Search

To assess clinical outcomes and patency after transjugular intrahepatic portosystemic shunt (TIPS) reduction for overshunting adverse events.This multicenter, retrospective observational study included 33 patients (male-to-female ratio, 20:13; mean age, 59 years; mean Model for End-Stage Liver Disease [MELD] score, 15) who underwent TIPS reduction between 2007 and 2020. Procedure indications included medically refractory hepatic encephalopathy (HE) (85%), post-TIPS hepatic insufficiency (HI) (12%), and heart failure (3%). The measured outcomes included improvement in HE (classified using the West Haven system) and HI, patency of reduced TIPS, and transplant-free survival (TFS).TIPS reductions were successfully performed using parallel stent (94%) or other (6%) techniques at a median of 120 days after TIPS creation (HE, median, 164 days; HI, median, 5 days). The portosystemic pressure gradient increased from a mean of 10 to 17 mm Hg (P.001). The overall HE rate after TIPS reduction was 54%; HE was persistent, improved, and resolved in 21%, 32%, and 46% cases, respectively. In patients with HI, the MELD score increased from a mean of 22 before TIPS to 34 after TIPS (P = .061), but without improvement (0%) in HI after TIPS reduction (mean MELD score, 30; P = .266). Recurrent ascites occurred in 14% of the patients. The median shunt patency was 961 days (95% confidence interval, 476-1,447). The 30-day, 6-month, 1-year, and 3-year shunt patency rates were 92%, 81%, 74%, and 37%, respectively. The median TFS was not reached. The 30-day, 6-month, 1-year, and 3-year survival rates were 97%, 90%, 81%, and 60%, respectively.Although TIPS reduction may be an effective and durable approach to treat post-TIPS medically refractory HE, shunt reduction may not achieve meaningful benefit for HI.

Purpose To determine the association between frailty, 30-day complications, rehospitalization, and transplant-free survival (TFS) following conventional and drug-eluting bead transarterial chemoembolization. Materials and Methods A retrospective analysis was performed on a cohort of 125 patients with treatment-naïve hepatocellular carcinoma who underwent conventional or drug-eluting beads chemoembolization at our institution between 2014 and 2015. Liver function parameters, Barcelona clinic liver cancer tumor stage, and all components of the five-item modified frailty index (mFI-5) were used to determine the patient's frailty status. Key end points included severe (grade 3 or above) adverse events of chemoembolization, 30-day rehospitalization rates, and TFS. Logistic regression analysis was performed on conventional predictors of postoperative complications after chemoembolization. Median survival was estimated and compared using the Kaplan–Meier's estimator and log-rank test. Results Among 125 patients who underwent first-time chemoembolization, higher frailty score was an independent predictor of both 30-day hospital readmission and severe liver toxicity (p = 0.01 and p = 0.03, respectively) on multivariate logistic regression analysis. Each point increase in mFI-5 conferred a threefold or twofold increase in the risk of experiencing 30-day rehospitalization or postoperative severe adverse events, respectively. At the data censor date, patients with mFI-5 score ≥ 2 had decreased overall TFS (28.1 vs. 39.8 months, p = 0.03). Conclusion Increasing frailty as determined by mFI-5 is an independent predictor of 30-day complications and lower TFS following chemoembolization.

Exogenous estrogen is associated with growth of hepatocellular adenomas (HCAs), although the influence of progestin-only agents is unknown. We therefore evaluated the association of progestin-only agents on HCA progression compared to no hormone exposure and compared to estrogen exposure in female patients.In this single-center, retrospective cohort study of reproductive-aged female patients (ages 16-45) with diagnosed HCAs between 2003 and 2021, we evaluated radiographic HCA growth during discrete periods of well-defined exogenous hormone exposures.A total of 34 patients were included. Nineteen (55.9%) had follow-up scans during periods without hormone exposure, seven (20.6%) during estrogen exposure, and eight (23.5%) during progestin-only exposure. Over a median follow-up of 11 months, percent change in sum of adenoma diameters from baseline to last available scan was -15.0% with progestin-only agents vs 29.4% with estrogen exposure (p=0.04), and -7.4% with no hormonal exposure (p=0.52 compared to progestin-only). Greater than 10% growth was observed in two individuals (25.0%) with progestin-only agent use (one patient on high-dose progestin for menorrhagia) vs five individuals (71.4%) with estrogen use (p=0.13), and 7 (36.8%) with no exogenous hormone use (p=0.68 vs progestin-only).During discrete periods of progestin-only use, HCA growth overall declined, similar to declining growth during periods without exogenous hormonal exposure. This differed from discrete periods of exogenous estrogen exposure, during which time HCAs demonstrated overall increased growth. Though larger studies are needed, these findings support recent guidance supporting progestin-only agents for female patients with HCAs seeking non-estrogen alternatives for contraception.

