RESUMEN
Refractory ascites is a costly and debilitating condition that occurs most frequently in the setting of substantial cirrhotic portal hypertension, where it portends a poor prognosis. Many treatment options are available, among them medical management, serial large volume paracenteses, transjugular intrahepatic portosystemic shunts, and implanted drainage devices. Although the availability of multiple therapies ensures that most patients will achieve satisfactory results, it can be challenging for the provider to select the appropriate treatment for each specific patient. This article reviews the available therapeutic options for refractory ascites and incorporates available data and clinical experience to suggest a linear stepwise management approach to enhance patient outcomes.
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Ascitis/etiología , Ascitis/terapia , Hipertensión Portal/complicaciones , Ascitis/diagnóstico por imagen , Ascitis/fisiopatología , Terapia Combinada , Humanos , Hipertensión Portal/diagnóstico por imagen , Hipertensión Portal/fisiopatología , PronósticoRESUMEN
PURPOSE: To compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs). MATERIALS AND METHODS: A single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n = 18) or TIPS alone (n = 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy. RESULTS: The mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P = .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P = .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P = .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P = .077). There was no difference in ascites (13% vs 11%, P = .63), hepatic encephalopathy (47% vs 55%, P = .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups. CONCLUSIONS: The GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs.
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Embolización Terapéutica , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Derivación Portosistémica Intrahepática Transyugular , Escleroterapia , Adulto , Anciano , Anciano de 80 o más Años , Terapia Combinada , Embolización Terapéutica/efectos adversos , Várices Esofágicas y Gástricas/diagnóstico por imagen , Várices Esofágicas y Gástricas/etiología , Femenino , Hemorragia Gastrointestinal/diagnóstico por imagen , Hemorragia Gastrointestinal/etiología , Humanos , Masculino , Persona de Mediana Edad , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Recurrencia , Estudios Retrospectivos , Escleroterapia/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The Viatorr Controlled Expansion (VCX) stent-graft was designed to mitigate hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) creation. AIMS: To determine the incidence and degree of HE after VCX TIPS. METHODS: Thirty-three patients (M:F 17:16, mean age 58 years, mean MELD score 12) who underwent VCX TIPS between 2018 and 2019 were retrospectively studied. 11/33 (33%) patients had medically controlled pre-TIPS HE. TIPS indications included variceal hemorrhage (n = 12, 30%) and ascites (n = 21, 70%). Measured outcomes were post-TIPS HE (overall, recurrent, de novo) graded using the West Haven system, time-to-HE occurrence, HE-related hospitalization rate, and TIPS reduction rate. RESULTS: VCX TIPS were 8 mm in 28/33 (85%) and 10 mm in 5/33 (15%). Mean final portosystemic pressure gradient was 6 mmHg. Cumulative HE incidence post-TIPS was 61% (20/33). 1-, 3-, 6-, and 12-month HE rates were 24%, 30%, 53%, and 61% over 247-day median follow-up. Median time-to-HE was 180 days. HE grades spanned grade 1 (n = 6), grade 2 (n = 8), and grade 3 (n = 6); 9 and 11 cases were recurrent and de novo HE, respectively. Medication non-compliance/infection was implicated in HE in 9/20 (45%) cases. Medical therapy addressed HE in 18/20 (90%) cases; however, HE still resulted in 39 hospitalizations among 13 patients, and median time to first hospitalization was 75 days. Shunt reduction was necessary in 2 (10%) cases of medically refractory HE. CONCLUSIONS: The incidence of HE after VCX TIPS is high. Though HE symptoms may be medically controlled, hospitalization rates are high, and shunt reduction may be necessary.
