Selective internal radiation therapy using yttrium-90 microspheres for treatment of localized and locally advanced intrahepatic cholangiocarcinoma.

OBJECTIVES: To evaluate safety and effectiveness of selective internal radiation therapy (SIRT) using yttrium-90 for localized and locally advanced intrahepatic cholangiocarcinoma (iCCA). METHODS: A retrospective review was performed of patients with localized iCCA treated with SIRT at a single institution. Overall survival (OS), local tumor response, progression-free survival (PFS), and toxicity were collected. Stratified analysis was performed based on surgical resection. Predictor analysis of OS was performed using the Fine-Grey regression analysis model with patients bridged to surgery regarded as competing events. RESULTS: A total of 28 consecutive patients with localized iCCA were treated with a total of 38 sessions of SIRT (17 segmental, 13 lobar, and 8 combined deliveries) and a mean dominant target dose per session of 238.4 ± 130.0 Gy. The cumulative radiologic response rate was 16/28 (57.1%) with a median PFS of 265 days. Median survival time (MST) was 22.9 months for the entire cohort with 1-year and 3-year survival of 78.4% and 45.1%, respectively. Ten patients (34.5%) were downstaged to surgical intervention (7 resection, 3 transplant) and showed longer OS (p = 0.027). The 1-year and 3-year OS for patients who received surgery were 100% and 62.5% (95% CI: 14.2-89.3%), respectively. Age (p = 0.028), Eastern Cooperative Oncology Group performance status (p = 0.030), and objective radiologic response (p=0.014) are associated with OS. Two ≥grade 3 hyperbilirubinemia, anemia, and one pleuro-biliary fistula occurred post-SIRT. CONCLUSIONS: SIRT for localized iCCA is safe and effective in achieving radiological response, downstaging to surgery and transplant, and resulting in pathologic necrosis. CLINICAL RELEVANCE STATEMENT: Selective internal radiation therapy should be considered for patients with localized and locally advanced intrahepatic cholangiocarcinoma. KEY POINTS: • The effectiveness of radioembolization for intrahepatic cholangiocarcinoma (iCCA) can be underestimated given the inclusion of extrahepatic disease. • Radioembolization is safe and effective for local and locally advanced iCCA. Age, Eastern Cooperative Oncology Group performance status, and radiologic response are associated with survival. • Radioembolization should be considered for patients with localized and locally advanced iCCA.

Modified Radiation Lobectomy Strategy of Radioembolization for Right-Sided Unresectable Primary Liver Tumors.

PURPOSE: To assess the safety and effectiveness of using modified radiation lobectomy (mRL) to treat primary hepatic tumors located in the right hepatic lobe (Segments V-VIII) and to determine future liver remnant (FLR) hypertrophy. MATERIALS AND METHODS: A retrospective review was performed at a single institution to include 19 consecutive patients (7 females, 12 males) who underwent single-session mRL for right-sided primary hepatic tumors: 15 received segmentectomy plus lobectomy (segmental dose of >190 Gy and lobar dose of >80 Gy); 4 were treated with the double-segmental approach (dominant segments of >190 Gy and nondominant segments of >80 Gy). Treated tumors included 13 hepatocellular carcinoma (HCC), 4 cholangiocarcinoma (CCA), and 2 mixed-type HCC-CCA with a median dominant tumor size of 5.3 cm (interquartile range [IQR], 3.7-7.3 cm). FLR of the left hepatic lobe was measured at baseline, T1 (4-8 weeks), T2 (2-4 months), T3 (4-6 months), and T4 (9-12 months). RESULTS: Objective tumor response and tumor control were achieved in 17 of the 19 (89.5%) and 18 of the 19 (94.7%) patients, respectively. FLR hypertrophy was observed at T1 (median, 47.8%; P = .025), T2 (median, 48.4%; P = .012), T3 (median, 50.4%; P = .015), and T4 (median, 59.1%; P < .001). Patients without cirrhosis demonstrated greater hypertrophy by 6 months (median, 55.8% vs 47.2%; P = .031). One patient developed a Grade 3 adverse event (ascites requiring paracentesis) at 1-month follow-up. Grade ≥2 serum toxicities were associated with worse baseline Child-Pugh Score, serum albumin, and total bilirubin (P < .05). Among 7 patients who underwent neoadjuvant mRL, 2 underwent resection and 1 received liver transplant. CONCLUSIONS: mRL appears safe and effective for treatment of right-sided primary hepatic tumors with the benefit of promoting FLR hypertrophy.