The purpose of this study was to compare intra-tumoral drug delivery, pharmacokinetics, and treatment response after doxorubicin (DOX) conventional (c-) versus drug-eluting embolic (DEE-) transarterial chemoembolization (TACE) in a rabbit VX2 liver tumor model. Twenty-four rabbits with solitary liver tumors underwent c-TACE (n = 12) (1:2 water-in-oil emulsion, 0.6 mL volume, 2 mg DOX) or DEE-TACE (n = 12) (130,000 70–150 µm 2 mg DOX-loaded microspheres). Systemic, intra-tumoral, and liver DOX levels were measured using mass spectrometry up to 7-day post-procedure. Intra-tumoral DOX distribution was quantified using fluorescence imaging. Percent tumor necrosis was quantified by a pathologist blinded to treatment group. Lobar TACE was successfully performed in all cases. Peak concentration (CMAX, µg/mL) for plasma, tumor tissue, and liver were 0.666, 4.232, and 0.270 for c-TACE versus 0.103, 8.988, and 0.610 for DEE-TACE. Area under the concentration versus time curve (AUC, µg/mL ∗ min) for plasma, tumor tissue, and liver were 18.3, 27,078.8, and 1339.1 for c-TACE versus 16.4, 26,204.8, and 1969.6 for DEE-TACE. A single dose of intra-tumoral DOX maintained cytotoxic levels through 7-day post-procedure for both TACE varieties, with a half-life of 1.8 (c-TACE) and 0.8 (DEE-TACE) days. Tumor-to-normal liver DOX ratio was high (c-TACE, 20.2; DEE-TACE, 13.3). c-TACE achieved significantly higher DOX coverage of tumor vs. DEE-TACE (10.8% vs. 2.3%; P = 0.003). Percent tumor necrosis was similar (39% vs. 37%; P = 0.806). In conclusion, in a rabbit VX2 liver tumor model, both c-TACE and DEE-TACE achieved tumoricidal intra-tumoral DOX levels and high tumor-to-normal liver drug ratios, though c-TACE resulted in significantly greater tumor coverage.

Purpose The purpose of this study was to evaluate the effectiveness and adverse outcomes of percutaneous cryoablation (CA) for treatment of renal masses in a large cohort of patients. Materials and Methods This retrospective analysis included 299 CA procedures (297 masses in 277 patients) performed between July 2007 and May 2018 at a single institution. The mean patient age was 66.1 years (range, 30–93 years) with 65.8% being male. A total of 234 (78.8%) masses were biopsy-proven renal cell carcinoma (RCC). The mean maximal tumor diameter was 2.5 cm (range, 0.7–6.6 cm). Efficacy was assessed only for ablations of biopsy-proven RCC, whereas the evaluation of adverse events and renal function included all masses. Complications were graded according to the Society of International Radiology classification. Results Major complications occurred in 3.0% of procedures (n = 9), none of which resulted in death or permanent disability. The mean imaging follow-up period was 27.4 months (range, 1–115) for the 199 RCC patients (204 ablated tumors) with follow-up imaging available. Complete response on initial follow-up imaging at mean 4.2 months (range, 0.3–75.6) was achieved in 195 of 204 tumors (95.6%) after a single session and in 200 of 204 tumors (98.0%) after 1 or 2 sessions. Of the RCC patients achieving complete response initially, local recurrence during the follow-up period occurred in 3 of 200 tumors (1.5%). Metastatic progression occurred in 10 of 193 (5.2%) RCC patients without prior metastatic disease during follow-up. Conclusions CA for renal masses is safe and remains efficacious through intermediate- and long-term follow-up.

To investigate the pharmacokinetics (PK) and early effects of conventional transarterial chemoembolization (TACE) using sorafenib and doxorubicin on tumor necrosis, hypoxia markers, and angiogenesis in a rabbit VX2 liver tumor model.VX2 tumor-laden New Zealand White rabbits (N = 16) were divided into 2 groups: 1 group was treated with hepatic arterial administration of ethiodized oil and doxorubicin emulsion (DOX-TACE), and the other group was treated with ethiodized oil, sorafenib, and doxorubicin emulsion (SORA-DOX-TACE). Animals were killed within 3 days of the procedure. Levels of sorafenib and doxorubicin were measured in blood, tumor, and adjacent liver using mass spectrometry. Tumor necrosis was determined by histopathological examination. Intratumoral hypoxia-inducible factor (HIF) 1α, vascular endothelial growth factor (VEGF), and microvessel density (MVD) were determined by immunohistochemistry.The median intratumoral concentration of sorafenib in the SORA-DOX-TACE group was 17.7 μg/mL (interquartile range [IQR], 7.42-33.5 μg/mL), and its maximal plasma concentration (CThe addition of sorafenib to DOX-TACE delivered to VX2 liver tumors resulted in high intratumoral and low systemic concentrations of sorafenib without altering the PK of doxorubicin.

Background Aneurysms are rare anomalies of the portomesenteric venous system. Thrombotic complications of these lesions can lead to mesenteric venous ischemia and bowel infarction, potentially requiring surgical intervention. Herein we describe a case of mesenteric ischemia due to a large thrombosed portomesenteric aneurysm treated with endovascular techniques. Case presentation A 37-year-old previously healthy male who presented with abdominal pain to his local emergency department was found to have a thrombosed 12.0 × 5.1 cm portomesenteric venous aneurysm with evidence of mesenteric ischemia on CT. When conservative management with anticoagulation failed, transhepatic pharmacomechanical thrombolysis was initially performed. This was followed by TIPS placement with additional trans-TIPS thrombectomy to improve sluggish portal outflow and prevent re-thrombosis. The patient’s symptoms and imaging findings of ischemia resolved after endovascular therapy. No surgical intervention was required, and the patient was discharged on enoxaparin before being transitioned to apixaban. The TIPS remained patent at 2-year follow-up, with no change in the size of the aneurysm or re-thrombosis noted. The patient’s synthetic liver function was preserved with no evidence of hepatic encephalopathy during the follow-up period. Conclusions Endovascular therapies may be used to manage thrombotic complications of portomesenteric venous aneurysms, obviating the need for surgical intervention in selected patients.

