Outcome of Transarterial Radioembolization in the Treatment of Hepatocellular Carcinoma: Glass Versus Resin Microsphere.

PURPOSE: To compare the treatment outcomes of glass and resin microspheres for the treatment of hepatocellular carcinoma (HCC) and evaluate the prognostic factors that influence the outcomes. MATERIALS AND METHODS: We retrospectively reviewed 251 consecutive patients who underwent radioembolization for the treatment of HCC at a single tertiary center. Imaging responses after radioembolization were evaluated using the modified Response Evaluation Criteria in Solid Tumors (mRECIST) 1.1. Progression-free survival (PFS) and overall survival (OS) were analyzed using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazard models were used to identify the prognostic factors. RESULTS: A total of 195 patients were included in this study (glass microsphere, n = 75; resin microsphere, n = 120). The complete and objective response rates were 16.0% and 50.7% in the glass microsphere group and 17.5% and 58.3% in the resin microsphere group, respectively. Median PFS was 241 days in the glass microsphere group and 268 days in the resin microsphere group (p = 0.871). Median OS was 29 months in the glass microsphere group and 40 months in the resin microsphere group (p = 0.669). The only significant prognostic factor was bilobar tumor distribution, which favored resin microspheres (p = 0.023). Procedure-related adverse events occurred more frequently in the resin microsphere group (glass, 2.7% vs. resin, 5.0%; p < 0.001). CONCLUSION: Glass and resin microspheres for the treatment of HCC did not show a significant difference in survival, though major adverse events occurred more frequently with the use of resin microspheres.

Clinical course of patients with hepatocellular carcinoma who experienced radiologic complete response after radioembolization.

Purpose: The purpose of this study is to elucidate the patterns of recurrence of hepatocellular carcinoma and to analyze factors that can predict recurrence after complete response to radioembolization. Materials and methods: A total of 289 consecutive patients who underwent radioembolization for the treatment of hepatocellular carcinoma at a single tertiary center were retrospectively reviewed. Baseline characteristics were collected and compared between the group showing complete response and the group showing noncomplete response. Data on recurrence status, time to recurrence, and the patterns of recurrence among the patients who showed radiologic complete response were collected. The group that maintained complete response and the group that experienced recurrence were compared, and the risk factors affecting recurrence were evaluated by logistic regression analysis. Results: The complete response rate was 24.9% (73/289). Age, sex, tumor markers, maximum tumor diameter, multiplicity, presence of vascular invasion, and target radiation dose were significantly different between the complete response and noncomplete response groups. The recurrence rate after complete response was 38.4% (28/73), and 67.9% (19/28) of recurrences occurred by 8 months after complete response. Eight patients who underwent resection/transplantation after complete response experienced no recurrence. Multiple tumors and a lower target radiation dose were independent risk factors of recurrence after complete response in the multivariate logistic regression. Conclusion: Hepatocellular carcinoma recurrence following complete response after radioembolization is not uncommon and frequently occurs within 1 year after complete response. Multiple tumors and a lower target radiation dose may be risk factors for recurrence.

Thoracic Duct Embolization for Treatment of Chyle Leakage After Thyroidectomy and Neck Dissection.

OBJECTIVE: This study aimed to evaluate the safety and efficacy of intranodal lymphangiography and thoracic duct embolization (TDE) for chyle leakage (CL) after thyroid surgery. MATERIALS AND METHODS: Fourteen patients who underwent intranodal lymphangiography and TDE for CL after thyroid surgery were included in this retrospective study. Among the 14 patients, 13 underwent bilateral total thyroidectomy with neck dissection (central compartment neck dissection [CCND], n = 13; left modified radical neck dissection (MRND), n = 11; bilateral MRND, n = 2), and one patient underwent left hemithyroidectomy with CCND. Ten patients (76.9%) had high-output CL (> 500 mL/d). Before the procedure, surgical intervention was attempted in three patients (thoracic duct ligation, n = 1; lymphatic leakage site ligation, n = 2). Lymphangiographic findings, technical and clinical successes, and complications were analyzed. Technical success was defined as the successful embolization of the thoracic duct after access to the lymphatic duct via the transabdominal route. Clinical success was defined as the resolution of CL or surgical drain removal. RESULTS: On lymphangiography, ethiodized oil leakage near the surgical bed was identified in 12 of 14 patients (85.7%). The technical success rate of TDE was 78.6% (11/14). Transabdominal antegrade access was not feasible due to the inability to visualize the identifiable cisterna chyli or a prominent lumbar lymphatic duct. Among patients who underwent a technically successful TDE, the clinical success rate was 90.1% (10/11). The median time from the procedure to drain removal was 3 days (with a range of 1-13 days) for the 13 patients who underwent surgical drainage. No CL recurrence was observed during the follow-up period (ranging from 2-44 months; median, 8 months). There were no complications, except for one case of chylothorax that developed after TDE. CONCLUSION: TDE appears to be a safe and effective minimally invasive treatment option for CL after thyroid surgery, with acceptable technical and clinical success rates.

