidocaine group. No statistically significant difference was noted in the pain score between groups at 0-24 h. The cumulative fentanyl dose administered during the first 24 h after UAE was not significantly different. After embolization, fibroid-related symptoms resolved in all patients. No significant difference was observed in the rate of complete infarction of the dominant fibroid. CONCLUSION: Lidocaine administration immediately after UAE resulted in a significant reduction in the inflammatory response. However, such a difference in the inflammatory reaction did not contribute to significant reductions in pain scores or fentanyl consumption.

Inhibition of Dickkopf-1 enhances the anti-tumor efficacy of sorafenib via inhibition of the PI3K/Akt and Wnt/ß-catenin pathways in hepatocellular carcinoma.

BACKGROUND: Sorafenib improves the overall survival in patients with advanced hepatocellular carcinoma (HCC). Dickkopf-1 (DKK1) is commonly overexpressed in HCC. In this study, we investigated whether the inhibition of DKK1 enhances the anti-tumor efficacy of sorafenib in HCC. METHODS: HCC cells were treated with sorafenib and WAY-262611, which is an inhibitor of DKK1. Transgenic mouse models were also developed using hydrodynamic tail vein injection. Mice were orally administered with sorafenib (32 mg/kg), WAY-262611 (16 mg/kg), or sorafenib + WAY-262611 for 10 days. Mechanisms of sorafenib and WAY-262611 were explored via western blotting, immunostaining, and RNA sequencing. RESULTS: DKK1 was significantly overexpressed in patients with HCC than in the healthy controls and patients with liver diseases except HCC (all P < 0.05). Compared with sorafenib alone, sorafenib + WAY-262611 significantly inhibited the cell viability, invasion, migration, and colony formation by promoting apoptosis and altering the cell cycles in HCC cells (all P < 0.05). Moreover, sorafenib + WAY-262611 decreased the p110α, phospho-Akt (all P < 0.05), active ß-catenin (all P < 0.05) and phospho-GSK-3ß (Ser9) expression levels, while increasing the phospho-GSK-3ß (Tyr216) expression levels compared with those in the sorafenib alone in vitro and in vivo. In addition, sorafenib + WAY-262611 inhibited tumor progression by regulating cell proliferation and apoptosis, significantly better than sorafenib alone in mouse models. CONCLUSIONS: Our results indicate that DKK1 inhibition significantly enhances the anti-tumor efficacy of sorafenib by inhibiting the PI3K/Akt and Wnt/ß-catenin pathways via regulation of GSK3ß activity, suggesting a novel therapeutic strategy for HCC. Video Abstract.

Feasibility of Percutaneous Pancreatic Stent Placement in Postoperative Pancreaticojejunostomy Stenosis.

OBJECTIVE: To evaluate the role of percutaneous pancreatic stent placement in postoperative pancreaticojejunostomy stenosis (PJS). MATERIALS AND METHODS: This retrospective single-center study included seven procedures in five patients (four males and one female; median age, 63 years) who underwent percutaneous pancreatic stent placement for postoperative PJS between January 2005 and December 2021. The patients were referred to interventional radiology because of unfavorable anatomy or bowel abnormalities. The pancreatic duct was accessed under ultrasound and/or computed tomography guidance. A stent was placed after balloon dilatation of the PJS. Moreover, plastic stents were placed for the first two procedures, whereas bare-metal stents were used for the remaining five procedures. Technical success was defined as the successful placement of stents for the PJS, meanwhile, clinical success was defined as the normalization of pancreatic enzymes without recurrence of pancreatitis. RESULTS: Pancreatic duct access and stent placement were successfully performed in all patients (technical success rate: 100%). All the procedures initially yielded clinical success. However, recurrence of pancreatitis was observed after two procedures that used plastic stents because of stent migration at 0.3 and 3 months after the procedure. In contrast, no instances of recurrent pancreatitis were noted after metal stent placement for a follow-up duration of 1-36 months. No serious procedure-related adverse events were observed. CONCLUSION: Percutaneous pancreatic stent placement may be a viable option for patients with postoperative PJS in whom an endoscopic approach is not feasible. Metal stents may be considered over plastic stents for the management of PJS, considering the possible lower stent migration and infeasibility of frequent endoscopic stent exchange due to the altered anatomy.

Effect of catheter-directed ethanol sclerotherapy on ovarian reserve in patients with recurrent endometrioma: comparative analysis with primary endometriosis.

