Selective Hepatic Artery Embolization Research Articles

Spontaneous hepatic haemorrhage after caesarean section in a patient with uraemia and superimposed preeclampsia: a case report

Perinatal spontaneous hepatic haemorrhage is a very rare disease affecting pregnant women, particularly those on long-term dialysis, that has a high maternal and infant mortality rate. Most patients experience preeclampsia with haemolysis, elevated liver enzymes and low platelets syndrome. Here, the case of a 35-year-old multigravida patient with known chronic kidney disease and chronic hypertension with uraemia, who developed spontaneous hepatic haemorrhage after caesarean section, is described. The patient experienced sudden massive circulatory failure, but hemodynamics were temporarily stabilized after emergency surgery. Following transfer to the intensive care unit for continued treatment, her blood pressure and haemoglobin level continued to drop. Selective hepatic artery embolization was performed on day 2 after delivery, and her vital signs gradually stabilized. On day 30 after delivery, the patient was discharged in a stable condition. The newborn recovered after therapy in neonatal intensive care for 2 months. The present case suggests that, for perinatal spontaneous hepatic haemorrhage, timely and accurate diagnosis, multidisciplinary management and determining the therapeutic approach according to clinical symptoms are essential.

Transcatheter Arterial Embolization for Blunt Hepatic Trauma in a Preschooler

Published reports regarding the use of transcatheter arterial embolization (TAE) for blunt hepatic trauma in young children, especially preschoolers (3–5 years old), are still scarce. We present a case report of a 4-year-old girl who was involved in a motor vehicle accident while sitting in the passenger seat without wearing a seatbelt. Focused Assessment with Sonography for Trauma and contrast-enhanced computed tomography scan showed severe liver injury with signs of active intraabdominal bleeding. Selective hepatic artery embolization was performed to control arterial hemorrhage. No procedure-related complications occurred, and she was discharged on foot on day 14. TAE is a safe and effective treatment for hemostasis in blunt hepatic trauma, and it should be strongly considered as a treatment option not only in adults but in young children as well.

Effect of drug-eluting bead transarterial chemoembolization loaded with cisplatin on normal dogs.

Transcatheter arterial embolization (TAE) and transcatheter arterial chemoembolization (TACE) are standard treatments for advanced hepatocellular carcinoma (HCC) and particularly for unresectable tumors or liver metastases in humans. However, reports on TACE used in veterinary medicine are few. This study aimed to evaluate the feasibility and safety of drug-eluting bead transarterial chemoembolization (DEB-TACE). We performed DEB-TACE in four clinically normal dogs and pharmacokinetically compared the results against hepatic arterial infusion (HAI) of cisplatin in two dogs. Drug-eluting beads (DEB) loaded with cisplatin were injected through a microcatheter for selective embolization of the left hepatic artery. After embolization, computed tomography (CT) images and histological examination findings were obtained during a 4-week observation period. Serum platinum concentrations were measured to evaluate cisplatin after each procedure. Biochemical analysis was performed during a 12-week observation period. Embolization was successful in all dogs, and there were no clinically apparent abnormalities. Embolization was confirmed up to 4 weeks after DEB-TACE in two of the four dogs and up to 1 week in the other two dogs using postoperative CT images. Cisplatin was not detected in peripheral veins in all dogs after DEB-TACE, but it was detected in trace amounts after HAI. DEB-TACE using cisplatin was safe and well tolerated by normal dogs. DEB-TACE may be useful in terms of determining systemic toxicity and drug concentration within tumors.

Hemodynamic course during ablation and selective hepatic artery embolization for metastatic liver carcinoid: a retrospective observational study

