Impact of anatomical features of the left atrial appendage on outcomes after cryoablation for atrial fibrillation

AimsPulmonary vein isolation (PVI) using cryoballoon has been accepted as a safe and effective method for treatment of atrial fibrillation (AF). Despite advances in catheter-based technologies, some patients still experience AF recurrence. In this study, we aimed to compare left atrial appendage (LAA) morphology in AF patients and subjects with sinus rhythm and also investigate the association between LAA morphology and success of PVI using cryoballoon in subjects with AF.MethodsIn this prospective study, 359 AF patients who underwent pre-ablation computed tomographic angiography (CTA) scan between January 2013–March 2016 were included as the patient group. 100 age and gender-matched subjects in sinus rhythm who had no AF episodes in 24-h Holter monitoring that underwent CTA were included as the control group.ResultsNon-chicken wing LAA morphology was more common in AF patients (p < 0.001). LAA was significantly deeper (p < 0.001) and short-axis diameter of LAA orifice and LAA orifice area were significantly larger (p < 0.001) in AF patients. Low take-off type morphology of LAA was more common in controls compared to AF patients (p = 0.006). At a median follow-up of 37 months, only longitudinal-axis left atrial diameter on CT (p = 0.003) and cauliflower-type LAA morphology (p = 0.004) were independent predictors of AF recurrence.ConclusionThis is the first study in the literature that investigates the relationship between anatomical variations of LAA and AF recurrence following cryoablation. Our findings demonstrate that cauliflower-type LAA morphology is associated with two-fold increased risk of AF recurrence.     

Higher coronary artery calcium score is associated with increased risk of atrial fibrillation recurrence after catheter ablation

BackgroundCoronary artery calcium score (CACS) is associated with an increased risk of atrial fibrillation (AF) development, but scarce data are available regarding the impact on AF recurrence. This study aims to assess the impact of CACS on AF recurrence following catheter ablation.MethodsRetrospective study of patients with AF undergoing cardiac computed tomography (CCT) before ablation (2017–2019). Patients with coronary artery disease (CAD), significant valvular heart disease and previous catheter ablation were excluded. A cut-off of CACS ≥ 100 was used according to literature.ResultsA total of 311 patients were included (median age 57 [48, 64] years, 65% men and 21% with persistent AF). More than half of the patients had a CACS > 0 (52%) and 18% a CACS ≥ 100. Patients with CACS ≥ 100 were older (64 [59, 69] vs 55 [46, 63] years, p ?< ?0.001), had more frequently hypertension (68% vs 42%, p ?< ?0.001) and diabetes mellitus (21% vs 10%, p ?= ?0.020). During a median follow-up of 34 months (12–57 months), 98 patients (32%) had AF recurrence. CACS ≥ 100 was associated with increased risk of AF recurrence (unadjusted Cox regression: hazard ratio [HR] 2.0; 95% confidence interval [CI], 1.3–3.1, p ?= ?0.002). After covariate adjustment, CACS ≥ 100 and persistent AF remained independent predictors of AF recurrence (HR, 1.7; 95% CI, 1.0–2.8, p ?= ?0.039 and HR, 2.0; 95% CI, 1.3–3.2, p ?= ?0.004, respectively).ConclusionAn opportunistic evaluation of CACS could be an important tool to improve clinical care considering that CACS ≥ 100 was independently associated with a 69% increase in the risk of AF recurrence after first catheter ablation.     

The predictive value of cardiac morphology for long-term outcome of patients undergoing catheter ablation for atrial fibrillation

