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Effect of neoadjuvant locoregional therapy on outcomes of orthotopic liver transplant for hepatocellular carcinoma
S100
’
Tuesday
Scientific Session
dropout due to treatment failure. Overall list dropout (40%) was voluntary (n¼3) and due to lack of adherence to listing requirements (n¼1). Conclusion: Bridging therapy using percutaneous microwave ablation prior to OLT in patients with HCC within the Milan Criteria demonstrates favorable short-term disease-free survival post-transplantation and low rates of tumor progression for listed patients, although additional longitudinal data is required to demonstrate long-term treatment durability.
4:33 PM
Abstract No. 213
Portal vein recanalization-transjugular intrahepatic portosystemic shunt using the trans-splenic approach to achieve transplant candidacy in patients with chronic portal vein thrombosis: proof of concept
TUESDAY: Scientific Sessions
B. Thornburg, K.R. Desai, R.M. Hickey, K.T. Sato, R.J. Lewandowski, R. Salem; Northwestern Memorial Hospital, Chicago, IL Purpose: The aim of this study is to test our hypothesis that the trans-splenic (TS) route can be employed as an alternate approach for portal vein recanalization-transjugular portosystemic shunts (PVR-TIPS) for chronic main portal vein thrombosis (mPVT) in potential transplant candidates. Materials and Methods: With IRB approval, 11 consecutive patients with cirrhosis-induced chronic mPVT underwent transsplenic PVR-TIPS in 2013-2014. All patients were denied listing by our transplant team due to the presence of mPVT, a relative contraindication at our center. Patients were followed for adverse events. PV patency at follow-up was assessed by 1-month splenoportography and subsequently by ultrasound/MRI every 3 months. Following PVR-TIPS, patients were reviewed (and subsequently listed) at weekly multidisciplinary conference. Results: PVR-TIPS using the TS approach was successful in all 11 patients with no major complications. Median age was 61 years (range: 33-67), 9/11 (82%) were male, and nonalcoholic steatohepatitis / hepatitis C were the leading causes of liver disease (8/11, 4 each). Complete mPVT was found in 8/ 11 (73%) patients. Four out of 11 patients (36%) had a MELD Patient 1 2 3 4 5
Pre-SAE volume/ event (mL) 3,000-10,200 4,200-9,100 3,750-7,950 1,500-5,000 4,100-6,700
Post-SAE volume/ event (mL) 1,000-2,200 4,700-7,700 3,900-9,600 1,100-2,200 3,700-6,700
4:42 PM
JVIR
Abstract No. 214
Efficacy of splenic artery embolization for refractory ascites in the post-liver transplant patient S.C. Williams, J.T. Salsamendi, A. Echenique; Interventional Radiology, University of Miami, Miami, FL Purpose: Refractory ascites (RA) in advanced liver disease is known to carry a poor prognosis. Although liver transplantation is usually effective for the treatment of RA, there are rare cases where transplantation is not effective. Previously, TIPS has been used for RA but TIPS is not as effective in liver transplant patients as in native liver patients. Given the high morbidity and mortality associated with RA, a safe intervention that reduces the incidence of this complication is warranted. Materials and Methods: Retrospective chart review evaluating the efficacy of splenic artery embolization (SAE) in posttransplant patients for the treatment of RA. Proximal SAE was performed with either an Amplatzer vascular plug or embolic coils. Frequency of large volume paracentesis, volume of paracentesis, and calculation of pre-embolization splenic volume on abdominal CT were calculated. Splenic volume calculations were performed to determine if larger splenic volume predicted improved response to SAE (Volume¼30þ0.58([Max Width Max Thickness Max Length]). Results: Five post-transplant patients with RA received proximal SAE at a single center in 2013-2014. Four patients were treated with an Amplatzer plug and one patient, due to limitations in anatomy, was treated with embolic coils. The results are listed in the table below. No patients presented with post-embolization complications. Conclusion: SAE is a safe and effective treatment for refractory ascites. Currently, there is limited data in the literature regarding efficacy of SAE for the treatment of RA in the postliver transplant population. This case series represents the second largest cohort of patients in the literature, with the largest cohort representing six patients. Given the high morbidity and mortality associated with RA and decreased effectiveness of TIPS in this population, SAE represents a safe alternative treatment for post-liver transplant refractory ascites.
