Amar Mukund

Efficacy of Balloon-occluded Retrograde Transvenous Obliteration of Large Spontaneous Lienorenal Shunt in Patients with Severe Recurrent Hepatic Encephalopathy with Foam Sclerotherapy: Initial Experience

PURPOSE Balloon-occluded retrograde transvenous obliteration (BRTO) is a widely accepted treatment for gastric varices, but data are limited in regard to its role in the management of hepatic encephalopathy (HE). This study evaluated the efficacy of BRTO with foam sclerotherapy in the management of HE arising as a result of spontaneous large portosystemic shunts. MATERIALS AND METHODS Eight sessions of BRTO with sodium tetradecyl sulfate foam were performed in seven patients with cirrhosis complicated by HE. All patients had portosystemic communication (ie, gastro-/lienorenal shunt) on preprocedure computed tomography. Clinical and laboratory parameters including arterial ammonia level were evaluated in all patients before and after the procedure. RESULTS Technical success rates were 86% (six of seven) for the first BRTO session and 100% (one of one) for the second. Follow-up imaging revealed complete obliteration of the varices in five of seven patients (71%) and partial obliteration in the remaining two. Immediate clinical improvement of HE was observed in six of seven patients (86%), with postprocedural decrease in arterial ammonia levels; one patient showed delayed improvement. Procedure-related complications (eg, abnormal liver function test results, acute kidney injury with leukocytosis) were encountered in two patients. All patients showed clinical and symptomatic improvement at the time of discharge and during a follow-up of 4 months (with visits at 1 mo and 3 mo later). CONCLUSIONS Initial experience suggests that BRTO is an effective procedure in the management of HE arising as a result of large portosystemic shunts.

Imaging and interventions in Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) consists of a group of disorders with obstruction of hepatic venous outflow leading to increased hepatic sinusoidal pressure and portal hypertension. Clinically, two forms of disease (acute and chronic) are recognized. Mostly the patients present with ascites, hepatomegaly, and portal hypertension. In acute disease the liver is enlarged with thrombosed hepatic veins (HV) and ascites, whereas in the chronic form of the disease there may be membranous occlusion of HV and/or the inferior vena cava (IVC), or there may be short or long segment fibrotic constriction of HV or the suprahepatic IVC. Due to advances in radiological interventional techniques and hardware, there have been changes in the management protocol of BCS with surgery being offered to patients not suitable for radiological interventions or having acute liver failure requiring liver transplantation. The present article gives an insight into various imaging findings and interventional techniques employed in the management of BCS.

Trans-arterial chemoembolization (TACE) in patients with unresectable Hepatocellular carcinoma: Experience from a tertiary care centre in India.

Aims: To evaluate the outcome following transarterial chemoembolization (TACE) and to identify the predictors of survival in patients with unresectable hepatocellular carcinoma (HCC). Material and Methods: HCC patients reporting to our hospital (2001-2007) were subjected to clinical, biochemical, and radiological examination. TACE was performed in those who fulfilled the inclusion criteria. Follow-up assessment was done with multiphase CT scan of the liver at 1, 3, and 6 months. Tumor response and survival rate were estimated. Univariate and multivariate analyses were done for determinants of survival. Results: A total of 73 patients (69 males, 4 females; mean age 49±13.4 years) were subjected to 123 sessions of TACE. The Childs classification was: A – 56 patients and B – 17 patients. Barcelona Clinic staging was: A – 20 patients, B – 38 patients, and C – 15 patients. Tumor size was ≤5cm in 28 (38%) patients, >5–10 cm in 28 (38%) patients, and >10 cm in 17 (23%) patients. Median follow-up was for 12 months (range: 1–77 months). No significant postprocedure complications were encountered. Overall survival rate was 66%, 47%, and 36.4% at 1, 2, and 3 years, respectively. Tumor size emerged as an important predictor of survival. Conclusion: TACE offers a reasonable palliative therapy for HCC. Initial tumor size is an independent predictor of survival.

