Covered Transjugular Intrahepatic Portosystemic Shunt Improves Hypersplenism-Associated Cytopenia in Cirrhosis.

BACKGROUND: Patients with cirrhosis often develop portal hypertension-associated splenomegaly and hypersplenism, potentially causing severe cytopenia. AIMS: Systematic assessment on the impact of transjugular intrahepatic portosystemic shunt (TIPS) implantation on platelet count (PLT), hemoglobin (Hb), and white blood cell count (WBC). METHODS: Patients with cirrhosis undergoing covered TIPS implantation were retrospectively included. Patients with malignancies or hematologic disorders were excluded. Hematology lab work was recorded at baseline (pre-TIPS) and at regular intervals after TIPS. RESULTS: One hundred ninety-two patients (male: 72.4%, age: 56 ± 10 years; MELD: 12.1 ± 3.6) underwent TIPS implantation. Higher-grade (≥ G2) thrombocytopenia (PLT < 100 G/L) was present in 54 (28.7%), ≥ G2 anemia (Hb < 10 g/dL) in 57 (29.7%), and ≥ G2 leukopenia (WBC < 2 G/L) in 3 (1.6%) patients pre-TIPS, respectively. Resolution of ≥ G2 thrombocytopenia, anemia, and leukopenia occurred in 24/55 (43.6%), 23/57 (40.4%), and 2/3 (66.7%), respectively. Similar results were also observed in the subgroup of patients without 'bleeding' TIPS-indication, with improvements of G ≥ 2 thrombocytopenia and of G ≥ 2 anemia in 19.8% and 10.2% of patients after TIPS, respectively. CONCLUSIONS: Thrombocytopenia, anemia, and leukopenia frequently improved after TIPS. Therefore, moderate- to higher-grade thrombocytopenia should not be regarded as a contraindication against TIPS, but rather be considered in case of severe thrombocytopenia-particularly prior to surgery or interventions.

Stent-graft surface movement after endovascular aneurysm repair: baseline parameters for prediction, and association with migration and stent-graft-related endoleaks.

OBJECTIVES: To evaluate the influence of baseline parameters on the occurrence of stent-graft surface movement after endovascular aneurysm repair (EVAR) and to investigate its association with migration and stent-graft-related endoleaks (srEL). METHODS: In this retrospective, cross-sectional study, three-dimensional surface models of the stent-graft, delimited by landmarks using custom-built software, were derived from the pre-discharge and last follow-up computed tomography angiography (CTA). Stent-graft surface movement in the proximal anchoring zone between these examinations was considered significant at a threshold of 9 mm. The Cox proportional hazards model was used to determine baseline variables associated with the occurrence of stent-graft surface movement. The association between migration and srEL with stent-graft surface movement was tested with the chi-square and the Fisher exact test, respectively. RESULTS: Stent-graft surface movement was observed in 54 (28.9%) of 187 patients. Multivariate analysis revealed that age ([HR] 1.05; p = 0.017), proximal neck diameter ([HR] 5.07; p < 0.001), infrarenal aortic neck angulation ([HR] 1.02, p = 0.002), and proximal neck length ([HR] 0.62, p < 0.001) were significantly associated with the occurrence of stent-graft surface movement. Migration and srEL occurred in 17 (31.5%) and 5 (9.3%) patients, with and 11 (8.3%) and 2 (1.5%) without stent-graft surface movement (p < 0.001, p = 0.022). CONCLUSIONS: Age, neck diameter, infrarenal neck angulation, and proximal neck length were significantly associated with the occurrence of stent-graft surface movement. Apart from possible use of adjunctive sealing systems, concerned patients may benefit from regular CTA surveillance, enabling timely diagnosis of subtle changes of stent-graft position. KEY POINTS: • Stent-graft surface movement, demonstrating subtle, three-dimensional changes in stent-graft position in the proximal anchoring zone, can be derived from CTA examinations. • Age, proximal neck diameter, and infrarenal neck angulation were significantly associated with an increased incidence of stent-graft surface movement. Stent-graft surface movement is significantly more frequent in patients with stent-graft migration and stent-graft-related endoleaks. • Consideration of risk factors for stent-graft surface movement may help to identify patients who might benefit from regular CTA surveillance and timely diagnosis of subtle changes of stent-graft position, enabling re-interventions to prevent migration and srEL.

