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Background and AimHemostasis in cirrhosis is dynamic and balanced. Thromboelastography (TEG) assesses global coagulation status. We aimed to assess whether TEG-guided blood product transfusions result in lower blood product requirements in patients with cirrhosis undergoing invasive liver-related procedures as compared to the conventional standard of care (SOC).MethodsIn this open-label, randomized controlled trial, cirrhosis patients with coagulopathy, undergoing invasive liver-related procedures, were randomized to either TEG-guided blood product transfusion or SOC. The primary outcome was difference in the amount of fresh frozen plasma (FFP) and platelet units transfused between the two groups. The secondary outcome was procedure-related bleeding complications within 5 days and any complications until 28 days.ResultsFrom November 2017 till June 2019, 58 patients were recruited (29: TEG and 29: SOC). Most common procedures performed were percutaneous liver biopsy (n = 48), followed by transjugular intrahepatic portosystemic shunt (n = 2), percutaneous acetic acid injection (n = 2), and transarterial chemoembolization (n = 2). There were no differences in baseline demographics, hemostatic profile, and types of procedures between the two groups. Only nine patients in TEG group received transfusions compared to all patients in SOC (31% vs 100%; P < 0.001). In TEG group, six (20.7%) received FFP (P = 0.753 vs. SOC), two (6.9%) received platelets (P < 0.001 vs. SOC), and 1(3.4%) patient received both FFP and platelet (P ≥ 0.999 vs. SOC) transfusion. None of the patients in either group developed procedure-related bleeding complications until 5 days post-procedure. The complication rates at 28-day follow-up were similar between the groups.ConclusionTEG-guided blood product transfusion strategy reduces blood product transfusion without increased risk of bleeding in cirrhotic patients undergoing invasive liver-related procedures (CTRI/2017/12/010822).

BackgroundInfected pancreatic necrosis (IPN) is a major complication of acute pancreatitis (AP), which may require necrosectomy. Minimally invasive surgical step-up therapy is preferred for IPN.AimTo assess the effectiveness of percutaneous endoscopic step-up therapy in patients with IPN and identify predictors of its success.MethodsConsecutive patients with AP hospitalized to our tertiary care academic center were studied prospectively. Patients with IPN formed the study group. The treatment protocol for IPN was percutaneous endoscopic step-up approach starting with antibiotics and percutaneous catheter drainage, and if required necrosectomy. Percutaneous endoscopic necrosectomy (PEN) was performed using a flexible endoscope through the percutaneous tract under conscious sedation. Control of sepsis with resolution of collection(s) was the primary outcome measure.ResultsA total of 415 patients with AP were included. Of them, 272 patients had necrotizing pancreatitis and 177 (65%) developed IPN. Of these 177 patients, 27 were treated conservatively with antibiotics alone, 56 underwent percutaneous drainage alone, 53 required underwent PEN as a step-up therapy, 1 per-oral endoscopic necrosectomy, and 52 required surgery. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully—34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died due to organ failure—7 after PEN and 4 after surgery. Independent predictors of mortality were > 50% necrosis and early organ failure.ConclusionPercutaneous endoscopic step-up therapy is an effective strategy for IPN. Organ failure and extensive pancreatic necrosis predicted a suboptimal outcome in patients with infected necrotizing pancreatitis.

