Arteriovenous Fistula after Endovenous Laser Ablation of Great Saphenous Vein Treated with Covered Stent: Case Report and Literature Review.

Endovenous ablation techniques (radiofrequency or laser) have become the less invasive choice of treatment for superficial venous insufficiency due to saphenous vein incompetence showing high effectiveness and few complications. We present a case of symptomatic arteriovenous fistula between the external iliac artery and vein after endovenous laser ablation repaired with covered stent. We also review the literature and discuss the possible causes and management of this unusual and potentially severe complication, and the feasibility of endovascular treatment.

Cadaveric Specimen Study of Prostate Microvasculature: Implications for Arterial Embolization.

PURPOSE: To describe the prostatic microvasculature anatomy and to measure the diameter of the intraprostatic vessels from human cadaveric specimens. MATERIAL AND METHODS: The prostates of 18 white males (35-68 years of age; mean prostate volume, 60.11 mL) were fixed in a solution of phosphate-buffered 10% formaldehyde and processed histologically with hematoxylin and eosin stain, Masson trichrome stain, immune peroxidase, and immunofluorescence. Fluorescence-conjugated antibodies (anti-CD34 and anti-actin smooth muscle) were used to mark the endothelium and the fibromuscular stroma, respectively. Each slide was digitally scanned and photographed under microscopy to measure the intraprostatic arterial diameters using image analysis software. RESULTS: In 28 hemipelvises (77.8%) a single dominant prostate artery was found (mean diameter, 1.96 mm). The microvasculature study identified 3 types of intraprostatic arterial distributions: internodal (IT), perinodal (PN), and intranodal (IN). The IT arteries are located at the trabeculae of the hyperplastic stroma between the nodules. The PN arteries were located at the periphery of each hyperplastic nodule before entering into it. The IN vessels were located inside the hyperplastic nodules as terminal arteries to the glands. The mean IT artery diameter was 317 µm (min-max range, 155-555 µm), mean PN artery diameter was 150 µm (min-max range, 59-266 µm), and the mean IN artery was 56 µm (min-max range, 24-104 µm). The diameters of intraprostatic arteries did not correlate with prostate volume (IT arteries, P = .303; PN arteries, P = .686; and IN arteries, P = .413). CONCLUSIONS: The description of the prostate microvasculature anatomy, as described by this cadaveric study, may provide useful information for prostate artery embolization.

Expected and Unexpected Imaging Findings after 90Y Transarterial Radioembolization for Liver Tumors.

Transarterial radioembolization (TARE), also called radioembolization or selective internal radiation therapy, is an interventional radiology technique used to treat primary liver tumors and liver metastases. The aim of this therapy is to deliver tumoricidal doses of radiation to liver tumors while selecting a safe radiation dose limit for nontumoral liver and lung tissue. Hence, correct treatment planning is essential to obtaining good results. However, this treatment invariably results in some degree of irradiation of normal liver parenchyma, inducing different radiologic findings that may affect follow-up image interpretation. When evaluating treatment response, the treated area size, tumor necrosis, devascularization, and changes seen at functional MRI must be taken into account. Unlike with other interventional procedures, with TARE, it can take several months for the tumor response to become evident. Ideally, responding lesions will show reduced size and decreased enhancement 3-6 months after treatment. In addition, during follow-up, there are many imaging findings related to the procedure itself (eg, peritumoral edema, inflammation, ring enhancement, hepatic fibrosis, and capsular retraction) that can make image interpretation and response evaluation difficult. Possible complications, either hepatic or extrahepatic, also can occur and include biliary injuries, hepatic abscess, radioembolization-induced liver disease, and radiation pneumonitis or dermatitis. A complete understanding of these possible posttreatment changes is essential for correct radiologic interpretations during the follow-up of patients who have undergone TARE. ©RSNA, 2019.

Intraoperative stent placement for the treatment of acute portal vein complications in pediatric living donor liver transplantation.

