Assessment of Plaque Characteristics by Contrast-Enhanced Ultrasound and Stent Restenosis following Carotid Artery Stenting: A Retrospective Study.

Background and objective: carotid artery stenosis contributes significantly to ischemic strokes, with management options including carotid endarterectomy (CEA) and carotid artery stenting (CAS) ischemic stroke risk can be reduced. Controversies persist regarding their efficacy and factors influencing complications, and understanding the relationship between atherosclerotic plaque characteristics and stent restenosis after CAS is crucial. Methods: we conducted a retrospective study involving 221 patients who underwent CAS for symptomatic or asymptomatic carotid artery stenosis. Comprehensive assessments of plaque morphology were performed using contrast-enhanced ultrasound (CEUS) before CAS. Patient demographics, including smoking status and diabetes, were also recorded. Stent restenosis was diagnosed using various imaging modalities, including ultrasound, angiography, and digital subtraction angiography (DSA). Results: plaque analysis using CEUS revealed a significant association between plaque grade and restenosis incidence (p < 0.001), particularly with grade 0 (11.1%) and grade 2 plaques (66.7%). Smoking was notably associated with plaque vascularization and restenosis (p < 0.001), while diabetes did not significantly impact plaque characteristics or restenosis risk (p > 0.05). The mean duration of restenosis was 17.67 months. Stenting was the most frequent treatment modality for restenosis (70.6%). However, no significant relationship was found between restenosis type and plaque morphology (p = 0.268). Furthermore, while no clear relationship was observed between plaque morphology and the type of restenosis, our findings underscored the importance of plaque characterization in predicting post-CAS outcomes. Conclusions: this study highlights the utility of CEUS in predicting stent restenosis following CAS. There was a significant association between stent restenosis within 12-24 months after the carotid stenting procedure and an elevated grade of plaque vascularization. Moreover, one of the main factors possibly determining the grade of plaque vascularization was smoking. Further research is warranted to elucidate the underlying mechanisms and refine risk stratification in this patient population.

Percutaneous Transhepatic Biliary Stenting with Uncovered Self-Expandable Metallic Stents in Patients with Malignant Biliary Obstruction - Efficacy and Survival Analysis.

BACKGROUND: The aim of this study was to assess short- and long-term outcomes of malignant biliary obstruction (MBO) treatment by percutaneous transhepatic biliary stenting (PTBS) with uncovered selfexpandable metallic stents (SEMS), and to identify predictors of survival. MATERIAL/METHODS: A nine-year, single-centre study from a prospectively collected database included 222 patients with inoperable MBO treated by PTBS with uncovered nitinol SEMS. RESULTS: Technical and clinical success rates were 95.9% and 82.4%, respectively. The total rate of postprocedural complications was 14.4%. The mean durations of the primary and secondary stent patency were 114.7±15.1 and 146.4±21.2 days, respectively. The 30-day mortality rate was 15.3% with no procedure-related deaths. The mean estimated length of survival was 143.3±20.6 days. Independent predictors increasing the risk of death included higher than 115 µmol/L serum bilirubin 2-5 days after biliary stenting (HR 3.274, P=0.019), distal (non-hilar) obstruction of the bile ducts (HR 3.711, P=0.008), Bismuth-Corlette type IV stricture (HR 2.082, P=0.008), obstruction due to gallbladder cancer (HR 31.029, P=0.012) and only partial drainage of liver parenchyma (HR 4.158, P=0.040). CONCLUSIONS: PTBS with uncovered SEMS is an effective and safe method for palliative treatment of MBO. Serum bilirubin higher than 115 µmol/L 2-5 days after the procedure has a significant negative impact on patients' survival. Lower survival is also determined by distal bile duct obstruction, Bismuth- Corlette type IV stricture, biliary obstruction caused by gallbladder cancer and when only partial liver drainage is applied.

Liver and spleen transient elastography predicts portal hypertension in patients with chronic liver disease: a prospective cohort study.