Feasibility of Percutaneous Pancreatic Stent Placement in Postoperative Pancreaticojejunostomy Stenosis.

OBJECTIVE: To evaluate the role of percutaneous pancreatic stent placement in postoperative pancreaticojejunostomy stenosis (PJS). MATERIALS AND METHODS: This retrospective single-center study included seven procedures in five patients (four males and one female; median age, 63 years) who underwent percutaneous pancreatic stent placement for postoperative PJS between January 2005 and December 2021. The patients were referred to interventional radiology because of unfavorable anatomy or bowel abnormalities. The pancreatic duct was accessed under ultrasound and/or computed tomography guidance. A stent was placed after balloon dilatation of the PJS. Moreover, plastic stents were placed for the first two procedures, whereas bare-metal stents were used for the remaining five procedures. Technical success was defined as the successful placement of stents for the PJS, meanwhile, clinical success was defined as the normalization of pancreatic enzymes without recurrence of pancreatitis. RESULTS: Pancreatic duct access and stent placement were successfully performed in all patients (technical success rate: 100%). All the procedures initially yielded clinical success. However, recurrence of pancreatitis was observed after two procedures that used plastic stents because of stent migration at 0.3 and 3 months after the procedure. In contrast, no instances of recurrent pancreatitis were noted after metal stent placement for a follow-up duration of 1-36 months. No serious procedure-related adverse events were observed. CONCLUSION: Percutaneous pancreatic stent placement may be a viable option for patients with postoperative PJS in whom an endoscopic approach is not feasible. Metal stents may be considered over plastic stents for the management of PJS, considering the possible lower stent migration and infeasibility of frequent endoscopic stent exchange due to the altered anatomy.

Hepatic arterial infusion in combination with systemic chemotherapy in patients with hepatic metastasis from colorectal cancer: a randomized phase II study - (NCT05103020) - study protocol.

BACKGROUND: Although 80% of patients with metastatic colorectal cancer (CRC) experience liver metastases, only 10-25% undergo resection at the time of diagnosis. Even in initially unresectable conditions, if appropriate treatment is provided, such as surgical conversion through a combination of hepatic arterial infusion (HAI) chemotherapy and systemic chemotherapy (sys-CT), better overall survival can be expected. Therefore, this study aims to evaluate the efficacy of HAI oxaliplatin in combination with sys-CT plus targeted therapy in patients with unresectable CRC with liver-only metastasis. METHODS: This is a single-center, randomized, open-label phase II trial (NCT05103020). Patients with untreated CRC, who have liver-only metastases and for whom liver resection is potentially possible but deemed infeasible at the time of initial diagnosis by a multidisciplinary team, will be eligible. Patients will be randomly assigned in a 1:1 ratio to either the combined HAI oxaliplatin and modified systemic 5-fluorouracil, folinic acid, and irinotecan (FOLFIRI) plus targeted therapy group or the systemic FOLFIRI plus targeted therapy group. Both regimens will be repeated every 2 weeks for a total of 12 cycles. The primary objective of this study is to compare the rate of conversion to liver resection. The surgical conversion rate is expected to increase by 25% with HAI oxaliplatin in combination with sys-CT plus targeted therapy (40% in the experimental arm versus 15% in the control arm) (power, 80%; two-sided alpha-risk, 5%). The secondary objectives include overall survival, progression-free survival, and objective response rate. DISCUSSION: This is the first randomized controlled trial to investigate the efficacy of HAI oxaliplatin in combination with sys-CT plus targeted therapy as first-line treatment from the initial diagnosis in patients with unresectable CRC with liver-only metastasis, aiming to significantly increase the surgical conversion rate. TRIAL REGISTRATION: ClinicalTrials.gov, (NCT05103020). Trial registration date: November 2, 2021.

Robot-Assisted Transarterial Chemoembolization of Hepatocellular Carcinoma Using a Coaxial Microcatheter Driving Controller-Responder Robot System: Clinical Pilot Study.