Segmental Yttrium-90 Radioembolization Using Glass Microspheres Greater than 400 Gray for the Treatment of Intrahepatic Cholangiocarcinoma: A Preliminary Experience.

Radiation segmentectomy with a dose of >190 Gy using yttrium-90 (90Y) glass microspheres for intrahepatic cholangiocarcinoma (iCCA) has been shown to be safe and effective. The present study further increased the dose to >400 Gy for treatment of iCCA as complete pathologic necrosis has been shown in hepatocellular carcinoma using this ablative approach. A total of 10 patients with 13 tumors (median size, 5.3 cm; range, 1.5-13.6 cm) at a single institution underwent >400-Gy segmental radioembolization. Objective response was achieved in all tumors (13 of 13, 100%). One patient developed a Grade 3 or greater major adverse event (stroke and hepatic decompensation). One patient was bridged to transplant (>95% pathologic necrosis), whereas another underwent resection (>99% necrosis). Contralateral hypertrophy was observed in 6 out of 6 patients treated with modified lobectomy dosing, with a functional liver reserve increase from a median of 31.5% to 57.1%. The present report suggests that segmental transarterial radioembolization with >400 Gy is feasible in terms of safety and effectiveness for treating iCCA.

Endovascular thrombectomy and repair of suprarenal inferior vena cava thrombosis: A case series.

OBJECTIVES: The objective of this study is to document the combined use of catheter-based thrombectomy/thrombolysis with endovascular repair of high-risk segments of the inferior vena cava in the setting of iatrogenic and traumatic injuries. While the use of endovascular techniques to treat caval thrombosis is well documented and often preferred due to its minimally invasive nature, there is still little literature that focuses on the nuances related to injury of high mortality areas of the IVC as a result of major trauma, transplant, and other surgical interventions. METHODS: An IRB-approved retrospective review of all patients undergoing IVC thrombectomy was performed at a single tertiary care academic center between January 2018 and July 2021. Cases were subsequently selected based on those who underwent primary mechanical thrombectomy followed by endovascular stenting (or angioplasty). Among this cohort, four patients who underwent this procedure in the context of iatrogenic and traumatic injuries were included. RESULTS: All four patients undergoing primary mechanical thrombectomy followed by endovascular stenting (or angioplasty) due to IVC thrombus and/or stenosis were technically successful with immediate positive clinical outcomes. CONCLUSIONS: Mechanical thrombectomy in conjunction with IVC recanalization via stenting may be a useful intervention with promising technical success and positive clinical outcomes for occlusive thrombosis and IVC stenosis.

Transarterial Radioembolization versus Transarterial Chemoembolization Plus Percutaneous Ablation for Unresectable, Solitary Hepatocellular Carcinoma of ≥3 cm: A Propensity Score-Matched Study.

PURPOSE: To compare the safety and effectiveness of transarterial radioembolization (TARE) and transarterial chemoembolization with drug-eluting embolic agents combined with percutaneous ablation (transarterial chemoembolization [TACE] + ablation) in the treatment of treatment-naïve, unresectable, solitary hepatocellular carcinoma (HCC) of ≥3 cm. MATERIALS AND METHODS: Twenty-nine patients with treatment-naïve, unresectable, solitary HCC of ≥3 cm received combined TACE + ablation, and 40 patients received TARE at a single institution. Local tumor response, tumor progression-free survival (PFS), overall survival, need for reintervention, bridge to transplant, and major complications were compared. Clinical variables and outcomes were compared before and after propensity score matching (PSM). RESULTS: Before PSM, patients who underwent TARE had a larger tumor size (3.7 vs 5.5 cm; P = .0005) and were older (61.5 vs 69.3 years; P = .0014). After PSM, there was no difference in baseline characteristics between the 2 groups, with the mean tumor sizes measuring 3.9 and 4.1 cm in the TACE + ablation and TARE cohorts, respectively. After PSM (n = 19 in each group), no statistically significant difference was observed in local radiological response (disease control rates, 100% vs 94.7%; P = .31), survival (subdistribution hazard ratio [SHR], 0.71; 95% confidence interval [CI], 0.28-1.80; P = .469), PFS (SHR, 0.61; 95% CI, 0.21-1.71; P = .342), bridge to transplant (21.1% vs 31.6%, P = .46), and major adverse event rates (15.8% vs 10.5%, P = .63) between the 2 groups. The mean total number of locoregional interventions was higher in the TACE + ablation cohort (1.9 vs 1.3 sessions, P = .02), with an earlier median reintervention trend (SHR, 0.61; 95% CI, 0.20-1.32; P = .167). CONCLUSIONS: The present study showed that TARE and the combination of TACE and ablation are comparable in safety and effectiveness for treating treatment-naïve, unresectable, solitary HCC of ≥3 cm.

