Recent advances in endovascular techniques for management of acute nonvariceal upper gastrointestinal bleeding

Over the past two decades,transcatheter arterial embolization has become the first-line therapy for the management of upper gastrointestinal bleeding that is refractory to endoscopic hemostasis.Advances in catheter-based techniques and newer embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options,have expanded the role of interventional radiology in the management of hemorrhage for a variety of indications,such as peptic ulcerbleeding,malignant disease,hemorrhagic Dieulafoy lesions and iatrogenic or trauma bleeding.Transcatheter interventions include the following:selective embolization of the feeding artery,sandwich coil occlusion of the gastroduodenal artery,blind or empiric embolization of the supposed bleeding vessel based on endoscopic findings and coil pseudoaneurysm or aneurysm embolization by three-dimensional sac packing with preservation of the parent artery.Transcatheter embolization is a fast,safe and effective,minimally invasive alternative to surgery when endoscopic treatment fails to control bleeding from the upper gastrointestinal tract.This article reviews the various transcatheter endovascular techniques and devices that are used in a variety of clinical scenarios for the management of hemorrhagic gastrointestinal emergencies.

Chinese expert consensus on diagnosis and treatment of trauma-induced hypercoagulopathy

Trauma-induced coagulopathy(TIC)is caused by post-traumatic tissue injury and manifests as hypercoagulability that leads to thromboembolism or hypocoagulability that leads to uncontrollable massive hemorrhage.Previous studies on TIC have mainly focused on hemorrhagic coagulopathy caused by the hypocoagulable phenotype of TIC,while recent studies have found that trauma-induced hypercoagulopathy can occur in as many as 22.2%–85.1%of trauma patients,in whom it can increase the risk of thrombotic events and mortality by 2-to 4-fold.Therefore,the Chinese People’s Liberation Army Professional Committee of Critical Care Medicine and the Chinese Society of Thrombosis,Hemostasis and Critical Care,Chinese Medicine Education Association jointly formulated this Chinese Expert Consensus comprising 15 recommendations for the definition,pathophysiological mechanism,assessment,prevention,and treatment of trauma-induced hypercoagulopathy.

Influence of breathing movements and Valsalva maneuver on vena caval dynamics

AIM: To study changes produced within the inferior vena cava(IVC) during respiratory movements and identify their possible clinical implications.METHODS: This study included 100 patients(46 women; 54 men) over 18 years of age who required an abdominal computed tomography(CT) and central venous access. IVC cross-sectional areas were measured on CT scans at three levels, suprarenal(SR), juxtarenal(JR) and infrarenal(IR), during neutral breathing and again during the Valsalva maneuver. All patientswere instructed on how to perform a correct Valsalva maneuver. In order to reduce the total radiation dose in our patients, low-dose CT protocols were used in all patients. The venous blood pressure(systolic, diastolic and mean) was invasively measured at the same three levels with neutral breathing and the Valsalva maneuver during venous port implantation. From CT scans, threedimensional models of the IVC were constructed and a collapsibility index was calculated for each patient. These data were then correlated with venous pressures and cross-sectional areas.RESULTS: The mean patient age was 51.64 ± 12.01 years. The areas of the ellipse in neutral breathing were 394.49 ± 85.83(SR), 380.10 ± 74.55(JR), and 342.72 ± 49.77 mm2(IR), and 87.46 ± 18.35(SR), 92.64 ± 15.36(JR) and 70.05 ± 9.64 mm2(IR) during the Valsalva(P s < 0.001). There was a correlation between areas in neutral breathing and in the Valsalva maneuver(P < 0.05 in all areas). Large areas decreased more than smaller areas. The collapsibility indices were 0.49 ± 0.06(SR), 0.50 ± 0.04(JR) and 0.50 ± 0.04(IR), with no significant differences in any region. Reconstructed three-dimensional models showed a flattening of the IVC during Valsalva, adopting an ellipsoid cross-sectional shape. The mean pressures with neutral breathing were 9.44 ± 1.78(SR), 9.40 ± 1.44(JR) and 8.84 ± 1.03 mmHg(IR), and 81.08 ± 21.82(SR), 79.88 ± 19.01(JR) and 74.04 ± 16.56 mmHg(IR) during Valsalva(P s < 0.001). There was a negative correlation between cross-sectional caval area and venous blood pressure, but this was not statistically significant in any of the cases. There was a significant correlation between diastolic and mean pressures measured during neutral breathing and in Valsalva.CONCLUSION: Respiratory movements have a major influence on IVC dynamics. The increase in intracaval pressure during Valsalva results in a significant de-crease in the IVC cross-sectional area.

