Survival Analysis Using Albumin-Bilirubin (ALBI) Grade for Patients Treated with Drug-Eluting Embolic Transarterial Chemoembolization for Hepatocellular Carcinoma.

PURPOSE: The albumin-bilirubin (ALBI) grade has been established as an improved predictor of survival in patients with hepatocellular carcinoma (HCC) treated with conventional transarterial chemoembolization and yttrium-90 radioembolization. The purpose of the study was to investigate the utility of ALBI grade in prognosticating outcomes in patients with HCC treated with drug-eluting embolic (DEE) transarterial chemoembolization (TACE). MATERIALS AND METHODS: A single-center retrospective review was performed to compare the efficacy of ALBI grade and Child-Pugh (CP) classification in predicting the survival of patients with HCC receiving DEE-TACE. A total of 303 patients with HCC were identified who had received DEE-TACE without concomitant locoregional therapy within 30 days. Survival analysis was performed using Kaplan-Meier methods and censored for curative therapy. Survival curves were stratified based on the ALBI grade, CP class, Barcelona Clinic Liver Cancer (BCLC) stage, Eastern Cooperative Oncology Group performance status, and presence of ascites. The discriminatory ability of survival curves was calculated by C-Index. RESULTS: Kaplan-Meier survival curves stratified by the ALBI grade produced distinct, nonoverlapping curves (P < .001), showing greater discriminatory ability than the CP classification (C-index = 0.568 and 0.545, respectively). The substratification of the BCLC stage by the ALBI grade yielded greater discriminatory ability than the substratification by the CP classification (C-index = 0.573 and 0.565, respectively). For patients with BCLC stage B, the substratification by the ALBI grade yielded distinct curves, whereas the substratification by the CP classification did not (P = .011 and P = .379, respectively). CONCLUSIONS: ALBI grade showed improved discriminatory ability compared with CP classification in differentiating overall survival among patients with HCC receiving DEE-TACE. Furthermore, ALBI grade was effective in substratifying survival among patients categorized as CP class A and patients with BCLC stage B, whereas CP classification was not effective.

Contemporary Management of Acute Pulmonary Embolism: Evolution of Catheter-based Therapy.

Acute pulmonary embolism (PE) affects more than 100 000 people in the United States annually and is the third leading cardiovascular cause of death. The standard management for PE is systemic anticoagulation therapy. However, a subset of patients experience hemodynamic decompensation, despite conservative measures. Traditionally, these patients have been treated with systemic administration of thrombolytic agents or open cardiac surgery, although attempts at endovascular treatment have a long history that dates back to the 1960s. The technology for catheter-based therapy for acute PE is rapidly evolving, with multiple devices approved over the past decade. Currently available devices fall into two broad categories of treatment methods: catheter-directed thrombolysis and percutaneous suction thrombectomy. Catheter-directed thrombolysis is the infusion of thrombolytic agents directly into the occluded pulmonary arteries to increase local delivery and decrease the total dose. Suction thrombectomy involves the use of small- or large-bore catheters to mechanically aspirate a clot from the pulmonary arteries without the need for a thrombolytic agent. A thorough understanding of the various risk stratification schemes and the available evidence for each device is critical for optimal treatment of this complex entity. Multiple ongoing studies will improve our understanding of the role of catheter-based therapy for acute PE in the next 5-10 years. A multidisciplinary approach through PE response teams has become the management standard at most institutions. An invited commentary by Bulman and Weinstein is available online. Online supplemental material is available for this article. ©RSNA, 2022.

Radiological and pathological assessment with EOB-MRI after Y90 radiation lobectomy prior to liver resection for hepatocellular carcinoma.