ObjectiveCatheter ablation (CA) is an established therapy for selected patients with atrial fibrillation (AF), but predictors of CA ablation outcome are still not fully elucidated. The aim of the study was to identify structural and morphological parameters from computed tomography (CT) as predictors of successful CA of AF in a single center prospective cohort.MethodsAn analysis of CT scans dedicated to LA evaluation was performed in 99 patients (63 ± 8 years old, 70% males, 59% paroxysmal AF) scheduled for CA of AF. Survival free of atrial fibrillation/flutter/tachycardia at 1- and 3-years was assessed.ResultsIn overall study population, both 1- and 3-year responders had smaller distance to the first division in left superior pulmonary vein (16.3 ± 5.42 mm vs. 19.1 ± 7.0 mm and 14.9 ± 3.6 mm vs. 18.7 ± 7.0 mm; p < 0.05). One-year responders had larger ostium area of left inferior pulmonary vein (median 236 mm² [IQR = 97] vs. 222 mm² [IQR = 71]; p = 0.03) and less acute angle between the interatrial septum and the right superior pulmonary vein (102 ± 20° vs. 95 ± 10°; p = 0.03). Three-years' responders had smaller ostium area of the right superior pulmonary vein (248 ± 94 mm² vs. 364 ± 282 mm²; p = 0.02). Multivariate Cox regression analysis identified different predictors in paroxysmal and non-paroxysmal AF. For patients with paroxysmal AF, the predictors were angle to right superior pulmonary vein and left superior/inferior pulmonary veins carina thickness with hazard ratios of 0.965 (95%CI 0.939 to 0.992, p = 0.010) and 0.747 (95%CI 0.591 to 0.944, p = 0.015). In patients with persistent AF, the predictors were gender and NYHA stage with hazard ratios of 4.9 (95%CI 1.758 to 13.579, p = 0.002) and 0.365 (95%CI 0.148 to 0.899, p = 0.028) respectively.ConclusionsThe anatomy of LA, especially morphology of pulmonary veins, seems to be one of the predictors of clinical outcome after CA for paroxysmal AF. In non-paroxysmal AF LA anatomy is less relevant in prediction of clinical outcome.     

Prospective-triggered sequential dual-source end-systolic coronary CT angiography for patients with atrial fibrillation: A feasibility study

BackgroundObtaining diagnostic coronary CT angiography with low radiation exposure in patients with irregular heart rhythms such as atrial fibrillation (AF) remains challenging.ObjectiveWe evaluated image quality and inter-reader variability with the use of prospective electrocardiographic (ECG)-triggered sequential dual-source acquisition at end systole for coronary artery disease (CAD) evaluation in patients with AF.MethodsThirty consecutive patients with AF who underwent prospective ECG-triggered sequential dual-source acquisition were evaluated. Images were reconstructed every 50 milliseconds from 250 to 400 milliseconds after the R wave. Two independent, blinded readers evaluated the coronaries for image quality on a 5-point scale (worst to best) and stenosis on 5-point semiquantitative (none to severe) and binary scales (>50% or <50%). Diagnostic image quality was graded for each reconstruction.ResultsEleven patients (37%) had significant (≥50% stenosis) CAD. Average heart rate was 82 ± 20 beats/min and variability range was 71 ± 22 beats/min. Mean effective radiation dose was 6.5 ± 2.4 mSv. Diagnostic image quality was noted in 97.9% of 304 coronary segments with median image quality of 3.0. The 300-millisecond reconstruction phase provided the highest image quality; 70% of patients showed diagnostic image quality. Combination of all phases (250–400 milliseconds) performed significantly better than single or other phase combinations (P < 0.0005 for all comparisons). Inter-reader variability for stenosis detection was excellent, with 98.4% concordance by using a binary scale (50% stenosis cutoff).ConclusionsProspective ECG-triggered sequential dual-source CT acquisition with the use of end-systolic acquisition provides diagnostic image quality with potentially low radiation doses for evaluation of CAD in patients with AF. Use of multiple end-systolic phases over a 150-millisecond window improves diagnostic image quality.     

