Multicenter evaluation of the safety and efficacy of selective internal radiation therapy with yttrium-90 resin microspheres in Taiwan: data from the RESIN registry.

BACKGROUND AND AIM: The REgistry of Selective Internal radiation therapy in AsiaNs (RESIN) was a multicenter, single-arm, prospective, observational study of 90Y resin microspheres in patients with hepatocellular carcinoma (HCC) or metastatic colorectal cancer (mCRC) from Taiwan. RESIN is the first real-life clinical study of this therapy in an Asian cohort. Study objectives were to evaluate the safety and efficacy of 90Y resin microspheres. METHODS: Adults with HCC or mCRC scheduled to receive SIRT with 90Y resin microspheres were included. Primary endpoints were best overall response rate (ORR), adverse events, and changes from baseline in liver function. Secondary efficacy endpoints included overall survival (OS). RESULTS: Of 107 enrolled patients, 83 had HCC, and 24 had mCRC. ORR was 55.41% (HCC) and 33.33% (mCRC). Of 58 HCC patients with 6-month post-SIRT data, 13.79% (n = 8) had resection, transplantation, transarterial chemoembolization, or radiofrequency ablation as the result of down-staging or down-sizing of their lesions. One hundred and ten treatment emergent adverse events (TEAEs) were reported in 51 patients, and five serious adverse events (SAEs) were reported in five patients. The most frequent TEAEs were abdominal pain, nausea and decreased appetite (HCC), and abdominal pain, decreased appetite, fatigue, and vomiting (mCRC). Two deaths due to SAEs (probably related to SIRT) were reported, both in patients with extensive HCC, active hepatitis infection, and other comorbidities. Median OS was 24.07 (HCC) and 12.66 (mCRC) months. CONCLUSIONS: Safety and efficacy outcomes with the routine use of SIRT with 90Y resin microspheres in Taiwan are consistent with published data.

A novel protocol for abdominal low-dose CT scans adapted with a model-based iterative reconstruction method.

PURPOSE: This study aims to introduce a novel low-dose abdominal computed tomography (CT) protocol adapted with model-based iterative reconstruction (MBIR), To validate the adaptability of this protocol, objective image quality and subjective clinical scores of low-dose MBIR images are compared with the normal-dose images. METHODS: Normal-dose abdominal CT images of 58 patients and low-dose abdominal CT images of 52 patients are reconstructed using both conventional filtered back projection (FBP) and MBIR methods with and without smooth applying. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) are used to compare image quality between the normal-dose and low-dose CT scans. CT dose indices (CTDI) of normal-dose and low-dose abdominal CT images on post-contrast venous phase are also compared. RESULTS: The SNR, CNR and clinical score of low-dose MBIR images all show significant higher values (Bonferroni p < 0.05) than those of normal-dose images with conventional FBP method. A total of around 40% radiation dose reduction (CTDI: 5.3 vs 8.7 mGy) could be achieved via our novel abdominal CT protocol. CONCLUSIONS: With the higher SNR/CNR and clinical scores, the low-dose CT abdominal imaging protocol with MBIR could effectively reduce the radiation for patients and provide equal or even higher image quality and also its adaptability in clinical abdominal CT image diagnosis.

Endovascular management of aorto-iliac occlusive disease (Leriche syndrome).

BACKGROUND: Bypass grafting is the standard of care for chronic aorto-iliac occlusive disease (AIOD, aka Leriche Syndrome) but is associated with mortality rates of up to 25% if surgical re-intervention is necessary. Despite a recent shift towards an endovascular-first strategy for TransAtlantic InterSociety Consensus II ("TASC II") C and D lesions, reports from Leriche Syndrome are still limited. PATIENTS AND METHODS: 15 high-risk patients (11 male, 4 female), mean age of 60.6 years, with chronic aorto-iliac occlusive disease were retrospectively reviewed. Retrograde approaches via the bilateral femoral arteries for aortic occlusion less than 4 cm in length and/or antegrade fashion from the brachial artery for juxtarenal type lesions were made. For the latter, thrombolysis prior to angioplasty was also performed. Intraluminal or if necessary, subintimal angioplasty was performed with deployment of either bare metal stents or stentgrafts in a kissing-stent fashion. RESULTS: A total of 28 iliac arteries and 14 occluded abdominal aorta were treated with 100% technical success, of which 25% success were achieved by using subintimal technique. Two minor complications occurred, including vascular rupture and distal emboli in one patient apiece, which were successfully managed via endovascular fashion. There were no complications of renal artery emboli. Primary and secondary patency rates at 1, 3 and 5 years were 92.3% and 100%; 83.9% and 100%; and 83.9% and 100%, respectively. CONCLUSION: Endovascular therapy for chronic aorto-iliac occlusion has a high technical success rate, with good short- and mid-term primary and secondary patency rates and may provide a valid alternative to surgery for high-risk patients.