PURPOSE: Pediatric living donor liver transplantation (LDLT) in low weight recipients remains one of the most complex surgical procedures, with portal vein (PV) complications occurring in up to 19% of cases. When decreased PV flow is diagnosed intra- or perioperatively, intraoperative stent placement is a good substitute for surgical adjustment. Still, at the present moment, little is known about the technical feasibility, safety, efficacy, and long-term outcome of intraoperative stenting in LDLT. METHODS: Between 2006 and 2017, seven pediatric recipients underwent PV stent placement during the transplant or in the immediate post-operative setting. Preoperative, operative, and post-operative parameters were documented retrospectively. RESULTS: In total, nine stents were placed in seven patients. Procedures were technically successful in all patients. During the mean imaging follow-up period of 1313 days, none of the patients showed PV abnormality and PV stent remained patent throughout the post-transplant course. There were no deaths or graft loses during the follow-up period. CONCLUSIONS: Intraoperative stenting through the inferior mesenteric vein approach offers both a high feasibility and satisfactory results, with the potential for excellent long-term primary patency despite continued growth in children.

Triamcinolone for the Treatment of Graves Ophthalmopathy Tested With Short Tau Inversion Recovery Magnetic Resonance.

PURPOSE: To evaluate if parabulbar triamcinolone reduces orbital swelling in patients with Graves ophthalmopathy. METHODS: This is a prospective study of a series of patients with active and moderate Graves ophthalmopathy. Short tau inversion recovery magnetic resonance was used to evaluate the intensity of the extraocular rectus muscles and orbital fat, before and after the treatment with parabulbar triamcinolone. RESULTS: The signal intensity ratio of the sum of the OD rectus muscles was 3.67 before treatment (95% CI, 3.26-4.09) and 2.83 after treatment (95% CI, 2.63-3.03) (p < 0.001), and of the muscles of the left orbit, 3.94 before treatment (95% CI, 3.50-4.38) and 2.85 after treatment (95% CI, 2.56-3.14) (p < 0.001). The signal intensity ratio of the fat decreased from 2.95 (95% CI, 2.69-3.21) to 2.33 (95% CI, 2.07-2.58) (p < 0.001). After treatment, there were no local or systemic complications. CONCLUSION: The use of parabulbar triamcinolone reduces orbital inflammation of patients with active and moderate Graves ophthalmopathy.

Prevalence of factors related to vascular calcifications in patients with chronic kidney disease on dialysis.

The main aim of the study was to determine the prevalence of vascular calcifications in patients with chronic kidney disease on dialysis in our population assessed by X-ray. The secondary objectives were to determine the cardiovascular risk factors associated with the presence of vascular calcifications and to evaluate the complementary use of the echocardiogram in a cross-sectional, observational, multicentric study. We included patients with chronic kidney disease on dialysis, age =18 years with at least 3 months of renal replacement therapy in 8 dialysis centres in Argentina. The degree of vascular calcification was determined using Adragao and Kauppila scores. The presence of valvular calcifications was established through a trans-thoracic doppler echocardiogram. Univariate and multivariate analysis were undertaken, considering the degree of vascular calcification as the dependent variable; 443 adult patients were evaluated at 8 centres across 5 provinces in Argentina. The prevalence of vascular calcifications by the X-rays was 63%, while 73% presented calcifications in hands and pelvis, with an Adragao score > 3, and 60% presented calcifications in the abdominal aorta with a Kauppila score > 4. The prevalence of valvular calcifications: 28%. We have shown a higher rate of vascular calcifications with the use of plain X-rays when compared to the prevalence of valvular calcifications obtained with echocardiograms. In this regard, valvular calcifications were present particularly in those patients with a severe level of radiological vascular calcification.

Does a Simplified 6-Joint Ultrasound Index Correlate Well Enough With the 28-Joint Disease Activity Score to Be Used in Clinical Practice?

