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A 64-year old man had developed a giant mediastinal lymphocele after undergoing esophagectomy for the treatment of esophageal squamous cell carcinoma. The thoracic duct was embolized with six micro-coils, followed by embolization using a 1:3 mixture of N-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) and ethiodized oil. Resolution of the lymphocele was achieved within 5 days after embolization. To the best of our knowledge, ours is the first reported case of thoracic duct embolization for the treatment of mediastinal lymphocele.

Background and aims Optimal candidates for early transjugular intrahepatic portosystemic shunt (TIPS) in patients with Child-Pugh B cirrhosis and acute variceal bleeding (AVB) remain unclear. This study aimed to test the hypothesis that risk stratification using the Chronic Liver Failure Consortium Acute Decompensation score (CLIF-C ADs) may be useful to identify a subgroup at high risk of mortality or further bleeding that may benefit from early TIPS in patients with Child-Pugh B cirrhosis and AVB. Approach and results We analyzed the pooled individual data from two previous studies of 608 patients with Child-Pugh B cirrhosis and AVB who received standard treatment between 2010 and 2017 in China. The concordance index values of CLIF-C ADs for 6-week and 1-year mortality (0.715 and 0.708) were significantly better than those of active bleeding at endoscopy (0.633 [P 56), with a 5.6%, 16.8%, and 25.4% risk of 6-week death, respectively. Nevertheless, the performance of CLIF-C ADs for predicting a composite endpoint of 6-week death or further bleeding was not satisfactory (area under the receiver operating characteristics curve [AUC], 0.588). A nomogram incorporating components of CLIF-C ADs and albumin, platelet, active bleeding, and ascites significantly improved the prediction accuracy (AUC, 0.725). Conclusions In patients with Child-Pugh B cirrhosis and AVB, risk stratification using CLIF-C ADs identifies a subgroup with high risk of death that may derive survival benefit from early TIPS. With improved prediction accuracy for 6-week death or further bleeding, the data-driven nomogram may help to stratify patients in randomized trials. Future external validation of these findings in patients with different etiologies is required.

Gastric varices are a major complication of portal hypertension in patients with liver cirrhosis and are associated with more massive bleeding events and higher mortality rate. Transjugular intrahepatic portosystemic shunt (TIPS) and balloon-occluded retrograde transvenous obliteration (BRTO) have been well documented as effective therapies for portal hypertensive gastric variceal bleeding. In China, TIPS are well accepted but BRTO is not well recieved due to the increase risk of complications associated with traditional BRTO. However, modified-BRTO, known as coil-assisted and plug-assisted retrograde transvenous obliteration (CARTO and PARTO, respectively), is receiving increased attention due to devoid of BRTO’s shortcomings. No CARTO case from China has been reported in literature thus far. Here, we present a Chinese case of CARTO to treat gastric varices bleeding.

OBJECTIVES To evaluate the safety of irreversible electroporation (IRE) on swine pancreatic tissue including its effects on peripancreatic vessels, bile ducts, and bowel. METHODS Eighteen Yorkshire pigs underwent IRE ablation of the pancreas successfully and without clinical complications. Contrast-enhanced computed tomography angiography and laboratory studies before the IRE ablation with follow-up computed tomography angiography, laboratory testing, and pathological examination up to 4 weeks postablation were performed. RESULTS In a subset of cases, anatomic peripancreatic vessel narrowing was seen by 1 week postablation, persisting at 4 weeks postablation, without apparent functional impairment of blood flow. Laboratory studies revealed elevated amylase and lipase at 24 hours post-IRE, suggestive of acute pancreatitis, which normalized by 4 weeks post-IRE. There was extensive pancreatic tissue damage 24 hours after IRE with infiltration of immune cells, which was gradually replaced by fibrotic tissue. Ductal regeneration without loss of pancreatic acinar tissue and glandular function was observed at 1 and 4 weeks postablation. CONCLUSIONS In our study, we demonstrated and confirmed the safety and minimal complications of IRE ablation in the pancreas and its surrounding vital structures. These results show the potential of IRE as an alternative treatment modality in patients with pancreatic cancer, especially those with locally advanced disease.

Author(s): Lee, Edward Wolfgang; Sue, Megan J; Saab, Sammy; DiNorcia, Joseph; McWilliams, Justin P; Kaldas, Fady; Ding, Peng-Xu; Padia, Siddharth A; Agopian, Vatche; Farmer, Douglas; Busuttil, Ronald W | Abstract: IntroductionThe purpose of this study was to investigate the rates of complications and diagnostic yield of transjugular liver biopsy (TJLB) in deceased donor liver transplant (DDLT) recipients.MethodsFrom January 2009 to December 2019, 1,055 TJLBs were performed in 603 adult DDLT recipients with a mean age of 54 (±12 years). Data were retrospectively reviewed to determine the diagnostic efficacy and incidence of major and minor complications in the 3-day and 1-month period after TJLB. In addition, data were stratified according to platelet count and international normalized ratio to determine the safety of TJLB in patients with varying degrees of coagulopathy.ResultsTJLB yielded diagnostic rate of 98.1% (1,035/1,055), with an overall complication rate of 8.3% (88/1,055). Major complications accounted for 0.85% (9/1,055), and minor complications occurred in 7.48% (79/1,055). When patients were stratified by platelet count (0-50, 51-100, 101-200, 201-300, and g300 × 103 platelets/μL), no significant difference was noted in complication rates (9.5%, 8.6%, 7.6%, 8.5%, and 10.7%, respectively). When grouped by international normalized ratio (0-1, 1.1-2.0, 2.1-3.0, and g3.0), there was no statistical difference in complication rates (8.3%, 8.5%, 7.7%, and 0%, respectively).DiscussionTJLB is a safe, adequate, and effective method to investigate hepatic disorders in DDLT recipients with severe coagulopathy.

