Hepatocellular carcinoma radiation segmentectomy treatment intensification prior to liver transplantation increases rates of complete pathologic necrosis: an explant analysis of 75 tumors.

PURPOSE: To verify the correlation between yttrium-90 glass microsphere radiation segmentectomy treatment intensification of hepatocellular carcinoma (HCC) and complete pathologic necrosis (CPN) at liver transplantation. METHODS: A retrospective, single center, analysis of patients with HCC who received radiation segmentectomy prior to liver transplantation from 2016 to 2021 was performed. The tumor treatment intensification cohort (n = 38) was prescribed radiation segmentectomy as per response recommendations identified in a previously published baseline cohort study (n = 37). Treatment intensification and baseline cohort treatment parameters were compared for rates of CPN. Both cohorts were then combined for an overall analysis of treatment parameter correlation with CPN. RESULTS: Sixty-three patients with a combined 75 tumors were analyzed. Specific activity, dose, and treatment activity were significantly higher in the treatment intensification cohort (all p < 0.01), while particles per cubic centimeter of treated liver were not. CPN was achieved in 76% (n = 29) of tumors in the treatment intensification cohort compared to 49% (n = 18) in the baseline cohort (p = 0.013). The combined cohort CPN rate was 63% (n = 47). ROC analysis showed that specific activity ≥ 327 Bq (AUC 0.75, p < 0.001), dose ≥ 446 Gy (AUC 0.69, p = 0.005), and treatment activity ≥ 2.55 Gbq (AUC 0.71, p = 0.002) were predictive of CPN. Multivariate logistic regression demonstrated that a specific activity ≥ 327 Bq was the sole independent predictor of CPN (p = 0.013). CONCLUSION: Radiation segmentectomy treatment intensification for patients with HCC prior to liver transplantation increases rates of CPN. While dose strongly correlated with pathologic response, specific activity was the most significant independent radiation segmentectomy treatment parameter associated with CPN.

Radiation Segmentectomy for the Treatment of Solitary Hepatocellular Carcinoma: Outcomes Compared with Those of Surgical Resection.

PURPOSE: To investigate the outcomes of radiation segmentectomy (RS) versus standard-of-care surgical resection (SR). MATERIALS AND METHODS: A multisite, retrospective analysis of treatment-naïve patients who underwent either RS or SR was performed. The inclusion criteria were solitary hepatocellular carcinoma ≤8 cm in size, Eastern Cooperative Oncology Cohort performance status of 0-1, and absence of macrovascular invasion or extrahepatic disease. Target tumor and overall progression, time to progression (TTP), and overall survival rates were assessed. Outcomes were censored for liver transplantation. RESULTS: A total of 123 patients were included (RS, 57; SR, 66). Tumor size, Child-Pugh class, albumin-bilirubin score, platelet count, and fibrosis stage were significantly different between cohorts (P ≤ .01). Major adverse events (AEs), defined as grade ≥3 per the Clavien-Dindo classification, occurred in 0 patients in the RS cohort vs 13 (20%) patients in the SR cohort (P < .001). Target tumor progression occurred in 3 (5%) patients who underwent RS and 5 (8%) patients who underwent SR. Overall progression occurred in 19 (33%) patients who underwent RS and 21 (32%) patients who underwent SR. The median overall TTP was 21.9 and 29.4 months after RS and SR, respectively (95% confidence interval [CI], 15.5-28.2 and 18.5-40.3, respectively; P = .03). Overall TTP subgroup analyses showed no difference between treatment cohorts with fibrosis stages 3-4 (P = .26) and a platelet count of <150 × 109/L (P = .29). The overall progression hazard ratio for RS versus SR was not significant per the multivariate Cox regression analysis (1.16; 95% CI, 0.51-2.63; P = .71). The median overall survival was not reached for either of the cohorts. Propensity scores were calculated but were too dissimilar for analysis. CONCLUSIONS: RS and SR were performed in different patient populations, which limits comparison. RS approached SR outcomes, with a lower incidence of major AEs, in patients who were not eligible for hepatectomy.

