90Y Radioembolization versus Drug-eluting Bead Chemoembolization for Unresectable Hepatocellular Carcinoma: Results from the TRACE Phase II Randomized Controlled Trial.

Background Transarterial chemoembolization (TACE) is the recommended treatment for intermediate hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer guidelines. Prospective uncontrolled studies suggest that yttrium 90 (90Y) transarterial radioembolization (TARE) is a safe and effective alternative. Purpose To compare the efficacy and safety of TARE with TACE for unresectable HCC. Materials and Methods In this single-center prospective randomized controlled trial (TRACE), 90Y glass TARE was compared with doxorubicin drug-eluting bead (DEB) TACE in participants with intermediate-stage HCC, extended to Eastern Cooperative Oncology Group performance status 1 and those with early-stage HCC not eligible for surgery or thermoablation. Participants were recruited between September 2011 and March 2018. The primary end point was time to overall tumor progression (TTP) (Kaplan-Meier analysis) in the intention-to-treat (ITT) and per-protocol (PP) groups. Results At interim analysis, 38 participants (median age, 67 years; IQR, 63-72 years; 33 men) were randomized to the TARE arm and 34 (median age, 68 years; IQR, 61-71 years; 30 men) to the DEB-TACE arm (ITT group). Median TTP was 17.1 months in the TARE arm versus 9.5 months in the DEB-TACE arm (ITT group hazard ratio [HR], 0.36; 95% CI: 0.18, 0.70; P = .002) (PP group, 32 and 34 participants, respectively, in each arm; HR, 0.29; 95% CI: 0.14, 0.60; P < .001). Median overall survival was 30.2 months after TARE and 15.6 months after DEB-TACE (ITT group HR, 0.48; 95% CI: 0.28, 0.82; P = .006). Serious adverse events grade 3 or higher (13 of 33 participants [39%] vs 19 of 36 [53%] after TARE and DEB-TACE, respectively; P = .47) and 30-day mortality (0 of 33 participants [0%] vs three of 36 [8.3%]; P = .24) were similar in the safety groups. At the interim, the HR for the primary end point, TTP, was less than 0.39, meeting the criteria to halt the study. Conclusion With similar safety profile, yttrium 90 radioembolization conferred superior tumor control and survival compared with chemoembolization using drug-eluting beads in selected participants with early or intermediate hepatocellular carcinoma. Clinical trial registration no. NCT01381211 © RSNA, 2022 Online supplemental material is available for this article.

Empiric cone-beam CT-guided embolization in acute lower gastrointestinal bleeding.

OBJECTIVES: To evaluate the clinical effect and safety of cone-beam CT (CBCT)-guided empirical embolization for acute lower gastrointestinal bleeding (LGIB) in patients with a positive CT angiography (CTA) but subsequent negative digital subtraction angiography (DSA). METHODS: A retrospective study of consecutive LGIB patients with a positive CTA who received a DSA within 24 h from January 2008 to July 2019. Patients with a positive DSA were treated with targeted embolization (TE group). Patients with a negative DSA underwent an empiric CBCT-guided embolization of the assumed ruptured vas rectum (EE group) or no embolization (NE group). Recurrent bleeding, major ischemic complications, and in-hospital mortality were compared by means of Fisher's exact test. Further subgroup analysis was performed on hemodynamic instability. RESULTS: Eighty-five patients (67.6 years ± 15.7, 52 men) were included (TE group, n = 47; EE group, n = 19; NE group, n = 19). If DSA was positive, technical success of targeted embolization was 100% (47/47). If DSA was negative and the intention to treat by empiric CBCT-guided embolization, technical success was 100% (19/19). Recurrent bleeding rates in the TE group, EE group, and NE group were 17.0% (8/47), 21.1% (4/19), and 52.6% (10/19) respectively. Empiric CBCT-guided embolization reduced rebleeding significantly in patients with a negative DSA and hemodynamic instability (EE group, 3/10 vs NE group, 10/12, p = .027). Major ischemic complications occurred in one patient (TE group). Overall, the in-hospital mortality rate was 7.1% (6/85). CONCLUSION: Empiric cone-beam CT-guided embolization proved to be a feasible, effective, and safe treatment strategy to reduce rebleeding and improve clinical success in hemodynamically unstable patients with acute LGIB, positive CTA but negative DSA. KEY POINTS: • A novel transarterial embolization technique guided by cone-beam CT could be developed extending the "empiric" embolization strategy to lower gastrointestinal bleeding. • By implementing the empiric treatment strategy, nearly all patients with an active lower gastrointestinal bleeding on CTA will be eligible for a superselective empiric embolization, even if subsequent catheter angiography is negative. • In patients with a negative catheter angiography, empiric embolization reduces the rebleeding rate and, particularly in hemodynamically unstable patients, improves clinical success compared with a conservative "wait-and-see" management.

