Feasibility and Safety of n-Butyl Cyanoacrylate-Lipiodol-Iopamidol as an Alternative Liquid Embolic Material.

PURPOSE: To evaluate the feasibility and safety of n-butyl cyanoacrylate (NBCA)-Lipiodol-Iopamidol (NLI) as a liquid embolic material. MATERIALS AND METHODS: In vitro, the ratio of NLI components was adjusted and the configuration of the mixtures was assessed visually in saline. In vivo, 14 wide-necked aneurysms were created on the common carotid and external iliac arteries of four female swine. Under balloon occlusion, 12 aneurysms were embolized with NLI prepared at a NBCA-Lipidol-Iopamidol ratio of 2:3:1 (NLI231), and two were embolized with NBCA-Lipiodol (NL) prepared at a NBCA-Lipiodol ratio of 1:2 (NL12) as a trial group. We performed angiography to evaluate the effectiveness of embolization and adhesion of the embolic material to the balloons or microcatheters. RESULTS: In vitro, NLI231 (33% NBCA) was considered to be the optimal ratio for aneurysm embolization based on its configuration and stability. In vivo, embolization using NLI231 was successful and no adhesion between the embolic material and the balloons or microcatheters was observed in all 12 aneurysms. Embolization with NL12 was impossible in the other two aneurysms due to leakage and adhesion of NL. CONCLUSION: The configuration of NLI changed at each ratio. NLI231 is a feasible and safe liquid embolic material for balloon-assisted embolization of wide-necked aneurysms in swine.

A Novel Technique for the Treatment of Type 2 Endoleak After Endovascular Aortic Repair: Sac Embolization with Balloon Occlusion of the Aorta (SEBOA).

PURPOSE: We presented a new method of sac embolization using n-butyl-cyanoacrylate (NBCA) with balloon occlusion of the aorta (SEBOA) that can facilitate decreasing flow rate of the involved branches with the goal of type 2 endoleak resolution after endovascular aortic repair (EVAR). TECHNIQUE: This technique is demonstrated in six patients who required type 2 endoleak treatment including previous technical failure. A transarterial approach was performed in four patients and transabdominal direct puncture in two. Technical success was defined as complete embolization of both involved branches and sac on postoperative CT. Sacography under balloon occlusion of the aorta demonstrated decreased flow rate of the all involved branches in all patients. SEBOA was performed using 25 or 33% of NBCA diluted with lipiodol. Technical success was obtained in 3 of 6 patients, and one major complication was observed with adhesion of NBCA to the microcatheter resulting in foreign body retention. CONCLUSION: SEBOA may help solve the difficulty of type 2 endoleak treatment after EVAR as decreased flow rate of the involved branches under balloon occlusion of the aorta was achieved in all patients. However, protocols regarding concentration of NBCA or using other embolic materials are needed to improve the success rate.

Titrate to equilibrate and not exsanguinate! Characterization and validation of a novel partial resuscitative endovascular balloon occlusion of the aorta catheter in normal and hemorrhagic shock conditions.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a significant advancement in the control of noncompressible truncal hemorrhage. However, its ischemic burden and reperfusion injury following balloon deflation limits its utilization. Partial restoration of aortic flow during REBOA has the potential to balance hemorrhage control and ischemia. This study validates the mechanics, physiology, and optimal partial flow rates using a prototype partial REBOA (pREBOA) device. METHODS: Twenty-five swine underwent placement of aortic flow probes and zone 1 pREBOA. Experiment 1 (N = 5) animals were not injured and assessed the tested the catheters ability to titrate and control flow. Experiment 2 (N = 10) added 20% hemorrhage and either solid organ, or abdominal vascular injury to compare flow rate and rebleeding from injuries. Experiment 3 (N = 10) swine were similarly prepared, hemorrhaged, and underwent pREBOA at set partial flow rates for 2 hours followed by complete deflation for 30 minutes. RESULTS: Balloon volume at minimum flow (mean, 0.09 L/min) was 3.5 mL to 6.0 mL. Half maximal flow was achieved with 56.5% of maximum balloon inflation. Partial REBOA allowed very fine titration of flow rates. Rebleeding occurred at 0.45 L/min to 0.83 L/min. Distal flow of 0.7 L/min had 50% survival, 0.5 had 100% survival, and 0.3 L had 50% survival with mean end lactates of 9.6, 12.6, and 13.3, respectively. There was a trend toward hyperkalemia and hypocalcemia in nonsurvivors. CONCLUSION: The pREBOA device demonstrated a high level of titratability for restoration of aortic flow. An optimal partial flow of 0.5 L/min was effective at hemorrhage control while limiting the burden of ischemic injury, and extending the tolerable duration of zone 1 occlusion. Aggressive calcium supplementation prior to and during partial occlusion and reperfusion may be warranted to prevent hyperkalemic arrest.

