Integrative multi-omics characterization of hepatocellular carcinoma in Hispanic patients.

Background: The incidence and mortality rates of hepatocellular carcinoma (HCC) among Hispanics in the United States are much higher than those of non-Hispanic whites. We conducted comprehensive multi-omics analyses to understand molecular alterations in HCC among Hispanic patients. Methods: Paired tumor and adjacent non-tumor samples were collected from 31 Hispanic HCC in South Texas (STX-Hispanic) for genomic, transcriptomic, proteomic, and metabolomic profiling. Additionally, serum lipids were profiled in 40 Hispanic and non-Hispanic patients with or without clinically diagnosed HCC. Results: Exome sequencing revealed high mutation frequencies of AXIN2 and CTNNB1 in STX Hispanic HCCs, suggesting a predominant activation of the Wnt/ß-catenin pathway. The TERT promoter mutation frequency was also remarkably high in the Hispanic cohort. Cell cycles and liver functions were identified as positively- and negatively-enriched, respectively, with gene set enrichment analysis. Gene sets representing specific liver metabolic pathways were associated with dysregulation of corresponding metabolites. Negative enrichment of liver adipogenesis and lipid metabolism corroborated with a significant reduction in most lipids in the serum samples of HCC patients. Two HCC subtypes from our Hispanic cohort were identified and validated with the TCGA liver cancer cohort. The subtype with better overall survival showed higher activity of immune and angiogenesis signatures, and lower activity of liver function-related gene signatures. It also had higher levels of immune checkpoint and immune exhaustion markers. Conclusions: Our study revealed some specific molecular features of Hispanic HCC and potential biomarkers for therapeutic management of HCC and provides a unique resource for studying Hispanic HCC.

Percutaneous Removal of Migrated Gastrointestinal Stents Using Gastrostomy Access.

This report describes the experience of removing migrated gastrointestinal (GI) stents using a gastrostomy (G) access. Four male patients aged 23-62 years (mean, 42 years) had 6 migrated stents removed using an existing (n = 3) or new (n = 1) G access. Removed stents included 5 covered esophageal stents that migrated into the stomach and 1 distal noncovered duodenal stent that migrated into the proximal duodenum. One patient had 2 stents removed during the same session. All stents were removed successfully without complications. Techniques used included the folding technique using a wire in 3 stents and forceps in 2 stents. Eversion technique was used in the duodenal stent. The G or gastrojejunostomy tubes were replaced after stent removal and used for enteral feedings. In conclusion, removing migrated GI stents using an existing or new G access is technically successful and safe.

A Comprehensive Review of Transjugular Intrahepatic Portosystemic Shunt-Related Complications.

Transjugular intrahepatic portosystemic shunt (TIPS) is one of the most technically complex procedures in interventional radiology, the need to connect two veins with variable anatomy, located in two different planes in hard and many times small cirrhotic livers using a needle, can be quite challenging. Despite more than 30 years of performing TIPS, the complex hemodynamics of the portal system are not fully understood, and sometimes unpredictable alterations of the portal flow can lead to serious unexpected complications. The best strategies to prevent TIPS complications are optimal patient selection, meticulous technique, operator experience, and immediate correction of identified adverse events. The purpose of this article is to review the technical complications with TIPS, the unique complications related to the use of stent grafts, and the late complications after the procedure, with emphasis on ways to prevent and treat them.

The rat eustachian tube: Anatomical, histological, and radiological features.

