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BACKGROUND AND AIMS: Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) improves survival in patients with cirrhosis with refractory ascites and portal hypertensive bleeding. However, the indication for TIPS in older adult patients (greater than or equal to 70 years) is debated, and a specific prediction model developed in this particular setting is lacking. The aim of this study was to develop and validate a multivariable model for an accurate prediction of mortality in older adults. APPROACH AND RESULTS: We prospectively enrolled 411 consecutive patients observed at four referral centers with de novo TIPS implantation for refractory ascites or secondary prophylaxis of variceal bleeding (derivation cohort) and an external cohort of 415 patients with similar indications for TIPS (validation cohort). Older adult patients in the two cohorts were 99 and 76, respectively. A cause-specific Cox competing risks model was used to predict liver-related mortality, with orthotopic liver transplant and death for extrahepatic causes as competing events. Age, alcoholic etiology, creatinine levels, and international normalized ratio in the overall cohort, and creatinine and sodium levels in older adults were independent risk factors for liver-related death by multivariable analysis. CONCLUSIONS: After TIPS implantation, mortality is increased by aging, but TIPS placement should not be precluded in patients older than 70 years. In older adults, creatinine and sodium levels are useful predictors for decision making. Further efforts to update the prediction model with larger sample size are warranted.
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Várices Esofágicas y Gástricas , Derivación Portosistémica Intrahepática Transyugular , Humanos , Anciano , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Várices Esofágicas y Gástricas/etiología , Ascitis/etiología , Ascitis/cirugía , Creatinina , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/cirugía , Cirrosis Hepática/complicaciones , Cirrosis Hepática/cirugía , Sodio , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
BACKGROUND AND AIMS: Post-surgical biliary leaks (PSBL) are one of the most prevalent and significant adverse events emerging after liver or biliary tract surgeries. Endoscopic retrograde cholangiopancreatography (ERCP) alone or combined with another approach (Rendez Vous) as treatment of PSBL obtains optimal outcomes due to the possibility of modifying the resistances in the biliary tree. METHODS: A retrospective double-center study was conducted in two tertiary centers. Consecutive patients who underwent at least one attempt of PSBL correction by ERCP or Rendez Vous procedure between January 2018 and August 2023 were included. The primary outcome was overall endoscopic clinical success. In contrast, the secondary outcomes were hospital stay exceeding five days and endoscopic clinical success with the first endoscopic procedure at the tertiary center. Both univariate and multivariate analyses were used to assess outcomes. RESULTS: 65 patients were included. Patients with one or multiple) leaks had more possibility to achieve the endoscopic clinical success compared to those affected by the association of leaks and stricture (96% vs 67%, p value 0.005). Leaks occurring in the main biliary duct had less probability (67%) to achieve the overall endoscopic clinical success compared to those in the end-to-end anastomosis (90%), in the resection plane or biliary stump (96%) or first or secondary order biliary branches (100%, p value 0.038). A leak-bridging stent positioning had more probability of achieving the endoscopic clinical success than a not leak-bridging stent (91% vs 53%, p value 0.005). CONCLUSIONS: ERCP and Rendez Vous procedures are safe and effective for treating PSBL, regardless of the type of preceding surgery, even if technical or clinical success was not achieved on the first attempt. A stent should be placed, if feasible, leak-bridging to enhance treatment efficacy.
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PURPOSE: To retrospectively compare outcomes of TIPS performed by puncturing left portal vein (LPV) vs right portal vein (RPV) to access the portal system. MATERIALS AND METHODS: One hundred ninety-three consecutive patients underwent TIPS with controlled expansion covered stent by using the LPV (37 patients) or the RPV (156 patients). Patients were followed until the last clinical evaluation, liver transplantation, or death. RESULTS: Demographics and clinical characteristics of the two groups were comparable. The median follow-up was 9.6 months (range 0.1-50.6). Portosystemic pressure gradient (PSG) before TIPS 15.7 mmHg ± 4.7 in RPV group (RPVG) vs 15.4 mmHg ± 4.5 in LPV group (LPVG) (p = 0.725). After TIPS, PSG 6.3 mmHg ± 2.8 in RPVG vs 6.2 mmHg ± 2.2 (p = 0.839). In LPVG, the stent was dilated to 8-mm in 95% of patients vs 77% of RPVG (p = 0.015). Two (5.4%) and 22 (14%) patients underwent TIPS revision in LPVG and RPVG (p = 0.15). The incidence of overt HE was 13% in LPVG and 24% in RPVG (p = 0.177). Rebleeding occurred in 3 of 49 patients (6%) with variceal bleeding as an indication: 2/41 patients (4.9%) in RPVG vs 1/8 patients (12.5%) in LPVG (p = 0.417). Among 126 patients with refractory ascites 20 patients (15.9%) needed paracentesis 3 months after the procedure: 18/101 patients (17.8%) in RPVG vs 2/25 patients (8%) in LPVG (p = 0.231). Thirty-seven patients (19%) died: 32 (21%) in RPVG and 5 (14%) in LPVG (p = 0.337). CONCLUSION: Compared with RPV puncture, in TIPS created through the LPV, the targeted PSG was reached with a smaller stent diameter. However, no significant difference in clinical outcomes was observed. KEY POINTS: ⢠A LPV approach for TIPS creation does not lead to better control of complications of portal hypertension as compared to a RPV approach.
