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Friday, April 3, 2020

Treatment of Arm Swelling in Hemodialysis Patients with Ipsilateral Arteriovenous Access and Central Vein Stenosis: Conversion to the Hemodialysis Reliable Outflow Graft versus Stent Deployment


Clinical question
How do outcomes after conversion to arteriovenous (AV) access to Hemodialysis Reliable Outflow (HeRO) graft vs stent deployment in patients with arm swelling due to central vein stenosis compare?

Take-away point
Both HeRO graft conversion and stent deployment are effective in alleviating arm swelling in the short term in these patients, but the HeRO graft has more durable results.

Reference
Cline, Brendan C. et al. Treatment of Arm Swelling in Hemodialysis Patients with Ipsilateral Arteriovenous Access and Central Vein Stenosis: Conversion to the Hemodialysis Reliable Outflow Graft versus Stent Deployment. Journal of Vascular and Interventional Radiology, Volume 31, Issue 2, 243 – 250.

Click here for abstract

Study design
Retrospective review

Funding source
Self-funded or unfunded

Setting
Single institution






Summary


Arm swelling can cause significant morbidity for AV access patients with central venous stenosis. Angioplasty is often performed to improve symptoms and to maintain satisfactory function of the AV access; however, central lesions have the propensity to resist angioplasty or to recur. Additionally, patients with treatment resistant central lesions may require access ligation in order to resolve symptoms. Therefore, the authors of this study evaluated two methods for symptom relief and access salvage in the AV access patient with central venous stenosis: HeRO graft creation vs central venous stent placement.

The authors reviewed 192 patients who underwent HeRO graft insertion over a 10-year period in addition to 27 patients who underwent central venous stent placement over the same time period. All patients studied had a central venous stenosis (with central veins being defined as the superior vena cava, brachiocephalic vein or subclavian vein) and documented clinically significant arm swelling. Factors favoring HeRO graft placement included patients with concerns about the quality of the existing cannulation segment, the presence of pacemaker leads, predicted poor central venous patency due to bony compression, or excessive length or multifocality of stenosis, although such factors were infrequently documented. The patients in the 2 treatment groups had similar characteristics, however, patients undergoing HeRO conversion were statistically significantly more likely to have > 1 stenotic segment than the stent group (43% vs 11%, P=.02) and also more likely to have SVC occlusions than the stent group (43% vs 15%, P=05). The outcomes of interest were symptomatic improvement in arm swelling, primary access patency and secondary access patency.

All HeRO graft insertions and stent deployments were technically successful. After stent deployment, improvement or resolution in arm swelling was found in 86% of patients compared with 95% after conversion to a HeRO graft (P =.35). Swelling recurred within 1 year in 16 patients (59%) treated with stents compared with 1 patient (5%) who underwent HeRO conversion (P < .001). Median primary access patency was significantly longer for HeRO conversions than stent deployments (15.6 months vs 5.4 months, P < .001). Primary patency for HeRO graft placement at 6, 12, and 24 months was 89%, 72%, and 9% and for stent deployment was 47%, 11%, and 0%. Secondary patency was also longer for HeRO conversions than stent deployment (P=.006), with 6-, 12-, and 24- month secondary patency rates of 95%, 95%, and 89% for HeRO grafts and 79%, 58%, and 51% for stent deployment. Finally, mean number of interventions to maintain secondary patency was 2.9 per 1,000 access days for HeRO conversions and 6.2 per 1,000 access days for stent deployments. There was only 1 severe complication observed in the analysis, which occurred in a patient in the HeRO group who had an anastomotic dehiscence 1 week after surgery. No severe complications occurred in the stent group.

Commentary


The data presented here suggests that, while both conversion to HeRO graft and stent deployment are effective for treating arm swelling in the short term, HeRO grafts are less likely in the long term to result in return of arm swelling and are associated with longer primary and secondary patency rates. This may be attributed to the high level of experience with HeRO graft implantation at the authors’ institution and the question remains as to whether or not this is generalizable. Should better patency be expected in the HeRO conversion patient considering that culprit central venous lesions, oftentimes exacerbated by external compression, are bypassed and that typical venous outflow stenosis and neointimal hyperplasia concerns are not to be expected? Intuitively, this makes sense. Future studies, including a potential head-to-head comparison of HeRO graft to costoclavicular bypass are anticipated with interest.

