Radiological assessment of local resectability status in patients with pancreatic cancer: Interreader agreement and reader performance in two different classification systems.

OBJECTIVES: To assess the interreader agreement and reader performance in the evaluation of patients with pancreatic cancer (PC) in two classification systems of local resectability status prior to initiation of therapy, namely the National Comprehensive Cancer Network (NCCN) and Karolinska classification system (KCS). METHODS: In this ethics review board-approved retrospective study, six radiologists independently evaluated pancreatic CT-examinations of 30 patients randomly selected from a tertiary referral centre's multidisciplinary tumour board database. Based on well-defined criteria of tumour-vessel relationship, each patient was assigned to one of three NCCN and six KCS categories. We assessed the intraclass correlation coefficient (ICC) and compared the percentages of correct tumour classification of the six readers in both systems (Chi-square test; a P-value <0.05 was considered significant). The standard of reference was a consensus evaluation of CT-examinations by three readers not involved in the image analysis. RESULTS: The ICC for NCCN and KCS was 0.82 and 0.84, respectively (very strong agreement). The percentages of correct tumour classification at NCCN and KCS were 53-83% and 30-57%, respectively, with no statistically significant differences in the overall reader comparison per classification system. In pair-wise comparison between readers for NCCN/KCS, there were statistically significant differences between reader 5 vs. readers 4 (P = 0.012) and 3 (P = 0.045)/ reader 5 vs. reader 4 (P = 0.037). CONCLUSION: Interreader agreement in both PC classification systems is very strong. NCCN may be advantageous in terms of reader performance compared to KCS.

Uterine artery embolization in a sheep model: biodegradable versus non-degradable microspheres.

Background Transarterial embolization with particles is a relatively common treatment method in both malignant and benign disorders. Permanent occlusion of the uterine arteries may sometimes be disadvantageous. Purpose To compare the local tissue effects, possible side effects, and extent of recanalization following uterine artery embolization, using either degradable or non-degradable microspheres in a sheep model. Material and Methods In 22 female sheep, the uterine artery (UA) was unilaterally, superselectively embolized, with either degradable starch microspheres-DSM (group A) or calibrated gelatin coated spherical shape tris-acryl microspheres-TGMS (group B). The completion of embolization was confirmed by angiography. The animals were kept in the animal research facilities for 14 days and sacrificed following new angiographic evaluation. Gross and histological examination of the uterus and other organs was performed. Results The procedure was successful in all animals. At final angiographic evaluation recanalization was found in 82% of the ewes in group A and in 18% in group B. At histopathological examination, tissue impairment was similar in both groups, whereas vascular changes were more pronounced in the TGMS-group. Conclusion Embolization with DSM was associated with significantly higher degree of recanalization, than after embolization with TGMS.

Treatment of the acute severe pulmonary embolism using endovascular methods.

PURPOSE: To present a single-centre experience with endovascular treatment of patients with severe symptoms secondary to acute pulmonary embolism (PE). MATERIAL AND METHODS: Twenty-five patients were treated due to contraindications or deficient effects of systemic thrombolytic therapy. The patients were treated with a combination of fragmentation and aspiration, only aspiration, or only fragmentation, and with catheter-directed thrombolytic therapy. RESULTS: The saturation was improved following treatment in all patients, except in one where the procedure could not be completed. There were no immediate or late procedure-related complications. CONCLUSIONS: Endovascular treatment of severe PE is a safe and efficient option in patients with failing effect or contraindication to systemic thrombolysis.

The effects of uterine artery embolization with a new degradable microsphere in an experimental study.

