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1.
J Am Coll Radiol ; 2019 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-31541656

RESUMO

PURPOSE: The aim of this study was to evaluate inpatient mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation compared with medical management (MM) in patients with hepatorenal syndrome (HRS). METHODS: Patients with cirrhosis admitted with HRS between 2005 and 2014 were identified using associated International Classification of Diseases, Ninth Revision, codes in the National Inpatient Sample (n = 153,112). Non-TIPS candidates and patients with parenchymal renal disease were excluded (n = 73,454). The remaining admissions were assigned to groups of TIPS (International Classification of Diseases, Ninth Revision, code 39.1; n = 971) or MM (n = 78,687). Inpatient mortality was analyzed by treatment type and patient gender using χ2 tests. Logistic regression was performed to control for baseline differences in patient demographics, comorbid disease, and pretreatment mortality risk. RESULTS: Baseline patient demographics were similar. Patients treated medically had higher baseline disease severity (median mortality risk score, 8.3 with MM versus 6.1 with TIPS; P < .01). Inpatient mortality was strongly modified by patient gender. TIPS creation conferred inpatient mortality benefit in men (28% of the MM group versus 10% of the TIPS group, P < .01) independent of all covariates (odds ratio, 0.4; 95% confidence interval, 0.17-0.78; P < .01). Women treated with TIPS creation experienced no mortality benefit (29% MM versus 32% TIPS; odds ratio, 1.5; 95% confidence interval, 0.75-3.23; P = .23). CONCLUSIONS: TIPS creation is associated with reduced inpatient mortality in men, but not women, admitted with HRS. Drivers of this gender-based disparity are currently unclear and warrant focused investigation.

2.
AJR Am J Roentgenol ; 213(5): 1152-1156, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31216197

RESUMO

OBJECTIVE. The purpose of this study was to evaluate the safety and technical feasibility of inferior vena cava filter (IVCF) removal when filter elements penetrate adjacent bowel. MATERIALS AND METHODS. A multicenter retrospective review of IVCF retrievals between 2008 and 2018 was performed. Adult patients with either CT or endoscopic evidence of filter elements penetrating bowel before retrieval were included. Technical success of IVCF retrieval was recorded. Patient records were assessed for immediate, 30-day, and 90-day complications after retrieval. RESULTS. Thirty-nine consecutive adult patients (11 men and 28 women; mean age, 51.2 years; age range, 18-81 years) qualified for inclusion. Filter dwell time was a median of 148 days (range, 32-5395 days). No IVCFs were known to have migrated or caused iliocaval thrombosis. Five IVCFs (12.8%) had more than 15° tilt relative to the inferior vena cava (IVC) before retrieval. Three IVCFs (7.7%) had fractured elements identified at the time of retrieval. Mean international normalized ratio (INR) was 1.24 ± 0.53 (SD), and mean platelet count was 262 ± 139 × 103/µL. Ten patients (25.6%) were on antibiotics at the time of retrieval. All 39 IVCFs were successfully retrieved (technical success = 100%). Two patients experienced minor complications in the immediate postprocedural period, which resulted in a minor complication rate of 5.1%. There were no complications (major or minor) identified in any patient at 30 or 90 days after retrieval. The overall major complication rate was 0%. CONCLUSION. Endovascular retrieval of IVCFs with CT evidence of filter elements that have penetrated adjacent bowel is both safe and technically feasible.

3.
Semin Intervent Radiol ; 36(2): 126-132, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31123385

RESUMO

Uterine artery embolization (UAE) is a ubiquitous procedure, and a broadly recognized alternative to surgical interventions for symptomatic leiomyomata when uterine preservation is desired. Aside from postembolization syndrome (typically considered an expected feature of recovery), the most frequently described complications are temporary or permanent amenorrhea and lingering vaginal discharge. Less frequently described complications include fibroid expulsion (FE), protracted or refractory pain, infection, urinary retention, and access-related injuries. Reported rates of transcervical FE vary in the literature from 3 to 50% but are most often quoted to be around 5 to 15%. Certain features predispose a patient to FE, including size and location of the tumor, with pedunculated submucosal, submucosal, and transmural lesions considered to be "high risk." While the optimal management of FE has not been definitively determined, high rates of nonoperative management of FE are noted in the literature. This article describes a case in which a fibroid was expulsed following UAE, as well as the management of the complication. A literature review and recommendations for the management of FE is also given.