Moyamoya Disease Revealed by Ruptured Intraventricular Aneurysm.

Teaching point: Narrowing and occlusion of the distal carotids in Moyamoya causes a change in blood flow dynamics, increasing the risk for intracranial aneurysm formation.

Correction to: No evidence of improved efficacy of covered stents over uncovered stents in percutaneous palliation of malignant hilar biliary obstruction: results of a prospective randomized trial.

On request from the Editors, the authors would like to clarify the following: the patient cohorts in the publications "No evidence of improved efficacy of covered stents over uncovered stents in percutaneous palliation of malignant hilar biliary obstruction: results of a prospective randomized trial".

CT Perfusion as a Selection Tool for Mechanical Thrombectomy, a Single-Centre Study.

BACKGROUND: Recently, CT perfusion (CTP) has been proposed as a selection tool for stroke patients to be treated with endovascular thrombectomy. We investigated whether functional outcome following endovascular treatment was improved after the introduction of CTP. METHODS: This retrospective single-centre study includes all patients with a major vessel occlusion in the anterior circulation that received a CTP and underwent a mechanical thrombectomy from 2014 up to 2015. CTP were visually evaluated. Demographics, stroke and time data, procedural data, functional outcomes as measured by the modified Rankin Scale (mRS) and the association between these variables were studied. A comparison was made with the results of a similar local retrospective study from before the CTP "era". RESULTS: Eighty-nine patients were included in this study. Median National Institutes of Health Stroke Scale (NIHSS) was 16 (Interquartile range 6). At three months, good functional outcome (GFO; mRS 0-2) was achieved in 48.4% and excellent functional outcome (EFO; mRS 0-1) in 34.4% of patients. The mortality rate at three months was 14.5%. GFO at one year was 44.8%, EFO was 31.3% and mortality 21.1%. The duration of the thrombectomy procedure and the EFO were associated (p = 0.032). The outcome improvement achieved with CTP was higher compared to the reference study (GFO 48.4% versus 44%; EFO 34.4% versus 29%) but remained below the statistical significance. CONCLUSIONS: Mechanical thrombectomy for anterior circulation strokes based on CTP did not result in a significant functional outcome improvement. The duration of the thrombectomy procedure was the sole time-interval related to improved functional outcome.

No evidence of improved efficacy of covered stents over uncovered stents in percutaneous palliation of malignant hilar biliary obstruction: results of a prospective randomized trial.

