More than 65,000 patients will be diagnosed with renal cell carcinoma (RCC) in the United States this year.1 RCC is the most common malignant renal neoplasm and accounts for 2% to 3% of all malignancies in the United States.2 The proliferation of cross-sectional imaging techniques (CT and ultrasound) for abdominal disease and symptomatology has led to increased diagnosis and awareness of incidental RCC. Incidental RCCs tend to be smaller and lower stage with an advantageous survival profile when compared to patients with regional or distant metastases.3
According to the Surveillance, Epidemiology, and End Result program of the National Cancer Institute, 48,960 new cases of pancreatic cancer are expected in United States in 2015.1 Pancreatic cancer has a peak incidence in the sixth and seventh decade of a person’s life, affecting men more commonly than women. Even though it is only the twelfth most common cancer by incidence (accounting for only 3% of all new cancers diagnosed), it is one of the most lethal cancers, with a 7.2% expected 5-year survival and 40,560 attributed deaths in 2015.1 One of the contributing factors leading to high mortality is delayed diagnosis due to vague early symptoms.
Thrombosis is a major complication of both cancer and its treatment. In up to 10% to 20% of patients, this can be the presenting sign of cancer, especially in older patients or those with idiopathic thrombosis. Furthermore, up to 25% of patients with spontaneous thrombosis will develop cancer within 2 years. Certain presentations are more worrisome for underlying cancer as the cause (ie, warfarin-refractory thrombosis, idiopathic bilateral deep vein thrombosis [DVT], or both arterial and venous thrombosis), and the most frequently associated cancers are adenocarcinoma of the lung and gastrointestinal tract, especially pancreatic cancer. Primary brain tumors, as well as kidney, ovarian, and uterine cancers, are also associated with a higher risk of thrombosis,1 but the risk does not appear to be as high for breast and prostate cancer.2
An association between venous thrombosis and malignancy is well established, with the first description of this phenomenon occurring in 1823.1 Malignancy is associated with a significantly increased risk of venous thrombosis, with relative risk estimates ranging from 4 to 7.1 In a large study that examined more than 3,000 cancer patients, malignancy was seen to increase the risk of venous thrombosis sevenfold (odds ratio, 6.7).2 Venous thrombosis risk in this study was particularly high in patients with distant metastasis, factor V Leiden, or prothrombin 20210A mutation, as well as in the first few months after cancer diagnosis. Cancer stage significantly influences the likelihood of thrombosis, with an adjusted relative risk of 2.9 and 17.1 in stage 1 and 4 disease, respectively.3 The level of risk also relates to malignancy type, with the highest incidence of thrombosis seen in patients with brain, pancreatic, lung, and ovarian cancer.1
Caval occlusion of malignant etiology is an insidious pathologic entity, resulting in substantial morbidity and limiting quality of life in severely ill and/or terminal patients. Relief from this condition relies upon astute recognition of the pathology and skilled intervention. Patients with long-standing chronic occlusions of the inferior vena cava (IVC) secondary to malignancy may present a diagnostic challenge. Onset can be slow, and the cause may not be obvious (ie, acquired symptomatology vs congenital defect).1 Symptoms and presentation vary between affected individuals based on various factors, including clot distribution, level of occlusion, activity level, and collateralization. Occlusion may commonly present as a dull aching pain in the extremities, as well as symptoms of venous claudication, in which lower limb swelling and discomfort are precipitated by exercise and relieved by rest and elevation. Venous ulceration can be seen in long-standing cases.2
Embolotherapy is a major part of today’s interventional medicine. Interventional radiologists started implementing different forms of embolotherapy in the 1970s. Since that time, newer methods and devices have been added to our armamentarium for a variety of indications. Some of these products provide temporary occlusion, whereas others have been designed for permanent occlusion.
