Change in Platelet Count after Transjugular Intrahepatic Portosystemic Shunt Creation: An Advancing Liver Therapeutic Approaches (ALTA) Group Study.

PURPOSE: To evaluate recovery of platelet count after transjugular intrahepatic portosystemic shunt (TIPS) creation and patient factors predicting platelet recovery after TIPS creation. MATERIALS AND METHODS: Adults with cirrhosis who underwent TIPS creation at 9 U.S. hospitals from 2010 to 2015 were included in this retrospective analysis. Change in platelets from before TIPS to 4 months after TIPS creation was characterized. Logistic regression was used to assess factors associated with top quartile percentage platelet increase after TIPS. Subgroup analyses were performed among patients with a pre-TIPS platelet count of ≤50 ×109/L. RESULTS: A total of 601 patients were included. The median absolute change in platelets was 1 × 109/L (-26 × 109/L to 25 × 109/L). Patients with top quartile percent platelet increase experienced ≥32% platelet increase. In multivariable analysis, pre-TIPS platelet counts (odds ratio [OR], 0.97 per 109/L; 95% CI, 0.97-0.98), age (OR, 1.24 per 5 years; 95% CI, 1.10-1.39), and pre-TIPS model for end-stage liver disease (MELD) scores (OR, 1.06 per point; 95% CI, 1.02-1.09) were associated with top quartile (≥32%) platelet increase. Ninety-four (16%) patients had a platelet count of ≤50 × 109/L before TIPS. The median absolute platelet change was 14 × 109/L (2 × 109/L to 34 × 109/L). Fifty-four percent of patients in this subgroup were in the top quartile for platelet increase. In multivariable logistic regression, age (OR, 1.50 per 5 years; 95% CI, 1.11-2.02) was the only factor associated with top quartile platelet increase in this subgroup. CONCLUSIONS: TIPS creation did not result in significant platelet increase, except among patients with a platelet count of ≤50 × 109/L before TIPS. Lower pre-TIPS platelet counts, older age, and higher pre-TIPS MELD scores were associated with top quartile (≥32%) platelet increase in the entire cohort, whereas only older age was associated with this outcome in the patient subset with a pre-TIPS platelet count of ≤50 × 109/L.

What referring clinicians value most: Accuracy of radiology results and personal interactions with radiologists.

PURPOSE: We sought to identify which aspects of the referring clinician experience are most strongly correlated with overall satisfaction, and hence of greatest relevant importance to referring clinicians. METHODS: A survey instrument assessing referring clinician satisfaction throughout 11 domains of the radiology process map was distributed 2720 clinicians. The survey contained sections assessing each process map domain, with each section including a question about satisfaction overall in that domain and multiple more granular questions. The final question on the survey was overall satisfaction with the department. Univariate logistic regression and multivariate logistic regression were performed to assess the association between individual survey questions and overall satisfaction with the department. RESULTS: 729 referring clinicians (27%) completed the survey. Using univariate logistic regression nearly every question was associated with overall satisfaction. Amongst the 11 domains of the radiology process map multivariate logistic regression identified the following as mostly strongly associated with overall satisfaction: results/reporting overall (odds ratio 4.71; 95% confidence interval 2.15-10.23), section with which work most closely overall (3.39; 1.28-8.64), and inpatient radiology overall (2.39; 1.08-5.08). Other survey questions associated with overall satisfaction on multivariate logistic regression were attending radiologist interactions (odds ratio 3.71; 95% confidence interval 1.54-8.69), timeliness of inpatient radiology results (2.91; 1.01-8.09), technologist interactions (2.15; 0.99-4.40), appointment availability for urgent outpatient studies (2.01; 1.08-3.64), and guidance for selecting correct imaging study (1.88; 1.04-3.34). CONCLUSION: Referring clinicians value most the accuracy of the radiology report and their interactions with attending radiologists, particularly within the section they work most closely.

North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension.

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.

Percutaneous approach options for embolization of endoleak after iliac artery aneurysm repair: stick the sac or stick the gluteal artery.

Internal iliac artery aneurysms (IIAAs), isolated or associated with abdominal aortic aneurysms, are at rupture risk with growth. Treatment is recommended when symptomatic or greater than 3 cm. Surgical or endovascular therapy should exclude the arterial origin and outflow branches. If all outflow branches are not completely embolized, an endoleak can develop, pressurizing the sac leading to growth and rupture. Accessing the arteries involved can be technically challenging and understanding potential targets is critical. We describe two percutaneous approaches for treatment: percutaneously accessing the sac from an anterior trans-iliopsoas approach and percutaneously accessing the gluteal artery from a posterior approach.

