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Abstract No. 87: Bleeding gastric varices obliteration with BRTO (balloon-occluded retrograde transvenous obliteration) utilizing sodium tetradecyl sulfate foam
Materials and Methods: Under IRB approval, the IR QA database was used to identify PTFE-TIPS placed between 2002-2007 for an indication of intractable ascites. Outcomes were then evaluated relative to the underlying renal function.
11:24 AM
Abstract No. 86
Results: 48 TIPS procedures were performed with clinical response evaluable at 6 months, censoring for transplant or death. 36/48 had normal renal function, ascites was controlled in 28/36 (78%). 12 patients had baseline renal insufficiency (creatinine ⬎1.3 mg/dl); ascites was controlled in 8/12 (67%).
Outcome of a retrieval stent filter and 30-mm balloon dilator for patients with Budd-Chiari syndrome and old inferior vena cava thrombosis: A prospective pilot study X. Han; 1st Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
Conclusion: Even in the presence of baseline renal insufficiency, PTFE-TIPS provides control of intractable ascites in 2/3 of patients, a success rate not substantially inferior to that achieved in the setting of normal renal function.
Purpose: To evaluate the safety and efficacy of a retrieval stent filter and 30-mm balloon dilator for Budd-Chiari syndrome (BCS) with chronic, old inferior vena cava (IVC) thrombosis.
11:12 AM
Abstract No. 85
Transjugular intrahepatic portosystemic shunts in liver transplant recipients for management of refractory ascites: Clinical outcome W.M. Darwish1, W.E. Saad1, M.G. Davies2, D. Butani3, D.L. Waldman3; 1University of Virginia, Charlottesville, VA; 2Methodist Hospital, Houston, TX; 3University of Rochester, Rochester, NY. Purpose: To determine clinical effectiveness of TIPS in liver transplant recipients with recurrent portal hypertension presenting with refractory ascites. Materials and Methods: A retrospective review of transplant recipients undergoing TIPS (07/2002-06/2008) was performed. Recipients were noted for age, gender, TIPS indication, MELD-score, cause of initial liver disease and time between first transplant and TIPS procedure. Clinical success was defined as graft survival more than 1 month with improvement in ascites (reduction in paracentesis sessions). New onset/worsening encephalopathy was noted. Major encephalopathy was defined as requiring TIPS reduction or resolving with re-transplant. Graft survival and patency were calculated using Kaplan-Meier method. PreTIPS, post-TIPS MELD (immediate post-TIPS MELD: ⬍24 hours, follow-up post-TIPS MELD: 10-20days) and degree of MELD increase as well as pre-TIPS, post-TIPS and degree of reduction of porto-systemic gradient (PSG) were evaluated for prediction of graft loss within 3 months from TIPS. Results: 19 liver transplant recipients underwent TIPS for ascites (none for bleeding). Mean time between transplant and TIPS: 3.5 years (range: 3.7-112.2 months). Viral hepatitis represented 79% of cases (n⫽15/19). Mean pre-TIPS MELD-score: 17 (range: 7-24). Mean follow-up was 11 months. Technical, hemodynamic and clinical success was 100%, 95%, and 16% respectively. Two patients (10.5%) had complete success and were independent of paracenteses procedures for 34 and 29 months respectively. 26% (n⫽5/19) developed encephalopathy: one patient major (5%) resolving with retransplantation. 30- and 90-day mortality was 16% (n⫽3) and 21% (n⫽4) respectively. None related to the TIPS procedure. Primary unassisted patency and graft survival at 1, 3, and 6 months was 100%, 90%, 90% and 79%, 58%, 47% respectively. MELD-score parameters were significant indicators (P⬍0.05) for graft survival beyond 3 months (The MELD-score increased after TIPS: P⬍0.05), the PSG parameters were not. S34
Conclusion: TIPS for management of ascites in liver transplant recipients appears not to be clinically effective as it is in patients with native livers (16% vs. 50-80% in literature).
