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Aim To perform a systematic review and meta-analysis of the effectiveness and complications of BRTO for gastric varices. Materials and Methods A systematic review was performed to identify relevant articles. Inclusion criteria were applied to select studies with at least ten patients with acute bleeding or at-risk gastric varices treated with BRTO. Meta-analysis with random effects model was performed to calculate data for immediate technical success, clinical success, and complications. Results A total of 1,016 Patients from 24 studies met inclusion criteria. Technical success rate for BRTO was 96.4 % (95 % CI 93.7, 98.3 %; Q  = 3,269.26, p  < 0.01, I 2  = 99.39 %). Clinical success (defined as no recurrence or rebleed of gastric varices, or complete obliteration of varices on subsequent imaging) rate was 97.3 % (95 % CI 95.2, 98.8 %; Q  = 3,105.91, p  < 0.01, I 2  = 99.29 %). Major complication rate was 2.6 % (95 % CI 1.1, 4.6 %; Q  = 3,348.98, p  < 0.01, I 2  = 99.34 %). Esophageal variceal recurrence rate was 33.3 % (95 % CI 24.6, 42.6 %; Q  = 7,291.75, p  < 0.01, I 2  = 99.74 %). Conclusion BRTO is safe and efficacious for gastric varices, and current best evidence suggests that BRTO could be considered as therapy for patients with gastric varices.

Hepatic Encephalopathy (HE) is a complication of liver disease, consisting of brain dysfunction often due to portosystemic shunting of blood flow in the liver. HE can range from minimal HE, presenting with normal neurological function, to overt HE, with neurological and neuropsychiatric abnormalities. Various clinical grading systems are used to differentiate HE to provide the appropriate treatments. Traditional treatment of HE aims to identify and resolve precipitating factors through targeting hyperammonemia and administering antibiotics or probiotics. While retrograde transvenous obliteration (RTO), including balloon-occluded retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration or plug-assisted retrograde tranvenous obliteration, is an established procedure to manage gastric varices, little is known about its potential to treat HE. RTO is a procedure to occlude a spontaneous portosystemic shunt, minimizing shunting of portal blood to systemic circulation. Though there is not a large study with HE patients who have undergone RTO; the results appear promising in reducing HE. Side effects, however, should be considered in the treatment of HE such as the transient worsening of portal hypertension and the formation of additional shunts. While additional studies are needed to assess the long-term success, RTO appears to be an effective alternative method to alleviate clinical symptoms of HE when pharmacological therapies and other conservative medical managements have failed.

BackgroundOvert hepatic encephalopathy (OHE) is a serious complication of liver dysfunction, which is associated with severe morbidity/mortality and healthcare resource utilization. OHE can be medically refractory due to spontaneous portosystemic shunts (SPSSs) and therefore a new treatment option for these SPSSs is critical.MethodsThis is a retrospective study of 43 patients with medically refractory OHE, who underwent CARTO (Coil-Assisted Retrograde Transvenous Obliteration) procedures between June 2012 and October 2016. The patient demographic characteristics, technical and clinical outcomes with an emphasis on HE improvement, and complications are reviewed and analyzed.ResultsThe overall clinical success rate was 91% with a significant HE improvement. Eighty-one percent of patients had clinically significant improvement from OHE and 67% of patients had complete resolution of their HE symptoms during our follow-up period of 893 ± 585 days (range 36–1881 days, median 755.0 days). The median WH score improved from 3 (range 2–4) pre-CARTO to 1 (range 0–4) post-CARTO (p < 0.001). The median ammonia level significantly decreased from 134.5 pre-CARTO to 70.0 post-CARTO (p < 0.001) in 3 days. The overall mean survival was 1465.5 days (95% CI of 1243.0 and 1688.0 days). Only three patients had recurrent HE symptoms. There were 39.6% minor complication rate including new or worsened ascites and esophageal varices, and only 2.3% major complication rate requiring additional treatment (one patient with bleeding esophageal varices requiring treatment). No procedure-related death is noted.ConclusionsCARTO appears to be a safe and effective treatment option for refractory overt hepatic encephalopathy (OHE) due to spontaneous portosystemic shunts. CARTO could be an excellent addition to currently available treatment options for these patients.

