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BACKGROUND AND AIM: Yttrium-90 resin microsphere radioembolization (RE) is not recommended for routine use in intermediate or advanced hepatocellular carcinoma (HCC) by recent guidelines. This study aims to establish pre-treatment variables which predict survival in HCC patients treated with RE to identify those who will benefit most from it, and to inform patient selection for future trials. METHODS: Single center, retrospective study of consecutive patients with HCC treated with RE from 2007 to 2018. Patients included if undergoing their first RE treatment for intermediate or advanced HCC; a Child-Pugh score of B7 or less; and a performance status of 1 or less. Multivariable Cox regression identified variables that were significantly associated with survival. A predictive score was developed based upon coefficients from the fitted Cox regression model, and cubic spline regression was used to identify prognostic groups. RESULTS: One hundred thirteen patients with intermediate (53.1%) and advanced HCC (45.1%) followed for a median of 13.2 months were included. Variables associated with superior survival used to derive the MAAPE score were lower Model for End-Stage Liver Disease score (≤ 7), lower Alpha-fetoprotein (≤ 150 IU/L), higher serum Albumin (> 37 g/L), absence of Portal vein tumor thrombus, and better performance status (Eastern Cooperative Oncology Group = 0). Three survival prognostic groups were identified: good (median overall survival 25.0 months), average (15.3 months), and poor (6.3 months) (overall log-rank test, P < 0.001). CONCLUSION: The MAAPE score accurately identifies HCC patients in whom RE is safe and effective. This will allow for optimal patient selection for future trials of RE versus systemic therapy.
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Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/radioterapia , Embolização Terapêutica/métodos , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/radioterapia , Microesferas , Projetos de Pesquisa , Radioisótopos de Ítrio/administração & dosagem , Idoso , Biomarcadores Tumorais/sangue , Carcinoma Hepatocelular/diagnóstico , Feminino , Humanos , Neoplasias Hepáticas/diagnóstico , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Segurança , Albumina Sérica , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do Tratamento , alfa-FetoproteínasRESUMO
BACKGROUND AND AIMS: 18F-fluorocholine positron emission tomography/computed tomography (18F-FCH PET/CT) is an emerging functional imaging technique in the diagnosis and management of hepatocellular carcinoma (HCC). The aim of this study was to assess the ability of a pre- and post-treatment 18F-FCH PET/CT to predict prognosis and treatment response in early-stage HCC. METHODS: Patients with early- or intermediate-stage HCC planned for locoregional therapy were prospectively enrolled. Baseline demographic and tumor information was collected and baseline and post-treatment 18F-FCH PET/CT performed. Maximum standardized uptake values (SUVmax) were determined for each HCC lesion, and the difference between baseline and post-treatment SUVmax values were compared with progression-free survival outcomes. RESULTS: A total of 29 patients with 39 confirmed HCC lesions were enrolled from a single clinical center. Patients were mostly men (89.7%) with hepatitis C or alcohol-related cirrhosis (65.5%) and early-stage disease (89.7%). Per-patient and per-lesion sensitivity of 18F-FCH PET/CT was 72.4% and 59.0%, respectively. A baseline SUVmax < 13 was associated with a superior median progression-free survival compared with an SUVmax of > 13 (17.7 vs. 5.1 months; p = 0.006). A > 45% decrease in SUVmax between baseline and post-treatment 18F-FCH PET/CT ("responders") was associated with a superior mean progression-free survival than a percentage decrease of < 45% ("non-responders," 36.1 vs. 11.6 months; p = 0.034). CONCLUSIONS: Baseline and post-treatment 18F-FCH PET/CT predicts outcomes in early-stage HCC undergoing locoregional therapy. This technique may identify patients with an objective response post-locoregional therapy who would benefit from further therapy.
