Purpose: To determine the efficacy and safety of transabdominal direct sac puncture embolization of type II endoleaks after endovascular
abdominal aortic aneurysm repair (EVAR).
Materials and Methods: This retrospective review included 30 patients (4 women, 26 men; mean age ¼ 79.1 years) who underwent
33 transabdominal direct sac puncture embolization procedures for type II endoleaks after EVAR. Embolization agents included
cyanoacrylate glue only (45.5%), glue/coils (36.4%), and Onyx with or without glue/coils (18.1%). Technical success was defined as
complete endoleak embolization on intraprocedural fluoroscopy. The primary outcome was freedom of aneurysm growth, which was
defined as 5% aneurysm sac volume change on follow-up computed tomography (CT) imaging or 5 mm aneurysm sac diameter
change on ultrasound without definite endoflow. Aneurysm sac volumes before and after embolization were manually segmented from
CT images. The procedural complication rate was calculated.
Results: Technical success was achieved in 97% of patients (29/30). Follow-up imaging was available in 27 patients (25 CT; 2 ultrasound),
and mean imaging follow-up duration was 15.5 months. Freedom of aneurysm growth was achieved in 85.2% of patients (23/
27) after 1 or more embolization procedures. Median fluoroscopic and procedure times were 11.3 minutes and 90 minutes, respectively.
The complication rate was 9.1% (3/33) and included 1 case of nontarget embolization with transient neuropraxia and 2 self-limiting
rectus sheath hematomas relating to the percutaneous puncture site. No aneurysm-related mortality occurred during the follow-up period.
Conclusions: Percutaneous transabdominal embolization is a safe and efficacious treatment for type II endoleak, with a short procedure
Purpose: To compare feasibility, 12-month outcome, and periprocedural and postprocedural risks between carotid artery stent (CAS)
placement and carotid endarterectomy (CEA) performed within 1 week after transient ischemic attack (TIA) or mild to severe stroke
onset in a single comprehensive stroke center.
Materials and Methods: Retrospective analysis of prospective data collected from 1,148 patients with ischemic stroke admitted to a single stroke unit between January 2013 and July 2015 was conducted. Among 130 consecutive patients with symptomatic carotid stenosis, 110 (10 with TIA, 100 with stroke) with a National Institutes of Health Stroke Scale (NIHSS) score < 20 and a prestroke modified Rankin Scale (mRS) score < 2 were eligible for CAS placement or CEA and treated according to the preference of the patient or a surrogate. Periprocedural (< 48 h) and postprocedural complications, functional outcome, stroke, and death rate up to 12 months were analyzed.
Results: Sixty-two patients were treated with CAS placement and 48 were treated with CEA. Several patients presented with moderate
or major stroke (45.8% CEA, 64.5% CAS). NIHSS scores indicated slightly greater severity at onset in patients treated with a CAS vs
CEA (6.6 ± 5.7 vs 4.2 ± 3.4; P ¼.08). Complication rates were similar between groups. mRS scores showed a significant improvement
over time and a significant interaction with age in both groups. Similar incidences of death or stroke were shown on survival analysis. A
subanalysis in patients with NIHSS scores 4 showed no differences in complication rate and outcome.
Conclusions: CAS placement and CEA seem to offer early safe and feasible secondary stroke prevention treatments in experienced
centers, even after major atherosclerotic stroke.
Purpose: To evaluate long-term effects of yttrium-90 (90Y) transarterial radioembolization (TARE) for unresectable hepatic metastases of neuroendocrine tumors (NETs).
Materials and Methods: Retrospective analysis of 93 patients (47 women, 46 men; mean age 59 y) who underwent resin-based 90Y TARE was performed. Variables associated with overall survival were analyzed using univariate and multivariate models. Changes in serologic values and imaging characteristics were assessed with long-term follow-up.