Pulmonary vein orientation is independently associated with outcomes following cryoballoon-based atrial fibrillation ablation

AimsSeveral studies have investigated the influence of pulmonary vein (PV) anatomy on outcomes of atrial fibrillation (AF) ablation. We aimed to evaluate the relationship between PV orientation and AF-free survival following cryoablation.Methods160 patients scheduled for cryoablation between September 2012–March 2014 were included. Patients underwent a pre-procedural cardiac CT scan with retrospective ECG gating. PV orientation was assessed according to the position of the PV orifice relative to the sagittal plane with reference to coronal and horizontal planes.Results160 patients (57 ± 9 years, 54% male, 33% persistent AF) were included and followed for a median of 17 (12–36) months. Excluding a blanking period of 3 months, freedom from AF after a single ablation procedure was 76%. Ventral-caudal left upper PV (p = 0.044) and ventral-caudal left lower PV orientation (p = 0.001) were more common in patients with AF recurrence. In multivariate Cox regression analysis, only left lower PV orientation [particularly dorsal-caudal (HR: 3.447, 95% CI: 1.180–10.070, p = 0.024) and ventral-caudal (HR: 3.391, 95% CI: 1.088–10.571, p = 0.035) orientations compared to dorsal-cranial orientation] as well as LA diameter (HR: 3.420, 95% CI: 1.809–6.465, p < 0.001) were significantly associated with AF recurrence.ConclusionThis is the first study to demonstrate the impact of PV orientation on prediction of AF recurrence following cryoablation. Preprocedural assessment of PV orientation may modify operator preferences on treatment strategies in AF.     

Analysis of the anatomical features of pulmonary veins on pre-procedural cardiac CT images resulting in incomplete cryoballoon ablation for atrial fibrillation

BackgroundTo investigate the anatomical features related to the failure of cryoballoon (CB) ablation for atrial fibrillation (AF) on pre-procedural CT images.MethodsWe retrospectively analyzed CT images of 100 patients with AF who had undergone a first CB ablation at our institution between June 2016 and April 2017. We measured the angle, short- and long axis length, and the area and ovality of 4 major pulmonary vein (PV) ostium on CT images. We performed logistic regression analysis to analyze the anatomical features related to the failure (incomplete CB ablation) of PV isolation. We also performed a receiver-operating characteristic (ROC) curve analysis to identify an appropriate cut-off value for anatomical features significantly associated with incomplete CB ablation.ResultsWe analyzed 400 PVs in 100 patients [aged 64 (range, 27–82) years, 59% male]. The rate of incomplete CB ablation was significantly higher for right-than left-sided PVs (p < 0.001). The anatomical feature significantly associated with incomplete CB ablation was the angle at the right inferior PV (RIPV) (AOR: 1.17; 95% CI: 1.09–1.27, p < 0.001) and the right superior PV (RSPV) (AOR: 1.12; 95% CI: 1.01–1.23; p = 0.014). In the ROC analysis, the optimal cut-off value for RIPV and RSPV angle to discriminate an incomplete CB ablation were 40.1° and 79.7°, respectively.ConclusionOur findings may help to select the appropriate ablation strategy to treat patients with AF. We show that the angle is an anatomical feature significantly related to failed CB ablation.     

心房颤动冷冻球囊消融与磁导航指导下消融放射暴露对比研究

目的对比分析心房颤动(房颤)冷冻球囊(CRYO)消融术与磁导航(RMN)指导下房颤消融术两种消融方式, 探讨房颤消融术中减少放射暴露的方法。方法回顾性分析本院144例冷冻消融患者(CRYO组)和121例磁导航指导下房颤消融患者(RMN组)术中在线随机参考点累积皮肤表面入射剂量(CD)和X射线照射时间, 分析不同类型患者辐射剂量及手术效果之间的差异。结果与RMN组相比, CRYO组患者的手术时间明显缩短[(165.0±23.6)、(97.8±18.4)min, t=26.05,P<0.001], 但X射线暴露时间明显延长[(8.1±3.1)、(23.4±6.2)min,t=-24.57, P<0.001]、CD值明显增加[(232.3±130.7)、(669.0±387.5)mGy, Z=-12.29,P<0.001]。随访两组患者总体维持窦性心律比例未见明显差异(71.9%、75.7%, P=0.618)。多元回归分析提示, 肥胖患者、非阵发性房颤患者、肺静脉存在变异患者与CRYO组患者CD值增加有关(t=5.47、2.23、3.39, P<0.05), 且CR...     

