Covered transjugular intrahepatic portosystemic shunt versus endoscopic therapy + ß-blocker for prevention of variceal rebleeding.

UNLABELLED: Gastroesophageal variceal bleeding in patients with cirrhosis is associated with significant morbidity and mortality, as well as a high rebleeding risk. Limited data are available on the role of transjugular intrahepatic portosystemic shunt (TIPS) with covered stents in patients receiving standard endoscopic, vasoactive, and antibiotic treatment. In this multicenter randomized trial, long-term endoscopic variceal ligation (EVL) or glue injection + ß-blocker treatment was compared with TIPS placement in 72 patients with a first or second episode of gastric and/or esophageal variceal bleeding, after hemodynamic stabilization upon endoscopic, vasoactive, and antibiotic treatment. Randomization was stratified according to Child-Pugh score. Kaplan-Meier (event-free) survival estimates were used for the endpoints rebleeding, death, treatment failure, and hepatic encephalopathy. During a median follow-up of 23 months, 10 (29%) of 35 patients in the endoscopy + ß-blocker group, as compared to 0 of 37 (0%) patients in the TIPS group, developed variceal rebleeding (P = 0.001). Mortality (TIPS 32% vs. endoscopy 26%; P = 0.418) and treatment failure (TIPS 38% vs. endoscopy 34%; P = 0.685) did not differ between groups. Early hepatic encephalopathy (within 1 year) was significantly more frequent in the TIPS group (35% vs. 14%; P = 0.035), but during long-term follow-up this difference diminished (38% vs. 23%; P = 0.121). CONCLUSIONS: In unselected patients with cirrhosis, who underwent successful endoscopic hemostasis for variceal bleeding, covered TIPS was superior to EVL + ß-blocker for reduction of variceal rebleeding, but did not improve survival. TIPS was associated with higher rates of early hepatic encephalopathy.

Percutaneous treatment of peripheral vascular malformations in children: long-term clinical outcome.

PURPOSE: This study was designed to assess the rate of complications and clinical failure at 3 and 12 months after percutaneous treatment of vascular malformations in children. Furthermore, we describe patient satisfaction of treatment results during 5 years of follow-up. METHODS: In a retrospective cohort study, we evaluated 26 patients younger than aged 19 years who were treated for symptomatic vascular malformations. Data on treatment outcomes and patient satisfactions were obtained with a precoded structured questionnaire. Patient files and imaging data were retrieved to obtain information regarding the vascular malformations and treatment. Clinical success was defined as disappearance or partial improvement of the complaints. Patient satisfaction was declared whenever patients answered in the questionnaire that they were satisfied with the treatment results. RESULTS: Of 26 eligible patients, we included 23 (88%). The mean follow-up was 36 (range, 15-127) months. Posttreatment, 87% (20/23; 95% confidence interval (CI), 66-97%) of patients reported clinical success at 3 months. At 1, 2, 3, 4, and 5 years of follow-up this percentage was 74%, 59%, 59%, 59%, and 59%, respectively. Eleven (48%, 95% CI 27-69%) patients had experienced complications and 22% (95% CI 7-44%) had major complications, of which 5 had required additional treatment. In all, 83% (19/23) of the patients reported satisfaction with the treatment. CONCLUSIONS: Percutaneous treatment of vascular malformations improved clinical symptoms in 87% of the patients at 3 months and were sustainable for half of all patients during a 5-year follow-up period. However, major complications were seen in 22%.

Retrograde transvenous ethanol embolization of high-flow peripheral arteriovenous malformations.

PURPOSE: To report the clinical efficiency and complications in patients treated with retrograde transvenous ethanol embolization of high-flow peripheral arteriovenous malformations (AVMs). Retrograde transvenous ethanol embolization of high-flow AVMs is a technique that can be used to treat AVMs with a dominant outflow vein whenever conventional interventional procedures have proved insufficient. METHODS: This is a retrospective study of the clinical effectiveness and complications of retrograde embolization in five patients who had previously undergone multiple arterial embolization procedures without clinical success. RESULTS: Clinical outcomes were good in all patients but were achieved at the cost of serious, although transient, complications in three patients. CONCLUSION: Retrograde transvenous ethanol embolization is a highly effective therapy for high-flow AVMs. However, because of the high complication rate, it should be reserved as a last resort, to be used after conventional treatment options have failed.

