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The objective of our study was to evaluate our experience with the use of endovascular treatments for superior mesenteric artery (SMA) pseudoaneurysms using covered stents.Between 2002 and 2011, six patients (mean age, 41.7 years; range, 23-65 years) with SMA pseudoaneurysms were treated percutaneously with the placement of covered stents at our institution. The causes of SMA pseudoaneurysms were penetrating trauma (n = 2), blunt trauma (n = 1), and previous surgical procedures (n = 3). The mean diameter of the SMA pseudoaneurysms was 16 mm (range, 4-24 mm). Technical success and clinical success were retrospectively analyzed.Immediate technical success, defined as exclusion of the pseudoaneurysm and lack of active extravasation, was achieved in all six patients. Secondary balloon angioplasty was needed in one patient with residual narrowing. There was a small dissection of the proximal SMA necessitating placement of a second bare stent across the dissection. A second covered stent (Fluency stent, 8 mm) was placed in the same patient because of recurrent bleeding due to a type II endoleak 5 days after the first covered stent had been placed. This patient had no subsequent episodes of bleeding or bowel ischemia. Follow-up CT in the remaining five patients (mean, 21 months; range, 1-58 months) confirmed stent patency and preserved distal arterial flow to the bowel without episodes of bleeding or bowel ischemia during follow-up (mean, 27 months; range, 11-58 months).Percutaneous endovascular treatment using a covered stent may be a safe and feasible tool for SMA pseudoaneurysms.

OBJECTIVE. We report the outcome of the care of 209 patients with hepatocellular carcinoma with a focus on relevant scoring systems for predicting overall survival and time to progression and on changes in presentation status and outcome from 1991 to 2006. MATERIALS AND METHODS. Hepatic arterial chemoembolization was performed on 209 patients in 375 sessions. Disease status was evaluated with the Child-Pugh, Okuda, Cancer of the Liver Italian Program, and American Joint Committee on Cancer (AJCC) systems. Changes in status at presentation from 1991 to 2006 and change in overall survival period and time to progression were analyzed. RESULTS. Median and mean overall survival periods for the entire group were 376 and 574 ± 61 days. Median and mean times to progression were 267 and 409 ± 54 days. Forty-nine patients underwent liver transplantation a median of 143 days after chemoembolization. The median and mean overall survival times among patients not undergoing transplantations were 466 and 574 ± 61 days. Okuda score (p < 0.0001) and AJCC stage (p = 0.014) were the best predictors of overall survival and time to progression, respectively. Patients with disease with an Okuda I score and in AJCC stage I or II had median and mean overall survival periods of 667 and 992 ± 176 days and times to progression of 378 and 589 ± 110 days. Clinical status at presentation, overall survival period (p = 0.64), and time to progression (p = 0.44) were unchanged from 1991 to 2006. The 30-day mortality was 3.2%. CONCLUSION. Patients treated with hepatic arterial chemoembolization for HCC in Okuda score I and AJCC stage I or II have more durable survival than previously reported in a U.S. population.

Hepatic artery chemoembolization and hepatic artery embolization (HAE) are accepted treatments of patients with hepatic metastasis from neuroendocrine tumors. Long-term outcome data are limited. We present our experience in the use of hepatic artery chemoembolization in the treatment of patients with hepatic metastasis from neuroendocrine tumors.Forty-six patients with carcinoid (n = 31) or islet cell (n = 15) tumors were treated. Overall and progression-free survival times starting with the first treatment were calculated. Potential factors affecting survival, including presence of extrahepatic disease and resection of the primary lesion, were analyzed. Relief of symptoms was subjectively determined for tumors with hormonal secretion.The 46 patients underwent 93 hepatic artery chemoembolization or HAE sessions. The mean overall survival time for the entire group was 1,273 +/- 185 days. The mean overall survival times for the carcinoid (1,255 +/- 163 days) and islet cell tumor (1,311 +/- 403 days) subgroups were similar (p = 0.66). The progression-free survival times for the carcinoid (602 +/- 144 days) and islet cell (501 +/- 107 days) tumor subgroups also were similar (p = 0.72). The survival time of patients without known extrahepatic metastasis (n = 18; 1,571 +/- 291 days) trended toward significance compared with that of patients with known extrahepatic disease (n = 26; 770 +/- 112 days; p = 0.08). Resection of the primary tumor in 19 of 46 patients did not affect survival (resection survival, 1,558 +/- 400 days; nonresection survival, 1,000 +/- 179 days; p = 0.44). Twenty of 25 patients with hormonally active tumors had relief of symptoms after one cycle of treatment. The 30-day mortality was 4.3%.The overall survival time after hepatic artery chemoembolization or HAE among patients with neuroendocrine tumors is approximately 3.5 years. The progression-free survival time approaches 1.5 years. The presence of extrahepatic metastasis or an unresected primary tumor should not limit the use of hepatic artery chemoembolization or HAE.