4.
J Am Coll Radiol ; 16(5S): S214-S226, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31054748

RESUMO

Venous thromboembolism (VTE)-deep vein thrombosis and pulmonary embolism-is a common cause of morbidity and mortality. The mainstay of VTE prophylaxis and therapy is anticoagulation. In select patients with VTE, inferior vena cava (IVC) filters are used to prevent pulmonary embolism by trapping emboli as they pass from the lower extremity venous system through the IVC. These guidelines review the indications for placement of IVC filters in acute and chronic VTE, as well as the indications for retrieval of implanted IVC filters. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

5.
J Am Coll Radiol ; 15(12): 1761-1764, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30245218

RESUMO

INTRODUCTION: The formation of integrated interventional radiology (IR) residency programs has changed the training paradigm. This change mandates the need to provide adequate exposure to allow students to explore IR as a career option and to allow programs to sufficiently evaluate students. This study aims to highlight the availability of medical student education in IR and proposes a basic framework for clinical rotations. MATERIALS AND METHODS: The Liaison Committee on Medical Education (LCME) website was utilized to generate a list of accredited medical schools in the United States. School websites and course listings were searched for availability of IR and diagnostic radiology rotations. The curricula of several well-established IR rotations were examined to identify and categorize course content. RESULTS: In all, 140 LCME-accredited medical schools had course information available. Of those schools, 70.5% offered an IR rotation; 84.6% were only available to senior medical students and only 2% were offered for preclinical students; and 8.1% of courses were listed as subinternships. Well-established IR clerkships included a variety of clinical settings, including preprocedure evaluation, experience performing procedures, postprocedure management, and discharge planning. CONCLUSION: Medical student exposure to IR is crucial to the success of integrated IR residency programs. Current research shows few institutions with formal IR subinternship rotations. Although 70.5% of institutions have some form of nonstandardized IR course, 84.6% are available only to fourth-year students, and 2% are offered to preclinical students. This suggests there is a significant opportunity for additional formal exposure to IR through increasing availability of IR rotations and exposure during the clinical and preclinical years.


Assuntos
Currículo , Educação de Pós-Graduação em Medicina , Educação de Graduação em Medicina , Radiologia Intervencionista/educação , Ensino , Escolha da Profissão , Previsões , Humanos , Faculdades de Medicina , Inquéritos e Questionários , Estados Unidos
7.
Semin Intervent Radiol ; 35(1): 9-16, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29628610

RESUMO

In the past 20 years, peripheral artery disease (PAD) has been increasingly recognized as a significant cause of morbidity and mortality in the United States. PAD has traditionally been identified as a male-dominant disease; however, recent population trends and studies in PAD suggest that women are affected at least as often as men. Women comprise a larger population of the elderly than men, as well as an increasing proportion of patients with PAD. Much of the existing research on PAD has focused on whole populations, and gender-specific data on PAD is sparse. This review focuses on gender-specific differences in presentation, management, and outcomes of PAD intervention that are important considerations for the interventional radiologist.

8.
Semin Intervent Radiol ; 35(1): 23-28, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29628612

RESUMO

As the reversible contraceptive arm implants grow more popular, there is an increasing need to recognize the complications resulting from implant migration and removal. This review summarizes the findings of imaging and removal methods. When an implant is lost, the axillary region should be investigated first. If the implant still cannot be found, visualization though different methods have been employed for non-radiopaque implants. Real-time fluoroscopic-guided localization and removal can be accomplished for radiopaque Nexplanon. Once the implant has been located, standard removal method and other modified techniques can be used to safely remove the implant depending on the implant's location.

9.
Semin Intervent Radiol ; 35(1): 35-40, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29628614

RESUMO

Pelvic venous insufficiency is now a well-characterized etiology of pelvic congestion syndrome (PCS). The prevalence of CPP is 15% in females aged 18 to 50 years in the United States and up to 43.4% worldwide. In addition to individual physical, emotional, and quality-of-life implications of CPP, there are profound healthcare and socioeconomic expenses with estimated annual direct and indirect costs in the United States in excess of 39 billion dollars. PCS consists of clinical symptoms with concomitant anatomic and physiologic abnormalities originating in venous insufficiency. The etiology of PCS is diverse involving both mechanical and hormonal factors contributing to venous dilatation (>5 mm) and insufficiency. Factors affecting the diagnosis of PCS include variance of causes and clinical presentations of pelvic pain and relatively low sensitivity of noninvasive diagnostic imaging and laparoscopy to identify insufficiency compared with catheter venogram. A systematic review of the literature evaluating patient outcomes following percutaneous treatment of PCS is presented.

