Intranodal Lymphangiography and Embolization for Management of Iatrogenic Chylous Ascites after Oncological Surgery.

PURPOSE: To investigate the safety and effectiveness of intranodal lymphangiography (INL) and lymphatic embolization (LE) in management of chylous ascites after oncologic surgery. MATERIALS AND METHODS: Retrospective review of records of patients who underwent INL with or without LE from January 2017 to June 2022 was performed. Adult patients with chylous ascites after oncologic surgery referred to interventional radiology after failure of conservative treatment were included. Thirty-nine patients who underwent 55 procedures were included (34 males and 5 females). Data on patient demographics, procedural technique, outcomes, and follow-up were collected. Descriptive statistics were used to illustrate technical success, clinical success, and adverse events. Univariate logistic regression analysis was performed to evaluate factors predicting clinical success. RESULTS: INL was technically successful in 54 of 55 procedures (98%; 95% confidence interval [CI], 90%-100%). A lymphatic leak was identified in 40 procedures, and LE was attempted in 36. LE was technically successful in 33 of the 36 procedures (92%; 95% CI, 78%-98%). Clinical success, defined as resolution of ascites with no need for peritoneovenous shunt placement or additional surgery, was achieved in 22 of 39 patients (56%; 95% CI, 40%-72%). Clinical success was achieved in 18 patients after 1 procedure, and patients who required repeat procedures were less likely to achieve clinical success (odds ratio, 0.16; 95% CI, 0.04-0.66; P = .012). Four grade 1 procedural adverse events were recorded. CONCLUSIONS: INL with or without LE is a safe minimally invasive tool that can help patients with chylous ascites after oncologic surgery who failed conservative treatment avoid more invasive interventions.

Preclinical assessment of a mathematical model for ablation zone prediction in thyroid laser ablation.

To develop and validate a 3D simulation model to calculate laser ablation (LA) zone size and estimate the volume of treated tissue for thyroid applications, a model was developed, taking into account dynamic optical and thermal properties of tissue change. For validation, ten Yorkshire swines were equally divided into two cohorts and underwent thyroid LA at 3 W/1,400 J and 3 W/1,800 J respectively with a 1064-nm multi-source laser (Echolaser X4 with Orblaze™ technology; ElEn SpA, Calenzano, Italy). The dataset was analyzed employing key statistical measures such as mean and standard deviation (SD). Model simulation data were compared with animal gross histology. Experimental data for longitudinal length, width (transverse length), ablation volume and sphericity were 11.0 mm, 10.0 mm, 0.6 mL and 0.91, respectively at 1,400 J and 14.6 mm, 12.4 mm, 1.12 mL and 0.83, respectively at 1,800 J. Gross histology data showed excellent reproducibility of the ablation zone among same laser settings; for both 1,400 J and 1,800 J, the SD of the in vivo parameters was ≤ 0.7 mm, except for width at 1,800 J, for which the SD was 1.1 mm. Simulated data for longitudinal length, width, ablation volume and sphericity were 11.6 mm, 10.0 mm, 0.62 mL and 0.88, respectively at 1,400 J and 14.2 mm, 12.0 mm, 1.06 mL and 0.84, respectively at 1,800 J. Experimental data for ablation volume, sphericity coefficient, and longitudinal and transverse lengths of thermal damaged area showed good agreement with the simulation data. Simulation datasets were successfully incorporated into proprietary planning software (Echolaser Smart Interface, Elesta SpA, Calenzano, Italy) to provide guidance for LA of papillary thyroid microcarcinomas. Our mathematical model showed good predictability of coagulative necrosis when compared with data from in vivo animal experiments.

Feasibility and Safety of Percutaneous CT-Guided Bone Biopsies in Patients with Cancer Using a Patient-Mounted Robotic System: A Retrospective Analysis of 40 Consecutive Biopsies.