Percutaneous transluminal balloon angioplasty (PTA) is the main treatment option for Budd–Chiari syndrome (BCS) with inferior vena cava (IVC) obstruction. However, IVC rupture caused by PTA has never been reported. Between August 2004 and December 2016, a consecutive cohort of 617 BCS patients with obstructed IVC who underwent PTA with or without stent placement were reviewed retrospectively to identify IVC rupture. Pre- and post-procedural imaging data, clinical and procedural technical data were analyzed. Of the 617 BCS patients, five patients had IVC rupture caused by PTA (0.81%). Four of these patients had retroperitoneal, intra-hepatic IVC rupture without extravasation into abdominal cavity which was successfully managed conservatively. One patient had supra-hepatic IVC rupture into the pericardial cavity which was surgically treated. IVC rupture is a rare complication of PTA treatment of BCS and most commonly located at the intra-hepatic IVC caused by oversized balloons which does not require additional treatment.

Increasing evidence has indicated that intimal hyperplasia is a common event in the pathophysiology of many vascular diseases including atherosclerosis (AS). Recently, deregulated microRNAs (miRNAs) have been reported to be associated with the pathophysiology of AS. However, the biological function and regulatory mechanisms of miRNAs in intimal hyperplasia in AS remain largely unclear. The aim of this study was to investigate the effects of miRNAs on intimal hyperplasia and reveal the underlying mechanisms of their effects. Firstly, the model of rat vascular injury was successfully constructed in vivo. Then, the miRNAs expression profiles were analyzed by miRNA microarray. It was observed that miR-451 was significantly downregulated in injury carotid arteries. Subsequently, we investigated miR-451 function and found that upregulation of miR-451 by agomir-451 improves intimal thickening in rats following vascular injury. It was also observed that miR-451 was downregulated in the VSMCs following platelet-derived growth factor type BB (PDGF-BB) stimulation. The upregulation of miR-451 attenuated PDGF-BB-induced VSMCs injury, as evidenced by inhibition of proliferation, invasion and migration. Besides, overexpression of miR-451 blocked the activation of p38 MAPK signaling pathway in PDGF-BB treated VSMCs, as demonstrated by the downregulation of phosphorylated (p-) p38. In addition, Ywhaz, a positive regulator of p38 MAPK signaling pathway, was found to be a direct target of miR-451 in the VSMCs and this was validated using a luciferase reporter assay. Overexpression of Ywhaz partially abolished the inhibitory effects of miR-451 overexpression on PDGF-BB induced VSMCs injury. Collectively, these findings indicated that miR-451 protected intimal hyperplasia and PDGF-BB-induced VSMCs injury by Ywhaz/p38 MAPK pathway, and miR-451 may be considered as a potential therapeutic target in the treatment of AS.

Objectives The aim was to evaluate individualised treatment and long-term outcomes of endovascular treatment of Budd–Chiari syndrome (BCS) complicated by inferior vena cava (IVC) thrombosis. Methods Between April 2005 and December 2015, 108 consecutive patients with BCS complicated by IVC thrombosis underwent endovascular treatment. According to the type, size, extent, and degree of organisation of the thrombus, agitation thrombolysis (n = 7), agitation thrombolysis combined with retrieval stent filter (n = 5), pre-dilation (n = 32), retrieval stent filter (n = 56), or direct large balloon dilation (n = 8) was performed. Peri- and post-operative follow-up data were recorded. Results The endovascular treatment was technically successful in 107 of the 108 patients (99.1%). The incidence of thrombosis related complications was 7.4% (8/108). Major and minor complications occurred in four patients. The mean follow-up duration was 61.7 ± 39.3 months (range 3–140 months). The cumulative 1, 2, 5, and 10 year primary patency rates were 91%, 88%, 79%, and 79%, respectively, and the cumulative 1, 2, 5, and 10 year secondary patency rates were 100%, 100%, 97%, and 97%, respectively. The cumulative 1, 5, and 10 year survival rates were 95%, 86%, and 81%, respectively. Serum albumin and total bilirubin values were independent predictors of survival. Conclusions For patients with BCS complicated by IVC thrombosis, an individualised endovascular treatment strategy based on the type, size, extent, and degree of organisation of the thrombus is associated with long-term patency of the IVC and favourable survival and complication rates.

// Yu-Ling Sun 1, 2 , Wen-Qi Li 1, 2 , Peng-Xu Ding 3 , Zhi-Wei Wang 3 , Chang-Hua Wei 4 , Xiu-Xian Ma 1, 2 , Rui-Fang Zhang 5 , Yan Wu 6 , Lin Zhou 7 , Ruo-Peng Liang 1, 2 , Yan-Peng Zhang 1, 2 , Yi-Pu Zhao 1, 2 , Rong-Tao Zhu 1, 2 and Jian Li 1, 2 1 Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China 2 Institute of Hepatobiliary and Pancreatic Diseases, Zhengzhou University, Zhengzhou, China 3 Department of Radioactive Intervention, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China 4 Department of Ultrasound Diagnosis, The People’s Affiliated Hospital, Zhengzhou University, Zhengzhou, China 5 Department of Ultrasound Diagnosis, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China 6 Department of Radiology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China 7 Department of Digestive Diseases, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China Correspondence to: Yu-Ling Sun, email: ylsun@zzu.edu.cn Keywords: Budd–Chiari syndrome; gut microbiota; prognosis Received: August 28, 2017 Accepted: November 14, 2017 Published: December 14, 2017 ABSTRACT Gut microbiota is associated with liver diseases. However, gut microbial characteristics of Budd-Chiari syndrome (B-CS) have not been reported. Here, by MiSeq sequencing, gut microbial alterations were characterized among 37 health controls, 20 liver cirrhosis (LC) patients, 31 initial B-CS patients (B-CS group), 33 stability patients after BCS treatment (stability group) and 23 recurrent patients after BCS treatment (recurrence group). Gut microbial diversity was increased in B-CS versus LC. Bacterial community of B-CS clustered with controls but separated from LC. Operational taxonomic units (OTUs) 421, 502 (Clostridium IV) and 141 (Megasphaera) were unique to B-CS. Genera Escherichia/Shigella and Clostridium XI were decreased in B-CS versus controls. Moreover, nine genera, mainly including Bacteroides and Megamonas, were enriched in B-CS versus LC. Notably, Megamonas could distinguish B-CS from LC with areas under the curve (AUCs) of 0.7904. Microbial function prediction revealed that L-amino acid transport system activity was decreased in B-CS versus both LC and controls. Furthermore, OTUs 27 (Clostridium XI), 137 (Clostridium XIVb) and 40 (Bacteroides) were associated with B-CS stability. Importantly, genus Clostridium XI was enriched in stability group versus both recurrence group and B-CS group. Also, PRPP glutamine biosynthesis was reduced in stability group versus recurrence group, but was enriched in stability group versus B-CS group. In conclusion, specific microbial alterations associated with diagnosis and prognosis were detected in B-CS patients. Correction of gut microbial alterations may be a potential strategy for B-CS prevention and treatment.

