Imaging of hepatocellular carcinoma recurrence after liver transplantation.

Liver transplantation (LT) provides the highest survival benefit to patients with unresectable hepatocellular carcinoma (HCC). The Milan criteria have been developed for the selection of LT candidates with the goal of improving survival and maintaining an acceptable risk of HCC recurrence. Despite this, recurrence of HCC after LT occurs in up to 20% of cases and represents a major concern due to the poor prognosis of these patients. Furthermore, several extended criteria for the selection of LT candidates have been proposed to account for the growing demand for organs and the resultant increase in the risk of HCC recurrence. Radiologists should be aware that HCC can recur after LT with multiple organ involvement. Knowledge of the location and radiologic appearance of recurrent HCC is necessary to ensure the choice of the most appropriate therapy. This paper aims to comprehensively summarize the spectrum of HCC recurrence after LT and to examine and discuss the imaging features of these lesions. CRITICAL RELEVANCE STATEMENT: This paper aims to share a review of imaging findings of HCC recurrence after LT and to make radiologists familiar with the spectrum of this disease.

Clinical outcomes of transjugular intrahepatic portosystemic shunt with PTFE-covered stents after liver transplantation and technical results in split and whole liver graft recipients.

OBJECTIVES: To assess the outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation using PTFE-covered stents in liver transplant (LT) recipients and to analyze the technical result of TIPS creation in split grafts (SG) compared with whole liver grafts (WG). METHODS AND MATERIALS: Single-center, retrospective study, analyzing LT patients who underwent TIPS using PTFE-covered stents. Clinical and technical variables were analyzed. RESULTS: Between 2005 and 2021, TIPS was created using PTFE-covered stents in 48 LT patients at a median of 43 months (range, 0.5-192) after LT. TIPS indications were refractory ascites (RA) in 33 patients (69%), variceal bleeding (VB) in 9 patients (19%), others in 6 (12%). Ten patients (21%) received a SG. Technical success rate was 100% in both groups: in two WG recipients, (5%) a second attempt was required. An unconventional approach (combined transhepatic or transplenic access) was needed in 2 WG (5%) and 2 SG recipients (20%). Two procedure-related death occurred in the WG group. After a median follow-up of 22 months (range, 0,1-144), 16 patients (48%) in the RA group did not require post-TIPS paracentesis, in the VB group rebleeding occurred in 3 patients (33%). Fifteen patients (31%) underwent TIPS revision. Overt hepatic encephalopathy occurred in 14 patients (29%). Patient survival at 6 months, 1 year, and 3 years was 77%, 66%, and 43%, respectively. CONCLUSIONS: The feasibility and safety of TIPS creation in SG are comparable to that of WG. TIPS creation using PTFE-covered stents represents a viable option to treat portal hypertensive complications in LT recipients. KEY POINTS: • TIPS creation using PTFE-covered stents represents a viable option to treat complications of PH in LT recipients. • TIPS creation in LT SG recipients appears to be safe and feasible as in WG. • Results from this study may help to refine the management of LT patients with recurrent portal hypertensive complications encouraging physicians to consider TIPS creation as a treatment option in both SG and WG recipients.

Right vs left portal branch puncture in TIPS creation with controlled expansion covered stent: comparison of hemodynamic and clinical outcomes.

