Trombosis y cavernomatosis portal: las claves para el éxito de un TIPS / The keys to successful TIPS in patients with portal vein thrombosis and cavernous transformation

La trombosis venosa portal (TVP) es una complicación frecuente en pacientes cirróticos. Una alternativa al tratamiento anticoagulante, dado el alto riesgo de hemorragia secundaria a hipertensión portal, es la inserción de un shunt portosistémico transyugular intrahepático (TIPS). Se han descrito tres estrategias para la inserción del TIPS: 1) recanalización portal e implantación convencional del TIPS por vía yugular; 2) recanalización portal mediante acceso percutáneo (transhepático/transesplénico), y 3) inserción del TIPS entre una vena suprahepática y una colateral periportal, sin recanalización portal. Describimos varios materiales útiles como diana fluoroscópica para la aguja del TIPS y para la recanalización portal. El objetivo de este artículo es dar a conocer el éxito en la implantación de TIPS usando las diferentes técnicas descritas combinadas, lo que representa una buena alternativa terapéutica para esos pacientes difíciles de manejar debido a su deficiente condición clínica. Por tanto, la TVP/cavernomatosis no debe considerarse como una contraindicación para TIPS

Portal vein thrombosis is a common complication in patients with cirrhosis. Anticoagulation involves a high risk of bleeding secondary to portal hypertension, so placing transjugular intrahepatic portosystemic shunts (TIPS) has become an alternative treatment for portal vein thrombosis. Three strategies for TIPS placement have been reported: 1) portal recanalization and conventional implantation of the TIPS through the jugular vein; 2) portal recanalization through percutaneous transhepatic/transsplenic) access; and (3) insertion of the TIPS between the suprahepatic vein and a periportal collateral vessel without portal recanalization. We describe different materials that can be used as fluoroscopic targets for the TIPS needle and for portal recanalization. This article aims to show the success of TIPS implantation using different combinations of the techniques listed above, which is a good treatment alternative in these patients whose clinical condition makes them difficult to manage, and to show that portal vein thrombosis/cavernous transformation should not be considered a contraindication for TIPS

Estudio histológico sobre el efecto de la quimioembolización con partículas precargadas con doxorrubicina en el hepatocarcinoma / Histologic study of the effects of chemoembolization with preloaded doxorubicin beads in patients with hepatocellular carcinoma

Objetivo. Determinar el grado de necrosis tumoral en la pieza quirúrgica de hepatocarcinomas tratados con microesferas precargadas con doxorrubicina (QETA-DEB) y su relación con factores morfológicos y biomarcadores de imagen. Material y Métodos. 21 pacientes a quienes se realizó quimioembolización arterial selectiva con partículas DC-Beads (Biocompatibles, UK) fueron posteriormente trasplantados y analizados los hígados histológicamente. Resultados. Se detectaron por diferentes técnicas de imagen 43 nódulos con un tamaño medio de 25 mm. Angiográficamente eran 25 nódulos hipervascularizados, 12 discretamente vascularizados y 6 avasculares. En la pieza se encontraron 81 HCCs con un tamaño medio de 15 mm.; dos presentaron infiltración vascular y otros dos infiltración capsular. La necrosis media conseguida tras QETA-DEB fue del 39% siendo >60% en 28 HCCs y <60% en 52. Encontramos correlación estadística entre el índice de necrosis conseguida con el tiempo que transcurre desde la última QETA-DEB hasta el trasplante (siendo significativamente menor la necrosis conforme aumenta el tiempo), con el número de nódulos encontrados en la pieza y con la infiltración capsular. Asimismo, podemos predecir que cuando por técnicas de imagen detectamos 1 ó 2 nódulos tendremos más probabilidad de conseguir de manera significativa índices de necrosis > 90%. Sin embargo, ni el tamaño de los nódulos detectados por técnicas de imagen, ni el patrón de realce post-contraste ni el número de QETA-DEBs realizadas influye significativamente en la necrosis conseguida. Conclusión. La necrosis producida depende del tiempo en lista de espera, del número de nódulos en la pieza y de la infiltración capsular del tumor (AU)

Objective. To determine the degree of tumor necrosis in surgical specimens of hepatocellular carcinomas treated with microspheres preloaded with doxorubicin and to analyze the relationship between the degree of necrosis and a) morphologic factors and b) imaging biomarkers. Material and methods. We studied the livers of 21 patients who had undergone selective arterial chemoembolization with DC beads (Biocompatibles, UK) before receiving liver transplants. Results. Imaging techniques detected 43 nodules (mean size, 25 mm). Angiography showed 25 hypervascularized nodules, 12 slightly vascularized nodules, and 6 avascular nodules. A total of 81 hepatocellular carcinomas (mean size, 15 mm) were detected in the specimens: two were capsular and two had vascular infiltration. The mean degree of necrosis after chemoembolization was 39%; necrosis was greater than 60% in 28 hepatocellular carcinomas and less than 60% in 52. The degree of necrosis correlated significantly with the time elapsed between the last chemoembolization treatment and liver transplantation (the degree of necrosis decreased as time increased), with the number of nodules in the specimen, and with capsular infiltration. When imaging techniques detected 1 or 2 nodules, there was a greater probability of achieving greater than 90% necrosis. No relation with the degree of necrosis achieved was found for the size of the nodules detected at imaging, the enhancement pattern, or the number of chemoembolization treatments. Conclusion. The degree of necrosis achieved depends on the time spent on the waiting list, on the number of nodules in the specimen, and on whether capsular infiltration is present (AU)