Online supplemental material is available for this article. See also the editorial by Grant in this issue.

Intrahepatic arterioportal fistulas may be complicated by portal hypertension. An associated portal venous aneurysm (PVA) may impinge upon adjacent structures or rupture. We present a 65-year-old man with an intrahepatic Intrahepatic arterioportal fistula and 6.4 × 5.8 cm right portal vein aneurysm extending within 0.4 cm of the hepatic margin, associated with pain concerning for impending rupture. The PVA was refractory to transarterial embolization due to recruitment of arterial collaterals. Therefore, it was additionally excluded from the portal vein with a 12 mm × 9.5 cm venous stent graft. Although endovascular therapy thrombosed the aneurysm and improved symptoms, it was complicated by a type 2 endoleak into the PVA. Keywords: Arterial-portal fistula, Portal vein aneurysm, Type 2 endoleak

The purpose of this study was to compare intra-tumoral drug delivery, pharmacokinetics, and treatment response after doxorubicin (DOX) conventional (c-) versus drug-eluting embolic (DEE-) transarterial chemoembolization (TACE) in a rabbit VX2 liver tumor model. Twenty-four rabbits with solitary liver tumors underwent c-TACE (n = 12) (1:2 water-in-oil emulsion, 0.6 mL volume, 2 mg DOX) or DEE-TACE (n = 12) (130,000 70-150 µm 2 mg DOX-loaded microspheres). Systemic, intra-tumoral, and liver DOX levels were measured using mass spectrometry up to 7-day post-procedure. Intra-tumoral DOX distribution was quantified using fluorescence imaging. Percent tumor necrosis was quantified by a pathologist blinded to treatment group. Lobar TACE was successfully performed in all cases. Peak concentration (C

A 37-year-old woman presented with chest pain and shortness of breath in the third trimester of pregnancy. Diagnostic imaging demonstrated a saddle pulmonary embolism, severe impairment of right ventricular function, and an extensive deep venous thrombus. She underwent catheter-directed thrombolysis with tissue plasminogen activator and delivered a healthy infant at term. (Level of Difficulty: Intermediate.), Graphical abstract

In patients with a liver malignancy and a history of biliary instrumentation who undergo transarterial radioembolization with 90Y microspheres, infectious complications and morbidities such as liver abscess and cholangitis occur but are uncommon.

To evaluate the capability of albumin–bilirubin (ALBI) and platelet–albumin–bilirubin (PALBI) grades in predicting transplant-free survival (TFS) in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation. This single-center retrospective study included 342 ALBI and 337 PALBI patients (62% men; age 53–54 years) with cirrhosis (median MELD 15) and portal hypertension complications (variceal bleeding, 55%; ascites, 35%; other, 10%) who underwent TIPS between 1998 and 2017. Serum albumin, bilirubin, and platelet levels within 24 h prior to TIPS were used to calculate ALBI and PALBI grades. The influence of ALBI and PALBI grade on 30-day, 90-day, and overall post-TIPS TFS was assessed using C-indices, binary logistic regression, and the Cox proportional model, adjusting for Child–Pugh (CP) and MELD scores. The cohort spanned 110 (32%) and 232 (68%) ALBI grades 2 and 3 patients, and 40 (12%) and 297 (88%) PALBI grades 2 and 3 patients. While there were no differences in 30-day survival between ALBI and PALBI grades 2/3 (P > 0.05), 90-day and overall TFS showed statistically significant differences in survival between ALBI and PALBI grades 2/3 (P

The rabbit VX2 tumor is an animal model commonly utilized for translational research regarding hepatocellular carcinoma (HCC) in the field of Interventional Radiology. This model employs an anaplastic squamous cell carcinoma that is easily and reliably propagated in the skeletal muscle of donor rabbits for eventual harvest and allograft implantation into the liver of naïve recipients. This tumor graft rapidly grows within the liver of recipient rabbits into an angiographically identifiable tumor characterized by a necrotic core surrounded by a viable hypervascular capsule. The physical size of the rabbit anatomy is sufficient to facilitate vascular instrumentation allowing for the application and testing of various interventional techniques. Despite these benefits, there exists a paucity of technical resources to act as a concrete reference for researchers working with the model. Herein, we present a comprehensive visual outline for the technical aspects of development, growth, propagation, and angiographic utilization of the rabbit VX2 tumor model for use by novice and experienced researchers alike.