Outcome and complications of adjustable continence therapy (ProACTTM ) in the treatment of urinary incontinence after transurethral resection of the prostate: A multicenter study.

AIM: To evaluate the outcome of adjustable continence balloons in the treatment of stress urinary incontinence (SUI) after transurethral resection of the prostate (TURP). METHODS: In two tertiary centers, adjustable continence balloons were implanted in 29 patients with post-TURP SUI between 2007 and 2018. Endpoints of this retrospective multicenter study were patient-reported changes in pad count and complications. Dry was defined as no pad or one security pad. RESULTS: Preoperative urinary incontinence was mild in 7 (24%), moderate in 12 (41%), and severe in 10 (35%) patients. The median follow-up duration was 21 (interquartile range [IQR], 11-43) months. Within 30 days postoperatively, a Clavien-Dindo grade less than or equal to II complication occurred in 24% of the patients. Reintervention rate was 24%. Six and 12 months after implantation, the International Prostate Symptom Score (IPSS) quality-of-life item improved significantly from 5 (IQR, 5-6) preoperatively to 3 (IQR, 1-4.5) and 1 (IQR, 0-3), respectively. At last visit (median 21 months after implantation), the outcome on continence had improved in 76% of the patients, including, 45% dry patients. After a median follow-up of 28 months (IQR, 13-63; N = 23), all but one patient reported improvement on the Patient Global Impression of Improvement (PGI-I) scale. In detail, 10 patients reported "very much better" condition compared with before the implantation, 10 patients "much better," two patients "a little better," and one patient "no change." Daily pad use decreased from three (IQR, 2-5) to one (IQR, 0-2) pads/day (P < 0.001). CONCLUSIONS: This is hitherto, the first study reporting results of adjustable continence balloons in the treatment of post-TURP SUI. The therapy was found to be safe and efficient. The majority of our study population reported improvement on their condition and greater than or equal to 50% reduction in daily pad use.

Guidelines for a system-wide multidisciplinary approach to institutional resuscitative endovascular balloon occlusion of the aorta implementation.

Resuscitative endovascular occlusion of the aorta (REBOA) is a rapidly evolving technology which requires careful system-wide multidisciplinary implementation for optimal success. These guidelines developed by experienced REBOA practitioners provide a framework for a key practitioner to use in the development of a REBOA program in their institution. They detail the importance of involving doctors, nurses, and staff across departments and disciplines in the application of this technique.

Transarterial Balloon-Assisted Glue Embolization of Pial Arteriovenous Fistulas.

OBJECTIVE: Endovascular disconnection of pial arteriovenous fistulas (AVFs) is challenging. The aim of this study was to evaluate safety and effectiveness of transarterial balloon-assisted glue embolization for treating pial AVFs. METHODS: We retrospectively reviewed medical and imaging records of 8 patients with high-flow pial AVFs treated by transarterial balloon-assisted glue embolization from August 2011 to July 2017. RESULTS: There were 6 male patients and 2 female patients with age range of 1-48 years. Presentation was seizure in 4 patients, headache in 3 patients, and subarachnoid hemorrhage in 1 patient. Seven lesions were located in the supratentorial region. All lesions were single-channel fistulas associated with venous varix. Five lesions had a single feeder, and 3 had multiple feeders. All lesions were obliterated completely in single-session embolization with no procedure-related complications. Two patients experienced symptomatic thrombosis of drainage venous system after embolization. One patient fully recovered on discharge, and another patient fully recovered after 8 months. With a mean clinical follow-up of 12.1 months, all patients were free of pretreatment symptoms. Follow-up angiograms revealed durable occlusion of fistulas. CONCLUSIONS: Transarterial balloon-assisted glue embolization is a feasible and effective option for treatment of high-flow pial AVFs.