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Encefalopatía Hepática/etiología , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Derivación Portosistémica Intrahepática Transyugular/instrumentación , Stents/efectos adversos , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Factores de Riesgo , Resultado del TratamientoRESUMEN
Background Despite increased use of moderate sedation in interventional radiology (IR), patient reactions to moderate sedation are difficult to predict. The rate, risk factors, and burden of respiratory compromise in patients who undergo IR procedures with moderate sedation in the United States are poorly understood. Purpose To identify risk factors and quantify the clinical and economic burden of respiratory compromise in inpatient IR procedures in the United States. Materials and Methods Primary inpatient IR procedures with moderate sedation conducted from October 1, 2012, to September 30, 2015, were analyzed by using a retrospective claims database. Exclusions included age younger than 18 years, use of anesthesia, pre-existing cardiac or respiratory arrest, and respiratory failure. Respiratory compromise was defined as use of naloxone or flumazenil, nonmechanical or cardiopulmonary resuscitation, or endotracheal intubation on the day of the IR procedure. Propensity score matching was performed to risk adjust patients for cost and outcomes analysis, including hospital and intensive care unit (ICU) length of stay, invasive mechanical ventilation, and death before hospital discharge. Results This study analyzed 525 151 patients (mean age, 60 years ± 17 [standard deviation]; 278 576 women). Respiratory compromise occurred in 1.0% (5235 of 525 151) of patients, predicted by long-term opioid therapy or active substance abuse (odds ratio [OR], 2.7; P < .001), age 65 years or older (OR, 1.4; P < .001), and sleep apnea (OR, 1.3; P < .001). Risk-adjusted patients with respiratory compromise compared with patients without respiratory compromise had $6904 higher costs (P < .001), 1.1-day longer hospital length of stay (P < .001), and higher rates of ICU admission (69.7% [3125 of 5235] vs 25.5% [1333 of 5235], respectively; P < .001), invasive mechanical ventilation (33.6% [1758 of 5235] vs 1.6% [85 of 5235], respectively; P < .001), and death (27.1% [1421 of 5235] vs 3.2% [166 of 5235], respectively; P < .001). Conclusion In the United States, respiratory compromise in interventional radiology procedures with moderate sedation contributes to worse clinical outcomes and higher costs. Respiratory compromise risk factors including long-term opioid therapy or active substance abuse, age 65 years or older, and sleep apnea should be preassessed and used to help guide intraprocedural monitoring to prevent respiratory compromise, improve patient outcomes, and reduce costs. © RSNA, 2019 See also the editorial by Rosen and Walz in this issue. Online supplemental material is available for this article.
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Sedación Consciente/efectos adversos , Pacientes Internos , Radiología Intervencionista/métodos , Insuficiencia Respiratoria/inducido químicamente , Anciano , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Respiración Artificial , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Estados UnidosRESUMEN
PURPOSE: To determine whether utilization and outcomes of dialysis access maintenance interventions vary by patient race or sex. MATERIALS AND METHODS: Data for this retrospective cohort study of first-time arteriovenous (AV) access recipients were drawn from a 5% sample of Medicare beneficiaries, containing claims from all clinical settings (2009-2014) in 2,693 patients who received their first AV fistula/graft in 2009. Maintenance interventions-angiography, angioplasty, thrombolysis, stent placement, and venous embolization-were identified by corresponding Current Procedural Terminology codes. Outcomes of primary patency (PP), postinterventional primary patency (PIPP), and postinterventional secondary patency (PISP) were calculated with utilization records. Associations between demographic data and patency times were evaluated by a multivariate survival approach, controlling for baseline differences in patient age, comorbid disease, type of dialysis access, and interventionist specialty. RESULTS: AV grafts (AVGs) were created with greater frequency in women (32% vs 23% in men; P < .001) and minority patients (39% in black, 32% in Hispanic, and 29% in Asian patients vs 21% in white patients; P < .001). Women were at greater hazards for loss of PP (hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.09-2.14) and PIPP (HR, 1.42; 95% CI, 1.01-2.00). Black patients were at greater hazards for loss of PP (HR, 1.37; 95% CI, 1.23-1.54) and PISP (HR, 1.29; 95% CI, 1.01-1.65). AVG creation predisposed patients to patency loss in all models (P < .001). CONCLUSIONS: Dialysis access patency rates are lower for women and black patients. More frequent primary AVG creation in women and minority patients additionally predisposes these patients to patency loss.
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Derivación Arteriovenosa Quirúrgica , Oclusión de Injerto Vascular/etnología , Oclusión de Injerto Vascular/prevención & control , Diálisis Renal , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Medicare , Persona de Mediana Edad , Estudios Retrospectivos , Factores Sexuales , Resultado del Tratamiento , Estados Unidos , Grado de Desobstrucción VascularRESUMEN
PURPOSE: To quantify and compare portosystemic pressure gradients (PSGs) between bleeding esophageal varices (EV) and gastric varices (GV). MATERIALS AND METHODS: In a single-center, retrospective study, 149 patients with variceal bleeding (90 men, 59 women, mean age 52 y) with EV (n = 69; 46%) or GV (n = 80; 54%) were selected from 320 consecutive patients who underwent successful transjugular intrahepatic portosystemic shunt (TIPS) creation from 1998 to 2016. GV were subcategorized using the Sarin classification as gastroesophageal varices (GEV) (n = 57) or isolated gastric varices (IGV) (n = 23). PSG before TIPS was measured from the main portal vein to the right atrium. PSGs were compared across EV, GEV, and IGV groups using 1-way analysis of variance. RESULTS: Overall mean baseline PSG was 21 mm Hg ± 6. PSG was significantly higher in patients with EV versus GV (23 mm Hg vs 19 mm Hg; P < .001). Mean PSG was highest among EV (23 mm Hg) with lower PSGs identified for GEV (20 mm Hg) and IGV (16 mm Hg); this difference was statistically significant (P < .001). Among 95 acute bleeding cases, a similar pattern was evident (EV 23 mm Hg vs GEV mm Hg 20 vs IGV 17 mm Hg; P < .001). At baseline PSG < 12 mm Hg, 13% (3/23) of IGV bled versus 9% (5/57) of GEV and 3% (2/69) of EVs (P = .169). Mean final PSG after TIPS was 8 mm Hg (IGV 6 mm Hg vs EV and GEV 8 mm Hg; P = .005). CONCLUSIONS: GV bleed at lower PSGs than EV. EV, GEV, and IGV bleeding is associated with successively lower PSGs. These findings highlight distinct physiology, anatomy, and behavior of GV compared with EV.
