GvHD results in death in the majority of steroid-resistant patients. This report assesses the safety and efficacy of two regional intra-arterial steroid (IAS) treatment protocols in the largest published cohort of patients with resistant/dependent hepatic and/or gastrointestinal GvHD, as well as identification of predictors of response to IAS and survival. One hundred and twenty patients with hepatic, gastrointestinal GvHD or both were given IAS. Gastrointestinal initial response (IR) and complete response (CR) were documented in 67.9% and 47.6%, respectively, whereas hepatic IR/CR in 54.9% and 33.3%, respectively. The predictors of gastrointestinal CR were lower peak GvHD and steroid-dependent (SD) GvHD. The predictors for hepatic CR were male patient, reduced intensity conditioning and SD GvHD. Twenty-six of the 120 patients (21.6%) are currently alive (median follow-up for the survivors 91.5 months). The 12 months' overall survival is 30% with no treatment-associated deaths. Predictors of 12 months' survival were as follows: first transplant, age<20 years, non-TBI regimen and GvHD CR. Shorter time to gastrointestinal IR but not time to hepatic IR was associated with improved 12 months' survival. IAS appears to be safe and effective. Gastrointestinal treatment is more effective than hepatic treatment. In our study, we conclude our current recommendations for IAS treatment.
The aim of the study was to show the capabilities of endovascular occlusion of giant posttraumatic pseudo-aneurysm of superior mesenteric artery (SMA) connected to a mesenteric arteriovenous fistula (AVF) under the conditions of portal hypertension and lifethreatening esophageal variceal bleeding. Materials and Methods. A 27-old male patient underwent endovascular occlusion; the patient being hospitalized with a clinical picture of gastrointestinal bleeding. The examinations: ultrasound, esophagogastroduodenoscopy, multispiral computed tomography with angiography-revealed the source of bleeding to be esophageal varices against the background of portal hypertension caused by massive arteriovenous shunt, its source being AVF with an aneurysmal component (32×35 mm in size) between SMA and superior mesenteric vein (SMV) dilated up to 50 mm in diameter. Patient's past medical history recorded that 4.5 years ago the patient had undergone the resection of a small intestine area due to a penetrating stab wound in the abdominal cavity. Taking into consideration an extremely high operative intervention risk due to the condition severity related to blood loss, portal hypertension, and ascites, it was decided to embolize AVF with a vascular occluder-Amplatzer Vascular Plug II (USA), 14×10 mm in size. Results. A unique endovascular intervention-transcatheter occlusion of pseudo-aneurysm and AVF separation-was performed in life-threatening esophageal variceal bleeding under the condition of a giant post-traumatic aneurysm of SMA and mesenteric AVF. Due to an extremely large-sized SMV and an arterial pseudo-aneurysm, first ever we used the technique applied for transcatheter occlusion of a cardiac septum defect. Occluder implantation enabled to completely close the communication of aneurysmatic AVF with SMV, and occlude the aneurysm cavity. During an immediate postoperative period portal hypertension was arrested. No recurrent bleedings occurred within 4 postoperative months.
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