BACKGROUND: Radiation lobectomy (RL) utilizes Yttrium-90 (Y90) radioembolization for achieving tumor control and inducing contralateral lobe hypertrophy. Our objective was to evaluate the chronological changes occurring radiologically and histopathologically after Y90 RL. METHODS: We retrospectively reviewed 22 patients with chronic liver disease who underwent Y90 RL prior to planned liver resection for hepatocellular carcinoma. Gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA) enhanced magnetic resonance imaging (EOB-MRI) was performed every 3 months. RESULTS: Future liver remnant volume (FLRV) significantly increased up to 9 months after Y90 RL. Gd-EOB-DTPA uptake in the treated lobe experienced a 40% reduction in enhancement ratio (ER) during ensuing first 3 months, and never recovered. The reduced ER in the non-tumoral parenchyma was significantly correlated with increased FLRV and FLR (r = 0.41 and r = 0.35, respectively; both p < 0.01). Histopathological evaluation of non-tumor liver tissue found features of sinusoidal obstruction syndrome as an early change after Y90 RL (median 5.7 months) and parenchymal collapse as a late change (mean 11 months). DISCUSSION: The reduced uptake of Gd-EOB-DTPA at 3 months post Y90 RL correlates with a significant increase in FLRV prior to liver resection. EOB-MRI evaluation at 3 months can guide future plan of action after Y90 RL.

Single-System Experience With Outpatient Transradial Uterine Artery Embolization: Safety, Feasibility, Outcomes, and Early Rates of Return.

OBJECTIVE. The purpose of this study was to assess feasibility and rate of patients returning to the hospital when a same-day discharge protocol is used for patients undergoing transradial uterine artery embolization (UAE) for symptomatic fibroids. MATERIALS AND METHODS. A total of 374 patients who underwent transradial UAE with a same-day discharge protocol between April 2013 and June 2019, with documented follow-up, were included in this single-health-system retrospective study. Angiographic images and procedural reports were reviewed for technical success (defined as bilateral embolization). Electronic medical records were reviewed for patient and fibroid characteristics, adverse events, clinical success (defined as documented improvement in symptoms or patient satisfaction), and unplanned clinic visits, emergency department visits, and readmissions within 30 days of UAE. Univariate and multivariate analyses were used to identify risk factors for unplanned visits. RESULTS. Eight (2.1%) patients required conversion to inpatient stay (mean length of stay, 1.4 days; range, 1-3 days). The median postprocedure observation time was 3.7 hours (range, 1.1-12.5 hours). Technical success was achieved in 94.7% of patients, with 2.4% requiring crossover to the femoral artery for access. Clinical success was achieved in 86.0% of patients, with 6-month reductions in uterus and dominant leiomyoma volume of 30.4% and 42.9%, respectively. Rates of unplanned clinic visits, emergency department visits, and readmissions were 3.2%, 5.1%, and 0.5%, respectively. Patients with submucosal fibroids or pain as an indication for UAE were significantly more likely to have unplanned visits. CONCLUSION. Transradial UAE for symptomatic fibroids can be performed using a same-day discharge protocol with low rates of patients returning to the hospital. Submucosal location and pain as an indication for UAE were predictors of early return.

Safety and Efficacy of Locoregional Treatment during Immunotherapy with Nivolumab for Hepatocellular Carcinoma: A Retrospective Study of 41 Interventions in 29 Patients.

PURPOSE: To assess the safety of locoregional treatment (LRT) combined with nivolumab for intermediate and advanced hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A single-center retrospective review included 29 patients undergoing 41 LRTs-transarterial chemoembolization or yttrium-90 transarterial radioembolization-60 days before or concurrently with nivolumab. Demographic, clinical, and laboratory values and adverse events were reviewed before and after nivolumab initiation and after each LRT. Treatment response and time to progression were assessed using Modified Response Evaluation Criteria in Solid Tumors. Clinical events, including nivolumab termination, death, and time of last follow-up, were assessed. RESULTS: Over a median nivolumab course of 8.1 months (range, 1.0-30) with a median of 14.2 2-week cycles (range, 1-53), predominantly Child-Pugh A (22/29) patients-12 Barcelona Clinic Liver Cancer (BCLC) B and 17 BCLC C-underwent 20 transarterial chemoembolization and 21 transarterial radioembolization LRTs at a median of 67 days (range, 48-609) after nivolumab initiation. Ten patients underwent multiple LRTs. During a median follow-up of 11.5 months (range, 1.8-35.1), no grade III/IV adverse events attributable to nivolumab were observed. There were five instances of grade III/IV hypoalbuminemia or hyperbilirubinemia within 3 months after LRT. There were no nivolumab-related deaths, and 30-day mortality after LRT was 0%. CONCLUSIONS: LRTs performed concurrently with nivolumab immunotherapy demonstrate an acceptable safety profile in patients with intermediate and advanced HCC.

