Percutaneous cryoablation of follicular thyroid carcinoma metastasis to the pancreas

The following is a technical report of the successful cryoablation of pancreatic metastasis originating from follicular thyroid carcinoma. The patient was a 72-year-old female who underwent total thyroidectomy and radioiodine ablation for follicular carcinoma. One year after surgery, a positron emission tomography-computed tomography (PET-CT) examination, performed to demonstrate the source of the increased thyroglobulin, showed a fluorodeoxyglucose (FDG) avid mass located in the body of the pancreas. A percutaneous tru-cut biopsy was performed that revealed follicular thyroid carcinoma metastasis to the pancreas. Because of the patient's comorbidities, the patient underwent percutaneous cryoablation and made a successful recovery over the following 13 months. At the most recent follow-up, the thyroglobulin level was undetectable, and a PET-CT scan showed no FDG avid mass in the pancreas. To our knowledge, follicular carcinoma metastasis of the pancreas is extremely rare, and this is the first report of successful cryoablation of a metastatic tumor in the pancreas.

Investigation of typhlitis in bone marrow transplant patients in a stem cell transplant unit.

Typhlitis is a special type of enterocolitis that specifically develops in immunosuppressive patients with hematological malignancies. Typhlitis is a common consideration after bone marrow transplantation due to high-dose chemotherapy that is used in conditioning regimens those contain high-dose cytotoxic chemotherapeutic agents. Although there are several studies about typhlitis during chemotherapy or in leukemia patients, there is not enough data evaluating its relationship between stem cell transplant in adults. Therefore, the current study aimed to analyze the possible causes that may lead to the development of typhlitis in hematopoietic stem cell recipient patients. This retrospective study included 210 adult patients who underwent bone marrow transplantation between January 2017 and December 2019. Pediatric patients (patients younger than 18 years of age) were excluded. Patients' data were evaluated to determine their effects on typhlitis and the mortality risk of the patients with typhlitis. The analysis of the variables was performed using the IBM SPSS Statistics for Windows version 26 (IBM Corp., Armonk, NY).Variables were analyzed at a 95% confidence level and a P value <0.05 was considered significant. Typhlitis developed in 23 (10.9%) transplant patients. Male sex, length of hospital stay, presence of febrile neutropenia, antibiotic and antifungal use, need for switching antibiotics, duration of neutropenia, diarrhea and antibiotic use in days were risk factors for development of typhlitis. It was observed that 100-days mortality was higher in typhlitis group reaching to a statistical significance (P < .05). In multiple logistic regression analysis, presence of mucositis and additional source of infection were determined as independent risk factors for the development of typhlitis in bone marrow transplant patients. This study provides valuable information for bone marrow transplant patients through an analysis of risk factors for the development of typhlitis. According to our results, mucositis and additional bacterial infections were found as risk factors for typhlitis therefore it would be beneficial for clinicians to consider these factors in patient follow-up. However, due to the retrospective nature of our study, prospective studies are needed to investigate risk factors and optimum treatment methods for typhlitis.

Use of cryoablation beyond the prostate.

UNLABELLED: Cryoablation has been used for many years as a surgical ablation technique in the prostate and kidney. However, since the introduction of high-intensity focused ultrasound (HIFU) and robotic surgery for prostate tumours, its popularity in the urologic community has declined. In the early 2000s, innovations in cryoablation technology allowed the use of thinner probes, which were suitable for percutaneous application. As a result, radiologists began using cryoablation, first in the liver, and then in other organs or tissues such as the kidney, lung, breast, pancreas, bone, and soft tissue. In most of these locations, cryoablation has great potential given its inherent advantages, including the use of local anaesthesia, little or no pain during and after the procedure, real-time monitoring of the ablation area on US, CT or MRI, the potential for ablation of large tumours with multiple probes, and the ability to change the shape of the ablation in non-spherical tumours. Yet despite these advantages, the use of percutaneous cryoablation among radiologists appears to be far lower than that of heat-based ablation techniques. The aim of this article is to outline specific aspects of cryoablation and to illustrate its potential clinical applications with case presentations. KEY POINTS: • Recent advances have made cryoablation suitable for percutaneous use by radiologists with image guidance. • Cryoablation has distinct advantages over heat-based ablation techniques. • Cryoablation is becoming increasingly popular for lung, breast, kidney, bone, and soft tissue tumours.

