Two-dimensional parametric parenchymal blood flow in transarterial chemoembolisation for hepatocellular carcinoma: perfusion change quantification and tumour response prediction at 3 months post-intervention.

AIM: To evaluate the feasibility and potential value of two-dimensional (2D) parametric parenchymal blood flow (2D-PPBF) for the assessment of perfusion changes during transarterial chemoembolisation with drug-eluting beads (DEB-TACE) and to analyse correlations of 2D-PPBF parameters and tumour response. MATERIALS AND METHODS: Thirty-two patients (six women, 26 men, mean age: 67±8.9 years) with unresectable hepatocellular carcinoma (HCC) who underwent their first DEB-TACE were included in this study. To quantify perfusion changes using 2D-PPBF, the acquired digital subtraction angiography (DSA) series were post-processed. Ratios were calculated between the reference region of interest (ROI) and the wash-in rate (WIR), the arrival to peak (AP) and the area under the curve (AUC) of the generated time-density curves. Comparisons between pre- and post-embolisation data were made using the Wilcoxon signed-rank test. Tumour response was assessed at 3 months using the modified Response Evaluation Criteria in Solid Tumours (mRECIST) and correlated to changes of 2D-PPBF parameters. RESULTS: All 2D-PPBF parameters derived from the ROI-based time-attenuation curves were significantly different pre-versus post-DEB-TACE. Although the AUC, the WIR and target lesion size measured in accordance with mRECIST decreased (p≤0.0001) significantly, AP values showed a significant increase (p = 0.0033). Tumour response after DEB-TACE correlated with changes in the AUC (p = 0.01, r = -0.45). CONCLUSION: 2D-PPBF offers an objective approach to analyse perfusion changes of embolised tumour tissue following DEB-TACE and can therefore be used to predict tumour response.

Percutaneous Transsplenic Balloon-Assisted Transjugular Intrahepatic Portosystemic Shunt Placement in Patients with Portal Vein Obliteration for Portal Vein Recanalization: Feasibility, Safety and Effectiveness.

PURPOSE: To assess the feasibility, safety and effectiveness of portal vein recanalization (PVR)-transjugular portosystemic shunt (TIPS) placement via splenic access using a balloon puncture technique. MATERIALS AND METHODS: In a single-center retrospective study from March 2017 to February 2021, 14 consecutive patients with portal hypertension, chronic liver disease and portal vein occlusion or near-complete (> 95%) occlusion were referred for PVR-TIPS placement. Feasibility, safety and effectiveness including procedural characteristics such as technical success, complication profile and splenic access time (SAT), balloon positioning time (BPT), conventional portal vein entry time (CPVET), overall procedure time (OPT), fluoroscopy time (FT), dose-area product (DAP) and air kerma (AK) were evaluated. RESULTS: Transsplenic PVR-TIPS using balloon puncture technique was technically feasible in 12 of 14 patients (8 men, 49 ± 13 years). In two patients without detectable intrahepatic portal vein branches, TIPS placement was not feasible and both patients were referred for further treatment with nonselective beta blockers and endoscopic variceal ligation. No complications grade > 3 of the Cardiovascular and Interventional Radiological Society of Europe classification system occurred. The SAT was 25 ± 21 min, CPVET was 33 ± 26 min, the OPT was 158 ± 54 min, the FT was 42 ± 22 min, the DAP was 167.84 ± 129.23 Gy*cm2 and the AK was 1150.70 ± 910.73 mGy. CONCLUSIONS: Transsplenic PVR-TIPS using a balloon puncture technique is feasible and appears to be safe in our series of patients with obliteration of the portal vein. It expands the interventional options in patients with chronic PVT.

Predictive Parameters in Patients Undergoing Percutaneous Hepatic Perfusion with Melphalan for Unresectable Liver Metastases from Uveal Melanoma: A Retrospective Pooled Analysis.