Objective: The objective of the study was to investigate whether hepatocellular carcinoma (HCC) histology is associated with clinical and computed tomographic/magnetic resonance imaging features and locoregional therapy (LRT) outcomes. Subjects and Methods: This single-center retrospective study included 124 consecutive patients (92 men, median age 59 years) with 132 HCC diagnosed by biopsy between 2008 and 2017 before LRT. Patients underwent chemoembolization (n = 51, 41%), ablation (n = 41, 33%), yttrium-90 radioembolization (n = 17, 13%), and chemoembolization/ablation (n = 15, 12%). Barcelona clinic liver cancer (BCLC) stage was 0/A (n = 48, 38%), B (n = 33, 26%), C (n = 27, 22%), and D (n = 16, 13%). Edmondson-Steiner (ES) grade and cytology were correlated with baseline features and radiologic response using logistic regression. Time to progression (TTP) and transplant-free survival (TFS) were analyzed using Cox proportional hazard models. Results: High ES grade was associated with α-fetoprotein (AFP) >50 ng/ml (odds ratio [OR] 4.6, 95% confidence interval [CI]: 1.5–13.9; P < 0.01), tumor diameter >5 cm (OR 3.1, 95% CI: 1.1–9.0; P < 0.05), infiltrative appearance (OR 5.0, 95% CI: 1.5–16.2; P < 0.01), and BCLC Stage C (OR 4.5, 95% CI: 1.3–16.4; P = 0.02). Clear-cell subtype was associated with non-viral cirrhosis (OR 5.3, 95% CI: 1.6–17.2; P < 0.01) and atypical enhancement (OR 3.1, 95% CI: 1.0–9.3; P < 0.05). AFP, BCLC Stage B, and diameter were associated with reduced TTP and TFS (P < 0.05). Neither ES grade nor clear-cell subtype was associated with objective response (OR 2.3, 95% CI: 0.7– 7.4; P = 0.15 and OR 1.1, 95% CI: 0.4–3.4; P = 0.87, respectively), TTP (P > 0.20), or TFS (P > 0.90) on univariate or stratified analysis. Conclusion: Histologic grade is associated with aggressive tumor features, while clear-cell HCC is associated with non-viral cirrhosis and atypical enhancement. Unlike AFP, BCLC stage, and tumor size, histologic features were not associated with LRT outcomes, supporting biopsy deferral for imaging diagnosed HCC.

Purpose To assess safety and efficacy of doxorubicin drug-eluting embolic (DEE) transarterial chemoembolization of hepatocellular carcinoma (HCC) by extrahepatic collateral arteries. Materials and Methods Records of 177 patients with HCC who underwent 338 consecutive DEE chemoembolization procedures from 2011 to 2014 were retrospectively reviewed. A subgroup of 16 patients (13 men, 3 women, median age 66 y) underwent 24 procedures for 17 HCCs via extrahepatic arteries and was included in the study. Median tumor size was 3.1 cm (range, 1.0–10.3 cm). Extrahepatic collaterals included right inferior phrenic (19 procedures; 12 patients), adrenal (4 procedures; 3 patients), and cystic arteries (2 procedures; 2 patients). Radiographic response was assessed by Modified Response Evaluation Criteria in Solid Tumors criteria. Complications were defined by National Cancer Institute Common Terminology Criteria for Adverse Events. Results DEE chemoembolization achieved stable disease in 6 (35.3%), partial response in 6 (35.3%), and complete response in 4 (23.5%) HCCs. Disease progression was ultimately observed in 8 tumors (47.1%), with mean time to progression of 8.3 months after chemoembolization (range, 2–13 mo). Three minor and 5 major complications occurred in 8 patients; 2 minor complications were rash in vascular distribution after right inferior phrenic artery DEE chemoembolization. The 5 major complications were transient hepatotoxicity that resolved within 4–80 days; 1 was accompanied by pleural effusion requiring hospitalization. A mean 13.4 months after DEE chemoembolization, 67% of transplant candidates proceeded to liver transplant. Conclusions DEE transarterial chemoembolization via extrahepatic collaterals was effective and facilitated bridging to transplant. It was generally well tolerated; transient hepatotoxicity was the most common major complication.

Purpose To assess the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation with or without variceal coil and/or plug embolization in decompressing or occluding gastric varices (GVs). Materials and Methods In this retrospective study, 78 patients with GV bleeding who underwent TIPS creation with or without embolotherapy with metallic coils and/or plugs from 1999 to 2014 were identified. Individuals who had a bare-metal TIPS and/or lacked post-TIPS imaging or endoscopic follow-up were excluded. The final cohort included 26 patients (16 men; median age, 54 y; median Model for End-stage Liver Disease score, 16). Variceal types, supplying vessels, and postprocedure GV patency on cross-sectional imaging or endoscopy were assessed. The primary study outcome measure was GV patency rate as a surrogate for efficacy of TIPS creation with or without embolization. Results GVs included gastroesophageal varix types 1 (n = 10) and 2 (n = 2), isolated GV types 1 (n = 4) and 2 (n = 2), and unspecified (n = 8). TIPS creation resulted in a median final portosystemic pressure gradient of 7 mm Hg. Multiple GV-supplying vessels (left/posterior/short gastric veins) were present in 65% of patients (n = 17). Embolization was performed in 69% (n = 18). Thirteen, four, and nine patients had imaging, endoscopic, or both imaging/endoscopic follow-up. GV patency rate was 65% (n = 17; 61%/75% with/without embolization) at a median of 128.5 days (range, 1–1,295 d) after TIPS creation. Incidence of recurrent bleeding was 27% (n = 7), and the 90-day mortality rate was 15% (n = 4). Conclusions In this study, most GVs showed persistent patency despite TIPS decompression and variceal embolization, and the incidence of recurrent bleeding was high. The findings suggest suboptimal efficacy for GVs, and indicate a need for study of alternative or adjunctive approaches to GV treatment, such as chemical obliteration.

