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Owen JW, Saad NE, Foster G, Fowler KJ. The Feasibility of Using Volumetric Phase-Contrast MR Imaging (4D Flow) to Assess for Transjugular Intrahepatic Portosystemic Shunt Dysfunction. J Vasc Interv Radiol 2018; 29:1717-1724. [PMID: 30396843 DOI: 10.1016/j.jvir.2018.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/09/2018] [Accepted: 07/23/2018] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To demonstrate the feasibility of detecting patency, stenosis, or occlusion of transjugular intrahepatic portosystemic shunt (TIPS) with four-dimensional (4D) flow MR imaging. MATERIALS AND METHODS Sequential adult patients with TIPS were eligible for enrollment. Volumetric phase-contrast sequence was used to image TIPS. Particle tracing cine images were used for qualitative assessment of stenosis. TIPS was segmented to generate quantitative data sets of peak velocity. Segmentation and quantitative measurement of flow throughout an entire TIPS defined technical success. Doppler US was used for comparison. Venography, when available, and 6-month clinical follow-up were used as reference standards. RESULTS 4D flow MR imaging was performed in 23 patient encounters and was technically successful in 16/23 (69.6%) encounters. Three cases demonstrated both focal turbulence and abnormal velocities (> 190 cm/s or < 90 cm/s) on 4D flow and had venography-confirmed stenosis (true-positive cases). Seven cases had normal velocities and no turbulence on 4D flow, and all were confirmed negative with clinical follow-up or venography (true-negative cases). Six cases had discordant 4D flow results, with abnormal velocities but no turbulence or focal turbulence but normal velocities. All 6 discordant cases had no evidence of dysfunction during 6-month follow-up. CONCLUSION 4D flow MR imaging can detect TIPS patency and stenosis, but further investigation is required before it can be used to assess for TIPS dysfunction.
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Affiliation(s)
- Joseph W Owen
- Department of Radiology, University of Kentucky College of Medicine, 800 Rose Street, HX315A, Lexington, KY 40536-0293.
| | - Nael E Saad
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York
| | - Glenn Foster
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Kathryn J Fowler
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
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Gunn AJ, Saad NE. A Novel Method for Achievement of Vascular Closure After Misdeployment of an Angio-Seal™ Device. Cardiovasc Intervent Radiol 2016; 39:1222-3. [DOI: 10.1007/s00270-016-1326-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 03/07/2016] [Indexed: 11/30/2022]
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Fowler K, Saad NE, Brunt E, Doyle MBM, Amin M, Vachharajani N, Tan B, Chapman WC. Biphenotypic Primary Liver Carcinomas: Assessing Outcomes of Hepatic Directed Therapy. Ann Surg Oncol 2015; 22:4130-7. [PMID: 26293835 DOI: 10.1245/s10434-015-4774-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Primary liver carcinomas with hepatocellular and cholangiocellular differentiation (b[HB]-PLC) are rare. Surgery offers the best prognosis, but there is a paucity of literature to guide therapy for patients with advanced or unresectable disease. This study aimed to evaluate outcomes of hepatic-directed therapy compared with those of systemic chemotherapy and surgery. METHODS A retrospective evaluation of patients with b(HB)-PLC from 1 January 2008 to 1 September 2014 was conducted. The patients were divided into the following four groups: transplantation (TX) group, surgical resection (SX) group, hepatic directed (HD) group, and systemic chemotherapy alone (SC) group. Overall and progression-free survival, treatment response, and clinicopathologic data were analyzed. RESULTS The study included 79 patients (37 females) with an average age of 62 years. The number of patients in each group were as follows: TX group (n = 6), SX group (n = 27), HD group (n = 18), and SC group (n = 28). The mean follow-up periods were 33 months for the TX group, 17 months for the SX group, 14 months for the HD group, and 7 months for the SX group. Overall, 28 % of the patients had cirrhosis and 35 % had viral hepatitis. The candidates for surgery comprised 42 % of the patients. The HD group (n = 18) had a significantly greater objective response than the SC group (n = 28) (47 vs. 6 %; p = 0.02). Two patients who underwent hepatic arterial infusion pump treatment were downstaged to resection. A trend toward improved OS/PFS was observed in the HD group versus the SC group, although statistically significant. The SX group had significantly improved survival (p < 0.001) as did the transplanted patients. CONCLUSIONS Although surgery offers the best survival for b(HB)-PLC patients, only a minority are candidates for surgery. Because HD therapy showed a superior objective response over SC therapy, it may offer a survival advantage and may downstage patients for surgical resection or transplantation.