Radial force measurements in carotid stents: influence of stent design and length of the lesion.

PURPOSE: To assess the differences in radial force of carotid stents and whether the length of the lesion influences the measurements. MATERIALS AND METHODS: Different models of tapered stents of similar size (length, 30 mm) were used. The tapered nitinol Acculink, Protégé, and Cristallo Ideale carotid artery stents and the straight, braided Elgiloy carotid Wallstent were compared. A measurement device consisting of three film loops along the stent body connected to aluminium rods with copper strain gauges was developed. Five stents of each type were deployed within 3-mm stenoses in simulated long (26 mm) and short (8 mm) stenoses. RESULTS: In the short stenosis simulation, the greatest radial force was seen in the Protégé stent, at 3.14 N ± 0.45, followed by the Cristallo Ideale stent (1.73 N ± 0.51), Acculink (1.16 N ± 0.21), and Wallstent (0.84 N ± 0.10; P < .001). In the long stenosis simulation, peak radial force again was highest in the Protégé stent (1.67 N ± 0.37), but the Acculink stent was second (0.95 N ± 0.12) and the Wallstent third (0.80 N ± 0.06). The Cristallo Ideale stent, in contrast to the short stenosis simulation, produced the least radial force (0.44 N ± 0.13) in the long stenosis simulation (P = .001). CONCLUSIONS: Radial forces exerted by carotid stents vary significantly among stent designs. Differences between stent types are dependent on the length of the stenosis. An understanding of radial force is necessary for a well-considered choice of stent type in each individual patient.

Endoscopic visible light spectroscopy: a new, minimally invasive technique to diagnose chronic GI ischemia.

BACKGROUND: The diagnosis of chronic GI ischemia (CGI) remains a clinical challenge. Currently, there is no single simple test with high sensitivity available. Visible light spectroscopy (VLS) is a new technique that noninvasively measures mucosal oxygen saturation during endoscopy. OBJECTIVE: To determine the diagnostic accuracy of VLS for the detection of ischemia in a large cohort of patients. DESIGN: Prospective study, with adherence to the Standards for Reporting of Diagnostic Accuracy. SETTING: Tertiary referral center. PATIENTS: Consecutive patients referred for evaluation of possible CGI. INTERVENTIONS: Patients underwent VLS along with the standard workup consisting of evaluation of symptoms, GI tonometry, and abdominal CT or magnetic resonance angiography. MAIN OUTCOME MEASUREMENTS: VLS measurements and the diagnosis of CGI as established with the standard workup. RESULTS: In 16 months, 121 patients were included: 80 in a training data set and 41 patients in a validation data set. CGI was diagnosed in 89 patients (74%). VLS cutoff values were determined based on the diagnosis of CGI and applied in the validation data set, and the results were compared with the criterion standard, resulting in a sensitivity and specificity of VLS of 90% and 60%, respectively. Repeated VLS measurements showed improvement in 80% of CGI patients after successful treatment. LIMITATIONS: Single-center study; only 43% of patients had repeated VLS measurements after treatment. CONCLUSIONS: VLS during upper endoscopy is a promising easy-to-perform and minimally invasive technique to detect mucosal hypoxemia in patients clinically suspected of having CGI, showing excellent correlation with the established ischemia workup.

Radiological imaging and gastrointestinal tonometry add value in diagnosis of chronic gastrointestinal ischemia.

BACKGROUND & AIMS: The diagnosis of chronic gastrointestinal ischemia (CGI) remains a clinical challenge. We aimed to assess the diagnostic value of clinical features, visualization of the gastrointestinal arteries, and evaluation of mucosal perfusion in patients clinically suspected of CGI. METHODS: A total of 186 patients referred for suspicion of CGI were prospectively included and followed up. All patients had an extensive diagnostic work-up, including visualization of the gastrointestinal arteries with computed tomography, magnetic resonance, or conventional angiography, and mucosal perfusion with tonometry. The reference standard for CGI was persistent clinical response after adequate therapy. The diagnostic value of individual and combined tests was assessed with multivariable logistic regression analysis. RESULTS: A total of 116 (62%) patients were diagnosed with CGI. In a multivariable model solely based on clinical features, the strongest predictors for CGI were the presence of postprandial pain, weight loss per month in kilograms, concomitant cardiovascular disease, and presence of an abdominal bruit. However, this model showed limited discriminative ability for the presence or absence of CGI (c-statistic, 0.62). Adding radiologic imaging to the prediction model improved the discriminative ability substantially (c-statistic, 0.81). Adding tonometry to the prediction model further improved the discriminative ability of the model (c-statistic, 0.90). The combination of clinical features and tonometry with a c-statistic of 0.88 approximated the discriminative ability of the latter model. CONCLUSIONS: Clinical features alone have a limited value to assess CGI correctly. Visualization of the gastrointestinal arteries and evaluation of mucosal perfusion substantially improve the diagnosis of CGI. The strongest diagnostic contribution comes from mucosal perfusion assessment.

