Predictors of early mortality after transjugular intrahepatic portosystemic shunt creation for the treatment of refractory ascites.

PURPOSE: Currently there is no consensus regarding a target portosystemic gradient (PSG) after transjugular intrahepatic portosystemic shunt (TIPS) creation for the treatment of refractory ascites. The goal of this study was to examine whether the PSG after TIPS creation is predictive of subsequent mortality risk. MATERIALS AND METHODS: Retrospective review of 99 patients who underwent successful TIPS creation for refractory ascites between January 1997 and December 2004 was performed. Follow-up consisted of clinic and emergency department visits, hospital admissions, and radiology studies (mean, 7 months). Comparison of baseline patient characteristics was performed between survivors and patients who died. Survival rates were calculated with use of the Kaplan-Meier method and compared with the log-rank test based on Model for End-stage Liver Disease (MELD) scores and PSGs before and after TIPS creation. Univariate and multivariate analysis of potential predictors of mortality was performed with Cox proportional-hazards analysis. RESULTS: Sixteen patients died during follow-up (mean, 1.9 months after TIPS creation). The patients who died had significantly higher MELD scores before TIPS creation than did survivors (P = .04) and significantly lower PSGs before and after TIPS creation (P = .02 and P = .03, respectively). Survival rates were significantly lower for patients with higher MELD scores (P = .01) and lower PSGs before TIPS creation (P = .01) and after TIPS creation (P = .01). Multivariate analysis demonstrated that Child class C cirrhosis, MELD score greater than 25, and PSG less than 8 mm Hg after TIPS creation were the most significant predictors of mortality (increased likelihood by factors of 4, 5, and 3, respectively). CONCLUSION: Excessive reduction of the PSG along with severe liver dysfunction is associated with an increased risk of mortality after TIPS creation in patients presenting with refractory ascites.

Tumor ablation with photodynamic therapy: introduction to mechanism and clinical applications.

Photodynamic therapy (PDT) has been used to treat cancer for more than 25 years. Although the focus has been primarily on surface or superficial lesions, there has been a rapid growth in its application to the treatment of deeper parenchymal malignancies. The photochemical reaction consists of a photosensitizer, which, when irradiated by light at a specific wavelength, generates a cytotoxic oxygen singlet. The end result is an efficient induction of cell death, primarily through apoptosis, microvascular damage, and an antitumor immune response. PDT is currently being used in the treatment of many cancers including lung cancer, head and neck cancers, liver metastases, cholangiocarcinoma, and prostate cancer. The growing body of evidence concerning its efficacy, the increasing use of imaging to guide PDT, and the innate minimally invasive characteristics of PDT suggest that it should become an important addition to the growing array of techniques in interventional oncology.

Abnormal portal venous flow at sonography predicts reduced survival after transjugular intrahepatic portosystemic shunt creation.

PURPOSE: To determine if ultrasound (US) findings of abnormal portal venous flow (APVF) before transjugular intrahepatic portosystemic shunt (TIPS) creation are predictive of increased mortality risk after TIPS creation. MATERIALS AND METHODS: Retrospective review of 141 patients with US before TIPS creation was performed. APVF was defined by (i) bidirectional flow, (ii) thrombus, and/or (iii) reversed flow. Model for End-stage Liver Disease (MELD) scores were calculated. Kaplan-Meier survival curves and log-rank tests were used to detect survival differences based on the presence of APVF. Multivariate analysis included APVF, MELD, Child-Pugh class, International Normalized Ratio, creatinine level, total bilirubin level, ascites, hepatocellular carcinoma, low serum sodium level, congestive heart failure, and myocardial infarction. RESULTS: Twenty-six percent of patients (36 of 141) exhibited APVF on US before TIPS creation. Patients with APVF had lower survival rates at 3 and 6 months after TIPS procedures in comparison with patients with normal portal flow (P = .02 at 3 months and P = .04 at 6 months). In patients with MELD scores lower than 18, there was decreased survival based on APVF at 1, 3, and 6 months (P = .04, P = .02, and P = .04, respectively). In patients with MELD scores of 18 or greater, there was a trend for lower survival rates with APVF, but it did not reach statistical significance. Multivariate analysis of patients with MELD scores lower than 18 demonstrated only APVF and low serum sodium levels as independent predictors of outcome, with APVF resulting in a greater than six-fold increased likelihood of mortality. CONCLUSION: US findings of APVF before TIPS creation are associated with increased mortality risk and may be useful in identifying patients otherwise considered safe candidates based on MELD score alone.

Outcomes of carotid angioplasty and stenting for radiation-associated stenosis.

BACKGROUND AND PURPOSE: In light of their high surgical risk, carotid angioplasty and stent placement may be preferred in patients with radiation-associated carotid stenosis. The purpose of this study was to determine the procedural complication rate, patency, and clinical outcomes after carotid angioplasty and stent placement in this small group of high-risk patients. METHODS: Sixteen patients (mean age, 65 years; 5 women and 11 men) who received radiation therapy for head and/or neck malignancy subsequently developed carotid stenosis (mean, 84%; range, 70%-99%) in a total of 19 carotid arteries, which were treated with angioplasty and stent placement. The patients were followed for a mean time of 28 months (range, 5-78 months) with periodic Doppler studies, angiography, CT angiography, or clinically. RESULTS: In the total 19 stented carotid arteries, 23 procedures were performed (22 stent placement procedures and one repeat angioplasty). The procedural stroke rate was 1/23 (4%). The procedural transient ischemic attack rate was 0/23 (0%). There was one other observed complication: a puncture site hematoma. The 30-day postprocedure complication rate was 0/23 (0%); no neurologic symptoms were reported. Fifteen of the 19 vessels (79%) developed no new stenosis throughout the follow-up period. Two of 19 (11%) vessels had repeat angioplasty and stent placement; 1/19 (5%) had a repeat angioplasty. One restented vessel has remained patent for 50 months. Another restented vessel required a third stent placement 17 months after the second. Two of 19 (11%) vessels occluded per Doppler examination 14 and 22 months postprocedure. CONCLUSION: Angioplasty and stent placement have low rates of complications and restenosis in the treatment of radiation-associated carotid occlusive disease.