Percutaneous insertion of long-covered biliary stents in patients with malignant duodenobiliary stricture.

OBJECTIVE: To investigate the technical feasibility, safety, and efficacy of a long-covered biliary stent in patients with malignant duodenobiliary stricture. METHODS: This retrospective study enrolled 57 consecutive patients (34 men, 23 women; mean age, 64 years; range, 32-85 years) who presented with malignant duodenobiliary stricture between February 2019 and November 2020. All patients were treated with a long (18 or 23 cm)-covered biliary stent. RESULTS: The biliary stent deployment was technically successful in all 57 patients. The overall adverse event rate was 17.5% (10 of 57 patients). Successful internal drainage was achieved in 55 (96.5%) of 57 patients. The median patient survival and stent patency times were 99 days (95% confidence interval [CI], 58-140 days) and 73 days (95% CI, 60-86 days), respectively. Fourteen (25.5%) of the fifty-five patients presented with biliary stent dysfunction due to sludge (n = 11), tumor overgrowth (n = 1), collapse of the long biliary stent by a subsequently inserted additional duodenal stent (n = 1), or rapidly progressed duodenal cancer (n = 1). A univariate Cox proportional hazards model did not reveal any independent predictor of biliary stent patency. CONCLUSIONS: Percutaneous insertion of a subsequent biliary stent was technically feasible after duodenal stent insertion. Percutaneous insertion of a long-covered biliary stent was safe and effective in patients with malignant duodenobiliary stricture. CLINICAL RELEVANCE STATEMENT: In patients with malignant duodenobiliary stricture, percutaneous insertion of a long-covered biliary stent was safe and effective regardless of duodenal stent placement. KEY POINTS: • Percutaneous insertion of long-covered biliary stents in patients with malignant duodenobiliary stricture is a safe and effective procedure. • Biliary stent deployment was technically successful in all 57 patients and successful internal drainage was achieved in 55 (96.5%) of 57 patients. • The median patient survival and stent patency times were 99 days and 73 days, respectively, after placement of a long-covered biliary stent in patients with duodenobiliary stricture.

Stent-Graft Placement for Hepatic Arterial Hemorrhage after Pancreaticobiliary Surgery: Long-Term Clinical Outcomes.

PURPOSE: To evaluate the safety and long-term clinical outcomes of stent-graft placement to treat hepatic arterial hemorrhage after pancreaticobiliary surgery. MATERIALS AND METHODS: Outcomes were retrospectively evaluated in 61 patients (50 men and 11 women; mean age, 63 years) who underwent stent-graft placement for delayed arterial hemorrhage (after 24 hours) after pancreaticobiliary surgery from 2006 to 2023. Bleeding sites included the gastroduodenal artery stump (n = 54), common or proper hepatic artery (n = 5), and right hepatic artery (n = 2). The stent-grafts used were Viabahn (n = 27), Comvi (n = 11), Jostent (n = 3), Covera (n = 11), and Lifestream (n = 7). Technical and clinical success and adverse events (AE) were evaluated. After stent-graft placement, overall survival (OS), hemorrhage-free survival (HFS), and stent patency were evaluated. RESULTS: The technical and clinical success rates of stent-graft placement were 97% and 93%, respectively. The severe AE rate was 12% and was significantly higher in patients who underwent pylorus-sacrificing rather than pylorus-preserving surgery (P = .001). None of the severe AEs were associated with patient mortality. Median OS after stent-graft placement was 854 days, and median HFS was 822 days. The 1-, 3-, 5-, and 10-year stent patency rates were 87%, 84%, 79%, and 72%, respectively. CONCLUSIONS: Stent-graft placement was safe and provided long-term control of hepatic arterial hemorrhage after pancreaticobiliary surgery.

Balloon-occluded transarterial chemoembolization versus conventional transarterial chemoembolization for the treatment of single hepatocellular carcinoma: a propensity score matching analysis.

