A Real-World Comparative Analysis of Atezolizumab Plus Bevacizumab and Transarterial Chemoembolization Plus Radiotherapy in Hepatocellular Carcinoma Patients with Portal Vein Tumor Thrombosis.

This study aimed to compare the treatment outcomes of atezolizumab-plus-bevacizumab (Ate/Bev) therapy with those of transarterial chemoembolization plus radiotherapy (TACE + RT) in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) and without metastasis. Between June 2016 and October 2022, we consecutively enrolled 855 HCC patients with PVTT. After excluding 758 patients, 97 patients (n = 37 in the Ate/Bev group; n = 60 in the TACE + RT group) were analyzed. The two groups showed no significant differences in baseline characteristics and had similar objective response and disease control rates. However, the Ate/Bev group showed a significantly higher one-year survival rate (p = 0.041) compared to the TACE + RT group, which was constantly displayed in patients with extensive HCC burden. Meanwhile, the clinical outcomes were comparable between the two groups in patients with unilobar intrahepatic HCC. In Cox-regression analysis, Ate/Bev treatment emerged as a significant factor for better one-year survival (p = 0.049). Finally, in propensity-score matching, the Ate/Bev group demonstrated a better one-year survival (p = 0.02) and PFS (p = 0.01) than the TACE + RT group. In conclusion, Ate/Bev treatment demonstrated superior clinical outcomes compared to TACE + RT treatment in HCC patients with PVTT. Meanwhile, in patients with unilobar intrahepatic HCC, TACE + RT could also be considered as an alternative treatment option alongside Ate/Bev therapy.

Percutaneous cholecystoduodenal stent as a definite treatment for acute cholecystitis in elderly or comorbid patients: a bicentric retrospective study

PURPOSE: To investigate the safety and efficacy of percutaneous cholecystoduodenal stent (CDS) placement to prevent recurrence of acute cholecystitis in patients who were unfit for cholecystectomy. METHODS: Between April 2016 and January 2022, 46 patients [median age (range) = 81 (37-99) years; men = 15] with acute cholecystitis who were unfit for surgery underwent percutaneous cholecystostomy followed by a CDS placement in two institutions. Plastic stents of three different materials were used [polyethylene, polyurethane (PU), and polycarbonate (PCB)-based PU]. Clinical outcomes, including technical and clinical success rates and early (<30 days) and delayed adverse events, were retrospectively assessed by stent type. RESULTS: CDS placement was technically successful in 39 patients. Clinical success, defined as cholecystostomy catheter removal, was achieved in 35 of 39 patients. Immediate complications, such as acute pancreatitis and peritonitis, occurred in two patients. Two patients experienced recurrent cholecystitis during a 113-day follow-up (range, 3-1,723). Three-stent groups had significantly different delayed complications on Fisher's exact test (P = 0.021). The Bonferroni post-hoc analysis showed the PCB-PU group tended to have fewer complications than the PU group (P = 0.060). CONCLUSION: CDS placement is applicable in treating acute cholecystitis patients who were initially unfit for surgery, but further investigation is needed. Although it was not statistically significant, a PCB-PU stent can be suitable for this use because it tends to have fewer delayed complications and is equipped with a drawstring and side holes.

Chemoembolization combined radiofrequency ablation vs. chemoembolization alone for treatment of beyond the Milan criteria viable hepatocellular carcinoma (CERFA): study protocol for a randomized controlled trial.