This retrospective study evaluated the feasibility and safety of percutaneous computed tomography (CT)-guided bone biopsies in patients with cancer using a patient-mounted robotic system with steering capabilities. The study included 39 patients (17 women, 22 men; median age, 65.5 years; interquartile range [IQR], 54.8-71.0 years). Forty biopsies were performed in the pelvis, spine, ribs, shoulder, femur, and sternum. The technical success rate was 100%, and the median trajectory length was 55.9 mm (IQR, 47.1-73.6 mm). Intermediate checkpoints were used in 8 biopsies. Median time from the first to final scan was 21 minutes (IQR, 17-37 minutes). The overall procedure time was 30 minutes (IQR, 24-36 minutes). The median dose length product and effective dose were 536.6 mGy⋅cm (IQR, 396.2-837.7 mGy∗cm) and 7.1 mSv (IQR, 4.7-10.8 mSv), respectively. No adverse events occurred. The diagnostic yield for cancer was 72.5%. Percutaneous robotic-assisted bone biopsies demonstrated high technical success, adequate diagnostic yield, and favorable safety profile.

Stent Graft Placement for the Treatment of Hepatic Artery Injury in Patients with Cancer: Primary Patency and Clinical Outcomes.

PURPOSE: To evaluate the safety, primary patency, and clinical outcomes of hepatic artery stent graft (SG) placement for vascular injuries. MATERIALS AND METHODS: Patients treated with hepatic arterial SG placement for vascular injuries between September 2018 and September 2021 were reviewed. Data on demographic characteristics, indication, stent graft characteristics, antiplatelet/anticoagulant use, clinical success rate, complications, and type of follow-up imaging were collected. Follow-up images were reviewed by 2 independent reviewers to assess primary patency. A time-to-event analysis was performed. The median duration of stent graft patency was estimated using Kaplan-Meier curves. A Cox proportional hazard model was used to evaluate factors related to stent graft patency. RESULTS: Thirty-five patients were treated with hepatic arterial SG placement, 11 for postoperative bleeds and 24 for hepatic artery infusion pump catheter-related complications. Clinical success was achieved in 32 (91%) patients (95% CI, 77-98). The median primary patency was 87 days (95% CI, 73-293). Stent grafts of ≥6-mm diameter retained patency for a longer duration than that with stent grafts of smaller diameters (6 mm vs 5 mm; hazard ratio, 0.35; 95% CI, 0.14-0.88; P = .026; and 7+ mm vs 5 mm; hazard ratio, 0.27; 95% CI, 0.09-0.83; P = .023). Anticoagulation/antiplatelet regimen was not associated with increased stent graft patency duration (P > .05). Only minor complications were reported in 2 (5.7%) patients. CONCLUSIONS: Stent grafts can be used safely and effectively to treat injuries of the hepatic artery. Stent graft diameters of ≥6 mm seem to provide more durable patency.

Preoperative Embolization of Metastatic Spinal Cord Compression with n-Butyl Cyanoacrylate: Safety and Effectiveness in Limiting Blood Loss.

PURPOSE: To evaluate the safety and effectiveness of preoperative embolization with n-butyl cyanoacrylate (nBCA) performed for metastatic spinal cord compression (MSCC) in limiting blood loss (BL). MATERIALS AND METHODS: In this institutional review board-approved retrospective study, clinical records from 2017 to 2022 were reviewed. Twenty consecutive patients (11 men and 9 women; mean age, 65.8 years ± 10.0; range, 45-82 years) underwent 21 preoperative spine tumor embolizations with nBCA. Angiograms were used to calculate the percentage reduction in tumor vascularity, and relevant clinical data (levels studied and embolized, fluoroscopy time [FT], reference dose [RD], and Kerma area product [KAP]) and operative data (BL and operative time [OT]) were analyzed. Adverse events and outcomes were recorded. RESULTS: A median of 2 levels were embolized per procedure (range, 1-5) but 4.9 were studied (range, 1-10). After embolization, tumor blush was reduced by a median of 87.3% (range, 50%-90%). The mean FT was 41 minutes ± 15.4 (range, 16-67 minutes), the mean RD was 1,977.1 mGy ± 1,794.3 (range, 450.2-6,319 mGy), and the mean KAP was 180.5 Gy·cm2 ± 166.2 (range, 30.4-504 Gy·cm2). The adverse event rate was 1 (4.7%) of the 21 embolizations because a weakness of lower extremities related to swelling was observed. Surgery was performed at a mean of 1.4 days ± 1 (range, 1-5 days) after embolization. The mean surgical estimated BL was 432.5 mL ± 328.5 (range, 25-1,100 mL), and the mean OT was 210.1 minutes ± 97.4 (range, 57-489 minutes). CONCLUSIONS: Preoperative embolization of tumors resected for MSCC with nBCA is a safe procedure allowing for performance of surgery with acceptable BL.

