Comparison of transjugular intrahepatic portosystemic shunt with covered stent and balloon-occluded retrograde transvenous obliteration in managing isolated gastric varices

OBJECTIVE: Although a transjugular intrahepatic portosystemic shunt (TIPS) is commonly placed to manage isolated gastric varices, balloon-occluded retrograde transvenous obliteration (BRTO) has also been used. We compare the long-term outcomes from these procedures based on our institutional experience. MATERIALS AND METHODS: We conducted a retrospective review of patients with isolated gastric varices who underwent either TIPS with a covered stent or BRTO between January 2000 and July 2013. We identified 52 consecutive patients, 27 who had received TIPS with a covered stent and 25 who had received BRTO. We compared procedural complications, re-bleeding rates, and clinical outcomes between the two groups. RESULTS: There were no significant differences in procedural complications between patients who underwent TIPS (7%) and those who underwent BRTO (12%) (p = 0.57). There were also no statistically significant differences in re-bleeding rates from gastric varices between the two groups (TIPS, 7% [2/27]; BRTO, 8% [2/25]; p = 0.94) or in developing new ascites following either procedure (TIPS, 4%; BRTO, 4%; p = 0.96); significantly more patients who underwent TIPS developed hepatic encephalopathy (22%) than did those who underwent BRTO (0%, p = 0.01). There was no statistically significant difference in mean survival between the two groups (TIPS, 30 months; BRTO, 24 months; p = 0.16); median survival for the patients who received TIPS was 16.6 months, and for those who underwent BRTO, it was 26.6 months. CONCLUSION: BRTO is an effective method of treating isolated gastric varices with similar outcomes and complication rates to those of TIPS with a covered stent but with a lower rate of hepatic encephalopathy

Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for the Treatment of Portal Hypertensive Variceal Bleeding: Preliminary Results.

ObjectivesTo describe the technical feasibility, safety, and clinical outcomes of coil-assisted retrograde transvenous obliteration (CARTO) in treating portal hypertensive non-esophageal variceal hemorrhage.MethodsFrom October 2012 to December 2013, 20 patients who received CARTO for the treatment of portal hypertensive non-esophageal variceal bleeding were retrospectively evaluated. All 20 patients had at least 6-month follow-up. All patients had detachable coils placed to occlude the efferent shunt and retrograde gelfoam embolization to achieve complete thrombosis/obliteration of varices. Technical success, clinical success, rebleeding, and complications were evaluated at follow-up.ResultsA 100% technical success rate (defined as achieving complete occlusion of efferent shunt with complete thrombosis/obliteration of bleeding varices and/or stopping variceal bleeding) was demonstrated in all 20 patients. Clinical success rate (defined as no variceal rebleeding) was 100%. Follow-up computed tomography after CARTO demonstrated decrease in size with complete thrombosis and disappearance of the varices in all 20 patients. Thirteen out of the 20 had endoscopic confirmation of resolution of varices. Minor post-CARTO complications, including worsening of esophageal varices (not bleeding) and worsening of ascites/hydrothorax, were noted in 5 patients (25%). One patient passed away at 24 days after the CARTO due to systemic and portal venous thrombosis and multi-organ failure. Otherwise, no major complication was noted. No variceal rebleeding was noted in all 20 patients during mean follow-up of 384±154 days.ConclusionsCARTO appears to be a technically feasible and safe alternative to traditional balloon-occluded retrograde transvenous obliteration or transjugular intrahepatic portosystemic shunt, with excellent clinical outcomes in treating portal hypertensive non-esophageal variceal bleeding

Balloon occlusion retrograde transvenous obliteration of gastric varices in two non-cirrhotic patients with portal vein thrombosis

This report describes two non-cirrhotic patients with portal vein thrombosis who underwent successful balloon occlusion retrograde transvenous obliteration (BRTO) of gastric varices with a satisfactory response and no complications. One patient was a 35-year-old female with a history of Crohn's disease, status post-total abdominal colectomy, and portal vein and mesenteric vein thrombosis. The other patient was a 51-year-old female with necrotizing pancreatitis, portal vein thrombosis, and gastric varices. The BRTO procedure was a useful treatment for gastric varices in non-cirrhotic patients with portal vein thrombosis in the presence of a gastrorenal shunt

A Rare Case of Reversible Encephalopathy Syndrome Accompanying Late Postpartum Eclampsia or Hypertensive Encephalopathy-A Clinical Dilemma

Posterior Reversible Encephalopathy Syndrome (PRES) refers to a clinic-radiologic diagnosis. Clinically it is characterized by non specific symptoms such as headache, confusion, visual disturbances and seizures. The radiological findings in PRES are thought to be due to vasogenic oedema, predominantly in the posterior cerebral hemispheres, and are reversible with appropriate management. We report a case of reversible encephalopathy diagnosed by MRI scan occurring in atypical areas like the caudate and lentiform nuclei of the brain following an uneventful lower segment caesarean section in a normotensive patient, who was successfully treated with antihypertensives, anticonvulsants and supportive treatment. The differential diagnosis of convulsions in the post-partum period is discussed

Using a novel source-localized phase regressor technique for evaluation of the vascular contribution to semantic category area localization in BOLD fMRI.