BACKGROUND: Many previous studies evaluated a combination of transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) for treating early hepatocellular carcinoma (HCC); however, studies evaluating combination therapy for beyond-the-Milan criteria HCC are scarce. METHODS: A total of 120 patients with beyond-the-Milan criteria HCC who have viable tumour after first TACE will be enrolled in this multi-institutional, parallel, pragmatic, randomized controlled trial. Patients with metastasis, vascular invasion, or a sum of tumour diameter > 8 cm will be excluded. Eligible patients will be randomly assigned to combination TACE and RFA therapy or TACE monotherapy groups. Patients in the combination therapy group will receive a second TACE and subsequent RFA at the viable tumour. Patients in the TACE monotherapy group will receive only second TACE. Patients in both groups will undergo magnetic resonance imaging 4-6 weeks after second TACE. The primary endpoint is 1-month tumour response, and secondary endpoints are progression-free survival, overall response rate, number of treatments until CR, overall survival, and change in liver function. DISCUSSION: Although TACE can be used to treat intermediate-stage HCC, it is difficult to achieve CR by first TACE in most intermediate-stage patients. Recent studies show a survival advantage of combination therapy over monotherapy. However, most studies evaluating combination therapy included patients with a single tumour sized < 5 cm, and no studies included patients with intermediate-stage but more advanced (i.e., beyond-the-Milan criteria) HCC. This study will evaluate the efficacy of combined TACE and RFA therapy for patients with advanced HCC within the intermediate stage. TRIAL REGISTRATION: Clinical Research Information Service (CRiS) KCT0006483.

Prostatic Artery Embolization for Lower Urinary Tract Symptoms via Transradial Versus Transfemoral Artery Access: Single-Center Technical Outcomes.

OBJECTIVE: To evaluate the safety and feasibility of prostatic artery embolization (PAE) via transradial access (TRA) compared with transfemoral access (TFA). MATERIALS AND METHODS: This retrospective study included 53 consecutive men with lower urinary tract symptoms (LUTS) who underwent PAE between September 2018 and September 2021. Thirty-one patients (mean age ± standard deviation: 70.6 ± 8.4 years) were treated with TFA, including 14 patients treated before adopting TRA. Since December 2019, TRA has also been attempted with the procedure's selection criteria of patent carpal circulation and a height ≤ 172 cm, with 22 patients treated via TRA (69.1 ± 9.6 years). Parameters of technical success (defined as successful bilateral embolization), clinical success (defined as LUTS improvement), procedural time, radiation dose, and adverse events were compared between the two groups using the Fisher's exact test, independent sample t test, Wilcoxon signed-rank test, or Mann-Whitney test. RESULTS: All patients received at least one-side PAE. Technical success of PAE was achieved in most patients (TRA, 21/22; TFA, 30/31; p > 0.999). No technical problem-related conversion from TRA to TFA occurred. The clinical success rate was 85% (11/13) in patients with TRA, and 89% (16/18) in patients with TFA for follow-up > 2 weeks post-PAE (median, 3 months) (p > 0.999). The median procedure time was similar in both groups (TRA, 81 minutes vs. TFA, 94 minutes; p = 0.570). No significant dose differences were found between the TRA and TFA groups in the dose-area product (median Gycm², 95 [range, 44-255] for TRA and 84 [34-255] for TFA; p = 0.678) or cumulative air kerma (median mGy, 609 [236-1584] for TRA and 634 [217-1594] for TFA; p = 0.551). No major adverse events occurred in either of the groups. CONCLUSION: PAE via TRA is a safe and feasible method comparable to conventional TFA. It can be safely implemented by selecting patients with patent carpal circulation and adequate height.

Effect of Stent Placement on Survival in Patients with Malignant Portal Vein Stenosis: A Propensity Score-Matched Study.

OBJECTIVE: Percutaneous portal vein (PV) stent placement can be an effective treatment for symptoms associated with portal hypertension. This study aimed to evaluate the effect of PV stenting on the overall survival (OS) in patients with malignant PV stenosis. MATERIALS AND METHODS: Two groups of patients with malignant PV stenosis were compared in this retrospective study involving two institutions. A total of 197 patients who underwent PV stenting between November 2016 and August 2019 were established as the stent group, whereas 29 patients with PV stenosis who were treated conservatively between July 2013 and October 2016 constituted the no-stent group. OS was compared between the two groups before and after propensity score matching (PSM). Risk factors associated with OS were evaluated using the Cox proportional hazards model. Procedure-associated adverse events were also evaluated. RESULTS: The stent group finally included 100 patients (median age, 65 [interquartile range, 58-71] years; 64 male). The no-stent group included 22 patients (69 [61-75] years, 13 male). Stent placement was successful in 95% of attempted cases, and the 1- and 2-year stent occlusion-free survival rate was 56% (95% confidence interval, 45%-69%) and 44% (32%-60%), respectively. The median stent occlusion-free survival time was 176 (interquartile range, 70-440) days. OS was significantly longer in the stent group than in the no-stent group (median 294 vs. 87 days, p < 0.001 before PSM, p = 0.011 after PSM). The 1- and 3-year OS rates before PSM were 40% and 11%, respectively, in the stent group. The 1-year OS rate after PSM was 32% and 5% in the stent and no-stent groups, respectively. Anemia requiring transfusion (n = 2) and acute thrombosis necessitating re-stenting (n = 1) occurred in three patients in the stent group within 1 week. CONCLUSION: Percutaneous placement of a PV stent may be effective in improving OS in patients with malignant PV stenosis.