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Carcinoma Hepatocelular/diagnóstico por imagem , Colina/análogos & derivados , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Primárias Múltiplas/diagnóstico por imagem , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Compostos Radiofarmacêuticos , Técnicas de Ablação , Idoso , Idoso de 80 Anos ou mais , Braquiterapia , Carcinoma Hepatocelular/etiologia , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/terapia , Quimioembolização Terapêutica , Feminino , Hepatite C Crônica/complicações , Humanos , Cirrose Hepática Alcoólica/complicações , Neoplasias Hepáticas/etiologia , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/terapia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Primárias Múltiplas/etiologia , Neoplasias Primárias Múltiplas/patologia , Neoplasias Primárias Múltiplas/terapia , Hepatopatia Gordurosa não Alcoólica/complicações , Prognóstico , Intervalo Livre de Progressão , Radiocirurgia , Carga TumoralRESUMO
BACKGROUND: The use of directional atherectomy (DA) with or without drug-coated balloon (DCB) may be considered for the management of common femoral artery (CFA) occlusive disease because of its minimally invasive nature with early mobilization, reduced incision complications, and infection rates. However, it has recognized complications, which may be related to the learning curve. We present our initial experience using DA and suggest changes that may, based on our practice, improve outcomes. METHODS: Retrospective analysis with a prospective data collection from 2 centers to analyze outcomes in all consecutive patients treated during 1 year (n = 25). Patients who underwent CFA DA with/without DCB for CFA >70% stenosis. Primary end points include technical success, primary patency of the CFA, morbidity, and mortality. Secondary end points include change in Rutherford-Becker class, length of stay, and target lesion revascularization rate. RESULTS: Between July 2017 and December 2018, 25 patients underwent CFA DA. Two had an occluded CFA, and 23 had >70% CFA stenosis as determined by ultrasound scan (USS) and/or computed tomography angiogram (CTA) preoperatively. There were no deaths within 30 days. Procedure-related complications included 2 cases of CFA pseudoaneurysm (one of them repaired by open surgery) and 1 CFA perforation (repaired with covered stent). No distal embolization or limb loss occurred. Mean length of stay was 1.9 days. Primary and secondary patency at 3 and 6 months was 100%. At 12 months, it was 96%. CONCLUSIONS: Early results suggest that CFA DA with/without DCB is safe and effective. Previous CTA, focused USS, and/or intravascular USS may be useful to minimize the risk of pseudoaneurysm or perforation by excessive thinning of the media. Experience is required to prevent localized dilatation over time.
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Aterectomia/efeitos adversos , Artéria Femoral , Doença Arterial Periférica/terapia , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Aterectomia/mortalidade , Constrição Patológica , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Humanos , Masculino , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Austrália OcidentalRESUMO
This report presents 3 procedures with visceral "chimney stenting" in conjunction with an endovascular aneurysm sealing (EVAS) device, known as chEVAS, for treatment of type 1a endoleak. It includes the first published chEVAS in a patient with previous fenestrated endovascular aneurysm repair (FEVAR). Cases include an 80-year-old man 8 years after FEVAR for a juxtarenal abdominal aortic aneurysm (AAA); an 85-year-old woman 9 months after endovascular aneurysm repair (EVAR) for a ruptured infrarenal AAA; and an 84-year-old woman 3 months after EVAR for a symptomatic infrarenal AAA. Technical success was achieved in all cases, with 1 postoperative death. The remaining 2 patients had no residual type 1a endoleak at 10 and 14 months respectively.
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Aneurisma Roto/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Endoleak/cirurgia , Procedimentos Endovasculares/métodos , Complicações Pós-Operatórias/cirurgia , Stents , Idoso de 80 Anos ou mais , Angiografia , Evolução Fatal , Feminino , Humanos , Masculino , Estudos RetrospectivosRESUMO
PURPOSE: To examine the efficacy, safety, and procedural costs of percutaneous aspiration thrombectomy (PAT) as a first-line treatment for noniatrogenic acute lower limb ischemia (ALI) compared with conventional catheter-directed thrombolysis (CDT). MATERIALS AND METHODS: All patients who underwent endovascular intervention for ALI from January 2015 to August 2017 were included. Fifteen patients were treated with the use of primary PAT and 27 patients were treated with the use of primary CDT. The primary end point was complete thrombus clearance with improvement in Thrombolysis in Myocardial Infarction (TIMI) score. Adjunctive treatment for thrombus removal was considered to indicate technical failure. Treatment of underlying chronic disease was not considered to indicate technical failure. Procedural costs for each patient were calculated by itemizing all disposable equipment, facility overheads, and staff costs. RESULTS: Of the 15 primary PAT patients, technical success was achieved in 8 (53%); the remaining 7 (47%) required adjunctive CDT. Of the 27 primary CDT patients, technical success was achieved in 25 (89%); the remaining 2 (11%) required adjunctive PAT. There were 4 complications in the primary PAT group: 2 were procedure related and of a minor grade. There were 8 complications in the primary CDT group: All were procedure-related, including 2 major groin/retroperitoneal hemorrhage and 1 death from intracranial hemorrhage. Limb salvage was attained in all patients. There were no significant differences in average procedural costs per patient between the 2 groups. CONCLUSIONS: First-line use of PAT for endovascular treatment of ALI can reduce the need for CDT, with no significant cost difference.
