Jeffrey L. Weinstein

Safety and efficacy of simeprevir plus sofosbuvir with or without ribavirin in patients with decompensated genotype 1 hepatitis C cirrhosis.

Combination antiviral therapy involving sofosbuvir (SOF) and simeprevir (SIM) is a treatment option in patients with genotype 1 chronic hepatitis C; however, the safety of this regimen in patients with decompensated cirrhosis is not established. Data from a combined treatment cohort of 2 large hepatology referral centers were evaluated to assess for safety and efficacy of SIM plus SOF with or without ribavirin (RBV) in patients with Child B or C cirrhosis. All (n = 42) patients included in the analysis had Child B (n = 35) or C (n = 7) cirrhosis and received 400 mg daily of SOF plus 150 mg daily of SIM, with (n = 7) or without (n = 35) RBV, for 12 weeks. Of the 42 patients in this cohort, 31 (74%) were male, 22 (52%) had failed prior treatments, and 28 (67%) were genotype 1a. Prior decompensating events included encephalopathy (57%), fluid overload (88%), or variceal hemorrhage (24%). Median Model for End‐Stage Liver Disease score was 12 (range, 6‐25). Treatment was well tolerated overall with more than one‐half (57%) reporting no adverse events. In those reporting adverse events, the most common were fatigue (n = 6), insomnia (n = 4), headache (n = 5), nausea (n = 4), and grade 1 rash (n = 1). One patient developed chemical pancreatitis that did not require treatment discontinuation. Three of 7 patients who received RBV developed anemia, with 2 requiring blood transfusions and 1 requiring a dose reduction. No episodes of decompensation requiring hospitalization or deaths occurred on treatment. Of 42 patients, 38 (90%) patients had negative viral load at end of treatment (EOT), and 31 of 42 patients (74%) achieved sustained virological response 12 weeks after EOT; 10 of 10 patients (100%) with HCV genotype 1b achieved sustained virological response for 12 weeks (SVR12). In conclusion, SOF plus SIM was very well tolerated in patients with advanced Child B/C decompensated cirrhosis. Overall, 74% of patients achieved SVR12; 100% of patients with genotype 1b decompensated cirrhosis achieved SVR12. Liver Transpl 22:281‐286, 2016.

Surgical and endovascular treatment of hepatic arterial complications following liver transplant.

Vascular complications after liver transplantation increase post‐operative morbidity and contribute to the incidence of retransplantation. Vascular complications comprise arterial, caval, and portal venous pathology, with the majority of complications being arterial in etiology, including anastomotic stricture, pseudoaneurysm, and thrombosis. There are two major therapeutic options for the treatment of these arterial complications: endovascular intervention and surgery. The former includes intra‐arterial thrombolysis, embolization, percutaneous transluminal angioplasty, and stent placement. The latter includes thrombectomy, reanastomosis, and retransplantation. Although surgical treatment has been considered the first choice for management in the past, advances in endovascular intervention have increased and make it a viable therapeutic option following orthotopic liver transplantation. This review focuses on the role of surgical and endovascular therapy in the management of hepatic arterial complications after liver transplantation.

Quality Improvement Guidelines for Transarterial Chemoembolization and Embolization of Hepatic Malignancy

From the Division of In ment of Radiology, Un 1740 West Taylor Stree Interventional Radiolog Northwestern Memoria (D.B.B.), Vanderbilt Univ Interventional Radiolog Therapy (S.G.), Massa Boston, Massachusetts Israel, New York, New Hospital, Barrie, Onta (A.M.E.), University of ventional Radiology (M Interventional Radiolog University School of M Radiology (S.A.P.), Dep at University of Californ Radiology (T.J.W.), Flor Radiology (J.L.W.), Dep Center, Boston, Massa Medical Center, Albany 2017. Address corres Fair Ridge Dr., Suite 40

Initiation of a Multidisciplinary, Rapid Response Team to Massive and Submassive Pulmonary Embolism

Pulmonary embolism (PE) can result in rapid clinical decompensation in many patients. With increasing patient complexity and advanced treatment options for PE, multidisciplinary, rapid response teams can optimize risk stratification and expedite management strategies. The Massive And Submassive Clot On-call Team (MASCOT) was created at our institution, which comprised specialists from cardiology, pulmonology, hematology, interventional radiology, and cardiac surgery. MASCOT offers rapid consultation 24 hours a day with a web-based conference call to review patient data and discuss management of patients with high-risk PE. We reviewed patient data collected from MASCOTs registry to analyze patient clinical characteristics and outcomes and describe the composition and operation of the team. Between August 2015 and September 2016, MASCOT evaluated 72 patients. Seventy of the 72 patients were admitted to our institution, accounting for 32% of all patients discharged with a primary diagnosis of PE. Average age was 62 ± 17 years with a female predominance (63%). Active malignancy (31%), recent surgery or trauma (21%), and recent hospitalization (24%) were common. PE clinical severity was massive in 16% and submassive in 83%. Patients were managed with anticoagulation alone in 65% (n = 46), systemic fibrinolysis in 11% (n = 8), catheter-directed therapy in 18% (n = 13), extracorporeal membrane oxygenation in 3% (n = 2), and an inferior vena cava filter was placed in 15% (n = 11). Thirteen percent (n = 9) experienced a major bleed with no intracranial hemorrhage. Survival to discharge was 89% (64% with massive PE and 93% with submassive PE). In conclusion, multidisciplinary, rapid response PE teams offer a unique coordinated approach to patient care.