Optimizing the management of patients with BCLC stage-B hepatocellular carcinoma: Modern surgical resection as a feasible alternative to transarterial chemoemolization.

OBJECTIVE: To analyse the impact of liver resection (LR) in patients with Hepatocellular Carcinoma (HCC) within the Barcelona-Clinic-Liver-Cancer (BCLC)-B stage. METHODS: Analysis of patients with BCLC-B HCC treated with LR or transarterial chemoembolization (TACE) between 2007 and 2012 in our hospital. Survival/recurrence analyses were performed by log-rank tests and Cox multivariate models. Further analyses were specifically obtained for the HCC subclassification (B1-2-3-4) proposed recently. RESULTS: Eighty patients were treated (44-TACE/36-LR). Number of nodules was [1.8(1.1)], being multinodular in 50% of cases. Although resected patients had a higher hospital stay than those who underwent TACE (14 ± 13 vs 7 ± 6; P = 0.004), the rate and severity of complications was lower measured by Dindo-Clavien scale (P < 0.05). Overall survival was 40% with a median follow-up of 29.5 months (0.07-96.9). Five-years survival rates were 62.9%, 28.1% and 15.4%, respectively (P = 0.004) for B1, B2 and B3-4 stages. Cox model showed that only total bilirubin [OR = 2.055(1.23-3.44)] and BCLC subclassification B3-4 [OR = 2.439(1.04-5.7)] and B2 [OR = 2.79(1.35-5.77)] vs B1 were independent predictors of 5-years-survival. In B1 patients, surgical approach led a significant decrease in 5-years recurrence-rate (25% vs 60%; P = 0.018). In the surgical subgroup analysis, better results were observed if well/moderate differentiation combined with no microvascular-invasion (VI) in 5-years-survival (84.6%; P = 0.001) and -recurrence (23.1%; P = 0.041), respectively. These survival and recurrence trends were remarkable in B1 stages. CONCLUSIONS: Management of Intermediate BCLC-B HCC stage should be more complex and include updated criteria regarding B-stage subclassifications, VI and tumour differentiation. Modern surgical resection would offer improved survival benefit with acceptable safety in selected BCLC-B stage patients.

TIPS recubierto en niños. Estudio preliminar sobre su seguridad y permeabilidad / Transjugular intrahepatic portosystemic shunting with covered stents in children: a preliminary study of safety and patency

Objetivo: Analizar retrospectivamente la seguridad y eficacia de derivación portosistémica intrahepática por vía transyugular (TIPS) recubierta en niños. Material y métodos: Presentamos 6 niños con una edad media de 10,6 años y un peso medio de 33,5 kg, a quienes se implantaron endoprótesis recubiertas tipo Viatorr® de 8 mm de diámetro por hemorragia digestiva alta (HDA) aguda (n = 4) o recurrente (n = 2) no controlable por medidas endoscópicas. Cinco niños eran cirróticos y otro un trasplantado hepático con trombosis y cavernomatosis portal. Se valoraron la recidiva de la HDA, las complicaciones y la permeabilidad con ecografías-Doppler secuenciales o hasta el trasplante. Resultados: En todos los niños se implantó una sola endoprótesis en una única sesión, sin mortalidad asociada. El gradiente transhepático medio inicial fue de 16 mmHg (12-21 mmHg) y disminuyó tras la implantación del TIPS a 9 mmHg (1-15 mmHg). Un paciente presentó encefalopatía leve y la niña con trombosis y cavernomatosis portal presentó una oclusión aguda del TIPS, que se resolvió con la implantación de una endoprótesis coaxial. Tres niños fueron sometidos a trasplante a los 7,9 y 10 meses, constatándose la permeabilidad del TIPS. En los 3 restantes se comprobó la permeabilidad con ecografía-Doppler a los 1,3 y 5 meses. Ninguno presentó una nueva HDA durante un seguimiento medio de 8,1 meses. Conclusión: Nuestros resultados indican que la seguridad y permeabilidad de las endoprótesis recubiertas tipo Viatorr® para el tratamiento de la HDA por varices gastroesofágicas en niños cirróticos pueden ser buenas, hecho que deberá ser corroborado con series mayores en un futuro (AU)