OBJECTIVES: To compare the safety and efficacy of balloon-occluded transarterial chemoembolization (B-TACE) and conventional TACE (C-TACE) in treating single hepatocellular carcinoma (HCC). METHODS: This single-center retrospective study included 523 patients who underwent C-TACE and 44 who underwent B-TACE as first-line treatment for single HCCs between November 2017 and December 2019. After propensity score matching (PSM), initial tumor response rates, local tumor progression (LTP), and major complication rates were evaluated in the 32 pairs of PSM matched population. RESULTS: In the 32 pairs of PSM cohort, B-TACE showed distinct superiority over C-TACE in treating single HCCs, with significantly higher initial complete response (CR) rates (93.8% vs. 62.5%, p = 0.005). During a median follow-up of 37 months (range, 12.7-46.5 months), 13 patients (40.6%) who underwent B-TACE and 16 (50%) who underwent C-TACE showed LTP of treated lesions. Size-based sub-group analysis showed that the median times to LTP in patients with medium- to large-sized tumors (> 3 cm) were significantly longer in the B-TACE (27 months; 95% confidence interval [CI], 19.7-34.3 months) than in the C-TACE (13 months; 95% CI, 3.9-22.1 months) group (p = 0.019). The major complication rate was similar between the two groups. CONCLUSIONS: B-TACE had a higher initial CR rate than C-TACE in treating single HCCs. Moreover, size-based subgroup analysis showed that time to LTP was significantly longer in patients with medium- to large-sized HCCs (> 3 cm) who underwent B-TACE rather than C-TACE. KEY POINTS: • B-TACE was superior to C-TACE in treating single HCC, with a significantly higher initial complete response rate after one session of treatment. • In size-based subgroup analysis, time to LTP was significantly longer in patients with medium- to large-sized HCCs (>3 cm) who underwent B-TACE rather than C-TACE. • B-TACE should be considered an alternative treatment option for medium- to large-sized single HCCs (>3 cm) in patients with a nonresectable condition and those who prefer nonsurgical treatment.

Intermediate-stage (BCLC stage B) infiltrative hepatocellular carcinoma: safety and efficacy of chemoembolization.

OBJECTIVES: To evaluate the safety and efficacy of chemoembolization in patients with intermediate-stage infiltrative Hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This retrospective study evaluated outcomes in treatment-naïve patients who received chemoembolization as first-line treatment for intermediate-stage infiltrative HCC between 2002 and 2022. Of the 2029 treatment-naïve patients who received chemoembolization as first-line treatment for intermediate-stage HCC, 244 (12%) were identified as having the infiltrative type. After excluding two patients lost to follow-up, 242 patients were evaluated. RESULTS: Median post-chemoembolization overall survival (OS) was 16 months. Multivariable Cox analysis identified four factors predictive of OS: Child-Pugh class B (hazard ratio [HR], 1.84; p = 0.001), maximal tumor size ≥ 10 cm (HR, 1.67; p < 0.001), tumor number ≥ 4 (HR, 1.42; p = 0.037), and bilobar tumor involvement (HR, 1.64; p = 0.003). These four factors were used to create pretreatment prediction models, with risk scores of 0-1, 2-4, and 5-7 defined as low, intermediate, and high risk, respectively. Median OS times in these three groups were 34, 18, and 8 months, respectively (p < 0.001). The objective tumor response rate following chemoembolization was 53%. The major complication rate was 9% overall and was significantly higher in the high-risk group (22%) than in the low (2%) and intermediate (3%) risk groups (p < 0.001). CONCLUSION: Chemoembolization is safe and effective in selected patients with intermediate-stage infiltrative HCC. Chemoembolization is not recommended in high-risk patients with intermediate-stage infiltrative HCC because of poor OS and high rates of major complications. CLINICAL RELEVANCE STATEMENT: A pretreatment prediction model was developed using four risk factors associated with overall survival following chemoembolization for intermediate-stage infiltrative hepatocellular carcinoma. This model may provide valuable information for clinical decision-making. KEY POINTS: • Four risk factors (Child-Pugh score B, maximal tumor size ≥ 10 cm, tumor number ≥ 4, and bilobar tumor involvement) were used to create pretreatment prediction models, with risk scores of 0-1, 2-4, and 5-7 defined as low, intermediate, and high risk, respectively. • Median overall survival (OS) times and major complication rate in these three groups were 34, 18, and 8 months, and 2%, 3%, and 22%, respectively (p < 0.001). Chemoembolization is not recommended in high-risk patients with intermediate-stage infiltrative Hepatocellular carcinoma (HCC) because of poor OS and high rates of major complications.

Short-Term Results of Plug-Assisted Retrograde Transvenous Obliteration for Portal Steal from Complicated Portosystemic Shunts in Living-Donor Liver Transplantation.

PURPOSE: To investigate the effectiveness of plug-assisted retrograde transvenous obliteration (PARTO) for portal steal from complicated portosystemic shunts (PSSs) in living-donor liver transplantation (LDLT). MATERIALS AND METHODS: This retrospective study included consecutive patients who underwent LDLT and intraoperative or postoperative PARTO for complicated PSS between January 2020 and December 2021. PARTO was performed when hepatofugal portal flow steal was identified during intraoperative cineportography, and afferent vein embolization was difficult because of multiple afferent veins or incomplete afferent vein embolization. Liver volume, complete obliteration of PSS, technical success, adverse events, and follow-up clinical and laboratory data were evaluated. RESULTS: Thirty-seven patients were included, and the technical success rate was 100% with no major adverse events. During the median follow-up of 20.0 months, all patients recovered well with suitable regeneration of the liver without graft dysfunction related to a portal steal. The liver volume significantly increased within 1 month (median, 956 vs 1,198 mL; P < .001). Complete obliteration of a PSS occurred in 36 of 37 (97.3%) patients, and there was no recurrence during follow-up. The Child-Pugh score, serum albumin and total bilirubin levels, and prothrombin time showed significant improvement over serial follow-up. Compared with preprocedural values (14.9 cm/s), follow-up portal flow (median) peaked on the first day (71.2 cm/s, P < .001) and then remained significantly high at 1 week (60.3 cm/s, P < .001) and 1 month (53.1 cm/s, P < .001), in accordance with the graft regeneration. CONCLUSIONS: PARTO is an effective procedure for the treatment of complicated PSS in LDLT.