Transarterial Infusion of Epirubicin and Cisplatin Combined With Systemic Infusion of 5-Flurouracil Versus Sorafenib for Hepatocellular Carcinoma With Refractoriness of Transarterial Chemoembolization Using Doxorubicin.

Transarterial chemoembolization using doxorubicin (TACE-DOX) is an effective therapy for advanced hepatocellular carcinoma (HCC). However, there are limited options for patients with TACE refractoriness. We compared the effectiveness between sorafenib and transarterial chemolipiodolization using epirubicin and cisplatin combined with systemic infusion of 5-fluorouracil (5-FU; TACL-ECF) in patients with previous TACE-DOX refractoriness. We retrospectively analyzed 742 consecutively enrolled cohort patients who received TACE-DOX as the first-line therapy for HCC. Among the 94 patients who failed with TACE-DOX, 49 patients were treated with TACL-ECF and 45 patients were treated with sorafenib as a rescue therapy. The TACL-ECF regimen comprised transarterial infusion of epirubicin and cisplatin combined with systemic infusion of 5-FU. Of the 94 patients, 22 and 72 patients were in Barcelona Clinic Liver Cancer stages B and C, respectively; 66% patients were classified as having Child-Pugh class A (CPC A). Overall survival (OS) after rescue therapy did not differ between the sorafenib and TACL-ECF groups (4.1 months vs 6.4 months, P = .355). Progression-free survival (PFS) did not differ between the sorafenib and TACL-ECF groups (2.8 months vs 3.5 months, P = .629). Adverse events of CTC grade 3/4 occurred more frequently in the sorafenib group than in the TACL-ECF group (P = .024). The present study showed that the OS and PFS did not differ between patients given rescue TACL-ECF therapy and those given sorafenib therapy. The TACL-ECF treatment was better tolerated than sorafenib. The TACL-ECF might be considered as an alternative therapy for the patients with TACE-DOX refractoriness, especially CPC B and sorafenib-intolerant patients.

Prevalence and predictors of peripherally inserted central venous catheter associated bloodstream infections in cancer patients: A multicentre cohort study.

Despite increasing use, the exact prevalence and predictors of peripherally inserted central catheter-associated bloodstream infection (PICC-CLABSI) in hospitalized patients with cancer are not elucidated.This retrospective cohort study included consecutive patients who underwent peripherally inserted central catheter (PICC) placement in 4 institutions (during 12 months in 3 hospitals and 10 months in 1 hospital). The prevalence of PICC-CLABSI was evaluated. The association between predictors and PICC-CLABSI were analyzed using Cox proportional hazards regression models and Kaplan-Meier survival analysis with log-rank tests.During the study period, 539 PICCs were inserted in 484 patients for a total of 10,841 catheter days. PICC-CLABSI occurred in 25 (5.2%) patients, with an infection rate of 2.31 per 1000 catheter days. PICC for chemotherapy (hazards ratio [HR] 11.421; 95% confidence interval (CI), 2.434-53.594; P = .019), double lumen catheter [HR 5.466; 95% CI, 1.257-23.773; P = .007], and PICC for antibiotic therapy [HR 2.854; 95% CI, 1.082-7.530; P = .019] were associated with PICC-CLABSI.PICC for chemotherapy or antibiotics, and number of catheter lumens are associated with increased risk of PICC-CLABSI in cancer patients. Careful assessment of these factors might help prevent PICC-CLABSI and improve cancer patients care.