PURPOSE: The aim of this study was to identify positive predictors for survival in uveal melanoma (UM) patients treated with percutaneous hepatic perfusion with melphalan (M-PHP), by retrospectively pooling data from three centers. MATERIALS AND METHODS: Retrospective analysis including patients ([Formula: see text] 18 years) treated with M-PHP between February 2014 and December 2019 for unresectable liver-dominant or liver-only metastases from UM. Predictors for OS were assessed using uni- and multivariate analyses. Other study outcome measures were response rate, progression-free survival (PFS), liver progression-free survival (LPFS), overall survival (OS) and complications according to CTCAEv5.0. RESULTS: In total, 101 patients (47.5% males; median age 59.0 years) completed a minimum of one M-PHP. At a median follow-up time of 15.0 months, complete response (CR), partial response (PR), stable disease (SD) and progressive disease were seen in five (5.0%), 55 (54.5%), 30 (29.7%) and 11 (10.9%) patients, respectively, leading to a 89.1% disease control rate. Median PFS, LPFS and OS were 9.0, 11.0 and 20.0 months, respectively. Survival analyses stratified for radiological response demonstrated significant improved survival in patients with CR or PR and SD category. Treatment of the primary tumor with radiotherapy, ≥ 2 M-PHP and lactate dehydrogenase (LDH) < 248 U/L were correlated with improved OS. Thirty-day mortality was 1.1% (n = 2). Most common complication was hematological toxicity (self-limiting in most cases). CONCLUSION: M-PHP is safe and effective in patients with UM liver metastases. Achieving CR, PR or SD is associated with improved survival. Primary tumor treatment with radiotherapy, normal baseline LDH and > 1 M-PHP cycles are associated with improved OS.

Adrenal venous sampling in primary hyperaldosteronism: correlation of hormone indices and collimated C-arm CT findings.

PURPOSE: To evaluate the feasibility and effect of an approach to adrenal venous sampling (AVS) analysis by combining established selective cortisol and aldosterone indices with the acquisition of a collimated C-arm CT(CACTColl). METHODS: Overall, 107 consecutive patients (45f,62 m; 54 ± 10 years) undergoing 111 AVS procedures without hormonal stimulation from 7/13 to 2/20 in a single institution were retrospectively analysed. Hormone levels were measured in sequential samples of the suspected adrenal veins and right iliac vein, and selectivity indices (SI) computed. Stand-alone SICortisol and/or SIAldosterone ≥ 2.0 as well as SICortisol and/or SIAldosterone ≥ 1.1 combined with positive right-sided CACTColl of the adrenals (n = 80; opacified right adrenal vein) were defined as a successful AVS procedure. Radiation exposure of CACT was measured via dose area product (DAP) and weighed against an age-/weight-matched cohort (n = 66). RESULTS: Preliminary success rates (SICortisol and/or SIAldosterone ≥ 2.0) were 99.1% (left) and 72.1% (right). These could be significantly increased to a 90.1% success rate on the right, by combining an adjusted SI of 1.1 with a positive CACTColl proving the correct sampling position. Sensitivity for stand-alone collimated CACT (CACTColl) was 0.93, with 74/80 acquired CACTColl confirming selective cannulation by adrenal vein enhancement. Mean DAPColl_CACT measured 2414 ± 958 µGyxm2, while mean DAPFull-FOV_CACT in the matched cohort measured 8766 ± 1956 µGyxm2 (p < 0.001). CONCLUSION: Collimated CACT in AVS procedures is feasible and leads to a significant increase in success rates of (right-sided) selective cannulation and may in combination with adapted hormone indices, offer a successful alternative to previously published AVS analysis algorithms with lower radiation exposure compared to a full-FOV CACT.

Percutaneous isolated hepatic perfusion (chemosaturation) with melphalan following right hemihepatectomy in patients with cholangiocarcinoma and metastatic uveal melanoma: peri- and post-interventional adverse events and therapy response compared to a matched group without prior liver surgery.