PURPOSE: To evaluate the feasibility and safety of robot-assisted transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) using a new coaxial microcatheter driving controller-responder robot (CRR) system. MATERIALS AND METHODS: A single-center prospective pilot study approved by the institutional review board was conducted using this CRR developed after analyzing 20 cases of conventional TACE procedures from May to October 2021. The study included 10 patients with HCCs: 5 (median age, 72 years; range, 64-73 years) underwent robot-assisted TACE, and 5 (median age, 57 years; range, 44-76 years) underwent conventional TACE for comparison. The feasibility and safety of robot-assisted TACE were evaluated by assessing the technical success, procedure time, adverse event rate, radiation dose, and early tumor response. RESULTS: The entire TACE procedure was divided into 30 steps, of which 8 could be robotized. In robot-assisted TACE, technical success was achieved in 4 (80%) of 5 patients. No procedure-related adverse event was observed. The median procedure time was 56 minutes. At the 1-month follow-up, 3 of the 4 patients showed a complete or partial response after robot-assisted TACE. The median radiation doses for the operator and patients were 0.4 and 2,167.5 µSv in robot-assisted TACE and 53.2 and 2,989.7 µSv in conventional TACE, respectively. CONCLUSIONS: Robot-assisted TACE using a new CRR system was feasible and safe for the treatment of HCC and could remarkably decrease radiation exposure for the operators.

Balloon Bronchoplasty for the Treatment of Bronchial Stenosis After Lung Transplantation: A Single-Center 10-Year Experience.

OBJECTIVE: To assess the safety and efficacy of balloon dilatation under dual guidance using fluoroscopy and bronchoscopy for treating bronchial stenosis following lung transplantation (LT), and to elucidate the factors associated with patency after the procedure. MATERIALS AND METHODS: From September, 2012, to April, 2021, 50 patients (mean age ± standard deviation, 54.4 ± 12.2 years) with bronchial stenosis among 361 recipients of LT were retrospectively analyzed. The safety of balloon dilatation was assessed by evaluating procedure-related complications. Efficacy was assessed by evaluating the technical success, primary patency, and secondary patency. Primary and secondary cumulative patency rates were calculated using the Kaplan-Meier method. The factors associated with patency after the procedure were evaluated using multivariable Cox hazard proportional regression analysis. RESULTS: In total, 65 bronchi were treated with balloon dilatation in 50 patients. The total number of treatment sessions was 277 and the technical success rate was 99.3% (275/277 sessions). No major procedure-related complications were noted. During the mean follow-up period of 34.6 ± 30.8 months, primary patency was achieved in 12 of 65 bronchi (18.5%). However, the patency rate improved to 76.9% (50 of 65 bronchi) after repeated balloon dilatation (secondary patency). The 6-month, 1-year, 3-year, and 5-year secondary patency rates were 95.4%, 90.8%, 83.1%, and 78.5%, respectively. The presence of clinical symptoms was a significant prognostic factor associated with reduced primary patency (adjusted hazard ratio [HR], 0.465; 95% confidence interval [CI], 0.220-0.987). Early-stage treatment ≤ 6 months (adjusted HR, 3.588; 95% CI, 1.093-11.780) and prolonged balloon dilatation > 5 min (adjusted HR, 3.285; 95% CI, 1.018-10.598) were associated with significantly higher secondary patency. CONCLUSION: Repeated balloon dilatation was determined to be safe and effective for treating bronchial stenosis following LT. Early-stage treatment and prolonged balloon dilatation could significantly promote long-term patency.

A deep learning algorithm to quantify AVF stenosis and predict 6-month primary patency: a pilot study.

Background: A deep convolutional neural network (DCNN) model that predicts the degree of arteriovenous fistula (AVF) stenosis and 6-month primary patency (PP) based on AVF shunt sounds was developed, and was compared with various machine learning (ML) models trained on patients' clinical data. Methods: Forty dysfunctional AVF patients were recruited prospectively, and AVF shunt sounds were recorded before and after percutaneous transluminal angioplasty using a wireless stethoscope. The audio files were converted to melspectrograms to predict the degree of AVF stenosis and 6-month PP. The diagnostic performance of the melspectrogram-based DCNN model (ResNet50) was compared with that of other ML models [i.e. logistic regression (LR), decision tree (DT) and support vector machine (SVM)], as well as the DCNN model (ResNet50) trained on patients' clinical data. Results: Melspectrograms qualitatively reflected the degree of AVF stenosis by exhibiting a greater amplitude at mid-to-high frequency in the systolic phase with a more severe degree of stenosis, corresponding to a high-pitched bruit. The proposed melspectrogram-based DCNN model successfully predicted the degree of AVF stenosis. In predicting the 6-month PP, the area under the receiver operating characteristic curve of the melspectrogram-based DCNN model (ResNet50) (≥0.870) outperformed that of various ML models based on clinical data (LR, 0.783; DT, 0.766; SVM, 0.733) and that of the spiral-matrix DCNN model (0.828). Conclusion: The proposed melspectrogram-based DCNN model successfully predicted the degree of AVF stenosis and outperformed ML-based clinical models in predicting 6-month PP.

