Current use of percutaneous image-guided tumor ablation for the therapy of liver tumors: lessons learned from the registry of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) 2018-2022.

OBJECTIVES: Percutaneous image-guided tumor ablation of liver malignancies has become an indispensable therapeutic procedure. The aim of this evaluation of the prospectively managed multinational registry of the voluntary German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) was to analyze its use, technical success, and complications in clinical practice. MATERIALS AND METHODS: All liver tumor ablations from 2018 to 2022 were included. Technical success was defined as complete ablation of the tumor with an ablative margin. RESULTS: A total of 7228 liver tumor ablations from 136 centers in Germany and Austria were analyzed. In total, 31.4% (2268/7228) of patients were female. Median age was 67 years (IQR 58-74 years). Microwave ablation (MWA) was performed in 65.1% (4703/7228), and radiofrequency ablation (RFA) in 32.7% (2361/7228). Of 5229 cases with reported tumor etiology, 60.3% (3152/5229) of ablations were performed for liver metastases and 37.3% (1950/5229) for hepatocellular carcinoma. The median lesion diameter was 19 mm (IQR 12-27 mm). In total, 91.8% (6636/7228) of ablations were technically successful. The rate of technically successful ablations was significantly higher in MWA (93.9%, 4417/4703) than in RFA (87.3%, 2061/2361) (p < 0.0001). The total complication rate was 3.0% (214/7228) and was significantly higher in MWA (4.0%, 189/4703) than in RFA (0.9%, 21/2361, p < 0.0001). Additional needle track ablation did not increase the rate of major complications significantly (24.8% (33/133) vs. 28.4% (23/81), p = 0.56)). CONCLUSION: MWA is the most frequent ablation method. Percutaneous image-guided liver tumor ablations have a high technical success rate, which is higher for MWA than RFA. The complication rate is generally low but is higher for MWA than RFA. CLINICAL RELEVANCE STATEMENT: Percutaneous image-guided liver ablation using microwave ablation and radiofrequency ablation are effective therapeutic procedures with low complication rates for the treatment of primary and secondary liver malignancies. KEY POINTS: • Percutaneous image-guided liver tumor ablations have a high technical success rate, which is higher for microwave ablation than radiofrequency ablation. • Microwave ablation is the most frequent ablation method ahead of radiofrequency ablation. • The complication rate is generally low but is higher for microwave ablation than radiofrequency ablation.

Low bone mineral density is a prognostic factor for elderly patients with HCC undergoing TACE: results from a multicenter study.

OBJECTIVES: Low bone mineral density (BMD) was recently identified as a novel risk factor for patients with hepatocellular carcinoma (HCC). In this multicenter study, we aimed to validate the role of BMD as a prognostic factor for patients with HCC undergoing transarterial chemoembolization (TACE). METHODS: This retrospective multicenter trial included 908 treatment-naïve patients with HCC who were undergoing TACE as a first-line treatment, at six tertiary care centers, between 2010 and 2020. BMD was assessed by measuring the mean Hounsfield units (HUs) in the midvertebral core of the 11th thoracic vertebra, on contrast-enhanced computer tomography performed before treatment. We assessed the influence of BMD on median overall survival (OS) and performed multivariate analysis including established estimates for survival. RESULTS: The median BMD was 145 HU (IQR, 115-175 HU). Patients with a high BMD (≥ 114 HU) had a median OS of 22.2 months, while patients with a low BMD (< 114 HU) had a lower median OS of only 16.2 months (p < .001). Besides albumin, bilirubin, tumor number, and tumor diameter, BMD remained an independent prognostic factor in multivariate analysis. CONCLUSIONS: BMD is an independent predictive factor for survival in elderly patients with HCC undergoing TACE. The integration of BMD into novel scoring systems could potentially improve survival prediction and clinical decision-making. KEY POINTS: • Bone mineral density can be easily assessed in routinely acquired pre-interventional computed tomography scans. • Bone mineral density is an independent predictive factor for survival in elderly patients with HCC undergoing TACE. • Thus, bone mineral density is a novel imaging biomarker for prognosis prediction in elderly patients with HCC undergoing TACE.

Transjugular Intrahepatic Portosystemic Shunt in Patients with Portal Hypertension: Patency Depends on Coverage and Interventionalist's Experience.

BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice in decompensated portal hypertension. TIPS revision due to thrombosis or stenosis increases morbidity and mortality. Our aim was to investigate patient- and procedure-associated risk factors for TIPS-revision. PATIENTS AND METHODS: We retrospectively evaluated 189 patients who underwent the TIPS procedure. Only patients who required TIPS revision within 1 year (Group I, 34 patients) and patients who did not require re-intervention within the first year (Group II [control group], 54 patients) were included. RESULTS: Out of 88 patients, the majority were male (69.3%) and mean age was 56 ± 11 years. Indications for TIPS were refractory ascites (68%), bleeding (24%), and Budd-Chiari syndrome (8%). The most frequent liver disease was alcohol-induced cirrhosis (60%). Forty-three patients (49%) received bare and 45 patients (51%) covered stents, thus resulting in reduction of hepatic venous pressure gradient (HVPG) from 19.0 to 9.0 mm Hg. When comparing patient- and procedure-related factors, the type of stent (p < 0.01) and interventionalist's experience (number of performed TIPS implantations per year; p < 0.05) were the only factors affecting the risk of re-intervention due to stent dysfunction, while age, gender, indication, Child-Pugh, and model of end-stage liver disease score, platelet count, pre- and post-HVPG, additional variceal embolization, stent diameter, and number of stents did not significantly differ. CONCLUSION: Patients undergoing TIPS procedure should be surveilled closely for shunt dysfunction while covered stents and high-level experience are associated with increased -patency.

Liver maximum capacity (LiMAx) test as a helpful prognostic tool in acute liver failure with sepsis: a case report.

BACKGROUND: Acute liver failure (ALF) is a life-threatening entity particularly when infectious complications worsen the clinical course. Urgent liver transplantation (LT) is frequently the only curative treatment. However, in some cases, recovery is observed under conservative treatment. Therefore, prognostic tools for estimating course of the disease are of great clinical interest. Since laboratory parameters sometimes lack sensitivity and specificity, enzymatic liver function measured by liver maximum capacity (LiMAx) test may offer novel and valuable additional information in this setting. CASE PRESENTATION: We here report the case of a formerly healthy 20-year old male caucasian patient who was admitted to our clinic for ALF of unknown origin in December 2017. Laboratory parameters confirmed the diagnosis with an initial MELD score of 28 points. Likewise, enzymatic liver function was significantly impaired with a value of 147 [> 315] µg/h/kg. Clinical and biochemical analyses for viral-, autoimmune-, or drug-induced hepatitis were negative. Liver synthesis parameters further deteriorated reaching a MELD score of 40 points whilst clinical course was complicated by septic pneumonia leading to severe hepatic encephalopathy grade III-IV, finally resulting in mechanical ventilation of the patient. Interestingly, although clinical course and laboratory data suggested poor outcome, serial LiMAx test revealed improvement of the enzymatic liver function at this time point increasing to 169 µg/h/kg. Clinical condition and laboratory data slowly improved likewise, however with significant time delay of 11 days. Finally, the patient could be dismissed from our clinic after 37 days. CONCLUSION: Estimating prognosis in patients with ALF is challenging by use of the established scores. In our case, improvement of enzymatic liver function measured by the LiMAx test was the first parameter predicting beneficial outcome in a patient with ALF complicated by sepsis.

Hepatic artery and biliary complications in liver transplant recipients with radioembolization bridging treatment for hepatocellular carcinoma.

BACKGROUND: Locoregional bridging treatments are commonly applied in patients with hepatocellular carcinoma (HCC) prior to liver transplantation to prevent tumor progression during waiting time. It remains unknown whether pre-transplant radioembolization treatment may increase the prevalence of hepatic artery and biliary complications post-transplant. METHODS: We performed a retrospective review of 173 consecutive patients with HCC who underwent liver transplantation at our transplant center between January 2007 and December 2016. RESULTS: Radioembolization bridging treatment was applied in 42 patients while 131 patients received other or no forms of bridging treatment. The overall prevalence of intra-operative and early post-operative hepatic artery complications was 9.5% in the radioembolization group and 9.2% in the control group (P = 1.000). Biliary complications were significantly less frequent in the radioembolization group (4.8% vs 17.6%, P = .0442). In multivariable analysis, radioembolization was not significantly associated with an increased risk of arterial complications. Considering biliary complications, radioembolization bridging treatment was the only factor significantly associated with decreased odds (OR 0.187 (0.039, 0.892), P = .036). CONCLUSIONS: Radioembolization is not associated with higher odds of hepatic artery complications following liver transplantation. There may even be a protective effect regarding biliary complications. Radioembolization as a bridge to transplantation may effectively be applied without compromising successful liver transplantation.

