Clinical Focus

  • Cancer
  • Interventional Radiology
  • Interventional Oncology
  • Vascular and Interventional Radiology

Academic Appointments

Administrative Appointments

  • Member, Technology Assessment Committee (2010 - Present)
  • Appointments and Promotions Committee, Dept. of Radiology (2010 - Present)

Professional Education

  • Internship:California Pacific Medical Center Dept of Ophthalmology (1992) CA
  • Fellowship:Stanford University School of Medicine Registrar (1997) CA
  • Medical Education:Stanford University School of Medicine (1991) CA
  • Board Certification: Diagnostic Radiology, American Board of Radiology (1996)
  • Board Certification: Vascular and Interventional Radiology, American Board of Radiology (1998)
  • Residency:UCSF Medical Center (1996) CA
  • AB, Harvard, Biochemistry Molecular Biology/ Visual & Environmental Studies (1983)
  • PhD, Stanford, Biophysics (1990)
  • MD, Stanford, Medicine (1991)

Research & Scholarship

Current Research and Scholarly Interests

Transarterial administration of chemotherapeutics, radioactive microspheres, and biologics for the treatment of unresectable tumors; management of portal hypertension and complications of cirrhosis (TIPS); treatment of complications of organ transplantation; Venous and pulmonary arterial thrombolysis and reconstruction; Stent and Stent-graft treatment of peripheral vascular diseases, aneurysms, aortic dissections

Clinical Trials

  • Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis Recruiting

    The purpose of this study is to determine if the use of adjunctive Pharmacomechanical Catheter Directed Thrombolysis, which includes the intrathrombus administration of rt-PA--Activase (Alteplase),can prevent the post-thrombotic syndrome(PTS)in patients with symptomatic proximal deep vein thrombosis(DVT)as compared with optimal standard DVT therapy alone.

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  • Hepatocellular Carcinoma Study Comparing Vaccinia Virus Based Immunotherapy Plus Sorafenib vs Sorafenib Alone Recruiting

    This is a randomized Phase 3 study to determine whether treatment with vaccinia virus based immunotherapy (Pexa-Vec) followed by sorafenib increases survival compared to treatment with sorafenib in patients with advanced hepatocellular carcinoma who have not received prior systemic therapy.

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  • Filter Initial & Long Term Evaluation After Placement and Retrieval Registry Recruiting

    A data registry for all patients who undergo IVC (Inferior Vena Cava) filter placement or retrieval at Stanford. Potential enrollees will already be undergoing the procedure. If patients are willing, they will be prospectively enrolled prior to the procedure. As part of the study, chart and clinical data reviews will be used to track patient progress and response to the treatment.

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  • Impact of C-arm CT in Decreased Renal Function Undergoing TACE for Tx of Hepato-Cellular Carcinoma Not Recruiting

    Impact on contrast dose or total volume of contrast required to effectively treat the targeted tumor.

    Stanford is currently not accepting patients for this trial. For more information, please contact Kamil Unver, (650) 725 - 9810.

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  • HepaSphere/Quadrasphere Microspheres for Delivery of Doxorubicin for the Treatment of Hepatocellular Cancer Not Recruiting

    The purpose of this study is to evaluate overall survival in patients treated with HepaSphere/QuadraSphere compared to conventional transarterial chemoembolization with particle PVA.

    Stanford is currently not accepting patients for this trial. For more information, please contact Risa Jiron, 650-736-1598.

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  • Efficacy Evaluation of TheraSphere Following Failed First Line Chemotherapy in Metastatic Colorectal Cancer Not Recruiting

    The effectiveness and safety of TheraSphere will be evaluated in patients with colorectal cancer with metastases in the liver, who are scheduled to receive second line chemotherapy. All patients receive the standard of care chemotherapy with or without the addition of TheraSphere.

    Stanford is currently not accepting patients for this trial. For more information, please contact Kamil Unver, 650-725-9810.

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  • Pulmonary Embolism Response to Fragmentation, Embolectomy, & Catheter Thrombolysis: PERFECT Recruiting

    A prospective observational study to evaluate the safety and effectiveness data of catheter-directed therapy (CDT) including percutaneous mechanical thrombectomy (PMT) for treatment of acute pulmonary embolism (PE)

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  • Prostate Artery Embolization With Embosphere Microspheres Compared to TURP for Benign Prostatic Hyperplasia Recruiting

    The purpose of this study is to evaluate improvement of symptoms from benign prostatic hyperplasia (BPH) as assessed by the International Prostate Symptom Score (IPSS) for prostatic artery embolization (PAE) using Embosphere Microspheres compared to conventional transurethral resection of the prostate (TURP).

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  • Transarterial Chemoembolization Compared With Stereotactic Body Radiation Therapy or Stereotactic Ablative Radiation Therapy in Treating Patients With Residual or Recurrent Liver Cancer Undergone Initial Transarterial Chemoembolization Recruiting

    This randomized phase III trial studies how well transarterial chemoembolization (TACE) works compared to stereotactic body radiation therapy (SBRT) or stereotactic ablative radiation therapy (SABR) in patients with liver cancer that remain after attempts to remove the cancer have been made (residual) or has come back (recurrent). TACE is a minimally invasive, image-guided treatment procedure that uses a catheter to deliver both chemotherapy medication and embolization materials into the blood vessels that lead to the tumors. SBRT or SABR may be able to send radiation directly to the tumor and cause less damage to normal liver tissue. It is not yet known whether TACE is more effective than SBRT or SABR in treating patients with persistent or recurrent liver cancer who have undergone initial TACE.

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  • Pulmonary Interstitial Lymphography in Early Stage Lung Cancer Not Recruiting

    The stereotactic body radiation therapy (SBRT) procedure is an emerging alternative to the standard treatment for early stage non-small cell lung cancer (NSCLC), typically lobectomy with lymphadenectomy. This procedure (lobectomy) does not fulfill the medical need as many patients are poor operative candidates or decline surgery. This study assesses the feasibility of stereotactic body radiation therapy (SBRT) as a tool to produce therapeutically useful computed tomography (CT) scans, using standard water-soluble iodinated compounds as the contrast agents.

    Stanford is currently not accepting patients for this trial. For more information, please contact Laura Gable, (650) 736 - 0798.

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  • A Humanitarian Device Exemption Treatment Protocol of TheraSphere For Treatment of Unresectable Hepatocellular Carcinoma Recruiting

    To provide Therasphere treatment for patients diagnosed with unresectable liver cancer.

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  • Transarterial Chemoembolization vs CyberKnife for Recurrent Hepatocellular Carcinoma Not Recruiting

    Primary Objective: To compare the efficacy of TACE vs. CyberKnife SBRT in the treatment of locally recurrent HCC after initial TACE. Secondary Objectives: 1. To determine the progression-free survival of TACE vs. CyberKnife SBRT 2. To determine the overall survival of TACE vs. CyberKnife SBRT for locally recurrent HCC 3. To determine the toxicities associated with TACE or CyberKnife SBRT for the treatment of recurrent HCC.

    Stanford is currently not accepting patients for this trial. For more information, please contact Laurie Ann Columbo, (650) 736 - 0792.

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  • The GORE Viabahn Endoprosthesis for the Treatment of Venous Occlusions and Stenoses Not Recruiting

    To study the safety and efficacy of drug coated stents for the treatment of venous occlusions and stenoses in the lower extremity. The use of the device for the treatment of peripheral arterial disease is approved by the FDA, however, the use of the device in venous occlusions and stenoses, although performed by some practitioners, has not yet been studied in detail.

    Stanford is currently not accepting patients for this trial. For more information, please contact Kamil Unver, 650-725-9810.

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  • To Evaluate the Safety and Efficacy for GORE TAG Thoracic Endoprosthesis in the Treatment of Thoracic Aortic Disease Not Recruiting

    PURPOSE OF RESEARCH: Endovascular stent-graft repair of aortic pathologies is a minimally-invasive alternative to open surgery that may decrease morbidity and mortality, particularly in high risk patients. Optimal patient selection, based on pathology and anatomy, is being defined. Technically successful implantation requires adequate assessment of pathology and anatomy, and development and execution of novel and delicate procedures that resolve the pathology while minimizing morbidity and mortality.

    Stanford is currently not accepting patients for this trial. For more information, please contact Archana Verma, (650) 736 - 0959.

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  • CyberKnife Radiosurgical Treatment of Inoperable Early Stage Non-Small Cell Lung Cancer Not Recruiting

    The purpose of this study is to assess the short and long-term outcomes after CyberKnife stereotactic radiosurgery for early stage non-small cell lung cancer (NSCLC) in patients who are medically inoperable.

    Stanford is currently not accepting patients for this trial. For more information, please contact Lisa Zhou, (650) 736 - 4112.

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  • Impact of C-arm CT in Patients With HCC Undergoing TACE: Optimal Imaging Guidance Not Recruiting

    Patients will be enrolled based on presence of HCC and eligibility for TACE. They will be randomized to one of two arms for imaging navigation to the optimal catheter location for chemotherapy injection to treat the first (possibly sole) tumor target. The two arms will be: TACE using C-arm CT supplemented by DSA or DSA only (only DSA images will be used for navigation and tumor vessel tracking). Navigation to subsequent treatment targets in all patients will be done with fluoroscopy, CACT, and DSA, as is standard of care at Stanford University Medical Center, and is not part of the study. Vascular complexity, which affects navigation difficulty and thus the need for imaging, will be assessed separately for use in data analysis by two radiologists on a four-point scale.

    Stanford is currently not accepting patients for this trial. For more information, please contact Kamil Unver, (650) 725 - 9810.

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  • Chemoembolization With or Without Sorafenib Tosylate in Treating Patients With Liver Cancer That Cannot Be Removed by Surgery Not Recruiting

    This randomized phase III trial studies chemoembolization and sorafenib tosylate to see how well they work compared with chemoembolization alone in treating patients with liver cancer that cannot be removed by surgery. Drugs used in chemotherapy, such as doxorubicin hydrochloride, mitomycin, and cisplatin, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Chemoembolization kills tumor cells by carrying drugs directly into blood vessels near the tumor and then blocking the blood flow to allow a higher concentration of the drug to reach the tumor for a longer period of time. Sorafenib tosylate may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. It is not yet known whether giving chemoembolization together with sorafenib tosylate is more effective than chemoembolization alone in treating patients with liver cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Fizaa Ahmed, (650) 725 - 6409.

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  • ExAblate (Magnetic Resonance-guided Focused Ultrasound Surgery) Treatment of Metastatic Bone Tumors for the Palliation of Pain Not Recruiting

    A Pivotal Study to Evaluate the Effectiveness and Safety of ExAblate Treatment of Metastatic Bone and Multiple Myeloma Tumors for the Palliation of Pain in Patients Who are not Candidates for Radiation Therapy

    Stanford is currently not accepting patients for this trial. For more information, please contact Kamil Unver, (650) 725 - 9810.

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  • Combination SBRT With TACE for Unresectable Hepatocellular Carcinoma Not Recruiting

    To determine the efficacy and toxicity of TACE combined with SBRT

    Stanford is currently not accepting patients for this trial. For more information, please contact Laurie Ann Columbo, 650-736-0792.

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2017-18 Courses


All Publications

  • Yttrium-90 Radioembolization for Unresectable Combined Hepatocellular-Cholangiocarcinoma. Cardiovascular and interventional radiology Chan, L. S., Sze, D. Y., Poultsides, G. A., Louie, J. D., Abdelrazek Mohammed, M. A., Wang, D. S. 2017


    Combined hepatocellular-cholangiocarcinoma (cHCC-CC) is a rare mixed cell type primary liver cancer with limited data to guide management. Transarterial radioembolization with yttrium-90 microspheres (RE) is an emerging treatment option for both hepatocellular carcinoma and intrahepatic cholangiocarcinoma. This study explored the safety and efficacy of RE for unresectable cHCC-CC.Patients with histopathologically confirmed cHCC-CC treated with RE were retrospectively evaluated. Clinical and biochemical toxicities were assessed using the Common Toxicity Criteria for Adverse Events v4.03. Radiological response was analyzed using the Response Criteria in Solid Tumors (RECIST) v1.1 and modified RECIST criteria. Survival times were calculated and prognostic variables identified.Ten patients (median age 59 years; six men, four women) with unresectable cHCC-CC underwent 14 RE treatments with resin (n = 6 patients) or glass (n = 4 patients) microspheres. Clinical toxicities were limited to grade 1-2 fatigue, anorexia, nausea, or abdominal pain. No significant biochemical toxicities were observed. Median overall survivals from the first RE treatment and from initial diagnosis were 10.2 and 17.7 months, respectively. Six of seven patients with elevated tumor biomarker levels before RE showed decreased levels after treatment (median decrease of 72%, range 13-80%). Best hepatic radiological response was 60% partial response and 40% stable disease by modified RECIST, and 100% stable disease by RECIST v1.1. Poor performance status and the presence of macrovascular invasion were identified as predictors of reduced survival after RE.RE appears to be a safe and promising treatment option for patients with unresectable cHCC-CC.Level 4.

    View details for DOI 10.1007/s00270-017-1648-7

    View details for PubMedID 28432387

  • The Role of Dual-Phase Cone-Beam CT in Predicting Short-Term Response after Transarterial Chemoembolization for Hepatocellular Carcinoma. Journal of vascular and interventional radiology Müller, K., Datta, S., Gehrisch, S., Ahmad, M., Mohammed, M. A., Rosenberg, J., Hwang, G. L., Louie, J. D., Sze, D. Y., Kothary, N. 2017; 28 (2): 238-245


    To identify computational and qualitative features derived from dual-phase cone-beam CT that predict short-term response in patients undergoing transarterial chemoembolization for hepatocellular carcinoma (HCC).This retrospective study included 43 patients with 59 HCCs. Six features were extracted, including intensity of tumor enhancement on both phases and characteristics of the corona on the washout phase. Short-term response was evaluated by modified Response Evaluation Criteria in Solid Tumors on follow-up imaging, and extracted features were correlated to response using univariate and multivariate analyses.Univariate and multivariate analyses did not reveal a correlation between absolute and relative tumor enhancement characteristics on either phase with response (arterial P = .21; washout P = .40; ∆ P = .90). On multivariate analysis of qualitative characteristics, the presence of a diffuse corona was an independent predictor of incomplete response (P = .038) and decreased the odds ratio of objective response by half regardless of tumor size.Computational features extracted from contrast-enhanced dual-phase cone-beam CT are not prognostic of response to transarterial chemoembolization in patients with HCC. HCCs that demonstrate a diffuse, patchy corona have reduced odds of achieving complete response after transarterial chemoembolization and should be considered for additional treatment with an alternative modality.

    View details for DOI 10.1016/j.jvir.2016.09.019

    View details for PubMedID 27914917

  • Yttrium-90 Radioembolization with Resin Microspheres without Routine Embolization of the Gastroduodenal Artery. Journal of vascular and interventional radiology Ward, T. J., Louie, J. D., Sze, D. Y. 2017; 28 (2): 246-253


    To evaluate safety of resin microsphere radioembolization (RE) without prophylactic embolization of the gastroduodenal artery (GDA).Between July 2013 and April 2015, all patients undergoing RE with resin microspheres for liver-dominant metastatic disease were treated without routine embolization of the GDA. Selective embolization of distal hepaticoenteric vessels was performed if identified by digital subtraction angiography, cone-beam computed tomography, or technetium-99m macroaggregated albumin scintigraphy. Resin microspheres were administered using 5% dextrose flush distal to the origin of the GDA in lobar or segmental fashion, with judicious use of an antireflux microcatheter in recognized high-risk situations. Gastrointestinal toxicity was evaluated by the performing physician for at least 3 months.RE with resin microspheres was performed in 62 patients undergoing 69 treatments. During planning angiography, embolization of 0 or 1 vessel (median, 1; range, 0-4) was performed in 86% of patients, most commonly the right gastric and supraduodenal arteries. Prophylactic embolization of the GDA was performed in only 2 patients (3%). In 6 treatments (9%), adjunctive embolization was required immediately before RE, and an antireflux microcatheter was used in 14% of treatments. Clinical follow-up was available in 60 of 62 patients (median, 134 d; range, 15-582 d). No signs or symptoms of gastric or duodenal ulceration were observed.RE using resin microspheres without embolization of the GDA can be performed safely.

    View details for DOI 10.1016/j.jvir.2016.09.002

    View details for PubMedID 27884683

  • Embolotherapy for Neuroendocrine Tumor Liver Metastases: Prognostic Factors for Hepatic Progression-Free Survival and Overall Survival. Cardiovascular and interventional radiology Chen, J. X., Rose, S., White, S. B., El-Haddad, G., Fidelman, N., Yarmohammadi, H., Hwang, W., Sze, D. Y., Kothary, N., Stashek, K., Wileyto, E. P., Salem, R., Metz, D. C., Soulen, M. C. 2017; 40 (1): 69-80


    The purpose of the study was to evaluate prognostic factors for survival outcomes following embolotherapy for neuroendocrine tumor (NET) liver metastases.This was a multicenter retrospective study of 155 patients (60 years mean age, 57 % male) with NET liver metastases from pancreas (n = 71), gut (n = 68), lung (n = 8), or other/unknown (n = 8) primary sites treated with conventional transarterial chemoembolization (TACE, n = 50), transarterial radioembolization (TARE, n = 64), or transarterial embolization (TAE, n = 41) between 2004 and 2015. Patient-, tumor-, and treatment-related factors were evaluated for prognostic effect on hepatic progression-free survival (HPFS) and overall survival (OS) using unadjusted and propensity score-weighted univariate and multivariate Cox proportional hazards models.Median HPFS and OS were 18.5 and 125.1 months for G1 (n = 75), 12.2 and 33.9 months for G2 (n = 60), and 4.9 and 9.3 months for G3 tumors (n = 20), respectively (p < 0.05). Tumor burden >50 % hepatic volume demonstrated 5.5- and 26.8-month shorter median HPFS and OS, respectively, versus burden ≤50 % (p < 0.05). There were no significant differences in HPFS or OS between gut or pancreas primaries. In multivariate HPFS analysis, there were no significant differences among embolotherapy modalities. In multivariate OS analysis, TARE had a higher hazard ratio than TACE (unadjusted Cox model: HR 2.1, p = 0.02; propensity score adjusted model: HR 1.8, p = 0.11), while TAE did not differ significantly from TACE.Higher tumor grade and tumor burden prognosticated shorter HPFS and OS. TARE had a higher hazard ratio for OS than TACE. There were no significant differences in HPFS among embolotherapy modalities.

    View details for DOI 10.1007/s00270-016-1478-z

    View details for PubMedID 27738818

  • Radioembolization of Hepatic Malignancies: Background, Quality Improvement Guidelines, and Future Directions JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Padia, S. A., Lewandowski, R. J., Johnson, G. E., Sze, D. Y., Ward, T. J., Gaba, R. C., Baerlocher, M. O., Gates, V. L., Riaz, A., Brown, D. B., Siddiqi, N. H., Walker, T. G., Silberzweig, J. E., Mitchell, J. W., Nikolic, B., Salem, R. 2017; 28 (1): 1-15

    View details for DOI 10.1016/j.jvir.2016.09.024

    View details for Web of Science ID 000392465200001

    View details for PubMedID 27836405

  • Embolotherapy for Neuroendocrine Tumor Liver Metastases: Prognostic Factors for Hepatic Progression-Free Survival and Overall Survival CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY Chen, J. X., Rose, S., White, S. B., El-Haddad, G., Fidelman, N., Yarmohammadi, H., Hwang, W., Sze, D. Y., Kothary, N., Stashek, K., Wileyto, E. P., Salem, R., Metz, D. C., Soulen, M. C. 2017; 40 (1): 69-80
  • Endovascular Management of May-Thurner Syndrome in Adolescents: A Single-Center Experience JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Goldman, R. E., Arendt, V. A., Kothary, N., Kuo, W. T., Sze, D. Y., Hofmann, L. V., Lungren, M. P. 2017; 28 (1): 71-77
  • Endovascular Management of May-Thurner Syndrome in Adolescents: A Single-Center Experience. Journal of vascular and interventional radiology Goldman, R. E., Arendt, V. A., Kothary, N., Kuo, W. T., Sze, D. Y., Hofmann, L. V., Lungren, M. P. 2016


    To report a single-center experience in regard to the technique, safety, and clinical outcomes of endovascular therapy for treatment of May-Thurner syndrome (MTS) in adolescent patients.A retrospective review identified 10 patients (6 female; mean age, 16 y; range, 12-18 y; mean weight, 73 kg; range, 50-116 kg) treated by endovascular therapy for MTS from 1998 to 2015. Clinical presentations consisted of acute thrombotic MTS (n = 6) and nonthrombotic MTS (n = 4). Catheter-directed thrombolysis was performed in all cases of thrombosis. Venoplasty and stent placement were performed in all cases. Self-expanding stents 12-16 mm in diameter and 4-9 cm in length were deployed.No major periprocedural complications were observed. Median follow-up was 32 months (range, 6-109 mo). Primary and secondary patency rates were 79% and 100% at 12 months and 79% and 89% at 36 months, respectively. In a single patient with permanent loss of flow in the treated segment, multiple risk factors for thrombosis were identified. Rates of posttreatment symptoms were 0% by Villalta score and 60% (n = 6; mild symptoms) by modified Villalta score at the last clinical follow-up.Endovascular therapy for the treatment of MTS in our adolescent cohort was safe and effective in relieving venous obstruction. Stent placement in patients with underlying thrombophilic disorders is associated with loss of secondary patency, suggesting the need for further consideration in this population.

    View details for DOI 10.1016/j.jvir.2016.09.005

    View details for PubMedID 27818112

  • Technical and Anatomic Factors Influencing the Success of Inferior Vena Caval Stent Placement for Malignant Obstruction. Journal of vascular and interventional radiology Devcic, Z., Techasith, T., Banerjee, A., Rosenberg, J. K., Sze, D. Y. 2016; 27 (9): 1350-1360 e1


    To evaluate the outcomes of inferior vena cava (IVC) stent placement for malignant obstruction and to identify anatomic and procedural factors influencing technical and clinical success.A total of 57 patients (37 male, 20 female; age range, 22-86 y) underwent 62 IVC stent placement procedures using 97 stents (47 Wallstents, 15 S.M.A.R.T. stents, 18 Wallflex stents, 17 others) from 2005 to 2016 for malignant IVC obstruction caused by hepatic metastases (n = 22; 39%), primary hepatic malignancy (n = 16; 28%), retroperitoneal metastases (n = 16; 28%), or other primary malignancy (n = 5; 9%). Presenting symptoms included lower-extremity edema (n = 54; 95%), ascites (n = 28; 50%), and perineal edema (n = 14; 25%). Sixteen percent (n = 10) and 10% (n = 6) of the procedures involved tumor and bland thrombus, respectively.Stent placements resulted in 100% venographic patency and significantly decreased pressure gradients (P < .0001). Lower-extremity swelling, perineal swelling, and abdominal distension improved within 7 days in 83% (35 of 42), 100% (9 of 9), and 40% (6 of 15) of patients, respectively, and at 30 days after the procedure in 86% (25 of 29), 89% (8 of 9), and 80% (4 of 5) of patients, respectively. Increased pre- and post-stent placement pressure gradients were associated with worse outcomes. A 4% stent misplacement rate (4 of 97) was related to the use of Wallstents with caudal stent tapering, asymmetric deployment superior to the obstruction, suprahepatic IVC involvement, and decreased stent adherence to the IVC wall as a result of local mechanical factors.Stent placement is reliable, rapid, and durable in improving malignant IVC syndrome. Understanding of technical and anatomic factors can improve accuracy and avoid complications of stent misplacement.

    View details for DOI 10.1016/j.jvir.2016.02.030

    View details for PubMedID 27117949

  • Occupational Radiation Exposure during Pregnancy: A Survey of Attitudes and Practices among Interventional Radiologists JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Ghatan, C. E., Fassiotto, M., Jacobsen, J. P., Sze, D. Y., Kothary, N. 2016; 27 (7): 1013-1020


    To assess attitudes of interventional radiologists toward occupational ionizing radiation exposure in pregnancy and to survey practice patterns and outcomes.A 34-question anonymous online survey on attitudes and work practices toward interventional radiologists who worked during pregnancy was sent to active SIR members, including 582 women.There were 534 (10%) respondents, including 142 women and 363 men. Among respondents, men were statistically older than women (P < .001) and had practiced interventional radiology (IR) longer (P < .001). Of female interventional radiologists, 55% had worked during pregnancy and reported no specific mutagenic events in their offspring. Spontaneous abortions (11%) and use of reproductive technology (17%) matched that of women with similar age and socioeconomic background. Although more women changed their work practice because of concerns of occupational exposure than men (23% vs 13%), this change was largely limited to the duration of a pregnancy. Among pregnant interventional radiologists, 4 (6%) completely abstained from performing fluoroscopically guided interventions (FGIs), whereas 31 (46%) continued to spend > 80% of their work week doing FGIs with additional protection. Perceptions of impact of pregnancy on daytime work redistribution varied significantly with gender (P < .001); however, perceptions regarding impact of pregnancy on on-call hours, distribution of complex cases, and need to hire for temporary coverage were similar between the genders.Most pregnant interventional radiologists continue to practice IR while pregnant. Pregnancy and fetal outcomes parallel that of the general population when matched for demographics. However, perceptions of impact of pregnancy on work lives of colleagues vary notably.

    View details for DOI 10.1016/j.jvir.2016.03.040

    View details for Web of Science ID 000379796500011

    View details for PubMedID 27236211

  • Assessing the Risk of Hemorrhagic Complication following Transjugular Liver Biopsy in Bone Marrow Transplantation Recipients. Journal of vascular and interventional radiology Ahmed, O., Ward, T. J., Lungren, M. P., Abdelrazek Mohammed, M. A., Hofmann, L. V., Sze, D. Y., Kothary, N. 2016; 27 (4): 551-557


    To determine if recipients of bone marrow transplants (BMTs) are at increased risk of hemorrhagic complications following transjugular liver biopsy (TJLB).TJLBs in BMT and non-BMT patients between January 2007 and July 2014 were reviewed. Patient demographic and pre- and postprocedural laboratory data were reviewed. Mean platelet count and International Normalized Ratio were 174,300 × 10(3)/µL ± 107.3 (standard deviation) and 1.2 ± 0.4, respectively, for BMT recipients, compared with 88,100 × 10(3)/µL ± 70.9 and 1.2 ± 0.5, respectively, for non-BMT. Patients in whom hemoglobin level decreased by > 1 g/dL and/or required transfusion within 15 days of TJLB were reviewed to determine the presence of a biopsy-related hemorrhagic complication.A total of 1,600 TJLBs in 1,120 patients were analyzed. Of these, 183 TJLBs in 159 BMT recipients and 1,417 TJLBs in 961 patients non-BMT patients were performed. Thirteen TJLBs were complicated by hemorrhage: five in BMT (2.9%) and eight in the non-BMT cohorts (0.6%; P < .01). Preprocedural platelet counts were within normal range (57-268 × 10(3)/µL) in all but one patient (8 × 10(3)/µL). BMT recipients had an odds ratio of 4.9 (95% confidence interval, 1.25-17.3) for post-TJLB bleeding/hemorrhage compared with those without BMTs (P < .01).TJLB continues to be a safe procedure in the vast majority of patients. However, hemorrhagic complications occurred at a rate of 2.9% in BMT recipients, compared with 0.6% in patients without BMTs, and therefore caution should be exercised when performing TJLB in this group.

    View details for DOI 10.1016/j.jvir.2016.01.007

    View details for PubMedID 26948328

  • Assessing the Risk of Hemorrhagic Complication following Transjugular Liver Biopsy in Bone Marrow Transplantation Recipients JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Ahmed, O., Ward, T. J., Lungren, M. P., Mohammed, M. A., Hofmann, L. V., Sze, D. Y., Kothary, N. 2016; 27 (4): 551-557
  • Complications During Transjugular Intrahepatic Portosystemic Shunt Creation. Techniques in vascular and interventional radiology Shah, R. P., Sze, D. Y. 2016; 19 (1): 61-73


    Transjugular intrahepatic portosystemic shunt (TIPS) creation is a widely adopted treatment for complications of portal hypertension, including variceal hemorrhage and refractory ascites. The creation of a TIPS requires establishing a pathway from the portal vein to a hepatic vein or inferior vena cava through hepatic parenchyma, using a stent or stent graft to sustain patency of this pathway. Because it is a technically challenging procedure and patients may be critically ill with severe comorbidities, the risk of procedural complications and mortality is substantial. This article discusses known complications of the TIPS procedure and ways to minimize their occurrence.

    View details for DOI 10.1053/j.tvir.2016.01.007

    View details for PubMedID 26997090

  • Superselective Chemoembolization of HCC: Comparison of Short-term Safety and Efficacy between Drug-eluting LC Beads, QuadraSpheres, and Conventional Ethiodized Oil Emulsion. Radiology Duan, F., Wang, E. Q., Lam, M. G., Abdelmaksoud, M. H., Louie, J. D., Hwang, G. L., Kothary, N., Kuo, W. T., Hofmann, L. V., Sze, D. Y. 2016; 278 (2): 612-621


    Purpose To study the comparative short-term safety and efficacy of transcatheter arterial chemoembolization (TACE) with drug-eluting LC Beads loaded with doxorubicin (DEBDOX), doxorubicin-eluting QuadraSpheres (hqTACE), and conventional TACE using ethiodized oil for superselective C-arm computed tomography (CT)-guided treatment of hepatocellular carcinoma (HCC) after the onset of drug shortages. Materials and Methods From March 2010 to March 2011, 166 patients with HCC were treated with 232 superselective TACE procedures using C-arm cone-beam CT at one institution. Patients underwent treatment depending on the availability of materials after the onset of drug shortages. Conventional TACE with doxorubicin, cisplatin, and Ethiodol was performed for 159 procedures, DEBDOX TACE was performed for 47, and hqTACE was performed for 26. Toxicity and objective response were compared at 3 months after treatment. Data were stratified for the high-risk population (Child-Pugh class B, performance status 1, bilobar disease, and/or post-resection recurrence) and initial versus repeat treatment. Kruskal-Wallis H test, Mann-Whitney U test, and Fisher exact test were used to compare the groups, with Bonferroni correction where needed. Results Whole liver response rates trended higher for conventional TACE (conventional TACE, 65.4%; DEBDOX, 63.8%; hqTACE, 53.8%) (P = .085). Only minor trends for differences in toxicity were observed between the three groups. Low-risk patients had higher whole liver (P = .001) and treated lesion (P = .007) response rates when treated with conventional TACE, but no significant differences were seen for DEBDOX and hqTACE. Treatment-naive patients also had higher whole liver (P = .012) and treated lesion (P = .056) response rates. No advantages for drug-eluting microspheres were found. Conclusion Within statistical power limitations, overall toxicity and efficacy were equivalent in patients treated with LC Beads, QuadraSpheres, or ethiodized oil emulsions, including in high-risk patients, when performed superselectively with cone-beam C-arm CT guidance. (©) RSNA, 2015.