Feasibility of Deep Learning-Based Analysis of Auscultation for Screening Significant Stenosis of Native Arteriovenous Fistula for Hemodialysis Requiring Angioplasty.

OBJECTIVE: To investigate the feasibility of using a deep learning-based analysis of auscultation data to predict significant stenosis of arteriovenous fistulas (AVF) in patients undergoing hemodialysis requiring percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: Forty patients (24 male and 16 female; median age, 62.5 years) with dysfunctional native AVF were prospectively recruited. Digital sounds from the AVF shunt were recorded using a wireless electronic stethoscope before (pre-PTA) and after PTA (post-PTA), and the audio files were subsequently converted to mel spectrograms, which were used to construct various deep convolutional neural network (DCNN) models (DenseNet201, EfficientNetB5, and ResNet50). The performance of these models for diagnosing ≥ 50% AVF stenosis was assessed and compared. The ground truth for the presence of ≥ 50% AVF stenosis was obtained using digital subtraction angiography. Gradient-weighted class activation mapping (Grad-CAM) was used to produce visual explanations for DCNN model decisions. RESULTS: Eighty audio files were obtained from the 40 recruited patients and pooled for the study. Mel spectrograms of "pre-PTA" shunt sounds showed patterns corresponding to abnormal high-pitched bruits with systolic accentuation observed in patients with stenotic AVF. The ResNet50 and EfficientNetB5 models yielded an area under the receiver operating characteristic curve of 0.99 and 0.98, respectively, at optimized epochs for predicting ≥ 50% AVF stenosis. However, Grad-CAM heatmaps revealed that only ResNet50 highlighted areas relevant to AVF stenosis in the mel spectrogram. CONCLUSION: Mel spectrogram-based DCNN models, particularly ResNet50, successfully predicted the presence of significant AVF stenosis requiring PTA in this feasibility study and may potentially be used in AVF surveillance.

Transarterial Radioembolization for Unresectable Hepatocellular Carcinoma: Real-Life Efficacy and Safety Analysis of Korean Patients.

Transarterial radioembolization (TARE) has become widely used in the treatment of HCC, one of the most common causes of cancer mortality worldwide. Here we investigated the long-term clinical outcomes of patients with hepatocellular carcinoma (HCC) treated with TARE in a multi-medical center in Korea. A total of 149 patients treated with TARE from 2008-2014 were recruited. The pre-treatment HCC stage was classified according to the BCLC stage, of which C and D were defined as advanced HCC. Advanced HCC stage and Child-Turcotte-Pugh (CTP) score A were identified in 62 (42%) and 134 (90%) patients, respectively. Portal vein thrombosis (PVT) was identified in 58 patients (38.9%). The median time to progression (TTP) was 14 months, and the median overall survival (OS) and progression-free survival (PFS) were 18.6 and 8.9 months, respectively. The overall tumor response was 47%, and the disease control rate was 78%. OS and PFS differed significantly according to the presence of liver cirrhosis, extrahepatic metastasis, tumor response and curative treatment after TARE (all, p < 0.05). Multiple tumors and major PVT were other independent factors related to OS, while the des-gamma carboxy protein level predicted PFS (all, p < 0.05). Tumor size was an independent predictor of tumor response. TTP, OS and PFS all differed among BCLC stages. The serious adverse effect after TARE was clinically not significant. Therefore, TARE is safe and effective in treating early to advanced HCCs.

Surgical Findings and Outcomes of Endotension Following Endovascular Aneurysm Repair.

