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Clearing the confusion on hepatic encephalopathy after TIPS creation: incidence, prognostic factors, and clinical outcomes
S120
’
Wednesday
2:24 PM
Scientific Session
Abstract No. 256
Renal transplant arterial stenosis treated with BMS vs DES stents: comparison of short term treatment outcomes
WEDNESDAY: Scientific Sessions
R.F. Hanna, V. Sheynzon, S.Z. Brejt, J. Susman, D.C. Sperling, J. Weintraub, P. Schlossberg; Interventional Radiology, NY Presbyterian Hospital, Columbia, New York, NY Purpose: Our study aim was to evaluate outcomes of bare metal stents (BMS) versus drug eluting stents (DES) in patients who undergo stenting for renal transplant arterial stenosis. Materials and Methods: We retrospectively reviewed records of renal transplant patients who underwent an IR procedure from September 2009 to September 2013 to identify those who underwent transplant arterial stenting. Because DES are only available in small diameters, all stents greater than 5 mm were excluded to allow for equivalent comparison between the two groups. Stenting indications were reviewed and recorded. Statistical comparisons were performed using a two tailed Fischer’s exact test. Results: Renal transplant arterial stenting was performed in 35 of 133 renal transplant patients who underwent an IR procedure. Of these, 18 received stents of 5 mm or smaller, 11 BMS and 7 DES, and were included in the final study population. Patients included 12 with rising creatinine, one with elevated blood pressure, four with elevated velocities/resistive indices on Doppler ultrasound, and one with two causes. Post-stenting, one BMS patient underwent re-stenting, three angioplasty, and seven required no reintervention; in DES, zero, zero, and seven, respectively. There were more reinterventions with BMS (n¼4/11) than DES (n¼0/7) but not statistically significant (p¼0.12). In BMS, two of five patients on dialysis recovered renal function after stenting; in DES, zero of three (p¼0.19). Conversely, in BMS, one of six patients not on dialysis before stenting never improved and required dialysis; in DES, zero of four (p¼1.0). Conclusion: Our 4 year records comparing patients with renal transplant arterial BMS versus DES of 5 mm or smaller diameter reveal that there is an absolute but not statistically significant difference in the incidence of restenosis requiring repeat intervention between the two groups. However, this may be due to our small sample size. Future larger studies will be needed to corroborate these findings.
2:33 PM
Scientific Session 28 Portal and Transplant Interventions II
’ FEATURED ABSTRACT Catheter-directed transmural IRE ablation in the porcine ureter: functional and histologic assessment over 1 month
Purpose: n a prior experimental study, we demonstrated the feasibility of intraluminal IRE using a catheter-mounted device with acute preservation of porcine ureter architecture
JVIR
and function. In this study, we examined renal function, imaging and histologic outcomes up to 4 weeks after intraluminal IRE in the healthy porcine ureter. Materials and Methods: Fluoroscopically guided cathetermounted intraluminal IRE ablation was performed on 8 healthy porcine ureters. Two ablations (2000V, 90 pulses of 100μs duration) were performed in each animal, one each in the proximal and distal ureter. Ureter patency was assessed by fluoroscopy immediately following ablation again by delayed contrast phase CT prior to ureter resection and histologic assessment at 24 hours, 1 week, 2 week or 4 weeks following treatment (4 treatments per time point). Renal function was assessed using blood creatinine levels. Histologic samples were analyzed using H&E and Masson’s Trichome stains. Results: IRE was successfully performed in all animals with preservation of luminal diameter and urine flow in the immediate post-ablation period. All animals tolerated the procedure well and survived through the intended period of observation. Histologically, urothelial loss was evident in regions of sharply demarcated transmural ablation by 24 hours. By 1 week, fibrosis replaced the normal ureteral architecture and surrounding tissue, though partial urothelial regeneration was seen. Between the 2 and 4 week time points, there was complete replacement of smooth muscle with granulation tissue and fibrosis of the ureter resulting in a stricture. Renal function measured by serum creatinine remained within normal range in all animals. Mild hydonephrosis and urinary stricture manifested on imaging in all animals at the one week timepoint, all cases progressed to moderate/severe hydronephrosis at 2 and 4 weeks respectively. Urinary leakage was observed in two animals. Conclusion: Intraluminal catheter directed IRE ablation extending into the smooth muscle layers of the porcine ureter leads to fibrosis and stricture formation over the course of 1 month. Use of IRE in the GU tract requires further investigation to improve safety and reduce adverse events.
Abstract No. 257
G. Srimathveeravalli1, T. Wimmer2, S. Monette1, S. Kimm3, J. Coleman3, S.B. Solomon1, J.C. Durack1; 1 Radiology, Memorial Sloan Kettering Cancer Center, New York, NY; 2Radiology, Medical University of Graz, Graz, Austria; 3Urology, Memorial Sloan Kettering Cancer Center, New York, NY
’
Wednesday, March 26, 2014 1:30 PM – 3:00 PM Room: 4 1:30 PM
Abstract No. 258
Clearing the confusion on hepatic encephalopathy after TIPS creation: incidence, prognostic factors, and clinical outcomes
JVIR
’
Scientific Session
Wednesday
’
S121
L.C. Casadaban, A. Parvinian, J. Minocha, M. Knuttinen, J.T. Bui, R.C. Gaba; Radiology, University of Illinois Hospital, Chicago, IL
5
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, 254 consecutive patients (M:F¼159:96, mean age 54 years, mean Model for End Stage Liver Disease or MELD score 16.5) who underwent TIPS creation between 1999-2013 were studied. Medical record review was used to identify demographic (age, gender), liver disease (etiology, Child-Pugh score, MELD score), procedure (stent type, portosystemic pressure gradient or PSG measurements), and outcome data (HE development, 90-day mortality). Post-TIPS HE was defined by new mental status changes (confusion) or alterations in level of consciousness, and was graded according to the West Haven classification system. The influence of data parameters on occurrence of HE was assessed using binary logistic regression. Results: TIPS were successfully created using covered (n¼195) or bare metal (n¼60) stents. Hemodynamic success was achieved in 97% cases. Mean final PSG was 7 mm Hg. Incidence of HE within 30-days of TIPS was 34% (86/255). Degrees of HE included grade 0 (n¼10, 11.5%), grade 1 (n¼43, 50%), grade 2 (n¼11, 13%), grade 3 (n¼12, 14%), and grade 4 (n¼10, 11.5%). Medical therapy generally addressed HE successfully; shunt reduction was necessary in only 2 cases. Patient age (P¼0.029) was significantly associated with HE development on univariate and multivariate analysis. Mean age of patients with and without HE were 56 versus 53 years. When 56 years was used as a threshold, incidence of HE was 42% versus 29% in older and younger patients (P ¼ 0.026), respectively. Occurrence of HE did not increase short-term (90day) mortality (19/86 or 22% versus 41/169 or 24%, P¼0.700). Conclusion: The incidence of HE post-TIPS is non-trivial, but symptoms are typically mild and occurrence does not adversely affect short-term patient survival. HE rates are higher in older patients, and age should be contemplated when counseling patients on expected TIPS outcomes and post-procedure course.
Purpose: To evaluate the feasibility of electromagnetic tracking (EMT) transjugular intrahepatic portosystemic shunt (TIPS) placement in a phantom and in vivo setting. Materials and Methods: A custom designed TIPS set consisting of a stainless steel stylet, a polypropylene catheter and a stainless steel outer canula was developed. In the tip of both stylet and outer canula coils were integrated to allow tip detection through an electromagnetic tracking system (Aurora, Northern Digital, Waterloo, Canada). For navigation of the TIPS set a software prototype was developed that allows visualization of both the stylet and the outer canula tip position in a previously acquired C-arm CT dataset. The EMT-TIPS procedure was performed in a custom made gel-wax phantom (n¼80 trials) and in 8 domestic pigs. Domestic pigs were chosen as an animal model for challenging TIPS procedures. Time/number of punctures aiming at the portal vein were recorded. Results: In the phantom setting intervention time to cannulate the portal vein (PV) was 144.0 ⫾ 62.8 s A mean of 1.2 ⫾ 0.4 punctures were needed for PV cannulation.In the in vivo trials the TIPS procedure was successfully performed in 5 out of 8 animals. Time for the complete TIPS procedure including prosthesis placement ranged from 40 to 562 minutes with a notable learning curve between the trials. Conclusion: EMT-guidance of TIPS placement proved to be feasible in vitro as well as in vivo. The system holds promise to substantially facilitate challenging TIPS procedures.