Rescue therapy of a refractory rectal variceal bleeding in a cirrhotic patient by Linton-Nachlas tube and TIPS implantation in combination with variceal embolization.

Background Transjugular intrahepatic portosystemic shunt (TIPS) is considered the gold standard for treatment of gastrointestinal variceal bleeding refractory to endoscopic therapy in patients with portal hypertension. Clinically relevant hemorrhage from rectal varices is less frequent than from other sources, and the therapeutic role of TIPS is still ambiguous. Case report A 57-year-old female patient was referred to us in December 2015 with severe signs of decompensated alcohol-induced liver cirrhosis. During hospitalization, she presented with recurrent hematochezia from rectal varices following electrosurgical snare removal of a rectal adenoma. Endoscopic treatment with hemoclips, epinephrine and fibrin glue injections, and thermocoagulation failed to permanently stop the bleeding. Recurrent hemorrhage led to a further deterioration of liver function and clinical status of the patient. After a total of 3 endoscopic treatment attempts, hemostasis was achieved by transanal placement of a Linton-Nachlas balloon tube. Additionally, TIPS implantation with embolization of the rectal varices was performed successfully 24 hours after tube insertion, resulting in reduction of the portosystemic pressure gradient from 24 to 12 mmHg. Subsequently, the patient recovered clinically, hemopressin and catecholamine treatment was discontinued, and liver function test as well as serum hemoglobin levels improved. No further blood transfusions were required. Conclusion In this patient, rescue therapy with balloon compression and TIPS implantation in combination with variceal embolization in a cirrhotic patient with refractory rectal variceal bleeding was effective. To our knowledge, it is the first description of this specific therapeutic approach.

7 Tesla quantitative hip MRI: T1, T2 and T2* mapping of hip cartilage in healthy volunteers.

OBJECTIVES: To evaluate the technical feasibility and applicability of quantitative MR techniques (delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), T2 mapping, T2* mapping) at 7 T MRI for assessing hip cartilage. METHODS: Hips of 11 healthy volunteers were examined at 7 T MRI with an 8-channel radiofrequency transmit/receive body coil using multi-echo sequences for T2 and T2* mapping and a dual flip angle gradient-echo sequence before (T10) and after intravenous contrast agent administration (T1Gd; 0.2 mmol/kg Gd-DTPA(2-) followed by 0.5 h of walking and 0.5 h of rest) for dGEMRIC. Relaxation times of cartilage were measured manually in 10 regions of interest. Pearson's correlations between R1delta = 1/T1Gd - 1/T10 and T1Gd and between T2 and T2* were calculated. Image quality and the delineation of acetabular and femoral cartilage in the relaxation time maps were evaluated using discrete rating scales. RESULTS: High correlations were found between R1delta and T1Gd and between T2 and T2* relaxation times (all p < 0.01). All techniques delivered diagnostic image quality, with best delineation of femoral and acetabular cartilage in the T2* maps (mean 3.2 out of a maximum of 4 points). CONCLUSIONS: T1, T2 and T2* mapping of hip cartilage with diagnostic image quality is feasible at 7 T. To perform dGEMRIC at 7 T, pre-contrast T1 mapping can be omitted. KEY POINTS: • dGEMRIC of hip cartilage with diagnostic image quality is feasible at 7 T. • To perform dGEMRIC at 7 T, pre-contrast T1 mapping can be omitted. • T2(*) mapping of hip cartilage with diagnostic image quality is feasible at 7 T. • T2 and T2* relaxation times of cartilage were highly correlated at 7 T. • Best delineation of femoral and acetabular cartilage was found in T2* maps.

Morphological imaging and T2 and T2* mapping of hip cartilage at 7 Tesla MRI under the influence of intravenous gadolinium.