Transjugular insertion of biliary stent in patients with malignant biliary obstruction complicated by ascites with/without coagulopathy: a prospective study of 12 patients.

PURPOSE: In patients with malignant biliary obstruction complicated by massive ascites, when endoscopy fails, safe routes for biliary decompression are needed as an alternative to percutaneous approach. We aimed to evaluate the safety and effectiveness of transjugular insertion of biliary stent (TIBS) in patients with malignant biliary obstruction complicated by massive ascites with or without coagulopathy. METHODS: From March 2012 to December 2017, a total of 12 consecutive patients with malignant biliary obstructions treated with TIBS were enrolled in this study. Five patients had jaundice and cholangitis, while seven had jaundice only. Clinical parameters including technical and clinical success rates and complications following TIBS were evaluated. Overall survival and stent occlusion-free survival were assessed using Kaplan-Meier analysis. RESULTS: The indications for transjugular approach were massive ascites with (n=2) or without (n=10) coagulopathy. TIBS was technically successful in 11 of 12 patients. Clinical success was defined as successful internal drainage and was achieved in eight patients. The mean serum bilirubin level was initially 13.9±6.3 mg/dL and decreased to 4.9±5.3 mg/dL within 1 month after stent placement (P = 0.037). Two patients had procedure-related complications (hemobilia). During the follow-up period (mean, 30 days; range, 1-146 days), all 12 patients died of disease progression. The median overall survival and stent occlusion-free survival times were 19 days (95% confidence interval [CI], 16-22 days) and 19 days (95% CI, 12-26 days), respectively. There was no stent dysfunction in the eight patients that had successful internal drainage. CONCLUSION: TIBS appears to be safe, technically feasible, and clinically effective for patients with malignant biliary obstruction complicated by massive ascites with or without coagulopathy.

Transhepatic Tract Embolisation After Biliary Intervention Using n-Butyl Cyanoacrylate and Autologous Blood: A Retrospective Analysis of 42 Patients.

PURPOSE: We evaluated the safety and efficacy of transhepatic tract embolisation after a biliary intervention using n-butyl cyanoacrylate (NBCA) and autologous blood. MATERIALS AND METHODS: Between January 2017 and December 2018, 42 consecutive patients (mean age: 71 ± 15 years, 24 men) with malignant (n = 26) or benign (n = 16) biliary obstructions underwent percutaneous biliary intervention followed by tract embolisation within 2 weeks. Forty-six transhepatic tracts (4 bilateral) in 42 patients were embolised using a NBCA and lipiodol mixtures (1:1-1:2 ratios) after intraductal infusion of peripherally obtained autologous blood. The indwelling catheter diameters were 8.5-14 Fr. The median interval between percutaneous biliary drainage and tract embolisation was 10 days (range 3-14 days). Glue-cast formation via fluoroscopy and immediate complications were reviewed retrospectively in medical records. Follow-up data (median: 135, range 11-720 days) including computed tomography (CT) images (n = 17) were evaluated for delayed complications and glue-cast formation. RESULTS: Successful glue-cast formations were achieved in all 46 tracts. No patients experienced haemorrhage, and only one patient had external bile leakage. Eight patients complained of abdominal pain (numerical scale ≤ 5) immediately after embolisation, which was controlled by analgesics. Two patients had transient fever. Segmental (n = 11) or sub-segmental (n = 6) glue-cast patterns were identified along the transhepatic tract by follow-up CT. No biliary obstructions were caused by inadvertent glue spread. Fragmented glue was detected outside the stent in one patient. CONCLUSION: Transhepatic parenchymal tract embolisation with NBCA and autologous blood is a safe and feasible method for preventing bile leakage. LEVEL OF EVIDENCE: Level 4, Case Series.

Preoperative discrimination of tumour stage in clear cell carcinoma of the ovary using computed tomography and magnetic resonance imaging.