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Várices Esofágicas y Gástricas , Encefalopatía Hepática , Derivación Portosistémica Intrahepática Transyugular , Humanos , Várices Esofágicas y Gástricas/cirugía , Várices Esofágicas y Gástricas/complicaciones , Estudios Retrospectivos , Resultado del Tratamiento , Encefalopatía Hepática/etiología , Hemorragia Gastrointestinal/etiología , Vena Porta/cirugía , Stents/efectos adversos , Punciones , HemodinámicaRESUMEN
OBJECTIVES: To assess the outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation using PTFE-covered stents in liver transplant (LT) recipients and to analyze the technical result of TIPS creation in split grafts (SG) compared with whole liver grafts (WG). METHODS AND MATERIALS: Single-center, retrospective study, analyzing LT patients who underwent TIPS using PTFE-covered stents. Clinical and technical variables were analyzed. RESULTS: Between 2005 and 2021, TIPS was created using PTFE-covered stents in 48 LT patients at a median of 43 months (range, 0.5-192) after LT. TIPS indications were refractory ascites (RA) in 33 patients (69%), variceal bleeding (VB) in 9 patients (19%), others in 6 (12%). Ten patients (21%) received a SG. Technical success rate was 100% in both groups: in two WG recipients, (5%) a second attempt was required. An unconventional approach (combined transhepatic or transplenic access) was needed in 2 WG (5%) and 2 SG recipients (20%). Two procedure-related death occurred in the WG group. After a median follow-up of 22 months (range, 0,1-144), 16 patients (48%) in the RA group did not require post-TIPS paracentesis, in the VB group rebleeding occurred in 3 patients (33%). Fifteen patients (31%) underwent TIPS revision. Overt hepatic encephalopathy occurred in 14 patients (29%). Patient survival at 6 months, 1 year, and 3 years was 77%, 66%, and 43%, respectively. CONCLUSIONS: The feasibility and safety of TIPS creation in SG are comparable to that of WG. TIPS creation using PTFE-covered stents represents a viable option to treat portal hypertensive complications in LT recipients. KEY POINTS: ⢠TIPS creation using PTFE-covered stents represents a viable option to treat complications of PH in LT recipients. ⢠TIPS creation in LT SG recipients appears to be safe and feasible as in WG. ⢠Results from this study may help to refine the management of LT patients with recurrent portal hypertensive complications encouraging physicians to consider TIPS creation as a treatment option in both SG and WG recipients.