Post authorZagum Bhatti, MD
Assistant Professor
Department of Radiology, Interventional Radiology Division
University of Texas Health Science Center at Houston, Houston, TX
@ZagumBhatti

Friday, March 27, 2020

Automated Quantitative Imaging Measurements of Disease Severity in Patients with Nonthrombotic Iliac Vein Compression


Clinical question
Can an automated segmentation technique (AST) quantify disease severity and treatment response on CT venography for patients with lower extremity venous disease?

Take-away point
Automated segmentation technique (AST) can quantify leg volume, skin thickness, and water content of fat on CT venography of patients with lower extremity venous disease.

Reference
Automated Quantitative Imaging Measurements of Disease Severity in Patients with Nonthrombotic Iliac Vein Compression. Reposar, A.L., Mabud, T.S., Eifler, A.C., Hoogi, A., Arendt, V., Cohn, D.M., Rubin, D.L., Hofmann, L.V. Journal of Journal of Vascular and Interventional Radiology (JVIR), Volume 33, Issue 2, 270-275.

Click here for abstract

Study design
Single arm, retrospective, cohort study

Funding source
No reported funding

Setting
Academic hospital, Stanford University School of Medicine, United States.




Figure 1. a) Automated segmentation technique (AST) algorithm depicting segmented skin, muscle, subcutaneous fat, and bone. b-d) Individually segmented tissue layers for muscle, fat, and bone, respectively.

Summary


Nonthrombotic iliac vein compression and its associated myriad clinical manifestations can lead to a significant reduction in quality of life. Early diagnosis is critical to ensure a better prognosis. However, there are no consensus imaging tools or quantitative diagnostic criteria. The authors performed a retrospective study of 21 patients with left-sided nonthrombotic iliac vein compression who underwent venous stent placement with pre- and post-stent CT venography and investigated the technical feasibility of an automated segmentation technique (AST) for quantitative disease severity measurements.

Patients included in this study were diagnosed with left-sided nonthrombotic iliac vein compression without right-sided disease, underwent iliofemoral venous stenting (indicated for at least 70% stenosis or axial diameters of less than 4 mm), and had pre- and post-stent diagnostic lower extremity CT venography. Images were obtained from the institutional picture archiving and communications system (PACS), de-identified, curtailed between the inguinal ligament to the ankle, and packaged using OsiriX. An automated segmentation technique (AST) algorithm developed in MATLAB was used for segmentation according to Hounsfield unit (HU) ranges for bone, fat, muscle, and skin with subsequent calculations of leg volume, skin thickness, and water content of fat.

Significant differences were found in all 3 measures of disease severity between the left diseased and right non-diseased legs on pre-stent CT venography. The differences in skin thickness and leg volume persisted on post-stent placement though to lesser degrees while no significant difference was observed in water content of fat between the diseased and non-diseased lower extremity after stent placement. Same leg comparison pre- and post-stent demonstrated significantly lower water content of fat in both the diseased left and the non-diseased right leg; no difference in skin thickness or leg volume was observed within the same leg pre- and post-stent in both the diseased left and the non-diseased right leg.

Commentary


The authors in the paper developed an automated segmentation technique (AST) algorithm and successfully quantified 3 measures of nonthrombotic iliac vein compression disease severity based on pre- and post-stent CT venography. Results demonstrated significant differences between diseased left and non-diseased right leg on pre-stent imaging which persisted on post-stent imaging except for water content of fat. These results suggested that AST quantification of disease severity is technically feasible and may provide a nonobjective perspective on venous disease treatment response in general. This is an important and encouraging first step. Future efforts should focus on larger patient cohort, longer follow-up period, fine-tuning of existing and development of other quantitative measures. Statistical analyses will need to be more robust with the inclusion of multiple-comparison correction.

Post author
Ningcheng (Peter) Li, MD, MS
Integrated Interventional Radiology Resident, PGY-3
Department of Interventional Radiology
Oregon Health and Science University, Dotter Interventional Institute
@NingchengLi

Monday, March 16, 2020

Final Two-Year Outcomes for the Sentry Bioconvertible Inferior Vena Cava Filter in Patients Requiring Temporary Protection from Pulmonary Embolism


Clinical question
What were the clinical outcomes and conversion rates of the Sentry bioconvertible IVC filter?

Take away point
The Sentry filter had a high conversion rate and high clinical success (97%) and no late IVC thrombosis or obstruction after bioconversion.

