Factors affecting survival following chemoembolization with doxorubicin-eluting microspheres for inoperable hepatocellular carcinoma.

PURPOSE: To assess factors associated with better overall survival (OS) and progression-free survival (PFS) following chemoembolization with doxorubicin-eluting microspheres for inoperable hepatocellular carcinoma (HCC) MATERIALS AND METHODS: Data of 130 patients (104 men; median age, 62 y) with inoperable HCC who underwent successful DEB chemoembolization with 100-300 -µm LC Bead particles loaded with 50 mg doxorubicin per vial were reviewed following human research committee approval. Effects of various clinical, imaging, and response factors on OS and PFS were assessed by univariate Kaplan-Meier survival analysis. Multiple Cox regression with backward elimination was performed for terms found significant (P ≤ .05) on univariate analysis. RESULTS: The number of DEB chemoembolization procedures per patient ranged from one to four (mean, 2 ± 1). The median PFS and OS were 5.7 months (95% confidence interval, 4.6-7.6 mo) and 14.7 months (95% confidence interval, 12.3-19.7 mo), respectively. On multivariate Cox regression, Cancer of the Liver Italian Program (CLIP) score of 1 or lower, necrosis of more than 50%, and response or stable disease per Response Evaluation Criteria In Solid Tumors after DEB chemoembolization were associated with better PFS. CLIP score of 1 or lower, Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 1 or lower, absence of portal vein (PV) thrombosis, and necrosis greater than 50% following DEB chemoembolization were associated with better OS. CONCLUSIONS: CLIP score of 1 or lower and necrosis of more than 50% are independent variables affecting PFS and OS after DEB chemoembolization, whereas absence of PV thrombosis and ECOG PS of 1 or lower affected OS but not PFS.

Embolization of angiographically visible type I and II utero-ovarian anastomoses during uterine artery embolization for fibroid tumors: impact on symptom recurrence and permanent amenorrhea.

PURPOSE: To compare the incidences of symptom recurrence and permanent amenorrhea following uterine artery embolization (UAE) for symptomatic fibroid tumors in patients with type I and II utero-ovarian anastomoses (UOAs) with versus without ovarian artery embolization (OAE). MATERIALS AND METHODS: A retrospective, institutional review board-approved study of 99 women who underwent UAE for symptomatic fibroid tumors from April 2005 to October 2010 was conducted to identify patients who had type I or II UOAs at the time of UAE. Based on the embolization technique, patients were categorized into standard (ie, UAE only), combined (ie, UAE and OAE), and control (patients without UOAs who underwent UAE) groups. Data collected included patient characteristics, procedural technique and findings, symptom recurrence, secondary interventions, and permanent amenorrhea. Statistical analysis was performed with the Fisher exact test, with significance reached at P < .05. RESULTS: Twenty patients (20.2%; mean age, 46.9 y ± 6.3) had type I (n = 3) or II (n = 17) UOAs. Thirteen (65%) underwent UAE only (standard group) and seven (35%) underwent UAE and OAE (combined group). There were no significant differences between groups in demographics or in the incidence of permanent amenorrhea after procedures (follow-up, 561 d ± 490). There was a significantly higher incidence of symptom recurrence in the standard group compared with the control group (P = .01), with no differences between combined and control groups (P = 1). CONCLUSIONS: There were no statistical differences in permanent amenorrhea rates in the groups studied, with significantly higher symptom recurrence rates observed when OAE was not performed in the setting of UOA.

Safety and effectiveness of chemoembolization with drug-eluting beads for advanced-stage hepatocellular carcinoma.