Frequency of paracentesis pre-SAE Weekly Biweekly Monthly Weekly-Biweekly Weekly
418 and 8/11 (73%) had a baseline Child-Pugh score 7-10. Minor adverse events occurred in 2/11 (fever, encephalopathy). Five out of eleven patients (45%) exhibited some minor remaining thrombus in the PV at the end of the procedure; of these patients, 3/5 had complete thrombus resolution at one month, with the remaining 2/5 resolving at 3 months (no anticoagulation). Three patients underwent successful transplantation with end-to-end anastomoses. Conclusion: Trans-splenic PVR-TIPS is a potentially safe and effective method to treat PVT and improve transplant candidacy.
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4:51 PM
Frequency of paracentesis post-SAE 3 events in 11 months 7 events in 9 months 9 events in 10 months 10 events in 11 months 12 events in 6 months
Splenic volume pre-SAE (cm3) 909 670 Not available 1,003 587
Abstract No. 215
Effect of neoadjuvant locoregional therapy on outcomes of orthotopic liver transplant for hepatocellular carcinoma G. Nadolski2,1, M. Mohammed2, E. Mills-Robertson3, T.P. Gade2,1, M.C. Soulen1, S. Hunt2,1; 1Hospital of the University of Pennsylvania, Philadelphia, PA; 2Penn Image Guided Interventions Laboratory, Philadelphia, PA; 3 Radiology, Pennsylvania Hospital, Philadelphia, PA
JVIR
’
Scientific Session
LRT (N¼206) No LRT (N¼167) p value
Median Age (years) 56 ⫾ 8 55 ⫾ 8 0.7
Tuesday
Male Gender 174 (84%) 135 (81%) 0.4
Calculated MELD at diagnosis 10 ⫾ 4 12 ⫾ 6 0.6
Mean longest diameter at diagnosis (mm) 30 ⫾ 0.8 27 ⫾ 0.9 0.02
Scientific Session 26 Arterial Interventions: GI Tuesday, March 3, 2015 3:30 PM – 5:00 PM Room: 304 3:30 PM
Abstract No. 216
’ FEATURED ABSTRACT Transradial approach for peripheral and visceral interventions: a single-center review of safety and feasibility in the first 1000 cases
Frequency of Transplantation 163 (79%) 137 (83%) 0.4
S101
Median OS from Diagnosis HCC (days) 1,895 ⫾ 1,285 1,952 ⫾ 1,555 0.7
R. Posham, R.S. Patel, E. Kim, N.E. Tabori, S. F. Nowakowski, R. Lookstein, A.M. Fischman; Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY Purpose: Transradial access (TRA) has been shown to decrease complications vs. transfemoral access (TFA) in coronary intervention. TRA for peripheral and visceral interventions is less common but has been reported to offer comparable therapeutic efficacy as TFA in chemoembolization with lower overall access-site complications. Additionally, the lack of need for an arterial closure device in TRA affords patients faster time to ambulation and discharge. We reviewed adverse events in patients undergoing TRA in a large academic medical center. Materials and Methods: Retrospective review was conducted on 1004 procedures performed in 668 patients undergoing TRA from 4/2012 to 10/2014. Procedures included: chemoembolization (n¼371), Y90 mapping (n¼249) and infusion (n¼168), renal/visceral intervention (n¼104), uterine artery embolization (n¼65), peripheral intervention (n¼37), endoleak (n¼8), and other (n¼2). A pulse oximeter was used on the ipsilateral thumb to confirm dual circulation and patency of the palmar arch (Barbeau Test). Ultrasound of the radial artery (RA) verified adequate vessel size. TRA contraindications included: RAo2mm and Barbeau D waveform. After RA puncture, a hydrophilic Glidesheath (Terumo Interventional Systems) was placed and 3000U heparin, 2.5mg verapamil, and 200mcg nitroglycerin was given to minimize vascular complication. Following the procedure, a TR band (Terumo) was used for hemostasis. Procedural details and 30day adverse events (AEs) were evaluated (CTCAE v4.0). Results: Technical success via TRA was obtained in 998/1004 cases (99.4%), with 6 cases requiring TFA crossover (0.6%). Overall major AEs were 0.3%: 1 large hematoma requiring TFA crossover, 1 pseudoaneurysm requiring intervention, and 1 verapamil induced seizure. Minor adverse event rate was 3.2%: RA occlusion (n¼11, 3 crossover), hematoma/bleeding (n¼9), RA thrombosis (n¼5, 1 crossover), arteritis (n¼3), pain/ numbness (n¼2), and severe vasospasm (n¼2, 1 crossover). All minor AEs were either asymptomatic or managed conservatively. There were no additional AEs at 30 days. Conclusion: TRA appears safe and well tolerated in a typical IR patient population with extremely low complication rates and warrants further large-scale investigation.
