Role of Interventional Radiology (IR) in vascular emergencies among cirrhotic patients.

Gastrointestinal hemorrhage remains one of the most common causes of morbidity and mortality among patients with liver cirrhosis. Mostly, these patients bleed from the gastroesophageal varices. However, nonvariceal bleeding is also more likely to occur in these patients. Because of frequent co-existing coagulopathy, cirrhotics are more prone to bleed from a minor vascular injury while performing percutaneous interventions. Ultrasound-guided bedside vascular access is an essential procedure in liver critical care units. Transjugular portosystemic shunts (TIPS) with/without variceal embolization is a life-saving measure in patients with refractory variceal bleeding. Whenever feasible, balloon-assisted retrograde transvenous obliteration (BRTO) is an alternative to TIPS in managing gastric variceal bleeding, but without a risk of hepatic encephalopathy. In cases of failed or unfeasible endotherapy, transarterial embolization using various embolic agents remains the cornerstone therapy in patients with nonvariceal bleeding such as ruptured hepatocellular carcinoma, gastroduodenal ulcer bleeding, and procedure-related hemorrhagic complications. Among various embolic agents, N-butyl cyanoacrylate (NBCA) enables better vascular occlusion in cirrhotics, even in coagulopathy, making it a more suitable embolic agent in an expert hand. This article briefly entails the different interventional radiological procedures in vascular emergencies among patients with liver cirrhosis.

Is salvage Plug-Assisted Retrograde Transvenous Obliteration (PARTO) safe and effective for bleeding gastric varices ?- A preliminary single-center experience.

BACKGROUND: Vascular plug-assisted retrograde transvenous obliteration (PARTO) obliterates the gastric varices and portosystemic shunt, thus resulting in a lower rebleeding rate than endoscopic glue/sclerotherapy. AIMS: To evaluate the safety and efficacy of PARTO as salvage therapy in liver cirrhosis with gastric variceal bleed (GVB) after failed endotherapy. We assessed the clinical success rate and changes in liver function at 6- months. MATERIALS AND METHODS: Patients who underwent salvage PARTO after failed endotherapy for GVB (between December 2021 and November 2022) were searched and analyzed from the hospital database. Clinical success rate and rebleed rate were obtained at six months. Child-Pugh score (CTP) and Model for end-stage liver disease (MELD) score were calculated and compared between baseline and 6-month follow-up. RESULTS: Fourteen patients (n = 14, Child-Pugh class A/B) underwent salvage PARTO. Nine had GOV-2, and five had IGV-1 varices. The mean shunt diameter was 11.6 ± 1.6 mm. The clinical success rate of PARTO was 100% (no recurrent gastric variceal hemorrhage within six months). No significant deterioration in CTP (6.79 ± 0.98 vs. 6.21 ± 1.52; p = 0.12) and MELD scores (11.5 ± 4.05 vs. 10.21 ± 3.19; p = 0.36) was noted at 6 months. All patients were alive at 6 months. One patient (n = 1, 7.1%) bled from esophageal varices after three days of PARTO and was managed with variceal banding. 21.4% (3/14) patients had progression of esophageal varices at 6 months requiring prophylactic band ligation. Three patients (21.4%) had new onset or worsening ascites and responded to low-dose diuretics therapy. CONCLUSIONS: PARTO is a safe and effective procedure for bleeding gastric varices without any deterioration in liver function even after six months. Patient selection is critical to prevent complications. Further prospective studies with larger sample size are required to validate our findings.

Diagnostic outcome and safety of plugged liver biopsy in high-risk patients: a systematic review and meta-analysis.