Bariatric Embolization of Arteries for the Treatment of Obesity (BEAT Obesity) Trial: Results at 1 Year.

Background Bariatric embolization is a new endovascular procedure to treat patients with obesity. However, the safety and efficacy of bariatric embolization are unknown. Purpose To evaluate the safety and efficacy of bariatric embolization in severely obese adults at up to 12 months after the procedure. Materials and Methods For this prospective study (NCT0216512 on ClinicalTrials.gov ), 20 participants (16 women) aged 27-68 years (mean ± standard deviation, 44 years ± 11) with mean body mass index of 45 ± 4.1 were enrolled at two institutions from June 2014 to February 2018. Transarterial embolization of the gastric fundus was performed using 300- to 500-µm embolic microspheres. Primary end points were 30-day adverse events and weight loss at up to 12 months. Secondary end points at up to 12 months included technical feasibility, health-related quality of life (Short Form-36 Health Survey ([SF-36]), impact of weight on quality of life (IWQOL-Lite), and hunger or appetite using a visual assessment scale. Analysis of outcomes was performed by using one-sample t tests and other exploratory statistics. Results Bariatric embolization was performed successfully for all participants with no major adverse events. Eight participants had a total of 11 minor adverse events. Mean excess weight loss was 8.2% (95% confidence interval [CI]: 6.3%, 10%; P < .001) at 1 month, 11.5% (95% CI: 8.7%, 14%; P < .001) at 3 months, 12.8% (95% CI: 8.3%, 17%; P < .001) at 6 months, and 11.5% (95% CI: 6.8%, 16%; P < .001) at 12 months. From baseline to 12 months, mean SF-36 scores increased (mental component summary, from 46 ± 11 to 50 ± 10, P = .44; physical component summary, from 46 ± 8.0 to 50 ± 9.3, P = .15) and mean IWQOL-Lite scores increased from 57 ± 18 to 77 ± 18 (P < .001). Hunger or appetite decreased for 4 weeks after embolization and increased thereafter, without reaching pre-embolization levels. Conclusion Bariatric embolization is well tolerated in severely obese adults, inducing appetite suppression and weight loss for up to 12 months. Published under a CC BY-NC-ND 4.0 license. Online supplemental material is available for this article.

Balloon-Occluded Transarterial Chemoembolization for the Treatment of Hepatocellular Carcinoma: A Single-Center US Preliminary Experience.

This report describes a single-center experience with balloon-occluded transarterial chemoembolization for liver-directed therapy. A total of 26 patients (11 male, 4 female; mean age, 65 y ± 7) with 28 tumors (mean diameter, 2.7 cm; range, 1.1-5.9 cm) were treated. Technical success rate was 100% (28 of 28 cases), with 1 minor complication of left portal vein thrombosis and small liver infarct. Of the 15 tumors analyzed for response, 60% (9 of 15) exhibited complete response, 33.3% (5 of 15) exhibited partial response, and 6.6% (1 of 15) had stable disease on follow-up. Eight patients exhibited overall progression with a new hepatic lesion and a median time to progression of 7.9 months (range, 5-11 mo).

Patient Experience and Preference in Transradial versus Transfemoral Access during Transarterial Radioembolization: A Randomized Single-Center Trial.

PURPOSE: To determine patient preference for transradial access (TRA) or transfemoral access (TFA) after experiencing both. MATERIALS AND METHODS: A randomized controlled crossover trial was conducted at a single institution. Thirty patients with hepatocellular carcinoma undergoing mapping and transarterial radioembolization (TARE) were enrolled to experience 1 TRA and 1 TFA procedure each, with randomization of which access approach was experienced first. Surveys assessing pain and quality of life (QOL) were administered after each procedure. Access site preference was collected after completion of both procedures. RESULTS: Twenty-two subjects (73.3%) preferred TRA, 4 (13.3%) preferred TFA, and 4 (13.3%) had no preference; 14 (46.7%) reported bruising after TRA, and 17 (53.3%) reported bruising after TFA. TRA was associated with significantly lower pain scores overall during the procedure, at the access site during the procedure, and in the recovery room compared with TFA (2.0 vs 2.9, P = .0046; 2.0 vs 3.0, P = .0004; 2.1 vs 2.9, P = .0357). Pain score after discharge was not significantly different (1.4 vs 1.5, P = .4235). QOL scores were not significantly different between TRA and TFA. No significant differences were found for fluoroscopy time, air kerma, dose-area product, or procedure time between TRA and TFA for either mapping (P = .1442, P = .5871, P = .6667, P = .6131) or radioembolization (P = .8574, P = .2344, P = .1119, P =.8474). For radioembolizations, TRA had significantly shorter recovery times compared with TFA (108 min vs 153 min, P = .0193). CONCLUSIONS: Patients exhibited a strong preference for TRA. With TRA, patients experienced less periprocedural pain and shorter recovery times without significant differences in radiation exposure or procedure length.