OBJECTIVES: Clear cell carcinoma (CCC) of the ovary shows distinct clinical characteristics depending on the stage. We aimed to investigate the imaging predictability for tumour stage in CCC. PATIENTS AND METHODS: Fifty-six tumours in 48 patients with pathologically proven CCC were enrolled. CCCs were divided into early and advanced stage based on the International Federation of Gynecology and Obstetrics staging. Two reviewers assessed diverse computed tomography (CT) and magnetic resonance imaging (MRI) findings associated with CCC: laterality, size, margin, cystic component features (internal architecture, CT attenuation, and T1 signal intensity of MRI), solid component features (amount, shape, growth pattern, signal intensity, enhancement pattern, and diffusion restriction), and secondary manifestations (ascites, endometriosis, and venous thromboembolism). RESULTS: There was a statistically significant difference between early and advanced CCC in laterality (p = 0.011), CT attenuation (p = 0.03), and T1 signal intensity of the cystic component (p = 0.04), T2 signal intensity of the solid component (p = 0.006), ascites (p < 0.001), coexisting endometriosis (p = 0.032), and venous thromboembolism (p = 0.011). Early-stage CCC tended to show unilaterality, higher CT attenuation values and T1 hyperintensities of the cystic component and endometriosis. Advanced-stage CCC showed bilaterality, T2 hyperintensities of the solid component, ascites, and venous thromboembolism. Laterality, CT attenuation of the cystic component, T2 signal intensity of the solid component, coexisting endometriosis, and ascites are independent predictors for advanced CCC. CONCLUSIONS: Imaging features can be a significant predictor for the discrimination of preoperative tumour staging in CCC.

Percutaneous Metallic Stent Placement for Palliative Management of Malignant Biliary Hilar Obstruction.

Objective: To investigate the outcomes of percutaneous metallic stent placements in patients with malignant biliary hilar obstruction (MBHO). Materials and Methods: From January 2007 to December 2014, 415 patients (mean age, 65 years; 261 men [62.8%]) with MBHO were retrospectively studied. All the patients underwent unilateral or bilateral stenting in a T, Y, or crisscross configuration utilizing covered or uncovered stents. The clinical outcomes evaluated were technical and clinical success, complications, overall survival rates, and stent occlusion-free survival. Results: A total of 784 stents were successfully placed in 415 patients. Fifty-five patients had complications. These complications included hemobilia (n = 19), cholangitis (n = 13), cholecystitis (n = 11), bilomas (n = 10), peritonitis (n = 1), and hepatic vein-biliary fistula (n = 1). Clinical success was achieved in 370 patients (89.1%). Ninety-seven patients were lost to follow-up. Stent dysfunction due to tumor ingrowth (n = 107), sludge incrustation (n = 44), and other causes (n = 3) occurred in 154 of 318 patients. The median overall survival and the stent occlusion-free survival were 212 days (95% confidence interval [CI], 186-237 days) and 141 days (95% CI, 126-156 days), respectively. The stent type and its configuration did not affect technical success, complications, successful internal drainage, overall survival, or stent occlusion-free survival. Conclusion: Percutaneous stent placement may be safe and effective for internal drainage in patients with MBHO. Furthermore, stent type and configuration may not significantly affect clinical outcomes.

Sustained multiple organ ischaemia after transarterial chemoembolization with drug-eluting beads for hepatocellular carcinoma.

Transarterial chemoembolization (TACE) with drug-eluting beads (DC beads) may enhance drug delivery to tumours and reduce systemic toxicity. TACE with DC beads leads to significantly fewer serious side-effects compared with conventional TACE. A 66-year-old man with hepatocellular carcinoma (HCC) complained of continuous abdominal pain 1 month after TACE with DC beads. At the time of TACE, angiography revealed severe stenosis of both hepatic arteries. The diagnostic work up on admission suggested severe bile duct injury with regional bile duct dilatation, segmental liver and spleen infarction, necrotizing pancreatitis, as well as gastric and duodenal ulcers. The pathology specimens of the duodenum contained DC beads that had passed through small vessels in the connective tissue. The patient's condition appeared to improve after 2 weeks of antibiotic treatment and supportive care, but new multifocal liver and spleen infarction subsequently developed. After 2 months, he was well enough to be discharged. His HCC partially responded to the TACE with DC beads but eventually progressed and he died after 11 months. The present case report highlights unexpected ongoing multiple organ ischaemia in a 66-year-old man treated for HCC using TACE with DC beads. The use of TACE with DC beads should be carefully considered in patients with vascular strictures or aberrant blood supply.