Results: Unilobar TARE was performed in 48 patients, and staged bilobar TARE was performed in 45 patients. In multivariate analysis, ascites (P 1⁄4 .002) and extrahepatic metastases (P 1⁄4 .038) at baseline were associated with poor survival. Among 52 patients who had> 1 year of follow-up, significant increases in alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase were observed; however, only 4 patients experienced grade 3 serologic toxicities. Imaging signs of cirrhosis-like morphology and portal hypertension were observed in 15 of 52 patients, more frequently in patients treated with bilobar TARE compared with unilobar TARE. Patients treated with bilobar TARE exhibited significantly increased hepatobiliary enzymes and decreased platelet count. Sustained increases in liver enzymes were observed in patients with > 4 years of follow-up. No radioembolization-related liver failure or grade 4 toxicity was observed.
Conclusions: 90Y radioembolization using resin microspheres demonstrated a high safety profile for NET liver metastases, with low-grade, although sustained, long-term liver toxicity evident > 4 years after treatment. Bilobar treatment suggested a trend for treatment-related portal hypertension. Ongoing research will help define parameters for optimizing durable safety and efficacy of radioembolization in this setting.
Pelvic congestion syndrome is associated with pelvic varicosities that result in chronic pelvic pain, especially in the setting of prolonged standing, coitus, menstruation, and pregnancy. Although the underlying pathophysiology of pelvic congestion syndrome sunclear, it probably results from acombination of dysfunctional venous valves, retrograde blood flow, venous hypertension, and dilatation. Asymptomatic women may also have pelvic varicosities, making pelvic congestion syndrome difficult to diognose.This article explore stheetiologies of pain, use of imaging techniques, and clinical management of pelvic
congestion syndrome. Possible explanations for the spectrum of pain among women with pelvic varicosities are also discussed.
Authors: Shivank Bhatia, MD, Sardis H. Harward, MPH, Vishal K. Sinha, BS, and Govindarajan Narayanan, MD
By: Sangik Park, MD, Ji Hoon Shin, MD, Dong-Il Gwon, MD, Hyoung Jung Kim, MD, Kyu-Bo Sung, MD, Hyun-Ki Yoon, MD, Gi-Young Ko, MD, and Heung Kyu Ko, MD
Abstract: To evaluate outcomes of transcatheter arterial embolization (TAE) for gastric cancer-related gastrointestinal (GI) bleeding and factors associated with successful TAE and improved survival after TAE.
Materials and Methods: This retrospective study included 43 patients with gastric cancer related GI bleeding undergoing angiography between January 2000 and December 2015. Clinical course, laboratory findings, and TAE characteristics were reviewed. Technical sucess of TAE was defined as target area revascularization, and clinical success was defined as bleeding cessatation with hemodynamic stability during 72 hours after TAE. Student t test was used for comparison of continuous variables, and Fischer exact test was used for categorical variables. Univariate and multivariate analysis were performed to identify predictors of successful TAE and 30-day survival after TAE.
Results: TAE was performed in 40 patients. Technical and clinical success rates of TAE were 85.0% and 65.0%, respectively. Splenic infarction occured in 2 patients as a minor complication. Rebleeding after TAE occured in 7 patients. Death related to bleeding occured in 5 patients. Active bleeding and higher transfusion requirement were associated with TAE failure. Successful TAE predicted improved 30-day survival after TAE on univariate and multiraviate analysis.
Conclusion: TAE for gastric cancer-associated GI bleeding may be a lifesaving procedure. Severe bleeding with a higher transfusion requirement and active bleeding on angiography predicted TAE failure.
Purpose: To evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter
(CVC) for prevention of pulmonary embolism (PE) in critically ill patients.
