Post Embolization Research Articles

Efficacy and Safety of Bronchial Artery Embolization on Hemoptysis in Chronic Thromboembolic Pulmonary Hypertension: A Pilot Prospective Cohort Study.

Managing hemoptysis in chronic thromboembolic pulmonary hypertension can be challenging due to the difficulties in maintaining coagulation homeostasis in affected patients. In this study, we evaluated the efficacy and safety of bronchial artery embolization in treating hemoptysis in chronic thromboembolic pulmonary hypertension patients. Pilot, prospective cohort study. A large respiratory medical institute. From January 1, 2012, to December 31, 2017, hospitalized chronic thromboembolic pulmonary hypertension patients were eligible for inclusion. Patients with pulmonary hypertension caused by other conditions, or who failed to participate in the follow-up were excluded. Hemoptysis in chronic thromboembolic pulmonary hypertension patients was treated with or without bronchial artery embolization based on whether the bleeding could be stopped with medication alone and patient willingness for bronchial artery embolization treatment. A total of 328 patients diagnosed with chronic thromboembolic pulmonary hypertension were consecutively collected, 317 patients were completed the follow-up. There were 15 chronic thromboembolic pulmonary hypertension patients with hemoptysis in total, and the occurrence rate of hemoptysis in chronic thromboembolic pulmonary hypertension patients was 4.7%. Among the hemoptysis chronic thromboembolic pulmonary hypertension patients, 10 (67%) underwent bronchial artery embolization, and five (33%) were treated with medication only. The median follow-up period for hemoptysis patients was 7.6 months. In patients underwent bronchial artery embolization treatment, oxygenation index and right heart function showed no significant difference between pre bronchial artery embolization and post bronchial artery embolization. Hemoptysis relapse (20% vs 80%; p = 0.025) and hemoptysis-related mortality (0% vs 40%; p = 0.032) were significantly lower, whereas the overall survival (90% vs 40%; p = 0.040) was higher in patients treated with bronchial artery embolization than in patients treated without bronchial artery embolization. Bronchial artery embolization procedure demonstrated effectiveness and safety to treat hemoptysis in chronic thromboembolic pulmonary hypertension patients at our center, but further controlled studies are needed before it can be considered as an effective therapy for these patients.

A 10-year-old boy with dyspnea and hypoxia: abernathy malformation masquerading as pulmonary arteriovenous fistula

BackgroundAbernethy malformation is an extremely rare congenital malformation characterised by an extrahepatic portosystemic shunt. Children with Abernathy malformation can develop hepatopulmonary syndrome (HPS) with pulmonary arteriovenous fistulas (PAVF) or pulmonary hypertension. PAVF manifests as central cyanosis with effort intolerance. We report a case of PAVF in a Ten-year-old Boy. Persistent symptoms identified Abernathy malformation as the cause of progressive symptoms and current understanding of this rare malformation is reviewed.Case presentationA case of 10-year-old boy with Abernethy malformation complicated with HPS initially managed as PAVF was presented. Selective lung angiography showed a typical diffuse reticular pattern on right lower lung, which suggested PAVF. However, cyanosis was not improved post transcatheter coil embolization. Then, liver disease was considered although the patient had normal aspartate aminotransferase and alanine aminotransferase. The significantly elevated serum ammonia was attracted our attention. Abdominal computed tomography also exhibited enlarged main portal vein (MPV), cirsoid spleen vein, and superior mesenteric vein (SMV). Angiography with direct opacification of the SMV with a catheter coming from the inferior vena cava (IVC) and going to the SMV via the shunt vessel (SHUNT) between the MPV and IVC. Occlusion the IVC with an inflated balloon, injection of contrast medium via a catheter placed in the SMV, MPV was showed and absence of intrahepatic branches. Abernethy malformation IB type is finally confirmed.ConclusionsAbernethy malformation is an unusual cause for development of PAVF and cyanosis in children. Clinicians must be suspicious of Abernethy malformation complicated with HPS. If patients have abnormal serum ammonia and enlarged MPV in abdominal CT, cathether angiography should be done to rule out Abernethy malformation.

