Treatment of Arm Swelling in Hemodialysis Patients with Ipsilateral Arteriovenous Access and Central Vein Stenosis: Conversion to the Hemodialysis Reliable Outflow Graft versus Stent Deployment

PurposeTo compare outcomes after conversion of arteriovenous (AV) access to Hemodialysis Reliable Outflow (HeRO) graft vs stent deployment in patients with arm swelling owing to ipsilateral central vein stenosis.Materials and MethodsThis single-center retrospective study comprised 48 patients (19 men, mean age 58 y) with arm swelling ipsilateral to AV access and central vein stenosis over a 13-year period who had clinical follow-up and without prior central stents. Twenty-one patients underwent placement of a HeRO graft with anastomosis of the HeRO graft to the existing graft or fistula, and 27 patients underwent central venous stent deployment. Symptomatic improvement in arm swelling and access patency rates after intervention were ascertained from medical records.ResultsImprovement in swelling within 1 month after HeRO conversion and stent deployment was found in 95% and 89%, respectively (P = .62). Swelling eventually recurred in 16 patients (59%) treated with stents compared with 1 patient (5%) who underwent HeRO conversion (P < .001). Primary access patency was statistically significantly longer after HeRO conversions than stent deployments, with 6- and 12-month primary patency rates of 89% and 72% vs 47% and 11% (P < .001). HeRO conversions also resulted in longer 6- and 12-month secondary access patency rates (95% and 95% vs 79% and 58%, P = .006). Mean number of interventions per 1,000 access days to maintain secondary patency was 2.7 for the HeRO group vs 6.3 for the stent group.ConclusionsAlthough stent deployment and HeRO graft conversion are effective for alleviating arm swelling in the short term in patients receiving hemodialysis with clinically significant arm swelling and functioning AV access, the HeRO graft has more durable results.     

Percutaneous Treatment of Benign Biliary Anastomotic Strictures: Retrievable Covered Self-Expandable Metal Stent with Fixation String Versus Large-Bore Catheters

PurposeTo retrospectively compare the safety and efficacy of a covered self-expandable metal stent (CSEMS) with a transhepatic fixation string and a large-bore catheter for benign biliary anastomotic stricture after hepatobiliary surgery.Materials and MethodsFrom March 2012 to June 2017, 49 patients with benign biliary anastomotic strictures, untreatable with endoscopy, were included. Twenty-three patients (catheter group) were treated with a large-bore catheter (with progressive catheter upsizing to 16–18 Fr), whereas 26 patients (stent group) were treated by CSEMS (10-mm stent) placement. Technical success, clinical success, primary patency, recurrent strictures, complication rate, and catheter or stent indwelling time were compared between the groups.ResultsTechnical success and clinical success were achieved in all patients. In the stent group, stent retrieval was successful in all patients. The overall complication rate was 24.5% (catheter group vs. stent group, 30.4% vs. 19.2%; P = .363). Stent migration occurred in 1 patient during follow-up (1/26, 3.8%). The mean indwelling time was 10.3 ± 3.0 months (range, 8–16 months; median, 10 months) in the catheter group and 4.0 ± 1.2 months (range, 3–7 months; median, 4 months) in the stent group (P < .001). Recurrent strictures occurred in 10 (43.5%) patients in the catheter group and 4 (15.4%) patients in the stent group (P = .030). The 1- and 3-year primary patency rates were 82.6% and 69.3% in the catheter group and 92.3% and 84.4% in the stent group (P = .042).ConclusionsPercutaneous placement of a retrievable CSEMS showed superior intermediate-term outcomes over a large-bore catheter in patients with benign biliary anastomotic strictures.     

