Magnetic Compression Anastomosis for the Treatment of Complete Biliary Obstruction After Cholecystectomy.

BACKGROUND & AIMS: Post-cholecystectomy biliary strictures can be treated surgically or non-surgically. Although endoscopic or percutaneous treatments are the preferred approaches, these methods are not feasible in cases where complete stricture occlusion prevents the successful passage of a guidewire. The utility of magnetic compression anastomosis (MCA) in patients with post-cholecystectomy complete biliary obstruction that cannot be treated conventionally was evaluated. METHODS: MCA was performed in 10 patients with post-cholecystectomy biliary strictures that did not resolve with conventional endoscopic or percutaneous treatment. One magnet was delivered through the percutaneous transhepatic biliary drainage tract, and another was advanced via endoscopic retrograde cholangiopancreatography(ERCP) of the common bile duct. After magnet approximation and recanalization, a fully covered self-expandable metal stent (FCSEMS) was placed for 3 months and then replaced for a further 3 months. Stricture resolution was evaluated after FCSEMS removal. RESULTS: Among the 10 patients who underwent MCA for post-cholecystectomy biliary stricture, the biliary injury was Strasberg type B in 2, type C in 3, and type E in 5. Recanalization was successful in all patients (technical success rate 100%). The mean follow-up period after recanalization was 50.2 months (range 13.2-116.8 months). Partial restenosis after MCA occurred in two patients at 24.1 and 1.6 months after stent removal. ERCP with FCSEMS placement resolved the recurrent stenosis in both patients. CONCLUSIONS: MCA is a useful alternative nonsurgical treatment for complete biliary obstruction after cholecystectomy that cannot be resolved by conventional methods.

Short fully covered self-expandable metal stent for treatment of proximal anastomotic benign biliary stricture after living-donor liver transplantation.

OBJECTIVES: Non-surgical methods have high success rates for treating benign biliary strictures (BBSs), but treatment of proximal strictures is difficult. Recent studies have reported that fully covered self-expandable metal stents (FCSEMSs) are useful for treating refractory BBSs. We investigated the efficacy of a short and removable FCSEMS with an anti-migration design for treatment of proximal BBSs. METHODS: Fully covered self-expandable metal stents were inserted endoscopically in patients with BBSs after living donor liver transplantation (LDLT). Each FCSEMS was initially maintained for 3 months and subsequently exchanged every 3 months until the stricture resolved. Adverse events and stricture recurrence after FCSEMS removal were assessed during follow-up. RESULTS: A total of 63 patients with a median age of 57 years were enrolled in this study; 50 were male. The most common underlying disease was hepatocellular carcinoma and the previous operation was LDLT. The mean duration from surgery to diagnosis of stricture was 8.5 months, and the mean stent indwelling time was 4.2 months. The technical success and stricture resolution rate were 100%. The recurrence rate was 23.8% and the adverse event rate was 12.7%. All stents were removable, and asymptomatic stent migration was observed in four patients (6.4%). CONCLUSIONS: The newly designed FCSEMS is effective in the treatment of proximal BBSs after LDLT.

Maintenance of the fistulous tract after recanalization via magnetic compression anastomosis in completely obstructed benign biliary stricture.

OBJECTIVE: This study compared the efficacy of a percutaneous transhepatic cholangioscopy (PTCS) catheter and a fully covered self-expandable metal stent (FCSEMS) for maintaining biliary tract patency after magnetic compression anastomosis (MCA). METHODS: This study included patients with completely obstructed benign biliary stricture (BBS), which was resolved by MCA and subsequent insertion of a PTCS catheter or FCSEMS. We compared the restenosis-free time after removal of the PTCS catheter or FCSEMS, and the rate of complications. RESULTS: A total of 49 patients were analyzed. The mean ages of the patients in these groups were 50.1 and 49.6 years, respectively. The predisposing conditions causing complete BBS were liver transplantation (n = 38), abdominal surgery (n = 10) and trauma (n = 1). The mean indwelling durations were 176 and 128 days in the PTCS catheter and FCSEMS groups, respectively. The mean follow-up duration after removal of the PTCS catheter and FCSEMS were 2259 and 680.5 days, respectively. Three patients in the PTCS group and three patients in the FCSEMS group experienced stricture relapse. The mean duration between recurrence and stent removal were 924 and 265 days, respectively, and the numbers of stricture-free days did not differ significantly between the two groups. The adverse event rate did not differ significantly between the PTCS and FCSEMS groups (50% vs. 24.2%, respectively). CONCLUSIONS: FCSEMSs have an efficacy and safety similar to those of PTCS catheters for maintaining biliary tract patency after MCA, but are more convenient for patients.