Materials and Methods: The interventional protocol and the prospective study were approved by our institutional review board, and all patients gave their written informed consent. 23 BCS consecutive patients with chronic, old IVC thrombosis were treated with a retrieval stent filter and 30-mm balloon dilator and subsequently underwent color Doppler ultrasound follow-up at our hospital. The data on the technical success, angiographic and ultrasound results, mortality, morbidity, and the final clinical outcome were collected and follow-up was performed at 1-, 3-, 6-, 12months, and yearly after the procedures. Results: Stent filter placement and balloon dilation were technically successful in all patients, without immediate procedural complications. The removal of the stent filter was technically successful in 22 of the 23 attempted stents giving a technical successful rate of 95.7% (95% CI: 87%, 105%) 8-28 days (mean 14.61 ⫾ 5.85 days) after placement. Inferior vena cavagram before stent removal demonstrated complete resolution of the old IVC thrombus without pulmonary embolism. The mean primary patency rates and 95% confidence intervals (CIs) at 3, 6, 12, and 24 months after venoplasty were 0.91 (95% CI: 0.79, 1.04), 0.87 (95% CI: 0.72, 1.02), 0.87 (95% CI: 0.72, 1.02), and 0.87 (95% CI: 0.72, 1.02), respectively. The primary assisted and secondary patency rates were 1.00 throughout the follow-up period. All patients are alive with resolution of the symptoms at the time of this report. Conclusion: The retrieval stent filter and 30-mm balloon dilator were a safe and effective treatment for BCS patients with chronic, old IVC thrombosis. 11:36 AM
Abstract No. 87
Bleeding gastric varices obliteration with BRTO (balloon-occluded retrograde transvenous obliteration) utilizing sodium tetradecyl sulfate foam S.S. Sabri1, W. Swee1, U.C. Turba1, A.M. Alosaimi2, S.H. Caldwell2, W.E. Saad1, J.F. Angle1; 1University of Virginia, Charlottesville, VA; 2Internal Medicine, University of Virginia, Charlottesville, VA. Purpose: BRTO (balloon-occluded retrograde transvenous obliteration) management of bleeding GV (gastric varices) is well described in the literature. Ethanolamine Oleate (EO) has been described as the sclerosing agent, which is not readily available in the U.S. We aim to describe our initial experience with BRTO using sodium tetradecyl sulfate (STS) foam as an alternative sclerosing agent to treat bleeding GV
Materials and Methods: We performed a retrospective review of our initial series in which STS foam was used to treat bleeding GV utilizing BRTO between 1/2007 and 7/2009. STS foam was made using a combination of agents with a 3:2:1 ratio of air: 3% STS : Lipiodol. Mean values and ranges were calculated for each variable and clinical and imaging outcomes assessed.
11:48 AM
Abstract No. 88
Balloon-Occluded retrograde transvenous obliteration for portosystemic encephalopathy in patients with liver cirrhosis M. Honda1, K. Sekiyama2, T. Baba3, K. Matsuura4, N. Seino1, T. Gokan1; 1Radiology, Showa University Hospital, Tokyo, Japan; 2Yokohama General Hospital, Yokohama, Japan; 3Internal Medicine, Showa University Hospital, Tokyo, Japan; 4Saitama Medical Center of Jichi Medical School, Saitama, Japan. Purpose: Balloon-occluded retrograde transvenous obliteration (B-RTO) was originally reported as a treatment for gastric varices with gastrorenal (G-R) shunt. Portosystemic encephalopathy can be treated with B-RTO. The purpose of this presentation is to evaluate the clinical efficacy of BRTO for portosystemic encephalopathy, and to describe technical problems and complications. Materials and Methods: We performed 28 procedures of B-RTO in 22 patients (range, 44-83 years; mean age, 64.3 years) with portosystemic encephalopathy. Portosystemic encephalopathy were associated with liver cirrhosis as a result of hepatitis B virus (1), hepatitis C virus (14), alcoholic (4), both hepatitis C virus and alcoholic (2), and primary biliary cirrhosis (1). According to the Child-Pugh classification, they were categorized in class A (1), B (14), and C (7). We had portosystemic shunts such as G-R shunt (10), splenorenal (S-R) shunt (4), both G-R and S-R shunts (2), and shunt tracts drained into the gonadal vein (4). (The figure in parentheses shows number of patients.) Four patients had hepatocellular carcinoma. A 6-F balloon catheter with a balloon was inserted from the right femoral or jugular vein. After balloon-occluded retrograde venography, the
Conclusion: B-RTO is a safe and effective method of treatment for portosystemic encephalopathy in patients with liver cirrhosis. B-RTO could be the first-line treatment for portosystemic encephalopathy.