OBJECTIVE: Ultrasound (US) has become an important tool in the management of rheumatoid arthritis (RA) but it is time consuming in clinical practice. We compared 3 US indices (with different numbers of joints) with disease activity measured by the 28-Joint Disease Activity Score (DAS28) in order to find the most parsimonious index still useful in clinical practice. METHODS: Sixty consecutive RA patients were included. The DAS28 score was calculated by the attending rheumatologist, and later in the day, they underwent US examination by another rheumatologist trained in US (bilateral gray-scale and power Doppler examination of the wrist and metacarpophalangeal and proximal interphalangeal joints). Three different US indices were constructed: index A (22 joints), index B (10 joints), and index C (6 joints). RESULTS: All 3 US indices were significantly higher in patients with active disease versus inactive disease (P < 0.05 for all 3). Ultrasound index C showed the best correlation with DAS28 (rho = 0.5020, P < 0.0001) and a very good discriminative value for moderate to high disease activity (DAS28 >3.2) and for absence of remission (DAS28 >2.6) (areas under receiver operating characteristic curve = 0.75 and 0.80, respectively). A cutoff value of 3 in US index C showed sensitivity of 88.89% and specificity of 66.67% for absence of remission. Correlation between the 3 US indices was excellent. CONCLUSIONS: A US index of 6 joints (both wrists and second and third metacarpophalangeal joints bilaterally) correlated well with disease activity measured by DAS28 and may be used to evaluate RA patients in daily practice.

Randomized controlled trial of irinotecan drug-eluting beads with simultaneous FOLFOX and bevacizumab for patients with unresectable colorectal liver-limited metastasis.

BACKGROUND: Reports have demonstrated the superior activity of combining both irinotecan and oxaliplatin (FOLFOXIRI) therapy. An option for gaining similar benefits with less toxicity would be the administration of irinotecan through a hepatic artery approach. The aim of this study was to assess the response and adverse event rates for irinotecan drug-eluting beads (DEBIRI) with folinic acid, 5-fluorouracil, and oxaliplatin (FOLFOX) and bevacizumab as a first-line treatment for unresectable colorectal liver metastasis. METHODS: Patients with colorectal liver metastases were randomly assigned to modified FOLFOX (mFOLFOX) and bevacizumab or mFOLFOX6, bevacizumab, and DEBIRI (FOLFOX-DEBIRI). The primary endpoint was the response rate. The secondary endpoints were adverse events, the rate of conversion to resection, and progression-free survival. RESULTS: The intention-to-treat population comprised 70 patients: 10 patients in the pilot and then 30 patients randomly assigned to the FOLFOX-DEBIRI arm and 30 patients randomly assigned to the FOLFOX/bevacizumab arm. The 2 groups were similar with respect to the extent of liver involvement (30% vs 30%), but a greater percentage of patients in the FOLFOX-DEBIRI arm had an Eastern Cooperative Oncology Group performance status of 1 or 2 (57% vs 31%) and extrahepatic disease (56% vs 32%, P = .02). The median numbers of chemotherapy cycles were similar (10 vs 9), and there were similar rates of grade 3/4 adverse events (54% for the FOLFOX-DEBIRI group vs 46% for the FOLFOX/bevacizumab group). The overall response rate was significantly greater in the FOLFOX-DEBIRI arm versus the FOLFOX/bevacizumab arm at 2 (78% vs 54%, P = .02), 4 (95% vs 70%, P = .03), and 6 months (76% vs 60%, P = .05). There was significantly more downsizing to resection in the FOLFOX-DEBIRI arm versus the FOLFOX/bevacizumab arm (35% vs 16%, P = .05), and there was improved median progression-free survival (15.3 vs 7.6 months). CONCLUSIONS: The simultaneous administration of mFOLFOX6 (with or without bevacizumab) and DEBIRI through the hepatic artery (FOLFOX-DEBIRI) is safe and does not cause treatment delays or increase the systemic toxicity of chemotherapy. This strategy leads to improved overall response rates, improved hepatic progression-free survival, and more durable overall progression-free survival in patients downsized to resection.