OBJECTIVE: Catheter-directed ethanol sclerotherapy (CDS) is known to less affect the ovarian function, with comparable efficacy. This study aims to investigate the change in ovarian reserve after catheter-directed ethanol sclerotherapy in patients with recurrent endometrioma, as compared to primary endometrioma. MATERIALS AND METHODS: Retrospective, observational study. Electronic medical records and images of patients with endometrioma who underwent CDS from August 2014 to April 2022 at a single institution were obtained. Patients aged > 18 years old and with anti-Müllerian hormone (AMH) level between 0.8 and 10.0 with regular menstruation were enrolled. Cyst diameter, laterality, AMH level, and CA-125 level before and after 1 month, 6 months, 1 year, 2 years, and 3 years of sclerotherapy were obtained. RESULTS: A total of 180 patients were fit for analysis. There was no statistical difference in age and cyst size between the two groups. Mean values of AMH in each group were 3.35 in the primary group and 3.00 in the recurrent group prior to the procedure (p = 0.347). There was no significant difference in delta value of AMH after sclerotherapy in both groups at each follow-up period. Also, this result was consistent when stratified by laterality, preprocedural AMH level, and initial size of endometrioma. No case of recurrence was reported in both groups. CONCLUSIONS: The effect of CDS on ovarian reserve is not inferior in recurrent endometrioma compared to primary endometrioma. Since sclerotherapy is known to less deteriorate the ovarian function than surgical removal of endometrioma, clinician could consider this as the first-line therapy in patients with recurrent endometrioma. CLINICAL RELEVANCE STATEMENT: Catheter-directed ethanol sclerotherapy for patients with recurrent endometrioma has similar effect on ovarian reserve compared to patients with primary endometrioma. KEY POINTS: • Secondary surgery for endometrioma has significant deleterious effect on ovarian function. • Catheter-directed sclerotherapy (CDS) for endometrioma had equally minimal adverse effect on ovarian reserve, represented as anti-Müllerian hormone (AMH), in both primary and recurrent groups. • Physicians should consider CDS for patients with recurrent endometrioma who desire to preserve ovarian function.

Hepatic arterial infusion in combination with systemic chemotherapy in patients with hepatic metastasis from colorectal cancer: a randomized phase II study - (NCT05103020) - study protocol.

BACKGROUND: Although 80% of patients with metastatic colorectal cancer (CRC) experience liver metastases, only 10-25% undergo resection at the time of diagnosis. Even in initially unresectable conditions, if appropriate treatment is provided, such as surgical conversion through a combination of hepatic arterial infusion (HAI) chemotherapy and systemic chemotherapy (sys-CT), better overall survival can be expected. Therefore, this study aims to evaluate the efficacy of HAI oxaliplatin in combination with sys-CT plus targeted therapy in patients with unresectable CRC with liver-only metastasis. METHODS: This is a single-center, randomized, open-label phase II trial (NCT05103020). Patients with untreated CRC, who have liver-only metastases and for whom liver resection is potentially possible but deemed infeasible at the time of initial diagnosis by a multidisciplinary team, will be eligible. Patients will be randomly assigned in a 1:1 ratio to either the combined HAI oxaliplatin and modified systemic 5-fluorouracil, folinic acid, and irinotecan (FOLFIRI) plus targeted therapy group or the systemic FOLFIRI plus targeted therapy group. Both regimens will be repeated every 2 weeks for a total of 12 cycles. The primary objective of this study is to compare the rate of conversion to liver resection. The surgical conversion rate is expected to increase by 25% with HAI oxaliplatin in combination with sys-CT plus targeted therapy (40% in the experimental arm versus 15% in the control arm) (power, 80%; two-sided alpha-risk, 5%). The secondary objectives include overall survival, progression-free survival, and objective response rate. DISCUSSION: This is the first randomized controlled trial to investigate the efficacy of HAI oxaliplatin in combination with sys-CT plus targeted therapy as first-line treatment from the initial diagnosis in patients with unresectable CRC with liver-only metastasis, aiming to significantly increase the surgical conversion rate. TRIAL REGISTRATION: ClinicalTrials.gov, (NCT05103020). Trial registration date: November 2, 2021.

Balloon Bronchoplasty for the Treatment of Bronchial Stenosis After Lung Transplantation: A Single-Center 10-Year Experience.