Pressure-Enabled Drug Delivery Approach in the Pancreas with Retrograde Venous Infusion of Lipiodol with Ex Vivo Analysis.

PURPOSE: To determine the safety and feasibility of pancreatic retrograde venous infusion (PRVI) utilizing a microvalvular infusion system (MVI) to deliver ethiodized oil (lipiodol) by means of the Pressure-Enabled Drug Delivery (PEDD) approach. METHODS: Utilizing transhepatic access, mapping of the pancreatic body and head venous anatomy was performed in 10 swine. PEDD was performed by cannulation of veins in the head (n = 4) and body (n = 10) of the pancreas with a MVI (Surefire® Infusion System (SIS), Surefire Medical, Inc (DBA TriSalus™ Life Sciences)) followed by infusion with lipiodol. Sets of animals were killed either immediately (n = 8) or at 4 days post-PRVI (n = 2). All pancreata were harvested and studied with micro-CT and histology. We also performed three-dimensional volumetric/multiplanar imaging to assess the vascular distribution of lipiodol within the glands. RESULTS: A total of 14 pancreatic veins were successfully infused with an average of 1.7 (0.5-2.0) mL of lipiodol. No notable change in serum chemistries was seen at 4 days. The signal-to-noise ratio (SNR) of lipiodol deposition was statistically increased both within the organ in target relative to non-target pancreatic tissue and compared to extra pancreatic tissue (p < 0.05). Histological evaluation demonstrated no evidence of pancreatic edema or ischemia. CONCLUSIONS: PEDD using the RVI approach for targeted pancreatic infusions is technically feasible and did not result in organ damage in this pilot animal study.

Outcomes of transjugular liver biopsies for liver transplant recipients with bicaval and piggyback hepatic vein anastomoses.

BACKGROUND: Liver transplant hepatic venous anastomoses are usually created using "bicaval" or "piggyback" techniques, which may result in unfavorable angulation between the inferior vena cava and hepatic veins, and makes hepatic vein catheterization and tissue sampling during transjugular liver biopsy (TLB) technically challenging. PURPOSE: To compare the technical successes and complications of TLBs for recipients of liver transplants with bicaval and piggyback hepatic vein anastomoses. MATERIAL AND METHODS: Information on type of hepatic vein surgical anastomosis was available for 190 adult patients in whom 306 consecutive TLBs were performed during 2009-2017: 158 with bicaval and 148 with piggyback anastomoses. The primary outcome of procedural success was defined as obtaining a tissue sample sufficient to make a pathologic diagnosis. RESULTS: A technical success rate of 97% with adequate liver tissue for diagnosis was similar between the anastomotic groups (P = 0.50). TLB was unsuccessful in 3% of patients with piggyback anastomoses due to unfavorable hepatic venous anatomy whereas biopsy was successful in all patients with bicaval anastomoses (P = 0.02). Fluoroscopy times were not significantly different (12.1 vs. 13.9 min, P = 0.08). Rates of major complication were similar between the two groups (3% vs. 3%, P > 0.99). CONCLUSION: TLB is safe and effective for liver transplant patients regardless of the type of hepatic vein anastomosis. While failure to catheterize or advance the stiffened biopsy cannula into the hepatic vein is more likely to occur in patients with piggyback anastomoses, this is a rare occurrence.

Updated guidelines for intravenous contrast use for CT and MRI.

Intravenous (IV) contrast material is used extensively for CT and MRI scans done in emergency departments (ED). Its use is essential to make many critical diagnoses in ED patients. While adverse reactions can occur, newer research has added to our knowledge of IV contrast media tolerance and safety leading to improved and more liberal guidelines for intravenous contrast use. The updated information described in this review article indicates how intravenous contrast can be used safely in more patients, more expeditiously and with fewer precautions than with prior guidelines. This review article explains the basis for the new recommendations for intravenous contrast material use and describes indicated precautions and preparations to avoid adverse reactions for iodinated agents used for CT and gadolinium agents for MRI.

Prospective Phase II trial of drug-eluting bead chemoembolization for liver transplant candidates with hepatocellular carcinoma and marginal hepatic reserve.

