CardioVascular and Interventional Radiology

Regarding “PET/CT Imaging Characteristics After Radioembolization of Hepatic Metastasis from Breast Cancer”

Lithotripsy-Facilitated Transfemoral Access for Transcatheter Aortic Valve Replacement

Predicting the Fibroid-Migratory Impact of UAE: Role of Pre-embolization MRI Characteristics Abstract Aim To investigate potential factors on MR imaging that could be used to predict migration of uterine fibroids post-UAE. Methods and Materials We retrospectively reviewed patients referred for UAE having pre-procedural and 6 months post-procedural MRI, at a tertiary centre, over a 1-year period. Pre- and post-UAE images were reviewed in 64 women by two radiologists to identify the sub-type, dimensions, and infarction rate of each dominant fibroid. The shortest distance between the fibroid and the endometrial wall was measured to determine intramural fibroid movement. Paired sample T tests and two-sample T tests were used to compare between pre- and post-embolization variations and between migrated and non-migrated intramural fibroids, respectively. After preliminary results suggested potential predictors of intramural fibroids migration, we tested our findings against the non-dominant intramural fibroids in the same patients. Results Review of images revealed 35 dominant intramural fibroids, of which eight migrated to become submucosal fibroids, while five were either partially or completely expelled. These 13 migrated fibroids had a shorter pre-procedural minimum endometrial distance (range 1–2.4 mm) and greater maximum fibroid diameter (range 5.1–18.1 cm), when compared to non-migrating fibroids. On image reassessment, the migrated non-dominant intramural fibroids had a minimum endometrial distance and maximum fibroid diameter within the same range. Conclusion Intramural fibroids with a minimum endometrial distance less than 2.4 mm and a maximum fibroid diameter greater than 5.1 cm have a high likelihood of migrating towards the endometrial cavity after UAE.

Catheter-Directed Computed Tomography Hepatic Angiography for Yttrium-90 Selective Internal Radiotherapy of Hepatocellular Carcinoma Reduces Prophylactic Embolization of Extrahepatic Vessels Abstract Objectives To determine the rate of prophylactic embolization of extrahepatic vessels in patients undergoing yttrium-90 selective internal radiotherapy (90Y SIRT) for hepatocellular carcinoma (HCC) with the use of catheter-directed computed tomography hepatic angiography (CD-CTHA). Materials and Methods This retrospective study included 186 HCC patients who received 90Y SIRT from May 2010 to June 2015 in a single institution. All procedures were performed in a hybrid angiography-CT suite equipped with digital subtraction angiography (DSA) and CD-CTHA capabilities. CD-CTHA was performed during pre-treatment hepatic angiography. 90Y SIRT was administered approximately 2 weeks later. Selective prophylactic embolization of extrahepatic vessels was performed if extrahepatic enhancement was seen on CD-CTHA or if an extrahepatic vessel opacified on DSA/CD-CTHA despite the final microcatheter position for 90Y microsphere delivery being beyond the origin of this vessel. Results Thirty-five patients (18.8%) required selective embolization of extrahepatic vessels. Technical success of 90Y SIRT was 99.5%. Two patients (1.1%) developed radiation-induced gastrointestinal ulceration, and one (0.54%) developed radiation-induced pneumonitis. Extrahepatic uptake of 90Y microspheres was seen in the gallbladder of one patient without significant complications. Conclusion The use of CD-CTHA in 90Y SIRT of HCC was associated with a low rate of prophylactic embolization of extrahepatic vessels while maintaining a high technical success rate of treatment and low rate of complications. Level of Evidence Level 4, case series.

