Recanalization of occlusive transjugular intrahepatic portosystemic shunts inaccessible to the standard transvenous approach

PURPOSEThe aim of this study was to evaluate the feasibility and safety of recanalization of occlusive transjugular intrahepatic portosystemic shunts (TIPS) that are inaccessible to the standard transvenous approach in patients with occlusive bare and covered stents. MATERIALS AND METHODSFrom July 1999 to July 2011, 430 consecutive TIPS were performed at a single institution in patients with chronic liver diseases and complications of portal hypertension. During the follow-up, a TIPS occlusion was detected in 20 cases that could not be crossed using a standard transvenous technique with a hydrophilic guidewire. RESULTSFive cases had a bare stent, and 15 cases had a covered stent. In 19 cases (95%), the Colapinto needle technique was used. The Colapinto needle was advanced at the mouth of the occluded TIPS (n=2) or within the thrombus in the middle-distal shunt (n=16) to provide aid in advancing the hydrophilic guidewire into the portal vein. In one patient, after failure of the Colapinto technique, the combined transhepatic and transvenous approach was used. All of the procedures were successfully performed without complications. CONCLUSIONIn patients with occlusive TIPS, stent recanalization is feasible and safe. The Colapinto needle technique should be used as the first approach, reserving the combined transhepatic and transvenous approach only for failure of this technique

Imaging of hepatocellular carcinoma recurrence after liver transplantation

Liver transplantation (LT) provides the highest survival benefit to patients with unresectable hepatocellular carcinoma (HCC). The Milan criteria have been developed for the selection of LT candidates with the goal of improving survival and maintaining an acceptable risk of HCC recurrence. Despite this, recurrence of HCC after LT occurs in up to 20% of cases and represents a major concern due to the poor prognosis of these patients. Furthermore, several extended criteria for the selection of LT candidates have been proposed to account for the growing demand for organs and the resultant increase in the risk of HCC recurrence. Radiologists should be aware that HCC can recur after LT with multiple organ involvement. Knowledge of the location and radiologic appearance of recurrent HCC is necessary to ensure the choice of the most appropriate therapy. This paper aims to comprehensively summarize the spectrum of HCC recurrence after LT and to examine and discuss the imaging features of these lesions. CRITICAL RELEVANCE STATEMENT: This paper aims to share a review of imaging findings of HCC recurrence after LT and to make radiologists familiar with the spectrum of this disease

Performance of the model for end-stage liver disease score for mortality prediction and the potential role of etiology

Bakground & aims Although discrimination of the model for end stage liver disease (MELD) is generally considered acceptable, its calibration is still unclear. In a validation study, we assessed the discrimination and calibration performance of 3 versions of the model: original MELD-TIPS, used to predict survival after transjugular intra-hepatic portosystemic shunt (TIPS); classic MELD-Mayo; MELD-UNOS, used by United Network for Organ Sharing (UNOS). Recalibration and model updating were also explored. Methods 776 patients submitted to elective TIPS (TIPS cohort), and 445 unselected patients (non-TIPS cohort) were included. Three, 6 and 12-month mortality predictions were calculated by the 3 MELD versions: discrimination was assessed by c-statistics and calibration by comparing deciles of predicted and observed risks. Cox and Fine and Grey models were used for recalibration and prognostic analyses. Results Major patient characteristics in TIPS/non-TIPS cohorts were: viral etiology 402/188, alcoholic 185/130, NASH 65/33; mean follow-up± SD 25±9/19±21months; 3-6-12 month mortality were respectively, 57-102-142/31-47-99. C-statistics ranged from 0.66 to 0.72 in TIPS and 0.66 to 0.76 in non-TIPS cohorts across prediction times and scores. A post-hoc analysis revealed worse c-statistics in non-viral cirrhosis with more pronounced and significant worsening in non-TIPS cohort. Calibration was acceptable with MELD-TIPS but largely unsatisfactory with MELD-Mayo and -UNOS whose performance improved much after recalibration. A prognostic analysis showed that age, albumin, and TIPS indication might be used for a MELD updating. Conclusions In this validation study the MELD performance was largely unsatisfactory, particularly in non-viral cirrhosis. MELD recalibration and candidate variables for a MELD updating are proposed. Lay summary While discrimination performance of the Model for End Stage Liver Disease (MELD) is credited to be fair to good, its calibration, the correspondence of observed to predicted mortality, is still unsettled. We found that application of 3 different versions of the MELD in two independent cirrhosis cohorts yielded largely imprecise mortality predictions particularly in non-viral cirrhosis and propose a validated model recalibration. Candidate variables for a MELD updating are proposed

