Journal of Vascular and Interventional Radiology

Development of a Research Agenda for the Management of Metastatic Colorectal Cancer: Proceedings from a Multidisciplinary Research Consensus Panel

2012-02-01

Colorectal cancer (CRC), the second leading cause of cancer death in the United States, occurs in an estimated more than 145,000 patients annually, with almost 50,000 deaths each year. Metastatic liver disease is the cause of death in the majority of them (). Liver-only metastases affect up to one half of patients with CRC (), with approximately 15% (range, 8%–26%) presenting synchronously () and an additional 15% found metachronously during the next 5 years (). Colorectal liver metastases (CLMs) are resectable in 20%–25% of patients only; some of the remaining 75%–80% may benefit from “downsizing” therapy, which can result in 10%–20% more patients becoming resectable. Overall survival rates in patients with either primarily or secondarily resectable CLMs can be as high as 58% at 5 years and 15% at 10 years (). Current front-line treatments available to improve downsizing and resectability include systemic therapies (chemotherapy with or without bevacizumab or cetuximab) and pre-operative portal vein embolization (PVE). Other approaches include local ablation therapies, regional intraarterial therapies with embolization (transcatheter arterial chemoembolization, or radioembolization by selective internal radiation therapy with Yttrium 90-loaded microspheres) or infusion (ie, hepatic arterial infusion [HAI] pump chemotherapy), and external beam radiation therapy (RT). The role of these liver-targeted therapies to promote conversion from unresectable to resectable liver disease remains an evaluation in progress. For the majority of patients with unresectable CRC liver metastases, standard of care is first- and second-line triplet chemotherapy, which is associated with a median survival of 18–24 months (). Multiple single-institution retrospective reports suggest the potential for improvement in survival time by the addition of liver-directed therapies such as chemoembolization, HAI, or radioembolization. This has not been prospectively evaluated in controlled trials, but could potentially represent a major development in Interventional Oncology (IO). The Society of Interventional Radiology (SIR) Foundation has identified the management of metastatic CRC (mCRC) as an emerging interventional radiologic research priority and convened a Research Consensus Panel (RCP) Meeting on October 3, 2011 to establish a prioritized research agenda. This article reports the proceedings from this meeting.

Society of Interventional Radiology Position Statement: Mini Training Courses in Interventional Radiology Techniques

2011-11-03

The rapid advancement and innovation of image-guided techniques, devices, procedures, and treatments has led to difficulty for individual interventional radiologists and interventionalists to keep pace with new developments. In part for this reason, numerous short industry-sponsored and weekend (1–2 d) training courses have been developed. These courses may last for a portion of a day or several days and have a device-oriented focus. Representatives from various groups and interests instruct physicians how to use novel devices directly or indirectly via physician proctors.

Endovascular Therapy for Acute Pulmonary Embolism

William T. Kuo — 2011-12-21

Abstract: Acute pulmonary embolism (PE) is the third most common cause of death among hospitalized patients. Treatment escalation beyond anticoagulation therapy is necessary in patients with massive PE (defined by hemodynamic shock) as well as in many patients with submassive PE (defined by right ventricular strain). The best current evidence suggests that modern catheter-directed therapy to achieve rapid central clot debulking should be considered as an early or first-line treatment option for patients with acute massive PE; and emerging evidence suggests a catheter-directed thrombolytic infusion should be considered as adjunctive therapy for many patients with acute submassive PE. This article reviews the current approach to endovascular therapy for acute PE in the context of appropriate diagnosis, risk stratification, and management of acute massive and acute submassive PE.