Protecting the ischaemic penumbra as an adjunct to thrombectomy for acute stroke.

After ischaemic stroke, brain damage can be curtailed by rescuing the 'ischaemic penumbra' - that is, the severely hypoperfused, at-risk but not yet infarcted tissue. Current evidence-based treatments involve restoration of blood flow so as to salvage the penumbra before it evolves into irreversibly damaged tissue, termed the 'core'. Intravenous thrombolysis (IVT) can salvage the penumbra if given within 4.5 h after stroke onset; however, the early recanalization rate is only ~30%. Direct removal of the occluding clot by mechanical thrombectomy considerably improves outcomes over IVT alone, but despite early recanalization in > 80% of cases, ~50% of patients who receive this treatment do not enjoy functional independence, usually because the core is already too large at the time of recanalization. Novel therapies aiming to 'freeze' the penumbra - that is, prevent core growth until recanalization is complete - hold potential as adjuncts to mechanical thrombectomy. This Review focuses on nonpharmacological approaches that aim to restore the physiological balance between oxygen delivery to and oxygen demand of the penumbra. Particular emphasis is placed on normobaric oxygen therapy, hypothermia and sensory stimulation. Preclinical evidence and early pilot clinical trials are critically reviewed, and future directions, including clinical translation and trial design issues, are discussed.

Treatment Effect or Effective Treatment? Cardiac Compression Fraction and End-tidal Carbon Dioxide Are Higher in Patients Resuscitative Endovascular Balloon Occlusion of the Aorta Compared with Resuscitative Thoracotomy and Open-Chest Cardiac Massage.

The purpose of this study is to compare end-tidal carbon dioxide (EtCO2) during resuscitation of open-chest cardiac massage (OCCM) with aortic cross-clamp (ACC) versus receiving resuscitative endovascular balloon occlusion of the aorta (REBOA) with closed-chest compressions (CCCs). Patients who received REBOA were compared with patients receiving OCCM for traumatic arrest using continuous vital sign monitoring and videography. Thirty-three patients were enrolled in the REBOA group and 18 patients were enrolled in the OCCM group. Of the total patients, 86.3 per cent were male with a mean age of 36.2 ± 13.9 years. Ninety-four percent of patients suffered penetrating trauma in the OCCM group compared with 30.3 per cent of the REBOA group (P = <0.001). Before aortic occlusion (AO), there was no difference in initial EtCO2 values, but mean, median, peak, and final EtCO2 values were lower in OCCM (P < 0.005). During CPR after AO, the initial, mean, and median values were higher with REBOA (P = 0.015, 0.036, and 0.038). The rate of return of spontaneous circulation was higher in REBOA versus OCCM (20/33 [60.1%] vs 5/18 [33.3%]; P = 0.04), and REBOA patients survived to operative intervention more frequently (P = 0.038). REBOA patients had greater total cardiac compression fraction (CCF) before AO than OCCM (85.3 ± 12.7% vs 35.2 ± 18.6%, P < 0.0001) and after AO (88.3 ± 7.8% vs 71.9 ± 24.4%, P = 0.0052). REBOA patients have higher EtCO2 and cardiac compression fraction before and after AO compared with patients who receive OCCM.

Safety and Efficacy of Sodium Tetradecyl Sulfate and Lipiodol Foam in Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) for Large Porto-Systemic Shunts.

OBJECTIVE: To evaluate the safety and efficacy sodium tetradecyl sulfate and lipiodol foam (STS foam) in BRTO for large (caliber ≥15 mm) porto-systemic shunt and gastric fundal varices. MATERIALS AND METHODS: It is a retrospective record-based study of patients who underwent BRTO using STS foam at the Institute of Liver and Biliary Sciences, New Delhi, for gastric variceal bleed or refractory hepatic encephalopathy (HE) who had large porto-systemic shunt (diameter ≥15 mm) with or without associated gastric varices. Clinical and laboratory parameters were evaluated before and after the procedure. All patients were followed for minimum of 12 months. RESULTS: Records of 22 patients were analyzed. Technical success was achieved in 22 of 22 sessions. Complete obliteration of shunt with clinical improvement was seen in 20 of 22 cases. Patients with gastric varices had no residual gastric varices on follow-up endoscopy. There were significant reduction in CTP scores and improvement in HE grades following BRTO. Post-procedure complication was encountered in 6 patients (5 minor and 1 major), and 7 patients showed worsening of esophageal varices and underwent endoscopic variceal ligation. One patient had succumbed to septicemia at a follow-up of 34 months. CONCLUSION: Our experience suggests STS foam is a safe and effective agent for patients with large shunt undergoing BRTO.

