Ablative or Surgical Treatment for Small Renal Masses (T1a): A Single-Center Comparison of Perioperative Morbidity and Complications.

The purpose of this study is to evaluate the treatment safety of thermal ablation compared to surgical treatment of T1a tumors (small renal masses) at a high-volume center. We conducted an observational single-center study based on data collected form the National Swedish Kidney Cancer Register (NSKCR) between 2015 and 2021. In total, 444 treatments of T1a tumors were included. Patients underwent surgery (partial or total nephrectomy) or ablative treatment-radiofrequency ablation (RFA) or microwave ablation (MWA). Patient characteristics were retrieved from patient records, and tumor complexity was estimated from pre-interventional CT scans. The odds ratio (OR) of suffering from a severe surgical complication following ablative treatment was estimated using a logistic regression model adjusted for age, BMI, ASA physical status classification, smoking status and RENAL nephrometry score. The frequency of severe surgical complications was 6.3% (16/256 treatments) after surgical intervention and 2.1% (4/188 treatments) following ablative treatment. Our primary hypothesis that ablative treatment is associated with a lower risk of severe surgical complications is supported by the results (OR 0.39; 0.19-0.79; p = 0.013). When adjusting for age, smoking status, ASA score, BMI score and RENAL nephrometry score, we see an even greater difference between the two groups (OR 0.34; 0.17-0.68; p = 0.002). Our study was limited by the differences in patient and tumor characteristics between the two compared groups and the study design. If oncological outcomes are found to be comparable, ablative treatment should be considered as a first-line treatment for all small renal masses.

Portal vein embolization with N-butyl-cyanoacrylate improves liver hypertrophy compared to microparticles - A Swedish multicenter cohort study.

Background: An adequate future liver remnant (FLR) is fundamental for major liver resections. To achieve sufficient FLR, portal vein embolization (PVE) may be used. The most effective material for PVE has yet to be determined. The aim of this study was to investigate the differences in FLR growth between n-butyl-cyanoacrylate glue (NBCA) and microparticles. Material/methodsa: retrospective study was performed at three Swedish hepatobiliary centers and included patients who underwent PVE 2013-2021. Electronic medical records were reviewed, and procedure-related data were collected. Data were analyzed with respect to embolizing material. Results: A total of 265 patients were included: 160 in the NBCA group and 105 in the microparticle group. The NBCA group had a higher degree of hypertrophy (12.1 vs. 9.4 % points, p = 0.003) and a higher resection rate (68 vs. 59 %, p = 0.01) than the microparticle group. Procedure-related data all indicated the superiority of NBCA. No difference in inducing hypertrophy was observed when comparing patients who received chemotherapy before PVE with those who received chemotherapy before and after PVE within the NBCA group. Discussion/conclusion: This retrospective multicenter study supports the superiority of NBCA compared to microparticles in the setting of PVE. Chemotherapy after PVE does not seem to negatively affect hypertrophy.

Prevalence, management and efficacy of treatment in portal vein obstruction after paediatric liver transplantation: protocol of the retrospective international multicentre PORTAL registry.

INTRODUCTION: Portal vein obstruction (PVO) consists of anastomotic stenosis and thrombosis, which occurs due to a progression of the former. The aim of this large-scale international study is to assess the prevalence, current management practices and efficacy of treatment in patients with PVO. METHODS AND ANALYSIS: The Portal vein Obstruction Revascularisation Therapy After Liver transplantation registry will facilitate an international, retrospective, multicentre, observational study, with 25 centres around the world already actively involved. Paediatric patients (aged <18 years) with a diagnosed PVO between 1 January 2001 and 1 January 2021 after liver transplantation will be eligible for inclusion. The primary endpoints are the prevalence of PVO, primary and secondary patency after PVO intervention and current management practices. Secondary endpoints are patient and graft survival, severe complications of PVO and technical success of revascularisation techniques. ETHICS AND DISSEMINATION: Medical Ethics Review Board of the University Medical Center Groningen has approved the study (METc 2021/072). The results of this study will be disseminated via peer-reviewed publications and scientific presentations at national and international conferences. TRIAL REGISTRATION NUMBER: Netherlands Trial Register (NL9261).

