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1.  A comparison of direct heating during radiofrequency and microwave ablation in ex vivo liver 
Purpose
To determine the magnitude and spatial distribution of temperature elevations when using 480 kHz RF and 2.45 GHz microwave energy in ex vivo liver models.
Materials and Methods
A total of sixty heating cycles (20 s at 90 W) were performed in normal, RF ablated and microwave ablated liver tissues (n=10 RF and n=10 microwave in each tissue type). Heating cycles were performed using a 480 kHz generator and 3 cm cooled-tip electrode (RF) or a 2.45 GHz generator and 14-gauge monopole (microwave) and designed to isolate direct heating from each energy type. Tissue temperatures were measured using fiberoptic thermosensors 5, 10 and 15 mm radially from the ablation applicator at the depth of maximal heating. Power delivered, sensor location, heating rates and maximal temperatures were compared using mixed effects regression models.
Results
No significant differences were noted in mean power delivered or thermosensor locations between RF and microwave heating groups (P>0.05). Microwaves produced significantly more rapid heating than RF at 5, 10 and 15mm in normal tissue (3.0 vs. 0.73, 0.85 vs. 0.21 and 0.17 vs. 0.09 °C/s; P<.05); and at 5 and 10mm in ablated tissues (2.3 ± 1.4 vs. 0.7 ± 0.3, 0.5 ± 0.3 vs. 0.2 ± 0.0 C/s, P<.05). The radial depth of heating was approximately 5mm greater for microwaves than RF.
Conclusions
Direct heating obtained with 2.45 GHz microwave energy using a single needle-like applicator is faster and covers a larger volume of tissue than 480 kHz RF energy. Keywords: microwave ablation, direct heating, thermal ablation
doi:10.1007/s00270-012-0405-1
PMCID: PMC3437379  PMID: 22572764
microwave ablation; direct heating; thermal ablation
3.  AS30D Model of Hepatocellular Carcinoma: Tumorigenicity and Preliminary Characterization by Imaging, Histopathology, and Immunohistochemistry 
Purpose
This study was designed to determine the tumorigenicity of the AS30D HCC cell line following orthotopic injection into rat liver and preliminarily characterize the tumor model by both magnetic resonance imaging (MRI) and ultrasound (US) as well as histopathology and immunohistochemistry.
Materials
AS30D cell line in vitro proliferation was assessed by using MTT assay. Female rats (N = 5) underwent injection of the AS30D cell line into one site in the liver. Rats subsequently underwent MR imaging at days 7 and 14 to assess tumor establishment and volume. One rat underwent US of the liver at day 7. Rats were euthanized at day 7 or 14 and livers were subjected to gross, histopathologic (H&E), and immunohistochemical (CD31) analysis to assess for tumor growth and neovascularization.
Results
AS30D cell line demonstrated an in vitro doubling time of 33.2 ± 5.3 h. MR imaging demonstrated hyperintense T2-weighted and hypointense T1-weighted lesions with tumor induction in five of five and three of three sites at days 7 and 14, respectively. The mean (SD) tumor volume was 126.1 ± 36.2 mm3 at day 7 (N = 5). US of the liver demonstrated a well-circumscribed, hypoechoic mass and comparison of tumor dimensions agreed well with MRI. Analysis of H&E- and CD31-stained sections demonstrated moderate-high grade epithelial tumors with minimal tumor necrosis and evidence of diffuse intratumoral and peritumoral neovascularization by day 7.
Conclusions
AS30D HCC cell line is tumorigenic following orthotopic injection into rat liver and can be used to generate an early vascularizing, slower-growing rat HCC tumor model.
doi:10.1007/s00270-012-0466-1
PMCID: PMC3904804  PMID: 22923329
Hepatocellular carcinoma; Rat model; Magnetic resonance imaging
4.  Chemoembolization of Hepatocellular Carcinoma with Hepasphere 30–60 μm. Safety and Efficacy Study 
Background
This study examined the safety, pharmacokinetics, and efficacy of transarterial chemoembolization of hepatocellular carcinoma (HCC) using a newly developed size of a superabsorbent polymer drug-eluting embolic material.