Endovascular Management of Hemarthrosis in Patients with Bleeding Diatheses: Systematic Review Abstract Purpose In this systematic review, we report the safety and efficacy of embolization for treating hemarthrosis in patients with bleeding diatheses with or without a history of prior arthroplasty. Materials and Methods A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A structured search was performed in PubMed, Web of Science, MEDLINE, and SCOPUS databases of patients undergoing embolization for hemarthrosis. Demographic data, clinical history, angiographic findings, interventions, and outcomes were extracted and tabulated. Results The search identified 97 unique titles of which 15 were deemed relevant comprising 78 patients with coagulopathies undergoing 93 embolization procedures. Mean follow-up time was 29 months (range 3–116.5). In the 29 patients who underwent arthroplasty prior to embolization for hemarthrosis, there were 11 bleeding recurrences (37.9%). Of these patients who experienced recurrences, 10 underwent repeat embolization as coagulation factor replacement was not sufficient to address the re-bleeding. In the 49 patients with bleeding diatheses who underwent embolization for hemarthrosis with no history of prior arthroplasty, there were 11 recurrences (22.4%) and 4 of these patients underwent repeat embolization with favorable results. There were four major procedure-related complications. Conclusion Transarterial embolization is safe and effective in addressing recurrent hemarthrosis in patients with bleeding diatheses with or without a history of arthroplasty of the affected joint.

The First 48 Consecutive Patients with 3-Year Symptom Score Follow-Up Post-Prostate Artery Embolization (PAE) at a Single-Centre University Hospital Abstract Introduction Few studies on prostate artery embolization (PAE) follow patients up after 12 months. We aimed to evaluate the symptomatic efficacy of PAE in our patient cohort at 3 years. Method A total of 48 consecutive patients undergoing PAE from June 2012 to August 2014 were included in this retrospective study. All patients underwent formal urodynamics to confirm bladder outflow obstruction prior to PAE. International Prostate Symptom Score (IPSS) was performed at baseline, 3 months, 12 months and 3 years post-PAE. Results Mean patient age was 65.6 ± 7.4, prostate volume 99.1 ± 56.6 cm3, IPSS 23.5 ± 6.0, quality-of-life score 4.6 ± 0.9, Qmax 8.4 ± 2.8 ml/s, post-void residual volume 185.8 ± 55.6 ml. Technical success (bilateral embolization) was achieved in 43 out of 48 cases (89.6%). 11/39 bilateral PAE patients completing follow-up (2 died, 2 lost to follow-up) underwent surgery, indicating a 71.8% clinical success rate at 3 years. No significant change was demonstrated in IPSS or QOL between 1 and 3 years for patients free from surgical intervention (IPSS 8.3 vs 10.0, p = 0.09 and QOL 1.3 vs 1.5, p = 0.23). 3/11 patients undergoing surgery had a prominent ‘ball-valve’ median lobe, and 1/11 patients had a high bladder neck elevation contributing to symptoms. Conclusion Clinical success post-PAE remains high with few patients opting for surgery or experiencing a worsening of symptoms after 12 months.

Efficacy of Paclitaxel Balloon for Hemodialysis Stenosis Fistulae After One Year Compared to High-Pressure Balloons: A Controlled, Multicenter, Randomized Trial Abstract Purpose A controlled, prospective, multicenter, randomized trial to compare primary patency after angioplasty with a drug-coated balloon versus plain angioplasty balloon in stenosis of dysfunctional fistulae and grafts for hemodialysis. Materials and Methods A total of 136 patients (148 angioplasties) at four centers were randomized to receive a drug-coated balloon or plain angioplasty balloon after satisfactory angioplasty with a high-pressure balloon. The inclusion criteria were clinical signs of vascular dysfunction confirmed by Doppler Ultrasound and/or angiography. The primary endpoint was target lesion patency defined as time elapsed between the completion of effective and the appearance of restenosis at 6 and 12 months after angioplasty. Secondary endpoints included the relationship between the location of the stenosis, previous angioplasty, demographic variables and survival. Results Primary patency after angioplasty was higher in the group treated with the drug-coated balloon than the plain angioplasty balloon (153.01 to 141.69 days at 6 months; 265.78 to 237.83 days at 12 months). Drug-coated balloon angioplasty resulted in superior patency after 6 and 12 months, but this result was not statically significant (P = 0.068 at 6 months; P = 0.369 at 12 months). There was no relation between target lesion patency and the other variables studied. Overall mortality in the plain angioplasty balloon group was higher (9% vs. 5.7%) but not statistically significant. Conclusions Drug-coated balloon angioplasty resulted in superior survival of dysfunctional peripheral vascular access at 6 and 12 months, but this result was not statistically significant. Both arms show equivalent complications and similar mortality. Level of Evidence Level Ia, therapeutic study, RCT. EBM ratings will be based on a scale of 1-5.