Detection of invisible dental biofilm using light-induced autofluorescence in adult patients–A systematic review

BackgroundAutofluorescence (AF) spectroscopy is a potent yet non-invasive technique with diagnostic and therapeutic applications. It identifies and characterizes changes occurring in the human body based on the changes in the fluorescence signatures.AimThe primary purpose of this systematic review is to address the question "Is it feasible to detect dental plaque using light-induced auto-fluorescence in adult patients with invisible grade 1 plaque?"Materials and methodsThe literature search was conducted independently MEDLINE, Embase, Cochrane Library, Web of Science, Google Scholar, and Scopus databases for relevant studies from January 2000 and June 2021, using the following terms in various combinations: detection, dental biofilm, plaque, light, auto-fluorescence, caries, gingivitis, sensitivity and specificity. Studies describing various fluorescence techniques for the detection of plaque, including sensitivity and specificity, were included.ResultsThe majority of the studies indicated that AF spectroscopy allows fluorescence-based detection of various diseases, including early-stage dental plaque. While results of conventional plaque detection techniques are inconsistent, the data from the AF technique is reliable and reproducible, which can be used for patient documentation. However, a wide range of non-uniformity existed in these studies. AF spectroscopy, as a non-invasive technique, represents a viable and patient-friendly clinical tool for the early detection of dental biofilm plaque, and its meticulous removal has been directly responsible for the prevention of this disease.ConclusionDespite the heterogeneity and limitations of studies included in this review, the future for light-induced autofluorescence spectroscopy technologies in diagnostic dentistry certainly presents an accurate and potentially applicable option.     

Radiolabelled monoclonal antibodies against alpha-fetoprotein for in vivo localization of human hepatocellular carcinoma by immunotomoscintigraphy

Two high affinity monoclonal antibodies, designated AF01 and AF04, directed against distinct epitopes of human alpha-fetoprotein (AFP) and the Fab fragments of one of them, were labelled with ¹³¹I and injected into 18 patients with AFP producing hepatocellular carcinoma (HCC) in order to carry out imaging studies by tomoscintigraphy. Twelve patients were injected with whole antibody, only three of seven patients injected with AF01 and two of five patients injected with AF04 had a positive scan. In contrast, five out of six patients injected with labelled Fab fragments of AF04 had positive imaging. These results confirm that tumour imaging of HCC using ¹³¹I labelled monoclonal antibody against AFP is feasible. Moreover, utilization of tomoscintigraphy in place of linear scintigraphy and Fab fragments instead of whole immunoglobulin may improve the sensitivity of radioimmunolocalization. This technique provides useful information on the in vivo distribution of monoclonal antibodies directed against AFP and on the practicability of the eventual therapeutic use of anti-AFP antibodies in HCC.This work was supported by Grant number 84D16 from the Institut Gustave-Roussy     

心房颤动患者心房组织中的胶原重构

 目的 研究风湿性心脏瓣膜病心房颤动(房颤)患者心房组织中胶原表达的变化,探讨房颤患者心房纤维化的机制及其在房颤发生、持续中的作用.方法 75例风湿性心脏瓣膜病接受换瓣置换手术者分为3组,其中窦性心律组34例,阵发性房颤组11例,慢性房颤组30例,于术中获取右心耳组织约100 mg,采用苦味酸天狼猩红染色法对心房组织胶原沉积量及分布情况进行分析,应用半定量反转录-聚合酶链反应(RT-PCR)方法,测定心房组织中Ⅰ型胶原、Ⅲ型胶原的mRNA水平.结果 (1)房颤患者心房组织存在明显纤维化,纤维化程度与左心房内径(r=0.390, P=0.001)、房颤持续时间呈正相关(r=0.320,P=0.005);(2)与窦性心律 组比较,Ⅰ型胶原的mRNA在阵发性房颤患者(P＜0.05)、慢性房颤患者(P＜0.001)心房组织中的表达均明显增加;房颤患者Ⅲ型胶原的mRNA表达虽有增加,但差异无统计学意义.Ⅰ型胶原的mRNA表达水平与左心房内径(r=0.336,P=0.004)、房颤持续时间 (r=0.339,P=0.003)呈正相关.结论 房颤患者心房组织存在明显纤维化,Ⅰ型胶原的分子重构可能是房颤时心房纤维化发生的分子机制之一,与房颤的发生和持续有关.     

