Voxel-based tumor dose correlates to complete pathologic necrosis after transarterial radioembolization for hepatocellular carcinoma.

PURPOSE: The transarterial radioembolization (TARE) dose is traditionally calculated using the single-compartment Medical Internal Radiation Dose (MIRD) formula. This study utilized voxel-based dosimetry to correlate tumor dose with explant pathology in order to identify dose thresholds that predicted response. METHODS: All patients with HCC treated with TARE using yttrium-90 [90Y] glass microspheres at a single institution between January 2015 - June 2023 who underwent liver transplantation were eligible. The [90Y] distribution and dose-volume histograms were determined using Simplicity90 (Mirada Medical, Oxford UK) with a Bremsstrahlung SPECT/CT. A complete response was assigned if explant pathology showed complete necrosis and the patient had not undergone additional treatments to the same tumor after TARE. Logistic regression and receiver operator characteristic (ROC) curves were constructed to evaluate dose thresholds correlated with response. RESULTS: Forty-one patients were included. Twenty-six (63%) met criteria for complete response. Dose to 95% (D95), 70% (D70), and 50% (D50) of the tumor volume were associated with likelihood of complete response by logistic regression (all p < 0.05). For lesions with complete response versus without, the median D95 was 813 versus 232 Gy, D70 was 1052 versus 315 Gy, and D50 was 1181 versus 369 Gy (all p < 0.01). A D95 > 719 Gy had the highest accuracy at 68% (58% sensitivity, 87% specificity) for predicting complete response. Median percent of tumor volume receiving at least 100 Gy (V100), 200 Gy (V200), 300 Gy (V300), and 400 Gy (V400) also differed by pathologic response: the median V100, V200, V300, and V400 was 100% versus 99%, 100% versus 97%, 100% versus 74%, and 100% versus 43% in the complete response versus non-complete response groups, respectively (all p < 0.05). CONCLUSION: Voxel-based dosimetry was well-correlated with explant pathology. The D95 threshold had the highest accuracy, suggesting the D95 may be a relevant target for multi-compartment dosimetry.

Hepatopulmonary Shunting: A Prognostic Indicator of Survival in Patients with Metastatic Colorectal Adenocarcinoma Treated with 90Y Radioembolization.

Purpose To determine if high lung shunt fraction (LSF) is an independent prognostic indicator of poor survival in patients who undergo yttrium 90 radioembolization for unresectable liver-dominant metastatic colorectal cancer. Materials and Methods Retrospective data were analyzed from 606 patients (62% men; mean age, 62 years) who underwent radioembolization to treat liver metastases from colorectal adenocarcinoma between July 2002 and December 2011 at 11 U.S. centers. Institutional review board exemptions were granted prior to the collection of data at each site. Overall survival was estimated by using Kaplan-Meier survival and univariate Cox proportional hazards models to examine the effect of LSF on survival and to compare this to other potential prognostic indicators. Multivariate analysis was also performed to determine whether LSF is an independent risk factor for poor survival. Results LSF higher than 10% was predictive of significantly decreased survival (median, 6.9 months vs 10.0 months; hazard ratio, 1.60; P < .001) and demonstrated a mild but significant correlation to serum carcinoembryonic antigen levels and tumor-to-liver volume ratio (Pearson correlation coefficients, 0.105 and 0.113, respectively; P < .05). A progressive decrease in survival was observed as LSF increased from less than 5% to more than 20% (P < .05). LSF did not correlate with the presence of extrahepatic metastases or prior administration of bevacizumab. Conclusion Increased LSF is an independent prognostic indicator of worse survival in patients undergoing radioembolization for liver-dominant metastatic colorectal adenocarcinoma. High LSF correlates poorly to other potential markers of tumor size, such as tumor-to-liver volume ratio or serum carcinoembryonic antigen level, and does not correlate to the presence of extrahepatic metastases. © RSNA, 2016 Online supplemental material is available for this article.

