Efficacy of TIPS Reduction for Refractory Hepatic Encephalopathy, Right Heart Failure, and Liver Dysfunction.

OBJECTIVE. The purpose of this study was to determine clinical outcomes of patients undergoing TIPS reduction. MATERIALS AND METHODS. In this institutional review board-approved, HIPAA-compliant study, all TIPS reductions performed at two institutions from January 1, 2008 to January 31, 2016, were retrospectively identified. Patients were divided into two groups according to pre-TIPS symptoms: volume overload due to ascites or hydrothorax (VO; n = 14) or variceal bleeding (VB; n = 12). Patient demographics, pre-TIPS model for end-stage liver disease score, pre- and post-TIPS portosystemic gradients, and clinical parameters were recorded. The primary endpoint was change in symptoms of hepatic encephalopathy (HE; West Haven criteria), right heart failure, or liver dysfunction. Secondary endpoints included paracentesis rate for the VO group and rebleeding for the VB group. RESULTS. The degree of HE increased in 24 of 26 patients (92%) after TIPS placement and decreased in 24 of 26 patients (92%) after TIPS reduction. Mean West Haven scores for the VO group decreased after TIPS reduction (from 2.57 ± 0.97 [SD] to 1.07 ± 0.70; p < .001). Mean West Haven scores for the VB group also decreased after TIPS reduction (from 2.45 ± 0.89 to 1.27 ± 0.86; p = .007). Right heart failure improved in two of three patients (67%), and total bilirubin improved in one of three patients (33%). Follow-up data were available up to median of 134 days (interquartile range, 44-286). TIPS reduction led to an increased paracentesis rate compared with before TIPS placement in four of 14 patients with VO (29%). One patient had a stable paracentesis rate after TIPS reduction compared with before TIPS placement. Variceal rebleeding did not occur in any patients with VB after TIPS reduction. At 54 days after TIPS reduction, one of the 12 patients with VB (9%) experienced hematemesis due to an endoscopically proven band-related ulcer. CONCLUSION. TIPS reduction successfully resolved HE and refractory right heart failure in most patients. In patients with VB, TIPS reduction with variceal embolization results in a low risk of short-term recurrent VB. However, in patients with VO, ascites may return or worsen after TIPS reduction despite improvement in HE.

Causes and Rates of 30-Day Readmissions After Transjugular Intrahepatic Portosystemic Shunts.

OBJECTIVE. The purpose of this study was to investigate the causes and rates of 30-day readmission after transjugular intrahepatic portosystemic shunt (TIPS) at a single liver transplant center. MATERIALS AND METHODS. We reviewed 165 TIPS procedures performed between 2003 and 2013. After excluding patients who died during the index admission (n = 16), any readmission within 30 days of discharge was identified, and cause of readmission was determined. Causes were categorized as planned or unplanned and interventional radiology (IR)-related or IR-unrelated. Unplanned readmissions were independently categorized as preventable or unpreventable by two interventional radiologists. Discrepant opinions were resolved by consensus. Factors predictive of 30-day readmission were identified by univariate and multivariate analysis. RESULTS. The reviewed TIPS procedures were performed in 165 patients (mean age ± SD, 56 ± 11 years; 69% male, 31% female). TIPS were placed for ascites or hydrothorax in 82 patients (50%) and variceal bleeding in 83 patients (50%). The 30-day readmission rate was 21% (31/149). The most common causes for readmissions were ascites or hydrothorax (23%, 7/31) and hepatic encephalopathy (23%, 7/31). All 30-day readmissions were unplanned; 17 (55%) of them were potentially preventable. Of the 17 potentially preventable readmissions, five (29%) were IR-related and 12 (71%) were IR-unrelated. In IR-related readmissions, all patients presented with a recurrence of symptoms (rebleeding or ascites) and were found to have TIPS stenosis or occlusion. Mortality rates were similar between patients who were and were not readmitted (p = 0.23). On multivariate analysis, spontaneous bacterial peritonitis during the index admission was the only variable associated with 30-day readmission (odds ratio = 4.81, p = 0.02). CONCLUSION. Over half of 30-day readmissions after TIPS could have been prevented by early outpatient follow-up and intraprocedural technique to optimize stent landing zones.

