Analysis of patient's X-ray exposure in hepatic chemosaturation procedures: a single center experience.

BACKGROUND: Hepatic chemosaturation is a technique in which a high dose of the chemotherapeutic agent melphalan is administered directly into the liver while limiting systemic side effects. We reviewed our institutional experience regarding patient's X-ray exposure caused by the procedure. METHODS: Fifty-five procedures, performed between 2016 and 2020 in 18 patients by three interventional radiologists (radiologist), were analyzed regarding the patient's exposure to radiation. Dose-area-product (DAP) and fluoroscopy time (FT) were correlated with the experience of the radiologist and whether the preprocedural evaluation (CS-EVA) and the procedure were performed by the same radiologist. Additionally, the impact of previous liver surgery on DAP/FT was analyzed. RESULTS: Experienced radiologist require less DAP/FT (50 ± 18 Gy*cm2/13.2 ± 3.84 min vs. 69 ± 20 Gy*cm2/15.77 ± 7.82 min; p < 0.001). Chemosaturations performed by the same radiologist who performed CS-EVA required less DAP/FT (41 ± 12 Gy*cm2/11.46 ± 4.41 min vs. 62 ± 11 Gy*cm2/15.55 ± 7.91 min; p < 0.001). Chemosaturations in patients with prior liver surgery with involvement of the inferior cava vein required significantly higher DAP/FT (153 ± 27 Gy*cm2/25.43 ± 4.57 min vs. 56 ± 25 Gy*cm2/14.44 ± 7.55 min; p < 0.001). CONCLUSION: There is a significant learning curve regarding the procedure of hepatic chemosaturation. Due to dose reduction the evaluation and chemosaturation therapy should be performed by the same radiologist. Procedures in patients with previous liver surgery require higher DAP/FT.

[Imaging diagnostics of chronic pancreatitis]. / Bildgebende Diagnostik bei chronischer Pankreatitis.

Chronic pancreatitis is characterized by recurrent inflammatory episodes. The diagnosis is based on the detection of pathognomonic morphological alterations by ultrasound-based methods as well as computed tomography and magnetic resonance imaging. In addition, imaging techniques play an important role for the differential diagnostics of potential complications in patients with chronic pancreatitis and for regular monitoring of patients with increased cancer risk. This article summarizes the current guideline recommendations for medical imaging procedures in chronic pancreatitis.

Chemosaturation of the Liver - an Update. / Chemosaturation der Leber ­ ein Update.

BACKGROUND: Percutaneous hepatic perfusion (CS-PHP) is a treatment option for primary and secondary liver neoplasms and subject of intensive research. This present article provides an overview of CS-PHP regarding patient safety, feasibility and effectiveness based on recent studies. METHOD: We performed a PubMed search including the search terms chemosaturation, hepatic chemosaturation, percutaneous perfusion and melphalan. RESULTS AND CONCLUSION: CS-PHP is a promising procedure for the treatment of uveal melanoma and cholangiocellular carcinoma. There are insufficient data regarding the effectiveness of CS-PHP with respect to other tumor entities. Since CS-PHP can be accompanied by multiple transient side effects and complications, close interdisciplinary cooperation is necessary. KEY POINTS: · Chemosaturation of the liver is a safe procedure.. · CS-PHP is a potent therapy for hepatic metastatic ocular melanoma and cholangiocellular carcinoma.. · The procedure requires close interdisciplinary coordination.. · CS-PHP is a repeatable and thus long-term therapeutic option for some patients.. CITATION FORMAT: · Ebel S, Struck MF, van Boemmel F et al. Chemosaturation of the Liver - an Update. Fortschr Röntgenstr 2023; 195: 30 - 37.

Prognostic Factors for Postoperative Bleeding Complications and Prolonged Intensive Care after Percutaneous Hepatic Chemosaturation Procedures with Melphalan.