Misplacement of an inferior vena cava (IVC) filter in a gonadal vein is a rare complication of IVC filter placement. We report a case of a filter misplaced in the ovarian vein of a pregnant woman with agenesis of the infrarenal IVC and bilateral lower extremity deep venous thrombosis. The filter was removed by a loop-snare technique through an internal jugular vein. IVC agenesis and dilated right gonadal vein should be kept in mind when an IVC filter is being inserted in the infrarenal location through the jugular approach.

Budd-Chiari syndrome (BCS) is a rare disease characterized by the obstruction of hepatic venous outflow due to occlusion of the hepatic vein (HV) or the inferior vena cava (IVC). The pathophysiology of IVC and HV membranous transformation, which can form in isolation or simultaneously, remains unclear in patients with combined-type BCS. Here we report three cases of patients with BCS demonstrating conversion from HV-type to combined-type. Three patients with only HV-type BCS underwent percutaneous balloon angioplasty (PTA) of the obstructed HV. During follow up, membranous transformation of the IVC was observed. This condition was subsequently treated with PTA of the IVC. These cases demonstrate that HV-type BCS may convert to combined-type BCS.

Importance Varices are one of the main clinical manifestations of cirrhosis and portal hypertension. Gastric varices are less common than esophageal varices but are often associated with poorer prognosis, mainly because of their higher propensity to bleed. Observations Currently, treatments used to control and manage gastric variceal bleeding include β-blockers, endoscopic injection sclerotherapy, endoscopic variceal ligation, endoscopic variceal obturation, shunt surgery, transjugular intrahepatic portosystemic shunts, balloon-occluded retrograde transvenous obliteration (BRTO), and modified BRTO. In the past few decades, Western (United States and Europe) interventional radiologists have preferred transjugular intrahepatic portosystemic shunts that aim to decompress the liver and reduce portal pressure. Conversely, Eastern radiologists (Japan and South Korea) have preferred BRTO that directly targets the gastric varices. Over the past 20 years, BRTO has evolved and procedure-related risks have decreased. Owing to its safety and efficiency in treating gastric varices, BRTO is now starting to gain popularity among Western interventional radiologists. In this review, we present a comprehensive literature review of current and emerging management options, including BRTO and modified BRTO, for the treatment of gastric varices in the setting of cirrhosis and portal hypertension. Conclusions and Relevance Balloon-occluded retrograde transvenous obliteration has emerged as a safe and effective alternative treatment option for gastric variceal hemorrhage. A proper training, evidence-based consensus and guideline, thorough preprocedural and postprocedural evaluation, and a multidisciplinary team approach with BRTO and modified BRTO are strongly recommended to ensure best patient care.

Aim To evaluate individualized treatment strategy (ITS) and long-term outcomes of endovascular treatment of Budd-Chiari syndrome (BCS) with obstructed inferior vena cava (IVC) based on different degrees of hepatic vein (HV) involvement. Methods From January 2006 to June 2017, 456 consecutive patients with BCS with obstructed IVC underwent endovascular treatment with ITS. All patients received IVC recanalization. Then, 426 patients with at least one patent HV received no additional treatment. Twenty-fivepatients with membranous or segmental occlusion of HVs underwent HV recanalization and for the remaining five patients with diffuse HVs occlusion, a transjugular intrahepatic portosystemic shunt (TIPS) was performed. Results The endovascular treatment was technically successful in 455 of the 456 patients (99.8%). The complication rate was 5.0% (23/456), with major complications in 13 patients (2.8%) and minor complications in 10 patients (2.2%). Median follow-up time was 60.5 months (range, 4-120 months). The cumulative 1-, 2-, 5- and 10-year primary vessel patency rates were 93.6%, 89.9%, 80.5% and 74.3% respectively and the cumulative 1-, 2-, 5-, 10- year secondary patency rates were 99.8%, 99.8%, 98.2% and 97.2% respectively. The cumulative 1-, 2-, 5- and 10-year survival rates were 98.4%, 95.8%, 91.2% and 76.5% respectively. Illness duration and decreased serum albumin were independent predictors of survival. Conclusion The ITS for Asian BCS with obstructed IVC and varying degrees of HV involvement appears to be effective and with good long-term outcomes.