OBJECTIVES: To investigate the influence of intravenous gadolinium on cartilage T2 and T2* relaxation times and on morphological image quality at 7-T hip MRI. METHODS: Hips of 11 healthy volunteers were examined at 7 T. Multi-echo sequences for T2 and T2* mapping, 3D T1 volumetric interpolated breath-hold examination (VIBE) and double-echo steady-state (DESS) sequences were acquired before and after intravenous application of gadolinium according to a delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) protocol. Cartilage relaxation times were measured in both scans. Morphological sequences were assessed quantitatively using contrast ratios and qualitatively using a 4-point Likert scale. Student's t-test, Pearson's correlation (ρ) and Wilcoxon sign-rank test were used for statistical comparisons. RESULTS: Pre- and post-contrast T2 and T2* values were highly correlated (T2: acetabular: ρ = 0.76, femoral: ρ = 0.77; T2*: acetabular: ρ = 0.80, femoral: ρ = 0.72). Gadolinium enhanced contrasts between cartilage and joint fluid in DESS and T1 VIBE according to the qualitative (p = 0.01) and quantitative (p < 0.001) analysis. The delineation of acetabular and femoral cartilage and the labrum predominantly improved with gadolinium. CONCLUSIONS: Gadolinium showed no relevant influence on T2 or T2* relaxation times and improved morphological image quality at 7 T. Therefore, morphological and quantitative sequences including dGEMRIC can be conducted in a one-stop-shop examination. KEY POINTS: • Hip cartilage T2 values correlate highly before and after gadolinium at 7 T • Hip cartilage T2* values correlate highly before and after enhancement at 7 T • Morphological hip cartilage imaging benefits from intravenous gadolinium at 7 T • The delineation of acetabular and femoral cartilage can be improved by gadolinium • Morphological and quantitative sequences including dGEMRIC can be combined as a one-stop-shop examination.

7 Tesla quantitative hip MRI: a comparison between TESS and CPMG for T2 mapping.

OBJECTIVES: We aimed to evaluate the feasibility of triple-echo steady state (TESS) T2 mapping as an alternative to conventional multi-echo-spin-echo (CPMG) T2 mapping for the quantitative assessment of hip joint cartilage at 7 T. MATERIALS AND METHODS: A total of eight healthy volunteers and three patients were included. Reproducibility of both techniques was evaluated in five volunteers in five scans each. T2 relaxation times were measured by manually drawing regions of interest in multiple regions of the hip joint. Data from both methods were compared using Pearson correlation coefficient, intra-class correlation coefficient, and coefficient of repeatability. The overall image quality and presence of artifacts was assessed. RESULTS: Cartilage transplant and surrounding fluid were well depicted by both methods. Compared to CPMG, TESS provided systematically reduced T2 values (43.3 ± 7.3 vs. 19.2 ± 5.5 ms for acetabular cartilage, and 41.4 ± 5.6 vs. 21.7 ± 5.2 ms for femoral cartilage), in line with previously reported values. No correlation between both methods was found. TESS yielded a slightly better reproducibility than CPMG, while CPMG showed pronounced sensitivity to B1 inhomogeneities. CONCLUSION: TESS seems to be an attractive alternative to CPMG for improvements in quantitative hip joint imaging at 7 T, allowing shortening of the total acquisition time paired with insensitivity to B1, while rendering comparable image quality with good repeatability.

3 Tesla high-resolution and delayed gadolinium enhanced MR imaging of cartilage (dGEMRIC) after autologous chondrocyte transplantation in the hip.

BACKGROUND: To evaluate the feasibility of 3 Tesla (T) high-resolution and gadolinium enhanced MRI of cartilage (dGEMRIC) in the thin and rounded hip cartilage of patients after acetabular matrix-based autologous chondrocyte transplantation (MACT). METHODS: Under general ethics approval, 24 patients were prospectively examined 6-31 months after acetabular MACT at 3T using high-resolution proton-density weighted (PDw) images (bilateral PD SPACE, 0.8 mm isotropic; unilateral PD-TSE coronal/sagittal, 0.8 × 0.8 resp. 0.5 × 0.5 × 2.5 mm) as well as T1 mapping (3D-FLASH, 0.78 mm isotropic) in dGEMRIC technique, and clinically scored. The cartilage transplant was evaluated using an adapted MOCART score (maximum 85 points). T1 relaxation times were measured independently by two radiologists. Here, regions of interest were placed manually in automatically calculated relaxation-maps, both in the transplant and adjacent healthy cartilage regions. Interobserver reliability was estimated by means of intraclass-correlation (ICC). RESULTS: The transplant was morphologically definable in the PDw images of 23 patients with a mean MOCART score of 69 points (60-80 points, SD 6.5). T1 maps showed a clear differentiation between acetabular and femoral cartilage, but correlation with PDw images was necessary to identify the transplant. Mean T1 relaxation times of the transplant were 616.3 ms (observer 1) resp. 610.1 ms (observer 2), and of adjacent healthy acetabular cartilage 574.5 ms (observer 1) resp. 604.9 ms (observer 2). Interobserver reliability of the relaxation times in the transplant was excellent (ICC-coefficient 0.88) and in adjacent healthy regions good (0.77). CONCLUSION: High-resolution PDw imaging with adapted MOCART scoring and dGEMRIC is feasible after MACT in the thin and rounded hip cartilage.