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Affiliation(s)
- Kathryn Fowler
- Department of Radiology, Washington University, St. Louis, MO, USA.
| | - Nael E Saad
- Department of Radiology, Washington University, St. Louis, MO, USA
| | - Elizabeth Brunt
- Department of Immunology and Pathology, Washington University, St. Louis, MO, USA
| | | | - Manik Amin
- Department of Internal Medicine and Oncology, Washington University, St. Louis, MO, USA
| | | | - Benjamin Tan
- Department of Internal Medicine and Oncology, Washington University, St. Louis, MO, USA
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Rafiei P, Kim SK, Kamran M, Saad NE. Retrospective Study in 40 Patients of Utility of C-arm FDCT as an Adjunctive Modality in Technically Challenging Image-Guided Percutaneous Drainage Procedures. Cardiovasc Intervent Radiol 2015; 38:1589-94. [PMID: 25832763 DOI: 10.1007/s00270-015-1091-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/28/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE To explore the utility of C-arm flat detector computed tomography (FDCT) as an adjunctive modality in technically challenging image-guided percutaneous drainage procedures. METHODS Clinical and image data were reviewed on 40 consecutive patients who underwent percutaneous drainage of fluid collections in technically challenging anatomic locations that required the use of C-arm FDCT between 2009 and 2013. Percutaneous drainage was performed under ultrasound and fluoroscopic guidance with the use of C-arm FDCT as a problem-solving tool to identify appropriate needle/wire placement prior to drainage catheter placement (n = 33) or to confirm catheter positioning within the fluid collection (n = 8). Technical success and procedural complications were recorded and retrospectively analyzed. RESULTS Forty one fluid collections were identified in 40 patients. Mean number of C-arm FDCT rotational acquisitions per patient was 1.25. Mean procedure time per patient was 59.3 min. Mean fluoroscopy time was 5.5 min, and mean air kerma was 394.3 mGy. Percutaneous drainage with the use of C-arm FDCT was successful in 35 of 40 patients (87.5%). Technical failure was encountered in 5 of 40 patients due to too narrow window (n = 1), too small or no fluid collection noted on C-arm FDCT images (n = 2), and poor image quality requiring the use of a conventional CT scan (n = 2). Three procedure-related complications occurred (7.5%), which included traversed rectum, traversed spleen, and sepsis. CONCLUSION C-arm FDCT is useful as an adjunctive modality in the interventional suite for technically challenging percutaneous drainage procedures by providing sufficient anatomic detail. Complications of catheter misplacement can be avoided if C-arm FDCT is used prior to tract dilatation. If C-arm FDCT image quality of needle and/or wire placement is poor, conventional CT guidance is recommended.
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Affiliation(s)
- Poyan Rafiei
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, 510 S Kingshighway Boulevard, Campus Box 8131, St Louis, MO, 63110, USA.
| | - Seung Kwon Kim
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, 510 S Kingshighway Boulevard, Campus Box 8131, St Louis, MO, 63110, USA.
| | - Mudassar Kamran
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, 510 S Kingshighway Boulevard, Campus Box 8131, St Louis, MO, 63110, USA.
| | - Nael E Saad
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, 510 S Kingshighway Boulevard, Campus Box 8131, St Louis, MO, 63110, USA.
