Benedictta O. Omene

Comprehensive Review of TIPS Technical Complications and How to Avoid Them

OBJECTIVE The goal of this article is to describe potential technical complications related to transjugular intrahepatic portosystemic shunts (TIPS) placement and to discuss strategies to avoid and manage complications if they arise. CONCLUSION TIPS is an established interventional therapy for complications of portal hypertension. Although TIPS remains a relatively safe procedure, direct procedure-related morbidity rates are as high as 20%. The technical complexity of this intervention increases the risk for methodologic mishaps during all phases of TIPS placement, including venous access and imaging, transhepatic needle puncture, shunt insertion, and variceal embolization. Thus, interventional radiologists require a thorough stepwise understanding of TIPS insertion, possible adverse sequela, and technical tips and tricks to maximize the safety of this procedure.

TIPS for Treatment of Variceal Hemorrhage: Clinical Outcomes in 128 Patients at a Single Institution over a 12-Year Period

PURPOSE To assess clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) treatment of variceal hemorrhage. MATERIALS AND METHODS A total of 128 patients (82 men and 46 women; mean age, 52 y) with liver cirrhosis and refractory variceal hemorrhage underwent TIPS creation from 1998 to 2010. Mean Child-Pugh and Model for End-stage Liver Disease (MELD) scores were 9 and 18, respectively. From 1998 to 2004, 12-mm Wallstents (n = 58) were used, whereas from 2004 to 2010, 10-mm VIATORR covered stent-grafts (n = 70) were used. Technical success, hemodynamic success, complications, shunt dysfunction, recurrent bleeding, and overall survival were assessed. RESULTS Technical and hemodynamic success rates were 100% and 94%, respectively. Mean portosystemic gradient reduction was 13 mm Hg. Complications at 30 days included encephalopathy (14%), renal failure (5.5%), infection (1.6%), and liver failure (0.8%). Shunt patency rates were 93%, 82%, and 60% at 30 days, 1 year, and 2 years, respectively. Dysfunction, or loss of TIPS primary patency, occurred more with Wallstent versus VIATORR TIPSs (29% vs 11%; P = .009). Recurrent bleeding incidences were 9%, 22%, and 29% at 30 days, 1 year, and 2 years, respectively, and were similar between Wallstent and VIATORR TIPSs (19% vs 19%; P = .924). Variceal embolization significantly reduced recurrent bleeding rates (5% vs 25%; P = .013). Overall survival rates were 80%, 69%, and 65% at 30 days, 1 year, and 2 years, respectively, and were similar between Wallstent and VIATORR TIPSs (35% vs 26% mortality rate; P = .312). Advanced MELD score was associated with increased mortality on multivariate analysis. CONCLUSIONS Wallstent and VIATORR TIPSs effectively treat variceal hemorrhage, particularly when accompanied by variceal embolization. Although TIPS with a VIATORR device showed improved shunt patency, patient survival is similar to that with Wallstent TIPS. These results further validate TIPS creation for refractory variceal bleeding.

Ethiodized oil uptake does not predict doxorubicin drug delivery after chemoembolization in VX2 liver tumors.

PURPOSE To investigate the accuracy of ethiodized oil as an imaging marker of chemotherapy drug delivery after liver tumor chemoembolization in an animal model of hepatocellular carcinoma. MATERIALS AND METHODS Eleven VX2 liver tumors (mean diameter, 1.9 cm ± 0.4) in six New Zealand White rabbits were treated with chemoembolization using ethiodized oil and doxorubicin emulsion, followed by immediate euthanasia. Postprocedure noncontrast computed tomography (CT) was used to evaluate intratumoral ethiodized oil distribution and calculate iodine content within four peripheral tumor quadrants and the tumor core at a central tumor slice (N = 55 total tumor sections). Liquid chromatography/tandem mass spectrometry (LC-MS/MS) was then used to directly measure doxorubicin concentration in the same tissue sections. Statistical correlation was performed between tissue iodine content and doxorubicin concentration by using linear regression. RESULTS Chemoembolization was successfully performed in all tumors via the left or proper hepatic artery. A mean of 0.9 mL ± 0.6 ethiodized oil and 1.8 mg ± 1.2 doxorubicin were injected. CT-calculated tissue iodine content averaged 335 mg/mL ± 218. Corresponding LC-MS/MS analysis yielded a mean doxorubicin concentration of 15.8 μg/mL ± 14.3 in each sample. Although iodine content (391 mg/mL vs 112 mg/mL; P = .000) and doxorubicin concentration (18.0 μg/mL vs 7.2 μg/mL; P = .023) were significantly greater along peripheral tumor sections compared with the tumor core, no significant predictable correlation was evident between these measures (R(2) = 0.0099). CONCLUSIONS Tissue ethiodized oil content is a poor quantitative predictor of local doxorubicin concentration after liver tumor chemoembolization. Future studies should aim to identify a better imaging marker for chemoembolization drug delivery.

