Arterioureteral fistula: overview of clinical characteristics, endovascular management, and outcomes.

BACKGROUND: Arterioureteral fistula (AUF) is a condition resulting from the pathologic connection between the ureter and the artery. Despite the low incidence, it can lead to devastating clinical consequences due to massive hematuria with a considerable mortality rate. MATERIAL AND METHODS: From January 2009 to December 2018, eight patients with AUF from two tertiary referral centers were included. Clinical data including presenting symptoms, previous pelvic surgery or radiotherapy, indwelling ureteral stents, primary vascular pathology, angiographic findings, type of treatment, survival, and recurrence were analyzed. RESULTS: All eight patients (six women, mean age 62.4 ± 14.5 years) presented with macroscopic hematuria and were successfully treated by endovascular management. One patient developed AUF due to an underlying iliac artery aneurysm, and the rest were due to secondary causes. Six patients had a history of an indwelling ureteral stent for a median of 5.5 months (1-84 months). All of the patients were successfully treated by endovascular management. For the median follow up of 987 days, three patients had recurrence of hematuria in a mean of 6.3 months, two patients were treated by surgery, while one was treated by endovascular treatment. CONCLUSION: AUF should be confirmed through a purposeful iliac angiogram or ureterography when suspected based on a relevant history or CT findings. AUF can be successfully treated by endovascular management. The surgical option should be considered in cases of recurrence. ABBREVIATIONS: AUF: arterioureteral fistula; CIA: common iliac artery; DJ: double J; EIA: external iliac artery; IIA: internal iliac artery; NBCA: N-butyl cyanoacrylate; PCN: percutaneous nephrostomy.

Technical Notes on Fluoroscopy-Guided Removal of Metallic Ureteral Stents.

This report describes various techniques for fluoroscopy-guided removal of metallic ureteral stents. Fifteen patients underwent 17 fluoroscopy-guided removal procedures of 22 metallic ureteral stents. The simple or modified snare or retrieval hook technique was primarily used for antegrade access, whereas the loop snare technique was primarily used for retrograde access. Overall, 64.7% of the stents were removed using the initial retrieval technique, and 82.4% of the stents were removed using an adjunct technique. Procedure-related complications included hematuria in 41.2% of cases and resolved spontaneously in all patients. Fluoroscopy-guided removal of metallic ureteral stents is safe and effective.

Percutaneous Gastrostomy Compared with Esophageal Stent Placement for the Treatment of Esophageal Cancer with Dysphagia.

PURPOSE: To compare the outcomes of self-expandable metal stent placement and percutaneous gastrostomy (PG) for the treatment of patients with esophageal cancer (EC) and dysphagia. MATERIALS AND METHODS: This retrospective observational study consisted of 113 patients with EC and dysphagia who underwent either stent placement (n = 47) or PG (n = 66) at a single center between June 2014 and June 2018. RESULTS: There were 63 men and 50 women, with a mean age of 76.5 years (standard deviation 4.9 years). The 2 groups had similar baseline characteristics, except that the PG group had a higher percentage of patients with cervical EC (22.7% vs 2.1%, P < .001). The PG group had better maintenance of nutritional status in terms of reduction in serum albumin level (P = .039) and weight loss (P = .041). Compared with the stent group, the PG group demonstrated a lower incidence of local severe pain (0% vs 21.3%, P < .001) and lower incidence of dislodgment of device (1.5% vs 19.1%, P = .002). The PG group demonstrated longer overall survival compared with the stent group for Stages II and III (201 vs 185 days, P = .034) and Stage IV (122 vs 86 days, P = .001). CONCLUSIONS: Compared with stent insertion, PG is associated with better maintenance of nutritional status, fewer complications, and better survival. Thus, PG may be the preferred choice for treating malnutrition in patients with EC and dysphagia.

Analysis of the factors influencing retrograde removal of double J ureteral stents using a simple snare technique in female patients.