Balloon-Occluded Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: A Single-Center Experience.

OBJECTIVE: To investigate whether balloon-occluded transcatheter arterial chemoembolization (b-TACE) can produce a more dense accumulation of iodized oil in various stages of hepatocellular carcinoma (HCC), from single to uncountable, to overcome inferior local control. MATERIALS AND METHODS: We studied 27 patients with HCC, including single to uncountable multiple lesions, who underwent b-TACE between August 2013 and April 2015. Dynamic CT was performed at baseline and 1-3 months after b-TACE. The treatment effect (TE) after b-TACE was evaluated using the Response Evaluation Criteria in Cancer of the Liver (RECICL) proposed by the Liver Cancer Study Group of Japan. RESULTS: In the countable HCC group, contrast-enhanced CT demonstrated RECICL TE4 in 43.8% (14/32), TE3 in 12.5% (4/32), TE2 in 37.5% (12/32), and TE1 in 6.3% (2/32) of patients. For the TACE-naïve cohort, the objective response rate was 52.9%. The objective response rate was 60% for the previously TACE-treated cohort. In the uncountable multiple HCC group, the objective response rate was 0% (0/10), with progressive disease in 90% (9/10) of patients. CONCLUSION: Our observations suggested that b-TACE did not reduce the efficacy of retreatment for HCC with an insufficient outcome from conventional TACE, but it could not improve the efficacy of treatment for uncountable multiple HCCs.

Preliminary findings of arterial embolization with balloon-occluded and flow-dependent histoacryl glue embolization in a swine model.

PURPOSE: To evaluate the potential usefulness of the balloon-occluded histoacryl glue embolization (B-glue) technique. MATERIALS AND METHODS: Both flow-dependent (no balloon occlusion) and B-glue techniques were used for 24 intercostal arteries of two female swine. N-butyl 2-cyanoacrylate (NBCA) was diluted with lipiodol to a 50 % solution, which was infused after occluding the arteries with microballoon catheters. The embolization range, fragmentation, reflux, adhesion, and glue particle attachment were compared between flow-dependent and B-glue techniques. RESULTS: The B-glue technique was performed in a controlled fashion resulting in successful arterial occlusion without fragmented migration of the injected glue cast. Reflux occurred less frequently with the B-glue technique and was significantly different (p = 0.039) [Corrected] from that for the flow-dependent technique. Catheters were safely removed from the arterial walls, although in one instance (8.3 %), large glue particles were found to be attached to the catheter tip on removal. Conversely, the flow-dependent technique was more difficult to control and resulted in several instances of higher rates of fragmentation. CONCLUSION: The B-glue technique can efficiently control NBCA delivery with lower rates of reflux.

Safety and efficacy of angiographic occlusion of duodenal varices as an alternative to TIPS: review of 32 cases.

UNLABELLED: BACKGROUND/RATIONALE OF STUDY: Analyze safety and efficacy of angiographic-occlusion-with-sclerotherapy/embolotherapy-without-transjugular-intrahepatic-portosystemic-shunt (TIPS) for duodenal varices. Although TIPS is considered the best intermediate-to-long term therapy after failed endoscopic therapy for bleeding varices, the options are not well-defined when TIPS is relatively contraindicated, with scant data on alternative therapies due to relative rarity of duodenal varices. Prior cases were identified by computerized literature search, supplemented by one illustrative case. Favorable clinical outcome after angiography defined as no rebleeding during follow-up, without major procedural complications. RESULTS: Thirty-two cases of duodenal varices treated by angiographic-occlusion-with-sclerotherapy/embolotherapy- without-TIPS were analyzed. Patients averaged 59.5 ± 12.2 years old (female = 59%). Patients presented with melena-16, hematemesis & melena-5, large varices-5, growing varices-2, ruptured varices-1, and other- 3. Twenty-nine patients had cirrhosis; etiologies included: alcoholism-11, hepatitis C-11, primary biliary cirrhosis- 3, hepatitis B-2, Budd-Chiari-1, and idiopathic-1. Three patients did not have cirrhosis, including hepatic metastases from rectal cancer-1, Wilson's disease-1, and chronic liver dysfunction-1. Thirty-one patients underwent esophagogastroduodenoscopy before therapeutic angiography, including fifteen undergoing endoscopic variceal therapy. Therapeutic angiographic techniques included balloon-occluded retrograde-transvenous-obliteration (BRTO) with sclerotherapy and/or embolization-21, DBOE (double-balloon-occluded-embolotherapy)-5, and other-6. Twenty-eight patients (87.5%; 95%-confidence interval: 69-100%) had favorable clinical outcomes after therapeutic angiography. Three patients were therapeutic failures: rebleeding at 0, 5, or 10 days after therapy. One major complication (Enterobacter sepsis) and one minor complication occurred. CONCLUSIONS: This work suggests that angiographic-occlusion-with sclerotherapy/ embolotherapy-without-TIPS is relatively effective (~90% hemostasis-rate), and relatively safe (3% major-complication-rate). This therapy may be a useful treatment option for duodenal varices when endoscopic therapy fails and TIPS is relatively contraindicated.