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Várices Esofágicas y Gástricas/fisiopatología , Várices Esofágicas y Gástricas/cirugía , Hemorragia Gastrointestinal/fisiopatología , Hemorragia Gastrointestinal/cirugía , Derivación Portosistémica Intrahepática Transyugular , Femenino , Humanos , Masculino , Persona de Mediana Edad , Radiografía Intervencional , Estudios RetrospectivosRESUMEN
PURPOSE: A method for adaptively optimized combination (AOC) of MR spectroscopic data from a coil array was recently introduced. The superior performance of the AOC method is evident when compared with the methods that assume uncorrelated noise between coil elements. However, it is unclear whether the AOC method represents the most optimal combination in the presence of correlated noise, when compared with the noise-decorrelated or whitened methods that specifically tackle the correlated noise between coil elements. METHODS: A new, unified theoretical framework was developed to illustrate the relationship between the AOC method and three noise-decorrelated or whitened methods, namely, noise-decorrelated combination (nd-comb), whitened singular value decomposition (WSVD), and improved WSVD (WSVD+Apod). Simulation-based comparisons and in vivo human brain experiments on a 3 Tesla (T) MRI scanner were performed using an 8-channel phased-array head coil. RESULTS: Compared with the noise-decorrelated or whitened methods, the AOC method consistently yielded the best combination in terms of the robustness against noise and maintaining the combined spectrum from distortion, and the superior performance was most evident at a low signal-to-noise ratio (SNR). CONCLUSION: The AOC method represents the theoretical optimal combination in the presence of correlated noise between coil elements, whereas the three noise-decorrelated or whitened methods are asymptotically optimal. Magn Reson Med 78:848-859, 2017. © 2016 International Society for Magnetic Resonance in Medicine.
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Imagen por Resonancia Magnética/métodos , Procesamiento de Señales Asistido por Computador , Encéfalo/diagnóstico por imagen , Simulación por Computador , Humanos , Relación Señal-RuidoRESUMEN
PURPOSE: To evaluate albumin-bilirubin (ALBI) and platelet-albumin-bilirubin (PALBI) grades in predicting overall survival in high-risk patients undergoing conventional transarterial chemoembolization for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This single-center retrospective study included 180 high-risk patients (142 men, 59 y ± 9) between April 2007 and January 2015. Patients were considered high-risk based on laboratory abnormalities before the procedure (bilirubin > 2.0 mg/dL, albumin < 3.5 mg/dL, platelet count < 60,000/mL, creatinine > 1.2 mg/dL); presence of ascites, encephalopathy, portal vein thrombus, or transjugular intrahepatic portosystemic shunt; or Model for End-Stage Liver Disease score > 15. Serum albumin, bilirubin, and platelet values were used to determine ALBI and PALBI grades. Overall survival was stratified by ALBI and PALBI grades with substratification by Child-Pugh class (CPC) and Barcelona Liver Clinic Cancer (BCLC) stage using Kaplan-Meier analysis. C-index was used to determine discriminatory ability and survival prediction accuracy. RESULTS: Median survival for 79 ALBI grade 2 patients and 101 ALBI grade 3 patients was 20.3 and 10.7 months, respectively (P < .0001). Median survival for 30 PALBI grade 2 and 144 PALBI grade 3 patients was 20.3 and 12.9 months, respectively (P = .0667). Substratification yielded distinct ALBI grade survival curves for CPC B (P = .0022, C-index 0.892), BCLC A (P = .0308, C-index 0.887), and BCLC C (P = .0287, C-index 0.839). PALBI grade demonstrated distinct survival curves for BCLC A (P = 0.0229, C-index 0.869). CPC yielded distinct survival curves for the entire cohort (P = .0019) but not when substratified by BCLC stage (all P > .05). CONCLUSIONS: ALBI and PALBI grades are accurate survival metrics in high-risk patients undergoing conventional transarterial chemoembolization for HCC. Use of these scores allows for more refined survival stratification within CPC and BCLC stage.