BackgroundManipulation of carcinoid tumors during ablation or selective hepatic artery embolization (transarterial embolization, TAE) can release vasoactive mediators inducing hemodynamic instability. The main aim of our study was to review hemodynamics and complications related to minimally invasive treatments of liver carcinoids with TAE or ablation. MethodsElectronic medical records of all patients with metastatic liver carcinoid undergoing ablation or TAE from 2003 to 2019 were abstracted. Noted were severe hypotension (mean arterial pressure [MAP] ..± 55.ßmmHg), severe hypertension (systolic blood pressure ... 180.ßmmHg), and perioperative complications. Associations of procedure type and pre-procedure octreotide use with intraprocedural hemodynamics were assessed using linear regression. A robust covariance approach using generalized estimating equation method was used to account for multiple observations. ResultsA total of 161 patients underwent 98 ablations and 207 TAEs. Severe hypertension was observed in 24 (24.5%) vs. 15 (7.3%), severe hypotension in 56 (57.1%) vs. 6 (2.9%), and cutaneous flushing observed in 2 (2.0%) vs. 48 (23.2%) ablations and TAEs, respectively. After adjusting for preprocedural MAP, ablation was associated with lower intraprocedural MAP compared to TAE (estimate -27.ßmmHg, 95%CI -30 to -24.ßmmHg, p.ß<.ß0.001). Intraprocedural declines in MAP were not affected by preprocedural use of octreotide (p.ß=.ß0.7 for TAE and p.ß=.ß0.4 for ablation). ConclusionsAblation of liver carcinoids was associated with substantial hemodynamic instability, especially hypotension. In contrast, a higher number of TAE patients had cutaneous flushing. Preprocedural use of octreotide was not associated with attenuation of intraprocedural hypotension.

Effect of Intrahepatic Arterial Delivery of Sorafenib on Normal Liver Tissue of Rabbit: An Experimental Study

Objective: To assess the safety, feasibility and eluting efficiency of intrahepatic arterial delivery of sorafenib on normal liver tissue of rabbit. Methods: 24 New Zealand rabbits were randomly divided into three groups: group Ⅰ (Lipiodol-sorafenid), group Ⅱ (Lipiodol) and group Ⅲ (Sorafenib). Group Ⅰ and Ⅱ were treated by transcatheter selective hepatic arterial embolization with emulsions of lipiodol and sorafenib or with only lipiodol, while group Ⅲ was given hepatic arterial infusion with sorafenib. Sorafenib concentration in plasma was determined by HPLC (high performance liquid chromatography) in 0 min, 20 min, 1h, 2h, 4h, 8h, 16h, 32h and 48h respectively. The breathing rate, heart rate, rectal temperature and body weight were measured, as well the blood routine test and the function of liver, kidney, and heart. Two animals of each group were respectively killed in the 3rd day, 1st, 3rd and 6th week after treatment. Histopathologic study was done to liver, heart, kinney, lung, brain, gall bladder and intestine. Result: ① The peak sorafenib concentration (Cmax)and AUC(Area under curve) in plasma in groupⅠwas 2.46±0.101μg/ml and 945.72 ± 52.3 μg/mL.min respectively, while in group Ⅲ which was 3.78±0.180 ug/ml and 546.98±21.1μg/mL.min. Compared with groupⅢ, the Cmax and AUC of groupⅠhad a significant statistics difference (p&lt;0.05). ② The breathing rate, heart rate, rectal temperature and AST/ALT,WBC,NEU% of group Ⅰand groupⅢhas a significant statistics difference(p&lt;0.05) in the 3rd day. ③CK ,CK-MB, DB, Cr，BUN,RBC,PLT in plasma did not change in all group.④Local necrosis was seen in group Ⅰand group Ⅱin the 3rd day and 1st week, but they did not seem to be different. Group Ⅲ showed no necrosis. Granulation tissue with bile duty, portal vein and microfossils hyperplasia were seen in local necrosis area in the 3rd week. No pathological changes were found in brain, heart, kidney, intestine and gallbladder. Conclusion: TAE with emulsions of lipiodol and sorafenib is feasible, safe and has some slow-release effect.

Experimental Study on Evaluation of Blood Supply Level and Embolization Ratio of Liver Cancer Based on I-Flow Software.