BACKGROUND: To assess correlation between liver or spleen stiffness measurement by transient elastography (TE) and hepatic venous pressure gradient (HVPG) in patients with chronic liver disease as well find optimal and rule in/rule out cut-offs for prognosis of clinically significant (CSPH) and severe (SPH) portal hypertension. METHODS: In this prospective study patients with different chronic liver diseases were included. TE was performed at the same day prior to HVPG measurement. HVPG was measured using catheter tip occlusion technique. Based on HVPG, patients were categorized into groups of CSPH and SPH. Cut-off values were established by applying ROC curve analysis. RESULTS: The study included 107 consecutive patients referred for HVPG measurement or transjugular liver biopsy. Successful spleen TE was performed in 99 of the patients. Liver and spleen TE strongly correlated with HVPG, r = 0.75 and r = 0.62, respectively. Accuracy to detect CSPH was 88.7% for liver stiffness of 17.4 kPa and 77.7% for spleen stiffness of 47.6 kPa. Accuracy to detect SPH was 83.1% for liver stiffness of 20.6 kPa and 77.7 % for spleen stiffness of 50.7 kPa. Liver stiffness <11.4 kPa could rule out CSPH with 55.2% specificity and >21.9 kPa rule in CSPH with 74.4% sensitivity. Liver stiffness <12.1 kPa could rule out SPH with 50.0% specificity and >35 kPa rule in SPH with 58.2% sensitivity. CONCLUSIONS: Liver and spleen stiffness correlate with HVPG and could be used to predict CSPH or SPH. Spleen elastography was not superior to liver elastography in predicting portal hypertension.

Acute and 14-day hepatic venous pressure gradient response to carvedilol and nebivolol in patients with liver cirrhosis.

BACKGROUND AND OBJECTIVE: Alternative drug therapies are needed for the treatment of portal hypertension. The aim of this randomized study was to evaluate and compare the effects of carvedilol and nebivolol on the hepatic venous pressure gradient (HVPG) response in the patients with liver cirrhosis. MATERIAL AND METHODS: In total, 20 cirrhotic patients were randomized into 2 groups and treated with carvedilol (n=10) or nebivolol (n=10). HVPG was measured at baseline, 60 minutes after the administration of carvedilol (25 mg) or nebivolol (5 mg), and after 14 days of carvedilol (25 mg) or nebivolol (5 mg) administered daily. RESULTS. Carvedilol significantly reduced HVPG from 22.2 mm Hg (SD, 4.4) to 15.2 mm Hg (SD, 3.7) after 60 minutes and to 16.4 mm Hg (SD, 2.9) after 14 days (P<0.01). Nebivolol reduced HVPG from 19.7 mm Hg (SD, 2.5) to 15.7 mm Hg (SD, 2.6) and 16.7 mm Hg (SD, 3.2), respectively (P<0.02). Carvedilol effectively decreased HVPG in a greater proportion of the patients after an acute probe (88% vs. 57%) and after 14 days of the treatment (88% vs. 28%, P<0.05) in comparison with nebivolol. CONCLUSION: Carvedilol and nebivolol reduce HVPG in cirrhotic patients; however, the effect of carvedilol on the HVPG reduction might be superior to that of nebivolol, especially after 14 days of treatment.

Circulating microbiome in patients with portal hypertension.

Portal hypertension (PH) in liver cirrhosis leads to increased gut permeability and the translocation of bacteria across the gut-liver axis. Microbial DNA has recently been detected in different blood compartments; however, this phenomenon has not been thoroughly analyzed in PH. This study aimed to explore circulating bacterial DNA signatures, inflammatory cytokines, and gut permeability markers in different blood compartments (peripheral and hepatic veins) of patients with cirrhosis and PH. The 16S rRNA blood microbiome profiles were determined in 58 patients with liver cirrhosis and 46 control patients. Taxonomic differences were analyzed in relation to PH, liver function, inflammatory cytokines, and gut permeability markers. Circulating plasma microbiome profiles in patients with cirrhosis were distinct from those of the controls and were characterized by enrichment of Comamonas, Cnuella, Dialister, Escherichia/Shigella, and Prevotella and the depletion of Bradyrhizobium, Curvibacter, Diaphorobacter, Pseudarcicella, and Pseudomonas. Comparison of peripheral and hepatic vein blood compartments of patients with cirrhosis did not reveal differentially abundant taxa. Enrichment of the genera Bacteroides, Escherichia/Shigella, and Prevotella was associated with severe PH (SPH) in both blood compartments; however, circulating microbiome profiles could not predict PH severity. Escherichia/Shigella and Prevotella abundance was correlated with IL-8 levels in the hepatic vein. In conclusion, we demonstrated a distinct circulating blood microbiome profile in patients with cirrhosis, showing that specific bacterial genera in blood are marginally associated with SPH, Model for End-Stage Liver Disease score, and inflammation biomarkers; however, circulating microbial composition failed to predict PH severity.