Imaging-Guided De Novo Retrograde Ureteral Access and Stent Placement without Cystoscopy in Women

PurposeTo evaluate the feasibility of a new technique for imaging-guided de novo retrograde ureteral double J (DJ) stent placement without cystoscopy in women.Materials and MethodsEighty-four women referred for ureteral stent placement between April 2019 and January 2022 were included. In all the patients, the initial attempt for stent placement was performed in a retrograde fashion. Successful ureteral catheterization and DJ stent placement were considered as technical success. The fluoroscopy time required to catheterize the ureter and that for the entire procedure were recorded. Factors affecting the technical success rate and fluoroscopy time were examined.ResultsA total of 108 ureteral stent placement procedures in 84 women, with a mean age of 57.5 years (range, 19–85 years), were performed. The most common underlying pathologies were cervical (n = 33, 31%) and ovarian (n = 32, 30%) carcinomas. The most commonly involved segments of the ureter were the lower half (n = 44, 40%) and trigone (n = 39, 36%). The technical success rate was 81.5%, and it reached 93% in the case of lower-half ureteral obstruction. Distorted trigonal anatomy caused by external compression of the bladder wall by a mass was associated with a higher rate of technical failure (90.6% vs 47.8%; P < .001). The use of ultrasound guidance to guide the sheath to the ureteral orifice allowed for a significant decrease in the fluoroscopy time for ureteral catheterization (4.6 minutes ± 3.91 vs 2.26 minutes ± 2.32; P = .003) and that for the entire procedure (9.42 minutes ± 4.95 vs 5.93 minutes ± 4.06; P = .001).ConclusionsImaging-guided de novo retrograde ureteral catheterization and stent placement can be successfully performed in a high percentage of patients within a reasonable fluoroscopy time without the need for cystoscopy in women.     

No Advantage of Expanded Polytetrafluoroethylene and Fluorinated Ethylene Propylene–Covered Stents over Uncovered Nitinol Stents for Percutaneous Palliation of Malignant Infrahilar Biliary Obstruction: Results of a Single-Center Prospective Randomized Trial

PurposeTo prove that covered stents are more efficacious than uncovered stents regarding patency, safety, enabling of chemotherapy, and survival in percutaneous palliation of malignant infrahilar biliary obstruction.Materials and MethodsAfter failed endoscopic treatment, 154 patients with obstructive jaundice caused by unresectable infrahilar malignancy were randomly allocated to receive an expanded polytetrafluoroethylene and fluorinated ethylene propylene–covered or an uncovered nitinol stent. Occlusion rate, patency, and survival were assessed. Safety and clinical success in terms of chemotherapy were compared.ResultsThree patients were excluded post hoc. Fifteen patients died within 7 d and were excluded from patency analysis. Occlusion rates were 32% (21 of 66) for covered and 29% (20 of 70) for uncovered stents (P = .7). Estimated median patency durations were 308 d (95% confidence interval [CI], 178–438 d) for covered and 442 d (95% CI, 172–712 d) for uncovered stents (P = .1). Serious adverse events (P = 1.0) and 30-day mortality (P = .5) were equivalent between groups. At hospital discharge, median bilirubin reduction of 8 mg/dL was found in both groups (P < .001). In the covered stent group, 35 patients (48%) received palliative chemotherapy, vs 29 (37%) in the uncovered stent group (P = .2). Estimated median survival times were 96 days (95% CI, 68–124 d) with covered stents and 75 days (95% CI, 42–108 d) with uncovered stents (P = .6).ConclusionsIn malignant infrahilar biliary obstruction not amenable to endoscopy, no improvement in patency or survival with percutaneously placed covered stents could be confirmed. Covered and uncovered stent types exhibit similar safety profiles and clinical success rates.     

Evaluation of Technical Success,Efficacy, and Safety of Portomesenteric Venous Intervention following Nontransplant Hepatobiliary or Pancreatic Surgery