Methods
Forty-five patients with documented HCC (Child–Pugh score A/B: 55.5 %/44.5 %) were embolized with HepaSphere microspheres 30–60 μm with escalation of lesion, dose, and frequency of re-embolization. Local response was evaluated with modified response evaluation criteria in solid tumors (mRECIST). Plasma levels of doxorubicin were measured in 24 patients at baseline and at 5, 20, 40, 60, and 120 min, at 6, 24, and 48 h, and at 7 days, respectively, to determine doxorubicin in plasma (Cmax) and area under the curve (AUC). Measurements of three patients who underwent lipiodol-based conventional chemoembolization (c-TACE) were also performed.
Results
TACE with HepaSphere was well tolerated with an acceptable safety profile and no 30-day mortality. Response rates were calculated on intention-to-treat basis with complete response (CR) in 17.8 % reaching 22.2 % for the target lesion. Overall partial response (PR) was seen in 51.1 %, stable disease in 20 %, and progressive disease in 11.1 % of patients. Overall objective response (CR + PR), including patients treated at all dosages of doxorubicin, was seen in 68.9 % of cases. After a median follow-up of 15.6 months, 1-year survival is 100 %. Doxorubicin AUC was significantly lower in patients with HepaSphere 30–60 μm (35,195 ± 27,873 ng × min/ml) than in patients with conventional TACE (103,960 ± 16,652 ng × min/ml; p = 0.009). Cmax was also significantly lower with HepaSphere 30–60 μm (83.9 ± 32.1 ng/ml) compared with c-TACE (761.3 ± 58.8 ng/ml; p = 0.002).
Conclusion
HepaSphere 30–60 μm is an effective drug-eluting embolic material with a favourable pharmacokinetic profile.
doi:10.1007/s00270-013-0777-x
PMCID: PMC3895279  PMID: 24263774
Conventional chemoembolization (c-TACE); Hepatocellular carcinoma (HCC); HepaSphere; Drug eluting chemoembolization
5.  Radiological Diagnosis and Management of Epistaxis 
The majority of episodes of spontaneous posterior epistaxis treated with embolisation are idiopathic in nature. The angiographic findings are typically normal. Specific angiographic signs are rare and may include the following: a tumour blush, telangiectasia, aneurysm, and/or extravasation. Selective internal carotid artery (ICA) angiography may show rare causes of epistaxis, such as traumatic or mycotic aneurysms, which require different treatment approaches. Complete bilateral selective external and internal carotid angiograms are essential to evaluation. The images should be analysed for detection of central retinal blush in the external carotid artery (ECA) and anastomoses between the branches of the ECA and ICA. Monocular blindness and stroke are two of the most severe complications. Embolisation aims to decrease flow to the bleeding nasal mucosa while avoiding necrosis of the nasal skin and palate mucosa. Embolisation is routinely performed with a microcatheter positioned in the internal maxillary artery distal to the origin of the meningeal arteries. A guiding catheter should be placed in the proximal portion of the ECA to avoid vasospasm. Embolisation with microparticles is halted when the peripheral branches of the sphenopalatine artery are occluded. The use of coils is not recommended because recurrent epistaxis may occur due to proximal embolization; moreover, the option of repeat distal embolisation is lost. The success rate of embolisation therapy (accounting for late recurrence of bleeding) varies between 71 and 94 %. Results from endoscopic surgery are quite comparable. When epistaxis is refractory to nasal packing or endoscopic surgery, embolisation is the treatment of choice in some centres.
doi:10.1007/s00270-013-0776-y
PMCID: PMC3895177  PMID: 24232035
Posterior epistaxis; Selective percutaneous embolisation; Endovascular intervention
6.  Multimodality Image Fusion Guided Procedures: Technique, Accuracy, and Applications 
Personalized therapies play an increasingly critical role in cancer care; Image guidance with multimodality image fusion facilitates the targeting of specific tissue for tissue characterization, and plays a role in drug discovery and optimization of tailored therapies. PET, MRI and contrast enhanced CT may offer additional information not otherwise available to the operator during minimally invasive image guided procedures such as biopsy and ablation. With use of multimodality image fusion for image-guided interventions, navigation with advanced modalities does not require the physical presence of the PET, MRI, or CT imaging system. Several commercially available methods of image fusion and device navigation are reviewed along with an explanation of common tracking hardware and software. An overview of current clinical applications for multimodality navigation is provided.