Legal aspects of cross-border teleradiology.

The growth of cross-border teleradiology has created legal challenges that are insufficiently addressed by nation health laws. New legislation is currently under development at the European level. This article will look at the details of the existing and proposed legislation and the still unsettled issues and will discuss the implications for international teleradiology.

Transjugular intrahepatic portosystemic shunt in patients with chronic portal vein occlusion and cavernous transformation.

GOALS: To determine the feasibility of transjugular intrahepatic portosystemic shunt (TIPS) creation as a possible salvage intervention in patients with variceal bleeding and chronic portal vein thrombosis with cavernous transformation, refractory to endoscopic therapy. BACKGROUND: TIPS is technically feasible in partial portal vein occlusion or complete occlusion due to fresh thrombosis. However, when the portal vein occlusion is complete and chronic, placement of TIPS is technically difficult. STUDY: In a tertiary referral center setting 4 patients with portal hypertension associated complications, received TIPS, as salvage therapy. In all patients a covered stent was placed to the cavernous transformation. RESULTS: Creation of TIPS to the dilated veins of a cavernous transformation was feasible in patients for whom recanalization of the portal vein was not possible. However, the collaterals need to be suitably wide for placement of TIPS and the high-pressure collaterals should communicate with the varices. CONCLUSIONS: TIPS should be considered as salvage therapy when endoscopic treatment is unsuccessful in patients with chronic portal vein thrombosis and cavernous transformation.

Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial.

BACKGROUND: Little is known about the efficacy and safety of renal artery stenting in patients with atherosclerotic renal artery stenosis (ARAS) and impaired renal function. OBJECTIVE: To determine the efficacy and safety of stent placement in patients with ARAS and impaired renal function. DESIGN: Randomized clinical trial. Randomization was centralized and computer generated, and allocation was assigned by e-mail. Patients, providers, and persons who assessed outcomes were not blinded to treatment assignment. SETTING: 10 European medical centers. PARTICIPANTS: 140 patients with creatinine clearance less than 80 mL/min per 1.73 m(2) and ARAS of 50% or greater. INTERVENTION: Stent placement and medical treatment (64 patients) or medical treatment only (76 patients). Medical treatment consisted of antihypertensive treatment, a statin, and aspirin. MEASUREMENTS: The primary end point was a 20% or greater decrease in creatinine clearance. Secondary end points included safety and cardiovascular morbidity and mortality. RESULTS: Forty-six of 64 patients assigned to stent placement had the procedure. Ten of the 64 patients (16%) in the stent placement group and 16 patients (22%) in the medication group reached the primary end point (hazard ratio, 0.73 [95% CI, 0.33 to 1.61]). Serious complications occurred in the stent group, including 2 procedure-related deaths (3%), 1 late death secondary to an infected hematoma, and 1 patient who required dialysis secondary to cholesterol embolism. The groups did not differ for other secondary end points. LIMITATION: Many patients were falsely identified as having renal artery stenosis greater than 50% by noninvasive imaging and did not ultimately require stenting. CONCLUSION: Stent placement with medical treatment had no clear effect on progression of impaired renal function but led to a small number of significant procedure-related complications. The study findings favor a conservative approach to patients with ARAS, focused on cardiovascular risk factor management and avoiding stenting.

Long-term patient satisfaction after percutaneous treatment of peripheral vascular malformations.

