Spontaneous regression of hepatocellular carcinoma: what three cases of regression and disease reoccurrence can tell US

Hepatocellular carcinoma (HCC) is a highly morbid disease both in the United States and worldwide. Chronic liver inflammation puts people at risk of developing HCC. As chronic liver disease prevalence increases in the United States there can be an expected rise in HCC. Spontaneous regression of HCC is a rare phenomenon but can provide much needed information on how to better understand disease characteristics and progression. The two proposed theories that may explain spontaneous regression are tumor hypoxia and immunologic reaction. In these cases, we describe 3 patients with heavy disease burden at presentation who showed spontaneous regression of cancer. The patient's characteristics correlate most with systemic immunologic reaction resulting in spontaneous regression. Unfortunately, all of these patients had disease recurrence shortly after regression. By studying patient data in cases of spontaneous regression, we can gain a better understanding of disease progression and which exogenous or endogenous factors determine HCC mortality. With this knowledge we hope to better characterize how spontaneous regression occurs, and how we can use this information to help in developing treatment options in the future.

A rare case of left colic branch aneurysm presenting with rupture and intra-abdominal hemorrhage

An aneurysm of the inferior mesenteric artery is a rarely described clinical presentation. We have presented the case of a ruptured aneurysm originating from a branch of the inferior mesenteric artery that might represent an aneurysm of the left colic artery or the arc of Riolan. Aneurysms of this anatomic location can develop secondary to mesenteric occlusive disease, alterations in mesenteric blood flow from previous operations, or connective tissue disease. In the present case, a patient with a ruptured inferior mesenteric artery branch aneurysm had presented with intra-abdominal hemorrhage, which was successfully treated with endovascular embolization.

Effects of a Consensus-Based Pulmonary Embolism Treatment Algorithm and Response Team on Treatment Modality Choices, Outcomes, and Complications

Pulmonary embolism (PE) treatment depends on disease severity and risk of complications. Physician and institutional expertise may influence the use of reperfusion therapy (RT) such as systemic thrombolysis (SL) and catheter-directed interventions (CDI). We aimed to investigate the effects of a consensus-based treatment algorithm (TA) and subsequent implementation of PE response team (PERT) on RT modality choices and patient outcomes. A cohort of PE patients admitted to a tertiary care hospital between 2012 and 2017 was retrospectively evaluated. Demographics, clinical variables, RT selections, and patient outcomes during 3 consecutive 2-year periods (baseline, with TA, and with TA+PERT) were compared. Descriptive statistics were used for data analysis. A total of 1105 PE patients were admitted, and 112 received RT. Use of RT increased from 4.7% at baseline to 8.2% and 16.1% during the TA and TA+PERT periods. The primary RT modality transitioned from CDI to SL, and reduced-dose SL became most common. Treatment selection patterns remained unchanged after PERT introduction. Hospital length of stay decreased from 4.78 to 2.96 and 2.81 days (P < .001). Most of the hemorrhagic complications were minor, and their rates were similar across all 3 periods and between SL and CDI. No major hemorrhages occurred in patients treated with reduced-dose SL. In conclusion, TA and PERT represent components of a decision support system facilitating treatment modality selection, contributing to improved outcomes, and limiting complications. Treatment algorithm emerged as a factor providing consistency to PERT recommendations.

Bilateral renal forniceal rupture due to retroperitoneal hematoma after femoral venous access

Retroperitoneal hematoma is a potential complication of femoral venous access that rarely leads to bilateral ureteral obstruction. We present the case of a 73-year-old woman who underwent an ablation procedure for atrial fibrillation complicated by laceration of an aberrant obturator artery during femoral venous cannulation, leading to a compressive retroperitoneal hematoma, bilateral ureteral obstruction, acute renal failure, and renal forniceal rupture. The patient was successfully treated with embolization of the inferior epigastric artery and aberrant obturator artery, hematoma evacuation, and ureteral stent placement. This case illustrates a rare complication of arterial laceration during femoral venous access without ultrasound guidance.