Anti-Mullerian hormone before and after uterine artery embolisation in reproductive-age women seeking treatment for symptomatic fibroids

Background. Uterine fibroids are the most common of the benign gynaecological tumours, the definitive traditional treatment for which is either myomectomy or hysterectomy. Uterine artery embolisation (UAE) offers an alternative non-invasive option for treatment. There remain concerns as to the effects of UAE on ovarian reserve in women desirous of preserving ovarian function. Objectives. To determine the effect of UAE on ovarian reserve, as assessed by anti-Mullerian hormone (AMH) measured before and after embolisation, and to assess the trend in serum AMH in the medium term, up to 12 months post UAE. Methods. A cohort study between October 2012 and May 2015 recruited 40 women with symptomatic uterine fibroids. Serum AMH was measured prior to embolisation and post embolisation, at 2 weeks, 6 months and 12 months. Using descriptive statistics and bivariate analysis, pre-embolisation and post-embolisation AMH concentrations were compared. P <0.05 was considered statistically significant. Results. The median participant age was 38.5 years (range 31 - 45). Of the women recruited, 47.5% (19) were nulliparous, and 72.5% (29 women) of the total desired a pregnancy in the future. The median (standard deviation) AMH immediately prior to embolisation was 1.3 ng/mL (1.53), and post embolisation at 2 weeks, 0.9 ng/mL (1.98); at 6 months, 2.2 ng/mL (2.63); and 12 months, 3.5 ng/mL (1.54) ( p = 0.96). Conclusion. In the short to medium term, UAE for treatment of symptomatic fibroids was not found to be detrimental to ovarian reserve. There is a need for longer-term studies evaluating its effects on fecundity, considering that most women in the present study had a strong desire to maintain their fertility.

An Unusual Case of Autoimmune Hemolytic Anemia-Thinking Outside the Box for Management

A 27 year old male with no significant past medical history presented to an outside hospital for chief complaints of nausea/vomiting, epigastric pain, and acute jaundice. Initial laboratory workup revealed a hemoglobin of 5.5 g/dl, normal WBC and platelet count, elevated direct bilirubin (10 mg/dl), elevated lactate dehydrogenase (969 IU/L), low haptoglobin (<8 mg/dl), a peripheral smear showing rare polychromasia and spherocytes, and positive direct antiglobulin test (DAT: BS +, IgG +, C3d -) with presence of warm autoantibodies. All infectious disease testing was negative. Initial CT abdomen showed a normal sized spleen. The patient was diagnosed with idiopathic warm autoimmune hemolytic anemia and was treated with pulsed steroids, one dose of Rituximab, and transfused with up to 13 units of packed red blood cells. The patient did not respond to medical treatment, and after one week, the patient was transferred to our institution for escalation of care.At our institution, the patient presented with similar symptoms. Due to lack of response to packed red blood cell transfusions, As the patient continued a downtrend in the hemoglobin despite continued transfusion support, Transfusion Medicine advised to only transfuse phenotypically matched, least incompatible, packed red blood cells for significantly symptomatic anemia or hemodynamic instability. High dose steroid were continued and IVIG, Cytoxan and Vincristine were added to his warm autoimmune hemolytic anemia (WAIHA) therapy. Despite these efforts, the patient's hemoglobin continued to decrease despite an additional 9 RBC units transfused at our institution, reaching a hemoglobin nadir of of 2.1 g/dL. In addition, the patient developed thrombocytopenia, NSTEMI, and left lower quadrant pain accompanied by bloody bowel movements. A repeat CT scan of the abdomen was performed, which revealed an enlarged spleen with a span of 16.5 cm in its maximum dimension. Due to concerns for splenic infarction and/or rupture, and since the patient was not a candidate for surgery, partial splenic artery embolization was performed. Thirty percent residual viable spleen remained. Within hours post embolization, a dramatic increase in hemoglobin was observed without any additional transfusion support. Shortly after splenic embolization the patient developed severe left upper quadrant abdominal pain with a peri-splenic fluid measuring slightly greater than simple fluid attenuation on CT which was managed medically. After close observation the patient was discharged home 2 weeks after admission. At home the patient was doing well with the exception of persistent left upper quadrant pain. He had no clinical or laboratory signs of recurrent hemolysis. Three months post discharge, due to persistent left upper quadrant pain and presence of a splenic cyst, the patient underwent a laparoscopic splenectomy that was performed without complications. During this hospitalization, in preparation for surgery, compatibility testing showed no autoantibodies. However new clinically significant alloantibodies were identified.Hypersplenism and/or reticulocytopenia are infrequent complications of a warm autoimmune hemolytic anemia, constituting a life threatening complication that may not respond to standard therapy and may not qualify for surgical intervention. The above patient did not improve with any medical therapies and displayed a decreasing trend in hemoglobin that was accompanied by increasing lactate levels and NSTEMI. Splenic embolization achieved a dramatic response that was maintained through follow up. Due to recurrent pain from the embolization, the patient eventually received a splenectomy once he was stable. Four months after initial presentation, post infusion of 4 doses of Rituxan and steroid therapy, the autoantibodies were not detectable. However, the patient developed 3 alloantibodies post multiple transfusions. DisclosuresNo relevant conflicts of interest to declare.