Interventional radiology treatment for pulmonary embolism

Venous thromboembolism(VTE) is an illness that has a potentially life-threatening condition that affects a large percentage of the global population. VTE with pulmonary embolism(PE) is the third leading cause of death after myocardial infarction and stroke. In the first three months after an acute PE, there is an estimated 15% mortality among submassive PE, and 68% mortality in massive PE. Current guidelines suggest fibrinolytic therapy regarding the clinical severity, however some studies suggest a more aggressive treatment approach. This review will summarize the available endovascular treatments and the different techniques with its indications and outcomes.

Role of transcatheter arterial embolization for massive bleeding from gastroduodenal ulcers

Intractable bleeding from gastric and duodenal ulcers is associated with significant morbidity and mortality. Aggressive treatment with early endoscopic hemostasis is essential for a favourable outcome. In as many as 12%-17% of patients,endoscopy is either not available or unsuccessful. Endovascular therapy with selective catheterization of the culprit vessel and injection of embolic material has emerged as an alternative to emergent operative intervention in high-risk patients. There has not been a systematic literature review to assess the role for embolotherapy in the treatment of acute upper gastrointestinal bleeding from gastroduo-denal ulcers after failed endoscopic hemostasis. Here,we present an overview of indications,techniques,and clinical outcomes after endovascular embolization of acute peptic-ulcer bleeding. Topics of particular relevance to technical and clinical success are also discussed. Our review shows that transcatheter arterial embolization is a safe alternative to surgery for massive gastroduodenal bleeding that is refractory to endoscopic treatment,can be performed with high technical and clinical success rates,and should be considered the salvage treatment of choice in patients at high surgical risk.

Yttrium-90 microsphere selective internal radiation therapy for liver metastases following systemic chemotherapy and surgical resection for metastatic adrenocortical carcinoma

Adrenocortical carcinoma(ACC)is a rare malignancy with generally poor outcomes and limited treatment options.While surgical resection can be curative for early local disease,most patients present with advanced ACC owing to nonspecific symptoms.For those patients,treatment options include systemic chemotherapy and locoregional therapies including radiofrequency ablation and transarterial chemoembolization.We present the first reported case of utilizing yttrium-90 microsphere selective internal radiation therapy(SIRT)in combination with first line EDP-M(Etoposide,Doxorubicin,Cisplatin,Mitotane)chemotherapy and debulking surgical primary tumor resection for treatment of metastatic ACC.Stable complete radiologic response has been maintained after twelve months with resolution of clinical symptoms.These findings prompt the need for further consideration and studies to elucidate the role of SIRT in combination with systemic and surgical treatment for metastatic ACC.

Tumor-feeding artery diameter reduction is associated with improved short-term effect of hepatic arterial infusion chemotherapy plus lenvatinib treatment

BACKGROUND Recently,hepatic arterial infusion chemotherapy(HAIC)plus lenvatinib has been frequently used to treat unresectable hepatocellular carcinoma(uHCC)in China.In the clinic,the hepatic arteries of some patients shrink significantly during this treatment,leading to improved short-term efficacy.AIM To investigate the relationship between the shrinkage of hepatic arteries and the short-term effect of HAIC plus lenvatinib treatment.METHODS Sixty-seven participants with uHCC were enrolled in this retrospective study.The patients received HAIC every 3 wk,followed by oral lenvatinib after the first HAIC course.Hepatic artery diameters were measured on CT before treatment and after 1 and 2 mo of treatment.Meanwhile,the changes in tumor capillaries were also examined on pathological specimens before and after 1 mo of treatment.The antitumor response after 1,3,and 6 mo of treatment was assessed using the modified Response Evaluation Criteria in Solid Tumors(mRECIST).The relationship between the changes in vessel diameters and the short-term effect of the combination treatment was evaluated by receiver-operating characteristic and logistic regression analyses.RESULTS The hepatic artery diameters were all significantly decreased after 1 and 2 mo of treatment(P<0.001),but there was no difference in the vessel diameters between 1 and 2 mo(P>0.05).The microvessel density in the tumor lesions decreased significantly after 1 mo of combination treatment(P<0.001).According to mRECIST,46,41,and 24 patients had complete or partial responses after 1,3,and 6 mo of treatment,respectively,whereas 21,21,and 32 patients had a stable or progressive disease at these times,respectively.Shrinkage of the tumor-feeding artery was significantly associated with the tumor response after 1,3,and 6 mo of treatment(P<0.001,P=0.004,and P=0.023,respectively);however,changes in other hepatic arteries were not significantly associated with the tumor response.Furthermore,shrinkage of the tumor-feeding artery was an independent factor for treatment efficacy(P=0.001,P=0.001,and P=0.002 and 1,3,and 6 mo,respectively).CONCLUSION The hepatic arteries shrank rapidly after treatment with HAIC plus lenvatinib,and shrinkage of the tumor-feeding artery diameter was closely related to improved short-term efficacy.