To evaluate feasibility, frequency and severity of peri-procedural complications and post-procedural adverse events (AEs) in patients with advanced cholangiocarcinoma or liver metastasis of uveal melanoma and prior hemihepatectomy undergoing chemosaturation percutaneous hepatic perfusion (CS-PHP) and to analyze therapy response and overall survival compared to a matched group without prior surgery. CS-PHP performed between 10/2014 and 02/2018 were retrospectively assessed. To determine peri-procedural safety and post-procedural adverse events, hospital records and hematological, hepatic and biliary function were categorized using Common Terminology Criteria for Adverse Events (CTCAE) v5.0 (1-5; mild-death). Significance was tested using Wilcoxon signed-rank and Mann-Whitney U test. Kaplan-Meier estimation and log-rank test assessed survival. Overall 21 CS-PHP in seven patients (4/7 males; 52 ± 10 years) with hemihepatectomy (grouphemihep) and 22 CS-PHP in seven patients (3/7 males; 63 ± 12 years) without prior surgery (groupnoresection) were included. No complications occurred during the CS-PHP procedures. Transient changes (CTCAE grade 1-2) of liver enzymes and blood cells followed all procedures. In comparison, grouphemihep presented slightly more AEs grade 3-4 (e.g. thrombocytopenia in 57% (12/21) vs. 41% (9/22; p = 0.37)) 5-7 days after CS-PHP. These AEs were self-limiting or responsive to treatment (insignificant difference of pre-interventional to 21-45 days post-interventional values (p > 0.05)). One patient in grouphemihep with high tumor burden died eight days following CS-PHP. No deaths occurred in groupnoresection. In comparison, overall survival after first diagnosis was insignificantly shorter in groupnoresection (44.7(32-56.1) months) than in grouphemihep (48.3(34.6-72.8) months; p = 0.48). The severity of adverse events following CS-PHP in patients after hemihepatectomy was comparable to a matched group without prior liver surgery. Thus, the performance of CS-PHP is not substantially compromised by a prior hemihepatectomy.

MRI of central venous anatomy: implications for central venous catheter insertion.

STUDY OBJECTIVES: To determine normative values for superior vena cava (SVC) length and the utility of radiographic landmarks for identifying the boundaries of the SVC for assisting central line placement. DESIGN: Cross-sectional study. SETTING: Urban tertiary care medical centers. PATIENTS: Patients undergoing thoracic MRI scanning for various indications. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The SVC dimensions and relationship to radiographic landmarks were determined from MRI scans of 42 patients (22 men, 20 women; median age, 57 years). The median length of the SVC was 6.8 cm (range, 4.4 to 10.0 cm) and did not correlate with gender or other measured cardiovascular dimensions. The right tracheobronchial angle was the best radiographic landmark for determining the cephalad origin of the SVC being always caudad and within a median of 1.5 cm (range, 0.1 to 3.8 cm) of the upper SVC. It was always at least 2.9 cm above the atriocaval junction. The right superior heart border was formed by the left atrium in 38% (95% confidence interval, 23 to 53%) of patients and did not reliably identify the atriocaval junction. CONCLUSIONS: The right tracheobronchial angle is the most reliable landmark for the upper margin of the SVC. Venous catheters placed caudad to this landmark and cephalad to the right superior cardiac silhouette or no more than 2.9 cm caudad to the tracheobronchial angle result in catheter tips within the SVC.

An open, minimally invasive approach to the lumbar spine.