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Várices Esofágicas y Gástricas , Hipertensión Portal , Trasplante de Hígado , Derivación Portosistémica Intrahepática Transyugular , Humanos , Trasplante de Hígado/efectos adversos , Várices Esofágicas y Gástricas/etiología , Hipertensión Portal/complicaciones , Estudios Retrospectivos , Derivación Portosistémica Intrahepática Transyugular/métodos , Resultado del Tratamiento , Hemorragia Gastrointestinal/etiología , Stents/efectos adversos , Ascitis/complicaciones , PolitetrafluoroetilenoRESUMEN
PURPOSE: Hepatic encephalopathy (HE) is a potential complication of cirrhosis. Magnetic resonance imaging (MRI) may demonstrate hyperintense T1 signal in the globi pallidi. The purpose of this study was to evaluate the performance of MRI-based radiomic features for diagnosing and grading chronic HE in adult patients affected by cirrhosis. METHODS: Adult patients with and without cirrhosis underwent brain MRI with identical imaging protocol on a 3T scanner. Patients without history of chronic liver disease were the control population. HE grading was based on underlying liver disease, severity of clinical manifestation, and number of encephalopathic episodes. Texture analysis was performed on axial T1-weighted images on bilateral lentiform nuclei at the level of the foramina of Monro. Diagnostic performance of texture analysis for the diagnosis and grading of HE was assessed by calculating the area under the receiver operating characteristics (AUROC) with 95% confidence interval (CI). RESULTS: The final study population consisted of 124 patients, 70 cirrhotic patients, and 54 non-cirrhotic controls. Thirty-eight patients had history of HE with 22 having an HE grade > 1. The radiomic features predicted the presence of HE with an AUROC of 0.82 (95% CI: 0.73, 0.90; P < .0001; 82% sensitivity, 66% specificity). Radiomic features predicted grade 1 HE (AUROC 0.75; 95% CI: 0.61, 0.89; P < .0001; 94% sensitivity, 60% specificity) and grade ≥ 2 HE (AUROC 0.82; 95% CI: 0.71, 0.93; P < .0001, 95% sensitivity, 57% specificity). CONCLUSION: In cirrhotic patients, MR radiomic is effective in predicting the presence of chronic HE and in grading its severity.
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Encefalopatía Hepática , Adulto , Encéfalo/patología , Globo Pálido , Encefalopatía Hepática/diagnóstico por imagen , Encefalopatía Hepática/etiología , Humanos , Cirrosis Hepática/complicaciones , Cirrosis Hepática/diagnóstico por imagen , Imagen por Resonancia Magnética/métodosRESUMEN
BACKGROUND & AIMS: Although the discriminative ability of the model for end-stage liver disease (MELD) score is generally considered acceptable, its calibration is still unclear. In a validation study, we assessed the discriminative performance and calibration of 3 versions of the model: original MELD-TIPS, used to predict survival after transjugular intrahepatic portosystemic shunt (TIPS); classic MELD-Mayo; and MELD-UNOS, used by the United Network for Organ Sharing (UNOS). We also explored recalibrating and updating the model. METHODS: In total, 776 patients who underwent elective TIPS (TIPS cohort) and 445 unselected patients (non-TIPS cohort) were included. Three, 6 and 12-month mortality predictions were calculated by the 3 MELD versions: discrimination was assessed by c-statistics and calibration by comparing deciles of predicted and observed risks. Cox and Fine and Grey models were used for recalibration and prognostic analyses. RESULTS: In the TIPS/non-TIPS cohorts, the etiology of liver disease was viral in 402/188, alcoholic in 185/130, and non-alcoholic steatohepatitis in 65/33; mean follow-up±SD was 25±9/19±21 months; and the number of deaths at 3-6-12 months was 57-102-142/31-47-99, respectively. C-statistics ranged from 0.66 to 0.72 in TIPS and 0.66 to 0.76 in non-TIPS cohorts across prediction times and scores. A post hoc analysis revealed worse c-statistics in non-viral cirrhosis with more pronounced and significant worsening in the non-TIPS cohort. Calibration was acceptable with MELD-TIPS but largely unsatisfactory with MELD-Mayo and -UNOS whose performance improved much after recalibration. A prognostic analysis showed that age, albumin, and TIPS indication might be used to update the MELD. CONCLUSIONS: In this validation study, the performance of the MELD score was largely unsatisfactory, particularly in non-viral cirrhosis. MELD recalibration and candidate variables for an update to the MELD score are proposed. LAY SUMMARY: While the discriminative performance of the model for end-stage liver disease (MELD) score is credited to be fair to good, its calibration, the correspondence of observed to predicted mortality, is still unsettled. We found that application of 3 different versions of the MELD in 2 independent cirrhosis cohorts yielded largely imprecise mortality predictions particularly in non-viral cirrhosis. Thus, we propose a recalibration and suggest candidate variables for an update to the model.