PurposeTo evaluate technical success, efficacy and safety of portomesenteric venous (PMV) intervention for PMV stenosis or occlusion following nontransplant hepatobiliary or pancreatic (HPB) surgery.Materials and MethodsA retrospective review identified 42 patients (mean age 60 y) with PMV stenosis (n = 33; 79%) or occlusion (n = 9; 21%) who underwent attempted PMV intervention following HPB surgery between June 1, 2011, and April 1, 2018. Main outcomes were technical success, primary patency rates, and complications. Technical success was compared by venous pathology and primary PMV patency based on anticoagulation status after the procedure using Fisher exact test. Rates of primary patency by stent group were estimated using Kaplan-Meier method.ResultsTechnical success was 91% (n = 38/42) and significantly higher in patients with stenosis (n = 33/33; 100%) vs occlusion (n = 5/9; 56%) (P = .001). Primary presenting symptom resolved in 28 (87%) patients, including 6 (100%) patients with gastrointestinal bleeding. At mean imaging follow-up of 8.6 months ± 8.8, primary stent patency was 76%. There was no significant difference in primary stent patency based on anticoagulation status after the procedure (P = .48). There were 2 (4.8%) periprocedural complications.ConclusionsPortomesenteric venoplasty and stent placement following nontransplant HPB surgery is safe with a high rate of technical success if performed before chronic occlusion.     

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.     

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.     

Association between Radiation Exposure and Endothelium-Dependent Vasodilation: Results from Clinical and Experimental Studies

PurposeThe association between occupational radiation exposure and endothelium-dependent vasodilation (EDV) remains unclear. This study evaluated the association between radiation exposure and EDV among fluoroscopy-guided interventional procedure specialists and explored the possible mechanisms.Materials and MethodsBrachial flow-mediated dilation was compared in 21 interventional cardiologists (the radiation group) and 15 noninterventional cardiologists (the nonradiation group). Animal radiation experiments were also performed to observe the impact of radiation on EDV.ResultsFlow-mediated dilation in both the left (radiation group, 3.63% vs. nonradiation group, 6.77%; P < .001) and right brachial arteries (5.36% vs. 7.33%, respectively; P = .04) and serum nitric oxide (NO) level (343.69 vs. 427.09 μmol/L, respectively; P = .02) were significantly reduced in the radiation group compared to those in the nonradiation group. EDV was significantly impaired in acetylcholine concentrations of 3 × 10⁻⁶ mol/L and 10⁻⁵ mol/L (60.09% vs.74.79%, respectively; P = .03; and 62.73% vs. 80.56%, respectively; P = .002), and reactive oxygen species levels in the aorta intima and media layers were significantly increased in mice after a single x-ray exposure, which could be partly rescued by pretreatment with folic acid (P < .05).ConclusionsRadiation exposure can lead to impairment of flow-mediated vasodilation in human or EDV in mice. In mice acutely exposed to radiation, folic acid alleviated radiation-induced EDV impairment by possible reduction of reactive oxidative species.     

Repeat Prostatic Artery Embolization for Patients with Benign Prostatic Hyperplasia

PurposeTo evaluate the safety and efficacy of repeat prostatic artery (PA) embolization (PAE) for benign prostatic hyperplasia (BPH).Materials and MethodsA single-center retrospective study was conducted from 2009 to 2018 in 108 patients with symptomatic BPH treated with repeat PAE: group A (n = 39; 36.1%) were patients who never showed a response to PAE, and group B (n = 69; 63.9%) were patients who had clinical improvement in the first 6 months following PAE but relapsing symptoms afterward. The main patterns of revascularization were 75% from the previously embolized PA and 25% from collateral vessels (superior vesical, posterior-lateral PA, penile branches). Technical outcomes and adverse events were registered. International Prostate Symptom Score (IPSS), quality of life (QOL), and clinical success were compared between groups.ResultsMedian follow-up was 18 months (range, 1–36 mo); median interval between PAE and repeat PAE was 420 days (range, 77–2,240 d). Mean procedural time was significantly longer for repeat PAE vs initial PAE (81.1 min vs 67.4 min; P = .0007). There were no major complications and no urinary incontinence. Mean IPSS/QOL improvements were greater in group B vs group A: 9.51 vs 6.13 and 1.30 vs 0.56, respectively (P < .001). The cumulative probability of clinical success after repeat PAE was higher in group B than in group A (P = .0001): 84.1% vs 46.2% at 1 month, 56.7% vs 28.2% at 12 months, and 51.9% vs 16.9% at 24–36 months.ConclusionsRepeat PAE is safe and effective for recurrence of lower urinary tract symptoms caused by BPH but has limited impact in patients who did not show a response to initial PAE.     

