Root Cause Analysis of Rebleeding Events following Transjugular Intrahepatic Portosystemic Shunt Creation for Variceal Hemorrhage.

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.

MELD score for prediction of survival after emergent TIPS for acute variceal hemorrhage: derivation and validation in a 101-patient cohort.

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.

Massive Hemorrhage from Arterial Access during Intracranial Aneurysm Stent-Assisted Embolization: Endovascular Diagnosis and Therapy.

Massive hemorrhage from arterial access in patients receiving anticoagulation and antiplatelet therapy is a rare but potentially devastating complication. The authors present a patient who developed a large retroperitoneal and anterior abdominal wall hemorrhage following an unintentional and unrecognized arterial injury during an endovascular procedure. Reversal of anticoagulation in patients who have undergone stent-assisted coil embolization of intracranial aneurysms is an undesirable approach due to the risk of thromboembolism; rather, transcatheter embolization of the bleeding source should be considered.

Tumor lysis syndrome and primary hepatic malignancy: case presentation and review of the literature.

Tumor lysis syndrome (TLS) represents a constellation of laboratory and clinical derangements that can occur following treatment of malignancies with high cellular turnover. Most commonly noted in hematologic malignancies, TLS has been reported to occur following liver-directed therapy in the form of both ablative therapies and transarterial therapies. Classification schemes exist, as do established diagnostic criteria, to aid in the definitive diagnosis of TLS. In addition, treatment algorithms are reported for patients with the diagnosis of TLS. This manuscript will review the risk factors associated with the development of TLS, the diagnostic criteria used, and treatment and preventative strategies employed. In addition, an algorithm for the diagnosis and treatment of TLS will be provided.

Staphylococcus aureus infection of the optic nerve.

A 71-year-old woman presented with painful vision loss in the right eye followed by ophthalmoplegia. Magnetic resonance imaging demonstrated optic nerve sheath enlargement and enhancement. Biopsy of the optic nerve sheath revealed purulent and necrotic material that was positive for methicillin-sensitive Staphylococcus aureus. The patient underwent enucleation of the right eye and was treated with systemic antibiotics with clinical stabilization. Imaging, pathological and treatment aspects of optic nerve sheath abscess are discussed.

Comparison of combination therapies in the management of hepatocellular carcinoma: transarterial chemoembolization with radiofrequency ablation versus microwave ablation.

PURPOSE: To compare retrospectively the outcomes and complications of transcatheter arterial chemoembolization with drug-eluting embolic agents combined with radiofrequency (RF) ablation or microwave (MW) ablation in treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: From 2003-2011, 89 patients with HCC received a combination therapy-transcatheter arterial chemoembolization plus RF ablation in 38 patients and transcatheter arterial chemoembolization plus MW ablation in 51 patients. Local tumor response, tumor progression-free survival (PFS), overall PFS, overall survival (OS), and complications were compared. Overall PFS and OS were compared between the two treatment groups in multivariate analysis controlling for Child-Pugh class, Barcelona Clinic Liver Classification stage, and index tumor size. RESULTS: Complete local tumor response was achieved in 37 (80.4%) of the tumors treated with transcatheter arterial chemoembolization plus RF ablation and 49 (76.6%) of the tumors treated with transcatheter arterial chemoembolization plus MW ablation (P = .67). The median tumor PFS and overall PFS were 20.8 months and 9.3 months (P = .72) for transarterial chemoembolization plus RF ablation and 21.8 months and 9.2 months for transarterial chemoembolization plus MW ablation (P = .32). The median OS of the transcatheter arterial chemoembolization plus RF ablation group was 23.3 months, and the median OS of the transcatheter arterial chemoembolization plus MW ablation group was 42.6 months, with no significant difference in the survival experience between the two groups (log-rank test, P = .10). In the multivariate analysis, Barcelona Clinic Liver Classification stage was the only factor associated with overall PFS and OS. One patient in the transcatheter arterial chemoembolization plus RF ablation cohort (3%) and two patients in the transcatheter arterial chemoembolization plus MW ablation cohort (4%) required prolonged hospitalization (< 48 h) for pain management after the procedure (P = 1.00). CONCLUSIONS: Based on similar safety and efficacy outcomes, both combination therapies, transcatheter arterial chemoembolization plus RF ablation and transcatheter arterial chemoembolization plus MW ablation, are effective treatments for HCC.

Adenoma localization for recurrent or persistent primary hyperparathyroidism using dynamic four-dimensional CT and venous sampling.