[Microwave ablation of the spleen: An easy and gentle method for treatment of secondary splenomegaly in children. A case report]. / Mikrovågsablation ­ en skonsam metod vid splenomegali hos barn.

Portal hypertension (PHT) in children may be caused by many different liver and vascular diseases and can lead to life threatening complications such as splenomegaly with thrombocytopenia. The treatment of choice for symptomatic splenomegaly is Partial Splenic Embolization (PSE) which is effective but painful, and therefore not offered to children younger than 10 years of age at the Karolinska University Hospital in Stockholm.  Percutaneous microwave ablation (MWA) is a well-established method in adults for the treatment of tumors in the liver and other organs. It has been used for the treatment of secondary splenomegaly in adults, but to the best of our knowledge MWA for treatment of pediatric splenomegaly has not been studied. We present a successful case report of MWA of the spleen in a young boy with splenomegaly and thrombocytopenia due to liver cirrhosis and PHT.

Mortality with Paclitaxel-Coated Devices in Peripheral Artery Disease.

BACKGROUND: The results of a recent meta-analysis aroused concern about an increased risk of death associated with the use of paclitaxel-coated angioplasty balloons and stents in lower-limb endovascular interventions for symptomatic peripheral artery disease. METHODS: We conducted an unplanned interim analysis of data from a multicenter, randomized, open-label, registry-based clinical trial. At the time of the analysis, 2289 patients had been randomly assigned to treatment with drug-coated devices (the drug-coated-device group, 1149 patients) or treatment with uncoated devices (the uncoated-device group, 1140 patients). Randomization was stratified according to disease severity on the basis of whether patients had chronic limb-threatening ischemia (1480 patients) or intermittent claudication (809 patients). The single end point for this interim analysis was all-cause mortality. RESULTS: No patients were lost to follow-up. Paclitaxel was used as the coating agent for all the drug-coated devices. During a mean follow-up of 2.49 years, 574 patients died, including 293 patients (25.5%) in the drug-coated-device group and 281 patients (24.6%) in the uncoated-device group (hazard ratio, 1.06; 95% confidence interval, 0.92 to 1.22). At 1 year, all-cause mortality was 10.2% (117 patients) in the drug-coated-device group and 9.9% (113 patients) in the uncoated-device group. During the entire follow-up period, there was no significant difference in the incidence of death between the treatment groups among patients with chronic limb-threatening ischemia (33.4% [249 patients] in the drug-coated-device group and 33.1% [243 patients] in the uncoated-device group) or among those with intermittent claudication (10.9% [44 patients] and 9.4% [38 patients], respectively). CONCLUSIONS: In this randomized trial in which patients with peripheral artery disease received treatment with paclitaxel-coated or uncoated endovascular devices, the results of an unplanned interim analysis of all-cause mortality did not show a difference between the groups in the incidence of death during 1 to 4 years of follow-up. (Funded by the Swedish Research Council and others; ClinicalTrials.gov number, NCT02051088.).

The cholinergic anti-inflammatory pathway in resistant hypertension treated with renal denervation.

BACKGROUND: Renal denervation (RDN) reduces sympathetic tone and may alter the sympathetic-parasympathetic balance. The autonomic nervous system is partly a regulator of innate immunity via the cholinergic anti-inflammatory pathway (CAP) which inhibits inflammation via the vagus nerve. Placental Growth Factor (PlGF) influences a neuro-immunological pathway in the spleen which may contribute to hypertension. The aim of this study was to investigate if modulation of renal sympathetic nerve activity affects CAP in terms of cytokine release as well as levels of PlGF. METHODS: Ten patients treated with RDN (Medtronic Inc), were analyzed for TNF, IL-1b and IL-10 and Lipopolysaccharide (LPS)-stimulated cytokine release before RDN, 1 day after and at 3- and 6-months follow-up. Four patients who underwent elective coronary angiography served as disease controls (DC). RESULTS: Baseline TNF was significantly lower 1 day after RDN (p = 0.03). LPS-stimulated (0, 10 and 100 ng/mL) TNF and IL-1b were significantly lower 1 day after RDN (TNF p = 0.0009, p = 0.0009 and p = 0.001, IL-1b; p = 0.0001, p = 0.002 and p = 0.005). IL-10 was significantly higher one day after RDN (p = ns, p = 0.02 and p = 0.01). These differences however declined during follow up. A more marked TNF reduction was achieved with a cholinergic analogue, GTS-21, in LPS-stimulated whole blood as compared with samples without GTS-21. Cytokine levels in controls did not differ before and 1 day after coronary angiography. PlGF was significantly higher in RDN patients and DC compared with healthy controls but did not change during follow-up. CONCLUSION: RDN has an immediate effect on TNF in vivo and cytokine release ex vivo but seems to wane over time suggesting that current RDN techniques may not have long-lasting immunomodulatory effect. Repeated and extended stimulation of CAP in resistant hypertension by targeting neural circuits may be a potential therapeutic strategy for treatment of both hypertension and inflammation.