Contrast-enhanced US-guided Radiofrequency Ablation of Hepatocellular Carcinoma

PURPOSE Contrast-enhanced ultrasound (US) has been shown to be an efficient imaging modality in guiding radiofrequency (RF) ablation of hepatocellular carcinomas (HCC). The purpose of the present study was to assess the usefulness of contrast-enhanced US in guiding RF ablation in patients with early-stage HCC that was not clearly visible on grayscale US or noncontrast computed tomography (CT). MATERIALS AND METHODS During a 17-month period, contrast-enhanced US-guided RF ablation was performed in 14 patients with 19 early-stage lesions that were poorly defined on grayscale US and noncontrast CT. Contrast-enhanced US was repeated after 30 minutes, and complete ablation was defined as absence of any arterial-phase enhancement within the ablated lesion. Patients were followed periodically with clinical evaluation, liver function tests, α-fetoprotein measurement, and multiphasic CT or magnetic resonance (MR) imaging for a minimum of 1 year after ablation to look for local recurrence or disease progression. Survival probability was estimated with the Kaplan-Meier method. RESULTS Complete tumor ablation was achieved in all 19 lesions, with no evidence of residual or recurrent tumor in the ablated areas after a mean follow-up of 16 months. No major complications were observed in any patient. However, new lesions developed in other parts of the liver on follow-up scans in three patients, and were accordingly treated with RF ablation. Two patients died of disease progression or liver failure within the 1-year follow-up. CONCLUSIONS For early-stage HCCs not well visualized on unenhanced US or CT, contrast-enhanced US provides an additional tool to guide RF ablation.

Endobiliary radiofrequency ablation for reopening of occluded biliary stents: a promising technique.

from the antegrade approach. From pedal access to wire retrieval, we spent an average of 22 minutes of procedure time (range, 15–30 minutes). Procedural time could have been saved if we resorted to the retrograde access prematurely. Lupattelli et al (7) cautioned against adopting SAFARI as a standard procedure. Their arguments regarding the risk of serious complications, such as flow-limiting dissection and thrombosis at the access site, are legitimate. The technique should also be avoided in patients with ulcers at the entry site. Lupattelli et al (7) consider SAFARI as time-consuming, which is a main limitation in critically ill patients, including patients with CLI. In the largest series of SAFARI reported to date (51 cases, 45 of which had CLI), Montereo-Baker et al (8) reported one major complication (1.9%) consisting of pedal access site occlusion requiring immediate surgery and four (7.8%) minor complications: three arterial perforations and one pedal hematoma. We could argue that patients presenting with IC might be more suitable for SAFARI than patients presenting with CLI. These patients usually have ‘‘healthier’’ infrapopliteal vessels, making access and wire manipulation less challenging. By definition, they have no ulcers or tissue loss at the access site. They are usually not as ill as patients with CLI, with relatively better tolerance of long procedures. At an average of follow-up period of 13.6 months (range, 9– 17 months), the DPA and ATA were widely patent, stable compared with baseline, and with no evidence of dissection or progression of atherosclerotic disease, as documented by CT angiography and duplex ultrasound. We believe that the poor results at 1 year are inherent to the nature of advanced infrainguinal peripheral arterial disease (all three patients had Inter-Society Consensus for the Management of Peripheral Arterial Disease [TASC II] D lesions) and not to the technique or the access per se. Poor patient compliance in terms of clinical follow-up examination and risk factor modification (all patients continued to smoke heavily) could have also played a role. Retrograde pedal arterial access might be used as a ‘‘bailout’’ technique during endovascular recanalization of challenging femoropopliteal chronic total occlusions, not only in patients with CLI but also in patients with IC. However, the technique should not be considered as a standard first-line therapy until large studies become available.

Endovascular management in abdominal visceral arterial aneurysms: A pictorial essay.

Visceral artery aneurysms (VAAs) include aneurysms of the splanchnic circulation and those of the renal artery. Their diagnosis is clinically important because of the associated high mortality and potential complications. Splenic, superior mesenteric, gastroduodenal, hepatic and renal arteries are some of the common arteries affected by VAAs. Though surgical resection and anastomosis still remains the treatment of choice in some of the cases, especially cases involving the proximal arteries, increasingly endovascular treatment is being used for more distal vessels. We present a pictorial review of various intra-abdominal VAAs and their endovascular management.

Ethanol ablation of renal cell carcinoma for palliation of symptoms in advanced disease.