doi:10.1007/s00270-012-0446-5
PMCID: PMC3447988  PMID: 22851166
7.  Successful Treatment of Mesenteric Varices by Retrograde Transvenous Obliteration by the Delivery of N-butyl-2-cyanoacrylate via an Abdominal Wall Vein 
Bleeding from mesenteric varices associated with portal hypertension is occasionally life-threatening. A 53-year-old man who had undergone esophageal transection for esophageal varices and balloon-occluded retrograde transvenous obliteration for gastric varices presented with melena due to ruptured mesenteric varices. He was treated by injecting N-butyl-2-cyanoacrylate via an abdominal wall vein to obtain retrograde transvenous obliteration.
doi:10.1007/s00270-013-0647-6
PMCID: PMC3953606  PMID: 23716126
8.  [No title available] 
PMCID: PMC3638027  PMID: 21057794
9.  [No title available] 
PMCID: PMC3638030  PMID: 21057795
10.  Phase II Study of Chemoembolization With Drug-Eluting Beads in Patients With Hepatic Neuroendocrine Metastases: High Incidence of Biliary Injury 
Purpose
To evaluate safety in an interim analysis of transarterial chemoembolization (TACE) with doxorubicin-eluting beads (DEB) in 13 patients with hepatic metastases from neuroendocrine tumors (NETs) as part of a phase II trial.
Methods
Institutional Review Board approval and informed consent were obtained. Thirteen patients completed preliminary safety analysis. Their mean age was 65 years, Eastern Cooperative Oncology Group status was 0/1, tumor burden range was 4–75 %, and mean targeted tumor size was 5.9 cm. Up to four DEB-TACE sessions (100–300 μm beads loaded with ≤100 mg doxorubicin) within 6 months were allowed. Tumor response was assessed by magnetic resonance imaging 1 month after treatment using contrast-enhancement [European Association for the Study of the Liver (EASL) and size Response Evaluation Criteria in Solid Tumors (RECIST)] criteria. Safety was assessed by National Cancer Institute Common Terminology Criteria.
Results
DEB-TACE was successfully performed in all 13 patients. At 1 month follow-up, there was a mean 12 % decrease in tumor size (p <0.0003) and a 56 % decrease in tumor enhancement (p <0.0001). By EASL criteria, the targeted lesion objective response rate was 78 %. Grade 3 to 4 toxicities were fatigue (23 %), increased alanine amino transferase (15 %), hyperglycemia (15 %), and abdominal pain (8 %). Seven patients developed bilomas (54 %); all of these patients had multiple small (<4 cm) lesions. Subsequently, four underwent percutaneous drainage, three for abscess formation and one for symptoms related to mass effect.
Conclusions
Although biloma and liver abscess are known risks after TACE, the high incidence in our study population was unexpected and forced interruption of the trial. Although this occurred in a small group of patients, we have changed our technique and patient selection as a result of these findings, thus allowing resumption of the trial.
doi:10.1007/s00270-012-0424-y
PMCID: PMC3596485  PMID: 22722717
Biliary injury; Chemoembolization; Drug-eluting beads; Neuroendocrine metastases
11.  Endovascular Treatment of Two Pseudoaneurysms Originating From the Left Ventricle 
A 67-year-old woman resented with an acute type A aortic dissection, which was treated surgically with aortic valve replacement as a composite graft with reimplantation of the coronary arteries. At the end of surgery, a left-ventricular venting catheter was placed through the apex and closed with a buffered suture. Consecutive computed tomography (CT) examinations verified a growing apex pseudoaneurysm. Communication between the ventricle and the pseudoaneurysm was successfully closed with an Amplatz septal plug by the transfemoral route. Follow-up CT showed an additional pseudoaneurysm, which also was successfully closed using the same method.
doi:10.1007/s00270-012-0540-8
PMCID: PMC3825576  PMID: 23334841
12.  A Budget Impact Model for Paclitaxel-eluting Stent in Femoropopliteal Disease in France 
Purpose
The Zilver PTX drug-eluting stent (Cook Ireland Ltd., Limerick, Ireland) represents an advance in endovascular treatments for atherosclerotic superficial femoral artery (SFA) disease. Clinical data demonstrate improved clinical outcomes compared to bare-metal stents (BMS). This analysis assessed the likely impact on the French public health care budget of introducing reimbursement for the Zilver PTX stent.