PURPOSE To compare outcomes of unresectable hepatocellular-cholangiocarcinoma (HCC-CC) with hepatocellular carcinoma (HCC) after locoregional therapy (LRT). MATERIALS AND METHODS Consecutive patients with histologically confirmed HCC-CC or HCC treated with LRT between 2007 and 2017 were retrospectively reviewed. Ten patients (8 men; median age, 60 y) with 12 HCC-CCs (mean diameter, 4.2 cm ± 1.9; mean number, 3.7 ± 3.3) treated with chemoembolization (n = 6), yttrium-90 radioembolization (n = 2), RF ablation (n = 1), or chemoembolization/RF ablation (n = 1) were compared with 124 patients (92 men; median age, 59 y) with 134 HCCs (mean diameter, 4.8 cm ± 4.0; mean number, 2.6 ± 2.2) treated with chemoembolization (n = 51), yttrium-90 radioembolization (n = 17), RF ablation (n = 41), or chemoembolization/RF ablation (n = 15). Propensity score-matched analysis with conditional logistic regression adjusted for age, sex, LRT modality, tumor-specific features, and Child-Pugh class. Tumor-volume doubling time (TVDT) before LRT and objective response rates were compared by Kruskal-Wallis and Fisher exact test; progression-free survival (PFS) and transplant-free survival (TFS) were compared by Cox proportional hazards model. RESULTS On univariate analysis, HCC-CC was associated with lower median TVDT (2.4 months vs 5.2 months, P = .03), objective response (30% vs 71%, P = .01), and median PFS (2.4 months vs 7.4 months, HR 4.3, 95% CI 2.2-8.4, P < .0001). Propensity score-matched analysis demonstrated greater distant progression (60% vs 30%, P = .003) and significantly shorter median PFS (2.4 months vs 6.0 months, HR 3.3, 95% CI 1.3-8.9, P = .017) for HCC-CC. No significant difference was observed in TFS (7.5 months vs 13.8 months, HR 1.5, 95% CI 0.4-6.1). CONCLUSIONS HCC-CC was associated with reduced PFS and greater distant progression after LRT compared with HCC, indicating a need for adjunctive treatment strategies to improve outcomes.

PurposeThis study used the Oncopig Cancer Model (OCM) to develop alcohol-induced fibrosis in a porcine model capable of developing hepatocellular carcinoma.Materials and methodsLiver injury was induced in 8-week-old Oncopigs (n= 10) via hepatic transarterial infusion of 0.75 mL/kg ethanol-ethiodized oil (1:3 v/v). Feasibility was assessed in an initial Oncopig cohort (n= 5) by histologic analysis at 8 weeks after induction, and METAVIR results were compared to age- and sex-matched healthy controls (n= 5). Liver injury was then induced in a second OCM cohort (n= 5) for a time-course study, with post-induction disease surveillance via biweekly physical exam, lab analysis, and liver biopsies until 20 weeks after induction.ResultsIn Cohort 1, 8-week post-induction liver histologic analysis revealed median METAVIR F3 (range, F3-F4) fibrosis, A2 (range, A2-A3) inflammation, and 15.3% (range, 5.0%-22.9%) fibrosis. METAVIR and inflammation scores were generally elevated compared to healthy controls (F0-F1, P= 0.0013; A0-A1, P= .0013; median percent fibrosis 8.7%, range, 5.8%-12.1%, P= .064). In Cohort 2, histologic analysis revealed peak fibrosis severity of median METAVIR F3 (range, F2-F3). However, lack of persistent alcohol exposure resulted in liver recovery, with median METAVIR F2 (range, F1-F2) fibrosis at 20 weeks after induction. No behavioral or biochemical abnormalities were observed to indicate liver decompensation.ConclusionsThis study successfully validated a protocol to develop METAVIR F3-F4 fibrosis within 8 weeks in the OCM, supporting its potential to serve as a model for hepatocellular carcinoma in a fibrotic liver background. Further investigation is required to determine if repeated alcohol liver injury is required to develop an irreversible METAVIR grade F4 porcine cirrhosis model.

There are currently limited data available summarizing the clinical outcomes and safety of transjugular intrahepatic portosystemic shunts (TIPS) in cases of advanced chronic kidney disease (CKD). The study aimed to assess efficacy and safety of TIPS in patients with advanced CKD.Seventeen patients (M :F 8 :9, age 55 years, MELD 24) with grade 4-5 CKD who underwent TIPS for ascites (n = 7) or varices (n = 10) were analyzed. The primary outcome was TIPS efficacy - assessed by comparing paracentesis frequency and diuretic regimen pre- and post-TIPS among ascites patients - and through bleeding cessation in variceal bleeding patients. Other outcomes included hepatic encephalopathy (HE), GFR increase, and mortality. Median baseline GFR was 19.9 mL/min. No patients were hemodialysis dependent. Median post-TIPS pressure gradient was 8 mm Hg. Among ascites patients, 5/6 (83%) were TIPS responsive, with reduced or stable diuretics in 4/5 (80%). Among variceal hemorrhage cases, bleeding cessation rate was 90% (9/10). New or worsening HE incidence was 47% (8/17), and one patient required shunt reduction. Of 8 patients with lab follow-up, 6 (75%) demonstrated significant GFR increase (42.2 versus 20.0 mL/min, P = 0.028). The 90-day mortality incidence was 29% (5/17).In conclusion, TIPS can potentially address ascites and variceal bleeding in advanced CKD patients, though HE incidence may be increased. Further investigation in larger cohorts may corroborate these results.