OBJECTIVE: To investigate whether covered stents show a higher efficacy than uncovered stents in percutaneous treatment of malignant hilar biliary obstruction. METHODS: Patients with obstructive jaundice caused by an unresectable hilar malignancy were included after failed endoscopic intervention in a prospective randomized trial comparing expanded polytetrafluoroethylene and fluorinated ethylene propylene (ePTFE-FEP)-covered nitinol stents with uncovered nitinol stents. Exclusion criteria were as follows: primary tumors existing more than 3 months, a biliodigestive anastomosis, previous stenting, and a Karnofsky score of less than 50. Safety, clinical success, and adjuvant chemotherapy were compared as well as occlusion rate, patency, and survival. RESULTS: A total of 120 patients were included. One patient was post hoc excluded. Fourteen patients who died within 7 days and one patient without patency data were excluded from patency analysis. Serious adverse events (p = 0.4), 30-day mortality (p = 0.5), and clinical success (p = 0.8) were equivalent for both stent groups. Twenty-one out of 61 (34%) patients in the covered and 24/58 (41%) in the uncovered stent groups received adjuvant chemotherapy (p = 0.5). Occlusion rate was 54% (27/50) in the covered stent group and 57% (31/54) in the uncovered stent group (p = 0.8). Median patency was 229 days (95% CI 113-345) for covered stents and 130 days (95% CI 75-185) for uncovered stents (p = 0.1). Median survival in patients with covered stents was 79 days (95% CI 52-106) and with uncovered stents 92 days (95% CI 60-124) (p = 0.3). CONCLUSION: In malignant hilar biliary obstruction, there is no evidence that ePTFE-FEP-covered stents are superior to uncovered stents in terms of safety, clinical success, adjuvant chemotherapy, patency, or survival. KEY POINTS: • Percutaneous palliation of hilar biliary obstruction is feasible with both uncovered and covered stents. • Clinical success in terms of bilirubin decrease and adjuvant chemotherapy is achievable with both stents. • Thirty-day mortality is considerable when stenting is also offered to patients with a low performance status.

No Advantage of Expanded Polytetrafluoroethylene and Fluorinated Ethylene Propylene-Covered Stents over Uncovered Nitinol Stents for Percutaneous Palliation of Malignant Infrahilar Biliary Obstruction: Results of a Single-Center Prospective Randomized Trial.

PURPOSE: To prove that covered stents are more efficacious than uncovered stents regarding patency, safety, enabling of chemotherapy, and survival in percutaneous palliation of malignant infrahilar biliary obstruction. MATERIALS AND METHODS: After failed endoscopic treatment, 154 patients with obstructive jaundice caused by unresectable infrahilar malignancy were randomly allocated to receive an expanded polytetrafluoroethylene and fluorinated ethylene propylene-covered or an uncovered nitinol stent. Occlusion rate, patency, and survival were assessed. Safety and clinical success in terms of chemotherapy were compared. RESULTS: Three patients were excluded post hoc. Fifteen patients died within 7 d and were excluded from patency analysis. Occlusion rates were 32% (21 of 66) for covered and 29% (20 of 70) for uncovered stents (P = .7). Estimated median patency durations were 308 d (95% confidence interval [CI], 178-438 d) for covered and 442 d (95% CI, 172-712 d) for uncovered stents (P = .1). Serious adverse events (P = 1.0) and 30-day mortality (P = .5) were equivalent between groups. At hospital discharge, median bilirubin reduction of 8 mg/dL was found in both groups (P < .001). In the covered stent group, 35 patients (48%) received palliative chemotherapy, vs 29 (37%) in the uncovered stent group (P = .2). Estimated median survival times were 96 days (95% CI, 68-124 d) with covered stents and 75 days (95% CI, 42-108 d) with uncovered stents (P = .6). CONCLUSIONS: In malignant infrahilar biliary obstruction not amenable to endoscopy, no improvement in patency or survival with percutaneously placed covered stents could be confirmed. Covered and uncovered stent types exhibit similar safety profiles and clinical success rates.

Benign anastomotic biliary strictures untreatable by ERCP: a novel percutaneous balloon dilatation technique avoiding indwelling catheters.

OBJECTIVE: To evaluate long-term patency rates of a novel percutaneous threefold balloon dilatation protocol in benign anastomotic biliary strictures. METHODS: Patients with a benign biliary stricture after hepatobiliary surgery or liver transplantation, untreatable with endoscopy, underwent a percutaneous treatment cycle consisting of a 20-min balloon dilatation session on day one, repeated on days three and five. No catheters were left behind after the last dilatation session. Technical and clinical success as well as complications were analysed. Mean primary and secondary patency times were assessed. Cumulative primary and secondary patency rates at 6 months and 1, 2 and 3 years were determined. RESULTS: Seventy patients underwent 135 dilatation treatment cycles (mean 1.9) with a technical success rate of 99%. Clinical success was achieved in 87% of the patients. Fifty-eight of 135 (43%) patients had minor and 15/135 (11%) had major complications. Mean primary and secondary patency times were 26 months and 46 months, respectively, with a median follow-up of 69 months. Cumulative primary patency rate at 6 months was 67%, at 1 year 56%, at 2 years 41% and at 3 years 36%. The cumulative secondary patency rate at 6 months was 83%, at 1 year 79%, at 2 years 70% and at 3 years 64%. CONCLUSION: In benign anastomotic biliary strictures, a percutaneous threefold balloon dilatation treatment is effective. As long indwelling catheters are avoided, patient comfort improves. KEY POINTS: • Percutaneous threefold balloon dilatation treatment is effective in benign anastomotic biliary strictures. • As indwelling catheters after dilatation are avoided, patient comfort improves. • The dilatation protocol can be repeated efficiently in case of recurrent stricture.