    View details for DOI 10.1148/radiol.2015141417

    View details for PubMedID 26334787

  • Cost Accounting as a Tool for Increasing Cost Transparency in Selective Hepatic Transarterial Chemoembolization. Journal of vascular and interventional radiology Ahmed, O., Patel, M., Ward, T., Sze, D. Y., Telischak, K., Kothary, N., Hofmann, L. V. 2015; 26 (12): 1820-1826 e1

    View details for DOI 10.1016/j.jvir.2015.09.004

    View details for PubMedID 26521766

  • Management of High Hepatopulmonary Shunting in Patients Undergoing Hepatic Radioembolization. Journal of vascular and interventional radiology Ward, T. J., Tamrazi, A., Lam, M. G., Louie, J. D., Kao, P. N., Shah, R. P., Kadoch, M. A., Sze, D. Y. 2015; 26 (12): 1751-1760

    View details for DOI 10.1016/j.jvir.2015.08.027

    View details for PubMedID 26525118

  • Percutaneous Cryoablation for Successful Treatment of a Persistent Urine Leak after Robotic-Assisted Partial Nephrectomy. Journal of vascular and interventional radiology Ward, T. J., Ahmed, O., Chung, B. I., Sze, D. Y., Hwang, G. L. 2015; 26 (12): 1867-1870

    View details for DOI 10.1016/j.jvir.2015.08.029

    View details for PubMedID 26596181

  • Watershed Hepatocellular Carcinomas: The Risk of Incomplete Response following Transhepatic Arterial Chemoembolization. Journal of vascular and interventional radiology Kothary, N., Takehana, C., Mueller, K., Sullivan, P., Tahvildari, A., Sidhar, V., Rosenberg, J., Louie, J. D., Sze, D. Y. 2015; 26 (8): 1122-1129


    Hepatocellular carcinomas (HCCs) bridging two or more Couinaud-Bismuth segments of the liver ("watershed tumors") can recruit multiple segmental arteries. The primary hypothesis of this study was that fewer watershed tumors show complete response (CR) after chemoembolization, with shorter time to local recurrence. Secondary analysis on the impact on transplantation eligibility in the presence of progressive disease was also performed.A total of 155 transplantation-eligible patients whose HCC met Milan criteria (watershed, n = 83; nonwatershed, n = 72) and was treated with chemoembolization were included. Cone-beam computed tomography (CT) was used for guidance and for confirmation of circumferential uptake. Local response to chemoembolization per modified Response Evaluation Criteria In Solid Tumors and local disease-free survival (DFS) for the index tumor were calculated. Differences were assessed by univariate and multivariate analyses.CR after a single of chemoembolization was observed in 55.4% of watershed tumors and in 72.2% of nonwatershed tumors (P = .045). Estimated DFS intervals were 151 days (95% confidence interval [CI], 93-245 d) and 336 days (95% CI, 231-747 d; P = .040) in the watershed and nonwatershed groups, respectively. Worse DFS was observed with a Model for End-Stage Liver Disease score > 20 (P = .0001), higher Child-Pugh-Turcotte score (P = .049), and watershed location (P = .040). Waiting list drop-off rates were statistically similar between groups.Hepatocellular carcinomas located in the watershed region of the liver have a poorer response to chemoembolization than those located elsewhere. These tumors are associated with worse DFS and require additional treatments to maintain transplantation eligibility per Milan criteria. Cone-beam CT can identify crossover supply and confirm complete geographic drug uptake, possibly reducing (but not eliminating) the risk of incomplete response.

    View details for DOI 10.1016/j.jvir.2015.04.030

    View details for PubMedID 26091800

  • Fusion dual-tracer SPECT-based hepatic dosimetry predicts outcome after radioembolization for a wide range of tumour cell types EUROPEAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING Lam, M. G., Banerjee, A., Goris, M. L., Iagaru, A. H., Mittra, E. S., Louie, J. D., Sze, D. Y. 2015; 42 (8): 1192-1201


    Fusion dual-tracer SPECT imaging enables physiological rather than morphological voxel-based partitioning and dosimetry for (90)Y hepatic radioembolization (RE). We evaluated its prognostic value in a large heterogeneous cohort of patients with extensive hepatic malignancy.A total of 122 patients with primary or secondary liver malignancy (18 different cell types) underwent SPECT imaging after intraarterial injection of (99m)Tc macroaggregated albumin (TcMAA) as a simulation of subsequent (90)Y microsphere distribution, followed by administration of an excess of intravenous (99m)Tc-labelled sulphur colloid (TcSC) as a biomarker for functional liver, and a second SPECT scan. TcMAA distribution was used to estimate (90)Y radiation absorbed dose in tumour (D T) and in functional liver. Laboratory and clinical follow-up were recorded for 12 weeks after RE, and radiographic responses according to (m)RECIST were evaluated at 3 and 6 months. Dose-response relationships were determined for efficacy and toxicity.Patients were treated with a median of 1.73 GBq activity of resin microspheres (98 patients) or glass microspheres (24 patients), in a whole-liver approach (97 patients) or a lobar approach (25 patients). The objective response rate was 41 % at 3 months and 48 % at 6 months. Response was correlated with D T (P < 0.01). Median overall survival was 10.1 months (95 % confidence interval 7.4 - 12.8 months). Responders lived for 36.0 months compared to 8.7 months for nonresponders (P < 0.01). Stratified for tumour cell type, D T was independently associated with survival (P < 0.01). Absorbed dose in functional liver was correlated with toxicity grade change (P < 0.05) and RE-induced liver disease (P < 0.05).Fusion dual-tracer SPECT imaging offers a physiology-based functional imaging tool to predict efficacy and toxicity of RE. This technique can be refined to define dosing thresholds for specific tumour types and treatments, but appears generally predictive even in a heterogeneous cohort.

    View details for DOI 10.1007/s00259-015-3048-z

    View details for Web of Science ID 000356809100005

    View details for PubMedID 25916740

    View details for PubMedCentralID PMC4480819

  • Emergent Salvage Direct Intrahepatic Portocaval Shunt Procedure for Acute Variceal Hemorrhage JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Ward, T. J., Techasith, T., Louie, J. D., Hwang, G. L., Hofmann, L. V., Sze, D. Y. 2015; 26 (6): 829-834


    To review the safety and effectiveness of direct intrahepatic portocaval shunt (DIPS) creation with variceal embolization for acute variceal hemorrhage after a failed transjugular intrahepatic portosystemic shunt (TIPS) creation attempt or in patients with prohibitive anatomy.Transjugular intrahepatic portosystemic shunt and DIPS procedures performed for variceal hemorrhage between January 2008 and July 2014 were reviewed. The default procedure was TIPS creation, with DIPS creation reserved for patients with unfavorable anatomy or who had technically unsuccessful TIPS creation. Thirteen patients underwent DIPS creation (mean age, 60 y ± 12; Child-Pugh class A/B/C, 8%/62%/30%; Model for End-stage Liver Disease score, 15 ± 5; range, 8-26) and 117 underwent TIPS creation. Four patients underwent a TIPS attempt and were converted to DIPS creation upon technical failure; 9 were treated primarily with DIPS creation because of preprocedural imaging revealing unfavorable anatomy (intrahepatic portal thrombosis, n = 2; venous distortion from prior hepatic resections, n = 2; severely angulated hepatic veins, n = 5).Direct intrahepatic portocaval shunt creation with variceal embolization (six gastric or esophageal; seven stomal, duodenal, or rectal) was successful in all patients; 11 also had concomitant variceal sclerotherapy. Mean DIPS procedure time was less than 2 hours. There was 1 major procedural complication. During a mean follow-up of 13.0 months ± 15.5, 1 patient developed DIPS thrombosis and recurrent hemorrhage; 1 patient underwent successful transplantation. Two deaths were observed within 30 days, neither associated with recurrent hemorrhage.Direct intrahepatic portocaval shunt creation appears to be a safe, expedient, and effective treatment for patients with acute variceal hemorrhage who are poor anatomic candidates for TIPS creation or who have undergone unsuccessful TIPS creation attempts.

    View details for DOI 10.1016/j.jvir.2015.03.004

    View details for Web of Science ID 000355963800009

    View details for PubMedID 25881512

  • Radioembolization Dosimetry: The Road Ahead CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY Smits, M. L., Elschot, M., Sze, D. Y., Kao, Y. H., Nijsen, J. F., Iagaru, A. H., de Jong, H. W., Van den Bosch, M. A., Lam, M. G. 2015; 38 (2): 261-269


    Methods for calculating the activity to be administered during yttrium-90 radioembolization (RE) are largely based on empirical toxicity and efficacy analyses, rather than dosimetry. At the same time, it is recognized that treatment planning based on proper dosimetry is of vital importance for the optimization of the results of RE. The heterogeneous and often clustered intrahepatic biodistribution of millions of point-source radioactive particles poses a challenge for dosimetry. Several studies found a relationship between absorbed doses and treatment outcome, with regard to both toxicity and efficacy. This should ultimately lead to improved patient selection and individualized treatment planning. New calculation methods and imaging techniques and a new generation of microspheres for image-guided RE will all contribute to these improvements. The aim of this review is to give insight into the latest and most important developments in RE dosimetry and to suggest future directions on patient selection, individualized treatment planning, and study designs.

    View details for DOI 10.1007/s00270-014-1042-7

    View details for Web of Science ID 000351155100002

    View details for PubMedID 25537310

  • Classification of Hypervascular Liver Lesions Based on Hepatic Artery and Portal Vein Blood Supply Coefficients Calculated from Triphasic CT Scans JOURNAL OF DIGITAL IMAGING Boas, F. E., Kamaya, A., Do, B., Desser, T. S., Beaulieu, C. F., Vasanawala, S. S., Hwang, G. L., Sze, D. Y. 2015; 28 (2): 213-223


    Perfusion CT of the liver typically involves scanning the liver at least 20 times, resulting in a large radiation dose. We developed and validated a simplified model of tumor blood supply that can be applied to standard triphasic scans and evaluated whether this can be used to distinguish benign and malignant liver lesions. Triphasic CTs of 46 malignant and 32 benign liver lesions were analyzed. For each phase, regions of interest were drawn in the arterially enhancing portion of each lesion, as well as the background liver, aorta, and portal vein. Hepatic artery and portal vein blood supply coefficients for each lesion were then calculated by expressing the enhancement curve of the lesion as a linear combination of the enhancement curves of the aorta and portal vein. Hepatocellular carcinoma (HCC) and hypervascular metastases, on average, both had increased hepatic artery coefficients compared to the background liver. Compared to HCC, benign lesions, on average, had either a greater hepatic artery coefficient (hemangioma) or a greater portal vein coefficient (focal nodular hyperplasia or transient hepatic attenuation difference). Hypervascularity with washout is a key diagnostic criterion for HCC, but it had a sensitivity of 72 % and specificity of 81 % for diagnosing malignancy in our diverse set of liver lesions. The sensitivity for malignancy was increased to 89 % by including enhancing lesions that were hypodense on all phases. The specificity for malignancy was increased to 97 % (p = 0.039) by also examining hepatic artery and portal vein blood supply coefficients, while maintaining a sensitivity of 76 %.

    View details for DOI 10.1007/s10278-014-9725-9

    View details for Web of Science ID 000351242500012

    View details for PubMedID 25183580

  • Optimal imaging surveillance schedules after liver-directed therapy for hepatocellular carcinoma. Journal of vascular and interventional radiology Boas, F. E., Do, B., Louie, J. D., Kothary, N., Hwang, G. L., Kuo, W. T., Hovsepian, D. M., Kantrowitz, M., Sze, D. Y. 2015; 26 (1): 69-73


    To optimize surveillance schedules for the detection of recurrent hepatocellular carcinoma (HCC) after liver-directed therapy.New methods have emerged that allow quantitative analysis and optimization of surveillance schedules for diseases with substantial rates of recurrence such as HCC. These methods were applied to 1,766 consecutive chemoembolization, radioembolization, and radiofrequency ablation procedures performed on 910 patients between 2006 and 2011. Computed tomography or magnetic resonance imaging performed just before repeat therapy was set as the time of "recurrence," which included residual and locally recurrent tumor as well as new liver tumors. Time-to-recurrence distribution was estimated by Kaplan-Meier method. Average diagnostic delay (time between recurrence and detection) was calculated for each proposed surveillance schedule using the time-to-recurrence distribution. An optimized surveillance schedule could then be derived to minimize the average diagnostic delay.Recurrence is 6.5 times more likely in the first year after treatment than in the second. Therefore, screening should be much more frequent in the first year. For eight time points in the first 2 years of follow-up, the optimal schedule is 2, 4, 6, 8, 11, 14, 18, and 24 months. This schedule reduces diagnostic delay compared with published schedules and is cost-effective.The calculated optimal surveillance schedules include shorter-interval follow-up when there is a higher probability of recurrence and longer-interval follow-up when there is a lower probability. Cost can be optimized for a specified acceptable diagnostic delay or diagnostic delay can be optimized within a specified acceptable cost.

    View details for DOI 10.1016/j.jvir.2014.09.013

    View details for PubMedID 25446423

  • FSI analysis of the blood flow and geometrical characteristics in the thoracic aorta COMPUTATIONAL MECHANICS Suito, H., Takizawa, K., Huynh, V. Q., Sze, D., Ueda, T. 2014; 54 (4): 1035-1045
  • The Efficacy of Hepatic 90Y Resin Radioembolization for Metastatic Neuroendocrine Tumors: A Meta-Analysis. Journal of nuclear medicine : official publication, Society of Nuclear Medicine Devcic, Z., Rosenberg, J., Braat, A. J., Techasith, T., Banerjee, A., Sze, D. Y., Lam, M. G. 2014; 55 (9): 1404-1410


    (90)Y resin radioembolization is an emerging treatment in patients with liver-dominant metastatic neuroendocrine tumors (mNETs), despite the absence of level I data. The aim of this study was to evaluate the efficacy of this modality in a meta-analysis of the published literature.A comprehensive review protocol screened all reports in the literature. Strict selection criteria were applied to ensure consistency among the selected studies: human subjects, complete response data with time interval, resin microspheres, more than 5 patients, not a duplicate cohort, English language, and separate and complete data for resin-based (90)Y treatment of mNET if the study included multiple tumor and microsphere types. Selected studies were critically appraised on 50 study criteria, in accordance with the research reporting standards for radioembolization. Response data (Response Evaluation Criteria in Solid Tumors) were extracted and analyzed using both fixed and random-effects meta-analyses.One hundred fifty-six studies were screened; 12 were selected, totaling 435 procedures for response assessment. Funnel plots showed no evidence of publication bias (P = 0.841). Critical appraisal revealed a median of 75% of desired criteria included in selected studies. Very high between-study heterogeneity ruled out a fixed-effects model. The random-effects weighted average objective response rate (complete and partial responses, CR and PR, respectively) was 50% (95% confidence interval, 38%-62%), and weighted average disease control rate (CR, PR, and stable disease) was 86% (95% confidence interval, 78%-92%). The percentage of patients with pancreatic mNET was marginally associated with poorer response (P = 0.030), accounting for approximately 23% of the heterogeneity among studies. The percentage of CR and PR correlated with median survival (R = 0.85; P = 0.008).This meta-analysis confirms radioembolization to be an effective treatment option for patients with hepatic mNET. The pooled data demonstrated a high response rate and improved survival for patients responding to therapy.

    View details for DOI 10.2967/jnumed.113.135855

    View details for PubMedID 25012459

  • Immediate postoperative percutaneous stenting of superior vena cava obstruction following heart transplantation in adult patients with pacemaker leads. Journal of cardiac surgery Asseff, D., Sheikh, A. Y., Sze, D., Ha, R., Hofmann, L., van der Starre, P. J. 2014; 29 (5): 733-736


    Vena cava superior syndrome is a serious complication after heart transplantation, leading to low cardiac output, cerebral edema, and multi-organ dysfunction. We report three adult patients who underwent heart and heart-lung transplantation and required immediate postoperative balloon angioplasty and stent placement by interventional radiology. The observed obstructions were located at sites of intraoperatively removed pacemaker or defibrillator wires. Percutaneous stent placement immediately improved the hemodynamic condition of the patients. Early recognition of the complication and availability of immediate intervention are essential to prevent further deterioration.

    View details for DOI 10.1111/jocs.12387

    View details for PubMedID 25039539

  • Immediate Postoperative Percutaneous Stenting of Superior Vena Cava Obstruction Following Heart Transplantation in Adult Patients with Pacemaker Leads JOURNAL OF CARDIAC SURGERY Asseff, D., Sheikh, A. Y., Sze, D., Ha, R., Hofmann, L., van der Starre, P. J. 2014; 29 (5): 733-736

    View details for DOI 10.1111/jocs.12387

    View details for Web of Science ID 000342851100031

  • Reply: 99mTc-MAA-based dosimetry for liver cancer treated using 90Y-loaded microspheres: known proof of effectiveness. Journal of nuclear medicine : official publication, Society of Nuclear Medicine Lam, M. G., Sze, D. Y. 2014; 55 (8): 1392-1393

    View details for DOI 10.2967/jnumed.114.141465

    View details for PubMedID 24925882

  • Splenomegaly-associated thrombocytopenia after hepatic yttrium-90 radioembolization. Cardiovascular and interventional radiology Lam, M. G., Banerjee, A., Louie, J. D., Sze, D. Y. 2014; 37 (4): 1009-1017


    Thrombocytopenia is often observed after yttrium-90 radioembolization (RE). Possible mechanisms include radiation toxicity to the bone marrow, consumption in the liver due to local radiation effects, and sequestration in the spleen. We sought to identify the causative factors.Patients with complete baseline and 3-month post-RE imaging and laboratory data were included in this retrospective analysis. Univariate and multivariate regression analyses were performed on clinical, procedural, and imaging data.A total of 116 patients were identified (65 male, 51 female; median age 64 years). Forty-six patients were treated for primary and 70 for metastatic liver malignancy. Of these, 86 were treated with resin and 30 with glass microspheres; median activity was 1.85 GBq. Eighty-three patients underwent whole-liver treatment. Maximum individual change in platelet count was -20.2 % leading to new or increased grade of thrombocytopenia in 48 patients (41.4 %) by National Cancer Institute Common Toxicity Criteria for Adverse Events version 4.02 criteria. Independent risk factors for decreased platelet count included change in spleen volume (median change +17.5 %; p = 0.001) and whole-liver (rather than lobar or segmental) treatment (p = 0.025). Administered activity and absorbed dose were not associated with change in platelet count. The change in spleen volume itself was associated with previous epidermal growth factor receptor-inhibitor treatment (p = 0.002), whole-liver absorbed dose (p = 0.027), and multiple-line chemotherapy (0.012) for whole-liver treatments only.Post-RE treatment increase of spleen volume is correlated with decreased peripheral platelet count suggesting a mechanism of increased portal hypertension and hypersplenism being responsible.

    View details for DOI 10.1007/s00270-013-0742-8

    View details for PubMedID 24091754

  • Limitations of body surface area-based activity calculation for radioembolization of hepatic metastases in colorectal cancer. Journal of vascular and interventional radiology Lam, M. G., Louie, J. D., Abdelmaksoud, M. H., Fisher, G. A., Cho-Phan, C. D., Sze, D. Y. 2014; 25 (7): 1085-1093


    To calculate absorbed radiation doses in patients treated with resin microspheres prescribed by the body surface area (BSA) method and to analyze dose-response and toxicity relationships.A retrospective review was performed of 45 patients with colorectal carcinoma metastases who received single-session whole-liver resin microsphere radioembolization. Prescribed treatment activity was calculated using the BSA method. Liver volumes and whole-liver absorbed doses (D(WL)) were calculated. D(WL) was correlated with toxicity and radiographic and biochemical response.The standard BSA-based administered activity (range, 0.85-2.58 GBq) did not correlate with D(WL) (mean, 50.4 Gy; range, 29.8-74.7 Gy; r = -0.037; P = .809) because liver weight was highly variable (mean, 1.89 kg; range, 0.94-3.42 kg) and strongly correlated with D(WL) (r = -0.724; P < .001) but was not accounted for in the BSA method. Patients with larger livers were relatively underdosed, and patients with smaller livers were relatively overdosed. Patients who received D(WL) > 50 Gy experienced more toxicity and adverse events (> grade 2 liver toxicity, 46% vs 17%; P < .05) but also responded better to the treatment than patients who received D(WL)< 50 Gy (disease control, 88% vs 24%; P < .01).Using the standard BSA formula, the administered activity did not correlate with D(WL). Based on this short-term follow-up after salvage therapy in patients with late stage metastatic colorectal carcinoma, dose-response and dose-toxicity relationships support using a protocol based on liver volume rather than BSA to prescribe the administered activity.

    View details for DOI 10.1016/j.jvir.2013.11.018

    View details for PubMedID 24457263

  • Limitations of Body Surface Area-Based Activity Calculation for Radioembolization of Hepatic Metastases in Colorectal Cancer JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Lam, M. G., Louie, J. D., Abdelmaksoud, M. H., Fisher, G. A., Cho-Phan, C. D., Sze, D. Y. 2014; 25 (7): 1085-1093
  • Reply to "the limitations of theoretical dose modeling for yttrium-90 radioembolization". Journal of vascular and interventional radiology Sze, D. Y., Lam, M. G. 2014; 25 (7): 1147-1148

    View details for DOI 10.1016/j.jvir.2014.04.004

    View details for PubMedID 24968733

  • Prognostic utility of 90Y radioembolization dosimetry based on fusion 99mTc-macroaggregated albumin-99mTc-sulfur colloid SPECT. Journal of nuclear medicine : official publication, Society of Nuclear Medicine Lam, M. G., Goris, M. L., Iagaru, A. H., Mittra, E. S., Louie, J. D., Sze, D. Y. 2013; 54 (12): 2055-2061


    Planning hepatic (90)Y radioembolization activity requires balancing toxicity with efficacy. We developed a dual-tracer SPECT fusion imaging protocol that merges data on radioactivity distribution with physiologic liver mapping.Twenty-five patients with colorectal carcinoma and bilobar liver metastases received whole-liver radioembolization with resin microspheres prescribed as per convention (mean administered activity, 1.69 GBq). As part of standard treatment planning, all patients underwent SPECT imaging after intraarterial injection of 37 MBq of (99m)Tc-macroaggregated albumin ((99m)Tc-MAA) to simulate subsequent (90)Y distribution. Immediately afterward, patients received 185 MBq of labeled sulfur colloid ((99m)Tc-SC) intravenously as a biomarker for normal hepatic reticuloendothelial function and SPECT was repeated. The SPECT images were coregistered and fused. A region-based method was used to predict the (90)Y radiation absorbed dose to functional liver tissue (DFL) by calculation of (99m)Tc-MAA activity in regions with (99m)Tc-SC uptake. Similarly, the absorbed dose to tumor (DT) was predicted by calculation of (99m)Tc-MAA activity in voxels without (99m)Tc-SC uptake. Laboratory data and radiographic response were measured for 3 mo, and the survival of patients was recorded. SPECT-based DT and DFL were correlated with parameters of toxicity and efficacy.Toxicity, as measured by increase in serum liver enzymes, correlated significantly with SPECT-based calculation of DFL at all time points (P < 0.05) (mean DFL, 27.9 Gy). Broad biochemical toxicity (>50% increase in all liver enzymes) occurred at a DFL of 24.5 Gy and above. In addition, in uni- and multivariate analysis, SPECT-based calculation of DT (mean DT, 44.2 Gy) correlated with radiographic response (P < 0.001), decrease in serum carcinoembryonic antigen (P < 0.05), and overall survival (P < 0.01). The cutoff value of DT for prediction of 1-y survival was 55 Gy (area under the receiver-operating-characteristic curve = 0.86; P < 0.01). Patients who received a DT of more than 55 Gy had a median survival of 32.8 mo, compared with 7.2 mo in patients who received less (P < 0.05).Dual-tracer (99m)Tc-MAA-(99m)Tc-SC fusion SPECT offers a physiology-based imaging tool with significant prognostic power that may lead to improved personalized activity planning.

    View details for DOI 10.2967/jnumed.113.123257

    View details for PubMedID 24144563

  • Prognostic Utility of Y-90 Radioembolization Dosimetry Based on Fusion Tc-99m-Macroaggregated Albumin-Tc-99m-Sulfur Colloid SPECT JOURNAL OF NUCLEAR MEDICINE Lam, M. G., Goris, M. L., Iagaru, A. H., Mittra, E. S., Louie, J. D., Sze, D. Y. 2013; 54 (12): 2055-2061
  • Root cause analysis of gastroduodenal ulceration after yttrium-90 radioembolization. Cardiovascular and interventional radiology Lam, M. G., Banerjee, S., Louie, J. D., Abdelmaksoud, M. H., Iagaru, A. H., Ennen, R. E., Sze, D. Y. 2013; 36 (6): 1536-1547


    INTRODUCTION: A root cause analysis was performed on the occurrence of gastroduodenal ulceration after hepatic radioembolization (RE). We aimed to identify the risk factors in the treated population and to determine the specific mechanism of nontarget RE in individual cases. METHODS: The records of 247 consecutive patients treated with yttrium-90 RE for primary (n = 90) or metastatic (n = 157) liver cancer using either resin (n = 181) or glass (n = 66) microspheres were reviewed. All patients who developed a biopsy-proven microsphere-induced gastroduodenal ulcer were identified. Univariate and multivariate analyses were performed on baseline parameters and procedural data to determine possible risk factors in the total population. Individual cases were analyzed to ascertain the specific cause, including identification of the culprit vessel(s) leading to extrahepatic deposition of the microspheres. RESULTS: Eight patients (3.2 %) developed a gastroduodenal ulcer. Stasis during injection was the strongest independent risk factor (p = 0.004), followed by distal origin of the gastroduodenal artery (p = 0.004), young age (p = 0.040), and proximal injection of the microspheres (p = 0.043). Prolonged administrations, pain during administration, whole liver treatment, and use of resin microspheres also showed interrelated trends in multivariate analysis. Retrospective review of intraprocedural and postprocedural imaging showed a probable or possible culprit vessel, each a tiny complex collateral vessel, in seven patients. CONCLUSION: Proximal administrations and those resulting in stasis of flow presented increased risk for gastroduodenal ulceration. Patients who had undergone bevacizumab therapy were at high risk for developing stasis.

    View details for DOI 10.1007/s00270-013-0579-1

    View details for PubMedID 23435742

  • Safety of (90)y radioembolization in patients who have undergone previous external beam radiation therapy. International journal of radiation oncology, biology, physics Lam, M. G., Abdelmaksoud, M. H., Chang, D. T., Eclov, N. C., Chung, M. P., Koong, A. C., Louie, J. D., Sze, D. Y. 2013; 87 (2): 323-329


    Previous external beam radiation therapy (EBRT) is theoretically contraindicated for yttrium-90 ((90)Y) radioembolization (RE) because the liver has a lifetime tolerance to radiation before becoming vulnerable to radiation-induced liver disease. We analyzed the safety of RE as salvage treatment in patients who had previously undergone EBRT.Between June 2004 and December 2010, a total of 31 patients who had previously undergone EBRT were treated with RE. Three-dimensional treatment planning with dose-volume histogram (DVH) analysis of the liver was used to calculate the EBRT liver dose. Liver-related toxicities including RE-induced liver disease (REILD) were reviewed and classified according to Common Terminology Criteria for Adverse Events version 4.02.The mean EBRT and RE liver doses were 4.40 Gy (range, 0-23.13 Gy) and 57.9 Gy (range, 27.0-125.9 Gy), respectively. Patients who experienced hepatotoxicity (≥grade2; n=12) had higher EBRT mean liver doses (7.96 ± 8.55 Gy vs 1.62 ± 3.39 Gy; P=.037), the only independent predictor in multivariate analysis. DVH analysis showed that the fraction of liver exposed to ≥30 Gy (V30) was the strongest predictor of hepatotoxicity (10.14% ± 12.75% vs 0.84% ± 3.24%; P=.006). All patients with V30 >13% experienced hepatotoxicity. Fatal REILD (n=2) occurred at the 2 highest EBRT mean liver doses (20.9 Gy and 23.1 Gy) but also at the highest cumulative liver doses (91.8 Gy and 149 Gy).Prior exposure of the liver to EBRT may lead to increased liver toxicity after RE treatment, depending on fractional liver exposure and dose level. The V30 was the strongest predictor of toxicity. RE appears to be safe for the treatment of hepatic malignancies only in patients who have had limited hepatic exposure to prior EBRT.

