Single-Center Retrospective Review of Radiofrequency Wire Recanalization of Refractory Central Venous Occlusions 

Summary

Recent retrospectively study reviewed the effectiveness and safety of radiofrequency (RF) wire recanalization of central venous occlusions (CVOs) and compared recurrent and nonrecurrent CVOs in terms of patient and occlusion characteristics. A total of twenty CVOs were treated in 18 patients including the superior vena cava (SVC), brachiocephalic veins, inferior vena cava and iliac veins. CVO traversal was first attempted with standard and advanced techniques before RF wire recanalization. Sixteen CVOs (80%) were successfully transversed and associated with symptom relief. SVC perforation into the pericardial space occurred in one patient, who recovered completely from the procedure. Primary CVO patency rate was 56% at a median follow-up of 14.1 months. Recurrent CVOs tended to be infradiaphragmatic (71% vs 12% for supradiaphragmatic; P = .02), longer (12.9 cm ± 10.0 vs 2.3 cm ± 1.3; P < .01), and associated with implanted venous stents, filters, or cardiac pacer/defibrillator leads (86% vs 22%; P = .01). Median time to restenosis/occlusion was 1.5 months. Follow-up with computed tomographic venography and clinic visits was performed approximately 1, 3, 6, and 12 months after treatment. The authors concluded that RF wire recanalization is a relatively effective and safe option for refractory CVOs. Longer, infradiaphragmatic CVOs associated with indwelling devices may require closer follow-up for CVO recurrence.



Figure 2. Recanalization of a refractory CVO involving a left common iliac vein stent in a 28-year-old woman with May–Thurner syndrome, an IVC filter, and multiple endovenous interventions. (a,b) Venograms from an outside hospital at which standard recanalization from caudal and cranial approaches had failed. (c) Advancement of an angled RF wire into the occlusion. (d) Posttreatment venogram shows resolution of the CVO.

Commentary

This paper presents further understanding of this previously described technique of sharp recanalization of CVO utilizing RF wire. We are all aware of the increasing incidence of CVO and how debilitating it can be to the patients. In addition, treatment of this condition is very challenging and pretty much limited to endovascular recanalization. In the present study the majority of the patients (80%) had technical and clinical success with only one major complication (SVC perforation) that resolved completely without further intervention. Infradiaphragmatic occlusions (iliac/IVC), longer occluded segments and presence of implanted devices (previous stents, IVC filter, defibrillator/pacemaker leads) were associated with higher incidence of recurrent stenosis/occlusion. As mentioned by the authors the study is limited by the small sample size and by the fact that all procedures were performed by a single operator, which may prevent reproducibility. Nonetheless, the research adds new knowledge regarding patient and lesion characteristics that may influence the outcome. This will certainly help interventionalists in their decision making process and to tailor more appropriate care for each patient. The study also highlights the need for further investigation on other methods of CVO recanalization and their potential associated predictive factors for recurrent stenosis/occlusion.

Keller EJ, Gupta SA, Bondarev S, Sato KT, Vogelzang RL, Resnick SA. Single-Center Retrospective Review of Radiofrequency Wire Recanalization of Refractory Central Venous Occlusions. Journal of Vascular and Interventional Radiology. 2018 Nov 1;29(11):1571-7.

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Post Author:
Ricardo Yamada, MD
Assistant Professor
Department of Radiology
Division of Vascular and Interventional Radiology
Medical University of South Carolina

Safety of Radioembolization in the Setting of Angiographically Apparent Arterioportal Shunting

Summary

The authors retrospectively evaluated all patients that underwent radioembolization for the treatment of HCC that also demonstrated angiographically apparent arterioportal shunting and investigated the association of adverse events with the different types of shunts. The authors divided the shunts into segmental, ipsilobar, contralobar and main lobar. Patients were excluded if the patients had undergone shunt mitigation techniques, had non-HCC liver malignancies or extrehepatic HCC, as well as insufficient follow up.

32 patients with 34 administrations were included with a median Na-MELD of 8.5. Patients underwent lobar and segmental treatments with >120 Gy and <120 Gy. Both glass and resin spheres were used. 28% of tumors were solitary, 22% multifocal and 50% infiltrative. 22% of patients were BCLC A, 12% B, 60% C and 6% D. Segmental shunts were seen in 35% of cases, ipsilobar 41%, contralobar 18% and main portal in 6%. Adverse events were graded using CTCAE version 4.0, and were considered significant if they were grade 3 or higher. The authors also analyzed CP class, ALBI grade, prior systemic chemotherapy, shunt direction and distribution, lobar vs. segmental dose administration and imaging of vascular invasion.

The authors found a statistical worsening of the ALBI score and a non-statistically significant trend to worsening of MELD and Na-MELD. A total of 15 AE were encountered, 7 of which were grade 3 or higher (22% clinically significant AEs). Radiation induced Liver Disease (ReILD) occurred in 4 patients, that showed lab abnormalities between 4-8 weeks, and death between 2-6 months. All ReILD cases were BCLC-C, underwent lobar administration and showed non-segmental shunts. This subgroup of patients had an AE rate of 38%, while the remainder of the cohort demonstrated AE rate of 12%. Response rates were higher for patients that presented with segmental shunts with 73% CR and 27% partial response. The overall survival for the cohort was 72% and 57% at 6 and 12 months respectively.

The authors found that all clinically significant AEs occurred in patients with non-segmental shunts. Furthermore, ReILD was seen in patients that presented with the triad of BCLC-C, non-segmental shunts and lobar Y90 administrations. A trend towards increased AEs was seen in patients that possessed this tried, with a clinically significant AE rate of 38%. No AE were seen in the resin Y90 patients, which the authors hypothesize could be due to the small sample of resin patients, the larger particle size or the lower dose when compared to glass spheres.

