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.

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.

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.

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.

Safety and efficacy of transhepatic and transsplenic access for endovascular management of portal vein complications after liver transplantation.

The purpose of this article is to evaluate and compare the safety and efficacy of endovascular management of the portal vein (PV) via percutaneous transsplenic access versus percutaneous transhepatic access in liver transplantation (LT) recipients. A total of 18 patients who underwent endovascular management of PV via percutaneous transhepatic (n = 8) and transsplenic (n = 10) access were enrolled. Transsplenic access was chosen if the spleen was located in a normal position, the splenic vein (SpV) was preserved, and the target lesion did not involve confluence of the superior mesenteric and SpVs. Accessibility of the percutaneous transsplenic puncture was confirmed via ultrasound (US) in the angiography suite. All procedures were performed under local anesthesia. Percutaneous transhepatic or transsplenic access was performed using a 21-gauge Chiba needle under US and fluoroscopic guidance, followed by balloon angioplasty, stent placement, or variceal embolization. The access tract was embolized using coils and a mixture (1:2) of glue and ethiodized oil. Transhepatic or transsplenic access was successfully achieved in all patients. A total of 12 patients underwent stent placement; 3 had balloon angioplasty only; 2 had variceal embolization only; and 1 had variceal embolization followed by successful stent placement. Regarding major complications, 1 patient experienced a SpV tear with extravasation during transsplenic balloon angioplasty, which was successfully managed using temporary balloon inflation, followed by transfusion. Clinical success was achieved in 9 of 11 (82%) patients who exhibited clinical manifestations. The remaining 7 patients who underwent prophylactic endovascular management were healthy. In conclusion, endovascular management of PV via percutaneous transsplenic access is a relatively safe and effective alternative that does not damage the liver grafts of LT recipients. Liver Transplantation 23 1133-1142 2017 AASLD.

New intermediate-stage subclassification for patients with hepatocellular carcinoma treated with transarterial chemoembolization.

BACKGROUND & AIM: The need for a subclassification of Barcelona Clinic Liver Cancer (BCLC) intermediate-stage (BCLC B) has arisen because of its diversity. We evaluated the prognostic capability of the BCLC B subclassification proposed by Bolondi et al. in patients treated with transarterial chemoembolization (TACE). Furthermore, we introduce a new subclassification for intermediate-stage hepatocellular carcinoma (HCC) by using a new parameter related to tumour burden (up-to-11 criteria). METHODS: Of 3268 patients treated with TACE as first-line treatment, 821 patients with intermediate-stage HCC were included in this study. RESULTS: According to the Bolondi subclassification, 208 (25.3%), 529 (64.5%), 43 (5.2%) and 41 (5%) patients were in B1, B2, B3 and B4 respectively. The B1, B2 and B3 subclasses in the Bolondi system showed significantly different survival between contiguous stages with median survival of 51.5, 26 and 14.8 months, respectively (both P<.001 for B1 vs B2 and B2 vs B3); however, survival was rather worse in B3 than B4 (14.8 vs 25 months, P=.025). According to the newly proposed subclassification, 410 (50%), 364 (44.3%) and 47 (5.7%) patients were in B1, B2 and B3 respectively. The median survival progressively decreased from B1 (44.8 months) to B2 (21.5 months) and B3 (11.3 months), with a significant difference between contiguous stages (both P<.001 for B1 vs B2 and B2 vs B3). CONCLUSIONS: Our new BCLC B substaging system, with up-to-11 criteria and Child-Pugh class as main parameters, has excellent discriminatory power to subclassify TACE-treated patients into three prognostic substages.

Transcatheter Arterial Embolization for Gastrointestinal Bleeding Associated with Gastric Carcinoma: Prognostic Factors Predicting Successful Hemostasis and Survival.

