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Purpose To evaluate the safety and efficacy of 2 locoregional therapies (LRTs) including hepatic artery embolization (HAE) and transarterial radioembolization (TARE) in the treatment of patients with metastatic ovarian cancer to the liver. Material and Methods From October 2010 to May 2019, the data of 15 consecutive patients (median age, 54 years ± 9.8; range, 35–78 years) with hepatic metastatic ovarian cancer who were treated with either HAE (n = 6; 40%) or TARE (n = 9; 60%) were reviewed. The most common histopathologic type was epithelial ovarian carcinoma (80%). The most common chemotherapy regimens used prior to embolization included carboplatin, paclitaxel, cisplatin, and bevacizumab. Patients received a mean of 4 lines ± 3 (range, 1–9) of chemotherapy. All patients with serous carcinoma were resistant to platinum at the time of embolization. Indications for embolization were progression of disease to the liver while receiving chemotherapy in 14 (93.3%) patients and palliative pain control in 1 patient. Results The overall response rates at 1, 3, and 6 months were 92.4%, 85.6%, and 70%, respectively. Median overall survival from the time of LRT was 9 (95% confidence interval [CI], 4–14) months. Median local tumor progression was 6.4 months ± 5.03 (95% CI, 3.3–9.5). No grade 3–5 adverse events were detected in either group. Conclusions HAE and TARE were well tolerated in patients with metastatic ovarian cancer to the liver and possibly ensured prolonged disease control in heavily treated, predominantly in patients resistant to platinum. Larger numbers are needed to verify these data.

PET has become an essential tool for staging and response assessment in oncologic imaging. Over the past decade it has also evolved into a tool for image-guided interventions, specifically in the rapidly growing field of interventional oncology. PET-guided biopsies have greater sensitivity and diagnostic yield for fluorodeoxyglucose-avid lesions. Real-time PET imaging can also provide valuable image guidance during therapeutic minimally invasive procedures such as ablation of PET-avid tumors. The increasing use of PET in the assessment of therapeutic response results in earlier identification of disease that is amenable to image-guided therapies.

To identify common gene mutations in patients with neuroendocrine liver metastases (NLM) undergoing transarterial embolization (TAE) and establish relationship between these mutations and response to TAE.Patients (n = 51; mean age 61 y; 29 men, 22 women) with NLMs who underwent TAE and had available mutation analysis were identified. Mutation status and clinical variables were recorded and evaluated in relation to hepatic progression-free survival (HPFS) (Cox proportional hazards) and time to hepatic progression (TTHP) (competing risk proportional hazards). Subgroup analysis of patients with pancreatic NLM was performed using Fisher exact test to identify correlation between mutation and event (hepatic progression or death) by 6 months. Changes in mutation status over time and across specimens in a subset of patients were recorded.Technical success of TAE was 100%. Common mutations identified were MEN1 (16/51; 31%) and DAXX (13/51; 25%). Median overall survival was 48.7 months. DAXX mutation status (hazard ratio = 6.21; 95% confidence interval [CI], 2.67-14.48; P .001) and tumor grade (hazard ratio = 3.05; 95% CI, 1.80-5.17; P.001) were associated with shorter HPFS and TTHP on univariate and multivariate analysis. Median HPFS was 3.6 months (95% CI, 1.7-5.3) for patients with DAXX mutation compared with 8.9 months (95% CI, 6.6-11.4) for patients with DAXX wild-type status. In patients with pancreatic NLMs, DAXX mutation status was associated with hepatic progression or death by 6 months (P = .024). DAXX mutation status was concordant between primary and metastatic sites.DAXX mutation is common in patients with pancreatic NLMs. DAXX mutation status is associated with shorter HPFS and TTHP after TAE.