Cerebral Lipiodol Embolization After Trans-Arterial Chemoembolization for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. Transcatheter arterial chemoembolization (TACE) is a frequently performed nonsurgical therapy for localized HCC. Common adverse effects of TACE include post embolization syndrome (50-60%), hepatic decompensation, hepatic abscess and gastroduodenal ulcers. Cerebral lipiodol embolism (CLE) is a rare complication of TACE and only few reports exist describing this complication. We report a case of cerebral lipoidal embolization. 62-year-old male with history of chronic hepatitis B (on treatment for 5 years) and Child Pugh A cirrhosis. Imaging done for HCC screening showed 1 lesion in the right lobe of the liver (segment 7/8) measuring up to 10.3 cm in maximum diameter (Image 1). This was proven to be HCC on biopsy. Initial treatment plan was to perform Y90 radioembolization followed by surgical resection. However hepatic angiogram for planned radioembolization revealed 55% pulmonary shunt. He subsequently underwent TACE. Few hours after the procedure, he was moved to ICU for lethargy, weakness and fever and was also noted to have bowel and bladder incontinence. Labs notable for AST 1327, ALT 435, Alk phos 2659, WBC 13.26, INR 1.4 and NH337.5.CT of the head without contrast showed no clear acute findings but small nonspecific area of increased attenuation in the superior colliculus were noted. Given high concern for cerebrovascular event, MRI of the brain was done which showed punctate acute infarcts throughout both cerebral hemispheres and pons highly suggestive of cerebral embolization of the lipoidal chemo particles (Image 2). CT angiogram of the head and neck was unrevealing. Subsequent Cardiac ECHO did not reveal any thrombus, valvular vegetation or atrial level shunt. This patient likely had right to left shunt (pulmonary arterio-venous or hepatopulmonary syndrome which are often times not well visualized on imaging). The exact embolization route often remains undetermined in the reported CLE cases. More sensitive studies to detect the presence of shunt were not pursued since they would not have changed the management. He was managed conservatively and was sent to rehabilitation on day 9 after the TACE. CLE is a rare but potentially serious complication in HCC patients receiving TACE. The clinical characteristics of CLE summarized in our study would help facilitate the ability of clinicians to careful select patients for TACE and provide timely diagnosis and management.2436_A Figure 1. Coronal view (MRI of the head) showing HCC in segment 7/8.2436_B Figure 2. Coronal view (MRI of the brain) showing multiple punctate infracts.

Utility of portal vein embolization in surgical management of locally advanced gallbladder cancer