Scientific Session 10 Ex Vivo and Animal Studies Monday, March 15, 2010 4:00 PM - 6:03 PM Room: 5/6 4:00 PM
Abstract No. 89
Biological processes triggered by uterine embolization: A DNA-microarray approach in an animal UAE model V. Verret1, I. Schwarz-Cornil2, J. Pelage3, L. Jouneau2, S. Ghegediban4, M. Wassef4, J. Golzarian5, A. Laurent1,6; 1APHP Lariboisie`re Hospital, University Paris 7 Denis Diderot, Faculty of Medicine, Paris, France; 2 INRA, Jouy-en-Josas, France; 3APHP Ambroise Pare´ Hospital, Boulogne sur Seine, France; 4APHP Lariboisie`re Hospital, Paris, France; 5University of Minnesota, Minneapolis, MN; 6APHP/INRA, Jouy-en-Josas, France. Purpose: DNA-microarray techniques are being commonly applied to evaluate safety and efficacy of implantable biomaterials including orthopaedic implants and coronary stents. FDA is proposing to evaluate more systematically the “toxico-genomics” on implants and materials by applying such techniques [FDA - CDRH - OSEL]. We applied DNA-microarrays to embolization microspheres in a UAE sheep model to analyze the numerous biological processes such as ischemia, necrosis, inflammation and tissue remodelling that are triggered after embolization. Materials and Methods: In 12 hormonally cycled sheep, both uterine arteries were selectively embolized with Embosphere 500-700m (ES) or Embozene 700m (EZ) microspheres. Animals were sacrificed at 1 or 4W. Six nonembolized animals (control) were sacrificed at 1 and 4W after cycling. At sacrifice RNA was extracted from uterine samples, reverse-transcribed into cDNA, labelled and hybridized (Agilent ovine 15k microarrays). Significantly differentially expressed genes in each group versus control (p⬍0.01) were classified by biological process with Ingenuity pathway analysis software. Results: Most of the modulated genes (up- or down-regulation) were involved in metabolism and cell cycle. Some genes involved in immunity and in signal transduction were modulated. These were related to chemotaxis (CCL2), vascular activation (Thrombospondin-1), complement activation (CFI, C7), cell adhesion (CD44, ICAM1) and extracelS35
MONDAY
Conclusion: Balloon-occluded retrograde transvenous obliteration was successful in treating bleeding GV. Sodium tetradecyl sulfate foam can be used successfully as a sclerosing agent for BRTO with good short- and mid-term outcomes and acceptable safety profile.
Results: Technical success was achieved in all 22 patients. Follow-up CT after the procedure revealed thrombosed shunt tracts. Portosystemic encephalopathy was improved in all 22 patients. However, one patient had recurrence of portosystemic encephalopathy. Extravasation of contrast media was seen in 2 patients. Portal vein thrombosis was seen in 2 patients. No serious sequela was experienced.
Scientific Sessions
Results: We performed BRTO in 14 cirrhotics (8 males and 6 females) with a mean age of 52 years (range: 23-79 years). All cases had endoscopic evidence of gastric variceal bleed. Pre-procedure MRI or CT imaging demonstrated a patent gastrorenal shunt (GRS) in all patients with a mean diameter of 14.5 mm (range: 9-18 mm). The overall mean dosage of STS was 62.6mg (range: 20-200 mg) and the mean total volume of sclerosing mixture used was 23 cc (range: 5-60 cc). Complications included a case of hematuria, which spontaneously resolved and a patient who had asymptomatic partial thrombosis of the main portal vein secondary to efflux of the sclerosing mixture. Follow-up imaging ( CT, MRI or endoscopic ultrasound)was available for all cases with a mean period of 69.6 days (range: 1-140 days). Eleven patients (78%) had complete obliteration of their GV. Three of 14 (22%) patients had partial obliteration of their GV; of which one patient had successful repeat BRTO, one is pending repeat BRTO and one was treated with endoscopic glue therapy. There were no cases of recurrent variceal bleeding in the follow-up period.
sclerosant (ethanolamine oleate: EO) was injected into the shunt tracts during balloon occlusion. The occlusion balloon catheter was placed over night. The maximum dose of EO at 5% was 20 ml/day. Coil embolization was combined in 8 patients. Follow-up CT was used to assess whether the shunt tracts were thrombosed.
