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Purpose To assess the incidence, prognostic factors, and clinical outcomes of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) creation. Materials and Methods In this single-institution retrospective study, 191 patients (m:f = 114:77, median age 54 years, median Model for End-Stage Liver Disease or MELD score 14) who underwent TIPS creation between 1999 and 2013 were studied. Medical record review was used to identify demographic characteristics, liver disease, procedure, and outcome data. Post-TIPS HE within 30 days was defined by new mental status changes and was graded according to the West Haven classification system. The influence of data parameters on HE occurrence and 90-day mortality was assessed using binary logistic regression. Results TIPS was successfully created with hemodynamic success in 99 % of cases. Median final PSG was 7 mmHg. HE incidence within 30 days was 42 % (81/191; 22 % de novo, 12 % stable, and 8 % worsening). Degrees of HE included grade 1 (46 %), grade 2 (29 %), grade 3 (18 %), and grade 4 (7 %). Medical therapy typically addressed HE, and shunt reduction was necessary in only three cases. MELD score ( P  = 0.020) and age ( P  = 0.009) were significantly associated with HE development on multivariate analysis. Occurrence of de novo HE post-TIPS did not associate with 90-day mortality ( P  = 0.400), in contrast to worsening HE ( P  < 0.001). Conclusions The incidence of post-TIPS HE is non-trivial, but symptoms are typically mild and medically managed. HE rates are higher in older patients and those with worse liver function and should be contemplated when counseling on expected TIPS outcomes and post-procedure course.

Recent reports have argued that screening for blunt carotid injury is futile and have called for a cost analysis. Our data previously supported screening asymptomatic trauma patients for blunt cerebrovascular injury (BCVI) to prevent associated neurologic sequelae. Our hypothesis is that aggressive angiographic screening for BCVI based on a patient’s injury pattern and symptoms allows for early diagnosis and treatment and is cost-effective because it prevents ischemic neurological events (INEs). Beginning in January 1996, we began comprehensive screening using 4-vessel cerebrovascular angiography based on injury patterns; these patients have been followed-up prospectively. Patients without contraindications received antithrombotic therapy immediately for documented BCVI. From January 1996 through June 2004, there were 15,767 blunt-trauma patient admissions to our state-designated level I urban trauma center, of which 727 patients underwent screening angiography. Twenty-one patients presented with signs or symptoms of neurologic ischemia before diagnosis. BCVI was identified in 244 patients (34% screening yield); the majority were men (68%) with a mean age of 35 ± 3.7 years and mean Injury Severity Score of 28 ± 3.8. Asymptomatic patients (n = 187) were treated (heparin in 117, low molecular–weight heparin in 11, and antiplatelet in 59); 1 patient had a stroke (0.5%). Using estimated stroke rate by grade of injury, we averted neurologic events in 32 asymptomatic patients with antithrombotic treatment. Of the 48 asymptomatic patients who did not receive adequate anticoagulation, 10 (21%) had an INE. Patients with BCVI-related neurologic events had a statistically higher percentage requiring discharge to rehabilitation facilities (50% vs. 77% for carotid artery injury [CAI]), a higher percentage requiring rehabilitation for BCVI-related stroke (0% vs. 55% for CAI), and a higher stroke-related mortality rate (0% vs. 21% for CAI and 0% vs. 17% for vertebral artery injury) than those without neurologic events. The cost of long-term rehabilitation care and human life after BCVI-associated neurologic events is substantial. Surgeons caring for the multiply injured should screen for carotid and vertebral artery injuries in high-risk patients.

