Development of a Model including MRI Features for Predicting Advanced-stage Recurrence of Hepatocellular Carcinoma after Liver Resection.

Background Identifying patients at high risk for advanced-stage hepatocellular carcinoma (HCC) recurrence after liver resection may improve patient survival. Purpose To develop a model including MRI features for predicting postoperative advanced-stage HCC recurrence. Materials and Methods This single-center, retrospective study includes consecutive adult patients who underwent preoperative contrast-enhanced MRI and curative-intent resection for early- to intermediate-stage HCC (from December 2011 to April 2021). Three radiologists evaluated 52 qualitative features on MRI scans. In the training set, Fine-Gray proportional subdistribution hazard analysis was performed to identify clinical, laboratory, imaging, pathologic, and surgical variables to include in the predictive model. In the test set, the concordance index (C-index) was computed to compare the developed model with current staging systems. The Kaplan-Meier survival curves were compared using the log-rank test. Results The study included 532 patients (median age, 54 years; IQR, 46-62 years; 465 male patients), 302 patients from the training set (median age, 54 years; IQR, 46-63 years; 265 male patients), and 128 patients from the test set (median age, 53 years; IQR, 46-63 years; 108 male patients). Advanced-stage recurrence was observed in 38 of 302 (12.6%) and 15 of 128 (11.7%) of patients from the training and test sets, respectively. Serum neutrophil count (109/L), tumor size (in centimeters), and arterial phase hyperenhancement proportion on MRI scans were associated with advanced-stage recurrence (subdistribution hazard ratio range, 1.16-3.83; 95% CI: 1.02, 7.52; P value range, <.001 to .02) and included in the predictive model. The model showed better test set prediction for advanced-stage recurrence than four staging systems (2-year C-indexes, 0.82 [95% CI: 0.74, 0.91] vs 0.63-0.68 [95% CI: 0.52, 0.82]; P value range, .001-.03). Patients at high risk for HCC recurrence (model score, ≥15 points) showed increased advanced-stage recurrence and worse all-stage recurrence-free survival (RFS), advanced-stage RFS, and overall survival than patients at low risk for HCC recurrence (P value range, <.001 to .02). Conclusion A model combining serum neutrophil count, tumor size, and arterial phase hyperenhancement proportion predicted advanced-stage HCC recurrence better than current staging systems and may identify patients at high risk. Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Tsai and Mellnick in this issue.

Predictors of Improvement of Sarcopenia after Transjugular Intrahepatic Portosystemic Shunt Creation in Cirrhotic Patients.

To investigate the risk factors affecting the improvement of sarcopenia after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients, this study retrospectively analyzed the data of 111 cirrhotic patients with sarcopenia who underwent TIPS creation. Computed tomography-based measurement of skeletal muscle area was used to calculate skeletal muscle index (SMI) in all patients at baseline and 6 months after TIPS creation. Multivariate logistic regression analysis was used to identify independent risk factors, which showed a significant increase in 6-month post-TIPS SMI compared with that at baseline in both men and women (for both, P < .001). Pre-TIPS SMI (odds ratio [OR], 0.93; 95% CI, 0.87-0.99; P = .031) and change in portal pressure gradient (OR, 1.13; 95% CI, 1.03-1.24; P = .009) were found to be independent risk factors for experiencing substantial improvement in post-TIPS SMI.

Sarcopenia Defined by Psoas Muscle Thickness Predicts Mortality After Transjugular Intrahepatic Portosystemic Shunt.