Materials and Methods: In a multicenter, prospective, single-arm clinical trial, the device was inserted at the bedside without fluoroscopy and subsequently retrieved before transfer from the intensive care unit (ICU). The primary efficacy endpoint was freedom from clinically significant PE or fatal PE 72 hours after device removal or discharge, whichever occurred first. Secondary endpoints were incidence of acute proximal deep venous thrombosis (DVT), catheter-related thrombosis, catheter-related bloodstream infections, major bleeding events, and clinically significant thrombus (occupying > 25% of volume of filter) detected by cavography before retrieval.
Results: The device was placed in 163 critically ill patients with contraindications to anticoagulation; 151 (93%) were critically ill trauma patients, 129 (85%) had head or spine trauma, and 102 (79%) had intracranial bleeding. The primary efficacy endpoint was achieved for all 163 (100%) patients (95% confidence interval [CI], 97.8%–100%, P < .01). Diagnosis of new or worsening acute proximal DVT was time dependent with 11 (7%) occurring during the first 7 days. There were no (0%) catheter-related bloodstream infections. There were 5 (3.1%) major bleeding events. Significant thrombus in the IVC filter occurred in 14 (8.6%) patients. Prophylactic anticoagulation was not initiated for a mean of 5.5 days ± 4.3 after ICU admission.
Conclusions: This novel device prevented clinically significant and fatal PE among critically ill trauma patients with low risk of complications.
Purpose: To retrospectively evaluate the results of endovascular therapy of vascular malformations principally treated with ethanol embolization at a single center.
Materials andMethods: From May1999 to December 2012, 46 patients (28 female,18 male) with vascular malformations (31 venous malformations,15 arteriovenousmalformations [AVMs]) throughout the body (nine upper extremity,31 lower extremity, and six truncal)who underwent ethanol embolization were studied and followed up. Demographic factors, clinical findings, imaging data, and patient reported changes in symptoms were collected and analyzed. Follow-up data were obtained by office visits,repeatimaging, and telephone contact.
Results: Twenty-four patients (52.2%)were considered cured,12 (26.1%) showed improvement, and 10 (21.7%) had no change or showed worsening. Similar rates of cure or improvement were seen for AVMs and venous malformations (P ¼ 0.67). Lesion location, depth, and size were not associated with differences in outcomes (P ¼ .87, P ¼ .37, and P ¼ .61, respectively). Type 1 and type 2 AVMs were cured more often than other AVM types. The overall complication rate was 24% (11 of 46 patients). Minor complications were seen in six individuals (13%), and major complications developed in five patients (11%).
Conclusions: Ethanol embolization of vascular malformations produces good outcomes, with control or relief of symptoms in a majority of patients
Purpose: To identify and compare predictors of local tumor progression (LTP)-free survival (LTPFS) after radiofrequency (RF) ablation and microwave (MW) ablation of colorectal liver metastases (CLMs).
Materials and Methods: This is a retrospective review of CLMs ablated from November 2009 to April 2015 (110 patients). Margins were measured on contrast-enhanced computed tomography (CT) 6 weeks after ablation. Clinical and technical predictors of LTPFS were assessed using a competing risk model adjusted for clustering.
Results: Technique effectiveness (complete ablation) was 93% (79/85) for RF ablation and 97% (58/60) for MW ablation (P 1⁄4 .47). The median follow-up period was significantly longer for RF ablation than for MW ablation (56 months vs. 29 months) (P < .001). There was no difference in the local tumor progression (LTP) rates between RF ablation and MW ablation (P 1⁄4 0.84). Significant predictors of shorter LTPFS for RF ablation on univariate analysis were ablation margins 5 mm or smaller (P < .001) (hazard ratio [HR]: 14.6; 95% confidence interval [CI]: 5.2–40.9) and perivascular tumors (P 1⁄4 .021) (HR: 2.2; 95% CI: 1.1–4.3); both retained significance on multivariate analysis. Significant predictors of shorter LTPFS on univariate analysis for MW ablation were ablation margins 5 mm or smaller (P < .001) (subhazard ratio: 11.6; 95% CI: 3.1–42.7) and no history of prior liver resection (P < .013) (HR: 3.2; 95%: 1.3–7.8); both retained significance on multivariate analysis. There was no LTP for tumors ablated with margins over 10 mm (median LTPFS: not reached). Perivascular tumors were not predictive for MW ablation (P 1⁄4 .43).