Feasibility and safety of prophylactic uterine artery catheterization and embolization in the management of placenta accreta.

PURPOSE: To evaluate the feasibility and safety of prophylactic uterine artery catheterization and embolization in the management of placenta accreta (PA). MATERIALS AND METHODS: Retrospective chart review was performed of 95 consecutive patients with prenatal suspicion of PA managed in a 10-year period with a strategy that included prophylactic bilateral uterine artery catheterization, delivery of the baby, uterine artery embolization if indicated, and subsequent surgery. Feasibility was defined as catheterization being possible to perform, technical success as embolization being possible when indicated and complete stasis of the vessels achieved, and clinical success as no maternal death or major blood loss. Median gestational age at delivery was 36 weeks (interquartile range, 24-39 wk). RESULTS: PA was confirmed in 79 patients (83%). Feasibility was 97% (92 of 95); in three cases (3%), acute early massive hemorrhage forced emergency delivery without catheterization. Embolization was performed in 83 of 92 patients (87%) to the extent of complete stasis; in the remaining nine, it was unnecessary because spontaneous placental detachment was visualized after fetal delivery (technical success rate, 100%). There were several complications, including bleeding requiring blood transfusion (49%) and bladder surgery (37%), but there were no major complications attributable to the endovascular procedures. There was one minor complication presumably related to embolization (transient paresthesia and decreased temperature of lower limb), with uneventful follow-up. Clinical success rate was 86%, with no maternal deaths, but 14% of patients received large-volume blood transfusion. CONCLUSIONS: Prophylactic uterine artery catheterization and embolization in the management of PA appeared to be feasible and safe in this consecutive series of patients.

Aortic Endoprosthesis for the Treatment of Native Aortic Coarctation and Concomitant Aneurysm in an Octogenarian Patient.

We report a case of an 82-year-old female patient with native coarctation of the aorta and poststenotic aneurysm of the descending thoracic aorta. On consultation, she was receiving 4 antihypertensive drugs, and physical examination revealed nonpalpable lower-limb pulses with intermittent claudication at 50 min. Because of her age, high surgical risk and combination of lesions, endovascular treatment was suggested. Placement of a Valiant thoracic aorta endoprosthesis followed by coarctation angioplasty was performed. At 48 hr, the patient was discharged on 1 antihypertensive drug, palpable pulses on both limbs and a normal ankle-brachial index. At 1 month follow-up, the patient remained as discharged and multislice computed tomography angiography depicted complete coarctation expansion without residual stenosis, exclusion of the aortic aneurysm, and no signs of endoleaks.

[Magnetic resonance and extramural vascular invasion in patients with rectal cancer and liver metastases]. / Resonancia magnética e invasión vascular extramural en pacientes con cáncer rectal y metástasis hepaticas.

BACKGROUND: Extramural vascular invasion (EMVI) in patients with rectal cancer (RC) is associated with more locally advanced tumors, and independently predicts local and distant recurrence and poor overall survival. OBJETIVE: To determine the association between EMVI and synchronous liver metastases in patients with RC. METHODS: We performed a retrospective cohort study including patients with cancer of middle and lower rectum, which were evaluated with magnetic resonance (MRI) for initial staging in the period from January 2011 to January 2012 inclusive. All patients were evaluated with MRI for EMVI and were followed for a year to detect synchronous liver metastases by imaging methods (January 2012 to January 2013 inclusive). Multivariate analysis was performed by logistic regression. RESULTS: We included 68 patients. Twenty had liver metastases during the observation period (29.41%), of whom 15 had signs of MRI EMVI (75%). The incidence of synchronous liver metastases had a marginally significant association with the presence of EMVI (RR 3.35, 95% CI: 1.0001-11.2187, P = 0.050). CONCLUSION: The presence of MRI EVMI is a poor prognostic predictor factor of development of synchronous liver metastases in patients with RC.

