Right vs left portal branch puncture in TIPS creation with controlled expansion covered stent: comparison of hemodynamic and clinical outcomes.

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.

Feasibility of Ultra-Low Volume Contrast-Saline Mixture Injection With Dual-Flow Technique in a Pre-TAVI Computed Tomography Angiography.

BACKGROUND: To explore the feasibility and image quality of ultra-low volume contrast-saline mixture injection with dual-flow injection technique in a computed tomography angiography (CTA) protocol in patients scheduled for transcatheter aortic valve implantation (TAVI). METHODS: Forty (40) TAVI candidates underwent investigation with CTA using a third-generation dual-source CT scanner between September and November 2020. Different volumes of a monophasic contrast-saline mixture at an 80:20 ratio were administered at an infusion rate of 3 mL/s in 20 patients (group A). The injected volume was based on patient body mass index (BMI): 50 mL if BMI <29 kg/m2 and 63 mL if BMI >29 kg/m2. The other 20 patients (group B)-the control cases-received a total of 65 mL of contrast medium (CM), in multiphasic injections at different flow rates, followed by 10 mL of saline. The images that were obtained were prospectively evaluated for image quality, vessel attenuation (HU), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and estimated radiation dose. RESULTS: Image quality of the aortic root and ilio-femoral vessels was diagnostic in all patients. Vascular attenuation was >200 HU and CNR >3 at any vessel level. CONCLUSIONS: Data from this study suggest that a monophasic ultra-low volume contrast-saline mixture injection with a dual-flow technique can provide clear visualisation of the aortic root and ilio-femoral vessels in pre-TAVI CTA, which is comparable with a standard multiphasic volume injection protocol.

Case 306: Ectopic Thyroid Goiter in the Porta Hepatis.

HISTORY: A 61-year-old woman was admitted to our institution to characterize an incidentally found mass in the porta hepatis. An episode of pulmonary embolism (18 months ago) and a pulmonary abscess (15 months ago) were reported. The patient had no history of known liver disease, previous cancer diagnosis, or trauma. She underwent total thyroidectomy for goiter several years ago, with initial iatrogenic hypothyroidism treated with levo-thyroxine hormone replacement therapy. During follow-up, this therapy was adjusted (50 µg per day) to induce euthyroidism and to achieve a target serum thyroid-stimulating hormone concentration of 1-2 mIU/L. Physical examination findings were unremarkable. Admission laboratory data were entirely normal, including tumor markers, such as carcinoembryonic antigen and carbohydrate antigen 19-9. Unenhanced and multiphasic contrast-enhanced CT imaging was performed in arterial, portal venous, and delayed (3 minutes after injection) phases. Axial and coronal maximum intensity projection reconstructed CT images were obtained in the arterial and portal venous phases. Because of the imaging findings of the mass in the porta hepatis and concerns about malignancy, the patient underwent endoscopy. Therefore, endoscopic US-guided fine-needle biopsy was performed in the same session. The patient also underwent whole-body iodine 131 (131I) scintigraphy.

Case 306.

HISTORY: A 61-year-old woman was admitted to our institution to characterize an incidentally found mass in the porta hepatis. An episode of pulmonary embolism (18 months ago) and a pulmonary abscess (15 months ago) were reported. The patient had no history of known liver disease, previous cancer diagnosis, or trauma. She underwent total thyroidectomy for goiter several years ago, with initial iatrogenic hypothyroidism treated with levo-thyroxine hormone replacement therapy. During follow-up, this therapy was adjusted (50 µg per day) to induce euthyroidism and to achieve a target serum thyroid-stimulating hormone concentration of 1-2 mIU/L. Physical examination findings were unremarkable. Admission laboratory data were entirely normal, including tumor markers, such as carcinoembryonic antigen and carbohydrate antigen 19-9. Unenhanced (Fig 1) and multiphasic contrast-enhanced CT imaging was performed in arterial (Fig 2A), portal venous (Fig 2B), and delayed (3 minutes after injection) (Fig 2C) phases. Axial and coronal maximum intensity projection reconstructed CT images were obtained in the arterial (Fig 3) and portal venous (Fig 4) phases. Because of the imaging findings of the mass in the porta hepatis and concerns about malignancy, the patient underwent endoscopy. Therefore, endoscopic US-guided fine-needle biopsy was performed in the same session. The patient also underwent whole-body iodine 131 scintigraphy (Fig 5).

Brain magnetic resonance imaging radiomics features associated with hepatic encephalopathy in adult cirrhotic patients.