Percutaneous hepatic melphalan perfusion (chemosaturation) in patients with liver metastases is known to be associated with procedure-related hemodynamic depression and coagulation impairment, which may cause bleeding complications and/or a prolonged intensive care unit length of stay (ICU LOS). We retrospectively analyzed possible predictive factors for bleeding complications and an ICU LOS > 1 d in a cohort of 31 patients undergoing 90 chemosaturation procedures. Using a multivariable mixed-model approach, we identified the amount of perioperative fluid volume (OR 12.0, 95% CI 2.3-60.0, p = 0.003) and protamine (OR 0.065, 95% CI 0.007-0.55, p = 0.012) to be associated with bleeding complications. Furthermore, the amount of perioperative fluid volume was associated with an ICU LOS > 1 d (OR 5.2, 95% CI 1.4-19.0, p = 0.011). Heparin dosage, melphalan dosage, extracorporeal circulation time, and noradrenaline dosage had no significant effects on outcomes. Protamine use was not associated with anaphylactic or thromboembolic complications. Despite the limited sample size, these results suggest a restrictive perioperative fluid regime to be beneficial, and support the use of protamine for heparin reversal after chemosaturation procedures. Further prospective randomized trials are needed to confirm these findings.

Analysis of Periprocedural X-ray Exposure in Transarterial Radioembolization with Glass or Resin Microspheres.

Background: Transarterial Radioembolization (TARE) is an effective treatment option for both primary and secondary liver malignancies. However, challenging anatomical conditions can lead to prolonged fluoroscopy times (FT), elevated doses of periprocedural X-radiation (DAP), and increased use of contrast agents (CAs). In this study, we examined the influence of our radiologists' experience and the choice of microspheres on X-ray exposure and CA doses in TARE. Material and Methods: Datasets comprising 161 TARE and 164 preprocedural evaluation angiographies (TARE-EVA) were analyzed. Our study focused on assessing DAP, FT, and CA concerning both microsphere types, the radiologist's experience, and whether the same radiologist performed both the TARE-EVA and the actual TARE. Results: In TARE, the use of resin microspheres resulted in significantly higher FT and CA compared to glass microspheres (14.3 ± 1.6 min vs. 10.6 ± 1.1 min and 43 ± 2.2 mL vs. 33.6 ± 2.1 mL, p < 0.05), with no notable differences in DAP (p = 0.13). Experienced radiologists demonstrated reduced FT/DAP, with a 19% decrease in DAP and 53% in FT during the evaluation angiography (p < 0.05) and a 49% reduction in DAP during the actual TARE (p < 0.05), with no statistical differences in FT. Performing TARE and TARE-EVA under the same radiologist led to a 43% reduction in DAP and a 25% decrease in FT (p < 0.05, respectively). Conclusions: To mitigate X-radiation exposure, it is advisable for radiologists to undergo thorough training, and, ideally, the same radiologist should conduct both the TARE and the TARE-EVA. While the use of glass spheres may decrease intraarterial CA, it does not significantly impact periprocedural X-ray exposure.

Percutaneous Aspiration Thrombectomy for Arterial Thromboembolic Occlusion Following Percutaneous Transluminal Angioplasty: Technical Success Rates and Clinical Outcomes.

PURPOSE: We aimed to analyze the technical success rate of manual percutaneous aspiration thrombectomy (PAT) in patients with peripheral arterial thromboembolism as a complication of infrainguinal percutaneous transluminal angioplasty (PTA) and we sought to evaluate the 30-day postintervention clinical outcome. MATERIALS AND METHODS: We retrospectively identified 29 patients (men/women, 18/11; mean age, 74 years) who underwent infrainguinal PAT to treat thromboembolic complications of infrainguinal PTA. Primary and secondary technical successes were defined as residual stenosis of < 50 % of the vessel diameter after PAT alone and PAT with additional PTA, respectively. Clinical outcome parameters (e. g., amputation, need for further intervention) were evaluated during the first 30 days after intervention. RESULTS: The primary and secondary technical success rates were 58.6 % (17/29) and 79.3 % (23/29), respectively. Clinical outcome data were available for 93.1 % (27/29) of patients. No further intervention was required within 30 days in 81.5 % (22/27) of patients. Four patients underwent minor amputations owing to preexisting ulcerations (Rutherford Category 5), and no patients underwent major amputations (Rutherford Category 6). Revascularization of the previously treated vessel segment with PTA was necessary on the first postintervention day in one patient. CONCLUSION: Manual PAT, with PTA if needed, has a good technical success rate and satisfactory early clinical outcome in patients with iatrogenic thromboembolic complications after infrainguinal PTA. KEY POINTS: · Manual PAT is a possible first-choice treatment of infrainguinal PTA-induced acute thromboembolism.. · Performing additional PTA increases the success rate of manual PAT.. · Unlike catheter-directed intraarterial lysis, manual PAT carries no risk of bleeding.. CITATION FORMAT: · Schicho A, Bäumler W, Verloh N et al. Percutaneous Aspiration Thrombectomy for Arterial Thromboembolic Occlusion Following Percutaneous Transluminal Angioplasty: Technical Success Rates and Clinical Outcomes. Fortschr Röntgenstr 2022; 194: 291 - 295.