PURPOSE: To assess and compare the value of psoas muscle thickness at the level of the third lumbar (L3) vertebra (TPML) or umbilicus (TPMU) and skeletal muscle index (SMI) for diagnosing sarcopenia and predicting mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS: Two hundred forty-nine patients undergoing TIPS were included in this retrospective study. The cut-offs of L3-SMI for sarcopenia were 42.0 cm2/m2 in men and 38.0 cm2/m2 in women. The cut-offs for TPML/height and TPMU/height to predict mortality was established using a receiver-operating characteristic analysis. The Kaplan-Meier and Cox regression were used for survival analyses. RESULTS: Compared with TPMU/height, TPML/height was more consistent with L3-SM for the diagnosis of sarcopenia (Kappa coefficient: 0.63 vs. 0.36 in men; 0.61 vs. 0.45 in women). The Cox analysis showed that both TPML/height and TPMU/height were independent risk factors for mortality. The optimal cut-off values of TPML/height and TPMU/height for mortality in men and women were 11.2 mm/m, 9.4 mm/m, 18.4 mm/m, 15.1 mm/m, respectively. There were 119 (47.8%), 87 (34.9%), and 82 (32.9%) patients diagnosed with sarcopenia in the TPMU/height, TPML/height, and L3-SMI models, respectively. Kaplan-Meier analysis showed that the overall survival was significantly lower in the sarcopenia group in all three models. CONCLUSION: TPMU/height and TPML/height have a similar survival prognostic value as L3-SMI. TPML/height has better consistency with L3-SMI in diagnosing sarcopenia and is a more stable alternative to L3-SMI for diagnosing sarcopenia in patients undergoing TIPS.

Sarcopenia in Patients with Cirrhosis after Transjugular Intrahepatic Portosystemic Shunt Placement.

Background Sarcopenia is frequently found in patients with cirrhosis and is associated with liver dysfunction, cirrhosis-related complications, and poorer quality of life. Purpose To evaluate changes in skeletal muscle and fat mass at CT and to evaluate the relationship of sarcopenia to mortality in patients with cirrhosis after transjugular intrahepatic portosystemic shunt (TIPS) placement. Materials and Methods Patients who underwent TIPS between August 2016 and May 2020 were included in this retrospective study. Skeletal muscle and fat mass were evaluated at CT at the L3 vertebra at baseline and at 2 months, 5 months, and 1 year after TIPS. Sarcopenia was defined as L3 skeletal muscle index (SMI) less than 50 cm2/m2 for men and less than 39 cm2/m2 for women. The primary end point was change in skeletal muscle and fat mass, and secondary end points included survival and the predictive factors for survival. Changes in skeletal muscle and fat mass over time were analyzed by generalized estimating equations. Results A total of 224 patients (159 men [113 with and 46 without sarcopenia] and 65 women [32 with and 33 without sarcopenia]) were included. In male patients with sarcopenia, the mean L3 SMI increased from 41.8 cm2/m2 (baseline) to 49.1 cm2/m2 (at 5-month follow-up; P < .001) and 49.6 cm2/m2 (at 1-year follow-up; P < .001) after TIPS. In female patients with sarcopenia, SMI increased from 33.7 cm2/m2 (at baseline) to 40.6 cm2/m2 (at 5-month follow-up; P < .001) and 42.0 cm2/m2 (at 1-year follow-up; P < .001) after TIPS. Sarcopenia (hazard ratio, 3.0; 95% CI: 1.2, 7.8) was identified as an independent risk factor for mortality after TIPS, and the patients who converted from sarcopenic to nonsarcopenic had higher cumulative survival rate than those who did not (96.4% vs 82.1%; log-rank P = .04). Conclusion In patients with sarcopenia, both skeletal muscle and fat mass increased after transjugular intrahepatic portosystemic shunt placement. The reversal of sarcopenia could reduce the risk of death. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Lee in this issue.

Natural History and Influence on Long-term Outcomes of Isolated Type II Endoleak after Endovascular Aneurysm Repair: A 10-year Experience at a Single Center.