11:24 AM
Abstract No. 86
Results: 48 TIPS procedures were performed with clinical response evaluable at 6 months, censoring for transplant or death. 36/48 had normal renal function, ascites was controlled in 28/36 (78%). 12 patients had baseline renal insufficiency (creatinine ⬎1.3 mg/dl); ascites was controlled in 8/12 (67%).
Outcome of a retrieval stent filter and 30-mm balloon dilator for patients with Budd-Chiari syndrome and old inferior vena cava thrombosis: A prospective pilot study X. Han; 1st Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
Conclusion: Even in the presence of baseline renal insufficiency, PTFE-TIPS provides control of intractable ascites in 2/3 of patients, a success rate not substantially inferior to that achieved in the setting of normal renal function.
Purpose: To evaluate the safety and efficacy of a retrieval stent filter and 30-mm balloon dilator for Budd-Chiari syndrome (BCS) with chronic, old inferior vena cava (IVC) thrombosis.
11:12 AM
Abstract No. 85
Transjugular intrahepatic portosystemic shunts in liver transplant recipients for management of refractory ascites: Clinical outcome W.M. Darwish1, W.E. Saad1, M.G. Davies2, D. Butani3, D.L. Waldman3; 1University of Virginia, Charlottesville, VA; 2Methodist Hospital, Houston, TX; 3University of Rochester, Rochester, NY. Purpose: To determine clinical effectiveness of TIPS in liver transplant recipients with recurrent portal hypertension presenting with refractory ascites. Materials and Methods: A retrospective review of transplant recipients undergoing TIPS (07/2002-06/2008) was performed. Recipients were noted for age, gender, TIPS indication, MELD-score, cause of initial liver disease and time between first transplant and TIPS procedure. Clinical success was defined as graft survival more than 1 month with improvement in ascites (reduction in paracentesis sessions). New onset/worsening encephalopathy was noted. Major encephalopathy was defined as requiring TIPS reduction or resolving with re-transplant. Graft survival and patency were calculated using Kaplan-Meier method. PreTIPS, post-TIPS MELD (immediate post-TIPS MELD: ⬍24 hours, follow-up post-TIPS MELD: 10-20days) and degree of MELD increase as well as pre-TIPS, post-TIPS and degree of reduction of porto-systemic gradient (PSG) were evaluated for prediction of graft loss within 3 months from TIPS. Results: 19 liver transplant recipients underwent TIPS for ascites (none for bleeding). Mean time between transplant and TIPS: 3.5 years (range: 3.7-112.2 months). Viral hepatitis represented 79% of cases (n⫽15/19). Mean pre-TIPS MELD-score: 17 (range: 7-24). Mean follow-up was 11 months. Technical, hemodynamic and clinical success was 100%, 95%, and 16% respectively. Two patients (10.5%) had complete success and were independent of paracenteses procedures for 34 and 29 months respectively. 26% (n⫽5/19) developed encephalopathy: one patient major (5%) resolving with retransplantation. 30- and 90-day mortality was 16% (n⫽3) and 21% (n⫽4) respectively. None related to the TIPS procedure. Primary unassisted patency and graft survival at 1, 3, and 6 months was 100%, 90%, 90% and 79%, 58%, 47% respectively. MELD-score parameters were significant indicators (P⬍0.05) for graft survival beyond 3 months (The MELD-score increased after TIPS: P⬍0.05), the PSG parameters were not. S34
Conclusion: TIPS for management of ascites in liver transplant recipients appears not to be clinically effective as it is in patients with native livers (16% vs. 50-80% in literature).