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.     

Endovascular Celiac Denervation for Glycemic Control in Patients with Type 2 Diabetes Mellitus

PurposeTo investigate the safety and efficacy of catheter-based endovascular denervation (EDN) at the celiac artery and abdominal aorta around the celiac artery on glycemic control in patients with type 2 diabetes mellitus (T2DM).Materials and MethodsWith a novel catheter system, EDN was conducted at the celiac artery along with the abdominal aorta around the celiac artery in patients with T2DM whose glycosylated hemoglobin (HbA1c) level was >7.5%. The primary outcome was HbA1c level at 6 months. Other outcomes included safety, oral glucose tolerance test, homeostasis model assessment of insulin resistance (HOMA-IR), fasting plasma glucose (FPG) level, 2-hour postprandial plasma glucose (2hPG) level, and C-peptide test.ResultsA total of 11 subjects were included for analysis. The technical success was 100%, and no severe treatment-related adverse events or major complications were observed. Both HbA1c level and HOMA-IR were significantly reduced at 6 months (9.9% vs 8.0%, P = .005; 13.3 vs 6.0, P = .016). Decreases in FPG and 2hPG levels were observed (227.2 vs 181.8 mg/dL, P < .001; 322.2 vs 205.2 mg/dL, P = .001). The C-peptide test indicated improved β-cell function (area under the curve, 0.23 vs 0.28 pmol/mL, P = .046). A reduction of daily insulin injection (P = .02) and improvement of liver function (alanine aminotransferase, P = .014; γ-glutamyl transpeptidase, P = .021) were also observed.ConclusionsEDN in the celiac artery and abdominal aorta around the celiac artery elicited a clinically significant improvement in glycemic control and insulin resistance in patients with T2DM, with good tolerability as demonstrated by 6-month follow-up.     

Impact of Renal Function Trajectory on Renal Replacement Therapy and Mortality Risk after Renal Artery Revascularization

PurposeTo determine the impact of renal function trajectory, defined as the change in renal function over time before and after renal artery stent placement, on long-term risk for renal replacement therapy (RRT) and mortality.Materials and MethodsEstimated glomerular filtration rates (eGFRs) 6–12 months before renal artery stent placement, at the time of intervention, and 6–12 months after intervention were determined in 398 patients. The effect of eGFR change before and after renal artery stent placement was calculated. Cox proportional-hazards ratio was used to determine the risks for RRT and all-cause mortality.ResultsThe risk for RRT was significantly influenced by eGFR change from the time of intervention to follow-up at 6–12 month after treatment (P = .02). In addition, among patients with a postintervention eGFR ≤ 40 mL/min/1.73 m², for every 1 unit of eGFR increase, there was a significant decrease in RRT and all-cause mortality (P < .001 and P < .001, respectively). Secondary parameters that increased RRT risk included diabetes at the time of intervention (P = .03), increased baseline proteinuria (P < .001), and stage 4 or 5 chronic kidney disease (CKD; P = .01 and P = .003, respectively). Multivariate analysis demonstrated higher all-cause mortality rates among patients with diabetes at the time of intervention (P = .009).ConclusionsPostintervention eGFR trajectory improvement approaching 40 mL/min/1.73 m² was associated with decreased RRT and mortality risk. These findings suggest that patients with advanced CKD and renal artery stenosis may benefit from revascularization regardless of their preinterventional renal function measurement.     

Portal Vein Recanalization for Noncirrhotic Portal Vein Cavernous Transformation: Transjugular Intrahepatic Portosystemic Shunt Creation versus Portal Vein Stent Placement