Methods
A model was developed in Microsoft Excel to estimate the impact of a progressive transition from BMS to Zilver PTX over a 5-year horizon. The number of patients undergoing SFA stenting was estimated on the basis of hospital episode data. The analysis from the payer perspective used French reimbursement tariffs. Target lesion revascularization (TLR) after primary stent placement was the primary outcome. TLR rates were based on 2-year data from the Zilver PTX single-arm study (6 and 9 %) and BMS rates reported in the literature (average 16 and 22 %) and extrapolated to 5 years. Net budget impact was expressed as the difference in total costs (primary stenting and reinterventions) for a scenario where BMS is progressively replaced by Zilver PTX compared to a scenario of BMS only.
Results
The model estimated a net cumulative 5-year budget reduction of €6,807,202 for a projected population of 82,316 patients (21,361 receiving Zilver PTX). Base case results were confirmed in sensitivity analyses.
Conclusion
Adoption of Zilver PTX could lead to important savings for the French public health care payer. Despite higher initial reimbursement for the Zilver PTX stent, fewer expected SFA reinterventions after the primary stenting procedure result in net savings.
doi:10.1007/s00270-012-0494-x
PMCID: PMC3595477  PMID: 23073560
Budget impact model; Drug-eluting stent; Paclitaxel-eluting stent; Peripheral artery disease; Superficial femoral artery
14.  [No title available] 
PMCID: PMC3646157  PMID: 22972586
15.  Prevention of Intracranial In-stent Restenoses: Predilatation with a Drug Eluting Balloon, Followed by the Deployment of a Self-Expanding Stent 
Purpose
Stenting in intracranial atherosclerotic disease (ICAD) is increasingly debated, due to issues of procedural safety, technical efficacy, and in-stent recurrent stenoses (ISR). In the present study, feasibility, safety, and efficacy of angioplasty using a drug-eluting balloon (DEB) followed by the implantation of a self-expanding stent (Enterprise) were evaluated for the treatment of ICAD lesions.
Methods
Fifty-two patients (median age: 71 years; range: 54–86 years; male/female ratio 37:15) underwent stenting of high-grade ICAD lesions between February 2010 and November 2011 in a single center. Angioplasty using a paclitaxel coated SeQuent Please (B. Braun, Germany) or DIOR (Eurocor, Germany) coronary PTCA balloon, followed by the implantation of a self-expanding stent (Enterprise, Codman, USA) was performed in 54 lesions. Angiographic and clinical follow-up was performed at 6 and 12 weeks, 6 and 12 months, and yearly thereafter. Technical success rate, periprocedural complications, occurrence of recurrent ischemic symptoms, and the development of an ISR were analyzed.
Results
Angioplasty using a DEB followed by stent implantation was successfully performed in 44 (81 %) cases. DEB insertion failed in 19 % of the cases and angioplasty was finally performed using a conventional PTCA balloon. The combined procedure related permanent neurologic morbidity and mortality rate (stroke, ICH, and subarachnoid hemorrhage) at 30 days and beyond was 5 %. Angiographic and clinical follow-up were obtained in 33 (61 %) lesions in 32 patients. Recurrent stenosis was seen in one (3 %) lesion.
Conclusion
Angioplasty and stenting using a DEB is safe and yields encouragingly low ISR rates. Further technical developments to improve lesion accessibility are, nevertheless, mandatory.
doi:10.1007/s00270-012-0450-9
PMCID: PMC3595472  PMID: 22869043
Neurointerventions; Arterial intervention; Angioplasty/angiogram
16.  Portal Vein Embolization Before Liver Resection: A Systematic Review 
Purpose
This is a review of literature on the indications, technique, and outcome of portal vein embolization (PVE).
Methods
A systematic literature search on outcome of PVE from 1990 to 2011 was performed in Medline, Cochrane, and Embase databases.
Results
Forty-four articles were selected, including 1,791 patients with a mean age of 61 ± 4.1 years. Overall technical success rate was 99.3 %. The mean hypertrophy rate of the FRL after PVE was 37.9 ± 0.1 %. In 70 patients (3.9 %), surgery was not performed because of failure of PVE (clinical success rate 96.1 %). In 51 patients (2.8 %), the hypertrophy response was insufficient to perform liver resection. In the other 17 cases, 12 did not technically succeed (0.7 %) and 7 caused a complication leading to unresectability (0.4 %). In 6.1 %, resection was cancelled because of local tumor progression after PVE. Major complications were seen in 2.5 %, and the mortality rate was 0.1 %. A head-to-head comparison shows a negative effect of liver cirrhosis on hypertrophy response. The use of n-butyl cyanoacrylate seems to have a greater effect on hypertrophy, but the difference with other embolization materials did not reach statistical significance. No difference in regeneration is seen in patients with cholestasis or chemotherapy.