Dickkopf-Related Protein 1 as Response Marker for Transarterial Chemoembolization of Hepatocellular Carcinomas.

Background and Aims: In the treatment of hepatocellular carcinoma (HCC), response prediction to transarterial chemoembolization (TACE) based on serum biomarkers is not established. We have studied the association of circulating Dickkopf-related protein 1 (DKK-1) with baseline characteristics and response to TACE in European HCC patients. Methods: Patients with HCC treated with TACE from 2010 to 2018 at a tertiary referral hospital were retrospectively enrolled. Levels of DKK-1 were measured in serum samples collected before TACE. Response was assessed according to mRECIST criteria at week 12 after TACE. Results: Ninety-seven patients were enrolled, including seventy-nine responders and eighteen refractory. Before TACE, median DKK-1 serum levels were 922 [range, 199−4514] pg/mL. DKK-1 levels were lower in patients with liver cirrhosis (p = 0.002) and showed a strong correlation with total radiologic tumor size (r = 0.593; p < 0.001) and with Barcelona Clinic Liver Cancer stages (p = 0.032). Median DKK-1 levels were significantly higher in refractory patients as compared to responders (1471 pg/mL [range, 546−2492 pg/mL] versus 837 pg/mL [range, 199−4515 pg/mL]; p < 0.001), and DKK-1 could better identify responders than AFP (AUC = 0.798 vs. AUC = 0.679; p < 0.001). A DKK-1 cutoff of ≤1150 pg/mL was defined to identify responders to TACE with a sensitivity of 78% and specificity of 77%. DKK-1 levels were suitable to determine response to TACE in patients with low AFP serum levels (AFP levels < 20 ng/mL; AUC = 0.843; 95% CI [0.721−0.965]; p = 0.003). Conclusion: DKK-1 levels in serum are strongly associated tumor size and with response to TACE in European HCC patients, including those patients with low AFP levels.

Evaluation of treatment options for postoperative and spontaneous chylothorax in adults.

OBJECTIVES: Both postoperative and spontaneous chylothorax remain therapeutic challenges without recommendations for a standardized treatment approach. Regardless of its aetiology, patients with chylothorax experience prolonged hospitalization and suffer from the associated complications or the invasive therapy administered. METHODS: We conducted a retrospective, observational review of adult patients with chylothorax treated between January 2010 and September 2019. The primary end point was successful management with sustained cessation and/or controlled chylous output. Therapy duration, inpatient stay and the incidence of complications were evaluated as secondary end points. RESULTS: Of the 36 patients included (22 men; median age 63 years), 24 patients (67%) suffered from a postoperative accumulation of chylous fluid in the pleural space; in the remaining 12 (33%) patients, chylothoraces occurred spontaneously. Initial conservative treatment was successful in 42% (n = 15); in the other 20 cases (56%) additional invasive therapeutic strategies were followed. A complicated course requiring more than 1 treatment was seen in 54% (n = 13) of the postoperative and in 58% (n = 7) of the spontaneous cases. The median length of hospitalization was significantly longer in the postoperative group (37.5 vs 15.5 days; P = 0.016). Serious complications were observed only in the postoperative group (P = 0.28). There were no in-hospital deaths. CONCLUSIONS: Basic treatment of both postoperative and spontaneous chylothorax should include dietary measures in all patients. Additional sclerosing radiotherapy and interventional or surgical therapy are often necessary. The choice of therapeutic approach should be indicated, depending on the aetiology and development of the chylothorax. Early, multimodal treatment is recommended.

Klebsiella Pneumoniae Liver Abscess Syndrome - A Challenge for Contrast-Enhanced Ultrasound.

Invasive liver abscess syndrome (ILAS) is caused by strains of hypervirulent Klebsiella pneumoniae (hvKp) and has emerged as the leading cause of liver abscesses in immuno-competent patients (L.K. Siu et al. Lancet Infect Dis 2012; 12: 881-87). ILAS is frequently associated with metastatic spread including the eyes, lungs, and the central nervous system. The morbidity and mortality of affected patients are increased compared to liver abscesses of other origin, especially in cases with concomitant diabetes mellitus (J. E. Choby et al. J Intern Med 2020; 287(3): 283-300). Immediate diagnosis and early intervention are essential for an optimal outcome. Therefore, ultrasound plays a crucial role if hvKp is suspected. However, experience with the characteristics of such abscesses on contrast-enhanced ultrasound (CEUS) is very limited.