PurposeTo evaluate the capability of albumin–bilirubin (ALBI) and platelet–albumin–bilirubin (PALBI) grades in predicting transplant-free survival (TFS) in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation.Materials and MethodsThis single-center retrospective study included 342 ALBI and 337 PALBI patients (62% men; age 53–54 years) with cirrhosis (median MELD 15) and portal hypertension complications (variceal bleeding, 55%; ascites, 35%; other, 10%) who underwent TIPS between 1998 and 2017. Serum albumin, bilirubin, and platelet levels within 24 h prior to TIPS were used to calculate ALBI and PALBI grades. The influence of ALBI and PALBI grade on 30-day, 90-day, and overall post-TIPS TFS was assessed using C-indices, binary logistic regression, and the Cox proportional model, adjusting for Child–Pugh (CP) and MELD scores.ResultsThe cohort spanned 110 (32%) and 232 (68%) ALBI grades 2 and 3 patients, and 40 (12%) and 297 (88%) PALBI grades 2 and 3 patients. While there were no differences in 30-day survival between ALBI and PALBI grades 2/3 (P > 0.05), 90-day and overall TFS showed statistically significant differences in survival between ALBI and PALBI grades 2/3 (P < 0.05). Nonetheless, using univariate logistic regression, ALBI–PALBI C-indices (0.55–0.58) were inferior to the MELD score (0.81–0.84). Moreover, ALBI–PALBI did not associate with TFS on multivariable models adjusting for CP and MELD. Only MELD independently associated with TFS (P < 0.001).ConclusionsALBI and PALBI grades do not stratify survival outcomes beyond MELD score following TIPS. MELD score remains the most robust metric for predicting post-TIPS survival outcomes.

Cholangiocarcinoma, a tumor of biliary epithelium, is increasing in incidence. The imaging appearance, behavior, and treatment of cholangiocarcinoma differ according to its location and morphology. Cholangiocarcinoma is usually classified as intrahepatic, perihilar, or distal. The three morphologies are mass-forming, periductal sclerosing, and intraductal growing. As surgical resection is the only cure, prompt diagnosis and accurate staging is crucial. In staging, vascular involvement, longitudinal spread, and lymphadenopathy are important to assess. The role of liver transplantation for unresectable peripheral cholangiocarcinoma will be discussed. Locoregional therapy can extend survival for those with unresectable intrahepatic tumors. The main risk factors predisposing to cholangiocarcinoma are parasitic infections, primary sclerosing cholangitis, choledochal cysts, and viral hepatitis. Several inflammatory conditions can mimic cholangiocarcinoma, including IgG4 disease, sclerosing cholangitis, Mirizzi’s syndrome, and recurrent pyogenic cholangitis. The role of PET in diagnosis and staging will also be discussed. Radiologists play a crucial role in diagnosis, staging, and treatment of this disease.

Purpose To perform a systemic review to determine the effect of anticoagulation on the rates of venous thromboembolism (pulmonary embolus, deep venous thrombosis, inferior vena cava (IVC) filter thrombosis) following placement of an IVC filter. Methods A comprehensive computerized literature search was performed to identify relevant articles. Data were abstracted by two reviewers. Studies were included if it could be determined whether or not subjects received anticoagulation following filter placement, and if follow-up data were presented. A meta-analysis of patients from all included studies was performed. A total of 14 articles were included in the final analysis, but the data from only nine articles could be used in the meta-analysis; five studies were excluded because they did not present raw data which could be analyzed in the meta-analysis. A total of 1,369 subjects were included in the final meta-analysis. Results The summary odds ratio for the effect of anticoagulation on venous thromboembolism rates following filter deployment was 0.639 (95% CI 0.351 to 1.159, p  = 0.141). There was significant heterogeneity in the results from different studies [Q statistic of 15.95 ( p  = 0.043)]. Following the meta-analysis, there was a trend toward decreased venous thromboembolism rates in patients with post-filter anticoagulation (12.3% vs. 15.8%), but the result failed to reach statistical significance. Conclusion Inferior vena cava filters can be placed in patients who cannot receive concomitant anticoagulation without placing them at significantly higher risk of development of venous thromboembolism.

As interventionalists become more involved with patients as care providers rather than solely as proceduralists, understanding and treating pain is a vital part of daily practice. This book provides an overview of the multiple techniques used in the management of pain in interventional radiology suites. Topics include techniques for the treatment and prevention of pain caused by interventional procedures, as well as minimally invasive techniques used to treat patients with chronic pain symptoms. Approximately half of the book is dedicated to the diagnosis and treatment of spinal pain; other chapters focus on intraprocedural and post-procedural pain management, embolization and ablation techniques used to treat patients with uncontrollable pain, and alternative treatments for pain relief. This book is a practical resource for anyone looking to acquire skills in locoregional or systemic pain control and wishing to improve the quality of life for patients undergoing procedures or suffering from disease-related pain.