Evaluation of Left Atrial Appendage Isolation Using Cardiac MRI after Catheter Ablation of Atrial Fibrillation: Paradox of Appendage Reservoir

ObjectiveTo assess the effect of left atrial appendage (LAA) isolation on LAA emptying and left atrial (LA) function using cardiac MRI in patients who underwent successful catheter ablation of atrial fibrillation (AF).Materials and MethodsThis retrospective study included 84 patients (mean age, 59 ± 10 years; 67 males) who underwent cardiac MRI after successful catheter ablation of AF. According to the electrical activity of LAA after catheter ablation, patients showed either LAA isolation or LAA normal activity. The LAA emptying phase (LAA-EP, in the systolic phase [SP] or diastolic phase), LAA emptying flux (LAA-EF, mL/s), and LA ejection fraction (LAEF, %) were evaluated by cardiac MRI.ResultsOf the 84 patients, 61 (73%) and 23 (27%) patients showed LAA normal activity and LAA isolation, respectively. Incidence of LAA emptying in SP was significantly higher in LAA isolation (91% vs. 0%, p < 0.001) than in LAA normal activation. LAA-EF was significantly lower in LAA isolation (40.1 ± 16.2 mL/s vs. 80.2 ± 25.1 mL/s, p < 0.001) than in LAA normal activity. Furthermore, LAEF was significantly lower in LAA isolation (23.7% ± 11.2% vs. 31.1% ± 16.6%, p = 0.04) than in LAA normal activity. Multivariate analysis demonstrated that the LAA-EP was independent from LAEF (p = 0.01).ConclusionLAA emptying in SP may be a critical characteristic of LAA isolation, and it may adversely affect the LAEF after catheter ablation of AF.     

Endobronchial Navigation Guided by Cone-Beam CT–Based Augmented Fluoroscopy without a Bronchoscope: Feasibility Study in Phantom and Swine

PurposeTo evaluate the accuracy of cone-beam computed tomography (CT)-based augmented fluoroscopy (AF) image guidance for endobronchial navigation to peripheral lung targets.MethodsPrototypic endobronchial navigation AF software that superimposed segmented airways, targets, and pathways based on cone-beam CT onto fluoroscopy images was evaluated ex vivo in fixed swine lungs and in vivo in healthy swine (n = 4) without a bronchoscope. Ex vivo and in vivo (n = 3) phase 1 experiments used guide catheters and AF software version 1, whereas in vivo phase 2 (n = 1) experiments also used an endovascular steerable guiding sheath, upgraded AF software version 2, and lung-specific low-radiation-dose protocols. First-pass navigation success was defined as catheter delivery into a targeted airway segment solely using AF, with second-pass success defined as reaching the targeted segment by using updated AF image guidance based on confirmatory cone-beam CT. Secondary outcomes were navigation error, navigation time, radiation exposure, and preliminary safety.ResultsFirst-pass success was 100% (10/10) ex vivo and 19/24 (79%) and 11/15 (73%) for in vivo phases 1 and 2, respectively. Phase 2 second-pass success was 4/4 (100%). Navigation errors were 2.2 ± 1.2 mm ex vivo and 4.9 ± 3.2 mm and 4.0 ± 2.6 mm for in vivo phases 1 and 2, respectively. No major device-related complications were observed in the in vivo experiments.ConclusionsEndobronchial navigation is feasible and accurate with cone-beam CT-based AF image guidance. AF can guide endobronchial navigation with endovascular catheters and steerable guiding sheaths to peripheral lung targets, potentially overcoming limitations associated with bronchoscopy.     