BACKGROUND: Endotension is one of the detrimental complications after endovascular aneurysm repair (EVAR) and surgical management has been considered as standard of care. However, there is a paucity of data regarding the findings, and outcomes of such surgical intervention. The aim of this study was to investigate intraoperative findings and outcomes of surgical treatment for endotension after EVAR. METHODS: Between January 2005 and October 2018, of the 708 patients who underwent EVAR for aneurysm aortic aneurysm; 12 patients (mean age of 76.1; range 66-88) who underwent open repair for endotension were retrospectively analyzed. The anatomical characteristics of the aorta and surgical findings were reviewed. The rates of early and late procedural complications, and overall mortality were evaluated. RESULTS: The median interval between the EVAR and surgical conversion was 45.9 months (range 17.1-46.9). Three of the twelve patients underwent emergency surgery due to aneurysm rupture. The median aneurysm sac size, the proximal neck diameter, and the proximal neck length before EVAR were 64 mm, 23.5 mm, and 30.5 mm, respectively, that changed before open repair to 93.5 mm (P = 0.02), 25 mm (P = 0.011), and 23 mm (P = 0.003), respectively. In four of the twelve patients, radiographically undetected endoleak was identified during surgery to be Type Ia, Ib, II, and III, respectively. The rates of early and late procedural complications, and overall mortality were 8.3%, 8.3% and 8.3%, respectively. CONCLUSIONS: Patients with endotension have a risk of delayed endoleak and aneurysm rupture; secondary intervention should be performed in such cases to prevent fatal complications. Surgical treatment appears to be a curative treatment for endotension with favorable outcomes. In addition, the possibility of an undetected endoleak should be considered as a potential cause of endotension.

Comparison of Retrievability and Indwelling Complications of Celect and Denali Infrarenal Vena Cava Filters: A Randomized, Controlled Trial.

PURPOSE: To compare the Celect and Denali filters in terms of complex filter retrieval and indwelling complications after a 2-month indwelling time. MATERIALS AND METHODS: In this prospective, randomized trial, 153 subjects were assessed for eligibility between May 2016 and July 2018. A total of 136 participants were randomly assigned to receive either Celect (n = 68) or Denali (n = 68) filter placement in the infrarenal inferior vena cava. Tilt angles at placement and retrieval and rates of overall filter retrieval, indwelling complication, and complex retrieval were compared. RESULTS: Of 136 participants (mean age, 62 ± 12.8 years, 55 male), 24 (17.6%) were lost to follow-up. The mean indwelling time of filter was 60.4 ± 7 days and there was no significant difference in the baseline characteristics between the two groups. Filter retrieval was successful in all participants (112/112, 100%). Significantly higher rates of filter tilt > 15° (n = 8) and strut penetration (n = 14) were found with the Celect filter than with the Denali filter (1 significant tilt and 1 penetration) (P = 0.033 and 0.001, respectively). No filter fractures were observed and there was no significant difference in tip embedment, filter fracture, filter migration, or mean fluoroscopy times. There were 3 cases of complex retrieval (1 for Denali vs. 2 for Celect, P = 0.500), for which the loop-snare technique was used. CONCLUSION: Denali filters demonstrated significantly lower rates of tilt angle > 15° and strut penetration. However, there was no significant difference in the complex filter retrieval rate between the Celect and Denali filters.

Prospective Multi-Center Korean Registry of Transcatheter Arterial Chemoembolization with Drug-Eluting Embolics for Nodular Hepatocellular Carcinoma: A Two-Year Outcome Analysis.

OBJECTIVE: To assess the two-year treatment outcomes of chemoembolization with drug-eluting embolics (DEE) for nodular hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This study was a prospective, multicenter, registry-based, single-arm trial conducted at five university hospitals in Korea. Patients were recruited between May 2011 and April 2013, with a target population of 200. A DC Bead loaded with doxorubicin was used as the DEE agent. Patients were followed up for two years. Per-patient and per-lesion tumor response analysis, per-patient overall survival (OS) and progression-free survival (PFS) analysis, and per-lesion tumor control analysis were performed. RESULTS: The final study population included 152 patients, with 207 target lesions for the per-lesion analysis. At one-month, six-month, one-year, and two-year per-patient assessments, complete response (CR) rates were 40.1%, 43.0%, 33.3%, and 19.6%, respectively. The objective response (OR) rates were 91.4%, 55.4%, 35.1%, and 19.6%, respectively. The cumulative two-year OS rate was 79.7%. The cumulative two-year PFS rate was 22.4% and the median survival was 9.3 months. In multivariable analysis, the Child-Pugh score (p = 0.019) was an independent predictor of OS, and tumor multiplicity (p < 0.001), tumor size (p = 0.020), and Child-Pugh score (p = 0.006) were independent predictors of PFS. In per-lesion analysis, one-month, six-month, one-year and two-year CR rates were 57.5%, 58.5%, 45.2%, and 33.3%, respectively, and the OR rates were 84.1%, 65.2%, 46.6%, and 33.3%, respectively. The cumulative two-year per-lesion tumor control rate was 36.2%, and the median time was 14.1 months. The Child-Pugh score (p < 0.001) was the only independent predictor of tumor control. Serious adverse events were reported in 11 patients (7.2%). CONCLUSION: DEE chemoembolization for nodular HCCs in the Korean population showed acceptable survival, tumor response, and safety profiles after a two-year follow-up. Good liver function (Child-Pugh score A5) was a key predictor of per-patient OS, PFS, and per-lesion tumor control.