Percutaneous hepatic melphalan perfusion: Single center experience of procedural characteristics, hemodynamic response, complications, and postoperative recovery.

BACKGROUND: Percutaneous hepatic melphalan perfusion (PHMP) for the selective treatment of hepatic metastases is known to be associated with procedural hypotension and coagulation disorders. Studies on anesthetic management, perioperative course, complications, and postoperative recovery in the intensive care unit (ICU) have not been published. METHODS: In a retrospective observational study, we analyzed consecutive patients who were admitted for PHMP over a 6-year period (2016-2021). Analyses included demographic, treatment, and outcome data with regard to short-term complications until ICU discharge. RESULTS: Fifty-three PHMP procedures of 16 patients were analyzed. In all of the cases, procedure-related hypotension required the median (range) highest noradrenaline infusion rate of 0.5 (0.17-2.1) µg kg min-1 and fluid resuscitation volume of 5 (3-14) liters. Eighty-four PHMP-related complications were observed in 33 cases (62%), of which 9 cases (27%) involved grade III and IV complications. Complications included airway constriction (requiring difficult airway management), vascular catheterization issues (which resulted in the premature termination of PHMP, as well as to the postponement of PHMP and to the performance of endovascular bleeding control after PHMP), and renal failure that required hemodialysis. Discharge from the ICU was possible after one day in most cases (n = 45; 85%); however, in 12 cases (23%), prolonged mechanical ventilation was required. There were no procedure-related fatalities. CONCLUSIONS: PHMP is frequently associated with challenging cardiovascular conditions and complications that require profound anesthetic skills. For safety reasons, PHMP should only be performed in specialized centers that provide high-level hospital infrastructures and interdisciplinary expertise.

[Intestinal small bowel lymphomas--diagnosis and treatment]. / Primär intestinale Lymphome--Diagnosestellung mittels CT und Therapie.

Primary intestinal lymphomas are most common in the stomach. The mucosa associated lymphatic tissue (MALT)-lymphoma which is closely associated with helicobacter pylori is very well known. In most cases, these malignancies are from B-Cells origin. Another possible point of manifestation, although not well known, is the small bowel. Both tumors have enormous capabilities to enlarge in the abdominal cave. This is responding to their often asymptomatic manifestation. The symptoms, if they occur, are widespread and unspecific. Ileus, diarrhae, abdominal pain or bleeding will be observed, in rare cases also perforation or gastrointestinal or cutaneous fistulas. Diagnostic imaging often demonstrates a tumour of massive size by then, which is echopoor in the abdominal ultrasound. Our report concerns two cases of small intestine lymphomas, which were diagnosed by CT-scanning and treated in our clinic in only a short period of time. The first case was a low malignant jejunal lymphoma which was almost asymptomatic, whereas the second case had an ileus, due to compression of the intestine because of a high malignant lymphoma of the ileocecal region.

Mitochondrial and nuclear localization of kanadaptin.

Kanadaptin has originally been isolated as a kidney Cl-/HCO3- anion exchanger 1 (kAE1)-binding protein. Initial studies suggested, that in the kidney of the rabbit kanadaptin is expressed exclusively in all epithelial cells of the collecting duct. Transcripts of kanadaptin were also found in tissues not expressing kAE1, indicating additional roles for kanadaptin. With respect to this, we could recently demonstrate translocation of kanadaptin into the nucleus of mammalian cells in a nuclear localization sequence- and importin-dependent manner (Hübner et al., Biochem. J. 361, 287-296, 2002). In this study, we provide evidence, that kanadaptin is widely expressed in many tissues and that expression of kanadaptin in the mouse occurs early in embryonic development. In rat kidney we found the most intense immunofluorescence for kanadaptin in cells of the proximal tubule, consistent with the detection by in situ hybridization of high amounts of kanadaptin messenger RNA in proximal tubule cells. Immunostaining revealed localization of kanadaptin in two subcellular locations, nuclei and mitochondria. Whereas nuclear localization was demonstrated in virtually all cells, mitochondrial staining was restricted to certain cell types. Nuclear staining was only seen in cryosections, whereas mitochondrial staining was observed in both cryosections and semithin sections of freeze-dried plastic-embedded tissue. In the kidney mitochondrial staining was particularly prominent in proximal tubular epithelium. Most surprisingly, in the collecting duct epithelium (including acid-secreting intercalated cells) only negligible immunostaining, if at all, could be observed. Immunoelectron microscopy showed immunolabelling of the entire cross-sectional profile of mitochondria (matrix/inner membrane). Mitochondrial localization of kanadaptin was further documented by immunoblotting of mitochondria-enriched cellular fractions. Utilizing an interspecies heterokaryon assay, we could further demonstrate that kanadaptin has nuclear export activity. Thus, kanadaptin can be regarded to be a highly mobile nucleocytoplasmic shuttling and multilocalizing protein, but its role in mammalian cells remains still obscure.