Six-Month Outcomes for COVID-19 Negative Patients with Acute Myocardial Infarction Before Versus During the COVID-19 Pandemic.

The Coronavirus disease 2019 (COVID-19) pandemic has changed the way patients seek medical attention and how medical services are provided. We sought to compare characteristics, clinical course, and outcomes of patients presenting with acute myocardial infarction (AMI) during the pandemic compared with before it. This is a multicenter, retrospective cohort study of consecutive COVID-19 negative patients with AMI in Lithuania from March 11, 2020 to April 20, 2020 compared with patients admitted with the same diagnosis during the same period in 2019. All patients underwent angiography. Six-month follow-up was obtained for all patients. A total of 269 patients were included in this study, 107 (40.8%) of whom presented during the pandemic. Median pain-to-door times were significantly longer (858 [quartile 1=360, quartile 3 = 2,600] vs 385.5 [200, 745] minutes, p <0.0001) and post-revascularization ejection fractions were significantly lower (35 [30, 45] vs 45 [40, 50], p <0.0001) for patients presenting during vs. prior to the pandemic. While the in-hospital mortality rate did not differ, we observed a higher rate of six-month major adverse cardiovascular events for patients who presented during versus prior to the pandemic (30.8% vs 13.6%, p = 0.0006). In conclusion, 34% fewer patients with AMI presented to the hospital during the COVID-19 pandemic, and those who did waited longer to present and experienced more 6-month major adverse cardiovascular events compared with patients admitted before the pandemic.

Endogenous motion of liver correlates to the severity of portal hypertension.

BACKGROUND: Degree of portal hypertension (PH) is the most important prognostic factor for the decompensation of liver cirrhosis and death, therefore adequate care for patients with liver cirrhosis requires timely detection and evaluation of the presence of clinically significant PH (CSPH) and severe PH (SPH). As the most accurate method for the assessment of PH is an invasive direct measurement of hepatic venous pressure gradient (HVPG), the search for non-invasive methods to diagnose these conditions is actively ongoing. AIM: To evaluate the feasibility of parameters of endogenously induced displacements and strain of liver to assess degree of PH. METHODS: Of 36 patients with liver cirrhosis and measured HVPG were included in the case-control study. Endogenous motion of the liver was characterized by derived parameters of region average tissue displacement signal (d antero, dr etro, d RMS) and results of endogenous tissue strain imaging using specific radiofrequency signal processing algorithm. Average endogenous strain µ and standard deviation σ of strain were assessed in the regions of interest (ROI) (1 cm × 1 cm and 2 cm × 2 cm in size) and different frequency subbands of endogenous motion (0-10 Hz and 10-20 Hz). RESULTS: Four parameters showed statistically significant (P < 0.05) correlation with HVPG measurement. The strongest correlation was obtained for the standard deviation of strain (estimated at 0-10 Hz and 2 cm × 2 cm ROI size). Three parameters showed statistically significant differences between patient groups with CSPH, but only d retro showed significant results in SPH analysis. According to ROC analysis area under the curve (AUC) of the σ ROI[0…10Hz, 2 cm × 2 cm] parameter reached 0.71 (P = 0.036) for the diagnosis of CSPH; with a cut-off value of 1.28 µm/cm providing 73% sensitivity and 70% specificity. AUC for the diagnosis of CSPH for µ ROI[0…10Hz, 1 cm × 1 cm] was 0.78 (P = 0.0024); with a cut-off value of 3.92 µm/cm providing 73% sensitivity and 80% specificity. D retro parameter had an AUC of 0.86 (P = 0.0001) for the diagnosis of CSPH and 0.84 (P = 0.0001) for the diagnosis of SPH. A cut-off value of -132.34 µm yielded 100% sensitivity for both conditions, whereas specificity was 80% and 72% for CSPH and SPH respectively. CONCLUSION: The parameters of endogenously induced displacements and strain of the liver correlated with HVPG and might be used for non-invasive diagnosis of PH.

Hepatic venous pressure gradient measurement in patients with liver cirrhosis: a correlation with disease severity and variceal bleeding.