The purpose of this study was to describe the morphologic and hemodynamic findings in the hepatic vasculature before and immediately after creation of a transjugular intrahepatic portosystemic shunt.We used gray-scale, duplex, and color Doppler sonography to prospectively examine 25 patients before and after percutaneous placement of a stent to create a transjugular intrahepatic portosystemic shunt. Patency and direction of flow were determined in the stent and in the main, right, and left portal veins. Flow velocity was measured in the stent and in the main portal vein.In all patients, the stent was easily identified as connecting branches of the portal and hepatic veins. Three thrombosed stents were correctly detected sonographically. One stent that was thought to be thrombosed at sonography was found to be patent at angiography. Flow velocities in the patent stents ranged from 73 to 185 cm/sec (mean, 130 +/- 33 cm/sec). Mean peak velocities in the main portal vein were 20 cm/sec before stent placement and 38 cm/sec after stent placement (p.002). In 14 patients, flow direction in the left or right portal vein was hepatofugal after the stent was placed. In two of these 14 patients, long-term follow-up showed subsequent conversion of flow in the portal vein branches from hepatofugal to hepatopetal. One of these two patients had a thrombosed stent and the other had a hepatic vein stenosis above the stent. The second patient also had a proven decrease in flow velocity in the stent at the time of stenosis.We conclude that high flow velocities are expected in the main portal vein and in the stent immediately after the shunt is created and that flow in portal vein branches is usually hepatofugal. We recommend sonography soon after the shunt is created, so that baseline flow velocity in the stent and flow direction in portal vein branches can be established, because a subsequent decrease in flow velocity in the stent or a change in direction of flow in a portal branch may indicate stent malfunction.

Technical problems encountered during percutaneous placement of 165 Bird's Nest filters over 16 months are described. Filter deployment was successful in all patients. Although frequent, the technical problems were all minor with no long-term sequelae. Several problems were inherent to the design of the filter. Other problems related to the patient's anatomy were seen as well. Because deployment of the Bird's Nest filter is more operator-dependent than is deployment of other types of inferior vena cava filters, knowledge of pitfalls and means to avoid problems are particularly important.

The treatment of patients with chronic gastrointestinal bleeding can be a frustrating diagnostic challenge. In the past 10-15 years, a variety of new diagnostic procedures (e.g., fiber-optic endoscopy, scintigraphy, and double-contrast barium studies) have become available to examine these patients. Despite these new procedures, a small number of patients continue to bleed without a defined cause. We sought to evaluate the role of visceral angiography in patients with chronic gastrointestinal bleeding in whom findings on an extensive noninvasive workup have been normal. Between 1983 and 1990, we obtained angiograms on 36 such patients. The cause of bleeding was established by angiography in 16 patients (44%). In 11 of these 16, angiography revealed only a structural abnormality without active bleeding. Twenty patients had normal angiographic findings. No angiograms were false-positive, but three were false-negative (8%). No complication occurred as a result of the angiographic procedures. Our experience shows that visceral angiography can provide a positive diagnosis in a significant number of patients with chronic gastrointestinal bleeding of obscure origin in whom all other diagnostic measures have been unrevealing. Despite improvements in noninvasive diagnostic techniques, angiography still remains an important tool for examining this group of patients.