Application of ozonated water for treatment of gastro-thoracic fistula after comprehensive esophageal squamous cell carcinoma therapy: A case report

BACKGROUND Gastro-thoracic fistula is a serious complication after radical surgery for esophageal cancer,and a conservative approach or endoscopic intervention is commonly applied to treat most cases.CASE SUMMARY Here we describe the case of a patient with a gastro-thoracic fistula which could not be closed during gastroscopy after receiving postoperative radiotherapy,together with severe multiple drug-resistant bacterial infection and chest wall fistula.The abscess was drained and local irrigation applied with ozonated water,together with oral ozonated water,which achieved a good effect and highlighted a new way to cure fistula in such patients.CONCLUSION Patients with gastro-thoracic fistula that cannot be closed and severe infection can be treated by drainage and flushing with ozonated water.

Artificial intelligence:Advances and new frontiers in medical imaging

Artificial intelligence(AI)has been entwined with the field of radiology ever since digital imaging began replacing films over half a century ago.These algorithms,ranging from simplistic speech-to-text dictation programs to automated interpretation neural networks,have continuously sought to revolutionize medical imaging.With the number of imaging studies outpacing the amount of trained of readers,AI has been implemented to streamline workflow efficiency and provide quantitative,standardized interpretation.AI relies on massive amounts of data for its algorithms to function,and with the wide-spread adoption of Picture Archiving and Communication Systems(PACS),imaging data is accumulating rapidly.Current AI algorithms using machine-learning technology,or computer aided-detection,have been able to successfully pool this data for clinical use,although the scope of these algorithms remains narrow.Many systems have been developed to assist the workflow of the radiologist through PACS optimization and imaging study triage,however interpretation has generally remained a human responsibility for now.In this review article,we will summarize the current successes and limitations of AI in radiology,and explore the exciting prospects that deep-learning technology offers for the future.

The efficacy of empiric arterial embolization for treating severe hemoptysis

Aim: Purpose of the study was to investigate the efficacy of empiric arterial embolization in order to achieve hemostasis in patients with massive hemoptysis. Materials and Methods: A retrospective review of histories and interventional studies of 56 patients (40 male, 16 female, median age 57 years;range, 16 - 83 years) referred for endovascular treatment of massive hemoptysis over a period of 17 years. Arteries supposed to supply the bleeding bronchoalveolar sections were embolized with particles in all cases. Digital subtraction angiographical (DSA) studies were analyzed with respect to the morphology of the embolized arteries. Arteries were termed pathologic when they were either hypertrophic or supplied hypervascular lung sections as well as actively bleeding branches. Empiric embolization was defined as endovascular occlusion of arteries without visible contrast-material extravasation on DSA studies. Results: Continuing hemoptysis was encountered in one (25%) of 4 patients with active contrast extravasation and in 11 (21%) of 52 empirically embolized patients: Six (19%) of 32 patients with pathologic arteries visible on aortography, 3 (18%) of 17 with pathologic arteries visible by selective arteriography and 2 (67%) of 3 with no visible pathologic arteries. From 6 patients (11%, 5 male, 1 female) who died within 30 days after embolization, 3 suffered from tuberculosis while 3 had malignant tumors. Three had ongoing hemoptysis. One patient died of multiple organ failure caused by post-interventional paraplegia and consecutive pneumonia. Conclusion: In patients with hemoptysis, empirical embolization is effective when pathologic bronchial arteries can be identified by DSA.