Application of Baseline Clinical and Morphological Parameters for Prediction of Late Stent Graft Related Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysm.

OBJECTIVES: To evaluate the influence of baseline clinical and morphological parameters on the occurrence of a late stent graft related endoleak (srEL; types 1 and 3) after endovascular aneurysm repair (EVAR). METHODS: This is a retrospective case control study of patients who were routinely followed up after EVAR of abdominal aortic aneurysms. Pre-interventional, pre-discharge, and last available multislice computed tomography angiogram (MSCTA) of 279 patients were analysed. Stent graft related endoleaks detected by follow up MSCTA at least six months after EVAR were specified as late srEL. Baseline demographic characteristics and morphological variables were derived from the pre-interventional and pre-discharge MSCTA. Univariable and multivariable analysis with a Cox proportional hazards model were used to determine baseline factors associated with the occurrence of a late srEL. RESULTS: Twenty-four (8.6%) of 279 patients suffered a late srEL, during a mean MSCTA follow up of 30.9 ± 25.8 (23.5, IQR 10.6-42.8) months. In the univariable analysis, age (hazard ratio [HR] 1.09; p = .001), female sex (HR 3.25; p = .014), right iliac sealing diameter (HR 10.04; p = .03), left iliac sealing diameter (HR 8.65; p = .001), infrarenal aortic neck angulation (HR 1.02; p = .011), and suprarenal fixation level (HR 3.47; p = .014) were significantly associated with an increased incidence of late srEL. Age (HR 1.08; p = .012), female sex (HR 2.72; p = .049), and left iliac sealing diameter (HR 4.48; p = .033) proved to be risk factors significantly associated with a higher incidence of late srEL in multivariable analysis. CONCLUSIONS: Older patients, those with female gender, and those with larger left iliac sealing diameters seem to experience higher rates of late srEL. Independent confirmation of these must be addressed in larger studies.

ePTFE-TIPS vs repetitive LVP plus albumin for the treatment of refractory ascites in patients with cirrhosis.

BACKGROUND & AIMS: Reduction in portal pressure by self-expandable polytetrafluoroethylene (ePTFE)-covered transjugular intrahepatic portosystemic shunts (TIPS) is a treatment option for refractory ascites. Data on clinical outcomes after ePTFE-TIPS vs repetitive large-volume paracentesis (LVP) plus albumin (A) administration for the treatment of patients with refractory ascites are limited. METHODS: Retrospective comparison of ePTFE-TIPS vs LVP+A in terms of (i) control of ascites, (ii) occurrence of overt hepatic encephalopathy (HE) and (iii) transplant-free survival in cirrhotic patients with refractory ascites. RESULTS: Among n = 221 patients with cirrhosis and refractory ascites, n = 140 received ePTFE-TIPS and were compared to n = 71 patients undergoing repetitive LVP+A. After ePTFE-TIPS, ascites was controlled without any further need for paracentesis in n = 76 (54%; n = 7 without and n = 69 with diuretics). The need for frequent large-volume paracentesis was significantly higher in the LVP+A group than with ePTFE-TIPS (median 0.67 (IQR: 0.23-2.63) months vs 49.5 (IQR: 5.07-102.60) months until paracentesis, log-rank P < .001). De-novo incidence of HE was similar in ePTFE-TIPS and LVP+A patients (log-rank P = .361). Implantation of ePTFE-TIPS was associated with improved 1-year survival as compared to LVP+A (65.6% vs 48.4%, log-rank P = .033). Age (odds ratio (OR):1.05; 95% confidence interval (95% CI):1.03-1.07; P < .001), serum albumin (OR: 0.95; 95% CI: 0.92-0.99; P = .013) and hepatocellular carcinoma (OR: 1.66; 95% CI: 1.06-2.58; P = .026) emerged as independent predictors of survival. CONCLUSIONS: ePTFE-TIPS results in superior control of ascites without increasing the risk for overt HE as compared to LVP+A. Although ePTFE-TIPS improved 1-year survival in cirrhotic patients with refractory ascites, its use was not independently associated with transplant-free survival.