Reference
Dake, Michael D. et al. Final Two-Year Outcomes for the Sentry Bioconvertible Inferior Vena Cava Filter in Patients Requiring Temporary Protection from Pulmonary Embolism. Journal of Vascular and Interventional Radiology, Volume 31, Issue 2, 221 - 230.e3

Click here for abstract

Study design
Prospective multicenter trial of 129 patients that underwent Sentry filter placement with a 2 year follow up.

Funding Source
BTG vascular

Setting
Multicenter, non-randomized single arm trial in 23 U.S. sites and 3 total countries.





Figure 1.  Clinical and technical outcomes in the 129 patients enrolled in the study that had a 24 month follow up.

Summary


While retrievable IVC filters are proven to provide protection against PE in patients that cannot be anticoagulated, retrieval rates for have rarely surpassed 50%, which may lead to complications such as tilting, fracture, embolization, IVC perforation etc. To this end, the Sentry bioconvertible IVC filter was created. This filter transforms from a filter to a non-filter scaffold after 60 days. This manuscript details the 2 year clinical and technical outcomes.

Patients included in the study had a contraindication to or failure of anticoagulation with a documented PE or DVT (40% had a prophylactic indication). 129 patients were included and followed for 24 months. The filter and its conversion was evaluated with CT and X-rays. At each clinical visit patients were evaluated for signs and symptoms of PE, DVT and adverse events.

There was 96.5% bioconversion of the filter at 24 months. Two patients suffered caval thrombosis within the first month with successful subsequent treatment. There were no instances of IVC thrombosis or obstruction after bioconversion at 24 months. Furthermore, there were no new symptomatic PE’s in the first 24 months. In the 5 patients in which the filter did not bioconvert, there were no instances of new DVT, PE or IVC related complications. While there were new DVTs in the study period, none were considered to be device related.

The authors highlight that the freedom from symptomatic PE was similar to what has been observed with retrievable IVC filter. After conversion, the filter did not cause IVC thrombosis or obstruction, and in patients that had thrombus in the filter prior to conversion did not experience a symptomatic PE after conversion.

The study was limited by the single arm design with its inherent bias. The authors conclude that the Sentry filter has a high rate of clinical and technical success in patients that require temporary PE prevention and are unable to be anticoagulated, with the benefit of not requiring removal to prevent long term complications associated with temporary filters.


Commentary


The study provides data to support the use of the Sentry filter in patients that do not require a permanent filter. In the current atmosphere of negative publicity and litigation against IVC filters, a bioconvertable filter is a viable option that removes the need for a second procedure to remove the filter. The data presented in this manuscript supports the conclusion that this filter provides adequate PE prevention in the first 6 months (before bioconversion) and does not cause mid-term complications related to IVC obstruction/thrombosis (after bioconversion).

Post author
Carlos J. Guevara, MD, FSIR
Assistant Professor of Radiology and Surgery
Department of Radiology, Interventional Radiology Division
Washington University in St. Louis, Mallinckrodt Institute of Radiology,
@CarlosGuevaraIR

Monday, March 9, 2020

Factors Influencing in-Stent Occlusion after Femoropopliteal Artery Stent Placement with Intravascular Ultrasound Evaluation


Clinical question
Can In Stent Re-Stenosis (ISR) or In Stent Occlusion (ISO) be predicted at time of stent placement?

Take-away point
Residual plaque after stent placement (>60% narrowing) was the most significant predictor of ISR or ISO.

Reference
Kurata N, Lida O, Asai M, Masuda M, Okamoto S, Ishihara T, Nanto K, Mano T. Factors Influencing In-Stent Occlusion after Femoropopliteal Artery Stent Placement with Intravascular Ultrasound Evaluation. J Vasc Interv Radiology. 2020. 21:213-220.

Click for abstract

Study design
Retrospective

Funding source
Self-funded or unfunded

Setting
Single center





Summary

Femoropopliteal artery lesions are commonly known to cause symptomatic presentation in patients with Peripheral Arterial Disease (PAD). Over the years, endovascular interventions of this anatomic region have surpassed surgical means as a first line (or often the only approach needed). On angiographic evaluation, patients may demonstrate plaque related stenosis or occlusions, as well as less commonly thrombosis. Plaque burden can be considered calcific or non-calcific. Evaluation of the specific underlying cause of the lesion is best confirmed with Intravascular Ultrasound (IVUS). Use of IVUS in peripheral arterial disease is operator and practice dependent. Common reasons for not using IVUS include concerns for time spent in utilization and added cost. No randomized controlled trial has been performed to date to validate outcomes bases on use of IVUS, thus utilization is again operator dependent. Interventional approached for femoropopliteal lesions include plain-old balloon angioplasty (POBA), Drug Coated Balloon angioplasty (DCB), atherectomy and Stent placement (bare metal (BMS), drug eluting stent (DES) and covered stent grafts).

