Direct translumbar inferior vena cava ports for long-term central venous access in patients with cancer.

PURPOSE: To evaluate the indications, complications, and long-term results of translumbar port placements to the inferior vena cava for long-term central venous access in a single tertiary center. MATERIALS AND METHODS: This retrospective study included all patients with cancer who underwent translumbar port placement from January 2000 to July 2012; 31 patients (all women) with an average age of 53.1 years ± 11.1 (range, 30-77 y) were included in the study. Of these patients, 26 (81%) had breast cancer, 3 had lung cancer, 1 had ovarian cancer, and 1 had rectal cancer. Indications included central venous occlusion in 9 patients (29%) and bilateral mastectomy and lymph node dissection in 22 patients (71%). RESULTS: All procedures were technically successful. The overall 30-day complication rate was 9.7% (n = 3). Average catheter use was 14.1 months ± 21 (range, 0.75-108 mo). Thirteen (41.9%) ports were removed because they were no longer needed; 4 (12.9%) ports required removal for port malfunction; 12 (38.7%) patients died with their ports still in place; 2 (6.5%) ports remain in use. Three (9.7%) ports required delayed secondary intervention to remain functional. One patient had a systemic infection attributed to the port, resulting in an overall infection rate of 0.08 per 1,000 catheter days. CONCLUSIONS: Translumbar inferior vena cava port placement is a technically feasible and safe alternative method for long-term central venous access.

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.

Identification of small compound biomarkers of pituitary adenoma: a bilateral inferior petrosal sinus sampling study.

Evaluation of the pathogenic mechanisms underlying Cushing disease (CD) is limited partly by the inaccessibility of the pituitary gland for biopsy. We used bilateral inferior petrosal sinus sampling (BIPSS), the gold standard in diagnosing pituitary sources of CD, to obtain central blood samples for in vivo metabolomic analysis of pathways involved in pituitary adenomas. We evaluated 16 samples from eight patients who underwent BIPSS to measure adrenocorticotropic hormone (ACTH) levels in the inferior petrosal sinus (IPS) bilaterally. Seven patients had CD with concordant BIPSS, surgical, and pathologic findings. Samples from the IPS contralateral to histologically proven lesions were used as controls. BIPSS of the eighth patient revealed no central pituitary ACTH source, and these samples were also included as controls. Plasma samples were profiled using a combination of three liquid chromatography tandem mass spectrometry methods, which assessed 259 metabolites. Following Bonferroni correction for multiple comparisons, three small compound biomarkers of CD (pyridoxate, deoxycholic acid, and 3-methyladipate) were identified to be significantly altered in pituitary adenomas. The pathway most significantly impacted in CD samples is one previously shown to be upregulated in other cancers. Exploiting the BIPSS technique, we showed a complete metabolite and lipid profile of pituitary adenomas in CD. These potential biomarkers of CD may elucidate tumor biology and suggest possible diagnostic molecular imaging probes as well as therapeutic targets in patients with recurrent disease after surgery.

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.

Barriers to drug delivery in interventional oncology.

Although much attention has been paid to mechanisms of anticancer drug resistance that focus on intracellular processes that protect tumor cells, it has recently become increasingly evident that the unique features of the tumor microenvironment profoundly impact the efficacy of cancer therapies. The properties of this extracellular milieu, including increased interstitial pressure, decreased pH, hypoxia, and abnormal vascularity, result in limited drug efficacy; this finding is true not only for systemic chemotherapy but also for catheter-based therapies, including chemoembolization and radioembolization. The present review summarizes the barriers to drug delivery imposed by the tumor microenvironment and provides methods to overcome these hurdles.

Intravascular ultrasound-guided inferior vena cava filter placement using a single-puncture technique in 99 patients.