PurposeTo compare the clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation versus portal vein stent placement (PVS) in patients with noncirrhotic cavernous transformation of the portal vein (CTPV).Materials and MethodsIn this retrospective study, clinical data from patients with noncirrhotic CTPV who underwent TIPS creation or PVS were compared. A total of 54 patients (mean age, 43.8 years ± 15.8; 31 men and 23 women) were included from January 2013 to January 2021; 29 patients underwent TIPS creation, and 25 patients underwent PVS. Stent occlusion, variceal rebleeding, survival, and postprocedural complications were compared between the 2 groups.ResultsThe mean follow-up time was 40.2 months ± 26.2 in the TIPS group and 35.3 months ± 21.1 in the PVS group. The stent occlusion rate in the PVS group (16%, 4 of 25) was significantly lower than that in the TIPS group (41.4%, 12 of 29) during the follow-up (P = .042). The cumulative variceal rebleeding rates in the TIPS group were significantly higher than those in the PVS group (28% vs 4%; P = .027). The procedural success rate was 69% in the TIPS group and 86% in the PVS group (P = .156). There was a higher number of severe adverse events after TIPS than after PVS (0% vs 24%; P = .012).ConclusionsPortal vein recanalization with PVS may be a preferable alternative to TIPS creation in the treatment of noncirrhotic CTPV because of higher stent patency rates, lower risk of variceal rebleeding, and fewer adverse events.     

Endovascular Revascularization as Primary Treatment for Acute Embolic Mesenteric Ischemia: Stent Thrombectomy plus Aspiration versus Aspiration Alone

PurposeTo investigate the outcomes of stent thrombectomy combined with aspiration versus aspiration alone in acute mesenteric ischemia (AMI).Materials and MethodsThis was a single-center, retrospective cohort study. Between May 1, 2012, and January 1, 2021, 41 patients (mean age, 73.8 years ± 7.9) with AMI who underwent stent thrombectomy plus aspiration (Group 1, n = 14) or aspiration alone (Group 2, n = 27) were included. The treatment regimens and clinical and follow-up outcomes of the patients were reviewed and analyzed. Group differences were compared using a χ² test, Fisher exact test, independent t test, or Mann-Whitney U test. The cumulative survival rate was calculated using a Kaplan-Meier curve.ResultsThe overall clinical success rate was 78.0% (32/41), and no significant differences were found between Group 1 and Group 2 (78.6% vs 77.8%, P = 1.00). Compared with Group 2, Group 1 was associated with a higher complete clearance rate (44.4% vs 78.6%, P = .04), less adjunctive local thrombolysis (48.1% vs 14.3%, P = .03), and a shorter length of hospital stay (10.7 days ± 9.0 vs 5.7 days ± 4.7, P = .03). The estimated survival rates at 1 month, 3 months, 6 months, 1 year, and 2 years were 73.2%, 72.5%, 71.4%, 65.3%, and 59.8%, respectively. No significant difference was found in the survival rate between the groups (log-rank test, P = .96). The recurrence rates for Group 1 and Group 2 were 8.3% (1/12) and 4.0% (1/25), respectively.ConclusionsCompared with aspiration alone, aspiration combined with stent thrombectomy showed a higher complete clearance rate, reduced adjunctive thrombolysis, and a shorter length of hospital stay.     

Transradial versus Transfemoral Access for Patients with Liver Cancer Undergoing Hepatic Arterial Infusion Chemotherapy: Patient Experience and Procedural Complications

PurposeTo determine whether transradial access (TRA) is a more favorable and safe method for hepatic arterial infusion chemotherapy (HAIC) than transfemoral access (TFA).Materials and MethodsRetrospective and prospective cohorts of patients with liver cancer were included. Sixty-seven patients in the retrospective cohort were divided into 2 groups: (a) TRA-HAIC (n = 24) and (b) TFA-HAIC (n = 43). Another 33 patients were prospectively enrolled to receive both TRA and TFA for HAIC in a crossover design. Prolonged arterial access was required for up to 48 hours. The primary endpoint was quality of life (QOL) using the visual analog scale. The secondary endpoints mainly included procedural success, adverse events, and operation time.ResultsPatient QOL measures revealed significantly lower scores of indices in the TRA-HAIC group than in the TFA-HAIC group in the retrospective cohort (all P < .001). The significant improvement of the QOL indices by TRA-HAIC, such as overall discomfort (P = .019) and pain at the access site (P = .018), was validated in the prospective cohort. The satisfaction scores were significantly higher in the TRA-HAIC group than in the TFA-HAIC group, and patients preferred TRA-HAIC (P < .001). Radial artery occlusion (RAO) as an access-related adverse event occurred more frequently in both the retrospective and prospective cohorts (38% and 33%, P < .001 and P = .001, respectively). Notably, the multivariate analysis of RAO-associated factors showed that enoxaparin use was significantly correlated with a reduced risk of postprocedural RAO (P = .036).ConclusionsTRA was superior to TFA in patient experience. However, because of the high incidence of access-related adverse events, especially for RAO with a total incidence of 35%, strategies should be optimized for patients to benefit from TRA in future procedures.     

