Percutaneous microwave ablation for early-stage intrahepatic cholangiocarcinoma: A single-institutional cohort.

Objectives: Cholangiocarcinoma (CCA) is the second-most common primary hepatic malignancy with an increasing incidence over the past two decades. CCA arises from the epithelial cells lining the bile ducts and can be classified as intrahepatic, perihilar, or distal based on the site of origin in the biliary tree. Surgical resection is the definitive curative therapy for early-stage intrahepatic CCA; however, only a minority of patients may be ideal surgical candidates. Percutaneous microwave ablation (MWA) is a minimally invasive procedure widely used for hepatocellular carcinoma and colorectal cancer metastases to the liver. Growing evidence suggests MWA can play a role in the management of patients with early-stage intrahepatic CCA. In this study, we aim to describe the safety and efficacy of MWA for the management of intrahepatic CCA. Material and Methods: A retrospective review of patients with intrahepatic CCA treated with MWA at our tertiary referral medical center was performed. Eight patients were treated between 2014 and 2019. Diagnosis of CCA was made based on histopathological studies of samples obtained by surgical resection or percutaneous liver biopsy. All procedures were performed under computed tomography (CT) guidance using a high-power single antenna MWA system. General anesthesia was used for all procedures. Patient medical history, procedural technical information, outcomes, and follow-up data were reviewed. Progression-free survival was estimated with a Kaplan-Meier curve. Results: A total of 25 tumors with an average size of 2.2 ± 1.7 cm (range 0.5-7.8) were treated with MWA. Our cohort consisted of eight patients (4 males and 4 females) with an average age of 69.3 ± 5.7 years (range 61-79). Three out of eight (3/8, 37.5%) patients were treated initially with surgical resection. NASH-related cirrhosis was documented in 3/8 (37.5%) patients, while 1/8 (12.5%) had alcoholic cirrhosis; the remaining 4 patients (4/8, 50%) did not have cirrhosis. All patients were discharged within 24 h after ablation. Average total follow-up time was 10.6 ± 11.8 months (range 0-41). The incomplete ablation rate and local recurrence rate were 4% (1/25 lesions) and 12% (3/25 lesions), respectively. Conclusion: In patients who do not qualify for surgical resection, MWA is a safe alternative therapy for the treatment of intrahepatic CCA.

Recurrent hepatic artery pseudoaneurysm repair with overlapping tapered stent-graft technique.

Hepatic artery pseudoaneurysms (HAPs) are rare but life-threatening complications associated with hepatic artery infusion pump (HAIP) therapy for unresectable liver metastases. Traditional management options include open surgery or stent placement, but these approaches have drawbacks. We present a unique case of a dislodged stent embedded in a HAP, resulting in delayed type-I endoleak. To address this, we employed a novel technique using multiple overlapping tapered stents to reconstruct the hepatic artery. This approach successfully excluded the pseudoaneurysm without endoleak. Stent-graft placement emerges as a safer and more effective option for managing HAP, preserving hepatic arterial flow, and reducing morbidity compared to other methods. However, further research is needed to evaluate this technique's long-term outcomes and potential complications.

Update on Endovascular Therapy for Fibroids and Adenomyosis.

Uterine fibroids and adenomyosis are prevalent benign neoplasms that can lead to serious deleterious health effects including life-threatening anemia, prolonged menses, and pelvic pain; however, up to 40% of women remain undiagnosed. Traditional treatment options such as myomectomy or hysterectomy can effectively manage symptoms but may entail longer hospital stays and hinder future fertility. Endovascular treatment, such as uterine artery embolization (UAE), is a minimally invasive procedure that has emerged as a well-validated alternative to surgical options while preserving the uterus and offering shorter hospital stays. Careful patient selection and appropriate techniques are crucial to achieving optimal outcomes. There have been advancements in recent times that encompass pre- and postprocedural care aimed at enhancing results and alleviating discomfort prior to, during, and after UAE. Furthermore, success and reintervention rates may also depend on the size and location of the fibroids. This article reviews the current state of endovascular treatments of uterine fibroids and adenomyosis.

Transjugular intrahepatic portosystemic shunt for pediatric portal hypertension: A meta-analysis.

