Transfemoral hepatic vein catheterization reduces procedure time in double vein embolization.

BACKGROUND: Double vein embolization with simultaneous embolization of the portal and hepatic vein aims to grow the future liver remnant in preparation for major hepatectomy. Transvenous hepatic vein embolization is usually done via a transjugular access. The purpose of this study is to describe the transfemoral approach as an alternative option and to discuss potential advantages. RESULTS: Twenty-three patients undergoing hepatic vein embolization via a transjugular (n = 10) or transfemoral access (n = 13) were evaluated retrospectively. In all cases the portal vein embolization was done first. All procedures were technically successful. There were no peri-interventional complications. Only two patients were not able to proceed to surgery. Standardized future liver remnant hypertrophy was non-inferior with the transfemoral approach compared to the transjugular route. Procedure time was significantly shorter in the transfemoral access group (40 ± 13 min) compared to the transjugular group (67 ± 13 min, p < 0.001). CONCLUSION: Transfemoral hepatic vein embolization is feasible, safe, and faster due to easier catheterization, improved stability, and simpler patient preparation. These findings will need to be validated in larger studies.

Safety of Percutaneous Transmesenteric and Transsplenic Access for Portosystemic Shunt Creation in Patients with Portal Vein Obstruction: Single-Center Experience and Review of Literature.

PURPOSE: To evaluate the safety of ultrasound-guided percutaneous mesenteric vein access compared to transsplenic portal vein access for portosystemic shunt placement in patients with portal vein obstruction. MATERIALS AND METHODS: Eight patients underwent portosystemic shunt creation through either a transsplenic (n = 4) or transmesenteric (n = 4) approach. The superior or inferior mesenteric vein was percutaneously accessed under ultrasound guidance using a 21G needle and a 4F sheath. Hemostasis at the mesenteric access site was achieved with manual compression. For transsplenic access, sheath sizes between 6 and 8F were used and tract embolization with gelfoam was performed. RESULTS: Portosystemic shunt placement was successful in all patients. While there were no bleeding complications with transmesenteric access, hemorrhagic shock requiring splenic artery embolization occurred in one patient in which the transsplenic approach was used. CONCLUSION: Ultrasound-guided mesenteric vein access seems feasible and a valid alternative to the transsplenic access in case of portal vein obstruction. Level of Evidence Level 4, case series.

Postinterventional Patient Comfort After Uterine Artery Embolization and Superior Hypogastric Nerve Block.

PURPOSE: To evaluate the duration and effect of superior hypogastric nerve block (SHNB) with ropivacaine and clonidine on postinterventional pain levels and opioid requirements in patients undergoing uterine artery embolization. MATERIALS AND METHODS: Postinterventional pain levels (numeric rating scale, NRS 0-10) and opioid doses were retrospectively analyzed in 53 patients undergoing transfemoral uterine artery embolization and intraprocedural superior hypogastric nerve block during 24 h. A mixture of 150 mg of ropivacaine and 150 µg of clonidine was used for the block. RESULTS: Postinterventional pain averaged between 1.4 and 2.0 during the first 9 h, after which a small but significant increase was observed (NRS 1.7 ± 1.6 vs. NRS 2.6 ± 2.2, p < 0.001). 70% of patients did not exceed a tolerable pain threshold of NRS 4 during the first 9 h after the intervention. Thirty-three patients (62%) did not require any opioid medication. Mean iv morphine dose was 3.1 ± 4.7 mg, whereas 71% of opioid doses were administered after 9 h. CONCLUSION: Superior hypogastric nerve block using a mixture of ropivacaine and clonidine provides good pain relief for 9 h after uterine artery embolization requiring only very low amounts of additional opioids.

"Apical thinning": Relations between myocardial wall thickness and apical left ventricular tracer uptake as assessed with positron emission tomography myocardial perfusion imaging.