Abstract No. 259
Electromagnetically navigated TIPS procedure: phantom and in vivo evaluation P. Isfort1, H. Na1, T. Penzkofer1,2, C. Wilkmann1, S. Osterhues3, A. Besting4, C. Hänisch5, S. Bisplinghoff5, J. Jansing5, S. von Werder6, J. Gooding6, M. de la Fuente5, A.H. Mahnken1, C. Disselhorst-Klug6, T. Schmitz-Rode6, C. Kuhl1, P. Bruners1; 1Department of Diagnostic and Interventional Radiology, RWTH Aachen University, Aachen, Germany; 2Surgical Planning Laboratory, Brigham and Women’s Hospital, Boston, MA; 3Vygon GmbH, Vygon GmbH, Aachen, Germany; 4 SurgitAIX AG, SurgitAIX AG, Herzogenrath, Germany;
1:48 PM
Abstract No. 260
Short term efficacy and safety of balloon-occluded retrograde transvenous obliteration of portosystemic shunt in patients with hepatic encephalopathy S. Suzuki1,2, A. Komemushi1, A. Sano3, S. Kariya1, S. Kanno1, M. Nakatani1, R.Y. Yoshida1, Y. Kono1, N. Tanigawa1; 1Radiology, Kansai medical university, Hirakata, Japan; 2Emergency and critical care medicine, Saiseikai noe hospital, Osaka, Japan; 3Radiology, Saiseikai izuo hospital, Osaka, Japan Purpose: Balloon-occluded retrograde transvenous obliteration (BRTO) is a widely accepted treatment for gastric varices, but data are limited in regard to its role in the management of hepatic encephalopathy (HE). This study evaluated efficacy and safety of BRTO in the management of HE due to portsystemic shunt. Materials and Methods: Seventeen sessions of BRTO were performed in sixteen patients with cirrhosis complicated by HE. All patients had portosystemic shunts. Clinical, radiological, endoscopic, and laboratory examinations including serum ammonia level were evaluated in all patients at preand post-procedure.
WEDNESDAY: Scientific Sessions
1:39 PM
Medical Engineering, RWTH Aachen University, Aachen, Germany; 6Applied Medical Engineering, RWTH Aachen University, Aachen, Germany
’
Wednesday
2:24 PM
Scientific Session
Abstract No. 256
Renal transplant arterial stenosis treated with BMS vs DES stents: comparison of short term treatment outcomes
WEDNESDAY: Scientific Sessions
R.F. Hanna, V. Sheynzon, S.Z. Brejt, J. Susman, D.C. Sperling, J. Weintraub, P. Schlossberg; Interventional Radiology, NY Presbyterian Hospital, Columbia, New York, NY Purpose: Our study aim was to evaluate outcomes of bare metal stents (BMS) versus drug eluting stents (DES) in patients who undergo stenting for renal transplant arterial stenosis. Materials and Methods: We retrospectively reviewed records of renal transplant patients who underwent an IR procedure from September 2009 to September 2013 to identify those who underwent transplant arterial stenting. Because DES are only available in small diameters, all stents greater than 5 mm were excluded to allow for equivalent comparison between the two groups. Stenting indications were reviewed and recorded. Statistical comparisons were performed using a two tailed Fischer’s exact test. Results: Renal transplant arterial stenting was performed in 35 of 133 renal transplant patients who underwent an IR procedure. Of these, 18 received stents of 5 mm or smaller, 11 BMS and 7 DES, and were included in the final study population. Patients included 12 with rising creatinine, one with elevated blood pressure, four with elevated velocities/resistive indices on Doppler ultrasound, and one with two causes. Post-stenting, one BMS patient underwent re-stenting, three angioplasty, and seven required no reintervention; in DES, zero, zero, and seven, respectively. There were more reinterventions with BMS (n¼4/11) than DES (n¼0/7) but not statistically significant (p¼0.12). In BMS, two of five patients on dialysis recovered renal function after stenting; in DES, zero of three (p¼0.19). Conversely, in BMS, one of six patients not on dialysis before stenting never improved and required dialysis; in DES, zero of four (p¼1.0). Conclusion: Our 4 year records comparing patients with renal transplant arterial BMS versus DES of 5 mm or smaller diameter reveal that there is an absolute but not statistically significant difference in the incidence of restenosis requiring repeat intervention between the two groups. However, this may be due to our small sample size. Future larger studies will be needed to corroborate these findings.