Impact of dual-energy CT prior to radioembolization (RE).

BACKGROUND: Depiction of the exact arterial liver anatomy as well as identifying potential extrahepatic non-target vessels is crucial for a successful preparation of radioembolization (RE). PURPOSE: To compare the diagnostic impact of dual-energy computed tomography (DECT) to digital subtraction angiography prior to RE. MATERIAL AND METHODS: DECT was applied in 46 patients with hepatocellular carcinoma (HCC) prior to RE. Eighty kV DE as well as reconstructed 120 kV equivalent DE datasets were evaluated in comparison to correlating digital subtraction angiography (DSA) datasets. Two radiologists evaluated in consensus the delineation of liver arteries and extrahepatic non-target vessels utilizing a 4-point scale (4 = excellent delineation; 1 = non-diagnostic). In addition, the arterial vascularization of liver segment IV was evaluated and classified: signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR; liver arteries to adjacent liver tissue) were obtained via ROI analysis. RESULTS: Both imaging techniques (DECT, DSA) enabled high-quality assessment of all analyzed liver arteries. Out of the two CT datasets, 80 kVp-DE datasets offered superior delineation of the right gastric artery (3.5 ± 0.7 vs. 2.5 ± 0.5), the vascularization of segment IV (3.9 ± 0.2 vs. 3.3 ± 0.5) as well as potential extrahepatic non-target vessels (3.9 ± 0.1 vs. 3.3 ± 0.5). In accordance to the results of the qualitative analysis, 80 kVp-DE datasets also yielded higher SNR (34.84 vs. 29.31) and CNR (28.29 vs. 21.8) values in comparison to the 120 kVp datasets. CONCLUSION: Eighty kVp DECT enables a significantly better assessment of the arteries of the upper abdomen for therapy planning in comparison to correlating 120 kVp datasets. This may allow for identification of potential extrahepatic non-target vessels and assessment of target volume for therapy planning prior to DSA.

Aspects of postoperative magnetic resonance imaging of patients with avascular necrosis of the femoral head, treated by advanced core decompression.

OBJECTIVE: To analyze remodeling processes after advanced core decompression (ACD) in patients with avascular femoral head necrosis by means of 3T MRI and to identify indicators for clinical outcome considering the defect size and characteristics of the bone graft and of the neighboring regeneration tissue. MATERIALS AND METHODS: Thirty-four hips, with preexisting preoperative MRIs in 21 cases, were examined 1-34 months (mean 12.7) postoperatively by 3T MRI. The volume of necrosis was measured manually pre- and postoperatively to calculate absolute as well as percentage necrosis reduction. The signal intensity of the bone graft was quantified using a 4-point scale. Border phenomena between the bone graft and bone were described and classified into groups. Wilcoxon sign-rank test was used to identify correlations between the analyzed items and clinical signs of femoral head collapse after a mean follow-up time of 28.6 months (10.4-46.8). RESULTS: Mean percentage reduction of necrosis was significantly higher in asymptomatic patients (59.36%) compared to patients with signs of femoral head collapse (28.78%, p = 0.008). Signal intensity of the bone graft increased in T1w and T2w TIRM sequences over time after surgery and was significantly higher in asymptomatic patients. Five border phenomena between the bone graft and healthy bone were identified. Among them, the so-called "rail sign" representing three layers of remodeling tissue correlated with the histological observations. CONCLUSION: A variety of border phenomena representing remodeling processes have been described using 3T MRI. Beneath the percentage amount of necrosis reduction, we identified the signal intensity of the bone graft as an indicator for clinical outcome.