This paper reviews diagnostic imaging techniques used to characterize liver masses and the imaging characteristics of the most common liver masses. The role of recently adopted ultrasound and magnetic resonance imaging contrast agents will be emphasized. Contrast-enhanced ultrasound is an inexpensive exam which can confirm benignity of certain liver masses without ionizing radiation. Magnetic resonance imaging using hepatocyte-specific gadolinium-based contrast agents can help confirm or narrow the differential diagnosis of liver masses.

PurposeTo evaluate albumin-bilirubin (ALBI) and platelet-albumin-bilirubin (PALBI) grades in predicting overall survival in high-risk patients undergoing conventional transarterial chemoembolization for hepatocellular carcinoma (HCC).Materials and methodsThis single-center retrospective study included 180 high-risk patients (142 men, 59 y ± 9) between April 2007 and January 2015. Patients were considered high-risk based on laboratory abnormalities before the procedure (bilirubin > 2.0 mg/dL, albumin < 3.5 mg/dL, platelet count < 60,000/mL, creatinine > 1.2 mg/dL); presence of ascites, encephalopathy, portal vein thrombus, or transjugular intrahepatic portosystemic shunt; or Model for End-Stage Liver Disease score > 15. Serum albumin, bilirubin, and platelet values were used to determine ALBI and PALBI grades. Overall survival was stratified by ALBI and PALBI grades with substratification by Child-Pugh class (CPC) and Barcelona Liver Clinic Cancer (BCLC) stage using Kaplan-Meier analysis. C-index was used to determine discriminatory ability and survival prediction accuracy.ResultsMedian survival for 79 ALBI grade 2 patients and 101 ALBI grade 3 patients was 20.3 and 10.7 months, respectively (P .05).ConclusionsALBI and PALBI grades are accurate survival metrics in high-risk patients undergoing conventional transarterial chemoembolization for HCC. Use of these scores allows for more refined survival stratification within CPC and BCLC stage.

The purpose of this study was to compare the efficacy and safety of microfibrillar collagen paste with those of gelatin sponge for liver track embolization after islet cell transplants.In a single-institution, retrospective study, 37 patients underwent 66 islet cell transplants from January 2005 through October 2015. Transplants were performed with 6-French transhepatic access, systemic anticoagulation, pretransplant and posttransplant portal venous pressure measurement, and image-guided liver track embolization with gelatin sponge (2005-2011) or microfibrillar collagen paste (2012-2015). The findings on 20 patients (two men, 18 women; mean age, 48 years) who underwent 35 gelatin sponge embolizations were compared with the findings on 13 patients (six men, seven women; mean age, 48 years) who underwent 22 microfibrillar collagen paste embolizations (four patients, nine procedures without embolization excluded). Medical record review was used to compare laboratory test results, portal venous pressures, and 30-day adverse bleeding events (classified according to Society of Interventional Radiology and Bleeding Academic Research Consortium criteria) between groups.The technical success rates were 100% in the microfibrillar collagen paste group and 91% in the gelatin sponge group. Group characteristics were similar, there being no differences in platelet count, partial thromboplastin time, or number of islet cell transplants per patient (p0.05). A statistical difference in international normalized ratio (1.0 versus 1.1) was not clinically significant (p = 0.012). Posttransplant portal venous pressure was slightly higher among patients treated with gelatin sponge (13 versus 9 mm Hg, p = 0.002). No bleeding occurred after microfibrillar collagen paste embolization, whereas nine bleeding events followed gelatin sponge embolization (0% versus 26%, p = 0.020). In univariate comparison of bleeding and nonbleeding groups, the use of gelatin sponge was statistically associated with postprocedure hemorrhage.Microfibrillar collagen paste is effective and safe for liver track embolization to prevent bleeding after islet cell transplants. It appears to be more efficacious than gelatin sponge.

Surgically placed dialysis access is an important component of dialysis replacement therapy. The vast majority of patients undergoing dialysis will have surgically placed accesses at some point in the course of their disease, and for many patients these accesses may represent their definitive renal replacement option. Most, if not all, arteriovenous fistulae and grafts will require interventions at some point in time. Percutaneous angioplasty is the typical first treatment performed for venous stenoses, with stents and stent grafts being reserved for patients in whom angioplasty and surgical options are exhausted. In some salvage situations, stent graft placement may be the only or best option for patients. This article describes, using case illustrations, placement of stent grafts in such patients; a focus will also be made on the techniques utilized in such salvage situations.