Inferior mesenteric artery embolization before endovascular aortic aneurysm repair using amplatzer vascular plug type 4.

PURPOSE: This study was designed to evaluate the efficacy and safety of Amplatzer Vascular Plug type 4 (AVP-4) for embolization of the inferior mesenteric artery (IMA) before endovascular aneurysm repair (EVAR) of the abdominal aorta to prevent endoleaks. METHODS: A single-center retrospective review of 31 patients who underwent IMA embolizations before EVAR using the AVP-4 was performed. We analyzed the insertion and detachment procedure, the technical success, and the final position of the plug. Technical success was defined as complete occlusion of the IMA. To compare the incidence of IMA-related type II endoleaks in patients with and without preoperative IMA embolization, we additionally reviewed the course of 43 patients with a preoperatively patent IMA who underwent no IMA embolization. RESULTS: Plugs with a diameter of 5, 6, and 8 mm were used in 5 (16.1 %), 21 (67.7 %), and 5 (16.1 %) patients, respectively (50-100 % oversizing). In 29 of 31 patients (93.5 %), we observed complete occlusion of the IMA within 10 min (mean 5.1 min). Precise placement of the plug in the proximal segment of the IMA without occlusion of the first IMA branches was achievable in all patients. The distance between the AVP-4 and the first branches was on average 12 (range 2-57) mm. Preoperative IMA embolization with AVP-4 significantly reduced the incidence of complex IMA-lumbar type II endoleaks after EVAR (0/31 vs. 11/43; p = 0.002). CONCLUSIONS: The AVP-4 is a safe, feasible, and technically effective embolization device for IMA embolization before EVAR.

Prosthesis sizing for transcatheter aortic valve implantation--comparison of three dimensional transesophageal echocardiography with multislice computed tomography.

BACKGROUND: The complex anatomy of the aortic annulus warrants the use of three dimensional (3D) modalities for prosthesis sizing in transcatheter aortic valve implantation (TAVI). Multislice computed tomography (MSCT) has been used for this purpose, but its use may be restricted because of contrast administration. 3D transesophageal echocardiography (3D-TEE) lacks this limitation and data on comparison with MSCT is scarce. We compared 3D-TEE with MSCT for prosthesis sizing in TAVI. METHODS: Aortic annulus diameters in the sagittal and coronal plane and annulus areas in 3D-TEE and MSCT were compared in 57 patients undergoing TAVI. Final prosthesis size was left at the operator's discretion and the agreement with 3D-TEE and MSCT was calculated. RESULTS: Sagittal diameters on 3D-TEE and MSCT correlated well (r=.754, p<.0001) and means were comparable (22.3±2.1 vs. 22.5±2.3 mm; p=0.2; mean difference: -0.3 mm [-3.3-2.8]). On 3D-TEE, coronal diameter and annulus area were significantly smaller (p<.0001 for both) with moderate correlation (r=0.454 and r=0.592). Interobserver variability was comparable for both modalities. TAVI was successful in all patients with no severe post-procedural insufficiency. Final prosthesis size was best predicted by sagittal annulus diameters in 84% and 79% by 3D-TEE and MSCT, respectively. Agreement between both modalities was 77%. CONCLUSIONS: Annulus diameters and areas for pre-procedural TAVI assessment by 3D-TEE are significantly smaller than MSCT with exception of sagittal diameters. Using sagittal diameters, both modalities predicted well final prosthesis size and excellent procedural results were obtained. 3D-TEE can thus be a useful alternative in patients with contraindications to MSCT.