Korean Multicenter Registry of Transcatheter Arterial Chemoembolization with Drug-Eluting Embolic Agents for Nodular Hepatocellular Carcinomas: Six-Month Outcome Analysis.

PURPOSE: To assess the efficacy and safety of transcatheter arterial chemoembolization with drug-eluting embolic (DEE) agents for nodular hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The study design was a prospective multicenter registry-based, single-arm clinical trial that included 152 patients. One hundred three (67.8%) had a Child-Pugh class/score of A5, 114 (75.0%) had a performance status of 0, and 77 (50.7%) had Barcelona Clinic Liver Cancer (BCLC) stage A disease. The DEE chemoembolization procedures were performed with DC Bead particles loaded with doxorubicin solution. The primary endpoint of the study was 6-month tumor response assessed per modified Response Evaluation Criteria In Solid Tumors. Secondary endpoints were treatment safety and overall survival. RESULTS: At 1-month posttreatment assessment, complete response (CR) and objective response (OR; ie, CR or partial response) rates were 40.1% and 91.4%, respectively. At 6-month assessment, 121 patients remained for analysis, and CR and OR rates were 43.0% and 55.4%, respectively. The cumulative progression-free survival (PFS) rate at 6 months was 65.0%. Child-Pugh score, tumor multiplicity, and tumor size were independent predictors of PFS (P = .020, P = .029, and P = .001, respectively). There was no 30-day mortality. The overall 6-month survival rate was 97.4%. There were no grade 4 adverse events or laboratory changes. Serious adverse events were reported in 7.2% of patients, and persistent deterioration of liver function was observed in 3.9%. Prominent biliary injury was demonstrated in 19.7% of patients. No liver abscess was observed. CONCLUSIONS: DEE chemoembolization for nodular HCC had an acceptable safety profile and acceptable 6-month tumor response and survival rates.

Recanalization of thrombosed arteriovenous fistulas for hemodialysis by minimal venotomy.

The present work describes the preliminary results of a new method of minimally invasive thrombectomy in the treatment of thrombosed arteriovenous fistula (AVF) with dilated aneurysm. Data from 25 patients who were treated with this minimal venotomy technique were retrospectively reviewed. The minimal venotomy was made on the dilated fistula, and thrombectomy was performed with forceps and Fogarty catheters through the venotomy site. Technical and clinical success was achieved in all 25 patients. There were two major and two minor complications (8% each). The two major complications consisted of bleeding at the venotomy site after early suture removal.

Liver abscess after transarterial chemoembolization in patients with bilioenteric anastomosis: frequency and risk factors.

OBJECTIVE: The purpose of this study was to clarify the frequency of and risk factors for liver abscess formation after transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma or metastatic hepatic tumors after undergoing bilioenteric anastomosis. MATERIALS AND METHODS: From January 1996 to June 2012, 25 patients (21 men, four women; age range, 34-74 years) with hepatocellular carcinoma (n = 12) or metastatic hepatic tumors (n = 13) with an underlying bilioenteric anastomosis underwent 65 TACE procedures. The incidence of liver abscess, predisposing factors (diabetes, Child-Pugh class, leukopenia, tumor number, tumor size, tumor burden, tumor type, portal vein thrombus, lipiodol dose, particulate embolization, embolization selectivity, oily portogram, antibiotic prophylaxis, and occurrence of liver abscess at initial TACE), and clinical outcome were evaluated. Statistical analysis for relations between liver abscess and predisposing factors was performed by Fisher exact test and linear-by-linear association. RESULTS: Liver abscess developed after 17 of 65 (26.2%) TACE procedures performed on 12 of 25 (48%) patients. Two patients died of progression of liver abscess into sepsis. Univariate and multivariate analyses showed that leukopenia (p = 0.029), occurrence of liver abscess at initial TACE (p = 0.082), and particulate embolization or oily portogram (grade 2) (p = 0.001) were associated with a higher incidence of liver abscess. CONCLUSION: The incidence of liver abscess was high among patients with bilioenteric anastomoses who underwent TACE. Leukopenia, occurrence of liver abscess at initial session of TACE, and particulate embolization or oily portogram (grade 2) were associated with the development of liver abscess.

Magnetic compression anastomosis for treatment of biliary stricture after cholecystectomy.

Video 1Magnetic compression anastomosis for treatment of biliary stricture after cholecystectomy.