Background and AimThere is a paucity of data on the clinical presentations and outcome of Budd–Chiari syndrome (BCS) patients presenting as acute-on-chronic liver failure (BCS-ACLF). We aimed to describe the profile and outcomes of endovascular interventions in patients with BCS-ACLF.MethodsAll BCS-ACLF patients presenting between October 2007 and April 2019 satisfying the Asian Pacific Association for the Study of the Liver (APASL) definition were studied. We compared 30- , 90- and, 180-day survival among BCS-ACLF patients who underwent endovascular intervention with those who did not, and with a historical cohort of Child-C BCS patients without ACLF who underwent endovascular intervention.ResultsTwenty-eight (5%) of 553 BCS patients presented as ACLF as per APASL definition. The majority (60.7%) were males, and mean age was 29.6 ± 11.2 years. The most common site of the block was isolated involvement of hepatic veins-HV (68%), followed by combined inferior vena cava (IVC) and HV block (25%) and isolated IVC block (7%). The acute precipitants were stent thrombosis (17.9%), acute HV thrombosis (10.7%), acute viral hepatitis (7.1%), and antituberculosis drug with hepatitis B virus reactivation (3.6%). In 60.7% patients, no acute precipitant could be identified. The 30- , 90- , and 180-day survival in BCS-ACLF post-endovascular intervention (n = 15), BCS-ACLF without endovascular intervention (n = 13), and Child-C BCS without ACLF who underwent endovascular intervention (n = 25) were (93%, 87%, and 87%), (46%, 28%, and 0%) and (96%, 92%, and 88%), respectively (log-rank test, p value < 0.001). On multivariate Cox proportional analysis, endovascular intervention and the presence of hepatic encephalopathy were independent predictors of mortality.ConclusionBudd–Chiari syndrome can present as acute-on-chronic liver failure. Endovascular intervention is associated with an improved outcome.

Lipoblastomatosis of mesentery is an extremely rare benign fat-containing mesenchymal tumour in infants and young children. On imaging, it appears as a solid infiltrating mass interspersed with macroscopic fat. We describe the distinctive imaging features of a large mesenteric Lipoblastomatosis, corroborated with intraoperative and histopathological features. We hope the case report and short review about this rare entity will increase the diagnostic confidence of reading radiologists while formulating differentials for lesions of similar appearance in the paediatric age group.

Chronic kidney disease (CKD) is a major public health problem with more than 850 million people affected worldwide and will become fifth biggest cause of Years of life lost (YLL) by the year 2040. Deaths due to CKD in India increased from 0.59 million in 1990 to 1.18 million in 2016. Due to the expected increase in life expectancy of the dialysis patient and the limited kidney donors available, the need for vascular access is critical, though challenging. The traditional routes of access such as arteriovenous fistulae and central tunnelled catheter insertions are not devoid of complications and drawbacks, such as infections, thrombosis and stenosis, and when these routes get exhausted, the unconventional routes come into the picture. In this article, we will discuss two unconventional routes i.e. Translumbar and Transhepatic tunnelled cuffed dialysis access. Numerous conventional access for haemodialysis is created in our institution on a regular basis; however, two unconventional procedures were also done in our institution, one each of translumbar and translumbar central tunnelled catheter insertions in DSA suit following proper instructions and guidelines. Both the central tunnelled catheter insertions were successful with no peri-procedural complications. Patient with translumbar and transhepatic central tunnelled catheter insertion received 15 and 21 cycles of haemodialysis, respectively, with subsequent successful renal transplant in both the patients. The lack of donors for renal transplant is a major roadblock for CKD patients, and so, renal replacement therapy is much needed by conventional routes of dialysis. The role of unconventional routes like transhepatic and translumbar tunnelled catheters comes into play for renal replacement therapy and as a bridging gap for renal transplant.

Persistent sciatic artery is an uncommon congenital lower limb vascular variant resulting from persistent embryonic vasculature. While up to 20% of individuals remain asymptomatic, the most frequently seen complication associated with this artery is the development of a pseudoaneurysm in the gluteal region (48%). Pseudoaneurysms may result in thrombosis, embolisation into distal vessels and radicular pain due to compression of the adjacent sciatic nerve.We present the case of a gentleman in his mid-50s with complaints of neuropathic lower limb pain secondary to sciatic nerve compression by a pseudoaneurysm of persistent sciatic artery, which was excluded from circulation using an endovascularly placed stent graft. Follow-up ultrasound (US) on post-op day 1 revealed thrombosis of the pseudoaneurysm with complete resolution of neuropathic pain, and the patient remaining pain-free at 1 year. Knowledge of this uncommon variant, with its varied presentations, can aid early diagnosis and planning of effective, minimally invasive endovascular management techniques.