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Bilirrubina/sangre , Plaquetas , Carcinoma Hepatocelular/sangre , Carcinoma Hepatocelular/terapia , Quimioembolización Terapéutica/métodos , Neoplasias Hepáticas/sangre , Neoplasias Hepáticas/terapia , Albúmina Sérica/análisis , Adulto , Biomarcadores de Tumor/sangre , Carcinoma Hepatocelular/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Pruebas de Función Hepática , Neoplasias Hepáticas/mortalidad , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Radiografía Intervencional , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: The purpose of this study was to compare the efficacy and safety of microfibrillar collagen paste with those of gelatin sponge for liver track embolization after islet cell transplants. MATERIALS AND METHODS: In a single-institution, retrospective study, 37 patients underwent 66 islet cell transplants from January 2005 through October 2015. Transplants were performed with 6-French transhepatic access, systemic anticoagulation, pretransplant and posttransplant portal venous pressure measurement, and image-guided liver track embolization with gelatin sponge (2005-2011) or microfibrillar collagen paste (2012-2015). The findings on 20 patients (two men, 18 women; mean age, 48 years) who underwent 35 gelatin sponge embolizations were compared with the findings on 13 patients (six men, seven women; mean age, 48 years) who underwent 22 microfibrillar collagen paste embolizations (four patients, nine procedures without embolization excluded). Medical record review was used to compare laboratory test results, portal venous pressures, and 30-day adverse bleeding events (classified according to Society of Interventional Radiology and Bleeding Academic Research Consortium criteria) between groups. RESULTS: The technical success rates were 100% in the microfibrillar collagen paste group and 91% in the gelatin sponge group. Group characteristics were similar, there being no differences in platelet count, partial thromboplastin time, or number of islet cell transplants per patient (p > 0.05). A statistical difference in international normalized ratio (1.0 versus 1.1) was not clinically significant (p = 0.012). Posttransplant portal venous pressure was slightly higher among patients treated with gelatin sponge (13 versus 9 mm Hg, p = 0.002). No bleeding occurred after microfibrillar collagen paste embolization, whereas nine bleeding events followed gelatin sponge embolization (0% versus 26%, p = 0.020). In univariate comparison of bleeding and nonbleeding groups, the use of gelatin sponge was statistically associated with postprocedure hemorrhage. CONCLUSION: Microfibrillar collagen paste is effective and safe for liver track embolization to prevent bleeding after islet cell transplants. It appears to be more efficacious than gelatin sponge.
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Colágeno/administración & dosificación , Embolización Terapéutica/métodos , Esponja de Gelatina Absorbible , Hemorragia/prevención & control , Hemostasis Quirúrgica/métodos , Hemostáticos/administración & dosificación , Trasplante de Islotes Pancreáticos , Hígado/irrigación sanguínea , Medios de Contraste/administración & dosificación , Femenino , Hemostasis Quirúrgica/instrumentación , Humanos , Yohexol/administración & dosificación , Masculino , Persona de Mediana Edad , Pomadas , Estudios Retrospectivos , Resultado del Tratamiento , Ultrasonografía DopplerRESUMEN
PURPOSE: To assess the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation with or without variceal coil and/or plug embolization in decompressing or occluding gastric varices (GVs). MATERIALS AND METHODS: In this retrospective study, 78 patients with GV bleeding who underwent TIPS creation with or without embolotherapy with metallic coils and/or plugs from 1999 to 2014 were identified. Individuals who had a bare-metal TIPS and/or lacked post-TIPS imaging or endoscopic follow-up were excluded. The final cohort included 26 patients (16 men; median age, 54 y; median Model for End-stage Liver Disease score, 16). Variceal types, supplying vessels, and postprocedure GV patency on cross-sectional imaging or endoscopy were assessed. The primary study outcome measure was GV patency rate as a surrogate for efficacy of TIPS creation with or without embolization. RESULTS: GVs included gastroesophageal varix types 1 (n = 10) and 2 (n = 2), isolated GV types 1 (n = 4) and 2 (n = 2), and unspecified (n = 8). TIPS creation resulted in a median final portosystemic pressure gradient of 7 mm Hg. Multiple GV-supplying vessels (left/posterior/short gastric veins) were present in 65% of patients (n = 17). Embolization was performed in 69% (n = 18). Thirteen, four, and nine patients had imaging, endoscopic, or both imaging/endoscopic follow-up. GV patency rate was 65% (n = 17; 61%/75% with/without embolization) at a median of 128.5 days (range, 1-1,295 d) after TIPS creation. Incidence of recurrent bleeding was 27% (n = 7), and the 90-day mortality rate was 15% (n = 4). CONCLUSIONS: In this study, most GVs showed persistent patency despite TIPS decompression and variceal embolization, and the incidence of recurrent bleeding was high. The findings suggest suboptimal efficacy for GVs, and indicate a need for study of alternative or adjunctive approaches to GV treatment, such as chemical obliteration.