Multimodality imaging of the Meso-Rex bypass.

Extrahepatic portal vein obstruction (EHPVO) is the most common cause of upper gastrointestinal bleeding in children. It is defined as thrombosis of the extrahepatic portal vein with or without extension to the intrahepatic portal veins. The Meso-Rex shunt is the gold standard treatment in children with favorable anatomy since it restores physiological portal liver reperfusion. This is achieved by rerouting the splanchnic venous blood through an autologous graft from the superior mesenteric vein (SMV) into the Rex recess of the left portal vein, curing portal hypertension by doing so. General and hepatobiliary radiologists must be familiar with multimodality imaging appearances of EHPVO and with the role of imaging in identifying suitable candidates for Meso-Rex bypass surgery. Imaging might also detect complications of this procedure, some of which might be treated via interventional radiology.

Temporal and Morphological Patterns Predict Outcome of Endovascular Repair in Acute Complicated Type B Aortic Dissection.

OBJECTIVES: The aim was to analyse early and late outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR) for acute or subacute non-traumatic type B aortic dissection (TBAD), with the particular aims of identifying prognostic morphological predictors, and to assess the magnitude of the impact of the timing of TEVAR. METHODS: This was a retrospective, two centre, population based consecutive case series. The study group consisted of all the 53 patients undergoing TEVAR for complicated TBAD in Stockholm during the 12 year period 2004-2015. Demographic data, risk factors, operative, and outcome variables were registered and analysed. The CT scans were thoroughly retrospectively examined. RESULTS: Nearly half (24 patients; 45%) underwent TEVAR within 48 h of the onset of the initial symptoms, another 20 within 2 weeks, and nine in the subacute phase (15-90 days). The median age was 63 years (range 32-88) and 20 patients (38%) were women. The 30 day mortality was 17% (nine patients). Eight of these nine patients were treated within the first 48 h; urgent intervention (0-48 h) was associated with increased mortality (crude OR 14.0; 95% CI 1.6-122). All the nine patients had a false lumen area (FLA) at the level of the tracheal bifurcation exceeding 50% of the aortic cross sectional area at that segment, a finding significantly associated with increased mortality (p = .04), with a 25% 30 day mortality if the FLA > 50% (n = 36) at that segment, but 0% if the FLA was <50%. Overall the one year survival was 79% and five year survival 65%. CONCLUSIONS: All the early deaths demonstrated a FLA >50% of the total aortic cross sectional area at the level of the tracheal bifurcation. Patients needing urgent TEVAR had markedly worse outcome. The first finding may become an additional tool for future risk stratification.

The importance of the costoclavicular space in upper limb primary deep vein thrombosis, a study with magnetic resonance imaging (MRI) technique enhanced by a blood pool agent.

