Statistical analysis plan for the multicenter, open, randomized controlled clinical trial to assess the efficacy and safety of intravenous tirofiban vs aspirin in acute ischemic stroke due to tandem lesion, undergoing recanalization therapy by endovascular treatment (ATILA trial)

RATIONALE

In-stent reocclusion after endovascular therapy has a negative impact on outcomes in acute ischemic stroke (AIS) due to tandem lesions (TL). Optimal antiplatelet therapy approach in these patients to avoid in-stent reocclusion is yet to be elucidated.

AIMS

To assess efficacy and safety of intravenous tirofiban versus intravenous aspirin in patients undergoing MT plus carotid stenting in the setting of AIS due to TL.

SAMPLE SIZE ESTIMATES

Two hundred forty patients will be enrolled, 120 in every treatment arm.

METHODS AND DESIGN

A multicenter, prospective, randomized, controlled (aspirin group), assessor-blinded clinical trial will be conducted. Patients fulfilling the inclusion criteria will be randomized at MT onset to the experimental or control group (1:1). Intravenous aspirin will be administered at a 500-mg single dose and tirofiban at a 500-mcg bolus followed by a 200-mcg/h infusion during the first 24 h. All patients will be followed for up to 3 months.

STUDY OUTCOMES

Primary efficacy outcome will be the proportion of patients with carotid in-stent thrombosis within the first 24 h after MT. Primary safety outcome will be the rate of symptomatic intracranial hemorrhage.

DISCUSSION

This will be the first clinical trial to assess the best antiplatelet therapy to avoid in-stent thrombosis after MT in patients with TL.

TRIAL REGISTRATION

The trial is registered as NCT05225961. February, 7th, 2022.

Large cystic lesions of the liver in adults: a 15-year experience in a tertiary center

BACKGROUND

Cystic lesions of the liver consist of a heterogeneous group of disorders and may present a diagnostic and therapeutic challenge. Large hepatic cysts tend to be symptomatic and can cause complications more often than smaller ones.

STUDY DESIGN

We performed a retrospective review of adults diagnosed with large (> or = 4 cm) hepatic cystic lesions at our center, over a period of 15 years. Polycystic disease and abscesses were not included.

RESULTS

Seventy-eight patients were identified. In 57 the lesions were simple cysts, in 8 echinococcal cysts, in 8 hepatobiliary cystadenomas, and in 1 hepatobiliary cystadenocarcinoma. In four patients, the precise diagnosis could not be ascertained. Mean size was 12.1 cm (range, 4 to 30 cm). Most simple cysts were found in women (F:M, 49:8). Bleeding into a cyst (two patients) and infection (one patient) were rare manifestations. Percutaneous aspiration of 28 simple cysts resulted in recurrence in 100% of the cases within 3 weeks to 9 months (mean 4(1/2) months). Forty-eight patients were treated surgically by wide unroofing or resection (laparoscopically in 18), which resulted in low recurrence rates (11% for laparoscopy and 13% for open unroofing). Four of the eight patients with echinococcal cysts were symptomatic. All were treated by open resection after irrigation of the cavity with hypertonic saline. There was no recurrence during a followup period of 2 to 14 years. Hepatobiliary cystadenomas occurred more commonly in women (F:M, 7:1) and in the left hepatic lobe (left:right, 8:0). Seven were multiloculated. All were treated by open resection, with no recurrence, and none had malignant changes. Cystadenocarcinoma was diagnosed in a 77-year-old man, and was treated by left hepatic lobectomy.

CONCLUSIONS

Large symptomatic simple cysts invariably recur after percutaneous aspiration. Laparoscopic unroofing can be successfully undertaken, with a low recurrence rate. Open resection after irrigation with hypertonic saline is a safe and effective treatment for echinococcal cysts. Hepatobiliary cystadenomas have predilection for women and for the left hepatic lobe. Malignant transformation is an uncommon but real risk. Open resection is a safe and effective treatment for hepatobiliary cystadenoma, and is associated with a low recurrence rate.