3:39 PM
Abstract No. 217
Negative flow phase Technetium-99m-labeled red blood cell scintigraphy independently predicts lack of extravasation on subsequent angiograms in patients with positive dynamic phase scintigraphy
TUESDAY: Scientific Sessions
Purpose: Patients with hepatocellular carcinoma (HCC) who are listed for liver transplant (OLT) commonly receive neoadjuvant locoregional therapy (LRT) to treat the tumor while awaiting OLT. A retrospective cohort study was performed to compare transplant related outcomes of patients with HCC listed for OLT treated with LRT to those who do not receive LRT. Materials and Methods: Review of the OTTR database was used to identify patients evaluated in multidisciplinary liver tumor clinic listed for OLT with HCC (1998-2010). Number and size of tumors, severity of liver disease, type of LRT, OLT waitlist time and outcome, and date of death were recorded. Survival from time of HCC diagnosis was analyzed using Cox proportional hazard ratios. Results: 373 patients met inclusion criteria; 206 received LRT (Group 1) and 167 did not (Group 2). Results are summarized in Table 1. Median length of follow up was 1900 days. In Group 1, type of LRT included 148 TACE, 28 RFA, 17 TACE plus RFA, and 13 other. Severity of liver disease and number of HCC were similar. Tumors in the LRT group were slightly larger at time of diagnosis (30 vs 27 mm; p¼0.02). Median time on wait list was significantly longer in the LRT group (132 vs 76 days; po0.01). Proportion of patients transplanted did not differ (79% vs 83%, LRT vs no LRT; p¼0.4). As a whole, intention to treat overall survival from HCC diagnosis did not differ between groups (1895 vs 1952 days, LRT vs no LRT, HR 0.95; p¼0.7). However, in patients with largest tumor diameter 438 mm, LRT was associated with a significantly longer median overall survival of 1838 days compared to 900 days for those who did not receive LRT (HR¼0.42, CI¼0.22-0.79, po0.01). Conclusion: Despite longer OLT wait list times and slightly larger tumors, patients with HCC on the OLT wait list treated with LRT have similar transplantation rate and overall survival compared to listed HCC patients not treated with LRT. Subgroup analysis suggests patients with larger tumor diameters have improved survival with LRT.
Median number Median time on of tumors Wait List (days) 1 ⫾ 0.8 132 ⫾ 253 1 ⫾ 0.7 76 ⫾ 182 0.09 o0.01
’
’
Tuesday
Scientific Session
dropout due to treatment failure. Overall list dropout (40%) was voluntary (n¼3) and due to lack of adherence to listing requirements (n¼1). Conclusion: Bridging therapy using percutaneous microwave ablation prior to OLT in patients with HCC within the Milan Criteria demonstrates favorable short-term disease-free survival post-transplantation and low rates of tumor progression for listed patients, although additional longitudinal data is required to demonstrate long-term treatment durability.
4:33 PM
Abstract No. 213
Portal vein recanalization-transjugular intrahepatic portosystemic shunt using the trans-splenic approach to achieve transplant candidacy in patients with chronic portal vein thrombosis: proof of concept
TUESDAY: Scientific Sessions
B. Thornburg, K.R. Desai, R.M. Hickey, K.T. Sato, R.J. Lewandowski, R. Salem; Northwestern Memorial Hospital, Chicago, IL Purpose: The aim of this study is to test our hypothesis that the trans-splenic (TS) route can be employed as an alternate approach for portal vein recanalization-transjugular portosystemic shunts (PVR-TIPS) for chronic main portal vein thrombosis (mPVT) in potential transplant candidates. Materials and Methods: With IRB approval, 11 consecutive patients with cirrhosis-induced chronic mPVT underwent transsplenic PVR-TIPS in 2013-2014. All patients were denied listing by our transplant team due to the presence of mPVT, a relative contraindication at our center. Patients were followed for adverse events. PV patency at follow-up was assessed by 1-month splenoportography and subsequently by ultrasound/MRI every 3 months. Following PVR-TIPS, patients were reviewed (and subsequently listed) at weekly multidisciplinary conference. Results: PVR-TIPS using the TS approach was successful in all 11 patients with no major complications. Median age was 61 years (range: 33-67), 9/11 (82%) were male, and nonalcoholic steatohepatitis / hepatitis C were the leading causes of liver disease (8/11, 4 each). Complete mPVT was found in 8/ 11 (73%) patients. Four out of 11 patients (36%) had a MELD Patient 1 2 3 4 5