I have been practicing interventional oncology (IO) for almost 25 years (most interventional radiologists probably have to a greater or lesser extent). The treatment of cancer by interventional radiologists dates back to the 1950s, even before interventional radiology (IR) was recognized as a discipline.1 Our “founding fathers” published extensively on minimally invasive, image-guided cancer therapy through the 1960s and ‘70s.2-4 Tumor embolization has been a standard of care for 3 decades, and tumor ablation has been common practice for the past 15 years. Palliative procedures for management of cancer-related obstruction, pain management, and provision of enteral and venous access are routine IR practice.
CVOs have historically been diagnosed using ultrasound while evaluating occlusions in the infrainguinal area. However, a large segment of patients with chronic venous disease has been overlooked and neglected for many years because practitioners—primarily primary care doctors and at times, even vascular specialists—are not looking above the inguinal ligament. For the past 15 years, it has been my practice to use cross-sectional imaging (either CT venography or MR venography) to understand the status of iliac veins and inferior vena cava (IVC). It has been shocking how much disease has been uncovered there, which explains the symptoms the patients have had for many years that have gone undiagnosed or untreated.
Since the introduction of retrievable filters, our division has kept a database of every patient in whom a retrievable filter was placed by the interventional radiology department. Over the years as we started to learn more about the complications of retrievable filters, we became more aggressive in reaching out to patients for filter retrieval. Today, our database has matured to include more detailed information such as the reason for filter placement, type of retrievable filter, and the referring physician to further improve patient follow-up.
Peripheral artery disease (PAD) is a chronic disorder that affects more than 8 million Americans and is defined by atherosclerotic stenosis and arterial occlusions in the extremities (typically the legs).1 Despite current therapies, PAD often leads to disability and, in some cases, amputation and death. This disease worsens over time due to the cumulative effects of cardiovascular risk factors that intensify with age (eg, hypertension, diabetes, and dyslipidemia), and thus the burden of PAD is projected to grow along with the aging population.2,3
There are multiple endovascular options for treatment of infrainguinal disease, but treatment of severe calcific disease of the superficial femoral artery (SFA), popliteal artery, and tibial vessels remains a challenge. Peripheral atherectomy is a unique treatment modality because it allows debulking of plaque with luminal gain and minimal barotrauma. This results in less injury to the vessel during initial treatment and theoretically reduces hyperplastic reaction to the initial treatment. In severely calcific vessels, calcium debulking changes the vessel wall compliance with the removal of calcium. It can then be treated with low-pressure balloon inflation with minimal injury to the vessel wall. This is now a particularly attractive concept with the availability of drug-coated balloons and drug-eluting stents, as the vessel can be prepared with atherectomy before delivery of these devices. This may ensure adequate drug delivery to the tissue, thereby reducing intimal hyperplastic reaction and increasing durability of the procedures. Prevailing concerns with atherectomy (ie, dissection, perforation, clinically significant embolization, and durability) have prevented the widespread use of atherectomy.1
The recently published JETSTREAM Calcium Study was a prospective, single-arm, multicenter study to evaluate the effect of the JETSTREAM™ Atherectomy System (Boston Scientific Corporation) when treating severely calcified peripheral arterial lesions in the common femoral, superficial femoral, or popliteal arteries causing claudication.
Peripheral artery disease (PAD) is a major cause of morbidity and mortality in the United States, affecting 8 to 12 million people. The incidence of PAD increases in the presence of well-defined atherosclerotic risk factors, including cigarette smoking, diabetes mellitus, hypertension, hyperlipidemia, and advanced age, and is estimated to affect > 20% of adults aged 55 years and older. When symptomatic, PAD may adversely have an impact on functional capacity, ability to work, and quality of life. Furthermore, PAD is associated with significant social and economic costs1 and increases the risk of future cardiovascular events.
With a 5-year head start using DCBs before US physicians, Prof. Jos van den Berg shares his take on best practices with this tool, as well as the available data.
Endovascular Today sat down with a multidisciplinary panel of esteemed interventionists to discuss their current practice paradigms for atherectomy, including the hot topic of Vessel Prep prior to drug-coated balloons and other adjunctive therapies.
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