Endovascular conversion into aorto-uniiliac configuration of acute failed endovascular aneurysm repair is associated with better one-year survival rates compared to open conversion.

BACKGROUND: Open conversions (OC) due to failed endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) are technically demanding because of preexisting prostheses and advanced aortic disease. This study evaluates the feasibility and outcomes of aorto-uniiliac endografting (AUI) as an alternative treatment option in acute failed EVAR. METHODS: From March 1995 through February 2012, 26 patients underwent acute conversion of failed EVAR at our tertiary care university center. All data were prospectively entered in our institutional database. Outcomes included 30-day or in-hospital mortality, postoperative complications, and mid-term survival. RESULTS: During the investigation period, a total of 692 patients received EVAR at our institution, while five of the 26 patients with acute conversion (19.2%) had an initial EVAR at an outlying institution and were referred for treatment. Therefore, our estimated institutional rate of acute conversions was 3% (21 of 692 EVAR). OC were performed in 14 patients (53.8%), while 12 patients underwent AUI (46.2%). An average time of 20.3 months (median: 18.6; interquartile range Q1-Q3: 0.0-38.6) elapsed between the initial EVAR and the acute conversion. All acute AUI conversion procedures were completed successfully. The 30-day mortality following acute conversions was 42.3% and since the use of AUI, it could be reduced to 33.3%. Kaplan-Meier estimates revealed a survival advantage for AUI at one year (p = 0.046), but the benefit was lost by mid-term follow-up (p = 0.103). CONCLUSIONS: AUI for the treatment of acute failed EVAR represents a feasible and less invasive alternative to OC, and is associated with better one-year survival rates.

Aortouni-iliac endografting as an alternative salvage procedure to open conversion in failed endovascular aneurysm repair.

PURPOSE: To present a single-center experience with failed EVAR requiring conversions comparing open surgery to a minimally invasive procedure modifying the existing stent-graft into an aortouni-iliac (AUI) configuration. METHODS: A prospectively maintained database at our tertiary care university hospital was interrogated to identify all patients with failed EVAR who had undergone either stent-graft modification into an AUI configuration or open conversion between March 1995 and January 2012. Patients with late aneurysm ruptures were excluded. The search found 30 patients (one had initial treatment elsewhere) who required conversion among the 688 patients who had undergone EVAR in that time period. Before conversion, 16 (53%) patients had prior endovascular corrections to maintain aneurysm exclusion. RESULTS: An average time of 52.2 months (median 46.9, IQR 0.0-92.5) elapsed between initial EVAR and conversion. There were 11 early conversions (including 7 on-table), while 19 procedures were done >30 days post EVAR. Twenty-two (73%) patients underwent AUI endografting, while open conversions were carried out in 8 (27%). Mean hospital stay after conversion was 19.5 days (median 13.0, IQR 8.0-17.0). Overall mortality after conversion was 3.3% (1 patient after on-table open conversion), but since the introduction of AUI endografting as an alternative treatment approach, 30-day mortality following conversions fell to zero. CONCLUSION: Modification of a failed stent-graft into an AUI configuration serves as a less invasive treatment option compared to open conversion and allows salvage of the failed device. With the implementation of this alternative approach, mortality after conversion parallels the mortality of elective abdominal aneurysm repair.

Extracorporeal membrane oxygenation in adult patients with hematologic malignancies and severe acute respiratory failure.

