Update on Embolization Therapies for Hepatocellular Carcinoma.

PURPOSE OF REVIEW: The purpose of the review is to summarize the latest applications for embolotherapy in the management of patients with HCC according to BCLC stage. RECENT FINDINGS: While traditionally reserved for patients with unresectable HCC and stage B disease, there is an important role for embolization therapies in earlier stage patients as an adjunct to ablation, bridging, or downstaging therapy, as a means to improve safety of resection, and potentially as an arterial ablative option in the case of radioembolization. Newer applications of radioembolization such as radiation segmentectomy have the potential to provide cure in localized unifocal disease, and transarterial chemoembolization-portal vein embolization and radiation lobectomy may provide a combination of treatment and future liver remnant hypertrophy for planned hepatic resection. There is also an increasing role for embolization in the treatment of stage C disease, and recent data suggest it can be used in combination with sorafenib with the potential for survival benefit over sorafenib alone, even in the case of portal vein tumor thrombus. Embolization therapies play an increasingly important role in patients with BCLC stage A-C hepatocellular carcinoma. While different therapies may be offered on a patient-specific basis, there are limited prospective RCT data to support superiority of one technique over another.

3D printing from diagnostic images: a radiologist's primer with an emphasis on musculoskeletal imaging-putting the 3D printing of pathology into the hands of every physician.

Three-dimensional (3D) printing has recently erupted into the medical arena due to decreased costs and increased availability of printers and software tools. Due to lack of detailed information in the medical literature on the methods for 3D printing, we have reviewed the medical and engineering literature on the various methods for 3D printing and compiled them into a practical "how to" format, thereby enabling the novice to start 3D printing with very limited funds. We describe (1) background knowledge, (2) imaging parameters, (3) software, (4) hardware, (5) post-processing, and (6) financial aspects required to cost-effectively reproduce a patient's disease ex vivo so that the patient, engineer and surgeon may hold the anatomy and associated pathology in their hands.

Patient Assessment: Clinical Presentation, Imaging Diagnosis, Risk Stratification, and the Role of Pulmonary Embolism Response Team.

Pulmonary embolism (PE) is currently the third leading cause of death and moreover is likely underdiagnosed. PE remains the most common preventable cause of hospital deaths in the United States, which may be attributable to its diagnostic challenges. Although difficult to diagnose, patient mortality rates are time-dependent, and thus, the suspicion and diagnosis of PE in a timely manner is imperative. Diagnosis based on several criteria which may dictate imaging workup as well as laboratory tests and clinical parameters are discussed. The evolution of treatment guidelines via various clinical trials and recommendations is outlined, setting the stage for the use of fibrinolytics, whether systemic or catheter directed. Treatment, including fibrinolytics, is predicated on patient triage into three large categories-massive, submassive, or low-risk PE. Additionally, a relatively new concept of a multidisciplinary team composed of several subspecialty experts known as the PE response team (PERT) is discussed. PERT's timely and unified recommendations have been shown to optimize care and decrease mortality while tailoring treatment to each individual afflicted by PE.

Declotting the Thrombosed Access.

Because a patent access is the lifeline for a dialysis patient, access declotting is extremely important. Before embarking on a declot, it is important to evaluate the patient for potential contraindications such as pulmonary hypertension, right-to-left shunts and access infection in order to be able to avoid potential complications such as symptomatic pulmonary embolism, stroke, and sepsis. Multiple methods to perform a percutaneous declot exist. Four common methods are described here. We also discuss how to avoid causing an arterial embolism and how to treat it if it does occur.

Complications in Percutaneous Dialysis Interventions: How to Avoid Them, and How to Treat Them When They do Occur.

Because of the increasing prevalence of end-stage renal disease, more percutaneous interventions are being performed. They serve an important role, allowing for restoration of access function, which is achieved with high level of technical success. However, complications are inevitable during any types of procedure, and percutaneous dialysis interventions are no exception. To provide safe and effective care these patients need, anyone performing endovascular dialysis interventions needs to understand the possible complications, how they can be avoided, and how they can be addressed if they are to occur. Topics in this article include complications seen while intervening on the thrombosed access, complications of angioplasty, potentially devastating complications of central venous interventions, and complications of dialysis catheter placement. Further, patients with end-stage renal disease are generally sicker than the average patient, usually afflicted by multiple comorbidities and are therefore more complicated from a medical perspective. This places them at higher risk for acute cardiopulmonary decompensation or arrest than any other interventional radiology patient subset. As result, we also briefly review general medical complications in this population.

Iatrogenic lymphocutaneous fistula secondary to right-sided pheresis catheter placement and its percutaneous treatment: a case report.