CME Test Questions: February 2012

2012-02-01

Removal of Fractured Inferior Vena Cava Filters: Feasibility and Outcomes

2011-12-19

Abstract: Purpose: To examine the feasibility and outcomes of removing retrievable inferior vena cava (IVC) filters that have fractured. Materials and Methods: Retrospective review of IVC filter retrievals over an 8-year period identified patients in whom there was an attempt to retrieve fractured filters and struts. Patient medical records were evaluated for filter type, recovery method for filter body and struts, removal attempt results, and complications. Results: Between January 2002 and December 2010, 148 IVC filters were retrieved, 15 of which were fractured. All 15 fractured filter bodies were successfully retrieved. Nine of 15 fractured filters (60%) were removed in their entirety by using endobronchial forceps to retrieve the filter body and/or fractured struts. In three cases, forceps were used to retrieve the filter body and the fractured strut was removed with a snare. In six patients (40%), only the filter body could be removed, three with the Recovery Cone and three with endobronchial forceps. Failed attempts to remove fractured struts were made in three cases, with no attempt made in the remaining three. These struts were incorporated in the right ventricle, embedded in the IVC wall, or extraluminal. Minor caval defect was identified in five of 15 retrievals (33%); mild hemoptysis was noted in one case in which the strut was snared from a pulmonary artery. No major complications occurred. Conclusions: Fractured IVC filter bodies can be safely removed. Fractured filter struts can be removed when accessible, but are often in a position that makes retrieval not possible.

Fractured Bard Recovery, G2, and G2 Express Inferior Vena Cava Filters: Incidence, Clinical Consequences, and Outcomes of Removal Attempts

2011-12-14

Purpose: To increase the understanding of risks of inferior vena cava (IVC) filter fracture and embolization and the safety of removing fractured filters via retrospective review of a prospectively collected database of fractured IVC filters. Materials and Methods: A total of 63 fractured IVC filters were discovered among 548 patients presenting for retrievable filter removal between April 2004 and November 2010 at a single institution. Device type, duration of implantation, component fracture, and embolization events were recorded. Success rates and techniques for removal of components were recorded. Results: A total of 63 fractured Recovery, G2, and G2 Express IVC filters were identified, for an overall fracture rate of 12%. Excluding foot process fractures, the fracture rate for only filter arms and/or legs was 6%. The incidence of fracture increased with longer filter dwell times. Success rates for removal of the nonfractured component (ie, main body) and fractured components (ie, arm or leg) were 98.4% and 53.4%, respectively. The distal embolization rate of fractured filter components was 13%. There were no immediate clinically significant complications associated with fracture component embolization or filter removal. A single patient was encountered with symptoms related to their fractured filter. Conclusions: IVC filter fracture rates increase with longer dwell times; however, removal of fractured filters and fractured components (ie, arms and legs) can be achieved safely and effectively. Clinically significant complications of IVC filter fracture are rare, and there were no immediate clinical sequelae related to embolization of fracture components.

Refrain, Recover, Replace

William J. Nicholson — 2012-02-01

In this issue of Journal of Vascular Interventional Radiology, two articles address the removal of fractured retrievable vena cava filters after prolonged dwell times (). Both of these articles shed light on the next steps in the management of fractured vena cava filters. As is often the case when business and legal implications cloud the waters of clinical practice, scientific reporting lends clarity to physicians and patients facing daunting treatment decisions. The two main issues that continue to challenge physicians and patients who have received a retrievable filter are as follows: (i) Is the filter durable over a prolonged time? (ii) If it is not durable, can it be removed safely years after its implantation?

Vena Cava Filter Fracture: Unplanned Obsolescence

Matthew S. Johnson — 2012-02-01

The United States Food and Drug Administration (FDA) classifies medical devices into one of three categories, from those posing the least risk to patients, class I, to those posing the highest risk, class III. Unlike class I and II devices, class III devices require an approved premarket approval application before commercial distribution in the United States (). That requirement mandates that a manufacturer demonstrate that the device is safe and effective. Demonstration of safety and efficacy requires performance of a well controlled trial, optimally a randomized controlled trial (RCT). Before 1976, when the FDA gained its current authority to regulate medical devices, vena cava filters (VCFs) were considered class III devices, but filters were reclassified in 2000 as class II devices. As such, VCFs could be cleared for commercial distribution through the less rigorous 510(k) process, which requires only that a manufacturer demonstrate that a device is “substantially equivalent” to a predicate device. It is not surprising, then, given the expense and complexity of RCTs, that no RCT of a VCF to support its commercial distribution has ever been performed.