Complete Response in Metastatic Hepatocellular Carcinoma with Cardiac and Lung Involvement via Multimodality Treatment.

Background: Until recently, advanced HCC patients with major vessel and cardiac involvement have had an extremely poor prognosis without satisfactory treatment. Case presentation: A 63-year-old Taiwanese male presented with metastatic HCC with RA and IVC thrombi, as well as pulmonary metastases that were successfully treated by multimodal management, encompassed by surgical thrombectomy, concurrent systemic sorafenib and locoregional therapies, and immunotherapy. The patient has achieved a complete response over the past 33 months. Conclusions: Through this case report, which shows a successful outcome via multimodal management, a more aggressive approach should be considered when a patient is expected to tolerate the risks and side effects of various treatments.

Hepatic Arterial Infusion Chemotherapy Followed by Lipiodol Infusion for Advanced Hepatocellular Carcinoma with Portal Vein Tumor Thrombus: A Single-Center Experience.

Background and Objectives: To evaluate the effectiveness of hepatic arterial infusion chemotherapy (HAIC) followed by lipiodol infusion in advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). Materials and Methods: Thirty-two patients with advanced HCC and PVTT who received HAIC with regimens of cisplatin, mitomycin-C, and 5-fluorouracil followed by lipiodol infusion were enrolled. The primary efficacy endpoint was tumor response rate. The modified Response Evaluation Criteria in Solid Tumors (mRECIST) was used for assessment of treatment response. The secondary endpoints were overall survival (OS) and progression free survival (PFS). Prognostic factors for survival also were evaluated. Results: The median OS and PFS were 11.9 and 9.5 months, respectively. Seventeen patients (53.1%) achieved objective response, and 23 patients (71.9%) achieved disease control. The length of survival in the responder and disease control groups was longer than in the non-responder and progressive disease groups after two cycles of HAIC (responder vs. non-responder: 16.5 vs. 7.9 months, p = 0.001; disease control vs. progressive disease: 12.3 vs. 5.6 months, p < 0.001) and after completing HAIC (responder vs. non-responder: 15.7 vs. 6.9 months, p = 0.001; disease control vs. progressive disease: 13.6 vs. 6.9 months, p < 0.001). Better survival was associated with Child-Pugh A liver function (p = 0.013), with early response to two HAIC cycles (p = 0.009), and with response (p = 0.02) and disease control (p = 0.001) after completing HAIC treatment. Conclusion: HAIC followed by lipiodol infusion is a safe and feasible treatment for advanced HCC with PVTT. Patients with early response could continue HAIC treatment with expected prolonged survival.

Doppler Flow Measurement of Lower Extremity Arteries Adjusted by Pulsatility Index.

OBJECTIVE. The purposes of this study were to estimate the blood volume flow of the lower extremities by means of Doppler technique; to establish a quantitative relationship between volume flow and pulsatility index (PI) in both healthy subjects and patients with peripheral artery disease (PAD); and to derive arterial blood flow equations in the lower extremities for more accurate volume flow estimations. SUBJECTS AND METHODS. Sixty healthy subjects were recruited. Arterial diameter, peak systolic velocity, PI, time-averaged mean velocity, and volume flow of right lower extremity arteries were measured with duplex Doppler ultrasound. Linear regression analysis was used to evaluate the relationship between volume flow and the reciprocal of PI. This quantitative relationship was also used to assess flow changes in 10 patients with PAD before, after, or both before and after percutaneous angioplasty. RESULTS. Volume flow in the common femoral artery was 434.4 mL/min; superficial femoral artery, 172.5 mL/min; popliteal artery, 92.1 mL/min; dorsalis pedis artery, 11.8 mL/min; and common plantar artery, 12.0 mL/min. Linear relationships between the reciprocal of PI and volume flow were found and expressed as linear blood flow equations. For the patients with PAD, no statistical increase in measured flow in the downstream artery after percutaneous angioplasty was found (p = 0.1), although four arteries had decreased flow. After normalization of flow measurements with PI values, however, statistical increases were observed between percentage increment (p < 0.001) calculations. CONCLUSION. When real-time PI values are factored into blood volume flow calculations in the evaluation of lower extremity arteries, discrepancies in flow measurements can be resolved, resulting in more accurate and stable measurements of clinical and diagnostic significance.