We present a case of an iatrogenic lymphocutaneous fistula secondary to placement of a tunneled, large bore (14.5 Fr) right-sided internal jugular vein for plasmapheresis to treat antibody-mediated kidney transplant rejection. While iatrogenic lymphatic leaks caused by neck and thoracic surgeries are well described in the literature, lymphatic leak or lymphocutaneous fistula resulting from image-guided placement of a central venous catheter through the right internal jugular vein has yet to be described. We also describe the successful percutaneous treatment of this lymphocutaneous fistula using a combination of n-butyl cyanoacrylate glue and embolization coils.

Tumor thrombus: incidence, imaging, prognosis and treatment.

Intravascular tumor extension, also known as tumor thrombus, can occur in many different types of cancer. Those with the highest proclivity include Wilm's tumor, renal cell carcinoma (RCC), adrenal cortical carcinoma (ACC) and hepatocellular carcinoma (HCC). The presence of tumor thrombus markedly worsens prognosis and impacts treatment approach. Imaging plays a key role in its diagnosis. Endovascular methods also play a large role in treatment.

Malignant Venous Obstruction: Superior Vena Cava Syndrome and Beyond.

Venous obstruction in the cancer population can result in substantial morbidity and, in extreme cases, mortality. While venous obstruction can be caused by both benign and malignant etiologies in this population, the management of malignant venous obstruction as a palliative measure can be somewhat nuanced with respect to nonprocedural and procedural management, both with respect to treatment of the underlying malignancy as well as treatment of venous hypertension, which may be associated with venous thrombosis. Symptom severity, primary malignancy, functional status, and prognosis are all fundamental to the patient workup and dictate both the timing and extent of endovascular intervention. The morbidity and mortality associated with malignant obstructions of central venous structures, specifically the superior vena cava and inferior vena cava, can be significantly improved with endovascular management in appropriately selected patients. Thus, the pertinent literature regarding the clinical presentation, workup, and endovascular management of malignant central venous obstruction syndromes, with directed attention to superior vena cava syndrome and inferior vena cava syndrome, will be reviewed in this article.

Deep hypothermic circulatory arrest effectively preserves neurocognitive function.

BACKGROUND: Few (conflicting) studies have quantitatively assessed neurocognitive effects of deep hypothermic circulatory arrest (DHCA). We assess neurocognitive function quantitatively before and after DHCA in comparison with non-DHCA patients. METHODS: Sixty-two aortic surgical patients underwent a battery of neuropsychometric tests, both preoperative and postoperative, evaluating multiple aspects of memory, processing speed, executive function, and global cognition. Thirty-three patients did not require DHCA, and 29 underwent DHCA as the sole means of cerebral protection. Neurocognitive deficit was defined as greater than 20% decline in 2 or more cognitive areas. Preoperative and postoperative test scores, as well as incidence of neurocognitive deficit, were compared within each group, and between the non-DHCA and DHCA groups. RESULTS: There were no significant differences in the postoperative versus preoperative scores in any cognitive area tested between DHCA and non-DHCA groups. There was also no difference between the 2 groups in incidence of neurocognitive deficit; 13 non-DHCA, 11 DHCA (p = 1.00). In addition, there was no correlation between time under DHCA and incidence of neurocognitive deficit. Within both groups, there was a decline in memory in the areas of acquisition, retention, and delayed recall. Within the DHCA group, recognition was also affected. CONCLUSIONS: While cardiac surgery had some effects on memory, overall neurocognitive function was well preserved and not different between DHCA and non-DHCA patients. Time under DHCA up to 40 minutes was also found to be safe neurocognitively. This study provides strong evidence that straight DHCA effectively preserves neurocognitive function.

Bicuspid aortic valve: clinical approach and scientific review of a common clinical entity.

Bicuspid aortic valve (BAV) disease is becoming increasingly respected by clinicians. This enhanced appreciation is based on recognition of how common and virulent this disease really is. This disease is now known to be the most common congenital lesion affecting the human heart (with potential competition in frequency posed by mitral valve prolapse). It is estimated that the BAV lesion alone accounts for more morbidity and mortality than all the other congenital cardiac lesions combined. Many authorities feel that this disease is so virulent that every individual with a BAV will, given enough time, develop aortic stenosis, aortic insufficiency or aortic aneurysm/dissection related to the bicuspid valve disease. This review looks in detail at clinical issues related to BAV disease, including genetics, pathophysiology, diagnosis, management and surgical decision making. The picture emerging from basic and clinical studies is of a defect in collagen metabolism affecting not only the aortic valve, but also the wall of the aorta itself. Timely intervention for bicuspid-related aortic valve disease or aneurysm can preserve both duration of life and quality of life in affected individuals.