Compliant neurovascular balloon catheters may not be compatible with liquid embolic materials: intraprocedural rupture of the protecting balloon during tumor embolization using n-butyl cyanoacrylate and lipiodol mixture.

BACKGROUND: Simultaneous use of balloon catheters with embolic materials can cause unwanted rupture of the balloon occlusion catheters, which might cause a serious problem. Therefore, knowledge of the compatibility of occlusion balloon catheters with liquid embolic materials is important in various interventional procedures. OBJECTIVE: To determine the compatibility of occlusion balloon catheters with commonly used embolic materials in vitro. METHODS: We used three types of occlusion balloon catheters (Scepter C, Microvention, Tustin, California, USA; Hyperform, Covidien, Irvine, California, USA; and Ascent, Codman Neurovascular, Raynham, Massachusetts, USA) to test their tolerances to Lipiodol, n-butyl cyanoacrylate (NBCA; Histoacryl; B Braun, Melsungen, Germany), and dimethyl sulfoxide (DMSO) with Onyx. The balloon was inflated just as it is in an endovascular procedure, then put on a Petri dish to observe its morphological change after one drop of liquid embolic material was added using a 1 mL syringe. The presence of rupture and the time to rupture were evaluated by constant video monitoring. Additionally, we observed morphological changes of the balloon catheter surface after contact with embolic materials with a scanning electron microscope. RESULTS: Lipiodol or a 33% NBCA-Lipiodol mixture dropping onto the three types of balloon catheter resulted in ruptures of all three. All three types of balloon catheter were tolerant to NBCA and to DMSO followed by Onyx. CONCLUSIONS: Glue embolization should not be performed with all three kinds of balloon catheter on the market, but DMSO and Onyx are compatible with those balloon catheters.

Successful treatment of central retinal artery thromboembolism with ocular massage and intravenous acetazolamide.

A 67-year-old woman presented with left-sided headache and blurred vision, worse during hypertensive episodes. CT angiography showed a 4 mm left internal carotid artery (ICA) aneurysm incorporating the ophthalmic artery. She passed a test balloon occlusion, so the aneurysm was coil occluded, without immediate complication. Four days postprocedure she experienced sudden loss of vision in the left eye and funduscopy showed central retinal artery occlusion secondary to emboli from the coiled aneurysm. She was treated promptly with intravenous acetazolamide and ocular massage and regained full visual acuity. Thromboembolism to the eye during or after neurointerventional treatment is a relatively rare but devastating complication. This report demonstrates the effectiveness of combined intravenous acetazolamide and ocular massage in dealing with this complication when delivered promptly.

Accelerated balloon-occluded retrograde transvenous obliteration without indwelling balloon occlusion for gastric varices with small gastrorenal shunts using a terminal gelfoam plug.

OBJECTIVE: We performed balloon-occluded retrograde transvenous obliteration in three consecutive patients with small gastric varices without indwelling balloon catheter occlusion. Foam of 3% sodium tetradecyl sulfate mixed with iodized oil and room air was injected retrograde through the gastrorenal shunt, followed by a thick absorbable gelatin sponge (Gelfoam, Pfizer) plug under only 10-minute balloon occlusion. CONCLUSION: Because complete obliteration of gastric varices was achieved in all patients without any complications, our technique is considered to be safe and effective for small gastric varices.