BACKGROUND: To identify the factors related to the effectiveness of retrograde removal of double J ureteral stents using a simple snare technique in female patients. METHODS: It was a retrospective observational study. From 2012 to 2017, 128 female patients underwent fluoroscopy-guided, retrograde double J stent removal with or without replacement using a simple snare technique. The position of the tip of the double J stent in the urinary bladder was classified according to position types A, B, C, and D, corresponding to the ipsilateral lateral, ipsilateral medial, contralateral medial, and contralateral lateral quadrants of the urinary bladder, respectively. The factors influencing the fluoroscopy time upon removal of the double J stent were analyzed. RESULTS: Technical success rate of 312 procedures performed was 97.44% (304/312) with the mean fluoroscopy time of 12.68±7.34 minutes. Eight double J stent removal procedures failed, and all of these occurred in the position type D patients. The position type and the number of curls of the double J stent had a significant influence on the fluoroscopy time (P<0.05). In addition, multiple regression analysis demonstrated that the position type and number of curls in the double J stent were factors independently influenced the fluoroscopy time (P=0.001). Type D exhibited the longest fluoroscopy time followed by types B and C, and type A had the shortest fluoroscopy time. There were only minor complications consisting of urethral orifice pain (5.1%, 16/312) or gross hematuria (3.2%, 10/312), all resolved conservatively within 24 hours. CONCLUSIONS: The position type and the number of curls in a double J stent have a significant influence on the effectiveness of retrograde removal of double J stents using a simple snare technique in female patients.

Management of life-threatening aortoesophageal fistula: experiences learned from eight patients.

BACKGROUND: Aortoesophageal fistula (AEF) is a rare but fatal condition causing massive upper gastrointestinal bleeding. PURPOSE: To report our experiences in the management of life-threatening AEF. MATERIAL AND METHODS: A total of eight patients (seven men, one woman; mean age = 59.4 years; age range = 43‒76 years) presenting with AEF between 2005 and 2018 were recruited from three different Korean hospitals. The medical records of these patients were reviewed for patient demographics, clinical features, diagnostic and therapeutic modalities, and outcomes. RESULTS: Two patients died as a result of massive hemorrhage before endovascular or surgical treatment could be undertaken. Of the six patients who were treated, five underwent endovascular interventions: embolization of the fistula using n-butyl cyanoacrylate (NBCA) and subsequent thoracic endovascular aortic repair (TEVAR) in two patients; TEVAR alone in two patients; and NBCA embolization alone in one patient. Among them, three patients who received TEVAR with or without NBCA embolization in a timely fashion recovered and were discharged. One patient who received delayed TEVAR died of disseminated intravascular coagulation, and one who received NBCA embolization alone died of hemorrhagic shock, both dying within three days of treatment. The remaining patient who underwent surgical aortic repair is alive after 13 years. CONCLUSION: Rapid identification and surgical treatment are necessary to increase the likelihood of survival, if emergency surgery is feasible. TEVAR in a timely fashion facilitates hemodynamic stabilization by rapidly controlling hemorrhage and saves the patient's life.

Clinical observation of local intervention combined with camrelizumab and apatinib in the treatment of metastatic soft-tissue sarcoma.

Aims: The study aimed to investigate the effectiveness and safety of the combination of immune checkpoint inhibitor, local interventional therapy, and anti-angiogenic therapy in patients with metastatic soft-tissue sarcoma (mSTS). Settings and Design: We retrospectively evaluated the medical records of patients with mSTS who started treatment between September 2018 and June 2020 at our hospital. Materials and Methods: Overall, 33 patients with different subtypes of mSTS were included. Most primary tumors originated from the lungs, and the rest were scattered throughout the body. All patients were treated with camrelizumab combined with apatinib within 5 days of local interventional therapy using transarterial chemoembolization (TACE) or radiofrequency ablation (RFA). Primary end point was progression-free survival (PFS), and secondary end points were objective response rate (ORR), disease control rate (DCR), and patient safety. Results: The median PFS, median overall survival (OS), ORR, and DCR were 8.8 months, 18.5 months, 36.4%, and 75.8%, respectively. Patients (n = 20) treated with RFA combined with TACE showed better responses than those treated with RFA alone (n = 13), with mPFS of 9.3 and 7.9 months (P = 0.044) and mOS of 19.0 and 16.2 months (P = 0.043), respectively. Patients (n = 8) with alveolar soft part sarcomas showed excellent efficacy, with ORR, DCR, mPFS, and mOS of 62.5%, 87.5%, 11.5 months, and 22.5 months, respectively. Grades 3 or 4 treatment-related adverse events occurred in 12 of 33 patients. Conclusions: Local intervention therapy combined with camrelizumab and apatinib is effective and safe for patients with mSTS and should be investigated in future clinical trials.

Transcatheter arterial embolization for intractable, nontraumatic bladder hemorrhage in cancer patients: a single-center experience and systematic review.

PURPOSE: To explore the effect of transcatheter arterial embolization (TAE) in controlling intractable, nontraumatic bladder hemorrhage in cancer patients. MATERIALS AND METHODS: A literature review (PubMed and EMBASE), followed by a retrospective analysis of all cancer patients with intractable hematuria from bladder treated by TAE at our tertiary referral center. RESULTS: At our institution, 27 consecutive cancer patients who underwent TAE for refractory hematuria from bladder were identified. The systematic review included 13 studies published between 1981 and 2019. In our local cohort, 27 patients were treated with 100% technical success, clinical success in 88.9%, no major complications, and rebleeding rate within the first month of 7.4%. In the systematic review cohort of 201 patients, there was technical success in 99.0%, clinical success in 80.9%, major complications in 5.5%, and a rebleeding rate within the first month of 4.5%. Bilateral embolization was performed in 81.1%, and embolization levels were mostly anterior division of internal iliac artery (73.7%) and vesical artery (23.2%). CONCLUSION: TAE is effective and safe to control intractable hematuria from bladder origin in cancer patients after failure of conservative management, providing effective temporary hemostasis. For bladder hemorrhage unsuitable for surgery, TAE should be considered at an early stage. A literature review, followed by retrospective analysis of all patients with intractable hematuria from bladder treated by transcatheter arterial embolization at our tertiary referral center. Transcatheter arterial embolization is effective and safe to control intractable hematuria from bladder. The major complication rate and rebleeding within the first month are acceptable.

Therapeutic Ureteral Occlusion with Use of Occlusion Stents for Urinary Leakage or Fistula: A Bicentric Study.

PURPOSE: To evaluate the safety and efficacy of ureteral occlusion stents for urinary diversion in patients with inoperable urinary leakage or fistula or intractable bladder bleeding. MATERIALS AND METHODS: A total of 13 ureters in 12 patients (M:F = 4:8) who underwent ureteral occlusion stenting were included in this study. The internally silicone membrane-coated occlusion stent was a self-expanding stent with constriction at the middle (M-type) or distal end (D-type) of the stent. RESULTS: The reasons for ureteral occlusion were surgery infeasibility for urinary leakage (n = 6), temporary ureteral occlusion for urinary leakage before surgical reconstruction (n = 2), urinary fistula (n = 3), or control of bleeding from bladder cancer (n = 1). Technical success defined as successful deployment of the occlusion stent with no contrast agent passing beyond the occlusion stent was achieved in 92.3% (12/13 ureters); in one ureter with contrast passage beyond the occlusion stent, additional n-butyl cyanoacrylate (NBCA) embolization was performed immediately so that there was no further leakage. There were no procedure-related complications. During the mean follow-up of 11.6 months, recurrence of urinary leakage was observed in two ureters (15.4%, 2/13) where a D-type occlusion stent was used on the 3-day follow-up antegrade ureterogram; the contrast agent passed through the widened constricted portion of the occlusion stent and repeat occlusion with microcoils, and NBCA was subsequently performed inside the occlusion stent and with no further urinary leakage until the last follow-up. CONCLUSION: The ureteral occlusion stent is safe and effective for ureteral occlusion. Recurrence of leakage can be managed with additional microcoil and NBCA embolization.

Inferior mesenteric artery embolization for persistent postpartum hemorrhage after sufficient bilateral iliac arteries embolization: safety and efficacy in eight patients.

OBJECTIVE: To assess the safety and efficacy of transcatheter arterial embolization (TAE) of the inferior mesenteric artery (IMA) for the management of post-partum hemorrhage (PPH). METHODS: A retrospective analysis was performed regarding eight patients (mean age, 34.4 y; age range, 31 - 40 y) who underwent TAE of the IMA for PPH between March 2001 and September 2018. Obstetric records, including maternal characteristics, clinical manifestations, complications, and clinical outcomes, as well as TAE details were obtained. RESULTS: All eight patients had primary PPH and the vaginal delivery mode. CT scans of two patients showed active bleeding from the lower uterus or hematoma and with the origin of contrast extravasation abutting the adjacent rectum. In seven patients, an aortogram or IMA arteriogram following persistent vaginal bleeding after sufficient embolization of the bleeding focus from the bilateral iliac arteries, found the bleeding focus of the IMA, while in one patient, the IMA bleeding focus was found at the second session 4 h after the first session. TAE of the IMA was technically successful in all eight patients and cessation of bleeding without repeated TAE or additional hemostatic surgery was achieved in all patients after TAE of the IMA. There were neither procedure-related complications nor bowel ischemia during follow-up. CONCLUSION: TAE of the IMA for PPH was safe and effective with successful hemostasis. Bleeding from the IMA should be suspected when there is persistent vaginal bleeding after sufficient embolization of bleeders from the bilateral iliac arteries. ADVANCES IN KNOWLEDGE: Bleeding from the IMA should be suspected when there is persistent vaginal bleeding after sufficient embolization of bleeders from the bilateral iliac arteries.

Recent Update of Embolization of Postpartum Hemorrhage.

Postpartum hemorrhage (PPH) is a life-threatening condition and remains a leading cause of maternal mortality. Transcatheter arterial embolization (TAE) is an effective therapeutic strategy for PPH with the advantages of fast speed, repeatability, and the possibility of fertility preservation. We reviewed the vascular anatomy relevant to PPH, the practical details of TAE emphasizing the timing of embolization, and various clinical conditions of PPH according to a recent literature review.

Sorafenib improves lipiodol deposition in transarterial chemoembolization of Chinese patients with hepatocellular carcinoma: a long-term, retrospective study.

OBJECTIVE: Though synergy of sorafenib and transarterial chemoembolization (TACE) in hepatocellular carcinoma (HCC) is well discussed in previous reports, association of lipiodol retention by sorafenib addition to TACE with the survival outcomes remain elusive. Therefore, we studied the impact of sorafenib addition to TACE on survival outcomes mediated by lipiodol retention. MATERIALS AND METHODS: This is a long-term, retrospective, single-center study using medical records of patients diagnosed with HCC at the Department of Interventional Radiology of Zhengzhou University Affiliated Cancer Hospital (China) between April 2004 and March 2012. RESULTS: Lipiodol deposition of > 50% was significantly increased in TACE + sorafenib group (70.87%) compared to TACE alone group (45.11%) (P = 0.0001). Significant increase in lipiodol deposition with sorafenib treatment was observed compared to TACE alone group (OR = 0.449, P = 0.041). The median overall survival in TACE + sorafenib and TACE alone groups were 38 months [95% CI = 9.772-56.228] and 31 months [95% CI = 21.855-40.145] respectively. Also, the hazard of death was comparatively greater in TACE alone group than TACE + sorafenib group [HR = 1.071]. Response rate to the therapy significantly increased after sorafenib administration to TACE patients, [compared to TACE alone treatment [69/103 (66.99%)] vs 55/133 (41.35%)], P = 0.0001. CONCLUSIONS: Lipiodol deposition is significantly increased upon sorafenib addition after TACE. However, there was no significant impact of lipiodol deposition on the survival benefits exerted by the synergistic combination and hence, future prospective trails are warranted to validate the findings of this study.

Tumor vascularity and lipiodol deposition as early radiological markers for predicting risk of disease progression in patients with unresectable hepatocellular carcinoma after transarterial chemoembolization.

This study evaluated the factors impacting overall survival (OS) and time to progression (TTP) in patients with unresectable hepatocellular carcinoma (HCC) who received transarterial chemoembolization (TACE). HCC patients were grouped based on tumor vascularity and lipidiol deposition after TACE. Tumor vascularity was classified based on contrast enhancement on arterial phase baseline CT scans. Lipiodol deposition was evaluated using CT scans. The progression-free rate was significantly higher in patients with good blood supply + good lipiodol deposition compared to those with good blood supply + poor lipiodol deposition. In patients with poor lipidiol deposition, risk of death was significantly positively correlated with stage, and negatively correlated with number of TACE procedures and degree of lipidiol deposition after the first TACE. Risk of disease progression in these patients was positively correlated with tumor size, and negatively correlated with number of TACE procedures and degree of lipidiol deposition after the first TACE. Our data showed that tumor vascularity and lipiodol deposition can be used as early radiological markers to identify patients who do not respond to TACE, and who can be considered earlier for alternative combination treatment strategies. Our data also indicated that poor lipiodol retention may predict a poor TTP and OS despite the blood supply status.

Ultrasound-guided RNA interference targeting HIF-1 alpha improves the effects of transarterial chemoembolization in rat liver tumors.

AIM: To investigate whether ultrasound-guided RNA interference (RNAi) targeting hypoxia-inducible factor-1alpha (HIF-1α) can enhance the efficacy of transarterial chemoembolization (TACE) in treating hepatocellular carcinoma. MATERIALS AND METHODS: Rats with orthotopic hepatocellular carcinoma were randomized to four groups and treated as follows: 1) control; 2) siHIF-1α; 3) TACE; 4) siHIF-1α+TACE. Lentivirus (4×10(8) transfection units) with or without small interfering RNA (siRNA) expression in 0.6 mL transduction reagent was injected into tumors using a standard 1 mL syringe under ultrasonic guidance. In the siHIF-1α+TACE and siHIF-1α groups, rats received siRNA-expressing lentivirus; the rats in the TACE and control groups received lentivirus without siRNA. TACE was performed by placing a microcatheter into the gastroduodenal artery. RESULTS: The median survival time, body weight, and tumor volume of the siHIF-1α+TACE group were better than those of the TACE, siHIF-1α, and control groups. A comparative analysis of the different treatment groups demonstrated that HIF-1α RNAi could downregulate the levels of HIF-1α and VEGF, inhibit tumor angiogenesis, and lessen metastases; all of these effects were enhanced by TACE. CONCLUSION: HIF-1α RNAi, which was administered in vivo in liver tumors under ultrasound guidance, improved the efficacy of TACE in treating hepatocellular carcinoma in an animal model.