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Crowley JJ, Hogan MJ, Towbin RB, Saad WE, Baskin KM, Marie Cahill A, Caplin DM, Connolly BL, Kalva SP, Krishnamurthy V, Marshalleck FE, Roebuck DJ, Saad NE, Salazar GM, Stokes LS, Temple MJ, Gregory Walker T, Nikolic B. Quality improvement guidelines for pediatric gastrostomy and gastrojejunostomy tube placement. J Vasc Interv Radiol 2014; 25:1983-91. [PMID: 25439676 DOI: 10.1016/j.jvir.2014.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 08/01/2014] [Indexed: 01/20/2023] Open
Affiliation(s)
- John J Crowley
- Department of Radiology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark J Hogan
- Department of Vascular and Interventional Radiology, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Richard B Towbin
- Department of Radiology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Wael E Saad
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, 1500 E. Medical Drive, SPC 5868, Cardiovascular Center, #5588, Ann Arbor, MI 48109-5868.
| | - Kevin M Baskin
- Advanced Interventional Institute, Pittsburgh, Pennsylvania
| | - Anne Marie Cahill
- Department of Interventional Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Drew M Caplin
- Department of Radiology, Division of Interventional Radiology, Northshore University Hospital, Manhasset, New York
| | - Bairbre L Connolly
- Centre for Image Guided Therapy, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Venkataramu Krishnamurthy
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, 1500 E. Medical Drive, SPC 5868, Cardiovascular Center, #5588, Ann Arbor, MI 48109-5868
| | - Francis E Marshalleck
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Derek J Roebuck
- Department of Radiology, Great Ormond Street Hospital, London, United Kingdom
| | - Nael E Saad
- Department of Radiology, Division of Vascular and Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri; Department of Surgery, Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Gloria M Salazar
- Department of Radiology, Division of Vascular Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts
| | - Leann S Stokes
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael J Temple
- Centre for Image Guided Therapy, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - T Gregory Walker
- Department of Radiology, Division of Vascular Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts
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Saad WEA, Lippert A, Saad NE, Caldwell S. Ectopic varices: anatomical classification, hemodynamic classification, and hemodynamic-based management. Tech Vasc Interv Radiol 2014; 16:158-75. [PMID: 23830673 DOI: 10.1053/j.tvir.2013.02.004] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Ectopic varices are dilated splanchnic (mesoportal) veins/varicosities and/or are dilated portosystemic collaterals that can occur along the entire gastrointestinal tract outside the common pathologic variceal sites. Ectopic varices are complex and highly variable entities that are not fully understood. Ectopic varices represent 2%-5% of a gastrointestinal tract variceal bleeding. However, ectopic varices have a 4-fold increased risk of bleeding when compared with esophageal varices and can have a mortality rate as high as 40%. All treatment strategies and techniques have been utilized in managing these potentially mortal varices and have shown poor outcomes. The debate of whether to manage these varices by decompression with a transjugular portosystemic shunt, or other portosystemic shunts, vs transvenous obliteration is unresolved. The rebleed rates after transjugular portosystemic shunt decompression are 20%-40%. The rebleed rates after transvenous obliteration and the mortality rate at 3-6 months are 30%-40% and 50%-60%, respectively. Hemodynamically from an etiology standpoint, there are 2 types: occlusive (type-b) and nonocclusive (oncotic or type-a). Hemodynamically from a vascular-shunting standpoint, there could be a component of portoportal or portosystemic shunting or both with varying dominance. This is the basis of the new classification system described herein. Management strategies (decompression vs sclerosis) are discussed. The ideal management strategy is a treatment that leads to prompt hemostasis but also addresses the etiology or hemodynamics of the ectopic varices. It is the hope that with better understanding, description, and categorization of ectopic varices comes a more systematic approach to this rare but menacing problem.