A minimum 2-year follow-up retrospective review was undertaken to assess our experience with an anterior paramedian muscle-sparing approach to the lumbar spine for anterior spinal fusion (ASF). The records of 28 patients (November 1991 through January 1996) undergoing ASF via a left lower quadrant transverse skin incision (6-10 cm) with a paramedian anterior rectus fascial Z-plasty retroperitoneal approach were reviewed. Diagnosis, number, and level of lumbar interspaces fused, types of fusion, estimated blood loss, length of procedure, length of hospital stay, and complications were analyzed. All cases were completed as either a same-day anterior/posterior (24 of 28) or as a staged procedure at least 1 week after posterior fusion (4 of 28). The General Surgery service performed the muscle-sparing approach, whereas the Orthopedic Spine service performed the ASF. There were 14 men and 14 women, with a mean age of 35.5 years (range, 11-52 years). Diagnoses included spondylolisthesis in 20 cases (including four grade III or IV slips), segmental instability (degenerative or postsurgical) in 7, and 1 flatback deformity. A single level was fused in 20 cases (L4/5 in 4 and L5/S1 in 16), two levels were fused in 5 cases (L4/5 and L5/S1) and three levels were fused in 2 cases (L3/4, L4/5, and L5/S1). The mean length of stay was 7.4 days (range, 5-12 days). The mean estimated blood loss was 300 mL for the anterior procedure alone and 700 ml for both anterior/posterior procedures on the same day. The mean length of operating room time for the anterior approach and fusion was 117 minutes (range, 60-330 minutes). Posterior instrumentation was used in all cases. Anterior interbody struts used included 19 autogenous tricortical grafts, 4 fresh-frozen allografts (2 femoral rings and 2 iliac crests), 3 carbon fiber cages packed with autogenous bone, and a Harms titanium cage with autograft. There was one L5 corpectomy for which a large tricortical allograft strut was utilized. There were no vascular, visceral, or urinary tract injuries. In three cases a mild ileus developed, which resolved spontaneously. We conclude that the anterior paramedian muscle-sparing retroperitoneal approach is safe, uses a small skin incision, avoids cutting abdominal wall musculature, and allows for multiple-level anterior spinal fusions by a variety of interbody fusion techniques. This approach does not require transperitoneal violation or added endoscopic instrumentation, nor does it limit fusion level and technique of fusion, as is the case with the recently popularized laparoscopic approach to the lumbar spine.

Cytological and molecular evaluation of the reproductive behavior of Tripsacum andersonii and a female fertile derivative (Poaceae).

Research was conducted to characterize the reproductive behavior of the highly sterile Tripsacum andersonii Gray and its viable progeny through breeding, cytological, and molecular studies. Four progeny were obtained from open-pollinated seeds of clones (M-34445, M-34450 and M-34455) of T. andersonii maintained at the USDA-ARS National Germplasm Repository, Miami, Florida. One of the progeny had 64 chromosomes, which is typical of T. andersonii, and probably resulted from apomictic reproduction. Karyotypes of the other three progeny indicated a tetraploid Tripsacum genomic constitution (2n = 4x = 72) plus a haploid set of Zea (1n = 1x = 10) chromosomes. Two of these progeny were completely sterile, whereas one (95-51) produced ∼5% seed set when crossed with diploid (2n = 36) T. dactyloides (L.)L. The partially fertile 95-51 produced four progeny, one with 2n = 72 (elimination of 10 Zea chromosomes), two with 2n = 82 (apomictic reproduction) and one with 2n = 100 (sexual polyploidization). Polymerase Chain Reaction - Random Amplified Polymerase DNA analysis verified that T. andersonii accessions from seven countries were genetically uniform, and that its progeny were derived through apomixis and sexual polyploidization. This analysis also confirmed that chromosome elimination, apomixis, and sexual polyploidization reproductive behaviors occur in the T. andersonii derivative 95-51.

Co-segregation of the gynomonoecious sex form1 gene (gsf1) of Tripsacum dactyloides (Poaceae) with molecular markers.

The only monogenic trait in Tripsacum to date was first identified in the prolific sex form variant Tripsacum dactyloides (L.) L. forma prolificum Dayton et Dewald. The expression of this trait is controlled by the presence of a single-gene, recessive pistillate mutation hereby designated the gynomonoecious sex form1 gene (gsf1), after the registered plant germplasm accession GSF-I (PI483447) from which it was first identified. This trait confers a high degree of feminization to the primarily male floral structure of the Tripsacum rachis. Two molecular markers were found to co-segregate with the gsf1 gene in a diploid (2n = 36) F2 population of Tripsacum dactyloides, where the female parent (GSF-I) had been previously determined to be homozygous recessive for the gene. Phenotypic scoring data were compared with restriction fragment length polymorphism data and linkage relationships were determined. The gsf1 gene is located ~7 cM from tda48, a Tripsacum-derived molecular marker, and ~9 cM from npi286, a maize-derived molecular marker. The marker npi286 also maps within ~5 cM of the tassel seed2 locus (ts2) of maize, which confers a similar change in the inflorescence of the maize tassel.