BACKGROUND: The management of type II endoleaks (T2ELs) remains controversial in current literature. Hence, this study aimed to explore the natural history of isolated type II endoleak after endovascular aneurysm repair (EVAR) and its influence on long-term outcomes based on a 10-year follow-up at a tertiary medical center. METHODS: From January 2011 to April 2021, consecutive patients who underwent elective EVAR were reviewed. The demographics, clinical characteristics, treatment details, imaging information, in the event of T2ELs, and outcomes were extracted. RESULTS: A total of 287 patients were included for analysis. Isolated T2EL was identified in 79 patients (27.5%), while no endoleak was found in 208 patients (72.5%). The mean age at EVAR was 68.1 ± 8.9 years (range, 41-92 years) and the majority of patients were male (81.5%). The mean follow-up duration was 42.7 months (range, 2-119.7 months). Among the 79 patients with isolated T2ELs, 33 (41.8%, 33/79) were early and 46 (58.2%, 46/79) were late. Spontaneous resolution of T2ELs was identified in 29 patients (36.7%, 29/79). Persistent T2ELs were observed in 50 patients (63.3%, 50/79). No sac growth was seen in 33 patients (66%, 33/50) and these patients were managed conservatively. The remaining 17 patients (34%, 17/50) showed significant sac growth. Six of them declined intervention due to various reasons and the remaining 11 patients underwent interventional embolization for T2ELs. Following the embolization, 2 patients had complete resolution of T2ELs and 9 patients had persistent T2ELs. Among the patients with persistent T2ELs, 2 patients (2/9) still showed progressive sac growth, and one of them died from aneurysm rupture; the remaining 7 patients (7/9) showed no sac growth. Patients with isolated T2ELs had a higher incidence of sac growth than patients without any endoleak (21.5% vs 4.3%, p < 0.001), while no difference was found in overall survival between the two groups. In Cox regression analysis, only higher age was independently associated with worse survival. CONCLUSIONS: Type II Endoleak was significantly associated with aneurysm sac growth and no association with survival was observed.

Late combination of transarterial chemoembolization with apatinib and camrelizumab for unresectable hepatocellular carcinoma is superior to early combination.

OBJECTIVE: The purpose of this study was to explore the efficacy and safety of transarterial chemoembolization (TACE) combined with apatinib and camrelizumab (TACE + AC) for unresectable hepatocellular carcinoma (HCC), and the impact of the timing of the combination on it. METHODS: In this single-arm retrospective study, consecutive data of patients with unresectable HCC treated to our hospital from March 2017 to September 2021 were collected. These patients were treated with TACE and started on camrelizumab and apatinib within one week of TACE. Camrelizumab 200 mg intravenously once every three weeks and apatinib 250 mg orally once daily. Repeat TACE treatment was available on an on-demand basis. The primary endpoints were overall survival (OS) and progression-free survival (PFS). Secondary endpoints included objective response rate (ORR), disease control rate (DCR), and safety. The univariate and multivariate Cox regression analyses were used to assess the effect of early and late combination on OS and PFS. RESULTS: A total of 80 patients were enrolled in this study. The median OS was 22.1 months (95% confidence interval [CI]: 13.8-30.5 months) and the median PFS was 15.7 months (95% CI: 14.7-16.6 months). The ORR was 58.8% (95% CI: 47.2-69.6) and DCR reached 81.2% (95% CI: 71.0-89.1). Multivariable Cox proportional hazard regression analyses showed that TACE late combined with apatinib and camrelizumab provided better OS than early combination (HR = 0.175, 95% CI:0.060-0.509, P = 0.001), as did PFS (HR = 0.422, 95% CI:0.184-0.967, P = 0.041). All treatment-related adverse events were tolerable, and no serious adverse events were observed. CONCLUSION: TACE combined with apatinib plus camrelizumab for patients with unresectable HCC has promising antitumor activity and a manageable safety profile. For unresectable HCC with large tumor burden, late combination provides better OS and PFS compared to early combination.

Thoracic Endovascular Aortic Repair for Retrograde Type A Intramural Hematoma With Intimal Disruption in the Descending Aorta.

PURPOSE: To evaluate the safety and efficacy of thoracic endovascular aortic repair (TEVAR) for retrograde type A intramural hematoma (IMH) with intimal disruption in the descending aorta and report our endovascular therapeutic experience. MATERIALS AND METHODS: From January 2014 to October 2020, a total of 24 consecutive patients with retrograde type A IMH with intimal disruption (intimal tear or ulcer-like projection) in the descending aorta underwent TEVAR. The demographics, clinical characteristics, treatment details, imaging information, and follow-up results were reviewed. RESULTS: Among all patients with retrograde type A IMH, 13 (54.2%) patients presented with ulcer-like projection and 11 (45.8%) with intimal tear (aortic dissection) in the descending aorta. Successful TEVAR was achieved in all patients. There was no 30-day mortality. During a mean follow-up of 37.5 months, 1 patient (4.2%) developed permanent paralysis, 1 patient (4.2%) underwent reintervention due to the expansion of the aorta distal to the stent resulting from the enlargement of distal intimal tear at the 2 month follow up, and no other adverse events were observed. The latest computed tomographic angiography images showed that the maximum diameter of the ascending aorta and descending aorta significantly decreased after TEVAR (both p<0.001), and the IMH/false lumen in the ascending aorta and the descending thoracic aorta were completely absorbed. CONCLUSION: Thoracic endovascular aortic repair for selected patients with retrograde type A intramural hematoma that presented with intimal disruption in the descending aorta is feasible and efficient, but close surveillance is needed to manage aortic-related adverse events.

