Percutaneous transluminal angioplasty for symptomatic hepatic vein-type Budd-Chiari syndrome: feasibility and long-term outcomes

For management of Budd-Chiari syndrome (BCS), a step-wise therapeutic approach starting with medical treatment, followed by endovascular recanalization, transjugular intrahepatic portosystemic shunt, and finally liver transplantation has been adopted. We retrospectively analyzed 51 patients with symptomatic short segment (<= 30 mm) hepatic vein (HV)-type BCS who underwent percutaneous transluminal balloon angioplasty (PTBA) with/without stenting to determine the feasibility, clinical effectiveness, and long-term outcomes. The intervention was technically successful in 94.1% of cases (48/51)-32 patients underwent PTBA and 16 patients underwent HV stenting. Procedure-related complications occurred in 14 patients (29.1%). The clinical success rate at 4 weeks was 91.7% (44/48). Nine patients underwent reintervention, six patients due to restenosis/occlusion and three patients with clinical failure. The mean primary patency duration was 64.6 +/- 19.9 months (CI, 58.5-70.8; range, 1.2-81.7 months). The cumulative 1-, 2-, and 5-year primary patency rates were 85.4, 74.5, and 58.3%, respectively. The cumulative 1-, 2-, and 5-year secondary patency rates were 93.8, 87.2, and 75%, respectively. The cumulative 1-, 2-, and 5-year survival rates were 97.9, 91.5, and 50%, respectively. Percutaneous transluminal angioplasty with and without stenting is effective and achieves excellent long-term patency and survival rates in patients with symptomatic HV-type BCS. With its lower incidence of re-occlusion and higher clinical success rate, HV angioplasty combined with stenting should be the preferred option especially in patients with segmental HV-type BCS

A radiomics-based model to classify the etiology of liver cirrhosis using gadoxetic acid-enhanced MRI

The implementation of radiomics in radiology is gaining interest due to its wide range of applications. To develop a radiomics-based model for classifying the etiology of liver cirrhosis using gadoxetic acid-enhanced MRI, 248 patients with a known etiology of liver cirrhosis who underwent 306 gadoxetic acid-enhanced MRI examinations were included in the analysis. MRI examinations were classified into 6 groups according to the etiology of liver cirrhosis: alcoholic cirrhosis, viral hepatitis, cholestatic liver disease, nonalcoholic steatohepatitis (NASH), autoimmune hepatitis, and other. MRI examinations were randomized into training and testing subsets. Radiomics features were extracted from regions of interest segmented in the hepatobiliary phase images. The fivefold cross-validated models (2-dimensional-(2D) and 3-dimensional-(3D) based) differentiating cholestatic cirrhosis from noncholestatic etiologies had the best accuracy (87.5%, 85.6%), sensitivity (97.6%, 95.6%), predictive value (0.883, 0.877), and area under curve (AUC) (0.960, 0.910). The AUC was larger in the 2D-model for viral hepatitis, cholestatic cirrhosis, and NASH-associated cirrhosis (P-value of 0.05, 0.05, 0.87, respectively). In alcoholic cirrhosis, the AUC for the 3D model was larger (P=0.01). The overall intra-class correlation coefficient (ICC) estimates and their 95% confident intervals (CI) for all features combined was 0.68 (CI 0.56-0.87) for 2D and 0.71 (CI 0.61-0.93) for 3D measurements suggesting moderate reliability. Radiomics-based analysis of hepatobiliary phase images of gadoxetic acid-enhanced MRI may be a promising noninvasive method for identifying the etiology of liver cirrhosis with better performance of the 2D- compared with the 3D-generated models

Impact of interventionalist’s experience and gender on radiation dose and procedural time in CT-guided interventions—a retrospective analysis of 4380 cases over 10 years

