Interventional Radiological Treatment Research Articles

A Review of Interventional Radiology Treatments for Chronic Pain

Interventional radiology procedures are being increasingly used to mitigate chronic pain. In addition to established therapies such as thermal bone lesion ablation, kyphoplasty, and chemical neurolysis, ongoing research has shown promising results for the use of embolization in treatment of osteoarthritic knee pain and chronic pain secondary to adhesive shoulder capsulitis. This review will highlight some of the most common interventional radiology pain procedures, as well as provide insight into future pain-relieving embolization.

Risk Factors for Complications Requiring Interventional Radiological Treatment After Hepatectomy

PurposeTo identify perioperative factors that are significantly associated with complications requiring interventional radiology (IR) treatment after hepatectomy. MethodsWe retrospectively reviewed data from 11,243 patients in the USA who underwent hepatectomy from 2014 to 2016 using the National Surgical Quality Improvement Program database. Data on the following IR procedures were extracted: abscess drain placement, endovascular treatment for bleeding, and postoperative percutaneous biliary drain (PBD) placement up to 30 days postoperatively. Patients’ clinical and intraoperative factors were examined. Population, univariate, and multivariable analyses were performed. P < 0.05 was considered significant. ResultsA total of 704 patients (6%) required IR treatment postoperatively, and 10,539 patients (94%) did not. On multivariable analysis, biliary reconstruction was a significant predictor of postoperative abscess drain placement (hazard ratio (HR), 3.5; 95% confidence interval (CI) 1.8, 6.5; P < .001), endovascular treatment for bleeding (HR, 3.3; 95% CI 1.4, 7.8 P = .006), and postoperative PBD placement (HR, 2.9; 95% CI 1.9, 4.2; P < .001). Compared with hepatectomy without biliary reconstruction, hepatectomy with biliary reconstruction was associated with significantly higher rates of complications treated with IR procedures (26% vs. 4.9%) and death within 30 days (6.0% vs. 1.2%) (both, P < .001). ConclusionBiliary reconstruction is a strong predictor of the need for postoperative IR treatment after hepatectomy. One in four patients who underwent biliary reconstruction required IR treatment of a complication during the first 30 days after hepatectomy.

Oligometastatic Colorectal Cancer Management: A Survey of the Italian College of Interventional Radiology.

European Society for Medical Oncology (ESMO) and National Comprehensive Cancer Network guidelines(NCCN) have recently included interventional procedures among the standard treatments for the management of colorectal cancer (CRC) oligometastatic disease (OMD). This study overviews the practice of Interventional Radiology (IR) in Italian centers. A practice focused questionnaire on locoregional treatments of CRC-OMD was submitted to all Italian IR centers to assess practice patterns. Thirty-three IR centers completed the questionnaire. The majority reported practice was established within a tumor board (97%), which included input from hepatobiliary surgery (94%). When considering the number of percutaneous ablation and liver-directed trans-arterial therapies performed for all tumor types, 33.5% and 13.4% were performed to specifically treat CRC-OMD. Lung ablations for CRC OMD were performed in 45.5% of centers. Regarding liver ablation,The most common technology was the microwave ablation (68.1%), which was typically performed under US guidance (78%) with conscious sedation used as the most common anaesthesia method (81%). While indication for percutaneous IR treatments was heterogeneous, 51% were performed in combination with chemotherapy in unresectable OMD. Despite new ESMOand NCCN guidelines, 59% of centers did not subjectively appreciate any change in the perception of IR treatments by other specialists; however, 63%of respondents believe that IR will have a more relevant role in the CRC-OMD management in the future. CRC-OMD treatment represents a relevant part of the everyday clinical practice of the IR Italian centers with promising future prospects. Heterogeneity persists in clinical indications, requiring more robust evidence to set indications and to diffuse clinical applications.