Two-step complete splenic artery embolization for the management of symptomatic sinistral portal hypertension.

BACKGROUND: Sinistral portal hypertension (SPH) is a rare clinical syndrome. The purpose of this study was to assess the clinical outcomes and safety of splenic artery embolization (SAE) in the treatment of SPH. METHODS: This retrospective study included 39 SPH patients who underwent SAE treatment between August 2009 and May 2021. The cases had esophageal, gastric, or ectopic varices detected by endoscopy or enhanced CT, with symptoms or signs of upper gastrointestinal (GI) bleeding and/or postprandial fullness. Clinical symptom improvement rate, complications, and symptomatic recurrence rate were observed and analyzed after treatment. RESULTS: All the procedures were performed successfully. Of all patients, 17 received the 2-step complete SAE procedure, 19 received only the first step of the 2-step protocol (i.e., partial splenic embolization [PSE] procedure), and the remaining three received the 1-step complete SAE procedure. After the procedures, the symptoms completely disappeared in all patients, and the main complications were post-embolization syndromes, with 27 patients (69.2%) developing a low-grade fever, 24 (61.5%) developing abdominal pain and 4 (10.3%) developing nausea or mild vomiting. During the prolonged follow-up, varicose veins were gradually reduced as detected by enhanced CT; liver function parameters and platelet count remained in the normal range. Only one patient who underwent PSE treatment developed upper GI rebleeding 7 months after the procedure. CONCLUSION: Two-step complete SAE is a safe and feasible procedure for the treatment of symptomatic SPH.

Covered vs. uncovered self-expandable metal stents for palliation of malignant afferent loop obstruction: a multicenter study.

BACKGROUND AND AIMS: Endoscopic stent placement is a palliative therapy for malignant digestive tract obstruction. However, its use for malignant afferent loop obstruction (mALO) has not been adequately investigated. METHODS: From March 2009 to December 2020, 137 patients with mALO who underwent endoscopic stent placement at three tertiary care centers were retrospectively enrolled. The primary aim of this study was to compare stent dysfunction (SD) between the covered self-expandable metal stent (CSEMS) and uncovered self-expandable metal stent (UCSEMS) groups, with subgroup analysis among patients with extrinsic and intrinsic tumors separately. RESULTS: Twenty-three patients developed SD in the CSEMS group and 29 patients in the UCSEMS group (log-rank p = .974). The primary contributors to SD included a higher risk of stent migration in the CSEMS group and stent ingrowth in the UCSEMS group (p = .003; p < .001). Among patients with extrinsic tumors, the CSEMS group showed a significantly higher probability of overall SD (p = .008) and stent migration (p = .001) with a shorter time to SD (log-rank p = .006) than the UCSEMS group. Among patients with intrinsic tumors, the CSEMS group showed a significantly lower incidence of overall SD (p < .001) and stent ingrowth (p < .001) with a longer time to SD (log-rank p = .011) than the UCSEMS group. CONCLUSIONS: Our results showed no significant difference in SD between the CSEMS and UCSEMS groups for palliation of mALO. Furthermore, subgroup analysis suggested using CSEMSs for patients with intrinsic tumors, and UCSEMSs for those with extrinsic tumors.

FIPS Score for Prediction of Survival After TIPS Placement: External Validation and Comparison With Traditional Risk Scores in a Cohort of Chinese Patients With Cirrhosis.