Usefulness of metal artifact reduction with WARP technique at 1.5 and 3T MRI in imaging metal-on-metal hip resurfacings.

OBJECTIVE: To evaluate the usefulness of the metal artifact reduction technique "WARP" in the assessment of metal-on-metal hip resurfacings at 1.5 and 3T in the context of image quality and imaging speed. MATERIALS AND METHODS: Nineteen patients (25 hip resurfacings) were randomized for 1.5 and 3T MRI, both including T1 and T2 turbo spin-echo as well as turbo inversion recovery magnitude sequences with and without view angle tilting and high bandwidth. Additional 3T sequences were acquired with a reduced number of averages and using the parallel acquisition technique for accelerating imaging speed. Artifact size (diameter, area), image quality (5-point scale) and delineation of anatomical structures were compared among the techniques, sequences and field strengths using the Wilcoxon sign-rank and paired t-test with Bonferroni correction. RESULTS: At both field strengths, WARP showed significant superiority over standard sequences regarding image quality, artifact size and delineation of anatomical structures. At 3T, artifacts were larger compared to 1.5T without affecting diagnostic quality, and scanning time could be reduced by up to 64 % without quality degradation. CONCLUSION: WARP proved useful in imaging metal-on-metal hip resurfacings at 1.5T as well as 3T with better image quality surrounding the implants. At 3T imaging could be considerably accelerated without losing diagnostic quality.

Contrast-enhanced time-resolved 4D MRA of congenital heart and vessel anomalies: image quality and diagnostic value compared with 3D MRA.

OBJECTIVES: To evaluate time-resolved interleaved stochastic trajectories (TWIST) contrast-enhanced 4D magnetic resonance angiography (MRA) and compare it with 3D FLASH MRA in patients with congenital heart and vessel anomalies. METHODS: Twenty-six patients with congenital heart and vessel anomalies underwent contrast-enhanced MRA with both 3D FLASH and 4D TWIST MRA. Images were subjectively evaluated regarding total image quality, artefacts, diagnostic value and added diagnostic value of 4D dynamic imaging. Quantitative comparison included signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and vessel sharpness measurements. RESULTS: Three-dimensional FLASH MRA was judged to be significantly better in terms of image quality (4.0 ± 0.6 vs 3.4 ± 0.6, P < 0.05) and artefacts (3.8 ± 0.4 vs 3.3 ± 0.5, P < 0.05); no difference in diagnostic value was found (4.2 ± 0.4 vs 4.0 ± 0.4); important additional functional information was found in 21/26 patients. SNR and CNR were higher in the pulmonary trunk in 4D TWIST, but slightly higher in the systemic arteries in 3D FLASH. No difference in vessel sharpness delineation was found. CONCLUSIONS: Although image quality was inferior compared with 3D FLASH MRA, 4D TWIST MRA yields robust images and added diagnostic value through dynamic acquisition was found. Thus, 4D TWIST MRA is an attractive alternative to 3D FLASH MRA. KEY POINTS: • New magnetic resonance angiography (MRA) techniques are increasingly introduced for congenital cardiovascular problems. • Time-resolved angiography with interleaved stochastic trajectories (TWIST) is an example. • Four-dimensional TWIST MRA provided inferior image quality compared to 3D FLASH MRA but without significant difference in vessel sharpness. • Four-dimensional TWIST MRA gave added diagnostic value.

No Differences in Rotational Thromboelastometry Measurements between Portal and Peripheral Circulation in Cirrhotic Patients Undergoing TIPS.