Apomixis in Tripsacum: comparative mapping of a multigene phenomenon.

A relationship has been established between the expression of apomixis in natural polyploids of Tripsacum dactyloides and fertility as measured by percent seed set. Thus, fertility may be reliably used as a defining phenotype for apomixis when scoring the progeny from diploid (2n = 2x = 36) x tetraploid (2n = 4x = 72) crosses in Tripsacum. By exploiting the relationship between apomixis and fertility, as defined by seed set, analyses were performed on a set of related second-generation triploid populations segregating for apomixis. These populations were derived from sexual (diploid) x apomictic (tetraploid) crosses. Six out of 25 genome-dispersed restriction fragment length polymorphism (RFLP) markers co-segregate with fertility. Five of these markers were previously reported and include: php20855, tda48, tda53, umc62, and umc83, and are linked to Tripsacum genetic linkage groups F, I, H, L, and A, respectively. Significantly, we report here the syntenic relationships of the maize chromosome intervals to Tripsacum that segregate for numerous meiosis-specific and fertility-associated genes. Utilizing RFLP locus comparative mapping based on conservation of chromosome (genic) regions between related species, it may be concluded that the genes controlling fertility have been preserved in both Tripsacum and maize. A sixth marker, umc166, has also been shown to co-segregate with fertility and is conserved in both grass species. Specifically, umc166 is linked to Tripsacum linkage group D and, by syntenic comparison, to the short arm of maize chromosome 5. Encoded within this marked interval is the gene Ameiotic1 (Am1) whose function is required for the initiation of meiosis in both micro- and megaspore mother cells and whose absence of expression in the female is, in all likelihood, a prerequisite for the expression of apomixis.

Evidence for a common sex determination mechanism for pistil abortion in maize and in its wild relative Tripsacum.

Cultivated maize (Zea mays) and several other members of the Tribe Andropogoneae produce unisexual florets. In maize, the formation of two staminate florets in each spikelet on the tassel and a single pistillate floret in each spikelet on the ear includes a pistil abortion process that requires the action of the TASSELSEED2 gene. In Eastern gamagrass (Tripsacum dactyloides) the GYNOMONOECIOUS SEX FORM1 gene appears to perform a similar role in pistil abortion. These genes were shown to be homeologs by restriction fragment length polymorphism mapping and by the failure of the gsf1 and ts2 alleles to complement one another in intergeneric hybrids. Molecular analysis of the gsf1 allele shows that it is caused by a 1.4-kb deletion mutation. Both TASSELSEED2 and GYNOMONOECIOUS SEX FORM1 show similar expression patterns in subepidermal cells of pistils just before abortion. These results suggest that the formation of staminate florets in the Andropogoneae represents a monophyletic trait.

Analysis of inflorescence organogenesis in eastern gamagrass, Tripsacum dactyloides (Poaceae): the wild type and the gynomonoecious gsf1 mutant.

Inflorescence organogenesis of a wild-type and a gynomonoecious (pistillate) mutant in Tripsacum dactyloides was studied using scanning electron microscopy. SEM (scanning electron microscope) analysis indicated that wild-type T. dactyloides (Eastern gamagrass) expressed a pattern of inflorescence organogenesis that is observed in other members of the subtribe Tripsacinae (Zea: maize and teosinte), family Poaceae. Branch primordia are initiated acropetally along the rachis of wild-type inflorescences in a distichous arrangement. Branch primordia at the base of some inflorescences develop into long branches, which themselves produce an acropetal series of distichous spikelet pair primordia. All other branch primordia function as spikelet pair primordia and bifurcate into pedicellate and sessile spikelet primordia. In all wild-type inflorescences development of the pedicellate spikelets is arrested in the proximal portion of the rachis, and these spikelets abort, leaving two rows of solitary sessile spikelets. Organogenesis of spikelets and florets in wild-type inflorescences is similar to that previously described in maize and the teosintes. Our analysis of gsf1 mutant inflorescences reveals a pattern of development similar to that of the wild type, but differs from the wild type in retaining (1) the pistillate condition in paired spikelets along the distal portion of the rachis and (2) the lower floret in sessile spikelets in the proximal region of the rachis. The gsf1 mutation blocks gynoecial tissue abortion in both the paired-spikelet and the unpaired-spikelet zone. This study supports the hypothesis that both femaleness and maleness in Zea and Tripsacum inflorescences are derived from a common developmental pathway. The pattern of inflorescence development is not inconsistent with the view that the maize ear was derived from a Tripsacum genomic background.