BACKGROUND. Various prognostic scores for patients with chronic liver disease have been applied for predicting survival after TIPS placement. In 2021, the Freiburg index of post-TIPS survival (FIPS) score was developed specifically for predicting survival after TIPS placement. The score has exhibited variable performance in initial investigations conducted in German and U.S. cohorts. OBJECTIVE. The purpose of this study was to compare the utility of the FIPS score and traditional scoring systems for predicting post-TIPS survival in a cohort of Chinese patients with cirrhosis. METHODS. This retrospective validation study compared four prognostic scores (model for end-stage liver disease [MELD], sodium MELD [MELD-Na], Chronic Liver Failure Consortium acute decompensation [CLIF-C AD], and FIPS) in 383 patients (mean age, 54.9 ± 11.7 years; 249 men, 134 women) with cirrhosis who underwent TIPS placement (341 for variceal bleeding, 42 for refractory ascites) at Wuhan Union Hospital between January 2016 and August 2021. Model performance was assessed in terms of discrimination (using concordance index) and calibration (using Brier score and observed-to-predicted ratios) for 6-, 12-, and 24-month post-TIPS survival. Discrimination was further stratified by TIPS indication. Risk stratification was performed using previously proposed cutoffs for each score. RESULTS. During postprocedural follow-up, 72 (18.8%) patients died. Discriminative performance for 6-month survival was highest for FIPS score (concordance index, 0.784), followed by CLIF-C AD (0.743), MELD-Na (0.699), and MELD (0.694). FIPS score also showed the highest calibration in terms of lower Brier scores and observed-to-predicted ratios closer to 1 and showed the strongest prognostic performance for 12- and 24-month survival and in subgroups of patients who underwent TIPS placement for either variceal bleeding or refractory ascites (except for similar performance of FIPS and CLIF-C AD in the refractory ascites subgroup). When prior cutoffs were applied, further application of FIPS score was significantly associated with survival among patients classified as low risk by the other scores. CONCLUSION. FIPS score outperformed traditional risk scores in predicting post-TIPS survival in patients with cirrhosis. CLINICAL IMPACT. The findings support utility of FIPS score in differentiating patients who are optimal candidates for TIPS placement versus those at high risk who may instead warrant close monitoring and early liver transplant.

Portal flow diversion based on portography is superior than puncture site in the prediction of overt hepatic encephalopathy after TIPS creation.

BACKGROUND: Targeted puncture of an appropriate portal venous branch during transjugular intrahepatic portosystemic shunt (TIPS) procedure may reduce the risk of postprocedural overt hepatic encephalopathy (HE). This study aimed to describe blood distribution under portography and combined it with puncture site to determine portal flow diversion, and to evaluate its prognostic value in predicting post-TIPS overt HE. METHODS: In this retrospective analysis of patients with cirrhosis undergoing TIPS, we included 252 patients to describe blood distribution under portography and 243 patients to assess the association between portal flow diversion and post-TIPS overt HE. RESULTS: At the first stage, 51 (20.2%) patients were identified as type A (unilateral type with the right portal branch receives blood from splenic vein [SV]), 16 (6.4%) as type B (unilateral type with the right branch receives blood from superior mesenteric vein [SMV]) and 185 (73.4%) as type C (fully mixed type). At the second stage, 40 patients were divided into the SV group, 25 into the SMV group and 178 into the mixed group. Compared with the mixed group, the risk of post-TIPS overt HE was significantly higher in the SMV group (adjusted HR 3.70 [95% CI 2.01-6.80]; p < 0.001), whereas the SV group showed a non-significantly decreased risk (adjusted HR 0.57 [95% CI 0.22-1.48]; p = 0.25). Additionally, the SMV group showed a substantial increase in ammonia level at 3 days and 1 month after procedure. CONCLUSIONS: Our results support the clinical use of portal flow diversion for risk stratification and decision-making in the management of post-TIPS overt HE.

Microwave ablation combined with anti-PD-1 therapy enhances systemic antitumor immunity in a multitumor murine model of Hepa1-6.