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.

COVID-19 safety measures at the Radiology Unit of a Transplant Institute: the non-COVID-19 patient's confidence with safety procedures.

PURPOSE: To support the wellbeing of both patients and their families, our aim was to investigate the satisfaction of non-COVID in- and out-patients regarding safety measures implemented at our radiology unit of a transplant institute against COVID infection. MATERIALS AND METHODS: Over a five-month period, adult patients' feedback was obtained by a questionnaire on the fear of contracting COVID-19 during a radiology examination, the perceived delay in treatment, and the following safety measures implemented: modified schedules to limit the number of patients in the waiting area and to maximize social distancing; assistance by staff when visitors were not admitted; cleaning and disinfection of machines; mask wearing and hand hygiene of staff; and staff advice on hand hygiene and infection control precautions. RESULTS: Over a five-month period, our preliminary results (387 patients) showed general patient satisfaction (99.1%) with safety measures applied at our radiology unit. Patients were satisfied with distancing and assistance by staff (100%), cleaning and disinfection (91%), mask wearing and hand hygiene of the staff (97%), and staff advice (94%). There was some criticism of the perceived delay in treatment (7.3%) and in the scheduling of the waiting list (5.4%), with 5.4% fearing contracting the virus. Patients' awareness of safety measures and confidence in the hospital preparedness policy was perceived by all interviewers, and 100% appreciated being questioned. CONCLUSION: The feedback given by the non-COVID patient helps to measure the quality in health care, to improve the quality service, and to protect and satisfy more vulnerable patients, also during the COVID-19 pandemic.

Portal vein puncture-related complications during transjugular intrahepatic portosystemic shunt creation: Colapinto needle set vs Rösch-Uchida needle set.

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.

Radiation exposure during transjugular intrahepatic portosystemic shunt creation in patients with complete portal vein thrombosis or portal cavernoma.

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  ±  5.1 mmHg to 7.5  ±  3.3 mmHg (P <  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.

Unusual venous collateral pathways allow for reperfusion of the intrahepatic portal venous system in children with portal vein thrombosis after split liver transplantation: Clinical relevance and management implications.

PVT is the most frequent vascular complication after LT in small children, and a higher incidence has been observed in those transplanted for biliary atresia or with a LLSG. Thrombosis of the PV causes extrahepatic portal hypertension and is associated with splenomegaly and the development of venous neo-collaterals, including gastro-oesophageal varices and splenorenal shunts. It has also been incidentally suggested in the literature that patients who have had a Roux-en-Y loop for a biliary reconstruction may present with a cavernomatous transformation of the distal portion of the loop. In this study, 13 children with CEPH caused by thrombosis of the PV after LT were analysed. The study evidenced the development of two types of hepatopetal venous networks: (a) a large cavernoma along the Roux loop and around the biliary anastomosis, and (b) a network of neo-collaterals in the gastro-duodeno-pancreatic area that connected to the intrahepatic portal branches directly through the liver capsule. These hepatopetal venous networks between the venous system of the surrounding organs or the omentum and the intrahepatic portal branches can be identified by radiologists. The relevance for the transplanting physician and the transplant surgeon is discussed.

Acute rejection after lung transplantation: association between histopathological and CT findings.

PURPOSE: To evaluate the predictive role of computed tomography (CT) on acute rejection in patients who underwent lung transplantation (LT). MATERIALS AND METHODS: Seventy-eight patients who underwent LT were evaluated in our study. The CT scans were reviewed by three different radiologists, who evaluated the findings potentially associated with acute rejection such as air trapping, tree-in-bud, consolidations, crazy paving, ground-glass opacity, bronchiectasis, thickening of intralobular or interlobular septa and presence of pleural effusion. The association between a tissue diagnosis of acute rejection and the above-mentioned CT findings was assessed using a multivariate model of logistic regression. RESULTS: Based on our results, none of the CT findings included in the study, alone or in combination, showed significant statistical association with the diagnosis of acute rejection. CONCLUSION: CT is a very useful technique for the assessment of lung transplant recipients although it has limited accuracy for the assessment of acute rejection. None of the radiological findings considered in our study was significantly associated with histologically proven acute rejection.

Assessment of cerebral microbleeds by susceptibility-weighted imaging at 3T in patients with end-stage organ failure.