OBJECTIVE: To assess the safety and efficacy of balloon dilatation under dual guidance using fluoroscopy and bronchoscopy for treating bronchial stenosis following lung transplantation (LT), and to elucidate the factors associated with patency after the procedure. MATERIALS AND METHODS: From September, 2012, to April, 2021, 50 patients (mean age ± standard deviation, 54.4 ± 12.2 years) with bronchial stenosis among 361 recipients of LT were retrospectively analyzed. The safety of balloon dilatation was assessed by evaluating procedure-related complications. Efficacy was assessed by evaluating the technical success, primary patency, and secondary patency. Primary and secondary cumulative patency rates were calculated using the Kaplan-Meier method. The factors associated with patency after the procedure were evaluated using multivariable Cox hazard proportional regression analysis. RESULTS: In total, 65 bronchi were treated with balloon dilatation in 50 patients. The total number of treatment sessions was 277 and the technical success rate was 99.3% (275/277 sessions). No major procedure-related complications were noted. During the mean follow-up period of 34.6 ± 30.8 months, primary patency was achieved in 12 of 65 bronchi (18.5%). However, the patency rate improved to 76.9% (50 of 65 bronchi) after repeated balloon dilatation (secondary patency). The 6-month, 1-year, 3-year, and 5-year secondary patency rates were 95.4%, 90.8%, 83.1%, and 78.5%, respectively. The presence of clinical symptoms was a significant prognostic factor associated with reduced primary patency (adjusted hazard ratio [HR], 0.465; 95% confidence interval [CI], 0.220-0.987). Early-stage treatment ≤ 6 months (adjusted HR, 3.588; 95% CI, 1.093-11.780) and prolonged balloon dilatation > 5 min (adjusted HR, 3.285; 95% CI, 1.018-10.598) were associated with significantly higher secondary patency. CONCLUSION: Repeated balloon dilatation was determined to be safe and effective for treating bronchial stenosis following LT. Early-stage treatment and prolonged balloon dilatation could significantly promote long-term patency.

Adenomyosis with cavitation and infection after uterine artery embolization: A case report.

Other than the expected abdominal pain post-embolization, only few complications occur after uterine artery embolization (UAE). Necrotic cavitation of adenomyosis is a particularly rare complication. Here, we describe a patient with adenomyosis who experienced persistent fever after UAE, which ultimately resolved with the spontaneous expulsion of adenomyosis.

Feasibility of Deep Learning-Based Analysis of Auscultation for Screening Significant Stenosis of Native Arteriovenous Fistula for Hemodialysis Requiring Angioplasty.

OBJECTIVE: To investigate the feasibility of using a deep learning-based analysis of auscultation data to predict significant stenosis of arteriovenous fistulas (AVF) in patients undergoing hemodialysis requiring percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: Forty patients (24 male and 16 female; median age, 62.5 years) with dysfunctional native AVF were prospectively recruited. Digital sounds from the AVF shunt were recorded using a wireless electronic stethoscope before (pre-PTA) and after PTA (post-PTA), and the audio files were subsequently converted to mel spectrograms, which were used to construct various deep convolutional neural network (DCNN) models (DenseNet201, EfficientNetB5, and ResNet50). The performance of these models for diagnosing ≥ 50% AVF stenosis was assessed and compared. The ground truth for the presence of ≥ 50% AVF stenosis was obtained using digital subtraction angiography. Gradient-weighted class activation mapping (Grad-CAM) was used to produce visual explanations for DCNN model decisions. RESULTS: Eighty audio files were obtained from the 40 recruited patients and pooled for the study. Mel spectrograms of "pre-PTA" shunt sounds showed patterns corresponding to abnormal high-pitched bruits with systolic accentuation observed in patients with stenotic AVF. The ResNet50 and EfficientNetB5 models yielded an area under the receiver operating characteristic curve of 0.99 and 0.98, respectively, at optimized epochs for predicting ≥ 50% AVF stenosis. However, Grad-CAM heatmaps revealed that only ResNet50 highlighted areas relevant to AVF stenosis in the mel spectrogram. CONCLUSION: Mel spectrogram-based DCNN models, particularly ResNet50, successfully predicted the presence of significant AVF stenosis requiring PTA in this feasibility study and may potentially be used in AVF surveillance.

Effects of irreversible electroporation on femoral nerves in a rabbit model.