Conclusions: Regardless of the thermal ablation modality used, margins larger than 5 mm are critical for local tumor control, with no LTP noted for margins over 10 mm. Unlike RF ablation, the efficiency of MW ablation was not affected for perivascular tumors.
By: Jo~ao Pisco, MD, PhD, Tiago Bilhim, MD, PhD, Nuno V. Costa, MD, Manuel Pinto Ribeiro, MD, Lucia Fernandes, MD, and Antonio G. Oliveira, MD, PhD
Directed Reading focused on the evaluation of the safety and outcomes of endovascular percutaneous removal of inferior vena cava filters (IVCFs) with elements penetrating an artery.
Purpose: To evaluate long-term clinical efficacy of uterine artery embolization (UAE) for uterine fibroids with respect to symptom control and improvement in quality of life.
Materials and Methods: Between October 2000 and October 2007, 380 consecutive women underwent UAE. To determine long- term efficacy, the rate of reinterventions (ie, repeat UAE, hysterectomy, myomectomy) and the clinical response regarding symptoms related to bleeding and bulk were documented. Persistence, worsening, or recurrence of symptoms and reinterventions were classified as treatment failure (TF). The cumulative rate of freedom fromTF was determined by Kaplan-Meieran alysis. Cox regression was used to identify possible clinical or morphologic predictors of outcome. Secondary outcome measures were changes in disease- specific quality of life and onset of menopause.
Results: Follow-up was available for a median of 5.7 years (range,3.1–10.1y) after treatment in 304 of 380 (80%) patients.There were 54 TFs with subsequent reintervention in 46 women. Kaplan-Meier analys is revealed a cumulative TF rate of 23.3% after 10 years. Cox regression demonstrated a significantly higher likelihood of TF in patients < 40 years old compared with patients > 45 years old (hazard ratio, 2.28; P = .049). Women without TF showed sustained normalization of disease-specific quality of life (P < .001). Cessation of menstruation at amedian age of 51 years was reported by 57 (22.8%) of 250 women.
Conclusions: UAE leads to long-term control of fibroid-related symptoms and normalization of quality of life in approximately 75% of patients.Younger women seem to have a higher risk of TF than older women closer to menopause.
Purpose: To compare safety and efficacy of vascular plugs (VPs) and fibered platinum coils (FPCs) for embolization in pelvic congestion syndrome (PCS).
Materials and Methods: A randomized, prospective, single-center study enrolled 100 women with PCS from January 2014 to January 2015. Patients were randomly assigned to 2 groups, and embolization was performed with FPCs (n 1⁄4 50) or VPs (n 1⁄4 50). Mean age of patients was 42.7 years ± 7.60, and mean visual analog scale (VAS) score for pelvic pain before treatment was 7.4 ± 7.60. Primary outcome (clinical success at 1 y using a VAS), number of devices, procedure and fluo- roscopy times, radiation doses, costs, and complications were compared, and participants were followed at 1, 3, 6, and 12 months.
Results: Clinical success and subjective improvement were not significantly different at 1-year follow-up (89.7% for FPCs vs 90.6% for VPs; P 1⁄4 .760). Mean number of devices per case was 18.2 ± 1.33 for FPCs and 4.1 ± 0.31 for VPs (P < .001). Three FPCs and 1 VP migrated to pulmonary vasculature approximately 3–6 months after the embolization procedure; all were retrieved without com- plications. The FPC group had a significantly longer fluoroscopy time (33.4 min ± 4.68 vs 19.5 min ± 6.14) and larger radiation dose (air kerma 948.0 mGy ± 248.45 vs 320.7 mGy ± 134.33) (all P < .001).