PURPOSE: Cerebral microbleeds (CMBs) are small rounded lesions representing cerebral hemosiderin deposits surrounded by macrophages that results from previous microhemorrhages. The aim of this study was to review the distribution of cerebral microbleeds in patients with end-stage organ failure and their association with specific end-stage organ failure risk factors. MATERIALS AND METHODS: Between August 2015 and June 2017, we evaluated 15 patients, 9 males, and 6 females, (mean age 65.5 years). Patients population was subdivided into three groups according to the organ failure: (a) chronic kidney failure (n = 8), (b) restrictive cardiomyopathy undergoing heart transplantation (n = 1), and (c) end-stage liver failure undergoing liver transplantation (n = 6). The MR exams were performed on a 3T MR unit and the SWI sequence was used for the detection of CMBs. CMBs were subdivided in supratentorial lobar distributed, supratentorial non-lobar distributed, and infratentorial distributed. RESULTS: A total of 91 microbleeds were observed in 15 patients. Fifty-nine CMBs lesions (64.8%) had supratentorial lobar distribution, 17 CMBs lesions (18.8%) had supratentorial non-lobar distribution and the remaining 15 CMBs lesions (16.4%) were infratentorial distributed. An overall predominance of supratentorial multiple lobar localizations was found in all types of end-stage organ failure. The presence of CMBs was significantly correlated with age, hypertension, and specific end-stage organ failure risk factors (p < 0.001). CONCLUSIONS: CMBs are mostly founded in supratentorial lobar localization in end-stage organ failure. The improved detection of CMBs with SWI sequences may contribute to a more accurate identification of patients with cerebral risk factors to prevent complications during or after the organ transplantation.

Intrahepatic mass-forming cholangiocarcinoma: enhancement pattern on Gd-BOPTA-MRI with emphasis of hepatobiliary phase.

PURPOSE: To describe the Gd-BOPTA MRI findings of intrahepatic mass-forming type cholangiocarcinomas (IMCs), with emphasis on the hepatobiliary phase (HBP). METHODS: We reviewed retrospectively 29 IMC patients who underwent Gd-BOPTA-MRI between June, 2004 and June, 2014. Images were acquired prior to, and after, administration of 15-20 mL of Gd-BOPTA in the dynamic phase (arterial phase, portal venous phase, and 3-5 min phase), 10-15-min late phase, and 2-3 h HBP phase. RESULTS: In the dynamic phase, 27 (93%) lesions showed a peripheral rim-like enhancement in the arterial and portal venous phases, followed by progressive filling-in on the delayed images. In 14 (56%) cases, a hypointense peripheral rim was identified in the 10-15-min late phase, delineating a target pattern. In the HBP, the cholangiocarcinoma showed a diffuse, mainly central and inhomogeneous enhancement (cloud of enhancement) in 28 (96%) patients; in 23 (79%) cases, there was an association between cloud appearance and a hypointense peripheral rim, showing a target pattern. CONCLUSIONS: Gd-BOPTA MRI pattern of IMC on dynamic study is similar to that of conventional extracellular agents, that is peripheral enhancement with progressive and concentric filling of contrast material on delayed phases. At 10-15 min delayed phases, IMC shows often a peripheral hypointense rim consistent with a target appearance. In the HBP, due to progressive central enhancement (cloud) and peripheral hypointense rim, an higher number of tumors show a target appearance; this pattern is not specific and would also be expected to be seen in metastases from adenocarcinoma.

Radiomics Analysis of Preprocedural CT Imaging for Outcome Prediction after Transjugular Intrahepatic Portosystemic Shunt Creation.

PURPOSE: To evaluate the role of radiomics in preoperative outcome prediction in cirrhotic patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) using "controlled expansion covered stents". MATERIALS AND METHODS: This retrospective institutional review board-approved study included cirrhotic patients undergoing TIPS with controlled expansion covered stent placement. From preoperative CT images, the whole liver was segmented into Volumes of Interest (VOIs) at the unenhanced and portal venous phase. Radiomics features were extracted, collected, and analyzed. Subsequently, receiver operating characteristic (ROC) curves were drawn to assess which features could predict patients' outcomes. The endpoints studied were 6-month overall survival (OS), development of hepatic encephalopathy (HE), grade II or higher HE according to West Haven Criteria, and clinical response, defined as the absence of rebleeding or ascites. A radiomic model for outcome prediction was then designed. RESULTS: A total of 76 consecutive cirrhotic patients undergoing TIPS creation were enrolled. The highest performances in terms of the area under the receiver operating characteristic curve (AUROC) were observed for the "clinical response" and "survival at 6 months" outcome with 0.755 and 0.767, at the unenhanced and portal venous phase, respectively. Specifically, on basal scans, accuracy, specificity, and sensitivity were 66.42%, 63.93%, and 73.75%, respectively. At the portal venous phase, an accuracy of 65.34%, a specificity of 62.38%, and a sensitivity of 74.00% were demonstrated. CONCLUSIONS: A pre-interventional machine learning-based CT radiomics algorithm could be useful in predicting survival and clinical response after TIPS creation in cirrhotic patients.