INTRODUCTION: Acute respiratory failure (ARF) is the main reason for intensive care unit (ICU) admissions in patients with hematologic malignancies (HMs). We report the first series of adult patients with ARF and HMs treated with extracorporeal membrane oxygenation (ECMO). METHODS: This is a retrospective cohort study of 14 patients with HMs (aggressive non-Hodgkin lymphoma (NHL) n = 5; highly aggressive NHL, that is acute lymphoblastic leukemia or Burkitt lymphoma, n = 5; Hodgkin lymphoma, n = 2; acute myeloid leukemia, n = 1; multiple myeloma, n = 1) receiving ECMO support because of ARF (all data as medians and interquartile ranges; age, 32 years (22 to 51 years); simplified acute physiology score II (SAPS II): 51 (42 to 65)). Etiology of ARF was pneumonia (n = 10), thoracic manifestation of NHL (n = 2), sepsis of nonpulmonary origin (n = 1), and transfusion-related acute lung injury (n = 1). Diagnosis of HM was established during ECMO in four patients, and five first received (immuno-) chemotherapy on ECMO. RESULTS: Before ECMO, the PaO2/FiO2 ratio was 60 (53 to 65), (3.3 to 3.7). Three patients received venoarterial ECMO because of acute circulatory failure in addition to ARF; all other patients received venovenous ECMO. All patients needed vasopressors, and five needed hemofiltration. Thrombocytopenia occurred in all patients (lowest platelet count was 20 (11 to 21) G/L). Five major bleeding events were noted. ECMO duration was 8.5 (4 to 16) days. ICU and hospital survival was 50%. All survivors were alive at follow-up (36 (10 to 58) months); five patients were in complete remission, one in partial remission, and one had relapsed. CONCLUSIONS: ECMO therapy is feasible in selected patients with HMs and ARF and can be associated with long-term disease-free survival.

Endovascular treatment of delayed rupture following prior abdominal aortic aneurysm repair achieves better survival rates.

PURPOSE: To test the hypothesis that endovascular treatment of delayed aneurysm rupture achieves significantly better survival rates compared to surgical conversion. METHODS: All patients sustaining delayed rupture following prior exclusion of an abdominal aortic aneurysm (AAA) either by endovascular aneurysm repair (EVAR) or open graft replacement from March 1995 through December 2011 were retrieved from a prospectively maintained database at a tertiary care university hospital. During the study period, 35 patients (32 men; mean age 72.9 years) presented with delayed rupture at a median 2.4 years (interquartile range 1.3-4.3) after initial AAA repair by EVAR (n=22) or open surgery (n=13). Causes of post-EVAR rupture were graft-related endoleaks, while ruptures after open repair occurred at anastomotic suture sites. Patients were divided into groups regarding type of treatment for delayed rupture: 20/35 (57%) underwent successful EVAR (10 redo procedures), 13/35 (37%) had surgery (3 redo procedures), and 2/35 (6%) patients received comfort care only. The primary endpoint was 30-day mortality. RESULTS: The 30-day mortality after curative treatment was 25% (5/20) for endovascular treatment compared to 54% (7/13) for surgery (p=0.14). Including additional deaths beyond 30 days, the overall in-hospital mortality was 52% (17/33). The Kaplan-Meier survival estimate for patients undergoing endovascular treatment was significantly higher (p=0.011). CONCLUSION: Endovascular treatment of delayed rupture is feasible and helps to reduce mortality. Our data suggest that endovascular procedures are a superior treatment option for EVAR-suitable patients with delayed rupture compared with surgical conversion.

Austrian consensus on the diagnosis and management of portal hypertension in advanced chronic liver disease (Billroth IV).

The Billroth IV consensus was developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on the 26th of November 2022 in Vienna.Based on international recommendations and considering recent landmark studies, the Billroth IV consensus provides guidance regarding the diagnosis and management of portal hypertension in advanced chronic liver disease.

Type II endoleaks after endovascular repair of abdominal aortic aneurysms: fate of the aneurysm sac and neck changes during long-term follow-up.