    View details for DOI 10.1016/j.ijrobp.2013.05.041

    View details for PubMedID 23849697

  • Safety of repeated yttrium-90 radioembolization. Cardiovascular and interventional radiology Lam, M. G., Louie, J. D., Iagaru, A. H., Goris, M. L., Sze, D. Y. 2013; 36 (5): 1320-1328


    PURPOSE: Repeated radioembolization (RE) treatments carry theoretically higher risk of radiation-induced hepatic injury because of the liver's cumulative memory of previous exposure. We performed a retrospective safety analysis on patients who underwent repeated RE. METHODS: From 2004 to 2011, a total of 247 patients were treated by RE. Eight patients (5 men, 3 women, age range 51-71 years) underwent repeated treatment of a targeted territory, all with resin microspheres (SIR-Spheres; Sirtex, Lane Cove, Australia). Adverse events were graded during a standardized follow-up. In addition, the correlation between the occurrence of RE-induced liver disease (REILD) and multiple variables was investigated in univariate and multivariate analyses in all 247 patients who received RE. RESULTS: Two patients died shortly after the second treatment (at 84 and 107 days) with signs and symptoms of REILD. Both patients underwent whole liver treatment twice (cumulative doses 3.08 and 2.66 GBq). The other 6 patients demonstrated only minor toxicities after receiving cumulative doses ranging from 2.41 to 3.88 GBq. All patients experienced objective tumor responses. In the whole population, multifactorial analysis identified three risk factors associated with REILD: repeated RE (p = 0.036), baseline serum total bilirubin (p = 0.048), and baseline serum aspartate aminotransferase (p = 0.043). Repeated RE proved to be the only independent risk factor for REILD in multivariate analysis (odds ratio 9.6; p = 0.002). Additionally, the administered activity per target volume (in GBq/L) was found to be an independent risk factor for REILD, but only in whole liver treatments (p = 0.033). CONCLUSION: The risk of REILD appears to be elevated for repeated RE. Objective tumor responses were observed, but establishment of safety limits will require improvement in dosimetric measurement and prediction.

    View details for DOI 10.1007/s00270-013-0547-9

    View details for PubMedID 23354961

  • Cancer Concepts and Principles: Primer for the Interventional Oncologist-Part I JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Hickey, R., Vouche, M., Sze, D. Y., Hohlastos, E., Collins, J., Schirmang, T., Memon, K., Ryu, R. K., Sato, K., Chen, R., Gupta, R., Resnick, S., Carr, J., Chrisman, H. B., Nemcek, A. A., Vogelzang, R. L., Lewandowski, R. J., Salem, R. 2013; 24 (8): 1157-1164


    A sophisticated understanding of the rapidly changing field of oncology, including a broad knowledge of oncologic disease and the therapies available to treat them, is fundamental to the interventional radiologist providing oncologic therapies, and is necessary to affirm interventional oncology as one of the four pillars of cancer care alongside medical, surgical, and radiation oncology. The first part of this review intends to provide a concise overview of the fundamentals of oncologic clinical trials, including trial design, methods to assess therapeutic response, common statistical analyses, and the levels of evidence provided by clinical trials.

    View details for DOI 10.1016/j.jvir.2013.04.024

    View details for Web of Science ID 000322924300011

    View details for PubMedID 23809510

  • Oncolytic virotherapy. Journal of vascular and interventional radiology Sze, D. Y., Reid, T. R., Rose, S. C. 2013; 24 (8): 1115-1122


    Oncolytic virotherapy is an emerging technology that uses engineered viruses to treat malignancies. Viruses can be designed with biological specificity to infect cancerous cells preferentially, and to replicate in these cells exclusively. Malignant cells may be killed directly by overwhelming viral infection and lysis, which releases additional viral particles to infect neighboring cells and distant metastases. Viral infections may also activate the immune system, unmask stealthy tumor antigens, and aid the immune system to recognize and attack neoplasms. Delivery of live virus particles is potentially complex, and may require the expertise of the interventional community.

    View details for DOI 10.1016/j.jvir.2013.05.040

    View details for PubMedID 23885911

  • Cancer Concepts and Principles: Primer for the Interventional Oncologist-Part II JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Hickey, R., Vouche, M., Sze, D. Y., Hohlastos, E., Collins, J., Schirmang, T., Memon, K., Ryu, R. K., Sato, K., Chen, R., Gupta, R., Resnick, S., Carr, J., Chrisman, H. B., Nemcek, A. A., Vogelzang, R. L., Lewandowski, R. J., Salem, R. 2013; 24 (8): 1167-1188


    This is the second of a two-part overview of the fundamentals of oncology for interventional radiologists. The first part focused on clinical trials, basic statistics, assessment of response, and overall concepts in oncology. This second part aims to review the methods of tumor characterization; principles of the oncology specialties, including medical, surgical, radiation, and interventional oncology; and current treatment paradigms for the most common cancers encountered in interventional oncology, along with the levels of evidence that guide these treatments.

    View details for DOI 10.1016/j.jvir.2013.04.023

    View details for Web of Science ID 000322924300013

    View details for PubMedID 23810312

  • Carbon Dioxide Contrast Enhancement for C-Arm CT Utility for Treatment Planning during Hepatic Embolization Procedures. Journal of vascular and interventional radiology Wong, A. A., Charalel, R. A., Louie, J. D., Sze, D. Y. 2013; 24 (7): 975-980


    A pilot study was performed to evaluate the use of carbon dioxide (CO2) as a contrast medium for C-arm computed tomography (CT). C-arm CT using CO2 was performed during embolization procedures in12 patients with hepatic malignancies and severe iodine allergy or high risk for nephrotoxicity. C-arm CT using gadolinium or iodinated contrast medium was performed for comparison. Of segmental arteries identified by conventional contrast enhancement, 96% were also seen with CO2 enhancement, but subsegmental arteries were not reliably depicted. CO2 enhancement identified 60% of tumors. Small, hypovascular, and infiltrative tumors were difficult to detect. CO2 is a promising alternative intraarterial contrast agent for C-arm CT.

    View details for DOI 10.1016/j.jvir.2013.03.029

    View details for PubMedID 23796085

  • Measuring (and Manipulating) Cellular Immune Activation. Journal of vascular and interventional radiology Sze, D. Y. 2013; 24 (6): 872-873

    View details for DOI 10.1016/j.jvir.2013.03.007

    View details for PubMedID 23707095

  • N-butyl Cyanoacrylate Glue Embolization of Arterial Networks to Facilitate Hepatic Arterial Skeletonization before Radioembolization. Cardiovascular and interventional radiology Samuelson, S. D., Louie, J. D., Sze, D. Y. 2013; 36 (3): 690-698


    Avoidance of nontarget microsphere deposition via hepatoenteric anastomoses is essential to the safety of yttrium-90 radioembolization (RE). The hepatic hilar arterial network may remain partially patent after coil embolization of major arteries, resulting in persistent risk. We retrospectively reviewed cases where n-butyl cyanoacrylate (n-BCA) glue embolization was used to facilitate endovascular hepatic arterial skeletonization before RE.A total of 543 RE procedures performed between June 2004 and March 2012 were reviewed, and 10 were identified where n-BCA was used to embolize hepatoenteric anastomoses. Arterial anatomy, prior coil embolization, and technical details were recorded. Outcomes were reviewed to identify subsequent complications of n-BCA embolization or nontarget RE.The rate of complete technical success was 80 % and partial success 20 %, with one nontarget embolization complication resulting in a minor change in treatment plan. No evidence of gastrointestinal or biliary ischemia or infarction was identified, and no microsphere-related gastroduodenal ulcerations or other evidence of nontarget RE were seen. Median volume of n-BCA used was <0.1 ml.n-BCA glue embolization is useful to eliminate hepatoenteric networks that may result in nontarget RE, especially in those that persist after coil embolization of major vessels such as the gastroduodenal and right gastric arteries.

    View details for DOI 10.1007/s00270-012-0490-1

    View details for PubMedID 23070102

  • Prophylactic Topically Applied Ice to Prevent Cutaneous Complications of Nontarget Chemoembolization and Radioembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Wang, D. S., Louie, J. D., Kothary, N., Shah, R. P., Sze, D. Y. 2013; 24 (4): 596-600


    Cutaneous complications can result from nontarget deposition during transcatheter arterial chemoembolization or radioembolization. Liver tumors may receive blood supply from parasitized extrahepatic arteries (EHAs) that also perfuse skin or from hepatic arteries located near the origin of the falciform artery (FA), which perfuses the anterior abdominal wall. To vasoconstrict cutaneous vasculature and prevent nontarget deposition, ice packs were topically applied to at-risk skin in nine chemoembolization treatments performed via 14 parasitized EHAs, seven chemoembolization treatments near the FA origin, and five radioembolization treatments in cases in which the FA could not be prophylactically coil-embolized. No postprocedural cutaneous complications were encountered.

    View details for DOI 10.1016/j.jvir.2012.12.020

    View details for Web of Science ID 000316828000022

    View details for PubMedID 23522163

  • Intra-arterial therapies for metastatic colorectal cancer. Seminars in interventional radiology Wang, D. S., Louie, J. D., Sze, D. Y. 2013; 30 (1): 12-20


    Intra-arterial therapies for unresectable hepatic metastases from colorectal cancer include radioembolization (RE) with yttrium-90 microspheres, transarterial chemoembolization (TACE), hepatic arterial infusion, and percutaneous hepatic perfusion using an organ isolation system. In this article, we discuss our approach toward treatment selection, followed by details of how RE and TACE are performed at our institution.

    View details for DOI 10.1055/s-0033-1333649

    View details for PubMedID 24436513

    View details for PubMedCentralID PMC3700785

  • Intra-Arterial Therapies for Metastatic Colorectal Cancer SEMINARS IN INTERVENTIONAL RADIOLOGY Wang, D. S., Louie, J. D., Sze, D. Y. 2013; 30 (1): 12-20
  • Migration of implanted markers for image-guided lung tumor stereotactic ablative radiotherapy JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS Hong, J. C., Eclov, N. C., Yu, Y., Rao, A. K., Dieterich, S., Quynh-Thu Le, Q. T., Diehn, M., Sze, D. Y., Loo, B. W., Kothary, N., Maxim, P. G. 2013; 14 (2): 77-89
  • Numerical simulation of blood flow in the thoracic aorta using a centerline-fitted finite difference approach 4th China-Japan-Korea Conference on Numerical Mathematics Suito, H., Ueda, T., Sze, D. KINOKUNIYA CO LTD. 2013: 701–10
  • Migration of implanted markers for image-guided lung tumor stereotactic ablative radiotherapy. Journal of applied clinical medical physics Hong, J. C., Eclov, N. C., Yu, Y., Rao, A. K., Dieterich, S., Le, Q., Diehn, M., Sze, D. Y., Loo, B. W., Kothary, N., Maxim, P. G. 2013; 14 (2): 4046-?


    The purpose of this study was to quantify postimplantation migration of percutaneously implanted cylindrical gold seeds ("seeds") and platinum endovascular embolization coils ("coils") for tumor tracking in pulmonary stereotactic ablative radiotherapy (SABR). We retrospectively analyzed the migration of markers in 32 consecutive patients with computed tomography scans postimplantation and at simulation. We implanted 147 markers (59 seeds, 88 coils) in or around 34 pulmonary tumors over 32 procedures, with one lesion implanted twice. Marker coordinates were rigidly aligned by minimizing fiducial registration error (FRE), the root mean square of the differences in marker locations for each tumor between scans. To also evaluate whether single markers were responsible for most migration, we aligned with and without the outlier causing the largest FRE increase per tumor. We applied the resultant transformation to all markers. We evaluated migration of individual markers and FRE of each group. Median scan interval was 8 days. Median individual marker migration was 1.28 mm (interquartile range [IQR] 0.78-2.63 mm). Median lesion FRE was 1.56 mm (IQR 0.92-2.95 mm). Outlier identification yielded 1.03 mm median migration (IQR 0.52-2.21 mm) and 1.97 mm median FRE (IQR 1.44-4.32 mm). Outliers caused a mean and median shift in the centroid of 1.22 and 0.80 mm (95th percentile 2.52 mm). Seeds and coils had no statistically significant difference. Univariate analysis suggested no correlation of migration with the number of markers, contact with the chest wall, or time elapsed. Marker migration between implantation and simulation is limited and unlikely to cause geometric miss during tracking.

    View details for DOI 10.1120/jacmp.v14i2.4046

    View details for PubMedID 23470933

  • Correlation of the Diameter of the Left Common Iliac Vein with the Risk of Lower-extremity Deep Venous Thrombosis JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Carr, S., Chan, K., Rosenberg, J., Kuo, W. T., Kothary, N., Hovsepian, D. M., Sze, D. Y., Hofmann, L. V. 2012; 23 (11): 1467-1472


    Compression of the left common iliac vein (CIV; LCIV) is a known risk factor for lower-extremity deep vein thrombosis (DVT). This study was performed to model the probability of DVT based on LCIV diameter and apply this to a quantitative DVT risk factor scoring system.Medical records were used to identify female patients younger than 45 years of age who were diagnosed with lower-extremity DVT (n = 21) and age-matched control subjects (n = 26) who presented to the emergency department with abdominal pain. Minimum CIV diameters were measured on computed tomography. Based on published reporting standards, 13 risk factors were scored for patients diagnosed with left-sided DVT and for control subjects. The association between vein diameter and DVT was examined by Mann-Whitney test. Odds of DVT based on vein diameter was assessed by logistic regression.Mean minimum LCIV diameters were 4.0 mm for patients with DVT and 6.5 mm for patients without DVT (P = .001). The odds of left DVT increased by a factor of 1.68 for each millimeter decrease in LCIV diameter (odds ratio = 1.68; P = .006; 95% confidence interval, 1.16-2.43). As the risk factor score increased, the relationship between diameter and risk for DVT became stronger; identical LCIV diameters were associated wtih a higher probability of developing DVT if the risk factor score was higher.Stenosis of the LCIV was found to be a strong independent risk factor for development of DVT. Moreover, each millimeter decrease in CIV diameter increased the odds of DVT by a factor of 1.68.

    View details for DOI 10.1016/j.jvir.2012.07.030

    View details for Web of Science ID 000311267900011

    View details for PubMedID 23101919

  • Complex Retrieval of Embedded IVC Filters: Alternative Techniques and Histologic Tissue Analysis CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY Kuo, W. T., Cupp, J. S., Louie, J. D., Kothary, N., Hofmann, L. V., Sze, D. Y., Hovsepian, D. M. 2012; 35 (3): 588-597


    We evaluated the safety and effectiveness of alternative endovascular methods to retrieve embedded optional and permanent filters in order to manage or reduce risk of long-term complications from implantation. Histologic tissue analysis was performed to elucidate the pathologic effects of chronic filter implantation.We studied the safety and effectiveness of alternative endovascular methods for removing embedded inferior vena cava (IVC) filters in 10 consecutive patients over 12 months. Indications for retrieval were symptomatic chronic IVC occlusion, caval and aortic perforation, and/or acute PE (pulmonary embolism) from filter-related thrombus. Retrieval was also performed to reduce risk of complications from long-term filter implantation and to eliminate the need for lifelong anticoagulation. All retrieved specimens were sent for histologic analysis.Retrieval was successful in all 10 patients. Filter types and implantation times were as follows: one Venatech (1,495 days), one Simon-Nitinol (1,485 days), one Optease (300 days), one G2 (416 days), five Günther-Tulip (GTF; mean 606 days, range 154-1,010 days), and one Celect (124 days). There were no procedural complications or adverse events at a mean follow-up of 304 days after removal (range 196-529 days). Histology revealed scant native intima surrounded by a predominance of neointimal hyperplasia and dense fibrosis in all specimens. Histologic evidence of photothermal tissue ablation was confirmed in three laser-treated specimens.Complex retrieval methods can now be used in select patients to safely remove embedded optional and permanent IVC filters previously considered irretrievable. Neointimal hyperplasia and dense fibrosis are the major components that must be separated to achieve successful retrieval of chronic filter implants.

    View details for DOI 10.1007/s00270-011-0175-1

    View details for Web of Science ID 000304162700018

    View details for PubMedID 21562933

  • Applying a Structured Innovation Process to Interventional Radiology: A Single-Center Experience JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sista, A. K., Hwang, G. L., Hovsepian, D. M., Sze, D. Y., Kuo, W. T., Kothary, N., Louie, J. D., Yamada, K., Hong, R., Dhanani, R., Brinton, T. J., Krummel, T. M., Makower, J., Yock, P. G., Hofmann, L. V. 2012; 23 (4): 488-494


    To determine the feasibility and efficacy of applying an established innovation process to an active academic interventional radiology (IR) practice.The Stanford Biodesign Medical Technology Innovation Process was used as the innovation template. Over a 4-month period, seven IR faculty and four IR fellow physicians recorded observations. These observations were converted into need statements. One particular need relating to gastrostomy tubes was diligently screened and was the subject of a single formal brainstorming session.Investigators collected 82 observations, 34 by faculty and 48 by fellows. The categories that generated the most observations were enteral feeding (n = 9, 11%), biopsy (n = 8, 10%), chest tubes (n = 6, 7%), chemoembolization and radioembolization (n = 6, 7%), and biliary interventions (n = 5, 6%). The output from the screening on the gastrostomy tube need was a specification sheet that served as a guidance document for the subsequent brainstorming session. The brainstorming session produced 10 concepts under three separate categories.This formalized innovation process generated numerous observations and ultimately 10 concepts to potentially to solve a significant clinical need, suggesting that a structured process can help guide an IR practice interested in medical innovation.

    View details for DOI 10.1016/j.jvir.2011.12.029

    View details for Web of Science ID 000302396300009

    View details for PubMedID 22464713

  • Yttrium-90 Radioembolization of Renal Cell Carcinoma Metastatic to the Liver JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Abdelmaksoud, M. H., Louie, J. D., Hwang, G. L., Kothary, N., Minor, D. R., Sze, D. Y. 2012; 23 (3): 323-330


    To investigate the safety and efficacy of yttrium-90 ((90)Y) hepatic radioembolization treatment of patients with liver-dominant metastatic renal cell carcinoma (RCC) refractory to immunotherapy and targeted therapies.Between March 2006 and December 2010, six patients with metastatic RCC underwent eight radioembolization treatments with (90)Y-labeled resin microspheres for unresectable liver-dominant metastases. All six patients had previous hepatic tumor progression despite targeted therapies or immunotherapies. All had bilobar disease and required whole-liver treatment. Clinical and biochemical toxicities were recorded, and tumor response was assessed every 2-3 months after treatment by cross-sectional imaging.The median dose delivered was 1.89 Gbq (range 0.41-2.03 Gbq). Grade 1 and 2 toxicities were noted in all patients, primarily fatigue. Follow-up imaging was available for five patients. In follow-up periods from 2-64 months (mean 25 months), three patients showed complete responses, and 1 patient showed a partial response by standard imaging criteria, and these patients are alive at 64 months, 55 months, 17 months, and 7 months after treatment. Two patients with rapid progression of disease died within 2 months of treatment, although hepatic malignancy or failure was not the cause of death in either patient.(90)Y radioembolization is a promising option for liver-dominant metastatic RCC with potential for providing long-term survival in patients refractory to or intolerant of targeted therapies.

    View details for DOI 10.1016/j.jvir.2011.11.007

    View details for Web of Science ID 000301328100007

    View details for PubMedID 22277275

  • Quality Improvement Guidelines for Transhepatic Arterial Chemoembolization, Embolization, and Chemotherapeutic Infusion for Hepatic Malignancy JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Brown, D. B., Nikolic, B., Covey, A. M., Nutting, C. W., Saad, W. E., Salem, R., Sofocleous, C. T., Sze, D. Y. 2012; 23 (3): 287-294

    View details for DOI 10.1016/j.jvir.2011.11.029

    View details for Web of Science ID 000301328100001

    View details for PubMedID 22284821

  • Transarterial Chemoembolization for Hepatocellular Carcinomas in Watershed Segments: Utility of C-Arm Computed Tomography for Treatment Planning JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Abdelmaksoud, M. H., Louie, J. D., Hwang, G. L., Sze, D. Y., Hofmann, L. V., Kothary, N. 2012; 23 (2): 281-283

    View details for DOI 10.1016/j.jvir.2011.11.008

    View details for Web of Science ID 000299656600021

    View details for PubMedID 22264556

  • Response to Intra-Arterial Oncolytic Virotherapy with the Herpes Virus NV1020 Evaluated by [F-18]Fluorodeoxyglucose Positron Emission Tomography and Computed Tomography HUMAN GENE THERAPY Sze, D. Y., Iagaru, A. H., Gambhir, S. S., de Haan, H. A., Reid, T. R. 2012; 23 (1): 91-97


    Oncolytic virotherapy poses unique challenges to the evaluation of tumor response. We hypothesized that the addition of [(18)F]fluorodeoxyglucose (FDG) positron emission tomography (PET) to standard computed tomography (CT) evaluation would improve diagnostic and prognostic power of the measurement of tumor response to oncolytic virotherapy. A phase I/II trial was conducted to investigate treatment of hepatic metastases from colorectal carcinoma using intra-arterial administration of the oncolytic herpes virus NV1020. Both contrast-enhanced CT and FDG PET were obtained on each patient at each time point. Quantitative FDG PET and CT responses were correlated with each other and with clinical outcome metrics. A majority of patients showed initial post-viral infusion increases in tumor size (69%) or in standardized uptake value (SUV) (80%) large enough to qualify as progressive disease. Most showed subsequent decreases in tumor size (64%) or SUV (83%) enough to be reclassified as partial response or stable disease. Late PET and CT imaging results correlated well with each other and with clinical outcomes, but results from early in the treatment scheme did not correlate with each other, with later results, or with clinical outcomes. The addition of FDG PET to the evaluation of tumor response to the oncolytic virus NV1020 did not provide useful diagnostic or prognostic data. More sophisticated molecular imaging will need to be developed to monitor the effects of this novel class of antineoplastic agents.

    View details for DOI 10.1089/hum.2011.141

    View details for Web of Science ID 000299604000011

    View details for PubMedID 21895536

  • Intravascular Ultrasound-Guided Mesocaval Shunt Creation in Patients with Portal or Mesenteric Venous Occlusion JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Hong, R., Dhanani, R. S., Louie, J. D., Sze, D. Y. 2012; 23 (1): 136-141


    Extrahepatic mesocaval shunts were successfully created in three patients with refractory variceal hemorrhage, complete portal vein or superior mesenteric vein occlusion, and contraindications to shunt surgery. The use of intravascular ultrasound guidance and covered stents allowed safe and effective transvenous shunt creation without the necessity of percutaneous transabdominal mesenteric venous puncture.

    View details for DOI 10.1016/j.jvir.2011.09.029

    View details for Web of Science ID 000299151400024

    View details for PubMedID 22221479

  • Percutaneous Cholecystostomy for Acute Cholecystitis: Ten-Year Experience JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Joseph, T., Unver, K., Hwang, G. L., Rosenberg, J., Sze, D. Y., Hashimi, S., Kothary, N., Louie, J. D., Kuo, W. T., Hofmann, L. V., Hovsepian, D. M. 2012; 23 (1): 83-88


    To review the clinical course of patients with acute cholecystitis treated by percutaneous cholecystostomy, and to identify risk factors retrospectively that predict outcome.A total of 106 patients diagnosed with acute cholecystitis were treated by percutaneous cholecystostomy during a 10-year period. Seventy-one (67%) presented to the emergency department (ED) specifically for acute cholecystitis, and 35 (23%) were inpatients previously admitted for other conditions. Outcomes of the two groups were compared with respect to severity of illness, leukocytosis, bile culture, liver function tests, imaging features, time intervals from onset of symptoms to medical and percutaneous intervention, and whether surgical cholecystectomy was later performed.Overall, 72 patients (68%) showed an improvement clinically, whereas 34 (32%) showed no improvement or a clinically worsened condition after cholecystostomy. Patients who presented to the ED primarily with acute cholecystitis fared better (84% of patients showed improvement) than inpatients (34% showed improvement; P < .0001). Gallstones were identified in 54% of patients who presented to the ED, whereas acalculous cholecystitis was more commonly diagnosed in inpatients (54%). Patients with sepsis had worse outcomes overall (P < .0001). Bacterial bile cultures were analyzed in 95% of patients and showed positive results in 52%, with no overall effect on outcome. There was no correlation between the time of onset of symptoms until antibiotic therapy or cholecystostomy in either group. Long-term outcomes for both groups were better for those who later underwent cholecystectomy (P < .0001).Outcomes after percutaneous cholecystostomy for acute cholecystitis are better when the disease is primary and not precipitated by concurrent illness.

    View details for DOI 10.1016/j.jvir.2011.09.030

    View details for Web of Science ID 000299151400015

    View details for PubMedID 22133709

  • Common iliac vein stenosis: a risk factor for oral contraceptive-induced deep vein thrombosis 36th Annual Scientific Meeting of the Society-of-Interventional-Radiology Chan, K. T., Tye, G. A., Popat, R. A., Kuo, W. T., Unver, K., Kothary, N., Sze, D. Y., Hofmann, L. V. MOSBY-ELSEVIER. 2011


    The objective of the study was to determine whether women with significant left common iliac vein stenosis who also use combined oral contraceptives (COCs) have a combined likelihood of deep vein thrombosis (DVT) greater than each independent risk.This was a case-control study comparing 35 women with DVT against 35 age-matched controls. Common iliac vein diameters were measured from computed tomography and magnetic resonance imaging. Logistic regression modeling was used with adjustment for risk factors.DVT was associated with COC use (P = .022) and with increasing degrees of common iliac vein stenosis (P = .004). Compared with women without venous stenosis or COC use, the odds of DVT in women with a 70% venous stenosis who also use COCs was associated with a 17-fold increase (P = .01).Venous stenosis and COC use are independent risk factors for DVT. Women concurrently exposed to both have a multiplicative effect resulting in an increased risk of DVT. We recommend further studies to investigate this effect and its potential clinical implications.

    View details for DOI 10.1016/j.ajog.2011.06.100

    View details for Web of Science ID 000297329200019

    View details for PubMedID 21893308

  • Imaging Guidance with C-arm CT: Prospective Evaluation of Its Impact on Patient Radiation Exposure during Transhepatic Arterial Chemoembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N., Abdelmaksoud, M. H., Tognolini, A., Fahrig, R., Rosenberg, J., Hovsepian, D. M., Ganguly, A., Louie, J. D., Kuo, W. T., Hwang, G. L., Holzer, A., Sze, D. Y., Hofmann, L. V. 2011; 22 (11): 1535-1544


    To prospectively evaluate the impact of C-arm CT on radiation exposure to hepatocellular carcinoma (HCC) patients treated by chemoembolization.Patients with HCC (N = 87) underwent digital subtraction angiography (DSA; control group) or combined C-arm CT/DSA (test group) for chemoembolization. Dose-area product (DAP) and cumulative dose (CD) were measured for guidance and treatment verification. Contrast agent volume and C-arm CT utility were also measured.The marginal DAP increase in the test group was offset by a substantial (50%) decrease in CD from DSA. Use of C-arm CT allowed reduction of DAP and CD from DSA imaging (P = .007 and P = .017). Experienced operators were more efficient in substituting C-arm CT for DSA, resulting in a negligible increase (7.5%) in total DAP for guidance, compared with an increase of 34% for all operators (P = .03). For treatment verification, DAP from C-arm CT exceeded that from DSA, approaching that of conventional CT. The test group used less contrast medium (P = .001), and C-arm CT provided critical or supplemental information in 20% and 17% of patients, respectively.Routine use of C-arm CT can increase stochastic risk (DAP) but decrease deterministic risk (CD) from DSA. However, the increase in DAP is operator-dependent, thus, with experience, it can be reduced to under 10%. C-arm CT provides information not provided by DSA in 33% of patients, while decreasing the use of iodinated contrast medium. As with all radiation-emitting modalities, C-arm CT should be used judiciously.

    View details for DOI 10.1016/j.jvir.2011.07.008

    View details for Web of Science ID 000296661800008

    View details for PubMedID 21875814

  • Consolidation of Hepatic Arterial Inflow by Embolization of Variant Hepatic Arteries in Preparation for Yttrium-90 Radioembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Abdelmaksoud, M. H., Louie, J. D., Kothary, N., Hwang, G. L., Kuo, W. T., Hofmann, L. V., Hovsepian, D. M., Sze, D. Y. 2011; 22 (10): 1364-1372


    Before yttrium-90 ((90)Y) radioembolization administration, the authors consolidated arterial inflow by embolizing variant hepatic arteries (HAs) to make microsphere delivery simpler and safer. The present study reviews the technical and clinical success of these consolidation procedures.Preparatory and treatment angiograms were retrospectively analyzed for 201 patients. Variant HAs were coil-embolized during preparatory angiography to simplify arterial anatomy. Collateral arterial perfusion of territories previously supplied by variant HAs was evaluated by digital subtraction angiography (DSA), C-arm computed tomography (CT), and technetium-99m ((99m)Tc)-macroaggregated albumin (MAA) scintigraphy, and by follow-up evaluation of regional tumor response.A total of 47 variant HAs were embolized in 43 patients. After embolization of variant HAs, cross-perfusion into the embolized territory was depicted by DSA and by C-arm CT in 100% of patients and by (99m)Tc-MAA scintigraphy in 92.7%. Uniform progressive disease prevented evaluation in 33% of patients, but regional tumor response in patients who responded supported successful delivery of microspheres to the embolized territories in 95.5% of evaluable patients.Embolization of variant HAs for consolidation of hepatic supply in preparation for (90)Y radioembolization promotes treatment of affected territories via intrahepatic collateral channels.