Budd-Chiari Syndrome Imaging Diagnosis: State of the Art and Future Perspectives.

Budd-Chiari syndrome (BCS) is a rare hepatic vascular disorder defined by the presence of partial or complete impairment of hepatic venous drainage in the absence of right heart failure or constrictive pericarditis. Several conditions can lead to BCS, from hypercoagulable states to malignancies. Primary BCS is the most common subtype, and usually bartends hypercoagulability states, while secondary BCS involves tumor invasion or extrinsic compression. A combination of clinical and imaging features leads to the diagnosis of BCS, including (1) direct signs: occlusion or compression of the hepatic veins and/or inferior vena cava, and the presence of venous collaterals; (2) indirect signs: morphological hepatic changes with caudate lobe enlargement; inhomogeneous enhancement, and hypervascular nodules. From a clinicopathological point of view, two forms of BCS can be distinguished: acute and subacute/chronic BCS, although asymptomatic and fulminant forms are also possible. Acute presentations are rare, and symptoms include hepatomegaly, ascites, and hepatic insufficiency. Subacute/chronic forms are the most common presentation, with dysmorphic liver and variable degrees of fibrosis deposition. Patients with chronic BCS can develop benign regenerative nodules (large regenerative nodules or FNH [Focal Nodular Hyperplasia]-like lesions), but are also at a higher risk of hepatocellular carcinoma (HCC). The radiologist role is therefore fundamental in both diagnosis and surveillance of BCS. The aim of this review is to present all clinical and imaging signs that can help to reach the diagnosis of BCS, with their clinical significance, providing tips and tricks for the cross-sectional diagnosis of this condition.

Imaging of hepatocellular carcinoma recurrence after liver transplantation.

Liver transplantation (LT) provides the highest survival benefit to patients with unresectable hepatocellular carcinoma (HCC). The Milan criteria have been developed for the selection of LT candidates with the goal of improving survival and maintaining an acceptable risk of HCC recurrence. Despite this, recurrence of HCC after LT occurs in up to 20% of cases and represents a major concern due to the poor prognosis of these patients. Furthermore, several extended criteria for the selection of LT candidates have been proposed to account for the growing demand for organs and the resultant increase in the risk of HCC recurrence. Radiologists should be aware that HCC can recur after LT with multiple organ involvement. Knowledge of the location and radiologic appearance of recurrent HCC is necessary to ensure the choice of the most appropriate therapy. This paper aims to comprehensively summarize the spectrum of HCC recurrence after LT and to examine and discuss the imaging features of these lesions. CRITICAL RELEVANCE STATEMENT: This paper aims to share a review of imaging findings of HCC recurrence after LT and to make radiologists familiar with the spectrum of this disease.

Cognitive outcomes in patients treated with neuromuscular electrical stimulation after coronary artery bypass grafting.

Objective: Mechanisms of neurocognitive injury as post-operative sequelae of coronary artery bypass grafting (CABG) are not understood. The systemic inflammatory response to surgical stress causes skeletal muscle impairment, and this is also worsened by immobility. Since evidence supports a link between muscle vitality and neuroprotection, there is a need to understand the mechanisms by which promotion of muscle activity counteracts the deleterious effects of surgery on long-term cognition. Methods: We performed a clinical trial to test the hypothesis that adding neuromuscular electrical stimulation (NMES) to standard rehabilitation care in post-CABG patients promotes the maintenance of skeletal muscle strength and the expression of circulating neuroprotective myokines. Results: We did not find higher serum levels of neuroprotective myokines, except for interleukin-6, nor better long-term cognitive performance in our intervention group. However, a greater increase in functional connectivity at brain magnetic resonance was seen between seed regions within the default mode, frontoparietal, salience, and sensorimotor networks in the NMES group. Regardless of the treatment protocol, patients with a Klotho increase 3 months after hospital discharge compared to baseline Klotho values showed better scores in delayed memory tests. Significance: We confirm the potential neuroprotective effect of Klotho in a clinical setting and for the first time post-CABG.