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Embolización Terapéutica/métodos , Várices Esofágicas y Gástricas/cirugía , Hemorragia Gastrointestinal/cirugía , Hipertensión Portal/cirugía , Cirrosis Hepática/complicaciones , Presión Portal , Derivación Portosistémica Intrahepática Transyugular , Adulto , Anciano , Anciano de 80 o más Años , Chicago , Angiografía por Tomografía Computarizada , Embolización Terapéutica/efectos adversos , Várices Esofágicas y Gástricas/diagnóstico , Várices Esofágicas y Gástricas/etiología , Várices Esofágicas y Gástricas/fisiopatología , Femenino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/fisiopatología , Humanos , Hipertensión Portal/diagnóstico , Hipertensión Portal/etiología , Hipertensión Portal/fisiopatología , Cirrosis Hepática/diagnóstico , Masculino , Persona de Mediana Edad , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
PURPOSE: To evaluate transjugular intrahepatic portosystemic shunt (TIPS) outcomes and procedure metrics with the use of three different image guidance techniques for portal vein (PV) access during TIPS creation. MATERIALS AND METHODS: A retrospective review of consecutive patients who underwent TIPS procedures for a range of indications during a 28-month study period identified a population of 68 patients. This was stratified by PV access techniques: fluoroscopic guidance with or without portography (n = 26), PV marker wire guidance (n = 18), or intravascular ultrasound (US) guidance (n = 24). Procedural outcomes and procedural metrics, including radiation exposure, contrast agent volume used, procedure duration, and PV access time, were analyzed. RESULTS: No differences in demographic or procedural characteristics were found among the three groups. Technical success, technical success of the primary planned approach, hemodynamic success, portosystemic gradient, and procedure-related complications were not significantly different among groups. Fluoroscopy time (P = .003), air kerma (P = .01), contrast agent volume (P = .003), and total procedural time (P = .02) were reduced with intravascular US guidance compared with fluoroscopic guidance. Fluoroscopy time (P = .01) and contrast agent volume (P = .02) were reduced with intravascular US guidance compared with marker wire guidance. CONCLUSIONS: Intravascular US guidance of PV access during TIPS creation not only facilitates successful TIPS creation in patients with challenging anatomy, as suggested by previous investigations, but also reduces important procedure metrics including radiation exposure, contrast agent volume, and overall procedure duration compared with fluoroscopically guided TIPS creation.
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Hipertensión Portal/cirugía , Vena Porta/cirugía , Derivación Portosistémica Intrahepática Transyugular , Radiografía Intervencional , Ultrasonografía Intervencional , Adolescente , Adulto , Anciano , Puntos Anatómicos de Referencia , Dióxido de Carbono/administración & dosificación , Medios de Contraste/administración & dosificación , Femenino , Fluoroscopía , Humanos , Hipertensión Portal/diagnóstico por imagen , Hipertensión Portal/etiología , Hipertensión Portal/fisiopatología , Cirrosis Hepática/complicaciones , Cirrosis Hepática/diagnóstico , Masculino , Persona de Mediana Edad , Tempo Operativo , Presión Portal , Vena Porta/diagnóstico por imagen , Vena Porta/fisiopatología , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Portografía , Dosis de Radiación , Exposición a la Radiación , Radiografía Intervencional/efectos adversos , Radiografía Intervencional/métodos , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Intervencional/efectos adversos , Adulto JovenRESUMEN
OBJECTIVE: The purpose of this study is to investigate the outcomes of conventional transarterial chemoembolization (TACE) treatment of hepatocellular carcinoma (HCC) in contemporary clinical practice. MATERIALS AND METHODS: In this single-institution retrospective study, 188 patients underwent conventional TACE for HCC between 2007 and 2013. Medical record and imaging review was used to collect baseline demographic and disease data, tumor response, time to progression (TTP), and progression-free survival (PFS) outcomes, as well as transplant-free survival, calculated from the time of the first conventional TACE treatment. Data were censored in April 2014. RESULTS: The study cohort included 140 men and 48 women (mean age, 60 years; Barcelona Clinic Liver Cancer [BCLC] stage 0 = 5%, BCLC stage A = 41%, BCLC stage B = 28%, BCLC stage C = 15%, and BCLC stage D = 11%) with 207 index tumors (mean size, 4.0 cm; 11% with portal vein invasion) treated with a mean of 1.6 selective (79%) or lobar (21%) conventional TACE sessions. Concurrent thermal ablation was performed for 19% of patients. Objective response rates included size response in 29% (World Health Organization) and 28% (Response Evaluation Criteria for Solid Tumors [RECIST]) of patients, and necrosis response in 79% (European Association for the Study of the Liver) and 70% (modified RECIST) of patients. Median local TTP, distant site TTP, local PFS, and other site PFS were 51.7, 11.2, 10.8, and 10.5 months. Eighteen percent of patients underwent liver transplantation; 48% of United Network for Organ Sharing stage T3 tumors were downstaged to stage T2. Transplant-free survival for the entire cohort was 16.8 months (not reached, 33.9, 16.0, 4.4, and 6.9 months for BCLC stages 0, A, B, C, and D, respectively). Postembolization syndrome requiring extended hospital stay or readmission occurred in only 6% of patients. CONCLUSION: Conventional TACE is effective and safe for HCC therapy and may confer a survival benefit. The current data are in line with reported conventional TACE outcomes, and the minor postembolization syndrome incidence supports the low morbidity of this approach.