Splenic artery embolization: a single center experience on the safety, efficacy, and clinical outcomes

PURPOSE We aimed to assess the safety, efficacy, and clinical outcomes of splenic artery embolization (SAE). MATERIALS AND METHODS A total of 50 patients (male:female, 33:17; mean age, 49 years) who underwent 50 SAEs between 1998 and 2011 were retrospectively studied. The procedure indications included aneurysm or pseudoaneurysm (n=15), gastric variceal hemorrhage (n=15), preoperative reduction of surgical blood loss (n=9), or other (n=11). In total, 22 procedures were elective, and 28 procedures were urgent or emergent. The embolic agents included coils (n=50), gelatin sponges (n=15), and particles (n=4). The measured outcomes were the technical success of the procedure, efficacy, side effects, and the 30-day morbidity and mortality rates. RESULTS All embolizations were technically successful. The procedure efficacy was 90%; five patients (10%) had a recurrent hemorrhage requiring a secondary intervention. Side effects included hydrothorax (n=26, 52%), thrombocytosis (n=16, 32%), thrombocytopenia (n=13, 26%), and postembolization syndrome (n=11, 22%). Splenic infarcts occurred in 13 patients (26%). The overall and procedure-specific 30-day morbidity rates were 38% (19/50) and 14% (splenoportal thrombosis, 3/50; encapsulated bacterial infection, 1/50; splenic abscess, 1/50; femoral hematoma requiring surgery, 1/50; hydrothorax requiring drainage, 1/50). The overall and procedure-specific 30-day mortality rates were 8% (4/50) and 0%. The multivariate analysis showed that advanced patient age (P = 0.037), postprocedure thrombocytopenia (P = 0.008), postprocedure hydrothorax (P = 0.009), and the need for a secondary intervention (P = 0.004) predicted the 30-day morbidity, while renal insufficiency (P < 0.0001), preprocedure hemodynamic instability (P = 0.044), and preprocedure leukocytosis (P < 0.0001) were prognostic factors for the 30-day mortality. CONCLUSION SAE was performed with high technical success and efficacy, but the outcomes showed nontrivial morbidity rates. Elderly patients with thrombocytopenia and hydrothorax after SAE, and patients who require secondary interventions, should be monitored for complications.

Hepatic steatosis: correlations of body mass index, CT fat measurements, and liver density with biopsy results.

PURPOSE To assess the relationship between body mass index (BMI), subcutaneous and intra-abdominal fat, liver density, and histopathologic hepatic steatosis. MATERIALS AND METHODS In this retrospective study, 143 patients (male/female, 67/76; mean age, 50 years) underwent a non-targeted transjugular (n = 125) or percutaneous (n = 18) liver biopsy between 2006 and 2010. The biopsy indications included chronic liver parenchymal disease staging (n = 88), elevated enzymes (n = 39), or other reasons (n = 16). The BMI and non-contrast liver computed tomography liver density were recorded for each patient. The thicknesses of the anterior, posterior, and posterolateral subcutaneous fat, along with the intra-abdominal fat, were measured. The values were then correlated with histopathologic steatosis. RESULTS Of the patients, 47/143 (32%), 39/143 (28%), and 57/143 (40%) were normal weight, overweight, and obese, respectively. Steatosis was present in 13/47 (28%) of normal weight, 18/39 (46%) of overweight, and 38/57 (67%) of obese patients. Significant differences in BMI (26.7 kg/m(2) vs. 31.7 kg/ m2 vs. 35.0 kg/m(2), P < 0.001), liver density (52.8 HU vs. 54.4 HU vs. 42.0 HU, P < 0.001), anterior subcutaneous (1.8 cm vs. 2.4 cm vs. 2.9 cm, P < 0.001), posterolateral subcutaneous (2.8 cm vs. 3.2 cm vs. 4.4 cm, P < 0.004), posterior subcutaneous (1.9 cm vs. 2.5 cm vs. 3.4 cm, P < 0.001), and intra-abdominal fat thickness (1.1 cm vs. 1.3 cm vs. 1.4 cm, P < 0.013) were identified in patients with different degrees of steatosis (none, minimal to mild, moderate to severe, respectively). BMI (r = 0.37, P < 0.001) and the anterior subcutaneous fat (r = 0.30, P < 0.001) had a moderate correlation with the presence of liver steatosis. A combination of a BMI ≥ 32.0 kg/ m(2) and an anterior subcutaneous fat thickness ≥ 2.4 cm had a 40% sensitivity and 90% specificity for the identification of steatosis. CONCLUSION Increase in the anthropomorphic metrics of obesity is associated with an increased frequency of liver steatosis.

