Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review.

Pelvic venous disorders (PeVD), previously known by various imprecise terms including pelvic congestion syndrome, have historically been underdiagnosed as a cause of chronic pelvic pain (CPP), a significant health problem associated with reduced quality of life. However, progress in the field has helped to provide heightened clarity with respect to definitions relating to PeVD, and evolution in algorithms for PeVD workup and treatment has been accompanied by new insights into the causes of a pelvic venous reservoir and associated symptoms. Ovarian and pelvic vein embolization, as well as endovascular stenting of common iliac vein compression, should be considered as management options for PeVD. Both treatments have been shown to be safe and effective for patients with CPP of venous origin, regardless of age. Current therapeutic protocols for PeVD exhibit significant heterogeneity owing to limited prospective randomized data and evolving understanding of the factors driving successful outcomes; forthcoming clinical trials are anticipated to improve understanding of CPP of venous origin as well as algorithms for PeVD management. This Expert Panel Narrative Review provides a contemporary update relating to PeVD, summarizing the entity's current classification, diagnostic workup, endovascular treatments, management of persistent or recurrent symptoms, and future research directions.

Antithrombotic Therapy After Venous Interventions: AJR Expert Panel Narrative Review.

Interventions for thrombotic and nonthrombotic venous disorders have increased with technical advances and more trained venous specialists. Antithrombotic therapy is essential to clinical and procedural success; however, postprocedural therapeutic regimens exhibit significant heterogeneity due to limited prospective randomized data and incomplete mechanistic understanding of the critical factors driving long-term patency. Postinterventional antithrombotic therapy for thrombotic venous disorders should adhere to existing venous thromboembolism management guidelines, which include 3-6 months of therapeutic anticoagulation at minimum and consideration of extended therapy in patients with higher risk of thrombosis because of procedural or patient factors. The added benefit of antiplatelet agents in the acute and intermediate period is unknown, having shown improved long-term stent patency in some retrospective studies. Dual- and/or triple-agent therapy should be limited based on individual risks of thrombosis and bleeding. The treatment of nonthrombotic disorders is more heterogeneous, though patients with limited flow, extensive stent material, or underlying prothrombotic states such as malignancy or chronic inflammation may benefit from single-agent or multiagent antithrombotic therapy. However, the agent, dose, and duration of therapy remain indeterminate. Future prospective studies are warranted to improve patient risk stratification and standardize postprocedural anti-thrombotic therapy in patients receiving venous interventions.

Transsplenic Portal System Catheterization: Review of Current Indications and Techniques.

Multiple diseases of the portal system require effective portal vein access for endovascular management. While percutaneous transhepatic and transjugular approaches remain the standard methods of portal vein access, transsplenic access (TSA) has gained recognition as an effective and safe technique to access the portal system in patients with contraindications to traditional approaches. Recently, the utility of percutaneous TSA has grown, with described treatments including recanalization of chronic portal vein occlusion, placement of stents for portal vein stenosis, portal vein embolization of the liver, embolization of gastric varices, placement of complicated transjugular intrahepatic portosystemic shunts, and interventions after liver transplant. The authors provide a review of percutaneous TSA, including indications, a summary of related portal vein diseases, and the different techniques used for access and closure. In addition, an imaging-based review of technical considerations of TSA interventions is presented, with a review of potential procedural complications. With technical success rates that mirror or rival the standard methods and reported low rates of major complications, TSA can be a safe and effective option in clinical scenarios where traditional approaches are not feasible. ©RSNA, 2022.

Conventional Ethiodized Oil Transarterial Chemoembolization for Treatment of Hepatocellular Carcinoma: Contemporary Single-Center Review of Clinical Outcomes.

