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.

The Italian Multicentre Registry of Fenestrated Anaconda™ Endografts for Complex Abdominal Aortic Aneurysms Repair.

OBJECTIVE: The aim was to describe the outcomes of the Anaconda™ Fenestrated endograft Italian Registry for complex aortic aneurysms (AAAs), unsuitable for standard endovascular aneurysm repair (EVAR). METHODS: Between 2012 and 2018 patients with a proximal neck unsuitable for standard EVAR, treated with the fenestrated Anaconda™ endograft, were prospectively enrolled in a dedicated database. Endpoints were peri-operative technical success (TS) and evaluation of type Ia/b or 3 endoleaks (T1/3 EL), target visceral vessel (TVV) occlusion, re-interventions, and AAA related mortality at 30 days, six months, and later follow up. RESULTS: One hundred twenty seven patients (74 ± 7 years, American Society Anesthesiology (ASA) II/III/IV: 12/85/30) were included in the study in 49 Italian Vascular Surgery Units (83 juxta/para-renal AAA, 13 type IV thoraco-abdominal AAA, 16 T1aEL post EVAR, and 15 short neck AAA). Configurations with one, two, three, and four fenestrations were used in 5, 56, 39, and 27 cases, respectively, for a total of 342 visceral vessels. One hundred and eight (85%) bifurcated and 19 (15%) tube endografts were implanted. In 35% (44/127) of cases the endograft was repositioned during the procedure, and 37% (128/342) of TVV were cannulated from brachial access. TS was 87% (111/127): five T1EL, six T3EL (between fenestration and vessel stent), and six loss of visceral vessels (one patient with a Type Ia EL had also a TVV loss) occurred. Thirty day mortality was 4% (5/127). Two of the five T1EL resolved spontaneously at 30 days. The overall median follow up was 21 ± 16 months; one T1EL (5%) occurred at six months and one T3EL (4%) at the three year follow up. Another two (3%) TVV occlusions occurred at six months and five (3%) at three years. The re-intervention rate at the 30 days, six months, and three year follow up was 5%, 7%, and 18 ± 5%, respectively. CONCLUSION: The fenestrated Anaconda™ endograft is effective in the treatment of complex AAA. Some structure properties, such as the re-positionability and the possibility of cannulation from above, are specific characteristics helpful for the treatment of some complex anatomies.

Endovascular approach for arteriovenous limb malformations: a single center experience.

BACKGROUND: To assess imaging findings, describe endovascular technical aspects and analyzed procedural outcomes in a population of patients underwent limb arteriovenous malformation (LAVMs). METHODS: From January 2015 to December 2018, all consecutive patients underwent an endovascular procedure for ICD-9-CM codex for arteriovenous malformation problems were retrospective reviewed. Among these, patients with LAVMs were selected. Demographic, preoperative imaging, interventional and postprocedural data were collected for each patient and procedure. The International Society of Vascular Anomalies, the Cho-Do angiographic classification and the Schobinger clinical stage were used to describe disease type, aspect and clinical severity. Angiographic and clinical outcomes were also described. RESULTS: During the study period, 76 intervention for AVMs were performed in 52 patients. Among these, 26 LAVMs were selected and analyzed in 21 patients (number of LAVMs per patient: 1.2±0.5), 14 affecting upper limbs, 17 lower limbs. Pain, discomfort and swelling were main symptoms reported (95%, 90% and 62%, respectively). Ultrasound scan, computed angiography tomography and magnetic resonance angiography were used - alone or in combination - as preoperative imaging in 67%, 62% and 48% of patients, respectively. Cho-Do class ≥3 was described in 70% of treated LAVMs and a Schobinger stage ≥2 in more than 90%. Ipsilateral femoral access with a 5F introducer was preferred. Selective embolization with glue was the most preferred technique (57%), in combination or not with microsphere embolization (19%) and/or direct nidus sclerotherapy (14%). Optimal and suboptimal results were achieved in 86% of cases. Further interventions were performed in 52% of cases, with more than two interventions in 29% of cases. CONCLUSIONS: Quality of life, clinical picture and anatomical structure are items of paramount importance during preoperative LAVMs endovascular treatment planning. Treatment must be focused on LAVMs type, minimizing invasiveness and number of interventions, although secondary intervention rate remains quite high.

Prostatic Artery Embolization as an Alternative to Indwelling Bladder Catheterization to Manage Benign Prostatic Hyperplasia in Poor Surgical Candidates.