BACKGROUND: To evaluate the changes of immune environment of distant tumors after combined microwave ablation (MWA) and anti- programmed death receptor - 1 (anti-PD-1) therapy, and assess the changes of systemic immune response. METHODS: Bilateral hepatocellular carcinoma model was established in mice, which were then subsequently treated with MWA, or anti-PD-1, or no treatment, or MWA + anti-PD-1. The contralateral tumor volume and mice survival time were recorded. Flow cytometry and immunohistochemistry were used for evaluation of the immune cells subgroup change of contralateral tumor. In addition, tumor rechallenge tests were conducted on unilateral tumor-bearing mice to examine the systemic immune effects of the combination therapy. RESULTS: We found that MWA treatment alone failed to produce a significant abscopal effect. In contrast, the combination group had longer survival than the MWA or anti-PD-1 group alone, with slower distant tumor growth. Moreover, the tumor-specific immune responses induced by combination therapy are stronger than anti-PD-1 or MWA alone. Combination therapy also elevated the levels of Th1-type cytokines in peripheral blood. In addition, after tumor rechallenge, the combination group showed more rejection to the reimplanted tumors (6 out of 10 mice). CONCLUSIONS: The combination of MWA and anti-PD-1 therapy resulted in the inhibition of distant tumor growth and the construction of a systemic anti-tumor immune environment that can reduce recurrence.

Management of spontaneous isolated intramural hematoma of the superior mesenteric artery: a single-center experience.

PURPOSE: To investigate the clinical course and optimal management for spontaneous isolated intramural hematoma of the superior mesenteric artery (SIHSMA). METHODS: From January 2015 to October 2020, a total of 31 consecutive patients with SIHSMA were included in this study. The demographics, clinical features, treatment details, imaging information, and outcomes were reviewed. RESULTS: There were 24 males and 7 females, with a mean age of 54.9 years (SD 6.9 years). Seven patients (7/31, 23%) were associated with ulcer-like projection (ULP), one patient (1/31, 3%) with intramural blood pool (IBP), and the remaining twenty-three patients (23/31, 74%) had no ULP or IBP. All patients were initially managed conservatively and underwent a median follow-up of 25.5 months (IQR 14.5, 39.9), which showed 3 patients (3/31, 10%) subsequently underwent stenting (2 within 7 days and 1 after 1.5 months), 1 patient (1/31, 3%) progressed to a localized dissection 7 months later but remained stable and asymptomatic until the time of writing, and the remaining patients (27/31, 87%) had no progression. In the present cohort, the overall survival was 100% (31/31). The free-from progression and stenting rate under conservative treatment was 87% (27/31). The invasive intervention rate was 10% (3/31). The natural complete regression rate of IMH in patients without ULP was higher than those with ULP (91% [21/23] vs. 29% [2/7], p = .003). CONCLUSION: The majority of patients with SIHSMA can be managed conservatively. Patients with ULP seemed to have a lower IMH regression rate than those without ULP.

Endovascular repair of traumatic aortic dissection: a single-center experience.

The data on endovascular aortic repair (EVAR) for traumatic aortic dissection (TAD) are lacking. Hence, this study aimed to evaluate the efficacy of EVAR for TAD and report our experience based on patients from our medical center with a relatively long follow-up. A total of 25 consecutive patients with TAD underwent EVAR from October 2015 to October 2020. The demographics, imaging characteristics, clinical features, treatment details, and follow-up results were reviewed. Urgent EVAR was performed in 3 patients (12%), while the remaining 22 patients (88%) underwent delayed EVAR. Systematic heparinization was used in all patients during the endovascular procedure. The EVAR was technically successful in all patients, with no cases converted into open surgery. No death occurred during the perioperative period. One patient presented with a type II endoleak on postoperative 1-month CT images during a mean follow-up of 42.3 ± 17.7 months (5-67.5 months) and showed spontaneous regression of the endoleak without any intervention during the subsequent follow-up. All the patients survived until the time of writing, and none of them showed late endoleak, stent migration, paraplegia, and reintervention. The patients with left subclavian artery covered (n = 8) had no obvious ischemia of the arm and brain. The study results demonstrated that EVAR for TAD proved to be safe and effective, and most patients could undergo delayed EVAR. Systematically heparinization during EVAR under the setting of multi-trauma was safe.

Impact of TIPS on Splenic Volume and Thrombocytopenia.