A Single-Institutional Comparative Analysis of Advanced Versus Standard Snare Removal of Inferior Vena Cava Filters.

PURPOSE: To investigate differences in procedure time, radiation exposure, and periprocedural complications associated with advanced inferior vena cava (IVC) filter retrieval compared with standard snare retrieval. MATERIALS AND METHODS: A total of 378 patients underwent standard or advanced IVC filter retrieval over a 5-year period. Technical success, retrieval techniques, fluoroscopy time, radiation dose, and complications were analyzed. All retrieval procedures with techniques other than a "snare-and-sheath" method were categorized as advanced, including failed standard attempts requiring intraprocedural conversion to advanced techniques. RESULTS: A total of 462 filter retrieval attempts were made in 378 patients (57% female). Success rates for standard and advanced retrieval attempts were 86.8% (317 of 365) and 91.8% (89 of 97), respectively. The rate of periprocedural complications was significantly higher in the advanced retrieval group (P = .006). Complication rates for standard and advanced retrievals were 0.6% (2 of 318; all minor) and 5.2% (5 of 97; 3 minor [3.1%] and 2 major [2.1%]), respectively. The 2 major complications during advanced retrievals included filter fracture and embolization. Average fluoroscopy time for advanced retrievals was significantly higher than for standard retrievals (23.1 min vs 4.3 min; P < .001). Average radiation dose for advanced retrievals was also significantly higher than for standard retrievals (557.2 mGy vs 156.9 mGy; P < .001). Use of general anesthesia was also significantly more common in advanced retrievals compared with standard retrievals (6.2% vs 0.9%; P = .002). CONCLUSIONS: Advanced filter retrieval results in a similarly high rate of technical success compared with standard snare retrieval but is associated with greater fluoroscopy time, anesthesia requirements, and radiation exposure.

Inferior Vena Cava Filter Evaluation and Management for the Diagnostic Radiologist: A Comprehensive Review Including Inferior Vena Cava Filter-Related Complications and PRESERVE Trial Filters.

Inferior vena cava filters are commonly encountered devices on diagnostic imaging that were highlighted in a 2010 Food and Drug Administration safety advisory regarding their complications from long-term implantation. The Predicting the Safety and Effectiveness of Inferior Vena Cava Filters (PRESERVE) trial is an ongoing after-market study investigating the safety and utility of commonly utilized filters in practice today. While most of these filters are safe, prompt recognition and management of any filter-associated complication is imperative to prevent or reduce the morbidity and mortality associated with them. This review is aimed at discussing the appropriate utilization and placement of inferior vena cava filters in addition to the recognition of filter-associated complications on cross-sectional imaging. An overview of the PRESRVE trial filters is also provided to understand each filter's propensity for specific complications.

Indwelling and Retrieval Complications of Denali and Celect Infrarenal Vena Cava Filters.