This study aimed to evaluate the long-term efficacy and safety of percutaneous transhepatic balloon angioplasty (PTBA) and transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the treatment of Budd–Chiari syndrome (BCS) with hepatic veins involvement. Between June 2008 and August 2016, a total of 60 BCS patients with hepatic vein involvement in our department were enrolled in this study. Thirty-three cases underwent hepatic vein balloon angioplasty in PTBA Group and 27 cases underwent TIPSS. Data were retrospectively collected, and follow-up observations were performed. TIPSS Group showed significantly higher thrombotic/segmental obstruction and peripheral stenosis/obstruction compared with PTBA Group. The success rates were 93.9% and 100.0% in PTBA Group and TIPSS Group, respectively. The mean portal vein pressure decreased significantly after stenting. Except for 1 patient died from repeated hemorrhage, other sever complications had not been observed in both group. Twenty-six patients and 21 patients were clinically cured in PTBA Group and TIPSS Group, respectively. The primary patency rates were 89.7%, 79.3%, and 79.3% for short-term, mid-term and longterm in PTBA Group, which were significantly higher than TIPSS Group for long-term follow up. The second patency rates were 100.0%, 96.6% and 96.6% for short-term, mid-term and long-term in PTBA Group, which were similar to TIPSS Group (P = 1.0000). In conclusion, PTBA and TIPSS are safe and effective in the treatment of BCS with hepatic veins involvement, with an excellent long-term patency rate of hepatic vein and TIPSS shunt. TIPSS can be used to treat patients with all 3 hepatic veins lesion and failure PTBA.

282 Background: Combination of transcatheter arterial chemoembolization (TACE) with apatinib are emerging as an effective treatment for patients with intermediate to advanced stage HCC. However, the data of HCC treated by apatinib in the real-world setting are not reported. In this real-world study, we aimed to explore the efficacy and safety of HCC pts which underwent TACE combine with apatinib. Methods: This was a prospective, multicenter observational study in a real-world setting and this study was approved by our Ethics Committee. Pts aged ≥18 years with well diagnosed intermediate or advanced stage HCC were included. The pts received apatinib plus TACE treatment as the first-line therapy. TACE treatment was performed on demand, the dose of apatinib was selected by the investigator. The primary endpoint was progression-free survival (PFS). The secondary endpoints were overall survival rate (OS), objective response rate (ORR), disease control rate (DCR) and safety profile. All of the objective response was assessed by independent central review per mRECIST criteria. Results: From Jun 2019 to Feb 2020, a total of 98 well diagnosed HCC pts with age from 31 to 86 were enrolled in this study. As of August 2020, the median follow-up was 9.5 months. The mPFS of 98 pts was 7 months. The ORR, DCR and 6 months OS rate was 35.7%, 76.5% and 82.6%, respectively.The PFS was 7.5 months in intermediate stage and 6.4 months in advanced stage. The ORR was 46.3% in intermediate stage (41 cases) and 28% in advanced stage (57 cases) HCC. And the 6 months OS rate was 90.2% in intermediate stage and 77.1% in advanced stage HCC. Overall, 17 (17.3%) pts had grade≥3 treatment-related AEs. All of the safety adverse effects can be tolerated or reduced after symptomatic treatment and no unexpected adverse events were observed. Conclusions: In this real-world study, apatinib showed a favorable efficacy and safety profile in pts with intermediate and advanced stage cancer. Apatinib combination TACE therapy might lead to better survival benefit in first-line treatment for HCC pts. Clinical trial information: ChiCTR1900024030.

Background and aims The restenosis following percutaneous transluminal balloon angioplasty (PTBA) is high for Budd-Chiari syndrome (BCS) patients with hepatic venous obstruction (HVO). We aim to evaluate the safety and long-term outcome of PTBA with a large balloon catheter in a large series of patients with HVO. Methods Between January 2005 and December 2013, 93 consecutive BCS patients with HVO were referred for PTBA and subsequently underwent color Doppler ultrasonography or angiography follow-up. Data were retrospectively collected, and follow-up observations were performed at 1-, 2-, 2- to 5-, and 5- to 8-years postoperatively. Results Percutaneous transluminal balloon angioplasty was technically successful in all patients. Ninety-one patients (97.85%) were treated with PTBA and two with PTBA and stent. Major procedure-related complications occurred in six of the 93 patients (6.45%). The cumulative 1-, 2-, 2- to 5-, and 5- to 8-year primary patency rates were 97.5%, 92.9%, 90%, and 86.5%, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year secondary patency rates were 100%, 100%, 98.6%, and 97.3%, respectively. Mean and median primary patency rates were 51.50 ± 3.01 months and 55.0 ± 3.63 months, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year survival rates were 98.75%, 98.6%, 100%, and 100%, respectively. Mean and median survival times were 53.10 ± 3.04 months and 55.0 ± 3.64 months, respectively. Conclusion Percutaneous transluminal balloon angioplasty with a large balloon is a safe and effective treatment that could provide excellent rates of long-term patency and survival for the majority of Chinese patients with BCS and HVO.

Budd-Chiari syndrome (BCS) is an uncommon disorder defined as an obstruction of the hepatic venous outflow. Percutaneous transluminal balloon angioplasty is a less invasive treatment option for BCS patients. However, there are no reports regarding inferior vena cava (IVC) rupture caused by perforation route through a collateral vein during treatment of BCS. Here, we report a male patient with BCS who had a long segmental obstruction of the IVC and its collateral vessels. Here, IVC rupture occurred at the distal end of the obstructed IVC during a percutaneous angioplasty; the rupture was repaired successfully with an endovascular stent graft.

To report the long-term results of endoluminal sharp recanalization of occluded inferior vena cava (IVC) in patients with the Budd-Chiari syndrome (BCS).Seventy-two consecutive patients with BCS and IVC occlusion underwent endoluminal recanalization of the IVC occlusion during a 6-year period. BCS with occlusive IVC was detected by reviewing patient history and color Doppler ultrasonography. Data on technical success, morbidity, mortality, complications, and color Doppler sonographic outcome were collected and analyzed.Seventy-seven recanalizations were performed in 72 patients. Technical success (patent IVC with good blood flow) was achieved in 70 (97.4%) patients. No perioperative death was observed. Six complications were found during recanalization, and 10 complications were found for total interventional procedures. The complication rates were 7.8% and 7.3% for recanalization and total procedure, respectively. Bleeding of access veins was the most common complication, and 2 patients showed slight rupture of IVC. The postoperative IVC diameter and blood speed of IVC increased significantly. Fifty-seven patients (79.2%) were clinical cured, and 2 patients (2.8%) showed no improvement. The 1-year, 3-year, and 5-year primary patency rates were 92.5%, 86.8%, and 77.3%, respectively. The second patency rates were 100.0%, 97.8%, and 91.8% for 1, 3, and 5 years, respectively. There were 2 deaths during follow-up.Endoluminal sharp recanalization of occluded IVC in patients with BCS is safe and effective with good long-term outcomes.