Percutane Image-Guided Cryoablation of Painful Osseous Metastases: A Retrospective Single-Center Review

PurposePainful osseous metastases are a common problem in patients with malignancy, and they can be associated with significant morbidity owing to immobility, pain, pathologic fracture, or neurovascular compromise or all of these. We retrospectively evaluated pain levels and tumor enhancement in patients who underwent palliative percutaneous cryoablation for painful bone metastasis.MethodsIn this institutional review board-approved, health insurance portability and accountability act-compliant study, we retrospectively searched our department׳s picture archiving system for patients who underwent computed tomography (CT)-guided percutaneous cryoablation for treatment of painful metastatic osseous disease over a 6-year period (1/1/2005-12/31/2011). The preprocedure and postprocedure images and imaging reports, primary tumor type, CT-guided cryoablation procedure details, treated tumor response, immediate and 3-month postprocedure complications, reported pain response to cryoablation, postprocedural tumor imaging characteristics, and imaging response of noncryoablated systemically treated metastatic lesions were reviewed in patients with metastatic osseous disease who underwent cryoablation.ResultsAll 16 patients reported improvement in pain within 1 week after the procedure and at 3-month clinical follow-up. A total of 6.2% had tumor growth and 93.8% had tumor arrest or shrinkage on follow-up CT, although all study patients had progression of noncryoablated metastases at other sites despite systemic therapy. A total of 62.5% of patients with posttreatment contrasted CT demonstrated marginal enhancement at the ablation site, although only single patient had interval growth.ConclusionMost of our patients had tumor arrest or shrinkage on follow-up imaging, despite progression of noncryoablated metastases treated with preprocedure and postprocedure systemic therapy. Radiation therapy, chemotherapy, and analgesics have a moderate failure rate and require repeat treatments where quality of life is the foremost objective. CT-guided cryoablation is a safe palliative treatment to reduce pain in patients with painful osseous metastatic disease, achieve effective local tumor control, and in some cases, provide a curative option for a target lesion.     

Altered vertebrobasilar flow in children: angiographic,MR, and MR angiographic findings.

PURPOSETo characterize the clinical, MR, MR angiographic, and conventional angiographic findings in vertebrobasilar disease in children.METHODSEight children with posterior circulation ischemia and infarction had conventional spin-echo MR and MR angiography of the head and neck. Six patients had conventional angiography.RESULTSSix patients had alteration of vertebral or basilar artery flow void on spin-echo images. MR angiography showed all six cases of angiographically proved vertebrobasilar dissection or occlusion despite overestimating the extent of arterial abnormality in two patients. In two patients the intracranial peripheral branch cutoff shown at angiography was correctly predicted on screening MR angiography.CONCLUSIONPosterior circulation infarction in children is usually secondary to traumatic injury to the vertebrobasilar circulation. MR and MR angiography noninvasively show vertebrobasilar flow disturbances and compare favorably with angiography in documenting dissection or occlusion of the vertebrobasilar circulation. MR angiography may obviate the need for invasive angiography in these children at diagnosis and during follow-up of anticoagulation therapy.     

Cerebral Venous Sinus Thrombosis Treated with Vacuum Aspiration Thrombectomy without Thrombolysis: A Descriptive and Retrospective Study of 5 Years’ Experience at a Single Center

PurposeCerebral venous sinus thrombosis (CVST) is a rare but life-threatening condition. Mechanical thrombectomy is a treatment option for patients who deteriorate or do not improve despite anticoagulation treatment or those who have a major contraindication to anticoagulation. The purpose of this study was to describe the authors’ 5 years of experience in treating CVST with vacuum aspiration thrombectomy without thrombolysis.Materials and MethodsFor this retrospective study, data were collected from consecutive patients with CVST who received anticoagulation as initial medical treatment and were treated with vacuum aspiration thrombectomy without thrombolysis. Patients were followed up at 3 months and after 1 year.ResultsThe 9 patients included in the study had a median age of 37 years, and 5 were women. All 9 patients had headaches at presentation; 7 had focal neurologic deficits, and 7 had intracranial hypertension. Risk factors for CVST were identified in 8 patients, and poor prognostic factors were identified in 7 patients. In the 9 patients, 24 CVST locations were treated; complete (70.8%) or partial (29.2%) recanalization was achieved in all CVST locations. No procedure-related complications occurred. One patient died of parenchymal hemorrhagic transformation of CVST and vasogenic edema, 6 hours after the procedure. Two patients required neurosurgical intervention. After 1 year (range, 13–30 months), all 8 surviving patients had good functional outcomes (modified Rankin Scale score 0–2).ConclusionsFor appropriately selected patients with CVST, vacuum aspiration thrombectomy without thrombolysis seemed to be an effective therapy.     

