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Optimal scoring system for clinical prognostic factors in patients with unresectable hepatocellular carcinoma (HCC) is currently uncertain. We aimed to develop and externally validate an easy to use tool, particularly for this population, and named it the unresectable hepatocellular carcinoma prognostic index (UHPI). We evaluated the data of patients with treatment-naive unresectable HCC who were diagnosed in the training center from 2010 to 2019 (n = 209). A simple prognostic model was developed by assigning points for each covariate in proportion to the beta coefficients in the Cox multivariable model. Predictive performance and distinction ability of the UHPI were further evaluated in an independent European validation cohort (n = 147) and compared with 11 other available models. A simple scoring system was derived, assigning 0.5/1/2 scores for six independent covariates including, the Child-Pugh score, Eastern Cooperative Oncology Group performance status, maximum tumor size, vascular invasion or extrahepatic metastasis, lymph node involvement, and alpha-fetoprotein. The UHPI score, ranging from 0 to 6, showed superior performance in prognosis prediction and outperformed 11 other staging or prognostic models, giving the highest homogeneity (c-index, 6-month and 1-year area under the receiver operator characteristic curves), lowest Akaike information criterion, and -2 log-likelihood ratio values. The UHPI score allocated well the risk of patients with unresectable HCC for mortality within the first year, using two cut-off values (low-risk, 2). Conclusion: The UHPI score can predict prognosis better than other systems in subjects with unresectable HCC and can be used in clinical practice or trials to estimate the 6-month and 1-year survival probabilities for this group.

Background In the last years, Selective Internal Radiation Therapy (SIRT), using biocompatible Yttrium-90 (90Y) labeled microspheres have emerged for the treatment of malignant hepatic tumors. Unfortunately, a significant part of 90Y-labeled microspheres may shunt to the lungs after intraarterial injection. It can be predictable by infusing technetium-99 m-labeled macro-aggregated albumin particles through a catheter placed in the proper hepatic artery depending on the lobe to be treated with performing a quantitative lung scintigraphy. Radiation pneumonitis (RP) can occur 1 to 6 months after the therapy, which is a rare but severe complication of SIRT. Prompt timing of steroid treatment is important due to its high mortality rate. On the other hand, pulmonary diffusion capacity measured by carbon monoxide (DLCO) is an excellent way to measure the diffusing capacity because carbon monoxide is present in minimal amount in venous blood and binds to hemoglobin in the same manner as oxygen. Some authors reported that the most consistent changes after radiation therapy (RT) are recorded with this quantitative reproducible test. The relationship between the proportional reductions in DLCO and the severity of RP developing after this therapy may prove to be clinically significant. Case presentation We herein present a patient who developed RP after SIRT that could be quantified using DLCO. To the best of our knowledge, this case is the first who developed unexpected RP after SIRT with significant decrease in DLCO with internal radiation exposure. Conclusions RP is a very rare complication and may lead to a fatal outcome. Decline in DLCO could be a valuable parameter for follow-up and to identify potential candidates for RP and could be also another trigger for administration of steroid therapy with prompt timing in this patient group.

Purposes: To evaluate changes in ocular blood flow and subfoveal choroidal thickness in patients with symptomatic carotid artery stenosis after carotid artery stenting. Methods: We included 15 men (mean age, 63.6 ± 9.1 years) with symptomatic carotid artery stenosis and 18 healthy volunteers (all men; mean age, 63.7 ± 5.3 years). All participants underwent detailed ophthalmologic examinations including choroidal thickness measurement using enhanced depth-imaging optic coherence tomography. The patients also underwent posterior ciliary artery blood flow measurements using color Doppler ultrasonography before and after carotid artery stenting. Results: Patients lacked ocular ischemic symptoms. Their peak systolic and end-diastolic velocities increased to 10.1 ± 13.1 (p=0.005) and 3.9 ± 6.3 (p=0.064) cm/s, respectively, after the procedure. Subfoveal choroidal thicknesses were significantly thinner in patients with carotid artery stenosis than those in the healthy controls (p=0.01). But during the first week post-procedure, the subfoveal choroidal thicknesses increased significantly (p=0.04). The peak systolic velocities of the posterior ciliary arteries increased significantly after carotid artery stenting (p=0.005). We found a significant negative correlation between the mean increase in peak systolic velocity values after treatment and the mean preprocedural subfoveal choroidal thickness in the study group (p=0.025, r=-0.617). Conclusions: In patients with carotid artery stenosis, the subfoveal choroid is thinner than that in healthy controls. The subfoveal choroidal thickness increases after carotid artery stenting. Carotid artery stenting treatment increases the blood flow to the posterior ciliary artery, and the preprocedural subfoveal choroidal thickness may be a good predictor of the postprocedural peak systolic velocity of the posterior ciliary artery.

