Portal hypertension increases the risk of hepatic decompensation after 90Yttrium radioembolization in patients with hepatocellular carcinoma: a cohort study.

Background: Transarterial radioembolization (TARE) is increasingly used in patients with hepatocellular carcinoma (HCC). This treatment can induce or impair portal hypertension, leading to hepatic decompensation. TARE also promotes changes in liver and spleen volumes that may modify therapeutic decisions and outcomes after therapy. Objectives: We aimed to investigate the impact of TARE on the incidence of decompensation events and its predictive factors. Design: In all, 63 consecutive patients treated with TARE between February 2012 and December 2018 were retrospectively included. Methods: We assessed clinical (including Barcelona Clinic Liver Cancer stage, portal hypertension assessment, and liver decompensation), laboratory parameters, and liver and spleen volumes before and 6 and 12 weeks after treatment. A multivariate analysis was performed. Results: In total, 18 out of 63 (28.6%) patients had liver decompensation (ascites, variceal bleeding, jaundice, or encephalopathy) within the first 3 months after therapy, not associated with tumor progression. Clinically significant portal hypertension (CSPH) and bilobar treatment independently predicted the development of liver decompensation after TARE. A significant volume increase in the non-treated hemi-liver was observed only in patients with unilobar treatment (median volume increase of 20.2% in patients with right lobe TARE; p = 0.007), especially in those without CSPH. Spleen volume also increased after TARE (median volume increase of 16.1%; p = 0.0001) and was associated with worsening liver function scores and decreased platelet count. Conclusion: Bilobar TARE and CSPH may be associated with an increased risk of liver decompensation in patients with intermediate or advanced HCC. A careful assessment considering these variables before therapy may optimize candidate selection and improve treatment planning.

A simple nomogram identifies patients with refractory ascites with worse outcome after transjugular intrahepatic portosystemic shunt.

OBJECTIVES: Transjugular intrahepatic portosystemic shunt (TIPS) is increasingly used in the management of refractory ascites. Controversy exists regarding the predictive factors of unfavorable outcomes, useful for patient selection. The primary aim was to identify predictive factors of 1-year survival or recurrent severe hepatic encephalopathy in patients with cirrhosis undergoing covered TIPS for refractory ascites. The secondary aim was overall survival. METHODS: Observational, retrospective, multicentric study, that included all cirrhotic patients treated with covered-TIPS for refractory ascites since 2001. Demographic, clinical, laboratory and hemodynamic data were collected at baseline and consecutively until dead, liver transplant or end of follow-up. The Cox model was used to identify predictive factors of overall survival. A Fine-Gray competing risk regression model was used to identify predictive factors of 1-year mortality or recurrent hepatic encephalopathy. A predictive nomogram was created based on those factors. RESULTS: In total 159 patients were included. Predictive factors of survival or recurrent severe encephalopathy were renal dysfunction [hazard ratio, 2.12 (95% CI, 1.11-4.04); P = 0.022], albumin [hazard ratio, 0.58 (95% CI, 0.34-0.97); P = 0.036], serum sodium [hazard ratio, 0.94 (95% CI, 0.89-0.98); P = 0.008] and international normalized ratio [hazard ratio 4.27 (95% CI, 1.41-12.88); P = 0.010]. In the competing risk analysis, predictive factors of 1-year mortality/recurrent severe encephalopathy in multivariate analysis were age [sub-distribution hazard ratio (sHR) 1.05 (95% CI, 1.02-1.09); P = 0.001], creatinine [sHR 1.55 (95% CI, 1.23-1.96); P = 0.001] and serum sodium [sHR 0.94 (95% CI, 0.90-0.99); P = 0.011] at baseline. CONCLUSIONS: Age, creatinine and sodium baseline levels strongly influence 1-year survival/recurrent severe hepatic encephalopathy in patients with cirrhosis undergoing covered TIPS for refractory ascites. A simple nomogram accurately and easily identifies those patients with worse prognosis.

