Long term impact of transjugular intrahepatic portosystemic shunt (TIPS) creation on hepatic morphology

PURPOSE

The purpose of this study was to evaluate long-term morphologic changes occurring in the liver after TIPS creation with correlation with hepatic function to gain insight on the physiologic impact of TIPS on the liver.

METHODS

This retrospective study included patients who underwent TIPS creation between 2005 and 2022 and had contrasted CT or MRI studies prior to and between 1 and 2 years post procedure. Strict exclusion criteria were applied to avoid confounding. Parenchymal volume and vessel measurements were assessed on the pre- and post-TIPS CT or MRI and MELD scores calculated.

RESULTS

Of 580 patients undergoing TIPS creation, 65 patients (mean age, 55 years; 36 males) had pre-TIPS and post-TIPS imaging meeting inclusion criteria at median 16.5 months. After TIPS, the mean MELD score increased (12.9 to 15.4; p = 0.008) and total liver volume decreased (1730 to 1432 mL; p < 0.001). However, the magnitude of volume change did not correlate with MELD change. Neither portosystemic gradient nor TIPS laterality correlated with total or lobar hepatic volume changes or MELD changes. The main portal vein diameter increased (15.0 to 18.7 mm; p < 0.001). Thrombosis of the hepatic vein used for TIPS creation resulted in a mean increase in MELD of +4.1 compared to -2.1 in patients who had a patent and normal hepatic vein (p = 0.007).

CONCLUSIONS

Given lack of correlation between portosystemic gradient, hepatic atrophy, hepatic function, and TIPS laterality, the alterations in portal flow dynamics after TIPS may not be impactful to hepatic function. However, hepatic vein patency after TIPS correlated with improved hepatic function.

Cerebral venous biomarkers and veno-arterial gradients: untapped resources in Alzheimer's disease

Blood based biomarkers (BBB) derived from forearm veins for estimating brain changes is becoming ubiquitous in Alzheimer's Disease (AD) research and could soon become standard in routine clinical diagnosis. However, there are many peripheral sources of contamination through which concentrations of these metabolites can be raised or lowered after leaving the brain and entering the central venous pool. This raises the issue of potential false conclusions that could lead to erroneous diagnosis or research findings. We propose the use of simultaneous sampling of internal jugular venous and arterial blood to calculate veno-arterial gradient, which can reveal either a surplus or a deficit of metabolites exiting the brain. Methods for sampling internal jugular venous and arterial blood are described along with examples of the use of the veno-arterial gradient in non-AD brain research. Such methods in turn could help better establish the accuracy of forearm venous biomarkers.

Probing gut-brain links in Alzheimer's disease with rifaximin

Gut-microbiome-inflammation interactions have been linked to neurodegeneration in Alzheimer's disease (AD) and other disorders. We hypothesized that treatment with rifaximin, a minimally absorbed gut-specific antibiotic, may modify the neurodegenerative process by changing gut flora and reducing neurotoxic microbial drivers of inflammation. In a pilot, open-label trial, we treated 10 subjects with mild to moderate probable AD dementia (Mini-Mental Status Examination (MMSE) = 17 ± 3) with rifaximin for 3 months. Treatment was associated with a significant reduction in serum neurofilament-light levels (P < .004) and a significant increase in fecal phylum Firmicutes microbiota. Serum phosphorylated tau (pTau)181 and glial fibrillary acidic protein (GFAP) levels were reduced (effect sizes of -0.41 and -0.48, respectively) but did not reach statistical significance. In addition, there was a nonsignificant downward trend in serum cytokine interleukin (IL)-6 and IL-13 levels. Cognition was unchanged. Increases in stool Erysipelatoclostridium were correlated significantly with reductions in serum pTau181 and serum GFAP. Insights from this pilot trial are being used to design a larger placebo-controlled clinical trial to determine if specific microbial flora/products underlie neurodegeneration, and whether rifaximin is clinically efficacious as a therapeutic.

Safety Profile of Particle Embolization for Treatment of Acute Lower Gastrointestinal Bleeding

PURPOSE

To assess ischemic adverse events following particle embolization when used as a second-line embolic to coil embolization for treatment of acute lower gastrointestinal bleeding(LGIB).

MATERIALS AND METHODS

This single-institution retrospective study examined 154 procedures where embolization was attempted for LGIB. In 122 patients (64 males, mean age 69.9 years), embolization was successfully performed using microcoils in 73 procedures, particles in 34 procedures, and both microcoils and particles in 27 procedures. Particles were used as second-line only when coil embolization was infeasible or inadequate. Technical success was defined as angiographic cessation of active extravasation after embolization. Clinical success was defined as absence of recurrent bleeding within 30 days of embolization.

RESULTS

Technical success for embolization of LGIB was achieved in 87.0% of cases (134/154), and clinical success was 76.1%(102/134) among technically successful cases. Clinical success was 82.2%(60/73) for coils alone and 68.9%(42/61) for particles +/- coils. Severe adverse events involving embolization-induced bowel ischemia occurred in 3 of 56 patients who underwent particle embolization +/- coils (5.3%) versus zero out of 66 patients when coils alone were used (P=0.09). In patients who had colonoscopy or bowel resection within 2 weeks of embolization, ischemic findings attributable to the embolization were found in 3 of 15 who underwent embolization with coils alone, versus 8 of 18 who underwent embolization with particles +/- coils (p=0.27).

CONCLUSION

Particle embolization for treatment of LGIB as second line to coil embolization was associated with a 68.9% clinical success rate and a 5.3% rate of ischemia-related adverse events.