OBJECTIVE: The purpose of this study is to investigate the outcomes of conventional transarterial chemoembolization (TACE) treatment of hepatocellular carcinoma (HCC) in contemporary clinical practice. MATERIALS AND METHODS: In this single-institution retrospective study, 188 patients underwent conventional TACE for HCC between 2007 and 2013. Medical record and imaging review was used to collect baseline demographic and disease data, tumor response, time to progression (TTP), and progression-free survival (PFS) outcomes, as well as transplant-free survival, calculated from the time of the first conventional TACE treatment. Data were censored in April 2014. RESULTS: The study cohort included 140 men and 48 women (mean age, 60 years; Barcelona Clinic Liver Cancer [BCLC] stage 0 = 5%, BCLC stage A = 41%, BCLC stage B = 28%, BCLC stage C = 15%, and BCLC stage D = 11%) with 207 index tumors (mean size, 4.0 cm; 11% with portal vein invasion) treated with a mean of 1.6 selective (79%) or lobar (21%) conventional TACE sessions. Concurrent thermal ablation was performed for 19% of patients. Objective response rates included size response in 29% (World Health Organization) and 28% (Response Evaluation Criteria for Solid Tumors [RECIST]) of patients, and necrosis response in 79% (European Association for the Study of the Liver) and 70% (modified RECIST) of patients. Median local TTP, distant site TTP, local PFS, and other site PFS were 51.7, 11.2, 10.8, and 10.5 months. Eighteen percent of patients underwent liver transplantation; 48% of United Network for Organ Sharing stage T3 tumors were downstaged to stage T2. Transplant-free survival for the entire cohort was 16.8 months (not reached, 33.9, 16.0, 4.4, and 6.9 months for BCLC stages 0, A, B, C, and D, respectively). Postembolization syndrome requiring extended hospital stay or readmission occurred in only 6% of patients. CONCLUSION: Conventional TACE is effective and safe for HCC therapy and may confer a survival benefit. The current data are in line with reported conventional TACE outcomes, and the minor postembolization syndrome incidence supports the low morbidity of this approach.

Should transjugular intrahepatic portosystemic shunt stent grafts be underdilated?

Although underdilation of transjugular intrahepatic portosystemic shunt (TIPS) stent grafts is commonly performed to limit complications arising from excessive portosystemic shunting, it is uncertain whether underdilated stents retain their smaller diameter indefinitely or eventually expand to nominal caliber. In this investigation, postprocedure computed tomography (CT) was used to compare diameters of underdilated TIPSs and TIPSs expanded to a nominal diameter of 10 mm in 61 cases. The groups had comparable shunt diameters on post-TIPS imaging (9.8 mm vs 9.9 mm; P = .079), with similar incidences of hepatic encephalopathy (34% vs 20%; P = .372), indicating stent self-expansion over time, and bringing into question the advantages of underdilation for customization of shunt caliber.

Clearing the Confusion over Hepatic Encephalopathy After TIPS Creation: Incidence, Prognostic Factors, and Clinical Outcomes.

PURPOSE: To assess the incidence, prognostic factors, and clinical outcomes of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS: In this single-institution retrospective study, 191 patients (m:f = 114:77, median age 54 years, median Model for End-Stage Liver Disease or MELD score 14) who underwent TIPS creation between 1999 and 2013 were studied. Medical record review was used to identify demographic characteristics, liver disease, procedure, and outcome data. Post-TIPS HE within 30 days was defined by new mental status changes and was graded according to the West Haven classification system. The influence of data parameters on HE occurrence and 90-day mortality was assessed using binary logistic regression. RESULTS: TIPS was successfully created with hemodynamic success in 99 % of cases. Median final PSG was 7 mmHg. HE incidence within 30 days was 42 % (81/191; 22 % de novo, 12 % stable, and 8 % worsening). Degrees of HE included grade 1 (46 %), grade 2 (29 %), grade 3 (18 %), and grade 4 (7 %). Medical therapy typically addressed HE, and shunt reduction was necessary in only three cases. MELD score (P = 0.020) and age (P = 0.009) were significantly associated with HE development on multivariate analysis. Occurrence of de novo HE post-TIPS did not associate with 90-day mortality (P = 0.400), in contrast to worsening HE (P < 0.001). CONCLUSIONS: The incidence of post-TIPS HE is non-trivial, but symptoms are typically mild and medically managed. HE rates are higher in older patients and those with worse liver function and should be contemplated when counseling on expected TIPS outcomes and post-procedure course.