To evaluate the feasibility of transjugular intrahepatic portosystemic shunt (TIPS) in children with portal hypertensive complications, PubMed and Cochrane Library were queried to identify clinical studies evaluating TIPS in patients <18 years old. Baseline clinical characteristics, laboratory values, and clinical outcomes were extracted. Eleven observational studies totaling 198 subjects were included in the study. The pooled technical success rate and hemodynamic success rate were 94% (95% confidence interval [CI]: 86-99%) and 91% (95% CI: 82-97%), respectively; ongoing variceal bleeding resolved in 99.5% (95% CI: 97-100%); refractory ascites was improved in 96% (95% CI: 69-100%); post-TIPS bleeding rate was 14% (95% CI: 1-33%); 88% of patients were alive or successfully received liver transplant (95% CI: 79-96%); and shunt dysfunction rate was 27% (95% CI: 17-38%). Hepatic encephalopathy occurred in 10.6% (21/198), though 85.7% (18/21) resolved with medical management only. In conclusion, based on moderate levels of evidence, TIPS is a safe and effective intervention that should be considered in pediatric patients with portal hypertensive complications. Future comparative studies are warranted.

A Comprehensive Research Schema for the Characterization of Aortic Aneurysms.

A robust, accurate, and standardized approach to measurement of the aorta is critical to improve the predictive accuracy of these aortic measurements, and to investigate other aortic imaging biomarkers. Developing a comprehensive and generic schema for characterization of the aorta to enable investigators to standardize data that are collected across all aorta research. A systematic review of the literature was conducted to identify and assess schemata of aortic measurement and description. The schemata were reported and discussed to guide the synthesis of a comprehensive schema. We propose the International College of Angiology Aortic Research Schema as a comprehensive design that fills the gaps left behind by previously reported schemata. It is intended to be applicable for all clinically relevant purposes, including endograft development for aneurysm repair and for the accurate characterization of the aortic anatomy. This schema divides the aorta into 14 segments and 2 sections (thoracic and abdominal aortas). The segmentation proposed can be used in addition to specific measurements taken for any aneurysm including the neck, and maximal and minimal diameters of the aneurysm.

Impact of intravenous access site on attenuation for thoracic computed tomographic angiography: A time-matched, nested, case-control study.

BACKGROUND: The objective of this study was to evaluate whether the choice of intravenous access (IVA) site affects aortic attenuation during thoracic computed tomographic angiography (T-CTA) and any associated risks with intravenous device placement. METHODS: All T-CTA exams performed between 1/1/2013 and 8/14/2015 were retrospectively reviewed to identify those performed with contrast media injection via alternative (i.e. non-antecubital) IVA (n = 1769). Using time matching, antecubital IVA exams (n = 1769) were selected as controls. For each exam, attenuation was measured in the ascending aorta. Patient and technical data was subsequently collected from all 3538 patients included in this study. Multiple linear regression was used to determine if IVA site affected attenuation. Lastly, data related to extravasations for the entire T-CTA cohort were collected and compared. RESULTS: Hand/wrist, arm, and central venous access device IVA were all equivalent to antecubital IVA in terms of attenuation (P = 0.579, P = 0.599, and P = 0.522 respectively). Forearm and intraosseous IVA had significantly higher attenuation (P = 0.010 and P = 0.002, respectively) than antecubital IVA. Right-sided IVA was associated with a small attenuation increase of 11 Hounsfield Units (P < 0.001) compared to left-sided IVA. In terms of extravasation, antecubital IVA was equivalent to hand/wrist, forearm, and upper arm IVA (P = 0.778, P = 0.060, and P = 0.090 respectively). CONCLUSIONS: Satisfactory aortic attenuation achieved with non-antecubital IVA is equivalent to attenuation achieved with antecubital IVA for T-CTA imaging. The risk of contrast media extravasation in peripheral IVA devices was relatively low, however, appropriate IVA site selection should be considered an important factor for successful administration of contrast media for future imaging studies. This prevents undue harm to patients through preventable device failures when using a peripheral IV device in areas of high flexion/range of movements undergoing pressure injection for contrast media.

18F-FDG PET/CT and MR imaging features of liver metastases in gastrointestinal stromal tumors: a cross-sectional analysis.