ObjectivesEarly placement of transjugular intrahepatic portosystemic shunt (TIPS) has been shown to improve survival in high-risk patients (Child-Pugh B plus active bleeding at endoscopy or Child-Pugh C 10–13) with cirrhosis and acute variceal bleeding (AVB). However, early TIPS criteria may overestimate the mortality risk in a significant proportion of patients, and the survival benefit conferred by early TIPS in such patients has been questioned. Alternative criteria have been proposed to refine the criteria used to identify candidates for early TIPS. Nevertheless, the true survival benefit provided (or not) by early TIPS compared with standard treatment in the different risk categories has not been investigated in specifically designed comparative studies.DesignWe collected data on 1425 consecutive patients with cirrhosis and AVB who were admitted to 12 university hospitals in China between December 2010 and June 2016. Of these, 206 patients received early TIPS, and 1219 patients received standard treatment. The Fine and Gray competing risk regression model was used to compare the outcomes between the two groups that were stratified based on the currently available risk stratification systems after adjusting for liver disease severity and other potential confounders.ResultsOverall, early TIPS was associated with an 80% relative risk reduction (RRR) in mortality at 6 weeks (adjusted HR=0.20; 95% CI: 0.10 to 044; pConclusionsEarly TIPS was associated with improved survival in patients with MELD ≥19 or Child-Pugh C cirrhosis but not in patients with MELD ≤11 or Child-Pugh A cirrhosis. For MELD 12–18 or Child-Pugh B patients, future studies addressing optimal selection criteria for early TIPS remain highly warranted.

To evaluate the safety and efficacy of percutaneous transhepatic route creation for hepatic vein (HV) angioplasty in Budd-Chiari syndrome (BCS).Between April 2012 and August 2016, a total of 19 BCS patients underwent percutaneous transhepatic route creation for HV angioplasty after transvenous catheterization failure in this study. Color Doppler ultrasonography was required in all patients after admission and during follow-up. Data were retrospectively collected, and follow-up observations were performed.Technical and clinical success was achieved in 18 patients. Except for 1 failure of route creation, 19 routes were successfully created in 18 patients, with a technology success rate of 95.0%. Twenty-two balloon angioplasties were performed in 18 patients, with a mean balloon diameter of 13.6 ± 0.5 mm. Blood pressure and length of occlusive HV decreased significantly, and blood flow velocity and diameter of HV increased significantly after procedure. Abdominal distension/pain and ascites decreased significantly after procedure. One procedure-related death occurred, who died of gastrointestinal bleeding 6 days later. Except for the failure case, the rest of 18 patients were successfully followed up. The remaining 18 patients survived during follow-up, with a 5-year survival rate of 94.9%. One patient had a restenosis of HV after 47 days, and had undergone successful dilation. The 5-year primary and second patency rates were 94.1% and 100%, respectively.Percutaneous transhepatic route creation is safe and effective for HV angioplasty, and can be used to treat BCS patients after transvenous catheterization failure.

Background and aim The aim of this study is to compare long-term outcomes of retrievable stents (RSs) and permanent stents (PSs) for Budd-Chiari syndrome (BCS) due to long-segment obstructive inferior vena cava (IVC). Methods Between July 2000 and August 2016, 42 patients with BCS due to long-segment obstructive IVC were treated with RSs, and 41 patients were treated with PSs. The RSs were removed eventually after thrombus disappeared. Patients were subsequently followed up by color Doppler sonography or computed tomography scanning. Results All RS placements were successful, and 37 RSs were retrieved 8 to 29 days later. Forty-two stents were implanted in PS group. One failure retrieval of RSs occurred, and two failures of cannulations were found in PS group. Two deaths may be procedure related and died from acute pulmonary thromboembolism perioperatively. One patient developed acute cerebral infarction and recovered after treatment. In PS group, minor complications were found in three patients. The length of IVC lesion segment and length and thickness of IVC thrombus decreased significantly, and diameter of retrocaval IVC and diaphragm IVC increased significantly in both groups. During follow-up, three patients died from liver failure in RS group, and two patients died in PS group. RS group showed a significantly higher primary patency rate than PS group. Cumulative 1-, 3-, and 5-year secondary patency rates were 95.2%, 89.6%, and 89.6% in RS group and 100%, 96.6%, and 96.6% in PS group (P = 0.7109). Conclusions Retrievable stents are effective for BCS because of long-segment obstructive IVC, with a higher primary patency rate.

