Outcomes of Preventive Embolization of the Inferior Mesenteric Artery during Endovascular Abdominal Aortic Aneurysm Repair

PurposeTo evaluate the impact of preemptive inferior mesenteric artery (IMA) embolization on outcomes of endovascular abdominal aortic aneurysm (AAA) repair (EVAR).Materials and MethodsFrom January 2015 to July 2017, all patients undergoing elective EVAR or fenestrated EVAR (F-EVAR) for asymptomatic AAA in a single tertiary hospital were retrospectively included. Three groups of patients were defined: patients with a patent IMA who underwent embolization during EVAR/F-EVAR (group 1), those with a patent IMA who did not undergo embolization during EVAR/F-EVAR (group 2), and those with a chronically occluded IMA (group 3). Preoperative aortic morphology, demographics, and procedural details were recorded. Aneurysmal growth (≥5 mm), reintervention, and overall mortality rates were analyzed using multivariate proportional hazard multivariate modeling. Propensity scores were constructed, and inverse probability weighting was applied to a new set of multivariate analyses to perform a sensitivity analysis.ResultsA total of 266 patients (male, 95% [n = 249]) with a median age of 70 (65–77) years were included, with F-EVAR procedures comprising 87 (32.7%) of the interventions. There were 52, 142, and 72 patients in groups 1, 2, and 3, respectively. Changes in aneurysmal sac size did not differ between groups, nor did overall survival or reintervention rates at 24 months. IMA embolization was not identified as an independently protective factor for aneurysmal growth during follow-up (relative risk [RR] = 2.82/mm [0.96–8.28], P = .060), whereas accessory renal arteries (RR = 5.07/mm [1.72–14.96], P = .003) and a larger preoperative aneurysmal diameter (RR = 1.09/mm [1.03–1.15], P = .004) were independent risk factors for sac enlargement.ConclusionsPreventive embolization of the IMA during EVAR or F-EVAR did not promote aneurysmal sac shrinking or decrease the reintervention rate at 2-year follow-up.     

Strain Ultrasound Elastography of Aneurysm Sac Content after Randomized Endoleak Embolization with Sclerosing vs. Non-sclerosing Chitosan-based Hydrogels in a Canine Model

PurposeTo compare the mechanical properties of aneurysm content after endoleak embolization with a chitosan hydrogel (CH) with that with a chitosan hydrogel with sodium tetradecyl sulfate (CH-STS) using strain ultrasound elastography (SUE).Materials and MethodsBilateral common iliac artery type Ia endoleaks were created in 9 dogs. Per animal, 1 endoleak was randomized to blinded embolization with CH, and the other, with CH-STS. Brightness-mode ultrasound, Doppler ultrasound, SUE radiofrequency ultrasound, and computed tomography were performed for up to 6 months until sacrifice. Radiologic and histopathologic studies were coregistered to identify 3 regions of interest: the embolic agent, intraluminal thrombus (ILT), and aneurysm sac. SUE segmentations were performed by 2 blinded independent observers. The maximum axial strain (MAS) was the primary outcome. Statistical analysis was performed using the Fisher exact test, multivariable linear mixed-effects models, and intraclass correlation coefficients (ICCs).ResultsResidual endoleaks were identified in 7 of 9 (78%) and 4 of 9 (44%) aneurysms embolized with CH and CH-STS, respectively (P = .3348). CH-STS had a 66% lower MAS (P < .001) than CH. The ILT had a 37% lower MAS (P = .01) than CH and a 77% greater MAS (P = .079) than CH-STS. There was no significant difference in ILT between treatments. The aneurysm sacs embolized with CH-STS had a 29% lower MAS (P < .001) than those embolized with CH. Residual endoleak was associated with a 53% greater MAS (P < .001). The ICC for MAS was 0.807 (95% confidence interval: 0.754–0.849) between segmentations.ConclusionsCH-STS confers stiffer intraluminal properties to embolized aneurysms. Persistent endoleaks are associated with increased sac strain, an observation that may help guide management.     