Impact of Intrahepatic Venovenous Shunt on Hepatic Venous Pressure Gradient Measurement

PurposeTo quantitatively analyze the impact of intrahepatic venovenous shunt (IHVS) on hepatic venous pressure gradient (HVPG) measurement.Materials and MethodsFrom 2015 to 2019, 222 HVPG measurements performed during transjugular intrahepatic portosystemic shunt creation were eligible for this study. Digital subtraction angiography (DSA) software color-coded each pixel of a two-dimensional DSA series by time-intensity curve to classify IHVS. Different degrees of IHVS were found in 36.5% of patients (81/222). Mild IHVS was found in 10.8% of patients (24/222), moderate IHVS was found in 10.8% of patients (24/222), and severe IVHS was found in 14.9% of patients (33/222).ResultsMean wedged hepatic vein pressure (WHVP) and HVPG were significantly lower in patients with IHVS compared with patients without IHVS (WHVP: 17.78 mm Hg ± 7.00 vs 24.89 mm Hg ± 8.69, P = .001; HVPG: 11.93 mm Hg ± 5.76 vs 18.6 mm Hg ± 6.85, P < .001). Mild IHVS had little effect on WHVP and HVPG. Mean WHVP and HVPG were 11 mm Hg lower in patients with moderate IHVS (WHVP: 20.38 mm Hg ± 8.38 vs 31.5 mm Hg ± 9.39, P = .026; HVPG: 13.88 mm Hg ± 6.33 vs 25.00 mm Hg ± 9.81, P < .001) and 15 mm Hg lower in patients with severe IHVS (WHVP: 13.45 mm Hg ± 5.28 vs 28.64 mm Hg ± 6.38, P = .017; HVPG: 8.27 mm Hg ± 3.85 vs 23.45 mm Hg ± 6.95, P < .001) than mean portal vein pressure and portal vein gradient.ConclusionsFor patients with moderate or severe IHVS, HVPG might greatly underestimate the actual value of portal vein pressure, and the portal vein should be catheterized to measure portal pressure.     

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.     

Uterine Artery Embolization following Cesarean Delivery but prior to Hysterectomy in the Management of Patients with Invasive Placenta

PurposeTo evaluate outcomes of patients with placenta accreta spectrum (PAS) disorders who underwent uterine artery embolization (UAE) following cesarean delivery but before hysterectomy.Materials and MethodsA retrospective review of patients with PAS treated with cesarean-hysterectomy (C-hyst) was performed. Patients in the UAE group underwent UAE after cesarean delivery but before hysterectomy; patients in the control group underwent C-hyst alone. Estimated blood loss (EBL), transfusion requirements, length of intensive care unit (ICU) stay, and adverse events were evaluated.ResultsThe study included 31 patients, 7 in the UAE group and 24 in the control group. Median EBL, transfusion requirements, and length of ICU stay in the UAE group compared with control group were 1,500 mL (range, 500–2,000 mL) vs 2,000 mL (range, 1,000–4,500 mL) (P = .04), 150 mL (range, 0–650 mL) vs 550 mL (range, 0–3,125 mL) (P = .10), and 0 d (range, 0–1 d) vs 0.5 d (range, 0–2 d) (P = .07). All patients in the UAE group had placenta increta; patients in the control group had placenta accreta (29%), increta (54%), and percreta (17%) (P = .10). Subgroup analysis of patients with placenta increta demonstrated that the UAE group had a significant decrease in median EBL (P = .004), transfusion requirements (P = .009), and length of ICU stay (P = .04). No adverse events following UAE were noted.ConclusionsUAE following cesarean delivery but before hysterectomy in patients with placenta increta appears to be safe and effective in decreasing EBL, transfusion requirements, and length of ICU stay compared with C-hyst alone.     