Rationale and Objectives There is lack of information on the learning curve and the effect of operator's experience on the quality outcomes of transarterial hepatic embolization (TAE). The aim of this study was to evaluate the effect of operator experience on outcomes of TAE of hepatocellular carcinoma. Materials and Methods Demographic characteristics and outcomes including overall survival (OS), time to local tumor progression (TLP), and post-procedure complications in patients with hepatocellular carcinoma treated with TAE were collected. Operators' experience was measured in years based on the years after completion of fellowship and the date of first embolization, and was divided into five groups: G1, less than 5 years of operator's experience (YOE) at the time of first embolization; G2, 5–10 YOE; G3, 10–15 YOE; G4, 15–20 YOE; and G5, more than 20 YOE. The effects of operator's experience and outcomes were assessed using linear regression. Results From January 2012 to January 2015, 93 patients (age range = 30–86 years) were treated. The number of patients treated by each group was as follows: G1 = 12; G2 = 8; G3 = 23; G4 = 5; and G5 = 45. All groups were similar in regard to degree of cirrhosis, Barcelona Clinic Liver Cancer staging, and Child-Pugh score (P > .05). Median TLP was 8.8 months. TLP was 7.0, 6.8, 19.2, 7.9, and 8.2 months in G1, G2, G3, G4, and G5, respectively (P = .56). OS for 1, 2, and 3 years was 75%, 56%, and 42% for G1; 87%, 54%, and 54% for G2; 91%, 71%, and 45% for G3, 100%, 50%, and 0 for G4; and 84%, 65%, and 40% for G5. Conclusion Among interventional radiology fellowship-trained operators in a tertiary cancer center, OS, TLP, and post-procedure complications of TAE were not affected by the years of post-fellowship experience.

Purpose To compare the performance of 4 metrics of metabolic response on FDG-PET/CT against RECIST 1.0 for determining response and predicting overall survival (OS) following 90 Y resin microspheres radioembolization of colorectal liver metastases (CLM). Methods We conducted an IRB-waived retrospective review of our radioembolization database to identify patients with unresectable CLM treated between December 2009 and December 2013. We included patients who had both PET/CT and contrast enhanced CT (CECT) available at baseline and on the first follow-up post-radioembolization. On baseline CECT up to five target tumors were chosen per patient according to RECIST 1.0. Four metrics of FDG-avidity (SUVmax, SUVpeak, metabolic tumor volume (MTV), and total lesion glycolysis (TLG)) on PET/CT were measured for the same target tumors. Using RECIST 1.0, patients were classified as no progression (partial response or stable disease) and progression. For each PET metric, a cut-off point of ≥30% decrease was chosen to define response. OS was calculated from the time of radioembolization using Kaplan-Meier methodology. The log-rank test was used for univariate analysis to identify predictors of OS. Results The study enrolled 49 patients with 119 target tumors; a median of 2 (range: 1–5) tumors were selected per patient. Median OS was 12.7 months (95%CI: 7.2-16.7). Response by MTV (P=0.035) and TLG (P=0.044) reached statistical significance in predicting OS. Response by SUVmax (P=0.21), SUVpeak (P=0.20) or no progression by RECIST 1.0 (P=0.44) did not predict OS. Conclusion Metabolic response based on changes in MTV and TLG can predict OS post-radioembolization of CLM.

Image-guided percutaneous thermal ablation is a widely acceptable local therapy for patients with colorectal liver metastases who are noneligible for surgery or present with recurrence after hepatectomy. The increasing knowledge of factors that affect oncologic outcomes has allowed selected patients with resectable small volume colorectal liver metastases to be treated by thermal ablation with curative intent. The continuous technological evolutions in imaging and image-guidance and the wide implementation of microwave ablation that overcomes most of the limitations of radiofrequency ablation have contributed to this paradigm shift. The importance of patient selection, ablation margin evaluation, and confirmation of complete tumor ablation (A0) are discussed in this article.