Ehlers-Danlos Syndrome Type IV: A Case Report

Ehlers-Danlos syndrome (EDS) encompasses a group of rare genetic connective tissue disorders. The vascular type (type IV) poses the most serious risk to patients. Diagnosis is usually difficult, especially if patients lack a family history. Life-threatening vascular emergency such as dissection or rupture can be the first presenting symptom. Management of the disease can pose a clinical challenge due to the emergency of presentation, tissue friability, and lack of clear management recommendations. We report a unique case of a 40-year-old man who presented with a ruptured celiac artery and a strong family history of EDS. This case highlights the difficulties and complications associated with treating this uncommon and serious disease.

Imaging Surveillance of Hypervascular Liver Lesions in Non-Cirrhotic Patients

A consensus surveillance protocol is lacking for non-cirrhotic patients with hypervascular liver lesions presumed to represent hepatocellular adenomas. Patients with hypervascular liver lesions <5 cm not meeting criteria for focal nodular hyperplasia or hepatocellular carcinoma underwent surveillance with contrast-enhanced magnetic resonance imaging (MRI) 6, 12, and 24 months after baseline imaging. If lesions remained stable or decreased in size, then surveillance imaging was discontinued. Between 2011 and 2014, 116 patients with hypervascular liver lesions were evaluated. Seventy-nine patients were eligible for the surveillance protocol. Median follow-up was 24 months (range, 1-144 months). One patient (1 %) continued oral contraceptive pill (OCP) use and presented with hemorrhage requiring embolization 5 months after initial diagnosis. Ten patients (13 %) underwent elective embolization or surgical resection for size ≥5 cm. The remaining 68 patients (86 %) continued surveillance without hemorrhage or malignant transformation. Risk factors for requiring intervention during the surveillance period included younger age, larger lesion size, and estrogen use (all p < 0.05). Patients with hepatocellular adenomas <5 cm can safely be observed after discontinuing OCP with serial imaging 6, 12, and 24 months after diagnosis. If lesions remain stable or decrease in size, then longer-term surveillance is unlikely to identify patients at risk for complications.

Case report and literature review of popliteal artery entrapment syndrome

Popliteal artery entrapment syndrome (PAES) is an uncommon condition resulting from an abnormal anatomic relationship between the popliteal artery and the surrounding musculature. The compression created by this variance in anatomy can lead to ischemia and vascular claudication. The diagnosis of PAES requires a thorough patient history and physical exam, a high index of suspicion, and dedicated imaging techniques. Several treatment options are available, including surgical intervention, thrombolysis, or a combination of these depending on the clinical indication. We present a case of PAES in a 34-year-old man who presented with typical symptoms illustrative of the complicated decision making related to this disorder.

Management of dysfunctional catheters and tubes inserted by interventional radiology

Minimally invasive percutaneous interventions are often used for enteral nutrition, biliary and urinary diversion, intra-abdominal fluid collection drainage, and central venous access. In most cases, radiologic and endoscopic placement of catheters and tubes has replaced the comparable surgical alternative. As experience with catheters and tubes grows, it becomes increasingly evident that the interventional radiologist needs to be an expert not only on device placement but also on device management. Tube dysfunction represents the most common complication requiring repeat intervention, which can be distressing for patients and other health care professionals. This manuscript addresses the etiologies and solutions to leaking and obstructed feeding tubes, percutaneous biliary drains, percutaneous catheter nephrostomies, and drainage catheters, including abscess drains. In addition, we will address the obstructed central venous catheter.

Accessory veins in nonmaturing autogenous arteriovenous fistulae: analysis of anatomic features and impact on fistula maturation

The appropriate management of nonmaturing arteriovenous (AV) fistulae continues to be a controversial issue. While coil embolization of accessory side-branch veins can be performed to encourage maturation of nonmaturing AV fistulae, the true efficacy and optimal patient population are not well understood. Fistulagrams performed on nonmaturing AV fistulae were retrospectively reviewed in 145 patients (86 males, median age 63 years) for the presence of accessory veins. Fistula and accessory vein measurements were obtained, as were rates of eventual fistula maturation after accessory vein coil embolization. Of 145 nonmaturing fistulae, 49 (34%) had a stenosis without any accessory veins, 76 (52%) had a stenosis and one or more accessory veins, and 20 (14%) had an accessory vein without concurrent stenosis. Eighteen AV fistulae had one or more accessory veins without coexisting stenosis. Nine fistulae had a caliber decrease immediately downstream from the accessory vein. Coil embolization of dominant accessory veins with a caliber decrease immediately downstream (n = 6) resulted in a 100% eventual fistula maturation rate versus 67% for fistulae without this configuration (n = 6, p = 0.15). Accessory vein size was not correlated with maturation rates (p = 0.51). The majority of nonmaturing fistulae with accessory veins had a coexisting stenosis. Higher maturation rates may result with selected anatomic parameters, although additional studies with more robust sample sizes are needed prior to definitive conclusions.