Lack of Growth of Small (≤2 mm Feeding Artery) Untreated Pulmonary Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia

PurposeTo assess pulmonary arteriovenous malformation (PAVM) growth among patients with untreated PAVMs using imaging from long-term follow-up per hereditary hemorrhagic telangiectasia international guidelines.Materials and MethodsAnalysis included 88 untreated PAVMs from 21 patients (6 male;15 female; mean age at presentation 47 y; range, 12–68 y). Two CT studies with the longest interval between were evaluated (mean 8.4 y; median 8.8 y; range, 3.1–14.1 y). Measurement of feeding artery diameter and anteroposterior (AP) and mediolateral (ML) sac dimensions for each PAVM was performed separately by 2 radiologists blinded to patient and CT order. Statistical analysis was performed to determine change in size between earliest and follow-up imaging.ResultsMean feeding artery diameter, AP sac dimension, and ML sac dimension were 1.4 mm (range, 0.8–3.7 mm), 4.3 mm (range, 2.1–11.1 mm), and 4.1 mm (range, 1.8–9.2 mm) on earliest imaging and 1.4 mm (range, 0.9–2.6 mm), 4.5 mm (range, 2.2–12.2 mm), and 4.3 mm (range, 2.0–9.6 mm) on follow-up. Model-based mean analysis showed no statistically significant change in dimension of any variable between earliest and follow-up imaging. Secondary analysis including age also found no statistically significant difference (feeding diameter, P = .09; AP sac dimension, P = .9; ML sac dimension, P = .1). Analysis including time between measurements found no significant relationship between change in variables and time (feeding artery diameter, P = .4; AP sac dimension, P = .3; ML sac dimension, P = .06).ConclusionsUntreated PAVMs grew slowly, if at all, in a near-decade span, and any demonstrated growth was minimal. These findings challenge the current recommendation of 3- to 5-year CT follow-up.     

Predictive Value of Preprocedural Computed Tomography Angiography for the Technical Success of Transarterial Embolization of Type II Endoleaks Arising from the Lumbar Arteries

PurposeTo evaluate the ability of preprocedural computed tomography angiography (CTA) to predict the technical success of embolization of type II endoleak arising from a lumbar artery after endovascular aortic repair (EVAR).Materials and MethodsAll patients at a single academic institution who underwent angiography with possible embolization for a post-EVAR lumbar-supplied type II endoleak from 2009 to 2018 were retrospectively reviewed. Patients who did not undergo CTA before the procedure were excluded. CTAs were reviewed for the ability to trace the entire course of a feeding vessel from the internal iliac artery (IIA) to the lumbar artery at the site of the endoleak. Procedural imaging was reviewed for technical success, defined as the catheterization and embolization of the aneurysm sac through a lumbar artery.ResultsFifty-seven angiograms with a type II endoleak and suspected feeding lumbar artery were identified. On CTA acquired before the procedure, the arterial path supplying this lumbar artery could be traced from the IIA to the aneurysm sac in 18 (32%) patients. Embolization was technically successful in 16 of these 18 (89%) procedures compared with 10 of 39 (26%) procedures in which the supplying artery could not be traced using CTA (P < .001).ConclusionsA potential catheter path from the IIA through the iliolumbar and lumbar arteries to the aneurysm sac can be traced on preprocedural CTA in the minority of lumbar-supplied type II endoleaks. The ability to trace these inflow vessels may predict technical success during embolization. The low rate of technical success when the feeding vessel could not be traced using CTA suggests that these patients should be considered for percutaneous or transcaval sac puncture.     

Angioscopic Ulcerated Plaques in the Femoropopliteal Artery Associated with Impaired Infrapopliteal Runoff

PurposeTo determine the correlation between upstream atherosclerosis in the femoropopliteal arteries, assessed using angioscopy, and impaired infrapopliteal runoff.Materials and MethodsThirty-one patients with peripheral arterial disease who underwent endovascular therapy and angioscopy were prospectively included. Yellow plaque color scores were semiquantitatively determined as 0, 1, 2, or 3. Irregular plaques with rough surfaces, similar to gastric ulcers, were defined as ulcerated plaques (UPs). Angioscopic data were correlated with angiographic runoff scores (ARS).ResultsUPs were detected in 74.2% of enrolled diseased legs using angioscopy. Mural thrombi were more commonly observed in the femoropopliteal artery in patients with UPs than in those without UPs (91.3% vs 37.5%, respectively; P = .006) and were frequently found on the UPs (21/23 patients with UPs). Univariate and multivariate linear regression analyses revealed that the presence of UPs was positively and independently associated with a poor ARS and that oral anticoagulant use was independently associated with a preferable ARS (standardized β = 0.462, P = .004 and standardized β = ?0.411, P = .009, respectively, in the multivariate analysis).ConclusionsUPs, associated with mural thrombi and diagnosed by angioscopic examination, were demonstrated to be one of the factors associated with poor infrapopliteal runoff.     