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Isquemia/terapia , Extremidade Inferior/irrigação sanguínea , Trombectomia/métodos , Terapia Trombolítica/métodos , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
AIMS: Ultrasound surveillance for hepatocellular carcinoma (HCC) is recommended in cirrhotic patients to allow early diagnosis. This study investigated risk factors for nonsurveillance and advanced HCC at diagnosis and their effect on survival. MATERIALS AND METHODS: Two hundred seventy HCC patients were included. Clinical data were collected from hospital databases. RESULTS: One hundred twenty-eight (47.1%) patients had 6-monthly ultrasound surveillance before HCC diagnosis. Ninety-two (34.1%) patients had advanced HCC (multifocal or total diameter ≥6 cm) at diagnosis. The nonsurveillance rate was significantly higher in nonalcoholic fatty liver disease (NAFLD) (79%) compared with other causes of chronic liver disease (31.6% to 58.1%, P<0.001). Nonrecognition of NAFLD was significantly higher (68.4%) compared with other causes of chronic liver disease (0% to 23.2%, P<0.001). In NAFLD HCC patients, 23.7% were noncirrhotic and smoking was significantly associated HCC in this noncirrhotic group (P=0.041). No-surveillance for HCC was significantly associated with advanced HCC at diagnosis with an odds ratio (OR) of 8.1. Compared with nondrinkers, heavy alcohol consumption was significantly associated with advanced HCC (OR=7.6). In the surveillance group, diagnosis using computed tomography rather than magnetic resonance imaging was significantly associated with advanced HCC (OR=3.36). Patients without HCC surveillance had a significantly shorter median survival compared with those who had HCC surveillance (27.4 vs. 52.0 mo, P=0.0006). CONCLUSIONS: The lack of HCC surveillance is associated with advanced HCC at diagnosis and decreased survival. NAFLD patients with HCC have a significantly lower rate of diagnosis of chronic liver disease and HCC surveillance compared with the other causes of chronic liver disease.
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Carcinoma Hepatocelular/diagnóstico por imagem , Detecção Precoce de Câncer/métodos , Cirrose Hepática/diagnóstico por imagem , Neoplasias Hepáticas/diagnóstico por imagem , Hepatopatia Gordurosa não Alcoólica/diagnóstico por imagem , Ultrassonografia , Idoso , Consumo de Bebidas Alcoólicas/efeitos adversos , Carcinoma Hepatocelular/etiologia , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/terapia , Doença Crônica , Bases de Dados Factuais , Feminino , Humanos , Cirrose Hepática/complicações , Cirrose Hepática/mortalidade , Cirrose Hepática/terapia , Neoplasias Hepáticas/etiologia , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/terapia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Hepatopatia Gordurosa não Alcoólica/complicações , Hepatopatia Gordurosa não Alcoólica/mortalidade , Hepatopatia Gordurosa não Alcoólica/terapia , Valor Preditivo dos Testes , Estudos Prospectivos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fumar/efeitos adversos , Fatores de Tempo , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND AND AIMS: The Hong Kong Liver Cancer (HKLC) system proposes to triage hepatocellular carcinoma (HCC) patients to more aggressive treatment and may be associated with superior survival compared with the Barcelona Clinic Liver Cancer (BCLC) system. We aimed to identify the influence of adherence to HKLC or BCLC treatment recommendations on survival and time to progression. METHODS: We examined a prospectively enrolled cohort of 292 patients undergoing 532 treatment episodes from a single clinical center. RESULTS: The BCLC and HKLC systems accurately predicted overall survival and time to progression after each treatment episode (BCLC: p < 0.001; HKLC: p < 0.001). Adherence to treatment recommendations was higher for HKLC than for BCLC (55.6 vs. 47.9%, p = 0.01). Survival was superior with adherence to HKLC recommendations compared to non-adherence (45.3 vs. 27.1 months, p < 0.001). There was no difference in survival in BCLC with adherence compared to non-adherence (34.6 vs. 32.3 months, p = 0.96). The survival benefit was limited to early- and very early stage disease for both HKLC (p < 0.001) and BCLC (p = 0.007). More patients were triaged to curative therapies by HKLC than BCLC (p = 0.004). The use of transarterial chemoembolization instead of ablation or resection in early- and very early stage disease for technical reasons was the major cause for non-recommended treatment and was associated with worse survival (p < 0.001). CONCLUSIONS: These data support the use of HKLC in early- and very early stage HCC. Efforts should be made to overcome technical reasons for not performing ablation in early- and very early stage disease.