Percutaneous gastrostomy and gastrojejunostomy with gastropexy: experience in 701 procedures.

PURPOSE: To evaluate the safety and efficacy of fluoroscopically directed percutaneous gastrostomy and gastrojejunostomy catheter placement with gastropexy. MATERIALS AND METHODS: The authors retrospectively reviewed the charts from 643 patients referred for fluoroscopically directed percutaneous gastrostomy or gastrojejunostomy during a 9 1/2-year period. In 615 patients, placement was attempted with use of three T-fastener gastropexy devices followed by percutaneous gastric puncture. Placement of a 14-F gastrostomy or gastrojejunostomy catheter was then accomplished with the Seldinger technique. RESULTS: A catheter could not be placed in 28 patients (4.4%) owing to overlying viscera or prior gastric surgery. In the remaining patients, 701 procedures, including revisions, were performed, including 643 gastrojejunostomies (92%) and 58 gastrostomies (8.3%). The success rate for catheter placement was 100%. Revision was necessary in 83 instances in 64 patients (13.5%). Forty-six (55%) of these were attributed to tube dislodgment, but only two repeat gastric punctures were necessary secondary to tract disruption. There were three major complications (0.5%) and 29 minor complications (5.3%). No complications were attributed directly to gastropexy. Thirty-day follow-up data were available for 393 patients (64%), and 14-day follow-up data were available for 550 (89%). The 30-day mortality rate was 5.8% (23 of 393 patients); none of the deaths were related to the procedure. CONCLUSION: Fluoroscopically directed percutaneous placement of gastrostomy and gastrojejunostomy catheters with routine gastropexy is a safe procedure. Catheter revision was necessary in 13% of patients and was usually secondary to tube dislodgment, with tract disruption an unusual complication.

Vena cavography with CO(2) versus with iodinated contrast material for inferior vena cava filter placement: a prospective evaluation.

PURPOSE: To determine whether carbon dioxide (CO(2)) vena cavography can safely guide the placement of inferior vena cava (IVC) filters. MATERIALS AND METHODS: One hundred nineteen patients were prospectively enrolled in this study. CO(2 )cavograms were obtained and evaluated for IVC diameter, location of renal veins, and presence of thrombus and venous anomalies. If CO(2 )cavography was judged to be adequate, an IVC filter was deployed. After filter placement, cavography was performed with iodinated contrast material; these images were compared with the CO(2) cavograms. RESULTS: Two patients experienced mild side effects related to venous CO(2) injection. Comparison of cavograms obtained with CO(2) and iodinated contrast-enhanced material showed the caval size to be within 3 mm in all 119 patients. In 116 patients (97.5%), CO(2) cavography was judged to be adequate, and in 115 patients, filters were placed. In three (2.5%) patients, it was necessary to perform iodinated contrast-enhanced cavography before filter deployment. All six cases of venous anomaly and 11 (78.6%) of 14 cases of thrombosis were clearly identified with CO(2) cavography. One filter was maldeployed owing to misinterpretation of the CO(2) cavogram. CONCLUSION: CO(2) cavography is well tolerated, safe, and adequate for identification of the parameters necessary for filter deployment. It is especially valuable in patients with a history of reaction to iodinated contrast material or renal insufficiency.