BACKGROUND: Percutaneous liver biopsy is the gold standard test for the assessment of liver disease. In patients with coagulopathy, ascites, post-transplantation, and hypervascular tumors, biopsy is associated with increased risk of adverse events (AEs). Transjugular liver biopsy (TJLB) is recommended in these conditions but is expensive and unavailable at many centers. Plugged liver biopsy (PLB) provides an alternate diagnostic modality in these high-risk cases. PURPOSE: To analyze the pooled diagnostic outcome and safety of PLB in high-risk cases. MATERIAL AND METHODS: A literature search of various databases from January 1990 to July 2022 was conducted for studies evaluating the outcome of PLB in high-risk cases. The primary outcomes were pooled sample adequacy and AEs. Pooled event rates across studies were expressed with summative statistics. RESULTS: A total of 17 studies (2329 patients) were included in the meta-analysis. The pooled proportion of sample adequacy was 98.9% (95% confidence interval [CI]=98.2-99.6). Severe AEs, major bleeding, and minor AEs were seen in 0.7% (95% CI=0.1-1.3), 0.4% (95% CI=0.1-0.8), and 11.5% (95% CI=2.4-20.6) of the patients. There was only one reported mortality, giving a pooled incidence of 0.0002% (95% CI=0.0-0.0038). Compared to TJLB (5 studies, n = 336), there was no difference in either sample adequacy (odds ratio [OR]=2.34, 95% CI=0.83-6.58) or risk of serious AEs (OR=0.47, 95% CI=0.173-1.31). CONCLUSION: PLB can be safely performed on patients with coagulopathy and/or ascites with high sample adequacy rates and low incidence of AEs and mortality.

Lower extremity pseudoaneurysms and their interventional radiological management: a pictorial review.

Lower extremity pseudoaneurysms (PsAs) are mostly developed after traumatic or iatrogenic injury to the arteries. Unless treated, they can be complicated by adjacent mass effects, distal embolism, secondary infection, and rupture. Imaging helps in the diagnosis and planning of therapeutic intervention. Ultrasonography (USG) is often diagnostic, while CT angiography aids in vascular mapping required for intervention. Image-guided therapy offers to manage these pseudoaneurysms in a minimally invasive approach, obviating the need for surgery. A smaller, superficial, and narrow-necked PsA can easily be managed with local USG-guided compression or thrombin injection. When the percutaneous approach is not a feasible option, PsA from expendable arteries can also be managed with coiling or glue injection. Wide-necked PsA from an unexpendable artery necessitates stent graft placement, although coiling of the neck may be a viable and cheaper alternative for a long- and narrow-necked PsA. Presently, vascular closure devices are also used to seal a small arterial rent through a direct percutaneous approach. This pictorial review entails various techniques to deal with lower extremity pseudoaneurysms. An idea about the various intervention radiological approaches will help in choosing appropriate methods to tackle lower extremity pseudoaneurysms.

Role of contrast-enhanced ultrasound for differentiation of benign vs. malignant portal vein thrombosis in hepatocellular carcinoma - A systematic review a meta-analysis.

Introduction/Purpose: Patients with cirrhosis and hepatocellular carcinoma (HCC) can develop both benign and malignant portal vein thrombosis (PVT). Characterising the nature of PVT is important for planning an optimal therapeutic strategy. In the absence of typical findings or contraindications to computed tomography (CT) or magnetic resonance imaging (MRI), contrast-enhanced ultrasound (CEUS) could help in this differentiation. The present meta-analysis aimed to evaluate the performance of CEUS for characterising PVT in patients with HCC. Methods: Electronic databases of PubMed, Embase and Scopus were searched from inception to 31 December 2022 for studies analysing the role of CEUS in the differentiation of benign and malignant PVT in HCC. Using the bivariate random effect model, pooled sensitivity and specificity were calculated, and the summary receiver operating characteristic (sROC) curve was plotted. Results: A total of 12 studies with data from 712 patients were included in the meta-analysis. The pooled sensitivity and specificity of CEUS for the diagnosis of tumour in vein were 97.0% (95% CI: 93.0-98.7) and 96.8% (95% CI: 92.1-98.7), respectively, without significant heterogeneity. A sROC curve was plotted, and the area under the receiver operating characteristic was 0.99 (95% CI: 0.98-1.00). Despite the presence of publication bias, sensitivity analysis did not show any change in sensitivity and specificity. Discussion: Our meta-analysis summarises the accuracy data from 12 studies, including >700 subjects. Contrast-enhanced ultrasound had excellent diagnostic accuracy with pooled sensitivity and specificity of 97.5% (95% CI: 93.5-99.1) and 98.2% (95% CI: 91.5-99.6), respectively, without any significant heterogeneity. Additionally, the pooled positive LR, negative LR and DOR were 54.6 (95% CI: 11.1-25.6), 0.02 (0.01-0.07) and 2186.8 (318.3-15022.2), respectively. A positive result increases the pretest probability of malignant PVT from 50% to 98%, whereas a negative result decreases it from 50% to 2%. Most of the studies included in our meta-analysis used identical techniques and 6-12-month follow-up scans to check for thrombus progression or regression. Our analysis showed no significant heterogeneity in the studies, and area under receiver operating characteristic curve (AUROC) with 95% CI was 1.00 (95% CI: 0.99-1.00). This critical meta-analysis thus propels CEUS to the forefront for differentiating benign from tumoural PVT and suggests routinely using CEUS in patients presenting with HCC and evidence of thrombus on greyscale ultrasound. Conclusion: Contrast-enhanced ultrasound is an effective diagnostic modality differentiation of benign and malignant PVT in patients with HCC and can be an alternative modality to CT or MRI. Further studies are required to study the role of CEUS as initial diagnostic modality for the characterisation of PVT in HCC.