Long-term outcomes of endoscopic ultrasound-guided gallbladder drainage versus in situ or ex situ percutaneous gallbladder drainage in real-world practice.

OBJECTIVES: Many studies showed better outcomes of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) when compared with percutaneous transhepatic gallbladder drainage (P-GBD) in which most tubes were left in situ. However, no studies have directly compared EUS-GBD with P-GBD after tube removal (ex situ). We compared the long-term outcomes of EUS-GBD and ex situ or in situ P-GBD in high surgical risk patients with acute cholecystitis. METHODS: We reviewed the records of 182 patients (EUS-GBD, n = 75; P-GBD, n = 107) who underwent gallbladder drainage. The procedural outcomes, long-term outcomes, and adverse events were compared. RESULTS: The EUS-GBD group and the P-GBD group had similar rates of technical and clinical success. Early adverse events were less common in the EUS-GBD group (5.5% vs. 18.9%, P = 0.010). The long-term outcomes were evaluated in 168 patients (EUS-GBD, n = 67; P-GBD ex situ, n = 84; P-GBD in situ, n = 17). The rate of cholecystitis recurrence in the EUS-GBD group (6.0%) was similar to that in the P-GBD ex situ group (9.6%, P = 0.422), but significantly lower than that in the P-GBD in situ group (23.5%, P = 0.049). P-GBD in situ was a significant predictor of recurrent cholecystitis (hazard ratio 14.6; 95% confidence interval 2.9-72.8). CONCLUSION: The long-term recurrence rate of acute cholecystitis in patients who underwent EUS-GBD was comparable to that in patients whose P-GBD could be removed. However, patients in whom P-GBD could not be removed showed higher rates of recurrent cholecystitis than patients with EUS-GBD.

Application of Proximal Splenic Vein Embolization to Interrupt Complicated Large Splenorenal Shunts in Adult Living Donor Liver Transplantation.

OBJECTIVE: The aim of the present study is to evaluate efficacy and safety of proximal splenic vein embolization (PSVE) for liver transplant recipients having complicated large splenorenal shunts (SRS). BACKGROUND: In adult living donor liver transplantation for a patient who has large splenorenal shunts (SRS), their interruption is utmost important to maintain adequate portal flow by avoidance of portal flow steal through the preexisting SRS. We effectively managed most of the recipients with surgical ligation and/or additional radiologic embolization using by intraoperative cine-portogram. However, when complete interruption is not achieved in a few recipients having complicated large SRS, it may leave a chance of lethal portal flow steal in the recipient afterward. METHODS: PSVE was performed in 13 patients between April 2014 and November 2017. We performed a retrospective analysis of preoperative images, postoperative graft and recipient outcomes, and presence of isolated portal hypertension. RESULTS: Ten patients underwent PSVE as an additional secondary method because of portal steal syndrome through the remaining SRS after surgical interruption and/or embolization, and 3 patients underwent PSVE only as a primary method of SRS interruption. In all 13 patients, portal steal on the final intraoperative cine-portogram completely disappeared after PSVE. All patients recovered with satisfactory regeneration of the partial liver graft without the reappearance of portosystemic collaterals, and there were no procedure-related complications. CONCLUSIONS: PSVE is an effective and safe procedure to secure adequate portal flow without portal steal for patients with complicated large SRS arising from multiple sites of the splenic vein or escaping to multiple terminal ends.

Usability of intraoperative cine-portogram during liver transplantation in young pediatric patients with biliary atresia.

BACKGROUND: Pediatric patients with biliary atresia (BA) often present liver cirrhosis-associated portal hypertension and portal vein (PV) hypoplasia. For successful liver transplantation (LT), it is essential to maintain sufficient PV inflow through stenosis-free PV reconstruction with effective ligation of collateral veins. The aim of this study was to assess the clinical usability of intraoperative cine-portogram (IOCP) in young pediatric patients who underwent LT for BA. METHODS: Medical records of pediatric patients younger than 10 years who underwent primary LT for BA from 2018 to 2020 were reviewed. RESULTS: A total of 31 patients had undergone Kasai portoenterostomy soon after birth. Their median ages at Kasai portoenterostomy and LT were 1 and 11 months, respectively. Types of LT were living-donor LT in 13, deceased-donor split LT in 15, and deceased-donor whole LT in three patients. PV interposition using an iliac vein homograft was performed in 28 patients receiving partial liver grafts. Side-to-side PV unification venoplasty was performed in three patients undergoing whole LT. All patients underwent ligation of collateral veins. IOCP was performed in 6 (19.4%) patients. Four showed no or faint residual venous collaterals. Collateral vein embolization and endovascular stenting were performed in one patient each. PV insufficiency-free survival rate was 100% at 1 year and 93.8% at 3 years. All patients are currently alive with a median follow-up period of 23 months. CONCLUSIONS: Intraoperative cine-portogram can be a useful method for identification and embolization of residual portosystemic collateral veins in young pediatric patients who undergo LT for biliary atresia.