PURPOSE: To determine long-term patient satisfaction for percutaneous treatment by using sclerosing agents (sclerotherapy) and/or arterial embolization for peripherally located vascular malformations (VMs). This treatment has been described as successful; however, there is a relative paucity of published long-term results. MATERIALS AND METHODS: This retrospective study was institutional review board approved; 107 patients treated for symptomatic VM were evaluated. After informed consent was obtained, 66 patients were sent a questionnaire regarding treatment effectiveness and patient satisfaction. Patient files and imaging data were retrieved to obtain information regarding the VMs and VM treatment. Kaplan-Meier survival curves were constructed to analyze clinical success rates over time. RESULTS: The most frequent reasons for patients to seek treatment were pain (89%, n = 59) and swelling (91%, n = 60). The majority of VMs were the low-flow venous type (83%, n = 55). Three months after treatment, clinical success was reported for 58% (n = 38) of patients and clinical failure was reported for 42% (n = 28). At 1-, 2-, 3-, 4-, and 5-year follow-up, clinical success was 49%, 49%, 42%, 42%, and 42%, respectively. Twenty-seven (40%) patients experienced complications, 12 of which required additional treatment. In all, 35 (53%) patients reported being satisfied with their treatment. Patient satisfaction was closely correlated with clinically successful long-term outcome of treatment. CONCLUSION: Initial partial or complete relief of VM complaints after percutaneous treatment is expected in 58% of patients, irrespective of VM size or classification. These results were durable over a 5-year follow-up period.

Intermittent claudication: clinical effectiveness of endovascular revascularization versus supervised hospital-based exercise training--randomized controlled trial.

PURPOSE: To compare clinical success, functional capacity, and quality of life during 12 months after revascularization or supervised exercise training in patients with intermittent claudication. MATERIALS AND METHODS: This study had institutional review board approval, and all patients gave written informed consent. Between September 2002 and September 2005, 151 consecutive patients who presented with symptoms of intermittent claudication were randomly assigned to undergo either endovascular revascularization (angioplasty-first approach) (n = 76) or hospital-based supervised exercise (n = 75). The outcome measures were clinical success, functional capacity, and quality of life after 6 and 12 months. Clinical success was defined as improvement in at least one category in the Rutherford scale above the pretreatment level. Significance of differences between the groups was assessed with the unpaired t test, chi(2) test, or Mann-Whitney U test. To adjust outcomes for imbalances of baseline values, multivariable regression analysis was performed. RESULTS: Immediately after the start of treatment, patients who underwent revascularization improved more than patients who performed exercise in terms of clinical success (adjusted odds ratio [OR], 39; 99% confidence interval [CI]: 11, 131; P < .001), but this advantage was lost after 6 (adjusted OR, 0.9; 99% CI: 0.3, 2.3; P = .70) and 12 (adjusted OR, 1.1; 99% CI: 0.5, 2.8; P = .73) months. After revascularization, fewer patients showed signs of ipsilateral symptoms at 6 months compared with patients in the exercise group (adjusted OR, 0.4; 99% CI: 0.2, 0.9; P < .001), but no significant differences were demonstrated at 12 months. After both treatments, functional capacity and quality of life scores increased after 6 and 12 months, but no significant differences between the groups were demonstrated. CONCLUSION: After 6 and 12 months, patients with intermittent claudication benefited equally from either endovascular revascularization or supervised exercise. Improvement was, however, more immediate after revascularization.

Assessment of biventricular functional reserve and NT-proBNP levels in patients with RV volume overload after repair of tetralogy of Fallot at young age.

PURPOSE: To assess biventricular functional reserve (FR), NT-proBNP levels and exercise performance, in relation to right ventricular volume in patients with pulmonary regurgitation (PR) after repair of tetralogy of Fallot (TOF) at young age. METHODS: In 53 TOF patients (maximum age at repair 2.0 years, interval since repair 15 (5) years) without residual lesions except PR, biventricular FR (derived from magnetic resonance imaging with dobutamine stress), NT-proBNP levels, maximal workload, and peak oxygen uptake were assessed. RESULTS: Mean right ventricular end-diastolic volume was 140(38) ml/m(2). Median pulmonary regurgitant fraction was 37% (range 0-57%). Biventricular systolic stress response was normal: mean (SD) ESV decreased (DeltaRVESV -17(8) ml/m(2), DeltaLVESV -11(5)), SV increased (DeltaRVSV +12(9) ml/m(2), DeltaLVSV +9(6)), FR was positive in all (RV-FR +11(5)%, LV-FR +13(6)). No serious adverse effects to dobutamine were encountered. NT-proBNP was increased in 2 patients. Median level was 10 pmol/L (range 2-42). NT-proBNP correlated with PR-percentage but not with right ventricular size. High-risk levels of NT-proBNP indicated a smaller RV-FR and a smaller decrease of biventricular ESV. Mean (SEM) VO2(max) was 96(3)%, mean Workload(max) 89(2)% of predicted. CONCLUSION: At mid to long term follow-up overall NT-proBNP levels are normal and biventricular functional reserve and exercise tolerance are well preserved in TOF repaired at young age, irrespective of RV volume. This questions the validity of isolated PR or RV volume criteria for pulmonary valve replacement in this group. Low-dose dobutamine stress testing is well tolerated and may be a useful additional tool for clinical decision making.