Intravascular Ultrasound in the Creation of Transhepatic Portosystemic Shunts Reduces Needle Passes, Radiation Dose, and Procedure Time: A Retrospective Study of a Single-Institution Experience.

PURPOSE: To assess whether intravascular ultrasound (US) guidance impacts number of needle passes, contrast usage, radiation dose, and procedure time during creation of transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS: Intravascular US-guided creation of TIPS in 40 patients was retrospectively compared with conventional TIPS in 49 patients between February 2010 and November 2015 at a single tertiary care institution. Patient sex and age, etiology of liver disease (hepatitis C virus, alcohol abuse, nonalcoholic steatohepatitis), severity of liver disease (mean Model for End-Stage Liver Disease score), and indications for TIPS (variceal bleeding, refractory ascites, refractory hydrothorax) in conventional and intravascular US-guided cases were recorded. RESULTS: The two groups were well matched by sex, age, etiology of liver disease, Child-Pugh class, Model for End-Stage Liver Disease scores, and indication for TIPS (P range = .19-.94). Fewer intrahepatic needle passes were required in intravascular US-guided TIPS creation compared with conventional TIPS (2 passes vs 6 passes, P < .01). Less iodinated contrast material was used in intravascular US cases (57 mL vs 140 mL, P < .01). Radiation exposure, as measured by cumulative dose, dose area product, and fluoroscopy time, was reduced with intravascular US (174 mGy vs 981 mGy, P < .01; 3,793 µGy * m(2) vs 21,414 µGy * m(2), P < .01; 19 min vs 34 min, P < .01). Procedure time was shortened with intravascular US (86 min vs 125 min, P < .01). CONCLUSIONS: Intravascular US guidance resulted in fewer intrahepatic needle passes, decreased contrast medium usage, decreased radiation dosage, and shortened procedure time in TIPS creation.

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.

Root Cause Analysis of Rebleeding Events following Transjugular Intrahepatic Portosystemic Shunt Creation for Variceal Hemorrhage.

PURPOSE: To identify fundamental causes underlying recurrent variceal hemorrhage (VH) after transjugular intrahepatic portosystemic shunt (TIPS) to ascertain opportunities for improvement of TIPS-based management of VH and prevention of rebleeding. MATERIALS AND METHODS: This single-center retrospective study comprised 166 patients (male-to-female ratio 101:65; median age, 52 y; median Model for End-Stage Liver Disease score, 14) who had TIPS created for VH in 1998-2014. Medical record review was used to identify patients who had recurrent VH events, and root cause analysis allowed identification of the most probable causal factors. A 5-person interventional radiology physician group generated quality improvement (QI) recommendations for process changes to address causal factors, with consensus achieved using a modified Delphi method. RESULTS: Variceal rebleeding occurred after TIPS in 25 (15%) patients. The 1-, 3-, and 5-year variceal rebleeding incidence was 17%, 21%, and 21%, respectively. Variceal rebleeding was associated with high 90-day all-cause mortality incidence (10/25; 40%). Male sex (P = .018) and Model for End-Stage Liver Disease score (P = .009) were statistically associated with variceal rebleeding. The most common primary and secondary causes of recurrent VH were lack of or insufficient variceal embolization (64%). Other causal factors included TIPS stenosis or occlusion (28%) with recurrent portosystemic gradient (PSG) elevation (20%), severe coagulopathy (20%), inadequate portosystemic gradient reduction (12%), and TIPS underdilation (4%). To potentially address variceal rebleeding, 14 preventive QI recommendations were developed. CONCLUSIONS: Although recurrent VH rates after TIPS are not trivial, rebleeding may be related to addressable underlying causal factors. Further investigation may assess the efficacy of QI-based procedure methodologic enhancements in reducing rebleeding incidence after TIPS.

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.

Sustained safety and efficacy of extended-shelf-life (90)Y glass microspheres: long-term follow-up in a 134-patient cohort.