Background Transarterial particle embolization is a common treatment of uterine fibroids, aiming to obtain ischemia resulting in shrinking of the fibroid with preservation of normal uterine tissue. Embolization with non-degradable microspheres is established, but causes permanent occlusion of the arteries, affecting both the uterus as well as the fibroids. Purpose To evaluate in vivo degradation, local tissue effects, and possible recanalization following intra-arterial deposition of the new, degradable starch microspheres (DSM), in a short-term experimental pilot study. Material and Methods Under general anesthesia, unilateral transarterial embolization of the uterine artery (UA) with DSM 500-700 µm was performed in five female sheep. The animals underwent renewed angiography at different intervals after embolization (19-65 h) and were subsequently sacrificed. Histological examination was performed. Results Embolization with absent flow in the UA could be completed in five of six animals. At final angiographic evaluation, recanalization of the embolized arteries was evident in three sheep. At the gross postmortem examination, edema and discoloration indicating ischemia of the uterus at the embolized side, was observed in all the sheep. At histopathological examination, different stages of DSM degradation in the arterial branches were observed in both endometrium and myometrium. Mild-to-moderate vasculitis and mild-to-extensive ischemic changes were present along with degeneration of the uterine glands. Conclusion This short-term pilot study proved efficacy of embolization with DSM causing ischemic changes in the embolized organ, but also degradation of the DSM with subsequent recanalization of the embolized arteries.

The impact of neoadjuvant chemotherapy on skeletal muscle depletion and preoperative sarcopenia in patients with resectable colorectal liver metastases.

BACKGROUND: Preoperative skeletal muscle depletion or sarcopenia has been suggested to predict worse outcome after resection of colorectal liver metastases. The aim of the present study was to investigate the impact of neoadjuvant chemotherapy on preoperative skeletal muscle mass prior to liver resection. METHODS: Patients operated with liver resection for colorectal liver metastases between 2010 and 2014 were retrospectively reviewed. Muscle mass was evaluated by measuring muscle area on a cross-sectional computed tomography image at the level of the third lumbar vertebra, and normalized for patient height, presenting a skeletal muscle index. RESULTS: Preoperative skeletal muscle mass was analysed in 225 patients, of whom 97 underwent neoadjuvant chemotherapy. In total 147 patients (65%) were categorized as sarcopenic preoperatively. Patients receiving neoadjuvant chemotherapy decreased in skeletal muscle mass (decrease by 5.5 (-1.1 to 11) % in skeletal muscle index, p < 0.001). Patients with muscle loss >5% during neoadjuvant chemotherapy were less likely to undergo adjuvant chemotherapy than others (68% vs 85%, p = 0.048). A >5% muscle loss did not result in worse overall (p = 0.131) or recurrence-free survival (p = 0.105). CONCLUSION: Skeletal muscle mass decreases during neoadjuvant chemotherapy. Skeletal muscle loss during neoadjuvant chemotherapy impairs the conditions for adjuvant chemotherapy.

Disappearing liver metastases from colorectal cancer: impact of modern imaging modalities.

BACKGROUND: Chemotherapy is often used before a resection for colorectal liver metastases. After chemotherapy, metastases may disappear on cross-sectional imaging but residual metastatic disease may still exist. The aim of this retrospective study was to investigate the impact of new advancements in imaging technology such as magnetic resonance imaging (MRI) with liver-specific contrast (Gd-EOB-DTPA) and contrast-enhanced intra-operative ultrasound (CE-IOUS) on disappearing liver metastases (DLM). METHODS: Twenty-nine patients with one or more DLM undergoing surgical exploration were included. Pre-operative imaging consisted of contrast-enhanced multi-detector computed tomography (MDCT) and/or MRI with liver-specific contrast. At surgery, CE-IOUS was used when tumours known from pre-chemotherapy imaging were not found by inspection or intra-operative ultrasound. RESULTS: Patients presented 66 DLM. At surgical exploration, 42 DLM were identified and treated (64%). CE-IOUS detected one additional DLM not found by intra-operative ultrasound. For metastases ≤10 mm on histological analysis, imaging sensitivities for MRI and MDCT before surgery but after chemotherapy were 26/49 (53%) and 24/66 (36%), respectively. CONCLUSION: A majority of DLM are identified during surgery using intra-operative ultrasound, with only little additional value of CE-IOUS. The sensitivities of post-chemotherapy imaging modalities for small metastases are low in the setting of DLM. For surgical planning, an optimized pre-chemotherapy imaging is essential.