Cost-effectiveness of endovascular revascularization compared to supervised hospital-based exercise training in patients with intermittent claudication: a randomized controlled trial.

BACKGROUND: The optimal first-line treatment for intermittent claudication is currently unclear. OBJECTIVE: To compare the cost-effectiveness of endovascular revascularization vs supervised hospital-based exercise in patients with intermittent claudication during a 12-month follow-up period. DESIGN: Randomized controlled trial with patient recruitment between September 2002-September 2006 and a 12-month follow-up per patient. SETTING: A large community hospital. PARTICIPANTS: Patients with symptoms of intermittent claudication due to an iliac or femoro-popliteal arterial lesion (293) who fulfilled the inclusion criteria (151) were recruited. Excluded were, for example, patients with lesions unsuitable for revascularization (iliac or femoropopliteal TASC-type D and some TASC type-B/C. INTERVENTION: Participants were randomly assigned to endovascular revascularization (76 patients) or supervised hospital-based exercise (75 patients). MEASUREMENTS: Mean improvement of health-related quality-of-life and functional capacity over a 12-month period, cumulative 12-month costs, and incremental costs per quality-adjusted life year (QALY) were assessed from the societal perspective. RESULTS: In the endovascular revascularization group, 73% (55 patients) had iliac disease vs 27% (20 patients) femoral disease. Stents were used in 46/71 iliac lesions (34 patients) and in 20/40 femoral lesions (16 patients). In the supervised hospital-based exercise group, 68% (51 patients) had iliac disease vs 32% (24 patients) with femoral disease. There was a non-significant difference in the adjusted 6- and 12-month EuroQol, rating scale, and SF36-physical functioning values between the treatment groups. The gain in total mean QALYs accumulated during 12 months, adjusted for baseline values, was not statistically different between the groups (mean difference revascularization versus exercise 0.01; 99% CI -0.05, 0.07; P = .73). The total mean cumulative costs per patient was significantly higher in the revascularization group (mean difference euro2318; 99% CI 2130 euros, 2506 euros; P < .001) and the incremental cost per QALY was 231 800 euro/QALY adjusted for the baseline variables. One-way sensitivity analysis demonstrated improved effectiveness after revascularization (mean difference 0.03; CI 0.02, 0.05; P < .001), making the incremental costs 75 208 euro/QALY. CONCLUSION: In conclusion, there was no significant difference in effectiveness between endovascular revascularization compared to supervised hospital-based exercise during 12-months follow-up, any gains with endovascular revascularization found were non-significant, and endovascular revascularization costs more than the generally accepted threshold willingness-to-pay value, which favors exercise.

Endovascular coils as lung tumour markers in real-time tumour tracking stereotactic radiotherapy: preliminary results.

To evaluate the use of endovascular coils as markers for respiratory motion correction during high-dose stereotactic radiotherapy with the CyberKnife, an image-guided linear accelerator mounted on a robotic arm. Endovascular platinum embolisation coils were used to mark intrapulmonary lesions. The coils were placed in subsegmental pulmonary artery branches in close proximity to the target tumour. This procedure was attempted in 25 patients who were considered unsuitable candidates for standard transthoracic percutaneous insertion. Vascular coils (n = 87) were successfully inserted in 23 of 25 patients. Only minor complications were observed: haemoptysis during the procedure (one patient), development of pleural pain and fever on the day of procedure (one patient), and development of small infiltrative changes distal to the vascular coil (five patients). Fifty-seven coils (66% of total inserted number) could be used as tumour markers for delivery of biologically highly effective radiation doses with automated tracking during CyberKnife radiotherapy. Endovascular markers are safe and allow high-dose radiotherapy of lung tumours with CyberKnife, also in patients who are unsuitable candidates for standard transthoracic percutaneous marker insertion.