Natural History of Incidental Enhancing Nodules on Cone-Beam Computed Tomography during Transarterial Therapy of Hepatocellular Carcinoma.

PURPOSE: To evaluate the natural history of incidental enhancing nodules (IENs) on contrast-enhanced cone-beam computed tomography (CT) during transarterial treatment of hepatocellular carcinoma (HCC). MATERIAL AND METHODS: A single-center retrospective analysis of 100 patients with HCC who underwent contrast-enhanced cone-beam CT prior to transarterial treatment from August 2015 to June 2019 was performed. Inclusion criteria were patients with segmental distribution sublobar HCC, contrast-enhanced cone-beam CT of the target lesion and nontarget liver parenchyma, and follow-up cross-sectional imaging. Patients with IENs ≥3 mm that did not meet imaging criteria for HCC were analyzed. Exclusion criteria included biphenotypic tumors and IEN present inside the treated area of the liver. RESULTS: Fifty-six patients demonstrated 154 IENs on contrast-enhanced cone-beam CT, of which 13 IENs (8.5%) progressed to HCC. The mean primary tumor size was 29 mm (range: 10.2-189 mm). Ten patients had ≥4 IENs, and 46 patients had 1-3 IENs. The mean IEN size was 6.8 mm (range: 3.0-16.3 mm). The median follow-up interval after contrast-enhanced cone-beam CT was 282 days (interquartile range: 143-522). Increased alpha-fetoprotein before treatment (≥15.5 ng/mL, P = .035), having ≥4 IENs (P = .020), and hepatitis C virus (P = .015) were significantly correlated with IEN progression to HCC. No statistically significant differences were identified in baseline neutrophil-to-lymphocyte ratio, targeted HCC characteristics (size, macrovascular invasion, infiltrative pattern, enhancement pattern, and satellite lesions), and IEN size between those with IEN progression to HCC and those without. CONCLUSIONS: Most IENs of ≥3 mm on contrast-enhanced cone-beam CT in patients with segmental distribution sublobar HCC do not progress to HCC. Patients with segmental distribution sublobar HCC with ≥4 IENs, alpha-fetoprotein elevation (≥15.5 ng/mL), or hepatitis C virus have an increased risk of IEN progression to HCC.

Percutaneous direct pancreatic duct intervention in management of pancreatic fistulas: a primary treatment or temporizing therapy to prepare for elective surgery.

BACKGROUND: This study evaluates preliminary results of image-guided percutaneous direct pancreatic duct intervention in the management of pancreatic fistula after surgery or pancreatitis when initially ineligible for surgical or endoscopic therapy. METHODS: Between 2001 and 2018 the medical records of all patients that underwent percutaneous pancreatic duct intervention for radiographically confirmed pancreatic fistula initially ineligible for surgical or endoscopic repair were reviewed for demographics, clinical history, procedure details, adverse events, procedure related imaging and laboratory results, ability to directly catheterized the main pancreatic duct, and whether desired clinical objectives were met. RESULTS: In 10 of 11patients (6 male and 5 female with mean age 60.5, range 39-89) percutaneous pancreatic duct cannulation was possible. The 10 duct interventions included direct ductal suction drainage in 7, percutaneous duct closure in 3 and stent placement in 1. Pancreatic fistulas closed in 7 of 10, 2 were temporized until elective surgery, and 1 palliated until death from malignancy. The single patient with failed duct cannulation resolved the fistula with prolonged catheter drainage of the peri-pancreatic cavity. There were no major adverse events related to intervention. CONCLUSION: In patients with pancreatic fistulas initially ineligible for endoscopic therapy or elective surgery, direct percutaneous pancreatic duct interventions are possible, can achieve improvement without major morbidity or mortality, and can improve and maintain the medical condition of patients in preparation for definitive surgery.