Endovascular Removal of the Viatorr Stent-Grafts. Report of Two Cases.

BACKGROUND: The dysfunction of misplaced or dislodged endovascular endoprostheses, may be a serious complication, and endovascular removal may be attempted in some cases. CASE REPORT: A Viatorr(®) stent-graft (Gore, Flagstaff, AR, USA) is an endoprosthesis designed and commonly used for creation of a transjugular intrahepatic portosystemic shunt (TIPS). Two Viatorrs were accidentally dislodged during TIPS procedure. In another patient, the Viatorr was malpositioned, with its distal end being placed in the bile duct. All endoprostheses were successfully removed without serious complications. CONCLUSIONS: Removal of a misplaced or dislodged Viatorr endoprosthesis is possible using interventional methods.

Concurrent biliary drainage and portal vein embolization in preparation for extended hepatectomy in patients with biliary cancer.

BACKGROUND: Patients with perihilar cholangiocarcinoma and gallbladder cancer extending into the hilum often present with jaundice and a small future liver remnant (FLR). If resectable, preoperative biliary drainage and portal vein embolization (PVE) are indicated. Classically, these measures have been performed sequentially, separated by 4-6 weeks. PURPOSE: To report on a new regime where percutaneous transhepatic biliary drainage (PTBD) and PVE are performed simultaneously, shortening the preoperative process. MATERIAL AND METHODS: Six patients were treated with concurrent PTBD and PVE under general anesthesia. RESULTS: Surgical exploration followed the combined procedure after 35 days (range, 28-51 days). The FLR ratio increased from 22% to 32%. Three patients developed cholangitis after the procedure. CONCLUSION: The combined approach of PTBD and PVE seems feasible, but more studies on morbidity are warranted.

Interventional treatment of mesenteric venous occlusion.

BACKGROUND: Mesenteric venous thrombus may be an incidental finding during imaging studies and asymptomatic patients are treated conservatively or with anticoagulant therapy only. Patients with symptomatic acute thrombosis causing bowel ischemia require urgent treatment, which frequently includes extensive surgery. Interventional treatment may be an alternative. PURPOSE: To present results of interventional treatment in patients with symptomatic occlusion of the mesenteric veins. MATERIAL/METHODS: Eight patients, four men and four women aged 24-74 years (mean 53 years) were treated due to symptomatic portomesenteric venous occlusion of thrombotic origin. Transhepatic (n=5), trans-splenic (n=2), and transjugular (n=4) accesses were used. Patients were treated with mechanical thrombus fragmentation (n=4), pharmacological thrombolysis (n=3) and stent placement (n=8). Additional transjugular intrahepatic portosystemic shunt (TIPS) was created to facilitate the outflow from the treated veins (n=4). RESULTS: The majority of the patients required combination of different treatment methods. Resolution of symptoms with initial clinical success was achieved in seven of the eight patients, and one patient died the day after the procedure due to sepsis. Two other patients had procedure-related complications; one of them required embolization. Two patients had documented long-term clinical success with patent stents and no symptoms at one year following intervention. CONCLUSIONS: Endovascular treatment of portomesenteric occlusion in patients with acute symptomatology showed good short-term clinical success rate.

Sharp recanalization of the esophageal occlusion using transjugular access set. Report of two cases.

Two male patients, 75 and 53 years old, with totally occluded esophagus were treated. Sharp recanalization was performed using a combined radiologic and endoscopic technique. Following successful penetration with the needle through the occluded segment and balloon dilation, the created channel was stabilized with esophageal stent, with subsequent palliative effect.

Acute right ventricular failure caused by concomitant coronary and pulmonary embolism: successful treatment with endovascular coronary and pulmonary thrombectomy.