Conclusions
Preoperative PVE has a high technical and clinical success rate. Liver cirrhosis has a negative effect on regeneration, but cholestasis and chemotherapy do not seem to have an influence on the hypertrophy response. The use of n-butyl cyanoacrylate may result in a greater hypertrophy response compared with other embolization materials used.
doi:10.1007/s00270-012-0440-y
PMCID: PMC3549243  PMID: 22806245
Liver; Resection; Portal vein; Embolization; Regeneration; Future remnant; Colorectal metastasis
17.  A Checklist to Improve Patient Safety in Interventional Radiology 
Purpose
To develop a specific RADiological Patient Safety System (RADPASS) checklist for interventional radiology and to assess the effect of this checklist on health care processes of radiological interventions.
Materials and Methods
On the basis of available literature and expert opinion, a prototype checklist was developed. The checklist was adapted on the basis of observation of daily practice in a tertiary referral centre and evaluation by users. To assess the effect of RADPASS, in a series of radiological interventions, all deviations from optimal care were registered before and after implementation of the checklist. In addition, the checklist and its use were evaluated by interviewing all users.
Results
The RADPASS checklist has two parts: A (Planning and Preparation) and B (Procedure). The latter part comprises checks just before starting a procedure (B1) and checks concerning the postprocedural care immediately after completion of the procedure (B2). Two cohorts of, respectively, 94 and 101 radiological interventions were observed; the mean percentage of deviations of the optimal process per intervention decreased from 24 % before implementation to 5 % after implementation (p < 0.001). Postponements and cancellations of interventions decreased from 10 % before implementation to 0 % after implementation. Most users agreed that the checklist was user-friendly and increased patient safety awareness and efficiency.
Conclusion
The first validated patient safety checklist for interventional radiology was developed. The use of the RADPASS checklist reduced deviations from the optimal process by three quarters and was associated with less procedure postponements.
doi:10.1007/s00270-012-0395-z
PMCID: PMC3595473  PMID: 22562482
Checklist; Interventional radiology; Patient safety
19.  Targeted Vessel Ablation for More Efficient Magnetic Resonance-Guided High-Intensity Focused Ultrasound Ablation of Uterine Fibroids 
Purpose
To report the first clinical experience with targeted vessel ablation during magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) treatment of symptomatic uterine fibroids.
Methods
Pretreatment T1-weighted contrast-enhanced magnetic resonance angiography was used to create a detailed map of the uterine arteries and feeding branches to the fibroids. A three-dimensional overlay of the magnetic resonance angiography images was registered on 3D T2-weighted pretreatment imaging data. Treatment was focused primarily on locations where supplying vessels entered the fibroid. Patients were followed 6 months after treatment with a questionnaire to assess symptoms and quality of life (Uterine Fibroid Symptom and Quality of Life) and magnetic resonance imaging to quantify shrinkage of fibroid volumes.
Results
In two patients, three fibroids were treated with targeted vessel ablation during MR-HIFU. The treatments resulted in almost total fibroid devascularization with nonperfused volume to total fibroid volume ratios of 84, 68, and 86%, respectively, of treated fibroids. The predicted ablated volumes during MR-HIFU in patients 1 and 2 were 45, 40, and 82 ml, respectively, while the nonperfused volumes determined immediately after treatment were 195, 92, and 190 ml respectively, which is 4.3 (patient 1) and 2.3 (patient 2) times higher than expected based on the thermal dose distribution. Fibroid-related symptoms reduced after treatment, and quality of life improved. Fibroid volume reduction ranged 31–59% at 6 months after treatment.
Conclusion
Targeted vessel ablation during MR-HIFU allowed nearly complete fibroid ablation in both patients. This technique may enhance the use of MR-HIFU for fibroid treatment in clinical practice.