Purpose: To determine whether chemoembolization using drug-eluting beads (DEB-TACE) is safe and effective for liver transplantation candidates with liver-limited hepatocellular carcinoma (HCC) without vascular invasion and baseline hepatic dysfunction. Materials and methods: Seventeen adult liver transplantation candidates (median age 66 years, range 58-73 years; 13 men) with HCC were treated with DEB-TACE as a part of Stage 1 of a prospective single-institution Phase II trial. All patients had marginal hepatic reserve based on at least one of the following criteria: ascites (n=14), bilirubin between 3 and 6 mg/dL (n=5), AST 5-10 times upper normal limit (n=1), INR between 1.6 and 2.5 (n=4), portal vein thrombosis (n=2), and/or portosystemic shunt (n=2). Primary study objectives were safety and best observed radiographic response. Results: Thirty-seven DEB-TACE procedures were performed. Objective response rate and disease control rate were 63% and 88%, respectively. HCC progression was observed in 12 patients. Median time to progression was 5.6 months (range 0.9-13.6 months). Within 1 month following DEB-TACE, 13 patients (76%) developed grade 3 or 4 AE attributable to the procedure. Four patients (all within Milan Criteria) were transplanted (2.7-6.9 months after DEB-TACE), and 12 patients died (1.8-32 months after DEB-TACE). All deaths were due to liver failure that was either unrelated to HCC (n=5), in the setting of metastatic HCC (n=5), or in the setting of locally advanced HCC (n=2). Mortality rate at 1 month was 0%. Conclusions: DEB-TACE achieves tumor responses but carries a high risk of hepatotoxicity for liver transplant candidates with HCC and marginal hepatic reserve.

Safety and Efficacy of Transjugular Liver Biopsy in Patients with Left Lobe-Only Liver Transplants.

PURPOSE: To evaluate efficacy and safety of transjugular liver biopsy (TJLB) via the left hepatic vein in patients with left lobe-only liver transplants (LLOTs). MATERIALS AND METHODS: Retrospective review revealed 43 TJLBs performed in 26 patients with LLOTs (mean age 51.3 y; range, 18-73 y) between January 2009 and June 2016 at a single institution. A comparison group of 44 randomly selected TJLBs performed in 37 orthotopic whole liver transplant (OWLT) recipients (mean age 57.6 y; range, 35-74 y) during the same time period was evaluated. Patient demographics, type and age of transplant, technical success, adequacy of samples, number of portal tracts obtained, pathologic diagnosis, and complication rate were reviewed. RESULTS: Technical success was achieved in 98% (42/43) of LLOT procedures. TJLB failed in 1 patient with LLOT, in whom no patent hepatic veins were identified. Technical success was achieved in 100% (44/44) in the OWLT group. Mean (SD) number of needle passes was 4.12 (1.25) in the LLOT group vs 3.95 (1.28) in the OWLT group (P = .54). Mean (SD) specimen length was 1.16 (0.75) cm in the LLOT group vs 1.19 (0.58) cm in the OWLT group (P = .78). Mean (SD) number of portal tracts obtained in the LLOT group was 10.7 (5.26) vs 12.3 (4.68) in the OWLT group (P = .17). No major complications were observed in either group. CONCLUSIONS: TJLB in adult patients with LLOTs appears safe and feasible, with favorable rates of technical success and adequacy of sampling.

Operator Dose Reduction during Transjugular Liver Biopsy Using a Radiation-Attenuating Drape: A Prospective, Randomized Study.

PURPOSE: To assess the effectiveness of disposable radiation-absorbing surgical drapes on operator radiation dose during transjugular liver biopsy (TJLB). MATERIALS AND METHODS: This dual-arm prospective, randomized study was conducted between May 2017 and January 2018 at a single institution. TJLB procedures (N = 62; patient age range, 19-80 y) were assigned at a 1:1 ratio to the use of radiation-absorbing surgical drapes or standard surgical draping. The primary outcome was cumulative radiation equivalent dose incident on the operator, as determined by an electronic personal dosimeter worn at the chest during each procedure. Cumulative kerma-area product (KAP), total fluoroscopy time, and total number of exposures used during each liver biopsy procedure were also determined. RESULTS: Mean radiation dose incident on the operator decreased by 56% with the use of radiation-absorbing drapes (37 µSv ± 35; range, 4-183 µSv) compared with standard draping (84 µSv ± 58; range, 11-220 µSv). Radiation incident on the patient was similar between groups, with no significant differences in mean KAP, total fluoroscopy time, and number of exposures acquired during the procedures. CONCLUSIONS: Use of disposable radiation-absorbing drapes reduces scatter radiation to interventionalists performing TJLB.

Radiation Dose Reduction during Uterine Fibroid Embolization Using an Optimized Imaging Platform.