[Anesthetic management of intra-aortic balloon occlusion (IABO) for seven cases of placenta accreta--a six year experience at our institute].

We studied retrospectively amount of bleeding, clamping time, and the presence or absence of ischemia-reperfusion injury in all seven cases of IABO performed for placenta accreta from 2007 to 2012 at our hospital. We also examined rSO2 change before and after clamping in four cases in which lower-limb rSO2 monitoring was performed with NIRS (near-infrared spectroscopy). There was no case suspected of ischemia-reperfusion injury during and after clamping with the amount of bleeding around 1,580-10,973 ml (mean 4,536 ml) and clamping time of 10-83 min (mean 44 min). No significant decrease was observed in lower-limb rSO2 with 73.5 ± 5.9% before clamping and 70.8 ± 5.6% (mean ± SD) after clamping.

Single-step multimodal locoregional treatment for unresectable hepatocellular carcinoma: balloon-occluded percutaneous radiofrequency thermal ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE).

PURPOSE: This study was undertaken to evaluate the feasibility, safety and efficacy of a new combined single-step therapy in patients with unresectable multinodular unilobar hepatocellular carcinoma (HCC), with at least one lesion >3 cm, with balloon-occluded radiofrequency ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE) of the main lesion and TACE of the other lesions. The second purpose of our study was to compare the initial effects in terms of tumour necrosis of this new combined therapy with those obtained in a matched population treated with TACE alone in a singlestep treatment in our centre in the previous year. METHODS AND MATERIALS: This pilot study was approved by the institutional review board, and informed consent was obtained from all patients. Ten consecutive patients with multinodular (two to six nodules) unilobar unresectable HCC and with a main target lesion >3 cm (range, 3.5-6 cm) not suitable for curative therapy were enrolled in our single-centre multidisciplinary pilot study. The schedule consisted of percutaneous RFA (single 3-cm monopolar needle insertion) of the target lesion during occlusion of the hepatic artery supplying the tumour, followed by selective TACE, plus lobar TACE for other lesions (450-mg carboplatin and lipiodol plus temporary embolisation with SPONGOSTAN). Adverse events and intra- and periprocedural complications were clinically assessed. Early local efficacy was evaluated on 1-month follow-up multiphasic computed tomography (CT) on the basis of the Modified Response Evaluation Criteria in Solid Tumors (m-RECIST). A separate evaluation of target lesions in terms of enhancement, necrotic diameter and presence and distribution of lipiodol uptake was also performed. RESULTS: No major complications occurred. Overall technical success, defined as complete devascularisation of all nodules during the arterial phase, was achieved in seven of 10 patients, with three cases of partial response (persistence of small hypervascular nodules). When considering only target lesions, technical success was obtained in all patients, with a nonenhancing area corresponding in shape to the previously identified HCC (necrotic diameter, 3.5-5 cm) and with circumferential peripheral lipiodol uptake (safety margin) of at least 0.5 cm (0.5-1.3cm). CONCLUSIONS: TACE and BO-RFA, plus TACE in a singlestep approach seems to be a safe and effective combined therapy for treating advanced, unresectable HCC lesions, allowing a high rate of complete local response to be achieved in large lesions also.

Pulmonary vein isolation with Mesh Ablator versus cryoballoon catheters: 6-month outcomes.

INTRODUCTION: We sought to compare the results of pulmonary vein (PV) ablation using the high-density Mesh Ablator catheter (MESH) versus the cryoballoon (CRYO). METHODS AND RESULTS: From August 2007 to November 2009, all patients with paroxysmal atrial fibrillation scheduled for a first procedure of PV isolation were screened by cardiac computed tomography for anatomical suitability to undergo ablation with a circumferential ostial ablation catheter. The procedure was finally performed in 79 out of 120 patients matching the criteria of four clearly separated PVs with an ostial diameter of 15-25 mm. The first consecutive 43 patients were treated with the MESH; the following 36 consecutive patients were treated with the CRYO. The procedures were performed with up to 900 s of either pulsed radiofrequency energy delivered by the MESH or cryoenergy applied with the CRYO. The clinical success rate was evaluated 6 months after a single procedure. Isolation of all PVs could be achieved in 40 patients (93%) in the MESH group compared to 31 patients (89%) in the CRYO group (p = ns). Major complications consisted of one tamponade in the MESH group and one reversible phrenic nerve palsy in the CRYO group. After 6 months, the clinical success rate was 44% (19/43 P) in the MESH versus 69% (25/36 P) in the CRYO group (p < 0.05). CONCLUSION: Both methods of simplified circumferential PV ablation reveal a high acute success rate. The clinical 6-month results of the MESH are statistically significant inferior compared to the CRYO.