Purpose: This study investigated the anatomical and histological characteristics of the rat Eustachian tube (E-tube) and the feasibility of Eustachian tubography in a rat model. Materials and methods: Fifteen male Wistar rats were used in this study, and the bilateral E-tubes of each rat were examined. Ten E-tubes were used for anatomical studies, another ten for histological analysis, and the other ten for Eustachian tubography. Five rats were euthanized and decapitated, and ten E-tubes were dissected to describe the anatomy of the E-tube. Ten E-tube specimens obtained from five other rats were sectioned to investigate E-tube histology. Eustachian tubography was performed on the bilateral E-tubes of the other five rats using the trans-tympanic approach. Results: The rat E-tubes consisted of bony and membranous parts. Cartilage and bone tissue covered only the bony part. The E-tubes' mean diameter and overall length were 2.97 â€‹mm and 4.96 â€‹mm, respectively. The tympanic orifices' mean diameter was 1.21 â€‹mm. The epithelium of E-tubes was mainly composed of pseudostratified ciliated and goblet cells. Eustachian tubography was successfully performed on both sides of the E-tube for each rat. The technical success rate was 100%, the average running time was 4.9 â€‹min, and no procedure-related complications occurred. On tubography images, the E-tube, tympanic cavity, and nasopharynx could be identified because of the visualization of bony landmarks. Conclusion: In this study, we described the anatomical and histological features of rat E-tubes. With the aid of these findings, E-tube angiography was successfully performed using a transtympanic approach. These results will facilitate further investigation of E-tube dysfunction.

Comparative outcomes of Inferior Vena Cava filters placed at bedside using digital radiography versus conventional fluoroscopy.

PURPOSE: To retrospectively assess the outcomes of Inferior Vena Cava (IVC) filters placed in critically ill patients in the ICU at bedside using digital radiograph (DR) guidance with previous cross-sectional imaging for planning, compared to IVC filters placed by conventional fluoroscopy (CF). METHOD AND MATERIALS: The cohort consisted of 129 IVC filter placements; 48 placed at bedside and 81 placed conventionally from July 2015 to September 2016. Patient demographics, indication, radiation exposures, access site, procedural duration, dwell time, and complications were identified by the EMR. IVC Filter positioning with measurements of tip to renal vein distance and lateral filter tilt were performed when cavograms or post placement CTs were available for review. Statistical analysis was performed using Stata IC 11.2. RESULTS: Technical success of the procedure was 100% in both groups. Procedural duration was longer at the bedside lasting 14.5 +/- 10.2 versus 6.7 +/- 6.0 â€‹min (p<0.0001). The bedside DR group had a median radiation exposure of 25 â€‹mGy (15-35) and the CF group had mean radiation exposure of 256.94 â€‹mGy +/- 158.6. There was no significant difference in distance of IVC tip to renal vein (p=0.31), mispositioning (p=0.59), degree of filter tilt (p=0.33), or rate of complications (p=0.65) between the two groups. CONCLUSION: IVCF placement at the bedside using DR is comparable to CF with no statistical difference in outcomes based on IVCF positioning, degree of lateral tilt or removal issues. It decreased radiation dose, but with overall increased procedural time.

Embolization in Trauma: Review of Basic Principles and Techniques.

Trauma is the leading cause of death in patients younger than 45 years. Over the last decade, there has been a progressive paradigm shift toward a nonoperative management of many blunt and penetrating injuries, placing interventional radiology in the forefront in this critical field. Transcatheter embolization is an established technique that plays a significant role in the modern treatment of traumatic injuries of the extremities, pelvis, and solid organs. The purpose of this article is to review the updated principles and techniques used in transcatheter embolization in trauma.

Digital radiograph (DR) guided bedside IVC filter placements in patients with intracranial pressure monitors.