Cardiac status after childhood growth hormone treatment of Turner syndrome.

CONTEXT: In Turner syndrome (TS), GH treatment is well established. Data on cardiac status after discontinuation of treatment are scarce. This study aimed to assess biventricular size and function in TS at least 6 months after discontinuation of GH treatment. METHODS: TS patients and healthy women prospectively underwent cardiac magnetic resonance imaging. Ventricular two-dimensional tomographic cine data were acquired to obtain biventricular volume, mass, and ejection fraction. Atrioventricular valve flow measurements were performed using a two-dimensional flow-sensitized sequence. Flow velocity curves were calculated and indices of biventricular diastolic filling were derived. RESULTS: Thirty-one patients [mean (sd) age 20 (2) yr, body surface area 1.75 (0.15) m(2), 5 (2) yr after GH discontinuation] and 23 normal control women [age 21 (2) yr, body surface area 1.80 (0.13) m(2)] were included. Compared with controls, patients had smaller mean end-diastolic volumes [right ventricle (RV), 84 (11) ml/m(2) vs. 79 (10), P = 0.02; left ventricle (LV), 81 (10) vs. 72 (9), P < 0.001], end-systolic volumes [RV 38 (7) ml/m(2) vs. 36 (6), P = 0.04; LV 34 (5) vs. 29 (4), P < 0.001], and stroke volumes [RV 46 (6) ml/m(2) vs. 43 (6), P = 0.03; LV, 47 (7) vs. 44 (4), P = 0.02]. Patients had a higher mean heart rate [79 (13) beats/min vs. 71 (10), P < 0.05]. Biventricular ejection fraction, mass, cardiac output, and diastolic filling pattern were comparable. CONCLUSION: After discontinuation of GH treatment TS patients showed no myocardial hypertrophy and well-preserved biventricular function. Ventricular volumes were smaller in Turner patients, compared with controls, whereas mean heart rate was higher. These last observations may be part of the natural development in TS and not linked to GH treatment, which at this point we consider safe.

Multicenter randomized controlled trial of the costs and effects of noninvasive diagnostic imaging in patients with peripheral arterial disease: the DIPAD trial.

OBJECTIVE: The purpose of our study was to compare the costs and effects of three noninvasive imaging tests as the initial imaging test in the diagnostic workup of patients with peripheral arterial disease. MATERIALS AND METHODS: Of 984 patients assessed for eligibility, 514 patients with peripheral arterial disease were randomized to MR angiography (MRA) or duplex sonography in three hospitals and to MRA or CT angiography (CTA) in one hospital. The outcome measures included the clinical utility, functional patient outcomes, quality of life, and actual diagnostic and therapeutic costs related to the initial imaging test during 6 months of follow-up. RESULTS: With adjustment for potentially predictive baseline variables, the learning curve, and hospital setting, a significantly higher confidence and less additional imaging were found for MRA and CTA compared with duplex sonography. No statistically significant differences were found in improvement in functional patient outcomes and quality of life among the groups. The total costs were significantly higher for MRA and duplex sonography than for CTA. CONCLUSION: The results suggest that both CTA and MRA are clinically more useful than duplex sonography and that CTA leads to cost savings compared with both MRA and duplex sonography in the initial imaging evaluation of peripheral arterial disease.

Long-term outcome of a covered vs. uncovered transjugular intrahepatic portosystemic shunt in Budd-Chiari syndrome.

BACKGROUND: The clinical outcome of a covered vs. uncovered transjugular intrahepatic portosystemic shunt (TIPS) for patients with Budd-Chiari syndrome (BCS) is as yet largely unknown. OBJECTIVES: To compare patency rates of bare and polytetrafluoroethylene (PTFE)-covered stents, and to investigate clinical outcome using four prognostic indices [Child-Pugh score, Rotterdam BCS index, modified Clichy score and Model for End-Stage Liver Disease (MELD)]. METHODS: Consecutive patients with BCS who had undergone TIPS between January 1994 and March 2006 were evaluated in a retrospective review in a single centre. RESULTS: Twenty-three TIPS procedures were performed on 16 patients. The primary patency rate at 2 years was 12% using bare and 56% using covered stents (P=0.09). We found marked clinical improvement at 3 months post-TIPS as determined by a drop in median Child-Pugh score (10-7, P=0.04), Rotterdam BCS index (1.90-0.83, P=0.02) and modified Clichy score (7.77-2.94, P=0.003), but not in MELD (18.91-17.42, P=0.9). Survival at 1 and 3 years post-TIPS was 80% (95% CI: 59-100%) and 72% (95% CI: 48-96%). Four patients (25%) died and one required liver transplantation. CONCLUSIONS: A transjugular intrahepatic portosystemic shunt using PTFE-covered stents shows better patency rates than bare stents in BCS. Moreover, TIPS leads to an improvement in important prognostic indicators for the survival of patients with BCS.