PURPOSE: To assess the feasibility and safety of intravascular ultrasound (IVUS) to guide inferior vena cava (IVC) filter placement using a single venous puncture technique. MATERIALS AND METHODS: Medical records of all patients who had IVC filters placed under IVUS guidance between January 1, 2005 and December 31, 2011 were retrospectively reviewed for pertinent history, results, and complications. All filters were placed using a single venous puncture technique. RESULTS: Filters were successfully placed within the IVC in 94% of the patients with 6 malpositioned filters (4 in the iliac veins and 2 in the suprarenal IVC). Complications included groin hematoma (4%), deep venous thrombosis at the site of vascular access (2%), and filter tilt >15° along the long axis of the IVC (2%). CONCLUSIONS: The IVUS-guided IVC filter placement using a single venous puncture technique is technically feasible and safe when compared to case series using a double venous puncture technique.

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.

Role of preoperative angiography in colon interposition surgery.

PURPOSE: The aim of this study was to evaluate the role of preoperative angiography in patients undergoing colonic interposition. MATERIALS AND METHODS: We searched the electronic database of our radiology department for the term "mesenteric angiography" over a 10-year period from January 1, 2001 to December 31, 2010. RESULTS: We identified 54 patients who had undergone mesenteric angiography before esophageal reconstruction, 16 of whom proceeded to have colonic interposition surgery. One patient (6.3%) developed graft necrosis, two (12.5%) developed an anastomotic leak, and three (18.8%) developed an anastomotic stricture. These complication rates are similar to those reported in the surgical literature for patients who did or did not undergo routine preoperative angiography. CONCLUSION: There is no significant difference in the rates of complications secondary to ischemia (graft necrosis, anastomotic stricture, and anastomotic leak) in patients who undergo routine preoperative angiography as compared with those who do not.

Image optimization during endovascular aneurysm repair.

OBJECTIVE: The purposes of this review are to examine various properties of the fluoroscopic imaging equipment used during endovascular aneurysm repair (EVAR) that can be modified to reduce radiation dose while optimizing image acquisition and display, to detail geometric aspects of EVAR intraprocedural imaging used to achieve consistently optimal EVAR results, and to describe acquisition parameters and strategies for minimizing contrast-induced nephropathy. CONCLUSION: The outcome of EVAR is strongly linked to image acquisition and interpretation, including the preprocedural, intraprocedural, and postprocedural display of relevant vascular anatomy, positions and configurations of the endograft components, and documentation of successful aneurysm exclusion. Operator familiarity with the imaging equipment, radiation and contrast dose reduction strategies, and image optimization techniques strongly influence the outcome of EVAR.

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.

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.

Nine-year single-center experience with transcatheter arterial embolization for hemoptysis: medium-term outcomes.

PURPOSE: To determine the medium-term efficacy of transcatheter arterial embolization (TAE) for hemoptysis. MATERIALS AND METHODS: A total of 128 TAE were performed from April 1999 to April 2008 in 58 patients (30:28 F:M) with mean age of 49 (range:16-89). Major causes of hemoptysis included cystic fibrosis/bronchiectasis (24 of 58); lung metastasis (8 of 58); lung cancer (7 of 58); fungal infection (4 of 58). Follow-up was available in 57 of 58 for a median of 1.28 years. Primary and secondary efficacy of TAE for hemoptysis was calculated using Kaplan-Meier estimates. RESULTS: Technical and clinical successes were estimated at 58 (100%) of 58 and 57 (98%) of 58, respectively. Recurrent hemoptysis occurred in 40% (23 of 58). In all, 34% (20 of 58) died during follow-up. Kaplan-Meier estimates for primary and secondary efficacy of TAE at 2, 4, 6, and 8 years were 0.82, 0.46, 0.17, and 0.09 (benign disease) and 0.30, 0, 0, and 0 (malignant disease), respectively. CONCLUSION: TAE is an effective treatment for hemoptysis in both short- and medium-terms, especially in benign lung disease.

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.

Expression of mRNA isoforms of latent transforming growth factor-ß binding protein-1 in coronary atherosclerosis and human tissues.

