Fracture and atypical migration of an implantable central venous access device.

Distal embolization of a fractured indwelling central catheter is a rare complication. The pinch-off syndrome (POS) should be known, prevented and early detected. We present a case in which further radiological exams were required to find the fragmented catheter with an atypical migration, requiring local surgery for removing. After chest and abdominal CT scan, neck X-ray, and heart echography, the catheter was found on the lower limbs X-ray on the internal side of right knee corresponding to a location of saphenous vein. Implanted catheters should be removed after completion of treatment and the integrity of the system should be monitored. To avoid POS, a catheter must be inserted into the subclavian vein as laterally as possible.

Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage.

Acute variceal hemorrhage, a life-threatening condition that requires a multidisciplinary approach for effective therapy, is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy, the presence of large esophageal varices with recent stigmata of bleeding, or fresh blood visible in the stomach with no other source of bleeding identified. Transfusion of blood products, pharmacological treatments and early endoscopic therapy are often effective; however, if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs, transjugular intrahepatic portosystemic shunt (TIPS) is recommended as rescue treatment. The TIPS represents a major advance in the treatment of complications of portal hypertension. Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS, which has a 90% to 100% success rate. However, TIPS is associated with a mortality of 30% to 50% in such a setting. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage, particularly as a rescue therapy following failure of endoscopic approaches.

C-arm dual-phase cone-beam CT: a revolutionary real-time imaging modality to assess drug-eluting beads TACE success in liver cancer patients.

The advent of cone-beam computed tomography (CBCT) in the angiography suite has been revolutionary in interventional radiology. CBCT offers 3 dimensions (3D) diagnostic imaging in the interventional suite and can enhance minimally-invasive therapy beyond the limitations of 2D angiography alone. The role of CBCT has been recognized in transcatheter arterial chemoembolization (TACE) treatment of liver cancer especially with the recent introduction of dual-phase CBCT (DP-CBCT) for unresectable hepatocellular carcinoma (HCC) treatment. Loffroy and colleagues proposed the use of intraprocedural C-arm DP-CBCT immediately after TACE with doxorubicin-eluting beads to predict HCC tumor response at 1-month magnetic resonance (MR) imaging follow-up. They reported a significant relationship between tumor enhancement seen at DP-CBCT after TACE and objective MR imaging response at 1-month follow-up, suggesting that DP-CBCT can be used to predict tumor response after TACE. If confirmed in larger studies, this imaging modality may play a key role in the improvement of treatment planning, especially with regard to the need for repeat treatment. More important, a potential clinical implication of using intraprocedural DP-CBCT in these patients might be elimination of 1-month follow-up MR imaging.

Lipiodol trans-arterial chemoembolization of hepatocellular carcinoma with idarubicin: first experience.

BACKGROUND: There is still no consensus about the best chemotherapeutic agent for transarterial chemoembolization (TACE). A recent in vitro study demonstrated that idarubicin, an anthracycline, was by far the most cytotoxic drug on human hepatocellular carcinoma (HCC) cell lines. Idarubicin is much more lipophilic than doxorubicin, leading to higher cell penetration through lipidic membranes and greater accumulation of the drug in the lipiodol. Furthermore, idarubicin has the ability to overcome multidrug resistance. Therefore, we designed this pilot human study to evaluate the safety and efficacy of lipiodol TACE using idarubicin. METHODS: In 21 consecutive patients treated by lipiodol TACE with idarubicin (10 mg) for HCC, safety data, tumor response (Response Evaluation Criteria in Solid Tumors, mRECIST), time to treatment failure (TTTF), and overall survival were evaluated. RESULTS: Postembolization syndrome was observed after 30.9% (17 of 55) of sessions. No patient died from a TACE-related complication. No hematological grade 3-5 adverse event was observed. At least one grade 3 or higher adverse event occurred in 19% (4 of 21) of patients. On imaging, no progression was encountered; four patients (24%) exhibited stable disease, 12 (57%) exhibited a partial response, and five (19%) exhibited a complete response. Median TTTF was 16.7 months (Kaplan-Meier analysis). At 6 months, 94.7% (95% confidence interval [CI] 68.1-99.2) of patients did not reach treatment failure, whereas treatment failure was not reached in 50.6% (95% CI 21.6-73.9) of patients at 1 year. Overall survival was 83.5% (95% CI 57-94.4) at 1 year. CONCLUSION: Idarubicin seems safe and effective in lipiodol TACE of HCC. This warrants further study to determine the potential of this drug to replace doxorubicin for TACE.

Transthoracic adrenal biopsy procedure using artificial carbon dioxide pneumothorax as outpatient procedure.

Many routes have been described for percutaneous adrenal gland biopsy. They require either a complex non-axial path or a long hydrodissection or even pass through an organ thereby increasing complications. We describe here an approach using an artificially-induced carbon dioxide (CO2) pneumothorax, performed as an outpatient procedure in a 57-year-old woman. Under local anaesthesia, 200 ml of CO2 was injected in the pleural space through a Veress needle under computed tomography fluoroscopy, to clear the lung parenchyma from the biopsy route. Using this technique, transthoracic adrenal biopsy can be performed under simple local anaesthesia as an safely outpatient procedure.

Transcatheter embolization as the new reference standard for endoscopically unmanageable upper gastrointestinal bleeding.

Acute nonvariceal upper gastrointestinal bleeding (UGIB) is a major medical emergency problem associated with significant morbidity and mortality. Endoscopy is considered the first method of choice to detect and treat UGIB. Endoscopic therapy usually achieves primary hemostasis, but 10%-30% of these patients have repeat bleeding. In patients in whom hemostasis is not achieved with endoscopic techniques, treatment with transcatheter angiographic embolization (TAE) or surgery is needed. Surgical intervention is usually an expeditious and gratifying endeavor, but it can be associated with high operative mortality rates. A large number of studies support the use of TAE as salvage therapy as an alternative to surgery. However, few studies have compared the results of TAE with that of emergency surgery in terms of efficiency, the frequency of repeat bleeding, and complications. Recently, Ang et al retrospectively compared the outcome of TAE and surgery as salvage therapy of UGIB after failed endoscopic treatment. There were no significant differences in 30 d mortality, complication rates and length of stay although higher rebleeding rates were observed after TAE compared with surgery. In this commentary, we discuss the advantages and drawbacks of these two therapeutic strategies for UGIB. We also attempt to define the exact role of TAE for acute nonvariceal UGIB.