Fracturas de pelvis con hematoma retroperitoneal asociado: tiempo hasta la angioembolización y resultados / Pelvic fractures with associated retroperitoneal hematoma: time until angioembolization and results

Introducción: El tratamiento de las fracturas de pelvis con hematoma retroperitoneal (HRP) es controvertido. Especialmente la necesidad de angioembolización (AE) cuando no hay extravasación de contraste (EC) en la tomografía computarizada (TC) o angiografía. Otro aspecto relevante es el retraso hasta la misma. Nuestro objetivo ha sido determinar si existen diferencias en el tiempo hasta la AE entre los pacientes admitidos durante el horario laboral y los admitidos fuera del mismo y durante los fines de semana y festivos. Nuestra hipótesis era que la angiografía y AE serían más frecuentes en el horario laboral, y el tiempo hasta las mismas sería superior fuera del horario laboral habitual, con una mortalidad mayor en este grupo para una gravedad global similar. Un objetivo secundario ha sido valorar la correlación entre EC en la TC y la angiografía. Métodos: Análisis retrospectivo de 2 cohortes de pacientes con HRP por fractura de pelvis. Se estudia la realización de angiografía dividiendo a los pacientes según su hora de llegada a lo largo de un periodo de 24 años (grupo A: horario laboral, y grupo B: fuera del mismo). La indicación de angiografía y AE fue realizada por la guardia de cirugía general, en consenso con el radiólogo intervencionista. Se han analizado variables demográficas, mecanismo lesivo, lesiones asociadas, gravedad fisiológica y anatómica, EC en la TC y la angiografía, necesidad de AE, estancia en unidad de cuidados intensivos (UCI) y mortalidad. Resultados: Se admitió a 104 pacientes con diagnóstico de HRP por fractura pélvica. Se realizó angiografía, con AE en 63 casos (61%). Los grupos eran comparables en las variables analizadas. En el 70% de los pacientes del grupo A se realizó angiografía, frente al 57% del grupo B, sin diferencias en tiempo hasta la AE. Se demostró EC en la TC en 53 de los 96 pacientes en los que se hizo, lo que se confirmó mediante angiografía en el 85%. No hubo diferencias estadísticamente significativas de mortalidad entre ambos grupos. Conclusiones: Se demuestra un tiempo corto entre la admisión en Urgencias y la AE, sin relación con el momento del ingreso durante el día, y una buena correlación entre la EC en la TC y la angiografía

Introduction: Two areas of controversy in the management of bleeding pelvic fractures are the need to perform angioembolization (AE) in patients with a retroperitoneal hematoma (RPH) but no contrast extravasation (CE) on Computerized Tomography (CT) and/or angiography, and the delay to AE. Our main objective was to assess whether there had been differences in the percentage and delay to AE between patients admitted on weekdays versus off-hours (weekends and admission after 3pm) at our hospital. Our hypothesis was that angiography and AE would be more frequent on weekdays, and the time delay would be longer during off-hours, with a higher mortality in this latter group for a similar overall severity. A secondary objective was to assess the correlation between CE on CT scan and angiography. Methods: Retrospective review of two cohorts of patients with RPH from a pelvic fracture during a period of 24 years. Patients were divided depending on the time of arrival (Group A: weekdays, and Group B: off-hours). The decision to perform angiography and AE was made by the general surgeons on call, in consensus with the interventional radiologist. We analyzed demographics, mechanism of injury, associated injuries, physiologic and anatomic trauma scores, CE on CT scan, need of AE, Intensive Care Unit (ICU) stay and mortality. Results: 104 patients were admitted with RPH from a pelvic fracture. We performed AE in 63 cases (61%). The groups were comparable in the variables analyzed. In 70% of patients in group A, angiography was done, vs 57% in group B, with the same median time delay. CE on CT scan was seen in 53 out of 96 patients and confirmed by angiography in 45 (85%) of them. No significant differences were found in mortality between the two groups. Conclusions: There was a short delay from admission to AE, even during off-hours, and a good correlation of CE on CT scan and angiography

Pelvic fractures with associated retroperitoneal hematoma: time until angioembolization and results. / Fracturas de pelvis con hematoma retroperitoneal asociado: tiempo hasta la angioembolización y resultados.