Liver resection for a congenital intrahepatic portosystemic shunt in a child with hyperammonemia and hypermanganesemia: a case report

BackgroundCongenital portosystemic shunt (CPSS) is a rare malformation that leads to hyperammonemia, hypermanganesemia, and various symptoms. CPSSs are divided into intrahepatic and extrahepatic shunts. In patients with persistent CPSS including an intrahepatic portosystemic shunt (IPSS), early intervention to occlude the shunt reverses the associated complications.Case presentationThe patient was a 1-year-and-7-month-old girl. She presented with hypergalactosemia and elevation of blood ammonia level (75 μg/dL) and total bile acid levels (68.2 μmol/L) during the neonatal period. Two IPSSs were detected using ultrasound and enhanced computerized tomography. Magnetic resonance imaging (MRI) at 1 year and 3 months of age showed abnormally high signal intensity in the pallidum of her brain. Spontaneous closure was not observed. We performed a right hepatectomy at 1 year and 7 months of age. The portal vein pressure was 16 mmHg after temporary occlusion of the right portal vein. Blood ammonia and serum manganese levels decreased immediately after the operation. The abnormal signal on brain MRI disappeared. She had a favorable course with no sign of recurrence of IPSS 5 years postoperatively.ConclusionLiver resection for an IPSS to control the symptoms of a portosystemic shunt is reasonable in a child for whom interventional radiological treatment is not indicated.

Salivary gland ablation: introducing an interventional radiology treatment alternative in the management of sialorrhea

BackgroundSialorrhea is common in children with neurological disorders and leads to social isolation, aspiration pneumonia and increased caregiver burden. Sialorrhea management includes anticholinergic medications and a variety of surgeries, but these are limited by side effects, recurrence and risks.ObjectiveWe present our method of salivary gland ablation, an interventional radiology treatment for sialorrhea, and report safety and efficacy data from pediatric patients who underwent salivary gland ablation.Materials and methodsSalivary gland ablation uses image-guided sotradecol and ethanol dual-drug injection into the salivary glands. Submandibular and sublingual glands are injected percutaneously using ultrasound. Parotid glands are injected retrograde through Stensen ducts using fluoroscopy. We conducted a retrospective review of the medical records of patients who underwent salivary gland ablation at our institution between 2005 and 2019. Pre- and post-procedure Drooling Frequency and Drooling Severity (DFDS) scale scores were compared and caregiver satisfaction was assessed. We devised two cohorts, one to study patient safety and a subcohort to study clinical efficacy using DFDS scores.ResultsOne hundred and seventy salivary gland ablation procedures were performed in the 99 patients comprising the safety cohort. Of the procedures, 88.8% resulted in no or minimal complications. Respiratory difficulty, temporary nerve palsy and infection represent the majority of the 11.2% of patients who experienced periprocedural complications. There were no complications resulting in permanent sequelae. Twenty-seven patients met our inclusion criteria for the efficacy subcohort with a mean follow-up time of 5.4 years. DFDS at follow-up decreased from a median score of nine to a seven post-procedure (P=0.000018). The proportion of caregivers who were satisfied with the procedure increased as more glands were ablated, which suggests a causal link between the number of glands ablated and the outcome.ConclusionSalivary gland ablation is a safe and effective procedure with the potential for permanent decrease in symptoms related to sialorrhea.

Lattice-Boltzmann interactive blood flow simulation pipeline.

Cerebral aneurysms are one of the prevalent cerebrovascular disorders in adults worldwide and caused by a weakness in the brain artery. The most impressive treatment for a brain aneurysm is interventional radiology treatment, which is extremely dependent on the skill level of the radiologist. Hence, accurate detection and effective therapy for cerebral aneurysms still remain important clinical challenges. In this work, we have introduced a pipeline for cerebral blood flow simulation and real-time visualization incorporating all aspects from medical image acquisition to real-time visualization and steering. We have developed and employed an improved version of HemeLB as the main computational core of the pipeline. HemeLB is a massive parallel lattice-Boltzmann fluid solver optimized for sparse and complex geometries. The visualization component of this pipeline is based on the ray marching method implemented on CUDA capable GPU cores. The proposed visualization engine is evaluated comprehensively and the reported results demonstrate that it achieves significantly higher scalability and sites updates per second, indicating higher update rate of geometry sites' values, in comparison with the original HemeLB. This proposed engine is more than two times faster and capable of 3D visualization of the results by processing more than 30 frames per second. A reliable modeling and visualizing environment for measuring and displaying blood flow patterns in vivo, which can provide insight into the hemodynamic characteristics of cerebral aneurysms, is presented in this work. This pipeline increases the speed of visualization and maximizes the performance of the processing units to do the tasks by breaking them into smaller tasks and working with GPU to render the images. Hence, the proposed pipeline can be applied as part of clinical routines to provide the clinicians with the real-time cerebral blood flow-related information.