Contribution to the Pathophysiology and Treatment of Varicoceles.

Anatomical differences between adults and adolescents and between left and right varicoceles were shown in this work. We designed a standardized and reproducible method for pressure measurement in the inguinal internal spermatic vein (ISV). We demonstrated that the mean absolute pressure in the ISV in the upright position is higher than the veno-capillary pressure in the testicle, and hence could impair spermatogenesis prompting the need for treatment in varicoceles. Histoacryl transparent and Glubran2, the current commercially available adhesives for the treatment of varicoceles, do not differ with regard to efficiency, safety and tolerance during and after embolization. Both adhesives cause a mild pain in 30% of the patients in the week after embolization. The radiation exposure is low during embolizations of varicoceles with highly viscous liquid products. Therefore, the endovascular treatment with glue is an efficient, safe and tolerable method of treatment for varicoceles when applicable.

Model for end-stage liver disease score and hemodynamic instability as a predictor of poor outcome in early transjugular intrahepatic portosystemic shunt treatment for acute variceal hemorrhage.

OBJECTIVE: To evaluate the outcome of early transjugular portosystemic shunt (TIPS) treatment in patients with a trial-compatible high-risk variceal bleeding and secondly to disclose other predictors of early mortality. MATERIALS AND METHODS: A cohort study was conducted on patients referred for a TIPS procedure with or without combined variceal embolization to control acute esophageal variceal bleeding. A total of 32 patients with Child-Pugh C score less than 14 or Child-Pugh B plus active bleeding at endoscopy, admitted for early-TIPS treatment (<72 h), were included. RESULTS: We noted one (3.7%) failure to control bleeding and no rebleeding during 1-year follow-up. Ten (31.3%) patients died within 6 weeks after TIPS placement. Early mortality was associated with model for end-stage liver disease (MELD) score (P=0.025), MELD score of at least 19 (P=0.008) and hemodynamic instability at time of admission (P=0.001). If hemodynamic instability is associated with a high MELD score, the 6-week mortality peaks at 77.8% (P=0.000). CONCLUSION: This study confirms the excellent survival results of early-TIPS treatment for acute variceal bleeding in a selected patient group with a low MELD score. Poor survival in hemodynamically unstable patients with high MELD scores (≥19) contests the guidelines that patients with Child-Pugh class C cirrhosis or Child-Pugh class B with active bleeding on endoscopy should deliberately receive preemptive TIPS treatment after endoscopic haemostasis.

Unruptured Brain Arteriovenous Malformations: Primary ONYX Embolization in ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations)-Eligible Patients.

BACKGROUND AND PURPOSE: In light of evidence from ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations), neurovascular specialists had to reconsider deliberate treatment of unruptured brain arteriovenous malformations (uBAVMs). Our objective was to determine the outcomes of uBAVM treated with primary embolization using ethylene vinyl alcohol (ONYX). METHODS: Patients with uBAVM who met the inclusion criteria of ARUBA and were treated with primary Onyx embolization were assigned to this retrospective study. The primary outcome was the modified Rankin Scale score. Secondary outcomes were stroke or death because of uBAVM or intervention and uBAVM obliteration. RESULTS: Sixty-one patients (mean age, 38 years) were included. The median observation period was 60 months. Patients were treated by embolization alone (41.0%), embolization and radiosurgery (57.4%), or embolization and excision (1.6%). Occlusion was achieved in 44 of 57 patients with completed treatment (77.2%). Forty-seven patients (77.1%) had no clinical impairment at the end of observation (modified Rankin Scale score of <2). Twelve patients (19.7%) reached the outcome of stroke or death because of uBAVM or intervention. Treatment-related mortality was 6.6% (4 patients). CONCLUSIONS: In uBAVM, Onyx embolization alone or combined with stereotactic radiosurgery achieves a high occlusion rate. Morbidity remains a challenge, even if it seems lower than in the ARUBA trial.

Internal Spermatic Vein Insufficiency in Varicoceles: A Different Entity in Adults and Adolescents?

OBJECTIVE: The purpose of this study was to determine whether phlebographic features can be used to discriminate adult from adolescent varicocele. MATERIALS AND METHODS: Left and right internal spermatic venograms of 191 adolescents (< 17 years) and 224 adults (≥ 25 years) were anonymized and evaluated. Phlebographic radioanatomic features (valves, duplications, collaterals, and classifications) were compared and analyzed with univariate tests. RESULTS: Insufficiency of the left internal spermatic vein (ISV) was confirmed in 409 of the 415 (99%) patients. Adults had no spontaneous opacification of the ISV during venography twice as frequently as adolescents (p = 0.001), a complex outflow into the renal vein 2.2 times as often (p = 0.021), and significantly more collaterals (p = 0.030). Adolescents had a significantly lower number of competent valves and significantly more instances of nutcracker phenomenon (p = 0.001). According to the Bähren classification, the distribution of the types of ISVs was significantly different between adults and adolescents (p = 0.009). Insufficiency of the right ISV was encountered 2.4 times as frequently in adults as in adolescents (p < 0.001). In adults the maximum diameter of the ISV was significantly larger (p = 0.023). Bilateral ISV insufficiency was 2.2 times as frequent in adults (p < 0.001) as in adolescents. CONCLUSION: Left-sided varicoceles in adults are distinct from those in adolescents. In adults, reflux is likely to be induced via collateral pathways, whereas in adolescents congenital venous abnormalities are predominantly present. The higher prevalence and the greater diameter of a right insufficient ISV in adults, combined with the absence of venous anatomic differences, supports the hypothesis that right-sided varicocele is an evolutive disease.

Tolerance of glue embolization under local anesthesia in varicoceles: a comparative study of two different cyanoacrylates.

PURPOSE: To find out whether in varicocele embolization the copolymer cyanoacrylate glue (NBCA-MS) has a better patient tolerance compared to the monomer n-butyl-2-cyanoacrylate (NBCA). MATERIALS AND METHODS: N=112 insufficient spermatic veins (left sided N=84, right sided N=28) diagnosed in N=83 adult males were prospectively randomized for blinded embolization with either NBCA N=54 (Histoacryl) or with NBCA-MS N=58 (Glubran2). Before, during and up to one week after embolization, patient discomfort was assessed by a standardized pain scale. Type, location and side of discomfort were noted. Statistical analysis was performed with the Mann-Whitney U-test, the McNemar test and the Fisher's exact test. RESULTS: Embolization caused discomfort in N=48/112 (43%) spermatic veins, comprising N=26/54 (48%) in the NBCA group and N=22/58 (38%) in the NBCA-MS group. During the week after embolization, the overall number of discomfort reports rose to N=62/106 (59%), with an increase to N=30/53 (57%) in the NBCA group and to N=32/53 (60%) in the NBCA-MS group. The number of immediate grade 2 to 4 pain reactions was N=22/112 (20%), and rose to N=37/106 (35%) after one week. No difference in discomfort during embolization and at 1 week after treatment was noted. Characteristics, severity grading, and location of discomfort were similar in both NBCA groups, regardless the time point of observation. CONCLUSION: Discomfort after glue embolization of varicocele is a common side effect, which might evolve to pain. The assumed lower inflammatory reaction on NBCA-MS was not translated in an improved tolerance.

Efficacy and safety of two different n-butyl-2-cyanoacrylates for the embolization of varicoceles: a prospective, randomized, blinded study.

PURPOSE: This was a prospective, randomized, blinded comparative study of the efficacy and safety of two different n-butyl-2-cyanoacrylates (NBCAs) for embolization of varicoceles. METHODS: A total of 112 insufficient spermatic veins (left-sided, n=84; right-sided, n=28) that were diagnosed in 83 adult males were prospectively randomized for blinded embolization with NBCA (n=54; Histoacryl, Braun, Germany) or NBCA-MS (n=58; Glubran2, General Enterprise Marketing, Viareggio, Lucca, Italy). Handling, embolic efficacy, and safety of both NBCAs were compared according the fulfillment of a standardized embolization plan, the occlusive effect on the spermatic vein, and the sticking to the microcatheter. Statistical analysis was performed with the Mann-Whitney U test and the Fisher's exact test. RESULTS: Patients of both study arms were comparable for age and clinical indication. Spermatic vein characteristics were comparable for varicocele classification and embolization side. Both NBCAs were equally efficient in occluding the spermatic vein and blocking reflux (NBCA, n=54/54, 100% vs. NBCA-MS, n=54/57, 94.7%; P=0.244). The embolization plan could be accomplished in an equal number of veins for both groups (NBCA, n=45/54, 83.3% vs. NBCA-MS, n=41/58, 70.7%; P=0.124). Adhesiveness of the glue to the microcatheter was the same in both NBCA groups (NBCA, n=25/54, 46.3% vs. NBCA-MS, n=29/58, 50%; P=0.71). No glue-related complications were noted. CONCLUSIONS: NBCA and NBCA-MS are equally efficient and safe glues for embolization of varicoceles.

Transsinusoidal portal vein embolization with ethylene vinyl alcohol copolymer (Onyx): a feasibility study in pigs.

PURPOSE: Portal vein embolization is performed to increase the future liver remnant before liver surgery in patients with liver malignancies. This study assesses the feasibility of a transsinusoidal approach for portal vein embolization (PVE) with the ethylene vinyl alcohol copolymer, Onyx. METHODS: Indirect portography through contrast injection in the cranial mesenteric artery was performed in eight healthy pigs. Onyx was slowly injected through a microcatheter from a wedged position in the hepatic vein and advanced through the liver lobules into the portal system. The progression of Onyx was followed under fluoroscopy, and the extent of embolization was monitored by indirect portography. The pigs were euthanized immediately (n = 2), at 7 days (n = 4), or at 21 days postprocedure (n = 2). All pigs underwent necropsy and the ex vivo livers were grossly and histopathologically analyzed. RESULTS: Transsinusoidal PVE was successfully performed in five of eight pigs (63%). In 14 of 21 injections (67%), a segmental portal vein could be filled completely. A mean of 1.6 liver lobes per pig was embolized (range 1-2 lobes). There were no periprocedural adverse events. Focal capsular scarring was visible on the surface of two resected livers, yet the capsules remained intact. Histopathological examination showed no signs of recanalization or abscess formation. Mild inflammatory reaction to Onyx was observed in the perivascular parenchyma. CONCLUSIONS: The porcine portal vein can be embolized through injection of Onyx from a wedged position in the hepatic vein. Possible complications of transsinusoidal PVE and the effect on contralateral hypertrophy need further study.

Transarterial embolization with ONYX for treatment of intracranial non-cavernous dural arteriovenous fistula with or without cortical venous reflux.