MELD score for prediction of survival after emergent TIPS for acute variceal hemorrhage: derivation and validation in a 101-patient cohort.

UNLABELLED: BACKGROUND AND RATIONALE FOR THE STUDY: The Model for End Stage Liver Disease (MELD) score has not been derived and validated for the emergent transjugular intrahepatic portosystemic shunt (TIPS) population. We sought to identify predictive factors for survival among emergent TIPS patients, and to substantiate MELD for outcomes prognostication in this population. RESULTS: 101 patients with acute life threatening variceal hemorrhage underwent emergent TIPS (defined by failed endoscopic therapy for active bleeding, acute hemoglobin drop, ≥ 2-unit transfusion requirement, and/or vasopressor need) at between 1998-2013. Demographic, clinical, laboratory, and procedure parameters were analyzed for correlation with mortality using Cox proportional hazards regression to derive the prognostic value of MELD constituents. Area under receiver operator characteristic (AUROC) curves was used to assess the capability of MELD prediction of mortality. TIPS were created 119 ± 167 h after initial bleeding events. Hemodynamic success was achieved in 90%. Median final portosystemic pressure gradient was 8 mmHg. Variceal rebleeding incidence was 21%. The four original MELD components showed significant correlation with mortality on multivariate Cox regression: baseline bilirubin (regression coefficient 0.366), creatinine (0.621), international normalized ratio (1.111), and liver disease etiology (0.808), validating the MELD system for emergent cases. No other significant predictive parameters were identified. MELD was an excellent predictor of 90-day mortality in the emergent TIPS population (AUROC = 0.842, 95% CI 0.755-0.928). CONCLUSIONS: Based on independent derivation of prognostic constituents and confirmation of predictive accuracy, MELD is a valid and reliable metric for risk stratification and survival projection after emergent TIPS.

Efficacy and safety of flow-directed pulmonary artery catheter thrombolysis for treatment of submassive pulmonary embolism.

OBJECTIVE: The purpose of this study was to assess the efficacy and safety of flow-directed catheter thrombolysis for treatment of submassive pulmonary embolism (PE). MATERIALS AND METHODS: In this single-institution retrospective study, 19 patients (nine men and 10 women; mean age [± SD], 54 ± 13 years) with submassive PE underwent catheter-directed thrombolysis between 2009 and 2013. Presenting symptoms included dyspnea in 18 of 19 (95%) cases. Submassive PE was diagnosed by pulmonary CT arteriography and right ventricular strain. PE was bilateral in 17 of 19 (89%) and unilateral in two of 19 (11%) cases. Thrombolysis was performed via a pulmonary artery (PA) catheter infusing 0.5- 1.0 mg alteplase per hour and was continued to complete or near complete clot dissolution with reduction in PA pressure. IV systemic heparin was administered. Measured outcomes included procedural success, PA pressure reduction, clinical success, survival, and adverse events. RESULTS: Procedural success, defined as successful PA catheter placement, fibrinolytic agent delivery, PA pressure reduction, and achievement of complete or near complete clot dissolution, was achieved in 18 of 19 (95%) cases. Thrombolysis required 57 ± 31 mg of alteplase administered over 89 ± 32 hours. Initial and final PA pressures were 30 ± 10 mm Hg and 20 ± 8 mm Hg (p < 0.001). All 18 (100%) technically successful cases achieved clinical success because all patients experienced symptomatic improvement. Eighteen of 19 (95%) patients survived to hospital discharge; 18 of 19 (95%) and 15 of 16 (94%) patients had documented 1-month and 3-month survival. One fatal case of intracranial hemorrhage was attributed to supratherapeutic anticoagulation because normal fibrinogen levels did not suggest remote fibrinolysis; procedural success was not achieved in this case because of early thrombolysis termination. No other complications were encountered. CONCLUSION: Among a small patient cohort, flow-directed catheter thrombolysis with alteplase effectively dissolved submassive PE and reduced PA pressure. Postprocedure short-term survival was high, and patients undergoing thrombolysis required close observation for bleeding events.

Characterization of liver function parameter alterations after transjugular intrahepatic portosystemic shunt creation and association with early mortality.