PURPOSE: To evaluate outcomes of transcatheter arterial embolization (TAE) for gastric cancer-related gastrointestinal (GI) bleeding and factors associated with successful TAE and improved survival after TAE. MATERIALS AND METHODS: This retrospective study included 43 patients (34 men; age 60.6 y ± 13.6) with gastric cancer-related GI bleeding undergoing angiography between January 2000 and December 2015. Clinical course, laboratory findings, and TAE characteristics were reviewed. Technical success of TAE was defined as target area devascularization, and clinical success was defined as bleeding cessation with hemodynamic stability during 72 hours after TAE. Student t test was used for comparison of continuous variables, and Fisher exact test was used for categorical variables. Univariate and multivariate analysis were performed to identify predictors of successful TAE and 30-day survival after TAE. RESULTS: TAE was performed in 40 patients. Technical and clinical success rates of TAE were 85.0% and 65.0%, respectively. Splenic infarction occurred in 2 patients as a minor complication. Rebleeding after TAE occurred in 7 patients. Death related to bleeding occurred in 5 patients. Active bleeding (P = .044) and higher transfusion requirement (3.3 U ± 2.6 vs 1.8 U ± 1.7; P = .039) were associated with TAE failure. Successful TAE predicted improved 30-day survival after TAE on univariate and multivariate analysis (P = .018 and P = .022; odds ratio, 0.132). CONCLUSION: TAE for gastric cancer-associated GI bleeding may be a lifesaving procedure. Severe bleeding with a higher transfusion requirement and active bleeding on angiography predicted TAE failure.

Arterial dissections during transcatheter arterial chemoembolization for hepatocellular carcinoma: a 19-year clinical experience at a single medical institution.

Background Arterial dissections during transcatheter arterial chemoembolization (TACE) procedures are not rare and can limit the successful treatment of unresectable hepatocellular carcinoma (HCC). Purpose To evaluate the incidence of arterial dissections during TACE procedures, the rate of spontaneous lumen recovery, and the predictive factors of dissecting stenosis during follow-up. Material and Methods Based on 69,651 TACE procedures from 1997 to 2016, patients who had procedure-related arterial dissections were identified by procedure report search. More than two months after the date of dissection, dissecting stenosis was evaluated using a three-grade scale: subclinical narrowing with diameter loss under 30%, overt stenosis with diameter loss over 30%, and occlusion. Pearson Chi-square and two-sample t-test were used to assess potential prognostic markers for dissecting stenosis. Results Eighty-four arterial dissections directly related to TACE were identified in 83 patients, resulting in an incidence of 0.12% (84/69651). After more than two months, normal or subclinical narrowing, overt stenosis, occlusion, and doubling were seen in 39 (46.4%), 26 (31.0%), 13 (15.5%), and one (1.2%) patients, respectively. No follow-up images were obtained for five (6.0%) patients. On univariate analysis, the dissection ratio (the ratio of the length to the diameter of the dissection) alone was related to dissecting stenosis ( P = 0.035). Conclusion The incidence of iatrogenic dissection during TACE was approximately 0.12%. Less than 50% of the iatrogenic dissections showed normal or subclinical narrowing during follow-up of at least two months. The dissection ratio alone was the predictive factor for dissecting stenosis during follow-up.

Endovascular management for significant iatrogenic portal vein bleeding.

Background Despite conservative treatment, hemorrhage from an intrahepatic branch of the portal vein can cause hemodynamic instability requiring urgent intervention. Purpose To retrospectively report the outcomes of hemodynamically significant portal vein bleeding after endovascular management. Material and Methods During a period of 15 years, four patients (2 men, 2 women; median age, 70.5 years) underwent angiography and embolization for iatrogenic portal vein bleeding. Causes of hemorrhage, angiographic findings, endovascular treatment, and complications were reported. Results Portal vein bleeding occurred after percutaneous liver biopsy (n = 2), percutaneous radiofrequency ablation (n = 1), and percutaneous cholecystostomy (n = 1). The median time interval between angiography and percutaneous procedure was 5 h (range, 4-240 h). Common hepatic angiograms including indirect mesenteric portograms showed active portal vein bleeding into the peritoneal cavity with (n = 1) or without (n = 2) an arterioportal (AP) fistula, and portal vein pseudoaneurysm alone with an AP fistula (n = 1). Successful transcatheter arterial embolization (n = 2) or percutaneous transhepatic portal vein embolization (n = 2) was performed. Embolic materials were n-butyl cyanoacrylate alone (n = 2) or in combination with gelatin sponge particles and coils (n = 2). There were no major treatment-related complications or patient mortality within 30 days. Conclusion Patients with symptomatic or life-threatening portal vein bleeding following liver-penetrating procedures can successfully be managed with embolization.