UNLABELLED: The aim of present study was to evaluate relationships between degree of portal hypertension, severity of the disease, and bleeding status in patients with liver cirrhosis. PATIENTS AND METHODS: All study patients with liver cirrhosis underwent hepatic venous pressure gradient measurements, endoscopy, clinical and biochemical evaluation. Liver function was evaluated according to Child-Turcotte-Pugh (Child's) scoring system. Patients with decompensated cirrhosis (presence of severe ascites, acute variceal bleeding occurring within 14 days, hepatorenal syndrome, cardiopulmonary disorders, transaminase levels >10 times higher the upper normal limit), active alcohol intake, use of antiviral therapy and/or beta-blockers were excluded from the study. RESULTS: One hundred twenty-eight patients with liver cirrhosis (male/female, 67/61; mean age, 53.8+/-12.7 years) were included into the study. Etiology of cirrhosis was viral hepatitis, alcoholic liver disease, cryptogenic and miscellaneous reasons in 57, 49, 14, and 8 patients, respectively. Child's stages A, B, and C of liver cirrhosis were established in 28 (21.9%), 70 (54.9%), and 30 (23.4%) patients, respectively. The mean hepatic venous pressure gradient significantly differed among patients with different Child's classes: 13.8+/-5.3 mm Hg, 17.3+/-4.6 mm Hg, and 17.7+/-5.05 mm Hg in Child's A, B, and C classes, respectively (P=0.003). The mean hepatic venous pressure gradient in patients with grade I, II, and III varices was 14.8+/-4.5, 16.1+/-4.3, and 19.3+/-4.7 mm Hg, respectively (P=0.0001). Since nonbleeders had both small and large esophageal varices, patients with large varices were analyzed separately. The mean hepatic venous pressure gradient in patients with large (grade II and III) varices was significantly higher than that in patients with small (grade I) varices (17.8+/-4.8 mm Hg vs 14.6+/-4.8 mm Hg, P=0.007). Thirty-four (26.6%) patients had a history of previous variceal bleeding; all of them had large (20.6% - grade II, and 79.4% - grade III) varices. In patients with large varices, the mean hepatic venous pressure gradient was significantly higher in bleeders than in nonbleeders (18.7+/-4.7 mm Hg vs 15.9+/-4.7 mm Hg, P=0.006). CONCLUSIONS: Hepatic venous pressure gradient correlates with severity of liver disease, size of varices, and bleeding status. Among cirrhotics with large esophageal varices, bleeders have a significantly higher hepatic venous pressure gradient than nonbleeders. Hepatic venous pressure gradient measurement is useful in clinical practice selecting cirrhotic patients at the highest risk of variceal bleeding and guiding to specific therapy.

Plasma Nogo-A and placental growth factor levels are associated with portal hypertension in patients with liver cirrhosis.

BACKGROUND: Clinically significant portal hypertension (CSPH) and severe portal hypertension (SPH) increase the risk for decompensation and life-threatening complications in liver cirrhosis. Pathologic angiogenesis might contribute to the formation of these conditions. Placental growth factor (PlGF) and Nogo-A protein are biomarkers of pathological angiogenesis, but data on their role in liver cirrhosis and portal hypertension is scarce. AIM: To determine plasma levels of PlGF and Nogo-A in patients with liver cirrhosis, CSPH, SPH and potential to predict portal hypertension. METHODS: A cohort of 122 patients with hepatitis C virus and/or alcohol-induced liver cirrhosis with characterized hepatic venous pressure gradient (HVPG) were included in the study. Demographic data, medical history, Child-Turcotte-Pugh and Model of End Stage liver disease score, clinical chemistry, liver stiffness values were recorded on the day of the procedure prior HVPG measurement. The degree of portal hypertension was determined by the invasive HVPG measurement. Nogo-A and PlGF plasma levels were evaluated using enzyme linked immunosorbent assay. The control group consisted of 30 healthy age- and sex- matched individuals. RESULTS: Peripheral PlGF levels were higher and Nogo-A levels were lower in patients with liver cirrhosis (23.20 vs 9.85; P < 0.0001 and 2.19 vs 3.12; P = 0.004 respectively). There was a positive linear correlation between peripheral levels of PlGF and HVPG (r = 0.338, P = 0.001) and negative linear correlation between the peripheral Nogo-A levels and HVPG (r = -0.267, P = 0.007). PlGF levels were higher in CSPH and SPH (P = 0.006; P < 0.0001) whereas Nogo-A levels were lower (P = 0.01; P < 0.033). Area under the curve for the diagnosis of CSPH for PlGF was 0.68 (P = 0.003) and for Nogo-A - 0.67 (P = 0.01); for SPH 0.714 (P < 0.0001) and 0.65 (P = 0.014) respectively. PlGF levels were higher and Nogo-A levels were lower in patients with esophageal varices (P < 0.05). PlGF cut-off value of 25 pg/mL distinguished patients with CSPH at 55.7% sensitivity and 76.7% specificity; whereas Nogo-A cut-off value of 1.12 ng/mL was highly specific (93.1%) for the diagnosis of CSPH. CONCLUSION: Plasma PlGF levels were higher while Nogo-A levels were lower in patients with liver cirrhosis and portal hypertension. Biomarkers showed moderate predictive value in determining CSPH and SPH.