US-guided femoral and sciatic nerve blocks for analgesia during endovenous laser ablation.

PURPOSE: Endovenous laser ablation may be associated with significant pain when performed under standard local tumescent anesthesia. The purpose of this study was to investigate the efficacy of femoral and sciatic nerve blocks for analgesia during endovenous ablation in patients with lower extremity venous insufficiency. METHODS: During a 28-month period, ultrasound-guided femoral or sciatic nerve blocks were performed to provide analgesia during endovenous laser ablation in 506 legs and 307 patients. The femoral block (n = 402) was performed at the level of the inguinal ligament, and the sciatic block at the posterior midthigh (n = 124), by injecting a diluted lidocaine solution under ultrasound guidance. After the blocks, endovenous laser ablations and other treatments (phlebectomy or foam sclerotherapy) were performed in the standard fashion. After the procedures, a visual analogue pain scale (1-10) was used for pain assessment. RESULTS: After the blocks, pain scores were 0 or 1 (no pain) in 240 legs, 2 or 3 (uncomfortable) in 225 legs, and 4 or 5 (annoying) in 41 legs. Patients never experienced any pain higher than score 5. The statistical analysis revealed no significant difference between the pain scores of the right leg versus the left leg (p = 0.321) and between the pain scores after the femoral versus sciatic block (p = 0.7). CONCLUSIONS: Ultrasound-guided femoral and sciatic nerve blocks may provide considerable reduction of pain during endovenous laser and other treatments, such as ambulatory phlebectomy and foam sclerotherapy. They may make these procedures more comfortable for the patient and easier for the operator.

Endovenous laser ablation and concomitant foam sclerotherapy: experience in 504 patients.

PURPOSE: To investigate the value of endovenous laser ablation (ELA) and concomitant ultrasound-guided foam sclerotherapy (USGFS) in patients with chronic venous insufficiency. METHODS: During a 6-year period, concomitant USGFS of the varicose veins were performed in 504 out of 610 patients who underwent ELA for truncal or perforating vein insufficiency. In these 504 patients (944 legs; bilateral in 440 patients), the incompetent veins were greater saphenous vein in 615 legs, small saphenous vein in 118 veins, perforating veins in 42 legs, and a combination of these in 169 legs. In all patients, after ELA of the incompetent veins, USGFS was performed for the remaining varicosities with 1-3% polidocanol foam. Patients were followed up clinically and with color Doppler ultrasound at 1, 6, and 12 months. RESULTS: ELA was technically successful in all cases, although another venous puncture was necessary in 29 legs. Concomitant USGFS was also technically successful in all cases, but one to three additional sclerotherapy sessions were performed in 203 legs with persistent varicosities. During the follow-up, recanalization of the laser-ablated refluxing veins occurred in 16 legs (1.7%) and was treated with repeat ELA or USGFS. Major complications occurred in 1.4% of the treated legs and included skin necrosis and calf vein thrombosis. CONCLUSION: ELA and concomitant foam sclerotherapy is feasible and effective. The procedures are associated with a low complication rate and can be performed in both legs in the same session. Concomitant use of laser and foam may potentially decrease the recanalization rate of laser-ablated vessels.

Management of concomitant coronary and bilateral carotid artery disease: a case report.

Patients with severe coexistent coronary and carotid artery stenosis represent a difficult and high-risk population. Herein we describe management of a patient with concomitant coronary artery and bilateral carotid artery disease. Firstly, left carotid artery stenting was done using a self-expandable monorail stent and a neurological protective device. Post-stent angiogram revealed satisfactory dilatation in the left carotid artery. Later, coronary artery bypass grafting to the four coronary arteries was done. Then right carotid endarterectomy was done. He had no neurological complication during or after any of the operation and he remains in good health since his last operation. We think the staged treatment, consisting of carotid artery stenting plus coronary artery bypass grafting plus carotid endarterectomy, in a patient with concomitant severe coronary artery and bilateral carotid artery disease is feasible, safe, and may be an alternative to combined coronary artery bypass grafting plus carotid endarterectomy.