The purpose of this study was to describe a single institution’s experience with transradial access (TRA) for angiographic interventions, and to compare technical success, complication rate and radiation dose of procedures performed with TRA to those performed with transfemoral access (TFA). A retrospective cohort study of patients undergoing peripheral interventions via TRA or TFA from 2015 to 2017 was performed. The cohort comprised 33 patients undergoing 44 procedures via TRA and 37 patients undergoing 44 procedures via TFA. Outcome measures were technical success, access-related complications, fluoroscopy time and radiation exposure. Differences at p < 0.05 were considered to be statistically significant. Baseline characteristics were similar between patients who had procedures via TRA versus those who had procedures via TFA, including age, sex and body mass index. Technical success was achieved in 41/44 (93.2%) of procedures performed via TRA, compared to 44/44 (100%) of procedures performed via TFA (p = 0.241). There were three access-related complications (6.8%) when TRA was performed, compared to none when TFA was performed (p = 0.241). Fluoroscopy time was longer in procedures performed with TRA compared to those performed with TFA (27.3 vs 20.4, p = 0.033). Dose area product (DAP) did not differ with access site choice (p = 0.186). TRA is a safe and feasible alternative to TFA for a range of peripheral interventions. However, TRA must be performed with prudence as it is not without complications and is technically challenging, leading to longer fluoroscopy time. • Transradial access (TRA) is feasible in a variety of peripheral interventions, achieving success in 93.2% of cases. • Access-related complications are comparable between transfemoral access (TFA) and TRA (p = 0.241), but prudence must be taken during TRA as it could be technically challenging. • Procedures performed with TRA tend to have longer fluoroscopy time compared to those performed with TFA (p = 0.033), but the DAPs are comparable (p = 0.186).

OBJECTIVES This study was conducted to evaluate the clinical value of computed tomographic (CT) angiography for diagnosis and therapeutic planning in patients with pulmonary sequestration. METHODS Forty-three patients with suspected pulmonary sequestration underwent CT angiography before undergoing digital subtraction angiography or surgery. For each patient, CT angiography was used to determine whether the pulmonary sequestration was suitable for coil embolization, surgical resection or conservative treatment. The treatments planned using CT angiography were compared with actual treatment decisions made or treatments administered using digital subtraction angiography or surgery. RESULTS Digital subtraction angiography and/or surgery confirmed pulmonary sequestration in 37 patients; six patients had no pulmonary sequestration. The diagnostic performance of CT angiography for pulmonary sequestration in the patient-based evaluation yielded an accuracy of 97.7%, sensitivity of 97.3%, specificity of 100%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 85.7%. The aberrant systemic artery-based evaluation yielded an accuracy of 98.0%, sensitivity of 97.8%, specificity of 100%, PPV of 100% and NPV of 85.7%. Treatments could be correctly planned using CT angiography with 100% accuracy, sensitivity, specificity, PPV and NPV according to the aneurysm-based evaluation. CONCLUSIONS We have obtained promising results with a CT angiography-based protocol, rather than a digital subtraction angiography-based protocol, as the only diagnostic and pretreatment planning tool in patients with pulmonary sequestration. The CT angiography-based selection of treatment strategies seems to be safe and effective in the majority of patients with pulmonary sequestration.

Treatment of inferior vena cava (IVC) over-long segmental occlusion in Budd–Chiari syndrome (BCS) remains challenging. IVC segmental occlusion in BCS is often associated mainly with hepatic vein lesions in BCS, while the accessory hepatic vein (AHV) is typically patent and more intrahepatic collateral vessels are widely well-developed. Herein, we report our use of angioplasty for hepatic venous or the accessory hepatic vein for long segmental occlusion of the IVC in two BCS cases, rather than opening the IVC, in cases with a well-developed intrahepatic collateral. This method provides satisfactory outcome in short follow-up period of 8 and 5 months respectively, and is practical and feasible.

This paper reports our initial experience with an integrated, self-expandable, Y-shaped, metallic stent (SEMS) for patients with complex anastomotic obstructions after gastrojejunostomy (Billroth II).Eight consecutive patients with complex anastomotic obstructions involving the afferent and efferent loops after gastrojejunostomy (Billroth II) were treated with an integrated Y-shaped SEMS. The stents were placed in the anastomosis under fluoroscopy. Technical and clinical success; complications, including recurrent obstruction and stent migration; reintervention; and survival were assessed during follow-up.Y-shaped SEMS placement in the anastomotic areas was technically successful and well tolerated in all patients, with no procedure-related complications. Clinical success was observed in all patients 1-7 days after the procedure. The improvement between pre- and postoperative gastric outlet obstruction scoring system (GOOSS) was statistically significant (p=0.01). During follow-up for 3.13 ± 1.81 months, all stenoses were resolved without stent-related complications, and general physical examination of the eight patents showed improvement. Five patients continued with follow-up health care after the procedures; the remaining three died of causes unrelated to stent insertion. The mean and median survival periods were 3.92 ± 0.81 months [95% confidence interval (CI) 2.34-5.50] and 3.0 ± 0.64 months (95% CI 1.74-4.26), respectively.Deployment of an integrated Y-shaped SEMS proved to be an expedient, simple, safe and minimally invasive procedure for treating complex anastomotic stenoses after gastrojejunostomy (Billroth II).

This study was undertaken to evaluate the safety and feasibility of thrombolytic urokinase treatment after predilation in patients with Budd-Chiari syndrome (BCS) with chronic inferior vena cava (IVC) thrombosis.Between December 2006 and September 2009, 13 consecutive BCS patients with chronic IVC thrombosis were treated with continuous urokinase infusion after predilation and subsequent (i.e. after thrombus resolution) IVC dilation with a 30-mm dilator. The procedural technical and angiographic, and ultrasonic results, as well as mortality, morbidity and the final clinical outcome, were evaluated immediately after the treatment or at 1 week and 1, 3, 6 and 12 months and then annually thereafter.The immediate and long-term procedural technical outcome was successful in all patients. Follow-up inferior vena cavagrams demonstrated complete resolution of the chronic IVC thrombi and full IVC patency, without occurrence of pulmonary embolism at any time during the study. Colour-Doppler ultrasound (US) follow-up for 16.92 months (± 12.04) showed full patency of the IVC, without thrombosis, restenosis or reobstruction, in all patients and resolution of all clinical symptoms. All patients were alive at the time of this report.Our preliminary results indicate that thrombolysis with continuous infusion of urokinase after predilation is a safe and feasible approach for treating BCS patients with chronic IVC thrombosis.