Increasing data on treatment of liver metastases with locoregional therapies have solidified the expanding role of interventional radiologists (IRs) in the treatment of liver metastases from colorectal cancer. Ablative approaches such as radiofrequency ablation and microwave ablation have shown durable eradication of tumors. Catheter-directed therapies such as transarterial chemoembolization, drug-eluting beads, yttrium-90 radioembolization, and intra-arterial chemotherapy ports represent potential techniques for managing patients with unresectable liver metastases. Understanding the timing and role of these techniques in multidisciplinary care of patients is crucial. Implementation of IRs for consultation enables better integration of these therapies into patients' overall care.

Introduction This prospective study assessed the safety and outcomes of selective internal radiation therapy (SIRT) using yttrium-90 ( 90 Y) resin microspheres as a salvage therapy for liver-predominant metastases of colorectal cancer in patients with documented progression after hepatic arterial chemotherapy (HAC) and systemic chemotherapy. Patients and Methods We recruited 19 patients who had received a mean of 2.9 prior lines of chemotherapy and ≥ 1 line of HAC. Dose-limiting toxicities (grade 3 or higher) were catalogued using Common Terminology Criteria for Adverse Events version 3.0. At 4 to 8 weeks and 3 to 4 months post SIRT, responses were assessed by carcinoembryonic antigen (CEA), and quantitative imaging using Response Evaluation Criteria in Solid Tumors (RECIST) and PET Response Criteria in Solid Tumors (PERCIST). Liver progression-free survival (LPFS), progression-free survival (PFS), and overall survival (OS) were calculated using Kaplan-Meier methodology. Results Median follow-up was 31.2 months after SIRT. Within 6 weeks of SIRT, 3 patients (15.8%) experienced grade 3 toxicity. There was no incidence of radiation-induced liver disease. Responses by RECIST, PERCIST, and CEA were, respectively, 0%, 20%, and 32% at 4 to 8 weeks and 5%, 33%, and 21% at 3 to 4 months post SIRT; 53% of patients had stable disease (by RECIST) at 3 to 4 months. Of 19 patients, 4 (21.1%) had liver ablation, 9 (47%) received additional HAC, and 17 (89%) received systemic chemotherapy after SIRT. Median LPFS, PFS, and OS after SIRT were 5.2 months, 2.0 months, and 14.9 months, respectively. Conclusion SIRT was well tolerated and did not prohibit subsequent treatment, resulting in a median OS of 14.9 months in this heavily pretreated population.

PURPOSE: To identify factors affecting periprocedural morbidity and mortality and long-term survival following hepatic artery embolization (HAE) of hepatic neuroendocrine tumor (NET) metastases. MATERIALS AND METHODS: This single-center, institutional review board–approved retrospective review included 320 consecutive HAEs for NET metastases performed in 137 patients between September 1996 and September 2007. Forty-seven HAEs (15%) were performed urgently to manage refractory symptoms in inpatients (urgent group), and 273 HAEs (85%) were elective (elective group). Overall survival (OS) was estimated by Kaplan–Meier methodology. Complications were categorized per Common Terminology Criteria for Adverse Events, version 4.0. Univariate and multivariate analyses were performed to determine independent predictors for OS, complications, and 30-day mortality. The independent factors were combined to develop clinical risk score groups. RESULTS: Urgent HAE (P = .007), greater than 50% liver replacement by tumor (P < .0001), and extrahepatic metastasis (P = .007) were independent predictors for shorter OS. Patients with all three risk factors had decreased OS versus those with none (median, 8.5 vs 86 mo; P < .001). Thirty-day mortality was significantly lower in the elective (1%) versus the urgent group (8.5%; P = .0009). There were eight complications (3%) in the elective group and five (10.6%) in the urgent group (P = .03). Male sex and urgent group were independent factors for higher 30-day mortality rate (P = .023 and P = .016, respectively) and complications (P = .012 and P =.001, respectively). CONCLUSIONS: Urgent HAE, replacement of more than 50% of liver by tumor, and extrahepatic metastasis are strong independent predictors of shorter OS. Male sex and urgent HAE carry higher 30-day mortality and periprocedural morbidity risks.