Radiofrequency Ablation Duration per Tumor Volume May Correlate with Overall Survival in Solitary Hepatocellular Carcinoma Patients Treated with Radiofrequency Ablation Plus Lyso-Thermosensitive Liposomal Doxorubicin

PurposeTo determine whether burn time per tumor volume (BPV) (min/mL), where burn time is the total time during which radiofrequency (RF) energy is being applied, is correlated with hepatocellular carcinoma (HCC) treatment outcomes using RF ablation and lyso-thermosensitive liposomal doxorubicin (LTLD).Materials and MethodsThe HEAT study was a double-blind, randomized controlled phase III trial of RF ablation only versus RF ablation + LTLD in patients with HCCs 3–7 cm in diameter. Effect of BPV on progression-free survival and overall survival (OS) was analyzed.ResultsBPV demonstrated statistically significant differences between study groups for OS (P = .038, hazard ratio [HR] = 0.85), but not for progression-free survival (P = .389, HR = 1.059). In a separate analysis, treatment groups were independently analyzed to determine the effect of BPV within each individual group. OS improved as BPV increased for patients receiving RF ablation + LTLD (P = .017, HR = 0.836, confidence interval [0.722, 0.968]). This same association was not observed in patients receiving RF ablation only (P = .57, HR = 0.99).ConclusionsBPV may be a useful metric for RF ablation + LTLD combination therapy for solitary HCC. The analysis suggested that the burn time for the tumor needs to be adjusted depending on the tumor volume. Because this is a post hoc study, the results are only suggestive and need to be confirmed with prospective studies.     

Prognostic Factors for Local Recurrence after Cryoablation of Desmoid Tumors

PurposeTo determine the risk factors for local of adult patients treated for desmoid tumors by cryoablation.Materials and MethodsEighty-four patients treated for nonabdominopelvic desmoid tumors by cryoablation from July 2012 to July 2020 were included in a retrospective study. The population was composed of 64 women (76.19%) and 20 men (23.81%), aged from 16 to 75 years (median, 35 years ± 14.25). Each patient underwent preprocedural gadolinium-enhanced magnetic resonance imaging and was followed up to 36 months with the same technique. Clinical features, such as tumor size and previous treatment, epidemiological features, and the technical parameters of cryoablation, were studied.ResultsLocal relapse was found in 19 (22.62%) of 84 patients. The 12-, 24-, and 36-month progression-free survival rates were 89% (95% confidence interval [CI], 79–94), 74% (95% CI, 60–83), and 68% (95% CI, 53–79), respectively. In univariate analysis, significant prognostic factors associated with local recurrence were non–abdominal wall location (P = .042), debulking strategy (P = .0105), risk of visceral injury (P = .034) or peripheral nerve injury during cryoablation (P = .033), previous radiation therapy (P = .043), and treatment before 2016 (P = .008). In multivariate analysis, abdominal wall tumors displayed the best outcome, whereas the neck and trunk showed a high rate of recurrence (hazard ratio, 7.307 [95% CI, 1.396–38.261]).ConclusionsThe local recurrence of desmoid tumors after cryoablation depends on a number of prognostic factors, in particular, a non–abdominal wall location of the tumor and previous local treatment such as surgery or radiation therapy.     

Prostatic Artery Embolization Using 100–300-μm Trisacryl Gelatin Microspheres to Treat Lower Urinary Tract Symptoms Attributable to Benign Prostatic Hyperplasia: A Single-Center Outcomes Analysis with Medium-Term Follow-up