Author(s): Patel, Darshan C; Gaba, Ron C; Liu, Li; Lokken, R Peter | Abstract: PURPOSE:The purpose of this study is to assess the incremental effect of tissue plasminogen activator (t-PA) dose on pulmonary artery pressure (PAP) and bleeding during catheter directed thrombolysis (CDT) of submassive pulmonary embolism (PE). MATERIALS AND METHODS:Records of 46 consecutive patients (25 men, 21 women, mean age 55±14 y) who underwent CDT for submassive PE between September 2009 and February 2017 were retrospectively reviewed. Mean t-PA rate was 0.7±0.3 mg/h. PAP was measured at baseline and daily until CDT termination. Mixed-effects regression modeling was performed of repeated PAP measures in individual patients. Bleeding events were classified by Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) and t-PA dose at onset. RESULTS:Mean t-PA dose was 43.0±30.0 mg over 61.9± 28.8 h. Mean systolic PAP decreased from 51.7±15.5 mmHg at baseline to 35.6±12.7 mmHg at CDT termination (pl0.001). Mixed-effects regression revealed a linear decrease in systolic PAP over time (β = -0.37 (SE = 0.05), pl0.001) with reduction in mean systolic PAP to 44.8±1.9 mmHg at 12 mg t-PA/20 h, 39.5±2.0 mmHg at 24 mg t-PA/40 h, and 34.9±2.1 mmHg at 36 mg/60 h. No severe, one moderate, and 8 mild bleeding events occurred; bleeding onset was more frequent at ≤24 mg t-PA (p l0.001). One patient expired from cardiopulmonary arrest after 16 h of CDT (15.4 mg t-PA); no additional intra-procedural fatalities occurred. CONCLUSION:Increased total t-PA dose and CDT duration were associated with greater PAP reduction without increased bleeding events.

BACKGROUND: Gestational age (GA) is frequently unknown or inaccurate in pregnancies in low-income countries. Early identification of preterm infants may help link them to potentially life-saving interventions. METHODS: We conducted a validation study in a community-based birth cohort in rural Bangladesh. GA was determined by pregnancy ultrasound ( RESULTS: In the live-born cohort (n = 1066), the mean ultrasound GA was 39.1 weeks (SD 2.0) and prevalence of preterm birth ( CONCLUSIONS: Newborn clinical assessment of GA is challenging at the community level in low-resource settings. Anthropometrics are also inaccurate surrogate markers for GA in settings with high rates of fetal growth restriction.

OBJECTIVE—To systematically evaluate the evidence for an association between physical activity of moderate intensity and risk of type 2 diabetes. RESEARCH DESIGN AND METHODS—We searched EMBASE and Medline through March 2006 and examined reference lists of retrieved articles. We excluded studies that did not assess physical activity of moderate intensity independent of activities of vigorous intensity (more than six times the resting metabolic rate). Information on study design, participant characteristics, assessment of physical activity, and outcomes and estimates of associations were extracted independently by two investigators. We calculated summary relative risks (RRs) using a random-effects model for the highest versus the lowest reported duration of activities. RESULTS—We identified 10 prospective cohort studies of physical activity of moderate intensity and type 2 diabetes, including a total of 301,221 participants and 9,367 incident cases. Five of these studies specifically investigated the role of walking. The summary RR of type 2 diabetes was 0.69 (95% CI 0.58–0.83) for regular participation in physical activity of moderate intensity as compared with being sedentary. Similarly, the RR was 0.70 (0.58–0.84) for regular walking (typically ≥2.5 h/week brisk walking) as compared with almost no walking. The associations remained significant after adjustment for BMI. Similar associations were observed in men and women and in the U.S. and Europe. CONCLUSIONS—These findings indicate that adherence to recommendations to participate in physical activities of moderate intensity such as brisk walking can substantially reduce the risk of type 2 diabetes.

Purpose To identify fundamental causes underlying recurrent variceal hemorrhage (VH) after transjugular intrahepatic portosystemic shunt (TIPS) to ascertain opportunities for improvement of TIPS-based management of VH and prevention of rebleeding. Materials and Methods This single-center retrospective study comprised 166 patients (male-to-female ratio 101:65; median age, 52 y; median Model for End-Stage Liver Disease score, 14) who had TIPS created for VH in 1998–2014. Medical record review was used to identify patients who had recurrent VH events, and root cause analysis allowed identification of the most probable causal factors. A 5-person interventional radiology physician group generated quality improvement (QI) recommendations for process changes to address causal factors, with consensus achieved using a modified Delphi method. Results Variceal rebleeding occurred after TIPS in 25 (15%) patients. The 1-, 3-, and 5-year variceal rebleeding incidence was 17%, 21%, and 21%, respectively. Variceal rebleeding was associated with high 90-day all-cause mortality incidence (10/25; 40%). Male sex ( P = .018) and Model for End-Stage Liver Disease score ( P = .009) were statistically associated with variceal rebleeding. The most common primary and secondary causes of recurrent VH were lack of or insufficient variceal embolization (64%). Other causal factors included TIPS stenosis or occlusion (28%) with recurrent portosystemic gradient (PSG) elevation (20%), severe coagulopathy (20%), inadequate portosystemic gradient reduction (12%), and TIPS underdilation (4%). To potentially address variceal rebleeding, 14 preventive QI recommendations were developed. Conclusions Although recurrent VH rates after TIPS are not trivial, rebleeding may be related to addressable underlying causal factors. Further investigation may assess the efficacy of QI-based procedure methodologic enhancements in reducing rebleeding incidence after TIPS.