Risks and benefits of transcatheter thrombolytic therapy in patients with splanchnic venous thrombosis.

Transcatheter local thrombolytic therapy in patients with acute, extended splanchnic venous thrombosis is controversial. Here we present our single-center experience with transcatheter thrombolytic therapy in these patients. All consecutive patients (n = 12) with acute, extended splanchnic venous thrombosis who underwent transcatheter thrombolytic therapy in our hospital, were included in this study. Thrombolytic therapy was successful for three thrombotic events and partially successful for four thrombotic events. Two patients developed minor procedure-related bleeding (17%). Six patients (50%) developed major procedure-related bleeding, with a fatal outcome in two. Transcatheter thrombolytic therapy in patients with acute, extended splanchnic vein thrombosis is found to be associated with a high rate of procedure-related bleeding. Therefore, thrombolysis should be reserved for patients in whom the venous flow cannot be restored by using conventional anticoagulant therapy or stent placement across the thrombosed vessel segment.

Changes during exercise of ECG intervals related to increased risk for ventricular arrhythmia in repaired tetralogy of Fallot and their relationship to right ventricular size and function.

PURPOSE: Our study aimed to assess pro-arrhythmogenic electrocardiographic changes during maximal physical exercise in patients operated for Tetralogy of Fallot (TOF). METHODS: TOF patients prospectively underwent: 1) bicycle ergometry, 2) cardiac MRI, and 3) 24-hour Holter. ECG data was analyzed at rest, at 60% of peak exercise and at peak exercise. R-R duration, QRS-, QT- and JT-duration and dispersions were assessed. Changes of ECG parameters during exercise were calculated and correlated to RV volume, RVEF, RV wall-mass, PR-percentage and VO(2max). Exercise ECG data from healthy controls were used as reference. RESULTS: Thirty-one patients (mean age at repair (SD) 0.8 (0.5) years, age at study 16 (5) years) and 25 controls (age 12 (2) years) were included. With exercise mean QTc and JTc dispersions increased in patients (p<0.001), but not in controls. At peak exercise JTc dispersion was larger in patients (p<0.01). QTc did not change with exercise in patients (p=0.14) and decreased in controls (p<0.05). At all levels of exercise mean QTc, QRS and QRS dispersion were larger in patients (all p<0.001). Significant associations were found for; 1) a larger increase of JTc dispersion with a higher PR-percentage, a larger RV volume, a larger RV wall-mass, 2) a larger QTc increase with a larger RV volume and worse RVEF. CONCLUSION: During physical exercise inhomogeneity of repolarisation, known to predispose for re-entry ventricular arrhythmia, increases in repaired TOF. Larger inhomogeneity is found with more severe PR.

Multi-detector row computed tomography angiography of peripheral arterial disease.

With the introduction of multi-detector row computed tomography (MDCT), scan speed and image quality has improved considerably. Since the longitudinal coverage is no longer a limitation, multi-detector row computed tomography angiography (MDCTA) is increasingly used to depict the peripheral arterial runoff. Hence, it is important to know the advantages and limitations of this new non-invasive alternative for the reference test, digital subtraction angiography. Optimization of the acquisition parameters and the contrast delivery is important to achieve a reliable enhancement of the entire arterial runoff in patients with peripheral arterial disease (PAD) using fast CT scanners. The purpose of this review is to discuss the different scanning and injection protocols using 4-, 16-, and 64-detector row CT scanners, to propose effective methods to evaluate and to present large data sets, to discuss its clinical value and major limitations, and to review the literature on the validity, reliability, and cost-effectiveness of multi-detector row CT in the evaluation of PAD.