Objectives: To investigate the impact of the interventionalist's experience and gender on radiation dose and procedural time in CT-guided interventions. Methods: We retrospectively analyzed 4380 CT-guided interventions performed at our institution with the same CT scanner from 2009 until 2018, 1287 (29%) by female and 3093 (71%) by male interventionalists. Radiation dose, number of CT fluoroscopy images taken per intervention, total procedural time, type of intervention, and degree of difficulty were derived from the saved dose reports and images. All 16 interventionalists included in this analysis performed their first CT-guided interventions during the study period, and interventions performed by each interventionalist were counted to assess the level of experience for each intervention in terms of the number of prior interventions performed by her or him. The Mann-Whitney U test (MWU test), multivariate regression, and linear mixed model analysis were performed. Results: Assessment of the impact of gender with the MWU test revealed that female interventionalists took a significantly smaller number of images (p < 0.0001) and achieved a lower dose-length product per intervention (p < 0.0001) while taking more time per intervention (p = 0.0001). This finding was confirmed for most types of interventions when additionally accounting for other possible impact factors in multivariate regression analysis. In linear mixed model analysis, we found that radiation dose, number of images taken per intervention, and procedural time decreased statistically significantly with interventionalist's experience. Conclusions: Radiation doses of CT-guided interventions are reduced by interventionalist's experience and, for most types of interventions, when performed by female interventionalists. Key points: • Radiation doses in CT-guided interventions are lower when performed by female interventionalists. • Procedural times of CT-guided interventions are longer when performed by female interventionalists. • Radiation doses of CT-guided interventions decrease with the interventionalist's experience

MR imaging of hepatocellular carcinoma: prospective intraindividual head-to-head comparison of the contrast agents gadoxetic acid and gadoteric acid

The routine use of dynamic-contrast-enhanced MRI (DCE-MRI) of the liver using hepatocyte-specific contrast agent (HSCA) as the standard of care for the study of focal liver lesions is not widely accepted and opponents invoke the risk of a loss in near 100% specificity of extracellular contrast agents (ECA) and the need for prospective head-to-head comparative studies evaluating the diagnostic performance of both contrast agents. The Purpose of this prospective intraindividual study was to conduct a quantitative and qualitative head-to-head comparison of DCE-MRI using HSCA and ECA in patients with liver cirrhosis and HCC. Twenty-three patients with liver cirrhosis and proven HCC underwent two 3 T-MR examinations, one with ECA (gadoteric acid) and the other with HSCA (gadoxetic acid). Signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), wash-in, wash-out, image quality, artifacts, lesion conspicuity, and major imaging features of LI-RADS v2018 were evaluated. Wash-in and wash-out were significantly stronger with ECA compared to HSCA (P < 0.001 and 0.006, respectively). During the late arterial phase (LAP), CNR was significantly lower with ECA (P = 0.005), while SNR did not differ significantly (P = 0.39). In qualitative analysis, ECA produced a better overall image quality during the portal venous phase (PVP) and delayed phase (DP) compared to HSCA (P = 0.041 and 0.008), showed less artifacts in the LAP and PVP (P = 0.003 and 0.034) and a higher lesion conspicuity in the LAP and PVP (P = 0.004 and 0.037). There was no significant difference in overall image quality during the LAP (P = 1), in artifacts and lesion conspicuity during the DP (P = 0.078 and 0.073) or in the frequency of the three major LI-RADS v2018 imaging features. In conclusion, ECA provides superior contrast of HCC-especially hypervascular HCC lesions-in DCE-MR in terms of better perceptibility of early enhancement and a stronger washout

Gadoxetic acid-enhanced magnetic resonance imaging as an imaging-based liver function test