    View details for DOI 10.1016/j.jvir.2011.06.014

    View details for Web of Science ID 000295708400004

    View details for PubMedID 21961981

  • INCIDENCE AND IMPLICATION OF DUAL BLOOD SUPPLY TO HEPATOCELLULAR CARCINOMA LOCATED IN WATERSHED REGIONS OF SEGMENT IV AND VIII DURING TACE 62nd Annual Meeting of the American-Association-for-the-Study-of-Liver-Diseases (AASLD) Kothary, N., Daugherty, T., Sze, D. Y., Hofmann, L. V., Concepcion, W. WILEY-BLACKWELL. 2011: 1390A–1390A
  • In Vitro Design and Characterization of the Nonviral Gene Delivery Vector lopamidol, Protamine, Ethiodized Oil Reagent JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Higgins, L. J., Hwang, G. L., Rosenberg, J., Katzenberg, R. H., Kothary, N., Sze, D. Y., Hofmann, L. V. 2011; 22 (10): 1457-1463


    To demonstrate cellular selectivity toward hepatoma cells and compare the efficiency of gene delivery of a novel nonviral vector of iopamidol, protamine, and ethiodized oil reagents (VIPER).Rat hepatocellular carcinoma (HCC) cells were transfected in triplicate under varying conditions by using firefly luciferase as a reporter gene. Conditions included variations of a protamine:DNA (P:D) complex (20:1, 50:1, 100:1, 200:1 mass ratios), iopamidol (0%, 10%, 33%), and ethiodized oil (0%, 1%, 2%, 4%, 8%, and 16%). The conditions affording efficient gene transfer and ease of translation to in vivo studies were selected for cell line comparison (HCC cells vs hepatocytes). Adenoviral transduction was compared with nonviral vector transfection.At low concentrations, ethiodized oil increased transfection efficiency regardless of P:D mass ratio. However, high concentrations resulted in significant attenuation. Unexpectedly, the addition of iopamidol to P:D complexes markedly improved transfection efficiency. When using an optimal P:D, iopamidol, and ethiodized oil solution, DNA transfection of normal liver and tumor cells showed significant selectivity for tumor cells. In the context of hepatoma cells, transfection efficiency with the nonviral vector was better than 10(4) pfu adenovirus.The development and characterization of the VIPER system provides a possible alternative to viral gene therapy of HCC.

    View details for DOI 10.1016/j.jvir.2011.06.025

    View details for Web of Science ID 000295708400018

    View details for PubMedID 21856173

  • Embolization of Parasitized Extrahepatic Arteries to Reestablish Intrahepatic Arterial Supply to Tumors before Yttrium-90 Radioembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Abdelmaksoud, M. H., Louie, J. D., Kothary, N., Hwang, G. L., Kuo, W. T., Hofmann, L. V., Hovsepian, D. M., Sze, D. Y. 2011; 22 (10): 1355-1362


    To perform embolization of parasitized extrahepatic arteries (EHAs) before radioembolization to reestablish intrahepatic arterial supply to large, peripheral tumors, and to evaluate the technical and clinical outcomes of this intervention.Among 201 patients retrospectively analyzed, embolization of 73 parasitized EHAs in 35 patients was performed. Most embolization procedures were performed during preparatory angiography using large particles and coils. Digital subtraction angiography (DSA), C-arm computed tomography (CT), and technetium-99m macroaggregated albumin ((99m)TcMAA) scintigraphy were used to evaluate the immediate perfusion via intrahepatic collateral channels of target tumor areas previously supplied by parasitized EHAs. Follow-up imaging of differential regional tumor response was used to evaluate microsphere distribution and clinical outcome.After embolization, reestablishment of intrahepatic arterial supply was confirmed by both DSA and C-arm CT in 94% of territories and by scintigraphy in 96%. In 32% of patients, the differential response of treatment could not be evaluated because of uniform disease progression. However, symmetric regional tumor response in 94% of evaluable patients indicated successful delivery of microspheres to the territories previously supplied by parasitized EHAs.Reestablishment of intrahepatic arterial inflow to hepatic tumors by embolization of parasitized EHAs is safe and effective and results in successful delivery of yttrium-90 microspheres to tumors previously perfused by parasitized EHAs.

    View details for DOI 10.1016/j.jvir.2011.06.007

    View details for Web of Science ID 000295708400002

    View details for PubMedID 21961979



    To compare the retention rates of two types of implanted fiducial markers for stereotactic ablative radiotherapy (SABR) of pulmonary tumors, smooth cylindrical gold "seed" markers ("seeds") and platinum endovascular embolization coils ("coils"), and to compare the complication rates associated with the respective implantation procedures.We retrospectively analyzed the retention of percutaneously implanted markers in 54 consecutive patients between January 2004 and June 2009. A total of 270 markers (129 seeds, 141 coils) were implanted in or around 60 pulmonary tumors over 59 procedures. Markers were implanted using a percutaneous approach under computed tomography (CT) guidance. Postimplantation and follow-up imaging studies were analyzed to score marker retention relative to the number of markers implanted. Markers remaining near the tumor were scored as retained. Markers in a distant location (e.g., pleural space) were scored as lost. CT imaging artifacts near markers were quantified on radiation therapy planning scans.Immediately after implantation, 140 of 141 coils (99.3%) were retained, compared to 110 of 129 seeds (85.3%); the difference was highly significant (p<0.0001). Of the total number of lost markers, 45% were reported lost during implantation, but 55% were lost immediately afterwards. No additional markers were lost on longer-term follow-up. Implanted lesions were peripherally located for both seeds (mean distance, 0.33 cm from pleural surface) and coils (0.34 cm) (p=0.96). Incidences of all pneumothorax (including asymptomatic) and pneumothorax requiring chest tube placement were lower in implantation of coils (23% and 3%, respectively) vs. seeds (54% and 29%, respectively; p=0.02 and 0.01). The degree of CT artifact was similar between marker types.Retention of CT-guided percutaneously implanted coils is significantly better than that of seed markers. Furthermore, implanting coils is at least as safe as implanting seeds. Using coils should permit implantation of fewer markers and require fewer repeat implantation procedures owing to lost markers.

    View details for DOI 10.1016/j.ijrobp.2010.04.037

    View details for Web of Science ID 000294093300012

    View details for PubMedID 20675070

  • Portal Venous Remodeling After Endovascular Reduction of Pediatric Autogenous Portosystemic Shunts JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Stewart, J. K., Kuo, W. T., Hovsepian, D. M., Hofmann, L. V., Bonham, C. A., Sze, D. Y. 2011; 22 (8): 1199-1205


    Patients with autogenous native vessel portosystemic shunts, whether surgical or congenital, may experience complications of excess shunt flow, including hepatopulmonary syndrome (HPS), hepatic encephalopathy (HE), and hepatic insufficiency. The authors explored endovascular reduction or occlusion of autogenous portosystemic shunts using methods commonly employed in transjugular intrahepatic portosystemic shunt (TIPS) reduction in four pediatric patients. Before treatment, the patients had hypoplastic, atrophic, or thrombosed portal veins. Following intervention, symptoms of overshunting resolved or improved in all patients without major complications. The innate plasticity of the pediatric portal venous system allowed for hypertrophy or development and maturation of cavernous transformations to accommodate increased hepatopetal blood flow and pressure.

    View details for DOI 10.1016/j.jvir.2011.01.438

    View details for Web of Science ID 000293482700020

    View details for PubMedID 21801995

  • Ruptured Biliary Cystadenoma Managed by Angiographic Embolization and Interval Partial Hepatectomy DIGESTIVE DISEASES AND SCIENCES Ghole, S. A., Bakhtary, S., Staudenmayer, K., Sze, D. Y., Pai, R. K., Visser, B. C., Norton, J. A., Poultsides, G. A. 2011; 56 (7): 1949-1953

    View details for DOI 10.1007/s10620-011-1677-z

    View details for Web of Science ID 000291481800006

    View details for PubMedID 21445579

  • Discriminant Analysis of Native Thoracic Aortic Curvature: Risk Prediction for Endoleak Formation After Thoracic Endovascular Aortic Repair JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Nakatamari, H., Ueda, T., Ishioka, F., Raman, B., Kurihara, K., Rubin, G. D., Ito, H., Sze, D. Y. 2011; 22 (7): 974-979


    To determine the association of native thoracic aortic curvature measured from computed tomographic (CT) angiography categorized by discriminant analysis with the development of endoleaks after thoracic endovascular aortic repair (EVAR).Forty patients (28 men, 12 women; mean age, 74 y; range, 40-89 y) with aortic diseases treated with thoracic EVAR were evaluated. Diseases treated included atherosclerotic aneurysm (n = 27), penetrating atherosclerotic ulcer (n = 4), intramural hematoma (n = 3), mycotic aneurysm (n = 3), and anastomotic pseudoaneurysm (n = 3). Quantitative analysis of native aortic morphology was performed on preprocedural CT angiograms with an original customized computer program, and regional curvature indices in each anatomic segment of the aorta were calculated. Patterns of native thoracic aortic morphology were analyzed by discriminant analysis. The association between the morphologic pattern of the aorta and the presence and type of endoleak was assessed.After leave-one-out cross-validation methods had been applied, the sensitivity, specificity, and accuracy to detect endoleak formation in a new population group by discriminant analysis of the patterns of native aortic curvature were estimated as 84.0%, 58.8%, and 73.8%, respectively. Compared with the no-endoleak group, the type Ia endoleak group had greater curvature at the aortic arch, the type Ib endoleak group had greater curvature at the thoracoabdominal junction, and the type III endoleak group had greater curvature in the midportion of the descending aorta.Discriminant analysis of native thoracic aortic morphology measured from CT angiography is a useful tool to predict the risk of endoleak formation after thoracic EVAR and should be implemented during treatment planning and follow-up.

    View details for DOI 10.1016/j.jvir.2011.02.031

    View details for Web of Science ID 000292431600012

    View details for PubMedID 21570875

  • Photothermal Ablation with the Excimer Laser Sheath Technique for Embedded Inferior Vena Cava Filter Removal: Initial Results from a Prospective Study JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kuo, W. T., Odegaard, J. I., Louie, J. D., Sze, D. Y., Unver, K., Kothary, N., Rosenberg, J. K., Hovsepian, D. M., Hwang, G. L., Hofmann, L. V. 2011; 22 (6): 813-823


    To evaluate the safety and effectiveness of the excimer laser sheath technique for removing embedded inferior vena cava (IVC) filters.Over 12 months, 25 consecutive patients undergoing attempted IVC filter retrieval with a laser-assisted sheath technique were prospectively enrolled into an institutional review board-approved study registry. There were 10 men and 15 women (mean age 50 years, range 20-76 years); 18 (72%) of 25 patients were referred from an outside hospital. Indications for retrieval included symptomatic filter-related acute caval thrombosis (with or without acute pulmonary embolism), chronic IVC occlusion, and bowel penetration. Retrieval was also performed to remove risks from prolonged implantation and potentially to eliminate need for lifelong anticoagulation. After failure of standard methods, controlled photothermal ablation of filter-adherent tissue with a Spectranetics laser sheath and CVX-300 laser system was performed. All patients were evaluated with cavography, and specimens were sent for histologic analysis.Laser-assisted retrieval was successful in 24 (96%) of 25 patients as follows: 11 Günther Tulip (mean 375 days, range 127-882 days), 4 Celect (mean 387 days, range 332-440 days), 2 Option (mean 215 days, range 100-330 days), 4 OPTEASE (mean 387 days, range 71-749 days; 1 failed 188 days), 2 TRAPEASE (mean 871 days, range 187-1,555 days), and 2 Greenfield (mean 12.8 years, range 7.2-18.3 years). There was one (4%) major complication (acute thrombus, treated with thrombolysis), three (12%) minor complications (small extravasation, self-limited), and one adverse event (coagulopathic retroperitoneal hemorrhage) at follow-up (mean 126 days, range 13-302 days). Photothermal ablation of filter-adherent tissue was histologically confirmed in 23 (92%) of 25 patients.The laser-assisted sheath technique appears to be a safe and effective tool for retrieving embedded IVC filters, including permanent types, with implantation ranging from months to > 18 years.

    View details for DOI 10.1016/j.jvir.2011.01.459

    View details for Web of Science ID 000291414500011

    View details for PubMedID 21530309

  • Intrahepatic Collateral Supply to the Previously Embolized Right Gastric Artery: A Potential Pitfall for Nontarget Radioembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Meer, A. B., Louie, J. D., Abdelmaksoud, M. H., Kothary, N., Hovsepian, D. M., Hofmann, L. V., Kuo, W. T., Hwang, G. L., Sze, D. Y. 2011; 22 (4): 575-577

    View details for DOI 10.1016/j.jvir.2010.12.031

    View details for Web of Science ID 000289340100024

    View details for PubMedID 21463762

  • Research Reporting Standards for Radioembolization of Hepatic Malignancies JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Salem, R., Lewandowski, R. J., Gates, V. L., Nutting, C. W., Murthy, R., Rose, S. C., Soulen, M. C., Geschwind, J. H., Kulik, L., Kim, Y. H., Spreafico, C., Maccauro, M., Bester, L., Brown, D. B., Ryu, R. K., Sze, D. Y., Rilling, W. S., Sato, K. T., Sangro, B., Ignacio Bilbao, J., Jakobs, T. F., Ezziddin, S., Kulkarni, S., Kulkarni, A., Liu, D. M., Valenti, D., Hilgard, P., Antoch, G., Muller, S. P., Alsuhaibani, H., Mulcahy, M. F., Burrel, M., Isabel Real, M., Spies, S., Esmail, A. A., Raoul, J., Garin, E., Johnson, M. S., Benson, A. B., Sharma, R. A., Wasan, H., Lambert, B., Memon, K., Kennedy, A. S., Riaz, A. 2011; 22 (3): 265-278

    View details for DOI 10.1016/j.jvir.2010.10.029

    View details for Web of Science ID 000288192400001

    View details for PubMedID 21353979

  • Common Iliac Vein Stenosis and Risk of Symptomatic Pulmonary Embolism: An Inverse Correlation JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Chan, K. T., Popat, R. A., Sze, D. Y., Kuo, W. T., Kothary, N., Louie, J. D., Hovsepian, D. M., Hwang, G. L., Hofmann, L. V. 2011; 22 (2): 133-141


    To test the hypothesis that a common iliac vein (CIV) stenosis may impair embolization of a large deep venous thrombosis (DVT) to the lungs, decreasing the incidence of a symptomatic pulmonary embolism (PE).Between January 2002 and August 2007, 75 patients diagnosed with unilateral DVT were included in a single-institution case-control study. Minimum CIV diameters were measured 1 cm below the inferior vena cava (IVC) bifurcation on computed tomography (CT) images. A significant stenosis in the CIV ipsilateral to the DVT was defined as having either a diameter 4 mm or less or a greater than 70% reduction in lumen diameter. A symptomatic PE was defined as having symptoms and imaging findings consistent with a PE. The odds of symptomatic PE versus CIV stenosis were assessed using logistic regression models. The associations between thrombus location, stenosis, and symptomatic PE were assessed using a stratified analysis.Of 75 subjects, 49 (65%) presented with symptomatic PE. There were 17 (23%) subjects with a venous lumen 4 mm or less and 12 (16%) subjects with a greater than 70% stenosis. CIV stenosis of 4 mm or less resulted in a decreased odds of a symptomatic PE compared with a lumen greater than 4 mm (odds ratio [OR] 0.17, P = .011), whereas a greater than 70% stenosis increased the odds of DVT involving the CIV (OR 7.1, P = .047).Among patients with unilateral DVT, those with an ipsilateral CIV lumen of 4 mm or less have an 83% lower risk of developing symptomatic PE compared with patients with a CIV lumen greater than 4 mm.

    View details for DOI 10.1016/j.jvir.2010.10.009

    View details for Web of Science ID 000287166600004

    View details for PubMedID 21276911

  • C-arm Computed Tomography for Hepatic Interventions: A Practical Guide JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Tognolini, A., Louie, J., Hwang, G., Hofmann, L., Sze, D., Kothary, N. 2010; 21 (12): 1817-1823


    With adoption of catheter-based techniques that require technically difficult catheterization, the need for imaging platforms that exploit the advantages of multiple modalities and offer three-dimensional visualization has correspondingly increased. At the authors' institution, C-arm computed tomography (CT) is routinely used to complement conventional digital subtraction angiography for transcatheter therapy. The goal of the present report is to share experience with the use of C-arm CT in hepatic interventions, with the aim to provide practical tips for optimizing image acquisition and postprocessing. Although the authors' direct experience is limited to the equipment of a single manufacturer, many of the principles and guidelines can be readily extrapolated to other C-arm CT systems.

    View details for DOI 10.1016/j.jvir.2010.07.027

    View details for Web of Science ID 000285372600003

    View details for PubMedID 20970354

  • Renewing Focus on Resident Education: Increased Responsibility and Ownership in Interventional Radiology Rotations Improves the Educational Experience JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N., Ghatan, C. E., Hwang, G. L., Kuo, W. T., Louie, J. D., Sze, D. Y., Hovsepian, D. M., Desser, T. S., Hofmann, L. V. 2010; 21 (11): 1697-1702


    To enhance the educational experience among residents rotating through interventional radiology (IR) by encouraging ownership and responsibility.In May 2006, the authors implemented changes in resident education in IR that included increased clinical responsibilities, structured didactics, and greater hands-on experience, including call. Residents were assigned as first assistants, ownership of cases was encouraged, and assignment to a week on the consult service was instituted to help residents better understand all aspects of IR practice. Additional faculty recruitment and program expansion ensured the same high level of training for the fellowship program. Evaluations were reviewed every year (July 1, 2007-June 30, 2009) for hands-on training, daily teaching, didactic conferences, and overall effectiveness of the clinical service. A graduated scale of 1-5 was used.In 2009, 3 years after the curricular changes were made, the quality of hands-on training, daily case reviews and consults, didactics, and overall education had markedly improved with 89%, 71%, 65%, and 82% of the residents rating these respective aspects of the training as "above expectations" (4 on a scale of 5) or "superior" (5 on a scale of 5) compared with 77%, 23%, 20%, and 60% in 2005-2006. Three years after the changes, the impact of these changes on recruitment patterns also showed improvement, with 28.6% of the class of 2010 pursuing a fellowship in IR.Increasing resident ownership, responsibility, and hands-on experience improves resident education in IR, which, in turn, promotes interest in the field.

    View details for DOI 10.1016/j.jvir.2010.07.009

    View details for Web of Science ID 000284244200009

    View details for PubMedID 20884234

  • Hepatic Arteriovenous Malformations from Hereditary Hemorrhagic Telangiectasia: Treatment with Liver Transplantation DIGESTIVE DISEASES AND SCIENCES Lee, M., Sze, D. Y., Bonham, C. A., Daugherty, T. J. 2010; 55 (11): 3059-3062

    View details for DOI 10.1007/s10620-010-1353-8

    View details for Web of Science ID 000283300400008

    View details for PubMedID 20844961

  • Development of New Hepaticoenteric Collateral Pathways after Hepatic Arterial Skeletonization in Preparation for Yttrium-90 Radioembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Abdelmaksoud, M. H., Hwang, G. L., Louie, J. D., Kothary, N., Hofmann, L. V., Kuo, W. T., Hovsepian, D. M., Sze, D. Y. 2010; 21 (9): 1385-1395


    Development of new hepaticoenteric anastomotic vessels may occur after endovascular skeletonization of the hepatic artery. Left untreated, they can serve as pathways for nontarget radioembolization. The authors reviewed the incidence, anatomy, management, and significance of collateral vessel formation in patients undergoing radioembolization.One hundred thirty-eight treatments performed on 122 patients were reviewed. Each patient underwent a preparatory digital subtraction angiogram (DSA) and embolization of all hepaticoenteric vessels in preparation for yttrium-90 ((90)Y) administration. Successful skeletonization was verified by C-arm computed tomography (CACT) and technetium-99m macroaggregated albumin ((99m)TcMAA) scintigraphy. During the subsequent treatment session, DSA and CACT were repeated before administration of (90)Y, and the detection of extrahepatic perfusion prompted additional embolization.Forty-two patients (34.4%) undergoing 43 treatments (31.2%) required adjunctive embolization of hepaticoenteric vessels immediately before (90)Y administration. Previous scintigraphy findings showed extrahepatic perfusion in only three cases (7.1%). Vessels were identified by DSA in 54.1%, by CACT in 4.9%, or required both in 41.0%. The time interval between angiograms did not correlate with risk of requiring reembolization (P = .297). A total of 19.7% of vessels were new collateral vessels not visible during the initial angiography. Despite reembolization, three patients (7.1%) had gastric or duodenal ulceration, compared with 1.3% who never had visible collateral vessels, all of whom underwent whole-liver treatment with resin microspheres (P = .038).Development of collateral hepaticoenteric anastomoses occurs after endovascular skeletonization of the hepatic artery. Identified vessels may be managed by adjunctive embolization, but patients appear to remain at increased risk for gastrointestinal complications.

    View details for DOI 10.1016/j.jvir.2010.04.030

    View details for Web of Science ID 000281620600012

    View details for PubMedID 20688531

  • Phase I/II Study of Oncolytic Herpes Simplex Virus NV1020 in Patients with Extensively Pretreated Refractory Colorectal Cancer Metastatic to the Liver HUMAN GENE THERAPY Geevarghese, S. K., Geller, D. A., de Haan, H. A., Hoerer, M., Knoll, A. E., Mescheder, A., Nemunaitis, J., Reid, T. R., Sze, D. Y., Tanabe, K. K., Tawfik, H. 2010; 21 (9): 1119-1128


    This multicenter phase I/II study evaluated the safety, pharmacokinetics, and antitumor effects of repeated doses of NV1020, a genetically engineered oncolytic herpes simplex virus, in patients with advanced metastatic colorectal cancer (mCRC). Patients with liver-dominant mCRC received four fixed NV1020 doses via weekly hepatic artery infusion, followed by two or more cycles of conventional chemotherapy. Phase I included cohorts receiving 3 × 10(6), 1 × 10(7), 3 × 10(7), and 1 × 10(8) plaque-forming units (PFU)/dose to determine the optimal biological dose (OBD) for phase II. Blind independent computed tomography scan review was based on RECIST (response evaluation criteria in solid tumors) to assess hepatic tumor response. Phase I and II enrolled 13 and 19 patients, respectively. Patients experienced transient mild-moderate febrile reactions after each NV1020 infusion. Grade 3/4 virus-related toxicity was limited to transient lymphopenia in two patients. NV1020 shedding was not detected. Simultaneous cytokine and grade 1 coagulation perturbations were dose-limiting at 1 × 10(8) PFU/dose, considered the OBD. All 22 OBD patients had previously received 5-fluorouracil; most had received oxaliplatin or irinotecan (50% had both), many with at least one targeted agent. After NV1020 administration, 50% showed stable disease. The best overall tumor control rate after chemotherapy was 68% (1 partial response, 14 stable disease); this did not correlate with baseline variables or chemotherapy. Median time to progression was 6.4 months (95% confidence interval: 2, 8.9); median overall survival was 11.8 months (95% confidence interval: 8.3, 20.7). One-year survival was 47.2%. We conclude that NV1020 stabilizes liver metastases with minimal toxicity in mCRC. It may resensitize metastases to salvage chemotherapy and extend overall survival. A randomized phase II/III trial now appears justified.

    View details for DOI 10.1089/hum.2010.020

    View details for Web of Science ID 000281720700012

    View details for PubMedID 20486770

  • Incomplete Endograft Apposition to the Aortic Arch: Bird-Beak Configuration Increases Risk of Endoleak Formation after Thoracic Endovascular Aortic Repair RADIOLOGY Ueda, T., Fleischmann, D., Dake, M. D., Rubin, G. D., Sze, D. Y. 2010; 255 (2): 645-652


    To determine the clinical importance of the bird-beak configuration after thoracic endovascular aortic repair (TEVAR).The institutional review board approved this retrospective study and waived the requirement to obtain informed consent from patients. Sixty-four patients (40 men, 24 women; mean age, 64 years) who underwent TEVAR were evaluated. The treated diseases included dissection (n = 29), degenerative aneurysm (n = 13), acute traumatic transection (n = 8), pseudoaneurysm (n = 4), penetrating aortic ulcer (n = 6), intramural hematoma (n = 2), and mycotic aneurysm (n = 2). Bird-beak configuration, defined as the incomplete apposition of the proximal endograft with a wedge-shaped gap between the device and the aortic wall, was assessed with postprocedural CT angiography. The presence and length of the bird-beak configuration were compared with the formation of endoleaks and adverse clinical events.Endoleaks were detected in 26 (40%) of the 64 patients, including 14 with type Ia endoleak formation, one with type Ib endoleak formation, six with type II endoleak formation (from the left subclavian artery), two with type IIo endoleak formation (from other arteries), and three with type III endoleak formation. Bird-beak configuration was observed in 28 (44%) of 64 patients and correlated significantly with the risk of developing a type Ia or IIa endoleak (P < .01). Mean bird-beak length was significantly longer (P < .01) in patients with a type Ia or II endoleak (mean length, 14.3 and 13.9 mm, respectively) than in patients without endoleaks (mean length, 8.4 mm). Adverse events included early aortic-related death in three patients, additional treatment for endoleak in eight patients, and stent-graft collapse or infolding in six patients.Detection of bird-beak configuration is helpful in the prediction of adverse clinical events after TEVAR.

    View details for DOI 10.1148/radiol.10091468

    View details for Web of Science ID 000276976200040

    View details for PubMedID 20413775

  • Utility of C-arm CT in Patients with Hepatocellular Carcinoma undergoing Transhepatic Arterial Chemoembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Tognolini, A., Louie, J. D., Hwang, G. L., Hofmann, L. V., Sze, D. Y., Kothary, N. 2010; 21 (3): 339-347


    To evaluate the utility of C-arm computed tomography (CT) on treatment algorithms in patients undergoing transhepatic arterial chemoembolization for hepatocellular carcinoma (HCC).From March 2008 to July 2008, 84 consecutive patients with HCC underwent 100 consecutive transhepatic arterial chemoembolizations with iodized oil. Unenhanced and iodinated contrast medium-enhanced C-arm CT with planar and three-dimensional imaging were performed in addition to conventional digital subtraction angiography (DSA) in all patients. The effect on diagnosis and treatment was determined by testing the hypotheses that C-arm CT, in comparison to DSA, provides (a) improved lesion detection, (b) expedient identification and mapping of arterial supply to a tumor, (c) improved characterization of a lesion to allow confident differentiation of HCC from pseudolesions such as arterioportal shunts, and (d) an improved evaluation of treatment completeness. The effect of C-arm CT was analyzed on the basis of information provided with C-arm CT that was not provided or readily apparent at DSA.C-arm CT was technically successful in 93 of the 100 procedures (93%). C-arm CT provided information not apparent or discernible at DSA in 30 of the 84 patients (36%) and resulted in a change in diagnosis, treatment planning, or treatment delivery in 24 (28%). The additional information included, amongst others, visualization of additional or angiographically occult tumors in 13 of the 84 patients (15%) and identification of incomplete treatment in six (7.1%).C-arm CT is a useful collaborative tool in patients undergoing transhepatic arterial chemoembolization and can affect patient care in more than one-fourth of patients.

    View details for DOI 10.1016/j.jvir.2009.11.007

    View details for Web of Science ID 000277367700005

    View details for PubMedID 20133156

  • Embolization of a Symptomatic Systemic to Pulmonary (Right-to-left) Venous Shunt Caused by Fibrosing Mediastinitis and Superior Vena Caval Occlusion JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Fleischmann, D., Ma, A. O., Price, E. A., McConnell, M. V. 2010; 21 (1): 140-143


    Paradoxical embolization can occur when a right-to-left shunt allows a venous thromboembolus to escape filtration by the lungs. Venous collateral pathways draining into the left heart incited by superior vena cava obstruction are a rare acquired right-to-left shunt. Herein, the authors report on a case of transient ischemic attack in a patient with vena caval occlusion secondary to histoplasmosis-related fibrosing mediastinitis, with subclavian vein thrombosis and a right-to-left extracardiac shunt diagnosed with echocardiography. Despite the complexity of the collateral network, this shunt was successfully eradicated with coil embolization.

    View details for DOI 10.1016/j.jvir.2009.09.022

    View details for Web of Science ID 000277367500017

    View details for PubMedID 20123198

  • High Retention and Safety of Percutaneously Implanted Endovascular Embolization Coils as Fiducial Markers for Image-guided Stereotactic Ablative Radiotherapy of Pulmonary Tumors 52nd Annual Meeting of the American-Society-for-Therapeutic-Radiation-Oncology (ASTRO) Hong, J. C., Yu, Y., Rao, A. K., Dieterich, S., Maxim, P. G., Le, Q. T., Diehn, M., Sze, D. Y., Kothary, N., Loo, B. W. ELSEVIER SCIENCE INC. 2010: S518–S519
  • High-risk Retrieval of Adherent and Chronically Implanted IVC Filters: Techniques for Removal and Management of Thrombotic Complications 34th Annual Conference of the Society-of-Interventional-Radiology Kuo, W. T., Tong, R. T., Hwang, G. L., Louie, J. D., Lebowitz, E. A., Sze, D. Y., Hofmann, L. V. ELSEVIER SCIENCE INC. 2009: 1548–56


    To evaluate the safety and efficacy of aggressive techniques for retrieving adherent and chronically implanted inferior vena cava (IVC) filters.A single-center retrospective review was performed on all patients who underwent attempted filter retrieval from October 2007 through October 2008. Patients were included in the study if they had an adherent filter, refractory to standard retrieval techniques, and underwent high-risk retrieval after procedural risks were deemed lower than risks of long-term filter implantation.Fourteen patients were diagnosed with an adherent filter, 13 (93%) of whom were candidates for high-risk retrieval. These patients included seven men and six women (mean age, 40 years; age range, 18-71 years). Nine of the 13 patients (69%) were referred from an outside hospital. Filter retrieval was performed for the following indications: to avoid the risk of long-term thrombotic complications in a young patient (n= 6), to treat symptomatic filter-related IVC stenosis (n= 5), to treat symptomatic filter penetration (n= 1), and to avoid the need for lifelong anticoagulation (n= 1). There were eight Günther-Tulip filters (mean dwell time, 356 days; range 53-1,181 days), two Optease filters (mean dwell time, 62 days; range, 52-72 days), one G2 filter (dwell time, 420 days), and two Recovery filters (mean dwell time, 1,630 days; range, 1,429-1,830 days). Three IVC occlusions necessitated recanalization to facilitate retrieval. High-risk retrieval with use of various techniques with aggressive force was successful in all 13 patients (100%). Partial caval thrombosis occurred in the first four patients (31%) but did not occur after procedural modifications were implemented. There were no complications at clinical follow-up (mean, 221 days; range, 84-452 days).Alternative techniques can be used to retrieve adherent IVC filters implanted for up to 3-5 years. Although caval thrombosis was an observed complication, protocol modifications appeared to reduce this risk.