Percutaneous transhepatic biliary stenting: the first experience and results of the Hospital of Kaunas University of Medicine.

Malignant biliary obstruction may be caused by cholangiocarcinoma and other nonbiliary carcinomas. At the time of diagnosis, 90% of patients with malignant obstructive jaundice may benefit from palliative treatment only. The objective of palliation is to relieve jaundice-related symptoms, prevent cholangitis, prolong survival, and improve quality of life. Percutaneous transhepatic biliary stenting is a well-established procedure used in patients with malignant obstruction of intra- and extrahepatic bile ducts. Twelve patients (9 women, 3 men; mean age, 68 years; range, 44-88 years) with inoperable malignant biliary obstruction were selected for percutaneous transhepatic biliary stenting with metallic stents in the period from January to December 2007. Technical and clinical success rate in this patient series was 83% and 80%, respectively. Minor and major complications occurred in 17% and 8% of cases, respectively, which is in the range reported by the others. This is our first experience of percutaneous transhepatic biliary stenting at the Hospital of Kaunas University of Medicine and, to our knowledge, the first reported patient series in Lithuania. These first results encourage expanding effective palliation by the employment of the percutaneous transhepatic biliary stenting in patients with nonresectable malignant biliary obstruction or in case of a recurrent disease after curative surgery. The cost effectiveness of percutaneous transhepatic biliary stenting against percutaneous transhepatic biliary drainage has yet to be evaluated in a prospective manner. However, immediate clinical benefits and positive short-term outcomes are unequivocal.

[Transcatheter renal arterial embolization in malignant renal neoplasms: clinical results and indications for use of the method in multi-profile hospitals]. / Perkateterinis inkstu arterijos embolizavimas sergantiesiems inkstu piktybiniais navikais: klinikiniai duomenys ir metodo panaudojimo galimybes daugiaprofilineje ligonineje.

The authors analyse the long-term and in-hospital results of treatment 29 patients with renal neoplasms, who underwent transcatheter renal arterial embolization and also discuss the benefits of transcatheter renal arterial embolization in other clinical situations. Transcatheter renal arterial embolization was performed with embosil for 23 patients (79.3%) and with concentrated alcohol for 6 patients (20.7%) before nephrectomy of advance renal tumour in 21 patients. Transcatheter renal arterial embolization was performed as palliative treatment in 8 patients. Complete embolization was achieved in 27 patients (93.1%), incomplete--in 2 patients (6.9%). Nephrectomy was performed after 22.14 +/- 9.28 days. The most evident post procedural reactions were moderately elevated temperature in 22 patients (75.9%), highly elevated temperature (> 38 degrees) in 7 patients (24.1%) and pain. Only 6 patients (20.7%) didn't feel pain. One hematoma was noticed in puncture region. After 5 years, 4 patients of 10 analysed patients are still alive (all-pT3, size of tumor 6.5-9 cm.). Two patients were not operated due to very big tumor and technical inoperability. Remaining 4 patients died during 2-3 years. As exclusion was one patient with inoperable renal tumor and lung metastases. After transcatheter renal arterial embolization he was alive 4 years. In conclusion, transcatheter renal arterial embolization was effective in diminishing the technical difficulties to remove advance tumors and in treatment of inoperable patients. It's rational to supply transcatheter renal arterial embolization with embolization and chemoembolization of primary and metastatic lesions.