Increasing Yttrium-90 Dose Conformality Using Proximal Radioembolization Enabled by Distal Angiosomal Truncation for the Treatment of Hepatic Malignancy.

PURPOSE: To evaluate safety and feasibility of improving radiation dose conformality via proximal radioembolization enabled by distal angiosomal truncation where selective administration was not practical. MATERIALS AND METHODS: Hepatic malignancies treated via angiosomal truncation between January 2017 and March 2019 were retrospectively evaluated. Thirty-three patients (8 women, 25 men; mean age, 62.2 y; range, 36-78 y) underwent 39 treatments. Of treatments, 74.3% (n = 29) were for hepatocellular carcinomas, 10.2% (n = 4) were for cholangiocarcinomas, and 15.4% (n = 6) were for metastatic tumors (1 colorectal adenocarcinoma, 1 pancreatic adenocarcinoma, 3 melanomas, and 1 endometroid carcinoma). Truncation was achieved using temporary embolic devices including a microvascular plug, detachable coil, gelatin slurry, and balloon microcatheter, after which proximal radioembolization was performed. Range of treatment activity was 0.47-5.75 GBq. Technetium-99m macroaggregated albumin and bremsstrahlung single photon emission computed tomography (CT)/CT threshold analysis was conducted to delineate and compare distribution of activity within the treatment angiosome before and after radioembolization. RESULTS: Dosimetric analysis of 14 patients demonstrated a significant reduction in nontarget liver radiation exposure at 5, 20, and 40% thresholds (P = .002, P = .001, and P = .008, respectively). There were no grade 3 or higher adverse events. There was no significant change in Albumin-Bilirubin grade and Eastern Cooperative Oncology Group Performance Status (P = .09 and P = .74) before and 3 months after the procedure. Truncated arteries were patent on subsequent angiography in 11 cases and on MR angiography or CT angiography in 38 of 39 cases. CONCLUSIONS: Proximal radioembolization enabled by distal angiosomal truncation is safe and decreases nontarget parenchymal radioembolization dose in cases not amenable to selective administration.

Comparison of Bleeding Complications between Transplenic versus Transhepatic Access of the Portal Venous System.

PURPOSE: To evaluate the incidence of bleeding complications between transplenic (TS) and transhepatic (TH) access in portal venous interventions. MATERIALS AND METHODS: Retrospective review of patients who underwent TS or TH access for portal venous system interventions from January 2000 to August 2017. Only procedures with clinical and laboratory follow-up were included (n = 148). Twenty-four TS procedures were performed in 22 patients, and 124 TH procedures were performed in 114 patients. The main indications were for angioplasty/stent, embolization of varices/shunt, or portal vein embolization, with no difference between the groups. Mean patient age and sex were not significantly different between the groups (P values .445 and .682, respectively). Mean follow up was 2.3 years (range 0.1-14.2). There was no significant difference between the international normalized ratio (P = .300) and platelets (P = .234) before the procedure between the 2 cohorts. RESULTS: Technical success of vascular access and procedural success was achieved in 22/24 (91.6%) TS procedures and 120/124 (96.8%) TH procedures (P = .238). There was no significant difference in bleeding complications between the 2 groups (3/24 [12.5%] TS vs 10/124 [8.1%] TH; P = .44). There was no significant difference in major bleeding complications (SIR classification ≥ C; 1/24 [4.2%] TS vs 4/124 [3.2%] TH; P = .789).There was no significant difference in the hemoglobin before or after the procedure (g/dL), with average change -1.1 g/dL (range -3.4 to +1.0) in the TS group and 1.0 g/dL (range -4.5 to +1.9) in the TH group (P = .540). Finally, there was no significant difference in proportion of patients requiring blood transfusion after the procedure (P = .520), with 2 (8.3%) in the TS group requiring an average of 4 units (range 2-6) and 17 (13.7%) in the TH group requiring an average of 3.5 units (range 1-26). CONCLUSIONS: These data suggest no significant difference in bleeding complications between TS and TH access for portal venous interventions.