Purpose: The purpose of this study is to report a single center experience with portable digital radiographically (DR) guided bedside IVC filters placed in intensive care unit (ICU) patients with high ICP and elevated head of bed (HOB). Materials and methods: A retrospective chart review was conducted on all bedside IVC filters placed from January 1, 2010 to September 16, 2020. Patients with high ICP and elevated head of bed requirements were included. Charts were reviewed for filter type, common femoral vein (CFV) access, filter location, pre procedure imaging, pre and post filter ICPs, glascow coma scale, number of radiographs taken, and filter removal. ICPs were obtained 1 â€‹h prior to procedure and 2 â€‹h post procedure and analyzed with a paired T test.Filters were placed by reviewing prior CT scan for IVC size, caval variants, renal and iliac veins and vertebral body landmarks. Then, CFV access was obtained and a Bentson wire was advanced 30-40 â€‹cm. A radiograph was used to confirm adequate position of the of the wire. The filter sheath was advanced and serial radiographs were used to position the filter sheath at the final predetermined position below the renal veins and above the iliac bifurcation. The filter was deployed, and a radiograph was obtained to confirm filter positioning. Results: A total of 9 DR guided bedside IVC filters were placed (4 Denali, 3 Option Elite, 2 Celect). Indications included prophylactic placement (n â€‹= â€‹8) and acute DVT (n â€‹= â€‹1). The average patient age was 35.8 years (range: 18-56 years) CT abdomen and pelvis was used to assess for the level of renal veins in all patients (n â€‹= â€‹9). No caval variants were encountered on pre-procedural planning. The average pre, intraprocedural, and post procedure intracranial pressure was 16 â€‹mmHg, 13 â€‹mmHg, and 16 â€‹mmHg, respectively. Confirmation of placement after final placement was available in 7 patients (4 DR, 2 CT and one fluoroscopic examination). Two non-procedural related deaths occurred.Technical success, defined as successful placement of IVC filter at the predetermined level, was achieved in 100% of patients (n â€‹= â€‹9). The right CFV was used in most patients (n â€‹= â€‹7). The left CFV was used for access in two patients due to right CFV thrombus (n â€‹= â€‹1) and existing right femoral venous central line (n â€‹= â€‹1). The average number of radiographs taken was 5.8 (range 4-9). In all cases, filters were placed below the level of the lowest renal vein (n â€‹= â€‹9). A comparison of pre, during and post intervention ICP pressures is shown in table, 2. No differences between pre and post filter ICP was noted (p â€‹= â€‹0.77). Three filters were later removed. One minor complication was reported, which was filter tilt (23%) in an Option filter. Conclusion: Bedside IVC filters can be safely placed in patients with head trauma and high ICP who are unable to lay supine using portable DR guidance with a high rate of technical success and minimal complications.

Superior vena cava filter placement over existing central venous lines: Is line removal necessary?

OBJECTIVES: To evaluate the technical feasibility and clinical safety of superior vena cava (SVC) filter placement over preexisting central venous lines (CVLs) in 23 patients who had upper extremity deep venous thrombosis with contraindications to anticoagulation. METHODS: A retrospective review of the images and electronic medical records of 23 patients from 2008 to 2018 with SVC filters placed over an existing central venous line was performed in a single tertiary medical center. Twenty-one filters were placed over smaller lines (<8 Fr), and two were placed over hemodialysis catheters. Venograms before and after filter placement were compared to detect any evidence of line displacement or entrapment. Medical records were reviewed to determine whether there was any difficulty during line removal. RESULTS: In two of five patients with dual lines, significant line displacement was noted in the left-sided lines, both lines were later removed without complications. In one patient with a hemodialysis catheter, the filter was deployed over the tip of the catheter resulting in the entrapment of one of the legs of the filter within a side hole of the line. Fourteen patients had their lines later removed 3 days to 3 months after filter placement without reported problems. Nine patients had their CVLs left in place until the patient's death or discharge to a long-term facility. CONCLUSIONS: SVC filter placement over preexisting CVLs seems to be technically feasible and clinically safe in patients with <8-Fr CVLs. However, placement of the filters over hemodialysis catheters can result in leg entrapment.

A Novel Biodegradable Tubular Stent Prevents Pancreaticojejunal Anastomotic Stricture.

Stricture of pancreatic-enteric anastomoses is a major late complication of a pancreaticoduodenectomy for the treatment of a periampullary tumor and can lead to exocrine and endocrine insufficiency such as malnutrition and diabetes mellitus. We investigated the safety and efficacy of a biodegradable tubular stent (BTS) for preventing a pancreaticojejunostomy (PJ) anastomotic stricture in both a rat and porcine model. The BTS was manufactured using a terpolymer comprising poly p-dioxanone, trimethylene carbonate, and glycolide. A cohort of 42 rats was randomized into 7 groups of 6 animals each after BTS placement into the duodenum for the biodegradation assay. A total of 12 pigs were randomized equally into a control and BTS placement group. The effectiveness of the BTS was assessed by comparing radiologic images with histologic results. Surgical procedures and/or BTS placements were technically successful in all animals. The median mass losses of the removed BTS samples from the rat duodenum were 2.1, 6.8, 11.2, 19.4, 26.1, and 56.8% at 1, 2, 3, 4, 6, and 8 weeks, respectively. The BTS had completely degraded at 12 weeks in the rats. In the porcine PJ model, the mean luminal diameter and area of the pancreatic duct in the control group was significantly larger than in the BTS group (all p < 0.05). BTS placement thus appears to be safe and effective procedure for the prevention of PJ anastomotic stricture. These devices have the potential to be used as a temporary stent placement to treat pancreatic-enteric anastomoses, but further investigations are required for optimization in human.