We aimed to present five patients presenting with hypertension and diagnosed as renal artery stenosis. Five patients with renal artery stenosis were studied retrospectively. Two of our cases were diagnosed as fibromuscular dysplasia, other cases were diagnosed as Takayasu arteritis and Moyamoya disease, and one of them had congenital vascular abnormality. Renovascular hypertension is one of the most important causes of secondary hypertension in children, and renal artery stenosis constitutes a significant proportion of renovascular disease. We must consider renal artery stenosis in children presenting with resistant hypertension.

Objective: We aimed to share our experience about the super-selective embolization of the vesical artery performed with micro-catheter technique which was used as a palliative approach to control intractable hematuria in patients with bladder cancer. Materials and Methods: Super-selective embolization of the vesical artery with micro-catheter technique was performed in 12 bladder cancer patients whose hematuria could not be controlled with other palliative methods in our clinic. Hemoglobin levels, blood transfusion amounts, complications and urethral catheter removal duration before and after embolization were evaluated. Results: The average age of the patients was 73.3 (65-85, range) years. For the embolization process, n-butyl-2cyaboacrylate (glue) was used as the primary method in 3 patients and polyvinylalcohol (PVA) particle was used in the remaining 9 patients. In two of the patients whose hematuria could not be controlled after PVA embolization glue embolization was performed as the secondary procedure within one week. Super-selective embolization of the vesical artery with micro-catheter technique was performed in all of our cases. In 4 cases, embolization of the vesical artery was performed only to the side of the tumor, which was determined with cystoscopy. Bilateral embolization was performed to the remaining 8 cases. The average hemoglobin value before and after the embolization procedure was 7.9 g/dL and 9.2 g/dL, respectively. The average blood transfusion amounts before and after the procedure were 4 (2-15) and 2.3 (1-4) units erythrocyte/whole blood, respectively. The average urethral catheter duration after the procedure was 7 (2-16) days in 10 patients, who were treated one single embolization session. Urethral catheters were removed once the hematuria dissolved completely. There were no major complications or mortality related to the treatment after the embolization procedure. Conclusion: Super-selective embolization of the vesical artery performed with micro-catheter technique is a safe and effective alternative in patients with intractable hematuria due to bladder cancer whose hematuria could not be controlled with other palliative methods.

IntroductionThe Woven EndoBridge (WEB) represents a novel intrasaccular therapeutic option for the treatment of intracranial wide-necked bifurcation aneurysms (WNBAs). The WEB-IT Study is a pivotal Investigational Device Exemption (IDE) study to determine the safety and effectiveness of the WEB device for the treatment of WNBAs located in the anterior and posterior intracranial circulations. We present the patient demographics, procedural characteristics, and 30-day adverse event data for the US WEB-IT study.MethodsWEB-IT is a prospective multicenter single-arm interventional study conducted at 25 US and 6 international centers. The study enrolled 150 adults with WNBAs of the anterior and posterior intracranial circulations. All patients were intended to receive a WEB device delivered via standard endovascular neurosurgical embolization techniques. The study was conducted under Good Clinical Practices and included independent adjudication effectiveness outcomes and all adverse events.ResultsOne hundred and fifty patients enrolled at 27 investigational sites underwent attempted treatment with the WEB. Mean age was 59 years (range 29–79) and 110 (73.3%) of the patients were female. Treated aneurysms were located at the basilar apex (n=59, 39.3%), middle cerebral artery bifurcation (n=45, 30%), anterior communicating artery (n=40, 26.7%), and internal carotid artery terminus (n=6, 4%). Average aneurysm size was 6.4 mm (range 3.6–11.4) with a mean neck size of 4.8 mm (range 2.0–8.2, mean dome to neck ratio 1.34). Nine patients presented with ruptured aneurysms. Of the enrolled patients, 98.7% were treated successfully with WEB devices. Mean±SD fluoroscopy time was 30.2±15.7 min. One primary safety event (PSE) (0.7%)—a delayed parenchymal hemorrhage 22 days after treatment—occurred between the index procedure and 30-day follow-up. In addition to the single PSE, there were seven (4.7%) minor ischemic strokes (5 resolved without sequelae and 2 had a modified Rankin Scale score of 1 at 30 days), five (2.7%) transient ischemic attacks, and two (1.3%) minor subarachnoid hemorrhages, which did not meet the prospectively established criteria for PSEs.ConclusionsThe WEB device can be used to treat WNBAs with a high level of procedural safety and a high degree of technical success.Trial registration numberNCT02191618; Pre-results.