Objective:To confirm the feasibility and accuracy of the method for evaluating blood supply and embolization rate of liver cancer based on I-flow software through animal experiments and clinical study.Methods:Rabbits underwent selective angiography under different perfusion conditions in the same kidney. The blood supply level was evaluated by I-flow software method. The results were analyzed for coefficient of variation. Thirty patients with liver cancer who underwent selective hepatic artery embolization were enrolled. The mathematical methods and 3 diagnostic specialists were used to evaluate the preoperative blood supply level and embolization rate. The results were recorded and the results were tested for consistency.Results:Animal experiments confirmed that the blood supply level analysis method designed by the research team was consistent under different contrast conditions (including total contrast agent, contrast medium perfusion rate, and limiting pressure) (coefficient of variation: 8.55%). The mathematical calculation results of preoperative blood supply level and embolization ratio of liver cancer are consistent with the average value of visual judgment results of diagnostic experts. (Preoperative blood supply level: concordance coefficient = 0.284, P = 0.003; embolization ratio: concordance coefficient = 0.218, P = 0.011).Conclusion:Based on I-flow software, the mathematical calculation method designed by this research group can effectively estimate the preoperative blood supply level of liver cancer and the embolization rate of single vascular embolization treatment, which can provide reliable data support for embolization treatment of liver cancer.

A clinical study comparing two different treatment methods in patients with polycystic liver disease using super selective hepatic arterial embolization

Objective To compare the effectiveness and safety of two different treatment methods for patients with polycystic liver disease using super selective hepatic arterial embolization. Methods This retrospective study enrolled 41 patients with polycystic liver disease treated from June 2008 to June 2016 in the First Medical Center of Chinese PLA General Hospital. The patients underwent transcatheter super-selective hepatic arterial embdization (TAE). There were 5 men and 36 women. The age ranged from 36 to 68 years. The patients were divided into the observation group (n=14) and the control group (n=27). The observation group underwent treatment using an emulsion of iodized oil and bleomycin and N-butyl-2-cyanoacrylate. The control group underwent iodized oil and N-butyl-2-cyanoacrylate. The clinical symptoms, operative complications, volumes of intrahepatic cysts, hepatic parenchyma volumes of pre-TAE and post-TAE at 3, 6 months and every 6 monthly were compared. Results TAE was technically successful in all the patients. The follow-up periods ranged from 24 to 72 months. The clinical symptoms improved remarkably in the observation group at 3 month, 6 months, 12 months, and 24 months, being 92.9% (13/14), 92.9% (13/14), 92.9% (13/14), 92.3% (12/13), respectively. One patient was lost to follow-up 24 months after operation. The clinical symptoms improved remarkably in the control group at 3 month, 6 months, 12 months, and 24 months, being 88.9% (24/27), 85.2% (23/27), 84.6% (22/26), 81.8% (18/22), respectively. One patient was lost to follow-up 12 months after operation and five patients were lost to follow-up 24 months after operation. Compared with preoperative, the abdominal circumference of two groups had decreased, the total volume of intrahepatic cyst and liver decreased at 6 months, 12 months, and 24 months after surgery (P<0.05). Conclusions TAE was a safe and effective treatment for polycystic liver disease. Patients in the observation group had more effective treatment outcomes on follow-up. Key words: Embolization, therapeutic; Angiography, digital subtraction; Treatment outcome; Polycystic liver disease

03:09 PM Abstract No. 219 Local immunotherapy: Intra-arterial liver tumor vaccination in a pig model of metastatic pancreatic cancer

Locoregional therapy lacks the ability to treat systemic disease. Systemic chemotherapy or immunotherapy has significant systemic side effects. Here, we present a proof-of-concept of intra-arterial immunotherapy using saponins (a vaccine adjuvant) in a pig tumor model. Liver and peripancreatic tumors were induced in an Oncopig (a transgenic pig with Cre-inducible p53 and Kras mutations) using an adenoviral vector carrying the Cre recombinase gene. A lipiodol/saponin emulsion was injected selectively into a branch of the hepatic artery through a 4 F catheter. Response to therapy was evaluated on contrast-enhanced CT and necropsy. As a negative control, selective hepatic artery embolization using 100-300 micron Embospheres was performed in a different pig. After selective hepatic artery immunoembolization using the lipiodol/saponin emulsion, CT performed 3 days later showed 19% decrease in size of the embolized liver tumors (n=2), 71% decrease in size of an unembolized liver tumor (n=1), and 25% decrease in size of peripancreatic tumors (n=2). On histology, tumor-infiltrating lymphocytes were seen in the necrotic liver tumors, and no viable tumor cells were seen in the liver or peripancreatic tumors. In the negative control pig (n=1), selective hepatic artery embolization using Embospheres resulted in tissue necrosis without a detectable local immune response on histology. In a pig model, intra-arterial tumor vaccination using lipiodol/saponin emulsion resulted in tumor-infiltrating lymphocytes, tumor necrosis, and regression of both intrahepatic and extrahepatic tumors. Additional experiments are necessary to confirm these encouraging preliminary results.