Radiation Segmentectomy versus Selective Chemoembolization in the Treatment of Early-Stage Hepatocellular Carcinoma.

PURPOSE: To compare outcomes of radiation segmentectomy (RS) and segmental transarterial chemoembolization in treatment of unresectable, solitary hepatocellular carcinoma (HCC) ≤ 3 cm. MATERIALS AND METHODS: From January 2012 to January 2016, 534 and 877 patients were treated with radioembolization and transarterial chemoembolization, respectively. A cohort of 112 (radiation segmentectomy [RS], 55; chemoembolization, 57) locoregional therapy-naïve patients with solitary HCC ≤ 3 cm without vascular invasion or metastasis was retrospectively identified and stratified according to baseline patient demographics, tumor characteristics, and laboratory values. Propensity score matching (PSM) was conducted using a nearest neighbor algorithm (1:1). Outcomes analyzed included laboratory toxicities, imaging response, time to secondary therapy (TTST), and overall survival. RESULTS: Before PSM, complete response (CR) rate was 81.2% for RS and 49.1% for chemoembolization (odds ratio 2.2; 95% confidence interval [CI], 1.4-3.3; P < .001). Median (95% CI) TTST after initial therapy was 246 days (135-250 d) in chemoembolization group and 700 days (308-812 d) in RS group (hazard ratio 0.71; 95% CI, 0.55-0.92; P = .009). Overall survival before PSM was not significantly different between the 2 groups (P = .29). Overall CR rate after PSM was 92.1% in RS group and 52.6% in chemoembolization group (P = .005). Median (95% CI) TTST after matching was 161 days (76-350 d) in chemoembolization group and 812 days (363-812 d) in RS group (P = .001). Overall survival after matching was not significantly different between the 2 groups (P = .71). CONCLUSIONS: RS results in improved imaging response and longer TTST compared with transarterial chemoembolization in treatment of early-stage HCC.

Patient Radiation Exposure in Transradial versus Transfemoral Yttrium-90 Radioembolization: A Retrospective Propensity Score-Matched Analysis.

PURPOSE: To compare differences in patient radiation exposure (PRE) during transarterial yttrium-90 (90Y) radioembolization (TARE) between transradial access (TRA) and transfemoral access (TFA). MATERIALS AND METHODS: A total of 810 consecutive first-time TARE procedures in patients from 2013 to 2017 were retrospectively reviewed. A propensity score-matching (PSM) analysis matched TRA and TFA groups on the basis of patient age, sex, weight, height, cancer type, 90Y microsphere type, and number of previous procedures from the same and opposite approaches. Matched groups were then compared by PRE measures fluoroscopy time (FT), dose-area product (DAP), and cumulative air kerma (AK). Effect size for each PRE measure was calculated. RESULTS: Before PSM, TRA and TFA groups differed significantly in mean age, weight, and number of previous procedures from the same and opposite approach (all P < .05). After PSM, each group consisted of 302 procedures (overall, n = 604) and no longer differed in any procedure performed before surgery measure. TRA did not differ from the matched TFA group regarding median FT (9.50 vs 9.40 minutes, P = .095), median DAP (67,066 vs 67,219 mGy·cm2; P = .19), or median AK (323.63 vs 248.46 mGy; P = .16). Effect sizes were 0.068, 0.054, and 0.110 for FT, DAP, and AK, respectively. CONCLUSIONS: No statistical differences were found for PRE measures between the matched TRA and TFA approach groups. Furthermore, practical effect sizes were considered to be small for AK and less than small for FT and DAP, and therefore, any differences in PRE between the radial and femoral approaches for TARE are minor and unlikely to be noticeable in everyday clinical practice.