In this article, the authors set out to determine if there were predictors of patients returning with In Stent Re-Stenosis (ISR) or In Stent Occlusion (ISO). This was a retrospective single center analysis of all of the patients with femoropopliteal lesions, that had utilization of IVUS pre and post stent placement. In total, 191 lesions in 162 patients were used in the analysis. Of the patients, approximately one third were Critical Limb Ischemia (CLI) patients, one third had coronary artery disease, and two thirds also had diabetes mellitus. In regard to the lesions, about 50% presented with chronic occlusions, two-thirds had calcified lesions, and the average lesion length was 17cm (+/- ~10cm). Type of stent type favored DES over BMS and Covered stent-grafts (51%/42%/6% respectively). 86% of patients had at least 1-2 vessel runoffs.

After data analysis, it was found that predictors of patients presenting with ISR or ISO were female gender, TASC II C/D, and residual plaque of >60% after stent placement. During the average total follow-up period (in clinic with duplex studies) of 19 months, there were 31% patients with ISR and 15% with ISO, with ISO patients presenting earlier than ISR patients. Patients that had less than 60% residual plaque after stenting had a 20-fold decrease in ISO.

Commentary

The finding that residual plaque of 60% or greater was the biggest predictor of ISR and ISO in this patient population does not seem surprising. Operators commonly encounter resistant stenosis when performing angioplasty of these lesions, especially calcified plaque, which may result in higher dissections and refractory stenosis necessitating a scaffold placement. This is one of the reasons why some chose to perform atherectomy of these lesions, regardless of whether initially presenting with stenosis or occlusion. This has been evaluated in regard to vessel preparation prior to DES placement and DCB use, however currently there is an element of uncertainty as to the safety of widespread use of Paclitaxel based devices. It is also not surprising that patients with greater severity of TASC II lesions would have increased rates of significant recurrent lesions, intervening on chronic occlusions and long multifocal long segment disease can be troubling. As newer technology continues to be developed, including endovascular tacking systems, absorbable scaffolds, and newer iterations of atherectomy, it will be interesting to evaluate if these will help decrease or prolong the recurrence of the disease.

This study demonstrates use of IVUS in these interventions demonstrates a value that may be underappreciated, which is that optimal vessel debulking/prepping with atherectomy, to result in less residual plaque before stent placement, may improve patency rates. This could be better validated with a randomized trial.

Post author
Kumar Madassery, MD
Assistant Professor, Vascular & Interventional Radiology
Director, Advanced Vascular & Interventional Radiology Fellowship
Rush University Medical Center, Chicago IL
Rush Oak Park Hospital, Oak Park IL
Twitter: @kmadass, @vir_rush

Friday, March 6, 2020

Risk of Death and Amputation with Use of Paclitaxel-Coated Balloons in the Infrapopliteal Arteries for Treatment of Critical Limb Ischemia: A systematic Review and Meta-Analysis of Randomized Controlled Trials


Clinical question
Does the use of drug coated balloons in infrapopliteal peripheral arterial disease during revascularization in patient’s with critical limb ischemia lead to an increased risk of death or amputation

Take-away point
Analysis of 8 randomized control trials demonstrated worse amputation-free survival with use of paclitaxel coated balloons

Reference
Konstantinos Katsanos et al. Risk of Death and Amputation with Use of Paclitaxel-Coated Balloons in the Infrapopliteal Arteries for Treatment of Critical Limb Ischemia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Journal of Vascular and Interventional Radiology. Feb, 2020: 31; 2.

Click for abstract

Study design
Meta-Analysis

Funding source
Self-funded or unfunded

Setting
Multi-study







Figure 3. (a) All-cause death and (b) major amputations. A generalized linear mixed (GLM) effects model was employed for sparse data. The summary effect was expressed as OR.