Background: Early detection of gastrointestinal stromal tumor (GIST) liver metastases is crucial for the management and prognosis. In our experience, GIST liver metastases can display hypermetabolism on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) and marked enhancement on magnetic resonance imaging (MRI), which are uncommon in other tumors before treatment. Most literature focus on the imaging evaluation, prognosis after treatment and less is known about imaging features on both imaging methods before treatment. This study analyzes the imaging features of newly diagnosed GIST liver metastases on 18F-FDG PET/CT and MRI, with goal of improving diagnostic accuracy. Methods: This retrospective study included 55 patients with pathological or radiographical confirmed GIST liver metastases who underwent PET/CT (n=29), MRI (n=22), or both methods (n=4). PET/CT and MRI interpretation including lesion's morphologic features, number, density or signal intensity, hemorrhage, cystic changes or necrosis, maximum standardized uptake value (SUVmax) of liver metastases and liver background on PET imaging, degree and pattern of enhancement on MRI were obtained by two experienced nuclear medicine physicians and two radiologists respectively. Data are presented as numbers, percentages, means ± standard deviations or median (interquartile range). The correlation between diameter and SUVmax of metastases, and primary tumor SUVmax and synchronous liver metastases SUVmax were analyzed by Spearman's rank test. Results: On PET/CT visual analysis, 38.9%, 23.9%, and 37.2% of lesions showed significant hypermetabolism, slightly higher metabolism, and equal or lower metabolism than liver, respectively. There was a weak correlation between the diameter and SUVmax of liver metastases (rs =0.370, P<0.001), and a moderate correlation between SUVmax of synchronous liver metastases and the primary tumors (rs =0.492, P<0.001). On contrast-enhanced MRI, 90.8% of lesions showed heterogeneous enhancement in the arterial phase with the variable presentation, and 74.3% had different enhancement patterns between margins and intratumoral parenchyma. Conclusions: Liver lesions in GIST displaying significant, slight hypermetabolism on 18F-FDG PET/CT, marked or heterogeneous gradual enhancement within the intratumoral parenchyma with ring-like enhancement on MRI may denote the diagnosis of liver metastasis. However, GIST liver metastases may also display equal or lower metabolism than liver parenchyma on PET, making small lesions more difficult to diagnose.

Identification of the hsa_circ_0039466/miR-96-5p/FOXO1 regulatory network in hepatocellular carcinoma by whole-transcriptome analysis.

Background: Circular RNAs (circRNAs) are important for the process of cancer initiation and progression. However, the role of circRNAs in hepatocellular carcinoma (HCC) remains incompletely understood. Therefore, we further explored the expression network of circRNAs in HCC. Methods: Whole-transcriptome microarrays of HCC and paired normal liver tissues were obtained from the Gene Expression Omnibus (GEO) database. The structures of tumor-associated circRNAs were acquired by the Cancer-Specific CircRNA Database (CSCD). StarBase, circBank, and R packages (miRNAtap and multiMiR) were used to predict miRNA targets of circRNAs and downstream molecules of miRNAs. Expression relationships between RNA-RNA interactions were evaluated by data from The Cancer Genome Atlas (TCGA) and GEO databases. ClusterProfiler and DOSE R packages were used for pathway enrichment to explore the biological functions of potential target genes. Finally, a possible circRNA-miRNA-mRNA regulatory network was established based on the competing endogenous RNA (ceRNA) hypothesis. Results: The differentially expressed circRNAs (DECs) were matched with cancer-specific circRNAs in the CSCD database and a screening analysis was performed to obtain 5 cancer-specific circRNAs. A total of 329 possible target miRNAs for 5 cancer-specific circRNAs were predicted by the circBank database, and intersection analysis with differentially expressed miRNAs (DEmiRNAs) revealed that miR-6746-3p and miR-96-5p were the two most suitable miRNAs targets for our selected circRNAs. Further expression verification and prediction of base complementary paired binding sites demonstrated the hsa_circ_0039466/miR-96-5p axis as a crucial pathway in HCC. Next, we found that FOXO1 and LEPR were two potential downstream molecules of the hsa_circ_0039466/miR-96-5p axis through target gene prediction analysis, differential expression analysis, and intersection analysis. The pathway enrichment results suggested that the hsa_circ_0039466/miR-96-5p axis affects the progression and outcome of HCC through the insulin resistance pathway. Finally, through multi-data crossover analysis and data analysis of HCC samples further confirmed the existence of the hsa_circ_0039466/miR-96-5p/FOXO1 ceRNA regulatory network and that the axis was closely related to clinical stage. Conclusions: hsa_circ_0039466 facilitates the expression of FOXO1 by sponging miR-96-5p, and ultimately inhibits tumor progression. These results provide a theoretical basis for further understanding of the gene expression network of HCC.

Non-surgical management of abdominal ectopic pregnancy with uterine artery embolization.

Abdominal pregnancy is a rare but life-threatening variation of ectopic pregnancy that is often treated with laparoscopic management; however, we present a case successfully treated using only minimally invasive techniques. A 36-year-old female G1P0 with a history of infertility is diagnosed with 11-weeks abdominal pregnancy by transvaginal ultrasound. She presented with vaginal bleeding and abdominal pain, and her beta-human chorionic gonadotropin was 53,680 mIU/mL. The location of the fetal sac was not amenable to surgery or percutaneous injection. We performed bilateral uterine artery embolization and subsequent intramuscular methotrexate injection. The procedure was successful with no complications. The patient was followed at postoperative week 11, and beta-human chorionic gonadotropin was 2 mIU/mL, and at 3 months, a transvaginal ultrasound revealed resolution of the abdominal pregnancy.