PURPOSE: To retrospectively compare outcomes of TIPS performed by puncturing left portal vein (LPV) vs right portal vein (RPV) to access the portal system. MATERIALS AND METHODS: One hundred ninety-three consecutive patients underwent TIPS with controlled expansion covered stent by using the LPV (37 patients) or the RPV (156 patients). Patients were followed until the last clinical evaluation, liver transplantation, or death. RESULTS: Demographics and clinical characteristics of the two groups were comparable. The median follow-up was 9.6 months (range 0.1-50.6). Portosystemic pressure gradient (PSG) before TIPS 15.7 mmHg ± 4.7 in RPV group (RPVG) vs 15.4 mmHg ± 4.5 in LPV group (LPVG) (p = 0.725). After TIPS, PSG 6.3 mmHg ± 2.8 in RPVG vs 6.2 mmHg ± 2.2 (p = 0.839). In LPVG, the stent was dilated to 8-mm in 95% of patients vs 77% of RPVG (p = 0.015). Two (5.4%) and 22 (14%) patients underwent TIPS revision in LPVG and RPVG (p = 0.15). The incidence of overt HE was 13% in LPVG and 24% in RPVG (p = 0.177). Rebleeding occurred in 3 of 49 patients (6%) with variceal bleeding as an indication: 2/41 patients (4.9%) in RPVG vs 1/8 patients (12.5%) in LPVG (p = 0.417). Among 126 patients with refractory ascites 20 patients (15.9%) needed paracentesis 3 months after the procedure: 18/101 patients (17.8%) in RPVG vs 2/25 patients (8%) in LPVG (p = 0.231). Thirty-seven patients (19%) died: 32 (21%) in RPVG and 5 (14%) in LPVG (p = 0.337). CONCLUSION: Compared with RPV puncture, in TIPS created through the LPV, the targeted PSG was reached with a smaller stent diameter. However, no significant difference in clinical outcomes was observed. KEY POINTS: • A LPV approach for TIPS creation does not lead to better control of complications of portal hypertension as compared to a RPV approach.

Mortality after transjugular intrahepatic portosystemic shunt in older adult patients with cirrhosis: A validated prediction model.

BACKGROUND AND AIMS: Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) improves survival in patients with cirrhosis with refractory ascites and portal hypertensive bleeding. However, the indication for TIPS in older adult patients (greater than or equal to 70 years) is debated, and a specific prediction model developed in this particular setting is lacking. The aim of this study was to develop and validate a multivariable model for an accurate prediction of mortality in older adults. APPROACH AND RESULTS: We prospectively enrolled 411 consecutive patients observed at four referral centers with de novo TIPS implantation for refractory ascites or secondary prophylaxis of variceal bleeding (derivation cohort) and an external cohort of 415 patients with similar indications for TIPS (validation cohort). Older adult patients in the two cohorts were 99 and 76, respectively. A cause-specific Cox competing risks model was used to predict liver-related mortality, with orthotopic liver transplant and death for extrahepatic causes as competing events. Age, alcoholic etiology, creatinine levels, and international normalized ratio in the overall cohort, and creatinine and sodium levels in older adults were independent risk factors for liver-related death by multivariable analysis. CONCLUSIONS: After TIPS implantation, mortality is increased by aging, but TIPS placement should not be precluded in patients older than 70 years. In older adults, creatinine and sodium levels are useful predictors for decision making. Further efforts to update the prediction model with larger sample size are warranted.

Transjugular intrahepatic portosystemic shunt (TIPS) complications: what diagnostic radiologists should know.

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for portal hypertension complications and can successfully treat variceal bleeding and refractory ascites. Although TIPS is relatively safe, procedural- or shunt-related morbidity can reach 20%, and procedural complications have a fatality rate of 2%. Delayed recognition and treatment of TIPS complications can lead to life-threatening clinical scenarios. Complications can vary from stent migration or malpositioning to nontarget organ injury, TIPS dysfunction, encephalopathy, or liver failure. This review aims to outline the role of diagnostic radiology in assessing post-TIPS complications.

Brain magnetic resonance imaging radiomics features associated with hepatic encephalopathy in adult cirrhotic patients.