An Aniline-Substituted Bile Salt Analog Protects both Mice and Hamsters from Multiple Clostridioides difficile Strains.

Clostridioides difficile infection (CDI) is the major identifiable cause of antibiotic-associated diarrhea. The emergence of hypervirulent C. difficile strains has led to increases in both hospital- and community-acquired CDI. Furthermore, the rate of CDI relapse from hypervirulent strains can reach up to 25%. Thus, standard treatments are rendered less effective, making new methods of prevention and treatment more critical. Previously, the bile salt analog CamSA (cholic acid substituted with m-aminosulfonic acid) was shown to inhibit spore germination in vitro and protect mice and hamsters from C. difficile strain 630. Here, we show that CamSA was less active in preventing spore germination by other C. difficile ribotypes, including the hypervirulent strain R20291. The strain-specific in vitro germination activity of CamSA correlated with its ability to prevent CDI in mice. Additional bile salt analogs were screened for in vitro germination inhibition activity against strain R20291, and the most active compounds were tested against other strains. An aniline-substituted bile salt analog, CaPA (cholic acid substituted with phenylamine), was found to be a better antigerminant than CamSA against eight different C. difficile strains. In addition, CaPA was capable of reducing, delaying, or preventing murine CDI signs with all strains tested. CaPA-treated mice showed no obvious toxicity and showed minor effects on their gut microbiome. CaPA's efficacy was further confirmed by its ability to prevent CDI in hamsters infected with strain 630. These data suggest that C. difficile spores respond to germination inhibitors in a strain-dependent manner. However, careful screening can identify antigerminants with broad CDI prophylaxis activity.

Lymphatic Interventions in the Cancer Patient.

PURPOSE OF REVIEW: The incidence of lymphatic leakage (iatrogenic and non-iatrogenic) is growing in cancer population due to the increased complexity of the surgical procedures and improved overall survival in cancer patients. The purpose of this article is to review the contemporary approach in the field of percutaneous lymphatic embolization in cancer patients with lymphatic leaks. RECENT FINDINGS: Since the advent of intranodal lymphangiography in 2011 alongside with the MR and CT lymphangiography, the accuracy of diagnosis of the lymphatic diseases has significantly improved significantly. These advancements have triggered a revival of minimally invasive lymphatic interventions. Lymphatic embolization is expanding from the classic indication, thoracic duct embolization, to other lymphatic disorders (chylous ascites, lymphoceles, liver lymphorrhea, protein-losing enteropathy). The growth of lymphatic research and the standardization of the lymphatic interventions require a multidisciplinary and collaborative approach between physicians and researchers.

Interventional Management of Portal Hypertension in Cancer Patients.

PURPOSE OF REVIEW: To provide an overview of the classifications and clinical hallmarks of common cancer-related conditions that contribute to the high incidence of portal hypertension in this population and provide an update on currently available interventional radiology therapeutic approaches. RECENT FINDINGS: In the last few decades, there have been significant advancements in understanding the pathophysiology of portal hypertension. This knowledge has led to the development of safer and more effective minimally invasive approaches. The main objective is to provide alternatives to prevent life-threatening complications from clinically significant portal hypertension and to allow the continuation of cancer treatment interventions that would otherwise be stopped. Clinicians involved in cancer care should be aware of risk factors, associated complications, and management of portal hypertension in cancer patients. Interventional radiology offers minimally invasive alternatives that play a central role in improving clinical outcomes and survival of these patients, allowing the continuation of cancer treatments.

Percutaneous liver venous deprivation: outcomes in heavily pretreated metastatic colorectal cancer patients.

BACKGROUND: To evaluate liver venous deprivation (LVD) outcomes in patients with colorectal liver metastasis (CRLM) heavily pretreated with systemic and hepatic arterial infusion pump (HAIP) chemotherapies that had an anticipated insufficient future liver remnant (FLR) hypertrophy after portal vein embolization (PVE). METHODS: PVE was performed with liquid embolics using a transsplenic or ipsilateral transhepatic approach. Simultaneously and via a trans-jugular approach, the right hepatic vein was embolized with vascular plugs. Liver volumetry was assessed on computed tomography before and 3-6 weeks after LVD. RESULTS: Twelve consecutive CRLM patients that underwent LVD before right hepatectomy or trisectionectomy were included, all previously treated with systemic chemotherapy for a mean of 11.9 months. Six patients had additional HAIP. After embolization, FLR ratio increased from 28.7% ± 5.9 to 42.2% ± 9.0 (P < 0.01). Mean kinetic growth rate (KGR) was 3.56%/week ± 2.3, with a degree of hypertrophy (DH) of 13.8% ± 7.1. In the HAIP subgroup, mean KGR and DH were respectively 3.58%/week ± 2.8 and 14.3% ± 8.7. No severe complications occurred. Ten patients reached surgery after 39 days ± 7.5. CONCLUSION: In heavily pretreated patients, LVD safely stimulated a rapid and effective FLR hypertrophy, with a resultant high rate of resection.

Percutaneous Lymphatic Embolization as Primary Management of Pelvic and Retroperitoneal Iatrogenic Lymphoceles.

PURPOSE: To evaluate the efficacy of lymphatic embolization (LE) in decreasing catheter output and dwell time in iatrogenic lymphoceles after percutaneous catheter drainage. MATERIALS AND METHODS: Retrospective review of patients who underwent intranodal lymphangiography (INL) with or without LE for management of iatrogenic lymphoceles between January 2017 and November 2020 was performed. Twenty consecutive patients (16 men and 4 women; median age, 60.5 years) underwent a total of 22 INLs and 18 LEs for 15 pelvic and 5 retroperitoneal lymphoceles. Lymphatic leaks were identified in 19/22 (86.4%) of the INLs. Three patients underwent INL only because a leak was not identified or was identified into an asymptomatic lymphocele. One patient underwent repeat INL and LE after persistent high catheter output, and 1 patient underwent repeat INL with LE after the initial INL did not identify a leak. Catheter output was assessed until catheter removal, and changes in output before and after the procedure were reported. The patients were followed up for 2-30 months, and procedural complications were reported. RESULTS: The median catheter output before the procedure was 210 mL/day (50-1,200 mL/day), which decreased to a median of 20 mL/day (0-520 mL/day) 3 days after the procedure, with a median output decrease of 160 mL (0-900 mL). The median time between INL with LE and catheter removal was 6 days, with no recurrence requiring redrainage. Four patients experienced minor complications of low-grade fever (n = 2) and lower limb edema (n = 2). CONCLUSIONS: Lymphangiogram and LE are safe and effective methods for the management of lymphoceles.

Studies on the Importance of the 7α-, and 12α- hydroxyl groups of N-Aryl-3α,7α,12α-trihydroxy-5ß-cholan-24-amides on their Antigermination Activity Against a Hypervirulent Strain of Clostridioides (Clostridium) difficile.

Chenodeoxycholic acid (CDCA) is a natural germination inhibitor for C. difficile spores. In our previous study (J. Med. Chem., 2018, 61, 6759-6778), we identified N-phenyl-3α,7α,12α-trihydroxy-5ß-cholan-24-amide as an inhibitor of C. difficile strain R20291 with an IC50 of 1.8 µM. Studies of bile salts on spore germination have shown that chenodeoxycholate, ursodeoxycholate and lithocholate are more potent inhibitors of germination compared to cholate. Given this, we created amide analogs of chenodeoxycholic, deoxycholic, lithocholic and ursodeoxycholic acids using amines identified from our previous studies. We found that chenodeoxy- and deoxycholate derivatives were active with potencies equivalent to those for cholanamides. This indicates that only 2 out of the 3 hydroxyl groups are needed for activity and that the alpha stereochemistry at position 7 is required for inhibition of spore germination.

Treatment of Chylous Ascites with Peritoneovenous Shunt (Denver Shunt) following Retroperitoneal Lymph Node Dissection in Patients with Urological Malignancies: Update of Efficacy and Predictors of Complications.

PURPOSE: We investigated the efficacy and analyzed the complication risk factors of peritoneovenous shunt in treating refractory chylous ascites following retroperitoneal lymph node dissection in patients with urological malignancies. MATERIALS AND METHODS: From April 2001 to March 2019 all patients with refractory chylous ascites after retroperitoneal lymph node dissection treated with peritoneovenous shunt were reviewed. Demographic characteristics, technical success, efficacy, patency period and complications were studied. Univariate and multivariate logistic regression analysis was performed to identify predictors of complications. RESULTS: Twenty patients were included in this study. Testicular cancer was the most common malignancy (85%). The mean number of days from surgery to detection of chylous ascites was 21 days (SD 15, range 4 to 65). Ascites permanently resolved after peritoneovenous shunt in 18 patients (90%), leading to shunt removal in 17 patients (85%) between 46 and 481 days (mean 162, SD 141). The mean serum albumin level increased 24% after shunt placement (mean 3.0±0.6 gm/dl before, 3.9±0.8 gm/dl after, p <0.05). The most common complication was occlusion (30%). Relative risk of complications increased significantly when shunt placement was more than 70 days after surgery and in patients with more than 5 paracenteses before peritoneovenous shunt placement (AR 0.71% vs 0.25%, RR 2.9, p <0.048 and AR 0.6% vs 0.125%, RR 4.8, p <0.04, respectively). CONCLUSIONS: Peritoneovenous shunt permanently treated chylous ascites in 90% of patients after retroperitoneal lymph node dissection. Peritoneovenous shunt was removed in 85% of patients. Shunt placement is an effective and safe treatment option for refractory chylous ascites. These patients might benefit from earlier intervention, after 4 to 6 weeks of conservative management as opposed to 2 to 3 months.

Effect of the Synthetic Bile Salt Analog CamSA on the Hamster Model of Clostridium difficile Infection.

Clostridium difficile infection (CDI) is the leading cause of antibiotic-associated diarrhea and has gained worldwide notoriety due to emerging hypervirulent strains and the high incidence of recurrence. We previously reported protection of mice from CDI using the antigerminant bile salt analog CamSA. Here we describe the effects of CamSA in the hamster model of CDI. CamSA treatment of hamsters showed no toxicity and did not affect the richness or diversity of gut microbiota; however, minor changes in community composition were observed. Treatment of C. difficile-challenged hamsters with CamSA doubled the mean time to death, compared to control hamsters. However, CamSA alone was insufficient to prevent CDI in hamsters. CamSA in conjunction with suboptimal concentrations of vancomycin led to complete protection from CDI in 70% of animals. Protected animals remained disease-free at least 30 days postchallenge and showed no signs of colonic tissue damage. In a delayed-treatment model of hamster CDI, CamSA was unable to prevent infection signs and death. These data support a putative model in which CamSA reduces the number of germinating C. difficile spores but does not keep all of the spores from germinating. Vancomycin halts division of any vegetative cells that are able to grow from spores that escape CamSA.

Hepatic artery infusion of melphalan in patients with liver metastases from ocular melanoma.