PurposeTo report medium-term outcomes of prostatic artery embolization (PAE) using 100–300-μm trisacryl gelatin microspheres to treat lower urinary tract symptoms (LUTS) from benign prostatic hyperplasia (BPH) and to evaluate how cone-beam computed tomography-measured prostate gland volume (PGV), median lobe enlargement (MLE), age, and Charlson Comorbidity Index (CCI) affect these results.Materials and MethodsSeventy-four consecutive patients who underwent PAE from April 2014 through August 2018 were retrospectively reviewed. Patients had International Prostate Symptom Score (IPSS) >12, Quality of Life (QoL) score >2, prostate gland volume (PGV) >40 mL, age older than 45 years, and medical therapy failure. Twelve patients were excluded for bladder pathology or prostate cancer. Patients (n = 62, age = 71.8 ± 9.3 years, CCI = 3.5 ± 1.7, PGV = 174 ± 110 mL) had pre-procedure IPSS = 22.4 ± 5.6, QoL score = 4.4 ± 0.9, and post-void residual (PVR) = 172 ± 144 mL. Post-procedure values were compared to baseline at 1, 3, 6, 12, and 24 months. Associations between outcomes and PGV, MLE, age, and CCI were evaluated. Adverse event recording used Clavien-Dindo classification.ResultsOne month after PAE (n = 37), IPSS improved to 7.6 ± 5.2 (P < .0001) and QoL score improved to 1.7 ± 1.4 (P < .0001). At 3 months (n = 32), improvements continued, with IPSS = 6.4 ± 5.1 (P < .0001), QoL score = 1.2 ± 1.2 (P < .0001), PVR = 53 ± 41 mL (P < .001), and PGV = 73 ± 38 mL (P < .0001). Results were sustained at 6 months (n = 35): IPSS = 6.4 ± 4.1 (P < .0001), QoL score = 1.2 ± 1.2 (P < .0001), PVR = 68 ± 80 mL (P < .0001), PGV = 60 ± 19 mL (P < .001). At 12 months, patients (n = 26) had IPSS = 7.3 ± 5.5 (P < .0001), QoL score = 1.2 ± 0.8 (P <.0001), PVR = 89 ± 117 mL (P < .0001), PGV = 60 ± 48 mL (P < .01). At 24 months, patients (n = 8) had IPSS = 8.0 ± 5.4 (P < .0001), QoL score = 0.7 ± 0.5 (P < .0001), PVR = 91 ± 99mL (P = 0.17), and PGV = 30 ± 5mL (P = .11). Improvements were independent of PGV, MLE, age, and CCI. Two grade II urinary infections occurred.ConclusionsPAE with 100–300-μm microspheres produced sustained substantial improvements in LUTS, PGV, and PVR, which were independent of baseline PGV, MLE, age, or CCI.     

Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes

PurposeTo compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs).Materials and MethodsA single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n = 18) or TIPS alone (n = 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy.ResultsThe mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P = .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P = .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P = .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P = .077). There was no difference in ascites (13% vs 11%, P = .63), hepatic encephalopathy (47% vs 55%, P = .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups.ConclusionsThe GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs.     

Stent Graft Placement for the Treatment of Hepatic Artery Injury in Patients with Cancer: Primary Patency and Clinical Outcomes

PurposeTo evaluate the safety, primary patency, and clinical outcomes of hepatic artery stent graft (SG) placement for vascular injuries.Materials and MethodsPatients treated with hepatic arterial SG placement for vascular injuries between September 2018 and September 2021 were reviewed. Data on demographic characteristics, indication, stent graft characteristics, antiplatelet/anticoagulant use, clinical success rate, complications, and type of follow-up imaging were collected. Follow-up images were reviewed by 2 independent reviewers to assess primary patency. A time-to-event analysis was performed. The median duration of stent graft patency was estimated using Kaplan-Meier curves. A Cox proportional hazard model was used to evaluate factors related to stent graft patency.ResultsThirty-five patients were treated with hepatic arterial SG placement, 11 for postoperative bleeds and 24 for hepatic artery infusion pump catheter–related complications. Clinical success was achieved in 32 (91%) patients (95% CI, 77–98). The median primary patency was 87 days (95% CI, 73–293). Stent grafts of ≥6-mm diameter retained patency for a longer duration than that with stent grafts of smaller diameters (6 mm vs 5 mm; hazard ratio, 0.35; 95% CI, 0.14–0.88; P = .026; and 7+ mm vs 5 mm; hazard ratio, 0.27; 95% CI, 0.09–0.83; P = .023). Anticoagulation/antiplatelet regimen was not associated with increased stent graft patency duration (P > .05). Only minor complications were reported in 2 (5.7%) patients.ConclusionsStent grafts can be used safely and effectively to treat injuries of the hepatic artery. Stent graft diameters of ≥6 mm seem to provide more durable patency.     