10.
J Vasc Interv Radiol ; 29(4): 476-481.e1, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29373244

RESUMO

PURPOSE: To determine whether utilization and outcomes of dialysis access maintenance interventions vary by patient race or sex. MATERIALS AND METHODS: Data for this retrospective cohort study of first-time arteriovenous (AV) access recipients were drawn from a 5% sample of Medicare beneficiaries, containing claims from all clinical settings (2009-2014) in 2,693 patients who received their first AV fistula/graft in 2009. Maintenance interventions-angiography, angioplasty, thrombolysis, stent placement, and venous embolization-were identified by corresponding Current Procedural Terminology codes. Outcomes of primary patency (PP), postinterventional primary patency (PIPP), and postinterventional secondary patency (PISP) were calculated with utilization records. Associations between demographic data and patency times were evaluated by a multivariate survival approach, controlling for baseline differences in patient age, comorbid disease, type of dialysis access, and interventionist specialty. RESULTS: AV grafts (AVGs) were created with greater frequency in women (32% vs 23% in men; P < .001) and minority patients (39% in black, 32% in Hispanic, and 29% in Asian patients vs 21% in white patients; P < .001). Women were at greater hazards for loss of PP (hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.09-2.14) and PIPP (HR, 1.42; 95% CI, 1.01-2.00). Black patients were at greater hazards for loss of PP (HR, 1.37; 95% CI, 1.23-1.54) and PISP (HR, 1.29; 95% CI, 1.01-1.65). AVG creation predisposed patients to patency loss in all models (P < .001). CONCLUSIONS: Dialysis access patency rates are lower for women and black patients. More frequent primary AVG creation in women and minority patients additionally predisposes these patients to patency loss.


Assuntos
Derivação Arteriovenosa Cirúrgica , Oclusão de Enxerto Vascular/etnologia , Oclusão de Enxerto Vascular/prevenção & controle , Diálise Renal , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Medicare , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Sexuais , Resultado do Tratamento , Estados Unidos , Grau de Desobstrução Vascular
11.
Curr Probl Diagn Radiol ; 47(3): 146-151, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28684055

RESUMO

PURPOSE: To survey residents who participated in the 2015 interventional radiology fellowship match regarding the overall process, including the number of interviews received, programs ranked, money spent, and perceived effect on board preparation. METHODS: An IRB-approved, anonymous web-based survey was distributed via email link to 151 individuals in 41 states who had interview at 1 of 2 IR fellowship programs in the United States. Most of the survey's 12 questions were based on a five-point Likert scale, while others were free-text response. RESULTS: Seventy-five out of 151 residents completed the survey (response rate 49.7%). When asked if the current timing of the core board examination worked well with the IR interview schedule, 62 (96.6%) either strong disagreed or disagreed. Sixty respondents (87%) reported that preparing for and traveling to IR interviews had a very negative or somewhat negative effect on boards preparation. When asked what change they would make to the timing of IR interviews or the core examination, 55 (79.7%) thought that IR fellowship interviews should occur earlier in the year. The median number of IR programs applied to, interviews offered, interviews completed, and programs ranked were 28, 13, 10, and 10, respectively. When asked how much money was spent on the application and interview process, 39% spent between $5000 and $9999, and 17% spent more than $10000. CONCLUSIONS: A substantial percentage of radiology residents who participated in the 2015 IR fellowship match have concerns about the proximity of board preparation to the match process. Consideration for restructuring the timing of this process is recommended.