Single-institution experience of radioembolization with yttrium-90 microspheres for unresectable metastatic neuroendocrine liver tumors.

BACKGROUND AND AIM: The aim of this study was to assess the effectiveness of yttrium-90 (90 Y) microspheres for the treatment of unresectable metastatic liver neuroendocrine tumors (NET). METHODS: From February 2006 to September 2015, 36 patients (19 male and 17 female, age 63.6 ± 9.4 years) who underwent 90 Y therapy for unresectable liver metastases of NET were included and analyzed retrospectively. All patients received a variety of treatments before 90 Y therapy. The radiological response, symptoms improvement of carcinoid syndrome, tumor marker changes, complications, side effects/toxicity, survival, and factors related to survival were evaluated and analyzed. RESULTS: Of the 36 patients, the mean delivered dose of 90 Y was 1.8 ± 0.7 GBq with a total of 40 treatments. Overall disease control rate was 88.9% (32/36) at 3 months following therapy. In 16 patients with carcinoid syndrome, 15 (93.8%) patients had symptomatic improvement. Tumor marker response (5-hydroxyindoleacetic acid [n = 7] and chromogranin A [n = 13]) at 3 months after treatment were as follows: none (n = 0, 4), partial (n = 6, 7), and complete (n = 1, 2). Radiation-induced gastrointestinal ulcers (n = 2, 5.6%) were identified. Side effects included fatigue (n = 31, 86.1%), anorexia (n = 26, 72.2%), nausea (n = 15, 41.7%), vomiting (n = 14, 38.9%), abdominal pain (n = 10, 27.8%), and fever (n = 8, 22.2%). The mean follow-up was 27.0 ± 16.4 months, with a median survival of 41.0 months. Child-Pugh classification (P = 0.008) and lymph node metastases (P = 0.045) had statistically significant influence on overall survival. CONCLUSIONS: Yttrium-90 radioembolization can be effective in the treatment of unresectable liver metastases of NET who failed to respond to other treatments.

Segmental arterial mediolysis: a case of mistaken hemorrhagic pancreatitis and review of the literature.

CONTEXT: Segmental arterial mediolysis is an uncommon, non-atherosclerotic, non-inflammatory arteriopathy that involves areas of dissecting aneurysms and strictures that are caused by outer media lysis of the arterial wall from areas of medial necrosis of uncertain pathogenesis. It has a predilection for splanchnic arteries and often presents as abdominal pain or hemorrhage in late middle-aged and elderly patients. Diagnosis can be established by computed tomography angiography, magnetic resonance angiography, or angiogram by visualizing typical abnormalities, in addition to excluding other vasculitides. Histological confirmation is the gold standard but is not easily accessible and, as such, is not frequently performed. CASE REPORT: Here we present an updated review of the literature and a case of segmental arterial mediolysis that presented with spontaneous intra-abdominal bleeding near the pancreas that was originally misdiagnosed as hemorrhagic pancreatitis. CONCLUSION: Diagnosis is important because immunosuppressants for vasculitis can worsen the arteriopathy. Segmental arterial mediolysis can be self-limiting without treatment or may require urgent surgical or endovascular therapy for bleeding and carries a 50% mortality rate. Therefore, it should be included in the differential of causes of abdominal pain as well as in cases of unexplained abdominal hemorrhage.

Remimazolam As a Sole Sedative Agent for Gastrostomy Tubes Placed in the Interventional Radiology Suite: A Case Series.