Intravascular Ultrasound-Guided Transvenous Biopsy of Abdominal and Pelvic Targets Difficult to Access by Percutaneous Needle Biopsy: Technique and Initial Clinical Experience

PURPOSE

To report initial clinical experience with intravascular ultrasound (US)-guided transvenous biopsy (TVB) for perivascular target lesions in the abdomen and pelvis using side-viewing phased-array intracardiac echocardiography catheters.

MATERIALS AND METHODS

In this single-institution, retrospective study, 48 patients underwent 50 intravascular US-guided TVB procedures for targets close to the inferior vena cava or iliac veins deemed difficult to access by conventional percutaneous needle biopsy (PNB). In all procedures, side-viewing phased-array intracardiac echocardiography intravascular US catheters and transjugular liver biopsy sets were inserted through separate jugular or femoral vein access sheaths, and 18-gauge core needle biopsy specimens were obtained under real-time intravascular US guidance. Diagnostic yield, diagnostic accuracy, and complications were analyzed.

RESULTS

Intravascular US-guided TVB was diagnostic of malignancy in 40 of 50 procedures for a diagnostic yield of 80%. There were 5 procedures in which biopsy was correctly negative for malignancy, with a per-procedure diagnostic accuracy of 90% (45/50). Among the 5 false negatives, 2 patients underwent repeat intravascular US-guided TVB, which was diagnostic of malignancy for a per-patient diagnostic accuracy of 94% (45/48). There were 1 (2%) mild, 2 (4%) moderate, and 1 (2%) severe adverse events, with 1 moderate severity adverse event (venous thrombosis) directly attributable to the intravascular US-guided TVB technique.

CONCLUSIONS

Intravascular US-guided TVB performed on difficult-to-approach perivascular targets in the abdomen and pelvis resulted in a high diagnostic accuracy, similar to accepted thresholds for PNB. Complication rates may be slightly higher but should be weighed relative to the risks of difficult PNB, surgical biopsy, or clinical management without biopsy.

Proton pump inhibitor use is associated with increased rates of post-TIPS hepatic encephalopathy: Replication in an independent patient cohort

PURPOSE

Proton pump inhibitor (PPI) use is a potential risk factor for hepatic encephalopathy (HE), but few studies have examined the effect on post-TIPS HE. The purpose of this study was to determine whether PPIs are associated with increased rates of post-TIPS HE in an independent patient cohort.

MATERIALS AND METHODS

This single-institution retrospective study analyzed 86 patients (54 male, mean age 58.2) following TIPS from 1/1/2017 to 12/31/2019. Dates of PPI usage and episodes of new or worsening HE were recorded. Poisson regression with generalized estimating equations was used to test for association between PPI use and post-TIPS HE and to test for dose dependence. Post-TIPS HE was also analyzed using the Andersen-Gill survival model for recurrent events.

RESULTS

There were 1.88 episodes of new or worsening post-TIPS HE per person-year among 35 patients on uninterrupted PPIs therapy, 1.95 on PPIs and 0.94 off PPIs among 35 patients on intermittent therapy, and 0.47 among 16 patients never on PPIs. PPI use was significantly associated with post-TIPS HE in both univariable (incidence rate ratio (IRR) = 2.62; CI = 1.41-4.84; p = 0.002) and multivariable (IRR = 2.31; CI = 1.37-3.89; p = 0.002) regression. Analysis of only those patients on PPIs showed increased rates of HE with higher doses (IRR = 1.17 per 10 mg omeprazole equivalent; CI = 1.04-1.33; p = 0.011). Recurrent events survival analysis supported the association between PPI use and HE in univariable (hazard ratio (HR) = 2.17; CI = 1.19-3.95; p = 0.011) and multivariable (HR = 1.87; CI = 1.12-3.13; p = 0.017) analysis.

CONCLUSION

In an independent patient cohort PPI use was associated with increased rates of new or worsening post-TIPS HE.

Percutaneous gastrojejunostomy tubes: Identification of predictors of retrograde jejunal limb migration into the stomach

PURPOSE

To identify whether technically modifiable factors during gastrojejunostomy (GJ) tube insertion are predictive of retrograde jejunal limb migration into the stomach.

MATERIALS AND METHODS

Retrospective review of our procedural database over a 5-year period revealed 988 successful primary GJ tube insertions. Medical records and imaging were reviewed for cases of retrograde jejunal limb migration. Primary analysis was performed on 74 patients with retrograde tip migration within 3 months after placement (37 males, mean age = 57). Comparison was performed on 67 control patients (34 males, mean age = 51) who had radiologically confirmed GJ tube stability for at least 6 months. Procedural fluoroscopic images were analyzed for multiple GJ tube configuration parameters. The stomach was designated into antrum, body, and fundus. Predictors of retrograde tip migration were analyzed with univariate and multivariate logistic regression analysis.

RESULTS

A total of 110 patients (11.1%) had retrograde jejunal limb migration, with 74 (7.5%) occurring within 3 months of placement. On multivariate analysis, the factors associated with a significantly lower risk of tip malposition included gastric puncture site in the antrum (OR: 0.27, 95% CI: 0.13-0.56, p < 0.001) and GJ tract angle less than 30 degrees away from the pylorus (OR: 0.35, 95% CI: 0.16-0.76, p = 0.008). No patient in either cohort had a major complication within 30 days of procedure.

CONCLUSION

To minimize the risk of retrograde tip migration, GJ tubes should be inserted into the gastric antrum with an entry tract oriented as directly towards the pylorus as possible.

Length of Stay Predicts Risk of Early Infection for Hospitalized Patients Undergoing Central Venous Port Placement

PURPOSE

To compare early totally implantable central venous port catheter-related infection rates after inpatient vs outpatient placement and to determine whether the risk associated with inpatient placement is influenced by length of hospital stay.

