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Preoperative PVE is a safe and effective method of increasing the remnant liver volume before extended hepatectomy. Increasing the remnant liver volume in patients with estimated postresection volumes of less than 25% appears to reduce postoperative liver dysfunction.

Tranarterial chemoembolization (TACE) has been established by a meta-analysis of randomized controlled trials as the standard of care for nonsurgical patients with large or multinodular noninvasive hepatocellular carcinoma (HCC) isolated to the liver and with preserved liver function. Although conventional TACE with administration of an anticancer-in-oil emulsion followed by embolic agents has been the most popular technique, the introduction of embolic drug-eluting beads has provided an alternative to lipiodol-based regimens. Experimental studies have shown that TACE with drug-eluting beads has a safe pharmacokinetic profile and results in effective tumor killing in animal models. Early clinical experiences have confirmed that drug-eluting beads provide a combined ischemic and cytotoxic effect locally with low systemic toxic exposure. Recently, the clinical value of a TACE protocol performed by using the embolic microsphere DC Bead loaded with doxorubicin (DEBDOX; drug-eluting bead doxorubicin) has been shown by randomized controlled trials. An important limitation of conventional TACE has been the inconsistency in the technique and the treatment schedules. This limitation has hampered the acceptance of TACE as a standard oncology treatment. Doxorubicin-loaded DC Bead provides levels of consistency and repeatability not available with conventional TACE and offers the opportunity to implement a standardized approach to HCC treatment. With this in mind, a panel of physicians took part in a consensus meeting held during the European Conference on Interventional Oncology in Florence, Italy, to develop a set of technical recommendations for the use of DEBDOX in HCC treatment. The conclusions of the expert panel are summarized.

Although the vascular system is presently being imaged by multiple high technology modalities, contrast angiography continues to be the gold standard; however, severe complications rarely occur. During the last 25 years (in over 1400 patients), CO2 has proven to be extremely safe (no allergy or renal failure). However, it is imperative to understand CO2's physical properties and potential dangers. Recently, CO2 is being routinely utilized not only because of safety, but for detection of minute amounts of bleeding, better collateral filling, and for most interventional procedures since unlimited volumes of CO2 can be injected between the catheter and guidewire. Presently, safe, reliable and "user-friendly" delivery systems are now commercially available. CO2 DSA images are now nearly comparable to iodinated contrast, and improvement in DSA images are evolving, including "stacking" software.

SUMMARY Background Standard of practice involves using transarterial therapy for multifocal hepatocellular carcinoma (HCC) alone and sorafenib only for more advanced HCC, but the sorafenib and transarterial therapy combination may provide greater efficacy. Aim To evaluate the safety and efficacy of concurrent sorafenib and transarterial therapy in HCC. Methods Consecutive cases of HCC were treated with sorafenib and transarterial therapy, receiving sorafenib 2 to 4 weeks before transarterial therapy. Baseline clinical parameters, adverse events (AEs) and survival were collected. Results A total of 47 patients received sorafenib and transarterial therapy. The majority of the patients were male (70%) with HCV (60%), median age of 60 years, good performance status (0–1), stable cirrhosis (Child: A 72%; B 28%), unresectable turnour (stage: B 81%; C 19%) and median AFP of 24 ng/mL. Median follow-up was 12 months and median time on sorafenib was 6 months. LC Bead TACE was used with a median frequency of 3. The majority of the patients (89%) experienced AEs. The most common AEs were fatigue (51%), hand-foot skin reaction (51%) and diarrhoea (43%). Grade 3 and 4 AEs included fatigue (13%) and hand-foot skin reaction (26%). Most patients required a dose reduction (66%). The main AE related to transarterial therapy was post-TACE syndrome (23%). The disease control rate was 68% at 6 months. Overall median survival rate was 18.5 months (95% CI 16.1–20.9 months). Conclusion Concurrent sorafenib and transarterial therapy is overall safe with no unexpected side effects and encouraging efficacy that warrants further study.

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OBJECTIVE. The intentof thisstudywasto substantiate theadvantages of theuseof sonographic guidancefor centralvenousaccessvia the right internaljugular vein. SUBJECTSAND METHODS. Eightysequential patients requiring central veinaccesswere examined with a hand-held sonography transducer to determine the size, patency, and locationof the right internaljugular vein beforepuncture. Accessto the right internaljugular vein was subsequently performed, under sterile conditions, using sonographic guidance. Periprocedural complications were prospectively recorded. Subsequently, we compared our findingswith publishedreportsof complicationswhen visible and palpableanatomicland marks were used for guidance during cannulation of the internal jugular vein. RESULTS.Amongthese 80patients, theanatomy of therightinternal jugularveinwastypical in only 57 (71%). In another 13 patients (16%), sonography showed a medial position of the right internal jugular vein, anterior to the common carotid artery. In three other patients (4%), the right internaljugular vein was positioned laterally by more than 1 cm. In the remain ing seven patients (9%), the vein was thrombosed. Its diameter, measured without use of the Valsalva maneuver, also varied, measuring 0.5-2.0 cm. Cannulation was achieved in all 73 pa tients with a patent right internaljugular vein. One puncture was required in 68 patients (93%);two puncturesin threeotherpatients(4%); andthreepuncturesin the remainingtwo patients (3%). In no case was the common carotid artery inadvertently punctured. Only one periproce duralcomplicationoccurred, andit wasunrelatedto the useof sonographic guidance. CONCLUSION. Sonographic guidance forcentral veinaccess viatherightinternal jugular vein is safer and more efficient than the traditional landmark approach. 2â€"5]. The traditional method of using ana tomic landmarksto guide cannulation of the right internal jugular vein has yielded various rates for successful access and complications [6][7][8][9]. These rates depend not only on the experi ence of the operator but also on the underlying patency and anatomy ofthe right internal jugular vein. We believe that the use of a hand-held transducer for real-time sonography before the procedure and for guidance during the procedure canimproveaccess to therightinternal jugular vein and limit complications. Subjects and MethodsDuring a 3-month interval, 80 consecutive patients in whom a right internaljugular vein approachwas beingused for centralveinaccesswereexaminedbe fore the procedure with hand-held real-time sono graphic transducers. Either a Sonolayer SSH-140A(ToshibaAmericaMedicalSystems,Carroilton,TX) ora Site-Rite II (Dymax, Pittsburgh, PA)wasused to determinethe size, patency,and locationof the right internal jugular vein before puncture. To simulate the landmark approach, the patient's head was rotated 30'to the leftand scanningwas performedat the apexof bothheadsofthe sternocleidomastoid muscle.Thirty seven males and 43 females 15â€"76 years old were examined. For those patients who proceeded t...