Patent foramen ovale (PFO) is present in approximately 25% of the general population. PFO is characterized by intermittent shunting of blood from the right to the left atrium, especially in the context of increased right-sided filling pressures, with risk of paradoxical embolism. We describe a 69-year-old woman presenting with acute chest pain, severe dyspnoea, and acute inferolateral ST-segment elevation on the electrocardiogram. The patient was diagnosed with myocardial infarction and failure of the right cardiac ventricle, which was considered to be secondary to extensive pulmonary embolism leading to increased filling pressures and paradoxical coronary embolism. The patient underwent emergent percutaneous interventions with coronary thrombus extraction and pulmonary thrombus fragmentation and local thrombolysis. The patient was free of symptoms at follow up 6 months later and echocardiography showed substantially improved right ventricular function. We discuss issues related to the diagnosis, treatment, and secondary prevention for patients with concomitant pulmonary and coronary arterial thrombosis.

Endovascular treatment of two pseudoaneurysms originating from the left ventricle.

A 67-year-old woman resented with an acute type A aortic dissection, which was treated surgically with aortic valve replacement as a composite graft with reimplantation of the coronary arteries. At the end of surgery, a left-ventricular venting catheter was placed through the apex and closed with a buffered suture. Consecutive computed tomography (CT) examinations verified a growing apex pseudoaneurysm. Communication between the ventricle and the pseudoaneurysm was successfully closed with an Amplatz septal plug by the transfemoral route. Follow-up CT showed an additional pseudoaneurysm, which also was successfully closed using the same method.

Positron emission tomography in malignancies of the liver, pancreas and biliary tract - indications and potential pitfalls.

Abstract Malignancies of the hepato-pancreatico-biliary (HPB) system are relatively common and generally characterized by a dismal prognosis. Positron emission tomography (PET) is a functional imaging technique that has emerged as an important modality in oncological decision-making. The principal radiopharmaceutical in PET imaging is the glucose analog (18)F-fluorodeoxyglucose, which is able to detect altered glucose metabolism in malignant tissue. PET is typically used in conjunction with computed tomography (CT), and previous studies have supported several uses of PET/CT in HPB malignancies, including staging, differential diagnostics and monitoring of treatment response and progress of disease. A review of PET/CT in the context of HPB malignancies will be presented, including indications and potential pitfalls.

Stent-graft placement for urgent treatment or prevention of bleeding.

BACKGROUND: Stent-graft treatment of the patients with ongoing bleeding may be beneficial in specific situations, especially when preservation of blood flow to the distant organs is important. PURPOSE: To present the results of stent-graft placement for urgent treatment or prevention of the bleeding. MATERIAL AND METHODS: Stent-graft placement was performed urgently for the treatment of active bleeding and/or pseudoaneurysm/aneurysm in 17 patients. Diagnoses were based on clinical findings and/or imaging studies. The etiology was previous major surgery and/or percutaneous intervention in 13, malignancy in one, pancreatitis and pseudocyst in one, multitrauma due to traffic accident in one and unknown cause in one patient. RESULTS: A total of 23 stent-grafts were placed. Angiograms obtained after placement revealed patent stent-graft with no further active extravasation or filling of pseudoaneurysm in 14 patients. Due to persistent bleeding, embolization was performed in two patients. In three patients, the stent-grafts were found to be thrombosed either immediately after placement (n = 1) or at follow-up (n = 2). Stent-grafts were patent in six of nine patients that could be followed (between 3 months and 6 years). CONCLUSION: Urgent stent-graft placement may be an alternative to endovascular embolization or surgery. It may be preferred when embolization is technically difficult or impossible and/or when preservation of blood supply to distal organs is essential such as in liver transplant grafts or extremity salvage.

Interventional radiological management of prehepatic obstruction of [corrected] the splanchnic venous system.