Measuring and improving the patient experience in radiology

Recently enacted healthcare legislation and the associated payment reforms have shifted the focus from traditional fee for service models to adding measurable and appreciable value to the patient experience. The value equation links quality to costs, and quality metrics are now directly related to patient outcomes and the patient experience. To participate effectively in this new paradigm requires not only that we provide excellent, timely and appropriate patient-centric care at all times, but that we are able to measure and manage the feedback we obtain from our patients. Of course, in order to provide value-added care, we must know not only who our customers are, but what they value. In this review, we explore factors that impact patient perception and experience with imaging services. We further illustrate different ways that patient feedback can be elicited and provide pros and cons of each approach. Collecting appropriate data is insufficient by itself; such data must be carefully analyzed, and opportunities for improvement must be identified, introduced, and monitored ahead of future surveys.

Percutaneous Ablation for Hepatocellular Carcinoma

OBJECTIVE The purpose of this article is to discuss the use, comparative efficacy, and general technical considerations of percutaneous ablation, alone or in combination with other therapies, for the treatment of hepatocellular carcinoma (HCC). CONCLUSION Percutaneous ablation is a mainstay treatment for early-stage HCC, offering survival comparable to that of surgical resection for small lesions. It can act as a primary curative therapy or bridge therapy for patients waiting to undergo liver transplant. New ablation modalities and combining tumor ablation with other therapies, such as transarterial chemoembolization, can improve clinical outcomes and allow treatment of larger lesions. Combining thermal ablation with systemic chemotherapy, including immunotherapy, is an area of future development.

Trans-Splenic Portal Vein Embolization: A Technique to Avoid Damage to the Future Liver Remnant

Portal vein embolization (PVE) induces hypertrophy of the future liver remnant (FLR) in patients undergoing extensive hepatic resection. Portal vein access for PVE via the ipsilateral hepatic lobe (designated for resection) places veins targeted for embolization at acute angles to the access site requiring reverse curve catheters for access. This approach also involves access close to tumors in the ipsilateral lobe and requires care to avoid traversing tumor. Alternatively, a contralateral approach (through the FLR) risks damage to the FLR due to iatrogenic trauma or non-target embolization. Two patients successfully underwent PVE via trans-splenic portal vein access, allowing easy access to the ipsilateral portal veins and eliminating risk of damage to FLR. Technique and advantages of trans-splenic portal vein access to perform PVE are described.

Primary Stent Placement for Hepatic Artery Stenosis After Liver Transplantation: Improving Primary Patency and Reintervention Rates: XXXX

Recent studies have reported high rates of reintervention after primary stenting for hepatic artery stenosis (HAS) due to the loss of primary patency. The aims of this study were to evaluate the outcomes of primary stenting after HAS in a large cohort with longterm follow‐up. After institutional review board approval, all patients undergoing liver transplantation between 2003 and 2017 at a single institution were evaluated for occurrence of hepatic artery complications. HAS occurred in 37/454 (8%) of patients. HAS was defined as >50% stenosis on computed tomography or digital subtraction angiography. Hepatic arterial patency and graft survival were evaluated at annual intervals. Primary patency was defined as the time from revascularization to imaging evidence of new HAS or reaching a censored event (retransplantation, death, loss to follow‐up, or end of study period). Primary stenting was attempted in 30 patients (17 female, 57%; median age, 51 years; range, 24‐68 years). Surgical repair of HAS prior to stenting was attempted in 5/30 (17%) patients. Endovascular treatment was performed within 1 week of the primary anastomosis in 5/30 (17%) of patients. Technical success was accomplished in 97% (29/30) of patients. Primary patency was 90% at 1 year and remained unchanged throughout the remaining follow‐up period (median, 41 months; interquartile range [IQR], 25‐86 months). Reintervention was required in 3 patients to maintain stent patency. The median time period between primary stenting and retreatment was 5.9 months (IQR, 4.4‐11.1 months). There were no major complications, and no patient developed hepatic arterial thrombosis or required listing for retransplantation or retransplantation during the follow‐up period. In conclusion, primary stenting for HAS has excellent longterm primary patency and low reintervention rates.

Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology

Monzer A. Chehab, MD, Avnesh Thakor, MD, PhD, Sheryl Tulin-Silver, MD, Bairbre L. Connolly, MB, MCh, FRCPC, FRCSI, Anne Marie Cahill, MD, Thomas J. Ward, MD, Siddharth A. Padia, MD, Maureen P. Kohi, MD, Mehran Midia, MD, Gulraiz Chaudry, MBChB, FRCR, Joseph J. Gemmete, MD, Jason W. Mitchell, MD, MPH, MBA, Lynn Brody, MD, John J. Crowley, MD, Manraj K.S. Heran, MD, Jeffrey L. Weinstein, MD, Boris Nikolic, MD, MBA, Sean R. Dariushnia, MD, Alda L. Tam, MD, MBA, and Aradhana M. Venkatesan, MD

Percutaneous Methods of Common Bile Duct Stone Retrieval

Percutaneous transhepatic stone removal, most commonly by expulsion into the duodenum through the papilla, is an effective and safe alternative to surgery particularly when endoscopic stone extraction has failed or is not possible. In specific patient populations, such as following Billroth II gastrectomy or laparoscopic Roux-en-Y gastric bypass, percutaneous approaches may be the best option for patients with symptomatic choledocholithiasis. With the increase in global obesity, the need for bariatric surgery will continue to incline in the future. Given the association of gallstones in bariatric patients following surgery, an increasing number of patients with surgically altered anatomy will require management for symptomatic stones. Therefore, an understanding of transhepatic percutaneous approaches is important to provide optimal care for these patients and those that are not candidates for ERCP.