Combined transhepatic and transjugular approach for mechanical thrombectomy of massive TIPS thrombosis.

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated decompressive therapy option to manage ascites and variceal bleeding secondary to portal hypertension. Complications following TIPS procedures include hepatic encephalopathy, liver failure, and TIPS dysfunction. TIPS dysfunction is due to occlusion or stenosis of the TIPS shunt and can be caused by acute or chronic thrombosis. TIPS thrombosis is often treated with mechanical thrombectomy or catheter-directed thrombolytic therapy. Most cases of in-stent occlusion can be treated via a transjugular approach with recanalization or placement of additional stents. We present a case of a 72-year-old female who presented with worsening ascites 17 months after initial TIPS procedure; she was found to have a large thrombus completely occluding the TIPS stent. In our case, a combined transhepatic and transjugular approach was required for TIPS revision given the extent of well-organized clot located near the hepatic venous end of the stent, resulting from prolonged stent occlusion. This was an extremely challenging scenario with two overlapping covered stents and a bare metal stent at the hepatic venous end in the setting of chronic thrombosis and a well-organized fibrous cap. The case highlights the need for optimal initial placement of the primary TIPS shunt to avoid the need for subsequent complex interventions to maintain TIPS shunt patency.

Endovascular management of HIV vasculopathy.

HIV is a multisystem disease process that can affect the cardiovascular system resulting in vasculopathy. As highly active anti-retroviral therapy has allowed patients to live longer with the disease, vascular complications such as aneurysms, occlusive disease, spontaneous arteriovenous fistulae, and arterial dissections have been described. The pathogenesis of vascular-related complications in HIV is poorly understood but is thought to involve an interplay between viral-induced inflammation, vascular smooth muscle changes, endothelial alterations, and circulating blood factors. The most well-described management strategies for symptomatic aneurysm-related complications are surgical in nature, with mostly anecdotal reports of endovascular intervention. We present a case of a 24-year-old male who was found to have findings consistent with HIV vasculopathy on angiography after presenting with acute GI hemorrhage secondary to left gastric artery bleeding. Our patient was managed with endovascular embolization. Although studies have shown promise regarding the endovascular management of HIV-related aneurysmal complications in the short term, more research is needed to evaluate the long-term success of these interventions.

CT-guided microwave ablation of hepatic malignancies via transpulmonary approach without ancillary techniques.

OBJECTIVES: The objectives of the study were to determine the safety and efficacy of computed tomography (CT)-guided transpulmonary percutaneous microwave ablation (MWA) for hepatic malignancies without the use of ancillary techniques. MATERIAL AND METHODS: A retrospective review was performed on patients who underwent MWA for hepatic malignancy between January 2014 and February 2020 at a single tertiary center. Imaging was reviewed for each procedure to identify MWA showing transpleural transgression on CT scans. For these patients, demographics, ablation data, pulmonary complication rate, and predictors of pneumothorax were analyzed. RESULTS: A total of 71 consecutive sessions (62.1 ± 11.3 years, 79% of males) of MWA were performed to treat 71 tumors (1.90 ± 0.96 cm) via transpulmonary approach under CT guidance. Technical success was achieved in all cases immediately after the procedure. At 1-month follow-up, 65/69 (94.2%) patients had no residual disease (two patients were lost to follow-up). Pulmonary complications occurred in 26/71 (36.6%) sessions, and 15/26 (57.7%) were minor requiring no intervention. Pneumothorax occurred in 14/71 (19.7%) sessions, and the rate of major pneumothorax requiring chest tube was 8/71 (11.3%). Lesions on the left side of the liver (segments I-IV) and intraprocedural probe adjustment were found to be independent predictors of developing major pneumothorax (P = 0.007 and 0.028, respectively). There were no reported pulmonary complications at the 1-month follow-up. CONCLUSION: CT-guided transpulmonary MWA is safe and effective in treating hepatic malignancies. Although it is associated with the risk of developing pulmonary complications, patients underwent successful ablation of their hepatic malignancies without life-threatening complications and mortality.

Percutaneous drainage for non-operative management of emphysematous pyelonephritis: Clinical characteristics and predictors of success.