Impact of nutritional status on the outcome of transjugular intrahepatic portosystemic shunt in patients with cirrhosis: a systematic review.

OBJECTIVES: Malnutrition and sarcopenia have been reported to adversely affect the outcome of patients with cirrhosis of the liver. There is an emerging body of evidence suggesting malnutrition and sarcopenia increase the risk of hepatic encephalopathy (HE) and mortality after transjugular intrahepatic portosystemic shunt (TIPS). The current systematic review aims to determine whether the body of evidence supports an association between nutritional status and post-TIPS outcomes in patients with cirrhosis. METHODS: Electronic databases of PubMed, Embase, and Scopus were searched from inception to June 3, 2023, for studies analysing the effect of nutritional status on post-TIPS outcomes in patients with cirrhosis. RESULTS: A total of 22 studies were included in the systemic review. Assessment of sarcopenia was done by skeletal muscle index (SMI) at the L3 level, transversal psoas muscle thickness, psoas muscle density, malnutrition as per ICD, relative sarcopenia with excess adiposity, lipid profile, controlling nutritional status score, body composition analysis, hospital frailty risk score, and visceral and subcutaneous fat area index. Ten out of 12 studies in this systematic review showed a significant association with the incidence of post-TIPS HE. Thirteen out of 14 studies reported that the presence of malnutrition was associated with increased odds of mortality following TIPS. One study reported sarcopenia as an independent predictor of liver failure, and another study reported that Pre-TIPS SMI was an independent predictor of substantial improvement in post-TIPS SMI. CONCLUSIONS: The current systematic review shows that the presence of pre-TIPS malnutrition or sarcopenia is an independent predictor of adverse outcomes after TIPS. Incorporating these parameters into present prediction models can provide additional prognostic information. ADVANCES IN KNOWLEDGE: Nutritional assessment should be part of the evaluation of patients planned for TIPS for prediction of adverse events after the procedure.

Bloody Bile and Rescue Intervention-A Case Series of Post-PTBD Hemorrhagic Complications With a Review of the Literature.

Percutaneous transhepatic biliary drainage (PTBD) is a routinely performed interventional radiological procedure. A myriad of complications can occur after PTBD, the most important being hemorrhagic complications that require immediate attention. Hemorrhage following PTBD may result from arterial, portal, or hepatic venous injury. A catheter or pull-back cholangiogram often demonstrates the venous injury. A computed tomogram angiogram aids in identifying bleeding sources and procedural planning. Catheter repositioning, upsizing, or clamping often suffice for minor venous bleeding. However, major venous injury necessitates tract embolization, portal vein embolization, or stent grafting. Arterial injury may lead to significant blood loss unless treated expeditiously. Transarterial embolization is the treatment of choice in such cases. Adequate knowledge about the hemorrhagic complications of PTBD will allow an interventional radiologist to take necessary precautionary measures to reduce their incidence and take appropriate steps in their management. This article entails four different hemorrhagic complications of PTBD and their interventional management. It also discusses the various treatment options to manage different kinds of post-PTBD hemorrhagic complications.