Biliary intraductal metastasis from advanced gastric cancer: radiologic and histologic characteristics, and clinical outcomes of percutaneous metallic stent placement.

OBJECTIVES: To investigate the radiologic and histological characteristics of biliary intraductal metastasis of advanced gastric cancer and the clinical outcomes of percutaneous, metallic stent placement. MATERIALS AND METHODS: We retrospectively assessed 24 patients with obstructive jaundice related to biliary intraductal metastasis of gastric cancers who underwent PTBD and subsequent metallic stent placement between 2003 and 2012. RESULTS: Intraductal metastases appeared as uniform, concentric, linear (n = 17) or band-like (n = 7), enhanced wall thickening on CT, and 20 patients (83.3 %) had cystic ductal lesions. On pathology specimens, malignant cells scattered in the submucosal layer caused a desmoplastic reaction. The technical and clinical success rate of stent placement was achieved in all 24 patients. The median survival time was 203 days. Stent occlusion was observed in four patients with 49-278 days following stent placement. The median stent patency time was 156 days. CONCLUSIONS: The radiologic and histological characteristics of biliary intraductal metastasis of advanced gastric cancer consist of uniform, linear or band-like, enhanced biliary wall thickening and malignant cells scattered in the submucosal layer, together with the desmoplastic reaction without any disruption of the epithelial layer. Uncovered metallic stent placement was also a safe and effective method of palliative treatment in these patients. KEY POINTS: • The CT findings of intraductal metastasis were linear/band-like, enhanced biliary wall thickening. • The histological finding was malignant cells scattered in the submucosal layer. • It showed a desmoplastic reaction without any disruption of the epithelial layer. • Uncovered metallic stent placement was a safe and effective palliative treatment.

Transcatheter Arterial Embolization of Angiographically Visible and Occult Renal Capsular Artery Hemorrhage in 28 Patients.

PURPOSE: To evaluate the effectiveness and safety of transcatheter arterial embolization to control bleeding from the renal capsular artery (RCA). MATERIALS AND METHODS: Embolization was performed in 28 patients (14 men; mean age, 49.7 y). Presence and type of previous invasive procedures, initial presentation, and coagulation profile were reviewed. Any preceding abdominal computed tomography (CT) findings were analyzed. Angiographic findings were categorized as active bleeding, suspicious for bleeding, or no bleeding. Technical and clinical success and clinical outcomes were evaluated. Changes in hemoglobin level and transfusion volume of packed red blood cells (pBRCs) before and after embolization were evaluated with the paired t test and Wilcoxon signed-rank test, respectively. RESULTS: Technical and clinical success rates of therapeutic embolization for active bleeding (n = 11) were 90.9% and 80%, respectively. One case of technical failure (5.9%) and 3 cases of postembolization bleeding (18.7%) were noted in the prophylactic embolization group in patients with suspicion of bleeding (n = 13) or no bleeding (n = 4). Transient renal insufficiency occurred in 4 patients (14.3%). The average hemoglobin level and volume of transfused pBRCs changed from 8.1 g/dL to 9.9 g/dL and from 871 mL to 543 mL, respectively (P < .05). Extravasation of contrast media or acute hematoma in the right subhepatic or perirenal space on CT was noted in 21 patients (78%). CONCLUSIONS: Embolization can provide an effective and safe method to control RCA bleeding. Perirenal invasive procedures and signs of active or recent right subhepatic or perirenal hemorrhage should raise the suspicion of an RCA source.

Portal Vein Embolization via Percutaneous Transsplenic Access prior to Major Hepatectomy for Patients with Insufficient Future Liver Remnant.