As far as response rates, both overall survival and initial response rates were similar to the current published outcomes.

The limitations of this study include the small sample, retrospective nature of the study and the heterogenous imaging follow up where MRI and CT were used.

The authors conclude that radioembolization in the setting of arterioportal shunting showed a variable safety profile. In one hand, segmental shunts appear to be well tolerated. On the other hand, caution should be taken in patients with advanced HCC stage, non-segmental shunts that undergo lobar administrations where clinically significant AEs were seen 38% of the time.



Figure- Early (1) and late (b) injection of the left hepatic artery demonstrates fugal shunting into the main portal vein (red arrows). (c) Demonstrates filling of the portal vein (yellow arrow) on the arterial phase scan.

Commentary

The authors found that radioembolization appears to be safe and effective in HCC patients with angiographically apparent segmental shunts. While BCLC-C patients with non-segmental shunts that undergo lobar treatment are at higher risk for clinically significant AEs, including ReILD. More studies are necessary to validate the imaging outcomes and survival in this patient cohort, as well as the safety of resin spheres in patients with AP shuts, that in this study did not show any AEs.

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Thornton LM, Geller BS, Pepin EW, Shah JL, Kapp M, Toskich BB. Safety of Radioembolization in the Setting of Angiographically Apparent Arterioportal Shunting. J Vasc Interv Radiol. 2018 Nov;29(11):1511-1518. doi: 10.1016/j.jvir.2018.06.012. Epub 2018 Oct 5. PubMed PMID: 30293727

Post Author:
Carlos J. Guevara, MD
Assistant Professor
Department of Radiology, Interventional Radiology Division
University of Texas Health Sciences, Houston
@CarlosGuevaraIR
@UTHouston_IR

Chemoembolization in Conjunction with Bevacizumab: Preliminary Results

Summary

“The whole is greater than the sum of its parts” – SYNERGY! This is a concept that has been utilized a lot in oncology and modern medicine. Interventional oncology is no exception especially as new cancer treatment options continue to emerge. What we have lacked however, is the robust evidence to support this concept in our blossoming interventional oncology sphere.

In a recently published proof of concept paper, researchers from Italy and Slovenia published their preliminary results for chemoembolization in combination with Bevacizumab in colorectal liver metastasis (CR-LM). In this prospective observational single center trial, 6 patients with unresectable CR-LM that were naïve to standard chemotherapy and had good performance status (ECOG 0 and 1).

The patients received two cycles of DEB-IRI chemoembolization using the PEG embolic delivery platform loaded with 100 mg irinotecan. Bevacizumab was initiated 15 days after the first chemoembolization and then biweekly for a total of 8 cycles. OS, PFS, TTP, mRECIST tumor response, adverse effects and QoL were measured.

At 3 months: 2 pts (33%) CR, 2 pts (33 %) PR, 1 pt (17%) SD and 1 patient progressed (patient had advanced disease and on 4th line chemotherapy). Median overall survival (OS) was 10 months (range 7–15 months), median time to progression was 3 months (range 2–5 months), and median progression-free survival was 7 months (range 3–15 months). There was a reported increase in quality of life in 4 patients (66%)

There were no complications during chemoembolization but mild to moderate adverse events related to post chemoembolization syndrome were reported. Bevacizumab related adverse effects were hypertension (17%) and skins rash (33%).



Figure 1. Tumor response at 1, 3, and 6 months after first transarterial chemoembolization. CR = complete response; PD = progressive disease; PR = partial response; SD = stable disease.

Commentary

Exploiting increased expression of VEGF post chemoembolization to create synergistic localized oncologic benefits was demonstrated with (Hepatocellular carcinoma) HCC where locoregional chemoembolization has had a very significant role over the last 3 decades. We have limited clinical data that this concept is also clinically beneficial to patients with CRC-LM.

Hepatocellular carcinoma tends to be hypervascular and largely depends on the hepatic arterial tree vs CRC - LM which are generally hypovascular and largely depend on portal venous circulation. The impact of these potential perfusion differences on the concept and ability to translate to meaningful clinical benefit or difference is still not known. This paper provides a platform and basis for us to continue to investigate this potentially beneficial option to patients and exciting frontier for interventional oncology.

The median OS of 10 months in this very small cohort is lower than previously published median OS of 14 months with DEB-IRI alone. It is important to note the study recruited technically the “worst” responders with >3 failed lines of systemic chemotherapy and attenuated expected OS. The 3 months mRECIST tumor control rates appeared comparable with previous trials of all comers. Therefore, the preliminary results suggest a very interesting trend which is potentially beneficial to patients with advanced CRC-LM.

This sets an excellent foundation for expanding this to larger multicenter cohorts to validate this concept in chemo naïve CRC-LM and also to perhaps consider trials that extend this concept to early treatment lines for CRM-LM.

The study has multiple weaknesses, not least: sample size, single center, lack of control group, no randomization to name a few. The authors do a good job to acknowledge these and many more.

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Fiorentini G, Sarti D, Aliberti C, Carandina R, Mulazzani L, Felicioli A, Guadagni S. Chemoembolization in Conjunction with Bevacizumab: Preliminary Results. J Vasc Interv Radiol. 2018 Sep;29(9):1236-1239. doi: 10.1016/j.jvir.2018.04.022. PubMed PMID: 30146190.

Post Author:
Rodrick C Zvavanjanja MD, MSc, FRCR, DABR(VIR/DR)
Assistant Professor
Department of Diagnostic and Interventional Radiology
University of Texas at Houston McGovern Medical School
@RodZvavanjanja