BACKGROUND: According to the Barcelona Clinic Liver Cancer (BCLC) algorithm, patients with advanced stage (BCLC-C) hepatocellular carcinoma (HCC) are recommended for systemic treatment or palliative therapy. However, chemoembolization with drug-eluting beads (DEB-TACE) has been shown to be safe in high-risk patients. The purpose of our study was to evaluate the safety and effectiveness of DEB-TACE in patients with an advanced-stage HCC. METHODS: In this institutional review board-approved, retrospective study, 80 patients with advanced-stage HCC underwent DEB-TACE with doxorubicin. Patients were evaluated for median hospital stay, incidence of Grade 3/4 toxicities, 30-day mortality, progression-free survival (PFS), and overall survival (OS) following DEB-TACE. Univariate and multivariate analysis were performed for predictors of better OS. RESULTS: The median hospital stay following DEB-TACE was 1 day (range: 1-11). The median PFS and OS were 5.1 months [95% confidence interval (CI): 4.1-7.7] and 13.3 months (95% CI: 10.1-18.6) respectively. On multivariate analysis ECOG PS ≤ 1 and >2 DEB-TACE procedures were associated with better OS. Patients with ECOG PS ≤ 1 demonstrated a median survival of 17.7 months compared with 5.6 months for patients with ECOG PS > 1 (p = 0.025). Multiple DEB-TACE procedures (>2 procedures) were associated with improved survival (26.8 months) compared with patients with one or two procedures (11.4 months, p = 0.01). Portal vein thrombosis or extrahepatic disease had no statistically significant association with OS. CONCLUSIONS: DEB-TACE is safe and effective in patients with advanced HCC. ECOG PS ≤ 1 and >2 DEB-TACE procedures were associated with better OS.

Propofol and the risk of delirium: exploring the anticholinergic properties of propofol.

Delirium is a common pathologic event in both medical and surgical patients. It is essential to note that patients who develop delirium have worse long term outcomes. The etiology and pathogenesis of delirium are extremely complex and not entirely understood. Certain medications classes are implicated in delirium. For example, medications targeting muscarinic acetylcholine receptors are well known to be associated with delirium and altered mentation. Propofol is a medication commonly used in anesthesiology practice and sedation in intubated patients. In vitro studies provided evidence that propofol actively interacts with muscarinic acetylcholine receptors. Additionally, some, but not all clinical studies demonstrated that propofol led to delirium. Therefore, future prospective studies investigating the use of propofol and delirium occurrence are of paramount importance. These studies should adjust for such common confounders as patients' demographics and age, comorbid conditions, use of other medications, type of surgery, baseline cognitive status, etc. Another important task would be to research the susceptibility for propofol-related delirium. By studying these critical questions, we will gain additional insights into the complex etiology and pathobiology of delirium in addition to a better understanding of the pharmacology of propofol.

Image-guided placement of port catheters: is there an increased risk of infection if the port is immediately accessed and used?

PURPOSE: To compare complication rates in patients who have port-a-catheters inserted and left accessed for immediate use and those who have ports inserted but not accessed. METHODS: In this retrospective, IRB-approved study, medical records of patients who received a port catheter between 9/2009 and 2/2010 were reviewed. The data collected included patient demographics, diagnosis, procedure and complications. The patients were categorized into two groups: accessed (patients in whom the port was accessed with a Huber needle for immediate intravenous use and the patient left the procedure area with needle indwelling) and control (patients in whom the ports were not accessed). Complications were classified according to Society of Interventional Radiology guidelines. Results are given as mean ±SD. Statistical analysis was performed with student t test and statistical significance was considered at P<.05. RESULTS: A total of 467 ports were placed in 465 patients (Men: 206); 10.7% in the accessed group (n=50, age: 60±13.9) and 89.3% in the control group (n=417, age: 59±13.5). There were no statistically significant differences in patient demographics between the groups. The overall complication rate was 0.6% (n=3). Two complications (hematoma causing skin necrosis and thrombosis of the port) occurred in the control group and one (infection) in the accessed group. Infection rates after procedures were 2% (1/50) in the accessed group and 0% (0/417) in the control group. There was no statistically significant difference in overall complication (P=.1) and infection (P=.1) rates among the groups. CONCLUSIONS: Leaving the port accessed immediately after placement does not increase the risk of infection or other complications.

Preliminary experience with Option inferior vena cava filter.