Local treatment for focal progression in metastatic neuroendocrine tumors.

New systemic treatments have improved the therapeutic landscape for patients with metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NETs). While drugs such as everolimus, sunitinib, temozolomide, and 177Lutetium-dotatate are appropriate for patients with widespread disease progression, local treatment approaches may be more appropriate for patients with unifocal progression. Surgical resection, radiofrequency ablation (RFA), hepatic arterial embolization (HAE), or radiation, can control discrete sites of progression, allowing patients to continue their existing therapy, and sparing them toxicities of a new systemic treatment. We identified 69 patients with metastatic GEP-NETs who underwent a local treatment for focal progression in the setting of widespread metastases. 26% underwent resection, 27% RFA, 23% external beam radiation, and 23% selective HAE. With a median follow-up of 25 months, 42 (61%) patients subsequently progressed to the point of requiring additional intervention (12 locoregional, 30 systemic) for disease control. Median time to new systemic treatment was 32 months (95% CI, 16.5 - 47.5 months). Median time to any additional intervention was 19 months (95% CI, 8.7 - 25.3 months). Control of local sites of progression enabled the majority of patients to remain on their existing systemic treatment and avoid potential toxicities associated with salvage systemic therapy.

Elective Regional Therapy Treatment for Hepatic Adenoma.

Locoregional therapy treatments for hepatic adenoma (HA) are typically limited to selective hepatic arterial embolization (HAE) to control acute hemorrhage. This systematic review sought to report the utilization of HAE and ablation for non-emergent treatment of HA. A PubMed query identified studies reporting ablation or embolization for HA patients. Abstracts were screened to exclude studies with only patients managed for acute hemorrhage. Outcomes of interest included rate of success, complications, and repeat procedures. Of 209 initial search results, 33 full-text publications were reviewed, and 10 were selected after applying the exclusion criteria. All were published from 2005 to 2016. A total of 105 patients were included, of which 66 patients with 138 adenomas underwent elective locoregional therapy treatment. The mean size of treated adenomas was 2.9 (range 0.8-8.3) cm. HAE was utilized in 25 patients with 58 adenomas, whereas 35 patients with 68 adenomas underwent radiofrequency ablation. Six patients with 12 adenomas received microwave ablation. Most patients were female (89/105), and adenomas were associated with oral contraceptive use or hormonal therapies in 49 of 105 patients. Success was reported in 115 of 138 first-time procedures, and repeat procedures were needed after 18 of 138. Mean follow-up time was 36.4months, with two complications. Reports of elective locoregional therapy for the treatment of HA are limited to case reports and small institutional series. In the select patients treated, outcomes are acceptable, with low rates of repeat procedures or complications. This systematic review warrants further discussion and broader consideration for the treatment of HA.

Portal vein aneurysm associated with arterioportal fistula after hepatic anterior segmentectomy: Thought-provoking complication after hepatectomy

BackgroundFew cases of postoperative arterioportal fistula (APF) have been documented. APF after hepatectomy is a very rare surgery-related complication.Case presentationA 62-year-old man was diagnosed with hepatocellular carcinoma in segments 5 and 8, respectively. Anterior segmentectomy was performed as a curative surgery. Each branch of the hepatic artery, portal vein, and biliary duct for the anterior segment was ligated together as the Glissonean bundle. The patient was discharged on postoperative day 14. Three months later, dynamic magnetic resonance imaging showed an arterioportal fistula and portal vein aneurysm. Surprisingly, the patient did not have subtle symptoms. Although a perfect angiographic evaluation could not be ensured, we performed angiography with subsequent interventional radiology to avoid sudden rupture. Arteriography was immediately performed to create a portogram via the APF from the stump of the anterior hepatic artery, and portography clearly revealed hepatofugal portal vein flow. Portography also showed that the stump of the anterior portal vein had developed a 40-mm-diameter portal vein aneurysm. Selective embolization of the anterior hepatic artery was accomplished in the whole length of the stump of the anterior hepatic artery, and abnormal blood flow through the APF was drastically reduced. The portal vein aneurysm disappeared, and portal flow was normalized. Dynamic computed tomography after embolization clearly demonstrated perfect interruption of the APF. The patient maintained good health thereafter.ConclusionsPost-hepatectomy APFs are very rare, and some appear to be cryptogenic. Our thought-provoking case may help to provide a possible explanation of the causes of post-hepatectomy APF.