MATERIALS AND METHODS

In this single-institution retrospective study, 5,301 patients (3,618 women; mean age 57 y) underwent port placement by interventional radiologists between October 2004 and January 2018. The 30-day infection rate was compared between inpatients and outpatients using survival analysis. Among inpatients, the effect of time from admission to port placement and from placement to discharge was analyzed using a survival regression tree.

RESULTS

The 30-day infection rate was 3.6% (95% confidence interval [CI] = 1.9%-6.1%) among 386 inpatients and 1.0% (95% CI = 0.7%-1.3%) among 4,915 outpatients (hazard ratio [HR] = 3.6, 95% CI = 2.0-6.6, P < .001). Inpatient placement was a significant risk factor after accounting for covariates in multivariate analysis (HR = 2.2, 95% CI = 1.0-4.7, P = .05) and controlling for demographic differences by propensity score matching (HR = 2.8, 95% CI = 1.0-7.8, P = .04). Infection rate was 11% (95% CI = 4.7%-22%) among 65 inpatients in whom time from admission to placement was ≥ 7 days, 5.1% (95% CI = 1.9%-11%) among 129 inpatients in whom admission to placement was < 7 days and time to discharge was > 3 days, and 0% (95% CI = 0%-2.1%) among 192 inpatients in whom admission to placement was < 7 days and time to discharge was ≤ 3 days (P < .001).

CONCLUSIONS

Inpatient port placement was associated with a higher risk of early infection. However, a clinical decision tree based on shorter length of stay before and after placement may identify a subset of hospitalized patients not at increased risk for infection.

No Increased Mortality After TIPS Compared with Serial Large Volume Paracenteses in Patients with Higher Model for End-Stage Liver Disease Score and Refractory Ascites

PURPOSE

To compare survival after transjugular intrahepatic portosystemic shunt (TIPS) creation versus serial large volume paracenteses (LVP) in patients with refractory ascites and higher Model for End-Stage Liver Disease (MELD) scores.

MATERIALS AND METHODS

In this retrospective study, from 1/1/2013 to 10/1/2018, 478 patients (294 male; mean age 58, range 23-89) underwent serial LVP (n = 386) or TIPS (n = 92) for ascites. Propensity-matched cohorts were constructed based on age, MELD, Charlson comorbidity index, varices, and hepatic encephalopathy. Survival was analyzed using a Cox proportional hazards model in which MELD score and TIPS were treated as time-dependent covariates. An interaction term was used to assess the impact of TIPS versus serial LVP on survival as a function of increasing MELD.

RESULTS

In the overall patient sample, higher MELD score predicted worse survival after either serial LVP or TIPS [hazard ratio (HR) = 1.13; p < 0.001], but there was no significant interaction between TIPS and higher MELD score conferring worse survival (HR = 1.01; p = 0.55). In 92 propensity-matched serial LVP and 92 TIPS patients, higher MELD score predicted worse survival after either serial LVP or TIPS (HR = 1.19; p < 0.001), but there was no significant survival interaction between TIPS and higher MELD (HR = 0.97; p = 0.22). In 30 propensity-matched serial LVP patients and 30 TIPS patients with baseline MELD greater than 18, TIPS did not predict worse survival (HR = 0.97; p = 0.94).

CONCLUSION

Higher MELD predicts poorer survival after either serial LVP or TIPS, but TIPS creation is not associated with worse survival compared to serial LVP in patients with higher MELD scores LEVEL OF EVIDENCE: Level 4, case series.

Hemorrhage risk with transjugular intrahepatic portosystemic shunt (TIPS) insertion at the main portal vein bifurcation with stent grafts

PURPOSE

The purpose of this study was to assess the incidence of major hemorrhage after transjugular intrahepatic portosystemic shunt (TIPS) insertion using a stent graft at the main portal vein bifurcation.

PATIENTS AND METHODS

TIPS insertion using stent grafts was performed in 215 patients due to non-variceal hemorrhage indications. There were 137 men and 78 women, with a mean age of 57 years±10.6 (SD) (range: 19-90 years). Based on retrospective review of portal venograms, TIPS inserted within 5mm from the portal vein bifurcation were considered "bifurcation TIPS", while those inserted 2cm or greater from the bifurcation were considered intrahepatic. Suspicion for acute major periprocedural hemorrhage were categorized as low, moderate, and high, based on the number of signs of hemorrhage.

RESULTS

Of 215 TIPS inserted for purposes other than hemorrhage, the TIPS was inserted at the portal bifurcation in 41 patients (29 men, 12 women; mean age, 55.9±11.7 (SD); range: 26-79 years) and intrahepatic in 62 patients (37 men, 25 women; mean age, 57.6±10.6 (SD), range: 34-82 years), whereas 112 were indeterminate in location. No active extravasations were identified on post-TIPS portal venograms. Suspicion for acute major hemorrhage was moderate or high in 3/41 (7%) of patients in the TIPS bifurcation group compared to 5/62 (8%) in the intrahepatic TIPS group (P>0.99). There were no significant differences in 30-day mortality rates (1/41 [2%] and 3/62 [5%] respectively; P> 0.99). No deaths or interventions were attributed to acute hemorrhage.

CONCLUSION

TIPS insertion at the portal bifurcation with stent grafts did not incur an elevated risk of hemorrhagic complications.