Aortoiliac kissing stents: long-term results and analysis of risk factors affecting patency.

PURPOSE: To present the early and long-term results of aortoiliac kissing stents implantation and evaluate the risk factors affecting patency. METHODS: The data were retrospectively reviewed on 68 patients (64 men; mean age 55+/-11, range 32-77) who underwent kissing stents implantation during a 12-year period. The majority of patients (64, 94%) had claudication; 4 patients had rest pain. All were smokers. There were bilateral or unilateral stenoses in 42 (62%) patients, and unilateral occlusion and contralateral stenosis in 26 (38%). Lesions were treated with simultaneous implantation of self-expanding (n=52) or balloon-expandable (n=16) stents. After the procedure, patency was determined with Doppler ultrasonography or angiography at 1, 3, 6, and 12 months and annually thereafter. Primary, assisted primary, and secondary patency rates were calculated with Kaplan-Meier analysis on an intention-to-treat basis, and risk factors affecting the patency rates were determined with the Cox regression analysis. RESULTS: All procedures were technically and clinically successful. Complications occurred in 12%, but none required surgery. The follow-up period was 35+/-31 months. Primary, assisted primary, and secondary patency rates, respectively, were 76%, 90%, and 94% at 1 year; 63%, 86%, and 92% at 3 years; and 63%, 64%, and 81% at 5 years. In multivariate analysis, age <50 years and presence of iliac occlusion were identified as risk factors for reduced primary and assisted primary patency; a crossed configuration of kissing stents was identified as a risk factor for reduced primary patency. CONCLUSION: Implantation of kissing stents is a safe and effective alternative in the treatment of aortoiliac obstructions. However, overall primary and assisted primary patency rates are inferior to those reported for surgery. Long-term patency comparable to surgery may be obtained in patients >50 years and in those without an iliac occlusion, particularly if a favorable stent configuration is achieved.

Persistent sciatic artery. Radiologic features and patient management.

Persistent sciatic artery PSA represents the persistence of the sciatic vessel in adult life that is responsible for the major blood supply to the lower limb in early embryologic development. The incidence of PSA has been estimated as low as 0.025-0.04%. We present 2 cases of PSA, one of which was complicated by an aneurysm that led to a life-threatening hemorrhage.

Transvenous embolization and stent placement for an internal iliac arteriovenous fistula with central iliac vein occlusion.

The authors present a case of traumatic arteriovenous fistula of the internal iliac vessels treated with attempted surgical ligation of the common iliac artery and external iliac artery. The fistula persisted after the operation, and because the patient received no further treatment for the following 6 years, a venous outflow occlusion also developed as a result of high-flow angiopathy. Because the arterial route was eliminated at previous surgery, the fistula and venous occlusion were percutaneously treated via a transvenous approach.

Subintimal versus intraluminal recanalization of chronic iliac occlusions.

PURPOSE: To present our experience with subintimal recanalization of chronic iliac occlusions and retrospectively compare the results of this technique with those of standard intraluminal recanalization. METHODS: A retrospective review was conducted of 98 patients (91 men; mean age 61+/-10 years, range 37-77) with unilateral chronic iliac occlusions who underwent standard intraluminal recanalization or subintimal recanalization if intraluminal wire passage failed. The technical success, complications, and patency rates were statistically compared between groups. RESULTS: In 59 (60%) of 98 patients, the occlusions were successfully crossed with ipsilateral intraluminal recanalization, while failure of intraluminal recanalization in the remaining 39 led to attempted subintimal recanalization (ipsilateral in 17 and antegrade-retrograde in 22). Overall, ipsilateral intraluminal recanalization was technically successful in 56 (57%) of 98 patients; subintimal recanalization was successful in 35 (90%) of 39 patients. Technical success was only 29% in 17 patients who underwent subintimal recanalization via an ipsilateral retrograde approach. During a follow of 27+/-16 months, primary and assisted primary patencies were not significantly different between the patients treated with intraluminal versus subintimal recanalization (p=0.81 and 0.64, respectively). CONCLUSIONS: Subintimal recanalization is a safe and effective supplement to standard intraluminal recanalization techniques in the endovascular treatment of chronic iliac occlusions. Because of the poor outcome associated with the ipsilateral route, subintimal recanalization of these lesions should preferably be performed via a combined antegrade-retrograde approach.