PURPOSE: Hepatic encephalopathy (HE) is a potential complication of cirrhosis. Magnetic resonance imaging (MRI) may demonstrate hyperintense T1 signal in the globi pallidi. The purpose of this study was to evaluate the performance of MRI-based radiomic features for diagnosing and grading chronic HE in adult patients affected by cirrhosis. METHODS: Adult patients with and without cirrhosis underwent brain MRI with identical imaging protocol on a 3T scanner. Patients without history of chronic liver disease were the control population. HE grading was based on underlying liver disease, severity of clinical manifestation, and number of encephalopathic episodes. Texture analysis was performed on axial T1-weighted images on bilateral lentiform nuclei at the level of the foramina of Monro. Diagnostic performance of texture analysis for the diagnosis and grading of HE was assessed by calculating the area under the receiver operating characteristics (AUROC) with 95% confidence interval (CI). RESULTS: The final study population consisted of 124 patients, 70 cirrhotic patients, and 54 non-cirrhotic controls. Thirty-eight patients had history of HE with 22 having an HE grade > 1. The radiomic features predicted the presence of HE with an AUROC of 0.82 (95% CI: 0.73, 0.90; P < .0001; 82% sensitivity, 66% specificity). Radiomic features predicted grade 1 HE (AUROC 0.75; 95% CI: 0.61, 0.89; P < .0001; 94% sensitivity, 60% specificity) and grade ≥ 2 HE (AUROC 0.82; 95% CI: 0.71, 0.93; P < .0001, 95% sensitivity, 57% specificity). CONCLUSION: In cirrhotic patients, MR radiomic is effective in predicting the presence of chronic HE and in grading its severity.

Portal vein puncture-related complications during transjugular intrahepatic portosystemic shunt creation: Colapinto needle set vs Rösch-Uchida needle set.

Transjugular portal vein puncture is considered the riskiest step in TIPS creation with possible incidence of portal vein puncture-related complications (PVPC). The Colapinto and the Rösch-Uchida needle sets are two different needle sets currently available. To date, there have been no randomized control trials or systematic reviews which compare the incidence of PVPC when using the two different needle sets. The aim of this literature review is to assess the rate of PVPC associated with the different needle sets used in the creation of TIPS. From the described search, 1500 articles were identified and 34 met the inclusion criteria. Outcome measured was the prevalence of PVPC using the different needle sets. Overall 212 (3.6%) PVPC were reported in 5865 patients; 142 (3.5%) reported in 4000 cases using the Rösch-Uchida set and 70 (3.7%) in 1865 patients using the Colapinto set (p = 0.69). PVPC in TIPS creation are not related to the choice of needle set used in the procedure. To our knowledge, this is the first review of its kind, the results of which support the theory that while the rate of PVPC is influenced by many factors, choice of needle set does not seem to be one of them.

Performance of the model for end-stage liver disease score for mortality prediction and the potential role of etiology.

BACKGROUND & AIMS: Although the discriminative ability of the model for end-stage liver disease (MELD) score is generally considered acceptable, its calibration is still unclear. In a validation study, we assessed the discriminative performance and calibration of 3 versions of the model: original MELD-TIPS, used to predict survival after transjugular intrahepatic portosystemic shunt (TIPS); classic MELD-Mayo; and MELD-UNOS, used by the United Network for Organ Sharing (UNOS). We also explored recalibrating and updating the model. METHODS: In total, 776 patients who underwent elective TIPS (TIPS cohort) and 445 unselected patients (non-TIPS cohort) were included. Three, 6 and 12-month mortality predictions were calculated by the 3 MELD versions: discrimination was assessed by c-statistics and calibration by comparing deciles of predicted and observed risks. Cox and Fine and Grey models were used for recalibration and prognostic analyses. RESULTS: In the TIPS/non-TIPS cohorts, the etiology of liver disease was viral in 402/188, alcoholic in 185/130, and non-alcoholic steatohepatitis in 65/33; mean follow-up±SD was 25±9/19±21 months; and the number of deaths at 3-6-12 months was 57-102-142/31-47-99, respectively. C-statistics ranged from 0.66 to 0.72 in TIPS and 0.66 to 0.76 in non-TIPS cohorts across prediction times and scores. A post hoc analysis revealed worse c-statistics in non-viral cirrhosis with more pronounced and significant worsening in the non-TIPS cohort. Calibration was acceptable with MELD-TIPS but largely unsatisfactory with MELD-Mayo and -UNOS whose performance improved much after recalibration. A prognostic analysis showed that age, albumin, and TIPS indication might be used to update the MELD. CONCLUSIONS: In this validation study, the performance of the MELD score was largely unsatisfactory, particularly in non-viral cirrhosis. MELD recalibration and candidate variables for an update to the MELD score are proposed. LAY SUMMARY: While the discriminative performance of the model for end-stage liver disease (MELD) score is credited to be fair to good, its calibration, the correspondence of observed to predicted mortality, is still unsettled. We found that application of 3 different versions of the MELD in 2 independent cirrhosis cohorts yielded largely imprecise mortality predictions particularly in non-viral cirrhosis. Thus, we propose a recalibration and suggest candidate variables for an update to the model.