评价不可切除的肝细胞癌经动脉化疗栓塞后的长期毒副作用——单中心研究

目的评价肝细胞癌(HCC)病人经动脉化疗栓塞治疗(TACE)后6个月及1a的毒副作用。病例均进行规范化肿瘤治疗,可以与全身化疗的肝癌病人比较。材料及方法

Arterial embolization is the best treatment for pancreaticojejunal anastomotic bleeding after pancreatoduodenectomy

Massive pancreaticojejunal anastomotic bleeding, mainly from the gastroduodenal stump, is one of the most common complications of pancreato-duodenectomy. Selective angiography should be systematically the first step of investigative procedure in such situations. Pharmacoarteriography may be used if the bleeding point is not spontaneously identified, and allows safe and effective treatment with transcatheter arterial embolization compared to blind open surgical hemostasis. Coil embolization of the common or proper hepatic artery on either side of the bleeding point with "sandwich technique" is then the preferred technique to prevent retrograde filling. Surgery should be performed only as a last resort.

Late polymicrobial transjugular intrahepatic portosystemic shunt infection in a liver transplant patient:A case report

BACKGROUND Infection of a transjugular intrahepatic portosystemic shunt(TIPS)stent is a rare and serious complication that most commonly occurs during TIPS creation and revision.Patients typically present with recurrent bacteremia due to shunt occlusion or vegetation.To date there are approximately 58 cases reported.We present a patient diagnosed with late polymicrobial TIPS infection five years following TIPS creation.CASE SUMMARY A 63-year-old female status-post liver transplant with recurrent cirrhosis and portal hypertension presented with sepsis and recurrent extended-spectrum betalactamase Escherichia coli bacteremia.Computed tomography of the abdomen revealed an occluded TIPS with thrombus extension into the distal right portal vein,and focal thickening of the cecum and ascending colon.Colonoscopy revealed patchy ulcers in these areas with histopathology demonstrating ulcerated colonic mucosa with fibrinopurulent exudate.Shunt thrombectomy and revision revealed infected-appearing thrombus.Patient initially cleared her infection with antibacterial therapy and TIPS revision;however,soon after,she developed Enterobacter cloacae bacteremia and Candida glabrata and C.albicans fungemia with recurrent TIPS thrombosis.She remained on antifungal therapy indefinitely and later developed vancomycin-resistant Enterococcus faecium with recurrent TIPS thrombosis.The option of liver re-transplant for removal of the infected TIPS was not offered given her critical illness and complex shunt anatomy.The patient became intolerant to linezolid and elected hospice care.CONCLUSION Clinicians should be aware that TIPS superinfection may occur as long as five years following TIPS creation in an immunocompromised patient.

Emerging curative-intent minimally-invasive therapies for hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is the most common cause of liver malignancy and the fourth leading cause of cancer deaths universally.Cure can be achieved for early stage HCC,which is defined as 3 or fewer lesions less than or equal to 3 cm in the setting of Child-Pugh A or B and an ECOG of 0.Patients outside of these criteria who can be down-staged with loco-regional therapies to resection or liver transplantation(LT)also achieve curative outcomes.Traditionally,surgical resection,LT,and ablation are considered curative therapies for early HCC.However,results from recently conducted LEGACY study and DOSISPHERE trial demonstrate that transarterial radio-embolization has curative outcomes for early HCC,leading to its recent incorporation into the Barcelona clinic liver criteria guidelines for early HCC.This review is based on current evidence for curativeintent loco-regional therapies including radioembolization for early-stage HCC.

Editorial comment:a review on radiofrequency,microwave and high-intensity focused ultrasound ablations for hepatocellular carcinoma with cirrhosis

We read with great interest the article by Cheung et al.(1)recently published in Hepatobiliary Surgery and Nutrition,presenting a narrative review of various ablation systems for hepatocellular carcinoma(HCC)in cirrhotic patients.We would like to provide several comments.We would first like to offer our congratulations to the authors for their review,which extensively discusses radiofrequency(RFA),high-intensity focused ultrasound(HIFU),and microwave ablation(MWA)ablation techniques.This review is a succinct summary to better understand the utility of various ablation techniques used in HCC treatment(1).