Aim To evaluate the mid-term safety and efficacy of a retrieval stent filter and 30 mm balloon dilator in the treatment of Budd–Chiari syndrome (BCS) patients with chronic inferior vena cava (IVC) thrombosis. Materials and methods Twenty-three consecutive patients with BCS and chronic IVC thrombosis were treated with a retrieval stent filter and a 30 mm balloon dilator, and subsequently underwent color Doppler ultrasound follow-up at our hospital. Data relating to the technical success, angiographic and ultrasound results, mortality, morbidity, and final clinical outcome were collected retrospectively and follow-ups were performed 1, 3, 6, and 12 months after placement of the stent, and annually thereafter. Results Stent filter placement and balloon dilation were technically successful in all patients, with no procedure-related complications. Removal of the stent filter was technically successful in 22 of 23 attempts, yielding a technical successful rate of 95.7% (95% confidence intervals (CI): 87%, 105%). Inferior vena cavagrams performed immediately before stent removal demonstrated that the IVC thrombus had completely resolved in all patients without pulmonary embolism. The mean primary patency rate 3, 6, 12, and 24 months after venoplasty was 0.91 (95% CI: 0.79–1.04), 0.87 (95% CI: 0.72–1.02), 0.87 (95% CI: 0.72–1.02), and 0.87 (95% CI: 0.72–1.02), respectively. The secondary patency rates were 1.00 throughout the follow-up period. All patients are alive with resolution of the symptoms at the time of this report. Conclusions The preliminary results indicate that the retrieval stent filter and 30 mm balloon dilator are a safe and effective treatment for BCS patients with chronic IVC thrombosis.

Purpose The purpose of this study was to evaluate the initial clinical efficacy of a retrieval stent filter for the management of Budd Chiari syndrome complicated with inferior vena cava thrombosis. Description The retrieval stent filter consists of two parts (ie, the filter and the Z-stent). The filter was composed of seven legs arranged in the shape of a cone with a retrieval hook at its apex. The filter and the Z-stent were connected with each other, and the retrieval of the stent filter was performed with an Amplatz gooseneck snare (MicroVena [White Bear Lake, MN]). Eight consecutive patients were treated with the stent filters. Evaluation The stent filter placement was technically successful in all patients. Inferior vena cavography demonstrated that all of the inferior vena cavae were patent without incidental pulmonary embolism after deploying the stent filter. A 3∼11 months follow-up study showed that all of the stent filters were removed after approximately 5 to 24 days of placement. All patients were still alive with resolution of the symptoms. Conclusions The use of a retrieval stent filter proved to be expedient, safe, and effective in the treatment of Budd Chiari syndrome complicated with inferior vena cava thrombosis.

The restenosis following percutaneous transluminal balloon angioplasty (PTBA) is high for Budd-Chiari syndrome (BCS) patients with hepatic venous obstruction (HVO). We aim to evaluate the safety and long-term outcome of PTBA with a large balloon catheter in a large series of patients with HVO.Between January 2005 and December 2013, 93 consecutive BCS patients with HVO were referred for PTBA and subsequently underwent color Doppler ultrasonography or angiography follow-up. Data were retrospectively collected, and follow-up observations were performed at 1-, 2-, 2- to 5-, and 5- to 8-years postoperatively.Percutaneous transluminal balloon angioplasty was technically successful in all patients. Ninety-one patients (97.85%) were treated with PTBA and two with PTBA and stent. Major procedure-related complications occurred in six of the 93 patients (6.45%). The cumulative 1-, 2-, 2- to 5-, and 5- to 8-year primary patency rates were 97.5%, 92.9%, 90%, and 86.5%, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year secondary patency rates were 100%, 100%, 98.6%, and 97.3%, respectively. Mean and median primary patency rates were 51.50 ± 3.01 months and 55.0 ± 3.63 months, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year survival rates were 98.75%, 98.6%, 100%, and 100%, respectively. Mean and median survival times were 53.10 ± 3.04 months and 55.0 ± 3.64 months, respectively.Percutaneous transluminal balloon angioplasty with a large balloon is a safe and effective treatment that could provide excellent rates of long-term patency and survival for the majority of Chinese patients with BCS and HVO.

Aim To evaluate the type of venous involvement in Chinese Budd-Chiari syndrome (BCS) patients and the relative diagnostic accuracy of the different imaging modalities. Methods Using digital subtraction angiography (DSA) as a reference standard, color Doppler ultrasound (CDUS), computed tomography angiography (CTA), and magnetic resonance angiography (MRA) were performed on 338 patients with BCS. We analyzed the course of the main and any accessory hepatic veins (HVs) and the inferior vena cava (IVC) to assess the etiology of obstructed segments and diagnostic accuracy of CDUS, CTA and MRA. Results Among the 338 cases, there were 8 cases (2.4%) of isolated IVC membranous obstruction, 45 cases (13.3%) of isolated HV occlusion, and 285 cases (84.3%) with both IVC membranous obstruction and HV occlusion. Comparing with DSA, CDUS, CTA had a diagnostic accuracy of 89.3% and 80.2% in detecting BCS, and 83.4% of cases correctly correlated by MRA. Conclusion In Henan Province, most patients with BCS have complex lesions combining IVC and HV involvement. The combination of CDUS and CTA or MRI is useful for diagnosis of BCS and guiding therapy.

Three patients with Budd-Chiari syndrome (BCS) and fresh inferior vena cava (IVC) thrombosis were treated by agitation thrombolysis as a mechanical thrombectomy procedure and followed up by duplex ultrasonography. Agitation thrombolysis was technically and clinically successful in all patients. Inferior vena cavagrams after the procedure showed complete resolution of the iatrogenic, fresh IVC thrombi without occurrence of pulmonary embolism. Duplex ultrasonography follow-ups after 12, 24, and 28 months, respectively, confirmed complete patency of the IVC without rethrombosis and reobstruction. The results indicate that agitation thrombolysis may be a safe and feasible approach for BCS patients with iatrogenic, fresh IVC thrombosis.