The aim of the study is to further corroborate the validity of gadoxetic acid-enhanced magnetic resonance imaging (MRI) as an imaging-based liver function test. In this context, we compared gadoxetic acid-enhanced MRI T1 relaxometry-derived indices with the 13C-methacetin breath test (LiMAx test) in 53 patients who underwent MRI examinations less than 30 days apart from the LiMAx test. [Original work1] For further validation, we assessed the consistency of gadoxetic acid-enhanced MRI as an imaging-based liver function test across serial examinations, different MRI scanners and field strengths (1.5 T and 3.0 T) and investigated variable factors that may affect the uptake of gadoxetic acid, i.e., predictors of relative enhancement (RE) of the liver in the hepatobiliary phase (HBP). We retrospectively investigated 554 patients who underwent two or more gadoxetic acid-enhanced MRI examinations. RE of the liver in the HBP, liver-to-muscle ratio (LMR), liver-to-spleen ratio (LSR) and T1 reduction rate (T1 RR) were calculated. [Original work 2] In a subgroup analysis of patients undergoing chemotherapy (n = 238), we observed a significant decrease in RE, i.e., liver function, between two consecutive MRI examinations. Based on this observation, we conducted a study to evaluate the hepatotoxicity of different chemotherapeutic agents using gadoxetic acid-enhanced MRI in 129 patients with neuroendocrine tumors (NETs) who underwent at least two serial MRI examinations (a total of 539 MRI). [Original work 3] In conclusion, the significant correlation of T1 relaxometry derived-indices with LiMAx test, the consistency and reproducibility of RE of the liver over time and across different MRI scanners and field strengths, as well as the possibility of estimating chemotherapy-induced liver impairment, i.e., the hepatotoxic effect of different chemotherapeutic agents using gadoxetic acid-enhanced MRI, represent the major findings in our studies. These observations further emphasize gadoxetic acid-enhanced MRI as an imaging-based liver function test, which could have a paramount influence on patient care as it may be easily integrated into clinical routine.Ziel der Studien war es, die Validität der Gadoxetsäure-verstärkten (Gd-EOB) MRT als bildgestützten Leberfunktionstest zu validieren. In diesem Zusammenhang haben wir bei 53 Patienten retrospektiv die Gd-EOB-verstärkte T1-Relaxometrie mit dem 13C-Methacetin-Atemtest (LiMAx-Test) verglichen, bei denen sowohl eine MRT als auch der LiMAx-Test durchgeführt wurde. [Originalarbeit1] Weitere Arbeiten hatten die Bewertung der longitudinalen Konsistenz und Reproduzierbarkeit der Gd-EOB-verstärkten MRT als Leberfunktionstest zum Ziel. Desweiteren sollte der Einfluß verschiedener Geräte und Magnetfeldstärken (1,5 T und 3,0 T) sowie die Bestimmung von Faktoren, die die Aufnahme von Gd-EOB beeinflussen können, d.h. Prädiktoren der relativen Enhancement der Leber untersucht werden [Originalarbeit 2]. In einer Subgruppen-Analyse von Patienten, bei denen eine Chemotherapie durchgeführt wurde (n = 238), beobachteten wir eine signifikante Abnahme des relativen Enhancements, d.h. der Leberfunktion, zwischen zwei konsekutiven MRT-Untersuchungen. Aufgrund dieser Feststellung führten wir eine weitere Studie durch, um mittels Gd-EOB-verstärkter MRT bei 129 Patienten die Hepatotoxizität verschiedener Chemotherapeutika mit neuroendokrinen Tumoren (NETs) zu bewerten, die sich zwei oder mehr seriellen MRT-Untersuchungen unterzogen (insgesamt 539 MRT). [Originalarbeit 3] Zusammenfassend stellen die signifikante Korrelation der T1-Relaxometrie mit dem LiMAx-Test, die Konsistenz und Reproduzierbarkeit des relativen Enhancements über die Zeit und über verschiedene Geräte und Magnetfeldstärken sowie die Möglichkeit der Abschätzung der Chemotherapie-induzierten Leberschädigung, d.h. der hepatotoxischen Wirkung verschiedener Chemotherapeutika, unter Verwendung der Gd-EOB-verstärkten MRT, die Hauptergebnisse unserer Studien dar. Diese Beobachtungen validieren die Gd-EOB-verstärkte MRT als bildgestützten Leberfunktionstest, der einen großen Einfluss auf die Patientenversorgung haben könnte, da er sich einfach in die klinische Routine integrieren lässt

Gadoxetic acid-enhanced MRI in primary sclerosing cholangitis: added value in assessing liver function and monitoring disease progression

Purpose: To investigate the added value of gadoxetic acid-enhanced MRI in monitoring liver function and disease progression in patients with primary sclerosing cholangitis (PSC). Methods: We retrospectively identified 104 consecutive patients (75 males; mean age 41.98 ± 12.5 years) with confirmed diagnosis of PSC who underwent 227 gadoxetic acid-enhanced MRI examinations between January 2008 and May 2019. Relative enhancement (RE) of the liver was correlated with the results of liver function tests (LFTs), scoring models (Model for End-Stage Liver Disease (MELD) score, Mayo Risk Score (MRS), Amsterdam-Oxford model (AOM)), and qualitative MRI findings. In addition, results were analyzed separately for excretory MRI examinations (n = 164) and nonexcretory examinations (n = 63) depending on excretion of gadoxetic acid into the common bile duct in the hepatobiliary phase (HBP). Results: There was a significant correlation of RE with MRS (r = − 0.652), MELD score (r = − 0.474), AOM (r = − 0.468), and LFTs (P < 0.001). RE and albumin were significantly higher in the excretory group whereas scoring models, bilirubin, aspartate aminotransferase, alkaline phosphatase, and international normalized ratio were lower (P < 0.001). RE was lower in segments with absent HBP gadoxetic acid excretion into dilated bile ducts, reduced HBP parenchymal enhancement, atrophy, T2 hyperintensity, and bile duct abnormalities (P < 0.001). Conclusion: Relative enhancement of the liver in gadoxetic acid-enhanced MRI can be used to evaluate global and regional liver function and monitor disease progression in patients with PSC. Hepatobiliary phase gadoxetic acid biliary excretion appears to be a reproducible qualitative parameter for evaluating disease severity that can be easily integrated into routine clinical practice