Hepatocellular Carcinoma:Diagnosis, Treatment Algorithms, and Imaging Appearance after Transarterial Chemoembolization

Hepatocellular carcinoma(HCC)is a common cause of cancer-related death,with incidence increasing worldwide.Unfortunately,the overall prognosis for patients with HCC is poor and many patients present with advanced stages of disease that preclude curative therapies.Diagnostic and interventional radiologists play a key role in the management of patients with HCC.Diagnostic radiologists can use contrast-enhanced computed tomography(CT),magnetic resonance imaging,and ultrasound to diagnose and stage HCC,without the need for pathologic confirmation,by following established criteria.Once staged,the interventional radiologist can treat the appropriate patients with percutaneous ablation,transarterial chemoem-bolization,or radioembolization.Follow-up imaging after these liver-directed therapies for HCC can be characterized according to various radiologic response criteria;although,enhancement-based criteria,such as European Association for the Study of the Liver and modified Response Evaluation Criter in Solid Tumors,are more reflective of treatment effect in HCC.Newer imaging technologies like volumetric analysis,dual-energy CT,cone beam CT and perfusion CT may provide additional benefits for patients with HCC.

Predicting Infiltrative Hepatocellular Carcinoma Patient Outcome Post-TACE:MR Bias Field Correction Effect on 3D-quantitative Image Analysis

Background and Aims:To investigate the impact of MR bias field correction on response determination and survival prediction using volumetric tumor enhancement analysis in patients with infiltrative hepatocellular carcinoma,after transcatheter arterial chemoembolization(TACE).Methods:This study included 101 patients treated with conventional or drug-eluting beads TACE between the years of 2001 and 2013.Semi-automated 3D quantification software was used to segment and calculate the enhancing tumor volume(ETV)of the liver with and without bias-field correction on multi-phasic contrast-enhanced MRI before and 1-month after initial TACE.ETV(expressed as cm3)at baseline imaging and the relative change in ETV(as%change,ETV%)before and after TACE were used to predict response and survival,respectively.Statistical survival analyses included Kaplan-Meier curve generation and Cox proportional hazards modeling.Q statistics were calculated and used to identify the best cut-off value for ETV to separate responders and non-responders(ETV cm3).The difference in survival was evaluated between responders and non-responders using Kaplan-Meier and Cox models.Results:MR bias field correction correlated with improved response calculation from baseline MR as well as survival after TACE;using a 415 cm3 cut-off for ETV at baseline(hazard ratio:2.00,95%confidence interval:1.23-3.26,p=0.01)resulted in significantly improved response prediction(median survival in patients with baseline ETV<415 cm3:19.66 months vs.≥415 cm3:9.21 months,p<0.001,log-rank test).A≥41%relative decrease in ETV(hazard ratio:0.58,95%confidence interval:0.37-0.93,p=0.02)was significant in predicting survival(ETV≥41%:19.20 months vs.ETV<41%:8.71 months,p=0.008,log-rank test).Without MR bias field correction,response from baseline ETV could be predicted but survival after TACE could not.Conclusions:MR bias field correction improves both response assessment and accuracy of survival prediction using whole liver tumor enhancement analysis from baseline MR after initial TACE in patients with infiltrative hepatocellular carcinoma.

经颈静脉肝内门体静脉分流术后肾功能改变及其与生存情况的关系:单中心经验

背景:经颈静脉肝内门体静脉分流术(TIPS)对于肾功能的影响以及TIPS之后血肌酐(Cr)水平与病死率的关系仍然不明。本研究旨在评估TIPS对肾功能的影响,以及TIPS治疗后Cr水平与死亡风险的关系。方法:2004-2017年间接受TIPS治疗的593例患者被纳入研究。收集TIPS术前7天内(T0)以及术后12天(T1)、512天(T2)、1540天(T3)的Cr水平。采用多变量线性回归和Cox比例风险模型评估TIPS后Cr水平对1年死亡率的预测价值。结果:593例患者中,127例(21.4%)基础Cr水平升高(≥1.5 mg/dL;平均2.51˘1.49 mg/dL),466例(78.6%)基础Cr水平正常(<1.5 mg/dL;平均0.92˘0.26 mg/dL)。TIPS术前Cr水平升高的患者TIPS之后Cr水平显著降低(0.60 mg/dL),而TIPS术前Cr水平正常的患者TIPS之后Cr水平无明显变化(<0.01 mg/dL)。全组患者TIPS之后30天、90天及1年死亡率分别为13%、20%和32%。静脉曲张出血、T0 Cr高水平及T3高Cr水平是1年死亡率的独立危险因素。结论:对于基础肾功能不全的患者,TIPS可改善其肾功能。TIPS之后Cr水平是1年死亡风险的有效预测指标。