Obstructive Uropathy because of a Large Rectus Sheath Haematoma: A Case Report of Combined Interventional Radiology and Surgical Approach.

INTRODUCTION: Rectus sheath haematomas associated with anticoagulation are often self limiting. When large, however, they can even extend into the pelvis and cause compression of adjacent organs such as the bladder. A combined endovascular and surgical approach can decrease the operative exposure necessary to treat this occurrence. REPORT: A 42 year old morbidly obese African American female on warfarin treatment for pulmonary embolism presented outside the hospital with pneumonia. During her hospitalisation, she developed a spontaneous right rectus abdominis haematoma below the level of the umbilicus with active bleeding in the extraperitoneal space causing mass compression of the bladder. She developed acute renal failure and became anuric. Following endovascular embolisation of the inferior epigastric artery, surgical exploration was successfully performed to remove the haematoma and relieve the urinary obstruction. Diuresis resumed and renal function normalised without any further evidence of bleeding. DISCUSSION: A large rectus sheath haematoma that extends into the bladder causing renal obstruction can be treated by endovascular embolisation and surgical exploration to limit operative risks and exposure in morbidly obese patients.

Survival benefit of TIPS versus serial paracentesis in patients with refractory ascites: a single institution case-control propensity score analysis.

AIM: To compare the impact of covered stent-graft transjugular intrahepatic portosystemic shunt (TIPS) versus serial paracentesis on survival of patients with medically refractory ascites. MATERIALS AND METHODS: In this retrospective study, cirrhotic patients who underwent covered stent-graft TIPS for refractory ascites from 2003-2013 were compared with similar patients who underwent serial paracentesis during 2009-2013. Demographic and liver disease data, Model for End-Stage Liver Disease (MELD) scores, and survival outcomes were obtained from hospital electronic medical records and the social security death index. After propensity score weighting to match study group characteristics, survival outcomes were compared using Kaplan-Meier statistics with log-rank analysis. RESULTS: Seventy TIPS (70% men, mean age 55.7 years, mean MELD 15.1) and 80 paracentesis (58% men, mean age 53.5 years, mean MELD 22.5) patients were compared. The TIPS haemodynamic success rate was 100% (mean portosystemic pressure gradient reduction 13 mmHg). Paracentesis patients underwent a mean of 7.9 procedures. After propensity score weighting to balance group features, TIPS patients showed a trend toward enhanced survival compared with paracentesis patients (median survival 1037 versus 262 days, p = 0.074). TIPS conferred a significant increase or trend toward improved survival compared with paracentesis at 1 (66% versus 44%, p = 0.018), 2 (56% versus 38%, p = 0.057), and 3 year (49% versus 32%, p = 0.077) time points. Thirty and 90 day mortality rates were not statistically increased by TIPS. CONCLUSION: Covered stent-graft TIPS improves intermediate- to long-term survival without significantly increasing short-term mortality of ascites patients, and suggests a greater potential role for TIPS in properly selected ascitic patients when medical management fails.

Impact of transjugular intrahepatic portosystemic shunt creation on intermediate-term model for end-stage liver disease score progression.

PURPOSE: To assess the impact of transjugular intrahepatic portosystemic shunt (TIPS) creation on Model for End-stage Liver Disease (MELD) score temporal progression in patients with liver cirrhosis. MATERIALS AND METHODS: In this single-institution retrospective study, 256 consecutive patients who underwent TIPS creation between 1999 and 2013 were identified for potential investigation. Inclusion criteria for analysis consisted of at least 6 months of post-TIPS clinical follow-up with available lab values at 1, 3, 6, and, if available, 12 months post-TIPS for MELD score calculation. Patients who were lost to follow-up or expired within 6 months, lacked sufficient lab follow-up, or underwent liver transplantation within 6 months of TIPS were excluded from the study cohort. Within-patient variance in MELD score was assessed using repeated-measures analysis of variance. RESULTS: Sixty-six patients met criteria for study inclusion. TIPS were created for variceal hemorrhage (n = 26) or ascites, hydrothorax, or portal vein thrombosis (n = 40). Hemodynamic success rate was 97% (64/66) and median portosystemic pressure gradient reduction was 13 mm Hg. Median baseline MELD score was 14 (range 7-26). Low MELD scores (≤ 10, n = 16) increased in sequential scores over 1-year follow-up (median increase +3.5), intermediate MELD scores (11-18, n = 34) showed general stability in successive scores over 1-year follow-up (median increase +1), and high MELD scores (≥ 19, n = 16) decreased in serial scores over 1-year follow-up (median decrease -4); these trends are compatible with published MELD progression tendencies in cirrhotic patients without TIPS. However, the MELD score changes were not statistically significant (P = .172) on within-subject comparison. CONCLUSIONS: Among patients with liver cirrhosis who recover from the procedure, TIPS creation does not alter the natural MELD score evolution during intermediate term follow-up, and as such does not significantly alter liver transplant candidacy.

Presurgical transarterial chemoembolization does not increase biliary stricture incidence in orthotopic liver transplant patients.