OBJECTIVES: To evaluate the safety and efficacy of Option inferior vena cava (IVC) filter during placement and short-term follow-up. METHODS: A total of 165 patients (mean age: 60-years) who received Option IVC filter from June 2009 to July 2011 were included. In all, 42 patients presented with deep vein thrombosis (DVT), 26 with pulmonary embolism (PE), and 17 with both. All outcomes were examined until April 30, 2012. RESULTS: The filters were successfully deployed in 161patients. During follow-up (mean, 9.5 ± 0.68months), 10 patients were diagnosed with post-filter PE and 13 patients with DVT. There were no instances of fatal PE. Follow-up abdominal computed tomography was available in 60 patients and demonstrated filter-related problems in 8 patients (2: penetration of filter legs, 5: asymptomatic nonocclusive thrombus, and 1: caval occlusion). There were no instances of filter migration or fracture. In total, 27 filters were successfully retrieved after a mean of 5.27 ± 0.76 months. CONCLUSION: The Option filter was effective and safe during implantation and short-term follow-up and associated with high technical success at retrieval.

Paradoxical air embolism following contrast material injection through power injectors in patients with a patent foramen ovale.

In patients with a patent foramen ovale, use of air filters during intravenous infusions is common, but they are not compatible with power injection. Therefore we aimed to assess the incidence of paradoxical air embolism on CT of the chest and brain following contrast material injection through a power injector in patients with a patent foramen ovale, without the use of a filter. In this IRB approved, HIPAA compliant retrospective study, two independent radiologists reviewed 289 CT scans of the chest (n = 233) and brain (n = 56) for vascular air embolism following contrast material injection through a power injector in 93 subjects (43 men, mean age 66 y) with a known patent foramen ovale. The location and amount of the air were assessed. The medical records were reviewed for embolic symptoms. The prevalence and location of right sided and systemic luminal air were determined and inter-observer agreement for detection of intraluminal vascular air was calculated. Vascular air embolism was observed in 19.3% (56/289) of the studies; small in 52 and moderate in 4. In 42 studies, intravascular air was seen in a single territory and 14 studies had intravascular air in multiple territories. None had air in the left side of the heart or brain to suggest paradoxical air embolism. The inter-observer agreement for detection of vascular air was moderate (k = 0.6). Paradoxical air embolism in patients with a patent foramen ovale following contrast material injection with a power injector is rare.

Long-term safety and effectiveness of inferior vena cava filters in patients with stroke.

PURPOSE: To assess the long-term safety and clinical effectiveness of inferior vena cava (IVC) filters in patients with stroke. METHOD AND MATERIALS: In this institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study, we reviewed the clinical data of patients who had stroke and were treated with an IVC filter from 2002 to 2009. The demographics, clinical data, indications for IVC filter, procedural complications, symptomatic post-filter pulmonary embolism (PE) and deep vein thrombosis (DVT), caval occlusion and incidental, imaging-evident filter-related complications were recorded. Safety was assessed through occurrence of filter-related complications during placement and follow-up. Effectiveness was assessed through occurrence of post-filter fatal and non-fatal PE. RESULTS: During this period, 371 patients (224 male; mean age 67.5 years) with stroke received an IVC filter. The stroke was hemorrhagic in 28%, ischemic in 20%, associated with intracranial malignancy in 21% and trauma in 31%. 235 (63%) patients (PE in 159) had venous thromboembolism on imaging. The indications for IVC filter included contraindication to anticoagulation in 251 (68%), prophylaxis in 83 (22%), added protection in 22 (6%) and complication or failure of anticoagulation in 15 (4%). There was one procedural complication. During a follow-up of 1.74±2.36 years, 180 (49%) patients died, three due to post-filter PE and the remainder all due to primary disease. Symptomatic post-filter PE and DVT occurred at a frequency of 15% (54/371) and 16% (60/371), respectively. Of these, 15 (4%) had imaging-proven PE. Three (0.8%) succumbed to post-filter PE. Imaging-proven new or recurrent DVT occurred in 6% and 8%, respectively. Symptomatic caval occlusion was seen in five (5/371, 1.3%). CONCLUSION: IVC filters have an acceptable safety profile in stroke patients. In our cohort, they were effective in preventing life-threatening PE.

Long-term safety and effectiveness of the "OptEase" vena cava filter.