Portal Vein Thrombosis after Partial Splenic Embolization in Liver Cirrhosis: Efficacy of Anticoagulation and Long-term Follow-up

PurposeTo investigate the treatment and long-term outcome of portal vein thrombosis (PVT) after partial splenic embolization (PSE).Materials and MethodsFrom January 2006 to December 2011, 145 patients with hypersplenism caused by cirrhotic portal hypertension underwent PSE. In 11 cases, PVT was detected 13–42 days after PSE. Among the 11 patients, 5 underwent anticoagulant therapy because of clinical symptoms, and 6 did not receive anticoagulation because they were symptom-free (4 patients) or experienced variceal bleeding (2 patients). The long-term follow-up data from these 11 patients were analyzed retrospectively.ResultsThe 11 patients with PVT had a mean splenic infarction ratio of 71.5%. The mean duration of follow-up was 37.6 months. During the follow-up period, none of the 5 patients who underwent anticoagulation developed variceal hemorrhage despite presenting with large esophagogastric varices. Four of the five patients achieved complete resolution of thrombosis, and one did not develop thrombus progression. However, among the 6 patients who did not undergo anticoagulation, 2 developed esophagogastric variceal hemorrhage secondary to thrombus progression, 3 developed cavernous transformation of the portal vein and variceal progression, and 1 had partial calcification of the thrombus. Two patients who had variceal bleeding or rebleeding underwent a transjugular intrahepatic portosystemic shunt. Complete recanalization of the portal vein was achieved after the procedures.ConclusionsPVT is a severe, potentially fatal complication of PSE. Early detection of PVT and prompt anticoagulation are effective to avoid serious consequences of PVT.     

Percutaneous transluminal angioplasty adjunct to thrombolysis for acute middle cerebral artery rethrombosis.

PURPOSETo report three patients, each of whom had acute rethrombosis of a reopened middle cerebral artery after urokinase treatment for proximal stenosis (percutaneous transluminal angioplasty of the stenosis was performed adjunctive to the thrombolytic treatment to preserve the success of the thrombolysis), and a fourth patient who had percutaneous transluminal angioplasty right after the completion of thrombolysis and had no rethrombosis despite a partial dilatation of the severe stenosis.METHODSThrombolytic treatment was carried out by a coaxial technique with a Tracker 18 catheter through a 5-F angiographic catheter; 80,000 U in 5 mL of urokinase were intermittently injected every 15 minutes after an initial dose of 250,000 U. All patients were given 3000 U of heparin with a booster dose of 1000 U every hour. Angioplasty was performed with a Stealth catheter balloon, 2 to 3 mm x 1.5 cm.RESULTSThree patients recovered without hemorrhage after percutaneous transluminal angioplasty and thrombolytic treatment. Percutaneous transluminal angioplasty was unsuccessful in one patient because of the inability to pass a 2-mm Stealth balloon catheter, and the result was a second rethrombosis. This patient had a poor recovery.CONCLUSIONAcute thrombosis of the middle cerebral artery may be associated with severe proximal stenosis. Rethrombosis may occur even after complete thrombolysis. Percutaneous transluminal angioplasty may be safely performed to prevent rethrombosis.     

MR of hereditary hemorrhagic telangiectasia: prevalence and spectrum of cerebrovascular malformations.