Value of CT-Guided Percutaneous Irreversible Electroporation Added to FOLFIRINOX Chemotherapy in Locally Advanced Pancreatic Cancer: A Post Hoc Comparison

PurposeTo compare survival after CT-guided percutaneous irreversible electroporation (IRE) and folinic acid, fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX) chemotherapy versus FOLFIRINOX only in patients with locally advanced pancreatic cancer (LAPC).Materials and MethodsA post hoc comparison was performed of data derived from a prospective IRE-FOLFIRINOX cohort and a retrospective FOLFIRINOX-only cohort. All patients received a minimum of 3 cycles of FOLFIRINOX for LAPC and were considered eligible for CT-guided percutaneous IRE. Endpoints included overall survival (OS), local and distant progression-free survival, and time to progression (TTP) and were compared using stratified Kaplan-Meier analysis. Patients who received > 8 cycles of FOLFIRINOX before IRE and who had tumors > 6 cm in the FOLFIRINOX-only group were excluded.ResultsOf 103 patients with a diagnosis of LAPC, 52 were deemed eligible (n = 30 IRE-FOLFIRINOX and n = 22 FOLFIRINOX-only). Patients in the FOLFIRINOX-only arm had larger tumors (53 mm ± 19 vs 38 mm ± 7, P = .340), had more locoregional lymph node metastases (23% vs 7%, P = .622), and more often received radiotherapy (7 patients vs 2 patients, P = .027); all other baseline characteristics were comparable. Median OS was 17.0 months (range, 5–35 mo; SD = 6) for IRE-FOLFIRINOX versus 12.4 months (range, 3–22 mo; SD = 6) for FOLFIRINOX-only (P = .038). After sensitivity analyses, median OS was 17.2 months (range, 6–27 mo; SD = 6) versus 12.4 months (range, 7–32 mo; SD = 10) (P = .05). Median TTP was longer in the IRE-FOLFIRINOX group: 14.2 months (range, 5–25 mo; SD = 4) versus 5.2 months (range, 2–22; SD = 6) (P = .0001).ConclusionsIn patients with LAPC after FOLFIRINOX chemotherapy, CT-guided percutaneous IRE may improve OS and TTP. This study may facilitate the design of randomized controlled trials to compare survival after IRE-FOLRINOX versus FOLFIRINOX-only.     

Evaluation of the Benefit of Extended Catheter-Directed Thrombolysis with Serial Angiography for Acute Pulmonary Embolism

PurposeTo evaluate whether extended catheter-directed thrombolysis (CDT) with repeat visits to the angiography suite provide added benefit in treatment of acute pulmonary embolism (PE).Materials and MethodsThis was a retrospective review of CDT procedures performed for acute PE in 156 patients (age 56.1 y ± 15.3, 46.2% women) between 2009 and 2019. All patients underwent at least 1 follow-up visit to the angiography suite for evaluation of pulmonary artery pressure (PAP) and thrombus burden (Miller score) before termination (111/156, 71.2%) or continuation of CDT (45/156, 28.8%).ResultsPatients who had CDT extended beyond the first follow-up visit required a higher total dose of tissue plasminogen activator (40.7 mg ± 14.3 vs 22.6 mg ± 9.9, P < .001) to achieve a similar final Miller score (6.4 ± 3.8 vs 7.6 ± 3.9, P = .1) and a similar reduction in systolic PAP (?14.4 mm Hg ± 10.2 vs ?12.6 mm Hg ± 11.9, P = .6). The initial Miller scores were similar in both groups (19.7 ± 5.8 vs 19 ± 4, P = .4) but were significantly higher during the first follow-up visit (after 18 hours ± 5.5 vs 20 hours ± 4.8, P = .06) in patients requiring multiple follow-up visits (12.2 ± 5 vs 7.6 ± 3.9, P < .001). Multiple regression analyses identified heart rate > 100 beats/min and systolic PAP > 55 mm Hg as associated with the need for extended CDT. Extended CDT did not result in a higher hemorrhagic complication rate (1/45 vs 6/111, P = .7).ConclusionsPatients presenting with higher heart rates and systolic PAP may benefit from extended CDT to achieve similar reductions in PAP and thrombus burden, without clear added risk of hemorrhage.     

