Obliteration of gastric varices guided by eco-endoscopy with coils insertion coated with expandable hydrogel polymers.

INTRODUCTION: gastric varices hemorrhage is a severe complication of portal hypertension, with high mortality rates and few management alternatives, especially when there is a contraindication to transjugular intrahepatic portosystemic shunts (TIPS). The usual therapeutic options are the injection of cyanoacrylate, the insertion of coils or both. Hydrocoils are special coils coated with different types of expandable hydrogel polymers conventionally used in neurovascular interventionism. They allow rapid occlusion of vessel, forming a mesh that favors the local formation of thrombus and the development of a neointima on the gel cover. We consider the use of endoscopic ultrasound (EUS) guided hydrocoil insertion in gastric varices, without using cyanoacrylate. OBJECTIVE: this study aimed to evaluate the safety and effectivity of the application of EUS-guided hydrocoils in patients with gastric varices hemorrhage with TIPS contraindication. MATERIAL AND METHODS: this was a retrospective case series of four patients with TIPS contraindication after interventional radiologist evaluation. Linear echoendoscopes, fluoroscopy, 19G needles and hydrocoils (Azur®, Terumo) and Progreat® 3 Fr microcatheters were used. An interventional radiologist expert advised the procedures and endoscopic ultrasound confirmed the varix obliteration. RESULTS: technical and clinical success occurred in all patients involved in this study. There were no adverse effects related to the procedure or endoscopic equipment damage. CONCLUSIONS: the application of EUS-guided hydrocoils can be a safe and effective method in the short term for gastric varices bleeding in patients who are not candidates for TIPS. Besides, a complete obliteration of the vascular lumen could occur and thus, dispense with the use of cyanoacrylate. Further studies are needed to corroborate these preliminary results.

Long-term clinical outcome and survival predictors in patients with cirrhosis after 10-mm-covered transjugular intrahepatic portosystemic shunt.

BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunts (TIPS) are successfully used in the management of portal hypertension (PH)-related complications. Debate surrounds the diameter of the dilation. The aim was to analyse the outcomes of and complications deriving from TIPS in patients with cirrhosis and identify predictors of survival. METHODS: This was a retrospective single-centre study, which included patients with cirrhosis who had a TIPS procedure for PH from 2009 to October 2018. Demographic, clinical and radiological data were collected. The Kaplan-Meier method was used to measure survival and predictors of survival were identified with the Cox regression model. RESULTS: A total of 98 patients were included (78.6% male), mean age was 58.5 (SD±/-9.9) and the median MELD was 13.3 (IQR 9.5-16). The indications were refractory ascites (RA), variceal bleeding (VB) and hepatic hydrothorax (HH). Median survival was 72 months (RA 46.4, VB 68.5 and HH 64.7) and transplant-free survival was 26 months. Clinical and technical success rates were 70.5% and 92.9% respectively. Age (HR 1.05), clinical success (HR 0.33), sodium (HR 0.92), renal failure (HR 2.46) and albumin (HR 0.35) were predictors of survival. Hepatic encephalopathy occurred in 28.6% of patients and TIPS dysfunction occurred in 16.3%. CONCLUSIONS: TIPS with 10-mm PTFE-covered stent is an effective and safe treatment for PH-related complications in patients with cirrhosis. Age, renal failure, sodium, albumin and clinical success are independent predictors of long-term survival.

Review of imaging techniques in the diagnosis of hepatocellular carcinoma in patients who require a liver transplant.

OBJECTIVES: The aim of the study was to retrospectively compare the diagnostic performance of ultrasound (US), contrast-enhanced multidetector computed tomography (MDCT) and contrast-enhanced MRI in cirrhotic patients who were candidates for liver transplantation. MATERIALS AND METHODS: A total of 273 consecutive patients with 218 hepatocellular carcinoma (HCC) nodules, who underwent imaging and subsequent transplantation, were examined. Diagnosis of HCC was based on explant correlation of the whole liver. Three different imaging data sets were evaluated: US, MDCT and MRI unenhanced and dynamic phases. Diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value, with corresponding 95% confidence intervals, were determined. Statistical analysis was performed for all lesions and for two lesion subgroups (≤2 and >2 cm). Preoperative tumour staging was analysed. RESULTS: Patient sensitivity to US, MDCT and MRI was 80.4, 81.1 and 90.5%, respectively. Specificity was 96.3, 96.2 and 82.1%. Combined US and MDCT improved sensitivity (88%) without significant loss in specificity (95.7%). Imaging tests resulted in accurate tumour staging in 83.4% of the patients. In per-nodule analysis, technique sensitivity was 55.6, 52.4 and 65.9%, respectively. Sensitivity figures improved when the nodule was larger than 2 cm. CONCLUSION: Combining imaging techniques is a good strategy for pretransplant HCC diagnosis and provides more accurate cancer staging in patients, which is necessary to decide the correct therapeutic approach.