PURPOSE: To compare indwelling and retrieval complications of Denali and Celect filters placed in the infrarenal inferior vena cava (IVC). MATERIALS AND METHODS: A retrospective study was conducted over 2 years at a single institution in which 171 Denali and 162 Celect filters were placed in 333 patients with a mean age of 62.3 years ± 15.7 (161 men; 48.3%). Filter indications included venous thromboembolic disease (n = 320; 96.1%) and surgical prophylaxis (n = 13; 3.9%). A jugular approach was used to place 303 filters (91.0%). Computed tomography (CT) follow-up, complications, and retrieval data were obtained. RESULTS: Follow-up CT imaging was performed on 58 filters from each group with lower incidences of caval strut penetration (one vs 12) and filter tilt (one vs 15) in the Denali filter group (P = .002 and P < .001, respectively). There was no difference in incidences of breakthrough pulmonary embolism (P = .68). Retrieval attempts were performed on 43 Denali and 53 Celect filters with mean indwelling times at retrieval of 128.2 and 144.1 days, respectively (P = .40). Mean fluoroscopy time at retrieval was lower in the Denali group (3.1 min vs 6.0 min; P = .01). There were fewer cases of complex retrieval in the Denali group (n = 2 vs 10; P = .06). Tilt, fluoroscopy time, and air kerma were associated with complex retrieval (P = .04, P < .001, and P < .001, respectively). There was one Denali filter deployment complication that led to retrieval failure. CONCLUSIONS: This study suggests that Denali filters are associated with lower incidences of strut penetration and filter tilt as well as shorter fluoroscopy time at retrieval compared with Celect filters when placed in the infrarenal IVC.

Comparison of combination therapies in the management of hepatocellular carcinoma: transarterial chemoembolization with radiofrequency ablation versus microwave ablation.

PURPOSE: To compare retrospectively the outcomes and complications of transcatheter arterial chemoembolization with drug-eluting embolic agents combined with radiofrequency (RF) ablation or microwave (MW) ablation in treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: From 2003-2011, 89 patients with HCC received a combination therapy-transcatheter arterial chemoembolization plus RF ablation in 38 patients and transcatheter arterial chemoembolization plus MW ablation in 51 patients. Local tumor response, tumor progression-free survival (PFS), overall PFS, overall survival (OS), and complications were compared. Overall PFS and OS were compared between the two treatment groups in multivariate analysis controlling for Child-Pugh class, Barcelona Clinic Liver Classification stage, and index tumor size. RESULTS: Complete local tumor response was achieved in 37 (80.4%) of the tumors treated with transcatheter arterial chemoembolization plus RF ablation and 49 (76.6%) of the tumors treated with transcatheter arterial chemoembolization plus MW ablation (P = .67). The median tumor PFS and overall PFS were 20.8 months and 9.3 months (P = .72) for transarterial chemoembolization plus RF ablation and 21.8 months and 9.2 months for transarterial chemoembolization plus MW ablation (P = .32). The median OS of the transcatheter arterial chemoembolization plus RF ablation group was 23.3 months, and the median OS of the transcatheter arterial chemoembolization plus MW ablation group was 42.6 months, with no significant difference in the survival experience between the two groups (log-rank test, P = .10). In the multivariate analysis, Barcelona Clinic Liver Classification stage was the only factor associated with overall PFS and OS. One patient in the transcatheter arterial chemoembolization plus RF ablation cohort (3%) and two patients in the transcatheter arterial chemoembolization plus MW ablation cohort (4%) required prolonged hospitalization (< 48 h) for pain management after the procedure (P = 1.00). CONCLUSIONS: Based on similar safety and efficacy outcomes, both combination therapies, transcatheter arterial chemoembolization plus RF ablation and transcatheter arterial chemoembolization plus MW ablation, are effective treatments for HCC.

Strut penetration: local complications, breakthrough pulmonary embolism, and retrieval failure in patients with Celect vena cava filters.

PURPOSE: To investigate strut penetration in patients with Celect filters, specifically local complications and association with breakthrough pulmonary embolism (PE) or retrieval failure. MATERIALS AND METHODS: A retrospective single-center study was conducted to evaluate patients who received Celect filters between January 2007 and May 2013. A total of 595 filters were placed during the study period. Primary indications included thromboembolic disease (93%) and primary surgical prophylaxis (7%). Complications and retrieval data were assessed by computed tomography (CT) and electronic medical records. RESULTS: A total of 193 patients underwent follow-up abdominal CT at a mean follow-up interval of 176.2 days (range, 0-1,739 d). The rate of strut penetration more than 3 mm outside the caval wall was 28.5% (n = 55). One patient had CT evidence of clinically major strut penetration (1.8%) with strut compression of the right ureter causing hydronephrosis. Indwelling filter time longer than 100 days was associated with strut penetration (P < .001). Age, sex, and history of thromboembolic disease were not associated with strut penetration (P = .51, P = .81, and P = .89). Sixty-three patients presented for follow-up CT pulmonary angiography at a mean of 128.1 days (range, 1-895 d). The rate of breakthrough PE was 12.7%. The overall retrieval success rate was 96.7% (n = 150). Strut penetration was not associated with breakthrough PE or retrieval failure (P = .49 and P = .22). CONCLUSIONS: Although strut penetration is a common complication with Celect filters, there is no association with breakthrough PE or retrieval failure. CT evidence of local complications associated with strut penetration is rare.