Comparison of primary jejunostomy tubes versus gastrojejunostomy tubes for percutaneous enteral nutrition

PURPOSE

To evaluate technical success and long-term outcomes of percutaneous primary jejunostomy tubes for postpyloric enteral feeding compared with percutaneous gastrojejunostomy (GJ) tubes.

MATERIALS AND METHODS

Over a 25-month interval, 41 consecutive patients (26 male; mean age, 55.9 y) underwent attempted fluoroscopy-guided direct percutaneous jejunostomy tube insertion. Insertions at previous jejunostomy tube sites were excluded. The comparison group consisted of all primary GJ tube insertions performed over a 12-month interval concomitant with the jejunostomy tube interval (N = 169; 105 male; mean age, 59.4 y). Procedural, radiologic, and clinical data were retrospectively reviewed. Intervention rates were expressed as events per 100 catheter-days.

RESULTS

The technical success rate for percutaneous jejunostomy tube insertion was 96%, versus 93% for GJ tubes (P = .47). Mean fluoroscopy times were similar for jejunostomy and GJ tubes (9.8 vs 10.0 min, respectively; P value not significant). Jejunostomy tubes exhibited a lower rate of catheter dysfunction than GJ tubes, with catheter exchange rates of 0.24 versus 0.93, respectively, per 100 catheter-days (P = .045). GJ tube tip retraction into the stomach occurred in 9.5% of cases, at a rate of 0.21 per 100 catheter-days. Intervention rates related to leakage were 0.19 and 0.03 for jejunostomy and GJ tubes, respectively (P < .01). Jejunostomy and GJ tubes exhibited similar rates of catheter exchange for occlusion and replacement as a result of inadvertent removal. No major complications were encountered in either group.

CONCLUSIONS

Percutaneous insertion of primary jejunostomy tubes demonstrated technical success and complication rates similar to those of GJ tubes. Jejunostomy tubes exhibited a lower dysfunction rate but a higher leakage rate compared with GJ tubes.

Tunneled internal jugular hemodialysis catheters: impact of laterality and tip position on catheter dysfunction and infection rates

PURPOSE

To determine rates of dysfunction and infection for tunneled internal jugular vein hemodialysis catheters based on laterality of insertion and catheter tip position.

MATERIALS AND METHODS

Retrospective review of a procedural database for tunneled internal jugular vein hemodialysis catheter placements between January 2008 and December 2009 revealed 532 catheter insertions in 409 patients (234 male; mean age, 54.9 y). Of these, 398 catheters were placed on the right and 134 on the left. The catheter tip location was categorized as superior vena cava (SVC), pericavoatrial junction, or mid- to deep right atrium based on review of the final intraprocedural radiograph. The rates of catheter dysfunction and catheter-related infection (reported as events per 100 catheter-days) were analyzed.

RESULTS

Catheters terminating in the SVC or pericavoatrial junction inserted from the left showed significantly higher rates of infection (0.50 vs 0.27; P = .005) and dysfunction (0.25 vs 0.11; P = .036) compared with those inserted from the right. No difference was identified based on laterality for catheter tip position in the mid- to deep right atrium. Left-sided catheters terminating in the SVC or pericavoatrial junction had significantly more episodes of catheter dysfunction or infection than catheters terminating in the mid- to deep right atrium (0.84 vs 0.35; P = .006), whereas no significant difference was identified for right-sided catheters based on tip position.

CONCLUSIONS

When inserted from the left internal jugular vein, catheter tip position demonstrated a significant impact on catheter-related dysfunction and infection; this relationship was not demonstrated for right-sided catheters.