Although sequelae of chronic liver disease are the most common causes of altered pressure dynamics in the portal and splanchnic circulations, there are other mechanisms resulting in increased venous pressures with subsequent development of splenic and gastric varices. We report a case of a patient without portal hypertension, but with bleeding gastric varices with a presumed splenorenal shunt (SRS) on CT. Venography revealed flow reversal through the shunt (directed from the renal vein, into the splenic vein and out the portal vein; a renal-splent shunt (RSR)) and thus an anatomically similar but functionally distinct systemic to mesenteric variant. While being anatomically similar to the well-known SRS, the different flow dynamics necessitate a different approach for treatment and important considerations for the use of any liquid embolic.

Extensive research supports an association between radiation exposure and cataractogenesis. New data suggests that radiation-induced cataracts may form stochastically, without a threshold and at low radiation doses. We first review data linking cataractogenesis with interventional work. We then analyze the lens dose typical of various procedures, factors modulating dose, and predicted annual dosages. We conclude by critically evaluating the literature describing techniques for lens protection, finding that leaded eyeglasses may offer inadequate protection and exploring the available data on alternative strategies for cataract prevention.

ObjectivesThe purpose of this study was to describe a single institution’s experience with transradial access (TRA) for angiographic interventions, and to compare technical success, complication rate and radiation dose of procedures performed with TRA to those performed with transfemoral access (TFA).MethodsA retrospective cohort study of patients undergoing peripheral interventions via TRA or TFA from 2015 to 2017 was performed. The cohort comprised 33 patients undergoing 44 procedures via TRA and 37 patients undergoing 44 procedures via TFA. Outcome measures were technical success, access-related complications, fluoroscopy time and radiation exposure. Differences at p < 0.05 were considered to be statistically significant.ResultsBaseline characteristics were similar between patients who had procedures via TRA versus those who had procedures via TFA, including age, sex and body mass index. Technical success was achieved in 41/44 (93.2%) of procedures performed via TRA, compared to 44/44 (100%) of procedures performed via TFA (p = 0.241). There were three access-related complications (6.8%) when TRA was performed, compared to none when TFA was performed (p = 0.241). Fluoroscopy time was longer in procedures performed with TRA compared to those performed with TFA (27.3 vs 20.4, p = 0.033). Dose area product (DAP) did not differ with access site choice (p = 0.186).ConclusionsTRA is a safe and feasible alternative to TFA for a range of peripheral interventions. However, TRA must be performed with prudence as it is not without complications and is technically challenging, leading to longer fluoroscopy time.Key Points• Transradial access (TRA) is feasible in a variety of peripheral interventions, achieving success in 93.2% of cases.• Access-related complications are comparable between transfemoral access (TFA) and TRA (p = 0.241), but prudence must be taken during TRA as it could be technically challenging.• Procedures performed with TRA tend to have longer fluoroscopy time compared to those performed with TFA (p = 0.033), but the DAPs are comparable (p = 0.186).

Background Although cardiovascular magnetic resonance venography (CMRV) is generally regarded as the technique of choice for imaging the central veins, conventional CMRV is not ideal. Gadolinium-based contrast agents (GBCA) are less suited to steady state venous imaging than to first pass arterial imaging and they may be contraindicated in patients with renal impairment where evaluation of venous anatomy is frequently required. We aim to evaluate the diagnostic performance of 3-dimensional (3D) ferumoxytol-enhanced CMRV (FE-CMRV) for suspected central venous occlusion in patients with renal failure and to assess its clinical impact on patient management. Methods In this IRB-approved and HIPAA-compliant study, 52 consecutive adult patients (47 years, IQR 32–61; 29 male) with renal impairment and suspected venous occlusion underwent FE-CMRV, following infusion of ferumoxytol. Breath-held, high resolution, 3D steady state FE-CMRV was performed through the chest, abdomen and pelvis. Two blinded reviewers independently scored twenty-one named venous segments for quality and patency. Correlative catheter venography in 14 patients was used as the reference standard for diagnostic accuracy. Retrospective chart review was conducted to determine clinical impact of FE-CMRV. Interobserver agreement was determined using Gwet’s AC1 statistic. Results All patients underwent technically successful FE-CMRV without any adverse events. 99.5% (1033/1038) of venous segments were of diagnostic quality (score ≥ 2/4) with very good interobserver agreement (AC1 = 0.91). Interobserver agreement for venous occlusion was also very good (AC1 = 0.93). The overall accuracy of FE-CMRV compared to catheter venography was perfect (100.0%). No additional imaging was required prior to a clinical management decision in any of the 52 patients. Twenty-four successful and uncomplicated venous interventions were carried out following pre-procedural vascular mapping with FE-CMRV. Conclusions 3D FE-CMRV is a practical, accurate and robust technique for high-resolution mapping of central thoracic, abdominal and pelvic veins and can be used to inform image-guided therapy. It may play a pivotal role in the care of patients in whom conventional contrast agents may be contraindicated or ineffective.