Interventional Radiological Treatment of Paediatric Liver Transplantation Complications.

To assess the efficacy of percutaneous techniques in managing paediatric liver transplantation complications. We carried out 105 paediatric cadaveric donor liver transplantations at our centre from 2001 to 2018. Percutaneous techniques were used to treat 25 cases involving transplantation complications in 23 patients. Biliary complications were treated in 14 cases (13.3%): 10 patients had bile duct obstruction, and 4 had biliary leaks. Vascular complications were treated in 11 cases (10.5%): 5 hepatic artery (HA) stenoses/occlusions, 2 inferior vena cava (IVC) stenoses, and 1 portal vein (PV) stenosis. Other interventions involved embolisation of the superior mesenteric artery branch to manage gastrointestinal bleeding in 2 patients and embolisation of an arteriobiliary fistula in 1 patient. Biliary: We carried out external-internal drainage and balloon dilatation of stenoses in 12 cases. The external-internal drainage catheter was removed after 6-8weeks in 7 patients, with the remaining 5 patients with persisting stenosis assigned for retransplantation. We failed to cross anastomotic occlusions in 2 patients before completing the procedures using external drainage; both individuals subsequently underwent retransplantation. Vascular: We performed PTA/stenting of HA stenoses/occlusions in 4 out of 5 patients. After the procedure, all 4 patients showed liver function normalisation. All 3 cases of embolisation were technically and clinically successful. Both IVC and PV stenoses treated with dilatation/stenting were also successful. Percutaneous techniques used to treat biliary and vascular complications after liver transplantation in paediatric patients are safe and efficient.

3018 Long Term Symptomatic Outcomes of Treatment of Uterine Fibroids in a Multidisciplinary Clinic

Study Objective To determine the utilization of medical, interventional radiologic, and gynecologic surgical treatments at a multidisciplinary fibroid clinic, also to assess pre- and post-intervention changes in fibroid symptoms, pelvic floor symptoms, and quality of life over a multi-year follow-up period. Design A retrospective survey study from 2013-2017. Setting Academic University Hospital. Patients or Participants 516 pre-menopausal women with pelvic MRI evidence of uterine fibroids seen at a multidisciplinary fibroid clinic from 2013-2017. Interventions Demographic and clinical information were collected including baseline Uterine Fibroid Symptoms – Quality of Life (UFS-QOL) and Pelvic Floor Distress Index (PFDI) questionnaires. All patients were sent a follow-up electronic survey at a single time point in 2018 assessing secondary treatments, fertility and re-administering UFS-QOL and PFDI questionnaires. Measurements and Main Results Our cohort of 516 patients utilized various treatments including hysterectomy (N=73, 17.1%), non-hysteroscopic myomectomy (N=68, 15.9%), and uterine fibroid embolization (N=117, 27.5%). Patients who underwent hysterectomy had worse baseline UFS-QOL and PFDI scores. 25.8% of patients responded to the follow-up survey with a mean follow-up interval of 28.6 months. Significant improvement was seen in UFS (-57.30% ± 66.90% vs -22.84% ± 55.50%, p=0.003) and PFDI (-61.20% ± 42.40% vs -11.82% ± 93.21%, p=0.012) scores for patients undergoing any intervention compared to expectant/medical management. There was no significant difference in UFS or PFDI improvement between interventional groups. Conclusion Patients undergoing any intervention reported better symptom improvement than patients undergoing expectant management or medical therapy. Symptomatic improvement based on UFS-QOL and PFDI scores were comparable between patients undergoing interventional radiologic procedures, myomectomy, and hysterectomy interventions.