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Enfermedad Hepática en Estado Terminal/clasificación , Enfermedad Hepática en Estado Terminal/etiología , Mortalidad/tendencias , Adulto , Anciano , Estudios de Cohortes , Enfermedad Hepática en Estado Terminal/mortalidad , Estudios de Seguimiento , Humanos , Italia , Persona de Mediana Edad , Modelos Biológicos , Pronóstico , Índice de Severidad de la Enfermedad , Factores de Tiempo , Estudios de Validación como AsuntoRESUMEN
Transjugular portal vein puncture is considered the riskiest step in TIPS creation with possible incidence of portal vein puncture-related complications (PVPC). The Colapinto and the Rösch-Uchida needle sets are two different needle sets currently available. To date, there have been no randomized control trials or systematic reviews which compare the incidence of PVPC when using the two different needle sets. The aim of this literature review is to assess the rate of PVPC associated with the different needle sets used in the creation of TIPS. From the described search, 1500 articles were identified and 34 met the inclusion criteria. Outcome measured was the prevalence of PVPC using the different needle sets. Overall 212 (3.6%) PVPC were reported in 5865 patients; 142 (3.5%) reported in 4000 cases using the Rösch-Uchida set and 70 (3.7%) in 1865 patients using the Colapinto set (p = 0.69). PVPC in TIPS creation are not related to the choice of needle set used in the procedure. To our knowledge, this is the first review of its kind, the results of which support the theory that while the rate of PVPC is influenced by many factors, choice of needle set does not seem to be one of them.
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Agujas , Derivación Portosistémica Intrahepática Transyugular/métodos , Complicaciones Posoperatorias/etiología , Punciones/efectos adversos , Diseño de Equipo , Humanos , Vena PortaRESUMEN
BACKGROUND: This study aims to evaluate radiation exposure in patients with complete portal vein thrombosis (CPVT) or portal cavernoma (PC) undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation using real-time ultrasound guidance for portal vein targeting. MATERIALS AND METHODS: This is a single institution retrospective analysis. Between August 2009 and September 2018, TIPS was attempted in 49 patients with CPVT or PC. Radiation exposure (dose area product [DAP], air KERMA (AK) and fluoroscopy time [FT]), technical success, clinical success, complications and survival were analyzed. RESULTS: In total, 29 patients had CPVT and 20 patients had PC. 41/49 patients had cirrhosis. TIPS indications were refractory ascites (n = 25), variceal bleeding (n = 16) and other (n = 8). TIPS was successfully placed in 94% (46/49) of patients via a transjugular approach alone (n = 40), a transjugular/transhepatic approach (n = 5) and a transjugular/transsplenic approach (n = 1). Median DAP was 261 Gy * cm2 (range 29-950), median AK was 0.2 Gy (range 0.05-0.5), and median FT was 28.2 min (range 7.7-93.7). Mean portosystemic pressure gradient decreased from 16.8⯠± â¯5.1 mmHg to 7.5⯠± â¯3.3â¯mmHg (P < â¯0.01). There were no major procedural complications. Overall clinical success was achieved in 77% of patients (mean follow-up of 21.1 months). Encephalopathy was observed in 16 patients (34%), grade II-III encephalopathy in 7 patients (15%). TIPS revision was performed in 15 patients (32%). Overall survival rate was 75%. CONCLUSION: In our experience, the use of real-time ultrasound guidance allowed the majority of the TIPS to be performed via a transjugular approach alone with a reasonably low radiation exposure considering the high technical difficulties of the selected cohort of patients with CVPT or PC.