OBJECTIVE: The purpose of this article is to characterize the temporal evolution and clinical impact of laboratory liver function parameters after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS: In this single-institution retrospective study, 157 patients (98 men and 59 women; median age, 55 years) underwent TIPS between 2000 and 2012 and had 1-month hepatobiliary laboratory follow-up. Medical record review was used to compare baseline, peak, and low bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, and international normalized ratio (INR) levels within 30 days after TIPS in surviving and dying patients to assess laboratory responses to shunt creation. RESULTS: TIPSs were created with a hemodynamic success rate of 98%, with median pressure gradient reduction of 13 mm Hg. Ninety-day mortality was 21%. Hepatobiliary laboratory values showed significant increases in the days after TIPS compared with baseline levels (bilirubin, 1.6 vs 3.5 mg/dL; AST, 49 vs 149 U/L; ALT, 26 vs 90 U/L; alkaline phosphatase, 97 vs 177 U/L; and INR, 1.5 vs 2.0; p<0.05 in all cases). Patients surviving to 90 days experienced statistically significant but transient laboratory value elevations-up to twofold over baseline-within days of TIPS, whereas patients dying within 90 days experienced three-to fourfold increases over a longer period that did not return to baseline. Differences in laboratory evolution were statistically significant in surviving versus dying patients. CONCLUSION: TIPS results in acute transient elevation of hepatobiliary enzymes, which may be more pronounced in patients with early mortality. An exaggerated laboratory elevation in excess of threefold greater than baseline or a prolonged increase exceeding 1 week may herald poorer clinical outcome.

Right atrial pressure may impact early survival of patients undergoing transjugular intrahepatic portosystemic shunt creation.

PURPOSE: To elucidate the impact of right atrial (RA) pressure on early mortality after transjugular intrahepatic portosystemic shunt (TIPS). MATERIAL AND METHODS: In this single institution retrospective study, 125 patients (M:F = 75:50, mean age 55 years) who underwent TIPS with recorded intra-procedural RA pressures between 1999-2012 were studied. Demographic (age, gender), liver disease (Child-Pugh, Model for End Stage Liver Disease or MELD score), and procedure (indication, urgency, Stent type, portosystemic gradient or PSG reduction, baseline and post-TIPS RA pressure) data were identified, and the influence of these parameters on 30- and 90-day mortality was assessed using binary logistic regression. RESULTS: TIPS were created for variceal hemorrhage (n = 55) and ascites (n = 70). Hemodynamic success rate was 99% (124/125) and mean PSG reduction was 13 mmHg. 30- and 90-day mortality rates were 18% (19/106) and 28% (29/106). Baseline and final RA pressure were significantly associated with 30- (12 vs. 15 mmHg, P = 0.021; 18 vs. 21 mmHg, P = 0.035) and 90-day (12 vs. 14 mmHg, P = 0.022; 18 vs. 20 mmHg, P = 0.024) survival on univariate analysis. Predictive usefulness of RA pressure was not confirmed in multivariate analyses. Area under receiver operator characteristic (AUROC) curve analysis revealed good pre- and post-TIPS RA pressure predictive capacity for 30- (0.779, 0.810) and 90-day (0.813, 0.788) mortality among variceal hemorrhage patients at 14.5 and 21.5 mm Hg thresholds. CONCLUSION: Intra-procedural RA pressure may have predictive value for early post-TIPS mortality. Pre-procedure consideration and optimization of patient cardiac status may enhance candidate selection, risk stratification, and clinical outcomes, particularly in variceal hemorrhage patients.

Older patient age may predict early mortality after transjugular intrahepatic portosystemic shunt creation in individuals at intermediate risk.