Safety and Efficacy of a Large-Bore Biliary Metallic Stent for Malignant Biliary Obstruction.

Self-expandable metallic stents (SEMSs) are typically inserted in patients with unresectable malignant biliary obstruction. However, SEMSs are susceptible to occlusion. To overcome this issue, we developed a large-bore, dumbbell-shaped, fully covered SEMS (FCSEMS-L) and compared its efficacy and safety with those of a conventional FCSEMS (FCSEMS-C) in patients with malignant biliary obstruction. METHODS: Patients with unresectable distal malignant biliary obstruction were retrospectively enrolled between January 2011 and February 2021. All patients underwent endoscopic insertion of FCSEMSs. Recurrent biliary obstruction (RBO), patient survival time, complications, and prognosis were analyzed. RESULTS: RBO occurred in 31 patients (35.6%) who received an FCSEMS-L, and in 34 (45.9%) who received an FCSEMS-C. Stent occlusion occurred in 19 patients (21.8%) who received an FCSEMS-L, and in 22 (29.7%) who received an FCSEMS-C. Stent migration occurred in 12 patients (13.8%) with an FCSEMS-L and 12 (16.2%) with an FCSEMS-C. The median time to RBO (TRBO) was 301 days with an FCSEMS-L and 203 days with an FCSEMS-C. The median survival time was 479 days with an FCSEMS-L and 523 days with an FCSEMS-C. The TRBO and patient survival time did not significantly differ between the two groups. CONCLUSIONS: There were no significant differences in efficacy and complication rates between the fully covered large bore SEMSs and conventional fully covered SEMSs.

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.

Phase I Radiation Dose-Escalation Study to Investigate the Dose-Limiting Toxicity of Concurrent Intra-Arterial Chemotherapy for Unresectable Hepatocellular Carcinoma.

Concurrent intra-arterial chemotherapy and radiotherapy (iA-CCRT) can increase the response rate in hepatocellular carcinoma (HCC), but may cause a higher toxicity. We conducted this Phase I study to investigate the dose-limiting toxicity of iA-CCRT for HCC. In total, 52.5 Gy in 25 fractions was prescribed as planning target volume (PTV) 1 at dose level 1. The dose escalation was 0.2 Gy per fraction and up to 2.5 Gy, with 62.5 Gy at level 3. Concurrent intra-arterial 5-fluorouracil was administered during the first and fifth weeks of radiotherapy (RT). Toxicities were graded using the Common Toxicity Criteria for Adverse Events, version 4.0. Results: Seventeen patients with HCC were analyzed: four at dose level 1, 6 at level 2, and 7 at level 3. The mean irradiated dose administered to the uninvolved liver at each dose level was 21.3, 21.6, and 18.2 Gy, respectively. There was no grade ≥3 gastrointestinal toxicity; two patients experienced grade 3 hyperbilirubinemia. All patients had Child-Pugh class A disease, but 3 patients developed class B disease after iA-CCRT. During a median follow-up of 13 months, the median progression-free survival (PFS) and overall survival (OS) were 10 and 22 months, respectively. Patients treated at dose level 3 showed improved PFS and OS. Conclusions: Radiation dose escalation of iA-CCRT did not cause any significant toxicities in patients with advanced HCC. Further large-scale studies with long-term follow-up are needed to determine the efficacy and feasibility of higher doses of iA-CCRT.

Detection of the normal appendix with low-dose unenhanced CT: use of the sliding slab averaging technique.

PURPOSE: To determine the frequency of normal appendix visualization at low-dose (LD) unenhanced computed tomography (CT) performed with a 16- or 64-detector row scanner when images are reviewed by using the sliding slab averaging technique. MATERIALS AND METHODS: The institutional review board approved the study and waived the informed consent requirement. A total of 259 patients, 37 (14.3%) of whom had previously undergone appendectomy, underwent LD unenhanced CT (mean effective dose, 1.7 mSv) performed with a 16- or 64-detector row scanner to assess urinary colic. Three readers used the sliding slab averaging technique to retrospectively review the thin-section (0.67- or 2.00-mm section thickness) images and grade the appendix as absent, unsurely or partly visualized, or clearly and entirely visualized. Interobserver agreement was measured with weighted kappa statistics. McNemar tests were used to compare sensitivity between the readers. Logistic regression analysis was performed to assess the effects of body mass index, patient sex, and type of CT scanner on appendiceal visualization. RESULTS: The kappa statistics for each reader pair were as follows: 0.97 for agreement between readers 1 and 2, 0.93 for agreement between readers 2 and 3, and 0.92 for agreement between readers 1 and 3. Each reader clearly identified the entire appendix in 213 (96.0%), 209 (94.1%), and 205 (92.3%) of the 222 patients without a history of appendectomy. When unsurely or partly visualized appendices were included, the frequencies increased to 99.1% (n = 220), 98.7% (n = 219), and 97.3% (n = 216), respectively, for readers 1, 2, and 3. These frequencies rarely differed between the readers. (P values ranged from .021 to greater than .99.) The three readers consistently reported that the appendix was not visualized in the 37 patients who had undergone appendectomy. None of the tested variables significantly affected appendix visualization. CONCLUSION: Most normal appendices are visualized on thin-section LD unenhanced CT images reviewed with the sliding slab averaging technique.