Purpose: To identify changes in plasma cytokine levels after image-guided thermal ablation of human tumors and to identify the factors that independently predict changes in plasma cytokine levels. Materials and Methods: Whole-blood samples were collected from 36 patients at three time points: before ablation, after ablation (within 48 hours), and at follow-up (1–5 weeks after ablation). Plasma levels of interleukin (IL)-1α, IL-2, IL-6, IL-10, and tumor necrosis factor (TNF)-α were measured using a multiplex immunoassay. Univariate and multivariate analyses were performed using cytokine level as the dependent variable and sample collection, time, age, sex, primary diagnosis, metastatic status, ablation site, and ablation type as the independent variables. Results: There was a significant increase in the plasma level of IL-6 after ablation compared with before ablation (9.6fold 31-fold, Po.002). IL-10 also showed a significant increase after ablation (1.9-fold 2.8-fold, Po.02). Plasma levels of IL-1α, IL-2, and TNF-α were not significantly changed after ablation. Cryoablation resulted in the largest change in IL-6 level (454-fold), whereas radiofrequency ablation and microwave ablation showed 3.6-fold and 3.4-fold changes, respectively. Ablation of melanomas showed the largest change in IL-6 48 hours after ablation (92� ), followed by ablation of kidney (26� ), liver (8� ), and lung (6� ) cancers. Multivariate analysis revealed that ablation type (Po.0003) and primary diagnosis (Po.03) were independent predictors of changes to IL-6 after ablation. Age was the only independent predictor of IL-10 levels after ablation (Po .019). Conclusions: Image-guided thermal ablation of tumors increases plasma levels of IL-6 and IL-10, without increasing plasma levels of IL-1α, IL-2, or TNF-α.

Colorectal cancer (CRC), the second leading cause of cancer death in the United States, occurs in an estimated more than 145,000 patients annually, with almost 50,000 deaths each year. Metastatic liver disease is the cause of death in the majority of them (1,2). Liver-only metastases affect up to one half of patients with CRC (1,2), with approximately 15% (range, 8%–26%) presenting synchronously (3,4) and an additional 15% found metachronously during the next 5 years (3). Colorectal liver metastases (CLMs) are resectable in 20%–25% of patients only; some of the remaining 75%–80% may benefit from “downsizing” therapy, which can result in 10%–20% more patients becoming resectable. Overall survival rates in patients with either primarily or secondarily resectable CLMs can be as high as 58% at 5 years and 15% at 10 years (5,6). Current front-line treatments available to improve downsizing and resectability include systemic therapies (chemotherapy with or without bevacizumab or cetuximab) and pre-operative portal vein embolization (PVE). Other approaches include local ablation therapies, regional intraarterial therapies with embolization (transcatheter arterial chemoembolization, or radio-embolization by selective internal radiation therapy with Yttrium 90-loaded microspheres) or infusion (ie, hepatic arterial infusion [HAI] pump chemotherapy), and external beam radiation therapy (RT). The role of these liver-targeted therapies to promote conversion from unresectable to resectable liver disease remains an evaluation in progress. For the majority of patients with unresectable CRC liver metastases, standard of care is first- and second-line triplet chemotherapy, which is associated with a median survival of 18–24 months (7–10). Multiple single-institution retrospective reports suggest the potential for improvement in survival time by the addition of liver-directed therapies such as chemoembolization, HAI, or radioembolization. This has not been prospectively evaluated in controlled trials, but could potentially represent a major development in Interventional Oncology (IO). The Society of Interventional Radiology (SIR) Foundation has identified the management of metastatic CRC (mCRC) as an emerging inter-ventional radiologic research priority and convened a Research Consensus Panel (RCP) Meeting on October 3, 2011 to establish a prioritized research agenda. This article reports the proceedings from this meeting.