Pilot Evaluation of Angiogenesis Signaling Factor Response after Transcatheter Arterial Embolization for Hepatocellular Carcinoma

Purpose To identify changes in a broad panel of circulating angiogenesis factors after bland transcatheter arterial embolization (TAE), a purely ischemic treatment for hepatocellular carcinoma (HCC). Materials and Methods This prospective HIPAA-compliant study was approved by the institutional review board. Informed written consent was obtained from all participants prior to entry into the study. Twenty-five patients (21 men; mean age, 61 years; range, 30-81 years) with Liver Imaging Reporting and Data System category 5 or biopsy-proven HCC and who were undergoing TAE were enrolled from October 15, 2014, through December 2, 2015. Nineteen plasma angiogenesis factors (angiopoietin 2; hepatocyte growth factor; platelet-derived growth factor AA and BB; placental growth factor; vascular endothelial growth factor A and D; vascular endothelial growth factor receptor 1, 2, and 3; osteopontin; transforming growth factor β1 and β2; thrombospondin 2; intercellular adhesion molecule 1; interleukin 6 [IL-6]; stromal cell-derived factor 1; tissue inhibitor of metalloproteinases 1; and vascular cell adhesion molecule 1 [VCAM-1]) were measured by using enzyme-linked immunosorbent assays at 1 day, 2 weeks, and 5 weeks after TAE and were compared with baseline levels by using paired Wilcoxon tests. Tumor response was assessed according to modified Response Evaluation Criteria in Solid Tumors (mRECIST). Angiogenesis factor levels were compared between responders and nonresponders by mRECIST criteria by using unpaired Wilcoxon tests. Results All procedures were technically successful with no complications. Fourteen angiogenesis factors showed statistically significant changes following TAE, but most changes were transient. IL-6 was upregulated only 1 day after the procedure, but showed the largest increases of any factor. Osteopontin and VCAM-1 demonstrated sustained upregulation at all time points following TAE. At 3-month follow-up imaging, 11 patients had responses to TAE (complete response, n = 6; partial response, n = 5) and 11 patients were nonresponders (stable disease, n = 9; progressive disease, n = 2). In nonresponders, the percent change in IL-6 on the day after TAE (P = .033) and the mean percent change in osteopontin after TAE (P = .024) were significantly greater compared with those of responders. Conclusion Multiple angiogenesis factors demonstrated significant upregulation after TAE. VCAM-1 and osteopontin demonstrated sustained upregulation, whereas the rest were transient. IL-6 and osteopontin correlated significantly with radiologic response after TAE. ^© RSNA, 2017.

Percutaneous biliary drainage catheter insertion in patients with extensive hepatic metastatic tumor burden

BACKGROUND

Patients with metastatic disease of the liver can have hyperbilirubinemia due to a number of reasons, including biliary obstruction. The purpose of this study was to analyze patient outcomes after percutaneous biliary drainage (PBD) catheter insertion in patients with extensive hepatic metastatic tumor burden.

METHODS

Out of 746 PBD insertions, 44 patients (24 males, 20 females, mean age 57.4 years, range, 34-80 years) had metastatic malignancy with a hepatic tumor burden of greater than 20% parenchymal volume based on pre-procedure computed tomography (CT) or magnetic resonance imaging (MRI). Laboratory data before and after PBD insertion were compared. Survival and outcomes analysis performed. A subanalysis was performed on patients with CT-demonstrated catheter traversal of tumoral tissue.

RESULTS

A PBD catheter was successfully inserted in all patients. The mean serum bilirubin level decreased significantly from 10.9±6.4 mg/dL immediately prior to PBD insertion to 7.1±5.6 mg/dL (P<0.001) within one month post PBD insertion. Four patients (11%) demonstrated normalization of bilirubin levels to less than 1.6 mg/dL. Of the 14 patients with a post-procedure CT or MRI, the PBD catheter traversed a tumor in 11 (79%). One of these patients required a transfusion after the procedure and one had recurrent catheter exchanges due to pericatheter leakage. The 30-day overall survival was 41% with a median survival of 19 days. The percentage decrease in serum bilirubin after PBD insertion and pre-procedure international normalized ratio (INR) were correlated with improved survival (OR =3.7, P=0.010 and OR =4.9, P=0.028 respectively). The PBD-associated major complication rate was 16%.

CONCLUSIONS

In patients with hyperbilirubinemia and extensive hepatic metastatic disease burden, survival was dismal after PBD catheter insertion. Serum bilirubin level normalization occurred rarely.

Postintervention Patency Rates and Predictors of Patency after Percutaneous Interventions on Intragraft Stenoses within Failing Prosthetic Arteriovenous Grafts

PURPOSE

To determine postintervention patency rates after endovascular interventions on intragraft stenosis within failing prosthetic arteriovenous (AV) grafts, as well as predictors of patency.

MATERIALS AND METHODS

Retrospective review of percutaneous interventions on prosthetic AV grafts presenting with first-time intragraft stenoses over a 7-year period revealed 183 patients (81 male; mean age, 59.7 y). "Intragraft" was defined as 2 cm or more from the arterial or venous anastomosis. Procedural imaging was retrospectively reviewed. Patency rates were estimated by Kaplan-Meier test. Predictors of patency were calculated by Cox proportional-hazards model.

RESULTS

Two-hundred twenty-nine intragraft stenoses were identified in 183 grafts. Intragraft stenoses were treated at a median of 20.7 months (interquartile range, 12.0-33.9 mo) after graft creation. Graft thrombosis was present in 62%. The anatomic success rate of angioplasty was 85%. Fifteen percent required stent or stent-graft deployment because of inadequate response to angioplasty. A concurrent nonintragraft stenosis within the access circuit was identified in 76% of grafts. At 3, 6, and 12 months, postintervention primary patency rates were 56%, 40%, and 23%, respectively. Secondary patency rates were 84%, 77%, and 67%, respectively. The lesion-specific patency rates were 89, 75%, and 63%, respectively. Graft thrombosis (hazard ratio [HR], 1.43; P = .048) and concurrent nonintragraft lesion (HR, 1.51; P = .047) were independent negative predictors of primary patency. Graft thrombosis (HR, 1.81; P = .029) was a negative predictor of lesion patency, and stent or stent-graft deployment (HR, 0.42; P = .045) was a positive predictor of lesion patency.