PURPOSE: To identify prognostic factors for early mortality among patients with intermediate-risk Model for End-stage Liver Disease (MELD) scores undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS: In this single-institution retrospective study, 47 patients (31 men; mean age, 54 y) with intermediate MELD scores (ie, 18-25) underwent TIPS creation between 1999 and 2012. Medical records were reviewed to identify demographic (age, sex), liver disease (Child-Pugh, MELD), and procedure data (indication, urgency, stent type, portosystemic pressure gradient reduction, complications), and the influence of these parameters on 90-day mortality was assessed by multivariate binary logistic regression analysis. RESULTS: TIPSs were successfully created for variceal hemorrhage (n = 24), ascites (n = 17), hydrothorax (n = 5), and portal vein thrombosis (n = 1). Hemodynamic success rate was 94% (44 of 47), and mean portosystemic pressure gradient reduction was 13 mm Hg. The 90-day mortality rate was 36% (17 of 47). Patient age (P = .026) was significantly associated with 90-day mortality. Mean ages of living versus dead patients were 51 and 60 years, and mortality rates in patients aged 54 years or younger versus 55 years or older were 21% (five of 24) and 52% (12 of 23), respectively. There was no difference in MELD scores between these age groups (20.6 vs 21.0; P = .600), and MELD score was not a predictive factor on regression analysis. CONCLUSIONS: Age is a prognostic factor for early mortality in TIPS recipients with intermediate MELD scores. Mortality rates are higher in patients at least 55 years of age, but MELD score does not predict survival in this subset. Age should be contemplated when selecting patients at intermediate risk for TIPS creation.

Prognostic capability of different liver disease scoring systems for prediction of early mortality after transjugular intrahepatic portosystemic shunt creation.

PURPOSE: To compare the performance of various liver disease scoring systems in predicting early mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS: In this single-institution retrospective study, eight scoring systems were used to grade liver disease in 211 patients (male-to-female ratio = 131:80; mean age, 54 y) before TIPS creation from 1999-2011. Scoring systems included bilirubin level, Child-Pugh (CP) score, Model for End-Stage Liver Disease (MELD) and Model for End-Stage Liver Disease sodium (MELD-Na) score, Emory score, prognostic index (PI), Acute Physiology and Chronic Health Evaluation (APACHE) 2 score, and Bonn TIPS early mortality (BOTEM) score. Medical record review was used to identify 30-day and 90-day clinical outcomes. The relationship of scoring parameters with mortality outcomes was assessed with multivariate analysis, and the relative ability of systems to predict mortality after TIPS creation was evaluated by comparing area under receiver operating characteristic (AUROC) curves. RESULTS: TIPS were successfully created for variceal hemorrhage (n = 121), ascites (n = 72), hepatic hydrothorax (n = 15), and portal vein thrombosis (n = 3). All scoring systems had a significant association with 30-day and 90-day mortality (P<.050 in each case) on multivariate analysis. Based on 30-day and 90-day AUROC, MELD (0.878, 0.816) and MELD-Na (0.863, 0.823) scores had the best capability to predict early mortality compared with bilirubin (0.786, 0.749), CP (0.822, 0.771), Emory (0.786, 0.681), PI (0.854, 0.760), APACHE 2 (0.836, 0.735), and BOTEM (0.798, 0.698), with statistical superiority over bilirubin, Emory, and BOTEM scores. CONCLUSIONS: Several liver disease scoring systems have prognostic value for early mortality after TIPS creation. MELD and MELD-Na scores most effectively predict survival after TIPS creation.

Transcatheter embolotherapy for gastrointestinal bleeding: a single center review of safety, efficacy, and clinical outcomes.