Fracture and Distant Migration of the Bard Recovery Filter: A Retrospective Review of 363 Implantations for Potentially Life-Threatening Complications

2011-12-21

Abstract: Purpose: To report the occurrence of fracture of the Recovery filter and incidence of potentially life-threatening complications associated with fractured fragment migration. Materials and Methods: A retrospective study of images obtained after placement of Recovery inferior vena cava (IVC) filters from 2003 to 2006 was conducted at a single tertiary-care center. Images were reevaluated for fracture and migration; complications related to filter fracture were investigated. Kaplan–Meier survival analysis was performed to investigate the relationship between time in situ and fracture. Results: A total of 363 Recovery filters were placed; 97 were retrieved, leaving 266 filters in situ (135 patients subsequently died of other causes). The following images were evaluated: 130 chest computed tomography (CT) scans, 153 abdominal CT scans, 254 chest radiographs, 148 radiographs of the abdomen/pelvis, and 106 cavagrams. Mean imaging follow-up interval was 18.4 months (maximum, 81.3 mo). No en bloc migration occurred outside the IVC. Twenty-six limb fractures (all short limbs) were identified in 20 patients; the earliest occurred at 4.1 months. Eight fragment migrations occurred into pulmonary arteries, seven into iliac/femoral veins, one into the right ventricle, and one into the renal vein. Seven fragments were intracaval near the filter, one was extracaval, and one could not be located. Kaplan–Meier survival estimates predicted a fracture rate of 40% at 5.5 years. Of the 20 patients with filter fractures, three died of unrelated causes and 17 remain asymptomatic. Conclusions: Recovery filter fractures occurred at the short limb only, with a suggested 5.5-year fracture risk of 40%. No life-threatening events occurred in patients with filter fracture.

Varicocele Retrograde Embolization with Boiling Contrast Medium and Gelatin Sponges in Adolescent Subjects: A Clinically Effective Therapeutic Alternative

2011-12-15

Abstract: Purpose: Varicoceles occur in approximately 15% of adolescent male subjects and may impair future fertility. The present study describes a varicocele treatment technique involving percutaneous retrograde embolization with boiling hot contrast medium and gelatin sponge pledgets. Materials and Methods: A retrospective review of medical records and imaging of all patients who underwent percutaneous retrograde varicocele embolization from 2005 to 2010 was performed. Pre- and postembolization symptoms, physical findings, and ultrasound findings were documented. Fifteen patients (16 embolizations) were identified, with an average age of 15.9 years (range, 12–18 y). Nine were referred because of persistent varicocele after surgical ligation. Three had grade 2 and nine had grade 3 varicoceles. Two had grade 1 varicoceles; one was painful and one was associated with poor semen quality. One varicocele was not clinically evident, but was associated with persistently decreased testicular size. Nine patients had pain or discomfort, and six had no discomfort. Clinical resolution was defined by a combination of symptom resolution and a lack of physical examination findings of varicocele or findings of treated varicocele. Results: Fifteen of the 16 embolizations (94%) were technically successful. Clinical resolution was documented in 14 of 15 patients (95%); one patient experienced a recurrence at 30 months, which was successfully reembolized. One patient experienced temporary paresthesia of the left thigh. There were no major postprocedural complications. Mean follow-up duration was 11 months. Conclusions: Retrograde embolization of varicoceles in adolescent subjects with the use of boiling hot contrast medium and gelatin sponges is a promising technique that appears effective.