Transient hepatopulmonary syndrome in a patient with acute hepatitis A

The hepatopulmonary syndrome is defined as the triad of liver disease, hypoxaemia and intrapulmonary vascular dilatation. This syndrome has been described in patients with liver cirrhosis, noncirrhotic portal hypertension, and fulminant hepatic failure, however, there are no previous descriptions of hepatopulmonary syndrome in patients with acute nonfulminant viral hepatitis. We report a 47-year-old, previously healthy man that presented with acute hepatitis A, and developed progressive dyspnoea, platypnoea and orthodeoxia with no evidence of parenchymal or thromboembolic lung disease. PaO2 on room air was 58 mmHg, O2 saturation was 88% and alveolar-arterial O2 gradient was 62%. During his hospitalization serum albumin level decreased to 3.1 g/dl and prothrombin time was prolonged to 16.8 s, however, he remained alert with no signs of hepatic encephalopathy. Contrast echocardiography revealed left heart chamber opacification 3-4 cardiac cycles after the opacification of the right heart chamber, consistent with hepatopulmonary syndrome. During the following days there was a gradual improvement in the patient's condition, with resolution of his dyspnoea and gradual increase of PaO2. Repeat contrast echocardiography and PaO2 determinations, 3 weeks later, were normal. On long-term follow-up the patient remained asymptomatic with normal liver function tests and normal O2 saturation. This report indicates that hepatopulmonary syndrome may be a transient manifestation of acute hepatitis A in the absence of fulminant liver failure.

Postoperative jaundice

Postoperative jaundice is often multifactorial (Fig. 2). A precipitating or causative factor may be identified but seldom can a specific therapy be offered. A systematic approach will help eliminate a hepatotoxic drug or identify a biliary tract problem. Treatment involves discontinuation of an offending drug; however, the drug, such as an anesthetic agent, may not be in use when the jaundice is detected. Recognition of an anesthetic-induced injury would certainly warn the physician not to repeat its use in future surgery for that patient. Hyperalimentation may contribute to jaundice, but patients developing postoperative jaundice are generally very ill and require nutrition. Extrahepatic biliary tract disease should be readily recognized and treated. The physician should be alert to the possibility of acalculous cholecystitis so that it can be appropriately diagnosed and treated.

Successful living related liver transplantation in an adult with fulminant hepatic failure

We report a case of an adult female who developed fulminant hepatic failure (FHF) during the second trimester of pregnancy and underwent a successful living related liver transplantation because no cadaveric donor was available during the development of life-threatening symptoms. A left lateral segment hepatic graft was procured from her brother, whose body weight was similar to hers. Her postoperative course was complicated by bleeding at the biliary anastomosis and subsequently by a biliary leak. Nevertheless, the complications were corrected surgically and the patient recovered well with a good quality of life 5 months after the transplant. This case suggests that living related liver transplantation should be considered more frequently for adult FHF patients. As the window of therapeutic opportunity is narrow for the dramatic condition of FHF, wide acceptance of this procedure will be of great benefit for the patients suffering from FHF.

Conservative management of esophageal nontransmural tears after pneumatic dilation for achalasia

OBJECTIVE

We sought to determine the incidence and outcome with conservative management of esophageal nontransmural tears after pneumatic dilation for achalasia.

METHODS

Retrospective review of 50 pneumatic balloon dilations in 30 patients with achalasia was performed at one center over an 18-month period.

RESULTS

Forty-four of 50 procedures (88%) were performed without complication. Two patients (4%) developed transmural perforations requiring immediate surgical repair; both recovered uneventfully. Four patients (8%) were found to have linear mucosal tears on routine postprocedure esophagrams. One patient was asymptomatic, and three had chest pain. No patient had fever. These four patients were managed conservatively with in-hospital observation for a mean of 4.3 days (range 3-6): nothing by mouth for a mean of 1.3 days (range 1-2) and i.v. antibiotics for a mean of 3 days (range 2-5). All were discharged within 6 days and were asymptomatic and tolerating a regular diet.

CONCLUSIONS

Esophageal nontransmural tears are not uncommon after pneumatic dilation for achalasia and can be safely treated with conservative medical management.

Pancreatic pseudocysts involving both hepatic lobes

We report a patient who developed pancreatic pseudocysts involving both hepatic lobes, after an episode of alcoholic pancreatitis. The possible routes by which pancreatic secretions may reach the liver, as well as diagnostic and therapeutic approaches, are discussed.