PURPOSE: To assess the long-term safety and effectiveness of the OptEase inferior vena cava (IVC) filter. MATERIALS AND METHODS: In this Institutional Review Board-approved, retrospective study, we reviewed data of 71 patients who received an OptEase filter at our institution from 2002 to 2007. Thirty-nine (55%) patients had symptoms of venous thromboembolism before filter placement. The indications for filter included contraindication to anticoagulation in 31 (44%) patients, prophylaxis against pulmonary embolism (PE) in 29 (41%) patients, and failure of anticoagulation in 11 (15%) patients. Procedure-related complications, such as symptomatic post-filter PE, deep venous thrombosis (DVT), IVC occlusion, and incidental imaging-evident filter-related complications, were recorded. Safety was assessed by the occurrence of filter-related complications during placement and follow-up. Effectiveness was assessed by the occurrence of post-filter PE. RESULTS: Sixty-five (92%) filters were placed under fluoroscopy, and 6 (8%) were placed using intravascular ultrasound guidance. Seventy (99%) filters were placed successfully. Seven (10%) filters were placed in the suprarenal cava. Retrieval was attempted in 14 (20%) patients, and 12 filters were successfully retrieved. Clinical follow-up was available for 20 ± 21 months. Symptoms of postfilter PE and DVT occurred in 15% (n = 11) and 10% (n = 7) patients, respectively. None of these patients had computed tomography (CT)-proven PE, and only one had ultrasound-proven new DVT. One patient had symptomatic IVC occlusion. Follow-up abdominal CT in 20 patients showed thrombus in the filter in two of them. There were no instances of filter migration, filter tilt, or caval wall penetration. CONCLUSION: The OptEase filter appears to have an acceptable long-term safety profile. The filter was effective against PE.

Angiographic intervention in patients with a suspected visceral artery pseudoaneurysm complicating pancreatitis and pancreatic surgery.

OBJECTIVE: To assess the clinical effectiveness of angiography and transcatheter intervention in patients suspected of visceral artery pseudoaneurysm complicating pancreatitis and pancreatic surgery. DESIGN: Retrospective study. SETTING: University hospital. PATIENTS: A total of 51 patients who underwent mesenteric angiography for a suspected visceral artery pseudoaneurysm following pancreatitis or pancreatic surgery from 1978 to 2010 were included in this study. There were 39 men and 12 women. The mean age was 66 years (range, 21-89 years) at the time of the angiography. Data on patients' demographics, medical history, angiographic findings, treatment, and outcomes were recorded. Of these 51 patients, 27 had acute pancreatitis, 22 had pancreatic cancer, and 2 experienced pancreatic trauma. Embolization was performed for patients with a pseudoaneurysm. One patient was treated with a stent graft. MAIN OUTCOME MEASURES: The technical success rate of the intervention, the 24-hour and 30-day rebleeding rates, and the 24-hour and 30-day mortality rates were calculated. A multivariate analysis was performed to determine the factors associated with survival following angiography. RESULTS: Of the 51 patients studied, 23 had a visceral artery pseudoaneurysm involving the gastroduodenal (7 patients), hepatic (5 patients), splenic (5 patients), and other arteries (7 patients). The technical success rate of the intervention (ie, embolization or exclusion with a Stent graft) was 100%. The 24-hour and 30-day rebleeding rates were 4% and 17%, respectively. The 24-hour and 30-day mortality rates were 0% and 9%, respectively. For the 27 patients who had a negative angiographic finding, the 24-hour and 30-day rebleeding rates were 0% and 11%, respectively, and the 24-hour and 30-day mortality rates were 4% and 21%, respectively. The requirement of a large number of blood products prior to angiography was associated with poor outcome. CONCLUSION: Embolization was highly effective in treating a pseudoaneurysm complicating pancreatitis and pancreatic surgery. The hemodynamic status at the time of angiography determines overall survival.

Transarterial chemoembolization with Doxorubicin-eluting microspheres for inoperable hepatocellular carcinoma.