Pre-SAE volume/ event (mL) 3,000-10,200 4,200-9,100 3,750-7,950 1,500-5,000 4,100-6,700
Post-SAE volume/ event (mL) 1,000-2,200 4,700-7,700 3,900-9,600 1,100-2,200 3,700-6,700
4:42 PM
JVIR
Abstract No. 214
Efficacy of splenic artery embolization for refractory ascites in the post-liver transplant patient S.C. Williams, J.T. Salsamendi, A. Echenique; Interventional Radiology, University of Miami, Miami, FL Purpose: Refractory ascites (RA) in advanced liver disease is known to carry a poor prognosis. Although liver transplantation is usually effective for the treatment of RA, there are rare cases where transplantation is not effective. Previously, TIPS has been used for RA but TIPS is not as effective in liver transplant patients as in native liver patients. Given the high morbidity and mortality associated with RA, a safe intervention that reduces the incidence of this complication is warranted. Materials and Methods: Retrospective chart review evaluating the efficacy of splenic artery embolization (SAE) in posttransplant patients for the treatment of RA. Proximal SAE was performed with either an Amplatzer vascular plug or embolic coils. Frequency of large volume paracentesis, volume of paracentesis, and calculation of pre-embolization splenic volume on abdominal CT were calculated. Splenic volume calculations were performed to determine if larger splenic volume predicted improved response to SAE (Volume¼30þ0.58([Max Width Max Thickness Max Length]). Results: Five post-transplant patients with RA received proximal SAE at a single center in 2013-2014. Four patients were treated with an Amplatzer plug and one patient, due to limitations in anatomy, was treated with embolic coils. The results are listed in the table below. No patients presented with post-embolization complications. Conclusion: SAE is a safe and effective treatment for refractory ascites. Currently, there is limited data in the literature regarding efficacy of SAE for the treatment of RA in the postliver transplant population. This case series represents the second largest cohort of patients in the literature, with the largest cohort representing six patients. Given the high morbidity and mortality associated with RA and decreased effectiveness of TIPS in this population, SAE represents a safe alternative treatment for post-liver transplant refractory ascites.
Frequency of paracentesis pre-SAE Weekly Biweekly Monthly Weekly-Biweekly Weekly
418 and 8/11 (73%) had a baseline Child-Pugh score 7-10. Minor adverse events occurred in 2/11 (fever, encephalopathy). Five out of eleven patients (45%) exhibited some minor remaining thrombus in the PV at the end of the procedure; of these patients, 3/5 had complete thrombus resolution at one month, with the remaining 2/5 resolving at 3 months (no anticoagulation). Three patients underwent successful transplantation with end-to-end anastomoses. Conclusion: Trans-splenic PVR-TIPS is a potentially safe and effective method to treat PVT and improve transplant candidacy.
’
4:51 PM
Frequency of paracentesis post-SAE 3 events in 11 months 7 events in 9 months 9 events in 10 months 10 events in 11 months 12 events in 6 months
Splenic volume pre-SAE (cm3) 909 670 Not available 1,003 587
Abstract No. 215
Effect of neoadjuvant locoregional therapy on outcomes of orthotopic liver transplant for hepatocellular carcinoma G. Nadolski2,1, M. Mohammed2, E. Mills-Robertson3, T.P. Gade2,1, M.C. Soulen1, S. Hunt2,1; 1Hospital of the University of Pennsylvania, Philadelphia, PA; 2Penn Image Guided Interventions Laboratory, Philadelphia, PA; 3 Radiology, Pennsylvania Hospital, Philadelphia, PA
JVIR
’
Scientific Session
LRT (N¼206) No LRT (N¼167) p value
Median Age (years) 56 ⫾ 8 55 ⫾ 8 0.7
Tuesday
Male Gender 174 (84%) 135 (81%) 0.4
Calculated MELD at diagnosis 10 ⫾ 4 12 ⫾ 6 0.6
Mean longest diameter at diagnosis (mm) 30 ⫾ 0.8 27 ⫾ 0.9 0.02
Scientific Session 26 Arterial Interventions: GI Tuesday, March 3, 2015 3:30 PM – 5:00 PM Room: 304 3:30 PM
Abstract No. 216
’ FEATURED ABSTRACT Transradial approach for peripheral and visceral interventions: a single-center review of safety and feasibility in the first 1000 cases
Frequency of Transplantation 163 (79%) 137 (83%) 0.4
S101
Median OS from Diagnosis HCC (days) 1,895 ⫾ 1,285 1,952 ⫾ 1,555 0.7