    View details for DOI 10.1016/j.jvir.2009.08.024

    View details for Web of Science ID 000272636200005

    View details for PubMedID 19864160

  • Catheter-directed Therapy for the Treatment of Massive Pulmonary Embolism: Systematic Review and Meta-analysis of Modem Techniques JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kuo, W. T., Gould, M. K., Louie, J. D., Rosenberg, J. K., Sze, D. Y., Hofmann, L. V. 2009; 20 (11): 1431-1440


    Systemic thrombolysis for the treatment of acute pulmonary embolism (PE) carries an estimated 20% risk of major hemorrhage, including a 3%-5% risk of hemorrhagic stroke. The authors used evidence-based methods to evaluate the safety and effectiveness of modern catheter-directed therapy (CDT) as an alternative treatment for massive PE.The systematic review was initiated by electronic literature searches (MEDLINE, EMBASE) for studies published from January 1990 through September 2008. Inclusion criteria were applied to select patients with acute massive PE treated with modern CDT. Modern techniques were defined as the use of low-profile devices (< or =10 F), mechanical fragmentation and/or aspiration of emboli including rheolytic thrombectomy, and intraclot thrombolytic injection if a local drug was infused. Relevant non-English language articles were translated into English. Paired reviewers assessed study quality and abstracted data. Meta-analysis was performed by using random effects models to calculate pooled estimates for complications and clinical success rates across studies. Clinical success was defined as stabilization of hemodynamics, resolution of hypoxia, and survival to hospital discharge.Five hundred ninety-four patients from 35 studies (six prospective, 29 retrospective) met the criteria for inclusion. The pooled clinical success rate from CDT was 86.5% (95% confidence interval [CI]: 82.1%, 90.2%). Pooled risks of minor and major procedural complications were 7.9% (95% CI: 5.0%, 11.3%) and 2.4% (95% CI: 1.9%, 4.3%), respectively. Data on the use of systemic thrombolysis before CDT were available in 571 patients; 546 of those patients (95%) were treated with CDT as the first adjunct to heparin without previous intravenous thrombolysis.Modern CDT is a relatively safe and effective treatment for acute massive PE. At experienced centers, CDT should be considered as a first-line treatment for patients with massive PE.

    View details for DOI 10.1016/j.jvir.2009.08.002

    View details for Web of Science ID 000271359000004

    View details for PubMedID 19875060

  • Computed Tomography-Guided Percutaneous Needle Biopsy of Pulmonary Nodules: Impact of Nodule Size on Diagnostic Accuracy CLINICAL LUNG CANCER Kothary, N., Lock, L., Sze, D. Y., Hofmann, L. V. 2009; 10 (5): 360-363


    This study was undertaken to compare the diagnostic accuracy and complication rate of computed tomography (CT)-guided percutaneous lung biopsies of lung nodules1.5 cm in diameter.A total of 139 patients (age range, 18-89 years; mean, 62.5 years) underwent CT-guided percutaneous fine-needle aspiration biopsy or 20-gauge core biopsy using an automated biopsy gun. In 37 patients, the lung nodule measured 1.5 cm (mean, 2.8 cm). Diagnostic accuracy was determined by cytopathology results. Major and minor complications were documented.Overall diagnostic accuracy, pneumothorax rate, and thoracostomy tube insertion rates were 67.6%, 34.5%, and 5%, respectively. Of the 98 patients with malignancy, 77 patients (78.6%) had a definite diagnostic biopsy. Overall, nodules>1.5 cm were statistically more likely to result in a diagnostic specimen (73.5%) than nodules1.5 cm than in those1.5 cm. However, the diagnostic accuracy for malignancy is high in both groups, with a low risk of complications.

    View details for DOI 10.3816/CLC.2009.n.049

    View details for Web of Science ID 000270224400007

    View details for PubMedID 19808195

  • Infolding and collapse of thoracic endoprostheses: Manifestations and treatment options JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Sze, D. Y., Mitchell, R. S., Miller, D. C., Fleischmann, D., Frisoli, J. K., Kee, S. T., Verma, A., Sheehan, M. P., Dake, M. D. 2009; 138 (2): 324-333


    We sought to review the clinical sequelae and imaging manifestations of thoracic aortic endograft collapses and infoldings and to evaluate minimally invasive methods of repairing such collapses.Two hundred twenty-one Gore endografts (Excluder, TAG; W. L. Gore & Associates, Inc, Flagstaff, Ariz) were deployed in 145 patients for treatment of pathologies including aneurysms and pseudoaneurysms, dissections, penetrating ulcers, transections, fistulae, mycotic aneurysms, and neoplastic invasions in 6 different prospective trials at a single institution from 1997 to 2007. Device collapses and infoldings were analyzed retrospectively, including review of anatomic parameters, pathologies treated, device sizing and selection, clinical sequelae, methods of repair, and outcome.Six device collapses and infoldings were identified. Oversized devices placed into small-diameter aortas and imperfect proximal apposition to the lesser curvature were seen in all proximal collapses, affecting patients with transections and pseudoaneurysms. Infoldings in patients undergoing dissection represented incomplete initial expansion rather than delayed collapse. Delayed collapse occurred as many as 6 years after initial successful deployment, apparently as a result of changes in the aortic configuration from aneurysmal shrinkage. Clinical manifestations ranged from life-threatening ischemia to complete lack of symptoms. Collapses requiring therapy were remedied percutaneously by bare stenting or in one case by branch vessel embolization.Use of oversized devices in small aortas carries a risk of device failure by collapse, which can occur immediately or after years of delay. When clinically indicated, percutaneous repair can be effectively performed.

    View details for DOI 10.1016/j.jtcvs.2008.12.007

    View details for Web of Science ID 000268157800011

    View details for PubMedID 19619775

  • Oncolytic virotherapy for advanced liver tumours JOURNAL OF CELLULAR AND MOLECULAR MEDICINE Chang, J., Chen, P., Sze, D. Y., Reid, T., Bartlett, D., Kirn, D. H., Liu, T. 2009; 13 (7): 1238-1247


    Primary and metastatic neoplasms of the liver account for more than a million deaths per year worldwide. Despite decades of research, effective novel therapies for these cancers are urgently needed. Oncolytic virotherapeutics represent a novel class of pharmacophore that holds promise for the treatment of hepatic neoplasms. Cancer-specific replication is followed by oncolysis, virus spreading and infection of adjacent cancer cells. This process is then repeated. Virotherapeutics target multiple genetic pathways involved in carcino-genesis, and demonstrate activity against apoptosis-resistant tumour cells. This platform can also exploit the advantage of multiple intrinsic anti-cancer therapeutic mechanisms, combining direct viral oncolysis with therapeutic transgene expression. Recent advances in pre-clinical and clinical studies are revealing the potential of this unique therapeutic class, in particular for liver cancers. This review summarizes the available data on applying oncolytic virotherapeutics to hepatic neoplasms to date, and discusses the challenges and future directions for virotherapy.

    View details for DOI 10.1111/j.1582-4934.2008.00563.x

    View details for Web of Science ID 000268589200006

    View details for PubMedID 19175689

  • A Primer on Image-guided Radiation Therapy for the Interventional Radiologist JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N., Dieterich, S., Louie, J. D., Koong, A. C., Hofmann, L. V., Sze, D. Y. 2009; 20 (7): 859-862


    The use of image-guided radiation therapy in thoracic and abdominal tumors is increasing. Herein, the authors review the process of image-guided radiation therapy and describe techniques useful for optimal implantation of fiducial markers.

    View details for DOI 10.1016/j.jvir.2009.03.037

    View details for Web of Science ID 000267613000001

    View details for PubMedID 19481470

  • Phase II efficacy results using an oncolytic herpes simplex virus (NV1020) in patients with colorectal cancer metastatic to liver (mCRC) 45th Annual Meeting of the American-Society-of-Clinical-Oncology (ASCO) Geevarghese, S. K., Chen, A., Geller, D. A., de Haan, H. A., Iagaru, A., Knoll, A., Nemunaitis, J., Reid, T. R., Sze, D. Y., Tanabe, K. AMER SOC CLINICAL ONCOLOGY. 2009
  • Transarterial Chemoinfusion for Hepatocellular Carcinoma as Downstaging Therapy and a Bridge toward Liver Transplantation AMERICAN JOURNAL OF TRANSPLANTATION De Luna, W., Sze, D. Y., Ahmed, A., Ha, B. Y., Ayoub, W., Keeffe, E. B., Cooper, A., Esquivel, C., Nguyen, M. H. 2009; 9 (5): 1158-1168


    Favorable outcomes after liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) are well described for patients who fall within defined tumor criteria. The effectiveness of tumor therapies to maintain tumor characteristics within these criteria or to downstage more advanced tumors to fall within these criteria is not well understood. The aim of this study was to examine the response to transcatheter arterial chemoinfusion (TACI) in HCC patients awaiting LT and its efficacy for downstaging or bridging to transplantation. We performed a retrospective study of 248 consecutive TACI cases in 122 HCC patients at a single U.S. medical center. Patients were divided into two groups: those who met the Milan criteria on initial HCC diagnosis (n = 95) and those with more advanced disease (n = 27). With TACI treatment, 87% of the Milan criteria group remained within the Milan criteria and 63% of patients with more advanced disease were successfully downstaged to fall within the Milan criteria. In conclusion, TACI appears to be an effective treatment as a bridge to LT for nearly 90% patients presenting within the Milan criteria and an effective downstaging modality for over half of those whose tumor burden was initially beyond the Milan criteria.

    View details for DOI 10.1111/j.1600-6143.2009.02576.x

    View details for Web of Science ID 000265222200023

    View details for PubMedID 19344435

  • Phase II Efficacy Results Using an Oncolytic Herpes Simplex Virus (NV1020) in Patients with Colorectal Cancer Metastatic to Liver (mCRC) 12th Annual Meeting of the American Society of Gene Therapy Nemunaitis, J., Geevarghese, S. K., Geller, D. A., de Haan, H. A., Iagaru, A., Knoll, A., Reid, T. R., Sze, D. Y., Tanabe, K. NATURE PUBLISHING GROUP. 2009: S304–S304
  • Incorporating Cone-beam CT into the Treatment Planning for Yttrium-90 Radioembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Louie, J. D., Kothary, N., Kuo, W. T., Hwang, G. L., Hofmann, L. V., Goris, M. L., Iagaru, A. H., Sze, D. Y. 2009; 20 (5): 606-613


    To prepare for yttrium-90 ((90)Y) microsphere radioembolization therapy, digital subtraction angiography (DSA) and technetium- 99m-labeled macroaggregated albumin ((99m)Tc MAA) scintigraphy are used for treatment planning and detection of potential nontarget embolization. The present study was performed to determine if cone-beam computed tomography (CBCT) affects treatment planning as an adjunct to these conventional imaging modalities.From March 2007 to August 2008, 42 consecutive patients (21 men, 21 women; mean age, 59 years; range, 21-75 y) who underwent radioembolization were evaluated by CBCT in addition to DSA and (99m)Tc MAA scintigraphy during treatment planning, and their records were retrospectively reviewed. The contrast-enhanced territories shown by CBCT with selective intraarterial contrast agent administration were used to predict intrahepatic and possible extrahepatic distribution of microspheres.In 22 of 42 cases (52%), extrahepatic enhancement or incomplete tumor perfusion seen on CBCT affected the treatment plan. In 14 patients (33%), the findings were evident exclusively on CBCT and not detected by DSA. When comparing CBCT versus (99m)Tc MAA scintigraphy, CBCT showed eight cases of extrahepatic enhancement (19%) that were not evident on (99m)Tc MAA imaging. CBCT findings directed the additional embolization of vessels or repositioning of the catheter for better contrast agent and microsphere distribution. One case of gastric ulcer from nontarget embolization caused by reader error was observed.CBCT can provide additional information about tumor and tissue perfusion not currently detectable by DSA or (99m)Tc MAA imaging, which should optimize (90)Y microsphere delivery and reduce nontarget embolization.

    View details for DOI 10.1016/j.jvir.2009.01.021

    View details for Web of Science ID 000265700900007

    View details for PubMedID 19345589

  • Factors Portending Endoleak Formation After Thoracic Aortic Stent-Graft Repair of Complicated Aortic Dissection CIRCULATION-CARDIOVASCULAR INTERVENTIONS Sze, D. Y., Van den Bosch, M. A., Dake, M. D., Miller, D. C., Hofmann, L. V., Varghese, R., Malaisrie, S. C., van der Starre, P. J., Rosenberg, J., Mitchell, R. S. 2009; 2 (2): 105-112


    Endoleaks after stent-graft repair of aortic dissections are poorly understood but seem substantially different from those seen after aneurysm repair. We studied anatomic and clinical factors associated with endoleaks in patients who underwent stent-graft repair of complicated type B aortic dissections.From 2000 to 2007, 37 patients underwent stent-graft repair of acute (< or =14 days; n=23), subacute (15 to 90 days; n=10) or chronic (>90 days; n=4) complicated type B aortic dissections using the Gore Thoracic Excluder (n=17) or TAG stent-grafts (n=20) under an investigator-sponsored protocol. Endoleaks were classified as imperfect proximal seal, flow through fenestrations or branches, or complex (both). Variables studied included coverage of the left subclavian artery, aortic curvature, completeness of proximal apposition, dissection chronicity, and device used. Endoleaks were found during follow-up (mean, 22 months) in 59% of patients, and they were associated with coverage of the left subclavian artery (complex, P<0.001), small radius of curvature (type 1 and complex, P=0.05), and greatest length of unapposed proximal stent graft (complex, P<0.0001). During follow-up, 10 endoleaks resolved spontaneously, 6 required reintervention for false lumen dilatation, and 2 were stable without clinical consequences.Endoleaks are common after stent-graft repair of aortic dissection and may lead to false lumen enlargement necessitating reintervention. Anatomic complexities such as acute aortic curvature and covered side branches were associated with endoleaks, illustrating the need for dissection-specific device development.

    View details for DOI 10.1161/CIRCINTERVENTIONS.108.819722

    View details for Web of Science ID 000276051600005

    View details for PubMedID 20031703

  • Percutaneous Implantation of Fiducial Markers for Imaging-Guided Radiation Therapy AMERICAN JOURNAL OF ROENTGENOLOGY Kothary, N., Dieterich, S., Louie, J. D., Chang, D. T., Hofmann, L. V., Sze, D. Y. 2009; 192 (4): 1090-1096


    The use of imaging-guided radiation therapy (IGRT) to treat thoracic and abdominal tumors is increasing. In this article, we review the process of IGRT and describe techniques to implant fiducial markers in the optimal geometry.Implantation of fiducial markers can be challenging. A better understanding of the physics of IGRT can help optimize fiducial marker placement for precise tumor targeting.

    View details for DOI 10.2214/AJR.08.1399

    View details for Web of Science ID 000264358900038

    View details for PubMedID 19304719

  • Safety and Efficacy of Percutaneous Fiducial Marker Implantation for Image-guided Radiation Therapy JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kothary, N., Heit, J. J., Louie, J. D., Kuo, W. T., Loo, B. W., Koong, A., Chang, D. T., Hovsepian, D., Sze, D. Y., Hofmann, L. V. 2009; 20 (2): 235-239


    To evaluate the safety and technical success rate of percutaneous fiducial marker implantation in preparation for image-guided radiation therapy.From January 2003 to January 2008, we retrospectively reviewed 139 percutaneous fiducial marker implantations in 132 patients. Of the 139 implantations, 44 were in the lung, 61 were in the pancreas, and 34 were in the liver. Procedure-related major and minor complications were documented. Technical success was defined as implantation enabling adequate treatment planning and computed tomographic simulation.The major and minor complication rates were 5% and 17.3%, respectively. Pneumothorax after lung implantation was the most common complication. Pneumothoraces were seen in 20 of the 44 lung implantations (45%); a chest tube was required in only seven of the 44 lung transplantations (16%). Of the 139 implantations, 133 were successful; in six implantations (4.3%) the fiducial markers migrated and required additional procedures or alternate methods of implantation.Percutaneous implantation of fiducial marker is a safe and effective procedure with risks that are similar to those of conventional percutaneous organ biopsy.

    View details for DOI 10.1016/j.jvir.2008.09.026

    View details for Web of Science ID 000263075000012

    View details for PubMedID 19019700

  • Biopsy of Cardiac Masses Using a Stabilized Intracardiac Echocardiography-guided System JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Lee, D. P., Hofmann, L. V., Petersen, B. 2008; 19 (11): 1662-1667


    Biopsy of a cardiac mass remains a difficult and risky procedure. Successful sampling of target tissue is hampered by continuous cardiac motion and blood flow. Because the surrounding tissues are vascular, complications can include hemorrhage, tamponade, arrhythmia, embolization, and death. Conventional imaging modalities are of limited utility in this dynamic environment. The present report describes the use of the instrumentation system originally designed for creation of direct portocaval shunts with intracardiac echocardiography imaging to perform core biopsies of cardiac and juxtacardiac masses in six patients. There were no hemorrhagic complications, and pathologic diagnoses were obtained in five of six cases.

    View details for DOI 10.1016/j.jvir.2008.08.001

    View details for Web of Science ID 000260694700020

    View details for PubMedID 18818096

  • Bidirectionally Adjustable TIPS Reduction by Parallel Stent and Stent-Graft Deployment JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Hwang, G. L., Kao, J. S., Frisoli, J. K., Kee, S. T., Razavi, M. K., Ahmed, A. 2008; 19 (11): 1653-1658


    Excessive shunting through transjugular intrahepatic portosystemic shunts (TIPS) can cause life-threatening hepatic encephalopathy and insufficiency. Intentional reduction of flow may be effective but difficult to control. The present report describes refinements of the parallel stent/stent-graft technique of flow reduction that is adjustable in either direction. Six patients underwent TIPS reduction with varying stent positioning and a variety of commercial products. Flow was adjusted by iterative balloon dilatation of the stent and stent-graft, resulting in a mean gradient increase of 8 mm Hg. All cases were technically successful, but 1-year survival was seen in only the patient who underwent liver transplantation.

    View details for DOI 10.1016/j.jvir.2008.08.011

    View details for Web of Science ID 000260694700018

    View details for PubMedID 18823797

  • SIR 2008 annual meeting film panel case: Arterial endofibrosis JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Olcott, C. 2008; 19 (9): 1271-1273

    View details for DOI 10.1016/j.jvir.2008.04.018

    View details for Web of Science ID 000259054900001

    View details for PubMedID 18725087

  • SIR 2008 annual meeting film panel case: Alagille syndrome JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Esquivel, C. O. 2008; 19 (9): 1278-1280

    View details for DOI 10.1016/j.jvir.2008.04.016

    View details for Web of Science ID 000259054900003

    View details for PubMedID 18725089

  • SIR 2008 annual meeting film panel case: Abernethy malformation JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Berquist, W. E. 2008; 19 (9): 1274-1277

    View details for DOI 10.1016/j.jvir.2008.04.017

    View details for Web of Science ID 000259054900002

    View details for PubMedID 18725088

  • SIR 2008 annual meeting film panel case: Castleman disease complicated by follicular dendritic cell sarcoma 33rd Annual Meeting of the Society-of-Interventional-Radiology (SIR) Sze, D. Y., Shelton, A. A. ELSEVIER SCIENCE INC. 2008: 1141–44

    View details for DOI 10.1016/j.jvir.2008.04.015

    View details for Web of Science ID 000258168100003

    View details for PubMedID 18656005

  • Catheter-directed embolectomy, fragmentation, and thrombolysis for the treatment of massive pulmonary embolism after failure of systemic thrombolysis CHEST Kuo, W. T., Van den Bosch, M. A., Hofmann, L. V., Louie, J. D., Kothary, N., Sze, D. Y. 2008; 134 (2): 250-254


    The standard medical management for patients in extremis from massive pulmonary embolism (PE) is systemic thrombolysis, but the utility of this treatment relative to catheter-directed intervention (CDI) is unknown. We evaluated the effectiveness of CDI as part of a treatment algorithm for life-threatening PE.A retrospective review was performed on 70 consecutive patients with suspected acute PE over a 10-year period (from 1997 to 2006) who had been referred for pulmonary angiography and/or intervention. The criteria for study inclusion were patients who received CDI due to angiographically confirmed massive PE and hemodynamic shock (shock index, > or = 0.9). CDI involved suction embolectomy and fragmentation with or without catheter thrombolysis.Twelve patients were treated with CDI. There were seven men and five women (mean age, 56 years; age range, 21 to 80 years). Seven patients (58%) were referred for CDI after failing systemic infusion with 100 mg of tissue plasminogen activator, and five patients (42%) had contraindications to systemic thrombolysis. Catheter-directed fragmentation and embolectomy were performed in all patients (100%). Additionally, catheter-guided thrombolysis was performed in eight patients (67%). Technical success was achieved in 12 of 12 cases (100%). There were no major procedural complications (0%). Significant hemodynamic improvement (shock index, < 0.9) was observed in 10 of 12 cases (83%). The remaining two patients (17%) died secondary to cardiac arrest within 24 h. Ten of 12 patients (83%) survived and remained stable until hospital discharge (mean duration, 20 days; range, 3 to 51 days).In the setting of hemodynamic shock from massive PE, CDI is potentially a life-saving treatment for patients who have not responded to or cannot tolerate systemic thrombolysis.

    View details for DOI 10.1378/chest.07-2846

    View details for Web of Science ID 000258492500008

    View details for PubMedID 18682455

  • SIR 2008 annual meeting film panel case: Radiation-induced angiosarcoma 33rd Annual Meeting of the Society-of-Interventional-Radiology (SIR) Sze, D. Y., Huang, J. H. ELSEVIER SCIENCE INC. 2008: 1133–37

    View details for DOI 10.1016/j.jvir.2008.04.010

    View details for Web of Science ID 000258168100001

    View details for PubMedID 18656003

  • SIR 2008 annual meeting film panel case: Solitary fibrous tumor of the pleura 33rd Annual Meeting of the Society-of-Interventional-Radiology (SIR) Sze, D. Y., Whyte, R. I. ELSEVIER SCIENCE INC. 2008: 1138–40

    View details for DOI 10.1016/j.jvir.2008.04.014

    View details for Web of Science ID 000258168100002

    View details for PubMedID 18656004

  • Complicated acute type B aortic dissection: Midterm results of emergency endovascular stent-grafting 31st Annual Meeting of the Western-Thoracic-Surgical-Association Verhoye, J. P., Miller, D. C., Sze, D., Dake, M. D., Mitchell, R. S. MOSBY-ELSEVIER. 2008: 424–30


    This study assessed midterm results of emergency endovascular stent-grafting for patients with life-threatening complications of acute type B aortic dissection.Between November 1996 and June 2004, 16 patients with complicated acute type B aortic dissections (mean age 57 years, range 16-88 years) underwent endovascular stent-grafting within 48 hours of presentation. Complications included contained rupture, hemothorax, refractory chest pain, and severe visceral or lower limb ischemia. Stent-graft types included custom-made first-generation endografts and second-generation commercial stent-grafts (Gore Excluder or TAG; W. L. Gore & Associates, Inc, Flagstaff, Ariz.). Follow-up was 100% complete, averaged 36 +/- 36 months, and included postprocedural surveillance computed tomographic scans.Early mortality was 25% +/- 11% (70% confidence limit), with no late deaths. No new neurologic complications occurred. According to the latest scan, 4 patients (25%) had complete thrombosis of the false lumen; the lumen was partially thrombosed in 6 patients (38%). Distal aortic diameter was increased in only 1 patient. Actuarial survival at 1 and 5 years was 73% +/- 11%; freedom from treatment failure (including aortic rupture, device fault, reintervention, aortic death, or sudden, unexplained late death) was 67% +/- 14% at 5 years.With follow-up to 9 years, endovascular stent-grafting for patients with complicated acute type B aortic dissection conferred benefit. Consideration of emergency stent-grafting may improve the dismal outlook for these patients; future refinements in stent-graft design and technology and earlier diagnosis and intervention should be associated with improved results.

    View details for DOI 10.1016/j.jtcvs.2008.01.046

    View details for Web of Science ID 000258535300026

    View details for PubMedID 18692652

  • Use of a targeted oncolytic poxvirus, JX-594, in patients with refractory primary or metastatic liver cancer: a phase I trial LANCET ONCOLOGY Park, B., Hwang, T., Liu, T., Sze, D. Y., Kim, J., Kwon, H., Oh, S. Y., Han, S., Yoon, J., Hong, S., Moon, A., Speth, K., Park, C., Ahn, Y., Daneshmand, M., Rhee, B. G., Pinedo, H. M., Bell, J. C., Kirn, D. H. 2008; 9 (6): 533-542


    JX-594 is a targeted oncolytic poxvirus designed to selectively replicate in and destroy cancer cells with cell-cycle abnormalities and epidermal growth factor receptor (EGFR)-ras pathway activation. Direct oncolysis plus granulocyte-macrophage colony-stimulating factor (GM-CSF) expression also stimulates shutdown of tumour vasculature and antitumoral immunity. We aimed to assess intratumoral injection of JX-594 in patients with refractory primary or metastatic liver cancer.Between Jan 4, 2006, and July 4, 2007, 14 patients with histologically confirmed refractory primary or metastatic liver tumours (up to 10.9 cm total diameter) that were amenable to image-guided intratumoral injections were enrolled into this non-comparative, open-label, phase I dose-escalation trial (standard 3x3 design; two to six patients for each dose with 12-18 estimated total patients). Patients received one of four doses of intratumoral JX-594 (10(8) plaque-forming units [pfu], 3x10(8) pfu, 10(9) pfu, or 3x10(9) pfu) every 3 weeks at Dong-A University Hospital (Busan, South Korea). Patients were monitored after treatment for at least 48 h in hospital and for at least 4 weeks as out-patients. Adverse event-monitoring according to the National Cancer Institute Common Toxicity Criteria (version 3) and standard laboratory toxicity grading for haematology, liver and renal function, coagulation studies, serum chemistry, and urinalysis were done. The primary aims were to ascertain the maximum-tolerated dose (MTD) and safety of JX-594 treatment. Data were also collected on pharmacokinetics, pharmacodynamics, and efficacy. Analysis was per protocol. This study is registered with, number NCT00629759.Of 22 patients with liver tumours who were assessed for eligibility, eight patients did not meet inclusion criteria. Therefore, 14 patients, including those with hepatocellular, colorectal, melanoma, and lung cancer, were enrolled. Patients were heavily pretreated (5.6 previous treatments, SD 2.8, range 2.0-12.0) and had large tumours (7.0 cm diameter, SD 2.7, range 1.8-10.9). Patients received a mean of 3.4 (SD 2.2, range 1.0-8.0) cycles of JX-594. All patients were evaluable for toxicity. All patients experienced grade I-III flu-like symptoms, and four had transient grade I-III dose-related thrombocytopenia. Grade III hyperbilirubinaemia was dose-limiting in both patients at the highest dose; the MTD was therefore 1x10(9) pfu. JX-594 replication-dependent dissemination in blood was shown, with resultant infection of non-injected tumour sites. GM-CSF expression resulted in grade I-III increases in neutrophil counts in four of six patients at the MTD. Tumour responses were shown in injected and non-injected tumours. Ten patients were radiographically evaluable for objective responses; non-evaluable patients had contraindications to contrast medium (n=2) or no post-treatment scans (n=2). According to Response Evaluation Criteria in Solid Tumors (RECIST), three patients had partial response, six had stable disease, and one had progressive disease.Intratumoral injection of JX-594 into primary or metastatic liver tumours was generally well-tolerated. Direct hyperbilirubinaemia was the dose-limiting toxicity. Safety was acceptable in the context of JX-594 replication, GM-CSF expression, systemic dissemination, and JX-594 had anti-tumoral effects against several refractory carcinomas. Phase II trials are now underway.

    View details for DOI 10.1016/S1470-2045(08)70107-4

    View details for Web of Science ID 000256749400016

    View details for PubMedID 18495536

  • Imaging characteristics and response after intraarterial administration of the oncolytic herpes virus NV1020 to treat hepatic colorectal metastases Sze, D. Y., Gambhir, S. S., Chari, R. S., Geller, D. A., Iagaru, A., Mescheder, A., Nemunaitis, J. J., Reid, T. R., Tanabe, K. AMER SOC CLINICAL ONCOLOGY. 2008
  • Persistent and recurrent postsurgical varicoceles: Venographic anatomy and treatment with n-butyl cyanoacrylate embolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Kao, J. S., Frisoli, J. K., McCallum, S. W., Kennedy, W. A., Razavi, M. K. 2008; 19 (4): 539-545


    To elucidate the mechanism of persistence or recurrence of varicoceles after surgical repair by examining the venographic anatomy, and to review the efficacy of treatment of these patients with n-butyl cyanoacrylate (NBCA) embolization.From 2001 to 2007, 17 patients with persistent or recurrent varicoceles were studied by retrograde venography 4 months to 18 years after open surgical repair. All patients were then treated with NBCA glue embolization of the entire gonadal vein and the venographically identified duplications and collateral vessels, with three patients undergoing bilateral procedures. Venographic anatomy and clinical success were retrospectively analyzed.The majority of patients (65%) exhibited duplications draining into a single left gonadal vein. Duplications were most frequently found to be confined to the pelvis and inguinal canal. Communication with other retroperitoneal veins, including the renal hilar, lumbar, iliac, and circumaortic renal vein, was relatively uncommon. NBCA embolization effectively treated the main gonadal vein as well as the duplications and communications, with only one patient developing thrombophlebitic complications.Duplication of the gonadal vein in the pelvic or inguinal region with apparent incomplete ligation or resection is a common finding in patients with persistence or recurrence of varicocele after surgery. NBCA embolization effectively treats these duplicated vessels, resulting in a high rate of clinical success on short-term follow-up.