CT urography is increasingly used as the initial imaging test in patients with hematuria. The aim of our study was to determine the yield of CT urography in young adults with hematuria to see whether single phase unenhanced CT would have been sufficient.We reviewed medical records of consecutive patients undergoing CT urography between March 2000 and July 2009 at our tertiary medical center. Of 5400 CT urograms performed, 375 (6.9%) in 359 patients aged 40 years or younger with hematuria were included in the study. Urographic findings were tabulated according to their clinical significance. CT images were reviewed to see whether contrast-enhanced images were necessary for diagnosis.A clinically significant source was found in 83 of 375 examinations (22.1%), including 42 of 142 (29.6%) for gross hematuria, 29 of 181 (16.0%) for microscopic hematuria, and 12 of 52 (23.1%) for hematuria of unspecified subtype. The most common clinically significant findings were renal or ureteral calculi (n = 73 [75.3%]); four malignancies were also detected. Ninety-two (94.8%) of 97 clinically significant findings were evident on unenhanced images. All significant findings that required contrast-enhanced images for diagnosis occurred in patients with predisposing medical conditions.A clinically significant source of hematuria was detected in 22.1% of CT urograms of young adults. However, an unenhanced CT alone may be sufficient in patients without additional predisposing medical conditions, thereby reducing radiation dose in this radiosensitive population.

Epidemiologic studies suggest an association between short-term fluctuations in ambient air pollution levels and risk of hospitalization for acute cardiovascular events, including ischemic stroke,1 myocardial infarction,2,3 and acute decompensated heart failure.4 Time-series studies using generalized additive models or generalized linear models represent a widely used approach to evaluating the acute health effects of ambient air pollution.5 More recently, case-crossover methods have been applied to time-series data yielding theoretically equivalent results under certain assumptions.6 Regardless of the analytic approach, the majority of previous time-series studies have utilized data from administrative databases in which the date of hospitalization is the only information available on the timing of the event. Accordingly, pollution exposure just prior to the index event is necessarily defined as the average exposure over a fixed period prior to the calendar day of admission. For example, to evaluate the association between ambient fine particulate matter (PM2.5) and risk of same-day hospitalization for acute ischemic stroke, each case is commonly assigned the mean daily (eg, midnight-midnight) PM2.5 level on the date of hospital admission. Such studies are limited by the fact that hospital admission may occur at any time of day and that the true onset of the event may occur hours or days prior to hospital admission (Fig. 1). Figure 1 An illustration of how measurement error in the onset time of an acute cardiovascular event may give rise to exposure misclassification. Most time-series studies of ambient air pollution and acute cardiovascular events have used fixed time periods (eg, ... The impact of misclassification of the time of event onset on the estimated association between ambient air pollution and the risk of acute cardiovascular events has not been evaluated. Accordingly, the aims of this study were to 1) investigate whether significant exposure misclassification may result from using the hospitalization date to estimate air pollution exposure at the true onset time of an acute cardiovascular event, and 2) evaluate the impact of the resulting exposure misclassification on the estimated association between ambient air pollution and the risk of acute cardiovascular events. We used data collected in the Boston metropolitan region as part of an ongoing study of ambient air pollution and the risk of acute ischemic stroke to accomplish the first aim and performed computer simulations to accomplish the second aim.

To systematically evaluate the evidence for an association between physical activity of moderate intensity and risk of type 2 diabetes.We searched EMBASE and Medline through March 2006 and examined reference lists of retrieved articles. We excluded studies that did not assess physical activity of moderate intensity independent of activities of vigorous intensity (more than six times the resting metabolic rate). Information on study design, participant characteristics, assessment of physical activity, and outcomes and estimates of associations were extracted independently by two investigators. We calculated summary relative risks (RRs) using a random-effects model for the highest versus the lowest reported duration of activities.We identified 10 prospective cohort studies of physical activity of moderate intensity and type 2 diabetes, including a total of 301,221 participants and 9,367 incident cases. Five of these studies specifically investigated the role of walking. The summary RR of type 2 diabetes was 0.69 (95% CI 0.58-0.83) for regular participation in physical activity of moderate intensity as compared with being sedentary. Similarly, the RR was 0.70 (0.58-0.84) for regular walking (typicallyor = 2.5 h/week brisk walking) as compared with almost no walking. The associations remained significant after adjustment for BMI. Similar associations were observed in men and women and in the U.S. and Europe.These findings indicate that adherence to recommendations to participate in physical activities of moderate intensity such as brisk walking can substantially reduce the risk of type 2 diabetes.

Nucleotide analog interference mapping (NAIM) is a powerful method for identifying RNA functional groups involved in protein–RNA interactions. We examined particles assembled on modified U1 small nuclear RNAs (snRNAs) in vitro and detected two categories of interferences. The first class affects the stability of two higher-order complexes and comprises changes in two adenosines, A65 and A70, in the loop region previously identified as the binding site for the U1 small nuclear ribonucleoprotein (snRNP)-specific U1A protein. Addition of an exocyclic amine to position 2 of A65 interferes strongly with protein binding, whereas removal or modification of the exocyclic amine at position 6 makes little difference. Modifications of A70 exhibit the opposite effects: Additions at position 2 are permitted, but modification of the exocyclic amine at position 6 significantly inhibits protein binding. These interactions, critical for U1A-U1 snRNA recognition in the context of in vitro snRNP assembly, are consistent with previous structural studies of the isolated protein with the RNA hairpin containing the U1A binding site. The second category of interferences affects all partially assembled U1-protein complexes by decreasing the stability of Sm core protein associations. Interestingly, most strong interferences occur at phosphates in the terminal stem-loop region of U1, rather than in the Sm binding site. These data argue that interactions with the phosphate backbone of the terminal stem loop are essential for the stable association of Sm core proteins with the U1 snRNA. We suggest that the stem loop of all Sm snRNAs may act as a clamp to hold the ring of Sm proteins in place.