Objective: To retrospectively analyze the safety and efficacy of transjugular intrahepatic portosystemic shunting (TIPS) using covered stents in children. Material and methods: We present 6 children (mean age, 10.6 years; mean weight, 33.5 kg) who underwent TIPS with 8mm diameter Viatorr® covered stents for acute (n=4) or recurrent (n=2) upper digestive bleeding that could not be controlled by endoscopic measures. Five of the children had cirrhosis and the other had portal vein thrombosis with cavernous transformation. We analyzed the relapse of upper digestive bleeding, the complications that appeared, and the patency of the TIPS shunt on sequential Doppler ultrasonography or until transplantation. Results: A single stent was implanted in a single session in each child; none of the children died. The mean transhepatic gradient decreased from 16mmHg (range: 12-21 mmHg) before the procedure to 9mmHg (range: 1-15 mmHg) after TIPS. One patient developed mild encephalopathy, and the girl who had portal vein thrombosis with cavernous transformation developed an acute occlusion of the TIPS that resolved after the implantation of a coaxial stent. Three children received transplants (7, 9, and 10 months after the procedure, respectively), and the patency of the TIPS was confirmed at transplantation. In the three remaining children, patency was confirmed with Doppler ultrasonography 1, 3, and 5 months after implantation. None of the children had new episodes of upper digestive bleeding during follow-up afterimplantation (mean: 8.1 months). Conclusion: Our results indicate that TIPS with 8mm diameter Viatorr® covered stents can be safe and efficacious for the treatment of upper digestive bleeding due to gastroesophageal varices in cirrhotic children; our findings need to be corroborated in larger series (AU)

Aspectos prácticos de la extracción percutánea de cuerpos extraños con lazo recuperador / Practical aspects in the percutaneous extraction of foreign bodies using a Goose-Neck Snare

Objetivo. Presentar nuestra experiencia clínica en la extracción de diferentes cuerpos extraños (vasculares o no) con lazo recuperador en 13 pacientes, incidiendo en aspectos técnicos prácticos empleados durante los procedimientos.Material y métodos. Se incluyen 13 cuerpos extraños siendo 9 intravasculares y 4 no vasculares. Los vasculares correspondieron a stents (2), coils (2), fragmentos rotos de catéteres venosos centrales (3)y fragmentos rotos de catéteres-balón (2). Los no vasculares fueron fragmentos rotos de catéter doble-J (2), un catéter doble-J completamente localizado en sistemas pielo-caliciales y un fragmento roto deuna guía metálica en vía biliar intrahepática. Para la extracción se utilizó el lazo Goose Neck Snare en diferentes diámetros (según la localización).En un paciente con un fragmento de catéter doble-J se utilizó un fórceps como material auxiliar, y en otro con un fragmento de catéter en vena pulmonar se utilizó también un catéter pigtail para movilizarlo y facilitar su extracción por el lazo.Resultados. Se pudieron extraer todos los cuerpos extraños excepto un TIPSS que migró a cavidades cardíacas derechas y que se reposicionó correctamente en tronco venoso braquiocefálico derecho. No huboningún tipo de complicación durante los procedimientos.Conclusiones. El lazo Goose Neck Snare es muy útil, seguro y versátil para extraer cuerpos extraños de diferente naturaleza y en distintos territorios. Sobre todo en el territorio vascular se requiere ampliaexperiencia en el manejo y conocimiento de las diferentes técnicas de cateterización

Objective. To present our clinical experience in the extraction of different foreign bodies (from vascular or other sites) using a gooseneck snare in 13 patients, with emphasis on practical and technical aspects used during the procedures.Material and methods. A total of 13 foreign bodies, including 9 intravascular objects and 4 in other locations, were included. The intravascular foreign bodies were stents (n = 2), coils (n = 2), fragments of broken central venous catheters (n = 3), and fragments of broken balloon catheters (n = 2). The nonvascular foreign bodies were fragments of broken double-J catheters (n = 2), one double-J catheter located entirely within the calyces of the kidney, and a fragment of a broken metallic guide wire in an intrahepatic bile duct. Goose-Neck Snares of different diameters (depending on the location) were used to extract the foreign bodies. Forceps were used as an auxiliary device in one patient with a fragment of double-J catheter, and in another case with a catheter fragment in a pulmonary vein, a pigtail catheter was also used to move the fragment and facilitate its extraction with the Goose-Neck Snare.Results. All of the foreign bodies were successfully extracted except a transjugular intrahepatic portosystemic shunt that migrated to the right heart cavities and was correctly repositioned in the right brachiocephalic venous trunk. No complications of any kind were seen during the procedures.Conclusions. The Goose-Neck Snare is very useful, safe, and versatile for the extraction of different types of foreign bodies in different territories. Especially in vascular territories, it is necessary to have ample knowledge about and experience in the different techniques used for catheterization