Comparative outcome of transjugular intrahepatic portosystemic shunt with or without variceal obliteration: a systematic review and meta-analysis.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) has been used for the secondary prevention of variceal bleeding. TIPS can be combined with variceal embolization (TIPS-VO), but its benefit remains controversial. The present systematic review and meta-analysis were conducted to compare the incidence of rebleeding, adverse events, and mortality among patients with TIPS alone and with TIPS-VO. METHODS: A literature search from January 2000 to June 2022 was done for studies comparing the outcome of patients undergoing TIPS alone or TIPS-VO. A subgroup analysis was conducted for patients undergoing TIPS with covered stents. RESULTS: A total of 11 studies with data from 1044 patients were included. The incidence of rebleeding was significantly higher in the TIPS alone group in both overall population OR 2.01 (1.42-2.83) and the subgroup (OR 1.92, 95% CI 1.21-3.04). There was no difference between the two groups concerning the risk of hepatic encephalopathy (OR 1.15, 95% CI 0.83-1.59), procedural adverse events (OR 0.86, 95% CI 0.54-1.39), shunt dysfunction (OR 1.20, 95% CI 0.82-1.75), overall mortality (OR 1.03, 95% CI 0.73-1.46), and mortality due to variceal rebleeding (OR 1.58, 95% CI 0.44-5.64). There was no significant heterogeneity or publication bias among the included studies. The certainty of evidence remains low for all the outcome expect for variceal rebleeding. CONCLUSION: The present meta-analysis provides a moderate-quality evidence for the benefit of TIPS-VO in reducing the incidence of rebleeding. However, the decision for combining variceal embolization with TIPS should be made on a case-to-case basis.

Hepatic Vascular Variants in Hereditary Haemorrhagic Telangiectasia: Imaging findings.

Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterised by vascular dysplasia. Hepatic vascular malformations (VMs) range from small telangiectases to significant vascular shunting. Here we report two cases of HHT. Case 1 had diffuse ectasia of the hepatic artery along its intrahepatic and extrahepatic course with a hepatic arterial aneurysm. Case 2 presented with ileal and hepatic telangiectases. Knowledge of these vascular variants is indispensable for clinicians and radiologists in aiding diagnosis and surgical and interventional management.

Noninvasive differentiation of porto-sinusoidal vascular disorder from cirrhosis: a systematic review.

BACKGROUND: Porto-sinusoidal vascular disorder (PSVD) is one of the common causes of portal hypertension and has overlapping features with early cirrhosis. The differentiation of PSVD from cirrhosis requires a liver biopsy, which is invasive and has potential complications. This systematic review aimed at summarizing the current evidence on the performance of noninvasive modalities for differentiating PSVD from cirrhosis. METHODS: A comprehensive search of electronic databases of MEDLINE, Embase, and Scopus was conducted from 2000 to October 2022 for the studies comparing the elastographic and radiological features of PSVD and cirrhosis, using liver biopsy as the gold standard. RESULTS: A total of 12 studies were included in the systematic review. Transient elastography (TE) as a modality was studied in five studies, MR elastography (MRE) in two, contrast CT in two, Contrast CT and MRI in two, and ARFI in only one. Both TE and MRE showed a significantly lower liver stiffness measurement and a higher splenic stiffness measurement with a higher SSM/LSM ratio with PSVD, compared to cirrhosis. Among the radiological features, focal nodular hyperplasia-like lesions, portal vein abnormalities (intrahepatic and extrahepatic), and a larger spleen size favored a diagnosis of PSVD. In contrast, surface nodularity and atrophy of segment IV with a segment I hypertrophy favored a diagnosis of cirrhosis. CONCLUSION: Elastography and cross-sectional imaging can help differentiate PSVD from early cirrhosis with good accuracy. Further studies are required to assess the diagnostic role of a combination of both modalities.