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Antineoplásicos/administración & dosificación , Carcinoma Hepatocelular/terapia , Quimioembolización Terapéutica , Aceite Etiodizado/administración & dosificación , Neoplasias Hepáticas/terapia , Anciano , Carcinoma Hepatocelular/etiología , Carcinoma Hepatocelular/patología , Estudios de Cohortes , Femenino , Humanos , Neoplasias Hepáticas/etiología , Neoplasias Hepáticas/patología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Although underdilation of transjugular intrahepatic portosystemic shunt (TIPS) stent grafts is commonly performed to limit complications arising from excessive portosystemic shunting, it is uncertain whether underdilated stents retain their smaller diameter indefinitely or eventually expand to nominal caliber. In this investigation, postprocedure computed tomography (CT) was used to compare diameters of underdilated TIPSs and TIPSs expanded to a nominal diameter of 10 mm in 61 cases. The groups had comparable shunt diameters on post-TIPS imaging (9.8 mm vs 9.9 mm; P = .079), with similar incidences of hepatic encephalopathy (34% vs 20%; P = .372), indicating stent self-expansion over time, and bringing into question the advantages of underdilation for customization of shunt caliber.
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Dilatación/instrumentación , Arteria Hepática/diagnóstico por imagen , Venas Hepáticas/diagnóstico por imagen , Derivación Portosistémica Intrahepática Transyugular/instrumentación , Derivación Portosistémica Intrahepática Transyugular/métodos , Ajuste de Prótesis/métodos , Adulto , Anciano , Anciano de 80 o más Años , Dilatación/métodos , Análisis de Falla de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Radiografía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
PURPOSE: To identify fundamental causes underlying recurrent variceal hemorrhage (VH) after transjugular intrahepatic portosystemic shunt (TIPS) to ascertain opportunities for improvement of TIPS-based management of VH and prevention of rebleeding. MATERIALS AND METHODS: This single-center retrospective study comprised 166 patients (male-to-female ratio 101:65; median age, 52 y; median Model for End-Stage Liver Disease score, 14) who had TIPS created for VH in 1998-2014. Medical record review was used to identify patients who had recurrent VH events, and root cause analysis allowed identification of the most probable causal factors. A 5-person interventional radiology physician group generated quality improvement (QI) recommendations for process changes to address causal factors, with consensus achieved using a modified Delphi method. RESULTS: Variceal rebleeding occurred after TIPS in 25 (15%) patients. The 1-, 3-, and 5-year variceal rebleeding incidence was 17%, 21%, and 21%, respectively. Variceal rebleeding was associated with high 90-day all-cause mortality incidence (10/25; 40%). Male sex (P = .018) and Model for End-Stage Liver Disease score (P = .009) were statistically associated with variceal rebleeding. The most common primary and secondary causes of recurrent VH were lack of or insufficient variceal embolization (64%). Other causal factors included TIPS stenosis or occlusion (28%) with recurrent portosystemic gradient (PSG) elevation (20%), severe coagulopathy (20%), inadequate portosystemic gradient reduction (12%), and TIPS underdilation (4%). To potentially address variceal rebleeding, 14 preventive QI recommendations were developed. CONCLUSIONS: Although recurrent VH rates after TIPS are not trivial, rebleeding may be related to addressable underlying causal factors. Further investigation may assess the efficacy of QI-based procedure methodologic enhancements in reducing rebleeding incidence after TIPS.