Anatomy of the Origin of the Gonadal Veins on CT

Brendan Barber, Alexander Horton, Uday Patel — 2011-12-21

Abstract: Purpose: To study gonadal vein (GV) anatomy on multidetector computed tomography (CT) and define guidelines to aid their identification. Materials and Methods: A total of 106 multidetector CT examinations obtained for abdominal pain were reviewed by three independent readers. The location and three-dimensional orientation of the GV ostia were investigated. Six studies were excluded because the GVs were incompletely visualized. Results: The anatomy of the right and left GVs was defined in 100 and 99 cases, respectively. On the left side, 97 of 99 inserted directly into the inferior wall of the left renal vein (> 85% within 45 mm of the edge of the inferior vena cava [IVC] or within 10 mm of the edge of the spine). Two patients showed variant caval anatomy, and the GV directly joined the variant IVC. On the right side, 92 of 100 inserted directly into the IVC (> 83% within 25 mm below the renal vein ostium). The right GV ostium was anterolaterally located (ie, between 270° and 360°) in the majority of cases. Eight right GVs joined the right renal vein within 2 cm of the renal vein ostium. Conclusions: When searching for the right GV, the right anterolateral quadrant should be searched first, as much as 25 mm caudal to the right renal vein ostium. If unsuccessful, the inferior wall of the right renal vein within 2 cm of its origin should be interrogated. On the left side, the inferior wall of the left renal vein should be examined. If a left-sided IVC is found, the GV will join it directly.

Endovascular Therapy of Saccular Aortic Aneurysm

Kothandam Sivakumar, Krishnaswami Murali, Velayudhan Bashi — 2012-02-01

Based on a computed tomographic (CT) angiography study, a 23-year-old woman with Takayasu aortitis and abdominal pain was diagnosed with large 5.2-cm saccular abdominal aortic aneurysm near an occluded left renal artery (a; available in color online at www.jvir.org) and nonfunctional left kidney, small ectasia of inferior mesenteric artery origin, and mild diffuse aortic disease. There was no previous trauma or abdominal sepsis. Open surgical repair was undesirable, as the aortic tissue in the vicinity of the aneurysm was abnormal. The close proximity to right renal artery precluded endovascular stent-grafting.

Hepatic Venous Pressure Measurements: Comparison of End-Hole and Balloon Catheter Methods

2011-12-30

Abstract: Purpose: To determine the difference in hepatic venous pressures measured with the use of an end-hole diagnostic catheter versus a balloon catheter. Materials and Methods: A total of 92 patients underwent transjugular hepatic venous pressure measurements with a 5-F diagnostic end-hole catheter and a balloon catheter, with the catheter type used initially determined randomly. With both catheters, free and wedged systolic, diastolic, and mean pressures were collected. Hepatic venous pressure gradients were calculated from each pressure set. Eighty-five patients (92%) also underwent concurrent transjugular biopsy after pressures were recorded. Demographic, histologic, and specific procedural information were also collected. Results: The study included 47 men and 45 women, with a mean age of 52.7 years (range, 19–84 y). For the entire population, there were statistically significant differences in mean measurements between the two catheters in wedged systolic (P = .004), diastolic (P = .021), and mean (P = .036) pressures. However, the differences between the means were only 0.783, 0.609, and 0.207 mm Hg, respectively. A subanalysis based on histologic stage revealed no difference between catheter types for normal or cirrhotic livers, but a significant (P = .017) difference in systolic wedged pressure (absolute difference of 0.67 mm Hg) in patients with mild to moderate fibrosis (stages 1–3). In all differences, the balloon catheter had the greater pressure reading. Conclusions: There was a significant difference in wedged pressure measurements between the two catheter systems in the overall population and among patients with a histologic grade indicating fibrosis. However, the absolute value differences between the two systems were comparatively small (< 1 mm Hg).