Outcomes of locoregional treatment for unifocal progression in widespread metastatic gastroenteropancreatic neuroendocrine tumors.

472 Background: New systemic treatments have improved the therapeutic landscape for patients with progressive, metastatic GEP-NETs. While drugs such as everolimus are appropriate for patients with widespread disease progression, local treatment approaches may be more appropriate for patients with unifocal progression. Surgical resection, radiofrequency ablation (RFA), hepatic arterial embolization (HAE), or radiation, can control discrete sites of progression, allowing patients to continue their existing therapy, and sparing them toxicities of a new systemic treatment. Methods: We reviewed records of patients treated at a large referral center to identify patients seen between 1/2014 and 5/2017 with metastatic GEP-NETs who underwent a local treatment for focal progression. Patients undergoing lobar HAE or cytoreductive hepatic surgery were not included. The primary endpoint was time to new systemic therapy. Secondary endpoints included time to any additional intervention (systemic or local), progression free survival, and side effects of treatment. Results: 59 patients were identified who underwent a form of local treatment for a progressive metastatic tumor in the setting of widespread metastases. 27% underwent resection, 29% RFA, 25% external beam radiation, and 19% selective HAE. With a median follow-up of 17 months, 19 patients (32.2%) eventually progressed to the extent that they received salvage systemic treatment. 6 patients (10.2%) progressed and received further local treatment. Median time to new systemic treatment was 42 months (95% CI, 9.7-74.3 months). Median time to any additional intervention was 21 months (95% CI, 11.4-30.6 months). 4 patients died, all of whom had progressed and received further systemic treatment. Conclusions: We identified a large cohort of patients with metastatic GEP-NETs who underwent a local treatment for unifocal progression in the setting of widespread metastases. Control of local sites of progression enabled the majority of patients to remain on their existing systemic treatment and avoid potential toxicities associated with salvage systemic therapy.

Hepatic Arterial Embolization Using Cone Beam CT with Tumor Feeding Vessel Detection Software: Impact on Hepatocellular Carcinoma Response.

Dedicated tumor feeding vessel detection software (TFVDS) using cone beam CT has shown a higher sensitivity to detect tumor feeding vessels during hepatic arterial embolization (HAE) of hepatocellular carcinoma (HCC) compared to 2D imaging. Our primary hypothesis was that HCC tumors treated with HAE guided by a TFVDS would show more complete response (CR) than when treated with 2D imaging alone. Secondary analysis of the impact on X-ray exposure was performed. Nineteen males and 8 females (median age: 69year, 46-85) with 44 tumors (median size: 38mm, 6-100) treated with selective HAE between January 2013 and December 2014 were included. Exclusion criteria were: extra-hepatic supply, >4 tumors, tumor size >10cm, and adjunctive local therapy. Baseline patient and procedure characteristics were reviewed. Differences in CR per modified Response Evaluation Criteria in Solid Tumors were assessed by univariate and multivariate analyses for tumor size, number, location, particles size, and use of TFVDS. Median imaging follow-up was 20.1months (2-33). Use of TFVDS (13 patients, 19 tumors) was the only factor predictive of CR (OR=3.85 [CI95%: 1.09, 13.67], p=0.04) on univariate analysis but not on multivariate analysis (OR=3.26 [0.87, 12.23], p=0.08). A higher rate of CR was observed for HAE using TFVDS guidance versus 2D imaging alone (68.4%, 13-19, vs. 36%, 9-25, p=0.03). Median dose area product was lower when TFVDS was used (149.7Gy.cm2, 38-365, vs. 227.8Gy.cm2, 85.3-468.6, p=0.05). HCC embolized with TFVDS may result in improved local tumor response without increasing the dose exposure.