OBJECTIVE. Splenomegaly and thrombocytopenia are common complications in patients with cirrhosis. The present study aimed to evaluate changes in splenic volumes and platelet counts after TIPS insertion. MATERIALS AND METHODS. A total of 104 patients who had a diagnosis of portal hypertension and had undergone TIPS placement between November 2015 and August 2019 were enrolled in this retrospective cohort study. We retrospectively calculated splenic volumes before TIPS placement and at 1-2 and 6-12 months after TIPS placement and monitored the platelet count at 1, 3, 6, and 12 months after TIPS placement. RESULTS. The mean (± SD) portal pressure gradient before TIPS placement was 28.3 ± 4.6 mm Hg; after TIPS placement, it was 11.3 ± 4.5 mm Hg (p < .001). The mean splenic volume of all 104 patients before TIPS placement was 868 ± 409 cm3, and at 1-2 months after TIPS placement, it was 710 ± 336 cm3 (p < .001). Among the 43 patients for whom splenic volume data were available at both 1-2 and 6-12 months after TIPS placement, the mean splenic volume decreased from 845 ± 342 cm3 to 691 ± 301 cm3 and then to 674 ± 333 cm3, respectively. Correspondingly, the number of patients with severe thrombocytopenia decreased from 25 patients (35.7%) before the TIPS procedure to 16 patients (22.9%) in the 1-2 months after TIPS placement and then to 11 patients (15.7%) in the 6-12 months after TIPS implantation. The increase in the platelet count was significantly correlated with decreasing splenic volume (r2 = 0.3735; p < .001). CONCLUSION. In most patients, TIPS placement resulted in a significant decrease in splenic volume and a significant increase in the platelet count during the same period.

Effect of splenectomy on the outcomes in patients with cirrhosis receiving transjugular intrahepatic portosystemic shunt.

BACKGROUND AND AIM: Patients indicated to transjugular intrahepatic portosystemic shunt (TIPS) placement may have splenectomy history due to thrombocytopenia. This study aimed to evaluate the effect of prior splenectomy on TIPS procedure and post-TIPS outcomes. METHODS: We conducted a longitudinal analysis based on a cohort of 284 patients with cirrhosis submitted to TIPS; 74 patients had splenectomy history (splenectomy group) and 210 did not (non-splenectomy group). Cox proportional hazards models were used to evaluate the association between splenectomy and outcomes after TIPS. The primary outcome was shunt dysfunction. Secondary outcomes included all-cause mortality, clinical recurrence of bleeding or ascites, and overt hepatic encephalopathy (OHE). RESULTS: During a median follow-up of 16.2 months, the splenectomy group had significantly lower rates of postoperative shunt patency (85.5% vs 95.6% at 1 year and 75.2% vs 86.5% at 2 years; adjusted hazard ratio [HR] 2.53; 95% confidence interval [CI] 1.21-5.12; P = 0.01) and higher risk of OHE (adjusted HR 1.82; 95% CI 1.03-3.54; P = 0.04). But the risk of mortality (adjusted HR 0.87; 95% CI 0.41-1.87; P = 0.73) and recurrent bleeding or ascites (adjusted HR 1.17; 95% CI 0.53-2.35; P = 0.77) showed no statistical difference. Multivariate analysis confirmed splenectomy history and endoscopic therapy as independent predictors of shunt dysfunction. Besides, pre-TIPS splenectomy increased the difficulty of TIPS procedure by complicating portal vein puncture. CONCLUSIONS: For patients with cirrhosis submitted to TIPS, prior splenectomy complicated TIPS procedure and increased the risk of shunt dysfunction and OHE after TIPS, but was not significantly associated with the occurrence of mortality and recurrent bleeding or ascites.

Transjugular intrahepatic portosystemic shunt for the treatment of hepatic sinusoidal obstruction syndrome caused by pyrrolizidine alkaloids: A multicenter retrospective study.

