Chemoembolization Combined with Radiofrequency Ablation for Medium-Sized Hepatocellular Carcinoma: A Propensity-Score Analysis

Clinical question
Compare the effectiveness of combined chemoembolization and RF ablation, chemoembolization alone, and RF ablation alone in the treatment of patients with medium-sized HCC’s (3-5cm in size).

Take away point Large-bore aspiration mechanical thrombectomy is safe with a high technical (100%) and clinical success (88%) rates.

Reference
Chu, Hee Ho et al. Chemoembolization Combined with Radiofrequency ablation for Medium-Sized Hepatocellular Carcinoma: A Propensity-Score Analysis. Journal of Vascular and Interventional Radiology, Volume 30, Issue 10, 1533-43

Click here for abstract

Study design
Single-center, retrospective, cohort study of 538 patients treated between March 2000 – December 2016, with follow up until March 2018

Funding Source
None

Setting
Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Figure 2
Flow chart to determine treatment of a single medium-sized (3.1-5.0 cm) HCC. Patients included in this study were unsuitable for surgery or liver transplantation and had one the three treatments.

Summary

Definitive treatment of single medium-sized HCC, according to Barcelona Clinic Liver Cancer (BCLC), is surgical resection. However, this is not always feasible secondary to patient comorbidities and/or tumor location. Radiofrequency (RF) ablation is considered as curative in patients with small (<3cm) HCC’s. However, no such definitive literature exits for single lesions that fall in the medium-size range, between 3-5 cm. Multiple treatment modalities have been used to treat these medium sized lesions including a combination of TACE and RF ablation, TACE alone, and RF alone. The authors performed a retrospective analysis of these treatment types in patients with single medium sized HCC. Additionally they took their data and performed a propensity-score analysis with inverse probability weighting to reduce bias in treatment selection and other confounding variables.

All patients in this study has single medium sized HCC’s and were treated with one of the three therapies. The treatment pathways were chosen as the digression of the interventionist. TACE was performed with a combination of Lipiodol and Cisplatin (1:1 ratio) with a cisplatin dose of 2mg/kg body weight. Gel-foam slurry was infused after administration until arterial stasis was achieved. RF ablation was performed under ultrasound guidance within 2 weeks of chemoembolization (if performed). Of note there were statistically significant differences in the patient population with regards to Child-Pugh class, serum albumin level and tumor size. No major complications were reported as defined by SIR criteria.

The primary endpoint was overall survival (OS) from initial procedure to death. The secondary endpoint was recurrence free survival (RFS), which was determined from initial treatment to recurrence or death. Recurrence included local or distant recurrence and local was defined by a margin of 1 cm.

The mean follow up time for all patients was 59.6 months (SD – 46.9 mo; range: 2-208). Overall survival in combined, chemoembolization-only, and RF-only were 85 mo (95% CI: 51.2-118.8 mo), 56.5 mo (95% CI: 51.7-61.3 mo), and 52.1 mo (95% CI: 40.7-63.5 mo), respectively. Treatment was found to be a significant independent factor associated with OS (P=0.023). During follow up recurrent disease was found in 68.8% of combined group, 78% of the chemoembolization-only group, and 74.8% of the RF-only group. RFS in the combined, chemoembolization-only, and RF-only were 26.5 mo (95% CI: 22-31 mo), 14.1 mo (95% CI: 10.9-17.3 mo), and 14.1 mo (95% CI 9.7-18.5 mo), respectively.

Inverse probability weighting was performed to balance baseline characteristics. The differences in OS remained statistically significant with a P value of 0.022 (Fig 4a). Additionally the differences in RFS values were statistically significant with a P value of 0.002 (Fig 4b).

Commentary

The authors performed a similar study to multiple previous authors, with a much larger patient sample. The findings of this study fit and reinforce all of the current data in treating “unresectable” medium-sized HCC’s. However, the retrospective nature of the study and single center analysis limits its broad applications. Taking this into consideration we now have a larger pool of retrospective data to help reinforce the current trend in treating medium-sized HCC’s. This study provides evidence for future prospective studies to look at this question and help solidify an evolving treatment paradigm.

Post author
Hasnain Hasham, MD
Interventional Radiology Fellow
Dotter Interventional Institute
Oregon Health and Science University, Portland, OR
@irhasham

Midterm outcomes of endovascular repair for Stanford type B aortic dissection with aberrant right subclavian artery

Clinical question
Is complete endovascular repair durable for Type B aortic dissections with aberrant right subclavian artery?

Take away point
Complete endovascular therapy for Type B aortic dissection with aberrant right subclavian artery is a feasible, durable option with positive early- and mid-term outcomes.

Reference
Midterm outcomes of endovascular repair for Stanford type B aortic dissection with aberrant right subclavian artery. Zhang et al. JVIR. 2019;30:1378-1385.

Click here for abstract

Study design
Single institution, single arm retrospective cohort study of 15 patients. 