Remimazolam is an ultrashort acting intravenous sedative-hypnotic approved for procedural sedation. We report a series of 8 cases of radiographically placed gastrostomy tubes using remimazolam as the sole anesthetic agent. Interventional radiology (IR) gastrostomy tube placement entails anesthetizing often complex patients in a nonoperating room environment. All 8 patients reported here underwent successful gastrostomy tube placement without the need for conversion to general anesthesia. Remimazolam is a feasible option to sedate patients for gastrostomy tube placement in the IR suite.

Histologic Findings of Sinusoidal Dilatation and Congestion in Liver Grafts Do Not Correlate with Hepatic Venous Anastomotic Gradients.

PURPOSE: Hepatic venous transplant anastomotic pressure gradient measurement and transjugular liver biopsy are commonly used in clinical decision-making in patients with suspected anastomotic hepatic venous outflow obstruction. This investigation aimed to determine if sinusoidal dilatation and congestion on histology are predictive of hepatic venous anastomotic outflow obstruction, and if it can help select patients for hepatic vein anastomosis stenting. MATERIALS AND METHODS: This is a single-center retrospective study of 166 transjugular liver biopsies in 139 patients obtained concurrently with transplant venous anastomotic pressure gradient measurement. Demographic characteristics, laboratory parameters, procedure and clinical data, and histology of time-zero allograft biopsies were analyzed. RESULTS: No relationship was found between transplant venous anastomotic pressure gradient and sinusoidal dilatation and congestion (P = 0.92). Logistic regression analysis for sinusoidal dilatation and congestion confirmed a significant relationship with reperfusion/preservation injury and/or necrosis of the allograft at time-zero biopsy (OR 6.6 [1.3-33.1], P = 0.02). CONCLUSION: There is no relationship between histologic sinusoidal dilatation and congestion and liver transplant hepatic vein anastomotic gradient. In this study group, sinusoidal dilatation and congestion is a nonspecific histopathologic finding that is not a reliable criterion to select patients for venous anastomosis stenting.

Are Standardized Video Interviews Useful for Selecting Integrated Interventional Radiology Residents?

The objective of this project is to evaluate the usefulness of the asynchronous or standardized video interview (SVI) for selecting integrated interventional radiology residents. All selected interviewees were asked to provide a brief recorded video answering 2 standardized questions. The applicants were interviewed in the virtual real-time format by 8 interviewers and ranked by group consensus. The SVIs were independently reviewed by a separate group of 4 interviewers and ranked by group consensus. These consensus ranks were compared to each other to determine similarities and differences in rank order. The results show that the SVIs are not statistically reliable as compared to the real-time interviews. There was a trend for an agreement for the lowest tiers in ranking; however, this was not statistically significant. The asynchronous interview is not equivalent to the virtual real-time interview and would not represent an equivalent replacement. However, the SVI may be useful for screening applicants to interview.

Forested watersheds provide the highest water quality among all land cover types, but the benefit of this ecosystem service depends on landscape context.

Conversion of natural land cover can degrade water quality in water supply watersheds and increase treatment costs for Public Water Systems (PWSs), but there are few studies that have fully evaluated land cover and water quality relationships in mixed use watersheds across broad hydroclimatic settings. We related upstream land cover (forest, other natural land covers, development, and agriculture) to observed and modeled water quality across the southeastern US and specifically at 1746 PWS drinking water intake facilities. While there was considerable complexity and variability in the relationship between land cover and water quality, results suggest that Total Nitrogen (TN), Total Phosphorus (TP) and Suspended Sediment (SS) concentrations decrease significantly with increasing forest cover, and increase with increasing developed or agricultural cover. Catchments with dominant (>90 %) agricultural land cover had the greatest export rates for TN, TP, and SS based on SPARROW model estimates, followed by developed-dominant, then forest- and other-natural-dominant catchments. Variability in modeled TN, TP, and SS export rates by land cover type was driven by variability in natural background sources and catchment characteristics that affected water quality even in forest-dominated catchments. Both intake setting (i.e., run-of-river or reservoir) and upstream land cover were important determinants of water quality at PWS intakes. Of all PWS intakes, 15 % had high raw water quality, and 85 % of those were on reservoirs. Of the run-of-river intakes with high raw water quality, 75 % had at least 50 % forest land cover upstream. In addition, PWS intakes obtaining surface water supply from smaller upstream catchments may experience the largest losses of natural land cover based on projections of land cover in 2070. These results illustrate the complexity and variability in the relationship between land cover and water quality at broad scales, but also suggest that forest conservation can enhance the resilience of drinking water supplies.

