Keywords:
Interventional vascular, Gastrointestinal tract, Haematologic, Catheter arteriography, Outcomes analysis, Catheters, Arterial access
Authors:
D. Bürgler, C. Bucher, J. Passweg, A. Fischmann; Basle/CH
DOI:
10.1594/ecr2013/C-1041
Conclusion
Catheter guided intraarterial steroid administration (IASA) is a feasible and seems to be an effective second line treatment option for systemic steroid refractory GI aGvHD.
GI aGvHD is characterized by both a reduction in the number of steroid receptors in diseased tissue and a decrease in the receptors’ affinity for steroids [6,
7].
Further and higher doses of systemic steroids have failed to improve symptoms of GI aGvHD and furthermore cause profound immunosuppression associated with increased risk of infection and tumor recurrence.
IASA delivers treatment directly to the diseased gastrointestinal tissue.
High concentrations of steroids can be applied locally,
thereby overcoming the underlying unresponsiveness without further depressing the already incompetent immune system in these patients.
Two small previous reports enrolling 11 and 15 patients reported the effect of IASA in steroid refractory GI aGvHD.
Shapira et al enrolled 15 patients with liver and / or GI aGvHD [4].
Another report of Weintraub et al enrolled 11 patients with GI aGvHD.
They used a study protocol comparable to ours.
Partial response was defined as improved symptoms at discharge and complete response was defined as complete resolution of symptoms at discharge [5].
In our cohort 33% of our patients showed a complete response,
while Shapira et al.
reported a complete response in 82% and Weintraub et al.
in 36% of the patients.
Contrary to Shapira et al,
who also included responders who died in hospital,
we and Weinberg et al.
evaluated death in hospital as non-response.
This possibly explains the slight difference in the response rate.
We found a lower response rate (50%) compared to Weintraub et al,
who reported improved symptoms at discharge in 72% of patients.
However both studies only enrolled a small number of patients,
with single cases affecting the results.
This is also visible in the long-term survival rate of 50% compared to 43% and 27% at a median of one year in Shapira and Weintraub’s data respectively.
However,
our study has a limitation in the fact,
that 3 patients currently only completed a follow-up of 64,
72 and 98 days respectively,
and can therefore not be evaluated in the one year survival rate.
No complications occurred during IASA.
One patient developed a duodenal ulcer two days after the second IASA during which we administrated higher doses of methylprednisolone (200 mg).
There is a high probability that this ulceration was related to IASA.
These data are encouraging and should promote further investigation.