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Hemangioma Cavernoso/diagnóstico por imagen , Neoplasias Hepáticas/diagnóstico por imagen , Vena Porta/diagnóstico por imagen , Derivación Portosistémica Intrahepática Transyugular , Exposición a la Radiación , Ultrasonografía Intervencional , Trombosis de la Vena/diagnóstico por imagen , Várices Esofágicas y Gástricas/diagnóstico por imagen , Várices Esofágicas y Gástricas/cirugía , Femenino , Fluoroscopía , Hemorragia Gastrointestinal/diagnóstico por imagen , Hemorragia Gastrointestinal/cirugía , Hemangioma Cavernoso/cirugía , Humanos , Neoplasias Hepáticas/cirugía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Trombosis de la Vena/cirugíaRESUMEN
Purpose To compare the efficacy and complications of transjugular intrahepatic portosystemic shunt (TIPS) creation performed by using a 10-mm or an 8-mm-diameter polytetrafluoroethylene (PTFE)-covered stent in a consecutive series of patients with cirrhosis with refractory ascites (RA). Materials and Methods The institutional review board approved this retrospective study and informed consent was waived. One hundred seventy-one patients with RA (mean age, 58.7 years ± 10.3; 95% confidence interval [CI]: 57.2 years, 60.3 years) had undergone TIPS placement by using 10-mm (60 patients) or 8-mm (111 patients) covered stent between January 2004 and December 2012. Median follow-up time was 16.8 months (range, 3.4-84.8 months). Hemodynamic changes, incidence of hepatic encephalopathy, and long-term (>3 months) need for paracentesis after TIPS placement were evaluated and calculated by using the Kaplan-Meier method and were compared by using the log-rank test. Results Pre-TIPS demographics and clinical characteristics of the two groups were comparable. The portosystemic gradient before TIPS was 17.0 mm Hg ± 4.2 (95% CI: 15.9 mm Hg, 18.1 mm Hg) in the 10-mm group versus 16.1 mm Hg ± 3.7 (95% CI: 15.4 mm Hg, 16.8 mm Hg) in the 8-mm group (P = .164). After TIPS, the portosystemic gradient was 6.5 mm Hg ± 3.4 (95% CI: 5.7 mm Hg, 7.4 mm Hg) in the 10-mm group versus 7.5 mm Hg ± 2.6 (95% CI: 6.9 mm Hg, 7.9 mm Hg) in the 8-mm group (P = .039). The long-term need for paracentesis was greater in the 8-mm group (64 of 111 patients [58%] vs 18 of 60 patients [31%], P = .003). Overall, hepatic encephalopathy was similar in both groups (45 of 111 patients [41%] vs 26 of 60 patients [44%], P = .728). Conclusion A10-mm PTFE-covered stent leads to better control of RA secondary to portal hypertension in patients with cirrhosis, compared with an 8-mm stent, without increasing the incidence of hepatic encephalopathy. © RSNA, 2017.
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Ascitis/cirugía , Cirrosis Hepática/cirugía , Derivación Portosistémica Intrahepática Transyugular , Stents , Adulto , Anciano , Ascitis/diagnóstico por imagen , Materiales Biocompatibles Revestidos , Medios de Contraste , Femenino , Humanos , Cirrosis Hepática/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Politetrafluoroetileno , Diseño de Prótesis , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to prospectively evaluate effective dose (E) of operators performing transjugular intrahepatic portosystemic shunts (TIPS) in a single centre. Patients' radiation exposure was also collected. METHODS: Between 8/2015 and 6/2016, 45 consecutive TIPS were performed in adult patients using a flat-panel detector-based system (FPDS) and real-time ultrasound guidance (USG) for portal vein targeting. Electronic personal dosimeters were used to measure radiation doses to the primary and assistant operators, anaesthesia nurse and radiographer. Patients' radiation exposure was measured with dose area product (DAP); fluoroscopy time (FT) was also collected. RESULTS: Mean E for the primary operator was 1.40 µSv (SD 2.68, median 0.42, range 0.12 - 12.18), for the assistant operator was 1.29 µSv (SD 1.79, median 0.40, range 0.10 - 4.89), for the anaesthesia nurse was 0.21 µSv (SD 0.67, median 0.10, range 0.03 - 3.99), for the radiographer was 0.42 µSv (SD 0.71, median 0.25, range 0.03 - 2.67). Mean patient DAP was 59.31 GyCm2 (SD 56.91, median 31.58, range 7.66 - 281.40); mean FT was 10.20 min (SD 7.40, median 10.40, range 3.8 - 31.8). CONCLUSION: The use of FPDS and USG for portal vein targeting allows a reasonably low E to operators performing TIPS. KEY POINTS: ⢠The operators' E vary according to the complexity of the procedure. ⢠FPDS and USG allow a reasonably low E to TIPS operators. ⢠FPDS and USG have an important role in reducing the occupational exposure.
