The impact of right atrial pressure on outcomes in patients undergoing TIPS, an ALTA group study.

BACKGROUND AND AIMS: Single-center studies in patients undergoing TIPS suggest that elevated right atrial pressure (RAP) may influence survival. We assessed the impact of pre-TIPS RAP on outcomes using the Advancing Liver Therapeutic Approaches (ALTA) database. APPROACH AND RESULTS: Total 883 patients in ALTA multicenter TIPS database from 2010 to 2015 from 9 centers with measured pre-TIPS RAP were included. Primary outcome was mortality. Secondary outcomes were 48-hour post-TIPS complications, post-TIPS portal hypertension complications, and post-TIPS inpatient admission for heart failure. Adjusted Cox Proportional hazards and competing risk model with liver transplant as a competing risk were used to assess RAP association with mortality. Restricted cubic splines were used to model nonlinear relationship. Logistic regression was used to assess RAP association with secondary outcomes.Pre-TIPS RAP was independently associated with overall mortality (subdistribution HR: 1.04 per mm Hg, 95% CI, 1.01, 1.08, p =0.009) and composite 48-hour complications. RAP was a predictor of TIPS dysfunction with increased odds of post-90-day paracentesis in outpatient TIPS, hospital admissions for renal dysfunction, and heart failure. Pre-TIPS RAP was positively associated with model for end-stage liver disease, body mass index, Native American and Black race, and lower platelets. CONCLUSIONS: Pre-TIPS RAP is an independent risk factor for overall mortality after TIPS insertion. Higher pre-TIPS RAP increased the odds of early complications and overall portal hypertensive complications as potential mechanisms for the mortality impact.

Non-operative management of biliary complications after Liver Transplantation in pediatric patients: A 30-year experience.

BACKGROUND: To evaluate the efficacy of percutaneous and endoscopic therapeutic interventions for biliary strictures and leaks following LT in children. METHODS: Retrospective analysis of 49 consecutive pediatric liver transplant recipients (27 girls, 22 boys, mean age at transplant 3.9 years) treated at our institution from 1989 to 2019 for biliary leak and/or biliary stricture was performed. Minimally invasive approach was considered clinically successful if it resulted in patency of the narrowed biliary segment and/or correction of the biliary leak. RESULTS: Forty-two patients had a stricture at the biliary anastomosis; seven had a biliary leak. After an average 13.8 years of follow-up, long-term clinical success with minimally invasive treatment (no surgery or re-transplant) was achieved for 24 children (57%) with biliary stricture and 4 (57%) with biliary leaks. Eight patients required re-transplant; however, only one was due to failure of both percutaneous and surgical management. For biliary strictures, failure of non-surgical management was associated with younger age at stricture diagnosis (p < .02). CONCLUSIONS: Percutaneous and endoscopic management of biliary strictures and leaks after LT in children is associated with a durable result in >50% of children.

Anastomosing hemangioma of liver.

Anastomosing hemangiomas are a rare subtype of benign vascular hemangioma which most commonly arise in the genitourinary tract and retroperitoneum. In only a small number of reports has this entity been shown originating within the liver parenchyma. Despite their benign behavior, on contrast-enhanced computer tomography and magnetic resonance imaging studies anastomosing hemangiomas can demonstrate enhancement characteristics similar to primary and metastatic liver lesions. This case report highlights the imaging features of this entity and provides a brief review of the limited literature that exists on this rare hepatic lesion.

Evasion of No-Hair Theorems and Novel Black-Hole Solutions in Gauss-Bonnet Theories.

We consider a general Einstein-scalar-Gauss-Bonnet theory with a coupling function f(ϕ). We demonstrate that black-hole solutions appear as a generic feature of this theory since a regular horizon and an asymptotically flat solution may be easily constructed under mild assumptions for f(ϕ). We show that the existing no-hair theorems are easily evaded, and a large number of regular black-hole solutions with scalar hair are then presented for a plethora of coupling functions f(ϕ).

Techniques for Transjugular Intrahepatic Portosystemic Shunt Reduction and Occlusion.

Transjugular intrahepatic portosystemic shunts (TIPS) effectively lower portal pressure and are commonly used to manage selected patients with variceal bleeding. Unfortunately, significant consequences are not infrequently encountered as a result of this diversion of portal venous flow. These consequences include disabling hepatic encephalopathy as well as hepatic decompensation. To manage these complications, therapeutic options include TIPS reduction and TIPS occlusion. TIPS reduction is the favored technique because of the potential for venous thrombosis and recurrent variceal hemorrhage after acute TIPS occlusion. Techniques and indications for TIPS reduction and TIPS occlusion are reviewed.

Catheter directed interventions for acute deep vein thrombosis.

Venous thromboembolism (VTE) is an extremely common form of vascular disease and impacts a great number of patients worldwide. Acute deep vein thrombosis (DVT) is a subset of VTE and is traditionally been treated with anticoagulation. There is good quality data which suggests the use of catheter directed interventions for the treatment of acute DVT with the aim of reducing post-thrombotic syndrome (PTS). The present review will discuss the various therapies available for acute DVT, focusing on catheter directed interventions, ranging from traditional anticoagulation to the most novel forms of aspiration thrombectomy.

Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek: a review of 47 cases.

We present a series of reconstruction of 47 patients with large full thickness cheek defects secondary to cancer ablative surgery. All patients were reconstructed primarily by bipaddle pectoralis major myocutaneous (PMMC) flap. The age of patients ranged from 25 to 85 years (mean 49.5 years). All patients were male. The size of the paddle used for mucosal defect repair ranged from 5 x 3 to 9 x 7 cm and the size of the paddle used for skin cover ranged from 4 x 4 to 9 x 8 cm. The total flap size ranged from 10 x 5 to 17 x 7 cm. One patient had complete loss of flap (2.12%). Sixteen patients had minor complications all of which settled with conservative management. The follow up period varied from 1 month to 4 years. The modification adopted in bipaddling the flap was based on anatomical location of perforators to ensure good blood supply to both paddles of flap. Placing the flap horizontally with inclusion of nipple and areola increased the reach and size of available flap. We found the technique to be anatomically sound, technically easy and reliable. Precautions taken included proper assessment of reach of the paddle, placing not more than one-third of the paddle outside the muscle and securing the skin paddle to the muscle to avoid shearing of perforators during flap raising. We conclude that this technique is a useful alternative where microsurgical free tissue transfer is not possible or as a salvage procedure in selected large full thickness oral cavity lesions. However, the disadvantages of this method include loss of nipple and areola and technical difficulty in obese patients and females.