2262 Too Much TAE: A Case of Tumor Lysis Syndrome After Repeat Transarterial Embolization of Hepatocellular Carcinoma

INTRODUCTION: Hepatocellular carcinoma (HCC) is the sixth most common cancer in the world &amp; the second highest cause of cancer-related deaths globally. In the US, HCC incidence has almost tripled since the 1980s &amp; has become the fastest rising etiology of cancer-related deaths. Tumor lysis syndrome (TLS) is a condition that results when malignant cells release their intracellular contents, either spontaneously or in response to cytoxic treatment. The cellular contents result in hyperuricemia, hyperkalemia, hyperphosphatemia, &amp; hypocalcemia; these disturbances can lead to arrhythmias, AKI &amp; death. TLS is common in leukemias &amp; lymphomas but is rare in solid tumors. CASE DESCRIPTION/METHODS: A 50-year-old female with biopsy proven HCC without cirrhosis was admitted for planned transarterial chemoembolization (TACE) of her large right lobe &amp; medial left lobe HCC, measuring 13.3 × 17.9 × 21.8 cm (Image 1), as too advanced for surgical resection or transplant &amp; she had large liver-lung shunt preventing radioembolization treatment. Interventional Radiology (IR) placed two vials of LC beads containing doxirubicin 100mg &amp; bland transarterial embolization (TAE) via 2.5 vials of Embospheres into right hepatic artery. Afterwards, she had acute drop in Hgb with CTA revealing multiple areas of active bleeding in the liver &amp; new hematoma centrally in the mass. IR performed complete embolization of the right hepatic artery using coils &amp; gelfoam to achieve hemostasis; patient was transferred to ICU. She received blood products &amp; lab monitoring, the latter demonstrated new hyperkalemia of 5.5 mmol/L, previously normal. Creatinine increased from 0.55mg/dL to 1.23, thought to be multifactorial. Additional workup revealed uric acid of 12.5mg/dL, calcium 6.9mg/dL &amp; phosphorous 7.4mg/dL. TLS was diagnosed &amp; treated with intravenous fluids for dilution, rasburicase for hyperuricemia, furosemide for renal dysfunction &amp; minimal urine output, &amp; insulin for hyperkalemia. DISCUSSION: HCC is a growing health burden, &amp; advanced tumors that are not candidates for surgical resection are commonly treated with radiofrequency ablation, TACE, TAE, &amp; chemotherapy. Early recognition of TLS is key for treatment &amp; involves awareness of the propensity for development of TLS in large tumor burdens, rapidly dividing tumors, multiple treatment sessions, &amp; pretreatment renal dysfunction. Oliguria after IR treatment of HCC should raise the suspicion for possible TLS &amp; not be easily dismissed as the common but less fatal contrast induced nephropathy.

Characteristics of patients treated for active lower gastrointestinal bleeding detected by CT angiography: Interventional radiology versus surgery

PurposeTo determine radiological or clinical criteria guiding treatment decisions in active lower gastrointestinal bleeding (LGIB). Materials and methodsWe consecutively and retrospectively included all patients admitted to our emergency department for acute LGIB proven by CT angiography (CTA) from 2004 to 2017. Patients were divided into two groups depending on whether they first underwent interventional radiological (IR) or surgical treatment. Two radiologists reviewed CTA and angiographic images. Patients’ hemodynamic and clinical parameters, delay between imaging and treatment, procedure characteristics, and outcomes were investigated to detect differences between the two groups. ResultsInitial management consisted of IR in 62 cases (70.5%) and surgery in 26 (29.5%). IR cases were older than surgical cases (74.3 vs 64.3y, p = 0.014). Baseline hemodynamic parameters were similar between the two groups. For colonic bleeding sources, the delay between CTA and IR was shorter than between CTA and surgery (p = 0.027), while there was a trend towards a shorter delay for all LGIB taken together (p = 0.061). In cases with hematochezia or melena, IR was more frequently performed than surgery (p = 0.001). Surgical cases showed higher base excesses (p = 0.039) and lactate levels (p = 0.042) after treatment compared with IR cases. Length of hospital stay was similar between the two groups (p = 0.728).During angiography, 41 (66%) cases were embolized. Complications occurred in three cases after IR (7%) and in five after surgery (19%). ConclusionInitial management of active LGIB revealed by CTA (i.e. IR versus surgery), may depend on age and clinical signs, rather than hemodynamic parameters.