Background: Selective internal radiation therapy (SIRT) with embolization of branches of the hepatic artery is a valuable therapeutic tool for patients with hepatic malignancies; however, it is also associated with lung injury risk due to shunting. Diffusion capacity of the lungs for carbon monoxide (DLCO) is a clinically significant lung function test, and worsening in DLCO is suggested to reflect a limited gas exchange reserve caused by the potential toxicity of chemoradiotherapy or it may be a marker of related lung injury. This study aimed to examine the changes in DLCO during SIRT with resin microspheres in newly treated and retreated patients. Forty consecutive patients who received SIRT for a variety of malignant conditions were included. All subjects were treated with Yttrium-90 labelled resin microspheres. DLCO tests were performed after the procedures. In addition, patients were specifically followed for radiation pneumonitis. Results: The mean DLCO did not significantly change after the first (82.8 +/- 19.4 vs. 83.1 +/- 20.9, p = 0.921) and the second treatments (87.4 +/- 19.7 vs. 88.6 +/- 23.2, p = 0.256). Proportion of patients with impaired DLCO at baseline was not altered significantly after the first (37.5 vs. 45.0%, p = 0.581) and the second treatments (27.3 vs. 27.3%, p = 1.000). Also, percent change in DLCO values did not correlate with radiation dose, lung shunt fraction, or lung exposure dose (p > 0.05 for all comparisons). None of the patients developed radiation pneumonitis. Conclusions: Our results suggest that no significant change in DLCO in association with SIRT occurs, both after the first or the second treatment sessions. Further larger studies possibly with different protocols are warranted to better delineate DLCO changes after SIRT in a larger spectrum of patients.

Objectives: The aim of this study was to evaluate intraocular pressure (IOP) and retinal nerve fiber layer (RNFL) changes in patients with carotid artery stenosis (CAS) after carotid artery stenting. Materials and Methods: This study was conducted as a cross-sectional, non-randomised clinical case series. Fifteen male patients (mean age: 63.6ae9.1) with CAS and more than 70% carotid artery narrowing were included. All of the patients were followed in the department of neurology and were operated in the interventional radiology division. Eighteen healthy male subjects (mean age: 63.7ae5.3) were included in the control group. All of the healthy subjects had a detailed ophthalmological examination and subjects with any chronic eye disease were excluded from the study. All of the participants had a detailed ophthalmological examination including tonometry using Goldmann applanation tonometry and RNFL analysis using optical coherence tomography (RTVue-100 5.1). Results: There were no ocular ischemic symptoms in any of the participants. The mean IOP value was 15.1ae2.1 mmHg in the control group and 16.6ae2.4 mmHg before stent implantation, 16.4ae2.2 mmHg at 1 week after implantation, 16.6ae2.5 mmHg at 1 month after implantation, and 16.7ae2.9 mmHg at 3 months after implantation in the CAS group. Mean RNFL thickness was 105ae6 mu m in the control group; in the CAS group, mean RNFL thickness values were 98ae27 mu m before stent implantation and 103ae11 mu m, 101ae10 mu m, and 101ae11 mu m at 1 week, 1 month, and 3 months after stenting. There were no significant differences between the CAS group and control group regarding IOP and RNFL thickness values (p> 0.05). IOP and RNFL thickness also did not show any statistically significant changes from preoperative measurements in 3 months postoperative follow-up in the CAS group (p> 0.05). Conclusion: IOP and RNFL thickness remained unchanged after carotid stent implantation in carotid artery stenosis patients with no signs of ocular ischemic syndrome.

Objective We present two treatment modalities, selective renal angioembolization and renorraphy, in massive renal hemorrage after percutaneous nephrolithotomy (PCNL) that could not be controlled by conservative methods. Materials and Methods One thousand two-hundred patients, who had undergone PCNL between January 2003 and February 2014, were retrospectively reviewed. From these cases, we selected patients with massive post procedural bleeding that could not be taken under control by conservative methods and we reviewed their clinical course and treatment results. Results Bleeding could not controlled by conservative methods in 6 patients and, angioembolization was done succesfully. In 3 patients, angioembolization was not available. Renorraphy was performed in 2 patients and nephrectomy in 1 patient at first attempt. Renorraphy could not solve the problem of massive hemorrage and these 2 patients eventually underwent nephrectomy. Conclusion Renal angiography and embolization is an effective and safe method and renorraphy should not be the first option in massive bleeding after PCNL that can not be taken under control by conservative methods.

Priapism in pediatric patients is a rare entity. We present an 8-yearold boy with known cerebral palsy. He came to the emergency department with sustained painful erection for 12 hours. Physical examination showed rigid penis. Blood count and biochemical analysis were normal. Although penile Doppler ultrasound revealed normal arterial and venous flow, cavernosal blood gas was hypoxic. A total of 50 mL of dark blood was aspirated, and 2 mL of 0.001% adrenalin solution was applied to both corpus cavernosum, twice within 20 minutes, which eventually did not achieve detumescence. A distal Winter shunt was performed at the end of which the penis was semi-flaccid. By the 18th hour of surgery, the penis re-gained painful erection status, so an Al-Ghorab shunt was performed. After the Al-Ghorab shunt, the penis was still in the semi-flaccid state. The next day, an angiography was performed and an arteriovenous fistula was discovered and treated by embolization. The flaccid state was achieved and the patient was discharged the day after the embolization.