Introduction: Portal vein embolization (PVE) enables surgical resection of hepatobiliary tumours which would otherwise be unresectable due to insufficient future liver remnant (FLR). Here, we evaluated the outcomes after PVE for carcinoma gallbladder (CaGB) cases necessitating major hepatectomy. Methods: Between August 2015 to July 2016, seventeen patients with CaGB needing extended right hepatectomy but having insufficient FLR on CT volumetry were offered PVE. Preoperative biliary drainage (PBD) was done to decrease bilirubin to <5mg/dL. Right PVE was done by ipsilateral approach using glue and lipiodal. Volumes were reassessed after 4 weeks before considering for surgery. Results: All the 17 cases were jaundiced and therefore required PBD. 2 patients had received neo-adjuvant chemo-radiotherapy. Technical success was achieved in all and there were no procedure related complications. Mean baseline segment 2+3 volume was 16.46 ± 5.07 % which increased to 25.34 ± 7.01% post embolization. Only 2 patients could undergo curative surgery despite increase in FLR, one of whom required ALPPS procedure due to inadequate FLR on intra-operative assessment. 8 cases had tumour progression, 2 developed main portal vein thrombosis, 1 developed portal hypertension, 3 had persistent sepsis or poor performance status and 1 defaulted. There was no post operative liver failure in the operated patients. Conclusions: FLR increase after PVE doesn't translate into improved resectabilty in locally advanced but resectable CaGB cases due to further disease progression. Hence, alternative approaches should be considered in these subset of patients.

Hepatic necrosectomy: an important procedure to manage massive hepatic necrosis

Just like pancreatic necrosectomy for infected pancreatic necrosis, here we describe a new term “hepatic necrosectomy” for infected hepatic necrosis. Infected hepatic necrosis is a rare but devastating complication after high grade liver injury and rarely post hepatic artery chemoembolization. Smaller areas of necrosis can be managed with antibiotics, but patients with sepsis and bacteremia needs percutaneous drainage. If both of these fails, then open or laparoscopic technique needs to be considered for hepatic necrosectomy. We present five patients whom we have managed with hepatic necrosectomy. First patient had post hepatic artery embolization left lobe necrosis and required open necrosectomy. Second patient had high grade liver trauma with right lobe hepatic necrosis. He developed sepsis and did not respond to antibiotics and percutaneous drainage. Finally, he required open debridement. Third and forth patients were post traumatic and had left portal vein branch and left hepatic artery -post traumatic thrombosis with devitalized segment II and III. Their triphasic CT Scans showed non-enhancing segment II and III. Subsequently both of them needed early curative debridement in form of left lateral segmentectomy. Fifth patient had blunt injury abdomen and presented late with sepsis. He had devitalised segment II and III with pancreatic neck transection and transverse colon crush injury. He required segment II-III resection with distal pancreatectomy and colectomy. Hepatic necrosis is common after high grade liver trauma and hepatic artery embolization. This complication can be safely managed with operative hepatic necrosectomy in conjunction with interventional procedures or with hepatic lobectomy.

Role of Renal Arterial Embolization (Rae) In Treatment of Iatrogenic Renal Arterial Injuries

Background: Trans-catheter renal arterial embolization (RAE) has emerged as a possible alternative to surgery in the management of iatrogenic renal arterial injuries. Objective: To discuss the role of renal arterial embolization in patients with iatrogenically-induced renal arterial injuries. Methodology: All cases were done at the Interventional Radiology Unit, Ain Shams University Hospital. Results: Technical and Clinical success rates of the RAE reached 90% for each, with post procedural complications that only amounted up to 30%, half of which was the post embolization syndrome that presents as fever, leukocytosis and pain and is treated conservatively. Conclusion: Renal artery embolization has proven to be a safe, minimally invasive option in the treatment of iatrogenic renal arterial injuries achieving high technical and clinical success rates.

Role of Renal Arterial Embolization (Rae) In Treatment of Iatrogenic Renal Arterial Injuries

Background: Trans-catheter renal arterial embolization (RAE) has emerged as a possible alternative to surgery in the management of iatrogenic renal arterial injuries. Objective: To discuss the role of renal arterial embolization in patients with iatrogenically-induced renal arterial injuries. Methodology: All cases were done at the Interventional Radiology Unit, Ain Shams University Hospital. Results: Technical and Clinical success rates of the RAE reached 90% for each, with post procedural complications that only amounted up to 30%, half of which was the post embolization syndrome that presents as fever, leukocytosis and pain and is treated conservatively. Conclusion: Renal artery embolization has proven to be a safe, minimally invasive option in the treatment of iatrogenic renal arterial injuries achieving high technical and clinical success rates.