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Carcinoma Hepatocelular/diagnóstico , Detecção Precoce de Câncer/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Neoplasias Hepáticas/diagnóstico , Triagem/estatística & dados numéricos , Adulto , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/terapia , Quimioembolização Terapêutica/métodos , Quimioembolização Terapêutica/normas , Progressão da Doença , Detecção Precoce de Câncer/normas , Feminino , Hong Kong , Humanos , Estimativa de Kaplan-Meier , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/terapia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Prospectivos , Estudos Retrospectivos , Espanha , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Sutton-Kadir Syndrome (SKS) describes true inferior pancreaticoduodenal artery (IPDA) aneurysms in the setting of coeliac artery (CA) stenosis or occlusion. Although rare, SKS aneurysms can rupture and cause morbidity. Due to its rarity and lack of controlled treatment data, correct treatment for the CA lesion is currently unknown. Our aim was to assess if endovascular embolisation alone was safe and effective in treatment of SKS aneurysms, in emergent and elective settings. Secondary objectives were to describe presentation and imaging findings. METHODS: A retrospective cohort study of patients treated at Sir Charles Gairdner Hospital between January 2014 and December 2021 was done. Data on presentation, diagnostics, aneurysm characteristics, CA lesion aetiology, treatment and outcomes were extracted from chart review. RESULTS: Twenty-four aneurysms in 14 patients were identified. Rupture was seen in 7/15 patients. Most aneurysms (22/24) were in the IPDA or one of its anterior or posterior branches. Median arcuate ligament (MAL) compression was identified in all. There was no difference in median (IQR) maximal transverse diameter between ruptured and non-ruptured aneurysms (6 mm (9), 12 mm (6), P = 0.18). Of ruptures, 6/7 had successful endovascular embolisation and 1/7 open surgical ligation. Of non-ruptures, 6/7 had successful endovascular embolisation, 1/7 open MAL division then endovascular CA stenting and aneurysm embolisation. No recurrences or new aneurysms were detected with computed tomography or magnetic resonance angiography over a median (IQR) follow-up period of 30 (10) months in 12 patients. CONCLUSION: Endovascular embolisation of SKS aneurysms without treatment of MAL compression is safe and effective in both the emergent and elective settings.
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Embolização Terapêutica , Procedimentos Endovasculares , Humanos , Embolização Terapêutica/métodos , Estudos Retrospectivos , Feminino , Masculino , Pessoa de Meia-Idade , Procedimentos Endovasculares/métodos , Artéria Celíaca/diagnóstico por imagem , Aneurisma/diagnóstico por imagem , Aneurisma/terapia , Idoso , Duodeno/irrigação sanguínea , Duodeno/diagnóstico por imagem , Adulto , Pâncreas/irrigação sanguínea , Pâncreas/diagnóstico por imagem , Resultado do Tratamento , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/terapiaAssuntos
Oclusão com Balão/métodos , Encefalopatia Hepática/diagnóstico por imagem , Encefalopatia Hepática/terapia , Derivação Esplenorrenal Cirúrgica/efeitos adversos , Instrumentos Cirúrgicos , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Varizes Esofágicas e Gástricas/terapia , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
Introduction The Flixene™ vascular graft (Maquet-Atrium Medical, Hudson, NH) has emerged as a new generation synthetic graft, which allows for early needling for haemodialysis. Most studies have shown satisfactory early results. The aim of this study is to report on long-term outcomes of the Flixene graft over eight years in a cohort of patients. Methods From February 2011 to September 2019, 61 patients had 64 arteriovenous graft fistulas (AVGs) by using the Flixene grafts. The median patient age was 67 years; the male to female ratio was 30:31. Diabetes was the reason for the majority of kidney failures (57%). The configuration of the grafts used was mostly upper arm straight AVG. The primary patency rate, secondary patency rate, and surgical complications were assessed. Results In a median follow-up of three years (interquartile range (IQR): 2 - 6), 36 of the AVGs required a fistulogram. Venous side stenosis was the most common cause of high venous pressure or AVG occlusion in 97%. The one-year primary patency rate was 30%. The secondary patency rate was 94.8%, 83.7%, and 77.7% at one, three, and five years, respectively. The longest functional AVG was observed for up to seven years. Conclusions This study has shown satisfactory long-term results of the Flixene graft used for hemodialysis. The Flixene graft could be needled within 72 hours without increased complications, which allows the creation of an AVG under an emergency setting to avoid the placement of a central venous catheter (CVC). This strategy should be advocated in future clinical practice.
