Jiesheng Qian

Partial splenic embolization for hypersplenism in cirrhosis: A long-term outcome in 62 patients

BACKGROUND Although partial splenic embolization (PSE) has been widely used for treatment of leucocytopaenia and thrombocytopaenia in cirrhosis, only few studies on the correlation between splenic infarction rate and long-term outcome of partial splenic embolization have been reported so far. AIM To evaluate long-term results of partial splenic embolization with different infarction rates in cirrhotic patients with hypersplenism. METHODS Sixty-two consecutive patients with hypersplenism in cirrhosis received partial splenic embolization. According to the splenic infarction rate after partial splenic embolization, the patients were divided into three groups: more than 70% in group A (n=12), 50-70% in group B (n=34), and less than 50% in group C (n=16). The post-partial splenic embolization following-up time was 5 years. RESULTS Before partial splenic embolization, there were no significant differences among the three groups with respect to sex, age, splenic volume, Child-Pugh class, oesophageal varices, and peripheral blood cell counts. After partial splenic embolization, the short- and long-term outcomes of leucocyte and platelet counts showed significant difference among the three groups (P<0.001). In groups A and B, the leucocyte and platelet counts after partial splenic embolization remained significantly higher than those before partial splenic embolization for 2 weeks to 5 years (P<0.05), the post-partial splenic embolization leucocyte and platelet counts was even higher in group A than in group B; while in group C, leucocyte and platelet count improvement only lasted for 6 months after partial splenic embolization. No significant changes were observed concerning blood red cell counts and liver function parameters after partial splenic embolization among the three groups. Severe complications occurred in six patients (50%) in group A and three patients (8.8%) in group B (P<0.05), while in group C, no severe complications developed. CONCLUSIONS In partial splenic embolization, the splenic infarction rate should be limited to 50%-70% in order to ensure the long-term efficacy in alleviating hypersplenism and reduce complications.

Uterine artery embolization combined with methotrexate in the treatment of cesarean scar pregnancy: results of a case series and review of the literature.

PURPOSE To explore the clinical value of uterine artery embolization (UAE) combined with methotrexate in the treatment of cesarean scar pregnancy (CSP) before and after uterine curettage. MATERIALS AND METHODS From August 2009 to April 2012, 15 patients with CSP treated with UAE (before or after uterine curettage) were analyzed retrospectively. Eleven subjects with a definite diagnosis of CSP were offered preventive UAE combined with methotrexate before uterine curettage. The other four patients, who were misdiagnosed as having an intrauterine pregnancy, were treated with emergency UAE for uncontrollable massive hemorrhage after uterine curettage. Clinical data, treatment sequence, and outcome were analyzed, and a brief review of the published literature summarizing UAE in the treatment of CSP was performed. RESULTS Eleven patients with definite CSP received preventive UAE combined with methotrexate followed by uterine curettage, and CSP was resolved successfully without hysterectomy. In the four misdiagnosed patients, three were treated successfully with emergency UAE. The other patient underwent uterine curettage and emergency UAE followed by repeat curettage, but hysterectomy was performed because of continued severe hemorrhage. CONCLUSIONS Based on a small number of patients, it appears that UAE may be an effective means of treating CSP, including treatment in an emergency setting. Further study is required before the safety and effectiveness of UAE can be confirmed.

Percutaneous Transsplenic Portal Vein Catheterization: Technical Procedures, Safety, and Clinical Applications

PURPOSE To evaluate the safety and feasibility of percutaneous transsplenic portal vein catheterization (PTSPC) by retrospective review of its use in patients with portal vein (PV) occlusion. MATERIALS AND METHODS From July 2004 to December 2010, 46 patients with a history of uncontrolled gastroesophageal variceal bleeding secondary to portal hypertension underwent endovascular PV interventions via a percutaneous transsplenic approach. All patients had occlusion of the main PV or central intrahepatic PV branches, which prevented the performance of a transhepatic approach. A vein within the splenic parenchyma was punctured under fluoroscopic guidance by referencing preoperative computed tomography images. PTSPC-related complications and clinical applications were analyzed. RESULTS PTSPC was successfully performed in 44 of 46 patients (96%); two failures were caused by inaccessible small intrasplenic veins. PTSPC-related major bleeding complications occurred in three patients (6.5%), including large intraperitoneal hemorrhage in one patient and large splenic subcapsular hemorrhage in two patients. Two of the three patients developed hypotension, and one developed severe anemia. All three of the patients required blood transfusions. PTSPC-related minor bleeding complications occurred in six patients (13%) as a result of a small splenic subcapsular hemorrhage. In addition, three patients exhibited mild left pleural effusion, which subsided spontaneously 1 week later. All 44 patients successfully treated via PTSPC received gastroesophageal variceal embolization. Eight patients received PV stents, five for treatment of PV occlusion and three during transjugular intrahepatic portosystemic shunt placement. CONCLUSIONS PTSPC is a safe and effective access for endovascular PV interventions in patients without a transhepatic window.