Subintimal angioplasty of long superficial femoral artery occlusions.

PURPOSE: To investigate the value of subintimal angioplasty (SA) and selective stent placement in the treatment of long (> or =15 cm) superficial femoral artery (SFA) occlusions. MATERIALS AND METHODS: During a period of 4.5 years, 67 long SFA occlusions in 61 patients (52 male, 9 female) were intended to be treated with SA, either retrogradely (n = 55) or antegradely (n = 12). Postprocedural medical treatment included aspirin + ticlopidine/clopidogrel (AT/C) combination. In 25 patients warfarin was also given for 3-6 months. Patients were followed up for 1-30 months (mean 12.5 +/- 9.0 months). Hemodynamic patencies were determined with the Kaplan-Meier method, risk factors affecting patency were evaluated with the Cox model, and the patencies of the subgroups were compared with log-rank test. RESULTS: Subintimal recanalization was technically successful in 59 of 67 occlusions. Technical success was 83% in the first 30 procedures, 92% in the last 37, and 100% in the last 29. Forty-six occlusions were treated with SA alone and 13 with SA and stent placement. On an intention-to-treat basis, primary patency at 6 and 12 months was 49% and 22%, respectively, and assisted primary patency at 6 and 12 months was 69% and 57%, respectively. Patency rates were not significantly different in patients with claudication versus critical limb ischemia, or in those treated with SA alone versus SA and stent placement. With the multivariate Cox model, medical treatment with AT/C combination was identified as the only significant risk factor for both primary patency and assisted primary patency. With the Kaplan-Meier analysis, primary and assisted primary patencies were significantly higher in the warfarin group than the AT/C group (P =.0002 and.0001, respectively). CONCLUSION: SA is a simple and safe method with a high technical success rate in the endovascular treatment of long SFA occlusions. Long-term patency rates, however, seem unsatisfactory, despite early reports. Subintimal stent placement provides cumulative patency at least as good as SA alone. Warfarin may significantly improve both primary patency and assisted primary patency after subintimal recanalization, but even with this treatment patency rates are still lower than those reported for bypass surgery. Therefore, in long SFA occlusions, SA is not recommended for claudicants but may be valuable in patients with critical limb ischemia.

Endovascular treatment of an acute superior mesenteric artery occlusion following failed surgical embolectomy.

PURPOSE: To present the successful primary stenting of a superior mesenteric artery (SMA) occlusion following failed surgical embolectomy. CASE REPORT: A 65-year-old woman with a history of atrial fibrillation underwent surgical embolectomy of an acute embolic occlusion of the superior mesenteric artery (SMA). The following day, symptom recurrence suggested reocclusion, which was confirmed with emergent arteriography. Two balloon-expandable stents were deployed primarily, which ameliorated the patient's symptoms. Follow-up angiography at 3 months showed continued SMA patency, with no evidence of distal embolization or restenosis. The patient remains asymptomatic at 9 months after the stent procedure. CONCLUSIONS: Although more experience is required, primary stenting may be a valuable alternative in the treatment of acute SMA occlusions, in particular, for reocclusions after failed surgery.

Laryngeal neurofibroma associated with neurofibromatosis type 2.

We present a case of laryngeal neurofibroma associated with neurofibromatosis type 2. Although laryngeal neurofibromas have previously been reported in cases of neurofibromatosis type 1, their presence has never been described in a patient with neurofibromatosis type 2.