Assuntos
Educação de Pós-Graduação em Medicina/economia , Financiamento Pessoal , Internato e Residência , Seleção de Pessoal , Radiologia Intervencionista/educação , Avaliação Educacional , Humanos , Entrevistas como Assunto , Inquéritos e Questionários , Viagem/economia , Estados Unidos
12.
J Am Coll Radiol ; 14(11S): S506-S529, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29101989

RESUMO

Obtaining central venous access is one of the most commonly performed procedures in hospital settings. Multiple devices such as peripherally inserted central venous catheters, tunneled central venous catheters (eg, Hohn catheter, Hickman catheter, C. R. Bard, Inc, Salt Lake City UT), and implantable ports are available for this purpose. The device selected for central venous access depends on the clinical indication, duration of the treatment, and associated comorbidities. It is important for health care providers to familiarize themselves with the types of central venous catheters available, including information about their indications, contraindications, and potential complications, especially the management of catheters in the setting of catheter-related bloodstream infections. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.


Assuntos
Cateterismo Venoso Central/métodos , Cateterismo Periférico/métodos , Radiografia Intervencionista/métodos , Medicina Baseada em Evidências , Humanos , Sociedades Médicas , Estados Unidos
13.
J Am Coll Radiol ; 14(11S): S530-S539, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29101990

RESUMO

Iliac artery occlusive disease can present as a sudden-onset acute thrombotic or thromboembolic event or as a chronic progressive atherosclerotic process that presents as claudication progressing to rest pain. Depending on the clinical presentation, the diagnosis is usually confirmed through Doppler vascular ultrasound, CT angiography, or MR angiography; the choice of imaging is usually based on modality availability and the presence of patient comorbidities such as chronic kidney disease. The Trans-Atlantic Inter-Society Consensus II classification system is commonly used to describe the extent of the peripheral vascular disease. Depending on the pathophysiology, clinical presentation, and radiologic extent of the disease process, therapeutic options for acute thrombotic cases can include supportive care, anticoagulation, thrombolytic therapy, surgical or catheter-directed mechanical thrombectomy, and surgical bypass. Therapeutic options for atherosclerotic disease include supportive measures such as behavior modification, a supervised exercise program, adjunctive treatment with anticoagulation and antiplatelet medications, angioplasty, stent placement, stent-graft placement, surgical or catheter-directed endarterectomy or plaque excision, and surgical bypass. This document describes the appropriateness of imaging in this patient population, treatment procedures for specific clinical scenarios, and the likely prognosis for these patients. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.


Assuntos
Arteriopatias Oclusivas/diagnóstico por imagem , Diagnóstico por Imagem/métodos , Artéria Ilíaca , Medicina Baseada em Evidências , Humanos , Prognóstico , Sociedades Médicas , Estados Unidos
14.
Expert Rev Med Devices ; 14(10): 805-810, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28885078

RESUMO

INTRODUCTION: Venous thromboembolic disease (VTD) encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE) is a commonly encountered condition with potentially fatal sequelae. When unable to be adequately anticoagulated, patients require a mechanical means to prevent PE. This review discusses the history of inferior vena cava interruption and the development of inferior vena cava filters (IVCF). Areas covered: Milestone innovations in the mechanical treatment of VTD, their successes and shortcomings are discussed. The unforeseen complications that have occurred with implantation of IVCF have a profound impact on the present utilization of retrievable filters. Particular attention is dedicated to the evidence for safe and effective use of IVCF and the challenges presented to further improvement of these technologies. Expert commentary: While evidence suggests that IVCF are effective in preventing PE, the recent 'de-volution' from permanent to retrievable design has unleashed an epidemic device-related complications. Retrievable filter design is reliant on a 'Goldilocks' premise: make the device stable (so it doesn't migrate), but not too stable (so you can still retrieve it). Efforts must be aimed at optimizing utilization using decision support tools, meticulous follow up after deployment, and conversion from retrievable to permanent devices if the patient requires lifelong mechanical prophylaxis.