CONCLUSIONS

Endovascular interventions on intragraft stenoses resulted in primary, secondary, and lesion-specific patency rates of 40%, 77%, and 75%, respectively, at 6 months. Stent or stent-graft deployment may prolong lesion patency.

Transjugular intrahepatic portosystemic shunt complications: prevention and management

Transjugular intrahepatic portosystemic shunt (TIPS) insertion has been well established as an effective treatment in the management of sequelae of portal hypertension. There are a wide variety of complications that can be encountered, such as hemorrhage, encephalopathy, TIPS dysfunction, and liver failure. This review article summarizes various approaches to preventing and managing these complications.

Comparison of primary jejunostomy tubes versus gastrojejunostomy tubes for percutaneous enteral nutrition

PURPOSE

To evaluate technical success and long-term outcomes of percutaneous primary jejunostomy tubes for postpyloric enteral feeding compared with percutaneous gastrojejunostomy (GJ) tubes.

MATERIALS AND METHODS

Over a 25-month interval, 41 consecutive patients (26 male; mean age, 55.9 y) underwent attempted fluoroscopy-guided direct percutaneous jejunostomy tube insertion. Insertions at previous jejunostomy tube sites were excluded. The comparison group consisted of all primary GJ tube insertions performed over a 12-month interval concomitant with the jejunostomy tube interval (N = 169; 105 male; mean age, 59.4 y). Procedural, radiologic, and clinical data were retrospectively reviewed. Intervention rates were expressed as events per 100 catheter-days.

RESULTS

The technical success rate for percutaneous jejunostomy tube insertion was 96%, versus 93% for GJ tubes (P = .47). Mean fluoroscopy times were similar for jejunostomy and GJ tubes (9.8 vs 10.0 min, respectively; P value not significant). Jejunostomy tubes exhibited a lower rate of catheter dysfunction than GJ tubes, with catheter exchange rates of 0.24 versus 0.93, respectively, per 100 catheter-days (P = .045). GJ tube tip retraction into the stomach occurred in 9.5% of cases, at a rate of 0.21 per 100 catheter-days. Intervention rates related to leakage were 0.19 and 0.03 for jejunostomy and GJ tubes, respectively (P < .01). Jejunostomy and GJ tubes exhibited similar rates of catheter exchange for occlusion and replacement as a result of inadvertent removal. No major complications were encountered in either group.

CONCLUSIONS

Percutaneous insertion of primary jejunostomy tubes demonstrated technical success and complication rates similar to those of GJ tubes. Jejunostomy tubes exhibited a lower dysfunction rate but a higher leakage rate compared with GJ tubes.

Hepatic venous pressure measurements: comparison of end-hole and balloon catheter methods

PURPOSE

To determine the difference in hepatic venous pressures measured with the use of an end-hole diagnostic catheter versus a balloon catheter.

MATERIALS AND METHODS

A total of 92 patients underwent transjugular hepatic venous pressure measurements with a 5-F diagnostic end-hole catheter and a balloon catheter, with the catheter type used initially determined randomly. With both catheters, free and wedged systolic, diastolic, and mean pressures were collected. Hepatic venous pressure gradients were calculated from each pressure set. Eighty-five patients (92%) also underwent concurrent transjugular biopsy after pressures were recorded. Demographic, histologic, and specific procedural information were also collected.

RESULTS

The study included 47 men and 45 women, with a mean age of 52.7 years (range, 19-84 y). For the entire population, there were statistically significant differences in mean measurements between the two catheters in wedged systolic (P = .004), diastolic (P = .021), and mean (P = .036) pressures. However, the differences between the means were only 0.783, 0.609, and 0.207 mm Hg, respectively. A subanalysis based on histologic stage revealed no difference between catheter types for normal or cirrhotic livers, but a significant (P = .017) difference in systolic wedged pressure (absolute difference of 0.67 mm Hg) in patients with mild to moderate fibrosis (stages 1-3). In all differences, the balloon catheter had the greater pressure reading.

CONCLUSIONS

There was a significant difference in wedged pressure measurements between the two catheter systems in the overall population and among patients with a histologic grade indicating fibrosis. However, the absolute value differences between the two systems were comparatively small (< 1 mm Hg).

Gastrostomy-to-gastrojejunostomy tube conversion: impact of the method of original gastrostomy tube placement

PURPOSE

To determine the outcome of gastrostomy tube-to-gastrojejunostomy tube conversion on the basis of the method of original gastrostomy tube placement.

MATERIALS AND METHODS

One hundred twenty-four patients (age range, 13-87 years; 72 male and 52 female patients) underwent conversion of a primarily placed gastrostomy tube to a gastrojejunostomy tube at the authors' institution between January 2000 and December 2008. The method of original gastrostomy tube placement was radiologic (n = 27), endoscopic (n = 75), laparoscopic (n = 2), or open surgery (n = 20). The method of placement was correlated with the success rates of gastrostomy-to-gastrojejunostomy tube conversion. Medical records and radiologic images were reviewed to determine the frequency of proximal migration of the jejunostomy tube into the stomach. Follow-up data were available for an average of 136 days after gastrostomy-to-gastrojejunostomy tube conversion (median, 63 days; range, 1-1,300 days).