PURPOSE: To evaluate the frequency of type II endoleaks after endovascular aneurysm repair (EVAR) and to compare sac diameter and neck changes in patients with type II endoleak to endoleak-free patients with at least 3-year imaging follow-up. METHODS: Among 407 consecutive EVAR patients, 109 patients (101 men; mean age 72.1 years, range 55-86) had at least 3-year computed tomography (CT) data and no type I or III endoleak. In this cohort, 49 patients presented with a type II endoleak at some time and 60 patients had no endoleak. Patients with type II endoleaks were further divided into subgroups based on the vessel origin and the perfusion status (persistent or transient). The course of the perfusion status of type II endoleaks and changes in the aneurysm sac diameters, neck diameters, and renal to stent-graft distances (RSD) were evaluated in the defined groups. Reintervention and death rates were also reported. RESULTS: The mean follow-up was 68.1 ± 23.8 months. Compared to the no endoleak group, overall sac diameter increased significantly in the type II endoleak group (p = 0.007), but vessel origin did not have any influence. With regard to the perfusion status of type II endoleaks, aneurysm sac changes were significantly higher (p = 0.002) in the persistent endoleak group. During the study period, the increase in the proximal neck diameter was significantly higher in the no endoleak group compared to the type II endoleak group (p = 0.025). No significant difference was found in RSD changes between the defined groups. Reinterventions were performed in 20 (18.3%) patients (13 for type II endoleak); 2 (1.8%) patients without type II endoleak died of ruptured aneurysm. CONCLUSION: Persistent type II endoleaks led to significant aneurysm sac enlargement, but without increased mortality or rupture rates.

Inverse probability of treatment analysis of open vs endovascular repair in ruptured infrarenal aortic aneurysm - Cohort study.

BACKGROUND: To compare open repair (OR) with EVAR for the management of ruptured infrarenal abdominal aortic aneurysms (RAAA) in a cohort study over a time period of 15 years with inverse probability of treatment weights. MATERIAL AND METHODS: From 2000/01 through 2015/12 136 patients were treated for RAAA, 98 (72.1%) underwent OR, 38 (27.9%) were treated with EVAR. Thirty-day and long-term mortality (survival) were analyzed in this IRB-approved retrospective cohort study. Treatment modalities were compared using inverse probability of treatment weights to adjust for imbalances in demographic data and risk factors. RESULTS: EVAR patients were older (75.11 ± 7.17 vs 69.79 ± 10.24; p=0.001). There was no statistical difference in gender, hypertension, COPD, CAD, or diabetes. GFR was significantly higher in OR patients (71.4 ± 31.09 vs. 53.68 ± 25.73). Postoperative dialysis was required more frequently in EVAR patients: 11% vs. 2% (p = 0.099). In the OR group, adjusted cumulative survival was 70.4% (61.1, 81.1) at 30 days, 47.0% (37.1, 59.6) at one year and 38.3% (28.6, 51.3) at 5 years. In the EVAR group the corresponding numbers were 77.0% (67.7, 87.5), 67.5% (57.0, 80.0) and 41.7% (30.4, 57.4), respectively. CONCLUSION: There is evidence for EVAR patients exhibiting a benefit in one-year survival, while patients treated with OR may have more favorable long-term survival given they survive for at least one year. Herein we provide a statistically rigorous comparison of OR and EVAR in short and long-term outcomes with up to 15 years of follow-up.

Mid-term results after endovascular stent-graft placement due to penetrating atherosclerotic ulcers of the thoracic aorta.

BACKGROUND: To determine mid-term durability of endovascular stent-graft placement in patients with penetrating atherosclerotic ulcers (PAU) involving the thoracic aorta and to identify risk factors for death as well as early and late cardiovascular events. METHODS: From 1997 to 2006, 27 patients (mean age 66 yrs) presented with PAU (rupture n=7). Mean numeric EuroScore was 11 and mean logistic EuroScore was 35. Median follow-up was 42 (10-86) months, being complete in all patients. Outcome variables included death and occurrence of early and late cardiovascular events. RESULTS: In-hospital mortality was 11%. Primary success rate was 100%. Actuarial survival rates at 1, 3 and 5 years were 93%, 78% and 70%, respectively. Hemodynamic instability (HR 2.5, 2.1-3.9; p=0.034) as well as logistic EuroScore (HR 2.8, 2.4-4.3; p=0.019) was identified as independent predictor of early and late cardiovascular events. CONCLUSIONS: Endovascular stent-graft placement in patients with PAU is an effective palliation for a life-threatening sign of a severe systemic process. Hemodynamic instability at referral and a high preoperative risk score predict adverse outcome. During mid-term follow-up, patients are mainly limited by sequelae of their underlying disease.