Assuntos
Desenho de Prótese , Embolia Pulmonar/prevenção & controle , Tromboembolia/prevenção & controle , Filtros de Veia Cava/efeitos adversos , Trombose Venosa/prevenção & controle , Remoção de Dispositivo , História do Século XX , Humanos , Filtros de Veia Cava/história
15.
16.
J Am Coll Radiol ; 14(5S): S266-S271, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28473083

RESUMO

Mesenteric vascular insufficiency is a serious medical condition that may lead to bowel infarction, morbidity, and mortality that may approach 50%. Recommended therapy for acute mesenteric ischemia includes aspiration embolectomy, transcatheter thrombolysis, and angioplasty with or without stenting for the treatment of underlying arterial stenosis. Nonocclusive mesenteric ischemia may respond to transarterial infusion of vasodilators such as nitroglycerin, papaverine, glucagon, and prostaglandin E1. Recommended therapy for chronic mesenteric ischemia includes angioplasty with or without stent placement and, if an endovascular approach is not possible, surgical bypass or endarterectomy. The diagnosis of median arcuate ligament syndrome is controversial, but surgical release may be appropriate depending on the clinical situation. Venous mesenteric ischemia may respond to systemic anticoagulation alone. Transhepatic or transjugular superior mesenteric vein catheterization and thrombolytic infusion can be offered depending on the severity of symptoms, condition of the patient, and response to systemic anticoagulation. Adjunct transjugular intrahepatic portosystemic shunt creation can be considered for outflow improvement. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.


Assuntos
Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/terapia , Angioplastia/métodos , Anticoagulantes/uso terapêutico , Endarterectomia , Medicina Baseada em Evidências , Humanos , Derivação Portossistêmica Transjugular Intra-Hepática , Radiologia , Sociedades Médicas , Stents , Estados Unidos , Vasodilatadores/uso terapêutico
17.
Semin Intervent Radiol ; 33(4): 342-346, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27904255
18.
J Vasc Interv Radiol ; 27(6): 838-45, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26965361

RESUMO

PURPOSE: To elucidate trends in transjugular intrahepatic portosystemic shunt (TIPS) use and outcomes over the course of a decade, including predictors of inpatient mortality and extended length of hospital stay. MATERIALS AND METHODS: The Nationwide Inpatient Sample was interrogated for the most recent 10 years available: 2003-2012. TIPS procedures and associated diagnoses were identified via International Classification of Diseases (version 9) codes, with the latter categorized into primary diagnoses in a hierarchy of disease severity. Linear regression analysis was used to determine trends of TIPS use and outcomes over time. Independent predictors of mortality and extended length of stay were determined by logistic regression. RESULTS: A total of 55,145 TIPS procedures were captured during the study period. Annual procedural volume did not change significantly (5,979 in 2003, 5,880 in 2012). The majority of TIPSs were created for ascites and/or varices (84%). Inpatient mortality (12.5% in 2003, 10.6% in 2012; P < .05) decreased but varied considerably by diagnosis (from 3.7% to 59.3%), with a disparity between bleeding and nonbleeding varices (18.7% vs 3.8%; P < .01). Multivariate predictors of mortality (P < .001 for all) included primary diagnoses (bleeding varices, hepatorenal and abdominal compartment syndromes), patient characteristics (age > 80 y, black race), and sequelae of advanced cirrhosis (comorbid hepatocellular carcinoma, spontaneous bacterial peritonitis, encephalopathy, and coagulopathy). CONCLUSIONS: National TIPS inpatient mortality has decreased since 2003 while procedural volume has not changed. Postprocedural outcome is a function of patient demographic and socioeconomic factors and associated diagnoses. Independent predictors of poor outcome identified in this large national population study may aid clinicians in better assessing preprocedural risk.


Assuntos
Ascite/cirurgia , Varizes Esofágicas e Gástricas/cirurgia , Hipertensão Portal/cirurgia , Derivação Portossistêmica Transjugular Intra-Hepática/tendências , Padrões de Prática Médica/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Ascite/diagnóstico , Ascite/mortalidade , Comorbidade , Bases de Dados Factuais , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/mortalidade , Feminino , Mortalidade Hospitalar/tendências , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/mortalidade , Tempo de Internação/tendências , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Derivação Portossistêmica Transjugular Intra-Hepática/mortalidade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
19.
J Vasc Interv Radiol ; 27(8): 1140-7, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26852944