PURPOSE: To prospectively assess discontinuation of indwelling bladder catheterization (IBC) and relief of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) following prostate artery embolization (PAE) in poor surgical candidates. METHODS: Patients ineligible for surgical intervention were offered PAE after at least 1 month of IBC for management of urinary retention secondary to BPH; exclusion criteria for PAE included eligibility for surgery, active bladder cancer or known prostate cancer. Embolization technical and clinical success were defined as bilateral prostate embolization and removal of IBC, respectively. Patients were followed for at least 6 months and evaluated for International Prostate Symptom Score, quality of life, prostate size and uroflowmetric parameters. RESULTS: A total of 43 patients were enrolled; bilateral embolization was performed in 33 (76.7%), unilateral embolization was performed in 8 (18.6%), and two patients could not be embolized due to tortuous and atherosclerotic pelvic vasculature (4.7%). Among the patients who were embolized, mean prostate size decreased from 75.6 ± 33.2 to 63.0 ± 23.2 g (sign rank p = 0.0001, mean reduction of 19.6 ± 17.3%), and IBC removal was achieved in 33 patients (80.5%). Clavien II complications were reported in nine patients (21.9%) and included urinary tract infection (three patients, 7.3%) and recurrent acute urinary retention (six patients, 14.6%). Nine patients (22.0%) experienced post-embolization syndrome. CONCLUSIONS: PAE is a safe and feasible for the relief of LUTS and IBC in highly comorbid patients without surgical treatment options.

Direct Transaortic TEVAR: An Alternative Option for Selected Patients With Unsuitable Peripheral Access.

Thoracic endovascular aortic repair (TEVAR) is effectively executed in patients with arch or descending aortic diseases. Peripheral access sites are preferably used as standard gates for TEVAR. Feasibility of a peripheral approach might need an intraoperative evaluation and alternative routes should have been carefully assessed. In this article, we report 2 successful cases of direct transaortic TEVAR, where stent grafts were directly introduced into the native ascending aorta without external conduits. A satisfactory result and the absence of aortic-related complications were observed at 2 and 5 years' follow-up, respectively.

Is percutaneous radiofrequency thermal ablation of hepatocellular carcinoma a safe procedure?

AIM: To assess the safety and efficacy of percutaneous radiofrequency thermal ablation (RFA) in the treatment of nonsurgical hepatocellular carcinoma (HCC) in daily practice. METHODS: A total of 63 consecutive patients with HCC (solitary nodule

Occlusion of postcatheterisation femoral pseudoaneurysms with percutaneous thrombin injection under ultrasound guidance.

PURPOSE: The incidence of iatrogenic femoral artery pseudoaneurysms is reported to occur in 1-7% by of all percutaneous catheterisations. These pseudoaneurysms are traditionally treated by ultrasound-guided compression or surgical repair. We report our experience in sealing postcatheterization femoral pseudoaneurysms with percutaneous thrombin injection under colour-Doppler ultrasound guidance. MATERIALS AND METHODS: Since June 2000 we have consecutively treated 31 pseudoaneurysms in 30 patients, (14 males and 16 females, age range 45 to 81 years); in one patient the pseudoaneurysm was bilateral. All patients had a clinical diagnosis of postcatheterization femoral pseudoaneurysm, later confirmed by colour-Doppler ultrasonography. We injected a bovine thrombin solution percutaneously at a concentration of 1000 U/mL using 21-22 gauge needles under colour Doppler ultrasound guidance. All patients underwent clinical and colour-Doppler US examination before, during and 24 hours after the procedure and were followed up after 1 and 3 months. RESULTS: The primary success rate was 83.8%. Complete and persistent occlusion of the pseudoaneurysm was achieved in less than 20 seconds by administering an average dose of 880 U of thrombin (0.8 mL of solution). In 5 cases (16.1%) reperfusion of the pseudoaneurysm was observed within 24 hours. These patients underwent a repeat procedure. The final result was successful in 96.7% of patients (30 of 31 cases). No thromboembolic complication was observed. Only 22.5% of patients reported a heat sensation in the treated limb, which resolved spontaneously within minutes. CONCLUSIONS: The percutaneous injection of thrombin under ultrasound colour-Doppler guidance should be regarded as the first choice treatment for postcatheterization femoral pseudoaneurysms, owing to its simplicity, safety, effectiveness and inexpensiveness.

Metastatic Psammomatous Somatostatinoma of the Pancreas Causing Severe Ketoacidotic Diabetes Cured by Surgery.

A case of somatostatin-producing pancreatic tumor associated with severe insulin-dependent diabetes mellitus and ketoacidotic coma is reported. The tumor, a 10-cm expansile mass arising from the pancreatic tail of a 70-yr-old woman, was first detected by ultrasonography, performed because of abdominal pain, and subsequently confirmed by computed tomography and fine-needle tumor aspiration. Pathologic investigation showed a predominantly solid-trabecular structure with scattered microacini and psammomatous bodies. A large proportion of tumor cells expressed somatostatin and/or calcitonin. Following resection of the primary tumor and three peripancreatic lymph nodes with metastases, the patient recovered rapidly from her diabetic syndrome and remained in substantially good health during a subsequent 8-yr follow-up period, without evidence of tumor recurrence.