Summary


Placlitaxel-coated balloons (PCBs) gained quick popularity due to multiple studies demonstrating reduced vessel restenosis and decreased target lesion revascularization compared to plain old balloon angioplasty for femoropopliteal disease in claudicants. Recent publications have demonstrated increased patient all-cause mortality at 2 and 5 years with PCBs. This present study performed a similar systematic review and meta-analysis of PCB use in the infrapopliteal segment for patients with critical limb ischemia. Ultimately, 8 studies were identified and included in their analysis. The studies demonstrated a significant reduction in target lesion revascularization. However, the studies homogeneously demonstrated that amputation free survival was significantly lower following treatment with PCBs (number needed to harm of 22 patients). This was demonstrated by both higher rates of amputations and death. Additionally, amputation free survival was worse with higher dose PCBs.

Commentary


This paper dovetails with the major 2018 publication demonstrating increased all-cause mortality with use of PCBs in claudicants with femoropopliteal disease which has since been confirmed by the FDA. This study similarly demonstrates adverse effects, specifically death and amputation, from use of PCBs, however now within the infrapopliteal critical limb ischemia population. This study has limitations, most notably that the meta-analysis does not allow individual patient level analysis and the relatively short follow up time of 1 year. While we still do not have a cause of these adverse outcomes, this further builds evidence to caution our use of PCBs, a marked change after these devices had quickly ascended to be used as near standard of care.

Post author:
David M Mauro, MD
Assistant Professor
Department of Radiology, Vascular and Interventional Radiology
University of North Carolina

@DavidMauroMD

Friday, February 28, 2020

Impact of Eliminating Postprocedural Antibiotic Prophylaxis in Patients without Biliary Instrumentation or Bypass Undergoing Hepatic Artery Embolization for Hepatic Malignancies



Clinical question
To assess the infection rate after eliminating postprocedural antibiotics in patients undergoing hepatic artery embolization (HAE) for primary and secondary hepatic malignancies.

Take away point
Eliminating postprocedural antibiotics in patients undergoing HAE did not lead to an increase in infectious complications.

Reference
Impact of Eliminating Postprocedural Antibiotic Prophylaxis in Patients without Biliary Instrumentation or Bypass Undergoing Hepatic Artery Embolization for Hepatic Malignancies. Seo, Susan K. et al. Journal of Vascular and Interventional Radiology, Volume 30, Issue 12, 1895 - 1900

Click here for abstract 

Study design 
Retrospective cohort study of hepatic artery embolization patients who received either pre and postprocedural antibiotics or only preprocedural antibiotics.

Funding Source 
Partially funded through the US National Institutes of Health/National Cancer Center

Setting
Memorial Sloan Kettering Cancer Center, New York






Table 2. Comparison of outcomes for Adult Patients without Prior Biliary Instrumentation or Bypass undergoing HAE.

Summary


The authors performed a retrospective cohort study to compare infectious complications in hepatic artery embolization (HAE) patients that either received either pre- and post-procedure antibiotic prophylaxis or only pre-procedure antibiotic prophylaxis. Only patients without a history of prior biliary instrumentation or bypass were included. Patients that also received ablation or selective internal radiation treatment (SIRT) were included.

Group A comprised of 150 patients who underwent 204 HAE procedures and received pre- and post-procedure antibiotic prophylaxis. Group B comprised of 171 patients who underwent 204 HAE procedures and received only pre-procedure antibiotic prophylaxis. The retrospective cohorts were chosen based on consecutive cases performed a year before and a year after the guidelines at the author’s institution were changed to no longer recommend post-procedure antibiotic prophylaxis.

The pre-procedure antibiotic prophylaxis regimen was 1g of cefazolin iv pre-procedure. Patients with a severe penicillin allergy received clindamycin (900 mg iv for 1 dose pre-procedure) and gentamicin (1 dose 1.5 mg/kg iv pre-procedure). In the group receiving post-procedure prophylaxis, the regimen was either 1g cefazolin every 8 hours post-procedure for 3 doses or clindamycin (900 mg iv q8H for 3 doses) plus gentamycin (1.5 mg/kg q8H post-procedure for 3 doses).

The primary outcome was any infection requiring antimicrobial treatment within 30 days of hepatic artery embolization. In the comparison of HAE patients with or without ablation or SIRT, with a competent sphincter of Oddi, receiving both pre- and post-procedure antibiotic prophylaxis and only pre-procedure antibiotic prophylaxis: No significant difference was identified in 30-day infection rates. No significant difference was identified in the average time to postprocedural imaging or in the proportion of patients with liver imaging within 14 days of the procedure. No significant difference was found in unplanned readmissions within 30 days or in 30-day all-cause mortality. Elimination of post-procedure antibiotics also led to better guideline adherence within the author’s institution.