Radiation Segmentectomy versus TACE Combined with Microwave Ablation for Unresectable Solitary Hepatocellular Carcinoma Up to 3 cm: A Propensity Score Matching Study.

Purpose To compare the outcomes of radiation segmentectomy (RS) and transarterial chemoembolization (TACE) combined with microwave ablation (MWA) in the treatment of unresectable solitary hepatocellular carcinoma (HCC) up to 3 cm. Materials and Methods This retrospective study was approved by the institutional review board, and the requirement to obtain informed consent was waived. From January 2010 to June 2015, a total of 417 and 235 consecutive patients with HCC underwent RS and TACE MWA, respectively. A cohort of 121 patients who had not previously undergone local-regional therapy (RS, 41; TACE MWA, 80; mean age, 65.4 years; 84 men [69.4%]) and who had solitary HCC up to 3 cm without vascular invasion or metastasis was retrospectively identified. Outcomes analyzed included procedure-related complications, laboratory toxicity levels, imaging response, time to progression (TTP), 90-day mortality, and survival. Propensity score matching was conducted by using a nearest-neighbor algorithm (1:1) to account for pretreatment clinical, laboratory, and imaging covariates. Postmatching statistical analysis was performed with conditional logistic regression for binary outcomes and the stratified log-rank test for time-dependent outcomes. Results Before matching, the complication rate was 8.9% and 4.9% in the TACE MWA and RS groups, respectively (P = .46). The overall complete response (CR) rate was 82.9% for RS and 82.5% for TACE MWA (odds ratio, 1.0; 95% confidence interval [CI]: 0.4, 2.8; P = .95). There were 41 (RS, 11; TACE MWA, 30) instances of progression occurring after an initial CR, of which 10 (24%) were classified as target progression (RS, one; TACE MWA, nine). Median overall TTP was 11.1 months (95% CI: 8.8 months, 25.6 months) in the RS group and 12.1 months (95% CI: 7.7 months, 19.1 months) in the TACE MWA group (P > .99). After matching, the overall CR rate (P = .94), TTP (P = .83), and overall survival (P > .99) were not significantly different between the two groups. The 90-day postoperative mortality rate was 0% in both groups. Conclusion Imaging response and progression outcomes of patients with solitary HCC up to 3 cm treated with RS were not significantly different when compared with those of patients treated with TACE MWA. © RSNA, 2016 Online supplemental material is available for this article.

Clinical Safety of Bariatric Arterial Embolization: Preliminary Results of the BEAT Obesity Trial.

Purpose To conduct a pilot prospective clinical trial to evaluate the feasibility, safety, and short-term efficacy of bariatric embolization, a recently developed endovascular procedure for the treatment of obesity, in patients with severe obesity. Materials and Methods This is an institutional review board- and U.S. Food and Drug Administration-approved prospective physician-initiated investigational device exemption study. This phase of the study ran from June 2, 2014, to August 4, 2015. Five severely obese patients (four women, one man) who were 31-49 years of age and who had a mean body mass index of 43.8 kg/m2 ± 2.9 with no clinically important comorbidities were enrolled in this study. Transarterial embolization of the gastric fundus with fluoroscopic guidance was performed with 300-500-µm Embosphere microspheres. The primary end point was 30-day adverse events (AEs). The secondary end points included short-term weight loss, serum obesity-related hormone levels, hunger and satiety assessments, and quality of life (QOL) surveys, reported up to 3 months. Simple statistics of central tendencies and variability were calculated. No hypothesis testing was performed. Results The left gastric artery, with or without the gastroepiploic artery, was embolized in five patients, with a technical success rate of 100%. There were no major AEs. There were two minor AEs-subclinical pancreatitis and a mucosal ulcer that had healed by the time of 3-month endoscopy. A hospital stay of less than 48 hours for routine supportive care was provided for three patients. Mean excess weight loss of 5.9% ± 2.4 and 9.0% ± 4.1 was noted at 1 month and at 3 months, respectively. Mean change in serum ghrelin was 8.7% ± 34.7 and -17.5% ± 29 at 1 month and 3 months, respectively. Mean changes in serum glucagon-like peptide 1 and peptide YY were 106.6% ± 208.5 and 17.8% ± 54.8 at 1 month. There was a trend toward improvement in QOL parameters. Hunger/appetite scores decreased in the first 2 weeks after the procedure and then rose without reaching preprocedure levels. Conclusion Bariatric embolization is feasible and appears to be well tolerated in severely obese patients. In this small patient cohort, it appears to induce appetite suppression and may induce weight loss. Further expansion of this study will provide more insight into the long-term safety and efficacy of bariatric embolization. © RSNA, 2017 Online supplemental material is available for this article.