Anatomy of the vasculature supplying hepatobiliary structures and celiac trunk branching patterns in the Thai population

Abstract Background Knowledge of the anatomy of the celiac trunk (CT) and arterial supply of the hepatobiliary system is essential for surgical and interventional radiological treatment of upper abdominal diseases. Objectives To determine the branching patterns of the CT and variation in origin and type of the right hepatic artery (RHA), left hepatic artery (LHA), and cystic artery (CA). Methods The anatomy of the CT in 100 cadavers from Thai adult donors was observed in 3 aspects: its branching pattern, the origin of the RHA and LHA, and the origin of the CA and its relation to the common bile duct (CBD) and common hepatic duct (CHD). Results The majority of the CT branching pattern was categorized as the type II classical pattern, which has 3 branches: the left gastric artery (LGA), splenic artery (SA), and common hepatic artery (CHA). The RHA branched from proper hepatic artery in 67 cadavers. The origin of the accessory RHA was either from the abdominal aorta or superior mesenteric artery (SMA), whereas the replaced RHA originated from the CHA, SMA, or CT. The accessory LHA ramified from CHA (2 cases) and LGA (1 case). The replaced LHA was found in 30 cadavers and 29 arose from the CHA. The single and double types of CA were found in 94 and 4 cadavers, respectively. In all, 57% of single CA passed posteriorly and 39% passed anteriorly to the CBD and CHD. Conclusions To lower posttreatment complications, variations in the anatomy and the vascular supply of hepatobiliary structures should be considered.

Endovascular stent placement for venous complications following pediatric liver transplantation: outcomes and indications.

Advances in interventional radiology (IVR) treatment have notably improved the prognosis of hepatic vein (HV) and portal vein (PV) complications following pediatric living donor liver transplantation (LDLT); however, graft failure may develop in refractory cases. Although endovascular stent placement is considered for recurrent stenosis, its indications are controversial. We enrolled 282 patients who underwent pediatric LDLT in our department from May 2001 to September 2016. 22 (7.8%) HV complications occurred after LDLT. Recurrence was observed in 45.5% of the patients after the initial treatment, and 2 patients (9.1%) underwent endovascular stent placement. The stents were inserted at 8 months and 3.8 years following LDLT, respectively. After stent placement, both patients developed thrombotic obstruction and are currently being considered for re-transplantation. 40 (14.2%) PV complications occurred after LDLT. Recurrence occurred in 27.5% of the patients after the initial treatment, and 4 patients (10.0%) underwent endovascular stent treatment. The stents of all the patients remained patent, with an average patency duration of 41 months. Endovascular stent placement is an effective treatment for intractable PV complications following pediatric LDLT. However, endovascular stent placement for HV complications should be carefully performed because of the risk of intrastent thrombotic occlusion and the possibility of immunological venous injury.

Cotreatment with lenvatinib and warfarin potassium caused prothrombin time prolongation.

Lenvatinib is approved as a standard systemic therapy for unresectable hepatocellular carcinoma (HCC) patients; however, experience with lenvatinib in clinical practice is insufficient. We present the case of a patient with advanced HCC whose prothrombin time - international normalized ratio (PT-INR) was elevated after cotreatment with lenvatinib and warfarin potassium. The patient was a 26-year-old man with congenital abnormalities who had to take warfarin potassium because he had a mechanical heart valve. He was diagnosed with unresectable HCC at 24years old and was treated by transcatheter arterial chemoembolization and transcatheter arterial infusion. After some interventional radiology treatments, lenvatinib was started. After 4days of treatment with lenvatinib and warfarin potassium, his PT-INR increased to 4.13, and the treatment had to be stopped. No changes were observed in other Child-Pugh score factors. The elevation in the PT-INR after cotreatment with lenvatinib and warfarin potassium was thought to be caused by pharmacological effects of concurrent use or pharmacological sensitivity to warfarin potassium in this patient with liver dysfunction. The PT-INR must be monitored when lenvatinib is given to advanced HCC patients taking warfarin potassium.