An anthropomorphic phantom study of computer-aided detection performance for polyp detection on CT colonography: a comparison of commercially and academically available systems.

OBJECTIVE: The objective of our study was to compare the diagnostic performances of two commercial computer-aided detection (CAD) systems and a CAD system developed in our laboratory, which we refer to as an "academic CAD system," for polyp detection on CT colonography (CTC) and to assess the detection characteristics of the CAD systems. MATERIALS AND METHODS: One hundred three polyps (48 polyps < 6 mm and 55 polyps > or = 6 mm; 45 sessile, 33 flat, and 25 pedunculated polyps) were created. Each CTC data set was analyzed using two commercial CAD systems (Computer Assisted Reader [CAR] and Polyp Enhanced View [PEV]) and one Hessian matrix-based academic CAD system. Per-polyp sensitivities according to polyp size and shape were compared among the three CAD systems. The average number and causes of false-positives (FPs) were analyzed and compared. RESULTS: Per-polyp sensitivity for all polyps was significantly better for the academic CAD system (83.5%) than for both commercial CAD systems (64.1%) (p < 0.01). However, the difference in per-polyp sensitivity for polyps > or = 6 mm was not significant (p > 0.017). According to morphology, per-polyp sensitivities as determined with the CAR, PEV, and academic CAD systems for flat, sessile, and pedunculated polyps were 51.5%, 57.6%, and 81.8%; 60.0%, 62.2%, and 84.4%; 88.0%, 76.0%, and 84.0%, respectively. The average number of FPs was not significantly different (p > 0.05); however, the distribution of the causes of FPs for the three systems was significantly different (p < 0.001). CONCLUSION: For polyps > or = 6 mm, the three CAD systems showed comparable per-polyp sensitivities. Although the number of FPs was not significantly different, the distribution of the causes of FPs for each of the CAD systems was significantly different.

Percutaneous Transhepatic Biliary Drainage in a Two-Month-Old Infant with Inspissated Bile Syndrome.

Inspissated bile syndrome (IBS) is a relatively rare condition. Many treatment options are available, including medication, surgery, and surgical interventions, such as insertion of cholecystostomy drain, endoscopic retrograde cholangiopancreatography, internal biliary drainage, and percutaneous transhepatic biliary drainage (PTBD). We herein report the first case of IBS that was successfully treated with PTBD in a two-month-old infant in Korea. PTBD was initiated on postnatal day 72. On postnatal day 105, we confirmed complete improvement and successfully removed the catheters. This report suggests that PTBD is a viable and safe treatment option for obstructive jaundice in very young infants.

Multiple-electrode radiofrequency ablation of in vivo porcine liver: comparative studies of consecutive monopolar, switching monopolar versus multipolar modes.

PURPOSE: To evaluate the in vivo efficiency of 2 multiple-electrode radiofrequency (RF) systems to create confluent areas of coagulation in porcine liver, compared with consecutive overlapping ablation. MATERIALS AND METHODS: A total of 18 coagulations were created with 3 RF devices and 3 internally cooled electrodes at laparotomy in 6 female pigs. RF was applied to the porcine livers in a consecutive, monopolar mode (group A), in a switching monopolar mode (group B), or in a multipolar mode (group C). Energy efficiency values for the RF systems, shape and dimensions, and the coefficients of variation of the coagulation zones were compared in the 3 groups. RESULTS: The duration of the RF ablation procedures in groups A, B, and C were 36 minutes, 18 minutes, and 21.2 +/- 1.9 minutes. The average energy delivered to produce 1 cm(3) coagulation was greater in group A (5.6 +/- 2.3 kJ/cm(3)) than in group B (1.8 +/- 0.5 kJ/cm(3)) or in group C (2.0 +/- 0.8 kJ/cm(3)) (P < 0.05). The mean volumes of the coagulations in groups A, B, and C were 28.8 +/- 13.2 cm(3) in group A, 49.1 +/- 12.3 cm(3) in group B, and 40.6 +/- 16.3 cm(3) in group C, respectively (P = 0.07). Regarding the shape of the coagulations, the coagulations of groups B (isoperimetric ratio; 0.88) and C (0.84) were more spherical than those of group A (0.69) (P < 0.05). In addition, the coefficients of variation of the volumes of the ablation zones in groups A, B, and C were 0.46, 0.25, and 0.40, respectively. CONCLUSIONS: Multiple-electrode RF systems in switching monopolar and multipolar modes more efficiently created a larger, confluent, spherical-shaped coagulation than conventional consecutive RF ablation.