INTRODUCTION: Irreversible electroporation (IRE) is a novel technique that uses a non-thermal ablation to avoid adjacent major structure injury. The aim of this study was to sequentially evaluate the effects of IRE on the femoral nerve during acute-to-delayed periods in a rabbit model. MATERIAL AND METHODS: Ultrasound-guided IRE of femoral neurovascular bundles was performed in seven rabbits. Functional and histopathologic evaluation was performed sequentially after IRE. The extent of nerve fiber affected, and the proportion of perineurial inflammation and surrounding tissue injury were recorded. RESULTS: After IRE, femoral nerve function was damaged before four weeks, but then gradually returned to normal. Perineural inflammatory cell infiltration was most severe three days after IRE (80-85%), and was normalized after eight weeks. Surrounding tissue injury was prominent at three days and one week after IRE (80-90%), and then gradually recovered. However, peripheral nerve fibers were markedly damaged at one and two weeks (80-100%). Nerve fibers then recovered and were normalized at eight weeks. CONCLUSION: Nerve tissue injury with transient functional impairment can occur after IRE. However, endoneurial and epineurial extracellular matrix were preserved with Schwann cell regeneration, which could lead to regeneration of nerve tissues within eight weeks.

Potential benefit of GnRH-agonist treatment before uterine artery embolization for large fibroids: MRI prediction of fibroid volume reduction.

BACKGROUND: Signal intensity (SI) of predominant fibroid (F1) on T2-weighted (T2W) images is useful for predicting the volume reduction response after gonadotropin-releasing hormone (GnRH)-agonist treatment. Few studies have been published regarding when and how to use GnRH agonist before UAE. PURPOSE: To investigate magnetic resonance imaging (MRI) prediction of volume reduction rate (VRR) of large fibroids after GnRH-agonist treatment before uterine artery embolization (UAE) as well as the efficacy of UAE based on MRI. MATERIAL AND METHODS: Data from 30 patients with a large fibroid and MRI results both before and after GnRH-agonist treatment were retrospectively analyzed. Indications for GnRH-agonist treatment are fibroids with a maximum diameter ≥10 cm or pedunculated submucosal fibroids ≥8 cm. GnRH agonist (3.75 mg leuprolide acetate) was administered subcutaneously once per month 2-6 times. SI of F1 on T2W imaging was measured: the SI was referenced to the SI of the rectus abdominis muscle (F/R). RESULTS: Mean maximum fibroid diameter was 11.1 ± 1.9 cm (range = 8.0-15.5 cm). Mean number of GnRH-agonist injections before UAE was 2.8 (range = 2-6). For predicting VRR ≥50% and <30%, the optimal cut-off values of F/R were 2.58 (sensitivity 80%, specificity 80%) and 1.69 (sensitivity 100%, specificity 70%), respectively. Of the 30 patients, fibroid infarction was complete in 29 (96.7%). CONCLUSION: SI of F1 on T2W imaging is useful for predicting the volume reduction response after GnRH-agonist treatment. After GnRH-agonist treatment for large fibroids, UAE is effective to achieve complete infarction of fibroids.

Surgical Findings and Outcomes of Endotension Following Endovascular Aneurysm Repair.

BACKGROUND: Endotension is one of the detrimental complications after endovascular aneurysm repair (EVAR) and surgical management has been considered as standard of care. However, there is a paucity of data regarding the findings, and outcomes of such surgical intervention. The aim of this study was to investigate intraoperative findings and outcomes of surgical treatment for endotension after EVAR. METHODS: Between January 2005 and October 2018, of the 708 patients who underwent EVAR for aneurysm aortic aneurysm; 12 patients (mean age of 76.1; range 66-88) who underwent open repair for endotension were retrospectively analyzed. The anatomical characteristics of the aorta and surgical findings were reviewed. The rates of early and late procedural complications, and overall mortality were evaluated. RESULTS: The median interval between the EVAR and surgical conversion was 45.9 months (range 17.1-46.9). Three of the twelve patients underwent emergency surgery due to aneurysm rupture. The median aneurysm sac size, the proximal neck diameter, and the proximal neck length before EVAR were 64 mm, 23.5 mm, and 30.5 mm, respectively, that changed before open repair to 93.5 mm (P = 0.02), 25 mm (P = 0.011), and 23 mm (P = 0.003), respectively. In four of the twelve patients, radiographically undetected endoleak was identified during surgery to be Type Ia, Ib, II, and III, respectively. The rates of early and late procedural complications, and overall mortality were 8.3%, 8.3% and 8.3%, respectively. CONCLUSIONS: Patients with endotension have a risk of delayed endoleak and aneurysm rupture; secondary intervention should be performed in such cases to prevent fatal complications. Surgical treatment appears to be a curative treatment for endotension with favorable outcomes. In addition, the possibility of an undetected endoleak should be considered as a potential cause of endotension.