TIPS for Treatment of Variceal Hemorrhage: Clinical Outcomes in 128 Patients at a Single Institution over a 12-Year Period

2011-12-19

Abstract: Purpose: To assess clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) treatment of variceal hemorrhage. Materials and Methods: A total of 128 patients (82 men and 46 women; mean age, 52 y) with liver cirrhosis and refractory variceal hemorrhage underwent TIPS creation from 1998 to 2010. Mean Child-Pugh and Model for End-stage Liver Disease (MELD) scores were 9 and 18, respectively. From 1998 to 2004, 12-mm Wallstents (n = 58) were used, whereas from 2004 to 2010, 10-mm VIATORR covered stent-grafts (n = 70) were used. Technical success, hemodynamic success, complications, shunt dysfunction, recurrent bleeding, and overall survival were assessed. Results: Technical and hemodynamic success rates were 100% and 94%, respectively. Mean portosystemic gradient reduction was 13 mm Hg. Complications at 30 days included encephalopathy (14%), renal failure (5.5%), infection (1.6%), and liver failure (0.8%). Shunt patency rates were 93%, 82%, and 60% at 30 days, 1 year, and 2 years, respectively. Dysfunction, or loss of TIPS primary patency, occurred more with Wallstent versus VIATORR TIPSs (29% vs 11%; P = .009). Recurrent bleeding incidences were 9%, 22%, and 29% at 30 days, 1 year, and 2 years, respectively, and were similar between Wallstent and VIATORR TIPSs (19% vs 19%; P = .924). Variceal embolization significantly reduced recurrent bleeding rates (5% vs 25%; P = .013). Overall survival rates were 80%, 69%, and 65% at 30 days, 1 year, and 2 years, respectively, and were similar between Wallstent and VIATORR TIPSs (35% vs 26% mortality rate; P = .312). Advanced MELD score was associated with increased mortality on multivariate analysis. Conclusions: Wallstent and VIATORR TIPSs effectively treat variceal hemorrhage, particularly when accompanied by variceal embolization. Although TIPS with a VIATORR device showed improved shunt patency, patient survival is similar to that with Wallstent TIPS. These results further validate TIPS creation for refractory variceal bleeding.

Limited Efficacy of Uterine Artery Embolization for Cervical Leiomyomas

2011-12-15

Abstract: Purpose: To explore the effectiveness of uterine artery embolization (UAE) in treating symptomatic fibroids in the uterine cervix. Materials and Methods: Among 537 patients who underwent UAE, 10 who had fibroids located in the cervix were retrospectively analyzed. The mean diameter of the fibroids was 6.0 cm. Seven of the 10 patients presented a total of 10 fibroids in the uterine body or fundus simultaneously. Fibroids of the cervix and fibroids in the body or fundus were compared in terms of the effects of UAE on the treatment thereof and vascularity on angiographic findings. Cervical leiomyomas were classified into three grades based on the vascularity seen on aortography, from grade I, indicating poor vascularity, to grade III, indicating hypervascularity. Necrosis of fibroids was assessed by magnetic resonance imaging 3 months after UAE. Results: Complete necrosis of leiomyomas in the uterine cervix was seen in only two of the 10 patients (20%), whereas all fibroids in the uterine body or fundus were completely infarcted (P < .05). Partial necrosis (PN) of the fibroid with a thin viable rim was seen in two patients, whereas PN with a thick rim was seen in four and no necrosis was seen in two. Grade I (ie, poor) vascularity was noted in five of nine patients (55.6%) with cervical fibroids larger than 3 cm. Conclusions: Poor vascularity was a frequent finding among cervical leiomyomas, and the outcomes of UAE for cervical leiomyomas were disappointing, indicating a need for caution in selecting and counseling patients for this treatment.

Evaluation of Treatment Response of Chemoembolization in Hepatocellular Carcinoma with Diffusion-Weighted Imaging on 3.0-T MR Imaging