Salvage therapy using self-expandable metal stents for recalcitrant anastomotic strictures after living-donor liver transplantation.

BACKGROUND: Recently, there has been an increase in clinical success rates using nonsurgical methods to resolve anastomotic biliary strictures (ABSs) that develop after liver transplantation (LT). However, some strictures are particularly refractory and cannot be completely resolved by an endoscopic or percutaneous procedure. Consequently, the aim of this study was to examine the feasibility and efficacy of using a newly designed fully covered self-expandable metal stent (FCSEMS) to resolve refractory ABS. METHODS: A total of 35 patients with an ABS that developed after LT, but could not be resolved by an endoscopic or percutaneous procedure, were included in this study. FCSEMSs were positioned endoscopically and removed after 2-3 months. After stent removal, the patients were followed to assess complications, including re-stenosis. RESULTS: The mean period from LT to stricture was 13.7 months, and the mean duration of the stricture was 31.8 months. The type and mean number of procedures previously attempted were endoscopic retrograde cholangiopancreatography (ERCP) (9.1 ± 5.1) in 19 patients and percutaneous transhepatic biliary drainage (9.2 ± 4.8) in 16 patients. All patients had successful FCSEMS insertions and removals; the mean stent indwelling time was 3.2 months. The mean follow-up period was 18.7 months (range: 6.4-37.8 months). Stricture recurrence was observed in 6 of 29 patients (recurrence rate: 20.7%). The anastomotic stricture resolved with the FCSEMS insertion in 29 of 35 patients (clinical success rate: 82.9%). CONCLUSIONS: The newly designed FCSEMS is a potentially feasible and effective treatment for anastomotic strictures that develop after LT but are not amenable to treatment by conventional procedures.

Effectiveness of Ambulatory Tru-Close Thoracic Vent for the Outpatient Management of Pneumothorax: A Prospective Pilot Study.

OBJECTIVE: This study aimed to assess the technical feasibility, procedural safety, and long-term therapeutic efficacy of a small-sized ambulatory thoracic vent (TV) device for the treatment of pneumothorax. MATERIALS AND METHODS: From November 2012 to July 2013, 18 consecutive patients (3 females, 15 males) aged 16-64 years (mean: 34.7 ± 14.9 years, median: 29 years) were enrolled prospectively. Of these, 15 patients had spontaneous pneumothorax and 3 had iatrogenic pneumothorax. A Tru-Close TV with a small-bore (11- or 13-Fr) catheter was inserted under bi-plane fluoroscopic assistance. RESULTS: Technical success was achieved in all patients. Complete lung re-expansion was achieved at 24 hours in 88.9% of patients (16/18 patients). All patients tolerated the procedure and no major complications occurred. The patients' mean numeric pain intensity score was 2.4 (range: 0-5) in daily life activity during the TV treatment. All patients with spontaneous pneumothorax underwent outpatient follow-up. The mean time to TV removal was 4.7 (3-13) days. Early surgical conversion rate of 16.7% (3/18 patients) occurred in 2 patients with incomplete lung expansion and 1 patient with immediate pneumothorax recurrence post-TV removal; and late surgical conversion occurred in 2 of 18 patients (11.1%). The recurrence-free long-term success rate was 72.2% (13/18 patients) during a 3-year follow-up period from November 2012 to June 2016. CONCLUSION: TV application was a simple, safe, and technically feasible procedure in an outpatient clinic, with an acceptable long-term recurrence-free rate. Thus, TV could be useful for the immediate treatment of pneumothorax.

Factors affecting survival after concurrent chemoradiation therapy for advanced hepatocellular carcinoma: a retrospective study.