2:33 PM
Scientific Session 28 Portal and Transplant Interventions II
’ FEATURED ABSTRACT Catheter-directed transmural IRE ablation in the porcine ureter: functional and histologic assessment over 1 month
Purpose: n a prior experimental study, we demonstrated the feasibility of intraluminal IRE using a catheter-mounted device with acute preservation of porcine ureter architecture
JVIR
and function. In this study, we examined renal function, imaging and histologic outcomes up to 4 weeks after intraluminal IRE in the healthy porcine ureter. Materials and Methods: Fluoroscopically guided cathetermounted intraluminal IRE ablation was performed on 8 healthy porcine ureters. Two ablations (2000V, 90 pulses of 100μs duration) were performed in each animal, one each in the proximal and distal ureter. Ureter patency was assessed by fluoroscopy immediately following ablation again by delayed contrast phase CT prior to ureter resection and histologic assessment at 24 hours, 1 week, 2 week or 4 weeks following treatment (4 treatments per time point). Renal function was assessed using blood creatinine levels. Histologic samples were analyzed using H&E and Masson’s Trichome stains. Results: IRE was successfully performed in all animals with preservation of luminal diameter and urine flow in the immediate post-ablation period. All animals tolerated the procedure well and survived through the intended period of observation. Histologically, urothelial loss was evident in regions of sharply demarcated transmural ablation by 24 hours. By 1 week, fibrosis replaced the normal ureteral architecture and surrounding tissue, though partial urothelial regeneration was seen. Between the 2 and 4 week time points, there was complete replacement of smooth muscle with granulation tissue and fibrosis of the ureter resulting in a stricture. Renal function measured by serum creatinine remained within normal range in all animals. Mild hydonephrosis and urinary stricture manifested on imaging in all animals at the one week timepoint, all cases progressed to moderate/severe hydronephrosis at 2 and 4 weeks respectively. Urinary leakage was observed in two animals. Conclusion: Intraluminal catheter directed IRE ablation extending into the smooth muscle layers of the porcine ureter leads to fibrosis and stricture formation over the course of 1 month. Use of IRE in the GU tract requires further investigation to improve safety and reduce adverse events.
Abstract No. 257
G. Srimathveeravalli1, T. Wimmer2, S. Monette1, S. Kimm3, J. Coleman3, S.B. Solomon1, J.C. Durack1; 1 Radiology, Memorial Sloan Kettering Cancer Center, New York, NY; 2Radiology, Medical University of Graz, Graz, Austria; 3Urology, Memorial Sloan Kettering Cancer Center, New York, NY
’
Wednesday, March 26, 2014 1:30 PM – 3:00 PM Room: 4 1:30 PM
Abstract No. 258
Clearing the confusion on hepatic encephalopathy after TIPS creation: incidence, prognostic factors, and clinical outcomes
JVIR
’
Scientific Session
Wednesday
’
S121
L.C. Casadaban, A. Parvinian, J. Minocha, M. Knuttinen, J.T. Bui, R.C. Gaba; Radiology, University of Illinois Hospital, Chicago, IL
5
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, 254 consecutive patients (M:F¼159:96, mean age 54 years, mean Model for End Stage Liver Disease or MELD score 16.5) who underwent TIPS creation between 1999-2013 were studied. Medical record review was used to identify demographic (age, gender), liver disease (etiology, Child-Pugh score, MELD score), procedure (stent type, portosystemic pressure gradient or PSG measurements), and outcome data (HE development, 90-day mortality). Post-TIPS HE was defined by new mental status changes (confusion) or alterations in level of consciousness, and was graded according to the West Haven classification system. The influence of data parameters on occurrence of HE was assessed using binary logistic regression. Results: TIPS were successfully created using covered (n¼195) or bare metal (n¼60) stents. Hemodynamic success was achieved in 97% cases. Mean final PSG was 7 mm Hg. Incidence of HE within 30-days of TIPS was 34% (86/255). Degrees of HE included grade 0 (n¼10, 11.5%), grade 1 (n¼43, 50%), grade 2 (n¼11, 13%), grade 3 (n¼12, 14%), and grade 4 (n¼10, 11.5%). Medical therapy generally addressed HE successfully; shunt reduction was necessary in only 2 cases. Patient age (P¼0.029) was significantly associated with HE development on univariate and multivariate analysis. Mean age of patients with and without HE were 56 versus 53 years. When 56 years was used as a threshold, incidence of HE was 42% versus 29% in older and younger patients (P ¼ 0.026), respectively. Occurrence of HE did not increase short-term (90day) mortality (19/86 or 22% versus 41/169 or 24%, P¼0.700). Conclusion: The incidence of HE post-TIPS is non-trivial, but symptoms are typically mild and occurrence does not adversely affect short-term patient survival. HE rates are higher in older patients, and age should be contemplated when counseling patients on expected TIPS outcomes and post-procedure course.