Endovascular management performed percutaneously of isolated iliac artery aneurysms.

PURPOSE: To report about the endovascular treatment of isolated iliac artery aneurysms (IIAA) with stentgraft placement and transluminal or CT-guided embolization of the internal iliac artery or the combination of these methods. METHODS AND MATERIALS: Over a period of 5.6 years, 36 interventions were performed in 20 patients with 23 IIAAs. In a retrospective analysis patient records were reviewed. The CT-angiography follow-up was evaluated for the presence of re-perfusion of the IIAA and for change of aneurysm diameter. RESULTS: Primary success was achieved in 15/23 aneurysms (65%), and secondary success in 21/23 aneurysms (91%). In 5/23 cases two interventions and in 1/23 cases three interventions were necessary to achieve secondary success. Embolization alone, as a therapy for aneurysms involving only the internal iliac artery, had a success rate of 27%. No procedure-related minor or major complications occurred. Mean decrease of aneurysm size during a mean observation period of 14.1 months was 6.9% which was not significant (p=0.3; 95% confidence interval +7-21%). CONCLUSION: Endovascular therapy of isolated iliac artery aneurysms performed percutaneously has become a treatment alternative to open surgical repair. This method is feasible and safe with low procedure-related morbidity and mortality. However, on average more than one intervention has to be performed to achieve successful permanent exclusion of the aneurysm and embolization alone in isolated internal iliac artery aneurysms is not sufficient.

Transjugular intrahepatic portosystemic shunts (TIPS) for the prevention of variceal re-bleeding - A two decades experience.

BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunts (TIPS) are used in patients with cirrhosis for the prevention of variceal rebleeding. METHODS: We retrospectively evaluated re-bleeding rate, patency, mortality, and transplant-free survival (TFS) in cirrhotic patients receiving TIPS implantation for variceal bleeding between 1994-2014. RESULTS: 286 patients received TIPS (n = 119 bare metal stents, n = 167 polytetrafluorethylene (PTFE)-covered stents) for prevention of variceal re-bleeding. Mean age was 55.1 years, median MELD was 11.8, and the main etiology of cirrhosis was alcoholic liver disease (70%). Median follow-up was 821 days. 67 patients (23%) experienced at least one re-bleeding event. Patients with PTFE-TIPS were at significantly lower risk for variceal re-bleeding than patients with bare metal stents (14% vs. 37%, OR:0.259; p<0.001) and had less need for stent revision (21% vs. 37%; p = 0.024). Patients with PTFE stent grafts showed lower mortality than patients with bare stents after 1 year (19% vs. 31%, p = 0.020) and 2 years (29% vs. 40%; p = 0.041) after TIPS implantation. Occurrence of hepatic encephalopathy after TIPS was similar between groups (20% vs. 24%, p = 0.449). CONCLUSIONS: PTFE-TIPS were more effective at preventing variceal re-bleeding than bare metal stents due to better patency. Since this tended to translate in improved survival, only covered stents should be implemented for bleeding prophylaxis when TIPS is indicated.

Mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies.