We present an unusual case of portal, mesenteric, and splenic vein thromboses after endovascular embolization for gastrointestinal bleeding caused by a splenic arteriovenous fistula. The thromboses were successfully treated with anticoagulation therapy. The patient was a 37-year-old woman who presented with portal hypertension manifested by gastrointestinal bleeding with no evidence of liver disease. Splenic arteriography confirmed the presence of a high-flow arteriovenous fistulous communication from the splenic artery directly into the splenic vein. The arteriovenous fistula was successfully treated with percutaneous transarterial embolization by embolization coils and the patient achieved effective hemostasis. Low-molecular-weight heparin and warfarin were administrated to prevent thrombosis in the portal venous system after the procedure. Although anticoagulants were immediately administered, thromboses of the portal, mesenteric, and splenic veins were diagnosed by contrast-enhanced computed tomography after 10 days. Complete recanalization of the portal venous system confirmed by contrast-enhanced computed tomography was achieved by administering warfarin orally for 3 months.

Purpose: To compare the efficacy of thrombolysis with and without predilation of the inferior vena cava (IVC) for Budd–Chiari syndrome (BCS) with old IVC thrombosis. Methods: We divided 40 patients with BCS with old IVC thrombosis into 2 groups, group A (n = 21), thrombolysis after dilation of the obstructed IVC and group B (n = 19), thrombolysis without predilation of the obstructed IVC. Thrombolysis was performed via urokinase administration through the dorsal vein of the foot. Results: Color Doppler ultrasonography at 30 days showed complete resolution of the thrombus in 21 (100%) group A patients and 6 group B patients (31.6%; P < .001). Thrombolysis was achieved using a lower dose of urokinase and within a shorter time frame in group A than in group B ( P < .001). Conclusions: Thrombolysis after dilation was superior to thrombolysis alone and was safe and efficacious in patients with BCS with old IVC thrombosis.

Budd-Chiari syndrome (BCS) caused by hepatic venous outflow obstruction may result in portal hypertension and the development of intrahepatic collaterals that bypass the obstruction. Spontaneous intrahepatic portosystemic venous shunt (SIPSVS) is uncommon and may be associated with portal hypertension. SIPSVS is extremely rare in patients with BCS and has not been well documented. We report a case of SIPSVS in a 42-year-old woman with BCS caused by membranous obstruction and chronic thrombosis in the inferior vena cava (IVC). A direct vascular communication between the left portal vein and IVC was confirmed by sonography and a computed tomography angiography scan. The patient underwent successful percutaneous balloon angioplasty of the IVC. Surgical or endovascular treatment for SIPSVS was not carried out because the patient was asymptomatic and remained asymptomatic in terms of encephalopathy at a 1-year follow-up.

A 57-year-old man presented with a rare extrahepatic portal vein bifurcation scar stenosis involving the proximal splenic vein and superior mesenteric vein after a Whipple procedure. He was treated with endovascular coil embolization for the gastroesophageal varices and kissing stents for the portal vein bifurcation stenosis. This case illustrates a rarely seen complication after the Whipple procedure and a novel management strategy that can be considered in the management of this complex disease.

We describe an elderly woman who presented with an unusual primary arterioportal fistula and cavernous transformation of the portal vein caused by portal thrombosis, which were subsequently managed with endovascular coil embolization and transjugular intrahepatic portosystemic shunt using 2 stents after balloon remodeling. This case shows a rarely seen condition in the elderly and a novel management strategy that should be considered in the management of this complex disease.

Aims: To evaluate the feasibility of using the Willis covered stent in the management of patients with traumatic carotid-cavernous fistulas (CCFs). Materials and Methods: Twelve consecutive patients with 14 post-traumatic CCFs referred for treatment with Willis covered stents were enrolled in this prospective study. Data on technical success, initial and final angiographic results, mortality, morbidity and final clinical outcome were collected. Follow- up was at one, three, six, and 12 months, and yearly thereafter. Results: Deployment of covered stents was technically successful in all the patients without complications. One covered stent was placed in eight patients and two covered stents in four. Angiographic results following stent placement showed a complete occlusion in nine patients with 11 CCFs, and an incomplete occlusion in three patients. Angiographic follow-up (mean, 14.00 ± 6.93 months; range, 6-24 months) revealed complete occlusion and no obvious in-stent stenosis in all the patients. Clinical follow-up (mean, 17.75 ± 7.05 months; range, 7-28 months) demonstrated full recovery in 11 patients, and improvement in one. Conclusion: This initial experience indicates that the use of the Willis covered stent is a feasible procedure and may be an alternative treatment option for CCFs.

Purpose To evaluate whether predilation approach yield intermediate-term results were better than those with stent filter approach. Materials and methods 59 BCS patients with old IVC thrombosis were selected for the treatment with a stent filter ( n = 33, group A) or predilation ( n = 26, group B) before thrombolysis, and subsequently underwent color Doppler ultrasound follow-up at our hospital. Data relating to the technical success, color Doppler ultrasound results, cost, mortality, morbidity, and final clinical results were collected prospectively and follow-ups were performed 1, 3, 6, and 12 months after the procedures, and annually thereafter. Results Sent filter placement, thrombolysis and predilation were technically successful in all patients, with no procedure-related complications. Stent migration upward occurred in two patients, and removal of the stent filter was technically successful in 32 of 33 patients in group A. Inferior vena cavagrams performed before dilation with a 30-mm balloon catheter demonstrated that the IVC thrombus had completely resolved in all patients without pulmonary embolism. Reobstruction of the IVC without thrombosis was observed in three patients. Short of higher overall complications and costs in group A when compared to group B, there were no other differences in the clinical and color Doppler ultrasound findings, and primary patency rate between the two groups. All patients are alive with no recurrence of thrombosis at the time of this report. Conclusions BCS patients with old IVC thrombosis treatment with predilation approach yielded intermediate-term results that were better than those with the stent filter approach.