Percutaneous cholecystostomy for acute cholecystitis after stent insertion in patients with malignant biliary obstruction: clinical outcomes of 107 patients.

BACKGROUND: The outcome of percutaneous cholecystostomy (PC) in malignant patients with acute cholecystitis (AC) after biliary stent insertion has not been investigated in a large group. PURPOSE: To evaluate the clinical outcomes of PC for AC after stent insertion in patients with malignant biliary obstruction. MATERIAL AND METHODS: From April 2007 to February 2019, 107 patients (57 men, 52 women; mean age = 67.5 years; age range = 27-93 years) who had undergone PC for AC after biliary stent insertion were retrospectively evaluated. Of the 107 patients, 86 underwent biliary stent insertion by the endoscopic approach and the remaining 21 patients by the percutaneous approach. All patients were classified into three groups: those with stent-induced AC; those with cancer-induced AC; and those with AC without mechanical cause (biliary stent, GB stone, or cancer invasion). The mean survival time, recurrence rate, symptom improvement, and cystic duct patency in each patient group were analyzed. RESULTS: Stent-induced AC (n = 40, 37.4%) developed with a mean onset time of six days (range = 0-14 days), AC without mechanical cause (n = 27, 25.2%), 87 days (range = 15-273 days), and cancer-induced AC (n = 40, 37.4%), 137 days (range = 15-447 days) after stent insertion. Symptom resolution and significant improvement in laboratory test values were achieved in 95 patients (88.8%) within four days after PC. CONCLUSION: PC is a technically safe and effective method for the treatment of AC after biliary stent insertion in patients with malignant biliary obstruction.

Risk Factors for Early and Late Type Ib Endoleak Following Endovascular Abdominal Aortic Aneurysm Repair.

OBJECTIVES: A type Ib endoleak (T1bEL) is a postoperative complication that usually requires additional interventions following endovascular aortic aneurysm repair. Previous studies have focused on iliac artery tortuosity or common iliac artery (CIA) diameter. However, we investigated the various risk factors for early and late T1bELs more comprehensively. METHODS: This retrospective case-control study of a prospectively maintained database compared anatomical, demographic and technical factors between patients with early or late T1bELs and a control group. Early T1bEL was defined as a T1bEL occurring within 6 months of endovascular aneurysm repair (EVAR), while late T1bEL was defined as a T1bEL, initially identified more than 6 months after EVAR. Anatomical values including neck diameter, length, and angle; maximum sac diameter and length; CIA length, diameter, and tortuosity; and distal sealing length were measured and included in the analysis. We performed uni- and multivariable analyses using logistic regression and Cox proportional hazard models. RESULTS: This study included 635 iliac limbs of 383 patients. Overall, T1bELs occurred in 22 iliac limbs during the follow-up period (22/635, 3.5%). Among them, the early and late T1bEL groups each included 11 limbs. The median follow-up duration of the 383 patients was 23 (8-58) months, and in the early T1bEL and early control groups, the durations were 15 (9-35) and 29 (15-60) months, respectively (P = 0.01). The median overall follow-up durations in the late T1bEL and late control groups were 87 (76-102) and 62 (48-80) months, respectively (P = 0.01). The median follow-up duration until the occurrence of late T1bEL was 44 (32-82) months, which was shorter than that of the late control group (P = 0.03). No significant differences in sex, age, or brand of stent-graft were observed between the T1bEL and control groups. In the multivariable analysis, patients in the early T1bEL group had significantly more tortuous and short CIAs, and short distal sealing lengths (P = 0.02, P = 0.04, P = 0.03, respectively), and the late T1bEL group had significantly larger maximum aortic aneurysm sac diameters, short CIAs and short distal sealing lengths (P < 0.001, P = 0.02, P = 0.002, respectively). The suspected mechanisms of the T1bELs were CIA dilatation with or without sac expansion and aggravation of sac angulation. Except for one patient with aortic dissection, T1bELs were treated with iliac limb extensions. CONCLUSIONS: The various mechanisms of T1bELs differed depending on the time of onset from the procedure. An extensive sealing length may be protective against T1bEL, especially when the size of the aortic aneurysm sac is large or when the CIA has risky features, including large diameter or short length. Careful preoperative consideration of aortic aneurysm size and CIA length and tortuosity is essential, and patients with risky features should undergo strict postoperative surveillance.