PURPOSE: The purpose of this study was to assess safety, efficacy, and clinical outcomes following transcatheter arterial embolization (TAE) of acute gastrointestinal (GI) bleeding. MATERIALS AND METHODS: Ninety-five patients (male:female ratio = 53:42, mean age 62 years) that underwent 95 TAEs for GI hemorrhage between 2002 and 2010 were retrospectively studied. Seventy-six of 95 (80 %) patients had upper GI bleeds and 19/95 (20 %) patients had lower GI bleeds. A mean of 7 (range 0-27) packed red blood cell units were transfused pre-procedure, and 90/95 (95 %) procedures were urgent or emergent. Twenty-seven of 95 (28 %) patients were hemodynamically unstable. Measured outcomes included procedure technical success, adverse events, and 30-day rebleeding and mortality rates. RESULTS: Bleeding etiology included peptic ulcer disease (45/95, 47 %), cancer (14/95, 15 %), diverticulosis (13/95, 14 %), and other (23/95, 24 %). Vessels embolized (n = 109) included gastroduodenal (42/109, 39 %), pancreaticoduodenal (22/109, 20 %), gastric (21/109, 19 %), superior mesenteric (12/109, 11 %), inferior mesenteric (8/109, 7 %), and splenic (4/109, 4 %) artery branches. Technical success with immediate hemostasis was achieved in 93/95 (98 %) cases. Most common embolic agents included coils (66/109, 61 %) and/or gelatin sponge (19/109, 17 %). Targeted versus empiric embolization were performed in 57/95 (60 %) and 38/95 (40 %) cases, respectively. Complications included bowel ischemia (4/95, 4 %) and coil migration in 3/95 (3 %). 30-day rebleeding rate was 23 % (22/95). Overall 30-day mortality rate was 18 % (16/89). Empiric embolization resulted in similar rebleeding (23 vs 24 %) but higher mortality (31 vs 9 %) rates compared to embolization for active extravasation. CONCLUSIONS: TAE controlled GI bleeding with high technical success, safety, and efficacy, and should be considered when endoscopic therapy is not feasible or unsuccessful.

Within-patient temporal variance in MELD score and impact on survival prediction after TIPS creation.

BACKGROUND: To assess within-patient temporal variability in Model for End Stage Liver Disease (MELD) scores and impact on outcome prognostication after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIAL AND METHODS: In this single institution retrospective study, MELD score was calculated in 68 patients (M:F = 42:26, mean age 55 years) at 4 pre-procedure time points (1, 2-6, 7-14, and 15-35 days) before TIPS creation. Medical record review was used to identify 30- and 90-day clinical outcomes. Within-patient variability in pre-procedure MELD scores was assessed using repeated measures analysis of variance, and the ability of MELD scores at different time points to predict post-TIPS mortality was evaluated by comparing area under receiver operating characteristic (AUROC) curves. RESULTS: TIPS were successfully created for ascites (n = 30), variceal hemorrhage (n = 29), hepatic hydrothorax (n = 8), and portal vein thrombosis (n = 1). Pre-TIPS MELD scores showed significant (P = 0.032) within-subject variance that approached ± 18.5%. Higher MELD scores demonstrated greater variability in sequential scores as compared to lower MELD scores. Overall 30- and 90-day patient mortality was 22% (15/67) and 38% (24/64). AUROC curves showed that most recent MELD scores performed on the day of TIPS had superior predictive capacity for 30- (0.876, P = 0.037) and 90-day (0.805 P = 0.020) mortality compared to MELD scores performed 2-6 or 7-14 days prior. CONCLUSIONS: In conclusion, MELD scores show within-patient variability over time, and scores calculated on the day of TIPS most accurately predict risk and should be used for patient selection and counseling.

TIPS for treatment of variceal hemorrhage: clinical outcomes in 128 patients at a single institution over a 12-year period.

PURPOSE: To assess clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) treatment of variceal hemorrhage. MATERIALS AND METHODS: A total of 128 patients (82 men and 46 women; mean age, 52 y) with liver cirrhosis and refractory variceal hemorrhage underwent TIPS creation from 1998 to 2010. Mean Child-Pugh and Model for End-stage Liver Disease (MELD) scores were 9 and 18, respectively. From 1998 to 2004, 12-mm Wallstents (n = 58) were used, whereas from 2004 to 2010, 10-mm VIATORR covered stent-grafts (n = 70) were used. Technical success, hemodynamic success, complications, shunt dysfunction, recurrent bleeding, and overall survival were assessed. RESULTS: Technical and hemodynamic success rates were 100% and 94%, respectively. Mean portosystemic gradient reduction was 13 mm Hg. Complications at 30 days included encephalopathy (14%), renal failure (5.5%), infection (1.6%), and liver failure (0.8%). Shunt patency rates were 93%, 82%, and 60% at 30 days, 1 year, and 2 years, respectively. Dysfunction, or loss of TIPS primary patency, occurred more with Wallstent versus VIATORR TIPSs (29% vs 11%; P = .009). Recurrent bleeding incidences were 9%, 22%, and 29% at 30 days, 1 year, and 2 years, respectively, and were similar between Wallstent and VIATORR TIPSs (19% vs 19%; P = .924). Variceal embolization significantly reduced recurrent bleeding rates (5% vs 25%; P = .013). Overall survival rates were 80%, 69%, and 65% at 30 days, 1 year, and 2 years, respectively, and were similar between Wallstent and VIATORR TIPSs (35% vs 26% mortality rate; P = .312). Advanced MELD score was associated with increased mortality on multivariate analysis. CONCLUSIONS: Wallstent and VIATORR TIPSs effectively treat variceal hemorrhage, particularly when accompanied by variceal embolization. Although TIPS with a VIATORR device showed improved shunt patency, patient survival is similar to that with Wallstent TIPS. These results further validate TIPS creation for refractory variceal bleeding.