To describe the technical feasibility, safety, and clinical outcomes of coil-assisted retrograde transvenous obliteration (CARTO) in treating portal hypertensive non-esophageal variceal hemorrhage. From October 2012 to December 2013, 20 patients who received CARTO for the treatment of portal hypertensive non-esophageal variceal bleeding were retrospectively evaluated. All 20 patients had at least 6-month follow-up. All patients had detachable coils placed to occlude the efferent shunt and retrograde gelfoam embolization to achieve complete thrombosis/obliteration of varices. Technical success, clinical success, rebleeding, and complications were evaluated at follow-up. A 100% technical success rate (defined as achieving complete occlusion of efferent shunt with complete thrombosis/obliteration of bleeding varices and/or stopping variceal bleeding) was demonstrated in all 20 patients. Clinical success rate (defined as no variceal rebleeding) was 100%. Follow-up computed tomography after CARTO demonstrated decrease in size with complete thrombosis and disappearance of the varices in all 20 patients. Thirteen out of the 20 had endoscopic confirmation of resolution of varices. Minor post-CARTO complications, including worsening of esophageal varices (not bleeding) and worsening of ascites/hydrothorax, were noted in 5 patients (25%). One patient passed away at 24 days after the CARTO due to systemic and portal venous thrombosis and multi-organ failure. Otherwise, no major complication was noted. No variceal rebleeding was noted in all 20 patients during mean follow-up of 384±154 days. CARTO appears to be a technically feasible and safe alternative to traditional balloon-occluded retrograde transvenous obliteration or transjugular intrahepatic portosystemic shunt, with excellent clinical outcomes in treating portal hypertensive non-esophageal variceal bleeding.

Background: The use of a transjugular intrahepatic portosystemic shunt (TIPS) has been established as an effective treatment for portal hypertension. Despite the rapid development of this use, serious peri-procedural complications have been reported in over 10% of cases. This has largely been attributed to the access to the portal vein, also referred to as a “blind puncture”, which often requires multiple attempts. The aim of this study was to demonstrate the safety, reproducibility and accuracy of the use of real-time 3D fusion image-guided (3DFIG) single puncture TIPS to minimize the complications that are related to the “blind puncture” of TIPS procedures. Methods: A 3DFIG TIPS approach was utilized on 22 pigs by combining pre-procedural cross-sectional imaging (CT, MR or CBCT) with intra-procedural cone beam CT or angiogram imaging, which allowed for the improved 3D visual spatial orientation of the portal vein and real-time tracking of the needle in 3D. Results: Thirty-five portosystemic shunts were successfully deployed in all 22 subjects without any peri-procedural complications. Overall, 91% (32/35) of the procedures were carried out using a single puncture. In addition, the mean fluoroscopy time in our study was more than 12 times lower than the proposed reference level that has previously been proposed for TIPS procedures. Conclusion: Multi-modality real-time 3DFIG TIPS can be performed safely using a single puncture, without complications, and can potentially be used in both emergency and non-emergency clinical situations.

A 47-year-old male with a remote renal transplant due to pediatric glomerulonephritis on oral anticoagulation for symptomatic deep venous thrombosis and pulmonary emboli presented with sudden hip and groin pain. The patient was found to have a spinal epidural hematoma, underwent reversal of anticoagulation, and subsequently developed worsening renal function. Imaging revealed occlusive iliocaval venous thrombosis with extension to the renal allograft. Given risk of epidural hematoma expansion, the patient was deemed high risk for thrombolysis. The AngioVac system was used for single session thrombus removal. The patient's renal function improved and no focal neurologic sequelae was noted postprocedure. Six-month follow-up showed persistent vessel patency.