Causes and Rates of 30-day Readmissions after Percutaneous Transhepatic Biliary Drainage Procedure.

Purpose To investigate rates and causes of 30-day readmission for patients who undergo percutaneous transhepatic biliary drainage (PTBD) procedures. Materials and Methods In this retrospective study, PTBD procedures performed at a tertiary care institution (June 2008 to May 2013) were reviewed. For each patient, the first 30-day readmission was used to determine cause of readmission. Two interventional radiologists independently categorized causes for readmission as planned or unplanned, and unplanned causes as related to or unrelated to interventional radiology. Interventional radiology-related readmissions were categorized as potentially preventable or unpreventable. Factors associated with higher odds for 30-day readmission were identified with univariable and multivariable analysis. Results There were 266 procedures in 266 patients (mean age, 67 years; interquartile range, 57-76 years; 53.4% men). The cause of obstruction was malignant in 50.0% of patients (133 of 266). There were 122 of 266 patients (45.9%) readmitted within 30 days. Of these readmissions, 44 of 122 (36.1%) were planned and 78 of 122 (63.9%) were unplanned. A majority of unplanned readmissions (57 of 78; 73%) were related to interventional radiology. Of unplanned interventional radiology-related readmissions, 16% (nine of 57) were related to periprocedural complications and 51% (29 of 57) were considered preventable. At multivariable analysis, Medicaid insurance (odds ratio, 3.68; 95% confidence interval: 1.52, 9.99; P = .009) and bilateral PTBDs (odds ratio, 5.81; 95% confidence interval: 1.79, 18.90; P = .003) were associated with 30-day readmission. Conclusion Thirty-day readmissions after primary biliary drainage are common and a majority of unplanned readmissions are drain-related. Nearly half of unplanned interventional radiology-related readmissions are potentially preventable. © RSNA, 2018 See also the editorial by Nikolic in this issue.

The Relevance of Readmissions after Common IR Procedures: Readmission Rates and Association with Early Mortality.

PURPOSE: To determine all-cause readmission rates for 12 IR procedures and association of time to readmission with risk-adjusted 90-day mortality. MATERIALS AND METHODS: Patients discharged after 12 inpatient IR procedures at a tertiary-care hospital between June 2008 and May 2013 (N = 4,163) were categorized as no readmission (n = 1,479; 40.5%) or readmission between 0 and 7 (n = 379; 10.4%), 8 and 30 (n = 650; 17.8%), 31 and 60 (n = 378; 10.3%), 61 and 90 (n = 169; 4.6%), or 91 and 180 days (n = 280; 7.7%). Readmission rate ≥ 15% was considered high based on published national readmission rates for procedures. Risk-adjusted 90-day mortality for each interval was calculated for transjugular intrahepatic portosystemic shunt (TIPS), transjugular and percutaneous liver biopsy (TJLB, PLB), ports, inferior vena cava (IVC) filter, lower extremity angioplasty (LEA), arteriovenous fistulagrams, vascular embolization (VE), percutaneous cholecystostomy (PC), percutaneous transhepatic biliary drainage (PTBD), primary urinary drainage, and feeding tube placement. Covariates included age, sex, race, insurance status, and Charlson Comorbidity Index. RESULTS: All procedures had high 30-day readmission rates (15%-50.5%). Readmissions were highest for ports (50.5%), TJLB (43.4%), PTBD (38.5%), PC (31.9%), and TIPS (31.3%). Readmissions occurred most frequently 8-30 days after discharge for all procedures except VE (31-60 d; 10.6%), PC (31-60 d; 23.4%), and LEA (91-180 d; 15.1%). On multivariate analysis, 30-day readmissions for LEA (AOR 3.19; 95% CI, 1.2-8.2; P = .02), VE (AOR 10.01; 95% CI, 3.1-32.9; P < .001), IVC filter (AOR 2.98; 95% CI, 1.3-6.9; P = .01), PLB (AOR 2.86; 95% CI, 1.71-4.79; P < .001), and PCN (AOR 3.09; 95% CI, 1.29-7.37; P = .01) were associated with 90-day mortality. CONCLUSIONS: Inpatient IR procedures have high 30-day all-cause readmission rates, which can be associated with increased 90-day mortality. Further evaluation to determine preventable causes for readmission may impact 90-day mortality.