A Modified Manual Compression Technique for the Treatment of Traumatic Pseudoaneurysm of Superficial Temporal Artery.

Traumatic Pseudoaneurysm of Superficial temporal artery (STA) is an uncommon entity. Surgical management is the treatment of choice, and endovascular management is also equally feasible particularly for the proximal STA aneurysm. The manual compression for the treatment of STA aneurysm is also described, but it has a high chance of failure. We report a case of traumatic pseudoaneurysm of STA in a pregnant female, successfully treated with a modified manual compression technique.

Bleeding Stomal Varices and Their Interventional Management- A Series of Three Cases.

Although stomal and parastomal varices are uncommon causes of variceal bleeding, the mortality rate might be as high as 40%. Timely intervention is essential for the management of these ectopic bleeding varices. Due to the rarity of such varices, no standard treatment guideline is available. We present three cases of bleeding stomal varices managed with an endovascular approach, one through percutaneous transhepatic and the other two through transjugular intrahepatic portosystemic shunt approach.

Abdominal Computed Tomography Findings among COVID-19 Patients with Index Gastrointestinal Manifestations: A Preliminary Single-center Experience.

BACKGROUND: About 20% of COVID-19 patients can have digestive symptoms, apart from the typical chest-related symptoms, and 10% of patients may have only gastrointestinal (GI) symptoms during their entire disease course. AIM AND OBJECTIVE: The purpose of this study was to describe the spectrum of abdominal computed tomographic (CT) findings in a cohort of 15 COVID-19 patients (confirmed on reverse transcription polymerase chain reaction (RT-PCR)) who presented with various GI presentations without preceding respiratory symptoms. MATERIALS AND METHODS: A total of 93 patients with COVID-19 (confirmed on RT-PCR) who underwent CT imaging (between September 28, 2020 and March 20, 2021) in our center were retrospectively searched from the existing database. Among those, 15 patients having index presentation with abdominal symptoms and underwent CT abdomen were further evaluated. RESULTS: Biliary stasis in the form of distended gallbladder and wall thickening was the most common finding, seen in 66.7% (n = 10) patients, followed by bowel wall thickening. Small bowel and large bowel thickenings were seen in 26.7% (n = 4) and 20% (n = 3) patients, respectively. Other findings include fluid-filled colon (n = 1), mesenteric venous thrombosis (MVT) (n = 2), paper-thin bowel wall and pneumatosis (n = 1), acute pancreatitis (n = 1), and ascites (n = 2). One patient who presented with abdominal pain did not show any obvious imaging findings on CT. CONCLUSION: Patients with COVID-19 can present with initial GI symptoms preceding typical respiratory symptoms. CT imaging helps in identifying the GI involvement, to rule out alternate etiologies, and also aids in appropriate management planning. HOW TO CITE THIS ARTICLE: Patel RK, Chandel K, Mittal S, et al. Abdominal Computed Tomography Findings among COVID-19 Patients with Index Gastrointestinal Manifestations: A Preliminary Single-center Experience. Euroasian J Hepato-Gastroenterol 2021;11(2):76-80.

A challenging case of a large intraorbital foreign body perforating the nasal septum in a child.

A 5 year old boy with a history of fall from a height of about 4 feet, presented after one week with swelling, watering and discharge of the right eye. He had severe conjunctival chemosis with superior displacement of the globe. Computed Tomography (CT) showed a linear low attenuation tract in the right orbit extending from the inferolateral wall up to the left uncinate process of the ethmoid bone with increasing Hounsfield unit after 10 days. The parents did not agree for early exploration. After 10 days an exploration was done and a large linear and irregular wooden foreign body (FB) measuring 4.5 x 1.5 cm2 was removed from the right orbit and a smaller one from the nasal cavity. Four weeks post surgery, his vision was 6/9 in the right eye with the eyeball in the normal position. This case was challenging because of the late presentation, parents not agreeing for early exploration, difficulty in diagnosing by CT and a large and very deep penetrating FB.