Baljendra Kapoor

Diagnosis and Management of Budd Chiari Syndrome: An Update

Imaging plays a crucial role in the early detection and assessment of the extent of disease in Budd Chiari syndrome (BCS). Early diagnosis and intervention to mitigate hepatic congestion is vital to restoring hepatic function and alleviating portal hypertension. Interventional radiology serves a key role in the management of these patients. The interventionist should be knowledgeable of the clinical presentation as well as key imaging findings, which often dictate the approach to treatment. This article concisely reviews the etiology, pathophysiology, and clinical presentation of BCS and provides a detailed description of imaging and treatment options, particularly interventional management.

Transjugular Intrahepatic Portosystemic Shunt: Indications, Contraindications, and Patient Work-Up

The transjugular intrahepatic portosystemic shunt (TIPS) procedure is effective in achieving portal decompression and in managing some of the major complications of portal hypertension. While many clinicians are familiar with the two most common indications for TIPS placement, secondary prophylaxis of esophageal variceal hemorrhage and treatment of refractory ascites, evidence for its usefulness is growing in other entities, where it has been less extensively studied but demonstrates promising results. Newer indications include early utilization in the treatment of esophageal variceal hemorrhage, Budd-Chiari syndrome, ectopic varices, and portal vein thrombosis. The referring clinician and interventionist must remain cognizant of the contraindications to the procedure to avoid complications and potential harm to the patient. This review is designed to provide an in-depth analysis of the most common as well as less typical indications for TIPS placement, and to discuss the contraindications and appropriate patient evaluation for this procedure.

Prevalence and Clinical Consequences of Fracture and Fragment Migration of the Bard G2 Filter: Imaging and Clinical Follow-up in 684 Implantations

PURPOSE To investigate the prevalence and clinical sequelae of G2 filter (Bard Peripheral Vascular, Tempe, Arizona) fractures and fragment migration. MATERIALS AND METHODS Patients who underwent G2 filter placement between October 2005 and February 2010 were assessed for filter fractures and complications. Fracture prevalence was estimated at various time points based on data from patients with known fracture status. RESULTS Among 829 patients who underwent G2 filter placement, 684 had follow-up imaging and qualified for the study (381 men and 303 women; average age, 60.3 y; range, 15.8-95.2 y). For 541 (79%) patients, at least one image was available that contained the filter (imaging follow-up interval, 14.9 mo ± 20.0; range, 0-78.6 mo); images that did not include the filter but may have shown the migrated fracture fragment were available for 143 (21%) patients (follow-up interval, 11.2 mo ± 19.3; range, 0-83.4 mo). There were 16 fractured limbs identified in 13 patients (incidence, 1.9%; follow-up interval, 30.4 mo ± 18.7; range, 5.5-76.5 mo). Fracture fragments were identified in the pulmonary arteries (n = 4), right ventricle (n = 2), pericardium (n = 1), iliac vein (n = 1), and kidney (n = 1). Four fracture limbs remained near the filter; the remaining three could not be located. All patients with filter fracture were asymptomatic. The estimated 5-year fracture prevalence was 38% (95% confidence interval, 22.9%, 54.8%). CONCLUSIONS The early occurrence of G2 filter fractures was low, but the incidence increased over time. No life-threatening events occurred in patients with filter fracture during the study time frame.

ACR appropriateness criteria management of vertebral compression fractures.

This is an updated review of management of vertebral compression fracture for both benign osteoporotic and malignant causes. Vertebral compression fracture radiologic imaging evaluation is discussed. A literature review is provided of current indications for vertebral augmentation with percutaneous vertebroplasty and kyphoplasty as well as medical management. Limitations and potential benefits of these procedures are discussed. Variant tables describing various clinical situations are also provided to assist in determining appropriate use of these treatments for patient care. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to formulate recommendations for imaging or treatment.

Early TIPS Versus Endoscopic Therapy for Secondary Prophylaxis After Management of Acute Esophageal Variceal Bleeding in Cirrhotic Patients: A Meta‐Analysis of Randomized Controlled Trials

American College of Gastroenterology and American Association for the Study of Liver Disease guidelines recommend endoscopic and pharmacologic treatment for esophageal variceal bleed. Transjugular intrahepatic portosystemic shunt (TIPS) placement is reserved for cases of therapeutic failure. Several studies have suggested improved prevention of rebleeding and improved survival without excess hepatic encephalopathy in patients who receive TIPS within the first 5 days after bleeding (early TIPS). In this meta‐analysis, we evaluated the safety and efficacy of early TIPS versus endoscopic therapy for secondary prophylaxis after acute esophageal variceal bleeding in cirrhotic patients.

Transjugular Intrahepatic Portosystemic Shunt Complications: Prevention and Management

Transjugular intrahepatic portosystemic shunt (TIPS) insertion has been well established as an effective treatment in the management of sequelae of portal hypertension. There are a wide variety of complications that can be encountered, such as hemorrhage, encephalopathy, TIPS dysfunction, and liver failure. This review article summarizes various approaches to preventing and managing these complications.