Local Heat Treatment for Suppressing Gastroduodenal Stent-Induced Tissue Hyperplasia Using Nanofunctionalized Self-Expandable Metallic Stent in Rat Gastric Outlet Model.

Despite the promising results from the placement of covered or uncovered self-expandable metallic stent (SEMS) as a nonsurgical therapeutic option for the malignant gastric outlet obstruction (GOO), the long patency of the stent is still limited because of stent-induced tissue hyperplasia. Here, a local heat treatment using a nanofunctionalized SEMS is proposed for suppressing stent-induced tissue hyperplasia during GOO treatment. Highly efficient photothermal gold nanoparticle (GNP) transducer-coated SEMSs (GNP-SEMSs) were prepared for local heat treatment in rat gastric outlet. The in vivo heating temperature in rat gastric outlet model was evaluated and compared with in vitro heating temperature. Three groups of our developed 45 rat gastric outlet models were used: group A, noncoated SEMS only; group B, GNP-SEMS plus local heating; and group C, GNP-SEMS only to investigate in vivo efficacy of GNP-SEMS mediated local heating. Ten rats per group were sacrificed for 4 weeks, and five rats per group were sacrificed immediately after local heat treatment. The in vivo heating temperature was found to be 10.8% lower than the in vitro heating temperatures. GNP-SEMSs were successfully placed through a percutaneous approach into the rat gastric outlet (n = 45). The therapeutic effects of GNP-SEMS were assessed by histologic examination including hematoxylin-eosin, Masson trichrome, immunohistochemistry (TUNEL and CD31), and immunofluorescence (Ki67), and the results showed significant prevention of tissue hyperplasia following stent placement without adjacent gastrointestinal tissue damage. GNP-SEMS-mediated local heating could be an alternative therapeutic option for the suppression of tissue hyperplasia following stent placement in benign and malignant GOOs.

A single center 10-year clinical experience with superior vena cava retrievable filters.

PURPOSE: To report a 10-year clinical experience with superior vena cava (SVC) retrievable filters. METHODS: A retrospective review of patients with SVC filters was performed between 2008 and 2018 in a single tertiary medical center. Patient demographics, indications for filter placement, type of filter placed, and clinical evolution were recorded. Complications during placement, retrieval, and follow-up were determined. RESULTS: Fifty patients ages 17-89 years (average 54) underwent SVC retrievable filter placement. Main indication for filter placement was deep venous thrombosis of the major upper extremity and/or internal jugular veins with contraindications to anticoagulation. Complications during placement included inadvertent filter placement in the right brachiocephalic vein in two patients, another patient had a leg of the filter entrapped in the tip of a hemodialysis catheter that required filter reposition and line exchange. Thirteen patients had attempted retrieval with 12 filters successfully removed 7-420 days after placement (mean 170). On follow-up images available in 24 patients, 13 filters were noted to be significantly tilted and 10 filters had evidence of leg penetration. No other serious late complications were noted. CONCLUSION: The use of retrievable SVC filters in patients with upper extremity DVT is highly questionable. There is a high incidence of filter malposition, filter tilting, and leg penetration.

Radiation Inhibits Lymph Drainage in an Acquired Lymphedema Mouse Hindlimb Model.