RESULTS

Of 124 gastrostomy tube-to-gastrojejunostomy tube conversions, 109 (87.9%) were successfully performed. Procedural conversion failure occurred in one of the 27 radiologically inserted gastrostomy tubes (3.7%) compared to 14 of the 97 (14%) nonradiologically inserted gastrostomy tubes (P = .19), of which 12 were inserted endoscopically and two were inserted surgically. Of the 109 patients with successful tube conversion, jejunal tip malposition occurred at follow-up in 18 (16.5%). Of these, four patients developed aspiration pneumonia (22%), which contributed to patient death in two. The frequency of jejunal tip malposition was 3.8% (one of 26 patients) for radiologically placed gastrostomy tubes and 20% (17 of 83 patients) for nonradiologically placed gastrostomy tubes (P = .07). Combined, 32% of gastrostomy tubes placed nonradiologically resulted in either procedural failure or eventual jejunal tip malposition, compared to 7.4% of radiologically placed gastrostomy tubes (P = .01).

CONCLUSIONS

The frequency of procedural failure or eventual jejunal tip malposition with conversion of radiologically placed gastrostomy tubes to gastrojejunostomy tubes is significantly lower with radiologically placed gastrostomy tubes than with nonradiologically inserted gastrostomy tubes.

Wireless surveillance for transjugular intrahepatic portosystemic shunts (TIPS): a feasibility study

RATIONALE AND OBJECTIVES

Shunt surveillance is a critical component of follow-up for patients with cirrhosis with transjugular intrahepatic portosystemic shunts (TIPS). Transabdominal Doppler ultrasound analysis of the shunt has been used as a noninvasive means of assessing shunt function. Doppler ultrasound analysis of the shunt is less sensitive than direct transjugular portosystemic pressure gradient measurement for detecting shunt failure. A wireless, noninvasive means of measuring the portosystemic pressure gradient in the clinic may facilitate follow-up in this group of patients. The aim of this study was to determine if two implanted wireless pressure sensors could accurately transmit a portosystemic pressure gradient across a TIPS.

MATERIALS AND METHODS

Two wireless microelectromechanical system pressure sensors were placed in a swine model for measuring the portosystemic pressure gradient across a TIPS. Catheter-based pressure transducers were also placed and used as the gold standard. Pressures from both systems were measured concurrently.

RESULTS

Wireless microelectromechanical system portal and systemic pressure measurements were accurate within +/-2 mm Hg (mean, 0.86 mm Hg) of the gold standard.

CONCLUSION

The use of wireless sensors may facilitate the surveillance of shunt function in patients with portal hypertension who have undergone placement of TIPS.

Treatment of TIPS/biliary fistula-related endotipsitis with a covered stent

"Infective endotipsitis" describes a recurrent bacteremia or fungemia in patients with a transjugular intrahepatic portosystemic shunt (TIPS) in place and no other identifiable source of infection. The present report describes a patient who developed polymicrobial endotipsitis 6 years after TIPS creation. Blood cultures remained positive for polymicrobial growth despite long courses of antibiotic therapy. Communication between the TIPS and an infected biliary tree, precipitated by cholecystitis, was ultimately recognized. The biliary/TIPS fistula was closed with a polytetrafluoroethylene-covered stent. The patient remains asymptomatic and follow-up blood cultures remain negative with a low dose of oral antibiotics 2 years after the procedure.

Radiation hand exposure during restoration of flow to the thrombosed dialysis access graft

PURPOSE

To determine radiation dose to the hands of interventional radiologists during restoration of flow to thrombosed dialysis access grafts.

MATERIALS AND METHODS

Sixty-two procedures were performed in 54 patients with thrombosed synthetic arteriovenous hemodialysis access grafts. For each procedure, five staff interventional radiologists wore thermoluminescent ring dosimeters on each hand. Overall hand doses were obtained, and patient and graft factors as well as technical factors were analyzed to determine the effects on hand exposure.

RESULTS

The mean right hand and left hand exposures were 0.78 mSv and 0.55 mSv (78 and 55 mrem), respectively, and there was a significant difference between the two (P = .01). There was a significant difference among the interventionalists, mostly based on the lower doses associated with a single operator (P < .01). Not unexpectedly, fluoroscopy times (P < .01) and, to a lesser degree, the number of angiographic runs (P = .05) were significant factors influencing hand radiation dose. Patient sex, age and location of the graft, previous thrombosis, the number of previous interventions, and success or failure of the procedure were not significant factors in hand dose.

CONCLUSIONS

Hand exposure during the restoration of flow to thrombosed dialysis access grafts is relatively high and is greater for the right hand than for the left. The exposures are dependent on technical factors, most notably fluoroscopy times, not on patient- or graft-related factors.

De-novo cholangiocarcinoma in the setting of recurrent primary sclerosing cholangitis following liver transplant

Orthotopic liver transplantation is the only definitive therapeutic option in patients with primary sclerosing cholangitis (PSC) and end-stage liver disease. However, PSC recurs in up to 20% of patients transplanted for this indication. To date, no patient has been reported to develop cholangiocarcinoma (CCA) post-transplant, without biliary tract cancer having been present pretransplant. Here, we report recurrent PSC complicated by de-novo CCA in a 31-year-old man transplanted for PSC 8 years earlier. Cholangiocarcinoma was confirmed using a combination of computed tomography, cholangiography, positron emission tomography and histological examination of biliary cytology. He has since been successfully re-transplanted following preoperative chemo-radiotherapy. No viable tumor was identified in the explanted liver. This case establishes that long-term complications associated with PSC and biliary-enteric surgery such as CCA may become apparent in new grafts post-transplant.

Gastrointestinal bleeding in adult patients with Meckel's diverticulum: the role of technetium 99m pertechnetate scan

Obscure gastrointestinal (GI) bleeding is often challenging for the primary care physician, but with improved diagnostic testing the cause of this blood loss is determined in most patients. However, approximately 5% of the time no underlying cause is found. One common etiology in patients younger than 40 years of age is a Meckel's diverticulum. The technetium 99m pertechnetate scan is the standard test for making this diagnosis. However, the sensitivity of the scan is only 62% in the adult population. In this case report, a patient with profound, hemodynamically significant GI blood loss had multiple negative studies. Subsequently, an abnormal vascular lesion was detected and during exploratory laparotomy, a Meckel's diverticulum was found and removed. Although the technetium pertechnetate scan is falsely negative in a number of cases, there are ways to increase its sensitivity and possibly avoid repeated testing.

Cryosurgery after chemoembolization for hepatocellular carcinoma in patients with cirrhosis

Most cirrhotic patients with hepatocellular carcinoma (HCC) are not candidates for resection. Transarterial chemoembolization (TACE) may ablate a significant portion of the tumor but has a high rate of recurrence. Cryosurgery may permit successful ablation of hepatic tumors but can be complicated by postoperative hemorrhage and is also associated with a significant risk of recurrence. The combination of the two techniques might be beneficial. We evaluated in a prospective study the safety and efficacy of this combination in cirrhotic patients with unresectable HCC. Fifteen patients were included in this study. All but one patient underwent one or several sessions of TACE before cryosurgery. Cryoablation was successfully performed in each patient. The patient who did not undergo preoperative TACE required reoperation for hemorrhage. Another patient with Child-Pugh class B cirrhosis died postoperatively of hepatic and multiorgan failure. At a mean follow-up of 2.5 years, three patients had recurrence of disease, and 13 of 15 patients were alive with the longest survival time being 5 years. The actuarial survival rate at 5 years was 79%. Cryosurgery after TACE is feasible in cirrhotic livers with HCC and can increase the cure rate in large tumors. TACE may reduce the risk of hemorrhage after cryosurgery but can increase the risk of hepatic failure in patients with poor hepatic function.

Direct percutaneous endoscopic jejunostomy with small bowel enteroscopy and fluoroscopy

BACKGROUND

Approaches to the creation of a percutaneous jejunostomy (PEJ) include enteroscopy with jejunal transillumination, fluoroscopy with small bowel distension and tract dilation, and jejunal enteral tube placement through a percutaneous endoscopic gastrostomy. Although all have been successful, the combination of enteroscopy and fluoroscopy may improve visualization and the success of PEJ placement. This is a description of such a technique and its successful use in 7 patients.

METHODS

The procedure was performed with the patient under conscious sedation in a manner similar to standard PEG placement. The proximal jejunum was visualized and a standard snare was passed though the enteroscope and was opened. A needle and guidewire were directed percutaneously though the snare by using fluoroscopic guidance. Under direct endoscopic visualization the snare was closed around the guidewire. A standard 20F push-type "gastrostomy" tube was passed over the guidewire and through the mouth and the dome seated in the jejunum. A bumper was passed externally over the tube and tightened at the skin.

RESULTS

PEJ placement was successful in all 7 patients. The average length of the procedure was 40 minutes (range 22-64 minutes). There were no major complications. Mean follow-up was 124 days (range 28-308 days). Feeding tubes remained functional until removal (2), death (1), or surgical removal for an unrelated reason (1). Three tubes are still in use.

CONCLUSIONS

Percutaneous endoscopic jejunostomy tube placement can be performed successfully with enteroscopy and fluoroscopy. This technique is safe and efficient and provides distal enteral nutritional support for patients in whom PEG cannot be used.

Biliary stricture secondary to donor B-cell lymphoma after orthotopic liver transplantation

Biliary complications after orthotopic liver transplantation (OLT) lead to considerable morbidity and occasional mortality after surgery. Bile duct strictures secondary to localized lymphoproliferative disorder of the porta hepatis is rare, with only 12 cases reported in the English literature. Posttransplant lymphoproliferative disorder develops in up to 9% of liver allograft recipients. We describe 2 adult patients who developed Epstein-Barr virus-associated localized B-cell lymphoma of donor-tissue origin confined to the porta hepatis 3 and 5 months after OLT. Both patients were administered cyclosporine (CyA) and prednisone as primary immunosuppression. One patient was administered basiliximab as induction therapy. Neither patient had CyA trough levels greater than 250 ng/mL. Both patients were treated with a hepatojejunostomy, 75% reduction in immunosuppression therapy, and acyclovir. One patient had complete involution of the tumor, and the second patient had an 80% reduction of the tumor at the 2-year follow-up visit. This report illustrates the need to consider localized lymphoma post-OLT as a cause of obstructive jaundice even within the first 6 months after surgery. Aggressive reduction of immunosuppression in conjunction with acyclovir remains a highly effective therapy.

Conversion of indwelling chest port catheters to tunneled central venous catheters

PURPOSE

To determine the safety and efficacy of the conversion of subcutaneous chest wall infusion ports to tunneled central venous catheters.

MATERIALS AND METHODS

During a period of 34 months, 67 patients were referred for conversion of indwelling subcutaneous chest wall ports to tunneled central venous catheters as part of a bone marrow transplant protocol. Six patients were deemed unacceptable for conversion and the remaining 61 underwent successful conversion. All patients had functioning surgically placed single-lumen (n = 50) or double-lumen (n = 11) chest ports, which were removed to maintain the original venous access sites for placement of a tunneled central venous catheter, incorporating the chest wall pocket for tunneling, in 46 patients (75%). A new tunnel was created in the other 15 patients. There were no immediate complications and all patients were followed until catheter removal or patient demise with the catheter in place.