PURPOSE: To validate our initial pilot study and confirm sustained safety and tumor response of extended-shelf-life (90)Y glass microspheres. We hypothesized that for the same planned tissue dose, the increase in number of glass microspheres (decayed to the second week of their allowable shelf-life) administered for the same absorbed dose would result in better tumor distribution of the microspheres without causing additional adverse events. METHODS: Between June 2007 and January 2010, 134 patients underwent radioembolization with extended-shelf-life (90)Y glass microspheres; data from 84 new patients were combined with data from our 50-patient pilot study cohort. Baseline and follow-up imaging and laboratory data were obtained 1 and 3 months after therapy and every 3 months thereafter. Clinical and biochemical toxicities were prospectively captured and categorized according to the Common Terminology Criteria. Response in the index lesion was assessed using WHO and EASL guidelines. RESULTS: The mean delivered radiation dose was 123 Gy to the target liver tissue. The mean increase in number of microspheres with this approach compared to standard (90)Y glass microsphere dosimetry was 103%, corresponding to an increase from 3.84 to 7.78 million microspheres. Clinical toxicities included fatigue (89 patients, 66%), abdominal pain (49 patients, 36.6%), and nausea/vomiting (25 patients, 18.7%). Grade 3/4 bilirubin toxicity was seen in three patients (2%). Two (1%) of the initial 50-patient cohort showed gastroduodenal ulcers; gastroduodenal ulcers were not seen in any of the subsequent 84 patients. According to WHO and EASL guidelines, response rates were 48% and 57%, respectively, and 21% demonstrated a complete EASL response. CONCLUSION: This study showed sustained safety and efficacy of extended-shelf-life (90)Y glass microspheres in a larger, 134-patient cohort. The increase in number of microspheres administered theoretically resulted in better tumor distribution of the microspheres without an increase in adverse events.

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.

Single-Session Ablative Transarterial Radioembolization for Patients with Hepatocellular Carcinoma to Streamline Care: An Initial Experience.

PURPOSE: Transarterial radioembolization (TARE) for hepatocellular carcinoma (HCC) is performed after a mapping angiogram involving infusion of radiolabeled macroaggregated albumin to assess for non-target embolization and pulmonary shunting. The purpose of this case series was to evaluate the safety and feasibility of single-session TARE without the initial procedure. MATERIALS AND METHODS: A single-institution case series of 16 consecutive procedures on 15 patients with 18 tumors who underwent an attempted single-session TARE procedures with glass microspheres are presented. A lung shunt fraction (LSF) of 5% was assumed for planning purposes. RESULTS: Sixty-seven percent (10/15) of patients were male with a median age of 72 years. Median tumor size was 2.5 cm (IQR 2.0-3.2 cm). Sixteen of the 18 targeted tumors were untreated prior to the single-session TARE. Rate of technical success was 88% (14/16). Two patients did not ultimately receive a single-session TARE due to intraprocedural findings. The mean administered activity was 2.0 GBq, and the mean MIRD dose was 464 Gy based on pre-treatment anatomic imaging and 800 Gy based on cone-beam CT. There were no cases of radiation pneumonitis. Mean post-procedural calculated lung dose was 4.9 Gy (range 3.1-9.3) based on SPECT. CONCLUSIONS: An initial experience with single-session TARE using Y-90 glass microspheres without pre-procedural mapping angiography and lung shunt estimation demonstrates that it is a feasible and safe treatment option for select patients with small (< 5 cm) HCC. LEVEL OF EVIDENCE IV: Level 4 case series.

Interdisciplinary Approach to Expedited Outpatient Gastrostomy Tube Placement in Head and Neck Cancer Patients: A Single Center Retrospective Study.