LI-RADS Version 2018 Treatment Response Algorithm: Diagnostic Performance after Transarterial Radioembolization for Hepatocellular Carcinoma.

OBJECTIVE: To assess the diagnostic performance of the Liver Imaging Reporting and Data System (LI-RADS) version 2018 treatment response algorithm (TRA) for the evaluation of hepatocellular carcinoma (HCC) treated with transarterial radioembolization. MATERIALS AND METHODS: This retrospective study included patients who underwent transarterial radioembolization for HCC followed by hepatic surgery between January 2011 and December 2019. The resected lesions were determined to have either complete (100%) or incomplete (< 100%) necrosis based on histopathology. Three radiologists independently reviewed the CT or MR images of pre- and post-treatment lesions and assigned categories based on the LI-RADS version 2018 and the TRA, respectively. Diagnostic performances of LI-RADS treatment response (LR-TR) viable and nonviable categories were assessed for each reader, using histopathology from hepatic surgeries as a reference standard. Inter-reader agreements were evaluated using Fleiss κ. RESULTS: A total of 27 patients (mean age ± standard deviation, 55.9 ± 9.1 years; 24 male) with 34 lesions (15 with complete necrosis and 19 with incomplete necrosis on histopathology) were included. To predict complete necrosis, the LR-TR nonviable category had a sensitivity of 73.3-80.0% and a specificity of 78.9-89.5%. For predicting incomplete necrosis, the LR-TR viable category had a sensitivity of 73.7-79.0% and a specificity of 93.3-100%. Five (14.7%) of 34 treated lesions were categorized as LR-TR equivocal by consensus, with two of the five lesions demonstrating incomplete necrosis. Inter-reader agreement for the LR-TR category was 0.81 (95% confidence interval: 0.66-0.96). CONCLUSION: The LI-RADS version 2018 TRA can be used to predict the histopathologic viability of HCCs treated with transarterial radioembolization.

Treatment efficacy by hepatic arterial infusion chemotherapy vs. sorafenib after liver-directed concurrent chemoradiotherapy for advanced hepatocellular carcinoma.

BACKGROUND: We compared the clinical efficacies of hepatic arterial infusion chemotherapy (HAIC) vs. sorafenib as sequential maintenance therapy following liver-directed concurrent chemoradiotherapy (LD-CCRT) for locally advanced-stage hepatocellular carcinoma (HCC). METHODS: Patients undergoing HAIC with 5-fluorouracil and cisplatin (HAIC-maintain group, n = 151) or sorafenib (Sorafenib-maintain group, n = 37) after LD-CCRT were consecutively enrolled. The study endpoints were overall survival (OS), progression-free survival (PFS), and treatment response rates. RESULTS: The median OS among HAIC-maintain and Sorafenib-maintain groups were 15.9 and 24.3 months (p = 0.287), whereas the median PFS were 8.1 and 9.1 months (p = 0.651), respectively. During the planned treatments, the radiological objective response rate (54.3% vs. 64.9%; p = 0.246), and conversion rate to surgical resection or liver transplantation after successful down-staging (15.9% vs. 18.9%; p = 0.657) were comparable between the HAIC-maintain and Sorafenib-maintain groups. Similar results were found after the inverse probability of treatment weighting and propensity score-matching analyses. Regarding treatment-related adverse events, the HAIC-maintain group showed worse profiles in terms of leukopenia (all grades [p = 0.001] and grades 3 or 4 [p = 0.041]) and hypoalbuminemia (p = 0.001) than the Sorafenib-maintain group. CONCLUSIONS: The overall clinical efficacies between the sequential treatment of HAIC vs. sorafenib after LD-CCRT were comparable for locally advanced HCC.