PURPOSE: To determine if parathyroid venous sampling (PVS) combined with four-dimensional (4D) computed tomography (CT) improves sensitivity and accuracy of identification of parathyroid adenoma in patients with recurrent or persistent primary hyperparathyroidism (pHPT) and negative technetium-99m methoxyisobutyl isonitrile ((99m)Tc-MIBI) and ultrasound (US) scans. MATERIALS AND METHODS: Both PVS and 4D CT were performed in 28 patients with recurrent or persistent pHPT and negative (99m)Tc-MIBI and US examinations. Localization by 4D CT alone and in combination with PVS and lateralization by PVS alone were retrospectively assessed for correlation with surgical results. Suspected adenomas on 4D CT were said to correlate with PVS if venous drainage identified on CT corresponded to sites of elevated parathyroid hormone concentration on PVS. Lesions difficult to identify on 4D CT were lesions < 1 cm in longest dimension. Results of 4D CT were classified as positive, negative, or equivocal. RESULTS: Surgery was performed in 22 of 28 patients. Surgery identified 23 parathyroid adenomas, 1 carcinoma, and 2 hyperplastic glands in 20 patients. 4D-CT alone localized 11 lesions in 10 patients. PVS helped localize 13 additional lesions in nine more patients and clarified two lesions that were equivocal on 4D CT. Comparing 4D CT alone with 4D CT plus PVS, the sensitivity increased from 50% to 95% (P = .004), and accuracy increased from 55% to 91% (P = .022). PVS lateralization had a sensitivity of 93.3%, positive predictive value of 66.7%, and accuracy of 63.6%. CONCLUSIONS: PVS significantly improves 4D CT localization of parathyroid adenomas in patients undergoing repeat surgery for pHPT with negative (99m)Tc-MIBI and US.

Technical and practical considerations for device selection in locoregional ablative therapy.

Percutaneous ablation therapy is an essential component of contemporary interventional oncologic therapy of primary and secondary malignancies. The growing armamentarium of available ablation technologies calls for thorough understanding of the different ablation modalities to optimize device selection in individual clinical settings. The goal of the current article is to provide direction on ablative device selection by reviewing device mechanisms of action, advantages and disadvantages, and practical considerations in real-life case scenarios.

Characteristics of primary and secondary hepatic malignancies associated with hepatopulmonary shunting.

PURPOSE: To identify liver tumor characteristics associated with low (<10%), intermediate (10%-20%), and high (>20%) lung shunt fraction (LSF) at technetium 99m ((99m)Tc) macroaggregated albumin (MAA) imaging performed before yttrium 90 ((90)Y) radioembolization (RE). MATERIALS AND METHODS: In this single-center retrospective study, 141 patients (70 with hepatocellular carcinoma [HCC], 71 with other tumors; 95 men, 45 women; median age, 61 years) underwent mapping arteriography with (99m)Tc-MAA LSF calculation before (90)Y RE from 2006 to 2012. Tumor characteristics, including tumor type, index lesion size and morphologic structure (circumscribed, infiltrative), focality (solitary oligonodular, multinodular), disease distribution (unilobar, bilobar), tumor burden (≤50%, 50%), portal vein invasion (present, absent), and arterioportal shunting (present, absent) were correlated with (99m)Tc-MAA imaging-calculated LSFs at univariate and multivariate analysis. RESULTS: Median LSF was 8.4% (HCC, 9.0%; other tumors, 8.3%). LSF greater than 20% occurred in 14% of HCCs, but only in 3% of other tumors (P = .004). For HCC, tumor morphologic structure (P = .022), tumor burden (P < .001), main portal vein invasion (P = .033), and arterioportal shunting (P < .001) were significantly associated with different LSF categories at univariate analysis; infiltrative morphologic structure, tumor burden greater than 50%, portal vein invasion, and shunting had confirmed association with high LSF at multivariate analysis. For other liver tumors, tumor size (P = .001) and tumor burden (P = .003) were significantly associated with different LSF categories at univariate analysis. Multivariate confirmation was precluded by small sample size. Patients underwent a median of one (90)Y RE session (range, one to six), with median per-treatment and cumulative lung doses of 6.0 Gy and 8.5 Gy, respectively. CONCLUSION: LSF greater than 20% periodically occurs in HCC but is uncommon in other liver tumors. Specific tumor characteristics are associated with LSF greater than 20% and may indicate need for interventions to reduce LSF.

Rosai-Dorfman disease (sinus histiocytosis with massive lymphadenopathy) of the pancreas: second case report.

INTRODUCTION: Rosai-Dorfman disease (RDD), originally described as sinus histiocytosis with massive lymphadenopathy, is a rare histiocytic proliferative disorder with a distinctive microscopic appearance. It formerly was thought to be a process limited to lymph nodes, yet RDD has been documented to occur in many organ systems, notably the bone, skin, soft tissue, central nervous system, eye and orbit, and upper respiratory tract. The digestive system, however, is affected only exceptionally, with this being only the second documented case involving the pancreas. CASE DESCRIPTION: In this case report, we present a case of a 63-year-old African-American female who was found to have a pancreatic head mass and right middle lobe pleural nodule during evaluation for obstructive jaundice. DISCUSSION AND CONCLUSION: She underwent a Whipple procedure. Her pathology of both the pancreatic mass and RML lung wedge resection showed sinus histiocytosis with massive lymphadenopathy, along with extensive fibrosis intertwined with nodular mixed inflammatory infiltrate. The histiocytes characteristically showed "emperipolesis," in which lymphocytes had penetrated the cytoplasm and remained viable within the histiocytes (lymphocytes continued to have free movement in the histiocyte). In addition, the histiocytic cells were positive with S-100 protein and CD68, hallmarks of RDD. Although rare, Rosai-Dorfman disease should be considered in the differential diagnosis of patients presenting with pancreatic and/or lung nodules, especially when biopsy or cytology results report atypical inflammatory findings.