BACKGROUND: In patients with liver cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) is considered a standardized treatment of refractory ascites or variceal bleeding. TIPS thrombosis (TT) and/or portal vein thrombosis (PVT) are possible complications during/after TIPS placement. Previous studies suggested increased clotting activity in portal circulation (PORC). This pilot study aimed to evaluate alterations and differences of coagulation function in PORC and in peripheral circulation (PERC) via rotational thromboelastometry during TIPS. METHODS: Blood samples were collected from cirrhotic patients (n = 13; median Model of End Stage Liver Disease, MELD Score: 12; median age: 60 years) undergoing TIPS (10/13 TIPSs were elective procedures due to refractory ascites) as follows: median cubital vein (MCV; PERC)-confluence of the three hepatic veins to the inferior cava vein (HV/ICV; PORC)-portal vein (PV; PORC)-TIPS (PORC). This research utilized four variables of the extrinsic test EXTEM, i.e., clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), and maximum lysis (ML). RESULTS: EXTEM results [mean, M (range) ± standard deviation, SD (range)] showed no significant differences for CT [M (70-73) ± SD (9-13); p = 0.93] or CFT [M (137-155) ± SD (75-112); p = 0.97] or MCF [M (51-54) ± SD (9-10); p = 0.90] or ML [M (9-10) ± SD (4-5); p = 0.89] between the compartments, i.e., MCV vs. HV/ICV vs. PV vs. TIPS. Overall, we detected no differences in coagulation function between PERC and PORC. CONCLUSION: These results are in contrast to previous reports suggesting increased clotting activity in PORC vs. PERC in association with liver cirrhosis. Rotational thromboelastometry-based evaluation of coagulation function in PERC appears to reliably reflect coagulation function in PORC with respect to risk estimation for TT and/or PVT in cirrhotic patients undergoing TIPS.

Preoperative Computed Tomography Volumetry and Graft Weight Estimation of Left Lateral Segment in Pediatric Living Donor Liver Transplant.

OBJECTIVES: Liver volumetry based on a computed tomography scan is widely used to estimate liver volume before any liver resection, especially before living donorliver donation. The 1-to-1 conversion rule for liver volume to liver weight has been widely adopted; however, debate continues regarding this approach. Therefore, we analyzed the relationship between the left-lateral lobe liver graft volume and actual graft weight. MATERIALS AND METHODS: This study retrospectively included consecutive donors who underwent left lateral hepatectomy for pediatric living donor liver transplant from December 2008 to September 2020. All donors were healthy adults who met the evaluation criteria for pediatric living donor liver transplant and underwent a preoperative contrast-enhanced computed tomography scan. Manual segmentation of the leftlateral liverlobe for graft volume estimation and intraoperative measurement of an actual graft weight were performed. The relationship between estimated graft volume and actual graft weight was analyzed. RESULTS: Ninety-four living liver donors were included in the study. The mean actual graft weight was ~283.4 ± 68.5 g, and the mean graft volume was 244.9 ± 63.86 mL. A strong correlation was shown between graft volume and actual graft weight (r = 0.804; P < .001). Bland-Altman analysis revealed an interobserver agreement of 38.0 ± 97.25, and intraclass correlation coefficient showed almost perfect agreement(r = 0.840; P < .001). The conversion formula for calculating graft weight based on computed tomography volumetry was determined based on regression analysis: 0.88 × graft volume + 41.63. CONCLUSIONS: The estimation of left liver graft weight using only the 1-to-1 rule is subject to measurable variability in calculated graft weights and tends to underestimate the true graft weight. Instead, a different, improved conversion formula should be used to calculate graft weight to more accurately determine donor graft weight-to-recipient body weightratio and reduce the risk of underestimation of liver graft weightin the donor selection process before pediatric living donor liver transplant.

Bilobar Radioembolization Carries the Risk of Radioembolization-Induced Liver Disease in the Treatment of Advanced Hepatocellular Carcinoma: Safety and Efficacy Comparison to Systemic Therapy with Atezolizumab/Bevacizumab.

Recommended treatment options for advanced-stage hepatocellular carcinoma (HCC) include systemic therapy (ST) and trans-arterial radioembolization (TARE) with Yttrium-90 (Y90). Before the approval of immune-checkpoint inhibitors, a similar safety profile was reported for TARE and ST with tyrosine kinase inhibitors (TKI). However, whole-liver treatment and underlying cirrhosis were identified as risk factors for potentially lethal radioembolization-induced liver disease (REILD). Therefore, the safety and efficacy of TARE and ST with atezolizumab/bevacizumab were compared in patients with advanced HCC involving at least both liver lobes in a retrospective real-world cohort. In total, 74 patients with new or recurrent advanced-stage HCC (BCLC stage B/C) were included if treated with either bilobar TARE (n = 33) or systemic combination therapy with atezolizumab plus bevacizumab (n = 41). Most patients had compensated liver function (90.5% were classified as Child-Pugh Score A, 73% as ALBI Grade 1) at baseline. Although not significant, patients treated with ST showed a more prolonged overall survival than those treated with Y90 TARE (7.1 months vs. 13.0 months, p = 0.07). While a similar disease control rate could be achieved with bilobar TARE and atezolizumab/bevacizumab, in the TARE group, overall survival was curtailed by the occurrence of REILD. In patients with underlying liver cirrhosis, the liver function at baseline was a predictor for REILD.