Clinical Safety and Efficacy of Locoregional Therapy Combined with Adoptive Transfer of Allogeneic γδ T Cells for Advanced Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma

PurposeTo investigate the safety and efficacy of locoregional therapy plus adoptive transfer of allogeneic gamma delta (γδ) T cells for patients with hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC).MethodsThirty patients with HCC and 29 patients with ICC were randomly assigned to receive locoregional therapy (HCC, Group A, n = 15; ICC, Group C, n = 15) or locoregional therapy plus γδ T cell therapy (HCC, Group B, n = 15; ICC, Group D, n = 14). Groups A and C only received locoregional ablation (cryoablation or irreversible electroporation), whereas Groups B and D received locoregional therapy followed by adoptive transfer of allogeneic γδ T cells. The primary endpoints were safety, distant progression-free survival (PFS), local PFS, and overall survival (OS).ResultsThe median distant PFS was significantly longer in the combined treatment groups than the locoregional treatment groups (HCC: 8 vs 4 months, P = .04; ICC: 8 vs 4 months, P = .021). There was no significant difference in local PFS between the 2 treatment modalities. Patients with HCC in the combined treatment group had a longer OS (median OS: 13 vs 8 months, P = .029). However, there was no significant difference in OS in patients with ICC between the 2 treatment modalities (median OS: 9.5 vs 8 months, P = .546). All adverse events were manageable with no significant difference in incidence between groups.ConclusionsThe novel combination of locoregional ablation with adoptive transfer of allogeneic γδ cells was safe, with encouraging clinical efficacy against HCC and ICC.     

Evaluation of a Novel Spun Polytetrafluoroethylene Stent Graft in an Ovine External Iliac Artery Model

PurposeTo evaluate the patency, cellular response, and thrombogenicity of a novel vascular stent graft.Materials and MethodsTest stent grafts, incorporating luminal spun polytetrafluoroethylene and a nonpermeable fluoropolymer layer, and control stent grafts, constructed of permeable expanded polytetrafluoroethylene, were implanted in the external iliac arteries of 14 adult sheep with a median weight of 73.4 kg ranging from 60.6–86.8 kg for 30 (n = 4), 90 (n = 4), and 180 (n = 6) days. Angiographic patency and percent diameter stenosis (%DS) were assessed at termination. Excised stent grafts were fixed and stained for histopathologic analysis, including neointimal coverage (NC) assessment.ResultsTest and control device migration occurred in 1 animal, resulting in test device thrombosis. Both devices were excluded from analysis. Mean %DS in test and control implants was 4.6% and 8.2% (P = .563), 2.0% and 10.9% (P = .363), and 2.1% and 10.3% (P = .009) at 30, 90, and 180 days, respectively. Median NC scores at 30, 90, and 180 days were significantly lower in middle test device sections (P < .05). Proximal and distal test and control sections exhibited similar median NC scores at all time periods (P > .05). When present, test and control devices exhibited no neointimal detachment from the graft surface. Except for the migrated test device, no thrombus was observed. Transgraft cellular migration was absent in test devices but present in control devices with tissue accumulation around the stent struts.ConclusionsTest and control devices demonstrated excellent patency in an ovine model. Compared to the control, test devices exhibited significantly lower %DS values at 180 days and significantly lower mid-device NC scores at 30, 90, and 180 days.     

Ultrasound-Guided Subgluteal Sciatic Nerve Block for Pain Management during Endovascular Treatment for Below-the-Knee Arterial Occlusions