Natural History of Persistent Pulmonary Subsolid Nodules: Long-Term Observation of Different Interval Growth.

BACKGROUND: The long-term natural course and outcomes of subsolid nodules (SSNs) in terms of true growth, substantial growth, and stage shift need to be clarified. METHODS: Between 2002 and 2016, 128 subjects with persistent SSNs of 3cm or smaller were enrolled. The baseline and interval changes in the series computed tomography (CT) findings during the follow-up period were subsequently reviewed. RESULTS: The mean follow-up period was 3.57±2.93years. The cumulative percentage of growth nodules of the part-solid nodule (PSN) group was significantly higher than that of the ground-glass nodule (GGN) group by Kaplan-Meier estimation (all p<0.0001). For true SSN growth, GGNs usually take a median follow-up of 7 years to grow; PSNs usually take a median follow-up of 3 years to grow. For substantial SSN growth, GGNs usually take a median follow-up of 9 years to grow; PSNs usually take a median follow-up of 3 years to grow. For stage shift, GGNs usually take a median follow-up of 12 years to grow; PSNs usually take a median follow-up of 9 years to grow. CONCLUSIONS: The natural course in terms of true growth, substantial growth, and stage shift differed significantly according to their nodule type, which could contribute to the development of follow-up guidelines and management strategy of pulmonary SSNs.

The Complication of Hepatic Artery Injuries of 1,304 Percutaneous Transhepatic Biliary Drainage in a Single Institute.

PURPOSE: To determine frequency of and assess risk factors for hepatic artery (HA) injury during percutaneous transhepatic biliary drainage (PTBD) and to discuss the technique and report the clinical outcome of embolization for HA injury. MATERIALS AND METHODS: Over a 14-year period (2002-2016), 1,304 PTBD procedures in 920 patients were recorded. The incidence of HA injury was determined, and possible associated risk factors were analyzed. When injury occurred, HA embolization was performed at the site as close to the bleeding point as possible. Clinical outcomes of these patients after embolization were reported. RESULTS: Of 1,304 PTBD procedures, a left-sided approach was used in 722 procedures (55.4%), and intrahepatic duct (IHD) puncture under ultrasound guidance was used in 1,161 procedures (90.1%). The IHD was nondilated in 124 (9.5%) patients. The punctured ductal entry site was peripheral in 1,181 (90.6%) patients. In this series, 8 procedures (0.61%) were complicated by HA injury. IHD dilatation status was the only risk factor (P = .017) for HA injury. Embolization was performed with technical and clinical success in all 8 patients. No recurrent hemobilia, intraabdominal bleeding, or other sequelae of HA injury after embolization was noted during 1 week to 84 months of follow-up. CONCLUSIONS: HA injury is a relatively rare complication of PTBD. IHD dilatation status was the only risk factor for HA injury in this study. When HA injury occurred, embolization therapy was effective in managing this complication.

Percutaneous Endovascular Creation of a Neo-arteriovenous Fistula in Dysfunctional Hemodialysis Fistulas.

PURPOSE: Arteriovenous fistulas (AVF) is the preferred type of hemodialysis access, but when an arteriovenous anastomosis (AVA) calcifies, surgical revision of the AVF may be required. We report a technique to create percutaneous artery-to-vein intervascular neo-fistulas for re-anastomosis of AVA and evaluate its safety and efficacy. MATERIALS AND METHODS: 9 patients who failed either guidewire navigation or conventional balloon dilation for calcified AVA stenosis/occlusion underwent a salvage procedure of their dialysis shunt by the percutaneous creation of a new arteriovenous fistula. Needle puncture of the adjacent supplying artery and outflow vein under ultrasonographic and/or fluoroscopic guidance was performed and followed by balloon dilation, with or without stent graft placement. The detailed techniques, technical success, primary neo-fistula patency, primary and secondary access patency rates were reported herein. RESULTS: Technical success was achieved in 100% of the 9 patients treated (7 neo-fistulas with stents and 2 neo-fistulas without stent placement). The median primary neo-fistula and access patencies were 15 and 5 months, respectively. The primary neo-fistula patency rates at 6, 12, and 18 months were 72.9%, 54.7% and 27.9%, respectively, with secondary neo-fistula and access patency rates of 72.9%, 72.9% and 72.9%, respectively. One delayed complication of pseudoaneurysm formation occurred, which was managed by the successful endovascular deployment of a stent graft on an out-patient basis. CONCLUSION: Percutaneous artery-to-vein intervascular neo-fistula creation is feasible for re-anastomosing calcified AVA, with low adverse effects and acceptable primary neo-fistula and secondary access patency.