Materials and Methods: The interventional protocol and the prospective study were approved by our institutional review board, and all patients gave their written informed consent. 23 BCS consecutive patients with chronic, old IVC thrombosis were treated with a retrieval stent filter and 30-mm balloon dilator and subsequently underwent color Doppler ultrasound follow-up at our hospital. The data on the technical success, angiographic and ultrasound results, mortality, morbidity, and the final clinical outcome were collected and follow-up was performed at 1-, 3-, 6-, 12months, and yearly after the procedures. Results: Stent filter placement and balloon dilation were technically successful in all patients, without immediate procedural complications. The removal of the stent filter was technically successful in 22 of the 23 attempted stents giving a technical successful rate of 95.7% (95% CI: 87%, 105%) 8-28 days (mean 14.61 ⫾ 5.85 days) after placement. Inferior vena cavagram before stent removal demonstrated complete resolution of the old IVC thrombus without pulmonary embolism. The mean primary patency rates and 95% confidence intervals (CIs) at 3, 6, 12, and 24 months after venoplasty were 0.91 (95% CI: 0.79, 1.04), 0.87 (95% CI: 0.72, 1.02), 0.87 (95% CI: 0.72, 1.02), and 0.87 (95% CI: 0.72, 1.02), respectively. The primary assisted and secondary patency rates were 1.00 throughout the follow-up period. All patients are alive with resolution of the symptoms at the time of this report. Conclusion: The retrieval stent filter and 30-mm balloon dilator were a safe and effective treatment for BCS patients with chronic, old IVC thrombosis. 11:36 AM
Abstract No. 87
Bleeding gastric varices obliteration with BRTO (balloon-occluded retrograde transvenous obliteration) utilizing sodium tetradecyl sulfate foam S.S. Sabri1, W. Swee1, U.C. Turba1, A.M. Alosaimi2, S.H. Caldwell2, W.E. Saad1, J.F. Angle1; 1University of Virginia, Charlottesville, VA; 2Internal Medicine, University of Virginia, Charlottesville, VA. Purpose: BRTO (balloon-occluded retrograde transvenous obliteration) management of bleeding GV (gastric varices) is well described in the literature. Ethanolamine Oleate (EO) has been described as the sclerosing agent, which is not readily available in the U.S. We aim to describe our initial experience with BRTO using sodium tetradecyl sulfate (STS) foam as an alternative sclerosing agent to treat bleeding GV
Materials and Methods: We performed a retrospective review of our initial series in which STS foam was used to treat bleeding GV utilizing BRTO between 1/2007 and 7/2009. STS foam was made using a combination of agents with a 3:2:1 ratio of air: 3% STS : Lipiodol. Mean values and ranges were calculated for each variable and clinical and imaging outcomes assessed.
11:48 AM
Abstract No. 88
Balloon-Occluded retrograde transvenous obliteration for portosystemic encephalopathy in patients with liver cirrhosis M. Honda1, K. Sekiyama2, T. Baba3, K. Matsuura4, N. Seino1, T. Gokan1; 1Radiology, Showa University Hospital, Tokyo, Japan; 2Yokohama General Hospital, Yokohama, Japan; 3Internal Medicine, Showa University Hospital, Tokyo, Japan; 4Saitama Medical Center of Jichi Medical School, Saitama, Japan. Purpose: Balloon-occluded retrograde transvenous obliteration (B-RTO) was originally reported as a treatment for gastric varices with gastrorenal (G-R) shunt. Portosystemic encephalopathy can be treated with B-RTO. The purpose of this presentation is to evaluate the clinical efficacy of BRTO for portosystemic encephalopathy, and to describe technical problems and complications. Materials and Methods: We performed 28 procedures of B-RTO in 22 patients (range, 44-83 years; mean age, 64.3 years) with portosystemic encephalopathy. Portosystemic encephalopathy were associated with liver cirrhosis as a result of hepatitis B virus (1), hepatitis C virus (14), alcoholic (4), both hepatitis C virus and alcoholic (2), and primary biliary cirrhosis (1). According to the Child-Pugh classification, they were categorized in class A (1), B (14), and C (7). We had portosystemic shunts such as G-R shunt (10), splenorenal (S-R) shunt (4), both G-R and S-R shunts (2), and shunt tracts drained into the gonadal vein (4). (The figure in parentheses shows number of patients.) Four patients had hepatocellular carcinoma. A 6-F balloon catheter with a balloon was inserted from the right femoral or jugular vein. After balloon-occluded retrograde venography, the
Conclusion: B-RTO is a safe and effective method of treatment for portosystemic encephalopathy in patients with liver cirrhosis. B-RTO could be the first-line treatment for portosystemic encephalopathy.