2011-10-24

Abstract: Purpose: To assess the treatment response of hepatocellular carcinoma (HCC) after transarterial chemoembolization with diffusion-weighted imaging and dynamic contrast-enhanced magnetic resonance (MR) imaging with a 3-T system. Materials and Methods: Between February 2010 and November 2010, 74 patients were treated with chemoembolization in our interventional radiology unit. Twenty-two patients (29%) who had liver MR imaging including diffusion and dynamic contrast-enhanced MR imaging on a 3-T system before and after transarterial chemoembolization were evaluated retrospectively. Tumor size, arterial enhancement, venous washout, and apparent diffusion coefficient (ADC) values of lesions, peritumoral parenchyma, normal liver parenchyma, and spleen were recorded before and after treatment. The significance of differences between ADC values of responding and nonresponding lesions was calculated. Results: The study included 77 HCC lesions (mean diameter, 31.4 mm) in 20 patients. There was no significant reduction in mean tumor diameter after treatment. Reduction in tumor enhancement in the arterial phase was statistically significant (P = .01). Tumor ADC value increased from 1.10 × 10−3 mm2/s to 1.27 × 10−3 mm2/s after treatment (P < .01), whereas the ADC values for liver and spleen remained unchanged. ADC values from cellular parts of the tumor and necrotic areas also increased after treatment. However, pretreatment ADC values were not reliable to identify responding lesions according to the results of receiver operating characteristic analysis. Conclusions: After transarterial chemoembolization, responding HCC lesions exhibited decreases in arterial enhancement and increases in ADC values in cellular and necrotic areas. Pretreatment ADC values were not predictive of response to chemoembolization.

Phase I Study of Heat-Deployed Liposomal Doxorubicin during Radiofrequency Ablation for Hepatic Malignancies

2011-12-19

Abstract: Purpose: A phase I dose escalation study was performed with systemically delivered lyso-thermosensitive liposomal doxorubicin (LTLD). The primary objectives were to determine the safe maximum tolerated dose (MTD), pharmacokinetic properties, and dose-limiting toxicity (DLT) of LTLD during this combination therapy. Materials and Methods: Subjects eligible for percutaneous or surgical radiofrequency (RF) ablation with primary (n = 9) or metastatic (n = 15) tumors of the liver, with four or fewer lesions as large as 7 cm in diameter, were included. RF ablation was initiated 15 minutes after starting a 30-minute intravenous LTLD infusion. Dose levels between 20 mg/m2 and 60 mg/m2 were evaluated. Magnetic resonance imaging, positron emission tomography, and computed tomography were performed at predetermined intervals before and after treatment until evidence of recurrence was seen, administration of additional antitumor treatment was performed, or a total of 3 years had elapsed. Results: DLT criteria were met at 60 mg/m2, and the MTD was defined as 50 mg/m2. RF ablation was performed during the peak of the plasma concentration–time curve in an effort to yield maximal drug deposition. LTLD produced reversible, dose-dependent neutropenia and leukopenia. Conclusions: LTLD can be safely administered systemically at the MTD (50 mg/m2) in combination with RF ablation, with limited and manageable toxicity. Further evaluation of this agent combined with RF ablation is warranted to determine its role in the management of liver tumors.

Radiopaque Drug-Eluting Beads for Transcatheter Embolotherapy: Experimental Study of Drug Penetration and Coverage in Swine

2011-12-19

Abstract: Purpose: To determine local doxorubicin levels surrounding radiopaque drug-eluting beads (DEBs) in normal swine liver and kidney following transcatheter arterial chemoembolization. The influence of bead size (70–150 μm or 100–300 μm) was compared with regard to tissue penetration and spatial distribution of the bead, as well as eventual drug coverage (ie, amount of tissue exposed to drug). Materials and Methods: Radiopaque DEBs were synthesized by suspension polymerization followed by incorporation of iodized oil and doxorubicin. Chemoembolization of swine liver and kidney was performed under fluoroscopic guidance. Three-dimensional tissue penetration of “imageable” DEBs was investigated ex vivo with micro–computed tomography (microCT). Drug penetration from the bead surface and drug coverage was evaluated with epifluorescence microscopy, and cellular localization of doxorubicin was evaluated with confocal microscopy. Necrosis was evaluated with hematoxylin and eosin staining. Results: MicroCT demonstrated that 70–150-μm DEBs were present in more distal arteries and located in a more frequent and homogeneous spatial distribution. Tissue penetration of doxorubicin from the bead appeared similar (∼300 μm) for both DEBs, with a maximum tissue drug concentration at 1 hour coinciding with nuclear localization of doxorubicin. The greater spatial frequency of the 70–150-μm DEBs resulted in approximately twofold improved drug coverage in kidney. Cellular death is predominantly observed around the DEBs beginning at 8 hours, but increased at 24 and 168 hours. Conclusions: Smaller DEBs penetrated further into targeted tissue (ie, macroscopic) with a higher spatial density, resulting in greater and more uniform drug coverage (ie, microscopic) in swine.