Commentary


The authors evaluated 321 patients who underwent 425 hepatic artery embolization procedures and received either pre- and post-procedure antibiotic prophylaxis or only pre-procedure antibiotic prophylaxis. No significant difference was seen in infectious complications or any of the other endpoints between the two groups. While this study is limited by its retrospective design and exclusion of patients with prior biliary intervention, these findings further confirm that a single pre-procedure prophylactic dose of either cefazolin or clindamycin plus gentamycin provides adequate antimicrobial coverage for these patients undergoing HAE and supports the 2018 SIR recommendations, and suggest the post-procedure antibiotic prophylaxis may be unnecessary.

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

Monday, February 24, 2020

Transarterial Chemoembolization Followed by Radiofrequency Ablation for Hepatocellular Carcinoma: Impact of the Time Interval between the Two Treatments on Outcome


Clinical question
Does the efficacy of radiofrequency (RF) ablation for recurrent hepatocellular carcinoma (HCC) differ within or beyond 30 days after transarterial chemoembolization (TACE)?

Take away point
RF ablation within 30 days after TACE was more effective for treatment of recurrent HCC than delayed ablation.

Reference
Liu, D. et al. Transarterial Chemoembolization Followed by Radiofrequency Ablation for Hepatocellular Carcinoma: Impact of the Time Interval between the Two Treatments on Outcome. J. Vasc. Interv. Radiol. 30, 1879–1886 (2019).

Click here for abstract

Study design
Single-institution, retrospective study with 135 patients from 2007-2015 who presented with a recurrent HCC and subsequently underwent TACE plus RF ablation. Outcomes of interest included overall survival (OS), progression-free survival (PFS) and complete response (CR) rate.

Funding source
Science and Technology Development Special Fund of Guangdong Province grant 2017A020215011 and National Natural Science Foundation Key Program grant K0109003

Setting
The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China





Summary


This study reviewed 135 patients between 2007 and 2015 with either a solitary tumor > 3 cm or multiple tumors < 5 cm of recurrent HCC. Inclusion criteria, among others, comprised of first intrahepatic HCC recurrence after curative treatment (resection or ablation), no evidence of invasion/metastatic disease, and Child-Pugh classes A-B.

Sixty-two patients underwent TACE followed by sequential RF ablation within 30 days and 73 patients underwent RF ablation more than 30 days following TACE. Superselective conventional TACE was performed by the same interventional radiologist utilizing a mixture of lipiodol and epirubicin followed by gelatin sponge particle embolization. RF ablation was performed with the Cool-tip electrode [Valleylab; Medtronic, Fridely, Minnesota] with 2-3 electrodes used for a safety margin > 5 mm with guidance of contrast enhanced ultrasound.

Follow up consisted of contrast-enhanced cross-sectional imaging. Tumor response was assessed by the Modified Response Evaluation Criteria in Solid Tumor guidelines. Overall survival (OS) and progression-free survival (PFS) were calculated from the day of RF ablation.

The median OS was 49.8 months for the sequential group and 31.0 months for the delayed group (P = 0.002). Median PFS was 38.0 months for the sequential group and 11.6 months for the delayed group (P = 0.021). Subgroup analysis showed that patients with multiple tumors or a single tumor > 5 cm had significant longer OS and PFS when RF ablation was performed sequentially. There was no significant difference among patients with solitary 3 to 5 cm tumors when RF ablation was performed within or after 30 days of TACE. Complete tumor response rates were significantly better for the sequential group compared to the delayed group (P = 0.035). Multivariate analysis showed predictors of OS and PFS included maximum tumor size and number of tumors.


Commentary


Combination therapy for HCC with TACE followed by thermal ablation is frequently utilized to prevent recurrence. However, there is little knowledge regarding the optimal time interval between TACE and ablation. This retrospective study supports efficacy of early ablation within 30 days after TACE for in the treatment of large (> 5 cm) or multiple recurrent HCCs. These benefits were not seen for solitary medium sized tumors. Although the authors took care to account for operator variability with TACE, technical variability, management of multiple tumors and timing of repeat TACE can vary significantly among unique patients situations. While early ablation is preferred and encouraged after TACE, addition prospective randomized clinical trials may be beneficial, especially for solitary medium sized tumors.

Post author
Teodora Bochnakova MD
Assistant Professor
Department of Interventional Radiology
Oregon Health and Science University, Portland, OR
@T_bochnakova