PurposeTo evaluate the ability of subgluteal sciatic nerve block (SSNB) to provide pain control during endovascular treatment of below-the-knee (BTK) occlusions.Materials and MethodsThis randomized prospective controlled study evaluated 60 consecutive adult patients who underwent endovascular treatment for BTK occlusions. The patients were randomized into 2 equal groups; the SSNB group underwent SSNB in the subgluteal space under ultrasound guidance, while the control group received fentanyl as an analgesic. The visual analog scale (VAS) and Face, Legs, Activity, Cry, Consolability (FLACC) scale scores were recorded.ResultsCompared with the control group, the SSNB group showed significantly lower median VAS (0 [range, 0–30] vs 70 [range, 20–100], P < .001) and median FLACC scale (0 [range, 0–2] vs 6 [range, 3–10], P < .001) scores. There was no statistically significant difference between the 2 groups regarding the remaining parameters. There was a very strong correlation between the VAS and FLACC scale scores in both the SSNB (r = 0.805, P < .001) and control (r = 0.950, P < .001) groups. The procedure time and total balloon inflation time correlated with the VAS (r = 0.411, P = .024, and r = 0.402, P = .031, respectively) and FLACC scale (r = 0.431, P = .017, and r = 0.414, P = .022, respectively) scores in the control group but not in the SSNB group (r = 0.364, P = .056, and r = 0.300, P =.085, respectively, for correlation with VAS score and r = 0.730, P = .068, and r = 0.704, P = .075, respectively, for correlation with the FLACC scale score).ConclusionsSSNB is a highly effective and safe pain management modality for the endovascular treatment of BTK occlusions.     

Stereotactic Body Radiotherapy for Stage I Renal Cell Carcinoma: National Treatment Trends and Outcomes Compared to Partial Nephrectomy and Thermal Ablation

PurposeTo assess use of stereotactic body radiotherapy (SBRT) for stage I renal cell carcinoma (RCC) and compare outcomes with thermal ablation and partial nephrectomy (PN).Materials and MethodsThe 2004–2015 National Cancer Database was investigated for histopathologically proven stage I RCC treated with PN, cryoablation, radiofrequency (RF) or microwave (MW) ablation, or SBRT. Patients were propensity score–matched to account for potential confounders, including patient age, sex, race, comorbidities, tumor size, histology, grade, tumor sequence, administration of systemic therapy, treatment in academic vs nonacademic centers, treatment location, and year of diagnosis. Overall survival (OS) was evaluated with Kaplan-Meier plots, log-rank tests, and Cox proportional hazards models.ResultsA total of 91,965 patients were identified (SBRT, n = 174; PN, n = 82,913; cryoablation, n = 5,446; RF/MW ablation, n = 3,432). Stage I patients who received SBRT tended to be older women with few comorbidities treated at nonacademic centers in New England states. After propensity score matching, a cohort of 636 patients was obtained with well-balanced confounders between treatment groups. In the matched cohort, OS after SBRT was inferior to OS after PN and thermal ablation (PN vs SBRT, hazard ratio [HR] = 0.29, 95% confidence interval [CI] 0.19–0.46, P < .001; cryoablation vs SBRT, HR = 0.40, 95% CI 0.26–0.60, P < .001; RF/MW ablation vs SBRT, HR = 0.46, 95% CI 0.31–0.67, P < .001). Compared with PN, neither cryoablation nor RF/MW ablation showed significant difference in OS (cryoablation vs PN, HR = 1.35, 95% CI 0.80–2.28, P = .258; RF/MW ablation vs PN, HR = 0.64, 95% CI 0.95–2.55, P = .079).ConclusionsCurrent SBRT protocols show lower OS compared with thermal ablation and PN, whereas thermal ablation and PN demonstrate comparable outcomes.     

Risk Factors for Hemorrhagic Adverse Events in Percutaneous Transhepatic Biliary Drainage: A Prospective Multicenter Study

PurposeTo determine risk factors (RFs) for hemorrhagic adverse events (AEs) associated with percutaneous transhepatic biliary drainage (PTBD) and to develop a risk assessment model.Materials and MethodsThis was a multicenter, prospective, case control study between 2015 and 2020. Adults with an indication for PTBD were included. Patients who had undergone recent previous drainage procedures were excluded. Multiple variables were controlled. The exposure variables were the number of capsular punctures and passes (using the same puncture). A multivariate analysis was performed (logistic regression analysis).ResultsA total of 304 patients (mean age, 63 years ± 14 [range, 23–87 years]; female, 53.5%) were included. Hemorrhagic AEs occurred in 13.5% (n = 41) of the patients, and 3.0% (n = 9) of the cases were severe. Univariate analysis showed that the following variables were not associated with hemorrhagic AEs: age, sex, bilirubin and hemoglobin levels, type of pathology, portal hypertension, location of vascular punctures, ascites, nondilated bile duct, intrahepatic tumors, catheter features, blood pressure, antiplatelet drug use, and tract embolization. Multivariate analysis showed that number of punctures (odds ratio [OR], 2.5; P = .055), vascular punctures (OR, 4.1; P = .007), fatty liver or cirrhosis (OR, 3.7; P = .021), and intrahepatic tumor obstruction (Bismuth ≥ 2; OR, 2.4; P = .064) were associated with hemorrhagic AEs. Patients with corrected coagulopathies had fewer hemorrhagic AEs (OR, ?5.5; P = .026). The predictability was 88.2%. The area under the curve was 0.56 (95% confidence interval, 0.50–0.61).ConclusionsPreprocedural and intraprocedural RFs were identified in relation to hemorrhage with PTBD. AE risk assessment information may be valuable for prediction and management of hemorrhagic AEs.     