Transcatheter arterial embolization in normal canine liver.

To determine the effects of selective transcatheter arterial embolization (TAE) in the normal canine liver. Experimental study. Adult Beagle dogs (n = 5). Gelatin sponge particles (GSPs) were injected through a microcatheter for selective embolization of the left hepatic artery in normal dogs. Computed tomography (CT) and histology were performed during an 8-week observation period; biochemical analysis data were obtained during a 12-week observation period after TAE. Embolization was successful in all dogs and did not induce any change in the clinical appearance of dogs. Postoperative CT was consistent with recanalization of the artery within 2 weeks of embolization in all dogs. Hepatic enzyme levels increased temporarily after embolization but gradually returned to normal ranges. Histological examinations did not differ between treated and untreated liver tissues. TAE appears safe in normal dogs observed for 12 weeks. Arterial recanalization seems to occur within 2 weeks after injection of GSPs in the left hepatic artery. Selective TAE of the hepatic artery was well tolerated in normal dogs. Selective TAE may be applicable to canine hepatocellular carcinoma.

Embolization of Liver Hemangiomas

Dear Editor, It was with great interest that we read the article entitled “Management of liver hemangioma using trans-catheter arterial embolization” by Firouznia et al. (1). By way of this article, we can comment on liver hemangiomas and their embolization. Does the embolization of liver hemangiomas have a therapeutic or a palliative role? In infants, the embolization of liver hemangiomas with congestive heart failure demonstrates therapeutic efficiency by the rapid resolution of heart failure. This is because of the collaterals between the hepatic artery and the hepatic veins. In adults, heart failure due to a giant hemangioma is very rare and the most common indication in adults is a kind of pain in the trunk. The expectation from the embolization of a liver hemangioma is the cessation of symptoms as a result of the shrinkage of the hemangioma. Although some authors (2-4) have reported satisfactory results with a significant decrease in the size of hemangiomas after embolization, others have found little or no effect on the symptoms (5, 6). After embolization, some amount of shrinkage almost always occurs in the hemangioma but this decrease in size may be far from the expectations of clinicians and patients. There are several reasons for this disappointment. First, although most patients wait for pain relief, the pain increases in the post-embolization period and some symptoms of the hemangioma may continue in the long term. Secondly, the amount of the decrease in the size of the hemangioma can be lower than expected. Whereas three-dimensional computed tomography calculations report a satisfactory decrease in the volume of hemangiomas after embolization (7), two-dimensional measurements usually fail to show any significant decrease in size (5). Thirdly, the shrinkage of a hemangioma after embolization is transient and it reaches its previous volume after a short period of time. It is, therefore, difficult to claim a clear therapeutic effect for the embolization of liver hemangiomas. Does the embolization of liver hemangiomas have any efficiency before surgery to decrease blood loss and to facilitate surgery? The embolization of a liver hemangioma before surgery results in its shrinkage and may confer an easier and quicker dissection of the hemangioma from the retroperitoneal space and its neighboring attachments (8). A remarkable volume reduction of the tumor may allow for a safe approach to the major vascularities of the liver (7). Much as the embolization of a liver hemangioma before surgery helps surgeons, the main determinant of blood loss still depends on the morphology of the hemangioma (i.e. size and location), surgical expertise, and technique. How long should the time interval between embolization and surgery be? It is well known that the embolizing effect is transient and that it is beneficial to surgery only if it is performed just before the operation. The studies that have justified preoperative embolization recommend it one day before the operation (9, 10). If the patient has a history of embolization in the past, a new embolization session is necessary before surgery. What are the adverse effects of embolization? The most common complications of embolization are related to the thrombosis and necrosis of the liver hemangioma. They include pain in the hemangioma region, fever, nausea, and decreased appetite, which usually lasts less than 1 week (2, 3, 5). Laboratory results demonstrate a frequent leukocytosis and some deterioration of the liver function tests. The values of the liver function tests usually rise for 3 days after the procedure and return to normal within 2 weeks (2). Serious complications are fortunately rare but possible. Liver abscess, liver failure, sepsis, and migration of the embolizing agent to an unrelated organ such as lungs, gallbladder, and kidneys as well as death due to embolization are all reported complications (2, 3, 5). Does the surgical technique matter after embolization? There is debate on the technique of surgery on liver hemangiomas in terms of liver parenchymal resection and enucleation through the hemangioma capsule. There is no randomized study yet to compare both techniques. It seems to us that preoperative hepatic arterial embolization and enucleation is a reasonable combination instead of embolization plus the formal liver resection. Selective embolization does not decrease the arterial supply of the line of the formal resection and it may even relatively increase the arterial supply of the remaining liver. This hypothesis may explain the more blood loss in the cases of preoperative selective hepatic arterial embolization combined with the formal hepatic resection (7).