BACKGROUND: Primary upper extremity deep vein thrombosis (UEDVT) can be divided into idiopathic and effort thrombosis. Anatomical factors probably play an important role in effort thrombosis, whereas the cause remains mostly unknown in idiopathic thrombosis. OBJECTIVES: The primary objective of this study was to examine the anatomy of the subclavian region and evaluate how these factors contribute to primary UEDVT. The secondary objective was to investigate if venous compression correlates with post thrombotic syndrome (PTS). PATIENTS AND METHODS: Fifteen patients and 15 controls were enrolled in the study. The subclavian region (the costoclavicular distance and vessel area) was examined by MRI enhanced by a blood-pool contrast agent (Vasovist). The MRI was performed in two arm positions: alongside and elevated. PTS and disability were quantified with the modified Villalta score and the Disability of the Arm, Shoulder and Hand (DASH) test. RESULTS: The costoclavicular distance was significantly narrower in the UEDVT patients with the arms alongside the body but there was a significant difference only in the left arm with the arms elevated. Area of the subclavian vein: When comparing the patients non-thrombotic arm with the controls, there was a significant difference only when the arms in the supine position. Disability: There was a high correlation between DASH, Villalta and VAS but no correlation between the MRI measurement and patient's symptoms or the Villalta Score. CONCLUSION: Our results suggest that primary UEDVT is dependent on the subclavian anatomy and area of vena subclavia.

Outcome after nitinol stenting in the superficial femoral and popliteal artery in an elderly population.

BACKGROUND: To assess outcomes in an elderly and diseased population after stenting in the femoropopliteal segment and evaluate risk factors for poor prognosis. METHODS: Retrospective study of femoropopliteal stents placed between March 2006 and January 2008. Patency was verified by duplex scanning. Risk factors associated with amputation or death and patency were analyzed using Cox regression. RESULTS: A total of 117 limbs in 112 patients were observed for a median of 18 months. Median age of the patients was 79 years; 68% were treated for critical limb ischemia and 85% had occlusive lesions. Mean lesion length was 15.4 cm (SD: 9.2) and mean stented length was 19.7 cm (standard deviation: 9.8). At 1 year, primary patency was 63%, primary-assisted patency was 67%, and secondary patency was 69%. Stent diameter ≤6 versus 7 mm was a risk factor for loss of patency with a hazard ratio (HR) of 2.9 (95% CI: 1.1-7.7). Significant risk factors for death or amputation were as follows: HR for rest pain versus claudication was 5.9 (1.1-32.8), HR for tissue loss versus claudication was 5.8 (1.1-29.6), HR for stent diameter ≤6 versus 7 mm was 3.6 (1.0-12.3), and HR for 3-4 stents versus 1-2 was 2.6 (1.1-6.1). CONCLUSION: Rutherford status is associated with death or amputation after stenting in the femoropopliteal segment. In addition, a smaller stent diameter and number of stents depict poorer prognosis independent of gender and anatomic level.

Should blunt arterial trauma to the extremities be treated with endovascular techniques?

Endovascular techniques are making progress in most aspects of vascular disease. Penetrating or blunt trauma to large arteries can in many cases be managed elegantly with endovascular techniques. However when it comes to arterial trauma of the extremities things are more complicated. There are no reports hitherto in the literature on endovascular treatment of blunt injuries to the arteries of the extremities. In the present report we describe two cases of blunt trauma to the brachial artery treated with balloon angioplasty (PTA) to fixate the dissected intima to the vessel wall. The "glueing" was effective in giving a long lasting patency.We anticipate that there may be a role, though limited, for using PTA as a means of "glueing" the intima. More advanced techniques such as insertion of stents or stent-grafts in traumatized extremity arteries would rarely be indicated.

Preserved pelvic circulation after stent-graft treatment of complex aortoiliac artery aneurysms: a new approach.

PURPOSE: To describe an endovascular technique that allows stent-graft treatment of aortoiliac aneurysmal disease affecting both common iliac arteries (CIA), with maintenance of pelvic circulation on one side. TECHNIQUE: For patients with aortoiliac aneurysms, both common femoral arteries (CFA) were surgically exposed. One internal iliac artery (IIA) was initially embolized with coils. A bifurcated stent-graft main body was deployed with the proximal end just below the renal arteries. On the ipsilateral side, the stent-graft limb was extended 3 cm beyond the orifice of the embolized IIA into the external iliac artery (EIA) using stent-graft limb extenders. On the contralateral side, the stent-graft limb was deployed so that the distal end was 10 to 15 mm proximal to the patent IIA orifice. Via a left brachial artery access, the IIA was catheterized, and stent-grafts were deployed from the distal end of the contralateral AAA stent-graft limb into the IIA. A femorofemoral crossover graft provided circulation to the leg ipsilateral to the IIA stent-graft, and the EIA on the same side was ligated. The technique can also be modified to treat isolated bilateral CIA aneurysms. CONCLUSIONS: By extending the distal aspect of the stent-graft into an IIA, bilateral CIA aneurysms can be excluded while preserving pelvic circulation on one side.