Human cadaveric specimen study of the prostatic arterial anatomy: implications for arterial embolization.

PURPOSE: To describe and illustrate the prostatic arterial anatomy from human cadaveric specimens, highlighting implications for prostatic arterial embolization. MATERIALS AND METHODS: Dissection of 18 male pelves from white adults 35-68 years old was performed in the anatomy laboratory. Arterial branches were identified according to standard dissection technique using a 20-diopter magnifying lens for the prostatic sector. The branches were colored with red acrylic paint to enhance contrast and improve visualization. RESULTS: Two main arterial pedicles to the prostate from each hemipelvis were identified in all cadaveric specimens: the superior and inferior prostatic pedicles. The superior prostatic pedicle provides the main arterial supply of the gland and provides branches to both the inferior bladder and the ejaculatory system. The inferior prostatic pedicle distributes as a plexus in the prostatic apex and anastomoses with the superior pedicle. This pattern of prostatic arterial distribution was constant in all cadaveric specimens. In contrast, the origin of the superior prostatic pedicle was variable from different sources of the internal iliac artery. CONCLUSIONS: The description and illustration of the prostatic arterial anatomy, as demonstrated by this cadaveric study, may provide useful information and guidance for prostatic arterial embolization.

Transarterial treatment of colorectal cancer liver metastases with irinotecan-loaded drug-eluting beads: technical recommendations.

Transcatheter hepatic arterial administration of irinotecan-loaded drug-eluting beads (DEBIRI) is used to treat liver-only or liver-dominant metastatic disease from colorectal cancer (CRC). Eligibility for DEBIRI should be established in each individual patient by a multidisciplinary team based on comprehensive clinical, imaging, and laboratory assessment. Standardization of DEBIRI technique and protocols would be expected to lead to improved efficacy and safety. The present article provides a set of technical recommendations for the use of DEBIRI in the treatment of hepatic CRC metastases.

Early experience with the AMPLATZER vascular plug IV for the occlusion of pulmonary arteriovenous malformations.

The recent generation of AMPLATZER Vascular Plug (AVP; ie, the AVP IV) was used for the occlusion of eight pulmonary arteriovenous malformations (PAVMs) in five patients. A treatment was considered successful when there was a reduction or disappearance of the aneurysmal sac. At a mean follow-up of 20.1 months, no recanalization of PAVMs was observed on multidetector computed tomographic angiography. This shows the AVP IV to be safe and effective as an embolic device to occlude PAVMs.

Long-term treatment with oral propranolol reduces relapses of infantile hemangiomas.

Oral propranolol (OP) has been shown to be effective in the treatment of complicated infantile hemangiomas (IHs), but optimal treatment duration to avoid relapses after stopping OP treatment has not been established. The objective of this study was to compare the frequency of relapses in long-term OP treatment with that of short-term OP treatment. This was a retrospective cohort study of 30 patients with complicated IHs who received treatment with OP. Patients were divided into two groups: OP treatment of 8 months or less and OP treatment of longer than 8 months. OP was started at 1 mg/kg/day in three doses every 8 hours for 1 week and increased to 1.5 to 4 mg/kg/day afterward. Ultrasound was used to objectively measure the response to treatment. Clinical and ultrasound assessment showed a decrease in IH size and resolution of complications in all patients (n = 30). In the short-term group (n = 10), nine patients (90%) relapsed after stopping treatment. In the long-term group (n = 20), the duration of treatment was 12 months in all patients, and only 1 patient out of the 20 treated (5%) showed relapse 2 months after finishing the full treatment (odds ratio = 18, 95% confidence interval 2.6, 123, p < 0.001. Twelve months of treatment of IH with OP is associated with a significantly lower rate of relapse than with shorter treatment.