The RETRIEVE trial: safety and effectiveness of the retrievable crux vena cava filter.

PURPOSE: To evaluate the safety and effectiveness of the Crux vena cava filter in patients at risk for pulmonary embolism (PE). MATERIALS AND METHODS: The Crux Biomedical Evaluation of the Crux Inferior Vena Cava Filter System trial was an international prospective, multicenter, single-arm clinical trial in 125 patients implanted with the Crux filter between June 2010 and June 2011. Follow-up was 180 days after filter placement and 30 days after filter retrieval. The primary objective was to determine whether the clinical success rate was at least 80%. Clinical success was defined as technical success of deployment and freedom from definite PE, filter migration, and device-related adverse events requiring intervention. RESULTS: The clinical success rate was 96.0% (120 of 125), with a one-sided lower limit of the 95% confidence interval of 91.8%. The rate of technical success was 98.4% (123 of 125). There were three cases of definite PE (2.4%), two cases of deployment failure, and no cases of device migration, embolization, fracture, or tilting. Investigators observed nine cases of thrombus (all nonocclusive) in or near the filter (six during retrieval evaluation vena cavography, two during computed tomography [CT] scans for PE symptoms, and one during CT for cancer management) and 13 cases of deep vein thrombosis. Device retrieval was attempted at a mean of 84.6 days±57.6 (range, 6-190 d) after implantation and was successful for 98.1% of patients (53 of 54). All deaths (n = 14) were determined to be unrelated to the filter or PE. CONCLUSIONS: The Crux vena cava filter performed safely, with high rates of clinical, technical, and retrieval success.

Percutaneous thrombin injection in an infant to treat hepatic artery pseudoaneurysm after failed embolization.

Percutaneous thrombin injection has been described in case reports as an alternative to surgical intervention for the treatment of hepatic artery pseudoaneurysms associated with high-grade liver lacerations in adults. However, there is limited description in the literature of this technique being applied in children, particularly in preadolescents, and no published literature describes its use in infants. The procedure can be performed by pediatric radiologists and pediatric interventional radiologists skilled in ultrasound-guided aspiration techniques. We report successful application of percutaneous thrombin injection in an infant to treat a pseudoaneurysm of a left hepatic arterial branch in an 11-month-old girl with a grade IV liver laceration after superselective transcatheter arterial embolization failed to achieve thrombosis.

Combination of transarterial radioembolization with atezolizumab and bevacizumab for intermediate and advanced staged hepatocellular carcinoma: A preliminary report of safety and feasibility.

Purpose: The IMbrave150 Phase III trial demonstrated the superiority of atezolizumab and bevacizumab (Atezo/Bev) over sorafenib for unresectable hepatocellular carcinoma (HCC). The present study aims to evaluate the feasibility of TARE in combination with Atezo/Bev for the treatment of intermediate and advanced staged HCC. Methods: A retrospective review at a single institution was performed between May 2021 and December 2022. Patients who received TARE using yttrium-90 (Y90) with concomitant or sequential Atezo/Bev systemic treatment were included. The following outcomes were retrieved: overall survival (OS), radiologic tumor response, progression-free survival, technical adverse events related to TARE, and toxicity based on the National Cancer Institute-Common Terminology Criteria for Adverse Events version 5.0. Results: Ten consecutive patients with intermediate (n â€‹= â€‹4) and advanced stage HCC (n â€‹= â€‹6) were treated with TARE and sequential/concomitant Atezo/Bev. Tumor control was achieved in all TARE-treated target lesions (100%). Overall disease progression occurred in 4 patients with PFS of 78.8% and 66.7% at 6- and 12- months, respectively. Two patients died at follow-up, with 6-month and 12-month OS rates of 90.0% and 77.1%, respectively. Three (75%) patients with intermediate stage disease were downstaged into Milan criteria. One patient developed grade 3 transaminitis and hypoglobulinemia, while Atezo/Bev was switched to Lenvatinib in another patient due to immunotherapy related myositis. Conclusion: This study demonstrates the initial safety and feasibility of combined TARE with Atezo/Bev for intermediate/advanced stage HCC. Further prospective studies with larger sample sizes are warranted.

Evaluation and treatment of suspected type II endoleaks in patients with enlarging abdominal aortic aneurysms.

PURPOSE: To evaluate angiographic diagnosis and embolotherapy of patients with enlarging abdominal aortic aneurysms and computed tomographic (CT) diagnosis of type II endoleak. MATERIALS AND METHODS: A retrospective review was performed of all patients referred to a single vascular and interventional radiology section from January 1, 2003, to June 1, 2011, with a diagnosis of enlarging aneurysm and type II endoleak. Twenty-five patients underwent 40 procedures between 12 and 82 months after endograft insertion (mean, 48 mo) for diagnosis and/or treatment of endoleaks. RESULTS: Type II endoleaks were treated with cyanoacrylate, coils, and ethylene vinyl alcohol copolymer in 16 patients. Technical success rate was 88% (14 of 16 patients) and clinical success rate was 100% (16 of 16 patients). Aneurysm growth was arrested in all cases over a mean follow-up of 27.5 months (range, 6-88 mo). Endoleaks in nine patients were misclassified on CT; two had type I endoleaks and seven had type III endoleaks. Four of the nine patients (two type I endoleaks and two type III endoleaks) were correctly classified after initial angiography. The other five type III endoleaks were correctly classified on CT after coil embolization of the inferior mesenteric artery. Direct embolization was performed via sac puncture with ethylene vinyl alcohol copolymer in two of the latter five patients and eliminated endoleaks in both. CONCLUSIONS: Aneurysm growth caused by type II endoleaks was arrested by embolization. CT misclassification occurred relatively commonly; type III endoleaks purported to be type II endoleaks were found in 28% of patients (seven of 25).

Use of retrievable filters in alternative common iliac vein location in high-risk surgical patients.

PURPOSE: To evaluate the use of retrievable filters placed in bilateral common iliac veins in high-risk surgical patients. MATERIALS AND METHODS: During the 4-year study period, 10 patients received bilateral common iliac vein placement of retrievable filters for pulmonary embolism (PE) prophylaxis. These patients were at risk for venous thromboembolism (VTE) but had no evidence of VTE at the time of filter placement. In nine patients undergoing bariatric surgery, placement of a filter in the inferior vena cava (IVC) was impossible because of megacava (defined as caval diameter ≥ 3.0 cm). In one patient who had planned dissection of an extensive retroperitoneal tumor, there was concern that IVC location of the filter would be prone to complications secondary to intraoperative manipulation. Filter placement and retrieval were evaluated. All patients were followed clinically until 4-6 weeks after filter retrieval. RESULTS: There were 20 filters placed in 10 attempts, 18 (nine patients) through the right internal jugular vein and 2 (one patient) through bilateral femoral veins. The mean (± standard deviation) dwell time of the filters was 40 days ± 10 (range 30-71 days). All filters were successfully removed. There were no procedural complications. No clinically evident PE was noted. CONCLUSIONS: Use of retrievable filters in the bilateral common iliac veins was found to be feasible and effective in preventing PE in patients with contraindications to filter placement in the IVC.

Comparing outcomes of percutaneous cholecystostomy drain placement between patients within and outside of Tokyo guidelines diagnostic criteria for acute cholecystitis.