PURPOSE: To evaluate the feasibility and safety of percutaneous transsplenic portal vein embolization (PVE) before major hepatectomy for patients with insufficient future liver remnant. MATERIALS AND METHODS: From May 2014 to June 2015, 27 transsplenic PVEs were attempted in 26 patients. In 16 patients, transsplenic PVE was indicated because of huge or multiple tumors in the trajectory of the puncture (n = 15) or a high-positioned liver (n = 1), which prevented safe ipsilateral transhepatic access. In the remaining 10 patients, transsplenic access was planned. A perihilar splenic vein was punctured using a 21-gauge Chiba needle under ultrasound and fluoroscopic guidance. Embolization of portal venous branches was performed using gelatin sponge particles followed by application of coils, an AMPLATZER Vascular Plug (AGA Medical Corporation, Golden Valley, Minnesota), or glue to prevent recanalization. Embolization of transsplenic routes was performed using coils followed by glue. RESULTS: Transsplenic PVE was successful in 24 (88.9%) of 27 sessions; 3 procedures failed because of splenic vein dissection (n = 1) and failed splenic vein puncture (n = 2). Major complications occurred in 1 patient (3.8%) with splenic vein dissection. Minor complications occurred in 2 patients: a small amount of fluid collection in the splenic hilar area in 1 patient and glue migration along the splenic vein in 1 patient. Planned liver resection was performed in 24 of 26 patients at 4.9 weeks ± 3.5 after PVE. CONCLUSIONS: Transsplenic PVE is safe and feasible and can be an effective alternative treatment for patients with a challenging ipsilateral, transhepatic route.

Impact of the Interval between Transarterial Chemoembolization Sessions on Survival in Patients with Unresectable Hepatocellular Carcinoma.

PURPOSE: To evaluate clinical impact of different intervals between multiple transarterial chemoembolization sessions in patients with unresectable hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A retrospective cohort study of 305 consecutive patients with HCC who underwent multiple sessions of on-demand transarterial chemoembolization by two independent physicians with different management policies in terms of transarterial chemoembolization interval was performed; 180 patients had intervals between the first and second transarterial chemoembolization session of < 60 days (short-interval group), and 125 patients had transarterial chemoembolization intervals of ≥ 60 days (conventional-interval group). RESULTS: The short-interval group had more cases of advanced-stage HCC, less favorable response to transarterial chemoembolization, and higher likelihood of having Child-Pugh class A. The short-interval group underwent more transarterial chemoembolization sessions (6.6 vs 5.5, P = .011), although the total number of admissions and total hospital stay were similar to the conventional-interval group. Overall survival was similar in the two groups in the full and the propensity score-matched cohorts. Although the overall survival of patients with Child-Pugh class A was comparable between the two groups in the full and propensity score-matched cohorts, the short-interval group showed inferior survival (P = .005) and a nonsignificant trend toward inferior survival (P = .117) in the full and propensity score-matched cohorts, respectively, for patients with Child-Pugh class B. CONCLUSIONS: Transarterial chemoembolization interval did not affect survival outcomes of patients with Child-Pugh class A. A shorter transarterial chemoembolization interval showed a nonsignificant trend of adversely affecting survival for patients with Child-Pugh class B.

Postpartum hemorrhage from extravasation or pseudoaneurysm: efficacy of transcatheter arterial embolization using N-butyl cyanoacrylate and comparison with gelatin sponge particle.

PURPOSE: To evaluate the safety and effectiveness of transcatheter arterial embolization (TAE) using N-butyl cyanoacrylate (NBCA) for the treatment of active postpartum hemorrhage (PPH) and compare the efficacy of NBCA with gelatin sponge particles. MATERIALS AND METHODS: From January 2004 to September 2013, 26 patients with PPH underwent TAE using NBCA as the primary embolic material. All patients were actively bleeding, and 12 (46.2%) had coagulopathy. TAE was performed using 1:2-1:4 mixtures of NBCA and ethiodized oil with or without use of a coil or gelatin sponge. To compare the efficacy of NBCA with conventional embolic material, 50 patients with active bleeding who underwent TAE using gelatin sponge were also analyzed. RESULTS: Angiograms demonstrated pseudoaneurysm or extravasation or both. The technical and clinical success rates were 100% and 92.3% (24 of 26 patients), respectively, for NBCA and 98% and 86.0% (43 of 50 patients), respectively, for gelatin sponge. In the NBCA group, one patient recovered with conservative management, and the other patient died because of multiorgan dysfunction. There were no major or minor procedure-related complications. CONCLUSIONS: TAE using NBCA as the primary embolic agent is an effective method for treating PPH with extravasation or pseudoaneurysm; NBCA is comparable to gelatin sponge particles. TAE using NBCA seems to fill pseudoaneurysms and make devascularization more effective than using gelatin sponge.

Vascular Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varices and Hepatic Encephalopathy: A Prospective Multicenter Study.