Effect of Median Lobe Enlargement on Early Prostatic Artery Embolization Outcomes

PurposeTo evaluate outcomes after prostatic artery embolization (PAE) in patients with severe intravesical prostatic protrusion (IPP).Materials and MethodsThis was a retrospective, single health system, 2-hospital study from April 2015 to December 2018 of 54 patients who underwent elective PAE procedures (age mean 67.5 years; standard deviation [SD] 8.5). The cohort had a mean ellipsoid prostate volume of 100.1 cm³ (SD 56.7), a mean baseline International Prostate Symptom Score (IPSS) of 18.7 (SD 8.2), a mean baseline quality of life (QOL) score of 4.1 (SD 1.4), and a median follow-up of 38 days (range 10–656 days). Outcomes including IPSS and QOL score reduction (where a lower QOL score indicates an improvement in QOL), and clinical success were compared between severe (≥10 mm) and nonsevere (<10 mm) IPP patients. A linear regression model was used to examine the impact of IPP on these outcomes.ResultsNo significant differences in patient characteristics were found between nonsevere (n = 17) and severe (n = 37) IPP patients. Both cohorts showed IPSS reduction (nonsevere 6.0, P = .0397; severe 8.2, P < .0001) and QOL score reduction (nonsevere 1.0, P = .102; severe 2.0, P < .0001). No significant differences in IPSS or QOL score reduction were found between the cohorts (P = .431 and P = .127). Linear regression found that baseline IPP was not a significant contributor to the outcomes (IPSS: R² = .5, P < .0001; IPP: P = .702; QOL: R² = .5, P = .0003; IPP: P = .108).ConclusionsThere were no significant differences in early outcomes in PAE between patients with severe and nonsevere IPP.     

Endovascular Outcomes in Aortic Arch Repair with Double and Triple Parallel Stent Grafts

PurposeTo report early and midterm outcomes of treating thoracic aortic aneurysm (TAA) and aortic dissection (AD) involving zone 1 and zone 0 with multiple parallel stent grafts (PSGs).Materials and MethodsFrom February 2011 to August 2018, 31 of 1,806 patients (1.7%) who underwent thoracic endovascular aortic repair (TEVAR) with double PSGs (DPSGs) (n = 20) or triple PSGs (TPSGs) (n = 11) were retrospectively reviewed. Procedures were performed in high-risk patients who had TAA or AD involving zone 1 or zone 0.ResultsFifteen patients (48.4%) who presented with symptomatic or impending rupture underwent urgent or emergent TEVAR with DPSGs or TPSGs. Nineteen patients (61.3%) were treated for zone 0 disease. Technical and clinical success rates were 70.0% for DPSG cohort and 45.5% for TPSG cohort. Intraoperative type Ia endoleak was observed in 30% of DPSG cohort and 45.5% of TPSG cohort. One patient in the DPSG cohort died of aortic sinus rupture intraoperatively. Minor stroke during the 30-day postoperative period was more frequent in the TPSG cohort (P = .042). Mean duration of follow-up was 28.9 months ± 17.7. The TPSG cohort had a higher incidence of major adverse events (72.7% vs 25.0%, P = .021). The most common adverse events were endoleaks (12.9%), endograft migration (9.7%), PSG stenosis or occlusion (6.5%), retrograde dissection (6.5%), and stroke (3.2%). Endograft migrations were more common in TPSG cohort (27.3%, P = .037). Overall mortality rate was 16.1% (5/31) perioperatively and during follow-up. There were no statistical differences in overall survival and reintervention-free survival.ConclusionsIn the context of TEVAR with multiple PSGs for aortic arch repair, TPSGs may have a high risk of major complications.