Risk Factors for Early and Late Iliac Limb Occlusions of Stent Grafts Extending to the External Iliac Artery after Endovascular Abdominal Aneurysm Repair.

BACKGROUND: Iliac limb stent grafting to the external iliac artery (EIA) is a commonly performed procedure in various situation during endovascular abdominal aneurysm repair (EVAR). However, this procedure is associated with a risk of graft occlusion. We evaluated risk factors affecting occlusion among patients who underwent iliac limb stent-graft extension to the EIA. MATERIALS AND METHODS: We compared occluded limbs with patent limbs during the follow-up period using variables, including anatomical values, demographics, and other factors. Thereafter, we divided the occluded limbs into early and late occlusion subgroups. The main and subgroup analyses used the same variables. Survival analysis was performed to evaluate time-dependent risk factors for late limb occlusion. RESULTS: From 2007 to 2016, 766 iliac limbs from 383 patients who underwent EVAR were initially included in our analysis. Among them, 134 iliac limbs underwent limb extension to the EIA. The limb extension was a significant risk factor for occlusion (hazard ratio = 6.34, P < 0.001). Occlusion occurred in 10 patients who underwent iliac limb extension. The size of common iliac artery (CIA) was associated with occlusion. The most significant factor was iliac bifurcation diameter (patent vs. occluded limbs, 21.6 ± 7.6 vs. 27.5 ± 9.5 mm, P = 0.005). Subgroup analysis revealed that the CIAs of the early occlusion subgroup were generally more tortuous (1.16 ± 0.33 vs. 1.47 ± 0.25, P = 0.091) and longer (53 ± 24 vs. 74 ± 9, P = 0.01) than those of the patent limb group. In addition, the EIA diameters of the late occlusion subgroup were narrower than those of the patent limb group (10.9 ± 1.6 mm vs. 9.1 ± 0.8 mm, P = 0.011). Using the log-rank test, those patients with an EIA diameter narrower than 10.1 mm had a higher risk for late limb occlusion (log-rank χ2 = 5.73, P = 0.017) and the patients who did not take at least a single antiplatelet agent had a significantly higher chance of limb occlusion (log-rank χ2 = 11.029, P = 0.001). In addition, the patients who did not take a statin had a higher risk for late limb occlusion (log-rank χ2 = 7.41, P = 0.007). CONCLUSIONS: Among patients who underwent EVAR with iliac limb extension, the CIA length affected early limb occlusion and predisposed patients to vessel injury or stent-graft kinking, and there was the possibility that CIA tortuosity was associated with a higher risk. The late occlusion subgroup had narrower EIAs than the patent limb group. Appropriate antiplatelet and statin therapy is expected to play a key role in the prevention of late limb occlusion after EVAR.

Percutaneous stent-in-stent placement with large cell-type stents for malignant hilar biliary obstruction.

BACKGROUND: To overcome the technical difficulty of bilateral stent-in-stent placement, large cell-type biliary stents have been developed. However, most of the studies using large cell-type stents were conducted with endoscopic method. PURPOSE: To evaluate the efficacy and safety of percutaneous stent placement with a stent-in-stent method using large cell-type stents in patients with malignant hilar biliary obstruction. MATERIAL AND METHODS: From December 2015 and October 2018, 51 patients with malignant hilar biliary obstruction were retrospectively studied. All of the patients underwent bilateral (n=46) or unilateral (n=5) stenting in a T, Y, or X configuration with a stent-in-stent method using large cell-type stents. Technical success, complications, successful internal drainage, stent patency, and patient survival were analyzed. RESULTS: A total of 118 stents were successfully placed in 51 patients (100.0%). Three patients had minor complications with self-limiting hemobilia. Major complications were not observed in any patient. Successful internal drainage was achieved in 45 patients (88.2%). Clinical follow-up information until death or the end of the study was available for 50 of 51 patients. The median patient survival was 285.5 days (95% confidence interval [CI] 197-374). Stent dysfunction occurred in 16 patients (35.6%) due to tumor ingrowth (n=9) or tumor ingrowth combined with biliary sludge (n=7) among the patients who achieved successful internal drainage. Median stent patency was 179 days (95% CI 104-271). CONCLUSION: Percutaneous stent-in-stent placement with large cell-type stents is technically feasible and safe, and can be an effective technique in patients with malignant hilar biliary obstruction.

Drug-Eluting Microsphere Versus Cisplatin-Based Transarterial Chemoembolization for the Treatment of Hepatocellular Carcinoma: Propensity Score-Matched Analysis.