PURPOSE: The purpose of this study was to retrospectively evaluate interventional radiological management of patients with symptomatic portal hypertension secondary to obstruction of splanchnic veins. MATERIAL AND METHODS: Twenty-four patients, 15 males and 9 females, 0.75 to 79 years old (mean, 36.4 years), with symptomatic portal hypertension, secondary to splanchnic venous obstruction, were treated by percutaneous methods. Causes and extent of splanchnic venous obstruction and methods are summarized following a retrospective evaluation. RESULTS: Obstructions were localized to the main portal vein (n = 22), intrahepatic portal veins (n = 8), splenic vein (n = 4), and/or mesenteric veins (n = 4). Interventional treatment of 22 (92%) patients included recanalization (n = 19), pharmacological thrombolysis (n = 1), and mechanical thrombectomy (n = 5). Partial embolization of the spleen was done in five patients, in two of them as the only possible treatment. TIPS placement was necessary in 10 patients, while an existing occluded TIPS was revised in two patients. Transhepatic embolization of varices was performed in one patient, and transfemoral embolization of splenorenal shunt was performed in another. Thirty-day mortality was 13.6% (n=3). During the follow-up, ranging between 2 days and 58 months, revision was necessary in five patients. An immediate improvement of presenting symptoms was achieved in 20 patients (83%). CONCLUSION: We conclude that interventional procedures can be successfully performed in the majority of patients with obstruction of splanchnic veins, with subsequent improvement of symptoms. Treatment should be customized according to the site and nature of obstruction.

Acute effects of liver vein occlusion by stent-graft placed in transjugular intrahepatic portosystemic shunt channel: an experimental study.

The purpose of this study was to evaluate the effects of hepatic vein occlusion by stent-graft used in transjugular intrahepatic portosystemic shunt (TIPS). The experiments were performed in six healthy pigs under general anesthesia. Following percutaneous transhepatic implantation of a port-a-cath in the right hepatic vein, TIPS was created with a stent-graft (Viatorr; W L Gore, Flagstaff, AZ, USA). The outflow from the hepatic vein, blocked by the stent-graft was documented by injection of contrast medium and repeated injections of (99)Tc(m)-labeled human serum albumin through the port-a-cath. After 2 weeks, the outflow was re-evaluated, the pigs were sacrificed, and histopathologic examination of the liver was performed. Occlusion of the hepatic vein by a stent-graft had a short and temporary effect on the outflow. Histopathological examination from the affected liver segment showed no divergent pattern. Stent-grafts used in TIPS block the outflow from the liver vein, but do not have a prolonged circulatory effect and do not affect the liver parenchyma.

Changes in the distribution of hepatic arterial blood flow following TIPS with uncovered stent and stent-graft: an experimental study.

PURPOSE: To evaluate changes in distribution of hepatic arterial blood flow in the liver following insertion of an uncovered stent and subsequently a stent-graft in the transjugular intrahepatic portosystemic shunt (TIPS) channel. METHODS: The experiments were performed in eight healthy pigs under general anesthesia. In a pilot study in one pig, scintigraphic evaluation of arterial perfusion to the liver was done before and after inflation of a balloon in the right hepatic vein. In the other pigs, outflow from the right liver vein was checked repeatedly by contrast injection through a percutaneously inserted catheter. The arterial perfusion through the liver was examined by scintigraphy, following selective injection of macro-aggregate of 99Tc m-labeled human serum albumin 99Tc m-HSA) into the hepatic artery. This examination was done before and after creation of a TIPS with an uncovered stent and subsequently after insertion of a covered stent-graft into the cranial portion of the shunt channel. RESULTS: In the pilot study changes in the arterial perfusion to the liver were easily detectable by scintigraphy. One pig died during the procedure and another pig was excluded due to dislodgement of the hepatic artery catheter. The inserted covered stent obstructed venous outflow from part of the right liver lobe. The 99Tc m-HSA activity in this part remained unchanged after TIPS creation with an uncovered stent. A reduction in activity was seen after insertion of a stent-graft (p= 0.06). CONCLUSION: The distribution of the hepatic arterial blood flow is affected by creation of a TIPS with a stent-graft, in the experimental pig model.