Imaging in liver transplantation

The aim of this study was to illustrate the role of non-invasive imaging tools such as ultrasonography, multi-detector row computed tomography, and magnetic resonance imaging in the evaluation of pediatric and adult liver recipients and potential liver donors, and in the detection of potential complications arising from liver transplantation

MDCT, MR and interventional radiology in biliary atresia candidates for liver transplantation

The multi-detector computed tomography (MDCT) scan and magnetic resonance (MR) of the abdomen play a key role in the work-up to liver transplantation (LT) by identifying congenital anomalies or cirrhosis-related modifications, conditions that can require changes in surgical technique. Moreover, the MDCT and MR scans allow identification of cirrhotic liver hepatic masses, extrahepatic porto-systemic shunts, eventual thrombosis of portal system and radiological signs of portal hypertension associated with biliary atresia (BA). The aim of this paper is to review MDCT, MR imaging and interventional radiology procedures performed to evaluate morphological changes and degree of portal hypertension in pediatric patients with end-stage liver disease secondary to BA, who are candidates for LT. Advances in the field of MR, MDCT and in percutaneous minimally invasive techniques have increased the importance of radiology in the management of pediatric patients with BA who are candidates for LT

A case of biliary stones and anastomotic biliary stricture after liver transplant treated with the rendez - vous technique and electrokinetic lithotritor

The paper studies the combined radiologic and endoscopic approach (rendez vous technique) to the treatment of the biliary complications following liver transplant. The “rendez-vous” technique was used with an electrokinetic lithotripter, in the treatment of a biliary anastomotic stricture with multiple biliary stones in a patient who underwent orthotopic liver transplant. In this patient, endoscopic or percutaneous transhepatic management of the biliary complication failed. The combined approach, percutaneous transhepatic and endoscopic treatment (rendez-vous technique) with the use of an electrokinetic lithotritor, was used to solve the biliary stenosis and to remove the stones. Technical success, defined as disappearance of the biliary stenosis and stone removal, was obtained in just one session, which definitively solved the complications. The combined approach of percutaneous transhepatic and endoscopic (rendez-vous technique) treatment, in association with an electrokinetic lithotritor, is a safe and feasible alternative treatment, especially after the failure of endoscopic and/or percutaneous trans-hepatic isolated procedures

Measurement of hepatic vein pressure gradient in children with chronic liver diseases

Background & Aims: The aim of this study is to present our preliminary experience with Hepatic Vein Pressure Gradient (HVPG) measurements in pediatric patients with chronic liver disease. Methods: Institutional review board approval was obtained. HVPG was measured in 20 pediatric patients, mean age 82 ± 54 months, with chronic liver disease, without extrahepatic portal vein obstruction. In nine patients the end-stage liver disease was secondary to biliary atresia; in the remaining 11, to various causes. Eleven patients had esophageal varices at endoscopy, 14 had perigastric and periesophageal collaterals at imaging scan, three had ascites, 12 had low platelet count, and all had splenomegaly. Results: Hepatic vein catheterization was technically possible in all patients without complications. HVPG values were elevated in all but three patients, ranging between 2 and 33 mmHg (mean 11.3 ± 7.2 mmHg), thus indicating a sinusoidal component in portal hypertension. A salient finding was the presence of hepatic venovenous shunts in 7 out of 9 patients with biliary atresia; however, the HVPG could still be measured distal to the shunts, but in three patients (with an HVPG of 8 mmHg) it was determined in an area with a small venovenous communication still visible, therefore underestimating the actual portal pressure gradient. No venovenous shunts were detected in the non-biliary atresia patients. Conclusions: HVPG is a feasible procedure in pediatric patients. Patients with biliary atresia very frequently have communicating vessels between hepatic veins. This hitherto unacknowledged finding can lead to the underestimation of portal pressure by HVPG measurement. © 2010 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved

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Predictive factors of tumor response to trans-catheter treatment in cirrhotic patients with hepatocellular carcinoma: A multivariate analysis of pre-treatment finding