Jordan Tasse

Simultaneous hepatic and portal vein ligation induces rapid liver hypertrophy: A study in pigs

Background: Liver hypertrophy induced by partial portal vein occlusion (PVL) is accelerated by adding simultaneous parenchymal transection (“ALPPS procedure”). This preclinical experimental study in pigs tests the hypothesis that simultaneous ligation of portal and hepatic veins of the liver also accelerates regeneration by abrogation of porto‐portal collaterals without need for operative transection. Methods: A pig model of portal vein occlusion was compared with the novel model of simultaneous portal and hepatic vein occlusion, where major hepatic veins draining the portal vein–deprived lobe were identified with intraoperative ultrasonography and ligated using pledgeted transparenchymal sutures. Kinetic growth was compared, and the portal vein system was then studied after 7 days using epoxy casts of the portal circulation. Portal vein flow and portal pressure were measured, and Ki‐67 staining was used to evaluate the proliferative response. Results: Pigs were randomly assigned to portal vein occlusion (n = 8) or simultaneous portal and hepatic vein occlusion (n = 6). Simultaneous portal and hepatic vein occlusion was well tolerated and led to mild cytolysis, with no necrosis in the outflow vein–deprived liver sectors. The portal vein–supplied sector increased by 90 ± 22% (mean ± standard deviation) after simultaneous portal and hepatic vein occlusion compared with 29 ± 18% after PVL (P < .001). Collaterals to the deportalized liver developed after 7 days in both procedures but were markedly reduced in simultaneous portal and hepatic vein occlusion. Ki‐67 staining at 7 days was comparable. Conclusion: This study in pigs found that simultaneous portal and hepatic vein occlusion led to rapid hypertrophy without necrosis of the deportalized liver. The findings suggest that the use of simultaneous portal and hepatic vein occlusion accelerates liver hypertrophy for extended liver resections and should be evaluated further.

The Changing Face of Hepatocellular Carcinoma: Forecasting Prevalence of Nonalcoholic Steatohepatitis and Hepatitis C Cirrhosis

Background/objectives The purpose of this research is to analyze the past and forecast the future prevalence of Hepatitis C Virus (HCV) and Nonalcoholic Steatohepatitis (NASH) and their respective contribution to Hepatocellular Carcinoma (HCC) incidence in the setting of novel anti-viral agents and rising obesity rates in the United States. Methods Existing data of HCV and NASH prevalence in the United States utilizing the National Health and Nutrition Examination Survey (NHANES) and Organ Procurement and Transplantation Network (OPTN) was collected and analyzed to project future prevalence trends. Results Prevalence of NASH and HCV are expected to increase and decline respectively over the next two decades with alcoholic cirrhosis expected to stay relatively unchanged. The estimated prevalence of NASH equaled and overtook the projected prevalence of HCV in 2007 at approximately 3 million persons. Estimates of NASHs contribution to HCC overtook HCV-HCC in 2015 at an approximately 25 million persons. Projection models suggest HCV prevalence declining to 1 million active cases by 2025, while NASH potentially increases to 17-42 million depending on a linear or exponential trendline. Projections of NASH-HCC similarly outpace HCV-HCC by 2025 with 45 million or 106 million (linear, exponential) versus 18 million persons respectively. Conclusions The future prevalence of HCV and NASH are expected to become further divergent with NASH emerging as the major contributor of cirrhosis and HCC in the United States.

MP100-13 IRREVERSIBLE ELECTROPORATION FOR RENAL MASSES NOT AMENABLE TO THERMAL ABLATION IN NON-SURGICAL CANDIDATES: MID-TERM CLINICAL FOLLOW-UP

INTRODUCTION AND OBJECTIVES: Irreversible Electroporation (IRE) is an emerging ablative modality for patients with renal tumors that are not candidates for surgery or conventional thermal ablation. This study aims to evaluate technical success, safety, and outcomes for IRE treated complicated renal tumors. METHODS: A single institution retrospective review of all renal tumors treatedwithComputed Tomography (CT) guided IREbetweenMay 2013 and February 2016 was performed. A total of 17 patients underwent IRE with NanoKnife (AngioDynamics, Queensbury, New York) for primary or secondary renal malignancies. Technical success was defined as delivery of all planned pulses during ablation and verifying complete ablation by immediatepost-procedureCT imaging. Local recurrencewasdefinedas residual enhancement or increased tumor size following technical success. Follow-up imaging was scheduled at 1, 3, 6, 12, 18, and 24 months. Complications were defined using Clavien-Dino (CD) classification. RESULTS: IRE was performed on 18 complicated renal tumors with median RENAL score of 6.5 ( 1st quartile 6, 3rd quartile 9) and median tumor size of 2.2 cm (1st quartile 2.0, 3rd quartile 3.1). Most were clear cell renal cell carcinomas (n1⁄413). Technical success was achieved in 17/18 tumor treatments (94.4%). One (5.6%) case was aborted due to bleeding (CD grade IIIb) requiring embolization. Minor CD grade one or two complications were present in 7/18 cases (38.9%), including post-procedural urinary retention (4/18, 22.2%), hypoglycemia (1/18, 5.6%), hematuria (1/18, 5.6%), and back pain (1/18, 5.6%). Patients lost to follow up were excluded (n1⁄43) from follow-up analysis. Median follow-up was 392 days, 1st quartile 203, 3rd quartile 696). Two local recurrences (14.2%) occurred on days 320 and 230 post-procedure with RENAL Scores of 9 and 8, respectively. Both cases were successfully treated with cryoablation and follow up showed no residual tumor at 723 and 617 days post cryoablation, respectively. CONCLUSIONS: IRE appears to be a safe and efficacious option for the treatment of renal tumors in patients that are not candidates for surgery or thermal ablation techniques. Further research is warranted with larger sample sizes and continued follow up.

Superselective retrograde lymphatic duct embolization for management of postoperative lymphatic leak.

Lymphatic leak is a well-documented complication following neck dissection surgeries. When conservative methods fail to control the leak, thoracic duct embolization becomes an option. Transabdominal access is the standard for this procedure; however, it is not always feasible. We discuss a technique of selective lymphatic vessel embolization utilizing retrograde transvenous access.

Isolated Stenosis of the Inferior Mesenteric Artery: To Treat or Not to Treat?

The indication for treatment of inferior mesenteric artery (IMA) is generally not clear. The IMA is frequently ignored owing to its size and the presence of alternate pathways within the mesenteric vasculature. However, IMA treatment may be indicated in certain clinical scenarios. In this article, we focus on the indications for IMA treatment and technical considerations when treatment is indicated.

A new technique in complex chronic total occlusions: puncture through a subintimally placed microsnare with a reentry device from the true lumen to achieve through and through antegrade-retrograde access

Effect of plantar arch integrity and number of crural vessel runoff on limb salvage rates Z. Tan, K. Tay, F. Irani, A. Gogna, S. Ramamurthy, R. Lo, A. Patel, S.X. Chan, C. Too, R. Jonathan, S.K. Sanamandra, B. Chua, S. Tan, S. Chng, S. Pasupathy, T. Chong, M. Pwint, B. Tan; Duke-NUS Graduate Medical School Singapore, Singapore, Singapore; Interventional Radiology Centre, Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore; Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore