Peptide Receptor Radionuclide Therapy for a Phosphaturic Mesenchymal Tumor.

Tumor-induced osteomalacia is a very rare paraneoplastic syndrome. It can be caused by phosphaturic mesenchymal tumor (PMT), a generally benign tumor that produces fibroblast growth factor 23 (FGF-23), which can cause a severe renal phosphate wasting syndrome. Upon complete surgical removal of the tumor, FGF-23 normalizes and the osteomalacia is cured. In cases in which surgery is not feasible, radiofrequency ablation (RFA) is the treatment of choice. We describe a case with a PMT situated in the sacrum, in close proximity to the sacral plexus. Both surgery and RFA were considered potentially nerve damaging. Since the tumor showed expression of somatostatin receptors, we opted for a peptide receptor radionuclide therapy (PRRT) with 177Lu-DOTATOC. However, the therapy did not show the expected success, since the FGF-23 level had even temporarily increased. The patient was then successfully treated with RFA. A partial remission of the tumor was achieved and FGF-23 levels nearly normalized. Despite some severe neurological side effects, the patient showed a remarkable clinical improvement, with no symptoms of osteomalacia within a few weeks.

Comparison of a 21G micropuncture needle and a regular 19G access needle for antegrade arterial access into the superficial femoral artery.

INTRODUCTION: The purpose of this prospective study was to compare a 21G micropuncture needle with a regular 19G access needle for direct superficial femoral artery (SFA) access. METHODS: A total of 100 consecutive patients were randomized to each group. Ultrasound-guided antegrade puncture of the SFA was performed using either a 21G or 19G needle. The time between injection of local anesthesia and flushing of the inserted sheath was measured. For hemostasis, either manual compression for 20 min or a closure device was used. All patients received an ultrasound exam 6 h after the procedure to assess the puncture site. RESULTS: Successful access was achieved in 49 of 50 (98%) in the 21G group and 50 of 50 (100%) in the 19G group. In one patient, access with the 21G failed due to severe calcification. Access was successful after switching to the 19G needle. Immediate hemostasis was achieved in all patients. Overall, 22 complications were observed: 10 pseudoaneurysms (4 using the 21G and 6 with the 19G) and 12 hematomas (9 with the 21G and 3 with the 19G). The differences were not statistically significant (p > 0.05). Time to access was significantly faster for the 19G needle (median time 205 s; range: 94-2,160 s) compared with the 21G needle (median time 330 s; range: 93-1,140 s; p = 0.002). CONCLUSIONS: The rate of pseudoaneurysms after SFA access was slightly lower using a 21G needle compared with a 19G needle; however, this was without statistical significance. On the other hand, there was an increase in access time and hematomas with the 21G needle.

Feasibility and safety of vascular closure devices in an antegrade approach to either the common femoral artery or the superficial femoral artery.

INTRODUCTION: The purpose of the present study was to analyze complications following antegrade puncture of the common femoral artery (CFA) and the superficial femoral artery (SFA) using vascular closure systems (VCS). METHODS: A single-center, retrospective study was performed after obtaining approval from the institutional review board and informed consent from all patients. At our center, the CFA or SFA are used for arterial access. All patients were evaluated clinically on the same day. If there was any suspicion of an access site problem, Duplex ultrasound was performed. RESULTS: Access location was the CFA in 50 patients and the SFA in 130 patients. The sheath size ranged from 4F to 10F. Two patients had to be excluded because of lack of follow-up. Successful hemostasis was achieved in 162 of 178 cases (91 %). The following complications were observed in 16 patients (8.9 %): 4 pseudoaneurysms (2.2 %), 11 hematomas (6.2 %), and 1 vascular occlusion (0.5 %). The two pseudoaneurysms healed spontaneously, in one case an ultrasound-guided thrombin injection was performed, and one aneurysm was compressed manually. No further medical therapy was needed for the hematomas. The one vascular occlusion was treated immediately with angioplasty using a contralateral approach. No significant difference was noted between the CFA and the SFA group with respect to complications (p = 1.000). CONCLUSIONS: The use of closure devices for an antegrade approach up to 10F is feasible and safe. No differences in low complication rates were observed between CFA and SFA.

Antegrade access to the superficial femoral artery with ultrasound guidance: feasibility and safety.