Nonfunctional Pancreatic Neuroendocrine Tumors: Advances in Diagnosis, Management, and Controversies.

In this article, we aimed to review the literature on the clinics and management of nonfunctional pancreatic neuroendocrine tumors (NPNET). Pancreatic neuroendocrine tumors (PNET) are rare tumors with a <1/100,000 incidence and constitute approximately 2 to 10% of all pancreatic tumors. Nonfunctional PNETs are difficult to detect at early stages since they have no symptoms. Except those detected accidentally during different diagnoses, the majority of PNETs are detected in the advanced stages, with symptoms related to tumor size or liver metastasis. We reviewed the studies published in the English medical literature through PubMed and summarized the clinical features and current approaches to the treatment and follow-up of the NPNET. The common imaging techniques used for the detection of tumor localization, size, locoregional, and metastatic involvement are contrasted computed tomography, magnetic resonance imaging, endoscopic ultrasonography, and somatostatin receptor scintigraphy. Surgical resection is the only curative treatment. However, in advanced locoregional disease and liver metastasis, interventive ablative therapies such as palliative reductive surgery, selective hepatic arterial embolization, radiofrequency ablation; and systemic therapies, such as peptide receptor radionuclide therapy, chemotherapy, somatostatin analogous therapy, interferon, VEGF inhibitor, and mTOR inhibitor may be used as symptom relieving or may improve progression-free survival and total survival. Current knowledge on NPNET shows that the treatment should be personalized considering the prognostic features and life expectancy of the patient.

Successful management of primary hepatic pregnancy with selective hepatic artery embolization and intra-arterial methotrexate infusion