Partial splenic artery embolization: an alternative management strategy for resistant thrombocytopenia of immune thrombocytopenic purpura (ITP)

A 69-year-old male presented with haematuria due to a recurrent carcinoma of the bladder in the background of resistant thrombocytopaenia with immune thrombocytopenic purpura. He required frequent platelet transfusions and was a high risk surgical candidate. Partial splenic artery embolization was performed with selective catheterization of the splenic artery. The initial platelet count of 32 x 109/L showed a marked increase after 48 hours, to 251 x 109/L. No complications such as post embolization syndrome were observed. This case report highlights that splenic artery embolization is a stand-alone alternative therapy, for selected patients with ITP having resistant thrombocytopaenia, especially in nonsurgical candidates.

Intraprocedural C-arm CT assisted trans-perforator embolization of deep arteriovenous malformations

Objective To explore the application of intraprocedural C-arm CT assisted trans-perforator embolization of deep arteriovenous malformations (AVM). Methods From July 2015 to June 2017 at Neurosurgery Department, Xuanwu Hospital Capital Medical University, a total of 21 cases of hemorrhagic deep AVM were retrospectively reviewed. There were 11 men and 10 women with the average age of 24.3 years old. Among them, 20 lesions were located at the basal ganglia and 1 lesion at the fourth ventricle. Three lesions were classified as Spetzler-Martin grade 4 and 18 lesions were grade 3. All patients were treated with transarterial embolization under general anesthesia. The tip of microcatheter was localized with intraoperative C-arm CT technique when trans-perforator embolization was intended. Results Among 21 patients, a total of 49 times of embolization were performed. Twenty-five times of intraoperative C-arm CT scans were used in 37 times of trans-perforator embolization. The tip of microcatheter was positioned 22 times at the safe region and 3 times at the dangerous area. The immediate post-operative angiography revealed complete occlusion or subtotal occlusion in 8 cases, obliteration of hemorrhage-related structures in 11 and partial embolization in 2. Intraoperative ventricular hemorrhage occurred in 2 cases and 1 of them presented with numbness of contralateral extremities post embolization. Twelve cases were followed up by DSA at 4-17 months post embolization. Five lesions which were obliterated completely or subtotally developed no further changes in follow-up angiogram when compared with immediate post-operative results. In 7 lesions which were treated with obliteration of hemorrhage-related structures, the nidus of 1 lesion disappeared completely and that in 6 other lesions had residues without hemorrhage-related structures. The remaining 9 cases were clinically followed up at 6 months post embolization. Recurrent hemorrhage and new-onset neurologic deficits were not found during follow-up period. Conclusion The tip of microcatheter could be localized with the assistance of intraoperative C-arm CT technique, which might facilitate more precise trans-perforator embolization for deep AVM. Key words: Intracranial arteriovenous malformations; Embolization, therapeutic; Tomography, X-ray computed; Perforator artery

Gel foam or microsphere particles for partial splenic artery embolization in managing patients with hypersplenism

Background and aim of studySpleen is the largest lymphoid organ on the human body, it has a very important immunological functions. Portal hypertension accompanied liver cirrhosis commonly leads to splenomegaly which may be complicated by hypersplenism. Also liver cirrhosis is frequently associated with decreased hematological indices with subsequent anemia, thrombocytopenia and leucopenia. Spontaneous bleeding can delay any surgical or endovascular intervention. Leucopenia with decreased immunity may interfere with treatment of cancer patients using chemotherapy. The objective of this prospective study is to achieve the maximum splenic tissue infarction with the least possible complications by performing partial splenic artery embolization in cases of hypersplenism through comparing two materials; gel foam in one group and microspheres in another group. Patients and methodsThe study was conducted from October 2014 to September 2015. Thirty patients included in this study were presented by hypersplenism. They were 14 males and 16 females with mean age of 51 years. All patients were subjected to full history taking, clinical examination, laboratory investigations, pelvi-abdominal US and interventional procedure (transcatheter partial splenic artery embolization). The patients were divided into two groups, group (1): Fifteen patients were subjected to partial splenic embolization (PSE) using gel foam, group (2): Fifteen patients were subjected to partial splenic embolization (PSE) using microspheres. ResultsMultiple complications appeared after the procedure some of them were of minor importance as post embolization syndrome (fever, pain and nausea) that continued for two days and disappeared in five patients. Haematemesis occurred in one patient of the first group. One case in the first group showed abscess formation after the procedure and this patient underwent the procedure using gel foam particles, four cases showed portal vein thrombosis, two in each group, Pleural effusion appeared in two patients of first group. Regarding the efficacy of the procedure, improvement in laboratory tests were nearly the same in both groups. However, regarding the occurrence of serious complications, the microsphere particles group show fewer complications than gel foam group. ConclusionPSE using gel foam or microsphere showed nearly the same efficacy with no significant difference between the improvement in laboratory tests. However, using microsphere particles was associated with fewer occurrences of serious complications when compared with using gel foam.