Purpose: To evaluate the feasibility of electromagnetic tracking (EMT) transjugular intrahepatic portosystemic shunt (TIPS) placement in a phantom and in vivo setting. Materials and Methods: A custom designed TIPS set consisting of a stainless steel stylet, a polypropylene catheter and a stainless steel outer canula was developed. In the tip of both stylet and outer canula coils were integrated to allow tip detection through an electromagnetic tracking system (Aurora, Northern Digital, Waterloo, Canada). For navigation of the TIPS set a software prototype was developed that allows visualization of both the stylet and the outer canula tip position in a previously acquired C-arm CT dataset. The EMT-TIPS procedure was performed in a custom made gel-wax phantom (n¼80 trials) and in 8 domestic pigs. Domestic pigs were chosen as an animal model for challenging TIPS procedures. Time/number of punctures aiming at the portal vein were recorded. Results: In the phantom setting intervention time to cannulate the portal vein (PV) was 144.0 ⫾ 62.8 s A mean of 1.2 ⫾ 0.4 punctures were needed for PV cannulation.In the in vivo trials the TIPS procedure was successfully performed in 5 out of 8 animals. Time for the complete TIPS procedure including prosthesis placement ranged from 40 to 562 minutes with a notable learning curve between the trials. Conclusion: EMT-guidance of TIPS placement proved to be feasible in vitro as well as in vivo. The system holds promise to substantially facilitate challenging TIPS procedures.
Abstract No. 259
Electromagnetically navigated TIPS procedure: phantom and in vivo evaluation P. Isfort1, H. Na1, T. Penzkofer1,2, C. Wilkmann1, S. Osterhues3, A. Besting4, C. Hänisch5, S. Bisplinghoff5, J. Jansing5, S. von Werder6, J. Gooding6, M. de la Fuente5, A.H. Mahnken1, C. Disselhorst-Klug6, T. Schmitz-Rode6, C. Kuhl1, P. Bruners1; 1Department of Diagnostic and Interventional Radiology, RWTH Aachen University, Aachen, Germany; 2Surgical Planning Laboratory, Brigham and Women’s Hospital, Boston, MA; 3Vygon GmbH, Vygon GmbH, Aachen, Germany; 4 SurgitAIX AG, SurgitAIX AG, Herzogenrath, Germany;
1:48 PM
Abstract No. 260
Short term efficacy and safety of balloon-occluded retrograde transvenous obliteration of portosystemic shunt in patients with hepatic encephalopathy S. Suzuki1,2, A. Komemushi1, A. Sano3, S. Kariya1, S. Kanno1, M. Nakatani1, R.Y. Yoshida1, Y. Kono1, N. Tanigawa1; 1Radiology, Kansai medical university, Hirakata, Japan; 2Emergency and critical care medicine, Saiseikai noe hospital, Osaka, Japan; 3Radiology, Saiseikai izuo hospital, Osaka, Japan Purpose: Balloon-occluded retrograde transvenous obliteration (BRTO) is a widely accepted treatment for gastric varices, but data are limited in regard to its role in the management of hepatic encephalopathy (HE). This study evaluated efficacy and safety of BRTO in the management of HE due to portsystemic shunt. Materials and Methods: Seventeen sessions of BRTO were performed in sixteen patients with cirrhosis complicated by HE. All patients had portosystemic shunts. Clinical, radiological, endoscopic, and laboratory examinations including serum ammonia level were evaluated in all patients at preand post-procedure.
WEDNESDAY: Scientific Sessions
1:39 PM
Medical Engineering, RWTH Aachen University, Aachen, Germany; 6Applied Medical Engineering, RWTH Aachen University, Aachen, Germany