doi:10.1007/s00270-011-0313-9
PMCID: PMC3447137  PMID: 22146977
Magnetic resonance-guided high-intensity focused ultrasound; MR-HIFU; Uterine fibroids; Vessel occlusion
20.  Radiologic–Pathologic Correlation of Hepatocellular Carcinoma Treated with Chemoembolization 
To correlate posttreatment radiologic and pathologic findings in patients who underwent transarterial chemoembolization before transplantation or resection. Thirty-five patients with postchemoembolization follow-up imaging underwent liver transplantation/resection. Pre- and posttreatment contrast-enhanced magnetic resonance imaging were used to evaluate radiologic findings. Imaging characteristics using World Health Organization (WHO) and European Association for the Study of the Liver (EASL) criteria after treatment were evaluated. Treated lesions were examined by pathology (gold standard) for the assessment of necrosis. Radiologic findings on magnetic resonance imaging were correlated to pathologic findings to assess the predictability by imaging of actual necrosis. Kappa (κ) statistics were used to determine intermethod agreement between WHO and EASL criteria. Fourteen (40%) of 35 lesions had biopsy-proven hepatocellular carcinoma. Thirteen (37%) of 35 target lesions showed complete pathologic necrosis. Complete pathologic necrosis was seen in 35% of lesions with pretreatment size <3 cm. Complete pathologic necrosis was seen in 1 (100%) of 1, 6 (67%) of 9, 6 (33%) of 18, and 0 (0%) of 7 of the lesions that exhibited complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD) by WHO criteria, respectively. Complete pathologic necrosis was seen in 9 (82%) of 11, 4 (36%) of 11, 0 (0%) of 8, and 0 (0%) of 5 of the lesions that showed CR, PR, SD, or PD by EASL criteria, respectively. EASL CR and WHO response were shown to have ≥85% specificity for predicting complete pathologic necrosis. The κ coefficient for agreement between WHO and EASL was 0.29. EASL and WHO criteria had minimal intermethod agreement. EASL CR and WHO response were able to predict pathologic necrosis.
doi:10.1007/s00270-009-9766-5
PMCID: PMC2921465  PMID: 19967371
Transarterial chemoembolization; Hepatocellular cancer; Imaging; Radiologic–pathologic correlation
21.  Patient Safety in Interventional Radiology: A CIRSE IR Checklist 
Interventional radiology (IR) is an invasive speciality with the potential for complications as with other invasive specialities. The World Health Organization (WHO) produced a surgical safety checklist to decrease the morbidity and mortality associated with surgery. The Cardiovascular and Interventional Society of Europe (CIRSE) set up a task force to produce a checklist for IR. Use of the checklist will, we hope, reduce the incidence of complications after IR procedures. It has been modified from the WHO surgical safety checklist and the RAD PASS from Holland.
doi:10.1007/s00270-011-0289-5
PMCID: PMC3298647  PMID: 22011783
Clinical practice; Patient safety; Interventional radiology
22.  Percutaneous Radiofrequency Ablation of a Small Renal Mass Complicated by Appendiceal Perforation 
Percutaneous radiofrequency ablation (RFA) has gained wide acceptance as nephron-sparing therapy for small renal masses in select patients. Generally, it is a safe procedure with minor morbidity and acceptable short-term oncologic outcome. However, as a result of the close proximity of vital structures, such as the bowel, ureter, and large vessels, to the ablative field, complications regarding these structures may occur. This is the first article describing appendiceal perforation as a complication of computed tomography-guided RFA despite hydrodissection. When performing this innovative and promising procedure one should be aware of the possibility of particular minor and even major complications.
doi:10.1007/s00270-011-0281-0
PMCID: PMC3353108  PMID: 22011782
Interventional oncology; Ablation; Radiofrequency ablation; Kidney/renal; Cancer; Ischemia
23.  Transcatheter Treatment of Hepatocellular Carcinoma with Doxorubicin-loaded DC Bead (DEBDOX): Technical Recommendations 
Tranarterial chemoembolization (TACE) has been established by a meta-analysis of randomized controlled trials as the standard of care for nonsurgical patients with large or multinodular noninvasive hepatocellular carcinoma (HCC) isolated to the liver and with preserved liver function. Although conventional TACE with administration of an anticancer-in-oil emulsion followed by embolic agents has been the most popular technique, the introduction of embolic drug-eluting beads has provided an alternative to lipiodol-based regimens. Experimental studies have shown that TACE with drug-eluting beads has a safe pharmacokinetic profile and results in effective tumor killing in animal models. Early clinical experiences have confirmed that drug-eluting beads provide a combined ischemic and cytotoxic effect locally with low systemic toxic exposure. Recently, the clinical value of a TACE protocol performed by using the embolic microsphere DC Bead loaded with doxorubicin (DEBDOX; drug-eluting bead doxorubicin) has been shown by randomized controlled trials. An important limitation of conventional TACE has been the inconsistency in the technique and the treatment schedules. This limitation has hampered the acceptance of TACE as a standard oncology treatment. Doxorubicin-loaded DC Bead provides levels of consistency and repeatability not available with conventional TACE and offers the opportunity to implement a standardized approach to HCC treatment. With this in mind, a panel of physicians took part in a consensus meeting held during the European Conference on Interventional Oncology in Florence, Italy, to develop a set of technical recommendations for the use of DEBDOX in HCC treatment. The conclusions of the expert panel are summarized.