Portal Hypertensive Biliopathy in Adult Patients: Findings and Interventional Radiologic Treatment-A Single-Center Experience.

The aim of this study was to evaluate the morphologic appearance, the clinical scenario, and the outcomes of patients with portal hypertensive biliopathy (PHB), particularly in the symptomatic subgroup treated with interventional radiology (IR) procedures. The outcome of 20 patients with PHB were retrospectively reviewed over a 5-year period. In all cases, the extrahepatic portal vein occlusion (EHPVO) and the compensatory cavernomatosis was the cause of PHB. Eight out of 20 patients had severe symptoms (jaundice and bleeding). Five out of these eight patients were successfully treated with IR procedures. PHB is a rare but serious complication of PH from EHPVO. IR treatments are highly effective in controlling symptoms. Moreover, IR procedures, as drainage and transjugular intrahepatic portosystemic shunt placement, are the first-line treatment in cases of life-threatening bleeding from ruptures of the varices.

Assessment of the response of hepatocellular carcinoma to interventional radiology treatments.

According to Barcelona Clinic Liver Cancer (BCLC) guidelines, interventional radiology procedures are valuable treatment options for many hepatocellular carcinomas (HCCs) that are not amenable to resection or transplantation. Accurate assessment of the efficacy of therapies at earlier stages enables completion of treatment, optimal follow-up and to prevent potentially unnecessary treatments, side effects and costly failure. The goal of this review is to summarize and describe the radiological strategies that have been proposed to predict survival and to stratify HCC responses after interventional radiology therapies. New techniques currently in development are also described.

Biliary injuries after pancreatic surgery: interventional radiology management.

Bile duct injuries are among the most feared complications after pancreatic surgery. Most of these surgical complications are related to iatrogenic injuries and include bile leakage, biliary duct obstruction or stricture and infection. A wide range of Interventional Radiology treatment options are currently available. The options include percutaneous transhepatic cholangiography (PTC), percutaneous transhepatic biliary drainage (PTBD), percutaneous balloon dilatation and stenting, image-guided percutaneous abscess drainage. The purpose of this review is to describe the current evidence in this continuously evolving field.

New real-time patient radiation dosimeter for use in radiofrequency catheter ablation.

In a previous study, we reported on a novel (prototype) real-time patient dosimeter with non-toxic phosphor sensors. In this study, we developed new types of sensors that were smaller than in the previous prototype, and clarified the clinical feasibility of our newly proposed dosimeter. Patient dose measurements obtained with the newly proposed real-time dosimeter were compared with measurements obtained using a calibrated radiophotoluminescence glass reference dosimeter (RPLD). The reference dosimeters were set at almost the same positions as the new real-time dosimeter sensors. We found excellent correlations between the reference RPLD measurements and those obtained using our new real-time dosimeter (r2 = 0.967). However, the new type of dosimeter was found to underestimate radiation skin dose measurements when compared with an RPLD. The most probable reason for this was the size reduction in the phosphor sensor of the new type of dosimeter. We believe that, as a result of reducing the phosphor sensor size, the backscattered X-ray irradiation was underestimated. However, the new dosimeter can accurately determine the absorbed dose by correcting the measured value with calibration factors. The calibration factor for the new type dosimeter was determined (by linear regression) to be ~1.15. New real-time patient dosimeter design would be an effective tool for the real-time measurement of patient skin doses during interventional radiology treatments.

Interventional treatment options in pseudoaneurysms: different techniques in different localizations.

Pseudoaneurysms are commonly experienced vascular abnormalities. The increase in the number of surgical and arteriographic procedures has caused a higher prevalence of pseudoaneurysms. Conventional angiography is still the gold standard method for diagnosis, but other imaging modalities such as duplex Doppler ultrasonography, magnetic resonance angiography and computed tomographic angiography are useful in noninvasive detection. Over the past few years, interventional radiological treatment has evolved and taken the place of surgery in management. There are different kinds of percutaneous and endovascular treatment methods in pseudoaneurysm management. Treatment options depend on certain conditions. We used a case-based approach to discuss pseudoaneurysms and their appropriate treatment by interventional radiological methods in this article.