Cryoballoon versus radiofrequency catheter ablation of paroxysmal atrial fibrillation: biomarkers of myocardial injury, recurrence rates, and pulmonary vein reconnection patterns.

BACKGROUND: Cryoballoon ablation has emerged as a novel treatment strategy for patients with atrial fibrillation (AF). OBJECTIVE: The purpose of this study was to compare pulmonary vein isolation (PVI) using cryoballoon ablation versus RF ablation with regard to myocardial injury, pulmonary vein (PV) reconnection patterns, and outcome. METHODS: Fifty patients (age 59 ± 9 years, ejection fraction 0.59 ± 0.06, left atrial size 41 ± 5 mm) with paroxysmal AF were studied. Twenty-five patients underwent PVI using a 28-mm cryoballoon. A control group of 25 patients underwent PVI using an open-irrigation RF ablation catheter. Myocardial injury was determined by measuring troponin T (TnT). PV reconnection patterns were studied in case of repeat procedures. RESULTS: Procedure duration was 166 ± 32 minutes in the cryoballoon group versus 197 ± 52 minutes in the RF group (P = .014), with similar ablation times (cryoballoon: 45 minutes [interquartile range 40-52.5 minutes]; RF: 47 minutes [interquartile range 44-65 minutes], P = .17). Postprocedural TnT in the RF group was 1.29 ± 0.41 µg/L versus 0.76 ± 0.55 µg/L in the cryoballoon group (P = .002). In 12 patients who underwent repeat ablation, 74% of PV reconnection sites were inferiorly located in the cryoballoon group compared to 17% in the RF group (P = .0004). With 1.2 ± 0.4 and 1.3 ± 0.6 procedures per patient, 88% of patients in the cryoballoon group and 92% in the RF group were in stable sinus rhythm after follow-up of 12 ± 3 months (P = NS). CONCLUSION: Differences in the extent of myocardial injury and patterns of PV reconnection were observed between cryoballoon ablation and RF ablation of paroxysmal AF.

A new approach to percutaneous transhepatic portal embolization using ethanolamine oleate iopamidol.

PURPOSE: We aimed to examine the therapeutic efficacy of ethanolamine oleate iopamidol (EOI) as an embolic material for percutaneous transhepatic portal embolization (PTPE). METHODS: Eighty-two patients with liver tumors were treated with PTPE. Fifty-eight patients had hepatocellular carcinomas, 11 had liver metastases, and 13 had other liver tumors. A total of 55 patients (group E) were treated with 5% ethanolamine oleate after gelatin sponge administration. As a control, we evaluated 27 patients (group F) who were treated with fibrin glue and iodized oil. PTPE was mainly indicated before hepatic resection, for patients with high nontumorous volumetric resection ratios (the nontumorous volumetric resection ratio was estimated to be greater than 65% in patients with an indocyanine green retention ratio of 15 min (ICG R15) of 10% or less, and the nontumorous volumetric resection ratio was estimated to be greater than 40% in the patients with an ICG R15 of 10-20%). RESULTS: All patients were successfully treated percutaneously under local anesthesia. Balloon-occluded and ipsilateral approaches were used in 81 patients (99%) and 62 (75%) patients, respectively. The rate of insufficient embolization or recanalization was significantly lower in group E (7.3%) in comparison to group F (25.9%; p < 0.05). The volumetric resection ratios, before and after PTPE, decreased from 60 to 45% in group E and from 63 to 55% in group F. The post-PTPE resection ratio was significantly decreased in group E. Before and after PTPE, average ICG R15 values changed from 17 to 27% in group E and from 18 to 26% in group F. The complication rates in groups E and F were similar (7.3 vs. 7.4%). CONCLUSION: EOI is a safe embolic material that can be used to induce greater liver hypertrophy, in comparison to fibrin glue, in PTPE for liver tumors.