    View details for DOI 10.1016/j.jvir.2007.11.009

    View details for Web of Science ID 000254760900011

    View details for PubMedID 18375298

  • Design, performance, and applications of a hybrid X-Ray/MR system for interventional guidance PROCEEDINGS OF THE IEEE Fahrig, R., Ganguly, A., Lillaney, P., Bracken, J., Rowlands, J. A., Wen, Z., Yu, H., Rieke, V., Santos, J. M., Pauly, K. B., Sze, D. Y., Frisoli, J. K., Daniel, B. L., Pelc, N. J. 2008; 96 (3): 468-480
  • Portosystemic pressure gradient during transjugular intrahepatic portosystemic shunt with Viatorr stent graft: what is the critical low threshold to avoid medically uncontrolled low pressure gradient related complications? Journal of gastroenterology and hepatology Chung, H., Razavi, M. K., Sze, D. Y., Frisoli, J. K., Kee, S. T., Dake, M. D., Hellinger, J. C., Kang, B. 2008; 23 (1): 95-101


    Inappropriately decreased portosystemic pressure gradient (PSG) during transjugular intrahepatic portosystemic shunt (TIPS) can cause fatal complications but the critical low threshold of PSG is still not clear. The aim of the present study was to evaluate the critical low threshold of PSG during TIPS.Sixty-six patients with cirrhosis who successfully underwent de novo TIPS with Viatorr stent grafts were studied. Medically uncontrolled low pressure gradient (LPR) complication was defined as when a patient died, or when acute transplantation or a TIPS reduction procedure was performed due to refractory encephalopathy or the deterioration of hepatic function within 3 months after the procedure. For the determination of the risk group for medically uncontrolled LPR complications, the Child-Pugh score and the model of end-stage liver disease (MELD) score showing a 100% negative predictive value was decided on as a threshold for each score. The risk group was defined when either of both scores was higher than its threshold. For the determination of a critical low post-TIPS PSG, a value of post-TIPS PSG showing the highest discrimination power on the receiver operating characteristic (ROC) curve in the risk group was decided on as a critical low threshold of PSG. The medically uncontrolled LPR complication rates of the patients with the determined threshold or lower were evaluated for the risk group.Medically uncontrolled LPR complications developed in nine patients (13.6%). Five patients died and four patients had TIPS reduction procedures. Patients with more than 10 on the Child-Pugh score or more than 14 on the MELD score were determined to be the risk group and 34 patients were included. The critical lower threshold of the post-TIPS PSG showing the highest discrimination power on the ROC curve was 5 mmHg (sensitivity 100%, specificity 72%), and the medically uncontrolled LPR complication rates of the patients with 5 mmHg or lower on the post-TIPS PSG were 56.3% (9/16) in the risk group.The critical threshold of the post-TIPS PSG to avoid the medically uncontrolled LPR complications of TIPS was >5 mmHg. The PSG should not be reduced below this level in the risk group.

    View details for DOI 10.1111/j.1440-1746.2006.04697.x

    View details for PubMedID 18171347

  • Hepatology - Portosystemic pressure gradient during transjugular intrahepatic portosystemic shunt with Viatorr stent graft: What is the critical low threshold to avoid medically uncontrolled low pressure gradient related complications? JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY Chung, H., Razavi, M. K., Sze, D. Y., Frisoli, J. K., Kee, S. T., Dake, M. D., Hellinger, J. C., Kang, B. 2008; 23 (1): 95-101
  • Design, performance, and applications of a hybrid x-ray/MR system for interventional guidance Proc IEEE Fahrig R, Ganguly A, Lillaney P, Bracken J, Rowlands JR, Wen Z, Yu H, Rieke V, Santos JM, Pauly KB, Sze DY, Frisoli JK, Daniel BL, Pelc NJ 2008; 96: 468-480
  • Imaging of the thoracic aorta before and after stent-graft repair of aneurysms and dissections. Seminars in thoracic and cardiovascular surgery Ueda, T., Fleischmann, D., Rubin, G. D., Dake, M. D., Sze, D. Y. 2008; 20 (4): 348-357


    Thoracic endovascular aortic repair (TEVAR) has become widely accepted as an important option for treatment of thoracic aortic diseases. Cross-sectional radiologic imaging plays a crucial role for evaluating a patient's candidacy for planning of the intervention and for assessment of postprocedural results and complications of TEVAR. Recent advances in imaging technologies, in part inspired by advances in stent-graft technology, have drastically changed the character and role of pre- and postprocedural imaging. Three-dimensional (3D) datasets acquired quickly by multidetector computed tomography (MDCT), angiography, or magnetic resonance angiography (MRA) allow multiplanar reformations and 3D viewing, as well as quantitative assessment of vessel lumens, walls, and surroundings. Catheter angiography, in contrast, is performed intraoperatively almost exclusively, and is no longer the gold standard for diagnostic or planning purposes. This article reviews state-of-the-art pre- and postprocedural imaging for TEVAR, especially focusing on the role of MDCT angiography.

    View details for DOI 10.1053/j.semtcvs.2008.11.008

    View details for PubMedID 19251176

  • Catheter-directed intervention for acute pulmonary embolism - A shining saber CHEST Kuo, W. T., Sze, D. Y., Hofmann, L. V. 2008; 133 (1): 317-318

    View details for DOI 10.1378/chest.07-2278

    View details for Web of Science ID 000252385600063

    View details for PubMedID 18187767

  • Treatment, outcomes of transcatheter arterial chemoinfusion (TACI) in patients with unresectable hepatocellular carcinoma (HCC) prior to orthotropic liver transplantation. 58th Annual Meeting of the American-Association-for-the-Study-of-Liver-Diseases de Luna, W., Ha, B. Y., Ahmed, A., Sze, D., Keeffe, E. B., Nguyen, M. H. WILEY-BLACKWELL. 2007: 517A–518A
  • Catheter-directed embolectomy, fragmentation,and thrombolysis for the treatment of massive pulmonary embolim after failure of systemic thrombolysis CHEST 2007 Conference Kuo, W. T., van den Bosch, M. A., Hofmann, L. V., Louie, J. D., Kothary, N., Sze, D. Y. AMER COLL CHEST PHYSICIANS. 2007: 663S–663S
  • Long-term survival of patients with unresectable hepatocellular carcinoma treated with transcatheter arterial chemoinfusion ALIMENTARY PHARMACOLOGY & THERAPEUTICS Ha, B. Y., Ahmed, A., Sze, D. Y., Razavi, M. K., Simpson, N., Keeffe, E. B., Nguyen, M. H. 2007; 26 (6): 839-846


    Transcatheter arterial chemoembolization (TACE) has become one of the most common treatments for unresectable hepatocellular carcinoma. Published studies of TACE report a 5-16% risk of serious complications. Compared with TACE, transcatheter arterial chemoinfusion (TACI) may have similar efficacy and fewer side effects.To examine the clinical outcomes of TACI.We performed a retrospective cohort study of 345 consecutive TACI cases in 165 patients performed at a single United States medical center between 1998 and 2002. Primary outcomes were tumour response and survival rates.Only seven patients were hospitalized for more than 24 h after the procedure, and only three patients had worsening of liver function within 30 days of TACI. Survival was significantly poorer for patients with tumour-node-metastasis (TNM) IV compared to those with TNM I-III and also for patients with Child's class B/C vs. A. Following adjustment for age, gender, ethnicity and aetiology of liver diseases, independent predictors of poor survival were Child's class B/C [Hazard Ratio (HR) = 1.69, P = 0.024] and TNM IV staging (HR = 1.63, P = 0.014).TACI appears to be safe and effective for unresectable hepatocellular carcinoma with TNM stage I-III; randomized controlled trials are needed to compare TACI to TACE.

    View details for DOI 10.1111/j.1365-2036.2007.03424.x

    View details for Web of Science ID 000249130100008

    View details for PubMedID 17767468

  • Treatment outcomes of transcatheter arterial chemoinfusion (TACI) in patients with unresectable hepatocellular carcinoma (HCC) prior to orthotropic liver transplantation 72nd Annual Meeting of the American-College-of-Gastroenterology de Lunq, W., Choi, B. Y., Ahmed, A., Sze, D., Keefe, E. B., Nguyen, M. H. NATURE PUBLISHING GROUP. 2007: S239–S239
  • Emergency retrieval of a G2 filter after complete migration in to the right ventricle JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kuo, W. T., Loh, C. T., Sze, D. Y. 2007; 18 (9): 1177-1182


    A G2 inferior vena cava filter migrated completely into the right ventricle, resulting in chest pain, ventricular tachycardia, and hypotension in a 63-year-old man. Due to the filter's position, the patient was at high risk for further life-threatening cardiopulmonary complications. Percutaneous filter retrieval was successfully performed as a less-invasive alternative to open cardiothoracic surgery.

    View details for DOI 10.1016/j.jvir.2007.06.006

    View details for Web of Science ID 000249547300018

    View details for PubMedID 17804782

  • Intraoperative monitoring of elephant trunk kinking with transesophageal echocardiography JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Oakes, D. A., Sze, D. Y., Frisoli, J. K., Mitchell, R. S., Harris, E. J., Thu, C., van der Starre, P. J. 2007; 21 (4): 584-586

    View details for DOI 10.1053/j.jvca.2006.11.002

    View details for Web of Science ID 000248766100023

    View details for PubMedID 17678793

  • Quiz page. Fibromuscular dysplasia of the right renal artery. American journal of kidney diseases van den Bosch, M. A., Sze, D. Y., Hofmann, L. V. 2007; 49 (5): A43-4

    View details for PubMedID 17687806

  • Minimal hepatic toxicity of Onyx-015: spatial restriction of coxsackie-adenoviral receptor in normal liver CANCER GENE THERAPY Au, T., Thorne, S., Korn, W. M., Sze, D., Kirn, D., Reid, T. R. 2007; 14 (2): 139-150


    We administered an adenoviral vector, Onyx-015, into the hepatic artery of patients with metastatic colorectal cancer involving the liver. Thirty-five patients enrolled in this multi-institutional phase I/II trial received up to eight arterial infusions of up to 2 x 10(12) viral particles. Hepatic toxicity was the primary dose-limiting toxicity observed in preclinical models. However, nearly 200 infusions of this adenoviral vector were administered directly into the hepatic artery without significant toxicity. Therefore, we undertook this analysis to determine the impact of repeated adenoviral exposure on hepatic function. Seventeen patients were treated at our institution, providing a detailed data set on the changes in hepatic function following repeated exposure to adenovirus. No changes in hepatic function occurred with the first treatment of Onyx-015 among these patients. Transient increases in transaminase levels occurred in one patient starting with the second infusion and transient increases in bilirubin was observed in two patients starting with the fifth treatment. These changes occurred too early to be explained by viral-mediated lysis of hepatocytes. In addition, viremia was observed starting 3-5 days after the viral infusion in half of the patient, but was not associated with hepatic toxicity. To further understand the basis for the minimal hepatic toxicity of adenoviral vectors, we evaluated the replication of adenovirus in primary hepatocytes and tumor cells in culture and the expression of the coxsackie-adenoviral receptor (CAR) in normal liver and colon cancer metastatic to the liver. We found that adenovirus replicates poorly in primary hepatocytes but replicates efficiently in tumors including tumors derived from hepatocytes. In addition, we found that CAR is localized at junctions between hepatocytes and is inaccessible to hepatic blood flow. CAR is not expressed on tumor vasculature but is expressed on tumor cells. Spatial restriction of CAR to the intercellular space in normal liver and diminished replication of adenovirus in hepatocytes may explain the minimal toxicity observed following repeated hepatic artery infusions with Onyx-015.

    View details for DOI 10.1038/sj.cgt.7700988

    View details for Web of Science ID 000243468600002

    View details for PubMedID 17139321

  • Diagnosis of chronic mesenteric ischemia by visible light spectroscopy during endoscopy GASTROINTESTINAL ENDOSCOPY Friedland, S., Benaron, D., Coogan, S., Sze, D. Y., Soetikno, R. 2007; 65 (2): 294-300


    Chronic mesenteric ischemia can be difficult to diagnose by means of currently available clinical techniques. We developed a novel endoscopic device for objective measurement of GI mucosal ischemia.Our purpose was to evaluate the performance of the device in patients with chronic mesenteric ischemia.A fiberoptic catheter-based visible light spectroscopy oximeter (T-Stat 303 Microvascular Oximeter, Spectros, Portola Valley, Calif) was used to evaluate 30 healthy control subjects and 3 patients with chronic mesenteric ischemia before and after successful percutaneous stenting.Veterans Affairs Palo Alto Health Care System hospital.Normal mucosal (capillary) hemoglobin oxygen saturation was 60% to 73% in the duodenum and jejunum. In the 3 patients with chronic mesenteric ischemia, ischemic areas in the duodenum or proximal jejunum were found with mucosal saturations of 16% to 30%. After successful angioplasty and stent placement of the celiac, superior mesenteric, or inferior mesenteric arteries, the mucosal saturation in these areas increased to 51% to 60%.This preliminary study suggests that chronic mesenteric ischemia is detectable during endoscopy by use of visible light spectroscopy and that successful endovascular treatment results in near normalization of mucosal oxygen saturation.

    View details for DOI 10.1016/j.gie.2006.05.007

    View details for Web of Science ID 000244041900023

    View details for PubMedID 17137857

  • Repeated intrahepatic infusion of oncolytic herpes simplex virus NV1020 prior to second-line chemotherapy for patients suffering from colorectal cancer metastatic to the liver ESMO Educational Conference Lugano (ECLU) Karrasch, M., Sze, D., Mescheder, A., Reid, T. OXFORD UNIV PRESS. 2007: 171–171
  • Virtual Angioscopy in type A dissection: Ascending aortic stent-graft repair ANNALS OF THORACIC SURGERY Verhoye, J., Sze, D. Y., Ihnken, K., Hellinger, J. C., Robbins, R. R., Dake, M. D. 2006; 82 (1): 347-347
  • Stent-graft repair of an aortic rupture caused by invasive hemangiopericytoma ANNALS OF THORACIC SURGERY van der Starre, P. J., Sze, D. Y., Guta, C., Mitchell, R. S., Dake, M. D. 2006; 81 (6): 2300-2302


    We describe a patient with a history of hemangiopericytoma, who had hemoptysis develop due to a pseudoaneurysm of the thoracic aorta from an intrathoracic metastasis. Stent-graft repair successfully excluded the aneurysm from the aorta. Transesophageal echocardiography showed to be an important guide for correct placement of the device.

    View details for DOI 10.1016/j.athoracsur.2005.07.016

    View details for Web of Science ID 000238027600059

    View details for PubMedID 16731179

  • Progressive asymptomatic occlusion of a TIPS in a patient with Budd-Chiari syndrome JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Frisoli, J. K., Macksood, D. J., Dovichi, E. A., Ahmed, A., Keeffe, E. B. 2006; 17 (4): 737-739
  • Transjugular intrahepatic portosystemic shunt creation in a polycystic liver facilitated by hybrid cross-sectional/angiographic imaging JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Strobel, N., Fahrig, R., Moore, T., Busque, S., Frisoli, J. K. 2006; 17 (4): 711-715


    Polycystic liver disease (PCLD) has long been considered to represent a contraindication to transjugular intrahepatic portosystemic shunt (TIPS) creation, primarily because of the risk of hemorrhage. Three-dimensional (3D) navigation within the enlarged and potentially disorienting parenchyma can now be performed during the procedure with the development of C-arm cone-beam computed tomography, which relies on the same equipment already used for angiography. Such a hybrid 3D reconstruction-enabled angiography system was used for safe image guidance of a TIPS procedure in a patient with PCLD. This technology has the potential to expedite any image-guided procedure that requires 3D navigation.

    View details for DOI 10.1097/01.RVI.0000208984.17697.58

    View details for Web of Science ID 000236836700015

    View details for PubMedID 16614155

  • Successful transfemoral creation of an intrahepatic portosystemic shunt with use of the Viatorr device JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Magsamen, K. E., Frisoli, J. K. 2006; 17 (3): 569-572


    Although the large majority of cases are anatomically favorable and therefore technically feasible, congenital or acquired conditions may complicate or even preclude successful creation of a transjugular intrahepatic portosystemic shunt (TIPS). The present report describes the use of the inferior right hepatic vein from a femoral vein access to obtain portal access and place a covered stent, reconstruct a partially occluded portal vein, and embolize large gastric varices in a patient with a persistent left superior vena cava (SVC) and absent right SVC.

    View details for DOI 10.1097/01.RVI.0000200054.73714.E1

    View details for Web of Science ID 000236443000018

    View details for PubMedID 16567683

  • Targeted drug delivery for refractory hemorrhagic Crohn disease JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y. 2006; 17 (1): 163-167


    Focal gastrointestinal inflammation and hemorrhage is a common problem associated with Crohn disease. The present report describes a case of chronic hemorrhage from an inflamed duodenum that was refractory to all endoscopic and systemic therapies, which was successfully treated with chemoembolization of the pancreaticoduodenal arcade with use of corticosteroids and gelatin sponge. The application of chemoembolization techniques need not be limited to treatment of malignancies.

    View details for DOI 10.1097/01.RVI.0000183192.01135.B1

    View details for Web of Science ID 000236517800020

    View details for PubMedID 16415147

  • Effects of Onyx-015 among metastatic colorectal cancer patients that have failed prior treatment with 5-FU/leucovorin CANCER GENE THERAPY Reid, T. R., Freeman, S., Post, L., MCCORMICK, F., Sze, D. Y. 2005; 12 (8): 673-681


    Despite recent improvements in the treatment of metastatic colorectal cancer, few patients are cured and the response rates to second-line treatments are poor. Onyx-015, an oncolytic virus, was administered to patients with metastatic colorectal cancer by hepatic artery infusion. No dose-limiting toxicities were observed in the phase I/II studies. Onyx-015 can kill tumor cells by mechanisms that are distinct from chemotherapeutic agents and may therefore have activity among patients who have failed first-line chemotherapy. The 24 patients included in this analysis had failed first-line therapy with 5-FU/leucovorin, 79% of the patients failed two or more regimens and 58% had failed treatment with Irinotecan. Despite the extensive prior therapy, the median survival of these patients was 10.7 months, 46% were alive at 1 year and two patients (8%) had partial responses. In all, 11 patients (46%) had stable disease at the completion of the four planned viral treatments (3 months). The median survival of this group of patients was 19 months, suggesting that stable disease may be an important predictor of benefit with oncolytic viruses. Eight of the 11 patients with stable disease at 3 months demonstrated a unique radiographic pattern of transient enlargement of tumor masses (10-48%) after the initial infusions of Onyx-015, followed by radiographic evidence of extensive tumor necrosis and regression. The initial enlargement and subsequent tumor necrosis resulted in a prolonged time to achieve objective tumor regression. In addition, the transient enlargement of the tumor masses may have resulted in premature removal of responding patients. Treatment of eight patients was stopped prior to completion of the planned four treatments due to presumed progression as defined by standard radiographic criteria (>25% increase in tumor size). Functional imaging, such as positron emission tomography (PET) scans, may help distinguish clinical responses from progressive disease following treatment with oncolytic viruses. Onyx-015 may benefit patients with refractory colorectal cancer and additional studies that include PET scans to assess clinical response are warranted.

    View details for DOI 10.1038/sj.cgt.7700819

    View details for Web of Science ID 000230587300003

    View details for PubMedID 15803147

  • Treatment of hepatic venous outflow obstruction after piggyback liver transplantation RADIOLOGY Wang, S. L., Sze, D. Y., Busque, S., Razavi, M. K., Kee, S. T., Frisoli, J. K., Dake, M. D. 2005; 236 (1): 352-359


    To evaluate retrospectively the endovascular management of hepatic venous outflow obstruction after piggyback orthotopic liver transplantation.The study was performed with the approval and under the guidelines of the institutional review board and complied with the Health Insurance Portability and Accountability Act. Informed consent from patients was not required by the institutional review board for this retrospective study. From 1995 to 2003, 13 patients (eight male, five female), including 12 adults and one adolescent (age range, 14-67 years; median age, 52 years), underwent endovascular treatment of hepatic venous outflow obstruction after piggyback orthotopic liver transplantation. Patients gave informed consent for all procedures. Eleven patients received whole livers, and two received living-related donor right liver lobes. Four underwent repeat piggyback orthotopic liver transplantation prior to intervention. Primary stent placement was performed in 12 patients. One patient refused primary stent placement and chose venoplasty alone, but required a stent 5 months later. Short balloon-expandable stents (mean diameter, 14.6 mm +/- 1.1 [standard deviation]) were used to minimize jailing of branch vessels and to resist recoil. Pre- and post-procedural pressure gradients were measured. Follow-up included venography, cross-sectional imaging, and laboratory tests. The Wilcoxon signed rank test or the sign test was performed to compare pre- and post-procedural pressure gradients, body weights, and laboratory values.Technical success (pressure gradient < or = 3 mm Hg) was achieved in 13 of 13 patients, and clinical success, in 12 of 13. Mean pre- and post-procedural pressure gradients were 13.0 mm Hg +/- 1.4 and 0.8 mm Hg +/- 0.3. Mean interval from transplantation to intervention was 348 days +/- 159. Mean follow-up was 678 days (range, 16-2880 days). Technical success did not result in clinical improvement in one patient. Biopsy demonstrated severe hepatic necrosis, likely from prolonged venous congestion, and the patient required repeat transplantation. Only one patient required reintervention for stent migration, and no other complications occurred. No significant restenosis was encountered after stent placement.Hepatic venous outflow obstruction is an uncommon but potentially fatal complication of piggyback orthotopic liver transplantation. Endovascular treatment with balloon-expandable stents is effective, safe, and apparently durable.

    View details for DOI 10.1148/radiol.2361040327

    View details for Web of Science ID 000229905300046

    View details for PubMedID 15955856

  • Minimal hepatic toxicity following infusion of adenoviral vector: Spatial restriction of CAR receptor in normal liver 41st Annual Meeting of the American-Society-of-Clinical-Oncology Sze, D., Au, T., Thorne, S., Sze, D., Kirn, D., Korn, M., Reid, T. AMER SOC CLINICAL ONCOLOGY. 2005: 223S–223S
  • Juvenile posttraumatic high-flow priapism: current management dilemmas JOURNAL OF PEDIATRIC SURGERY Marotte, J. B., Brooks, J. D., Sze, D., Kennedy, W. A. 2005; 40 (4)


    High-flow priapism results from disruption of the intercavernosal artery resulting in an arteriocavernosal fistula and is rarely encountered in the pediatric and adolescent population. Clinically it manifests as a painless, prolonged erection after perineal trauma. Treatment has ranged from expectant management to open surgical exploration with vessel ligation. Internal pudendal arteriogram and superselective embolization with autologous blood clot has emerged as a safe and effective treatment modality in the young male population. Here the authors present 3 patients with high-flow priapism and discuss management of this rare clinical entity.

    View details for DOI 10.1016/j.jpedsurg.2005.01.023

    View details for Web of Science ID 000229359300042

    View details for PubMedID 15852259

  • Portal hypertensive hemorrhage from a left gastroepiploic vein caput medusa in an adhesed umbilical hernia. Journal of vascular and interventional radiology Sze, D. Y., Magsamen, K. E., McClenathan, J. H., Keeffe, E. B., Dake, M. D. 2005; 16 (2): 281-285


    Caput medusa is a frequent incidental finding in patients with portal hypertension that usually represents paraumbilical vein portosystemic collateral vessels draining into body wall systemic veins. A symptomatic caput medusa was seen in a morbidly obese patient after an umbilical hernia repair, which was fed not by the left portal vein but by the left gastroepiploic vein, in a recurrent adhesed umbilical hernia that likely contained herniated omentum. Refractory hemorrhage from this caput medusa was successfully treated by transjugular intrahepatic portosystemic shunt creation and balloon-occluded variceal sclerosis.

    View details for PubMedID 15713931

  • Portal hypertensive gastroepiploic vein adhesed umbilical hemorrhage from a left caput medusa in an hernia JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Magsamen, K. E., McClenathan, J. H., Keeffe, E. B., Dake, M. D. 2005; 16 (2): 281-285
  • Treatment outcomes of transcatheter arterial chemoinfusion (TACI) in patients with unresectable hepatocellular carcinoma (HCC) 69th Annual Meeting of the American-College-of-Gastroenterology Choi, B. Y., Ahmed, A., Razavi, M., Sze, D., Simpson, N., Garcia, R. T., Keeffe, E. B., Nguyen, M. H. NATURE PUBLISHING GROUP. 2004: S83–S83
  • Stent-graft treatment of extracranial carotid and vertebral arterial lesions JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Saket, R. R., Razavi, M. K., Sze, D. Y., Frisoli, J. K., Kee, S. T., Dake, M. D. 2004; 15 (10): 1151-1156


    Five patients with pseudoaneurysms of the carotid artery (n = 4) and an arteriovenous fistula of the vertebral artery (n = 1) were treated with stent-grafts. Commercially made devices were used in all but one of the patients. In four of the five patients, the pathology was successfully excluded. One patient had a small type-I endoleak. There were no immediate procedure-related complications or neurologic sequalae. All experienced immediate resolution of symptoms. One patient was lost to follow-up after discharge and another died 2 weeks after intervention. The remaining patients remained asymptomatic with patent stent-grafts after follow-up periods of 14, 16, and 46 months, respectively.

    View details for DOI 10.1097/01.RVI.0000134496.71252

    View details for Web of Science ID 000227678700018

    View details for PubMedID 15466804

  • Transcatheter embolization for the treatment of upper gastrointestinal bleeding. Techniques in vascular and interventional radiology Frisoli, J. K., Sze, D. Y., Kee, S. 2004; 7 (3): 136-142


    Over the past 20 years, the treatment of upper gastrointestinal bleeding (UGIB) that is refractory to endoscopic treatment has been revolutionized by transcatheter embolization. Embolization techniques have evolved with the use of microcatheters and new embolic materials. The majority of patients are successfully treated by minimally invasive techniques and can avoid having surgery.

    View details for PubMedID 16015558

  • Arterial infusion of Onyx-O15: Response rate and survival among patients with metastatic colorectal cancer refractory to 5-fu 40th Annual Meeting of the American-Society-of-Clinical-Oncology Sze, D., Freeman, S., Reid, T. R. AMER SOC CLINICAL ONCOLOGY. 2004: 211S–211S
  • TIPS reduction with use of stents or stent-grafts JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Saket, R. R., Sze, D. Y., Razavi, M. K., Kee, S. T., Frisoli, J. K., Semba, C. P., Dake, M. D. 2004; 15 (7): 745-751


    This report describes new techniques to perform TIPS reduction in patients with post-TIPS complications. Methods included hourglass-shaped stents and stent-grafts, and parallel stents and stent-grafts. All procedures were technically successful, resulting in increased portosystemic gradients and decreased symptoms, although patient outcomes were mixed. None of the patients experienced recurrent variceal hemorrhage or ascites in short-term follow-up. Stent-grafts have the advantage of immediate exclusion of blood flow outside the reducing stent, resulting in an immediate reduction of the caliber of the shunt. Techniques that allow fine adjustment of shunt diameters may have further advantages.

    View details for DOI 10.1097/01.RVI.0000133526.80425.16

    View details for Web of Science ID 000227678400012

    View details for PubMedID 15231889

  • Thrombolysis for lower extremity deep venous thrombosis. Techniques in vascular and interventional radiology Semba, C. P., Razavi, M. K., Kee, S. T., Sze, D. Y., Dake, M. D. 2004; 7 (2): 68-78


    Catheter-directed thrombolysis (CDT) has been proposed as an alternative mode of therapy to anticoagulation in patients with massive, symptomatic deep vein thrombosis of the extremity. The major goal of therapy is to rapidly restore venous blood flow, reduce the pain and edema of the extremity, preserve venous valve function, and reduce chronic symptoms related to chronic venous hypertension (postthrombotic syndrome). In patients with iliofemoral deep venous thrombosis (DVT) standard angiographic techniques are used to instrument a lower extremity vein (popliteal) and venography is performed followed by catheter-directed infusion of a plasminogen activator directly into the thrombus. Following lytic infusion, the interventionalist must evaluate the venous drainage to determine if there is an anatomic lesion that requires further endovascular treatment (eg, iliac vein compression syndrome). Posttreatment therapy usually consists of warfarin therapy and venous compression stockings for at least 3 to 6 months. The purpose of this article is to review the technical approach used in treating iliofemoral DVT and highlight the hurdles that face interventionalists in attempting to broaden this procedure to most types of lower extremity DVT.

    View details for PubMedID 15252763

  • Novel intravascular ultrasound-guided method to create transintimal arterial communications: Initial experience in peripheral occlusive disease and aortic dissection JOURNAL OF ENDOVASCULAR THERAPY Saket, R. R., Razavi, M. K., Padidar, A., Kee, S. T., Sze, D. Y., Dake, M. D. 2004; 11 (3): 274-280


    To report our experience using a commercially available catheter-based system equipped with an intravascular ultrasound (IVUS) transducer to achieve controlled true lumen re-entry in patients undergoing subintimal angioplasty for chronic total occlusions (CTO) or aortic dissections.During an 8-month period, 10 patients (6 men; mean age 73.4 years) with lower extremity (LE) ischemia from CTOs (n=7) or true lumen collapse from aortic dissections (n=3) were treated. Subintimal access and controlled re-entry of the CTOs were performed with a commercially available 6.2-F dual-lumen catheter, which contained an integrated 64-element phased-array IVUS transducer and a deployable 24-G needle through which a guidewire was passed once the target lumen was reached. The occluded segments were balloon dilated; self-expanding nitinol stents were deployed. In the aortic dissections, fenestrations were performed using the same device, with the IVUS unit acting as the guide. The fenestrations were balloon dilated and stented to support the true lumen.Time to effective re-entry ranged from 6 to 10 minutes (mean 7) in the CTOs; antegrade flow was restored in all 7 CTOs, and the patients were free of ischemic symptoms at up to 8-month follow-up. In the aortic dissection cases, the fenestrations equalized pressures between the lumens and restored flow into the compromised vessels. There were no complications related to the use of this device in any of the 10 patients.Our preliminary results demonstrate the feasibility of using this catheter-based system for subintimal recanalization with controlled re-entry in CTOs and for aortic flap fenestrations in aortic dissections. This approach can improve the technical success rate, reduce the time of the procedure, and minimize potential complications.