To describe outcomes in patients undergoing percutaneous biliary drainage to reduce total serum bilirubin level for administration of chemotherapy.A total of 647 consecutive patients underwent percutaneous biliary drainage between September 2001 and December 2008. In 168, the indication for biliary drainage was to decrease total serum bilirubin level to permit administration of chemotherapy. Of these, 20 were excluded because they had hepatic arterial infusion pumps, leaving 148 patients as the study group. The primary diagnoses for these patients were gallbladder cancer (n = 23), cholangiocarcinoma (n = 21), pancreatic cancer (n = 36), and other metastatic cancers (n = 68). Medical records and imaging studies were reviewed for demographic data, procedural information, pre- and postdrainage total serum bilirubin level levels, 30-day complications, and subsequent biliary procedures.The probability of attaining a total serum bilirubin level of 1 mg/dL or lower by 100 days was 31% (95% CI, 23%-39%). Predrainage total serum bilirubin level of 9 mg/dL or lower (hazard ratio [HR], 3.27; 95% CI, 1.86-5.75; P.001), 100% liver drainage (HR 2.73, 95% CI, 1.56-4.78; P.001), and lower predrainage International Normalized Ratio (INR; HR, 0.80; 95% CI, 0.70-0.92; P = .002) were associated with an increased likelihood of attaining a total serum bilirubin level of 1 mg/dL or lower. The most common indication for follow-up was pericatheter leakage, which occurred in nearly one third of cases. During follow-up, patients required three visits per 100 catheter-days, or approximately one per month. Median overall survival in this population was approximately 3.5 months.Only 31% of patients attained a normal serum bilirubin level by 100 days, and median overall survival was 107 days. Careful patient selection is warranted before biliary drainage for this indication. Maximal biliary drainage, a preprocedure total serum bilirubin of less than 9 mg/dL, and a lower INR were factors associated with serum bilirubin normalization in this cohort.

Purpose To identify and compare predictors of local tumor progression (LTP)-free survival (LTPFS) after radiofrequency (RF) ablation and microwave (MW) ablation of colorectal liver metastases (CLMs). Materials and Methods This is a retrospective review of CLMs ablated from November 2009 to April 2015 (110 patients). Margins were measured on contrast-enhanced computed tomography (CT) 6 weeks after ablation. Clinical and technical predictors of LTPFS were assessed using a competing risk model adjusted for clustering. Results Technique effectiveness (complete ablation) was 93% (79/85) for RF ablation and 97% (58/60) for MW ablation (P = .47). The median follow-up period was significantly longer for RF ablation than for MW ablation (56 months vs. 29 months) (P .001). There was no difference in the local tumor progression (LTP) rates between RF ablation and MW ablation (P = 0.84). Significant predictors of shorter LTPFS for RF ablation on univariate analysis were ablation margins 5 mm or smaller (P .001) (hazard ratio [HR]: 14.6; 95% confidence interval [CI]: 5.2–40.9) and perivascular tumors ( P = .021) (HR: 2.2; 95% CI: 1.1–4.3); both retained significance on multivariate analysis. Significant predictors of shorter LTPFS on univariate analysis for MW ablation were ablation margins 5 mm or smaller (P .001) (subhazard ratio: 11.6; 95% CI: 3.1–42.7) and no history of prior liver resection (P .013) (HR: 3.2; 95%: 1.3–7.8); both retained significance on multivariate analysis. There was no LTP for tumors ablated with margins over 10 mm (median LTPFS: not reached). Perivascular tumors were not predictive for MW ablation (P = .43). Conclusions Regardless of the thermal ablation modality used, margins larger than 5 mm are critical for local tumor control, with no LTP noted for margins over 10 mm. Unlike RF ablation, the efficiency of MW ablation was not affected for perivascular tumors.