Stent performance in palliative transhepatic treatment of malignant biliary obstruction: a randomized study comparing covered versus uncovered stents

Background: Considering the limitations in both uncovered self-expandable metallic stents (USEMS) and covered selfexpandable metallic stents (CSEMS), it is difficult to make a general recommendation for their application in percutaneous decompression of malignant biliary obstruction (MBO). Purpose: To compare percutaneous transhepatic CSEMSs versus USEMSs for the palliative treatment of MBO in terms of technical success, clinical success, stent patency, patient survival, complications, and stent dysfunction. Material and Methods: This prospective randomized study included 66 patients with unresectable MBO. CSEMSs were inserted in 31 patients (26 men, 5 women; mean age¼63.8 7.96 years) and USEMSs were inserted in 35 patients (26 men, 9 women; mean age¼62.3 11.7 years). Results: Mean primary stent patency duration was 138 92.7 days in CSEMSs versus 150 77.9 days in USEMSs (P¼0.578). Tumor overgrowth occurred exclusively in one patient with CSEMS (P¼0.470) and tumor ingrowth exclusively in two patients with USEMS (P¼0.494). Stent migration occurred in two patients with CSEMSs versus one patient with USEMSs (P¼0.579). Hemobilia occurred in five patients with CSEMSs versus three patients with USEMSs while bile leakage occurred in one patient in each group despite the larger introducer sheath caliber with CSEMSs (9 F vs. 6–7 F). There was no significant difference regarding patient survival (P¼0.969). Conclusion: In our cohort of patients with rather poor life expectancy, there was no significant difference between covered and uncovered stents for the palliative treatment of MBO. However, considering the higher cost of CSEMs and the larger introducer diameter necessary for their placement, USEMSs can be preferred

Treatment of right hepatic artery stump bleeding after pylorus-preserving pancreaticoduodenectomy by covered stent endoprosthesis placement

Serious complications after pancreaticoduodenectomy include rupture of pseudoaneurysms arising from pancreatic fistula and pancreatojejunostomy leakage. We report a case of successful endovascular minimally invasive treatment using a covered stent endoprosthesis of a right hepatic artery stump bleeding following pylorus-preserving pancreaticoduodenectomy that was not suitable for coil or glue embolization due to an insufficiently short neck

Evaluation of a prototype metal artifact reduction algorithm for cone beam CT in patients undergoing radioembolization

Abstract Metal artifacts notoriously pose significant challenge in computed tomography (CT), leading to inaccuracies in image formation and interpretation. Artifact reduction tools have been designed to improve cone beam computed tomography (CBCT) image quality by reducing artifacts caused by certain high-density materials. Metal artifact reduction (MAR) tools are specific algorithms that are applied during image reconstruction to minimize or eliminate artifacts degrading CBCT images. The purpose of the study is to evaluate the effect of a MAR algorithm on image quality in CBCT performed for evaluating patients before transarterial radioembolization (TARE). We retrospectively included 40 consecutive patients (aged 65 ± 13 years; 23 males) who underwent 45 CBCT examinations (Allura FD 20, XperCT Roll protocol, Philips Healthcare, Best, The Netherlands) in the setting of evaluation for TARE between January 2017 and December 2018. Artifacts caused by coils, catheters, and surgical clips were scored subjectively by four readers on a 5-point scale (1 = artifacts affecting diagnostic information to 5 = no artifacts) using a side-by-side display of uncorrected and MAR-corrected images. In addition, readers scored tumor visibility and vessel discrimination. MAR-corrected images were assigned higher scores, indicating better image quality. The differences between the measurements with and without MAR were most impressive for coils with a mean improvement of 1.6 points (95%CI [1.5 1.8]) on the 5-point likert scale, followed by catheters 1.4 points (95%CI [1.3 1.5]) and clips 0.7 points (95%CI [0.3 1.1]). Improvements for other artifact sources were consistent but relatively small (below 0.25 points on average). Interrater agreement was good to perfect (Kendall’s W coefficient = 0.68–0.95) and was higher for MAR-corrected images, indicating that MAR improves diagnostic accuracy. A metal artifact reduction algorithm can improve diagnostic and interventional accuracy of cone beam CT in patients undergoing radioembolization by reducing artifacts caused by diagnostic catheters and coils, lowering interference of metal artifacts with adjacent major structures, and improving tumor visibility