Scientific Session 10 Ex Vivo and Animal Studies Monday, March 15, 2010 4:00 PM - 6:03 PM Room: 5/6 4:00 PM
Abstract No. 89
Biological processes triggered by uterine embolization: A DNA-microarray approach in an animal UAE model V. Verret1, I. Schwarz-Cornil2, J. Pelage3, L. Jouneau2, S. Ghegediban4, M. Wassef4, J. Golzarian5, A. Laurent1,6; 1APHP Lariboisie`re Hospital, University Paris 7 Denis Diderot, Faculty of Medicine, Paris, France; 2 INRA, Jouy-en-Josas, France; 3APHP Ambroise Pare´ Hospital, Boulogne sur Seine, France; 4APHP Lariboisie`re Hospital, Paris, France; 5University of Minnesota, Minneapolis, MN; 6APHP/INRA, Jouy-en-Josas, France. Purpose: DNA-microarray techniques are being commonly applied to evaluate safety and efficacy of implantable biomaterials including orthopaedic implants and coronary stents. FDA is proposing to evaluate more systematically the “toxico-genomics” on implants and materials by applying such techniques [FDA - CDRH - OSEL]. We applied DNA-microarrays to embolization microspheres in a UAE sheep model to analyze the numerous biological processes such as ischemia, necrosis, inflammation and tissue remodelling that are triggered after embolization. Materials and Methods: In 12 hormonally cycled sheep, both uterine arteries were selectively embolized with Embosphere 500-700m (ES) or Embozene 700m (EZ) microspheres. Animals were sacrificed at 1 or 4W. Six nonembolized animals (control) were sacrificed at 1 and 4W after cycling. At sacrifice RNA was extracted from uterine samples, reverse-transcribed into cDNA, labelled and hybridized (Agilent ovine 15k microarrays). Significantly differentially expressed genes in each group versus control (p⬍0.01) were classified by biological process with Ingenuity pathway analysis software. Results: Most of the modulated genes (up- or down-regulation) were involved in metabolism and cell cycle. Some genes involved in immunity and in signal transduction were modulated. These were related to chemotaxis (CCL2), vascular activation (Thrombospondin-1), complement activation (CFI, C7), cell adhesion (CD44, ICAM1) and extracelS35
MONDAY
Conclusion: Balloon-occluded retrograde transvenous obliteration was successful in treating bleeding GV. Sodium tetradecyl sulfate foam can be used successfully as a sclerosing agent for BRTO with good short- and mid-term outcomes and acceptable safety profile.
Results: Technical success was achieved in all 22 patients. Follow-up CT after the procedure revealed thrombosed shunt tracts. Portosystemic encephalopathy was improved in all 22 patients. However, one patient had recurrence of portosystemic encephalopathy. Extravasation of contrast media was seen in 2 patients. Portal vein thrombosis was seen in 2 patients. No serious sequela was experienced.
Scientific Sessions
Results: We performed BRTO in 14 cirrhotics (8 males and 6 females) with a mean age of 52 years (range: 23-79 years). All cases had endoscopic evidence of gastric variceal bleed. Pre-procedure MRI or CT imaging demonstrated a patent gastrorenal shunt (GRS) in all patients with a mean diameter of 14.5 mm (range: 9-18 mm). The overall mean dosage of STS was 62.6mg (range: 20-200 mg) and the mean total volume of sclerosing mixture used was 23 cc (range: 5-60 cc). Complications included a case of hematuria, which spontaneously resolved and a patient who had asymptomatic partial thrombosis of the main portal vein secondary to efflux of the sclerosing mixture. Follow-up imaging ( CT, MRI or endoscopic ultrasound)was available for all cases with a mean period of 69.6 days (range: 1-140 days). Eleven patients (78%) had complete obliteration of their GV. Three of 14 (22%) patients had partial obliteration of their GV; of which one patient had successful repeat BRTO, one is pending repeat BRTO and one was treated with endoscopic glue therapy. There were no cases of recurrent variceal bleeding in the follow-up period.
sclerosant (ethanolamine oleate: EO) was injected into the shunt tracts during balloon occlusion. The occlusion balloon catheter was placed over night. The maximum dose of EO at 5% was 20 ml/day. Coil embolization was combined in 8 patients. Follow-up CT was used to assess whether the shunt tracts were thrombosed.