RNAi Knockdown of Hypoxia-Inducible Factor-1α Decreased the Proliferation, Migration, and Invasion of Hypoxic Hepatocellular Carcinoma Cells.

The obstruction of hepatic arterial blood flow results in tumor tissue hypoxia and elevated expression of hypoxia-inducible factor-1alpha (HIF-1α). Our study evaluated whether lentivirus-mediated short interference RNA against HIF-1α inhibits proliferation, invasion, and migration of hepatocellular carcinoma (HCC) cells under hypoxia. RNA interference knockdown of HIF-1α was achieved by HIF-1α-directed lentiviral shRNA, in a rat HCC cell line cultured under hypoxia condition for varying length of times. The expression levels of HIF-1α and vascular endothelial growth factor were examined using reverse transcription polymerase chain reaction and western blot analyses. Cell proliferation, migration, and invasion were measured by cell viability, transwell migration, and invasion assays, respectively. Inhibition of HIF-1α expression by shRNA suppressed vascular endothelial growth factor mRNA and protein levels under both normoxia and hypoxia. It also suppressed cell migration and invasion, which were enhanced under hypoxic conditions. RNAi knockdown of HIF-1α further suppressed hypoxia-mediated inhibition of the cell proliferation. These data suggest that shRNA of HIF-1α could antagonize the hypoxia-mediated increase in hepatic cancer cell migration and invasion, and synergize with hypoxia to inhibit the cell proliferation in HCC cells.

The efficacy of TACE combined sorafenib in advanced stages hepatocellullar carcinoma.

BACKGROUND: The long-term survival in hepatocellullar carcinoma (HCC) patients after transarterial chemoembolization (TACE) remains dismal due to local and/or regional recurrence as well as distant metastasis. The efficacy of sorafenib in advanced HCC has been demonstrated and brought great hope. Recently, the use of sorafenib in combination with TACE for BCLC stage B and C HCC patients was recommended. However, data on this dual-modality treatment is little, and its advantage over TACE alone has not been addressed. The present study sought to understand the efficacy of the combination of TACE and sorafenib in the treatment of advanced HCC. METHODS: Between June 2008 and Feb 2011, 45 patients with advanced HCC were enrolled and treated with sorafenib in combination with TACE according to an institutional protocol of the Zhongshan hospital, Fudan University. The control group of 45 other HCC patients with similar characteristics treated with TACE alone in the same period of time in our institute were selected for retrospective comparison of the treatment outcomes especially overall survival time. Adverse reactions induced by sorafenib were observed and recorded. RESULTS: The median overall survival time of the combined treatment group was 27 (95% Confidence Interval: 21.9-32.1) months, and that of TACE alone group was 17 months (95% Confidence Interval: 8.9-25.0) months (P = 0.001). Patients required significantly less frequent TACE for their symptomatic treatment after the initiation of sorafenib therapy. The most common adverse events associated with sorafenib were hand-foot skin reaction, rash and diarrhea. Of CTCAE grade IV or V toxicity was observed. CONCLUSION: TACE combined sorafenib significantly prolonged median overall survival time of patients with advanced HCC.

RNA interference of hypoxia-inducible factor-1 alpha improves the effects of transcatheter arterial embolization in rat liver tumors.

Transcatheter arterial embolization (TAE) and transcatheter arterial chemoembolization are widely used palliative treatments for patients with nonsurgical hepatocellular carcinoma. TAE has been shown to increase levels of hypoxia-inducible factor-1 alpha (HIF-1α) in tumors. In this study, we investigated whether RNA interference (RNAi) of HIF-1α could improve the efficacy of TAE to treat HCC. Four treatment groups were assessed using a rat allograft model of HCC: RNAi of HIF-1α combined with TAE, RNAi of HIF-1α only, TAE only, and a control group. Rats were treated by TAE by retrograde placement of a microcatheter into the gastroduodenal artery. The results demonstrated that the RNAi of HIF-1α visibly reduced the expression of HIF-1α and vascular endothelial growth factor, suppressed tumor angiogenesis, and attenuated metastasis, which were all enhanced by TAE. The RNAi of HIF-1α synergized with TAE to significantly inhibit tumor growth. In conclusion, RNAi of HIF-1α augmented the therapeutic effects of TAE and diminished its undesirable effects.