Clinical Significance of the Initial and Best Responses after Chemoembolization in the Treatment of Intermediate-Stage Hepatocellular Carcinoma with Preserved Liver Function

PurposeTo evaluate the clinical implications of initial and best responses during repeated transarterial chemoembolization procedures for hepatocellular carcinoma (HCC).Materials and MethodsThis study included 726 patients who received a diagnosis of intermediate-stage HCC with Child-Pugh class A liver function between 2007 and 2016, and who were treated with transarterial chemoembolization as the first-line treatment. Evaluation of treatment response was based on the modified response evaluation criteria in solid tumors. Overall survival (OS) was compared between response categories after implementation of landmark analysis.ResultsOf the 726 patients, an objective response (complete response [CR] or partial response [PR]) was observed as the initial response in 78.1% of patients. Regarding the best response during the transarterial chemoembolization series, 87.2% of patients were overall responders. The median OS of initial responders (n = 483) was not significantly different from that of subsequent responders at the 1-year landmark (stable disease [SD] after first transarterial chemoembolization but CR or PR after repeated transarterial chemoembolization; n = 61; 46.2 vs 40.1 months, respectively; P = .145). Likewise, the median OS of initial CR patients (n = 326) was not significantly different from that of the subsequent CR group (n = 126) at the 1-year landmark (PR or SD after first transarterial chemoembolization but CR after repeated transarterial chemoembolization; 53.4 vs 46.3 months, respectively; P = .455). Multivariate Cox analyses showed that the objective responses, the initial responses (hazard ratio [HR], 0.638; P = .001), and the best responses (HR, 0.304; P < .001) had the significant prognostic significance for OS.ConclusionsBoth the initial and best responses during repeated transarterial chemoembolization were significantly associated with OS in patients with intermediate-stage HCC and preserved liver function.     

Sex-Related Differences in the Long-Term Outcomes of Patients with Femoropopliteal Arterial Disease Treated with the IN.PACT Drug-Coated Balloon in the IN.PACT SFA Randomized Controlled Trial: A Post Hoc Analysis

PurposeTo evaluate sex-related disparities in long-term outcomes of patients with peripheral artery disease (PAD) treated with IN.PACT drug-coated balloon (DCB) or percutaneous transluminal angioplasty (PTA).Materials and MethodsA post hoc analysis of the IN.PACT SFA trial was performed. Participants with Rutherford Clinical Classification 2–4 PAD and femoropopliteal artery lesions up to 18 cm long were randomly assigned to treatment with DCB (n = 220) or PTA (n = 111). Effectiveness outcomes were evaluated, including 36-month primary patency (freedom from binary restenosis and freedom from clinically driven [CD] target lesion revascularization [TLR]).ResultsIn the DCB group, women were significantly older (69.4 y ± 9.9) than men (66.4 y ± 9.1; P = .025). Mean reference vessel diameter (RVD) was significantly smaller in women (4.4 mm ± 0.68) compared with men (4.8 mm ± 0.89, P < .001). Primary patency was 65.4% in women and 71.8% in men (P = .302). Freedom from CD-TLR was 81.1% in women and 86.4% in men (P = .285). Women treated with PTA were older (70.4 y ± 8.3) than men (66.9 y ± 9.5; P = .063). Mean RVD was significantly smaller in women (4.2 mm ± 0.77) compared with men (4.9 mm ± 0.77, P < .001). Primary patency was 42.3% in women and 46.7% in men (P = .551). Freedom from CD-TLR was 59.4% in women and 75.5% in men (P = .109). No significant differences were noted in safety and mortality outcomes.ConclusionsIn both groups, women were older and had smaller vessels. Particularly in the PTA group, women had worse clinical outcomes, though not reaching statistical significance. Further evaluation is necessary to understand the disparate nature of disease progression and outcomes following endovascular treatment in women compared with men.