Objective PSMA expression is seen in many solid tumours in addition to prostate cancer and several studies and case reports have shown PSMA expression and 68 Ga-PSMA imaging of hepatocellular carcinoma (HCC). Our prospective study evaluates the role of 68 Ga-PSMA in HCC patients and compares it to conventional imaging (CE-CT/MRI). Methods Patients with radiologically and/or histopathologically confirmed HCC were included and all had undergone serum alpha-fetoprotein (S.AFP) assessment as well as CE-CT/MRI prior to PSMA PET/CT. Acquired whole-body PET/CTs were analysed both visually and quantitatively by two experienced nuclear medicine physicians. Results Forty-one (41) patients (36 male; 5 female) with known HCC and a mean age of 53.9 ± 10.9 years underwent 68 Ga-PSMA PET/CT. All patients had lesions on conventional imaging but only 38/41 patients showed 68 Ga-PSMA uptake. Conventional imaging revealed 18 patients with single lesions, all of which were tracer avid. Twenty-three (23) of 41 patients had multifocal (> 2) hepatic lesions on CE-CT/MRI of which 3 patients showed no 68 Ga-PSMA uptake, 7 showed tracer uptake in a single lesion only and 13 patients had multifocal tracer avid lesions. There was no correlation observed between S. AFP level and tumour SUV max on 68 Ga-PSMA PET/CT. Conclusion 68 Ga-PSMA PET/CT imaging of HCC may complement conventional imaging and identify patients for potential theranostic intervention.

BackgroundAdvanced fibrosis and cirrhosis (compensated advanced chronic liver disease [cACLD]) are clinically indistinguishable and increase risk of developing clinically significant portal hypertension. Baveno VII recommends using elastography to rule out and diagnose cACLD with liver stiffness measurement (LSM) cut-offs of 10/15 kPa.MethodsIn a retrospective analysis of 330 nonalcoholic fatty liver disease (NAFLD) patients, performance of the Baveno VII cut-offs for diagnosing cACLD was compared with newly suggested lower cut-offs (8/12 kPa). A model for detecting cACLD among those with LSM between 8 and 12 kPa was developed and compared with recently published models.ResultsSeventy (21.2%) of the 330 NAFLD patients had biopsy-proven cACLD. The Baveno VII cut-offs (10/15 kPa) had a lower sensitivity of 72.8% (60.9–82.8%) and a specificity of 93.4% (89.7–96.1%). Sensitivity and specificity of lower cut-offs (8/12 kPa) were 91.4% (82.3–96.8%) and 88.5% (83.9–92.1%), respectively. Modeling based on the presence of diabetes (odds ratio [OR] 3.625[1.161–11.320], p = 0.027) and serum aspartate aminotransferase (AST) levels (OR 1.636[1.098–2.436], p = 0.015) correctly identified 75.7% of patients with LSM between 8 and 12 kPa. Our model performed best with an area under receiver operator curve (AUROC) of 0.725 (95%CI 0.609–0.822), compared to Papatheodoridi (AUROC 0.626, CI 0.506–.736) and Zhou (AUROC 0.523, CI 0.403–0.640) models. A two-step strategy comprising application of lower LSM cut-offs followed by the predictive model correctly identified the presence of cACLD in 83% of the patients as compared to 75% by the Baveno VII cut-offs.ConclusionA two-step strategy employing lower LSM cut-offs and modeling based on diabetes and AST levels outperforms Baveno VII cut-offs for identifying cACLD in NAFLD patients.

Visceral artery pseudoaneurysms occur mostly as a result of inflammation and trauma. Owing to high risk of rupture, they require early treatment to prevent lethal complications. Knowledge of the various approaches of embolization of pseudoaneurysms and different embolic materials used in the management of visceral artery pseudoaneurysms is essential for successful and safe embolization. We review and illustrate the endovascular, percutaneous and endoscopic ultrasound techniques used in the treatment of visceral artery pseudoaneurysm and briefly discuss the embolic materials and their benefits and risks.

Renal vascular injuries are more devastating than parenchymal injuries alone, thus account for higher injury grade and require prompt recognition. Revised AAST organ injury scale (OIS) for renal trauma has incorporated CT-diagnosed vascular injuries into renal injury grading which includes pseudoaneurysm and arteriovenous fistula, along with addition of some new descriptors of renovascular injury. Dual-phase contrast-enhanced CT (with both arterial and venous phase) can easily pick up renovascular injuries and is the modality of choice for imaging renovascular trauma. Radiologist should be well versed with the imaging findings of renovascular injuries so that accurate injury grading can be done and further management can be planned at the earliest.