MR tracking of magnetically labeled mesenchymal stem cells in rats with liver fibrosis

PURPOSE In vivo magnetic resonance (MR) tracking of magnetically labeled bone marrow mesenchymal stem cells (BMSCs) administered via the mesenteric vein to rats with liver fibrosis. MATERIALS AND METHODS Rat BMSCs were labeled with superparamagnetic iron oxide (SPIO) and the characteristics of the BMSCs after labeling were investigated. Eighteen rats with CCL4-induced liver fibrosis were randomized to three groups to receive SPIO-labeled BMSCs (BMSC-labeled group), cell-free SPIO (SPIO group), or unlabeled BMSCs (control group). MR imaging of the liver was performed at different time points, and signal-to-noise ratio (SNR) of the liver was measured. In vivo distribution of delivered BMSCs was assessed by histological analysis. RESULTS Labeling of BMSCs with SPIO did not significantly alter cell viability and proliferation activity. In BMSC-labeled group, the liver SNR immediately decreased from 8.56+/-0.26 to 3.53+/-0.41 at 1 h post injection and remained at a significantly lower level till 12 days (P<.05 versus the level before). By contrast, the liver SNR of the SPIO group almost recovered to the preinjection level (P=.125) at 3 days after a transient decrease. In control group, the liver SNR demonstrated no significant difference at the tested time points. Additionally, Prussian blue-positive cells were mainly distributed in the liver parenchyma, especially in injured areas. CONCLUSION The magnetically labeled BMSCs infused through the mesenteric vein can be detected in the fibrotic liver of rats using in vivo MR imaging up to 12 days after injection.

Gastric varices in patients with portal hypertension: evaluation with multidetector row CT.

Background Gastric varices (GVs) are a major cause of gastrointestinal bleeding in patients with portal hypertension. Few studies have evaluated GVs with multidetector row computed tomography (MDCT). Goals To assess the diagnostic performance of MDCT in detecting GVs and revealing variceal hemodynamic changes in patients with cirrhosis. Study A total of 127 consecutive cirrhotic patients who underwent both liver MDCT and esophagogastroduodenoscopy (EGD) were analyzed retrospectively. Two independent radiologists reviewed MDCT images for the detection of GVs. The variceal hemodynamic changes were assessed by the 2 radiologists in consensus on MDCT portography. Results On the basis of EGD, of the 127 patients, 36 had GVs (28.4%), including small GVs in 15 patients and large GVs (≥5 mm) in 21 patients. In detecting and grading GVs, there were moderate agreements (κ value: 0.514 to 0.563) between MDCT and EGD, but in differentiating large varices requiring prophylactic therapy, a substantial agreement (κ value: 0.804 for radiologist 1 and 0.796 for radiologist 2) was found. For radiologist 1, the sensitivity, specificity, accuracy, and positive and negative predictive values of MDCT for the identification of large GVs were 85.7%, 96.2%, 94.5%, 81.8%, and 97.1%, respectively; whereas for radiologist 2, they were 81.0%, 97.2%, 94.5%, 85.0%, and 96.3%, respectively. In evaluating the afferent and efferent veins of varices, the sensitivity, specificity, accuracy, and positive predictive value of MDCT portography were more than 80.0%. Conclusions MDCT is an effective screening tool for differentiating large GVs and revealing the afferent and efferent veins of varices in patients with cirrhosis.

MR tracking of SPIO-labeled mesenchymal stem cells in rats with liver fibrosis could not monitor the cells accurately