Association between Cumulative Fluid Balance and Outcomes in Acute Respiratory Distress Syndrome Patients Treated with Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has become increasingly accepted as a life-saving procedure for patients with severe acute respiratory distress syndrome (ARDS). This study investigated the relationship between cumulative fluid balance (CFB) and outcomes in adult ARDS patients treated with ECMO. METHODS: We retrospectively analyzed the data of adult ARDS patients who received ECMO between December 2009 and December 2019 at Korea University Anam Hospital. CFB was calculated during the first 7 days after ECMO initiation. The primary endpoint was 28-day mortality. RESULTS: The 74 patients were divided into survivor (n=33) and non-survivor (n=41) groups based on 28-day survival. Non-survivors showed a significantly higher CFB at 1-7 days (p<0.05). Cox multivariable proportional hazard regression revealed a relationship between CFB on day 3 and 28-day mortality (hazard ratio, 3.366; 95% confidence interval, 1.528-7.417; p=0.003). CONCLUSION: In adult ARDS patients treated with ECMO, a higher positive CFB on day 3 was associated with increased 28-day mortality. Based on our findings, we suggest a restrictive fluid strategy in ARDS patients treated with ECMO. CFB may be a useful predictor of survival in ARDS patients treated with ECMO.

Comparison of Hemodynamic Energy between Expanded Polytetrafluoroethylene and Dacron Artificial Vessels.

BACKGROUND: Artificial grafts such as polyethylene terephthalate (Dacron) and expanded polytetrafluoroethylene (ePTFE) are used for various cardiovascular surgical procedures. The compliance properties of prosthetic grafts could affect hemodynamic energy, which can be measured using the energy-equivalent pressure (EEP) and surplus hemodynamic energy (SHE). We investigated changes in the hemodynamic energy of prosthetic grafts. METHODS: In a simulation test, the changes in EEP for these grafts were estimated using COMSOL MULTIPHYSICS. The Young modulus, Poisson ratio, and density were used to analyze the grafts' material properties, and pre- and post-graft EEP values were obtained by computing the product of the pressure and velocity. In an in vivo study, Dacron and ePTFE grafts were anastomosed in an end-to-side fashion on the descending thoracic aorta of swine. The pulsatile pump flow was fixed at 2 L/min. Real-time flow and pressure were measured at the distal part of each graft, while clamping the other graft and the descending thoracic aorta. EEP and SHE were calculated and compared. RESULTS: In the simulation test, the mean arterial pressure decreased by 39% for all simulations. EEP decreased by 42% for both grafts, and by around 55% for the native blood vessels after grafting. The in vivo test showed no significant difference between both grafts in terms of EEP and SHE. CONCLUSION: The post-graft hemodynamic energy was not different between the Dacron and ePTFE grafts. Artificial grafts are less compliant than native blood vessels; however, they can deliver pulsatile blood flow and hemodynamic energy without any significant energy loss.

Superselective transcatheter arterial embolization for acute small bowel bleeding: clinical outcomes and prognostic factors for ischemic complications.

BACKGROUND: Small bowel bleeding (SBB) accounts for 5%-10% of all cases of acute gastrointestinal bleeding. Transcatheter arterial embolization (TAE) plays an important role in the treatment of SBB. PURPOSE: To evaluate the safety and efficacy of superselective TAE exclusively for SBB and to assess factors associated with clinical outcomes. MATERIAL AND METHODS: From January 2006 to April 2017, 919 patients were admitted with signs and symptoms of gastrointestinal bleeding; 74 patients (mean age = 57.5 years; age range = 14-82 years) with positive angiographic findings for SBB were retrospectively analyzed. The technical success of TAE and clinical outcomes, including recurrent bleeding, major complications, and in-hospital mortality were evaluated. The associations of various clinical and technical factors with clinical outcomes were analyzed. RESULTS: The bleeding foci were in the ileum in 48 (65%) patients and the jejunum in 26 (35%). Technical success was achieved in 72 (97%) patients. The rates of recurrent bleeding, major complications, and in-hospital mortality were 12% (7/57), 21% (15/71), and 25% (18/72), respectively. Superselective embolization was a significant prognostic factor associated with fewer major complications (OR = 0.069; P = 0.003). The increased number of embolized vasa recta was significantly associated with a higher probability of major complications (OR = 2.64; P < 0.001). The use of N-butyl cyanoacrylate was associated with lower rates of major complication (OR = 0.257; P = 0.027). CONCLUSION: TAE is a safe and effective treatment modality for SBB. In addition, whenever possible, TAE should be performed in a superselective manner to minimize ischemic complications.