Transcatheter Arterial Embolization in Lower Gastrointestinal Bleeding: Ischemia Remains a Concern Even with a Superselective Approach

PurposeTo evaluate the safety, efficacy, and feasibility of transcatheter arterial embolization (TAE) in the treatment of lower gastrointestinal bleeding (LGIB). MethodsStudy group comprised all patients receiving angiography for LGIB in the Helsinki University Hospital during the period of 2004–2016. Hospital medical records provided the study data. Rebleeding, complication, and mortality rates (≤30 days) were the primary outcomes. Secondary outcomes included need for blood transfusions, durations of intensive care unit and hospital admissions, incidence of delayed rebleeding, and long-term complications, as well as overall survival. ResultsDuring the study period, angiography for LGIB was necessary on 123 patients. Out of 123, 55 (45%) underwent embolization attempts. TAE was technically successful in 53 (96%). Rebleeding occurred in 14 (26%). The complication rate was 36%, minor complications occurring in 10 (19%) and major in nine (17%). Major complications resulted in bowel resection in seven (13%). Post embolization ischemia was the most common single complication seen in nine (17%). The mortality rate was 6%. Survival estimates of 1 and 5 years were 79 and 49%. DiscussionLGIB is a severe physiological insult occurring in patients who are often elderly and moribund. Although major post embolization complications occur, transcatheter arterial embolization should be the first-line approach over surgery in profuse LGIB in patients with hemodynamic instability, when colonoscopy fails or is unavailable, or when computerized tomography angiography detects small intestinal bleeding.

3:54 PM Abstract No. 328 Aspirin is associated with lower bilirubin after embolization of hepatocellular carcinoma

In retrospective studies, aspirin is associated with improved survival when combined with TACE or TAE for HCC. However, the mechanism is unclear. An IRB-approved retrospective review was performed of 304 patients with HCC who were treated with TAE. The patients were divided into two groups, based on whether the patient took aspirin (n = 42) or did not take aspirin (n = 262) at the time of initial TAE. For each patient, the following information was collected: response of embolized tumors (mRECIST, 1 month post embolization), time-to-progression after initial embolization, initial site of progression (treated tumor, untreated liver tumor, or extrahepatic tumor), survival, and bilirubin pre- and post-embolization. Kaplan-Meier curves were compared using the log rank test. Proportions were compared using Fisher’s exact test. Bilirubin was compared using two-tailed t-tests. Patients taking aspirin versus not taking aspirin at the time of initial TAE for HCC had no difference in: initial response rate (88% vs 90% CR or PR, p = 0.59), median time-to-progression (6.2 mo vs 5.2 mo, p = 0.42), initial site of progression (p = 0.77), and fraction of patients dying with disease progression on imaging (88% vs 89%, p = 1). Prior to embolization, there was no difference in average bilirubin (0.8 vs 0.9, p = 0.11) or numerical Child Pugh score (5.5 vs 5.5, p = 0.65) for patients taking versus not taking aspirin. After embolization, bilirubin was significantly lower for patients taking aspirin, at 1 day (0.9 vs 1.3, p<0.001), 1 month (0.9 vs 1.2, p = 0.048), and 1 year (0.8 vs 1.0, p = 0.021) postprocedure. Median overall survival after initial embolization was higher for patients taking aspirin (57 vs 23 months, p = 0.008). Aspirin is associated with lower bilirubin and improved survival after TAE for HCC. It is not associated with any differences in response or time-to-progression.