Funding source
China Medical Board Distinguished Professorship Award and the National Natural Science Foundations of China

Setting
Second Xiangya Hospital, Central South University, Hunan, People’s Republic of China 

Summary 

A treatment algorithm for patients with Stanford Type B aortic dissection with the aberrant right subclavian artery (ARSA) was created based on the distance between the entry tear to the ARSA. If the distance was >15 mm (Type 1), TEVAR would be performed without any technical modifications owing to a favorable proximal landing zone. If the distance was <15 mm but >15 mm existed between the tear and the left subclavian artery (Type 2), the artery supplying the dominant vertebral artery was preserved while the contralateral artery was sacrificed. If <15 mm existed between the tear and left subclavian artery (Type 3), the artery supplying the dominant vertebral artery was preserved while the contralateral artery was sacrificed. In patients with codominant vertebral arteries, the ARSA was preserved in Type 2 patients while both subclavian arteries were preserved in Type 3 patients.

Technical modifications to TEVAR included fenestration for patients with an entry tear on the inner curve of the aorta, chimney (stent-graft preservation dependent on antegrade flow) for preservation of the left subclavian artery from left brachial approach, and periscope/snorkel (stent-graft preservation dependent on retrograde flow) for preservation of the ARSA from femoral approach.

Stent-grafts were oversized to account for concomitant diverticulum of Kommerell to cover the diverticulum without additional embolization of the diverticulum.

Follow-up included clinic visit and CTA at 2 weeks, 3 months, 6 months, and 12 months post-procedure. Mean follow-up was 33 +/- 20 months. There was 100% technical success. No mortalities were noted. No neurologic sequelae were noted. All stent-grafts remained patent with shrinking of the false lumen at 2 weeks.

Commentary

Although this paper is a small series from a single institution, the authors included a relatively high number of patients considering the rarity of this anatomy, which had previously only been described in case reports. Notably, the outcome for this cohort was remarkable with no delayed endoleaks and no clinically significant adverse events. Even with 13 patients undergoing chimney modification for preservation of the left subclavian artery, no delayed Type 1A endoleaks were identified. Whether this can be attributed to the wide variation in the duration of follow-up should be further investigated, since three patients with dominant left vertebral artery had less than 8 months of follow-up.

In the short- and mid-term outcomes of completely endovascular repair appear superior compared to outcomes of hybrid approach, with rates of brachial plexus injury of 12.5% and Type 1A endoleak of 18.8%. This study shows promise for completely endovascular repair although longer-term follow up is needed.

This paper also expands on previously published treatment algorithms for endovascular repair of aortic anatomy in a technically challenging population.


Post Authors 
Eric King, MD
Vascular & Interventional Radiology Fellow
Rush University Medical Center
Chicago, Illinois
@ercking

Sreekumar Madassery, MD
Assistant Professor, Vascular & Interventional Radiology
Director, Advanced Vascular & Interventional Radiology Fellowship
Rush University Medical Center
Rush Oak Park Hospital
Chicago, Illinois
@kmadass, vir_rush

Distal Radial Artery Access for Noncoronary Endovascular Treatment Is a Safe and Feasible Technique

Clinical question
Is distal radial artery (DRA) access for noncoronary interventional radiology procedures feasible and safe?

Take away point
DRA access is a feasible and safe technique for abdominal interventional radiology embolization procedures. No radial artery occlusion or other major complications were observed in patients who underwent follow-up ultrasound.

Reference
van Dam, Lievay et al. Distal Radial Artery Access for Noncoronary Endovascular Treatment Is a Safe and Feasible Technique. Journal of Vascular and Interventional Radiology, Volume 30, Issue 8, 1281 - 1285

Click here for abstract

Study design
Retrospective review of 82 punctures in 56 patients.

Funding Source
No reported funding

Setting
Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands






Figure 1. 

Optimal location of distal radial artery access at the deep palmar arch superficial to the scaphoid and trapezium.


Summary
Distal radial artery access has shown to be a safe technique for interventional radiology embolization procedures. The authors performed a retrospective review of 82 DRA procedures in 56 patients. Procedural details and complications were reviewed during the admission and at follow up.

The Barbeau test was used to evaluate radioulnar collateral circulation before the procedure. The preferred puncture site was at the DRA at the anatomical snuffbox (radial fossa). A mixture of 300 μg nitroglycerin and lidocaine 2% was given for analgesia and vasodilation, access was gained with ultrasound guidance using a 21-gauge needle and radial artery sheath, and an anti-spasmolytic mixture of 200 μg nitroglycerin, 2.5 mg verapamil, and 5000 IE heparin was administered. Patent hemostasis was achieved using a Safeguard Radial Compression Device.

Procedures included transarterial chemoembolization, Y-90 pretreatment work up, Y-90 treatment, and hepatic, renal, and splenic artery embolization. The mean number of DRA accesses per patient was 1.46. There was a 97.6% technical success rate. There were 8 minor complications, including 3 hematomas and 1 case of pain without hematoma. All minor complications resolved without treatment. Follow up ultrasound was available after 54 procedures at a mean time of 55 days. Only 1 complication at the DRA was seen on ultrasound. There was 1 case of a non-flow limiting focal dissection, which had resolved on follow up procedure 38 days later.

Commentary
The authors retrospectively reviewed 82 distal radial artery procedures. The results were promising and showed a 97.6% technical success rate without any major complications or cases of radial artery occlusion. Follow up ultrasound imaging provides further reassurance of the safety of DRA access. Access at the distal radial artery, distal to the superficial palmar arch shows theoretical benefit without increased complication. While the data is encouraging, larger patient populations and long term follow up would be helpful to further understand the safety and benefits.

Post Author
Maxwell R. Cretcher, DO
Resident Physician, Integrated Interventional Radiology
Dotter Department of Interventional Radiology
Oregon Health & Science University