RESULTS

57 of 61 (93%) catheters were used without evidence of infection for 23-164 days (mean, 57 d) after placement. Two (3%) were removed (both at 26 days) because of persistent neutropenic fever without physical signs or laboratory evidence of catheter infection, and two (3%) were removed (at 11 and 77 days) because of proven catheter infection, yielding an overall infection rate of 1.2 per 1,000 catheter days. Two catheters required exchange and two required stripping because of decreased function, resulting in an overall catheter-related complication rate of 2.4 per 1,000 catheter days.

CONCLUSIONS

Indwelling subcutaneous chest wall infusion ports can be safely converted to tunneled central venous catheters, even in an immunocompromised patient population, with a low risk of complications such as infection.

Idiopathic splenic vein stenosis: a cause of gastric variceal hemorrhage

We report the case of a patient with isolated gastric variceal bleeding. Obesity precluded the use of noninvasive means for assessing splenic vein patency. Splenic vein stenosis was diagnosed by transhepatic portal and splenic venography with pressure measurements. A cause for the stenosis could not be found. Splenectomy was used as a curative measure.

Transjugular intrahepatic portosystemic shunts (TIPS): effects of respiratory state and patient position on the measurement of Doppler velocities

OBJECTIVE

The purpose of this prospective study was to examine the effects of patient position and respiratory state on the measurements of Doppler velocities in transjugular intrahepatic portosystemic shunts.

SUBJECTS AND METHODS

Thirty-eight transjugular intrahepatic portosystemic shunts in 34 consecutive patients were studied using Doppler sonography. Peak velocities were measured in the mid shunt with the patient in three positions (supine, sitting upright, and left lateral decubitus) and two respiratory states (deep inspiration and quiet respiration). A mixed linear regression model was used to assess statistically significant differences among the six velocity measurements.

RESULTS

Peak velocities in the mid stent averaged 22 cm/sec greater in quiet respiration than in deep inspiration, which was a significant difference (p < 0.00001). Differences in velocities in the three patient positions were not significant (p = 0.53). Using 90-190 cm/sec as the normal range, the peak velocity shifted from normal to abnormal levels by changing respiratory state in 17 (45%) of 38 studies. Using 60 cm/sec as the lower normal limit, the peak velocity fell below the normal range with inspiration in 10 (26%) of 38 studies. In 12 (32%) of 38 studies, a decline in peak velocity exceeding 50 cm/sec could be induced by inspiration.

CONCLUSION

Peak systolic velocity in transjugular intrahepatic portosystemic shunts is substantially altered by the respiratory state of the patient at the time of the measurement, but not by the patient position. Respiratory state must be taken into account in the interpretation of peak velocity for shunt stenosis.

Incarceration of umbilical hernia following transjugular intrahepatic portosystemic shunt for the treatment of ascites

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for patients with medically refractory ascites. Many patients with refractory ascites have umbilical herniation. Incarceration of umbilical hernia has been reported following diuresis, paracentesis, and peritoneovenous shunting. We report 2 cases of umbilical hernia incarceration following resolution of ascites after TIPS.

Injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay

OBJECTIVE

The purpose of this study was to determine the prevalence of injured aberrant bile ducts in a population with complications after cholecystectomy and to determine whether such injury resulted in significant delay in the diagnosis and treatment of bile duct injuries.

MATERIALS AND METHODS

The cholangiograms of 82 patients who sustained bile duct injury during cholecystectomy were reviewed. Prevalence of aberrant bile duct anatomy in the injured ducts was noted. The time periods from injury to diagnosis and treatment of bile duct leaks in patients with aberrant bile duct anatomy were compared with those in patients with normal anatomy.

RESULTS

Seventeen percent (14/82) of the patients were found to have aberrant bile duct anatomy. Fifteen percent (12/82) were found to have had an aberrant bile duct involved in the injury. Eleven of the patients had an aberrant bile duct leak, and one patient had an aberrant bile duct clipping injury. The time period required for diagnosis and treatment of a leaking aberrant bile duct was significantly longer (p < .005) than that required for a bile leak in an anatomically normal bile duct.

CONCLUSION

Aberrant bile ducts are present in a significant number of patients who sustain bile duct injuries during cholecystectomy. Diagnosis of an aberrant bile duct leak may be delayed because of nonfilling of the bile duct during standard cholangiographic techniques. Careful examination of cholangiograms for nonfilling segments and contrast material injection of biloma drains and T tubes may shorten the time to definitive treatment for this group of patients.

Transjugular intrahepatic portosystemic shunt (TIPS) in patients with refractory ascites: effect on body weight and Child-Pugh score

OBJECTIVE

This study suggests that patients with medically refractory ascites treated with transjugular intrahepatic portosystemic shunt (TIPS) may have improved in overall clinical status.

METHODS

We performed a retrospective study of 35 patients with medically refractory ascites treated with TIPS. Body weight, ascites, and Child-Pugh score were assessed at baseline, at 2 months, and after a mean 8.8-month follow-up interval.

RESULTS

After TIPS, there was significant improvement in Child-Pugh score from 9.7+/-1.5 to 8.2+/-2.3. Ascites completely resolved or improved in 23 of 24 patients (96%) who had long term follow-up. Two months after TIPS, there was a significant decrease in weight of 6.1 kg corresponding to a loss of ascites. Between 2 and 8.8 months, there was a significant mean weight gain of 5.5 kg.

CONCLUSION

This study suggests that patients treated with medically refractory ascites with TIPS may have improvement in overall clinical status, as measured by increase in lean body mass and improvement in Child-Pugh score.

Hereditary hemorrhagic telangiectasia causing high output cardiac failure: treatment with transcatheter embolization

We report a case of hereditary hemorrhagic telangiectasia complicated by high output heart failure caused by intrahepatic arteriovenous malformations. This patient was treated using transcatheter embolization of the intrahepatic arteriovenous malformations with concurrent measurement of cardiac output to monitor progress of the embolization.