Latent transforming growth factor-ß binding protein-1 (LTBP1) has been implicated in the control of secretion, localization, and activation of TGFß (transforming growth factor-ß). We developed a quantitative reverse-transcriptase polymerase chain reaction (Q-RT-PCR) assay using an RNA internal standard to examine the expression of three alternatively spliced isoforms of LTBP1 (LTBP1Δ41, LTBP1Δ53, and LTBP1Δ55) in a variety of human tissues. The assays were also used to determine the expression of LTBP1L and LTBP1S isoforms and total LTBP1. The Q-RT-PCR assays were highly reproducible and showed that in most tissues LTBP1Δ55 and LTBP1L were minor components of LTBP1. The proportion of LTBP1Δ41 ranged from 2% of total LTBP1 mRNA in early coronary atherosclerotic lesions to 54% in advanced lesions.

Angiogenesis and current antiangiogenic strategies for the treatment of cancer.

Angiogenesis is a complex process critical for embryonic development and for survival. It is also a critical player in many pathologic processes, most notably in neoplasia. The cell signaling pathways involved in angiogenesis have become key targets for drug design, with more than 2,500 clinical trials currently under way. This review summarizes the essential features of angiogenesis and discusses therapeutic strategies that have been applied to specific diseases known to be associated with perturbation of normal angiogenic control.

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.

Wound dehiscence or failure to heal following venous access port placement in patients receiving bevacizumab therapy.

PURPOSE: To determine the incidence of wound dehiscence or failure to heal after port placement in patients receiving bevacizumab therapy. A hypothesis was tested that the mean interval between bevacizumab administration and port placement was shorter in patients who had dehiscence than in those who did not. MATERIALS AND METHODS: Medical records of all patients who had venous access ports placed from July 2006 through December 2007 were retrospectively reviewed. A total of 195 ports were placed in 189 patients (106 men) who were treated with bevacizumab within 120 days of port placement. The incidence of wound dehiscence and the significance of dose timing relative to port placement in these patients were calculated. RESULTS: Six of 195 ports (3.1%) were associated with wound dehiscence requiring port removal. The mean interval between bevacizumab dosing and port placement in patients without dehiscence (n = 189) was 16.9 days. The mean interval in patients with dehiscence (n = 6) was 10.8 days. A two-tailed Wilcoxon test was performed, which yielded a P value of .0150. A statistically significant difference in the mean interval between bevacizumab dosing and port placement exists between patients with dehiscence and those without. CONCLUSIONS: Wound dehiscence after port placement was related to timing of bevacizumab therapy. Patients receiving bevacizumab within 10 days of port placement had a higher incidence of wound dehiscence.

Arterial interventions for renovascular hypertension.

Renovascular hypertension is a major cause of secondary hypertension. It affects relatively younger patients. The unifying pathology is renal artery stenosis. The most common cause is atherosclerosis accounting for about 90% of cases with fibromuscular dysplasia being the second most common cause. Both of these are amenable to percutaneous interventional therapy. With the advent of new medical therapies, the control of blood pressure has improved significantly. In well-selected patients, renal arterial intervention has a good outcome. The intervention includes renal angioplasty and stenting. In this article, the authors review the role of percutaneous intervention and the techniques involved with renal angioplasty and stenting for the treatment of renovascular hypertension.

Recent advances in transarterial therapy of primary and secondary liver malignancies.

The management of liver malignancies presents many challenges. Few patients with primary hepatocellular carcinoma or metastatic disease of the liver are eligible for surgery, which is the only curative therapeutic option. Because the hepatic tumor burden is often a determinant of eligibility for surgery and is a primary contributor to morbidity and mortality, an increasing number of innovative techniques based on the transarterial administration of liver-directed drug-eluting or radiation-emitting microspheres are being tested for use in cytoreductive and palliative therapy. The delivery of therapy via a transarterial route takes advantage of the fact that hepatic malignancies are primarily supplied by the hepatic artery. The early results of clinical trials are promising; the clinical effectiveness and safety of drug-eluting and yttrium-90-bearing microspheres have been demonstrated; however, further clinical investigation is needed to verify a benefit in survival. Transarterially administered gene therapy holds promise but is still in the early stages of investigation. For all transarterial therapies, the outcome depends heavily on meticulous patient selection, careful preparation and administration of therapy, and early and regular follow-up evaluations by using an interdisciplinary approach.