PURPOSE: To assess radiation dose reduction during uterine fibroid embolization (UFE) using an optimized angiographic processing and acquisition platform. MATERIALS AND METHODS: Radiation dose data for 70 women (mean age, 46 y; range, 34-67 y) who underwent UFE were retrospectively analyzed. Twenty-one patients underwent UFE using the baseline fluoroscopic and angiographic image acquisition platform, and 49 underwent UFE after implementing an optimized imaging platform in otherwise identical angiography suites. Cumulative kerma-area product (CKAP), cumulative air kerma (CAK), total fluoroscopy time, and image exposure number were collected for each procedure. Image quality was assessed by 3 interventional radiologists blinded to the platform used for image acquisition and processing. RESULTS: Patients undergoing UFE using the new x-ray fluoroscopy platform had significantly lower CKAP and CAK indicators than patients for whom baseline settings were used. Mean CKAP decreased by 60% from 438.5 Gy · cm2 (range, 180.3-1,081.1 Gy · cm2) to 175.2 Gy · cm2 (range, 47.1-757.0 Gy · cm2; P < .0001). Mean CAK decreased by 45% from 2,034.2 mGy (range, 699.3-5,056.0 mGy) to 1,109.8 mGy (range, 256.6-4,513.6 mGy; P = .001). No degradation of image quality was identified through qualitative evaluation. CONCLUSIONS: Significant reduction in patient radiation dose indicators can be achieved with use of an optimized image acquisition and processing platform.

Intraperitoneal metastases after transarterial embolization of hepatocellular carcinoma: An observational study.

PURPOSE: Transarterial embolization is frequently used to treat local hepatocellular carcinoma (HCC). While various complications are known to occur following transarterial embolization, only one prior case of peritoneal spread of HCC occurring shortly after transarterial chemoembolization has been reported. We present five cases of peritoneal spread of HCC following transarterial embolization (including bland embolization, conventional transarterial chemoembolization (TACE), and doxorubicin-eluting beads TACE) and identify features common among those cases. METHODS: Search of electronic radiology reports and images identified five patients with imaging before and after treatment of HCC with transarterial embolization and with newly developed peritoneal metastases after treatment. Various patient demographics and tumor characteristics were noted. RESULTS: The mean maximal diameter of the treated HCC tumors was 3.7 cm (range 1.4-11.9 cm). Three of the patients had ascites and treated tumors in the posterior right hepatic lobe, and all patients had subcapsular tumors treated with transarterial embolization before developing peritoneal metastases. The mean time from treatment with transarterial embolization to the development of peritoneal metastases was four months. CONCLUSIONS: Intraperitoneal metastatic disease should be considered a rare but potential complication of transarterial embolization of subcapsular HCC, particularly in patients with ascites and tumors that are in the posterior segments of the right lobe. This potential complication should perhaps be considered when planning transarterial HCC treatment, and radiologists interpreting imaging after transarterial embolization of HCC should assess for peritoneal metastases.

Safety and Efficacy of Doxorubicin Drug-Eluting Embolic Chemoembolization of Hepatocellular Carcinoma Supplied by Extrahepatic Collateral Arteries.

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.

Radioembolization with 90Y glass microspheres for the treatment of unresectable metastatic liver disease from chemotherapy-refractory gastrointestinal cancers: final report of a prospective pilot study.

BACKGROUND: This prospective pilot single-institution study was undertaken to document the feasibility, safety, and efficacy of radioembolization of liver-dominant metastatic gastrointestinal cancer using 90Y glass microspheres. METHODS: Between June 2010 and October 2013, 42 adult patients (26 men, 16 women; median age 60 years) with metastatic chemotherapy-refractory unresectable colorectal (n=21), neuroendocrine (n=11), intrahepatic bile duct (n=7), pancreas (n=2), and esophageal (n=1) carcinomas underwent 60 lobar or segmental administrations of 90Y glass microspheres. Data regarding clinical and laboratory adverse events (AE) were collected prospectively for up to 5.5 years after radioembolization. Radiographic responses were evaluated using Response Evaluation Criteria in Solid Tumors (RECIST), version 1.1. Time to maximum response, response duration, progression-free survival (PFS) (hepatic and extrahepatic), and overall survival (OS) were measured. RESULTS: Median target dose and activity were 109.4 Gy and 2.6 GBq per treatment session, respectively. Majority of clinical AE were grade 1 or 2 in severity. Patients with colorectal cancer had hepatic objective response rate (ORR) of 25% and a hepatic disease control rate (DCR) of 80%. Median PFS and OS were 1.0 and 4.4 months, respectively. Patients with neuroendocrine tumors (NET) had hepatic ORR and DCR of 73% and 100%, respectively. Median PFS was 8.9 months for this cohort. DCR and median PFS and OS for patients with cholangiocarcinoma were 86%, 1.1 months, and 6.7 months, respectively. CONCLUSIONS: 90Y glass microspheres device has a favorable safety profile, and achieved prolonged disease control of hepatic tumor burden in a subset of patients, including all patients enrolled in the neuroendocrine cohort.