Effectiveness of alternative routes of intra-arterial chemotherapy administration for retinoblastoma: Potential for response and complications

Objective Intra-arterial chemotherapy (IAC) is now the first line treatment for selected patients with retinoblastoma (Rb). Typically, IAC is infused following the selective catheterization of the ophthalmic artery (OA) on the affected side. However, in some patients, the OA alone may not provide vascular supply to the tumor, whereas in other instances the efficacy of IAC could be compromised due to the presence of prominent collateral vessels from the external carotid artery (ECA). We report our experience with catheterizing vessels other than the OA for IAC treatment for Rb. Methods After institutional review board approval, a retrospective analysis was conducted of electronic medical records and imaging of our Rb population. Results We identified 13 patients who received IAC for Rb treatment. Of these, five patients required alternative methods of chemotherapy delivery other than through the OA, totaling 17 treatments. Two patients needed balloon-assisted occlusion of the ECA, two patients required selective catheterization of the middle meningeal artery, and one patient had no internal carotid artery supply to the choroidal blush, thus the superficial temporal artery provided access for IAC. Total globe salvage rate was 76% and 80% with the alternative route subset. Conclusions Alternatives to the OA may be necessary to deliver IAC for selected cases of Rb. These routes can be safe and effective. However, thorough understanding of the orbital blood supply is essential. Whether these alternative IAC methods result in similar outcomes to OA infusions has not been established.

Radial Arterial Access for Hepatobiliary and Gastrointestinal Arterial Interventions: Initial Experience

Introduction Radial artery access is being more commonly used for visceral and peripheral arterial interventions. Its use in the Indian subcontinent is not well reported. The aim of this study was to report outcomes of radial arterial access during arterial interventions of the hepatobiliary and gastrointestinal system. Methods In this retrospective study, patients who underwent radial artery access for hepatobiliary and gastrointestinal interventions from January 2015 to June 2017 were identified from the interventional database. Complications related to radial artery access and catheter placement in the visceral arteries, procedural modifications, and conversion to the standard femoral arterial access were analyzed. Results Total 32 patients were included in this study. Total 46 procedures (radial artery access) were performed. Nine patients had radial artery access on more than two occasions; 95% of the procedures involved interventional oncologic treatments. Patients were followed up for an average of 4 months following radial arterial access. Technical success was 98.7%. One patient developed radial artery spasm, and the access was abandoned. This patient subsequently underwent brachial arterial access. No patient required conversion to a femoral arterial access. No other complications were encountered during the follow-up. Compared with femoral arterial access, radial arterial access required longer catheters were needed for super selective catheterization of the visceral arteries. Conclusion Radial arterial access for arterial interventions in the hepatobiliary and gastrointestinal systems was technically feasible with no significant complications. Long catheters are required for selective catheterization of the visceral arteries with this approach.

Splenic embolization as an alternative to surgical splenectomy for the restoration of blood counts suitable for effective chemotherapy in gastrointestinal malignancies (GIM).

396 Background: Chemotherapy regimens used for GIM are often notably myelosuppressive and may also engender hypersplenism. This can result in platelet (plt) and/or absolute neutrophil counts (ANC) too low for the maintenance of required dose intensity or frequency. One successful approach to this problem is surgical splenectomy but this is both morbid and invasive. An alternative strategy uses super-selective embolization of the splenic arterial tree, which is performed as an outpatient, and is far better tolerated. The true efficacy of this technique is uncertain and the optimal patients (pts) for this procedure are not well defined. Methods: Between 11/2012 and 6/2015, pts with ECOG PS 0/1 currently on active therapy for GIM in our clinics, whose plts and/or ANC were consistently below threshold values for appropriate frequency or intensity of therapy, were referred to Interventional Radiology for splenic embolization. Selective catheterization of the splenic artery was achieved via a femoral approach. This was followed by super-selective catheterization of branches of the splenic artery, as distally as possible, with subsequent embolization using Embosphere particles (300-500 micron spheres). All pts received prophylactic IV antibiotics. Results: 10 pts were identified and referred and all were deemed suitable for embolization. The mean plt count prior to the procedure was 73,000 (39,000-167,000) and the mean ANC was 3.5 (1.3 – 5.3). Following one procedure in 9 pts and 2 procedures in 1 pt, the mean plt count rose to 175,000 (55,000-432,000) and the ANC to 7.2 (2.9 – 13.2) immediately, and to a maximum of 253,000 (76,000-511,000) and 9.3 (5.0 – 14.5) within one to two months.Splenic enlargement was noted in 6 pts (mean size 18.3 cm) prior to the procedure and was not present in 4 pts. Following embolization all patients were able to resume chemotherapy with previously effective doses and/or frequency. Conclusions: In our cohort of pts with GIM, splenic embolization was successful at restoring acceptable plt and/or ANC levels for the resumption of effective chemotherapy. Splenomegaly does not appear to be a prerequisite for success.