Advanced hepatocellular carcinoma with major portal vein invasion: Therapeutic outcomes of hepatic arterial infusion chemotherapy vs concurrent radiotherapy.

BACKGROUND: Hepatocellular carcinoma (HCC) with major portal vein invasion (MPVI) presents very poor outcomes. Hepatic artery infusion chemotherapy (HAIC) and radiation therapy (RT) have both been found to be effective for advanced HCC. In this retrospective study, we compared the therapeutic outcomes of our "new" HAIC regimen with and without concurrent RT, before and after propensity score matching (PSM) in treating HCC patients with MPVI. METHODS: One hundred forty patients with MPVI received HAIC alone and 35 patients underwent concurrent HAIC and RT during a 16-year period. The left subclavian artery was adopted as the entry site for a temporary catheter placement for a 5-day chemoinfusion. The Modified Response Evaluation Criteria in Solid Tumors (mRECIST) was adopted to assess the objective response rate (ORR). The Kaplan-Meier curve was used to calculate progression-free survival (PFS) and overall survival (OS) between the two groups. Univariate and multivariate analyses by Cox regression model were used to assess hazard ratios. RESULTS: Of the 140 patients with Child-Pugh A liver function, the median OS was 17.0 months. In the initial cohort, higher ORR and PFS were found in the concurrent RT group than in the HAIC alone group (80% vs 66.4% and 9 vs 8 months, respectively) but shorter OS (10.5 vs 14.5 months, p = 0.039) was observed. After PSM, the OS was 10 and 15 months ( p = 0.012), respectively. Multivariable Cox regression analysis revealed that the significant factors for adjusting hazard ratios for OS were Child-Pugh classification, alpha fetal protein (AFP) level, and hepatic vein invasion. CONCLUSION: HAIC is an effective treatment for advanced HCC patients with MPVI. Concurrent HAIC and full-dose RT were associated with worse clinical outcomes.

Linear echoendoscope-guided ERCP for the diagnosis of occult common bile duct stones.

BACKGROUND: Less than 67% of patients with intermediate risk for common bile duct (CBD) stones require therapeutic intervention. It is important to have an accurate, safe, and reliable method for the definitive diagnosis of CBD stones before initiating therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Few publications detail the diagnostic efficacy of linear echoendoscopy (EUS) for CBD stones. METHODS: 30 patients with biliary colic, pancreatitis, unexplained derangement of liver function tests, and/or dilated CBD without an identifiable cause were enrolled in the study. When a CBD stone was disclosed by linear EUS, ERCP with stone extraction was performed. Patients who failed ERCP were referred for surgical intervention. If no stone was found by EUS, ERCP would not be performed and patients were followed-up for possible biliary symptoms for up to three months. RESULTS: The major reason for enrollment was acute pancreatitis. The mean predicted risk for CBD stones was 47% (28-61). Of the 12 patients who were positive for CBD stones by EUS, nine had successful ERCP, one failed ERCP (later treated successfully by surgical intervention) and two were false-positive cases. No procedure-related adverse events were noted. For those 18 patients without evidence of CBD stones by EUS, no false-negative case was noted during the three-month follow-up period. Linear EUS had sensitivity, specificity, positive and negative predicted values for the detection of CBD stones of 1, 0.9, 0.8 and 1, respectively. CONCLUSION: Linear EUS is safe and efficacious for the diagnosis of occult CBD stones in patients with intermediate risk for the disease.

Balloon-occluded retrograde transvenous obliteration for intractable gastric variceal bleeding.