Ethiodized Oil Uptake Does Not Predict Doxorubicin Drug Delivery after Chemoembolization in VX2 Liver Tumors

2011-12-19

Abstract: Purpose: To investigate the accuracy of ethiodized oil as an imaging marker of chemotherapy drug delivery after liver tumor chemoembolization in an animal model of hepatocellular carcinoma. Materials and Methods: Eleven VX2 liver tumors (mean diameter, 1.9 cm ± 0.4) in six New Zealand White rabbits were treated with chemoembolization using ethiodized oil and doxorubicin emulsion, followed by immediate euthanasia. Postprocedure noncontrast computed tomography (CT) was used to evaluate intratumoral ethiodized oil distribution and calculate iodine content within four peripheral tumor quadrants and the tumor core at a central tumor slice (N = 55 total tumor sections). Liquid chromatography/tandem mass spectrometry (LC-MS/MS) was then used to directly measure doxorubicin concentration in the same tissue sections. Statistical correlation was performed between tissue iodine content and doxorubicin concentration by using linear regression. Results: Chemoembolization was successfully performed in all tumors via the left or proper hepatic artery. A mean of 0.9 mL ± 0.6 ethiodized oil and 1.8 mg ± 1.2 doxorubicin were injected. CT-calculated tissue iodine content averaged 335 mg/mL ± 218. Corresponding LC-MS/MS analysis yielded a mean doxorubicin concentration of 15.8 μg/mL ± 14.3 in each sample. Although iodine content (391 mg/mL vs 112 mg/mL; P = .000) and doxorubicin concentration (18.0 μg/mL vs 7.2 μg/mL; P = .023) were significantly greater along peripheral tumor sections compared with the tumor core, no significant predictable correlation was evident between these measures (R2 = 0.0099). Conclusions: Tissue ethiodized oil content is a poor quantitative predictor of local doxorubicin concentration after liver tumor chemoembolization. Future studies should aim to identify a better imaging marker for chemoembolization drug delivery.

“Chest Tube” Removal after Liver Transgression

Chris Hegarty, Jan F. Gerstenmaier, David Brophy — 2012-02-01

Chest drain insertion in a 26-year-old female patient without imaging guidance resulted in inadvertent insertion of the drain into the liver. The diagnosis was suspected clinically and confirmed with computed tomography (CT) (). CT of the abdomen and pelvis with intravenous administration of contrast medium showed a 30-F chest drain traversing the liver with its tip adjacent to the porta hepatis.

Temporary Balloon Occlusion of the Common Hepatic Artery for Administration of Yttrium-90 Resin Microspheres in a Patient with Patent Hepatoenteric Collaterals

2012-02-01

Abstract: The most common serious complication of yttrium-90 (90Y) therapy is gastrointestinal ulceration caused by extrahepatic microsphere dispersion. The authors describe the use of a balloon catheter for temporary occlusion of the common hepatic artery to reverse hepatoenteric flow for lobar administration of resin microspheres when coil embolization of a retroportal artery was impossible. At 9 months after treatment, the patient had no gastrointestinal side effects and showed a partial response.