OBJECTIVE: To evaluate mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies. METHODS: From October 2002 to July 2006, 27 patients (mean age 72 years) with aortic arch diseases were treated (arch aneurysms n=18, type B dissections n=5, perforating ulcers n=4). Strategy for distal arch disease was autologous sequential transposition of the left carotid artery and of the left subclavian artery in 17 patients. Strategy for entire arch disease was total supraaortic rerouting using a reversed bifurcated prosthesis in 10 patients. Endovascular stent-graft placement was performed metachronously thereafter. RESULTS: Two in-hospital deaths occurred (myocardial infarction on the day prior to discharge n=1, rupture while waiting for stent-graft placement n=1). At completion angiography, all reconstructions were fully patent. Four patients had small type Ia endoleaks, two of them resolving spontaneously. Mean follow-up is 15 months (1-43 months). Three late deaths occurred (myocardial infarction n=2, sudden unknown death n=1). One-year survival was 83% and 3-year survival was 72%, respectively. Redo stent-graft placement was performed in one patient after 25 months (type III endoleak). The remaining patients had normal CT scans with regular perfusion of the supraaortic branches without any signs of endoleaks. CONCLUSIONS: Mid-term results of alternative treatment approaches in elderly patients with aortic arch pathologies are satisfying. Extended applications provide safe and effective treatment in patients at high risk for conventional repair.

Re-bleeding rates and survival after early transjugular intrahepatic portosystemic shunt (TIPS) in clinical practice.

BACKGROUND: Early implantation (<72h) of a transjugular intrahepatic portosystemic shunt (TIPS) after acute variceal bleeding (AVB) improves survival in highly selected patients. METHODS: We retrospectively assessed bleeding control and survival of unselected cirrhotic patients undergoing early TIPS implantation within 72h. We compared the outcomes to patients meeting early TIPS criteria but receiving late TIPS within 3-28days after AVB and endoscopic/medical treatment. RESULTS: Forty-nine patients were included. Mean MELD was 14.4 (±4.4). Thirteen patients (26.5%) presented characteristics that were exclusion criteria in previous early TIPS trials (age>75, CPS>13, HCC>Milan, previous beta-blocker/band-ligation, renal insufficiency). Bare metal and PTFE-covered stents were used in n=32 (65.3%) and n=17 (34.7%) patients, respectively, and showed similar early re-bleeding rates (9.9% vs. 7.1%; p=0.6905) and bleeding-related mortality (25.0% vs. 23.5%; p=0.9906). However, overall re-bleeding rate was lower with PTFE-TIPS (7.7% vs. 64.2%; p=0.0044) over a median follow-up of 18.5 months with a tendency towards improved survival (median 70.5 vs. 13.8 months; p=0.204). Additional 68 patients meeting stringent criteria but receiving late TIPS also showed a favorable bleeding-related mortality (8.8%), which was not achieved in similar n=34 patients by a medical/endoscopic strategy with bleeding-related mortality of 35.7%. CONCLUSIONS: An early TIPS strategy using covered stents and implementation of 'stringent criteria' results in a favorable outcome in patients with acute variceal bleeding.

Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III).

The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.

Transposition of the supraaortic branches for extended endovascular arch repair.

BACKGROUND: Supraaortic branches limit extended application of endovascular aortic repair. For this purpose, we applied extensive reconstructions. METHODS: Between October 2002 and March 2005, 11 patients (mean age 72.3 years) presented with acute or chronic aortic diseases originating from the aortic arch (arch aneurysms n=8, type B dissections n=3). Treatment was by autologous sequential transposition of the left carotid artery into the brachiocephalic trunk and of the left subclavian artery into the already transposed left common carotid artery in nine patients and by additional reconstruction of the brachiocephalic trunk in two patients. Endovascular stent-graft placement was successfully performed thereafter. RESULTS: Procedure-related mortality was 0%. At completion angiography, all reconstructions were fully patent. One patient had a small type Ia endoleak that resolved spontaneously within one week. Mean follow-up was 18 months (1-29 months). One patient underwent redo stent-graft placement after 25 months due to a type III endoleak. The remaining patients had normal follow-up CT scans with regular perfusion of the supraaortic branches without any signs of endoleaks. CONCLUSIONS: Extended application of this technique will enable safe and effective treatment of a highly selected group of patients by avoiding conventional repair.

Type 2 Endoleaks: The Diagnostic Performance of Non-Specialized Readers on Arterial and Venous Phase Multi-Slice CT Angiography.