PURPOSE: To evaluate the feasibility and safety of antegrade superficial femoral artery (SFA) access with the use of ultrasound (US) guidance. MATERIALS AND METHODS: One hundred consecutive patients (56% men) were prospectively enrolled, with a median age of 76 years. The SFA was punctured in antegrade fashion with a 19-gauge needle with US guidance, followed by sheath placement. The time from local anesthesia until successful blood aspiration from the sheath was measured. At the end of the case, hemostasis was achieved with a closure device or by manual compression. All cases were followed with US for access complications. RESULTS: Antegrade arterial access was successful in all cases. The arterial sheath was successfully placed into the SFA in 98 of 100 patients. In 95 of 98, the sheath was inserted with US guidance only; additional fluoroscopy was needed in three cases. In two of 100 patients, the common femoral artery (CFA) was accessed, accidentally in one case and deliberately in the other because the SFA was considered too small. Both patients were excluded from further analysis. The median time for arterial access was 3.5 minutes (interquartile range, 3.1-6.2 min). All complications directly related to vascular access were minor (16; 15.68%): 10 pseudoaneurysms (10.2%; median diameter, 15 mm) and six hematomas (6.12%; median diameter, 31.5 mm). CONCLUSIONS: Antegrade puncture into the SFA with US guidance is feasible and fast. The rate of minor complications is similar to other reported series, but a direct comparison with other studies is difficult because study designs vary.

Malignant gastroduodenal obstruction: treatment with self-expanding uncovered wallstent.

PURPOSE: To retrospectively evaluate the clinical effectiveness of a self-expanding uncovered Wallstent in patients with malignant gastroduodenal obstruction. MATERIALS AND METHODS: Under combined endoscopic and fluoroscopic guidance, 29 patients with a malignant gastroduodenal stenosis were treated with a self-expanding uncovered metallic Wallstent. A dysphagia score was assessed before and after the intervention to measure the success of this palliative therapy. The dysphagia score ranged between grade 0 to grade 4: grade 0 = able to tolerate solid food, grade 1 = able to tolerate soft food, grade 2 = able to tolerate thick liquids, grade 3 = able to tolerate water or clear fluids, and grade 4 = unable to tolerate anything perorally. Stent patency and patients survival rates were calculated. RESULTS: The insertion of the gastroduodenal stent was technically successful in 28 patients (96.5%). After stenting, 25 patients (86.2%) showed clinical improvement by at least one score point. During follow-up, 22 (78.5%) of 28 patients showed no stent occlusion until death and did not have to undergo any further intervention. In six patients (20.6%), all of whom were treated with secondary stent insertions, occlusion with tumor ingrowth and/or overgrowth was observed after the intervention. The median period of primary stent patency in our study was 240 days. CONCLUSION: Placement of an uncovered Wallstent is clinically effective in patients with malignant gastroduodenal obstruction. Stent placement is associated with high technical success, good palliation effect, and high durability of stent function.

Recanalization of acute and subacute femoropopliteal artery occlusions with the rotarex catheter: one year follow-up, single center experience.

PURPOSE: To assess the efficacy and safety of a new rotational catheter for percutaneous removal of fresh and organized thrombi in the femoropopliteal artery. METHODS: Forty-one limbs in 38 patients (age 56--90 years, mean 75.6 years) with acute, subacute or chronic femoropopliteal occlusions of 1--180 days' duration (mean 31.6 days) were treated with the Rotarex device. The Fontaine stage was mainly IIB (Rutherford 2--3, 22 patients) or III (Rutherford 4, 14 patients). The length of occlusion varied from 2 to 35 cm (mean 13.1 cm). After recanalization percutaneous transluminal angioplasty (PTA) was performed if there was a residual stenosis of >25%. Patients were followed up with color Doppler ultrasound at 48 hr and clinically with Doppler pressures and oscillometry at 3, 6, and 12 months. RESULTS: After an average of two passages with the Rotarex catheter all but two limbs required PTA for residual stenosis >25%. Five patients needed additional stenting. Major complications were one groin hematoma requiring blood transfusion and one arteriovenous fistula spontaneously thrombosing after unsuccessful primary prolonged balloon dilation. Distal embolizations occurred in 10 patients; 6 clinically relevant emboli were aspirated. All occlusions were technically successfully recanalised there were 2 early reocclusions after 1 day and two at 2 weeks. Brachial-ankle indices improved from an average of 0.41 before to 0.93 after recanalization. Primary and secondary patency rates were 62% / 84% after 6 months and 39% / 68% after 1 year. The amputation-free survival at 12 months was 100%. CONCLUSION: The Rotarex mechanical thrombectomy device is an efficient, quick, easy to handle, and safe tool for the treatment of acute, subacute or even chronic peripheral arterial thromboembolic occlusions. It can be used for short or long occlusions with equal success, provided the obstruction is not heavily calcified and has been safely passed with a guidewire first.