Etiology, Diagnosis, and Management of Bilomas: A Current Update

A biloma is a well-demarcated collection of bile outside the biliary tree. Traumatic and iatrogenic injuries, most commonly secondary to cholecystectomy, are the usual causes. Although bilomas are relatively uncommon, this pathologic entity may lead to significant morbidity and mortality if not promptly diagnosed and properly managed. As clinical signs and symptoms of bilomas are often nonspecific and laboratory values may be unremarkable, imaging modalities including ultrasound, computed tomography, magnetic resonance imaging, and hepatobiliary cholescintigraphy play a crucial role in the diagnosis of this condition. It is paramount that interventional radiologists not only be well versed in the management of bilomas but also be knowledgeable in the diagnosis as well as key imaging findings that dictate the interventional management. The purpose of this article is to review the etiology, pathophysiology, and clinical presentation of bilomas to primarily focus on the relevant multimodal imaging findings and the minimally invasive management options.

Comparative study of endoscopy vs. transjugular intrahepatic portosystemic shunt in the management of gastric variceal bleeding

Background and Aim: Gastric varices are associated with high mortality. There have been conflicting reports on whether endoscopic treatment with cyanoacrylate or the placement of a transjugular intrahepatic portosystemic shunt (TIPS) is more effective in the treatment of gastric varices. We compared the outcomes of patients treated with cyanoacrylate glue or TIPS for the management of acute gastric variceal bleeding. Methods: The study was designed as a retrospective cohort analysis of patients undergoing either TIPS or endoscopic treatment with cyanoacrylate for acute gastric variceal bleeding at our institution from 2001 to 2011. Primary compared to studied between the two treatment modalities were the short-term treatment outcomes, including re-bleeding within 30 days, length of hospital stay and in-hospital mortality. Kaplan-Meier survival analysis was performed to assess factors associated with in-hospital mortality. Results: A total of 169 patients were included in the analysis. The TIPS arm contained 140 patients and the cyanoacrylate arm contained 29 patients. There was no evidence to suggest any significant differences in demographics or disease severity. There were no differences between the TIPS arm and the cyanoacrylate armtwo groups in treatment outcomes including re-bleeding within 30 days (17.4% vs. 17.2%; P = 0.98), median length of stay in the hospital (4.5 days vs. 6.0 days; P = 0.35) or in-hospital mortality (9.0% vs. 11.1%; P = 0.74). In-hospital mortality was evaluated for 149 patients and lower albumin (P = 0.015), higher MELD score (P < 0.001), higher CTP score (P = 0.005) and bleeding (P = 0.008) were all significantly associated with in-hospital death. Conclusion: These findings suggest that both treatments are equally effective. Cyanoacrylate offers a safe, effective alternative to TIPS for gastric varices, and physician may choose the best therapy for each patient, factoring in the availability of TIPS or cyanoacrylate, the individual patient’s presentation, and cost.

Choledocholithiasis: Diagnosis and Management

Common bile duct stones constitute the main etiology of nonmalignant biliary obstruction. Endoscopic retrieval of common bile duct stones has been adopted as the primary treatment modality for extrahepatic biliary stones. However, endoscopic therapy may fail in patients who have had previous gastrointestinal tract surgeries, including partial gastrectomy with Billroth II reconstruction or bilioenteric anastomosis, or in patients with anatomical anomalies such as a duodenal periampullary diverticulum, which makes the biliary duct difficult to access via an endoscopic approach. Endoscopic therapy may also not be suitable for hepatolithiasis with large and impacted stones. In such situations, a percutaneous approach is generally the best option. A variety of percutaneous techniques are available for removal of intrahepatic and extrahepatic bile duct stones via transhepatic approach and T-tube tract. These techniques include extraction, fragmentation, and expulsion of stones into the duodenum. In this article, clinical presentations, imaging modalities, and different management options, particularly percutaneous techniques for the management of choledocholithiasis or hepatolithiasis, are reviewed.

Iatrogenic hepatopancreaticobiliary injuries: a review.

Iatrogenic hepatopancreaticobiliary injuries occur after various types of surgical and nonsurgical procedures. Symptomatically, these injuries may lead to a variety of clinical presentations, including tachycardia and hypotension from hemobilia or hemorrhage. Iatrogenic injuries may be identified during the intervention, immediately afterwards, or have a delayed presentation. These injuries are categorized into nonvascular and vascular injuries. Nonvascular injuries include biliary injuries such as biliary leak or stricture, pancreatic injury, and the development of fluid collections such as abscesses. Vascular injuries include pseudoaneurysms, arteriovenous fistulas, dissection, and perforation. Imaging studies such as ultrasound, computed tomography, magnetic resonance imaging, and digital subtraction angiography are critical for proper diagnosis of these conditions. In this article, we describe the clinical and imaging presentations of these iatrogenic injuries and the armamentarium of minimally invasive procedures (percutaneous drainage catheter placement, balloon dilatation, stenting, and coil embolization) that are useful in their management.