PURPOSE: To define the diagnostic precision of non-specialized readers in the detection of type 2 endoleaks (T2EL) in arterial versus venous phase acquisitions, and to evaluate an approach for radiation dose reduction. METHODS: The pre-discharge and final follow-up multi-slice CT angiographies of 167 patients were retrospectively analyzed. Image data were separated into an arterial and a venous phase reading set. Two radiology residents assessed the reading sets for the presence of a T2EL, feeding vessels, and aneurysm sac size. Findings were compared with a standard of reference established by two experts in interventional radiology. The effective dose was calculated. RESULTS: Overall, experts detected 131 T2ELs, and 331 feeding vessels in 334 examinations. Persistent T2ELs causing aneurysm sac growth > 5 mm were detected in 20 patients. Radiation in arterial and venous phases contributed to a mean of 58.6% and 39.0% of the total effective dose. Findings of reader 1 and 2 showed comparable sensitivities in arterial sets of 80.9 versus 85.5 (p = 0.09), and in venous sets of 73.3 versus 79.4 (p = 0.15), respectively. Reader 1 and 2 achieved a significant higher detection rate of feeding vessels with arterial compared to venous set (p = 0.04, p < 0.01). Both readers correctly identified T2ELs with growing aneurysm sac in all cases, independent of the acquisition phase. CONCLUSION: Arterial acquisitions enable non-specialized readers an accurate detection of T2ELs, and a significant better identification of feeding vessels. Based on our results, it seems reasonable to eliminate venous phase acquisitions.

Paclitaxel-Eluting Balloon Versus Standard Balloon Angioplasty in In-Stent Restenosis of the Superficial Femoral and Proximal Popliteal Artery: 1-Year Results of the PACUBA Trial.

OBJECTIVES: The hypothesis that paclitaxel-eluting balloon angioplasty provides higher 1-year patency rates in femoropopliteal artery in-stent restenosis compared with standard percutaneous transluminal angioplasty (PTA) was tested. BACKGROUND: Several trials have demonstrated that paclitaxel-eluting balloon angioplasty reduces late luminal loss in comparison with PTA. METHOD: In a prospective, randomized, single-blind, dual-center study, 74 patients with symptomatic peripheral artery disease due to in-stent restenosis were treated with either paclitaxel-based drug-eluting balloon (DEB) angioplasty (n = 35) or standard PTA (n = 39). Clinical outcomes and patency rates were assessed at 1, 6, and 12 months. RESULTS: The mean lesion length was 17.3 ± 11.3 cm in the DEB group and 18.4 ± 8.8 cm in the PTA group. A single major complication (bleeding) was observed once (1.4%). The mean ankle-brachial index before endovascular treatment was 0.65 ± 0.16 in both groups and 0.79 ± 0.2 versus 0.84 ± 0.3 (p = 0.70, Student t test) in the DEB versus PTA group at 12 months. The 12-month primary patency rates were 40.7% (95% confidence interval [CI]: 0.26 to 0.64) versus 13.4% (95% CI: 0.05 to 0.36) (log-rank p = 0.02) in the DEB versus PTA group. The odds ratio for PTA over DEB angioplasty for experiencing an event was estimated at 2.8 (95% CI: 1.2 to 6.6). Freedom from clinically driven target lesion revascularization was 49.0% (95% CI: 0.32 to 0.75) versus 22.1% (95% CI: 0.10 to 0.48) (log-rank p = 0.11) in the DEB versus PTA group. Clinical improvement by ≥1 Rutherford-Becker category was 68.8% versus 54.5% (p = 0.87) in the DEB versus PTA group at 12 months. CONCLUSIONS: When treating peripheral artery disease in patients with in-stent restenosis in the femoropopliteal artery, paclitaxel-eluting balloon angioplasty provides significantly higher patency rates than standard PTA. (Paclitaxel Balloon Versus Standard Balloon in In-Stent Restenoses of the Superficial Femoral Artery [PACUBA I Trial] [PACUBA 1]; NCT01247402).