Therapeutic Efficacy of Catheter-directed Ethanol Sclerotherapy and Its Impact on Ovarian Reserve in Patients with Ovarian Endometrioma at Risk of Decreased Ovarian Reserve: A Preliminary Study.

STUDY OBJECTIVE: To investigate the therapeutic efficacy of catheter-directed ethanol sclerotherapy (CDS) and its effect on ovarian reserve in patients with endometrioma at risk of decreased ovarian reserve. DESIGN: Retrospective study. SETTING: Teaching hospital. PATIENTS: We evaluated 18 patients with ovarian endometrioma measuring ≥3 cm and preprocedural serum antimüllerian hormone (AMH) levels of <2 ng/mL. INTERVENTIONS: An 8.5-F catheter was inserted either transabdominally or transvaginally into the endometrioma. After aspiration, sclerotherapy with 99% ethanol was performed, with a subsequent 20-minute ethanol retention. MEASUREMENTS AND MAIN RESULTS: Ultrasonography was performed preprocedurally and 6 months after CDS to evaluate any recurrence or changes in cyst size. Furthermore, serum AMH levels, cancer antigen 125 (CA-125) levels, and the visual analog scale scores for dysmenorrhea were obtained to analyze the ovarian reserve and treatment efficacy, preprocedurally and at 6 months after CDS. The mean cyst size on ultrasonography and serum CA-125 levels decreased 6 months after CDS (p <.001 and p = .001, respectively). All patients reported a decreased visual analog scale score for dysmenorrhea (p <.001). However, the difference in serum AMH levels before and after CDS was statistically insignificant (p = .875). CONCLUSION: CDS was efficacious in reducing pain and serum CA-125 levels in patients with low AMH levels without adversely affecting their ovarian reserve.

Comparison of Retrievability and Indwelling Complications of Celect and Denali Infrarenal Vena Cava Filters: A Randomized, Controlled Trial.

PURPOSE: To compare the Celect and Denali filters in terms of complex filter retrieval and indwelling complications after a 2-month indwelling time. MATERIALS AND METHODS: In this prospective, randomized trial, 153 subjects were assessed for eligibility between May 2016 and July 2018. A total of 136 participants were randomly assigned to receive either Celect (n = 68) or Denali (n = 68) filter placement in the infrarenal inferior vena cava. Tilt angles at placement and retrieval and rates of overall filter retrieval, indwelling complication, and complex retrieval were compared. RESULTS: Of 136 participants (mean age, 62 ± 12.8 years, 55 male), 24 (17.6%) were lost to follow-up. The mean indwelling time of filter was 60.4 ± 7 days and there was no significant difference in the baseline characteristics between the two groups. Filter retrieval was successful in all participants (112/112, 100%). Significantly higher rates of filter tilt > 15° (n = 8) and strut penetration (n = 14) were found with the Celect filter than with the Denali filter (1 significant tilt and 1 penetration) (P = 0.033 and 0.001, respectively). No filter fractures were observed and there was no significant difference in tip embedment, filter fracture, filter migration, or mean fluoroscopy times. There were 3 cases of complex retrieval (1 for Denali vs. 2 for Celect, P = 0.500), for which the loop-snare technique was used. CONCLUSION: Denali filters demonstrated significantly lower rates of tilt angle > 15° and strut penetration. However, there was no significant difference in the complex filter retrieval rate between the Celect and Denali filters.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders.

[Box: see text]With the support of the American College of Obstetricians and Gynecologists, the American Vein & Lymphatic Society, the American Venous Forum, the Canadian Society of Phlebology, the Cardiovascular and Interventional Radiology Society of Europe, the European Venous Forum, the International Pelvic Pain Society, the International Union of Phlebology, the Korean Society of Interventional Radiology, the Society of Interventional Radiology, and the Society for Vascular Surgery.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders.

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology ("SVP") classification for PeVD, includes three domains-Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVPA,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

Laparoscopic pancreaticoduodenectomy with excision of aberrant right hepatic artery after preoperative segmental embolization in mid-bile duct cancer.

Laparoscopic pancreaticoduodenectomy has proven to be a safe and effective alternative to open pancreaticoduodenectomy with similar oncologic outcomes. Cases including excision of the hepatic artery with or without reconstruction during pancreaticoduodenectomy have been reported for periampullary cancer. Here we present a case of an 82-year-old patient who underwent laparoscopic pancreaticoduodenectomy following preoperative arterial embolization of an aberrant right hepatic artery arising from the superior mesenteric artery.