Transfemoral Filter Eversion Technique following Unsuccessful Retrieval of Option Inferior Vena Cava Filters: A Single Center Experience.

This report describes the technical feasibility of using the filter eversion technique after unsuccessful retrieval attempts of Option and Option ELITE (Argon Medical Devices, Inc, Athens, Texas) inferior vena cava (IVC) filters. This technique entails the use of endoscopic forceps to evert this specific brand of IVC filter into a sheath inserted into the common femoral vein, in the opposite direction in which the filter is designed to be removed. Filter eversion was attempted in 25 cases with a median dwell time of 134 days (range, 44-2,124 d). Retrieval success was 100% (25/25 cases), with an overall complication rate of 8%. This technique warrants further study.

Transradial Access for Interventional Radiology: Single-Centre Procedural and Clinical Outcome Analysis.

PURPOSE: The study sought to describe a single centre's technical approach to transradial intervention and report on clinical outcomes and safety. METHODS: A total of 749 transradial access (TRA) procedures were performed at a single hospital in 562 patients (174 women and 388 men). Procedures included 445 bland embolizations or chemoembolizations of the liver, 88 uterine artery embolizations, and 148 procedures for Selective Internal Radiation Therapy (Y90), which included mapping and administration. The mean age of the patients was 62 years (range 27-96 years). RESULTS: Four cases (0.5%) required crossover to transfemoral (tortuous anatomy, inability to secure a stable position for embolization, vessel spasm and base catheter not being of a sufficient length). A single asymptomatic, short-segment radial artery occlusion occurred (0.3%), 3 patients (0.4%) developed small hematomas postprocedurally, and 2 patients (0.7%) had transient neurological pain, which was resolved within a week without treatment. It was found that 98% of patients who had a previous femoral access procedure would choose radial access for subsequent procedures. CONCLUSIONS: Transradial access is a safe, effective technique, with a learning curve; however, this procedure has the potential to significantly improve departmental workflow and cost savings for the department and patient experience.

Transradial Approach for Noncoronary Interventions: A Single-Center Review of Safety and Feasibility in the First 1,500 Cases.

PURPOSE: To review safety and feasibility in a single center using transradial access (TRA) for noncoronary interventions. MATERIALS AND METHODS: Retrospective analysis was performed of 946 patients evaluated for 1,531 consecutive TRA procedures from April 2012 to July 2015. Exclusion criteria included sheath > 6 F, Barbeau D waveform, radial artery (RA) diameter < 2 mm on ultrasound, history of severe aortic tortuosity or RA occlusion, and dialysis. TRA was attempted in 936 patients (62% men; median age, 62.4 y) who underwent 1,512 consecutive procedures (chemoembolization [n = 485], yttrium-90 mapping [n = 391] and infusion [n = 293], renal/visceral intervention [n = 172], uterine artery embolization [n = 116], peripheral intervention [n = 43], endoleak repair [n = 10], and other [n = 2]). Patients were evaluated for complications during follow-up at ~30 days. RESULTS: Technical success was 98.2% (1,485/1,512). Major complications (0.13%) included pseudoaneurysm (n = 1) and seizure (n = 1). Minor complications (2.38%) included hematoma/bleeding (n = 13), RA occlusion (n = 11), arm pain (n = 6), and RA spasm (n = 6). Univariate analysis demonstrated a lower rate of adverse events in African American patients (hazard ratio [HR], 0.25; 95% confidence interval [CI], 0.07-0.86; P = .027). Twenty-seven cases (1.8%) required crossover to transfemoral access (TFA). Crossover rates were higher in female patients (P = .0055), height < 1.7 m (P = .024), renal/visceral interventions (P = .0003), and endoleak interventions (P = .0357). Multivariate analysis demonstrated intervention type to be the only significant predictor of TFA crossover (renal/visceral [HR, 4.48; 95% CI, 1.84-10.9; P = .001]; endoleak repair [HR, 9.54; 95% CI, 1.09-83.8; P = .042]). CONCLUSIONS: TRA was safe and well tolerated in a heterogeneous patient population across a range of peripheral vascular interventions.