BACKGROUND: Concurrent chemoradiation therapy (CCRT) followed by hepatic arterial infusional chemotherapy (HAIC) was reported to be effective for advanced hepatocellular carcinoma (HCC) with portal vein thrombosis. However, transarterial chemoembolization (TACE) is not preferred in this setting. The aim of this study was to assess the factors affecting survival after CCRT, including additional TACE during repeated HAIC. METHODS: Thirty-eight patients who underwent CCRT as the initial treatment for Barcelona Clinic Liver Cancer stage C HCC with vascular invasion between 2009 and 2016 were reviewed retrospectively. During CCRT, 5-fluorouracil (5-FU) was infused via chemoport during the first and last five days of five weeks of external beam radiation therapy. After CCRT, repeated HAIC with cisplatin and 5-FU was performed monthly. Nineteen patients (50%) underwent additional TACE between repeated HAICs. Factors related to overall survival and progression free survival (PFS) were analyzed. RESULTS: The mean age of patients was 55 years (male:female, 33:5). Underlying liver diseases were hepatitis B, hepatitis C and non-B/C in 29, 1 and 8 patients, respectively. The median radiation dose was 4500 cGy. The objective response (OR) rate at one months after CCRT was 36.8%. The median PFS was 7.4 (range, 1.8 - 32.1) months. The median overall survival was 11.6 (range 2.8-65.7) months. Achieving an OR after CCRT (hazard ratio [HR], 0.028; P < 0.001), additional TACE (HR, 0.134, P < 0.001), and further rounds of HAIC (HR, 0.742, P = 0.001) were independent significant factors related to overall survival. The overall survival duration of patients with an OR after CCRT (median 44.2 vs. 6.6 months, P < 0.001) and additional TACE (median 19.8 vs. 9.1 months, P = 0.001) were significantly greater than those without an OR after CCRT or additional TACE. CONCLUSION: Patients who achieved an OR after CCRT, underwent additional TACE, and were subjected to repeated rounds of HAIC following CCRT showed better survival after CCRT for advanced stage of HCC with vascular invasion. A further prospective study is needed to confirm the positive effect of additional TACE after CCRT.

Optimized Performance of FlightPlan during Chemoembolization for Hepatocellular Carcinoma: Importance of the Proportion of Segmented Tumor Area.

OBJECTIVE: To evaluate retrospectively the clinical effectiveness of FlightPlan for Liver (FPFL), an automated tumor-feeding artery detection software in cone-beam CT angiography (CBCTA), in identifying tumor-feeding arteries for the treatment of hepatocellular carcinoma (HCC) using three different segmentation sensitivities. MATERIALS AND METHODS: The study included 50 patients with 80 HCC nodules who received transarterial chemoembolization. Standard digital subtracted angiography (DSA) and CBCTA were systematically performed and analyzed. Three settings of the FPFL software for vascular tree segmentation were tested for each tumor: the default, Group D; adjusting the proportion of segmented tumor area between 30 to 50%, Group L; and between 50 to 80%, Group H. RESULTS: In total, 109 feeder vessels supplying 80 HCC nodules were identified. The negative predictive value of DSA, FPFL in groups D, L, and H was 56.8%, 87.7%, 94.2%, 98.5%, respectively. The accuracy of DSA, FPFL in groups D, L, and H was 62.6%, 86.8%, 93.4%, 95.6%, respectively. The sensitivity, negative predictive value (NPV), and accuracy of FPFL were higher in Group H than in Group D (p = 0.041, 0.034, 0.005). All three segmentation sensitivity groups showed higher specificity, positive predictive value, NPV, and accuracy of FPFL, as compared to DSA. CONCLUSION: FlightPlan for Liver is a valuable tool for increasing detection of HCC tumor feeding vessels, as compared to standard DSA analysis, particularly in small HCC. Manual adjustment of segmentation sensitivity improves the accuracy of FPFL.

Balloon-Supported Passage of a Stent-Graft into the Aortic Arch.

A 62-year-old man was admitted, and thoracic endovascular aortic repair (TEVAR) procedure was performed to treat an accidentally detected aortic aneurysm, which was 63 mm in diameter. While performing TEVAR, the passage of the stent-graft introducer system was impossible due to the prolapse of the introducer system into a wide-necked aneurysm; this aneurysm was located at the greater curvature of the proximal descending thoracic aorta. In order to advance the introducer system, a compliant balloon was inflated. Thus, we created an artificial wall in the aneurysm with this inflated balloon. Finally, we were able to advance the introducer system into the target zone.