Biomedical subjects
Publications and source records attributed to C Charnsangavej.
Varices of the gallbladder were demonstrated angiographically in four patients. One patient who had had a mesocaval shunt developed gallbladder varices as a result of hepatoportal shunting. Three patients had gallbladder varices owing to collateral circulation from portal vein occlusion.
A percutaneous approach was developed for the performance of regional isolation-perfusion, a surgical chemotherapeutic procedure for the intraarterial treatment of neoplasms. This technique was compared with percutaneous transcatheter arterial occlusion-infusion concerning local and systemic drug levels. Floxuridine (FUDR) was administered into a femoral artery of adult mongrel dogs, first by arterial occlusion-infusion, and 4 weeks later by regional isolation-perfusion of the opposite hind limb. Local and systemic plasma samples and local muscle specimens were collected for determination of FUDR levels. Results indicated not only that regional isolation-perfusion could be accomplished percutaneously, using balloon catheters, but also that the technique produced significantly greater local tissue FUDR levels (P less than 0.05) than those achieved with arterial occlusion-infusion.
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Calcification in the portal vein is a rare radiologic finding, occurring almost always in patients with portal hypertension. Calcium may be deposited in a thrombus or, as in this patient, in the vein wall. The characteristic position, location, and pattern of portal vein wall calcification permit its diagnosis from radiographs of the abdomen.
Reflecting on the studies by O'Riordan et al. and Doppman and Girton that are reported in this issue, the authors discuss the safety of using ethanol for hepatic artery embolization (HAE) and stress that the optimal indications for this procedure are still to be established. They indicate that the caution necessary with any technique can direct rather than inhibit action.
A 59-year-old woman was evaluated for a mass in the right lobe of the liver. Ultrasonography (US) demonstrated multiple anechoic areas with enlargement of portal and hepatic veins. These areas were enhanced uniformly after bolus injection of contrast material during computed tomography (CT). The diagnosis of portal-hepatic venous fistula was confirmed by the portal venous phase of a superior mesenteric angiogram.
Twenty-four patients with hepatocellular carcinoma or cholangiocarcinoma were treated with hepatic artery infusion (HAI) of chemotherapeutic agents (14 patients) or hepatic artery embolization (HAE) (11 patients). One patient had a combination of the two treatments. Ten of the 14 (71%) patients who underwent HAI demonstrated partial remission. The median survival time was 12.3 months. Six of the 9 patients (67%) who underwent HAE and for whom follow-up was available responded to treatment. The median survival time for those patients was 17.4 months.
Twenty-nine patients with hepatic artery occlusion were treated with additional hepatic infusion or embolization through extrahepatic collaterals. Seventeen courses of hepatic infusion were performed in 13 patients through the inferior pancreaticoduodenal artery, left gastric artery, or right gastric artery. Twenty-five hepatic embolization procedures were performed in 16 patients through the right and left phrenic arteries, left and right gastric arteries, pancreaticoduodenal artery, gastroduodenal artery, or omentoepiploic artery. In one patient gastric ulcers developed following left gastric artery infusion. No complication related to the embolization procedure was observed in the embolization group. The extrahepatic collaterals are important alternative routes for continuous transcatheter management of hepatic neoplasms following hepatic artery occlusion.
Intra-arterial infusion of chemotherapeutic agents (CDDP alone or combined with DTIC) was used to treat recurrent melanoma in 22 patients. In 17 cases, sequential arteriograms were obtained before and after infusion to monitor the procedure. Pre-treatment angiograms usually demonstrated rounded nodules with a homogeneous, hypervascular stain. In 3 patients, additional deep-seated lesions which were not palpable clinically were detected by angiography. Arteriograms of those patients who responded to chemotherapy revealed partial or complete disappearance of tumor stain. A 46% response rate was observed. The authors feel that angiography is valuable in pre-treatment diagnosis and post-treatment evaluation of recurrent melanoma.
Injury to the intima of the hepatic artery is an uncommon complication of selective arteriography. Eleven such cases were followed up for less than or equal to 12 months. The status of the vessels, the experience of the angiographer, and the materials used for catheterization all affected the frequency of injury, which was manifested by a spectrum of changes including an intimal flap, aneurysm, dissection, and occlusion. No patient had significant changes in liver function. Progression to complete arterial occlusion and regression with complete healing both occurred in this series.
Hepatic artery collaterals in 40 patients who had had hepatic artery occlusion following peripheral or central embolization, surgical ligation, intra-arterial chemotherapy, or intimal injury from catheterization were studied. The collaterals were classified as intrahepatic or extrahepatic collaterals. Intrahepatic arterial collaterals develop in the portal triads and subcapsular area between the lobes of the liver. Extrahepatic arterial collaterals develop in the ligaments that suspend the liver in the peritoneal cavity and through the structures that are closely attached to the liver. A simplified angiographic classification of hepatic arterial collaterals is presented.
Segmental and complete hepatic artery embolization with Ivalon (polyvinyl alcohol) particles (0.25 to 1 mm) was performed in 12 dogs to evaluate hepatic function alterations and histopathological changes. In dogs undergoing segmental embolization, liver function alterations were minimal and the liver was normal, both grossly and microscopically, at autopsy. In dogs undergoing complete hepatic embolization, only two had significant elevation of SGOT and alkaline phosphatase levels, which normalized in 2 and 4 weeks; one of these two dogs also had an elevated bilirubin level. A focal hepatic infarct was observed both grossly and microscopically in one dog and only microscopically in four dogs. Two dogs died of pancreatic abscess due to unintentional pancreatic embolization. The study suggested that segmental embolization with Ivalon particles was well tolerated by dogs, and complete hepatic embolization resulted in hepatic function changes and focal infarction comparable with Gelfoam embolization.
Ivalon particles were used for 80 hepatic artery embolizations in 50 patients who had either primary or metastatic hepatic neoplasms. Ten patients died within 1-5 months and the remaining 40 patients were still alive. The post-hepatic embolization syndrome was identical to that following Gelfoam embolization. Follow-up hepatic angiography in 20 patients revealed tumor response to embolization in 17 patients. Ivalon particles were easier to use and caused more peripheral and persistent occlusion than Gelfoam. The results suggest that Ivalon particles were safe and feasible for hepatic artery embolization.
Transcatheter arterial infusion has improved the preoperative control of osteosarcoma. The conventional radiographs and angiograms of osteosarcoma were evaluated in 53 patients before and after treatment. In the responders, two types of calcifications representing healing are observed: peripheral and central. The calcification is readily differentiated from that of tumor new bone. Angiography revealed a decrease in tumor vascularity and stain in responding tumors. Excellent angiographic and pathologic correlation of these changes is presented.
Surgical treatment of hypervascular bone lesions can result in excessive operative blood loss. We reviewed the cases of eight patients who were operated on for hypervascular bone metastases from renal carcinoma after preoperative transcatheter embolization. The embolization was successful in six of these patients and their operative blood loss averaged only 550 milliliters (range, 450 to 750 milliliters). The reasons for failure in two patients were failure to recognize and embolize all major vessels supplying the tumor in the first and the presence of too many small vessels arising directly from the superficial femoral artery to embolize safely in the second. When surgical treatment of hypervascular bone metastases is indicated, consideration should be given to preoperative arterial embolization.
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