    View details for Web of Science ID 000222157100007

    View details for PubMedID 15174902

  • Successful treatment of a Stanford type A dissection by percutaneous placement of a covered stent graft in the ascending aorta JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Ihnken, K., Sze, D., Dake, M. D., Fleischmann, D., van der Starre, P., Robbins, R. 2004; 127 (6): 1808-1810

    View details for DOI 10.1016/j.jteves.2003.12.019

    View details for Web of Science ID 000221895700036

    View details for PubMedID 15173740

  • Chylothorax after heart/lung transplantation JOURNAL OF HEART AND LUNG TRANSPLANTATION Ziedalski, T. M., Raffin, T. A., Sze, D. Y., Mitchell, J. D., Robbins, R. C., Theodore, J., Faul, J. L. 2004; 23 (5): 627-631


    Chylothorax is a potentially serious complication of lung and heart-lung transplantation. This article describes the clinical course of chylothorax in 3 heart-lung allograft recipients. We discuss management options, including dietary modifications, octreotide infusion, thoracic duct ligation and embolization, and surgical pleurodesis. In addition, we describe the novel use of aminocaproic acid to reduce lymph flow. We propose a multidisciplinary approach for the management of chylothorax that includes both medical and surgical options.

    View details for Web of Science ID 000221393700018

    View details for PubMedID 15135382

  • Percutaneous bypass: subintimal recanalization of peripheral occlusive disease with IVUS guided luminal re-entry. Techniques in vascular and interventional radiology Saketkhoo, R. R., Razavi, M. K., Padidar, A., Kee, S. T., Sze, D. Y., Dake, M. D. 2004; 7 (1): 23-27


    Angioplasty of chronic total occlusions (CTOs) has lower technical success rates with longer procedure times and poorer outcomes. Subintimal recanalization remains limited by the lack of controlled re-entry into the true lumen of the target vessel. We report our experience using a commercially available catheter-based system equipped with an intravascular ultrasound scanner to achieve controlled true lumen re-entry in patients with peripheral CTOs. In a 4-month period, 6 patients with lower extremity (LE) ischemia from CTOs were treated. Occluded segments were crossed subintimally, and controlled re-entry was secured using the CrossPoint TransAccess catheter. This 6.2 F dual-lumen catheter contains an integrated 64-element phased array intravascular ultrasound scanner enabling targeting of structures. Intravascular ultrasound-guided luminal re-entry was achieved by advancing a 24-gauge needle to a desired length and delivering a 0.014" guide wire into the target lumen. The occluded segments were balloon dilated and stented using self-expanding nitinol stents. Effective luminal re-entry and re-establishment of antegrade flow occurred in all 6 patients. Time to recanalization ranged from 5 to 10 minutes. All patients were free of ischemic symptoms at 1 to 5 month follow-up. There were no procedure-related complications. Our preliminary results demonstrate the feasibility of using this catheter system for subintimal recanalization with controlled re-entry in CTOs. This approach can improve the technical success rate, reduce the time of the procedure, and minimize potential complications.

    View details for PubMedID 15071777

  • Midterm results of endovascular repair of descending thoracic aortic aneurysms with first-generation stent grafts 29th Annual Meeting of the Western-Thoracic-Surgical-Association Demers, P., Miller, D. C., Mitchell, R. S., Kee, S. T., Sze, D., Razavi, M. K., Dake, M. D. MOSBY-ELSEVIER. 2004: 664–73


    Five years after reporting our initial stent-graft repair of descending thoracic aortic aneurysms experience, we determined the 5- to 10-year results of stent-graft treatment and identified risk factors for adverse late outcomes.Between 1992 and 1997, 103 patients (mean age 69 +/- 12 years) underwent repair using first-generation (custom-fabricated) stent grafts. Sixty-two patients (60%) were unsuitable candidates for conventional open surgical repair ("inoperable"). Follow-up was 100% complete (mean 4.5 +/- 2.5 years; maximum 10 years). Outcome variables included death and treatment failure (endoleak, aortic rupture, reintervention, and/or aortic-related or sudden death).Overall actuarial survival was 82% +/- 4%, 49% +/- 5%, and 27% +/- 6% at 1, 5, and 8 years. Survival in open surgical candidates was 93% +/- 4% and 78% +/- 6% and at 1 and 5 years compared with 74% +/- 6% and 31% +/- 6% in those deemed inoperable (P <.001). Independent risk factors for death were older age (hazard ratio = 1.1; P =.008), previous stroke (hazard ratio = 2.8; P =.003), and being designated an inoperable candidate (hazard ratio = 1.9; P =.04). Actuarial freedom from aortic reintervention and treatment failure at 8 years was 70% +/- 6% and 39% +/- 8%, respectively. Earlier operative year (hazard ratio = 1.2; P =.07), larger distal landing zone diameter (hazard ratio = 1.1; P =.001), and transposition of the left subclavian artery (hazard ratio = 3.3; P =.008) were determinants of treatment failure.Survival after aneurysm repair using crude, first-generation stent grafts was satisfactory in good operative candidates but bleak in the inoperable cohort, raising the question of whether asymptomatic patients should have even been treated. Late aortic complications were detected in many patients, reemphasizing the importance of serial imaging surveillance.

    View details for DOI 10.1016/j.jtcvs.2003.10.047

    View details for Web of Science ID 000220115400013

    View details for PubMedID 15001894

  • CT-guided transthoracic needle aspiration biopsy of pulmonary nodules: Needle size and pneumothorax rate RADIOLOGY Geraghty, P. R., Kee, S. T., McFarlane, G., Razavi, M. K., Sze, D. Y., Dake, M. D. 2003; 229 (2): 475-481


    To evaluate the effect of coaxial needle size on pneumothorax rate and the diagnostic accuracy of computed tomography (CT)-guided transthoracic needle aspiration biopsy (TNAB) of pulmonary nodules.Retrospective review of 846 consecutive CT-guided TNAB procedures was performed. A coaxial approach was implemented in all patients by using an 18- or 19-gauge outer stabilizing needle through which a smaller aspiration needle or automated biopsy gun was inserted for tissue sampling. Univariate and multivariate regression analyses were used to analyze coaxial needle size, age, sex, smoking history, lesion size, use of an automated core biopsy gun, number of needle passes, and frequency of chest tube placement. Sensitivity, specificity, and diagnostic accuracy were calculated for 676 patients with at least 18 months of clinical follow-up.Pneumothorax occurred in 226 of 846 patients. Coaxial needle size and patient age had a significant effect on pneumothorax rate. Pneumothorax occurred in 124 (38%) of 324 patients who underwent procedures with 18-gauge needles and in 121 (23%) of 522 patients who underwent procedures with 19-gauge needles (P <.001). The overall diagnostic accuracy was 96% for procedures performed with 18-gauge needles and 92% for procedures performed with 19-gauge needles, with a sensitivity of 95% and 89% and a specificity of 100% and 99%, respectively. Pneumothorax occurred in 153 patients older than 60 years, in 99 patients 60 years and younger (P <.02), in 90 patients older than 70 years, and in 162 patients younger than 70 years (P <.01). The relationship between pneumothorax rate and age as a continuous distribution was not significant (P <.07), nor were the 50- or 75-year age cutoffs (P <.06 and P <.9, respectively).Use of a smaller coaxial stabilizing needle produces a substantially decreased risk of pneumothorax with comparable diagnostic accuracy, sensitivity, and specificity for histopathologic diagnosis of pulmonary nodules.

    View details for Web of Science ID 000186169700027

    View details for PubMedID 14595149

  • The "Y" stent: A technique using nitinol stents to treat bifurcations JOURNAL OF ENDOVASCULAR THERAPY Sze, D. Y., Razavi, M. K., Mitri, R. K., Regala, A. C., Dake, M. D. 2003; 10 (4): 780-787


    To investigate a new method of stent deployment using commercially available self-expanding stents to treat bifurcation lesions, providing complete lesion coverage without obstructing branches.After preliminary in vitro and clinical testing with biliary obstructions, 11 vascular obstructive lesions in 10 patients (7 men; mean age 63 years, range 32-81) were treated by percutaneous Y-shaped stenting. Five patients had iliac arterial stenoses involving the iliac bifurcation; the other 5 patients had 6 central venous obstructions involving branch points. Bifurcated stents were constructed in situ by deploying a nitinol stent extending into one branch and selective balloon fracturing of struts to create a fenestration. A second stent was deployed through the hole, followed by symmetrical fracturing of struts in the second stent to form a Y-shaped configuration.All deployments were technically successful and resulted in complete coverage of the bifurcation lesions. Protrusion of fractured stent material into flow lumens was minor as determined by angiography, intravascular ultrasound, and passage of balloons, but it required the stents to be oversized. The lengths and luminal diameters were tailored for each arm of the Y-shaped stents.In situ creation of a Y-shaped stent using 2 self-expanding nitinol stents is a feasible option with potential advantages in the treatment of obstructive lesions involving a bifurcation.

    View details for Web of Science ID 000186217600015

    View details for PubMedID 14533963

  • Imaging and intervention in the hepatic veins AMERICAN JOURNAL OF ROENTGENOLOGY Desser, T. S., Sze, D. Y., Jeffrey, R. B. 2003; 180 (6): 1583-1591

    View details for Web of Science ID 000183149200015

    View details for PubMedID 12760925

  • Dr. Gary J. Becker Young Investigator Award: Intraarterial adenovirus for metastatic gastrointestinal cancer: Activity, radiographic response, and survival JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Freeman, S. M., Slonim, S. M., Samuels, S. L., Andrews, J. C., Hicks, M., Ahrar, K., Gupta, S., Reid, T. R. 2003; 14 (3): 279-290


    To determine the antitumoral activity and radiographic response pattern of intraarterial administration of a selective replication-competent adenovirus in patients with hepatic metastases from gastrointestinal carcinomas.Thirty-five patients were treated, seven in the dose-escalation phase and 28 at high doses. Inclusion criteria allowed mild laboratory value and performance status abnormalities and as much as 50% replacement of hepatic volume by tumor. An attenuated adenovirus that selectively replicates in p53-deficient cells (Onyx-015) was administered by hepatic arterial infusion at doses as high as 2 x 10(12) particles for two cycles. Subsequent cycles (maximum of eight total) were administered in combination with intravenous 5-fluorouracil (5-FU) and leucovorin.Tumor responses were demonstrated in combination with chemotherapy, even in 5-FU-resistant patients. The 15 patients who responded radiographically showed a pattern of acute tumor enlargement despite normalization of laboratory and clinical parameters, followed by very slow regression of tumor size. Radiographic response did not correlate with p53 status. Median survival of radiographic responders (475 days) was significantly longer than that of nonresponders (143 days).Hepatic arterial infusion of the replication-selective adenovirus Onyx-015 in combination with chemotherapy resulted in tumor regressions in select patients, including some in whom previous chemotherapy had failed. A biphasic radiographic response pattern was demonstrated. The mechanism of action appears to be more complex than that seen in vitro.

    View details for DOI 10.1097/01.RVI.0000058422.01661.1E

    View details for Web of Science ID 000181601400002

    View details for PubMedID 12631632

  • Mechanical thrombectomy for the treatment of lower extremity deep vein thrombosis. Techniques in vascular and interventional radiology Frisoli, J. K., Sze, D. 2003; 6 (1): 49-52


    Deep venous thrombosis (DVT) has potentially debilitating long-term sequelae if left untreated. Conventional treatment (systemic anticoagulation with heparin followed by coumadin or low molecular weight heparin) often does not adequately relieves clot burden or symptoms, and patients may be left with post-thrombotic syndrome. Although the advent of catheter-directed thrombolysis has markedly improved the treatment of DVT and long-term outcomes of patients treated for DVT, it remains only partially effective on subacute or chronic clot. Mechanical thrombolysis may work synergistically with catheter-directed thrombolysis to decrease clot burden, treatment time, and complication rates, thereby improving outcomes.

    View details for PubMedID 12772129

  • The safety, efficacy, and pharmacoeconomics of low-dose alteplase compared with urokinase for catheter-directed thrombolysis of arterial and venous occlusions JOURNAL OF VASCULAR SURGERY Sugimoto, K., Hofmann, L. V., Razavi, M. K., Kee, S. T., Sze, D. Y., Dake, M. D., Semba, C. P. 2003; 37 (3): 512-517


    The purpose of this study was to compare the efficacy, complications, and costs associated with low-dose (<2 mg/h) alteplase (tissue plasminogen activator [t-PA]) versus urokinase for the catheter-directed treatment of acute peripheral arterial occlusive disease (PAO) and deep vein thrombosis (DVT).A retrospective review was performed during sequential time periods on two groups with involved extremities treated with either t-PA with subtherapeutic heparin (TPA group) or urokinase with full heparin (UK group) at a single center. Treatment group characteristics, success rates, complications, dosages, infusion time, and costs were compared.Eighty-nine patients with 93 involved limbs underwent treatment (54 with DVT, 39 with PAO). The treatment groups were statistically identical (TPA: 45 limbs; 24 with DVT, 53.3%; 21 with PAO, 46.7%; UK: 48 limbs; 30 with DVT, 62.5%; 18 with PAO, 37.5%). The overall average hourly infused dose, total dose, infusion time, success rates, and cost of thrombolytic agent were as follows (+/- standard deviation): TPA, 0.86 +/- 0.50 mg/h, 21.2 +/- 15.1 mg, 24.6 +/- 11.2 hours, 89.4%, $466 +/- $331; and UK, 13.5 +/- 5.6 (10(4)) U/h, 4.485 +/- 2.394 million U, 33.3 +/- 13.3 hours, 85.7%, $6871 +/- $3667, respectively. Major and minor complication rates were: TPA, 2.2% and 8.9%; and UK, 2.1% and 10.4%, respectively. No statistical differences in success rates or complications were observed; however, t-PA was significantly (P <.05) less expensive and faster than urokinase.Low-dose t-PA combined with subtherapeutic heparin is equally efficacious and safe compared with urokinase. Infusions with t-PA were significantly shorter and less expensive than those with urokinase.

    View details for DOI 10.1067/mva.2002.41

    View details for Web of Science ID 000181364400005

    View details for PubMedID 12618684

  • Hepatic arterial infusion of a replication-selective oncolytic adenovirus (dl1520): Phase II viral, immunologic, and clinical endpoints CANCER RESEARCH Reid, T., Galanis, E., Abbruzzese, J., Sze, D., Wein, L. M., Andrews, J., Randlev, B., Heise, C., Uprichard, M., Hatfield, M., Rome, L., Rubin, J., Kirn, D. 2002; 62 (21): 6070-6079


    Replication-selective oncolytic adenoviruses are being developed for the treatment of cancer, but the safety and feasibility of repeated adenovirus delivery to tumors via the bloodstream was unknown, particularly in light of a patient death after hepatic artery infusion of a replication-defective adenovirus vector. We performed a Phase II trial of an oncolytic replication-selective adenovirus (dl1520, also known as Onyx-015) administered by hepatic artery infusion in patients with gastrointestinal carcinoma metastatic to the liver (n = 27). dl1520 was infused into the hepatic artery (2 x 10(12) particles) on days 1 and 8 as a single agent, and thereafter starting on day 22 in combination with i.v. 5-fluorouracil and leucovorin every 28 days. Repeated viral infusions were feasible, and no deaths occurred on study; reversible grade 3/4 hyperbilirubinemia occurred in 2 patients. Systemic inflammatory cytokine responses varied greatly between patients and even between cycles within a given patient. Proinflammatory cytokines [e.g., tumor necrosis factor, IFN-gamma, and interleukin (IL) 6] typically rose within 3 h and were followed at 18 h by a rise in IL-10. However, in the single patient who suffered a severe but reversible systemic inflammatory response, a unique cytokine profile was detected: marked acute increases of IL-6 (20-fold higher than average for all of the patients) and inhibition of IL-10 production. Delayed secondary peaks of viremia were reproducibly detected 3-6 days after treatment, even in the presence of high level neutralizing antibody titers and antiviral cytokines. Mathematical modeling was used to calculate the number of virus particles produced and shed into the blood with each replication cycle. The combination of virotherapy and chemotherapy had antitumoral activity in some chemotherapy-resistant colorectal tumors. The intra-arterial infusion of oncolytic adenoviruses warrants additional study.

    View details for Web of Science ID 000179062400015

    View details for PubMedID 12414631

  • Initial clinical results of tenecteplase (TNK) in catheter-directed thrombolytic therapy JOURNAL OF ENDOVASCULAR THERAPY Razavi, M. K., Wong, H., Kee, S. T., Sze, D. Y., Semba, C. P., Dake, M. D. 2002; 9 (5): 593-598


    To investigate the safety and immediate efficacy of 2 different doses of tenecteplase (TNK) in peripheral catheter-directed thrombolytic therapy of arterial occlusions and deep vein thrombosis (DVT).Over a 20-month period, 63 nonconsecutive patients underwent catheter-directed thrombolytic therapy with either 0.25 mg/h or 0.50 mg/h of TNK in a nonrandomized, open-label study. Of these, 55 patients (60 limbs) were treated for DVT (36 limbs in 16 men and 15 women; mean age 41 years, range 21-73) or peripheral arterial occlusions (24 limbs in 16 men and 8 women; mean age 63 years, range 32-91). The primary endpoints were major bleeding complications and angiographic reduction in clot burden.The mean duration of infusion was 18 +/- 4 hours in patients with arterial occlusions and 30 +/- 13 in those with DVT. Twenty-one (87.5%) patients with occlusive disease had marked or complete lysis of clot. Thirty (83.3%) limbs with DVT had either marked or complete resolution of thrombus. There were 4 (7.3%) episodes of minor bleeding with 1 (1.8%) major hemorrhagic event. Fibrinogen levels dropped by an average of 23%.Preliminary evidence suggests that TNK doses of 0.25 mg/h to 0.50 mg/h appear to be safe and effective. The potential benefits of TNK therapy warrant further investigation.

    View details for Web of Science ID 000179638100009

    View details for PubMedID 12431142

  • Developments in medical oncology and their implications for interventional radiology. Techniques in vascular and interventional radiology Reid, T. R., Sze, D. Y. 2002; 5 (3): 177-181


    Although surgery and radiation therapy have always been spatially targeted, chemotherapy as administered by oncologists has remained steadfastly committed to non-targeted systemic delivery. Decades of pharmaceutical research have yielded agents appropriate for intravenous use, but countless potentially efficacious agents have been discarded because of pharmacokinetic and toxicity profiles unsuitable for systemic delivery. With the emerging technology of biological agents comes a new series of challenges. These agents tend to be larger, less long-lived, and antigenic when compared with the agents of the past. Meanwhile, interventional radiologists have shown that targeted methods of delivery can have substantial impact on the efficacy and toxicity of agents. Laboratory scientists have developed new bullets; we interventional radiologists have developed new guns. It is time we take advantage of potential synergies.

    View details for PubMedID 12524649

  • Angiographic classification of ovarian artery-to-uterine artery anastomoses: Initial observations in uterine fibroid embolization RADIOLOGY Razavi, M. K., Wolanske, K. A., Hwang, G. L., Sze, D. Y., Kee, S. T., Dake, M. D. 2002; 224 (3): 707-712


    To prospectively study and classify the anastomoses between the ovarian and uterine arteries in women undergoing uterine fibroid embolization, and to compare the presence of such with procedural failures and premature menopause.Angiographic ovarian artery-to-uterine artery anastomoses were studied in 76 consecutive patients undergoing uterine fibroid embolization. Mean patient age was 44.7 years (range, 29-56 years). Clinical follow-up consisted of a standard questionnaire. Procedural failure and complications were compared with the presence of various types of ovarian artery-to-uterine artery connections.Three types of anastomoses were identified. In type I (33 [21.7%] of 152 arteries), flow from the ovarian artery to the uterus was through anastomoses with the main uterine artery. In type II (six arteries [3.9%]), the ovarian artery supplied the fibroids directly. In type III (10 arteries [6.6%]), the major blood supply to the ovary was from the uterine artery. Seven patients (9%) were considered to have clinical failure, with three of the six women with type II anastomoses being in this group. Three of the five women who experienced menopause after fibroid embolization had bilateral ovarian artery-to-uterine artery anastomoses that were classified as high risk.Delineation of ovarian artery-to-uterine artery anastomosis is of practical relevance in avoiding nontarget ovarian embolization, in identification of those who would be at risk of uterine artery embolization or ovarian failure, and in those in whom the ovarian artery can be embolized safely.

    View details for DOI 10.1148/radiol.2243011513

    View details for Web of Science ID 000177621700013

    View details for PubMedID 12202703

  • Treatment of hepatocellular carcinoma with sub-selective transcatheter arterial oily chemoinfusion. Techniques in vascular and interventional radiology Kim, P., Prapong, W., Sze, D. Y., So, S. K., Razavi, M. K. 2002; 5 (3): 127-131


    Transarterial therapy for primary liver cancer is gaining more acceptance. The technique of transarterial treatment of such cancers is, however, quite varied. To determine the value of our approach, we analyzed our experience with transarterial oily chemoinfusion (TOCI) of primary liver cancer over a 4.9-year period. Since 1997, over 300 such procedures have been performed at our institution. We report the results of the first 253 procedures, which were performed using a subsegmental technique with a mixture of doxorubicin, cisplatin, ethiodol, with selective Gelfoam embolization. Actuarial survival rates at 1, 2, and 3 years were calculated with Kaplan-Meier and multivariate analysis was performed by Cox regression. The median overall survival was 28.6 +/- 4.5 months following diagnosis. By univariate analysis, TNM clinical stage I or II, Karnofsky score above 80%, absence of extrahepatic disease, absence of vascular invasion, unifocal disease, pretreatment alpha-fetoprotein levels less than 500 ng/ml, hypervascularity of lesions, and lesion size less than 5 cm were all strong predictors of favorable patient survival at 1, 2, and 3 years (75%, 60%, and 50% respectively). Based on our experience, TOCI with selective embolization has similar survival benefit as the traditional chemoembolization but is associated with fewer complications.

    View details for PubMedID 12524643

  • MR guidance of sympathetic nerve blockade: Measurement of vasomotor response-initial experience in seven patients RADIOLOGY Sze, D. Y., Mackey, S. C. 2002; 223 (2): 574-580


    The authors performed sympathetic nerve blockades in seven patients with peripheral ischemia and possible autonomic dysfunction. Magnetic resonance (MR) imaging was used to guide needle placement, to monitor distribution of injected agents, and to measure increases in blood flow, which were as much as 10-fold. MR imaging can provide both procedural imaging guidance and measurement of efficacy for sympathetic nerve blocks.

    View details for DOI 10.1148/radiol.2231010751

    View details for Web of Science ID 000175270000043

    View details for PubMedID 11997570

  • The role of interventional radiology in a pediatric liver transplant program PEDIATRIC TRANSPLANTATION Sze, D. Y., Esquivel, C. O. 2002; 6 (1): 1-4

    View details for Web of Science ID 000174799300001

    View details for PubMedID 11906633

  • Treatment of massive pulmonary embolus with catheter-directed tenecteplase JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Carey, M. B., Razavi, M. K. 2001; 12 (12): 1456-1457

    View details for Web of Science ID 000172724000016

    View details for PubMedID 11742026

  • Intra-arterial administration of a replication-selective adenovirus CI-1042 (Onyx-015) in patients with colorectal carcinoma metastatic to the liver: safety, feasibility and biological activity Reid, T., Galanis, E., Abbruzzese, J., Sze, D., Andrews, J., Randley, B., Rubin, J., Kim, D. NATURE PUBLISHING GROUP. 2001: S10–S11
  • Use of curved needles to perform biopsies and drainages of inaccessible targets JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y. 2001; 12 (12): 1441-1444


    Percutaneous image-guided biopsies and fluid drainages are usually feasible with use of standard, mass-produced, straight needles. Occasionally, target lesions are completely surrounded by interposed structures, such as bone, bowel, colon, pancreas, bladder, or blood vessels, so percutaneous access appears impossible. Although the commercial availability of curved needles is very limited, custom bending of needles may allow unconventional access to these well-protected targets. This technique has been used to reach biopsy and drainage targets that would have otherwise required either high-risk transgression of interposed structures or more invasive surgical procedures.

    View details for Web of Science ID 000172724000012

    View details for PubMedID 11742022

  • Impact of multidetector CT hepatic arteriography on the planning of chemoembolization treatment of hepatocellular carcinoma AMERICAN JOURNAL OF ROENTGENOLOGY Sze, D. Y., Razavi, M. K., So, S. K., Jeffrey, R. B. 2001; 177 (6): 1339-1345


    We examined the impact of the increased sensitivity for hypervascular masses of multidetector CT hepatic arteriography on treatment decisions involving selective chemoembolization of hepatocellular carcinomas.Thirty patients were referred for chemoembolization of unresectable hepatocellular carcinoma. Initial selective chemoembolization plans were formulated on the basis of diagnostic biphasic CT or MR imaging. Ultrafast CT hepatic arteriography was performed using a multidetector CT scanner and selective contrast material injection into the hepatic artery. The entire liver was scanned in a single breath-hold of approximately 20 sec with a slice thickness of 1 mm. Lesions and their arterial supplies were identified, and these data were immediately used to formulate a final plan for chemoembolization.Hypervascular masses were detected in 29 patients. In 16 (53%) of the patients, preprocedural CT or MR imaging underestimated the number of lesions. In nine (30%) of these 16 patients, the additional lesions were detected only on CT hepatic arteriography, not on conventional angiography. CT hepatic arteriography findings had a major impact on planning the way in which chemoembolization treatment was performed. In three of the nine patients, the previously undetected lesions were treated with additional superselective chemoembolization. In the other six patients, chemoembolization was performed less selectively than originally planned.Primarily because of the high sensitivity of multidetector CT hepatic arteriography in revealing small and multifocal hepatomas, findings of this modality frequently alter treatment plans involving selective administration of chemoembolic material.

    View details for Web of Science ID 000172326800019

    View details for PubMedID 11717079

  • Truly hybrid interventional MR/x-ray system: Investigation of in vivo applications ACADEMIC RADIOLOGY Fahrig, R., Butts, K., Wen, Z. F., Saunders, R., Kee, S. T., Sze, D. Y., Daniel, B. L., Laerum, F., Pelc, N. J. 2001; 8 (12): 1200-1207


    The purpose of this study was to provide in vivo demonstrations of the functionality of a truly hybrid interventional x-ray/magnetic resonance (MR) system.A digital flat-panel x-ray system (1,024(2) array of 200 microm pixels, 30 frames per second) was integrated into an interventional 0.5-T magnet. The hybrid system is capable of MR and x-ray imaging of the same field of view without patient movement. Two intravascular procedures were performed in a 22-kg porcine model: placement of a transjugular intrahepatic portosystemic shunt (TIPS) (x-ray-guided catheterization of the hepatic vein, MR fluoroscopy-guided portal puncture, and x-ray-guided stent placement) and mock chemoembolization (x-ray-guided subselective catheterization of a renal artery branch and MR evaluation of perfused volume).The resolution and frame rate of the x-ray fluoroscopy images were sufficient to visualize and place devices, including nitinol guidewires (0.016-0.035-inch diameter) and stents and a 2.3-F catheter. Fifth-order branches of the renal artery could be seen. The quality of both real-time (3.5 frames per second) and standard MR images was not affected by the x-ray system. During MR-guided TIPS placement, the trocar and the portal vein could be easily visualized, allowing successful puncture from hepatic to portal vein.Switching back and forth between x-ray and MR imaging modalities without requiring movement of the patient was demonstrated. The integrated nature of the system could be especially beneficial when x-ray and MR image guidance are used iteratively.

    View details for Web of Science ID 000172759200002

    View details for PubMedID 11770916

  • Intra-arterial administration of a replication-selective adenovirus (dl1520) in patients with colorectal carcinoma metastatic to the liver: a phase I trial GENE THERAPY Reid, T., Galanis, E., Abbruzzese, J., Sze, D., Andrews, J., Romel, L., Hatfield, M., Rubin, J., Kirn, D. 2001; 8 (21): 1618-1626


    Both replication-incompetent and replication-selective adenoviruses are being developed for the treatment of cancer and other diseases. Concerns have been raised about the safety of intra-vascular adenovirus administration following a patient death on a clinical trial with a replication-defective adenovirus. In addition, the feasibility of vascular delivery to distant tumors has been questioned. dl1520 (ONYX-015) is a replication-selective adenovirus that has previously shown safety and antitumoral activity following intratumoral injection. This is the first report of intra-vascular administration with a genetically engineered, replication-selective virus. A phase I dose-escalation trial was performed in patients with liver-predominant gastrointestinal carcinoma (n = 11 total; primarily colorectal). dl1520 was infused into the hepatic artery at doses of 2 x 10(8)-2 x 10(1)2 particles for two cycles (days 1 and 8). Subsequent cycles of dl1520 were administered in combination with intravenous 5-fluorouracil (5-FU) and leucovorin. No dose-limiting toxicity, maximally tolerated dose or treatment-emergent clinical hepatotoxicity were identified following dl1520 infusion. Mild to moderate fever, rigors and fatigue were the most common adverse events. Antibody titers increased significantly in all patients. Viral replication was detectable in patients receiving the highest two doses. An objective response was demonstrated in combination with chemotherapy in a patient who was refractory to both 5-FU and dl1520 as single agents. Therefore, hepatic artery infusion of the attenuated adenovirus dl1520 was well-tolerated at doses resulting in infection, replication and chemotherapy-associated antitumoral activity.