doi:10.1007/s00270-011-0287-7
PMCID: PMC3447142  PMID: 22009576
Chemoembolization; Doxorubicin; Drug-eluting bead; Hepatocellular carcinoma
24.  Transsinusoidal Portal Vein Embolization with Ethylene Vinyl Alcohol Copolymer (Onyx): A Feasibility Study in Pigs 
Purpose
Portal vein embolization is performed to increase the future liver remnant before liver surgery in patients with liver malignancies. This study assesses the feasibility of a transsinusoidal approach for portal vein embolization (PVE) with the ethylene vinyl alcohol copolymer, Onyx.
Methods
Indirect portography through contrast injection in the cranial mesenteric artery was performed in eight healthy pigs. Onyx was slowly injected through a microcatheter from a wedged position in the hepatic vein and advanced through the liver lobules into the portal system. The progression of Onyx was followed under fluoroscopy, and the extent of embolization was monitored by indirect portography. The pigs were euthanized immediately (n = 2), at 7 days (n = 4), or at 21 days postprocedure (n = 2). All pigs underwent necropsy and the ex vivo livers were grossly and histopathologically analyzed.
Results
Transsinusoidal PVE was successfully performed in five of eight pigs (63%). In 14 of 21 injections (67%), a segmental portal vein could be filled completely. A mean of 1.6 liver lobes per pig was embolized (range 1–2 lobes). There were no periprocedural adverse events. Focal capsular scarring was visible on the surface of two resected livers, yet the capsules remained intact. Histopathological examination showed no signs of recanalization or abscess formation. Mild inflammatory reaction to Onyx was observed in the perivascular parenchyma.
Conclusions
The porcine portal vein can be embolized through injection of Onyx from a wedged position in the hepatic vein. Possible complications of transsinusoidal PVE and the effect on contralateral hypertrophy need further study.
doi:10.1007/s00270-011-0285-9
PMCID: PMC3447144  PMID: 21979794
Liver; Portal vein embolization; Wedged hepatic venography; Pig; Onyx
25.  Optimizing the Protocol for Pulmonary Cryoablation: A Comparison of a Dual- and Triple-Freeze Protocol 
The purpose of this study was to compare a double freeze–thaw protocol to a triple freeze–thaw protocol for pulmonary cryoablation utilizing an in vivo porcine lung model. A total of 18 cryoablations were performed in normal porcine lung utilizing percutaneous technique with 9 each in a double- (10-5-10) and triple-freeze (3-3-7-7-5) protocol. Serial noncontrast CT images were obtained during the ablation. CT imaging findings and pathology were reviewed. No imaging changes were identified during the initial freeze cycle with either protocol. However, during the first thaw cycle, a region of ground glass opacity developed around the probe with both protocols. Because the initial freeze was shorter with the triple freeze–thaw protocol, the imaging findings were apparent sooner with this protocol (6 vs. 13 min). Also, despite a shorter total freeze time (15 vs. 20 min), the ablation zone identified with the triple freeze–thaw protocol was not significantly different from the double freeze–thaw protocol (mean diameter: 1.67 ± 0.41 cm vs. 1.66 ± 0.21 cm, P = 0.77; area: 2.1 ± 0.48 cm2 vs. 1.99 ± 0.62 cm2, P = 0.7; and circularity: 0.95 ± 0.04 vs. 0.96 ± 0.03, P = 0.62, respectively). This study suggests that there may be several advantages of a triple freeze–thaw protocol for pulmonary cryoablation, including earlier identification of the imaging findings associated with the ablation, the promise of a shorter procedure time or larger zones of ablation, and theoretically, more effective cytotoxicity related to the additional freeze–thaw cycle.
doi:10.1007/s00270-010-9868-0
PMCID: PMC3155994  PMID: 20437048
Interventional radiology; Radiofrequency ablation; Pulmonary

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