RATIONALE AND OBJECTIVE: Treatment for head and neck cancer (HNC) can lead to decreased oral intake which often requires gastrostomy tube (g-tube) placement to provide nutritional support. A multidisciplinary team (MDT) consisting of interventional radiology (IR), HNC oncology and surgery, nutrition, and speech language pathology departments implemented an expedited outpatient g-tube placement pathway to reduce hospital stays and associated costs, initiate feeds sooner, and improve communication between care teams. This single center study investigates differences in complications, time to procedure and costs savings with implementing this pathway. METHODS: 142 patients with HNC who underwent elective image guided g-tube placement by IR from 2015 to 2022 were identified retrospectively. 52 patients underwent the traditional pathway, and 90 patients underwent the expedited pathway. Patient demographics, procedure characteristics, periprocedural costs and 90-day complication rates were collected and compared statistically. RESULTS: The 90-day complication rate was comparable between groups (traditional=32.7%; expedited=22.2%; p-value=0.17). The expedited pathway decreased the time from consult to procedure by 11.1 days (95% CI 7.6 - 14.6; p < 0.001) and decreased charge per procedure by $2940 (95% CI $989-$4891; p < 0.001). CONCLUSION: A MDT for the treatment of patients with HNC successfully provided enteral nutrition support faster, with fewer associated costs, and in a more patient centered approach than previously done at this institution.

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.

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.

Successful mechanical thrombectomy and stent exclusion of sacral chordoma tumor thrombus.

A 77-year-old man with history of sacral chordoma and pulmonary embolism presented to the emergency room with a 1-day history of diffuse left flank and lower extremity swelling. The patient was found to have thrombus in the left common and external iliac veins. The patient was brought to Interventional Radiology for mechanical thrombectomy using the Inari ClotTriever and a sample of extracted thrombus was sent to pathology. Analysis on the sample was positive for sacral chordoma, consistent with tumor thrombus. The patient returned after 6 weeks with similar symptoms and repeat mechanical thrombectomy was performed with the Inari ClotTriever and stent placement through the left common and external iliac vein with an Ovation iX stent graft. The patient remained asymptomatic following the second procedure at repeat follow-up at 6 weeks.

Boosted-Dose Yttrium-90 Radiation Segmentectomy or Lobectomy for Hepatocellular Carcinoma Refractory to Prior Transarterial Embolization or Chemoembolization: A Single Institution Retrospective Case Series.

PURPOSE: To assess the tumor response rates and liver toxicity of boosted-dose transarterial radioembolization (TARE) for treatment of hepatocellular carcinoma (HCC) refractory to previous transarterial embolization (TAE) and/or chemoembolization (TACE). MATERIALS AND METHODS: All patients were identified who had HCC treated between 2017 and 2020 that had been refractory to prior TAE or TACE, then treated with boosted-dose segmental or lobar TARE. Tumor response was assessed by multiphasic CT or MRI using localized mRECIST imaging criteria and serological alpha-fetoprotein levels at three and six months after TARE, if available. Liver toxicity was evaluated using serial serological liver function tests, platelet counts, and clinical Child-Pugh and MELD scores. RESULTS: Twenty-four patients met inclusion criteria. Mean age was 68.7 years (54-89); 8 were females. Three (12.5%) patients had Barcelona Clinical Liver Cancer stage A, 4 (16.7%) stage B, and 17 (70.8%) stage C disease. Three months after TARE, 52% of patients had a complete response and 33% had a partial response. Mean AFP decreased from 33.2 ng/mL at baseline to 17 ng/mL at 3 months (p = 0.782). The median MELD-Na score increased from 11 at baseline to 16 at 6 months post-TARE (p = 0.044); the mean Child-Pugh score rose from 5 at baseline to 6 at 3 months post-TARE (p < 0.01). CONCLUSION: Boosted-dose TARE resulted in statistically significant favorable tumor responses by imaging criteria in 85% of patients previously refractory to TAE or TACE. TARE resulted in transient but acceptable deterioration of liver function and clinical scores.