Balloon-occluded retrograde transvenous obliteration (BRTO) is an interventional radiologic technique that obliterates gastric varices (GV) from draining veins under balloon occlusion. A 54-year-old man presented with Stage IV hepatocellular carcinoma and tumor thrombi in main portal vein. Intractable GV bleeding had no response to repeated endoscopic sclerotherapy and pharmacotherapy well. Additionally, his medical condition could not allow transjugular intrahepatic portosystemic shunt or surgical portal decompression. Due to spontaneous gastrorenal shunt proved with abdominal computed tomography, we conducted BRTO to prevent further bleeding. The immediate postprocedural venogram showed total occlusion of the gastrorenal shunt and no visualization of the GV. Follow-up endoscopy was performed at 1 month, 2 months, and 4 months after BRTO. It revealed shrinkage of gastric varices and no worsening of esophageal varices after 4 months of BRTO. The patient was free from repeated GV bleeding for 4 months. Our experience proved BRTO could be the other effective treatment for intractable GV bleeding.

Pulsatility index-adjusted doppler flow measurement of pedal arteries in peripheral artery disease patients.

BACKGROUND: To examine the feasibility of using pulsatility index-adjusted (PI) flow equations to accurately characterize blood volume flow changes using Doppler technique in patients with peripheral artery disease (PAD) before and after percutaneous transluminal angioplasty (PTA). METHODS: PTA was performed on 17 PAD patients (23 target vessels treated, 16 anterior tibial arteries, and 7 posterior tibial arteries). Arterial diameter, peak systolic velocity, PI, time-averaged mean velocity, and measured volume flow (MVF) of dorsalis pedis artery (DPA) and common plantar artery (CPA) were measured with duplex Doppler ultrasound before and after PTA. PI-adjusted volume flows (PIVF) were calculated as part of the MVF/PIVF relative percentage metric. RESULTS: Significant changes (p < 0.001) of the MVF (mean: 33.0 mL/min, range: -20.9-102.2 mL/min) and MVF/PIVF relative percentages (mean: 51.8, range: 5.1-127.2%) in the DPA existed between before and after PTA, whereas no significant changes could be found in the CPA (mean:10.9 mL/min, p = 0.148 and mean: 21.3%, p = 0.146, respectively). Of the 7 treated posterior tibial arteries, the increments of the MVF/PIVF (mean: 60.4%, p = 0.033) was significant but not in the MVF (mean: 26.5 mL/min, p = 0.125). The ankle-brachial index also showed non-significant changes (p = 0.081). All PI-adjusted results matched clinical observations after blood flow restoration. CONCLUSION: No conclusions can be drawn from the comparison of actual measured volume flow between before and after PTA. However, using the MVF/PIVF relative percentage allows for a more objective framework upon which to base clinical observations and provides clarity in situations where direct measurement provides a counter-intuitive or contradictory picture.

Multidisciplinary Taiwan consensus for the use of conventional TACE in hepatocellular carcinoma treatment.

Developed in early 1980s, transarterial chemoembolization (TACE) with Lipiodol was adopted globally after large-scale randomized control trials and meta-analyses proving its effectiveness were completed. Also known as "conventional TACE" (cTACE), TACE is currently the first-line treatment for patients with unresectable intermediate stage hepatocellular carcinoma (HCC) and delivers both ischemic and cytotoxic effects to targeted tumors. Although new technology and clinical studies have contributed to a more comprehensive understanding of when and how to apply this widely-adopted therapeutic modality, some of these new findings and techniques have yet to be incorporated into a guideline appropriate for Taiwan. In addition, differences in the underlying liver pathologies and treatment practices for transcatheter embolization between Taiwan and other Asian or Western populations have not been adequately addressed, with significant variations in the cTACE protocols adopted in different parts of the world. These mainly revolve around the amount and type of chemotherapeutic agents used, the type of embolic materials, reliance on Lipiodol, and the degree of selectiveness in catheter positioning. Subsequently, interpreting and comparing results obtained from different centers in a systematic fashion remain difficult, even for experienced practitioners. To address these concerns, we convened a panel of experts specializing in different aspects of HCC treatment to devise modernized recommendations that reflect recent clinical experiences, as well as cTACE protocols which are tailored for use in Taiwan. The conclusions of this expert panel are described herein.

Primary Catheter-Directed Thrombolysis for Porto-Mesenteric Venous Thrombosis (PMVT) in Non-Cirrhotic Patients.