BACKGROUND AND OBJECTIVES: Ocular melanoma has a predilection for liver metastases. Systemic treatment is ineffective and the optimal regional therapy approach is poorly defined. Isolated hepatic perfusion (IHP) with melphalan has emerged as a viable treatment option, however a subset of patients are not candidates for this treatment. We therefore sought to determine if melphalan could be safely administered via the hepatic artery for these patients. METHODS: A retrospective review of patients treated with hepatic artery infusion (HAI) of melphalan was undertaken. All patients had contraindications to IHP and were without other therapy options. Melphalan infusion was repeated every four weeks with consideration for dose escalation in the absence of toxicity or significant disease progression. RESULTS: Fourteen patients were treated with HAI of melphalan from 2010 to 2015. All patients had hepatic dysfunction or prohibitive tumor volume precluding IHP. There were no procedure-related complications. Three patients (21%) died within 30 days and the median survival was 2.9 months. Elevated baseline bilirubin > 2.5 mg/dL was associated with worse overall survival (0.93 vs 6.3 months, P < 0.05). CONCLUSION: HAI of melphalan is safe and feasible for patients with metastatic ocular melanoma. Further study to determine the optimal utilization of this treatment approach is warranted.

Initial Treatment of Unresectable Neuroendocrine Tumor Liver Metastases with Transarterial Chemoembolization using Streptozotocin: A 20-Year Experience.

BACKGROUND: The majority of patients with neuroendocrine tumor liver metastases (NELM) present with multifocal disease and are not surgical candidates. We present our 20-year experience with transarterial chemoembolization (TACE) using streptozotocin (STZ) in patients with initially unresectable NELM. METHODS: Patients with unresectable NELM treated with TACE using STZ at a single institution from 1995 to 2015 were identified after institutional board approval. Imaging was independently reviewed by a radiologist to evaluate for RECIST 1.1 responses. RESULTS: Ninety-one patients with NELM who underwent 474 TACE treatments during the past 20 years were identified. Median age was 62 years, and 54 % of the patients were females. Median number of TACE treatments per patient was four (range 1-22). TACE treatment with STZ was very well tolerated with 10.3 % of treatments being associated with side effects, predominantly transient, including hyper/hypotension, bradycardia, or postembolization syndrome. Median overall survival from the start of TACE was 44 months (5-year OS from TACE 40.8 % and 5-year PFS 20.3 %), and 54 % of the patients who had carcinoid syndrome reported improved symptoms after TACE treatments. Age, grade, liver tumor burden, and ability to undergo multiple TACE treatments were independent predictors of overall survival in multivariable analysis. Chromogranin A levels >115 ng/ml were associated with worse overall survival (p < 0.001). CONCLUSIONS: In patients with unresectable NELM, TACE with STZ is well tolerated with minimal toxicity and can lead to diminished carcinoid syndrome and long-term survival. This is a novel, conservative approach for the initial treatment of unresectable NELM.

Comparative Analysis of Intranodal Lymphangiography with Percutaneous Intervention for Postsurgical Chylous Effusions.

PURPOSE: To evaluate clinical success and time to resolution of intranodal lymphangiography (INL) alone or with thoracic duct embolization (TDE) or thoracic duct disruption (TDD) based on initial effusion volume for postsurgical chylothorax. MATERIALS AND METHODS: Retrospective review was performed of 57 patients (mean age 63 y; 65% male) undergoing INL alone or in conjunction with other percutaneous techniques for postsurgical chylous effusions. INL alone was performed when chylothorax output was ≤ 500 mL/d and no leak was identified during fluoroscopy. RESULTS: INL was technically successful in all patients. There was 1 major and 2 minor complications. Clinical success rate was 71% (40/56). Clinical success rate meeting algorithmic inclusion criteria was 71.4% (5/7) for INL only, 41.7% (5/12) in INL with TDD, and 90.5% (19/21) in INL with TDE. Hazard ratio (HR) of clinical success of INL with TDE versus INL only was not statistically significant (HR 2.3, 95% confidence interval [CI], 0.70-5.87, P = .19). Median time to resolution was 14 days for INL only (95% CI, 0 days to not reached), 7 days for INL with TDD (95% CI, 4 days to not reached), and 3 days for INL with TDE (95% CI, 2 to 5 days) (P = .007). No statistically significant difference in median time to resolution existed between INL with TDE and INL only (P = .04). CONCLUSION: In patients with postsurgical chylothorax, INL alone had similar rates of clinical success and time to resolution compared with INL with TDE when initial effusion volume was ≤ 500 mL/d and no leak was visualized during fluoroscopy.