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Affiliation(s)
- Wael E A Saad
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Thompson CM, Saad NE, Quazi RR, Darcy MD, Picus DD, Menias CO. Management of iatrogenic bile duct injuries: role of the interventional radiologist. Radiographics 2013; 33:117-34. [PMID: 23322833 DOI: 10.1148/rg.331125044] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Bile duct injuries are infrequent but potentially devastating complications of biliary tract surgery and have become more common since the introduction of laparoscopic cholecystectomy. The successful management of these injuries depends on the injury type, the timing of its recognition, the presence of complicating factors, the condition of the patient, and the availability of an experienced hepatobiliary surgeon. Bile duct injuries may lead to bile leakage, intraabdominal abscesses, cholangitis, and secondary biliary cirrhosis due to chronic strictures. Imaging is vital for the initial diagnosis of bile duct injury, assessment of its extent, and guidance of its treatment. Imaging options include cholescintigraphy, ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and fluoroscopy with a contrast medium injected via a surgically or percutaneously placed biliary drainage catheter. Depending on the type of injury, management may include endoscopic, percutaneous, and open surgical interventions. Percutaneous intervention is performed for biloma and abscess drainage, transhepatic biliary drainage, U-tube placement, dilation of bile duct strictures and stent placement to maintain ductal patency, and management of complications from previous percutaneous interventions. Endoscopic and percutaneous interventional procedures may be performed for definitive treatment or as adjuncts to definitive surgical repair. In patients who are eligible for surgery, surgical biliary tract reconstruction is the best treatment option for most major bile duct injuries. When reconstruction is performed by an experienced hepatobiliary surgeon, an excellent long-term outcome can be achieved, particularly if percutaneous interventions are performed as needed preoperatively to optimize the patient's condition and postoperatively to manage complications.
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Affiliation(s)
- Colin M Thompson
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110, USA.
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Saad WE, Saad NE, Koizumi J. Stomal Varices: Management With Decompression TIPS and Transvenous Obliteration or Sclerosis. Tech Vasc Interv Radiol 2013; 16:176-84. [DOI: 10.1053/j.tvir.2013.02.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Kim EH, Tanagho YS, Bhayani SB, Saad NE, Benway BM, Figenshau RS. Percutaneous cryoablation of renal masses: Washington University experience of treating 129 tumours. BJU Int 2012; 111:872-9. [DOI: 10.1111/j.1464-410x.2012.11432.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Eric H. Kim
- Division of Urology; Washington University School of Medicine; Saint Louis MO USA
| | - Youssef S. Tanagho
- Division of Urology; Washington University School of Medicine; Saint Louis MO USA
| | - Sam B. Bhayani
- Division of Urology; Washington University School of Medicine; Saint Louis MO USA
| | - Nael E. Saad
- Department of Radiology; Washington University School of Medicine; Saint Louis MO USA
| | - Brian M. Benway
- Division of Urology; Washington University School of Medicine; Saint Louis MO USA
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Uliel L, Royal HD, Darcy MD, Zuckerman DA, Sharma A, Saad NE. From the Angio Suite to the γ-Camera: Vascular Mapping and 99mTc-MAA Hepatic Perfusion Imaging Before Liver Radioembolization—A Comprehensive Pictorial Review. J Nucl Med 2012; 53:1736-47. [DOI: 10.2967/jnumed.112.105361] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Nagui N, El Nabarawy E, Mahgoub D, Mashaly HM, Saad NE, El-Deeb DF. Estimation of (IgA) anti-gliadin, anti-endomysium and tissue transglutaminase in the serum of patients with psoriasis. Clin Exp Dermatol 2010; 36:302-4. [PMID: 21418272 DOI: 10.1111/j.1365-2230.2010.03980.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Studies have indicated an association between psoriasis and coeliac disease (CD), an immune-mediated gluten-dependent enteropathy; however, the precise relationship between psoriasis and CD remains controversial. We aimed to assess the prevalence of the CD-associated IgA antibodies antigliadin antibody (AGA), tissue transglutaminase (tTG) and antiendomysium antibody (EMA) in patients with psoriasis. In total, 41 patients with psoriasis and 41 healthy controls were enrolled in this study. Blood samples were taken from all participants, and screened for AGA, tTG and EMA. We found a significantly higher level of AGA in patients with psoriasis than in controls, but levels of tTG and EMA were not significant. There was also a significantly higher prevalence of AGA, tTG and EMA in the patient group (34.1%, 34.1% and 14.6%, respectively) than in the control group (2.4%, 22% and 4.9%, respectively). We conclude that the significantly high prevalence of AGA antibodies in patients with psoriasis supports the possibility of a link between psoriasis and gluten-sensitive enteropathies, especially CD.
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Affiliation(s)
- N Nagui
- Department of Dermatology, Faculty of Medicine, Cairo University, Cairo, Egypt
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