OBJECTIVE. The purpose of this study was to compare the safety and efficacy of transarterial chemoembolization (TACE) with 30- to 60-µm drug-eluting microspheres with those of cisplatin-based TACE in the treatment of unresectable hepatocellular carcinoma (HCC). MATERIALS AND METHODS. This retrospective single-center study included 607 patients who underwent drug-eluting microsphere (30-60 µm, loaded with doxorubicin) TACE (n = 119) or cisplatin-based TACE (n = 488) as first-line treatment of unresectable HCC between April 2017 and April 2018. With a propensity model correcting for selection bias, patients were selected from each treatment group to compare the effectiveness of drug-eluting microsphere TACE with that of cisplatin TACE. RESULTS. In the entire study population, the rates of major complications (1.7% vs 1.8%, p > 0.999), objective tumor response (80.7% vs 79.7%, p = 0.899), and time to progression (p = 0.536) were not significantly different between the drug-eluting microsphere TACE and cisplatin TACE groups. However, the drug-eluting microsphere TACE group had significantly higher objective tumor regression rates in subgroups with Barcelona Clinic Liver Cancer (BCLC) stage C disease (p = 0.033) and a maximal tumor size larger than 5 cm (p = 0.011). After adjustment by propensity score matching, the rates of major complications, objective tumor response, and time to progression remained similar between the two groups. CONCLUSION. Both TACE with 30- to 60-µm drug-eluting microspheres and cisplatin TACE were safe and effective for treating unresectable HCC. In patients with BCLC stage C disease and patients with large (> 5 cm) HCCs, TACE with 30- to 60-µm drug-eluting micro-spheres may have a better chance of obtaining an objective tumor response than conventional TACE performed with the protocol used in this study.

Sequential transcatheter arterial chemoembolization and portal vein embolization before right hemihepatectomy in patients with hepatocellular carcinoma.

BACKGROUND: Recent studies showed that sequential selective transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE) provided better future liver remnant (FLR) regeneration rate and disease-free survival following surgery compared with PVE alone. The present study aimed to clarify whether preoperative sequential TACE and PVE before right hemihepatectomy can reduce postoperative hepatocellular carcinoma (HCC) recurrence and improve long-term disease-free and overall survival. METHODS: Recurrence and survival outcomes were retrospectively evaluated in 205 patients with HCC who underwent right hemihepatectomy by a single surgeon from November 1993 to November 2017. Patients were divided into four groups according to the procedure performed before the surgery: sequential TACE and PVE (TACE-PVE), PVE-only, TACE-only, or naïve control groups. The baseline patient and tumor characteristics, postoperative outcomes, recurrence-free survival and overall survival were analyzed. RESULTS: Baseline patient and tumor characteristics upon diagnosis were similar in all four groups, while sequential TACE and PVE were well tolerated. The TACE-PVE group had a higher mean increase in percentage FLR volume compared with that of the PVE-only group (17.46% ± 6.63% vs. 12.14% ± 5.93%; P = 0.001). The TACE-PVE group had significantly better overall and disease-free survival rates compared with the other groups (both P < 0.001). CONCLUSIONS: Sequential TACE and PVE prior to surgery can be an effective therapeutic strategy for patients with HCC scheduled for major hepatic resection. The active application of preoperative sequential TACE and PVE for HCC would allow more patients with marginal FLR volume to become candidates for major hepatic resection by promoting compensatory FLR hypertrophy without the deterioration of basal hepatic functional reserve or tumor progression.

Relationship of Lower-extremity Deep Venous Thrombosis Density at CT Venography to Acute Pulmonary Embolism and the Risk of Postthrombotic Syndrome.

Background Acute deep venous thrombi (DVT) have higher Hounsfield unit values than chronic (bland) thrombi at CT venography. Purpose To determine the relationship between DVT thrombus density found on CT venography images to the presence of acute pulmonary embolism (PE) and the future risk of postthrombotic syndrome (PTS) in patients with DVT. Materials and Methods In this retrospective study, patients were divided into two groups: PE with DVT group and DVT-only group. Wells scores were recorded. Thrombus density ratios were calculated (DVT thrombus Hounsfield units/surrounding vein Hounsfield units). The presence or absence of PTS was determined from the results of the Venous Insufficiency Epidemiologic and Economic Study on Quality of Life (VEINES-QOL) questionnaires given to the patients with DVT. Statistical analyses used receiver operating characteristic curves and Spearman correlation analyses. Results Eighty-six patients were included; the mean age was 60 years ± 17 (51 men; PE with DVT group, 54 patients [63%]; DVT-only group, 32 patients [37%]). The mean thrombus density ratio was significantly higher in the PE with DVT group than in the DVT-only group (53.6% ± 12.4 [standard deviation] vs 42.8% ± 11.9, respectively; P < .001). At multivariable analysis, Wells score greater than 4 (odds ratio, 12.0; 95% confidence interval [CI]: 3.0, 47; P < .001) and higher thrombus density ratio (odds ratio, 1.1; 95% CI: 1.0, 1.2; P = .001) were independent predictors of PE. The diagnostic performance for the thrombus density ratio (area under the receiver operating characteristic curve, 0.74; 95% CI: 0.63, 0.85; P < .001) may be more discriminative than that of the Wells score (area under the receiver operating characteristic curve, 0.70; 95% CI: 0.59, 0.81; P = .002) for the presence of PE. In subgroup analysis, the thrombus density ratio and VEINES-QOL score were correlated (r = 0.61; 95% CI: 0.30, 0.80; P < .001). Conclusion Deep venous thrombosis (DVT) density ratio at CT venography was associated with acute pulmonary embolism in patients with lower-extremity DVT. © RSNA, 2019 Online supplemental material is available for this article.