INTRODUCTION: The goal of this study was to compare the incidence of biliary strictures in orthotopic liver transplant (OLT) patients treated with previous transarterial chemoembolization (TACE) versus those with no TACE history. PATIENTS AND METHODS: A single-center retrospective review was performed on 248 patients who underwent OLT from 2006 to 2012. Patient demographic characteristics, history of TACE for treatment of hepatocellular carcinoma, OLT data, and biliary stricture data were obtained. TACE was generally performed in a segmental manner using chemotherapy to ethiodized oil mixture (1:1). Clinically significant biliary strictures resulting in cholestasis or obstructive jaundice were diagnosed by using endoscopic retrograde cholangiopancreatography. Group characteristics were compared by using the Wilcoxon rank sum test, χ(2) analysis, and Kaplan-Meier statistics with log-rank comparison. RESULTS: Forty-six patients (35 men, 11 women; median age, 58 years) with a history of pre-OLT TACE were compared with 185 patients (111 men, 74 women; median age, 54 years) with no history of TACE. TACE and non-TACE patients had 30% and 31% cumulative incidence of biliary stricture, respectively. The median time to stricture was not reached in either group. There was no statistically significant difference in biliary stricture incidence (P = .928) or time to biliary stricture development (P = .803). Biliary strictures were primarily anastomotic in location in both groups: 79% in TACE patients and 84% in non-TACE patients (P = .233). CONCLUSIONS: Selective TACE treatment of hepatocellular carcinoma in pretransplant patients does not increase the rate of posttransplant biliary strictures. These findings corroborate the safety of TACE in the treatment of hepatocellular carcinoma in potential OLT patients as a bridge to transplantation.

Unconventional extrahepatic neovascularization after transplant hepatic artery thrombosis: a case report.

Liver neovascularization preserves hepatic function and improves survival in the setting of post-transplant hepatic artery thrombosis (HAT). In this report, we have presented a unique case of a neovascularized liver after subclinical HAT in a 46-year-old liver transplant patient in whom a collateral supply was recruited from three unconventional sources: The right colic, right intercostal, and right inferior adrenal arteries. We propose systematic angiographic evaluation of all potential sources of collateral vessel formation for patients with HAT to accurately assess patient risk and determine the need for further intervention or revascularization.

Amplatzer vascular plug for arteriovenous hemodialysis access occlusion: initial experience.

PURPOSE: The Amplatzer Vascular Plug (AVP; AGA Medical, Golden Valley, MN) is a recently developed self-expanding metallic device indicated for peripheral vascular embolizations. Herein, we describe use of this device in the treatment of vascular complications related to arteriovenous hemodialysis fistulas and grafts. MATERIALS AND METHODS: This HIPAA compliant retrospective study was approved by the institutional review board with informed consent waived. Six patients with problematic arteriovenous access underwent access occlusion using the AVP. Procedure indications included vascular steal syndrome in five patients, and enlarging vascular aneurysms in one patient. Contraindications for surgical correction were determined by the referring surgeon. AVP embolizations were performed using devices oversized by 50% introduced through vascular sheaths positioned within vein segments just beyond the arteriovenous anastomoses. Noninvasive evaluation of the involved extremity was performed pre- and post-embolization in addition to clinical follow-up examinations. Measured outcomes included success of angiographic occlusion, improvement in distal arterial flow, AVP number, AVP diameter, time to access occlusion, and clinical symptomatic improvement. RESULTS: Technical success was 100%, with complete arteriovenous access occlusion accomplished in all cases, with an average of 1.5 AVPs used per patient. Mean time to access occlusion was 19.3 minutes. Angiographic improvement in distal arterial flow was immediately evident and resolution of clinical symptoms occurred in all patients, with mean long-term follow-up of 16 months. No procedure-related complications were encountered. CONCLUSION: The Amplatzer Vascular Plug provides a minimally invasive and efficacious method for embolization of problematic arteriovenous hemodialysis access.

Sustained release of granulocyte-macrophage colony-stimulating factor from a modular peptide-based cancer vaccine alters vaccine microenvironment and enhances the antigen-specific T-cell response.

The recent identification and molecular characterization of tumor antigens provides the opportunity to explore the rational development of peptide-based cancer vaccines. However, the response to these vaccines remains variable, and peptide-based cancer vaccines may even produce tolerance induction and enhanced tumor growth. The authors have developed a unique method for the isolation of a polysaccharide polymer of chemically pure poly- N -acetyl glucosamine (p-GlcNAc). This highly purified polysaccharide can be formulated into a stable gel matrix (designated F2 gel matrix) with unique properties of a sustained-release delivery system that has previously been shown to be an effective immune adjuvant. F2 gel matrix is capable of providing sustained release of antigenic peptide and cytokine in vitro. The purposes of this study were to characterize the ability of F2 gel matrix to provide sustained local release of cytokines in vivo and to test the hypothesis that such sustained release can enhance the microenvironment for antigen presentation, leading to a more effective antitumor response. Subcutaneous administration of F2 gel/cytokine matrix resulted in sustained release of cytokine at the vaccine site for up to 120 hours. Sustained release of granulocyte-macrophage colony-stimulating factor (GM-CSF) was associated with an increased inflammatory infiltrate at the vaccine site and enhanced dendritic cell activation. Further, accination with F2 gel/SIINFEKL/GM-CSF matrix resulted in enhanced antigen-specific immunity. Addition of GM-CSF to the F2 gel matrix resulted in an increase in the percentage of antigen-specific T cells in the draining lymph nodes, enhanced cytotoxicity, a sustained presence of antigen-specific T cells in the peripheral blood, and protection from E.G7 tumor challenge. These results support the potential of an F2 gel matrix modular vaccine delivery system that can provide sustained local release of cytokine in vivo, and confirm the powerful effects of GM-CSF as an immune adjuvant.