Percutaneous Trans-Hepatic Embolization of an Iatrogenic Extra-Hepatic Pseudoaneurysm of the Right Hepatic Artery in a Patient With Previous Occlusion of the Proper Hepatic Artery: An Endovascular Procedure to Avoid a Difficult Surgical Repair.

We report a case of successful percutaneous transhepatic, embolization of an iatrogenic extra-hepatic pseudoaneurysm (PsA) of the right hepatic artery (RHA) under combined fluoroscopic and ultrasonographic guidance. A 73-year-old man underwent percutaneous transhepatic biliary drainage placement in another hospital, complicated by haemobilia and development of a RHA PsA. Endovascular embolization was attempted, resulting in coil embolization of the proper hepatic artery, and persistence of the PsA. At this point, the patient was referred to our hospital. Computed tomography and direct angiography confirmed the iatrogenic extra-hepatic PsA of the RHA, refilled by small collaterals from the accessory left hepatic artery (LHA) and coil occlusion of the proper hepatic artery. Attempted selective catheterization of these vessels was unsuccessful due to the tortuosity and very small caliber of the intra-hepatic collaterals, the latter precluding endovascular treatment of the PsA. Percutaneous trans-hepatic combined fluoroscopic and ultrasound-guided embolization of the PsA was performed with Lipiodol® and cyanoacrylate-based glue (Glubran®2). Real time fluoroscopic images and computed tomography confirmed complete occlusion of the pseudoaneurysm. Surgical repair, although feasible, was considered at high risk. In our patient, we decided to perform a percutaneous trans-hepatic combined fluoroscopic and ultrasound-guided embolization of the PsA using a mix of Lipiodol® and Glubran®2 because of the fast polymerization time of the glue allowing the complete occlusion of the PsA in few seconds, thus eliminating the risk of coil migration, reducing the risk of PsA rupture and avoid a difficult surgical repair.

Imaging of calcified hepatic lesions: spectrum of diseases.

Hepatic calcifications have been increasingly identified over the past decade due to the widespread use of high-resolution Computed Tomography (CT) imaging. Calcifications can be seen in a vast spectrum of common and uncommon diseases, from benign to malignant, including cystic lesions, solid neoplastic masses, and inflammatory focal lesions. The purpose of this paper is to present an updated review of CT imaging findings of a wide range of calcified hepatic focal lesions, which can help radiologists to narrow the differential diagnosis.

Radiation exposure during transjugular intrahepatic portosystemic shunt creation in patients with complete portal vein thrombosis or portal cavernoma.

BACKGROUND: This study aims to evaluate radiation exposure in patients with complete portal vein thrombosis (CPVT) or portal cavernoma (PC) undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation using real-time ultrasound guidance for portal vein targeting. MATERIALS AND METHODS: This is a single institution retrospective analysis. Between August 2009 and September 2018, TIPS was attempted in 49 patients with CPVT or PC. Radiation exposure (dose area product [DAP], air KERMA (AK) and fluoroscopy time [FT]), technical success, clinical success, complications and survival were analyzed. RESULTS: In total, 29 patients had CPVT and 20 patients had PC. 41/49 patients had cirrhosis. TIPS indications were refractory ascites (n = 25), variceal bleeding (n = 16) and other (n = 8). TIPS was successfully placed in 94% (46/49) of patients via a transjugular approach alone (n = 40), a transjugular/transhepatic approach (n = 5) and a transjugular/transsplenic approach (n = 1). Median DAP was 261 Gy * cm2 (range 29-950), median AK was 0.2 Gy (range 0.05-0.5), and median FT was 28.2 min (range 7.7-93.7). Mean portosystemic pressure gradient decreased from 16.8  ±  5.1 mmHg to 7.5  ±  3.3 mmHg (P <  0.01). There were no major procedural complications. Overall clinical success was achieved in 77% of patients (mean follow-up of 21.1 months). Encephalopathy was observed in 16 patients (34%), grade II-III encephalopathy in 7 patients (15%). TIPS revision was performed in 15 patients (32%). Overall survival rate was 75%. CONCLUSION: In our experience, the use of real-time ultrasound guidance allowed the majority of the TIPS to be performed via a transjugular approach alone with a reasonably low radiation exposure considering the high technical difficulties of the selected cohort of patients with CVPT or PC.