CIRSE Standards of Practice on Diagnosis and Treatment of Pulmonary Arteriovenous Malformations

The Efficacy of Coil Embolization to Obtain Intrahepatic Redistribution in Radioembolization: Qualitative and Quantitative Analyses Abstract Purpose To evaluate the efficacy of coil embolization to obtain intrahepatic redistribution in patients undergoing radioembolization. Materials and Method All patients treated with radioembolization at our institute were retrospectively analyzed, and all cases in which a tumor-feeding vessel was coil-embolized were selected. Two nuclear medicine physicians visually assessed the effect of redistribution. Furthermore, the redistribution of microspheres was measured by quantifying the activity distributed to the coil-embolized (dependent) segment relative to the other (non-dependent) segments and to the tumor(s) in that segment. Quantitative analysis was performed on post-treatment 90Y-PET and 166Ho-SPECT using Simplicit90Y software. Lesion response was measured according to RECIST 1.1 criteria at 3 months post-treatment. Results Out of 37 cases, 32 were suitable for quantitative analysis and 37 for qualitative analysis. In the qualitative analysis, redistribution was deemed successful in 69% of cases. The quantitative analysis showed that the median ratio of the activity to the dependent embolized segments and the non-dependent segments was 0.88 (range 0.26–2.05) and 0.80 (range 0.19–1.62) for tumors in dependent segments compared with tumors in non-dependent segments. Using a cutoff ratio of 0.7 (30% lower activity concentration in comparison with the rest of the liver), 57% of cases were successful. At 3 months post-treatment, 6% of dependent tumors had partial response, 20% progressive disease, and 74% stable disease. In non-dependent tumors, this was, respectively, 16%, 20%, and 64%. Conclusion Coil embolization of hepatic arteries to induce redistribution of microspheres has a limited success rate. Qualitative assessment tends to overrate redistribution.

Improved Local Tumor Control and Survival Rates by Obtaining a 3D-Safety Margin in Superselective Transarterial Chemoembolization for Small Hepatocellular Carcinoma Abstract Objective To investigate technical factors affecting local tumor control of small hepatocellular carcinoma (HCC) treated by superselective conventional transarterial chemoembolization (cTACE) using lipiodol and to compare prognoses between groups with and without these factors. Materials and Methods Sixty-three consecutive patients with 73 HCC nodules (diameter, 1–3 cm) treated by cTACE were retrospectively analyzed. A positive or a negative 3D-safety margin was defined as a ≥ 1-mm area of lipiodol accumulation or as a diameter of lipiodol accumulation < 1 mm in liver parenchyma surrounding the tumor using plain CT images obtained within a week after TACE. Uni- and multivariate analyses were performed to identify technical factors determining local tumor control rate. Subgroup analysis of survival rates in treatment-naïve patients was performed according to the detected factors. Results In univariate analyses, three-dimensional (3D)-safety margin and portal vein visualization were associated with local tumor control rates. In multivariate analysis, only positive 3D-safety margin remained a significant contributor (p = 0.001). Two-year cumulative local disease-free survival rates with positive and negative 3D-safety margin were 82.8% and 19.3%, respectively (p = 0.001). In subgroup survival analysis of the 36 newly diagnosed patients, the 1-, 2-, 3-, 4-, and 5-year cumulative OS rates for patients with and without positive margins were 100% versus 100%, 96.4% versus 75.0%, 81.8% versus 62.5%, 74.4% versus 41.7%, and 47.0% versus 0%, respectively (median survival time; 57.6 months vs. 37.1, p = 0.047). Conclusion Obtaining a 3D-safety margin can suppress local tumor recurrence and prolong survival in superselective cTACE for small HCC.