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Embolização Terapêutica , Púrpura Trombocitopênica Idiopática , Ruptura Esplênica , Trombocitopenia , Vacinas , Embolização Terapêutica/efeitos adversos , Humanos , Púrpura Trombocitopênica Idiopática/complicações , Púrpura Trombocitopênica Idiopática/terapia , Ruptura Esplênica/diagnóstico por imagem , Ruptura Esplênica/etiologia , Ruptura Esplênica/cirurgia , Trombocitopenia/induzido quimicamente , Trombocitopenia/complicações , Trombocitopenia/terapia , Vacinas/efeitos adversosRESUMO
BACKGROUND: A review of the effectiveness and outcomes in liver abscess drainage performed by different operators using percutaneous aspiration (PA) and catheter drainage (PCD), respectively, from 2008-2013 at Sir Charles Gairdner Hospital, a tertiary hospital in Australia. METHODS: Forty-two patients (29 males and 13 females; aged between 28-93 years; median age of 67 years) with liver abscesses underwent either ultrasound or CT-guided PA (n=22) and PCD (n=20) in conjunction with appropriate antimicrobial therapy. A median of 18 Gauge needle and 10 French catheters were utilised. RESULTS: Nineteen (86.4 per cent) PA cases and 12 (60 per cent) PCD cases were successfully drained on a single attempt (p=0.08). More male patients (69 per cent) than females (31 per cent) were observed. Portal sepsis (42.9 per cent) was the most common cause identified. Fever (47.6 per cent) was the most frequent clinical presentation on admission. Thirty-two patients (76.2 per cent) had solitary abscesses with a right lobe (59.5 per cent) predilection. CRP was significantly raised. The PCD group observed a significantly larger abscess size (p=0.01). Klebsiella pneumoniae was the most common organism isolated in both pus (33.3 per cent) and blood cultures (11.9 per cent). Five procedure-related complications were noted, all in the PCD group. Thirty-day mortality was 2.4 per cent. No difference was observed in clinical and treatment outcomes in both groups. CONCLUSION: The null hypothesis that both PA and PCD are equally effective in the drainage of liver abscess cannot be rejected. Apart from PA being simpler and safer to perform, the higher incidence of indwelling catheter-associated complications suggests that a trial of PA should always be attempted first.
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PURPOSE: Avoidance of nontarget microsphere deposition via hepatoenteric anastomoses is essential to the safety of yttrium-90 radioembolization (RE). The hepatic hilar arterial network may remain partially patent after coil embolization of major arteries, resulting in persistent risk. We retrospectively reviewed cases where n-butyl cyanoacrylate (n-BCA) glue embolization was used to facilitate endovascular hepatic arterial skeletonization before RE. METHODS: A total of 543 RE procedures performed between June 2004 and March 2012 were reviewed, and 10 were identified where n-BCA was used to embolize hepatoenteric anastomoses. Arterial anatomy, prior coil embolization, and technical details were recorded. Outcomes were reviewed to identify subsequent complications of n-BCA embolization or nontarget RE. RESULTS: The rate of complete technical success was 80 % and partial success 20 %, with one nontarget embolization complication resulting in a minor change in treatment plan. No evidence of gastrointestinal or biliary ischemia or infarction was identified, and no microsphere-related gastroduodenal ulcerations or other evidence of nontarget RE were seen. Median volume of n-BCA used was <0.1 ml. CONCLUSION: n-BCA glue embolization is useful to eliminate hepatoenteric networks that may result in nontarget RE, especially in those that persist after coil embolization of major vessels such as the gastroduodenal and right gastric arteries.