Transarterial Chemoembolization for Hepatocellular Carcinomas in Watershed Segments: Utility of C-Arm Computed Tomography for Treatment Planning

2012-02-01

Navigating tortuous, overlapping vessels and assessing complete geographic uptake of lipiodol in a hepatocellular carcinoma (HCC) treated with selective transhepatic arterial chemoembolization are becoming two of the most useful roles of C-arm computed tomography (CT). Digital subtraction angiography (DSA) alone is limited in its ability to discern multiple segmental arteries supplying a single tumor in the setting of corkscrew vessels, which are commonly observed in advanced cirrhosis. Projectional imaging is limited by its two-dimensionality, carrying the inherent risk of overestimating complete and circumferential lipiodol uptake in an HCC at the time of treatment. This risk is of particular importance in anatomic regions along segmental boundaries or “watershed” regions, where tumors may receive a dual arterial supply from both the right and the left hepatic arteries regardless of tumor size (). We describe the impact C-arm CT can have on determining a dual blood supply in watershed region tumors and, more importantly, its ability to portray incomplete treatment at the time of the procedure itself. An exemption from obtaining informed consent was provided by the institutional review board for this retrospective report. All data were handled in compliance with the Health Insurance Portability and Accountability Act.

Bronchopleural Cutaneous Fistula after Pulmonary Radiofrequency Ablation: Treatment with Low-Adherent Paraffin Gauze Dressing

2012-02-01

The commonest complications of radiofrequency (RF) ablation of the lung include pneumothorax, pleural effusions, and pneumonia. In this report, we describe management of an unusual bronchopleural cutaneous (BPC) fistula in a patient with primary lung cancer.

Editorial Board

2012-02-01

Contents in Brief

2012-02-01

Subscription Information Page

2012-02-01

Forthcoming Articles: March 2012

2012-02-01

Journal of Vascular and Interventional Radiology

Development of a Research Agenda for the Management of Metastatic Colorectal Cancer: Proceedings from a Multidisciplinary Research Consensus Panel

Society of Interventional Radiology Position Statement: Mini Training Courses in Interventional Radiology Techniques

Endovascular Therapy for Acute Pulmonary Embolism

CME Test Questions: February 2012

Removal of Fractured Inferior Vena Cava Filters: Feasibility and Outcomes

Fractured Bard Recovery, G2, and G2 Express Inferior Vena Cava Filters: Incidence, Clinical Consequences, and Outcomes of Removal Attempts

Refrain, Recover, Replace

Vena Cava Filter Fracture: Unplanned Obsolescence

Fracture and Distant Migration of the Bard Recovery Filter: A Retrospective Review of 363 Implantations for Potentially Life-Threatening Complications

Varicocele Retrograde Embolization with Boiling Contrast Medium and Gelatin Sponges in Adolescent Subjects: A Clinically Effective Therapeutic Alternative

Anatomy of the Origin of the Gonadal Veins on CT

Endovascular Therapy of Saccular Aortic Aneurysm

Hepatic Venous Pressure Measurements: Comparison of End-Hole and Balloon Catheter Methods

TIPS for Treatment of Variceal Hemorrhage: Clinical Outcomes in 128 Patients at a Single Institution over a 12-Year Period

Limited Efficacy of Uterine Artery Embolization for Cervical Leiomyomas

Evaluation of Treatment Response of Chemoembolization in Hepatocellular Carcinoma with Diffusion-Weighted Imaging on 3.0-T MR Imaging

Phase I Study of Heat-Deployed Liposomal Doxorubicin during Radiofrequency Ablation for Hepatic Malignancies

Radiopaque Drug-Eluting Beads for Transcatheter Embolotherapy: Experimental Study of Drug Penetration and Coverage in Swine

Ethiodized Oil Uptake Does Not Predict Doxorubicin Drug Delivery after Chemoembolization in VX2 Liver Tumors

“Chest Tube” Removal after Liver Transgression

Temporary Balloon Occlusion of the Common Hepatic Artery for Administration of Yttrium-90 Resin Microspheres in a Patient with Patent Hepatoenteric Collaterals

Transarterial Chemoembolization for Hepatocellular Carcinomas in Watershed Segments: Utility of C-Arm Computed Tomography for Treatment Planning

Bronchopleural Cutaneous Fistula after Pulmonary Radiofrequency Ablation: Treatment with Low-Adherent Paraffin Gauze Dressing

Editorial Board

Contents in Brief

Table of Contents

Subscription Information Page

Forthcoming Articles: March 2012