Numerous studies have shown that gradient-echo blood oxygen level dependent (BOLD) fMRI is biased toward large draining veins. However, the impact of this large vein bias on the localization and characterization of semantic category areas has not been examined. Here we address this issue by comparing standard magnitude measures of BOLD activity in the Fusiform Face Area (FFA) and Parahippocampal Place Area (PPA) to those obtained using a novel method that suppresses the contribution of large draining veins: source-localized phase regressor (sPR). Unlike previous suppression methods that utilize the phase component of the BOLD signal, sPR yields robust and unbiased suppression of large draining veins even in voxels with no task-related phase changes. This is confirmed in ideal simulated data as well as in FFA/PPA localization data from four subjects. It was found that approximately 38% of right PPA, 14% of left PPA, 16% of right FFA, and 6% of left FFA voxels predominantly reflect signal from large draining veins. Surprisingly, with the contributions from large veins suppressed, semantic category representation in PPA actually tends to be lateralized to the left rather than the right hemisphere. Furthermore, semantic category areas larger in volume and higher in fSNR were found to have more contributions from large veins. These results suggest that previous studies using gradient-echo BOLD fMRI were biased toward semantic category areas that receive relatively greater contributions from large veins

Portal vein grafts in hepatic transplantation

Confirmation of patency of the portal vein by either ultrasound or angiography is a routine part of the evaluation of patients being considered for hepatic transplantation. Complete thrombosis of the portal vein usually has been viewed as precluding successful orthotopic hepatic replacement. In addition, some pediatric patients present with extremely small portal veins which, although patent, have proved to be thick walled and sclerotic. Our recent experience has shown that, in both of these situations, successful and complete revascularization of hepatic allografts is quite feasible by using a vein graft to ensure adequate portal venous flow

Imaging the Effects of Oxygen Saturation Changes in Voluntary Apnea and Hyperventilation on Susceptibility-Weighted Imaging

BACKGROUND AND PURPOSE: Cerebrovascular oxygenation changes during respiratory challenges have clinically important implications for brain function, including cerebral autoregulation and the rate of brain metabolism. SWI is sensitive to venous oxygenation level by exploitation of the magnetic susceptibility of deoxygenated blood. We assessed cerebral venous blood oxygenation changes during simple voluntary breath-holding (apnea) and hyperventilation by use of SWI at 3T. MATERIALS AND METHODS: We performed SWI scans (3T; acquisition time of 1 minute, 28 seconds; centered on the anterior commissure and the posterior commissure) on 10 healthy male volunteers during baseline breathing as well as during simple voluntary hyperventilation and apnea challenges. The hyperventilation and apnea tasks were separated by a 5-minute resting period. SWI venograms were generated, and the signal changes on SWI before and after the respiratory stress tasks were compared by means of a paired Student t test. RESULTS: Changes in venous vasculature visibility caused by the respiratory challenges were directly visualized on the SWI venograms. The venogram segmentation results showed that voluntary apnea decreased the mean venous blood voxel number by 1.6% (P < .0001), and hyperventilation increased the mean venous blood voxel number by 2.7% (P < .0001). These results can be explained by blood CO2 changes secondary to the respiratory challenges, which can alter cerebrovascular tone and cerebral blood flow and ultimately affect venous oxygen levels. CONCLUSIONS: These results highlight the sensitivity of SWI to simple and noninvasive respiratory challenges and its potential utility in assessing cerebral hemodynamics and vasomotor responses

Bilateral nonthrombotic subclavian vein obstruction causing upper extremity venous claudication

Venous complications of thoracic outlet obstruction are frequently the result of acute axillosubclavian vein thrombosis, leading to symptoms consistent with venous claudication, including pain, swelling, and cyanotic discoloration. Nonthrombotic subclavian vein obstruction, however, is an uncommon cause of veno-occlusive symptoms. We report the case of a patient who, while running, developed pain consistent with venous claudication in her left arm and subsequently in her right arm. Clinical and hemodynamic evaluation revealed nonthrombotic subclavian vein obstruction, which was relieved by thoracic outlet decompression following first rib resection

Stable Atrial Sensing on Long-Term Follow Up of VDD Pacemakers

Background: The hemodynamic advantages of maintaining AV synchrony through AV synchronous pacing are widely known as compared to single chamber pacing. DDD pacemaker implantation entails higher cost and is technically more challenging than the VDD pacemaker. Methods: Seventy one patients underwent VDD lead (Biotronik GmbH, St. Jude Medical and Medtronic Inc.) implantation at KEM hospital, Mumbai during a period of 3 years through subclavian, axillary and cephalic routes for degenerative, post-surgical or congenital high grade atrioventricular or complete heart block. They were followed up regularly for ventricular threshold and P wave amplitude of the floating atrial dipole. Results: Follow up data of almost 95% of patients is available for a period of 15.8 ± 6.7 months. P wave amplitude at implant was 2.1 ± 0.7mV and at follow up 1.1 ± 0.6mV with mean ventricular threshold of <0.5V at implant and <1V at follow-up. Conclusion: Implantation of a single lead VDD pacemaker is possible in all patients with symptomatic AV block and intact sinus node function without any technical complications. P wave sensing is reliable and consistent with floating atrial lead at an average follow up of 15.8 months, providing an excellent alternative to DDD pacemaker implantation