Purpose: To report our thrombolytic technique, treatment strategy, and clinical outcomes for porto-mesenteric venous thrombosis (PMVT) in non-cirrhotic patients. Methods: Sixteen acute or chronic non-cirrhotic PMVT patients (mean age: 48.6 years) with imminent intestinal ischemia were enrolled from 2004 to 2020. Eight patients presented thrombus extension into the peripheral mesenteric vein, close to the venous arcade. Transhepatic catheter-directed thrombolysis (CDT) was performed by urokinase infusion (60,000-30,000 IU/h concomitant with heparin 300-400 IU/h), catheter aspiration, and/or balloon dilation/stent placement. Additional intra-arterial mesenteric infusion of urokinase (30,000 IU/h) was given in patients with the peripheral mesenteric venules involved. Transjugular intrahepatic porto-systemic shunt (TIPS) was created in patients with poor recanalization of the intrahepatic portal flow (PV). Results: The transhepatic route was adopted in all patients, with adjunct indirect mesenteric arterial thrombolytic infusion in eight patients. A total of up to 20.4 million IU urokinase was infused for 1-21 days' treatment duration. TIPS was created in three patients with recanalization failure of the intrahepatic PV. Technical success was achieved in 100% of patients with complete recanalization of 80% and partial recanalization of 20%. No major procedure-related complications were encountered. The 30-day mortality rate was 6.7%. The overall two-year primary patency was 84.6%. Conclusions: CDT can be performed as a primary salvage treatment once the diagnosis is made. CDT via the transhepatic route with tailored thrombolytic regimen is safe and effective for both acute and chronic PMVT. TIPS creation can be preserved in non-cirrhotic PMVT patients if intrahepatic PV recanalization fails.

Management of acute lower gastrointestinal bleeding by pharmaco-induced vasospasm embolization therapy.

BACKGROUND: To report the clinical outcomes of vasospasm embolization technique in treating lower gastrointestinal bleeding (LGIB). METHODS: Fifty LGIB patients (32 men and 18 women; mean age, 70.4 years) with positive contrast extravasation on multidetector computed tomography were treated with pharmaco-induced vasospasm embolization by semiselective catheterization technique. Distal rectal bleeding was excluded. The bleedings in three patients were considered to be tumor related. Eighteen underwent regular hemodialysis, and 22 showed unstable hemodynamic at intervention. RESULTS: Forty-two bleeders were found in superior mesenteric territory and eight in the inferior mesenteric territory. Successful, immediate hemostasis was achieved in 49 (98%) patients. Early recurrent bleeding (<30 days) was found in 13 (26.5%) patients with 6 local rebleeding (12.2%), 5 new-foci bleeding (10.2%), and 2 uncertain foci bleeding (4.1%). Repeated vasospasm embolization therapy was given to five patients, with successful hemostasis in four. All the three tumor-related bleeding patients undergoing vasospasm embolization had ceased bleeding and discharged. Patient-based primary and overall clinical successes were achieved in 73.5% and 83.7%, and lesion-based primary and overall clinical successes were 83.0% and 86.7%, respectively. The 30-day mortality rate was 21.3%, and the 1- and 2-year survival rates were 51.5% and 43.8%. No major procedure-related complications (eg, bowel ischemia) were encountered. CONCLUSION: This study confirmed our prior preliminary conclusion that pharmaco-induced vasospasm embolization is easy, safe, and effective for LGIB. This treatment may be considered the first-line alternative approach for LGIB, especially for patients of advanced age with complex medical problems and/or when vasa rectal embolization isn't feasible.

New Regimen of Combining Hepatic Arterial Infusion Chemotherapy and Lipiodol Embolization in Treating Hepatocellular Carcinoma with Main Portal Vein Invasion.

BACKGROUND: The prognosis of HCC patients with main portal vein invasion (Vp4) is poor. We retrospectively reviewed the therapeutic outcomes with our new HAIC regimen in treating Vp4 HCC patients. PATIENTS AND METHODS: Seventy-one patients received the new regimen of combining HAIC (daily infusion of cisplatin (10 mg/m2), mitomycin-C (2 mg/m2) and Leucovorin (15 mg/m2) plus 100 mg/m2 of 5-fluorouracil (5-FU) using an infusion pump for 5 consecutive days) with Lipiodol embolization between 2002 and 2018. Twenty-two patients (31.0%) also received sorafenib. The Kaplan-Meier curve was used to calculate progression-free survival (PFS) and overall survival (OS). The OS of patients with or without additional sorafenib use or extrahepatic spread (EHS) was also compared. RESULTS: Fifty-six patients (78.9%) had Child-Pugh A liver function. The mean maximal tumor size was 10.3 cm. Twenty patients (28.2%) had EHS at their initial diagnosis. The objective response rate according to the Modified Response Evaluation Criteria in Solid Tumors (mRECIST) and median OS were 64.8% and 13 months. The 1-, 2- and 3-year survival rates were 53.1%, 21.5% and 18.7%, respectively. In the subgroup analysis, there were no significant survival difference between patients with HAIC only vs. HAIC plus sorafenib (14 vs. 13 months) and between patients with vs. without EHS (12 vs. 13 months). CONCLUSIONS: Our new HAIC regimen is effective in treating Vp4 HCC patients. Additional sorafenib use with our new HAIC regimen provided no survival benefit.