Outcomes of Radiation Segmentectomy for Hepatocellular Carcinoma in Patients with Non-Alcoholic Fatty Liver Disease versus Chronic Viral Hepatitis.

Purpose: To compare the outcomes of radiation segmentectomy for early-stage hepatocellular carcinoma (HCC) in patients with non-alcoholic fatty liver disease (NAFLD) versus hepatitis C virus (HCV). Materials and Methods: A retrospective analysis of consecutive patients with NAFLD- or HCV-related HCC treated with radiation segmentectomy from 01/2017-06/2022 was performed. Eligibility criteria included solitary tumor ≤8 cm or up to 3 HCC ≤3 cm, ECOG 0-1, and absence of vascular invasion or extrahepatic spread. Imaging best response was assessed per modified Response Evaluation Criteria in Solid Tumors. Target tumor and overall progression, time-to-progression (TTP), and overall survival (OS) were calculated. All outcomes were censored for liver transplantation (LT). Complete pathologic response (CPN) was assessed in patients who underwent LT. Results: Of 142 patients included (NAFLD: 61; HCV: 81), most had cirrhosis (NAFLD: 87%; HCV: 86%) and small tumors (median size NAFLD: 2.3 cm; HCV: 2.5 cm). Patients with NAFLD had higher BMI (p<0.001) and worse ALBI scores (p=0.003). Patients with HCV were younger (p<0.001) and had higher AFP levels (p=0.034). Median radiation dose (NAFLD: 508 Gy; HCV: 452 Gy) and specific activity (NAFLD: 700 Bq; HCV: 698 Bq) were similar between cohorts. Objective response was 100% and 97% in the NAFLD and HCV cohorts, respectively. Target tumor progression occurred in 1 (2%) NAFLD and 8 (10%) HCV patients. Target tumor TTP was not met for either cohort. Overall progression occurred in 23 (38%) NAFLD and 39 (48%) HCV patients. Overall TTP was 17.4 months (95% CI 13.5-22.2) in NAFLD and 13.5 months (95% CI 0.4-26.6) in HCV patients (p=0.86). LT was performed in 27 (44%) NAFLD and 33 (41%) HCV patients, with a CPN rate of 63% and 54%, respectively. OS was not met in the NAFLD cohort and was 53.9 months (95% CI 32.1-75.7) in the HCV cohort (p=0.15). Conclusion: Although NAFLD and HCV are associated with different mechanisms of liver injury, patients with early-stage HCC treated with radiation segmentectomy achieve comparable outcomes.

Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation of Prostate Cancer: A Systematic Review.