RESUMO

PURPOSE: To evaluate transjugular intrahepatic portosystemic shunt (TIPS) outcomes and procedure metrics with the use of three different image guidance techniques for portal vein (PV) access during TIPS creation. MATERIALS AND METHODS: A retrospective review of consecutive patients who underwent TIPS procedures for a range of indications during a 28-month study period identified a population of 68 patients. This was stratified by PV access techniques: fluoroscopic guidance with or without portography (n = 26), PV marker wire guidance (n = 18), or intravascular ultrasound (US) guidance (n = 24). Procedural outcomes and procedural metrics, including radiation exposure, contrast agent volume used, procedure duration, and PV access time, were analyzed. RESULTS: No differences in demographic or procedural characteristics were found among the three groups. Technical success, technical success of the primary planned approach, hemodynamic success, portosystemic gradient, and procedure-related complications were not significantly different among groups. Fluoroscopy time (P = .003), air kerma (P = .01), contrast agent volume (P = .003), and total procedural time (P = .02) were reduced with intravascular US guidance compared with fluoroscopic guidance. Fluoroscopy time (P = .01) and contrast agent volume (P = .02) were reduced with intravascular US guidance compared with marker wire guidance. CONCLUSIONS: Intravascular US guidance of PV access during TIPS creation not only facilitates successful TIPS creation in patients with challenging anatomy, as suggested by previous investigations, but also reduces important procedure metrics including radiation exposure, contrast agent volume, and overall procedure duration compared with fluoroscopically guided TIPS creation.


Assuntos
Hipertensão Portal/cirurgia , Veia Porta/cirurgia , Derivação Portossistêmica Transjugular Intra-Hepática , Radiografia Intervencionista , Ultrassonografia de Intervenção , Adolescente , Adulto , Idoso , Pontos de Referência Anatômicos , Dióxido de Carbono/administração & dosagem , Meios de Contraste/administração & dosagem , Feminino , Fluoroscopia , Humanos , Hipertensão Portal/diagnóstico por imagem , Hipertensão Portal/etiologia , Hipertensão Portal/fisiopatologia , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Pressão na Veia Porta , Veia Porta/diagnóstico por imagem , Veia Porta/fisiopatologia , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Portografia , Doses de Radiação , Exposição à Radiação , Radiografia Intervencionista/efeitos adversos , Radiografia Intervencionista/métodos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos , Adulto Jovem
20.
Oral Oncol ; 53: 74-9, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26705064

RESUMO

BACKGROUND: This phase 1, dose-finding study determined the safety, maximum tolerated dose (MTD)/recommended phase 2 dose (RP2D), antitumor activity, and molecular correlates of IPI-926, a Hedgehog pathway (HhP) inhibitor, combined with cetuximab in patients with relapsed/metastatic squamous cell carcinoma of the head and neck. PATIENTS AND METHODS: Cetuximab was given with a 400mg/m(2) loading dose followed by 250mg/m(2) weekly. IPI-926 was given daily starting two weeks after cetuximab initiation. A "3+3" study design was used. Prior therapy with cetuximab was allowed. Tumor biopsies occurred prior to cetuximab initiation, prior to IPI-926 initiation, and after treatment with both drugs. RESULTS: Nine patients were enrolled. The RP2D was 160mg, the same as the single-agent IPI-926 MTD. Among 9 treated, 8 evaluable patients, the best responses were 1 partial response (12.5%), 4 stable disease (50%), and 3 disease progressions (37.5%). The median progression free survival was 77days (95% confidence interval 39-156). Decreases in tumor size were seen in both cetuximab-naïve patients (one HPV-positive, one HPV-negative). The most frequent treatment-emergent adverse events were fatigue, muscle cramps, and rash. No DLTs were observed. Tumor shrinkage and progression free survival were associated with intra-tumoral ErbB and HhP gene expression down-regulation during therapy, supporting the preclinical hypothesis. CONCLUSION: Treatment with IPI-926 and cetuximab yielded expected toxicities with signs of anti-tumor activity. Serial tumor biopsies were feasible and revealed proof-of-concept biomarkers.


Assuntos
Antineoplásicos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma de Células Escamosas/tratamento farmacológico , Cetuximab/uso terapêutico , Neoplasias de Cabeça e Pescoço/tratamento farmacológico , Recidiva Local de Neoplasia/tratamento farmacológico , Intervalo Livre de Doença , Feminino , Expressão Gênica/efeitos dos fármacos , Proteínas Hedgehog/antagonistas & inibidores , Proteínas Hedgehog/genética , Humanos , Masculino , Dose Máxima Tolerável , Pessoa de Meia-Idade , Projetos Piloto , Resultado do Tratamento
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