The aim of this study was to evaluate the efficacy of transarterial alcohol ablation of renal cell carcinoma (RCC) with distant metastasis for control of symptoms caused by primary disease. This was a retrospective study consisting of eight patients having stage IV RCC. The primary indication for embolization was hematuria in seven patients and flank pain in one patient. All eight patients underwent renal artery embolization with ethanol and gelatin sponge pledgets. After embolization periodic evaluation was done every 3 months up to 1 year. Patients treated for hematuria did not complain of hematuria at 3- and 6-month follow-up except one who died of disease after 5 months. At 9-month follow-up five patients were free of hematuria while one developed hematuria after 6 months of treatment and died after 8 months. After 1 year three patients had no hematuria. One patient who developed hematuria at 9 months died after 11 months, another patient died of cardiac arrest at 10 months. The only patient who was treated for flank pain did not complain of pain up to 1-year follow-up. To conclude, transarterial embolization of renal tumor using ethanol is very effective in controlling local symptoms such as hematuria and pain. Thus, it may be an alternative treatment offered to symptomatic patients who are either not fit for surgery or not willing to undergo surgery.

Imaging Diagnosis of Splanchnic Venous Thrombosis.

Splanchnic vein thrombosis (SVT) is a broad term that includes Budd-Chiari syndrome and occlusion of veins that constitute the portal venous system. Due to the common risk factors involved in the pathogenesis of these clinically distinct disorders, concurrent involvement of two different regions is quite common. In acute and subacute SVT, the symptoms may overlap with a variety of other abdominal emergencies while in chronic SVT, the extent of portal hypertension and its attendant complications determine the clinical course. As a result, clinical diagnosis is often difficult and is frequently reliant on imaging. Tremendous improvements in vascular imaging in recent years have ensured that this once rare entity is being increasingly detected. Treatment of acute SVT requires immediate anticoagulation. Transcatheter thrombolysis or transjugular intrahepatic portosystemic shunt is used in the event of clinical deterioration. In cases with peritonitis, immediate laparotomy and bowel resection may be required for irreversible bowel ischemia. In chronic SVT, the underlying cause should be identified and treated. The imaging manifestations of the clinical syndromes resulting from SVT are comprehensively discussed here along with a brief review of the relevant clinical features and therapeutic approach.

CT patterns of nodal disease in pediatric chest tuberculosis

AIM To highlight various patterns of nodal involvement and post treatment changes in pediatric chest tuberculosis based on contrast enhanced computed tomography (CECT) scans of chest. METHODS This was a retrospective study consisting of 91 patients aged less than 17 years, who attended Paediatrics OPD of All India Institute of Medical Sciences with clinically diagnosed tuberculosis or with chest radiographs suggestive of chest tuberculosis. These patients had an initial chest radiograph as well as CECT of the chest and follow up imaging after 6 mo, and in some cases 9 mo, of completion of anti-tubercular treatment (ATT). CECT of these patients was reviewed for the location and extent of nodal involvement along with determination of site, size, enhancement pattern and calcification. RESULTS Enlargement of mediastinal or hilar lymph nodes was found in 88/91 patients (96.7%), with the most common locations being paratracheal (84.1%), and subcarinal (76.1%). The most common pattern of enhancement was found to be inhomogenous. The nodes were conglomerate in 56.8% and discrete in 43.2%. In addition, perinodal fat was obscured in 84.1% of patients. In the post-treatment scan, there was 87.4% reduction in the size of the nodes. All nodes post-treatment were discrete and homogenous with perinodal fat present. Calcification was found both pre- and post-treatment, but there was an increase in incidence after treatment (41.7%). There was hence a reduction in size, change in enhancement pattern, and appearance of perinodal fat with treatment. CONCLUSION Tubercular nodes have varied appearance and enhancement pattern. Conglomeration and obscuration of perinodal fat suggest activity. In residual nodes decision to continue ATT requires clinical correlation.

Isolated Pancreatic Tuberculosis: A Rare Occurrence

Isolated tuberculosis of the pancreas is rare even in developing countries where abdominal tuberculosis continues to be prevalent. We present a case of pancreatic tuberculosis in an immunocompetent male with confounding imaging findings and non-contributory clinical details.