BACKGROUND: Therapy with drug-eluting microspheres was recently introduced with an aim to decrease the high postoperative morbidity associated with chemoembolization with lipiodol. The purpose of our study was to assess the safety and efficacy of chemoembolization with doxorubicin-eluting microspheres (DEB-TACE) for inoperable hepatocellular carcinoma (HCC). MATERIAL AND METHODS: In this IRB-approved retrospective study, 54 patients (44 men; median age, 61 years) with inoperable HCC were treated with DEB-TACE. HCC was diagnosed by biopsy in 43 and with a combination of α-fetoprotein (AFP) and imaging in 11. Patients with Child-Pugh A, B, C cirrhosis were 27, 25, 2, respectively. Twenty-one patients had received local therapies prior to DEB-TACE. Tumor was multifocal in 30. Eight patients had branch portal vein thrombosis. DEB-TACE was performed using 300-500µ LC Beads™ mixed with 100 mg of doxorubicin. Twenty-two patients had one DEB-TACE procedure, 23 patients had 2, 8 patients had 3, and 1 had four procedures. Response rate (RR) was assessed using AFP, RECIST, and EASL criteria on CT/MRI at 1 and 3 months. Overall median survival and survival rates at 6, 12, and 24 months were calculated. RESULTS: DEB-TACE was technically successful in all. Mean hospital stay after the procedure was 1.59 days. Thirty-day mortality was 0%. RR based on AFP was 26%. At 1 and 3 months, CR + PR were 14.8% and 35%, SD 74.1% and 50%, and PD 11.1% and 15%. Overall median survival was 445 days (95% CI 312-590). The survival rates at 6 months, 1 year, and 2 years were 77%, 59%, and 32% respectively. CONCLUSIONS: Chemoembolization with doxorubicin-eluting microspheres is safe and well tolerated in patients with inoperable HCC. Its efficacy is comparable to the historical controls. However, further prospective studies are required to confirm its efficacy.

Clinical sequelae of thrombus in an inferior vena cava filter.

The purpose of this study was to assess the long-term clinical sequelae of inferior vena cava (IVC) filter thrombus and the effect of anticoagulation on filter thrombus. Of 1,718 patients who had IVC filters placed during 2001-2008, 598 (34.8%) had follow-up abdominal CT. Filter thrombus was seen in 111 of the 598 (18.6%). There were 44 men (39.6%). The mean age at filter placement was 64 years. The medical diseases included cancer in 64, trauma in 15, stroke in 12, and others in 20. The frequency of filter thrombus on CT and asymptomatic filter thrombus on CT was calculated. The frequency of pulmonary embolism (PE) in patients with filter thrombus was calculated. The frequency of thrombus progression or regression (on CT, available in 56) was calculated. The effect of anticoagulation on filter thrombus regression/progression was evaluated using the Fisher exact test by comparing the group of patients who received anticoagulants versus those who did not. A P-value of <0.05 was considered significant. The overall frequency of filter thrombus was 18.6%. Total occlusion of the IVC filter was seen in 12 of 598 (2%). The filter thrombus was asymptomatic in 110 (18.3%). Filter thrombus was detected after a median of 35 days (range, 0-2082) following filter placement. Thrombus extended above the filter in 4 (3.6%); IVC thrombus below the filter was seen in 35(31.5%). Thrombus in the filter occluded <25% of the filter volume in 58 (52.3%), 25-50% in 21 (18.9%), and 50-75% in 20 (18%). Total IVC occlusion was seen in 12 (10.8%). Eighty-three patients received anticoagulation. Sixteen patients developed symptoms of PE. PE was confirmed on CT in 3 of 15 (2.7%). On follow-up, filter thrombus regressed completely in 19 (33.9%) after a median of 6 months. Filter thrombus decreased in size in 13 (23.2%) and it progressed without IVC occlusion in 7 (12.6%). In one (1.7%), filter thrombus progressed to IVC occlusion. Filter thrombus remained stable in 16 (28.6%). There was no significant difference in thrombus regression or progression rates whether or not the patients received anticoagulation for filter thrombus. In conclusion, asymptomatic thrombus in the filter is common and it rarely progresses to complete caval occlusion. Anticoagulation has little effect on the resolution of filter thrombosis and future occurrence of PE.