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Enfermedad Hepática en Estado Terminal/mortalidad , Enfermedad Hepática en Estado Terminal/cirugía , Várices Esofágicas y Gástricas/mortalidad , Hemorragia Gastrointestinal/mortalidad , Derivación Portosistémica Intrahepática Transyugular/estadística & datos numéricos , Complicaciones Posoperatorias/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Causalidad , Comorbilidad , Diagnóstico Diferencial , Várices Esofágicas y Gástricas/prevención & control , Femenino , Hemorragia Gastrointestinal/prevención & control , Humanos , Illinois/epidemiología , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Recurrencia , Estudios Retrospectivos , Medición de Riesgo , Tasa de Supervivencia , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: The objective of this study was to determine the point in time at which tunneled peritoneal catheter placement becomes less costly than repeat large-volume paracentesis (LVP) for patients with malignant ascites. MATERIALS AND METHODS: Procedure costs were based on 2013 Medicare reimbursement rates. Rates for specific complications were obtained from the literature and were assigned costs. A decision tree-based Markov chain Monte Carlo model was designed with 11 cycles of 10 days, to simulate 4000 subjects per trial. Patients were grouped according to initial treatment decision (LVP vs catheter placement), and the total cost at the end of each 10-day cycle was calculated. The point at which catheter placement became less costly than LVP was determined. Additional simulations were used for bivariate analyses of all cost and probability variables and for trivariate analysis of cycle length and volume of fluid drained per cycle. RESULTS: Individual input probabilities were not significantly different from corresponding simulation outcomes (p value range, 0.068-0.95). When complications were included in the model, the cost curves crossed at a mean (± SD) of 82.8 ± 3.6 days (range, 75.8-89.6 days), corresponding to a time between the performance of the ninth and 10th LVP procedures. Intersection occurred earlier in simulations with a shorter cycle length and less fluid per cycle, but it was minimally affected by changing individual complication probabilities and costs. CONCLUSION: For patients with malignant ascites, LVP becomes more costly once the procedure is performed nine or 10 times or at approximately 83 days, if paracentesis is repeated every 10 days, with 5 L of fluid removed each time. Use of a tunneled peritoneal catheter improves the cost advantage for patients who receive LVP more frequently or patients who have less than 5 L of fluid drained per procedure.
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Ascitis/terapia , Catéteres de Permanencia , Paracentesis/métodos , Ascitis/economía , Ascitis/etiología , Catéteres de Permanencia/economía , Control de Costos , Análisis Costo-Beneficio , Humanos , Cadenas de Markov , Método de Montecarlo , Neoplasias/complicaciones , Paracentesis/economía , Peritoneo , Complicaciones Posoperatorias , Radiografía IntervencionalRESUMEN
OBJECTIVE. The purpose of this study was to determine the overall survival rates in patients with advanced hepatocellular carcinoma (HCC) who undergo treatment with drug-eluting bead (DEB) therapy. MATERIALS AND METHODS. A retrospective review of the clinical HCC database of a single institution was undertaken for patients treated between September 2008 and December 2011. Demographic information, laboratory and imaging findings, procedural details, and outcomes after treatment were obtained. The primary outcome was overall survival, which was stratified by Barcelona Clinic Liver Cancer (BCLC) stage, Child-Pugh class, Eastern Cooperative Oncology Group (ECOG) score, serum bilirubin level, and ethnicity. Multiple secondary independent variables were also measured. RESULTS. Of 239 consecutive patients treated during the prescribed time frame, 43 patients met the inclusion criteria. Thirty patients met the criteria for BCLC stage C, and 13 met the criteria for BCLC stage D based largely on ECOG score. Eight patients had venous invasion or portal venous thrombosis, and four had limited extrahepatic metastases. Eight patients had Child-Pugh class C liver disease but remained candidates for liver transplant based on the Milan criteria. The median overall survival was 596 days; 23 patients are still alive, 12 of whom underwent liver transplant. The only independent variables affecting survival were serum bilirubin value of 2.0 mg/dL or greater (hazard ratio [HR] = 3.96; 95% CI, 1.46-10.7; p = 0.007) and Child-Pugh class B or C disease (HR = 3.33; 95% CI, 1.07-10.34; p = 0.037). CONCLUSION. The use of DEBs for TACE therapy is safe and effective in carefully selected patients with advanced HCC.
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Carcinoma Hepatocelular/mortalidad , Carcinoma Hepatocelular/terapia , Quimioembolización Terapéutica , Portadores de Fármacos , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/terapia , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma Hepatocelular/patología , Femenino , Humanos , Neoplasias Hepáticas/patología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
PURPOSE: To assess the incidence, prognostic factors, and clinical outcomes of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS: In this single-institution retrospective study, 191 patients (m:f = 114:77, median age 54 years, median Model for End-Stage Liver Disease or MELD score 14) who underwent TIPS creation between 1999 and 2013 were studied. Medical record review was used to identify demographic characteristics, liver disease, procedure, and outcome data. Post-TIPS HE within 30 days was defined by new mental status changes and was graded according to the West Haven classification system. The influence of data parameters on HE occurrence and 90-day mortality was assessed using binary logistic regression. RESULTS: TIPS was successfully created with hemodynamic success in 99 % of cases. Median final PSG was 7 mmHg. HE incidence within 30 days was 42 % (81/191; 22 % de novo, 12 % stable, and 8 % worsening). Degrees of HE included grade 1 (46 %), grade 2 (29 %), grade 3 (18 %), and grade 4 (7 %). Medical therapy typically addressed HE, and shunt reduction was necessary in only three cases. MELD score (P = 0.020) and age (P = 0.009) were significantly associated with HE development on multivariate analysis. Occurrence of de novo HE post-TIPS did not associate with 90-day mortality (P = 0.400), in contrast to worsening HE (P < 0.001). CONCLUSIONS: The incidence of post-TIPS HE is non-trivial, but symptoms are typically mild and medically managed. HE rates are higher in older patients and those with worse liver function and should be contemplated when counseling on expected TIPS outcomes and post-procedure course.