Purpose To determine the survival of patients with hepatocellular carcinoma (HCC) treated with a standardized method of transcatheter arterial embolization (TAE) with small embolic particles intended to impart terminal vessel blockade, and to evaluate prognostic factors that impact overall survival. Materials and Methods A total of 322 patients with HCC who underwent 766 embolizations from January 1997 to December 2004 were retrospectively reviewed. Selective embolization of vessels feeding individual tumors was performed with small (50 μm) polyvinyl alcohol or spherical embolic particles (40–120 μm) intended to cause terminal vessel blockade. Repeat embolization was performed in cases of evidence of persistent viable tumor or development of new lesions. Patient, tumor, and treatment characteristics were prospectively recorded and tested for prognostic significance by univariate and multivariate analysis. Results The median survival time was 21 months, with 1-, 2-, and 3-year overall survival rates of 66%, 46%, and 33%, respectively. In patients without extrahepatic disease or portal vein involvement by tumor, the overall 1-, 2-, and 3-year survival rates increased to 84%, 66%, and 51%, respectively. Okuda stage, extrahepatic disease, diffuse disease (≥5 tumors), and tumor size were independent predictors of survival on multivariate analysis. There were 90 complications (11.9%) in 75 patients, including eight deaths (2.5%), within 30 days of embolization. Conclusions Hepatic arterial embolization with small particles to cause terminal vessel blockade is an effective treatment method for patients with unresectable HCC. These data support our hypothesis that particles alone may be the critical component of catheter-directed embolotherapy.

The authors to describe the technique and report the results of percutaneous displacement of endoscopically placed plastic biliary endoprostheses into the duodenum at the time of transhepatic intervention in 34 patients. Displacement into the duodenum was effected by simply passing a guide wire through the stent, and then pushing it into the gut with a catheter. Thirty-three of 36 stents (92%) were successfully displaced in this manner. No complications related to stent passage out of the gastrointestinal tract were encountered. Plastic biliary stents can be safely displaced into the duodenum when patients undergo transhepatic biliary procedures, thus avoiding repeated endoscopy.

PURPOSE To evaluate the safety and efficacy of direct computed tomography (CT)–guided fine needle aspiration biopsy (FNAB) of pancreatic and peripancreatic masses via a posterior approach that traverses the inferior vena cava (IVC) or renal vein. MATERIALS AND METHODS From January 2000 to July 2003, 55 patients underwent 58 biopsies of masses located within the pancreas ( n = 28) or in a peripancreatic location ( n = 30) with use of a posterior approach that crossed the IVC or renal vein. Biopsies were performed with needles ranging in size from 18 to 22. Cytology reports and medical records of all patients were retrospectively reviewed to evaluate diagnostic accuracy and complication rates. RESULTS Masses were safely accessed with a direct (noncoaxial) pathway traversing the IVC ( n = 54), renal vein ( n = 4), or both ( n = 3). Overall diagnostic accuracy was 86% (50 of 58). Cytologic examination was positive for malignancy in 39 of 58 biopsies (67%). Benign lesions were demonstrated in 12 of 58 biopsies. In seven cases (12%), the sample was deemed nondiagnostic. Of those, four were diagnosed later by endoscopy ( n = 1), surgical biopsy ( n = 2), or repeat FNAB ( n = 1). A false-negative result was noted in one case, which was later diagnosed by repeat biopsy. A total of four inadvertent passes through the right renal artery were recorded. CT evidence of perilesional blood was seen in eight of 55 patients (eight of 58 cases). Three of these occurred after a passage via the right renal artery. All patients remained asymptomatic, and no transfusion or change in management was necessary. No other complications occurred. CONCLUSION CT-guided noncoaxial FNAB with an approach that traverses the IVC or renal vein is safe and effective in obtaining diagnostic specimens from pancreatic and peripancreatic masses.