New Imaging Protocol to Assess Endotracheal Tube Placement: A Case-control Study.

PURPOSE: After intubation, a frontal chest radiograph (CXR) is obtained to assess the endotracheal tube (ETT) position by measuring the ETT tip-to-carina distance. ETT tip location changes with neck position and can be determined by assessing the position of the mandible. As the mandible is typically not visualized on standard CXRs, we developed a new protocol where the mandible is seen on the CXR, hypothesizing that it will improve the accuracy of the ETT position assessment. PATIENTS AND METHODS: Two groups of intubated patients studied (February 9, 2021 to May 4, 2021): CXR taken in either standard or new protocol (visible mandible required). Two observers independently assessed the images for the neck position (neutral, flexed, and extended) based on the mandible position relative to the vertebral bodies. With the mandible absent (ie, neck position unknown), we established terms: "gray zone" (difficult to assess the ETT position adequately) and "clear zone" (confident recommendation to retract, advance, or maintain ETT position). We compared the rate of confident assessment of the ETT in the standard versus the new protocol. RESULTS: Of 308 patients, 155 had standard CXRs and 153 had the new protocol. Interrater agreements for the distance between the ETT and the carina and mandible height based on vertebral bodies were 0.986 ( P < 0.001) and 0.955 ( P < 0.001), respectively. The mandible was visualized significantly more often ( P < 0.001) with the new protocol (92%; 141/153) than with the standard protocol (21%; 32/155). By visualizing the mandible or the presence of the ETT within the clear zone, a reader could confidently assess the ETT position more often using the new protocol (96.7% vs 51.6%, P < 0.001). CONCLUSIONS: Mandible visibility on postintubation CXR is helpful for assessing the ETT position. The new protocol resulted in a significant increase in both visualizing the mandible and accurately determining ETT position on postintubation CXR.

Left Ventricular Noncompaction in Concomitance With Heroin Use Disorder.

Left ventricular noncompaction (LVNC) is a rare congenital condition defined by the presence of prominent trabeculations in the myocardial layer of the left ventricle. The clinical presentation is varied as some patients are asymptomatic and others have symptoms of decompensated heart failure, arrhythmias, or thromboembolism. We present the case of a 42-year-old female with a past medical history of asthma and substance use disorder who presented to the Emergency Department following a syncopal event. The patient had used heroin intranasally, following which she became unresponsive for several minutes. Her husband witnessed the event and initiated chest compressions. When examined by emergency medical services (EMS), she had a palpable pulse and was given naloxone. The patient underwent further evaluation and was admitted for the treatment of aspiration pneumonia. Throughout her hospital stay, she complained of chest pain with musculoskeletal characteristics, likely secondary to chest compressions. However, due to the persistence of pain, she had further cardiac evaluation done. Her electrocardiography (EKG) revealed a normal sinus rhythm with no acute ischemic changes. Her echocardiography revealed left ventricular apical trabeculations with normal systolic and diastolic function, in line with the diagnosis of LVNC. Upon discharge, she was extensively counseled to abstain from substance use and to follow up with cardiology for a cardiac event monitor. Given her initial syncopal event and high-risk substance use behavior, she would benefit from close follow-up for the presence of arrhythmias.