Inhibitory effect of indole analogs against Paenibacillus larvae, the causal agent of American foulbrood disease.

Paenibacillus larvae, a Gram-positive bacterium, causes American foulbrood (AFB) in honey bee larvae (Apis mellifera Linnaeus [Hymenoptera: Apidae]). P. larvae spores exit dormancy in the gut of bee larvae, the germinated cells proliferate, and ultimately bacteremia kills the host. Hence, spore germination is a required step for establishing AFB disease. We previously found that P. larvae spores germinate in response to l-tyrosine plus uric acid in vitro. Additionally, we determined that indole and phenol blocked spore germination. In this work, we evaluated the antagonistic effect of 35 indole and phenol analogs and identified strong inhibitors of P. larvae spore germination in vitro. We further tested the most promising candidate, 5-chloroindole, and found that it significantly reduced bacterial proliferation. Finally, feeding artificial worker jelly containing anti-germination compounds to AFB-exposed larvae significantly decreased AFB infection in laboratory-reared honey bee larvae. Together, these results suggest that inhibitors of P. larvae spore germination could provide another method to control AFB.

Covered Stents and Coil Embolization for Treatment of Postpancreatectomy Arterial Hemorrhage.

PURPOSE: To evaluate the efficacy and clinical outcomes associated with stent-graft placement and coil embolization for postpancreatectomy arterial hemorrhage (PPAH). MATERIALS AND METHODS: Retrospective review of 38 stent-graft and/or embolization procedures in 28 patients (23 men; mean age, 65.1 y) for PPAH between 2007 and 2014 was performed. Time of bleeding, source of hemorrhage, intervention and devices used, repeat intervention rate, time to recurrent bleeding, complications, and 30-day mortality were assessed. Independent risk factors for recurrent bleeding and 30-day mortality were identified. RESULTS: Median onset of hemorrhage was at 39 days (mean, 27.9 d; range, 5-182 d). Covered stents were used in 65.7% of interventions, coil embolization in 23.6%, stent-assisted embolization in 5.2%, and stent-graft angioplasty in 2.6%. A total of 28 stent-grafts were placed, of which 19 were self-expandable and nine were balloon-mounted. Mean stent-graft diameter was 6.6 mm (range, 5-10 mm). Recurrent bleeding occurred following 26.3% of interventions in seven patients at a mean interval of 22 days. The site of recurrent bleeding was new in 80% of cases. There was no significant difference in recurrent bleeding rate in early-onset (< 30 d; n = 22) versus late-onset PPAH (> 30 d; n = 6; P > .05). No ischemic hepatic or bowel complications were identified. The 30-day mortality rate was 7.1% (n = 2) and was significantly higher in patients with initial PPAH at ≥ 39 days (n = 5; P = .007). CONCLUSIONS: Covered stents and coil embolization are effective for managing PPAH and maintaining distal organ perfusion to minimize morbidity and mortality. Recurrent bleeding is common and most often occurs from new sites of vascular injury rather than previously treated ones.

ent-Labdane Diterpenoids from the Aerial Parts of Eupatorium obtusissmum.

Six new ent-labdane diterpenoids, uasdlabdanes A-F (1-6), were isolated from the aerial parts of Eupatorium obtusissmum. The new structures were elucidated through spectroscopic and spectrometric data analyses. The absolute configurations of compounds 1 and 2 were established by X-ray crystallography, and those of 3-6, by comparison of experimental and calculated electronic circular dichroism spectra. The antiproliferative activity of the compounds was studied in a panel of six representative human solid tumor cell lines and showed GI50 values ranging from 19 to >100 µM.