Background: Radiation therapy has been applied to prolong the duration of lymphedema. This study aimed to evaluate the effect of radiation on the development of lymphedema in a mouse hindlimb model. Methods and Results: A total of 24 Balb/c mice underwent the right popliteal lymph node excision and the afferent and efferent lymphatics blockage. The radiation group (n = 12) received a single 20 Gy radiation 1 day before surgery in the right hindlimb of each mouse, whereas the control group (n = 12) only received surgery without radiation. The right hindpaw thickness of each mouse was measured twice a week for 4 weeks. Fluorescence microscopy images using fluorescein isothiocyanate-dextran tracer were obtained once weekly. Immunohistochemical (IHC) staining images using anti-lymphatic vessel endothelial hyaluronan receptor-1 (anti-LYVE-1) were obtained at 4 weeks after surgery. The radiation group showed significant increase in the thickness of the right hind paws from 0.5 to 2 weeks compared with the control group. As for fluorescence lymphography, the radiation group showed a lower number of regenerated lymphatics and more congestion of tracers in the operated limb at the surgery sites at 1, 2, 3, and 4 weeks after surgery. For the IHC analysis, the radiation group showed a lower number of regenerated lymphatics per high-power field at the surgery site than the control group. Conclusion: Radiation therapy transiently aggravated the extent of lymphedema by inhibiting regenerated lymphatics in a mouse hindlimb model. However, it did not prolong the duration of lymphedema because the cutaneous interstitial flow contributes to the lymphatic fluid clearance.

The Amplatzer Vascular Plug: Review of Evolution and Current Applications.

The Amplatzer Vascular Plug (AVP) was created for peripheral embolization as a modification of the family of Amplatz septal occluders used in the treatment of congenital heart malformations. The device has evolved over the years and multiple versions have been launched into the market. Each of the versions of the device has some important modifications in terms of the size of the introducer's system, number of layers, and resultant thrombogenicity. It is very important for the operator to become familiar with the unique features of the AVP, and to understand the advantages and limitations of each model in the AVP family to achieve an optimal embolic result. The purpose of this article is to review the evolution and current clinical applications of the AVP in the field of interventional radiology, with emphasis on the advantages and limitations of this device in comparison with other embolization agents.

Segmental liver ischemia/infarction after elective transjugular intrahepatic portosystemic shunt creation: clinical outcomes in 10 patients.

PURPOSE: To determine the clinical significance and potential mechanisms of segmental liver ischemia and infarction following elective creation of a transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS: A retrospective review of 374 elective TIPS creations between March 2006 and September 2014 was performed, yielding 77 contrast-enhanced scans for review. Patients with imaging evidence of segmental perfusion defects were identified. Model for End-stage Liver Disease scores, liver volume, and percentage of liver ischemia/infarct were calculated. Clinical outcomes after TIPS creation were reviewed. RESULTS: Ten patients showed segmental liver ischemia/infarction on contrast-enhanced imaging after elective TIPS creation. Associated imaging findings included thrombosis of the posterior division (n = 7) and anterior division (n = 3) of the right portal vein (PV). The right hepatic vein was thrombosed in 5 patients, as was the middle hepatic vein in 3 and the left hepatic vein in 1. One patient had acute thrombosis of the shunt and main PV. Three patients developed acute liver failure: 2 died within 30 days and 1 required emergent liver transplantation. One patient died of acute renal failure 20 days after TIPS creation. A large infarct in a transplant recipient resulted in biloma formation. Five patients survived without additional interventions with follow-up times ranging from 3 months to 5 years. CONCLUSIONS: Segmental perfusion defects are not an uncommon imaging finding after elective TIPS creation. Segmental ischemia was associated with thrombosis of major branches of the PVs and often of the hepatic veins. Clinical outcomes varied significantly, from transient problems to acute liver failure with high mortality rates.

An international multicenter comparison of time-SLIP unenhanced MR angiography and contrast-enhanced CT angiography for assessing renal artery stenosis: the renal artery contrast-free trial.

