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CARTO (coil-assisted retrograde transvenous obliteration) for the treatment of hepatic encephalopathy
JVIR
’
Scientific Session
1.54 PM
Tuesday
Abstract No. 202
CARTO (coil-assisted retrograde transvenous obliteration) for the treatment of hepatic encephalopathy E.W. Lee1, S. Saab2, S. Cho3, R.W. Busuttil4, J. McWilliams1, F. Durazo2, S.H. Han2, A.S. Gomes1, S.T. Kee1; 1Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, Los Angeles, CA; 2Division of Hepatology, Department of Medicine, UCLA Medical Center, Los Angeles, CA; 3 Division of Interventional Radiology, Department of Radiology, Samsung Medical Center, Seoul, Korea (the Republic of); 4Division of Transplant Surgery, Department of Surgery, UCLA Medical Center, Los Angeles, CA
S95
we applied n-butyl cyanoacrylate (NBCA) plug instead of long balloon occlusion. Materials and Methods: For 36 patients with GV, BRTO was performed. After temporary balloon occlusion at the gastrorenal shunt (GRS), sclerosants were injected and C-arm CT was performed to confirm the reach of sclerosants into GV. Eighteen of 36 patients, NBCA plug was put a few centimeters away from the balloon via a microcatheter. After confirming the immobilization of the plug at balloon deflation, the whole system was retrieved. Whether GV were thrombosed or not was investigated by postcontrast CT. The fluoroscopy and whole procedure times were compared in without vs. with plug. Results: 47.0⫾10.8% of 1.5⫾0.6mL glue was injected. The fluoroscopy and procedure times were 32.4⫾18.9 vs. 49.7⫾41.1 minutes (p¼0.271) and 919.6⫾566.4 vs. 112.8⫾63.0 minutes (po0.01) in without vs. with plug. In one patient partial migration of glue cast occurred at balloon deflation without any symptom. This patient and another patient without plug required antegrade obliteration (94.4% of success rates in both groups). Conclusion: NBCA plug allowed fast BRTO maintaining similar success rates.
2.12 PM
Abstract No. 204
Decreased efficacy of transjugular intrahepatic portosystemic shunts for refractory hydrothorax in comparison with ascites Z.L. Bercu, A.M. Fischman, E. Kim, S.F. Nowakowski, R.S. Patel, R.A. Lookstein; Division of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY Purpose: This study represents a single center retrospective cohort study in the use of transjugular intrahepatic portosystemic shunts (TIPS) for refractory hydrothorax and ascites. Materials and Methods: At a single center institution, 109 patients from 2004 to 2013 underwent TIPS for refractory hydrothorax with/without ascites or refractory ascites alone. Records were reviewed for demographics, technical success of TIPS and stent follow-up. Analysis of TIPS angles was performed on patients with refractory hydrothorax and age and sex-matched controls who had refractory ascites without hydrothorax. Results: TIPS were placed in 15 and 94 patients for refractory hydrothorax and ascites, respectively. 1-year survival was 67.0% versus 79.8%. 1-year transplant or revision free survival was 20% versus 50%. 61.5% versus 94.1% experienced a partial or complete Table 1 Baseline Characteristics
2.03 PM
Abstract No. 203
Fast balloon-occluded retrograde transvenous obliteration using n-butyl cyanoacrylate after foam sclerosants for gastric varices J. Koizumi1, C. Itou1, T. Hara1, T. Sekiguchi1, B. Janne d’Othee2; 1Diagnostic Radiology, Tokai University, Isehara, Japan; 2University of Maryland, Baltimore, MD Purpose: To obtain complete thrombosis of gastric varices (GV) and to prevent pulmonary embolism, long balloon occlusion is desirable during balloon-occluded retrograde transvenous obliteration (BRTO). However, long cannulation is a burden for patients and risky for unstable patients. Thus,
Average age Number with Hepatitis B or C Average pre-TIPS Child Pugh score Average pre-TIPS MELD score Average pre-TIPS portosystemic gradient Average post-TIPS portosystemic gradient
Refractory hydrothorax 58.3 7 (46.7%)
Refractory ascites 55.8 34 (36.1%)
8.9
9.8
14
13.6
13.4
19.3
5.7
7.8
TUESDAY: Scientific Sessions
Purpose: To evaluate the technical feasibility, safety and clinical outcomes of CARTO in treating refractory hepatic encephalopathy. Materials and Methods: From June 2012 to July 2014, 20 patients (mean age 60; M:F ¼ 18:2) received CARTO using coils with gelfoam for treatment of hepatic encephalopathy. All patients had refractory hepatic encephalopathy with the West Haven Grade of 2 or higher. All patients had detachable coils placed to occlude the efferent shunt and retrograde gelfoam embolization to achieve partial or complete thrombosis of the shunt. Technical success, clinical success and complications were followed for 495 ⫾ 243 days. Results: 100% technical success rate (defined as achieving complete occlusion of efferent shunt with partial or complete thrombosis of the shunt) was demonstrated in all 20 patients. Clinical success rate (defined as resolution or improvement of hepatic encephalopathy) was 85%. Five patients received liver transplant during follow up. Four patients (20%) required additional CARTO procedure as new shunts appeared or due to no clinical improvement from partial thrombosis. A 20% mortality rate was noted during follow up. Minor postprocedure complications (transient increase of LFTs, fever, abdominal discomfort) were noted in 9 patients (45%). The mean pre-/post-CARTO Ammonia levels were 139.83 ⫾ 39.20 and 61.5 ⫾ 16.02, respectively. Conclusion: CARTO appears technically feasible and relatively safe method of treating refractory hepatic encephalopathy for patients otherwise considered as palliative and nontransplant candidates.