OBJECTIVE: To compare outcomes following percutaneous cholecystostomy drain placement based on presence or absence of Tokyo Guidelines diagnostic criteria for acute cholecystitis. METHODS: Chart review was performed to identify the presence or absence of Tokyo Guidelines diagnostic criteria for acute cholecystitis in 146 patients who underwent percutaneous cholecystostomy between 2012 and 2015. Those who met criteria were compared to those who did not in terms of demographics, laboratory values, drain indwelling time, treatment response, eventual surgical management, and 30-day mortality. RESULTS: 94 patients (64%) met Tokyo Guidelines diagnostic criteria, while 52 did not (36%). Patients within criteria had a shorter mean length of stay (13.5 days vs 18.9 days), were more likely to have a positive gallbladder fluid culture (64.5% vs 28.6%), demonstrated greater response to treatment (87.2% vs 32.7%), and had lower 30-day mortality (6.4% vs 37.8%). There was no significant difference in terms of ICU requirement (38.3% vs 38.9%), mean drain indwelling time (58.8 days vs 65.3 days), eventual laparoscopic cholecystectomy (40.4% vs 25.0%), or open cholecystectomy performed (9.5% vs 9.6%). CONCLUSION: Patients outside of Tokyo Guidelines diagnostic criteria for acute cholecystitis were less likely to respond to treatment with percutaneous cholecystostomy and had worse outcomes. Further research may be indicated to better define the indications for percutaneous cholecystostomy placement in this group.

Hybrid angiography-CT for transarterial radioembolization: a pictorial essay.

Although hybrid angiography-CT (Angio-CT) has a long history of use for interventional oncology procedures, its applications for transarterial radioembolization (TARE) are not as well described in the literature. This pictorial essay demonstrates a single-institution experience with the utilization of an Angio-CT system for TARE treatment of hepatocellular carcinoma. Procedural images and clinical data for twenty-four patients who underwent initial angiographic mapping with hepatopulmonary shunt fraction assessment and or administration of Yttrium-90 (Y-90) microspheres using the Angio-CT system to date were reviewed. Cases were reviewed for examples that highlight the specific utility of Angio-CT. Three representative TARE cases were selected which illustrate unique advantages and applications of the Angio-CT system when performing TARE. These include the ability to optimally delineate hepatic vascular anatomy, accurately calculate liver volumes for dosimetry, and improve the detection and characterization of equivocal lesions. Angio-CT has unique advantages which can be applied to TARE treatment of patients with HCC. The technology has potential to be an especially effective tool for those who aim to be at the cutting edge of the rapidly growing field of interventional oncology.

Safety and efficacy of repeat Y90 radioembolization to the same hepatic arterial territory.

OBJECTIVE: To study the efficacy and safety of repeat transarterial radioembolization (TARE) to similar hepatic arterial territories. METHODS: Between 3/2011 and 4/2019, 26 patients (25 males and 1 Female, Mean Age: 65 yo, SD: 11.7 yo, Range: 18-83.0 yo) received TARE with Y90 glass microspheres to treat recurrent or residual primary disease in similar hepatic arterial lobe or segments. Tumor response was evaluated by imaging using the modified-RECIST criteria. Incidence of RILD and adverse events were categorized by a standardized scale using the Common Terminology Criteria for Adverse Events (CTCAE) v.4.0. RESULTS: Mean cumulative activity after the first treatment was 2.50 GBq (SD:1.04 GBq, Range:0.61-4.93 GBq) and second treatment was 2.27 GBq (SD:1.01 GBq, Range:0.92-5.46 GBq). Mean interval time between initial and repeat treatments was 9.6 months (Range: 1-53 months). Tumor responses were complete, partial, or progression in 73% (n = 19/26), 23% (n = 6/26), and 4% (n = 1/26) in repeat treatment patients, respectively. The incidence of RILD was 0%. Toxicity after first and second treatment was seen in 19% (n = 5/26) & 23% (n = 6/26) patients, respectively, and were all of CTCAE Grade 2. No significant predictors of treatment toxicity for repeat treatment were identified except increased MELD score (p = 0.04). Kaplan-Meier survival analysis in patients with repeat treatment showed a median survival of 15.0 months (95% CI 8.8-21.1 months) and 19.0 months (95% CI 8.1-29.9 months) in patients who only received one treatment with a p value of 0.485. CONCLUSION: Repeat TARE with glass microspheres was an effective and safe treatment strategy for disease management in patients with residual or recurrent disease to the similar hepatic arterial territories without any major treatment related toxicity. ADVANCES IN KNOWLEDGE: Although safety and efficacy of repeat radioembolism has been studied, no study has focused on repeat treatment to similar hepatic arterial territories. The current study shows that repeat treatment to the same hepatic arterial territory is as safe as single treatment to the same territory.