BACKGROUND: A reduction in left ventricular apical tracer uptake (apical thinning) is frequently observed in myocardial perfusion imaging (MPI), yet its cause remains a matter of debate, particularly in perfusion emission tomography (PET). This analysis sought to determine whether apical thinning in PET-MPI is attributable to true anatomical thinning of the left ventricular apical myocardium. METHODS AND RESULTS: We retrospectively analyzed 57 patients without any history or signs of apical myocardial infarction who underwent rest PET-MPI with 13N-ammonia and contrast-enhanced cardiac computed tomography (CT). Semi-quantitative normalized percent apical 13N-ammonia uptake at rest, myocardial blood flow (MBF), and k2 wash-out rate constants were compared to apical myocardial wall thickness measurements derived from CT and base-to-apex gradients were calculated. Apical thinning was found in 93% of patients and in 74% when analysis of normalized apical tracer uptake was confined to end-systole. No significant correlation was found between apical myocardial thickness and apical tracer uptake (r = - 0.080, P = .553), MBF (r = - 0.211, P = .115), or k2 wash-out rate (r = - 0.023, P = .872), nor between apical myocardial thickness and any gradients. A statistically significant but small difference in apical myocardial thickness was observed in patients with moderately to severely reduced apical tracer uptake vs patients with normal to mildly reduced uptake (4.3 ± 0.7 mm vs 4.7 ± 0.7 mm; P = .043). CONCLUSIONS: Apical thinning is a highly prevalent finding during 13N-ammonia PET-MPI that is not solely attributable to true anatomical apical wall thickness or the partial volume effect. Other factors that yet need to be identified seem to have a more prominent impact.

Sports Behavior in Middle-Aged Individuals with Anomalous Coronary Artery from the Opposite Sinus of Valsalva.

OBJECTIVES: Recommendations regarding sports restriction are lacking for middle-aged athletes with anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS). METHODS: Sixty-three patients with ACAOS were subdivided into ACAOS with (n = 38) or without (n = 25) an interarterial course (IAC). Sports behavior, either competitive (COMP) or recreational (REC), was evaluated at the time of diagnosis and after a median follow-up of 4.2 years. RESULTS: Mean age was 56 ± 11 years and 48 (76.2%) patients were engaged in sports. Three individuals (4.8%) were surgically corrected after diagnosis. Thirty-eight (60.3%) patients were aware of their diagnosis at follow-up and 12 (19.0%) were counseled by their physician about sports restrictions. Sports behavior at the time of diagnosis and at follow-up did not differ significantly, neither in patients engaged in COMP (17.5 vs. 12.7%, p = 0.619) nor those engaged in REC (58.7 vs. 61.9%, p = 0.856). Sport-related symptoms were not significantly different between ACAOS patients with and without IAC. No athlete had died at follow-up. CONCLUSIONS: The majority of middle-aged individuals with ACAOS were involved in sports activities at the time of diagnosis and at follow-up. Awareness and counseling about ACAOS diagnosis had no significant effect on sports behavior. IAC did not have an impact on sport-related symptoms, and outcomes were favorable in all athletes, regardless of surgical correction.

Outcome in middle-aged individuals with anomalous origin of the coronary artery from the opposite sinus: a matched cohort study.

AIMS: Anomalous origin of a coronary artery from the opposite sinus (ACAOS) has been associated with adverse cardiac events in the young. It remains unknown whether this holds true for middle-aged patients with uncorrected ACAOS as well. We assessed the outcome in middle-aged patients with newly diagnosed ACAOS by coronary computed tomography angiography (CCTA) compared with a matched cohort. METHODS AND RESULTS: We retrospectively identified 68 consecutive patients with ACAOS documented by CCTA. ACAOS with a course of the anomalous vessel between the aorta and pulmonary artery were classified as interarterial course (IAC). Each patient with ACAOS was matched to two controls without ACAOS. Major adverse cardiac events (i.e. myocardial infarction, revascularization and cardiac death) were recorded for all patients and controls. Two (3%) patients were lost to follow-up. Thus, 66 patients with ACAOS were included in the final analysis and matched with 132 controls. Mean age of patients was 56 ± 11 years, 73% were male and the mean follow-up was 49 months. Forty (65%) patients were classified as having ACAOS with IAC. The annual event rate of ACAOS vs. controls was 4.9 and 4.8%, the hazard ratio (HR) 0.94 (0.39-2.28, P = 0.89). The annual event rate of ACAOS with IAC compared with their matched controls was 5.2 and 4.3%, and the HR 1.01 (95% CI 0.39-2.58, P = 0.99). CONCLUSIONS: In middle-aged individuals with newly diagnosed ACAOS mid-term outcome is not statistically different to a matched control cohort without coronary artery anomalies, regardless of whether ACAOS with or without IAC variants are present.