INTRODUCTION: Two areas of controversy in the management of bleeding pelvic fractures are the need to perform angioembolization (AE) in patients with a retroperitoneal hematoma (RPH) but no contrast extravasation (CE) on Computerized Tomography (CT) and/or angiography, and the delay to AE. Our main objective was to assess whether there had been differences in the percentage and delay to AE between patients admitted on weekdays versus off-hours (weekends and admission after 3pm) at our hospital. Our hypothesis was that angiography and AE would be more frequent on weekdays, and the time delay would be longer during off-hours, with a higher mortality in this latter group for a similar overall severity. A secondary objective was to assess the correlation between CE on CT scan and angiography. METHODS: Retrospective review of two cohorts of patients with RPH from a pelvic fracture during a period of 24 years. Patients were divided depending on the time of arrival (Group A: weekdays, and Group B: off-hours). The decision to perform angiography and AE was made by the general surgeons on call, in consensus with the interventional radiologist. We analyzed demographics, mechanism of injury, associated injuries, physiologic and anatomic trauma scores, CE on CT scan, need of AE, Intensive Care Unit (ICU) stay and mortality. RESULTS: 104 patients were admitted with RPH from a pelvic fracture. We performed AE in 63 cases (61%). The groups were comparable in the variables analyzed. In 70% of patients in group A, angiography was done, vs 57% in group B, with the same median time delay. CE on CT scan was seen in 53 out of 96 patients and confirmed by angiography in 45 (85%) of them. No significant differences were found in mortality between the two groups. CONCLUSIONS: There was a short delay from admission to AE, even during off-hours, and a good correlation of CE on CT scan and angiography.

Intracardiac thrombosis in Behçet's Disease successfully treated with immunosuppressive agents: A case of vascular pathergy phenomenon.

Behçet's Disease (BD) is a rare multi-systemic inflammatory disorder classified as a systemic vasculitis of unknown aetiology. Vascular involvement occurs in approximately 5-51.6% cases, affecting venous and arterial vessels. Cardiac involvement is rare in BD (6%). There have been published approximately 93 cases of BD associated with intracardiac thrombosis, with different treatments and courses. We present a case of a 35-year-old spanish male that, after a percutaneous pharmacomechanical thrombectomy with venous stent placement, developed high fever and extensive venous thrombosis despite anticoagulation including intracardiac thrombosis (ICT) in the right ventricle and pulmonary embolism that leaded to the diagnosis of BD. The patient was successfully treated with immunosuppressants, achieving the complete resolution of ICT. We hypotesize that the endovenous procedure could have acted as a trigger for the posterior acute attack of the disease, representing a 'vascular pathergy phenomenon'. Vascular BD has to be suspected in cases of thrombosis recurrence despite correct anticoagulation, and intense immunosuppressive treatment should be considered.

Embolization through the thyrocervical trunk: vascular anatomy, variants, and a case series.

BACKGROUND AND PURPOSE: The thyrocervical trunk (TCT) is the second ascending branch of the subclavian artery. It is considered a 'border territory' between interventional vascular radiology and interventional neuroradiology because it gives rise to branches both cervical and to the upper limbs. We describe the TCT branches anatomy, the most frequent variants, and expose eight endovascular procedures performed through the thyrocervical trunk. METHODS: A retrospective review of all the interventional radiology procedures carried out through the TCT in our tertiary care center from August 2014 to January 2017 is presented. RESULTS: A total of eight endovascular procedures through the TCT including six preoperative embolizations: three paragangliomas, a cervical vertebral metastasis, a cervical vertebral aneurysmal bone cyst, and a very rare case of nerve root extradural cervical hemangioblastoma, as well as two emergency embolizations: a patient with a cervical traumatic active bleeding hematoma and a recurrent hemoptysis in a single ventricle patient. CONCLUSIONS: A correct knowledge of the vascular anatomy, anatomical variants, and anastomosis (especially with the anterior spinal artery) of the TCT is essential for a safe embolization, both preoperatively and on an emergency basis. In cases of recurrent hemoptysis and severe lower-neck injuries, the TCT should always be reviewed.