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Exposición Profesional/estadística & datos numéricos , Vena Porta/diagnóstico por imagen , Derivación Portosistémica Intrahepática Transyugular/métodos , Dosis de Radiación , Exposición a la Radiación/estadística & datos numéricos , Radiología Intervencionista , Anciano , Femenino , Fluoroscopía/estadística & datos numéricos , Humanos , Internado y Residencia , Masculino , Persona de Mediana Edad , Enfermeras Anestesistas , Tempo Operativo , Vena Porta/cirugía , Estudios Prospectivos , Radiólogos , Cirugía Asistida por Computador , UltrasonografíaAsunto(s)
Fuga Anastomótica/diagnóstico , Conductos Biliares/lesiones , Fístula Biliar/etiología , Colestasis/diagnóstico , Hemobilia/diagnóstico , Adolescente , Aloinjertos/diagnóstico por imagen , Aloinjertos/patología , Anastomosis Quirúrgica/efectos adversos , Fuga Anastomótica/etiología , Fuga Anastomótica/cirugía , Conductos Biliares/patología , Conductos Biliares/cirugía , Atresia Biliar/cirugía , Fístula Biliar/diagnóstico , Fístula Biliar/cirugía , Bilirrubina/sangre , Biopsia con Aguja/efectos adversos , Biopsia con Aguja/instrumentación , Colestasis/sangre , Colestasis/terapia , Constricción Patológica/sangre , Constricción Patológica/diagnóstico , Constricción Patológica/cirugía , Descompresión , Drenaje , Hemobilia/sangre , Hemobilia/etiología , Hemobilia/cirugía , Humanos , Biopsia Guiada por Imagen/instrumentación , Hígado/diagnóstico por imagen , Hígado/patología , Trasplante de Hígado/efectos adversos , Imagen por Resonancia Magnética , Masculino , Agujas/efectos adversos , Ultrasonografía IntervencionalRESUMEN
Purpose To evaluate the incidence, outcomes, and prognostic factors of early liver failure (ELF) after transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with cirrhosis with Model for End-Stage Liver Disease (MELD) score of 12 or less. Materials and Methods Institutional review board approved this retrospective study, with waiver of written informed consent. Two-hundred sixteen consecutive patients with cirrhosis (140 men, 76 women; mean age, 55.9 years; virus-related cirrhosis, 67.6% [146 of 216 patients]) with baseline MELD score of 12 or less who underwent TIPS placement between September 1999 and July 2012 were followed until last clinical evaluation, liver transplantation, or death. The Kaplan-Meier method, log-rank test, area under the receiver operating characteristic curve, and univariate and multivariate analyses were used, as appropriate. Results Twenty of 216 patients (9.2%) developed ELF within 3 months of TIPS (10 patients died, one required liver transplantation, and nine increased the MELD score to >18). ELF was associated with lower survival, 37% versus 95% at 6 months, and 24% versus 86% at 12 months (P < .001) compared with patients without ELF. ELF occurred in 16 of 95 (16.8%) patients with refractory ascites and in four of 121 (3.3%) patients with other indications for TIPS. Multivariate analysis confirmed MELD scores of 11 or 12 (odds ratio, 3.96 [95% confidence interval: 1.07, 14.67]; P = .040), decreased hemoglobin level (odds ratio, 0.68 [95% confidence interval: 0.49, 0.95]; P = .022), and decreased platelet count (odds ratio, 0.99 [95% confidence interval: 0.99, 0.99]; P = .024) as predictors for ELF in patients with refractory ascites. Conclusion ELF is not uncommon in cirrhotic patients with a MELD score of 12 or less who undergo TIPS placement for refractory ascites (especially in patients with MELD of 11 or 12) and decreased hemoglobin level and platelet count. (©) RSNA, 2016.
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Cirrosis Hepática/complicaciones , Cirrosis Hepática/terapia , Fallo Hepático/epidemiología , Derivación Portosistémica Intrahepática Transyugular , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Estudios de Cohortes , Comorbilidad , Enfermedad Hepática en Estado Terminal/complicaciones , Enfermedad Hepática en Estado Terminal/diagnóstico , Femenino , Humanos , Incidencia , Fallo Hepático/diagnóstico , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Adulto JovenRESUMEN
We describe the use of an Amplatzer Vascular Plug (AVP) II for embolizing a large high-flow splenic arteriovenous fistula and an aneurysm in a young patient. This patient presented to our center with persistent mild abdominal discomfort, 5 years after open splenectomy. Contrast-enhanced computed tomography angiography showed the presence of a fistula between the splenic arterial and splenic venous remnants and a resultant fusiform aneurysmal dilatation of the residual splenic vein. We decide to embolize the splenic artery with a 12-mm diameter AVP II with an oversizing by 70% of the vessel diameter. Celiac angiography performed 5 min postembolization revealed complete obliteration of the splenic artery and closure of the arteriovenous fistula. The overall procedure time was 40 min, and overall radiation exposure was 32 Gy cm(2) (dose-area product).