Intramural blood pools accompanying aortic intramural hematoma: CT appearance and natural course.

PURPOSE: To evaluate multidetector computed tomographic (CT) images to investigate the prevalence, morphology, natural course, and prognostic effect of intramural blood pools (IBPs) in patients with acute intramural hematoma (IMH). MATERIALS AND METHODS: Institutional review board approval and written informed consent were obtained. Sixty-five patients (41 men; mean age, 65.9 years ± 11.3 [standard deviation]) with acute IMH undergoing three or more multidetector CT examinations during follow-up for 12 months or longer (median = 18 months), except for those undergoing surgery (n = 16), were enrolled. Associated factors of developing and resorption of IBP in IMH were analyzed by using logistic regression. RESULTS: There were 40 IBPs in 10 patients at initial multidetector CT, and 15 new IBPs developed in 11 patients during follow-up. IBPs occurred most in the descending thoracic (55% [31 of 56]) and abdominal (41% [23 of 56]) aorta in 28% (18 of 65) of patients. During 33.8 months (range, 2.8-50 months) of follow-up in these 18 patients, 57% (32 of 56) of IBPs showed complete resorption in 15 patients, 29% (16 of 56) of IBPs showed incomplete resorption in eight patients, and 14% (eight of 56) of IBPs had interrupted follow-up because of surgery or death in three patients. Logistic regression showed that age younger than 70 years (odds ratio [OR], 8.74; 95% confidence interval [CI]: 1.03, 76.9) and IMH wall thickness greater than 10 mm (OR, 4.93; 95% CI: 1.04, 23.0) were associated with developing IBP at initial multidetector CT, while IBP with larger transmural diameter (OR, 1.16; 95% CI: 1.02, 1.31) and multidetector CT-demonstrated connection with intercostal or lumbar artery (63% [35 of 56]) (OR, 5.44; 95% CI: 1.43, 20.9) were associated with incomplete resorption. CONCLUSION: IBPs are frequently observed at multidetector CT in patients with IMH. They may resolve over time or appear during follow-up. These findings are not associated with a poor prognosis, and IBPs should be distinguished from ulcerlike projections.

TIPS in patients with cranial porta hepatis: ultrasound-guided transhepatic portohepatic-portocaval puncture in single needle pass.

OBJECTIVE: The purpose of this study was to describe our technique of transhepatic serial puncture of the portal vein and hepatic vein-inferior vena cava in one needle pass under ultrasound guidance to place a transjugular intrahepatic portosystemic shunt (TIPS) in patients with a porta hepatis cranial to the usual location. MATERIALS AND METHODS: Six patients (five men, one woman) underwent transhepatic TIPS procedures at our institution. The indications for portal decompression were recurrent variceal bleeding in four patients and refractory ascites and hydrothorax in one patient each. In five patients initial attempts at a classic transjugular approach failed because of an unusual angle between the hepatic vein and the portal vein; in the other patient, revision of an occluded shunt had failed. Two patients had main portal vein thrombosis. RESULTS: Technical success was achieved in all six patients. Two patients received a portohepatic venous shunt and four a portocaval shunt (inferior vena cava to right portal vein in three patients and inferior vena cava to left portal vein in one patient).The portosystemic pressure gradient before TIPS was 17-35 mm Hg and after TIPS was 6-10 mm Hg. No procedure-related complications occurred. One patient had severe hepatic encephalopathy. Two patients had shunt occlusion, which was successfully revised 17 and 10 months after the procedure. CONCLUSION: Our technique is a safe, effective, and universally applicable method for establishment of a TIPS in patients with either normal venous anatomy or severely distorted liver parenchyma.