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Encefalopatía Hepática/epidemiología , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Chicago/epidemiología , Femenino , Encefalopatía Hepática/etiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Reoperación , Estudios Retrospectivos , Factores de RiesgoRESUMEN
UNLABELLED: BACKGROUND AND RATIONALE FOR THE STUDY: The Model for End Stage Liver Disease (MELD) score has not been derived and validated for the emergent transjugular intrahepatic portosystemic shunt (TIPS) population. We sought to identify predictive factors for survival among emergent TIPS patients, and to substantiate MELD for outcomes prognostication in this population. RESULTS: 101 patients with acute life threatening variceal hemorrhage underwent emergent TIPS (defined by failed endoscopic therapy for active bleeding, acute hemoglobin drop, ≥ 2-unit transfusion requirement, and/or vasopressor need) at between 1998-2013. Demographic, clinical, laboratory, and procedure parameters were analyzed for correlation with mortality using Cox proportional hazards regression to derive the prognostic value of MELD constituents. Area under receiver operator characteristic (AUROC) curves was used to assess the capability of MELD prediction of mortality. TIPS were created 119 ± 167 h after initial bleeding events. Hemodynamic success was achieved in 90%. Median final portosystemic pressure gradient was 8 mmHg. Variceal rebleeding incidence was 21%. The four original MELD components showed significant correlation with mortality on multivariate Cox regression: baseline bilirubin (regression coefficient 0.366), creatinine (0.621), international normalized ratio (1.111), and liver disease etiology (0.808), validating the MELD system for emergent cases. No other significant predictive parameters were identified. MELD was an excellent predictor of 90-day mortality in the emergent TIPS population (AUROC = 0.842, 95% CI 0.755-0.928). CONCLUSIONS: Based on independent derivation of prognostic constituents and confirmation of predictive accuracy, MELD is a valid and reliable metric for risk stratification and survival projection after emergent TIPS.
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Urgencias Médicas , Enfermedad Hepática en Estado Terminal/mortalidad , Várices Esofágicas y Gástricas/cirugía , Hemorragia Gastrointestinal/cirugía , Derivación Portosistémica Intrahepática Transyugular , Enfermedad Aguda , Enfermedad Hepática en Estado Terminal/complicaciones , Várices Esofágicas y Gástricas/complicaciones , Femenino , Estudios de Seguimiento , Hemorragia Gastrointestinal/etiología , Humanos , Illinois/epidemiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia/tendenciasRESUMEN
PURPOSE: To assess downstaging rates in patients with United Network for Organ Sharing stage T3N0M0 hepatocellular carcinoma (HCC) treated with doxorubicin-eluting bead transarterial chemoembolization to meet Milan criteria for transplantation. MATERIALS AND METHODS: A single-center retrospective review of 239 patients treated with doxorubicin-eluting bead (DEB) chemoembolization between September 2008 and December 2011 was undertaken. Baseline and follow-up computed tomography or magnetic resonance imaging was assessed for response based on the longest enhancing axial dimension of each tumor (ie, modified Response Evaluation Criteria In Solid Tumors measurements), and medical records were reviewed. Fisher exact tests and exact logistic regression were used to test the association of patient and disease characteristics with downstaging. RESULTS: After exclusions, 22 patients remained in the analysis, 17 of whom (77%) had their HCC downstaged to meet Milan criteria. Among those whose disease was downstaged, seven underwent transplantation, one remained listed for transplantation, six had disease progression beyond Milan criteria, two underwent conventional transarterial chemoembolization, and one underwent radiofrequency ablation. The seven patients who received transplants were still living, but recurrent HCC developed in two. Baseline age (P = .25), Model for End-stage Liver Disease score (P = .77), and α-fetoprotein (AFP) level (P = 1.00) were similar between patients with and without downstaged HCC. No associations were observed between the odds of downstaging and sex (P = .21), Child-Pugh class (P = .14), Child-Pugh class controlling for baseline tumor multiplicity (P = .15), Eastern Cooperative Oncology Group performance status (P = 1.00), tumor burden (P = .31), multiple tumors (P = .31), or hepatitis C virus infection (P = 1.00). Fifteen patients who did not receive transplants were alive at 1 year, with two progression-free. Baseline AFP levels differed between those who survived 1 year and those who did not (P = .02), but did not differ by progression-free survival status (P = .62). CONCLUSIONS: T3N0M0 HCC treatment with DEB chemoembolization has a high likelihood (77%) of downstaging the disease to meet Milan criteria.