Conclusions: Embolization for PCS resulted in pain relief in 90% of patients; clinical success was not affected by embolic device. VPs were associated with decreased fluoroscopy time and radiation dose.
Purpose: To identify clinical predictors of port infections in adult patients with hematologic malignancies.
Materials and Methods: A retrospective chart review identified 223 adult patients (age ! 18 y) with hematologic malignancies, including lymphoma (n 1⁄4 163), leukemia (n 1⁄4 49), and others (n 1⁄4 11), who had a port placed from 2012 to 2015. Early (< 30 d after port placement) and overall port infections (bloodstream and site infections) were recorded. To elucidate clinical predictors for early and overall port infections, proportional subdistribution hazard regression (PSHREG) analyses were conducted with variables including patients’ demographics, medications used, laboratory data, and port characteristics.
Results: Total duration of follow-up was 83,722 catheter-days (median per patient, 274 catheter-days). Early and overall port infections were identified in 8 (3.6%) and 26 (11.7%) patients, respectively. Early and overall infection rates were 1.2 and 0.3 infections/1,000 catheter-days, respectiv
Purpose: To determine facility and patient demographics associated with survival in early-stage non-small cell lung cancer (NSCLC)treated with radiofrequency (RF) ablation.
Materials and Methods: The National Cancer Database was queried for cases of stage 1a NSCLC treated with RF ablation without chemotherapy or radiotherapy from 2004 to 2014. High-volume centers (HVCs) were defined as the top 95th percentile of facilities by number of procedures performed. Overall survival (OS) was estimated with the Kaplan-Meier method, and comparisons between survival curves were performed with the log-rank test. Propensity score-matched cohort analysis was performed. P values less than .05 were considered statistically significant.
Results: In the final cohort, 967 cases were included. Estimated median survival and follow-up were 33.1 and 62.5 months, respectively. Of 305 facilities, 15 were determined to be HVCs, treating 13 or more patients from 2004 to 2014. A total of 335 cases (34.6%) were treated at HVCs. On multivariate Cox regression analysis, treatment at an HVC was independently associated with improved OS (hazard ratio [HR] 1⁄4 0.766; P 1⁄4 .006). After propensity score adjustment, 1-, 3-, and 5-year OS was 89.8%, 51.2%, and 27.7%, respectively, for patients treated at HVCs, compared to 85.2%, 41.5%, and 19.6%, respectively, for patients treated at non-HVCs (P 1⁄4 .015). Increasing age (HR 1⁄4 1.012; P 1⁄4 .013) and higher T-classification (HR 1⁄4 1.392; P < .001) were independently associated with worse OS.
Conclusion: Patients with early-stage NSCLC treated with RF ablation at HVCs experienced a significant increase in OS, suggesting regionalization of lung cancer management as a means of improving outcomes.
In the high-volume and increasingly complex world of image-guided therapy and medical imaging, awareness of the potential risks secondary to occupational radiation exposure in medical professionals needs greater focus. One of these risks is radiation- induced cataracts, a recently recognized entity, which may impact the physician’s professional proficiency, quality of life, and career span. This review article aims to explain the pathogenesis of radiation-induced cataracts, exploring emerging evidence regarding their development. It also explores the existing monitoring and protection measures available to protect against such radiation-induced pathologic conditions.
The AVIR is pleased to announce that our Annual VI Board Prep course, offered at our annual meeting each year, is now available as an online webinar.
This second edition of the VI Review Course was created for the 2018 annual meeting and includes 4 hours of lectures from new speakers and reviews all of the sections of the ARRT exam matrix. This package also includes AVIR's proprietary mock registry exam and answer sheet to prepare for your test. Both the lecture and the exam can be watched and practiced as many times as you would like, but you must complete the post lecture quiz ot recieve CE credits for you time.
This course is approved for 4.5 CE credits.