Microwave lung ablation complicated by bronchocutaneous fistula: Case report and literature review

Microwave ablation is a developing treatment option for unresectable lung cancer. Early experience suggests that it may have advantages over radiofrequency (RF) ablation with larger ablation zones, shorter heating times, less susceptibility to heat sink, effectiveness in charred lung, synergism with multiple applicators, no need for grounding pads, and similar survival benefit. Newer microwave ablation devices are being developed and as their use becomes more prevalent, a greater understanding of device limitations and complications are important. Herein we describe a microwave lung ablation complicated by bronchocutaneous fistula (BCF) and its treatment. BCF treatment options include close monitoring, surgical closure, percutaneous sealant injection, and endoscopic plug or sealant in those who are not surgical candidates.

Tract Seeding Following Radiofrequency Ablation for Hepatocellular Carcinoma: Prevention, Detection, and Management

Radiofrequency ablation (RFA) has become an important tool in the armamentarium of interventional oncology, particularly in the treatment of primary hepatocellular carcinoma and metastatic tumors. This procedure has proven to be an effective adjunct in treating hepatic tumors as a bridge to liver transplantation, and has a low complication profile. Although adverse events are rare and usually minor, a notable negative outcome is dissemination and implantation of viable tumor cells into the route of applicator entry, or tract seeding. Counter to the goal of treating a patients cancer, this results in metastatic disease. In this report, the authors present 2 cases of tract seeding after RFA, methods of detection, and means of reducing the incidence of this relatively rare, but significant, complication.

Angiographic Patterns of Transjugular Intrahepatic Portosystemic Shunt Dysfunction and Interventional Approaches to Shunt Revision

Transjugular intrahepatic portosystemic shunt (TIPS) is an established and effective treatment for the complications of portal hypertension. The non-trivial rates of shunt dysfunction inherent to TIPS mandate familiarity with the imaging diagnosis and endovascular management of this phenomenon. Herein, we present a pictorial review of the various angiographic patterns of TIPS dysfunction and illustrate traditional and innovative technical approaches to shunt revision.

Endovascular management of bleeding events following robotic pancreaticobiliary surgery.

PURPOSE To describe the utility, safety, and efficacy of endovascular intervention for treating bleeding events after robotic pancreaticobiliary surgery. MATERIALS AND METHODS In this retrospective study, six patients (male/female, 3/3; mean age, 64 years) with histories of robotic pancreaticobiliary resection were referred for endovascular management of delayed postoperative intra-abdominal hemorrhage. Visceral angiography was performed, and the sites of suspected arterial hemorrhage were interrogated with selective microcatheter arteriography. The visualized bleeding sources were treated using catheter-directed embolotherapy with metallic coils, bare metal or covered stent insertion, or a combination of the two. The measured outcomes included the technical success of the angiographic occlusion, procedure safety, and procedure efficacy. RESULTS Pseudoaneurysms resulted in bleeding in six cases (100%). The endovascular interventions included coil embolization in three cases (50%), covered stent exclusion in two cases (33%), and bare metal stent-assisted coil embolization in one case (17%). The technical success was 100%, with complete cessation of bleeding in all cases. No immediate or delayed procedure-related complications were encountered in any of the patients. The efficacy of the endovascular therapy was 100% in this series, with no recurrent hemorrhage during the mean clinical follow-up period of 262 days (range, 67-446 days). CONCLUSION Endovascular therapy provides a minimally invasive, safe, and effective method for managing hemorrhagic events after complicated pancreaticobiliary surgery.