Outcomes of Radioembolization in the Treatment of Hepatocellular Carcinoma with Portal Vein Invasion: Resin versus Glass Microspheres.

PURPOSE: To compare outcomes of yttrium-90 radioembolization performed with resin-based ((90)Y-resin) and glass-based ((90)Y-glass) microspheres in the treatment of hepatocellular carcinoma (HCC) with associated portal vein invasion. MATERIALS AND METHODS: A single-center retrospective review (January 2005-September 2014) identified 90 patients ((90)Y-resin, 21; (90)Y-glass, 69) with HCC and ipsilateral portal vein thrombosis (PVT). Patients were stratified according to age, sex, ethnicity, Child-Pugh class, Eastern Cooperative Oncology Group status, α-fetoprotein > 400 ng/mL, extent of PVT, tumor burden, and sorafenib therapy. Outcome variables included clinical and laboratory toxicities (Common Terminology Criteria Adverse Events, Version 4.03), imaging response (modified Response Evaluation Criteria in Solid Tumors), time to progression (TTP), and overall survival (OS). RESULTS: Grade 3/4 bilirubin and aspartate aminotransferase toxicities developed at a 2.8-fold (95% confidence interval [CI], 1.3-6.1) and 2.6-fold (95% CI, 1.1-6.1) greater rate in the (90)Y-resin group. The disease control rate was 37.5% in the (90)Y-resin group and 54.5% in the (90)Y-glass group (P = .39). The median (95% CI) TTP was 2.8 (1.9-4.3) months in the (90)Y-resin group and 5.9 (4.2-9.1) months in the (90)Y-glass group (P = .48). Median (95% CI) survival was 3.7 (2.3-6.0) months in the (90)Y-resin group and 9.4 (7.6-15.0) months in the (90)Y-glass group (hazard ratio, 2.6; 95% CI, 1.5-4.3, P < .001). Additional multivariate predictors of improved OS included age < 65 years, Eastern Cooperative Oncology Group status < 1, α-fetoprotein ≤ 400 ng/mL, and unilobar tumor distribution. CONCLUSIONS: Imaging response of (90)Y treatment in patients with HCC and PVT was not significantly different between (90)Y-glass and (90)Y-resin groups. Lower toxicity and improved OS were observed in the (90)Y-glass group.

Transradial Approach for Hepatic Radioembolization: Initial Results and Technique.

OBJECTIVE: The transradial approach (TRA) has been shown to reduce the morbidity and mortality associated with arterial coronary interventions. Selective internal radiation therapy (SIRT) performed via the TRA can enhance patient comfort, compared with the traditional transfemoral approach (TFA), by allowing immediate ambulation and precluding potential complications associated with the TFA, such as closure device injury or retroperitoneal hematoma. We report our initial experience with and technique for using the TRA for SIRT. MATERIALS AND METHODS: Between May 1, 2012, and April 30, 2015, a total of 574 procedures, including planning angiograms (n = 329) and infusions of 90Y (n = 245), were performed for 318 patients (mean age, 64.5 years). Of the 245 patients who received 90Y infusions, 52 had SIRT performed with the use of a permanent single-use implant of 90Y resin microspheres and 193 had SIRT performed with the use of millions of small glass microspheres containing radioactive 90Y. Procedural details, technical success, the radial artery (RA) occlusion rate noted at 30 days (as assessed via pulse examination), and the major and minor adverse events noted at 30 days were evaluated. RESULTS: Technical success was achieved in 561 of 574 cases (97.7%). The reasons for crossover to use of the TFA included an RA loop (n = 2), RA occlusion (n = 9), and type D response as determined by use of a Barbeau test (n = 2). Patients had undergone between zero and six previous TRA procedures. The mortality rate at 30 days was 0%. Superficial bruising occurred in 13 of 574 cases (2.3%). A grade 2 hematoma that required a second nonocclusive hemostasis cuff occurred in one case. Transient forearm numbness or pain occurred in two of 574 cases. One patient had a transient convulsive event occur after receiving intraarterial infusion of verapamil. RA occlusion occurred in nine of 574 cases (1.6%). CONCLUSION: Use of the TRA for SIRT is safe, feasible, and well tolerated and is associated with high rates of technical success and rare complications.