Purpose: MRI-guided transurethral ultrasound ablation (TULSA) uses real-time MR thermometry feedback to target prostate disease. We systematically review the literature to synthesize efficacy, functional, and safety outcomes and assess the influence of planned ablation fraction on outcome. Materials and Methods: PubMed, Embase, and the Cochrane Library were searched from inception to June 2021 following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies reporting at least one efficacy, functional, or safety outcome after a single TULSA treatment were included. The relationship of freedom from salvage treatment and potency preservation with planned ablation volume was modeled. Results: Two hundred twenty-four patients were treated in 10 studies with up to a 5-year follow-up, mainly for primary localized prostate cancer (PCa) plus smaller cohorts with recurrent PCa, and locally advanced PCa (LAPC). The prostate-specific antigen decline from baseline up to 2 years, including focal to whole-gland ablation plans, was 54% to 97%. The rate of salvage treatment after one TULSA treatment for primary PCa was 7% to 17%. Continence and potency preservation were from 92% to 100% and from 75% to 98%. Urinary symptoms were stable in men with good voiding function at baseline, and 85% of men with concurrent PCa and lower urinary tract symptoms met the criteria for improvement. Symptom relief in a small cohort of men with LAPC was observed. Grade III adverse events were incurred by 13/224 men (6%), with no rectal injury/fistula or Grade IV complication. The planned ablation fraction was linearly related to salvage-free survival. The relationship between potency preservation and planned ablation fraction followed a sigmoid curve. Conclusions: As an alternative to conventional treatments, TULSA is safe and effective for prostate tissue ablation in men with primary PCa. There is also evidence that TULSA delivers effective relief of urinary symptoms while treating PCa in a single, low-morbidity procedure. The likelihood of freedom from additional treatment or potency preservation is associated with the planned ablation fraction.

Radiation Segmentectomy for the Treatment of Primary Hepatic Malignancies of the Caudate Lobe: A Case Series.

PURPOSE: Tumors involving the caudate lobe present a unique therapeutic challenge due to their complex anatomy and the safety and efficacy of locoregional therapy can be variable. The purpose of this study is to analyze the outcomes of radiation segmentectomy for primary caudate lobe tumors. MATERIALS AND METHODS: Eight patients [5 women and 3 men; median age = 69 y (range 50-79)] that underwent transarterial radioembolization (TARE) using yttrium-90 (Y90) glass microspheres for primary caudate lobe tumors (hepatocellular carcinoma = 6, intrahepatic cholangiocarcinoma = 2) from August 2017 to March 2021 were retrospectively analyzed. Descriptive statistics, treatment parameters, tumor response (using modified response evaluation criteria in solid tumors), adverse events [using common terminology criteria for adverse events (CTCAE)], and survival outcomes were evaluated. RESULTS: Eight primary caudate lobe tumors with a median size of 2.2 cm [interquartile range (IQR), 1.7-3.3] and Child-Pugh class A liver function underwent TARE of the caudate lobe. The median radiation dose was 596 Gy (IQR 356-1585), median total activity was 0.84 GBq (IQR 0.56-1.31), median specific activity was 473 Bq/sphere (IQR 226-671), and the median number of Y90 microspheres used was 1.4 million (IQR 1.2-3.4). All complications were CTCAE grade 1, and no clinically significant hilar plate complications were observed. In targeted tumors, complete response was seen in all patients.  At a median follow-up period of 16.6 months (IQR 6.6-21.6) 75% (6/8) of patients were alive with no in-field progression. CONCLUSION: Radiation segmentectomy of primary caudate lobe tumors appears effective and is well tolerated in this limited case series within the described treatment parameters. LEVEL OF EVIDENCE: Level 4, Case Series.

Iliocaval reconstruction of chronically thrombosed cylindrical inferior vena cava filters with balloon expandable covered stent-grafts.

The use of a Viabahn VBX endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) to exclude chronically thrombosed inferior vena cava (IVC) filters refractory to exclusion with self-expanding stents was evaluated. The mean duration of TrapEase IVC (Cordis, Milpitas, Calif) implantation was 7.6 years (range, 2-11 years). Symptoms included leg pain, edema, color changes, and back pain. The mean Villalta score and venous clinical severity score were 17 (range, 13-23) and 13 (range, 11-15), respectively. Indirect ultrasound evidence of stent patency was demonstrated at a mean of 8 months after intervention. The mean Villalta score and venous clinical severity score had decreased by 13 and 10, respectively, at a mean of 9.5 months after intervention. Iliocaval reconstruction with Viabahn VBX balloon expandable stent-graft exclusion of chronically thrombosed TrapEase IVC filters is safe, with favorable short-term results.