OBJECTIVE: The unenhanced MR angiography (MRA) technique time-spatial labeling inversion pulse (time-SLIP) may provide a safe alternative for evaluating the renal arteries for stenosis. This international multicenter trial tested the hypothesis that time-SLIP unenhanced MRA is accurate and robust for assessing the renal arteries for stenosis in comparison with contrast-enhanced CT angiography (CTA). SUBJECTS AND METHODS: Four centers (United States, Europe, Asia) enrolled 75 patients (average age ± SD, 58 ± 13 years; 41 [55%] men and 34 [45%] women). Each patient underwent abdominal contrast-enhanced CTA and abdominal unenhanced MRA using time-SLIP with balanced steady-state free precession. All images were visually assessed for quality (arterial signal intensity) and for the absence or presence of renal artery stenosis (≤ 50% or > 50% stenosis, respectively). In addition, for arteries with any visible disease, the severity of the stenosis was quantified. Two blinded readers evaluated each study. No arteries were excluded from analysis. RESULTS: Unenhanced MRA image quality was excellent for 56 of 75 patients (75%) and good for 16 of 75 patients (21%). CTA was used as the reference standard and showed that 23 of 161 renal arteries (14.3%) had stenosis > 50%. Unenhanced MRA correctly classified 17 of the 23 renal arteries with > 50% stenosis and correctly classified 128 of the 138 renal arteries as not having disease (≤ 50% stenosis) to yield a sensitivity of 74%, specificity of 93%, and accuracy of 90% (χ(2) = 0.56; p = 0.45, no statistically significant difference). Of the 16 misclassified arteries, only three had a clinically relevant misclassification (CTA ≥ 70% stenosis and unenhanced MRA ≤ 50% stenosis or unenhanced MRA ≥ 70% stenosis and CTA ≤ 50% stenosis). On average, measured stenotic severity (n = 28 arteries) was similar for unenhanced MRA (64% ± 17%) and CTA (62% ± 16%) (p = 0.51). CONCLUSION: Compared with contrast-enhanced CTA, the unenhanced MRA technique time-SLIP shows promise for assessing the renal arteries for stenosis. The unenhanced MRA technique time-SLIP may provide a safe alternative for evaluating the renal arteries for stenosis.

Superior vena cava (SVC) filters placed over central lines - analysis of line trapping and difficulties with line retrieval: an in-vitro experimental study.

BACKGROUND: Placement of superior vena cava (SVC) filters has been shown to be both safe and effective in preventing symptomatic pulmonary embolism in patients with upper extremity deep venous thrombosis that have contraindications to anticoagulation therapy. In many patients, existing central lines pose a challenge to SVC filter placement due to the theoretical risk of line displacement and/or entrapment. PURPOSE: To assess the risk of catheter entrapment by filter legs during SVC filter deployment and the risk of subsequent filter migration during catheter removal. MATERIAL AND METHODS: A model was created by placing a 22 mm vascular graft inside a plastic tube and submerged in a warm saline bath. Five types of filters were deployed under fluoroscopic guidance over different types of central lines of varying calibers (5-14 Fr). Each filter was deployed five times over each type of central line. The positioning of the legs of the filters in relationship to the central lines was studied by fluoroscopic and direct inspection. The lines were then removed under fluoroscopic guidance noting any line trapping, migration, and/or tilting of the filters. RESULTS: Movement of the lines during filter expansion was commonly seen after deployment of all filters with varying frequencies. During line removal slight resistance was encountered with the Celect filter (10%) and the Option filter (5%), while significant resistance was only encountered when using the OptEase filter (20%). Filter migration was only observed when the OptEase filter was deployed over large (>10 Fr) caliber lines (10%). CONCLUSION: When SVC filters are placed over existing central lines, the risk of catheter entrapment is very low in this in-vitro model. Filter migration during line retrieval was only observed when the OptEase filter was placed over >10 Fr caliber lines.

Transjejunal biliary interventions: going back to a road less traveled.

Percutaneous transhepatic biliary interventions are not without risk and potential complications. In patients with bilioenteric anastomosis in whom repeat biliary interventions are expected, percutaneous transjejunal access is a very useful approach that is not frequently used nowadays. We provide a brief review of the history, indications, and current status of transjejunal biliary interventions. Transjejunal biliary access provides a relatively atraumatic pathway to the biliary system in patients that need repeat interventions. Multiple studies have provided convincing data that in appropriately chosen patients receiving a bilioenteric anastomosis, an antecolic limb of jejunum should be placed for subsequent access in biliary intervention.