Abstract 190: Hybrid Strategy of Damage Control IR (DCIR) and REBOA Would be Feasible for Traumatic Hemorrhagic Shock Patients Suffering From Severe Pelvic Injuries

Introduction: Massive hemorrhage with pelvic injury is sometimes lethal. So, success or failure of hemostatic intervention in the hyperacute phase leads to survival of patients directly. Recently, a hybrid strategy with Operative Management (OM) and Interventional Radiology (IR) and/or Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for torso or pelvic severe trauma has been recognized world-widely. But, awareness of Damage control IR (DCIR) which is conscious of time and coagulopathy as Damage control surgery (DCS) is still not enough. So, we studied the possibility of the hybrid strategy with DCIR and REBOA for traumatic hemorrhagic shock patients with pelvic fracture. Methods: This study included patients who underwent traditional IR or DCIR with REBOA, if it were needed, for a traumatic shock state mainly due to pelvic fracture, at our emergency and trauma center. They were sorted into traditional IR group (group IR) and DCIR group (group DCIR). The primary endpoint was a survival rate in the first 30 days after injured. Secondary endpoints were fluid factors such as total amount of crystalloid infusion and blood transfusion within the first 24 hours, and for the duration of the recovery from shock state. Results: 64 trauma shock patients were sorted into group IR (n=38) and group DCIR (n=26). All REBOA patients (n=18) were in group DCIR. Initial systolic BP (group IR vs DCIR; 75mmHg vs. 54), RTS (5.66 vs. 4.12) and Ps (0.61 vs. 0.39) were significantly lower in group DCIR. ISS (32.8 vs. 41.5) and initial Shock Index (1.9 vs. 2.4) were higher in group DCIR significantly. There were no significant differences in the amount of total crystalloid infusion (7353+/-3152ml vs. 7140+/-5342ml) and blood transfusion (4183+/-3485ml vs. 3972+/-3188ml), and the survival rate (30/38 (79%) vs. 16/28 (62%)). But the required time to recovery from shock state was significantly shorter in group DCIR (65min vs. 43min). Conclusion: The hybrid strategy with DCIR and REBOA did not increase any amount of blood transfusion or crystalloid infusion or the mortality rate. But it could shorten the duration of shock state compared with traditional IR treatment. Thus, this hybrid strategy would be feasible for hemorrhage shock patients suffering from pelvic severe trauma.

Long-Term Tumor Control with Radiation Therapy for Symptomatic Spine Hemangioma

Data are scarce on long-term results of radiotherapy for symptomatic hemangioma of the spine. The purpose of our study is to report imaging and clinical evidence of tumor control with long-term follow-up after radiotherapy for visible tumor that was not well suited to surgical or interventional radiology treatment. Our study population is all 10 patients treated at our institution between 1968 and 2008 for symptomatic hemangioma of the spine. All patients in our series had substantial pain from visible hemangioma at the time of radiotherapy for which surgical resection or interventional radiology procedures where likely to result in high morbidity. Tumor location in the spine included lumbar in 40%, thoracic in 50%, and cervical in 10% of patients. The mean dose delivered was 47 Gy. Clinical follow-up was defined as no symptoms of recurrent tumor after RT. Imaging follow-up was defined as no increase in tumor size after RT. The mean imaging follow-up was 8.1 years and the mean clinical follow-up was 21.2 years. The crude calculation rate of local tumor control was 90% (9/10). The only patient with recurrence demonstrated tumor progression 30 years after RT. The actuarial rate of tumor control was 100% at 5, 10, 20, and 25 years. There were no grade 3+ treatment toxicities, no evidence of malignant transformation, and no evidence of second tumors in the treatment area. RT for symptomatic hemangioma of the spine provides long-term tumor control without complications. Radiation therapy should be considered in patients for whom surgical resection would result in unacceptable morbidity. Our preferred dose program is 45 Gy at 1.8 Gy per treatment.