Ultrasound-Guided Phrenic Nerve Block for Lung Nodule Biopsy: Single-Center Initial Experience.

RATIONALE AND OBJECTIVES: Biopsy of lung nodules in the lower lung fields can be difficult because of breathing motion. Ipsilateral phrenic nerve block (PNB) before biopsy should make the biopsy safer, easier, and more precisely targeted. We describe the use of ultrasound-guided PNB before lung nodule biopsy, including relevant anatomy and variations, complications, and technique, along with our first 40 cases. MATERIALS AND METHODS: We retrospectively reviewed patients who underwent PNB before computed tomography (CT)- or ultrasound-guided lung nodule biopsy from April 2015 through March 2020. Patient demographics, CT fluoroscopy time, radiation dose, complications, diagnostic yield, and effectiveness of PNB were recorded. Effectiveness of PNB was based on direct observation of diaphragmatic motion. Control group data for biopsies during the same time frame were collected and matched with nodules ≤1 cm from the PNB group. RESULTS: Among 40 patients identified, no complications occurred related to the PNB. Mean (SD) nodule size was 12.4 (6.2) mm. True-positive results were obtained in 39 patients (98%), with 1 false-negative after an ineffective PNB. PNB was effective in 70%. When CT fluoroscopy was used for the biopsy, radiation dose was significantly lower after an effective PNB than an ineffective PNB (p < .001). Effective PNB was significantly more common with injection of ≥4 mL of local anesthetic (p = .01). Comparison with 19 matched controls showed significantly fewer instances of pneumothorax (p = .02) and greater diagnostic success (p = .03) for the PNB group. CONCLUSION: Ultrasound-guided PNB is safe and effective and can improve outcomes when used before lung nodule biopsy.

Comprehensive review of TIPS technical complications and how to avoid them.

OBJECTIVE: The goal of this article is to describe potential technical complications related to transjugular intrahepatic portosystemic shunts (TIPS) placement and to discuss strategies to avoid and manage complications if they arise. CONCLUSION: TIPS is an established interventional therapy for complications of portal hypertension. Although TIPS remains a relatively safe procedure, direct procedure-related morbidity rates are as high as 20%. The technical complexity of this intervention increases the risk for methodologic mishaps during all phases of TIPS placement, including venous access and imaging, transhepatic needle puncture, shunt insertion, and variceal embolization. Thus, interventional radiologists require a thorough stepwise understanding of TIPS insertion, possible adverse sequela, and technical tips and tricks to maximize the safety of this procedure.

Microwave lung ablation complicated by bronchocutaneous fistula: case report and literature review.

Microwave ablation is a developing treatment option for unresectable lung cancer. Early experience suggests that it may have advantages over radiofrequency (RF) ablation with larger ablation zones, shorter heating times, less susceptibility to heat sink, effectiveness in charred lung, synergism with multiple applicators, no need for grounding pads, and similar survival benefit. Newer microwave ablation devices are being developed and as their use becomes more prevalent, a greater understanding of device limitations and complications are important. Herein we describe a microwave lung ablation complicated by bronchocutaneous fistula (BCF) and its treatment. BCF treatment options include close monitoring, surgical closure, percutaneous sealant injection, and endoscopic plug or sealant in those who are not surgical candidates.