R. Posham, R.S. Patel, E. Kim, N.E. Tabori, S. F. Nowakowski, R. Lookstein, A.M. Fischman; Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY Purpose: Transradial access (TRA) has been shown to decrease complications vs. transfemoral access (TFA) in coronary intervention. TRA for peripheral and visceral interventions is less common but has been reported to offer comparable therapeutic efficacy as TFA in chemoembolization with lower overall access-site complications. Additionally, the lack of need for an arterial closure device in TRA affords patients faster time to ambulation and discharge. We reviewed adverse events in patients undergoing TRA in a large academic medical center. Materials and Methods: Retrospective review was conducted on 1004 procedures performed in 668 patients undergoing TRA from 4/2012 to 10/2014. Procedures included: chemoembolization (n¼371), Y90 mapping (n¼249) and infusion (n¼168), renal/visceral intervention (n¼104), uterine artery embolization (n¼65), peripheral intervention (n¼37), endoleak (n¼8), and other (n¼2). A pulse oximeter was used on the ipsilateral thumb to confirm dual circulation and patency of the palmar arch (Barbeau Test). Ultrasound of the radial artery (RA) verified adequate vessel size. TRA contraindications included: RAo2mm and Barbeau D waveform. After RA puncture, a hydrophilic Glidesheath (Terumo Interventional Systems) was placed and 3000U heparin, 2.5mg verapamil, and 200mcg nitroglycerin was given to minimize vascular complication. Following the procedure, a TR band (Terumo) was used for hemostasis. Procedural details and 30day adverse events (AEs) were evaluated (CTCAE v4.0). Results: Technical success via TRA was obtained in 998/1004 cases (99.4%), with 6 cases requiring TFA crossover (0.6%). Overall major AEs were 0.3%: 1 large hematoma requiring TFA crossover, 1 pseudoaneurysm requiring intervention, and 1 verapamil induced seizure. Minor adverse event rate was 3.2%: RA occlusion (n¼11, 3 crossover), hematoma/bleeding (n¼9), RA thrombosis (n¼5, 1 crossover), arteritis (n¼3), pain/ numbness (n¼2), and severe vasospasm (n¼2, 1 crossover). All minor AEs were either asymptomatic or managed conservatively. There were no additional AEs at 30 days. Conclusion: TRA appears safe and well tolerated in a typical IR patient population with extremely low complication rates and warrants further large-scale investigation.
3:39 PM
Abstract No. 217
Negative flow phase Technetium-99m-labeled red blood cell scintigraphy independently predicts lack of extravasation on subsequent angiograms in patients with positive dynamic phase scintigraphy
TUESDAY: Scientific Sessions
Purpose: Patients with hepatocellular carcinoma (HCC) who are listed for liver transplant (OLT) commonly receive neoadjuvant locoregional therapy (LRT) to treat the tumor while awaiting OLT. A retrospective cohort study was performed to compare transplant related outcomes of patients with HCC listed for OLT treated with LRT to those who do not receive LRT. Materials and Methods: Review of the OTTR database was used to identify patients evaluated in multidisciplinary liver tumor clinic listed for OLT with HCC (1998-2010). Number and size of tumors, severity of liver disease, type of LRT, OLT waitlist time and outcome, and date of death were recorded. Survival from time of HCC diagnosis was analyzed using Cox proportional hazard ratios. Results: 373 patients met inclusion criteria; 206 received LRT (Group 1) and 167 did not (Group 2). Results are summarized in Table 1. Median length of follow up was 1900 days. In Group 1, type of LRT included 148 TACE, 28 RFA, 17 TACE plus RFA, and 13 other. Severity of liver disease and number of HCC were similar. Tumors in the LRT group were slightly larger at time of diagnosis (30 vs 27 mm; p¼0.02). Median time on wait list was significantly longer in the LRT group (132 vs 76 days; po0.01). Proportion of patients transplanted did not differ (79% vs 83%, LRT vs no LRT; p¼0.4). As a whole, intention to treat overall survival from HCC diagnosis did not differ between groups (1895 vs 1952 days, LRT vs no LRT, HR 0.95; p¼0.7). However, in patients with largest tumor diameter 438 mm, LRT was associated with a significantly longer median overall survival of 1838 days compared to 900 days for those who did not receive LRT (HR¼0.42, CI¼0.22-0.79, po0.01). Conclusion: Despite longer OLT wait list times and slightly larger tumors, patients with HCC on the OLT wait list treated with LRT have similar transplantation rate and overall survival compared to listed HCC patients not treated with LRT. Subgroup analysis suggests patients with larger tumor diameters have improved survival with LRT.
Median number Median time on of tumors Wait List (days) 1 ⫾ 0.8 132 ⫾ 253 1 ⫾ 0.7 76 ⫾ 182 0.09 o0.01
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