Purpose: To assess the impact of transjugular intrahepatic portosystemic shunt (TIPS) on clinical outcomes and liver histology in patients with hepatic sinusoidal obstruction syndrome (HSOS) caused by pyrrolizidine alkaloids (PA), and compare these results with those of patients who received supportive treatment alone. Materials and methods: From June 2015 to August 2022, 164 patients diagnosed with PA-HSOS in six tertiary care centers were retrospectively included in this study and divided into TIPS group (n = 69) and supportive treatment (ST) group (n = 95). The main endpoint was to determine whether TIPS placement could improve survival in PA-HSOS patients. The clinical symptoms associated with portal hypertension were also evaluated in this study. Additionally, a small TIPS-subgroup of 7 patients received liver biopsies before and after TIPS for histological analysis. Results: The incidence of death was markedly lower in the TIPS group than in the ST group (log-rank p = 0.026). Multivariate Cox model revealed that group assignment (hazard ratio (HR) 5.146; 95 % confidence interval (CI) 1.587-16.687; p = 0.006), total bilirubin (HR 1.029; 95 % CI 1.020-1.038; p < 0.001), and INR (HR 13.291; 95 % CI 3.637-48.566; p < 0.001) were independent predictors for mortality. In addition, TIPS placement reduced the risk of complications associated with portal hypertension but did not increase the rate of overt hepatic encephalopathy (log-rank p = 0.731). Furthermore, six of 7 TIPS patients receiving liver biopsies improved after TIPS placement, and one patient developed fibrosis. Conclusions: TIPS placement decreased the mortality and risk of complications associated with portal hypertension. Histological evaluation in a few patients showed a potential improvement by TIPS.

Prediction of late recurrence after curative-intent resection using MRI-measured spleen volume in patients with hepatocellular carcinoma and cirrhosis.

BACKGROUND: Late recurrence of hepatocellular carcinoma (HCC) after liver resection is regarded as a de novo tumor primarily related to the severity of underlying liver disease. We aimed to investigate risk factors, especially spleen volume, associated with late recurrence in patients with HCC and cirrhosis. METHODS: We retrospectively analyzed 301 patients with HCC and cirrhosis who received curative resection and preoperative MRI. Patients were followed for late recurrence for at least 2 years. Spleen volume was automatically measured on MRI with artificial intelligence techniques, and qualitative MRI imaging features reflecting tumor aggressiveness were evaluated. Uni- and multivariable Cox regression analyses were performed to identify independent predictors and a risk score was developed to predict late recurrence. RESULTS: Eighty-four (27.9%) patients developed late recurrence during follow-up. Preoperative spleen volume was independently associated with late recurrence, and patients with a volume > 370 cm3 had significantly higher recurrence risk (hazard ratio 2.02, 95%CI 1.31-3.12, p = 0.002). Meanwhile, no qualitative imaging features were associated with late recurrence. A risk score was developed based on the APRI score, spleen volume, and tumor number, which had time-dependent area under the curve ranging from 0.700 to 0.751. The risk score at a cutoff of 0.42 allowed for the identification of two risk categories with distinct risk of late recurrence. CONCLUSIONS: Preoperative spleen volume on MRI was independently associated with late recurrence after curative-intent resection in patients with HCC and cirrhosis. A risk score was proposed for individualized risk prediction and tailoring of postoperative surveillance strategies. CRITICAL RELEVANCE STATEMENT: Spleen volume measured on MRI with the aid of AI techniques was independently predictive of late HCC recurrence after liver resection. A risk score based on spleen volume, APRI score, and tumor number was developed for accurate prediction of late recurrence. KEY POINTS: • Preoperative spleen volume measured on MRI was independently associated with late recurrence after curative-intent resection in patients with HCC and cirrhosis. • Qualitative MRI features reflecting tumor aggressiveness were not associated with late recurrence. • A risk score based on spleen volume was developed for accurate prediction of late recurrence and risk stratification.

Machine Learning Combined with Radiomics Facilitating the Personal Treatment of Malignant Liver Tumors.

In the realm of managing malignant liver tumors, the convergence of radiomics and machine learning has redefined the landscape of medical practice. The field of radiomics employs advanced algorithms to extract thousands of quantitative features (including intensity, texture, and structure) from medical images. Machine learning, including its subset deep learning, aids in the comprehensive analysis and integration of these features from diverse image sources. This potent synergy enables the prediction of responses of malignant liver tumors to various treatments and outcomes. In this comprehensive review, we examine the evolution of the field of radiomics and its procedural framework. Furthermore, the applications of radiomics combined with machine learning in the context of personalized treatment for malignant liver tumors are outlined in aspects of surgical therapy and non-surgical treatments such as ablation, transarterial chemoembolization, radiotherapy, and systemic therapies. Finally, we discuss the current challenges in the amalgamation of radiomics and machine learning in the study of malignant liver tumors and explore future opportunities.