Selective internal radiation therapy of hepatocellular carcinoma: potential hepatopulmonary shunt reduction after sorafenib administration.

Sorafenib, a protein kinase inhibitor, is a systemic drug that has been licensed for the treatment of hepatocellular carcinoma (HCC). This retrospective study assessed whether the administration of sorafenib can result in a reduction of the hepatopulmonary shunt (HPS) before selective internal radiation therapy (SIRT). After exclusion from SIRT because of high HPS, computed tomography scan indicated a shunt reduction in seven patients with HCC receiving sorafenib. Repeated measurements revealed HPS reduction (from 26.5% to 7.5% on average), and subsequent SIRT became possible. In conclusion, sorafenib may reduce HPS in patients with advanced HCC in some cases.

Bridging treatment prior to liver transplantation for hepatocellular carcinoma: radioembolization or transarterial chemoembolization?

BACKGROUND: In hepatocellular carcinoma (HCC) patients, intraarterial therapies are regularly employed as a bridge to liver transplantation to prevent tumor progression during waiting time. Objective of this study was to compare HCC recurrence after liver transplantation following TACE or radioembolization bridging treatment. METHODS: We retrospectively analyzed prospectively collected data on 131 consecutive HCC patients who underwent liver transplantation between January 2007 and December 2017 at our liver transplant center (radioembolization n = 44, TACE n = 87). Multivariable logistic regression and cox proportional hazard regression models were used to evaluate factors associated with tumor recurrence and post-transplant survival. RESULTS: Between groups, patients were comparable with regards to age and gender. In the radioembolization group, Milan criteria for HCC were met significantly less frequently (20.5% vs. 65.5%, p < 0.0001). Patients in the radioembolization group required significantly fewer intraarterial treatments (1 [1-2] vs. 1 [1-7], p = 0.0007). On explant specimen, tumor differentiation, microvascular invasion and tumor necrosis were comparable between the groups. HCC recurrence and overall survival were similar between the groups. Multivariable analysis detected increasing recipient age, male gender, complete tumor necrosis and absence of microvascular invasion being independently associated with decreased odds for HCC recurrence. Increasing model of end-stage liver disease (MELD) score and tumor recurrence were independently associated with increased odds of post-transplant death. CONCLUSIONS: Intraarterial bridging treatment leading to tumor necrosis may not only prevent waitlist drop-out but also facilitate long-term successful liver transplantation in HCC patients. Both radioembolization and TACE represent potent treatment strategies.

Radiation Dose Aspects of Hepatic Artery Infusion Chemotherapy in Uveal Melanoma Patients with Liver Metastases.

PURPOSE: In uveal melanoma patients, liver metastases can be treated by hepatic artery infusion chemotherapy (HAIC). During this procedure, melphalan or, less frequently, fotemustine is infused into the hepatic artery or the hepatic lobe arteries in regularly repeated interventions to achieve local tumor control. The aim of this study was to investigate the radiation exposure of HAIC. MATERIAL AND METHODS: In this retrospective study, dose data from 841 procedures in 140 patients (mean age 65.3 ± 9.9 years, 74 female) who underwent HAIC between 06/2017 and 10/2021 at one of three different angiography systems were analyzed. RESULTS: In the overall population, dose area product (DAP) (median (IQR)) was 1773 cGy·cm2 (884-3688). DAP was significantly higher in the first intervention, where a complete diagnostic workup of the vasculature was performed, than in follow-up interventions: 5765 cGy·cm2 (3160-8804) versus 1502 cGy·cm2 (807-2712) (p < 0.0001). DAP also increased significantly with the number of infusion positions (median, (IQR)): one position 1301 cGy·cm2 (633-2717), two positions 1985 cGy·cm2 (1118-4074), three positions 6407 cGy·cm2 (2616-11590) (p < 0.0001). CONCLUSION: In uveal melanoma patients with liver metastases undergoing HAIC, radiation exposure is significantly higher both at the first intervention compared to follow-up interventions, but also with increasing number of infusion positions.