OCCUPATIONAL RADIATION DOSE PERFORMING HEPATOBILIARY MINIMALLY INVASIVE PROCEDURES IN CHILDREN WEIGHING LESS THAN 20 kg.

Our objective is to retrospectively evaluate the effective dose (E) of operators performing pediatric Hepatobiliary Minimally Invasive Procedures (HMIP). Between October 2015 and December 2017, 58 consecutive HMIP were performed on 26 children weighing less than 20 kg (mean 12.3 kg, median 13 kg, range 2.4-20 kg). About 31 vascular procedures (n = 9 hepatic venograms with/without stenting; n = 9 retrograde wedge portography; n = 8 transhepatic portography with angioplasty and/or stenting and n = 5 hepatic arteriography/embolization) and 27 non-vascular procedures (n = 6 percutaneous transhepatic biliary drainage (PTBD); n = 3 bilioplasty; n = 15 biliary catheter change and n = 3 cholangiogram) were performed. Electronic personal dosimeters were used to measure radiation doses to the interventional radiologist, radiographer and anesthesia nurse. The results shows the highest mean effective dose: interventional radiologist's in PTBD (1.18 µSv); radiographer's in hepatic veins phlebography with/without stenting (0.25 µSv) and nurse's in hepatic arteriography/embolization (0.26 µSv). Operators' E can vary depending on the complexity of procedure performed and the position of the operators within the angiosuite.

Transjugular Intrahepatic Portosystemic Shunt Using the New Gore Viatorr Controlled Expansion Endoprosthesis: Prospective, Single-Center, Preliminary Experience.

OBJECTIVES: To evaluate short-term clinical efficacy, complications and possible passive stent expansion of transjugular intrahepatic portosystemic shunt (TIPS) creation using the new controlled expansion ePTFE covered stent (VCX), for portal hypertension complications. METHODS: Between 7/2016 and 3/2018, 75 patients received TIPS using VCX. Thirty-nine patients with VCX dilated with an 8-mm angioplasty balloon underwent computed tomography (CT) study during follow-up and CT data were used to measure stent diameter. The CT measurement technique was validated by ex vivo experiment. RESULTS: TIPS indications were: refractory ascites (n = 45), variceal bleeding (n = 22), other (n = 8). Mean follow-up was 5.8 months (± 4.5, range 1-20). In 69 patients, TIPS was dilated to 8 mm of diameter reaching the hemodynamic target of a portosystemic pressure gradient (PSG) < 12 mmHg. In six patients, not reaching the hemodynamic target the stent was dilated to 10 mm of diameter during the same session with a final PSG < 12 mmHg. Overall clinical success was achieved in 66/75 (88%) patients (80% in refractory ascites, 95% variceal bleeding, 100% other). Grade II-III encephalopathy was observed in five patients (6%). TIPS revision with stent dilatation to 10 mm was performed in seven patients: in three patients with ascites persistence, without evidence of stent dysfunction and in four patients for stent stenosis. One patient underwent stent reduction. Fourteen patients (18%) died during follow-up of causes not related to TIPS. Five patients (6%) underwent liver transplant. No passive stent expansion was detected by CT measurements. CONCLUSION: VCX for TIPS creation retains its diameter over a short-term period and is associated with a good clinical outcome with a reasonably low complication rate.