[Thoracic and abdominal aorta aneurysms demand an experienced team work]. / Aneurysm i bröst- och bukaorta kräver vältrimmat lagarbete.

Patients with combined aneurysms in the thoracic and abdominal aorta need to be treated at experienced centres. These complicated aneurysms are today treated with various combinations of open and/or endovascular techniques. The complexity of the interventions is associated with high morbidity and mortality. By forming a structured organisation for care of these patients a better outcome can be expected. In this article we present the approach taken in Göteborg to meet these challenges.

Management of aneurysm sac hygroma.

PURPOSE: To document the management strategies and outcome of patients diagnosed with sac hygroma following open or endovascular abdominal aortic aneurysm (AAA) repair. METHODS: Seven men (median 68 years, range 43-79) with previous open (n=3) or endovascular (n=4) AAA repairs and increasing aneurysm diameters documented on spiral computed tomography (CT) were diagnosed with sac hygroma based on the lack of a demonstrable endoleak on CT imaging; the presence of a gelatinous, clear fluid in the sac; and a nonpulsatile sac pressure that was about one third of the systemic blood pressure. The patients were followed at regular intervals with spiral CT and percutaneous CT-guided translumbar intrasac pressure measurements. Surgical interventions were performed for sac diameter increase >5 mm or expansion-related pain. Blood samples and fluid aspirated from the sac were analyzed to detect activation of the coagulation and fibrinolytic systems. RESULTS: Over a median 21.5-month follow-up, open fenestration with resection of the aneurysm wall or open tight wrapping of the wall around the graft in 4 patients did not prevent hygroma reoccurrence, nor did repeated punctures with aspiration of fluid in the other 3 patients. Aneurysm diameters remained unchanged during the observation period. CONCLUSIONS: Only symptomatic hygromas need be treated, but the treatment of choice remains to be established, since puncture, fenestration, or resection of the sac do not seem to be adequate.

Transhepatic placement of an enteral stent to treat jaundice in a tumor recurrence obstructed afferent loop after a whipple procedure.

Tumour recurrence that obstructs the afferent limb, blocking outflow of bile and pancreatic juice, constitutes a major clinical problem after a Whipple procedure. The endoscopic route is often not a possible alternative. Surgery may be difficult and perhaps dangerous to the often very sick patient and decompression with fine bore catheters may lead to cholangitis. External drainage is inconvenient to the patient. The present case describes a less invasive method to provide adequate drainage of the obstructed jejunal limb by insertion of a 22-mm enteral Wallstent transhepatically. The patient became and stayed anicteric during 7 months' follow-up.

Endovascular treatment of type B thoracic aortic dissections.

PURPOSE: To evaluate the initial experience of endovascular repair of aortic dissections from a single center. MATERIALS AND METHODS: From June 1999 to March 2002, endovascular stent grafting was performed in 20 high-risk patients (16 to 80 years). Eighteen patients had a type B dissection (14 acute and 4 chronic). Two patients had chronic type A dissection. Preoperative work-up included CT and MRI to evaluate the extent of the dissection, the relation to the left subclavian artery, the size of false and true lumen, and branch complications. RESULTS: Stent-graft deployment was technically successful in all cases. None was converted to open repair. Three patients died within 30 days, i.e., a 15% mortality rate. Four patients (20%) had a perioperative stroke. Paraplegia was observed in one case. No migration of the stent grafts or endoleaks was observed during the mean follow-up period of 13 months. In all but two patient thrombosis of the false lumen was noted. CONCLUSIONS: Endovascular treatment of thoracic dissections is feasible. Early results are encouraging. While endovascular repair with stent-grafts is progressing rapidly as a viable strategy for aortic dissections in selected patients careful investigations must continue to focus on its safety. Randomized controlled trials are urgently needed.