Yttrium-90 Glass-Based Microsphere Radioembolization in the Treatment of Hepatocellular Carcinoma Secondary to the Hepatitis B Virus: Safety, Efficacy, and Survival.

PURPOSE: To evaluate outcomes of yttrium-90 radioembolization performed with glass-based microspheres in the treatment of hepatocellular carcinoma (HCC) secondary to the hepatitis B virus (HBV). MATERIALS AND METHODS: A total of 675 patients treated between January 2006 and July 2014 were reviewed, of which 45 (age 62 y ± 10; 91% male) received glass-based radioembolization for HCC secondary to HBV. All patients were stratified according to previous therapy (naive, n = 14; 31.1%), Child-Pugh class (class A, n = 41; 91%), Eastern Cooperative Oncology Group (ECOG) performance status (PS; < 1, n = 21; 47%), solitary (n = 26; 58%) and unilobar (n = 37; 82%) tumor distribution, tumor size < 5 cm (n = 29; 64%), portal vein thrombosis (n = 14; 31%), α-fetoprotein level > 400 ng/mL (n = 17; 38%), and Barcelona Clinic Liver Cancer stage (A, n = 8; B, n = 9; C, n = 28). RESULTS: A total of 50 radioembolization treatments were performed, with a 100% technical success rate (median target dose, 120 Gy). Clinical toxicities included pain (16%), fatigue (12%), and nausea (4%). Grade 3/4 laboratory toxicities included bilirubin (8%) and aspartate aminotransferase (4%) toxicities. Observed toxicities were independent of treatment dose. The objective response rates were 55% per modified Response Evaluation Criteria In Solid Tumors and 21% per World Health Organization criteria, and the disease control rate was 63%. Disease progression was secondary to new, nontarget HCC in 45% of cases. Median time to progression and overall survival were 6.0 mo (95% confidence interval [CI], 4.4-8.0 mo) and 19.3 mo (95% CI, 11.2-22.7 mo), respectively. Multivariate analysis demonstrated ECOG PS ≥ 1 and AFP level > 400 ng/mL to be independent predictors of inferior overall survival. CONCLUSIONS: Glass-based radioembolization for HCC secondary to HBV can be safely performed, with favorable target lesion response and overall survival.

TIPS for refractory ascites: a 6-year single-center experience with expanded polytetrafluoroethylene-covered stent-grafts.

OBJECTIVE. This single-center study evaluated the use of expanded polytetrafluoroethylene (ePTFE)-covered stent-grafts for transjugular intrahepatic portosystemic shunt (TIPS) placement to manage portal hypertension-related refractory ascites. MATERIALS AND METHODS. One hundred patients at a single tertiary care center in a major metropolitan hospital underwent TIPS placement with an ePTFE-covered stent-graft (Viatorr TIPS Endoprosthesis). Patients with portal hypertension-related ascites and preexisting hepatocellular carcinoma or liver transplant were excluded from the analysis. Records were reviewed for demographic characteristics, technical success of the TIPS procedures, and stent follow-up findings. Clinical results were assessed at 90- and 180-day intervals. RESULTS. Immediate technical success of the TIPS procedure was 100%. Of the 61 patients with documented follow-up, 55 (90.2%) had a partial or complete ascites response to TIPS creation. Of these 55 patients, nine experienced severe encephalopathy. Six of 61 patients (9.8%) did not experience a significant ascites response. Overall survival was 78.7% at 365-day follow-up. The 365-day survival was 84.2% for patients with a model for end-stage liver disease (MELD) score of less than 15, 67.0% for those with a score of 15-18, and 53.8% for those with a score of greater than 18 (p = 0.01). For patients with a MELD score of less than 18, the 365-day survival was 88.0% for those with an albumin value of 3 mg/dL or greater and 72.8% for those with an albumin value of less than 3 mg/dL (p = 0.04). CONCLUSION. TIPS placement using an ePTFE-covered stent-graft is an efficacious therapy for refractory ascites. Patients with preserved liver function-characterized by a MELD score of less than 15 or a MELD score of less than 18 and an albumin value of 3 mg/dL or greater-experience the greatest survival benefit.