BACKGROUND AND PURPOSE: To report our experience with transarterial ONYX embolization of intracranial non-cavernous dural arteriovenous fistulas (DAVFs) with or without cortical venous reflux. MATERIALS AND METHODS: Retrospective analysis of transarterial ONYX embolization in 20 patients with 21 DAVFs, presenting with intracranial hemorrhage (n=7), pulsatile bruit (n=7), vertigo (n=3), non-pulsatile bruit (n=1), headache (n=1) and epilepsy (n=1). Risk grading of DAVFs was Borden type I (n=6), type II (n=4) and type III (n=11). RESULTS: 18 of 21 (85.7%) DAVFs were angiographically occluded immediately after embolization, with ONYX embolization only, in either one (n=12) or two sessions (n=2); with a combination of ONYX and glue or transvenous coiling in a single session (n=2) or in two sessions (n=1); or after previous transvenous coiling/glue embolization (n=1). At the 6 (4-14) month control digital subtraction angiography (DSA), available in 14 of 18 occluded DAVFs, one patient showed a small residual fistula (17/21 or 81% occluded). Mid-term DSA was not available because of early death (n=2) or patients were awaiting the examination (n=2). In three cases, treatment was incomplete. Of six Borden type I DAVFs, four were cured and two partially occluded with resolution of symptoms. In two DAVFs, neurosurgical access to the feeding artery allowed distal microcatheterization and successful embolization. CONCLUSION: Transarterial ONYX embolization offers an effective and safe treatment for all non-cavernous DAVFs, whether with or without cortical venous reflux.

Therapeutic decision-making in endoscopically unmanageable nonvariceal upper gastrointestinal hemorrhage.

The purpose of this study was to identify endoscopic and clinical parameters influencing the decision-making in salvage of endoscopically unmanageable, nonvariceal upper gastrointestinal hemorrhage (UGIH) and to report the outcome of selected therapy. We retrospectively retrieved all cases of surgery and arteriography for arrest of endoscopically unmanageable UGIH. Only patients with overt bleeding on endoscopy within the previous 24 h were included. Patients with preceding nonendoscopic hemostatic interventions, portal hypertension, malignancy, and transpapillar bleeding were excluded. Potential clinical and endoscopic predictors of allocation to either surgery or arteriography were tested using statistical models. Outcome and survival were regressed on the choice of rescue and clinical variables. Forty-six arteriographed and 51 operated patients met the inclusion criteria. Univariate analysis revealed a higher number of patients with a coagulation disorder in the catheterization group (41.4%, versus 20.4% in the laparotomy group; p = 0.044). With multivariate analysis, the identification of a bleeding peptic ulcer at endoscopy significantly steered decision-making toward surgical rescue (OR = 5.2; p = 0.021). Taking into account reinterventions, hemostasis was achieved in nearly 90% of cases in both groups. Overall therapy failure (no survivors), rebleeding within 3 days (OR = 3.7; p = 0.042), and corticosteroid use (OR = 5.2; p = 0.017) had a significant negative impact on survival. The odds of dying were not different for embolotherapy or surgery. In conclusion, decision-making was endoscopy-based, with bleeding peptic ulcer significantly directing the choice of rescue toward surgery. Unsuccessful hemostasis and corticosteroid use, but not the choice of rescue, negatively affected outcome.

Radiolabeled lipiodol therapy for hepatocellular carcinoma in patients awaiting liver transplantation: pathology of the explant livers and clinical outcome.

BACKGROUND: Liver transplantation has become an important curative treatment option for hepatocellular carcinoma (HCC). Criteria for transplantation are strict and, therefore, it is crucial that patients awaiting transplantation do not suffer disease progression. One of the therapeutic options to achieve disease stabilization is neoadjuvant radiolabeled lipiodol treatment. This study aimed to document the dropout rate on the waiting list, the pathological findings on the explant livers, and the long-term outcome of patients treated with radionuclide therapy while awaiting transplantation. METHODS: Patients eligible for transplantation were treated with 2.1 GBq (131)I-lipiodol or 4.1 GBq (188)Re-HDD/lipiodol by transfemoral catheterization of the hepatic arteries. Tumor necrosis was assessed in the explant livers and follow-up data, such as dropout from the waiting list, recurrence, and survival following transplantation were retrospectively documented. RESULTS: In 5 of 22 explants, necrosis exceeded 90%. Two patients died while on the waiting list (10%) and 4 of 20 transplanted patients (20%) suffered recurrent disease. The overall recurrence-free survival was 19.7 months (range, 1.75-56), with a mean follow-up of 20.1 months. CONCLUSION: Our data support the evaluation on larger patient numbers to confirm the benefit of radiolabeled lipiodol in candidates for liver transplantation who are suffering from HCC.