New predictors of aneurysm sac behavior after endovascular aortic aneurysm repair.

OBJECTIVES: This study aimed to identify new predictors of sac behavior after endovascular aortic aneurysm repair (EVAR) and to investigate whether sac behavior is associated with long-term clinical outcomes. METHODS: A total of 168 patients undergoing successful EVAR for abdominal aortic aneurysms with CTA follow-up of at least 1 year were included. Predictors of aneurysm sac behavior and its impact on long-term clinical outcomes were retrospectively analyzed. RESULTS: According to sac behavior, eligible patients were stratified into the sac regression group (n = 79, 47.0%) and the sac non-regression group (n = 89, 53.0%). Patients in the regression group were younger (p = 0.036) and more likely to take sarpogrelate hydrochloride postoperatively (p = 0.011) than those in the non-regression group. The incidence of postimplantation syndrome (PIS) was significantly higher in the regression group (p = 0.005). On multivariate analysis, sac regression was more likely to occur in those with PIS (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.07-2.64; p = 0.023) and less likely to occur in those with transient type II endoleaks (HR, 0.43; 95% CI, 0.20-0.95; p = 0.037) and higher thrombus density within the sac on follow-up CTA (HR, 0.97; 95% CI, 0.95-0.99; p = 0.013). Non-regression of the sac was associated with significantly higher rates of re-intervention during the follow-up period (p = 0.001). CONCLUSIONS: In addition to type II endoleaks, PIS and thrombus density are new predictors of aneurysm sac behavior, and sac regression is significantly associated with lower rates of re-intervention. KEY POINTS: • After endovascular aortic aneurysm repair (EVAR), patients with sac regression were younger and more likely to take sarpogrelate hydrochloride postoperatively than those with sac non-regression. • The incidence of postimplantation syndrome (PIS) was significantly higher in patients with sac regression. • In our analysis, PIS and thrombus density within the sac were newly identified predictors of aneurysm sac behavior after EVAR.

Chemoembolization Combined with Radiofrequency Ablation for Medium-Sized Hepatocellular Carcinoma: A Propensity-Score Analysis.

PURPOSE: To compare survival outcomes of patients with single medium-sized hepatocellular carcinomas (HCCs) who underwent treatment with transarterial chemoembolization, radiofrequency (RF) ablation, or a combination of the 2 therapies. MATERIALS AND METHODS: Between 2000 and 2016, 538 patients underwent combined chemoembolization and RF ablation (n = 109), chemoembolization alone (n = 314), or RF ablation alone (n = 115) as first-line treatment for a single medium-sized (3.1-5.0 cm) HCC. Baseline demographic data (age, sex, etiology, Eastern Cooperative Oncology Group performance status, presence of liver cirrhosis, and serum bilirubin, albumin, and α-fetoprotein levels) were similar among groups except for Child-Pugh class, albumin level, and tumor size. Propensity-score analysis with inverse probability weighting (IPW) was used to reduce any bias in treatment selection and other potential confounding factors. RESULTS: Median follow-up time was 46.2 months. Before IPW, overall survival (OS) durations were significantly different among the 3 groups (median, 85 months for combined therapy, 56.5 months for chemoembolization alone, and 52.1 months for RF ablation alone; P = .01). The 10-year OS rates were 40.1%, 25.5%, and 19.5% for the combined, chemoembolization-only, and RF ablation-only groups, respectively. After IPW, OS remained superior in the combined chemoembolization/RF ablation group compared with the monotherapy groups (10-y OS, 41.8% with combined therapy, 28.4% with chemoembolization alone, and 11.9% with RF ablation alone; P = .022). CONCLUSIONS: Chemoembolization plus RF ablation may provide better survival outcomes than chemoembolization or RF ablation monotherapy, and can be considered a viable alternative treatment for unresectable single medium-sized HCCs.

Angiographic management of percutaneous renal procedure-related bleeding: A single-center experience.