Primary hepatic pregnancy is an extremely rare and lifethreatening condition. Fatal hemorrhage after rupture of an ectopic pregnancy is the most feared complication, and any rupture must be managed with emergency surgery. A 31-year-old patient (G6, P2) presented with amenorrhea of 8 weeks’ duration and acute onset of right upper abdominal pain. The patient was hemodynamically unstable and had diffused abdominal tenderness. Hemoglobin concentration was 6.8 g/dL. Coagulation function was normal. Serum hCG level was 23 824 mIU/mL. Pelvic ultrasonography revealed marked echogenic fluid in the pouch of Douglas, but no gestational sac was identified. The patient underwent emergency exploratory laparotomy through a lower abdominal midline incision. The abdominal cavity contained approximately 1000 mL of blood. The uterus, ovaries, and fallopian tubes were normal. Further exploration of the abdomen revealed that the hemorrhage arose from the hepatic area, and the incision was extended vertically to the upper abdomen with the assistance of a general surgeon. The active bleeding continued from a rupture in a 3.0 x 4.0-cm whitish, villiform nodule on the inferior surface of the liver. The nodule could not be removed completely because of deep implantation into the hepatic parenchyma and hilum. Hemostasis was obtained by plication of the bleeding site using absorbable sutures. Histopathologic examination of the liver nodule revealed normal chorionic villi, consistent with the diagnosis of primary hepatic pregnancy. The patient’s hCG level dropped to 10 355 mIU/mL on postoperative day 1, but rose to 11 230 mIU/mL 2 days later. Given the residual elevated hCG level and associated risk of secondary hemorrhage, transcatheter arterial chemoembolization (TACE) with intra-arterial methotrexate infusion was performed to diminish the local blood supply to the lesion and degenerate residual trophoblasts using methotrexate at the same time. The patient’s liver and renal functions were normal before TACE. A common femoral artery approach was used, and hepatic angiography showed a 2.5 x 3.0-cm mass supplied by the right hepatic artery (Fig. 1A). A mixture of 6 mL of Lipiodol (iodized oil; Guerbet, Roissy, France) and 50 mg (1 mg/kg) of methotrexate was infused via the microcatheter as close as possible to the feeding branch, followed by embolization of the feeding artery with gelatin sponge particles (0.5–1.0 mm).A methotrexate–Lipiodol emulsion was used to localize the methotrexate inside the hepatic lesion and release it slowly [1]. After embolization, X-ray examination was performed to confirm the deposition of Lipiodol inside the lesion (Fig. 1B). The patient’s recovery was uneventful. Serum hCG level decreased steadily and was undetectable 12 days after TACE. Liver and renal function tests were performed every 3 days until the patient’s hCG level normalized and remained within limits. One month later, ultrasound examination of the patient’s liver revealed no trace of the ectopic pregnancy. A previous report described slow hemorrhage from hepatic pregnancy managed by laparoscopy and postoperative administration of methotrexate [2]. In two unruptured cases, local methotrexate injection into the hepatic gestational sac was performed under direct [3] or ultrasound guidance [4]. However, additional methotrexate administration was often required for persistently elevated hCG level after surgery and caused prolonged recovery time. TACE induces an acute ischemic degeneration of trophoblasts and avoids secondary hemorrhage. Moreover, the block of blood flow to the lesion exposes the local trophoblastic mass to a higher concentration of methotrexate than intramuscular administration and prevents severe adverse effects. The combination of these two mechanisms may help accelerate the decrease in serum hCG level and shorten the time to resolution of the trophoblastic mass. TACE with intraInternational Journal of Gynecology and Obstetrics 122 (2013) 78–86

Biliary stricture formation as a compication of transcatheter arterial chemotherapy

Purpose To determine the incidence of biliary stricture formation after transarterial chemoetherapy of primary or metastatic hepatic carcinoma and evaluate whether selectivity of transarterial therapy affects stricture formation. Materials and Methods A total of 1771 patients with hepatocellular carcinoma (HCC) or other primary malignancy with metastatic disease to the liver between 2004-2012 were studied. Among them, 318 were treated with transcatheter arterial chemoembolization (TACE) or transcatheter arterial chemoinfusion (TACI). Patients were excluded if they received any therapy at institutions other than the University of Southern California. Results Of the 318 patients that received transcatheter arterial chemotherapy, 6 (1.9%) developed biliary tract abnormalities after treatment. Average time to presentation was 11 months (range 4-23). 3 developed focal biliary strictures while another 3 developed biliary ductal dilatation. In one patient, a biliary stricture developed after the second treatment while in the other two patients, strictures developed after the third treatment. All patients whose therapy was complicated by biliary stricture formation received non-selective treatment to the right hepatic artery. One patient’s stricture occurred at the confluence of the right and left hepatic ducts. A second patient’s stricture occurred at the junction of the right hepatic duct with the common bile duct. The third patient had bilateral strictures. All strictures where treated with biliary drains. Of those that experienced biliary ductal dilatation without definite stricture formation, one received selective left hepatic artery embolization whereas the other two underwent non-selective right hepatic artery embolization. Conclusion Biliary stricture formation is a rare but serious complication of transcatheter arterial chemoembolization. While the pathogenesis has not yet been elucidated, ischemia may play an important role. This study suggests non selective embolization of right hepatic lobe lesions may lead to increased stricture formation. Additionally, increasing selectivity may help mitigate this risk.

Selective hepatic arterial embolization for the treatment of polycystic liver: its relevant study

Selective hepatic arterial embolization for the treatment of polycystic liver: its relevant study

Successful First‐line Treatment With Propranolol of Multifocal Infantile Hepatic Hemangioma With High‐flow Cardiac Overload

Successful First‐line Treatment With Propranolol of Multifocal Infantile Hepatic Hemangioma With High‐flow Cardiac Overload