’
’
Scientific Session
1.54 PM
Tuesday
Abstract No. 202
CARTO (coil-assisted retrograde transvenous obliteration) for the treatment of hepatic encephalopathy E.W. Lee1, S. Saab2, S. Cho3, R.W. Busuttil4, J. McWilliams1, F. Durazo2, S.H. Han2, A.S. Gomes1, S.T. Kee1; 1Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, Los Angeles, CA; 2Division of Hepatology, Department of Medicine, UCLA Medical Center, Los Angeles, CA; 3 Division of Interventional Radiology, Department of Radiology, Samsung Medical Center, Seoul, Korea (the Republic of); 4Division of Transplant Surgery, Department of Surgery, UCLA Medical Center, Los Angeles, CA
S95
we applied n-butyl cyanoacrylate (NBCA) plug instead of long balloon occlusion. Materials and Methods: For 36 patients with GV, BRTO was performed. After temporary balloon occlusion at the gastrorenal shunt (GRS), sclerosants were injected and C-arm CT was performed to confirm the reach of sclerosants into GV. Eighteen of 36 patients, NBCA plug was put a few centimeters away from the balloon via a microcatheter. After confirming the immobilization of the plug at balloon deflation, the whole system was retrieved. Whether GV were thrombosed or not was investigated by postcontrast CT. The fluoroscopy and whole procedure times were compared in without vs. with plug. Results: 47.0⫾10.8% of 1.5⫾0.6mL glue was injected. The fluoroscopy and procedure times were 32.4⫾18.9 vs. 49.7⫾41.1 minutes (p¼0.271) and 919.6⫾566.4 vs. 112.8⫾63.0 minutes (po0.01) in without vs. with plug. In one patient partial migration of glue cast occurred at balloon deflation without any symptom. This patient and another patient without plug required antegrade obliteration (94.4% of success rates in both groups). Conclusion: NBCA plug allowed fast BRTO maintaining similar success rates.
2.12 PM
Abstract No. 204
Decreased efficacy of transjugular intrahepatic portosystemic shunts for refractory hydrothorax in comparison with ascites Z.L. Bercu, A.M. Fischman, E. Kim, S.F. Nowakowski, R.S. Patel, R.A. Lookstein; Division of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY Purpose: This study represents a single center retrospective cohort study in the use of transjugular intrahepatic portosystemic shunts (TIPS) for refractory hydrothorax and ascites. Materials and Methods: At a single center institution, 109 patients from 2004 to 2013 underwent TIPS for refractory hydrothorax with/without ascites or refractory ascites alone. Records were reviewed for demographics, technical success of TIPS and stent follow-up. Analysis of TIPS angles was performed on patients with refractory hydrothorax and age and sex-matched controls who had refractory ascites without hydrothorax. Results: TIPS were placed in 15 and 94 patients for refractory hydrothorax and ascites, respectively. 1-year survival was 67.0% versus 79.8%. 1-year transplant or revision free survival was 20% versus 50%. 61.5% versus 94.1% experienced a partial or complete Table 1 Baseline Characteristics
2.03 PM
Abstract No. 203
Fast balloon-occluded retrograde transvenous obliteration using n-butyl cyanoacrylate after foam sclerosants for gastric varices J. Koizumi1, C. Itou1, T. Hara1, T. Sekiguchi1, B. Janne d’Othee2; 1Diagnostic Radiology, Tokai University, Isehara, Japan; 2University of Maryland, Baltimore, MD Purpose: To obtain complete thrombosis of gastric varices (GV) and to prevent pulmonary embolism, long balloon occlusion is desirable during balloon-occluded retrograde transvenous obliteration (BRTO). However, long cannulation is a burden for patients and risky for unstable patients. Thus,
Average age Number with Hepatitis B or C Average pre-TIPS Child Pugh score Average pre-TIPS MELD score Average pre-TIPS portosystemic gradient Average post-TIPS portosystemic gradient
Refractory hydrothorax 58.3 7 (46.7%)
Refractory ascites 55.8 34 (36.1%)
8.9
9.8
14
13.6
13.4
19.3
5.7
7.8
TUESDAY: Scientific Sessions
Purpose: To evaluate the technical feasibility, safety and clinical outcomes of CARTO in treating refractory hepatic encephalopathy. Materials and Methods: From June 2012 to July 2014, 20 patients (mean age 60; M:F ¼ 18:2) received CARTO using coils with gelfoam for treatment of hepatic encephalopathy. All patients had refractory hepatic encephalopathy with the West Haven Grade of 2 or higher. All patients had detachable coils placed to occlude the efferent shunt and retrograde gelfoam embolization to achieve partial or complete thrombosis of the shunt. Technical success, clinical success and complications were followed for 495 ⫾ 243 days. Results: 100% technical success rate (defined as achieving complete occlusion of efferent shunt with partial or complete thrombosis of the shunt) was demonstrated in all 20 patients. Clinical success rate (defined as resolution or improvement of hepatic encephalopathy) was 85%. Five patients received liver transplant during follow up. Four patients (20%) required additional CARTO procedure as new shunts appeared or due to no clinical improvement from partial thrombosis. A 20% mortality rate was noted during follow up. Minor postprocedure complications (transient increase of LFTs, fever, abdominal discomfort) were noted in 9 patients (45%). The mean pre-/post-CARTO Ammonia levels were 139.83 ⫾ 39.20 and 61.5 ⫾ 16.02, respectively. Conclusion: CARTO appears technically feasible and relatively safe method of treating refractory hepatic encephalopathy for patients otherwise considered as palliative and nontransplant candidates.
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