PURPOSEOur goal was to describe the prevalence and types of cerebral vascular malformations (CVMs) seen with MR imaging in patients with hereditary hemorrhagic telangiectasia (HHT).METHODSWe reviewed retrospectively the brain MR images of 184 consecutive patients with HHT. Catheter angiography was performed in 17 patients with CVMs detected on MR images.RESULTSMR imaging revealed 63 CVMs in 42 patients. Classic arteriovenous malformations (n = 10) had a conspicuous network of vessels with flow voids and enlarged adjacent pial vessels. Apparent venous malformations (n = 5) were best seen after administration of contrast material as a prominent vessel coursing through normal brain parenchyma. Indeterminate vascular malformations (n = 48) had a spectrum of appearances characterized by variable combinations of heterogeneous signal intensity, enhancement, or hemosiderin. Angiography in 17 patients revealed 47 CVMs. Forty-six were arteriovenous malformations (AVMs), including 25 CVMs not seen with MR imaging and 21 CVMs that by MR criteria included 8 AVMs and 13 indeterminate vascular malformations. Angiography confirmed 1 venous malformation seen with MR imaging but failed to detect 3 indeterminate lesions revealed by MR imaging.CONCLUSIONMR imaging of a large cohort of consecutive patients with HHT revealed a CVM prevalence of 23% (42/184). Most CVMs (48/63) have an atypical appearance for vascular malformations on MR images. Angiographic correlation suggests that MR imaging underestimates the prevalence of CVMs and that the majority of indeterminate CVMs, despite their variable MR appearance, are AVMs.     

Prospective Evaluation of Patients with Early-/Intermediate-stage Hepatocellular Carcinoma with Disease Progression Following Arterial Locoregional Therapy: Candidacy for Systemic Treatment or Clinical Trials

PurposeDuring the course of cancer treatment, patients whose disease progresses despite therapy are offered alternative options. Similarly, patients with hepatocellular carcinoma (HCC) whose disease progresses following arterial locoregional therapies (LRTs) cross over to undergo systemic therapies or participate in clinical trials. Per current guidelines, patients must meet inclusion criteria (most importantly Child–Pugh class A status) to qualify for systemic options. The present study analyzed the candidacy for systemic agents or clinical trials of patients whose disease progresses despite LRTs.Materials and MethodsA total of 245 patients with HCC were treated with LRTs (chemoembolization, n = 123; yttrium-90 [⁹⁰Y] radioembolization, n = 122) as part of a previously published comparative effectiveness study; 96 patients exhibiting disease progression were followed prospectively. Modes of progression (cancer stage, Child–Pugh class) were analyzed to determine candidacy for systemic therapy or clinical trials, as well as assess ultimate treatment(s) received.ResultsAmong the 96 patients with disease progression, 52% and 48% had Child–Pugh class A and class B/C disease, respectively, thereby substantially limiting the latter group’s eligibility for systemic therapy and/or clinical trials. Of those whose disease progressed who had advanced-stage HCC, 63% had Child–Pugh class B/C disease. By size and necrosis criteria, the local disease progression rate was higher with chemoembolization than with ⁹⁰Y radioembolization (P = .006 and P = .016, respectively). Of the 96 patients with disease progression, only 13 (13%) ultimately received systemic agents or entered clinical trials.ConclusionsMost patients with advanced HCC that progresses following LRTs were not candidates for clinical trials or systemic agents. There is a need for future research efforts directed at treatment options or novel trial designs that will permit inclusion of patients with progressive liver disease and suboptimal liver function.     

Radiolabelled monoclonal antibodies against alpha-fetoprotein for in vivo localization of human hepatocellular carcinoma by immunotomoscintigraphy

Two high affinity monoclonal antibodies, designated AF01 and AF04, directed against distinct epitopes of human alpha-fetoprotein (AFP) and the Fab fragments of one of them, were labelled with 131I and injected into 18 patients with AFP producing hepatocellular carcinoma (HCC) in order to carry out imaging studies by tomoscintigraphy. Twelve patients were injected with whole antibody, only three of seven patients injected with AF01 and two of five patients injected with AF04 had a positive scan. In contrast, five out of six patients injected with labelled Fab fragments of AF04 had positive imaging. These results confirm that tumour imaging of HCC using 131I labelled monoclonal antibody against AFP is feasible. Moreover, utilization of tomoscintigraphy in place of linear scintigraphy and Fab fragments instead of whole immunoglobulin may improve the sensitivity of radioimmunolocalization. This technique provides useful information on the in vivo distribution of monoclonal antibodies directed against AFP and on the practicability of the eventual therapeutic use of anti-AFP antibodies in HCC.