Common Peroneal Neuropathy With Anterior Tibial Artery Occlusion: A Case Report.

Peroneal neuropathy is a common mononeuropathy of the lower limb. Some studies have reported cases of peroneal neuropathy after vascular surgery or intervention. However, no cases of peroneal neuropathy with occlusion of a single peripheral artery have been previously reported. A 73-year-old man was referred with a 3-week history of left-sided foot drop. He had a history of valvular heart disease and arrhythmia, and had previously been treated with percutaneous coronary intervention. Computed tomography angiogram of the lower extremity showed proximal occlusion of the left anterior tibial artery. An electrodiagnostic study confirmed left common peroneal neuropathy. After diagnosis, anticoagulation therapy was started and he received physical therapy.

Portal vein stent placement with or without varix embolization of jejunal variceal bleeding after hepatopancreatobiliary surgery.

Background Extrahepatic portal hypertension after surgery involving the duodenum or jejunum might result in massive ectopic variceal bleeding. Purpose To report the results of portal vein stent placement with the addition of variceal embolization. Material and Methods Between January 2000 and June 2015, portal vein stent placement was attempted in 477 patients. Of these, 22 patients (age, 63 ± 10 years) with jejunal variceal bleeding caused by portal vein obstruction after surgery were included in this study. Computed tomography (CT) findings before and after treatment and the rates of technical and clinical success, complications, and clinical outcomes were retrospectively evaluated. Results Stent placement was successful in 19 of 22 patients. Additional variceal embolization was performed in five cases. Clinical success, defined as the cessation of bleeding without recurrence within 1 month, was achieved in 18 of 19 patients with technical success. One patient developed recurrent bleeding 4 days after stent placement and was successfully treated with additional variceal embolization. There were no procedure-related complications. A regression of the jejunal varices was noted in 14 of 19 patients on follow-up CT scans. During the follow-up period (258 days; range, 7-1196 days), stent occlusion and recurrent bleeding occurred in six and four patients, respectively, of the 19 patients who achieved technical success. Statistical analyses revealed no significant differences regarding stent patency between benign and malignant strictures. Conclusion Percutaneous, transhepatic, portal vein stent placement with or without jejunal variceal embolization appears to be a safe and effective treatment for jejunal variceal bleeding after surgery.

The detection of pulmonary embolisms after a coronary artery bypass graft surgery by the use of 64-slice multidetector CT.

The purpose of this study was to examine the incidence of pulmonary embolism (PE) after a coronary artery bypass graft (CABG) using 64-slice multidetector CT (MDCT), and to determine the correlations between the occurrence of a PE and the clinical or surgical parameters. Three hundred and twenty-six consecutive patients, who underwent coronary CT angiography using 64-slice MDCT to assess the graft patency after CABG, were enrolled in this study. Additional axial CT images, which were reconstructed by adopting a large field of view and thinner image slices, were reviewed for the presence of PE. The relationship between the occurrence of a PE and the type of surgery (off-pump CABG versus conventional CABG), number of target vessels, use of a saphenous vein graft, and length of stay in the intensive care unit (ICU) were evaluated. PE was detected on the CT images of 33 patients (10.1%), which involved the lobar or more proximal arteries in seven patients and the segmental or subsegmental arteries in 26. PE occurred more frequently after off-pump CABG (16.5%, 14/85) than after conventional CABG (7.9%, 19/241) (P = 0.024). Patients with PE were older (67 years vs. 62.7 years) and had longer stays in the ICU (5.6 days vs. 3.8 days) than those without (P = 0.013 and P = 0.007, respectively). No significant difference was observed in the number of target vessels and use of a saphenous vein graft between patients with and without an embolism. In a multi-variable analysis, the age of the patient, surgical methods, and ICU stay were independent predictors for the occurrence of PE (P = 0.013, P = 0.017, and P = 0.005, respectively). MDCT helps detect PE in patients after CABG. It is encountered more frequently after off-pump CABG than after conventional CABG and in older patients with longer ICU stays.