Emphysematous pyelonephritis (EPN) is a necrotizing renal infection that can rapidly progress without urgent intervention. The purpose of this study was to evaluate the safety and efficacy of percutaneous nephrostomy (PN) in the management of EPN, as well as the relationship of outcomes with initial classification by the Huang-Tseng classification system and other prognostic factors such as thrombocytopenia. A retrospective review of medical records revealed seven patients with EPN treated with PN. Thirty-day survival rate was 86%, with the only mortality due to an arrhythmia secondary to underlying cardiomyopathy rather than a complication from EPN or PN. A single nephrostomy procedure served as definitive treatment in 3 patients (43%). Reintervention due to recurrence of EPN symptoms was required in 4 patients (57%), all of which initially presented with Class 3 disease or higher. Two of these four patients required nephrectomy, while the other two were successfully managed with a second drainage procedure without further recurrence of symptoms. PN appears to be a safe and generally effective management option for EPN, especially in patients who are considered poor surgical candidates. PN may serve as definitive treatment in hemodynamically stable patients with lower class of disease. In patients with higher class of disease, PN may be definitive treatment in patients who lack additional risk factors such as thrombocytopenia or serve as an effective bridge to nephrectomy.

Current perspectives on microwave ablation of liver lesions in difficult locations.

Microwave ablation (MWA) is becoming the standard of care in treating liver lesions smaller than 3 cm benefiting from a plethora of radiofrequency ablation (RFA) data in the literature. Some of the advantages of MWA compared to RFA are as follows: Faster ablations, more reproducible and predictable heating, better thermal conductivity in different liver tissue environments, and less susceptibility to heat-sink effect. Despite its many advantages, there are still concerns regarding MWA use in high-risk locations such as near portal veins, near the bile ducts, and near the heart. Some centers have historically considered these tumor locations as a contraindication to percutaneous thermal ablation. In this review, we summarize the current data on the safety of MWA of liver tumors in challenging locations. We also discuss several technical tips with examples provided.

Seurat Spleen: A Pathognomonic Sign in Angiography.

Splenic injury commonly occurs following abdominal trauma and can result in severe complications and death if it goes unrecognized. The Seurat spleen is a term used to describe the angiographic appearance of splenic injury following blunt trauma, given its resemblance to the pointillistic artwork of French neo-impressionist Georges Seurat. We present a case of a 43-year-old man who presented following a motor vehicle collision and was found to have multiple punctate foci of contrast extravasation in the spleen consistent with the Seurat spleen angiographic sign. This angiographic pattern can be used as a pathognomonic sign to identify splenic injury, with early identification crucial to preventing further complications of the injury.

Percutaneous microwave ablation of hepatic lesions near the heart.

BACKGROUND: Early stage liver cancer is often treated with hepatic resection or transplantation for curative intent. Microwave ablation (MWA) is often performed in patients who are poor surgical candidates, patients with limited multifocal disease, disease close to hepatic vasculature, but can also be performed with curative intent in case of small lesions. The purpose of this study is to evaluate safety and efficacy of MWA of liver tumors with final ablation zone ≤5 mm from the heart. METHODS: A retrospective review was conducted on patients with hepatic cancer who underwent MWA between 1/2015 and 6/2019. Patients with a final ablation zone ≤5 mm to the heart were included. For these patients, imaging obtained prior, during and after procedure along with procedure reports were used to identify tumor and ablation characteristics, and electronic medical records were used to identify patient demographics and disease status. RESULTS: A total of 17 patients had liver tumors with ablation zone ≤5 mm to the heart. Mean lesion size was 18.2 mm (range, 10-33 mm) and mean follow-up period was 10.4 months. Of note 82% of patients had multifocal disease at time of MWA of lesion close to the heart. Two patients had pneumothorax, one of which required chest tube placement. None of the patients had cardiac arrhythmias or other complications. Overall 12/17 of the patients had disease progression within the liver at different sites from ablated lesions. One patient had residual disease and one had local recurrence. In addition, 4/17 patients, had no disease progression or recurrence and one underwent liver transplantation prior to follow-up imaging. CONCLUSIONS: MWA of liver lesions with ablation zone ≤5 mm to the heart is safe and effective, however, it can be technically challenging.

Rapid 3D reconstruction guided embolization for catastrophic bleeding following vacuum assisted breast biopsy; A case report and review of the literature.

The most clinically significant complication associated with stereotactic core needle biopsy of the breast is hematoma formation, which only occurs in less than 1% of biopsies and may require treatment. Cases of uncontrollable bleeding, refractory to repeated compression, resulting from biopsy are exceedingly rare. We present a case of catastrophic, uncontrollable bleeding and large hematoma formation resulting from stereotactic vacuum-assisted breast biopsy of a breast mass identified in screening mammography. Percutaneous embolization was planned and guided using 3D reconstructions from computed tomographic angiography, and bleeding was successfully controlled with micro-coil embolization.