PURPOSE: To evaluate technical and clinical outcomes of vascular plug-assisted retrograde transvenous obliteration (PARTO) for the treatment of gastric varices (GVs) and hepatic encephalopathy (HE). MATERIALS AND METHODS: From March 2012 to June 2014, 73 consecutive patients (47 men, 26 women; mean age, 59 y; range, 28-79 y) who had undergone PARTO were evaluated in a prospective multicenter study. Among 57 patients with GVs, 28 had GVs in danger of rupture, 23 had experienced recent bleeding, and 6 had active variceal bleeding. The 16 patients with HE had been treated unsuccessfully with medical therapies. RESULTS: Placement of the vascular plug and subsequent gelatin sponge embolization were technically successful in all 73 patients. There were no procedure-related complications. Follow-up CT obtained within 1 wk after PARTO showed complete thrombosis of GVs and portosystemic shunts in 72 of 73 patients (98.6%). Sixty patients who underwent follow-up longer than 3 mo showed complete obliteration of GVs and portosystemic shunts. There were no cases of variceal bleeding or HE at the end of follow-up (mean, 544 d). Improvement in Child-Pugh score was observed in 24 patients (40%) at 1-mo follow-up. Worsening of ascites and esophageal varices was observed in 14 (23.3%) and 16 (26.7%) patients at 3-mo follow-up. CONCLUSIONS: The present results of PARTO indicate that it can be rapidly performed with high technical success and durable clinical efficacy for the treatment of GVs and HE in the presence of a portosystemic shunt. Therefore, PARTO might be considered a first-line treatment in appropriate patients.

Nomograms for Predicting Outcomes after Chemoembolization in Patients with Nonmetastatic Hepatocellular Carcinoma.

PURPOSE: To construct prognostic nomograms capable of estimating individual probabilities of tumor progression and overall survival (OS) at specific time points during serial transarterial chemoembolization for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The study included 1,181 consecutive patients with nonmetastatic HCC undergoing repeated transarterial chemoembolization at a single tertiary referral center. Patients were assigned to 2 cohorts according to the first transarterial chemoembolization date: derivation (2004-2006; n = 854) and validation (2007; n = 327) sets. Multivariate Cox proportional hazards models were developed based on covariates derived before transarterial chemoembolization and assessed for their association with 5-year OS and 3-year progression-free survival (PFS). The accuracy of the models was internally and externally validated. RESULTS: The 5-year OS of the derivation set was 25.4%, and 3-year PFS was 20.8%. Nomograms for OS and PFS were built into the derivation set incorporating the following factors: log [tumor volume] calculated as 4/3 × 3.14 × (maximum radius of tumor in cm(3)); tumor number; tumor type (nodular or infiltrative); Child-Pugh class (A or B); (model for end-stage liver disease score/10)(-2); log [α-fetoprotein]; and portal vein invasion. The models had good discrimination and calibration abilities with C-indexes of 0.80 (5-y survival) and 0.77 (3-y progression). The results of external validation confirmed that these models performed well in terms of discrimination and goodness-of-fit (C-indexes 0.77 for 5-y survival and 0.73 for 3-y progression). CONCLUSION: Nomograms quantifying the survival and progression outcomes in patients treated with transarterial chemoembolization are useful clinical aids in providing personalized care.

A prospective, multicenter study of a double stent system for palliative treatment of malignant extrahepatic biliary obstructions.

BACKGROUND: A double stent system (covered stent in uncovered stent) was designed to provide long-term patency without tumor ingrowth or stent-related complications, such as stent migration, cholecystitis, or pancreatitis. PURPOSE: To investigate the safety and efficacy of double stents in patients with malignant extrahepatic biliary obstructions. MATERIAL AND METHODS: This prospective, nonrandomized, multicenter study enrolled 160 consecutive patients (102 men; mean age, 64 years; range, 33-91 years) with malignant extrahepatic biliary obstructions treated with a double stent system from January 2010 to March 2012. RESULTS: The technical success rate of the double stent placement was 100%. No stent migration was observed. Procedure-related minor (self-limiting hemobilia [n = 6] and cholangitis [n = 2]) and major (pancreatitis [n = 16], cholecystitis [n = 3], and hepatic abscess [n = 2]) complications occurred in a total of 29 patients. The mean serum bilirubin level, which was 8.9 ± 5.6 mg/dL before drainage, decreased to 2.2 ± 4.6 mg/dL 1 month after stent placement (P < 0.001). Successful internal drainage was achieved in 148 patients (92.5%). During the mean follow-up period of 205 days, acute cholecystitis (n = 3) and hepatic abscess (n = 2) occurred in five patients. The median patient survival and stent patency time were 135 days (95% confidence interval [CI], 96-160 days) and 114 days (95% CI, 83-131 days), respectively. Of 153 patients, 22 (14.4%) presented with stent dysfunction due to sludge incrustation (n = 17), tumor overgrowth (n = 4), or blood clot (n = 1), and required repeat intervention. Tumor ingrowth was not observed in any of these patients. CONCLUSION: Percutaneous treatment of malignant extrahepatic biliary obstruction using a double stent safely and effectively achieves internal biliary drainage.