Introduction / objective: To describe and evaluate percutaneous treatment methods of complications occurring during recanalization of thrombosed hemodialysis access grafts. Methods and materials: A retrospective review of 579 thrombosed hemodialysis access grafts revealed 48 complications occurring during urokinase thrombolysis (512) or mechanical thrombectomy (67). These include 12 venous or venous anastomotic ruptures not controlled by balloon tamponade, eight arterial emboli, 12 graft extravasations, seven small hematomas, four intragraft pseudointimal ‘dissections', two incidents of pulmonary edema, one episode of intestinal angina, one procedural death, and one distant hematoma. Results: Twelve cases of post angioplasty ruptures were treated with uncovered stents of which 10 resulted in graft salvage allowing successful hemodialysis. All arterial emboli were retrieved by Fogarty or embolectomy balloons. The 10/12 graft extravasations were successfully treated by digital compression while the procedure was completed and the graft flow was restored. Dissections were treated with prolonged Percutaneous Trasluminal Angioplasty (PTA) balloon inflation. Overall technical success was 39/48 (81%). Kaplan–Meier Primary and secondary patency rates were 72 and 78% at 30, 62 and 73% at 90 and 36 and 67% at 180 days, respectively. Secondary patency rates remained over 50% at 1 year. There were no additional complications caused by these maneuvers. Discussions and conclusion: The majority of complications occurring during percutaneous thrombolysis/thrombectomy of thrombosed access grafts, can be treated at the same sitting allowing completion of the recanalization procedure and usage of the same access for hemodialysis.

Purpose To assess the use of endovascular stents for treating rupture after percutaneous transluminal angioplasty (PTA) in the maintenance of hemodialysis grafts. Materials and Methods From February 1, 1994, to August 1, 1997, 683 hemodialysis-related angioplasty procedures were performed on 277 patients to treat thrombosed or poorly functioning polytetrafluoroethylene (PTFE) hemodialysis bridge grafts. In each of these procedures, angioplasty of the venous anastomosis or the outflow vein was performed. This study is a retrospective review to analyze uncovered endovascular stents placed to treat ruptures after PTA. Results Fourteen ruptures were treated with use of an uncovered metal stent. Stent placement was technically successful in 11 of 14 patients, with clinical success in 11 of 14 cases. The primary patencies at 30, 60, 90, and 120 days were calculated by means of Kaplan-Meier life-table analysis; these were 63%, 54%, 46%, and 46%, respectively. The secondary patencies at 60, 120, and 180 days were 85%, 75%, and 75%, respectively. No complications were attributable to stent placement. The results are comparable to those of stents placed for reasons other than rupture, and support the efficacy of their use for this indication. Conclusion Endovascular stent placement is a safe and effective means of salvaging angioplasty-induced rupture that occurs during the treatment of hemodialysis grafts.

Purpose To evaluate the potential of two models of bilirubin decay to predict response to drainage in patients who underwent biliary drainage to lower serum bilirubin prior to chemotherapy. Materials and Methods IRB-approved retrospective review identified 77 patients with malignant biliary obstruction who underwent a single biliary drainage to decrease bilirubin prior to chemotherapy administration and who had at least four subsequent serum bilirubin determinations (regardless of value) at 7-10 day intervals for the first 4 weeks following the procedure. Data were analyzed in both mono-exponential (ME) (bilirubin level is described in terms of pure exponential decay) and mono-exponential-static (MS) (bilirubin level is described in terms of exponential decay followed by an inflection point where the bilirubin level levels off to a constant value) models. Responders were defined as patients who achieved total serum bilirubin levels Results Across all patients, the MS model had better fit with total serum bilirubin values after drainage than the ME model (R2 0.82 vs 0.62, respectively). When patients were stratified into responders and non-responders, the MS model similarly had better fit to patient data (responders: R2 0.91 v 0.71; non-responders R2 0.66 v 0.45). Parameters extracted from both models (ME and MS) suggest that both estimated pre-drainage bilirubin (10.4 and 10.7 mg/dL, respectively) and the exponential decay rate (0.14 and 0.22 mg/dL/day) of responders was significantly different from the estimated pre-drainage bilirubin (15.0 and 15.1 mg/dL) (P=0.0003 and P Conclusion Models of bilirubin response to percutaneous drainage may be useful to provide early clinical separation of responders from non-responders, prompting additional drainage or internalization of drainage when clinically appropriate.