Spontaneous Rupture of a Fibrolamellar Variant Hepatocellular Carcinoma in an Innocent Liver

Introduction: Fibrolamellar hepatocellular carcinoma (FL-HCC) is a unique variant of hepatocellular carcinoma. The majority of cases present with nonspecific symptoms like vague abdominal pain, weight loss and fatigue. Ruptured FL-HCC occurs rarely and mortality in the acute phase is very high. We report a rare case of a ruptured FL-HCC successfully managed with transarterial embolization for hemostasis. Case: A 37-year-old male previously in good health presented with a severe, sharp epigastric pain that started one hour prior to the presentation. He denied trauma, fever, nausea, vomiting, diarrhea. Tenderness in the epigastrium was noted, with no palpable masses, guarding or rigidity. His blood pressure and pulse were 159/105 mmHg and 105 beats/min. Platelets and coagulation parameters were within normal limits, while hemoglobin of 12 g/dL, wbc of 11 k/mL and elevated transaminases (AST of 214 IU/L, ALT of 138 IU/L, ALP 98 IU/L, T.Billi 1.5 mg/dL) were noted. Abdominal CT scan with contrast revealed an 8 cm lobulated mass with central hypodensity in the left hepatic lobe with perilesional blood and free pelvic fluid, indicating tumor rupture (figure 1). CT angiography showed tumor neovascularization from a branch of the left hepatic artery which was embolized using transarterial gelfoam. Liver MRI (figure 2) and biopsy (figure 3) were consistent with fibrolamellar variant hepatocellular carcinoma. Hepatitis serologies and AFP levels were unremarkable. After 4 days, as the symptoms resolved and the lab results were stable, patient was discharged and underwent a left hepatectomy 3 weeks later. Discussion: FL-HCC occurs commonly in the left lobe of a young and non-cirrhotic liver. Typically cross sectional imaging reveals a lobulated mass with well-defined margins, areas of hypervascularity and a central calcified scar. Histologic appearance is characterized by eosinophilic polygonal shaped cells separated by lamellar fibrosis. Surgical resection is the treatment of choice with better outcome when compared to conventional HCC. Disease recurrence after complete surgical resection is however high in the first 5 years. Tumors > 5 cm in size are at high risk for rupture with high mortality and recurrence rates secondary to significant spillage of tumor. While an emergency hepatectomy is preferred in unstable patients, those that are hemodynamically stable can undergo radiologic transarterial embolization for hemostasis followed by staged hepatectomy.Figure: Axial section of CT Abdomen and Pelvis with IV contrast: (on the left) An 8 x 7 cm heterogeneous lobulated mass with central hypo density in the left hepatic lobe with arrow pointing perilesional blood concerning for tumor rupture. (on the right) An arrow pointing hyperdensity fluid surrounding urinary bladder likely blood from tumor rupture.Figure: MRI of the abdomen with liver protocol post embolization showing a 7.7 x 6.6 cm well circumscribed expansile lesion in left lobe of liver with global hypo T2 signal intensity with areas of hyper T2 signal intensities as well as central stellate shaped scar of low T2 signal intensity.Figure: Histopathologic examination of haematoxylin and eosin stained liver biopsy specimen (on the left) under high power magnification showing tumor cells with hepatocellular appearance: large polygonal cells, ample eosinophilic cytoplasm, with focal bile pigment, marked nuclear atypia, and Intranuclear pseudoinclusions. (on the right) under low power magnification showing tumor cells separated by hyaline collagen.

EUS-Guided Coil Embolization and Glue Injection in the Management of Bleeding Gastric Varices