Our previous study showed that in vivo magnetic resonance (MR) imaging is effective in tracking superparamagnetic iron oxide (SPIO)-labeled bone marrow mesenchymal stem cells (BMSCs) in rats with liver fibrosis. SPIO-labeling-induced signal reduction on MR images was completely reversed within 15 days after transplantation. It is still unclear whether the signal changes in MR imaging could reflect the number of transplanted cells in the liver. In the present study, BMSCs of male rats were doubly labeled with enhanced green fluorescent protein (EGFP) and SPIO and injected intravascularly into female rats with liver fibrosis. At different time points after injection, MR imaging was performed. The distribution of SPIO particles and EGFP-positive cells was determined by Prussian blue staining and EGFP immunohistochemistry, respectively. The distribution of transplanted BMSCs in various organs was assessed by detection of the SRY gene using real-time quantitative PCR. At 15 days post transplantation, the numbers of transplanted cells were significantly decreased in the lung, kidney, spleen and muscle, but not liver and heart, in comparison with those at 7 days after transplantation. EGFP staining-positive cells were observed in the liver intralobular parenchyma, while Prussian blue staining was negative at 42 days after transplantation. Taken together, SPIO particles and EGFP-labeled BMSCs show a different tissue distribution pattern in rats with liver fibrosis after a long-term period of monitoring. SPIO-based MR imaging may not be suitable for long-term tracking of transplanted BMSCs in vivo.

DDX24 Mutations Associated with Malformations of Major Vessels to the Viscera

Vascular malformations present diagnostic and treatment challenges. In particular, malformations of vessels to the viscera are often diagnosed late or incorrectly due to the insidious onset and deep location of the disease. Therefore, a better knowledge of the genetic mutations underlying such diseases is needed. Here, we evaluated a four‐generation family carrying vascular malformations of major vessels that affect multiple organs, which we named “multiorgan venous and lymphatic defect” (MOVLD) syndrome. Genetic analyses identified an association between a mutation in DEAD‐box helicase 24 (DDX24), a gene for which the function is largely unknown, and MOVLD. Next, we screened 161 patients with sporadic vascular malformations of similar phenotype to our MOVLD family and found the same mutation or one of the two additional DDX24 mutations in 26 cases. Structural modeling revealed that two of the mutations are located within the adenosine triphosphate–binding domain of DDX24. Knockdown of DDX24 expression in endothelial cells resulted in elevated migration and tube formation. Transcriptomic analysis linked DDX24 to vascular system–related functions. Conclusion: Our results provide a link between DDX24 and vascular malformation and indicate a crucial role for DDX24 in endothelial cell functions; these findings create an opportunity for genetic diagnosis and therapeutic targeting of malformations of vessels to the viscera.

Percutaneous transhepatic intrahepatic portosystemic shunt for variceal bleeding with chronic portal vein occlusion after splenectomy

ObjectivesThe purpose of this study was to introduce a modified transjugular intrahepatic portosystemic shunt (TIPS), a percutaneous transhepatic intrahepatic portosystemic shunt (PTIPS), and to evaluate its feasibility and efficacy in patients with variceal bleeding with chronic portal vein occlusion (CPVO) after splenectomy.MethodsTwenty-four cirrhotic patients with CPVO after splenectomy who received PTIPS between 2010 and 2015 were included in this retrospective study. The indication was elective control of variceal bleeding. Success rates, effectiveness and complications were evaluated, with comparison of the pre- and post-portosystemic pressure gradient (PPG). Patients’ clinical outcomes and shunt patency were followed periodically.ResultsPTIPS was successfully placed in 22 patients (91.7%) and failed in two. The mean PPG fell from 22.0 ± 4.9 mmHg to 10.6 ± 1.6 mmHg after successful PTIPS (p < 0.05). No fatal procedural complications occurred. During the median follow-up of 29 months, shunt dysfunction occurred in five cases and hepatic encephalopathy in four cases. Three patients died because of rebleeding, hepatic failure and pulmonary disease, respectively. The other patients remained asymptomatic and the shunts patent.ConclusionsWe conclude that PTIPS, as a modified TIPS procedure with a high success rate, is safe and effective for variceal bleeding with CPVO after splenectomy.Key Points• Portal vein occlusion used to be contraindication to transjugular intrahepatic portosystemic shunt.• Portal vein thrombosis is common in patients with previous splenectomy.• We developed a new method, percutaneous transhepatic intrahepatic portosystemic shunt (PTIPS).• PTIPS is feasible in patients with portal vein thrombosis and splenectomy.• PTIPS is effective and safe for these kind of complicated portal hypertension.

Successful Hemostasis of Ectopic Variceal Bleedingusing Endovascular Therapy: A Case Report

Ectopic varices (EcVs) are defined as large portosystemic venous collaterals located at sites other than the gastric and esophageal regions. A patient with a bleeding EcVs may present with anemia, shock, hematemesis, melena or hematochezia. Although bleeding EcVs are rare, they should be paid special attention because of their association with high mortality rates. However, optimal treatment for bleeding EcVs remains controversial because of the lack of standardized guidelines and randomized controlled studies. Herein, we report a case of bleeding EcV who was successfully treated with transjugular intrahepatic portosystemic shunt (TIPS) combined with variceal embolization.