Percutaneous biliary covered stent insertion in patients with malignant duodenobiliary obstruction.

BACKGROUND: Although the use of polytetrafluoroethylene (PTFE)-covered biliary stents has proven to be feasible for the treatment of benign and malignant biliary disease, less is known regarding the outcomes of percutaneous placement of a covered stent in patients with malignant duodenobiliary obstruction. PURPOSE: To investigate the technical and clinical efficacy of the percutaneous placement of a PTFE-covered biliary stent in patients with malignant duodenobiliary obstruction. MATERIAL AND METHODS: From April 2007 to September 2012, the medical records of 45 consecutive patients with malignant duodenobiliary obstruction were retrospectively reviewed. All percutaneous biliary stent deployment was performed using PTFE-covered stents, whereas duodenal stent insertion was performed either fluoroscopically or endoscopically using covered or uncovered stents. RESULTS: Biliary stent deployment was technically successful in all patients. None of the stents migrated after deployment. Procedure-related minor complications, including self-limiting hemobilia, occurred in three (7%) patients. Successful internal drainage was achieved in 39 (87%) of the 45 patients. The median survival time after biliary stent placement was 62 days (95% confidence interval, 8-116 days), and the cumulative stent patency rates at 1, 3, 6, and 12 months were 96%, 92%, 75%, and 38%, respectively. The causes of biliary stent dysfunction included stent occlusion caused by a subsequently inserted duodenal stent (n = 7), food impaction (n = 3), and sludge incrustation (n = 1). One patient developed acute cholecystitis 131 days after biliary stent placement and underwent percutaneous transhepatic gallbladder drainage. CONCLUSION: Percutaneous insertion of a PTFE-covered stent is a safe and effective method for palliative treatment of patients with malignant duodenobiliary obstruction. If possible, subsequent biliary stent insertion is preferable in order to prevent possible biliary stent dysfunction caused by subsequent insertion of a duodenal stent.

Transarterial chemoembolization vs. radiofrequency ablation for the treatment of single hepatocellular carcinoma 2 cm or smaller.

OBJECTIVES: To compare the effectiveness of transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for treating small (≤2 cm) hepatocellular carcinomas (HCCs). METHODS: This retrospective study consisted of 287 patients (mean age, 57.1 years; age range, 29-84 years; 221 men, 66 women; 73.5% with HBV; 100% with liver cirrhosis) with Barcelona Clinic Liver Cancer very early-stage HCC (≤2 cm single HCC) who were initially treated with TACE (n=122) or RFA (n=165). The primary study end point was overall patient survival. Secondary study end points were time to progression and tumor response. RESULTS: The RFA and TACE groups were well balanced in terms of baseline variables. The two groups did not differ significantly in overall survival (P=0.079) or major complication (P>0.999) rates. The respective cumulative survival rates at 1, 3, 5, and 8 years were 97.6, 86.7, 74.5, and 60.0% for RFA and 93.4, 75.4, 63.1, and 51.1% for TACE. Their objective tumor regression (complete or partial response) rates were 100% (165/165) and 95.9% (117/122), respectively (P=0.013). The median times to progression for RFA and TACE were 27.0±3.8 (95% confidence intervals (CIs): 19.6-34.4) and 18.0±2.9 (95% CIs: 12.2-23.8) months, respectively. RFA yielded a significantly longer time to progression (P=0.034). CONCLUSIONS: TACE may be a viable alternative treatment for ≤2 cm HCCs when RFA is not feasible.