Endoscopic cyanoacrylate injection is the standard primary intervention for management of large gastric varices due to benefits seen in hemostasis and rebleeding rates when it is compared to sclerotherapy or with band ligation. This case demonstrates a the role of EUS guided coil embolization and glue injection utilizing Tornado coils and Cyanoacrylate glue in the management of such large bleeding gastric varices. The patient is a 55-year-old Hispanic male with a past medical history of a twenty-year alcohol intake and peptic ulcer disease who presented with hematemesis and melena. Physical exam of the patient was non contributory. He was started on a proton pump inhibitor, octreotide, and ceftriaxone. An initial EGD demonstrated moderate sized esophageal varices without stigmata of recent bleeding and large gastric varices with red wale marks. The patient underwent repeat EGD and EUS with Doppler imaging which demonstrated visualization of large gastric varices in the fundus. Doppler ultrasound techniques demonstrated large flow within the gastric varices. A Tornado coil and Cyanoacrylate glue were loaded into a Cook 19 gauge EchoTip needle. The large varices were injected with the Tornado coil and 3 cc of Cyanoacrylate glue leading to embolization and cessation of blood flow as demonstrated through Doppler investigation. The patient had no subsequent gastrointestinal bleeding and was discharged home on a proton pump inhibitor, propranolol, ceftriaxone, and Carafate with a plan to follow up in clinic in one week. Utilization of tornado coil's synthetic fibers in conjuntion with cyanoacrylate injection allows for a space occupation effect of the coil and cyanoacrylate retention leading to obliteration of the varix lumen with the added benefit of the need for less volume of cyanoacrylate. The techniques demonstrate the novel ability to manage large gastric varices specifically, with tornado coil and cyanoacrylate glue embolization through EUS guidance.Figure: EUS scope visualization of the gastric varices including Doppler views demonstrating large varices with turbulent flow.Figure: A FNA 19 gauge needle can be visualized puncturing the large cluster of gastric varices and the coil was introduced through the stylet followed by an injection of 3 ccs of cyanoacrylate glue.Figure: Doppler visualization post injection demonstrating decreased flow in the gastric varices post embolization.

Toxicity of Liver-Directed Therapies for Hepatocellular Carcinoma

AbstractThe purpose of this review is to outline the various toxicities of liver-directed therapy approaches employed for treatment of liver-limited hepatocellular carcinoma. The covered topics span toxicities related to ablative and transarterial treatment approaches, including radiofrequency and microwave ablation, cryoablation, percutaneous ethanol injection, transarterial chemoembolization, and yttrium-90 radioembolization. Both common entities, such as postablation, and post(radio)embolization syndrome and hepatotoxicity, as well as uncommon topics (nontarget organ damage, cryoshock, infections, bile duct injuries) are described. Appropriate treatments for management of these side effects are suggested.

Posterior Reversible Encephalopathy Syndrome Due To Carcinoid Crisis Complicating Transarterial Chemoembolization for Metastatic Carcinoid Tumour

Posterior Reversible Encephalopathy Syndrome Due To Carcinoid Crisis Complicating Transarterial Chemoembolization for Metastatic Carcinoid Tumour

The histological growth patterns of colorectal cancer liver metastasis are associated with disease progression post portal vein embolization

The histological growth patterns of colorectal cancer liver metastasis are associated with disease progression post portal vein embolization

In situ forming biodegradable poly(ε-caprolactone) microsphere systems: a challenge for transarterial embolization therapy. In vitro and preliminary ex vivo studies

ABSTRACTBackground: In situ forming biodegradable poly(ε-caprolactone) (PCL) microspheres (PCL-ISM) system was developed as a novel embolic agent for transarterial embolization (TAE) therapy of hepatocellular carcinoma (HCC). Ibuprofen sodium (Ibu-Na) was loaded on this platform to evaluate its potential for the treatment of post embolization syndrome.Methods: The influence of formulation parameters on the size/shape, encapsulation efficiency and drug release was investigated using mixture experimental design. Regression models were derived and used to optimize the formulation for particle size, encapsulation efficiency and drug release profile for TAE therapy. An ex vivo model using isolated rat livers was established to assess the in situ formation of microspheres.Results: All PCL-ISM components affected the studied properties and fitting indices of the regression models were high (Radj2 = 0.810 for size, 0.964 encapsulation efficiency, and 0.993 or 0.971 for drug release at 30 min or 48 h). The optimized composition was: PCL = 4%, NMP = 43.1%, oil = 48.9%, surfactant = 2% and drug = 2%. Ex vivo studies revealed that PCL-ISM was able to form microspheres in the hepatic arterial bed.Conclusions: PCL-ISM system provides a novel tool for the treatment of HCC and post-embolization syndrome. It is capable of forming microspheres with desirable size and Ibu-Na release profile after injection into blood vessels.