Comparison of the therapeutic efficacy and ovarian reserve between catheter-directed sclerotherapy and surgical excision for ovarian endometrioma.

OBJECTIVES: To compare the efficacies of catheter-directed sclerotherapy (CDS) with 99% ethanol and surgery for ovarian endometrioma and their impact on the ovarian reserve. METHODS: From January 2011 to June 2019, 71 patients who underwent surgical excision (n = 51) or CDS (n = 20) for symptomatic ovarian endometriomas were reviewed. To analyze the effect on the ovarian reserve, serum anti-Müllerian hormone (AMH) levels were compared before and after the procedure. Symptoms, serum cancer antigen 125 (CA-125), lesion size, recurrence, hospitalization, and complications were reviewed retrospectively. RESULTS: During a mean follow-up of 22.3 months (range, 6 to 94 months), no significant difference in symptom relief was found between CDS and surgery (95.0% [19/20] and 92.2% [47/51], respectively, p > 0.999). The hospital stay was shorter with CDS than with surgery (2.6 ± 0.6 days and 4.1 ± 0.5 days, respectively, p < 0.001). There was no significant difference in serum AMH levels before and after CDS (2.3 (interquartile range (IQR) 1.1-5.3) ng/mL and 2.6 (IQR 0.9-4.9) ng/mL, respectively, p = 0.243), but there was a significant decrease in serum AMH in the surgery group (3.0 (IQR 1.3-5.5) ng/mL and 1.6 (IQR 0.7-3.2) ng/mL, respectively, p < 0.001). CA-125 decreased in both CDS and surgery groups (p = 0.001 and < 0.001, respectively). Two minor complications occurred in the surgery group, while no complication was observed in the CDS group. CONCLUSIONS: The therapeutic efficacy of CDS appears to be comparable to that of surgical resection for ovarian endometrioma. Ovarian function was well-preserved, and a shorter hospital stay was required in patients who underwent CDS. KEY POINTS: • There was no significant difference in symptom relief between CDS and surgery (95.0% [19/20], 92.2% [47/51], respectively, p >0.999). • No significant difference in serum AMH levels was seen before and after CDS (2.3 (1.1, 5.3)* ng/mL, 2.6 (0.9, 4.9)* ng/mL, respectively, p = 0.243), whereas serum AMH levels significantly decreased after surgical resection (3.0 (1.3, 5.5)* ng/mL, 1.6 (0.7, 3.2)* ng/mL, respectively, p <0.001). *Median (25 quartiles, 75 quartiles) • The hospitalization period was shorter with CDS than with surgery (2.6 ± 0.6 days, 4.1 ± 0.5 days, respectively, p <0.001).

Renal mass cryoablation: Melting time analysis of radiographic ice-ball after 5-minute active thawing by using serial ultrasound.

OBJECTIVE: Cryoneedles removal before sufficient thawing may lead to tissue damage and bleeding. We analyzed melting time of radiographic ice-ball in renal percutaneous cryoablation (PCA) using ultrasound. MATERIALS AND METHODS: Consecutive 27 patients who underwent PCA using cryoneedles of 2-4 for the renal mass (median size, 1.9 cm; range, 1.1-4.1 cm) were evaluated. Reconstructed CT images obtained during freezing were used to measure radiographic ice-ball volume. After completing final freezing, 5-min active thawing and following passive thawing were performed. Melting time of radiographic ice-ball during the thawing was analyzed by serial ultrasound examination. Melting time was defined as the time of complete disappearance of intrarenal posterior acoustic shadowing generated by radiographic ice-ball, which was analyzed by two independent radiologists. The relationship between total melting time and radiographic ice-ball volume was also analyzed by Spearman's rank correlation. RESULTS: Median radiographic ice-ball volume was 30.5 cm3 (range, 26.6-37.3 cm3). After 5-min active thawing, radiographic ice-ball needed additional passive thawing of median 8-min or 9-min for complete melting in analyses of two independent radiologists, respectively (p > 0.05). The range of total melting time during active and passive thawing was 9-min-to-15-min for both radiologists, respectively. A positive correlation was found between total melting time and radiographic ice-ball volume (Spearman's rho, 0.644 and 0.479 for radiologist 1 and 2). CONCLUSION: In our PCA protocol, radiographic ice-ball needed approximately 10-min passive thawing after 5-min active thawing for complete melting. This may help determine safe removal time of cryoneedles.