OBJECTIVES: To present the radiological and clinical results of transcatheter arterial embolization in patients with active bleeding after percutaneous renal procedures. METHODS: A total of 79 consecutive patients who underwent angiography for percutaneous renal procedure-related bleeding were included in the present retrospective analysis. Patient characteristics, angiographic management and clinical outcomes were analyzed. RESULTS: On angiography, bleeding foci were observed in 81.0% of the patients (64/79), all of whom underwent transcatheter arterial embolization. Among the 15 patients (19.0%) with negative angiographic findings, empirical transcatheter arterial embolization was carried out in six patients (40.0%). The technical success rate in 64 patients with positive angiographic findings was 100%, and the clinical success rate in 70 patients who underwent transcatheter arterial embolization was 85.7% (60/70). A total of 14.3% (10/70) of patients with clinical failure underwent repeat transcatheter arterial embolization and all achieved clinical recovery. There were no major complications. There was no statistical difference in estimated glomerular filtration rate values before the percutaneous renal procedure and those measured 7 days after transcatheter arterial embolization (43.4 ± 24.4 to 44.6 ± 25.1 mL/min/1.73 m2 ; P = 0.189). Clinical failure was not associated with age, sex, type of renal procedures, bleeding tendency, presence of active bleeding on angiography, latency time and embolic agents used (P > 0.05). CONCLUSIONS: Transcatheter arterial embolization is a safe and effective method of treating percutaneous renal procedure-related bleeding without renal function deterioration.

Role of percutaneous cholecystostomy for acute acalculous cholecystitis: clinical outcomes of 271 patients.

OBJECTIVES: To examine the outcomes of percutaneous cholecystostomy (PC) in patients with acute acalculous cholecystitis (AAC). METHODS: The study population comprised 271 patients (mean age, 72 years; range, 22-97 years, male, n=169) with AAC treated with PC with or without subsequent cholecystectomy. Clinical data from total 271 patients were analysed, and outcomes were assessed according to whether the catheter was removed or remained indwelling. Patient survival and recurrence rates were calculated. RESULTS: Symptom resolution and significant improvement of laboratory test values were achieved in 235 patients (86.7%) within 4 days after PC. Complications occurred in six patients (2.2%). Interval elective cholecystectomy was performed in 127 (46.8%) patients. Among the remaining 121 patients, successful removal of the PC catheter was achieved in 88 patients (72.7%) at a mean of 30 days (range, 4-365 days). Of the catheter removal group, 86/88 (97.7%) were successfully treated with the initial PC, whereas two (2.3%) experienced recurrence of cholecystitis. Cumulative recurrence rates were 1.1%, 2.7%, and 2.7% at 1, 2, and 8 years, respectively. CONCLUSIONS: The good therapeutic outcomes of PC and low recurrence rate suggest that PC can be a definitive treatment option in the majority of AAC patients. KEY POINTS: • Many patients with AAC are too ill to undergo cholecystectomy. • PC in AAC patients shows low complication and recurrence rate. • PC solely can be a definitive treatment option in the majority of AAC patients.

Long-Term Outcome of Portal Vein Stent Placement in Pediatric Liver Transplant Recipients: A Comparison with Balloon Angioplasty.

PURPOSE: To evaluate the long-term efficacy of stent placement versus balloon angioplasty for portal vein (PV) stenosis in pediatric liver transplant (LT) recipients. MATERIALS AND METHODS: Fifty patients (<18 years old; median, 14 months) who underwent percutaneous transhepatic balloon angioplasty (n = 12), transhepatic stent placement (n = 18), or intraoperative transmesenteric stent placement (n = 20) between 1994 and 2015 were retrospectively analyzed. The median intervals from LT to percutaneous transhepatic angioplasty, stent, and intraoperative stent were 145 days (range, 27-2072), 98 days (range, 5-2289), and 0 days (range, 0-14), respectively. The primary study endpoint was the primary patency of each group. Secondary study endpoints included procedural complications, functional stent stenosis, and stent fractures. RESULTS: The median clinical follow-up periods were 81 months (range, 13-179), 118 months (range, 65-181), and 112 months (range, 47-168) in each group, respectively. In the angioplasty group, the 1-, 5-, and 10-year primary patency rates were all 75% ± 13%. The corresponding rates were all 100% in the percutaneous transhepatic stent group and 90% ± 7%, 90% ± 7%, and 85% ± 8%, respectively, in the intraoperative transmesenteric stent group (P = .103). Major procedural complications occurred in 4 patients, including 1 case with PV tear after percutaneous transhepatic post-stent angioplasty, and 3 cases with acute PV thrombosis after intraoperative transmesenteric stent. Functional stent stenosis and stent fractures occurred in 1 and 2 patients, respectively. CONCLUSIONS: No statistically significant difference was observed between the 3 groups in terms of the long-term primary patency rates. Therefore, angioplasty should be considered first to treat PV stenosis in pediatric LT recipients.