    View details for Web of Science ID 000172171200004

    View details for PubMedID 11895000

  • Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Wang, M. Q., Sze, D. Y., Wang, S. P., Wang, Z. Q., Gao, Y. A., Dake, M. D. 2001; 12 (4): 465-474


    To evaluate delayed complications after esophageal expandable metallic stent placement.From April 1993 to December 1997, 90 expandable metallic stents were placed in 82 consecutive patients with inoperable malignant esophageal obstruction (n = 49) or malignant esophagorespiratory fistula (n = 33). Stents used included covered Gianturco-Rosch Z stents (n = 20), Wallstents (covered, n = 31; uncovered, n = 13), and Ultraflex stents (covered, n = 8; uncovered, n = 10). Patients were followed prospectively and monitored for delayed complications, defined as major (hemorrhage, tracheal compression, stent migration, perforation or fistula formation, granulomatous obstruction, tumor ingrowth and overgrowth, funnel phenomenon, and stent covering disruption) or minor (reflux, chest pain, and food impaction).Mean survival was 4.5 months after stent placement (range, 3 weeks to 26 months). The overall incidence of delayed complications was 64.6%, with 17 patients (20.7%) experiencing more than one complication. The rates of delayed complications in patients with Z stents, Wallstents, and Ultraflex stents were 75.0%, 68.1%, and 44.4%, respectively (P <.05). Most complications were life-threatening and occurred more frequently when stents were placed in the proximal third of the esophagus, compared with more distally (P <.05). Thirteen patients (15.9%) died from complications directly related to stent placement.Esophageal stent placement for malignant obstruction or fistula is associated with a substantial incidence of delayed complications.

    View details for Web of Science ID 000167928600010

    View details for PubMedID 11287534

  • Catheter-directed thrombolytic therapy for iliofemoral venous thrombosis in the posturokinase era Sem Interv Radiol Semba CP, Razavi MK, Kee ST, Sze DY, Dake MD 2001; 18: 145-153
  • Phase I/II study of intra-arterial administration of a replication-selective adenovirus CI-1042 (Onyx-015) in patients with metastatic colorectal carcinoma. Reid, T., Galanis, E., Abbruzzese, J., Sze, D., Andrews, J., Randlev, B., Romel, L., Rubin, J., Kirn, D. AMER ASSOC CANCER RESEARCH. 2000: 4570S–4570S
  • Mesenteric and portal venous thrombosis treated by transjugular mechanical thrombolysis AMERICAN JOURNAL OF ROENTGENOLOGY Sze, D. Y., O'Sullivan, G. J., Jahnson, D. L., Dake, M. D. 2000; 175 (3): 732-734

    View details for Web of Science ID 000088910300026

    View details for PubMedID 10954458

  • Endovascular management of iliac vein compression (May-Thurner) syndrome JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY O'Sullivan, G. J., Semba, C. P., Bittner, C. A., Kee, S. T., Razavi, M. K., Sze, D. Y., Dake, M. D. 2000; 11 (7): 823-836


    To evaluate the feasibility of endovascular techniques in treating venous outflow obstruction resulting from compression of the iliac vein by the iliac artery of the left lower extremity (May-Thurner syndrome).A retrospective analysis of 39 patients (29 women, 10 men; median age, 46 years) with iliac vein compression syndrome (IVCS) was performed. Nineteen patients presented with acute deep vein thrombosis (DVT) and 20 patients presented with chronic symptoms. All patients presented with leg edema or pain. In the acute group, patients were treated with catheter-directed thrombolysis (120,000-180,000 IU urokinase/h) and angioplasty followed by stent placement. In the chronic group, patients were treated with use of angioplasty and stent placement alone (n = 8), or in combination with thrombolysis (n = 12). Patients were then followed-up with duplex ultrasound and a quality-of-life assessment.Initial technical success was achieved in 34 of 39 patients (87%). The overall patency rate at 1 year was 79%. Symptomatically, 85% of patients were completely or partially improved compared with findings before treatment. Thirty-five of 39 patients received stents. The 1-year patency rate for patients with acute symptoms who received stents was 91.6%; for patients with chronic symptoms who received stents, the 1-year patency rate was 93.9%. Five technical failures occurred. Major complications included acute iliac vein rethrombosis (< 24 hours) requiring reintervention (n = 2). Minor complications included perisheath hematomas (n = 4) and minor bleeding (n = 1). There were no deaths, pulmonary embolus, cerebral hemorrhage, or major bleeding complications.Endovascular reconstruction of occluded iliac veins secondary to IVCS (May-Thurner) appears to be safe and effective.

    View details for Web of Science ID 000088217200002

    View details for PubMedID 10928517

  • Internal iliac artery embolization in the stent-graft treatment of aortoiliac aneurysms: Analysis of outcomes and complications JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Razavi, M. K., DeGroot, M., Olcott, C., Sze, D., Kee, S., Semba, C. P., Dake, M. D. 2000; 11 (5): 561-566


    To analyze the complications of internal iliac artery (IIA) embolization in conjunction with stent-graft treatment of aortoiliac aneurysms.Seventy-one patients with aortoiliac (n = 47) or iliac (n = 24) aneurysms were treated with endoluminal placement of stent-grafts. Thirty-two patients (31 men, one woman; mean age, 73 years; range, 56-88 years) had embolization or occlusion of one (n = 27) or both (n = 5) IIAs. Status of the IIAs and the collateral circulation was assessed by retrospective review of angiographic images. Follow-up consisted of a standardized patient questionnaire and review of radiologic and medical records.The mean follow-up time was 35 months (range, 5-64 months). Eleven of the 47 patients with abdominal aortic aneurysms (AAA) (23%) and 19 of the 24 patients with iliac aneurysms (79%) required IIA embolization. One patient with AAA and another with iliac aneurysm had unintentional occlusion of an IIA by extension of the stent-graft over their origins. A total of seven patients had bilateral occlusion of the IIAs after the procedure. Additionally, the inferior mesenteric arteries (IMAs) of two other patients with AAA were also embolized. In six patients, all three vessels were occluded after placement of the stent-grafts. Symptoms were reported in nine of the 20 (45%) patients with iliac aneurysms and in three of the 12 (25%) patients with AAA. Symptoms consisted of buttock claudication (nine of 32, 28%), new sexual dysfunction (two of 16, 12%), and transient urinary retention (3%). Seven of the claudicants had resolution of symptoms after a mean interval of 14 months (range, 1-36 months). There were no instances of bowel ischemia, neurologic sequelae, or buttock necrosis related to these procedures.Embolization of the IIA is associated with symptoms in a significant number of patients. While symptoms are transient in most patients, they can be problematic. Efforts should be made to preserve the pelvic circulation if possible.

    View details for Web of Science ID 000087118200003

    View details for PubMedID 10834485

  • Stent-graft therapy for subclavian artery aneurysms and fistulas: Single-center mid-term results JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Hilfiker, P. R., Razavi, M. K., Kee, S. T., Sze, D. Y., Semba, C. P., Dake, M. D. 2000; 11 (5): 578-584


    To evaluate the potential of covered stents to replace surgery in the treatment of subclavian artery aneurysms and traumatic injuries.Nine patients (five men, four women; age range, 20-83 years; mean, 54 years) with subclavian artery aneurysms (n = 5) or fistulas (n = 4) were treated with stent-grafts. All devices used were custom-made, consisting of polytetrafluoroethylene (PTFE)-covered Palmaz (n = 5), Wallstent (n = 2), Z stents (n = 8), or a polyester-covered Z stent (n = 1). One patient was lost to follow-up after 2 months. All others were followed up with clinical evaluation, computed tomography (CT), and/or ultrasound.All devices were deployed successfully with exclusion of the aneurysms and fistulas. There were two procedure-related complications (22%), consisting of groin pseudoaneurysms requiring surgical repair 3 and 9 days after the procedure. One of those patients required additional oral antibiotic therapy for a postsurgical groin wound infection. One patient developed a stenosis at 12 months, which required angioplasty. The stent-graft thrombosed in one patient because of a kink 2 months after placement, which was successfully treated by thrombolysis and placement of a Wallstent. The primary and secondary patencies are 89% and 100%, respectively, after a mean follow-up of 29 months (2-66 mo).Mid-term results of stent-graft therapy of subclavian artery aneurysms and fistulas are encouraging, with low morbidity and excellent clinical outcome.

    View details for Web of Science ID 000087118200006

    View details for PubMedID 10834488

  • Placement of SVC stents over pacemaker wires for the treatment of SVC syndrome JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Slonim, S. M., Semba, C. P., Sze, D. Y., Dake, M. D. 2000; 11 (2): 215-219

    View details for Web of Science ID 000085585200011

    View details for PubMedID 10716393

  • Current diagnostic and therapeutic strategies for effort vein thrombosis Tech Vasc Interv Radiol Sze DY, Shifrin RY, Semba CP 2000; 3: 12-20
  • Chronically occluded inferior venae cavae: Endovascular treatment RADIOLOGY Razavi, M. K., Hansch, E. C., Kee, S. T., Sze, D. Y., Semba, C. P., Dake, M. D. 2000; 214 (1): 133-138


    To report the results of endoluminal recanalization and stent placement in patients with chronic occlusions of the inferior vena cava (IVC).Seventeen consecutive patients (12 male, five female patients; mean age, 40.6 years; age range, 15-77 years) with chronic IVC occlusions were treated during a 6-year period. The mean duration of symptoms was 32 months. Underlying active malignancy was the cause of occlusion in four patients. Five patients with superimposed acute thrombus underwent catheter-directed thrombolysis prior to IVC recanalization. Clinical patency was defined as absence or improvement of symptoms. Clinical follow-up was supplemented with ultrasonography, vena cavography, or both in 10 patients.Technical success was achieved in 15 (88%) patients. Additional thrombolytic therapy and stent placement was needed in two patients to maintain patency at 4 and 6 months after the procedure. Twelve patients had IVCs that remained patent after a mean follow-up of 19 months for a primary patency rate of 80%. The primary assisted patency rate was 87% (13 of 15). There were four deaths owing to underlying disease 6-21 months after the procedures. There were no procedure-related complications.Endoluminal recanalization and stent placement in chronically occluded IVCs has a good intermediate-term outcome and should be considered in patients who have symptoms and who often do not have adequate alternative therapy.

    View details for Web of Science ID 000084414400021

    View details for PubMedID 10644112

  • Diagnostic yield of MR-guided liver biopsies compared with CT- and US-guided liver biopsies 1999 SCVIR Annual Meeting Schmidt, A. J., Kee, S. T., Sze, D. Y., Daniel, B. L., Razavi, M. K., Semba, C. P., Dake, M. D. ELSEVIER SCIENCE INC. 1999: 1323–29


    To compare diagnostic yield and complication rates of magnetic resonance (MR)-guided versus computed tomography (CT)- and ultrasound (US)-guided liver biopsies.MR-, CT-, and US-guided liver biopsies performed between 9/96 and 9/98 were compared. Sixty patients (21 men and 39 women, mean age 60 years) underwent MR-guided biopsy of liver lesions. Thirty patients (16 men and 14 women, mean age 59 years) underwent CT-guided biopsy. Eighteen patients (seven men and 11 women, mean age 50 years) underwent US-guided biopsy. MR procedures were performed in an open-configuration 0.5-T Signa SP MR unit. Lesion localization used standard T1 and T2 sequences, whereas biopsies were performed with multiplanar spoiled gradient recalled echo and fast gradient recalled echo sequences. A coaxial system with an MR-compatible 18-gauge stabilizing needle and a 21-gauge aspiration needle was used to obtain all samples. In CT and US procedures, a 19-gauge stabilizing needle and a 21-gauge aspiration or a 20-gauge core biopsy needle were used. A cytotechnologist was present to determine the adequacy of samples.MR had a diagnostic yield of 61%. CT and US had diagnostic yields of 67% and 61%, respectively. No serious complications were reported for MR and US procedures. Two CT biopsies resulted in postprocedural hemorrhage. One patient required surgical exploration and died.MR-guided biopsy of liver lesions with use of a 0.5-T open-configuration magnet is safe and accurate when compared with CT and US. No statistical difference was observed between the diagnostic yield of biopsies performed with MR, CT, and US guidance. MR enabled biopsy of a number of lesions in the hepatic dome and lesions with low contrast, which would normally be difficult to sample safely with use of CT or US.

    View details for Web of Science ID 000083881500004

    View details for PubMedID 10584646

  • Hepatic artery infusion of ONYX-015 in combination with 5-FU/leukovorin for metastatic gastrointestinal cancer metastatic to the liver: a phase I/II study. Reid, T., Rubin, J., Galanis, E., Abbruzzese, J., Lowe, A., Sze, D., Romel, L., Kirn, D. AMER ASSOC CANCER RESEARCH. 1999: 3798S–3798S
  • Endovascular treatment of hepatic venous outflow obstruction after piggyback technique liver transplantation TRANSPLANTATION Sze, D. Y., Semba, C. P., Razavi, M. K., Kee, S. T., Dake, M. D. 1999; 68 (3): 446-449


    The piggyback technique of orthotopic liver transplantation is an attractive alternative that preserves the recipient inferior vena cava and allows uninterrupted venous blood return during the anhepatic phase. As with other transplantation techniques, the vascular anastomoses required by the piggyback technique can develop strictures.Review of records of 264 piggyback transplantations revealed two cases of delayed-onset hepatic venous obstruction from anastomotic strictures. Both patients also had symptoms of inferior vena cava obstruction, with azotemia and lower extremity edema. Both patients were treated percutaneously with balloon-expandable stents.Rapid, dramatic resolution of symptoms was achieved in both patients. Patients remain completely asymptomatic at 39 and 3 months of follow-up.Hepatic venous anastomotic strictures in recipients of piggyback technique transplants are a very uncommon complication. They may be easily and effectively treated by minimally invasive endovascular intervention.

    View details for Web of Science ID 000082050600018

    View details for PubMedID 10459550

  • Recurrent TIPS failure associated with biliary fistulae: Treatment with PTFE-covered stents CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY Sze, D. Y., Vestring, T., Liddell, R. P., Kato, N., Semba, C. P., Razavi, M. K., Kee, S. T., Dake, M. D. 1999; 22 (4): 298-304


    To evaluate the efficacy of covered stents for the treatment of transjugular intrahepatic portosystemic shunt (TIPS) obstruction in human subjects with identified or suspected biliary fistulae.Five patients were treated for early failure of TIPS revisions. All had mid-shunt thrombus, and four of these had demonstrable biliary fistulae. Three patients also propagated thrombus into the native portal venous system and required thrombolysis. TIPS were revised in four patients using a custom-made polytetrafluoroethylene (PTFE)-covered Wallstent, and in one patient using a custom-made PTFE-covered Gianturco Z-stent.All identified biliary fistulae were successfully sealed. All five patients maintained patency and function of the TIPS during follow-up ranging from 2 days to 21 months (mean 8.4 months). No patient has required additional revision. Thrombosis of the native portal venous system was treated with partial success by mechanical thrombolysis.Early and recurrent failure of TIPS with mid-shunt thrombosis, which may be associated with biliary fistulae, can be successfully treated using covered stents. Stent-graft revision appears to be safe, effective, and potentially durable.

    View details for Web of Science ID 000081733100006

    View details for PubMedID 10415219

  • Descending thoracic aortic aneurysm: Thoracic CT findings after endovascular stent-graft placement RADIOLOGY Sakai, T., Dake, M. D., Semba, C. P., Yamada, T., ARAKAWA, A., Kee, S. T., Hayashi, N., Razavi, M. K., Sze, D. Y. 1999; 212 (1): 169-174


    To evaluate the usefulness of thoracic computed tomography (CT) after placement of an endovascular stent-graft for the treatment of descending thoracic aortic aneurysm.From 1992 to 1996, 85 patients with thoracic aortic aneurysm underwent stent-graft placement. In 63 patients, thoracic CT scans were obtained both before and within 10 days after placement. The CT findings were retrospectively studied, and their clinical effect analyzed. In 20 of 63 patients, long-term follow-up CT findings were also evaluated.After stent-graft placement in the 63 patients, CT demonstrated an increase in pleural effusion in 46 (73%), periaortic changes in 21 (33%), perigraft leak in 13 (21%), atelectasis in six (10%), mural thrombus within the stent-graft in two (3%), and new aortic dissection in one (2%). The mean maximum diameter of the aneurysm was 58.8 mm before and 60.0 mm after stent-graft insertion. Sixty-two (98%) patients were successfully treated until discharge. Interventional procedures were performed to eliminate the leakage into the aneurysm sac in 10 patients with perigraft flow depicted at CT. Other complications were managed conservatively.Thoracic CT is useful in the treatment of patients after stent-graft insertion for the management of descending thoracic aortic aneurysm.

    View details for Web of Science ID 000081086900027

    View details for PubMedID 10405738

  • 1999 Gary J. Becker Young Investigator Award. MR-guided transjugular portosystemic shunt placement in a swine model. Journal of vascular and interventional radiology Kee, S. T., Rhee, J. S., Butts, K., Daniel, B., Pauly, J., Kerr, A., O'Sullivan, G. J., Sze, D. Y., Razavi, M. K., Semba, C. P., Herfkens, R. J., Dake, M. D. 1999; 10 (5): 529-535


    To evaluate the performance of portal venous puncture with use of magnetic resonance (MR) guidance, and to place a transjugular intrahepatic portosystemic shunt (TIPS) in a swine model.A study of 12 swine was performed to evaluate the ability of interventional MR imaging to guide portal vein puncture and TIPS placement. Six swine had catheters placed in the right hepatic vein under C-arm fluoroscopy. A nitinol guide wire was left in the vein and the animals were then moved into an open configuration MR imaging unit. A TIPS needle set was used to puncture the portal vein using MR fluoroscopy. The animals were transferred to the C-arm, and venography confirmed portal vein puncture. A follow-up study was performed in six additional swine to place a TIPS using only MR imaging guidance. MR tracking was used to advance a catheter from the right atrium into the inferior vena cava. Puncture of the portal vein was performed and a nitinol stent was placed, bridging the hepatic parenchyma. MR venogram confirmed placement.Successful portal vein puncture was achieved in all animals. The number of punctures required decreased from 12 in the first animal to a single puncture in the last eight swine. A stent was successfully placed across the hepatic tract in all six swine.Real-time MR imaging proved to be a feasible method to guide portal vein puncture and TIPS placement in pigs.

    View details for PubMedID 10357476

  • MR-guided transjugular portosystemic shunt placement in a swine model JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kee, S. T., Rhee, J. S., Butts, K., Daniel, B., Pauly, J., Kerr, A., O'Sullivan, G. J., Sze, D. Y., Razavi, M. K., Semba, C. P., Herfkens, R. J., Dake, M. D. 1999; 10 (5): 529-535
  • Results of a multicenter feasibility study of the hemobahn stent-graft, in iliofemoral occlusive disease Dake, M., Semba, C., Kee, S., Razavi, M., Slonim, S., Samuels, S., Sze, D. INT SOC ENDOVASCULAR SPECIALIST. 1999: 188–88
  • Endografts for the treatment of descending thoracic aortic aneurysm: Results of the first 150 procedures Dake, M., Semba, C., Kee, S., Razavi, M., Slonim, S., Samuels, S., Sze, D., Mitchell, R., Miller, D. INT SOC ENDOVASCULAR SPECIALIST. 1999: 189–89
  • Percutaneous ureteral stenting Tech Vasc Interv Radiol Sze DY 1999; 2: 53-58
  • Image-guided therapy for hepatic malignancies J Gastroenterol Hepatol Razavi MR, Sze DY 1999; 14(suppl): A312-314
  • Abdominal aortic aneurysm repair with the W. L. Gore Excluder endovascular stent-graft: technique and potential pitfalls Tech Vasc Interv Radiol Semba CP, Dake MD, Razavi MK, Kee ST, Sze DY, Olcott C, Mitchell RS 1999; 2: 127-132
  • Custom-made stent-graft of polytetrafluoroethylene-covered wallstents: Technique and applications JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kato, N., Sze, D. Y., Semba, C. P., Razavi, M. K., Kee, S. T., Dake, M. D. 1999; 10 (1): 9-16

    View details for Web of Science ID 000078191100002

    View details for PubMedID 10872483

  • Percutaneous treatment of bronchial artery aneurysm with use of transcatheter coil embolization and thoracic aortic stent-graft placement JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Sakai, T., Razavi, M. K., Semba, C. P., Kee, S. T., Sze, D. Y., Dake, M. D. 1998; 9 (6): 1025-1028

    View details for Web of Science ID 000077125300027

    View details for PubMedID 9840053

  • Endovascular stent-graft placement to obliterate the entry tear: A new treatment for acute aortic dissection Dake, M. D., Kato, N., Slonim, S. M., Razavi, M. K., Semba, C. P., Kee, S. T., Sze, D. Y., Samuels, S. L., Mitchell, R. S., Miller, D. C. LIPPINCOTT WILLIAMS & WILKINS. 1998: 67–67
  • Superior vena cava syndrome after heart transplantation: Percutaneous treatment of a complication of bicaval anastomoses JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Sze, D. Y., Robbins, R. C., Semba, C. P., Razavi, M. K., Dake, M. D. 1998; 116 (2): 253-261


    Our objectives were (1) to investigate the incidence and cause of symptomatic superior vena caval anastomotic stenosis and central venous thrombosis in patients receiving heart or heart-lung transplantation and (2) to explore percutaneous methods of thrombolysis and endoluminal intervention to treat these complications.Review of 1016 cases revealed three cases of superior vena cava syndrome. Anatomy, surgical technique, and medical risk factors were examined. Percutaneous treatments, including urokinase thrombolysis, mechanical thrombolysis, balloon angioplasty, and stent placement, were attempted.All three of these patients underwent transplantation by means of the bicaval anastomotic technique. In addition, the diameters of the donor and recipient cavae were grossly mismatched in all three. Stenoses in all three patients were successfully treated percutaneously with balloon angioplasty and stent placement. Treatment of the accompanying large-volume thrombosis was problematic in these patients, and two had hemorrhagic complications of urokinase thrombolysis. A mechanical thrombolysis device was used successfully in the third patient.Anastomotic stricture and central venous thrombosis is an uncommon complication of the bicaval anastomotic technique of heart and heart-lung transplantation. Discrepancy between donor and recipient caval diameters appears to be the major risk factor. Endoluminal thrombolysis and stenting provides rapid and enduring relief of symptoms and precludes repeat sternotomy, cardiopulmonary bypass, and general anesthesia.

    View details for Web of Science ID 000075104300011

    View details for PubMedID 9699577

  • Endovascular Procedures for the Treatment of Aortic Dissection: Techniques and Results. Cardiovasc Surg Dake MD, Semba CP, Razavi MK, Kee ST, Sze DY, Slonim SM, Samuels SL, Mitchell RS, Miller DC 1998; 39: 45-52
  • High-resolution proton NMR studies of lymphocyte extracts. ImmunoMethods Sze, D. Y., Jardetzky, O. 1994; 4 (2): 113-126


    Anatomic imaging is now a well-developed application of magnetic resonance. Greater capabilities for physiologic characterization should become possible by concomitant application of spectroscopic methods. High-resolution in vitro spectroscopy must first provide a framework upon which in vivo and diagnostic interpretation may be based. Biochemical profiles consisting of quantitation of extracted aqueous metabolites and lipids of particular cells or organs establish an in vitro glossary for what may be found in the intact cell or living subject. A large variety of amino acids, intermediary metabolites, membrane precursors, and nucleotides are detectable in extracts of human peripheral blood lymphocytes, and significant changes in intracellular concentrations have been monitored after lectin-induced activation. Corresponding changes in lipid profile have also been noted. An increasing variety of other cells and tissues are being similarly characterized. Despite its limitations, NMR analysis possesses the unique prospect of providing a noninvasive and nondestructive source of biochemical information.

    View details for PubMedID 8069531

  • Musculoskeletal magnetic resonance imaging: Turbo (fast) spin-echo versus conventional spin-echo and gradient-echo imaging at 0.5 Tesla Skeletal Radiol Vahlensieck M, Lang P, Seeles K, Sze DY, Grampp S, Reiser M 1994; 23: 607-610


    Recent in vivo NMR studies have raised interest in the structural changes of cellular lipids during proliferative activity. We investigated the changes in plasma membrane lipid and total cell lipid during mitogenically-stimulated proliferation of human peripheral blood lymphocytes by extraction of lipids and assay by 500 MHz 1H-NMR. Resonances were assigned using one- and two-dimensional spectroscopic techniques, and signals unique to certain species of lipid were identified. Choline and ethanolamine-containing lipids, glycerophospholipid backbones, sphingolipids, cholesterol, plasmalogens and triacylglycerols were readily detected. Resolution of a number of lipid species was not possible, despite the use of high-resolution techniques. NMR values for proliferation-induced changes in the most easily determined parameters, namely the total cholesterol to total phospholipid molar ratio, and phosphatidylcholine, phosphatidylethanolamine and sphingolipid composition, were found to agree with traditional methods. Differences in phospholipid and fatty acid profiles were found between plasma membranes and total cell lipid for resting values and for response to mitogen.

    View details for Web of Science ID A1990DZ01600008

    View details for PubMedID 2400782



    Nuclear magnetic resonance (NMR) studies of extracts have proven to be a powerful window onto the intracellular machinery of cells and tissues. The major advantages of in vitro 1H-NMR, namely chemical preservation, simultaneous detection, identification, and quantitation of compounds, and sensitivity to a large variety of classes of compounds, are employed in this study to characterize the metabolic course of mitogen-stimulated proliferation of human peripheral lymphocytes. A reliable method to quantitate amino acids, metabolic intermediates, soluble membrane lipid precursors, and purine, pyridine and pyrimidine nucleotides is presented, using samples as small as 30 mg wet weight. A total of 53 substances were detected in lymphocytes and other blood cells. During the course of lymphocyte culture, changes in intracellular concentrations of lactate, taurine, inositol and nucleotides, including NAD, IMP and high-energy phosphates, were especially marked. 1H-NMR compares favorably to 31P-NMR and to HPLC, and is especially attractive in light of expectations for future in vivo application.

    View details for Web of Science ID A1990DZ01600007

    View details for PubMedID 2119233



    Lanthanide shift reagents have opened a new avenue in the study of membrane biochemistry, but their stabilities and biological reactivities remain questionable. We present evidence that shift reagents are not biologically inert, and that they exhibit the ability to inhibit stimulation of human peripheral lymphocytes at commonly used concentrations. A survey of various mitogens yielded no shift reagent-resistant modes of stimulation, and a survey of various shift reagents yielded no effective and nontoxic alternatives. Involvement of calcium-regulating mechanisms was not apparent. The assumption that lanthanide shift reagents used in NMR studies are nondestructive and physiologically innocuous is thus shown to be unwarranted.

    View details for Web of Science ID A1990CJ68300003

    View details for PubMedID 2138693



    Evidence is presented indicating that Escherichia coli requires the Na+/H+ antiporter and external sodium (or lithium) ion to grow at high pH. Cells were grown in plastic tubes containing medium with a very low Na+ content (5-15 microM). Normal cells grew at pH 7 or 8 with or without added Na+, but at pH 8.5 external Na was required for growth. A mutant with low antiporter activity failed to grow at pH 8.5 with or without Na+. On the other hand, another mutant with elevated antiporter activity grew at a higher pH than normal (pH 9) in the presence of added Na+ or Li+. Amiloride, an inhibitor of the antiporter, prevented cells from growing at pH 8.5 (plus Na+), although it had no effect on growth in media of lower pH values.

    View details for Web of Science ID A1989AA50300004

    View details for PubMedID 2541789

  • Factors influencing the quantitative analysis of shift reagent-facilitated biological 23Na-NMR Magn Reson Med Biol Sze DY, Jardetzky O 1989; 2: 235-248
  • MEASUREMENT OF THE SODIUM MEMBRANE-POTENTIAL BY NMR FEBS LETTERS Cowan, B. E., Sze, D. Y., MAI, M. T., Jardetzky, O. 1985; 184 (1): 130-133


    Using nuclear magnetic resonance (NMR), we have developed a method of noninvasively determining the transmembrane sodium potential in erythrocytes by measuring intracellular and extracellular sodium concentrations. The experimental values correlated well with values obtained from standard flame photometric methods.

    View details for Web of Science ID A1985AGS4300029

    View details for PubMedID 3987899



    Combinations of antiarrhythmic drugs are frequently used to treat refractory ventricular tachycardia (VT), but few scientific data support this practice. We examined the efficacy and electrophysiology of 110 antiarrhythmic drug combination trials at electrophysiologic study in 74 patients with recurrent ventricular tachycardia. Lidocaine was combined with quinidine in 33 trials, procainamide in 22 and encainide in 20. Propranolol was combined with quinidine in 17 trials, procainamide in 12 and encainide in six. All individual drugs tested (except propranolol, which was usually not tested individually) had failed at electrophysiologic study or clinically in the presence of usually accepted plasma concentrations. Lidocaine in combination with quinidine was effective in 3% of the trials, with procanamide in 5% and with encainide in none of the trials. Propranolol in combination with quinidine was effective in 18% of the trials, with procainamide in 17% and with encainide in none of the trials. The electrophysiologic effects of the tested drug combinations were dominated by the individual effects of the type 1 antiarrhythmic agents. We conclude that the tested antiarrhythmic drug combinations are infrequently effective in preventing VT induction at electrophysiologic study when each agent has failed individually. The addition of lidocaine or propranolol to quinidine, procainamide or encainide does not produce significant synergistic or new effects on the electrophysiologic variables analyzed.

    View details for Web of Science ID A1982PR37200012

    View details for PubMedID 6814784