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Aneurisma/terapia , Fístula Arteriovenosa/terapia , Embolización Terapéutica/instrumentación , Esplenectomía/efectos adversos , Arteria Esplénica/fisiopatología , Vena Esplénica/fisiopatología , Adulto , Aneurisma/diagnóstico , Aneurisma/etiología , Aneurisma/fisiopatología , Angiografía de Substracción Digital , Fístula Arteriovenosa/diagnóstico , Fístula Arteriovenosa/etiología , Fístula Arteriovenosa/fisiopatología , Velocidad del Flujo Sanguíneo , Femenino , Humanos , Dosis de Radiación , Exposición a la Radiación , Flujo Sanguíneo Regional , Arteria Esplénica/diagnóstico por imagen , Vena Esplénica/diagnóstico por imagen , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
PURPOSE: Ultrasound (US) guidance is currently used for placement of wire-guided thoracic drains, and its use is associated with a decreased risk of complications. However, most studies conducted to date in this field have been performed on adult patients. The aim of this study was to report the technical success and complication rates observed during real-time US-guided placement of a thoracic pigtail catheter in pediatric liver-transplant recipients with symptomatic pleural effusion. METHODS: This was a single-center retrospective review of the clinical records and images from pediatric liver-transplant patients with symptomatic pleural effusion who had undergone real-time US-guided pleural-space puncture followed by placement (via the Seldinger technique) of a pigtail catheter for drainage, between May 2006 and June 2014. RESULTS: We identified 25 patients who had undergone 41 pigtail catheter-placement procedures during the study period. The patients' mean age (± SD) was 4.2 ± 3.9 years (range, 2 months to 16 years), and their mean weight was 14.2 ± 7.2 kg (range, 4.5-33 kg). Seventeen procedures had been performed in the intensive care unit, and 8, in patients undergoing mechanical ventilation. Twelve of the 41 procedures had been performed in patients with altered hemostasis (ie, platelet count < 50 × 10(3) /µl and/or international normalized ratio > 1.5). The size of the pigtail catheters ranged from 5 F to 8.5 F. The technical success rate was 100%, with no major complications such as pneumothorax or hemothorax. Accidental dislocation of the catheter occurred in four patients (9%) over 3-10 days after the first procedure. CONCLUSIONS: In our experience, real-time US-guided pleural-space puncture, performed at bedside, with the patient in the supine position, followed by placement of a pigtail catheter for drainage of effusion, is safe to use and has a high rate of technical success in pediatric patients. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound 44:284-289, 2016.
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Cateterismo/métodos , Drenaje/instrumentación , Trasplante de Hígado , Derrame Pleural/terapia , Complicaciones Posoperatorias/terapia , Ultrasonografía Intervencional/métodos , Adolescente , Niño , Preescolar , Drenaje/métodos , Femenino , Humanos , Lactante , Masculino , Estudios Retrospectivos , Posición Supina , Resultado del TratamientoRESUMEN
PURPOSE: To determine whether the use of a low-dose acquisition protocol (LDP) in digital subtraction angiography during transjugular intrahepatic portosystemic shunt (TIPS) creation/revision results in significant reduction of patient radiation exposure and adequate image quality, as compared to a default reference standard-dose acquisition protocol (SDP). METHODS: Two angiographic runs were performed during TIPS creation/revision: the first following catheterization of the portal venous system and the second after stent deployment/angioplasty. Constant field of view, object to image-detector distance, and source to image-receptor distance were maintained in each patient during the two angiographic runs. 17 consecutive adult patients who underwent TIPS creation (n = 11) or TIPS revision (n = 6) from December 2013 to March 2014 were considered eligible for this single centre prospective study. In each patient, the LDP and the SDP were used in a random order for the two runs, with each patient serving as his/her own control. The dose-area product (DAP) was calculated for each image and compared. Image quality was graded by two interventional radiologists other than the operator. RESULTS: In all runs acquired with the LDP, image quality was considered adequate for a successful procedural outcome. The DAP per image of the LDP was numerically inferior as compared to the DAP per image of the SDP in all patients. The mean reduction in DAP per image was 75.24% ± 5.7% (p < 0. 001). CONCLUSION: Radiation exposure during TIPS creation/revision was significantly reduced by selecting a LDP in our flat-panel detector-based system, while maintaining adequate image quality.