Long term impact of transjugular intrahepatic portosystemic shunt (TIPS) creation on hepatic morphology

PURPOSE

The purpose of this study was to evaluate long-term morphologic changes occurring in the liver after TIPS creation with correlation with hepatic function to gain insight on the physiologic impact of TIPS on the liver.

METHODS

This retrospective study included patients who underwent TIPS creation between 2005 and 2022 and had contrasted CT or MRI studies prior to and between 1 and 2 years post procedure. Strict exclusion criteria were applied to avoid confounding. Parenchymal volume and vessel measurements were assessed on the pre- and post-TIPS CT or MRI and MELD scores calculated.

RESULTS

Of 580 patients undergoing TIPS creation, 65 patients (mean age, 55 years; 36 males) had pre-TIPS and post-TIPS imaging meeting inclusion criteria at median 16.5 months. After TIPS, the mean MELD score increased (12.9 to 15.4; p = 0.008) and total liver volume decreased (1730 to 1432 mL; p < 0.001). However, the magnitude of volume change did not correlate with MELD change. Neither portosystemic gradient nor TIPS laterality correlated with total or lobar hepatic volume changes or MELD changes. The main portal vein diameter increased (15.0 to 18.7 mm; p < 0.001). Thrombosis of the hepatic vein used for TIPS creation resulted in a mean increase in MELD of +4.1 compared to -2.1 in patients who had a patent and normal hepatic vein (p = 0.007).

CONCLUSIONS

Given lack of correlation between portosystemic gradient, hepatic atrophy, hepatic function, and TIPS laterality, the alterations in portal flow dynamics after TIPS may not be impactful to hepatic function. However, hepatic vein patency after TIPS correlated with improved hepatic function.

Tumor size and survival in intrahepatic cholangiocarcinoma treated with surgical resection or ablation

OBJECTIVES

We performed a retrospective analysis within a national cancer registry on outcomes following resection or ablation for intrahepatic cholangiocarcinoma (iCCA).

METHODS

The National Cancer Database was queried for patients with clinical stage I-III iCCA diagnosed during 2010-2018, who underwent resection or ablation. Overall survival (OS) was compared with Kaplan-Meier and multivariable Cox proportional hazards methods.

RESULTS

Of 2140 patients, 1877 (87.7%) underwent resection and 263 (12.3%) underwent ablation, with median tumor sizes of 5.5 and 3 cm, respectively. Overall, resection was associated with greater median OS (41.2 months (95% confidence interval [95% CI]: 37.6-46.2) vs. 28 months (95% CI: 15.9-28.6) on univariable analysis (p < 0.0001). There was no significant difference on multivariable analysis (p = 0.42); however, there was a significant interaction between tumor size and management. On subgroup analysis of patients with tumors <3 cm, there was no difference in OS between resection versus ablation. However, ablation was associated with increased mortality for tumors ≥3 cm.

CONCLUSION

Although resection is associated with improved OS for tumors ≥3 cm, we observed no difference in survival between management strategies for tumors < 3 cm. Ablation may be an alternative therapeutic strategy for small iCCA, particularly in patients at risk for high surgical morbidity.

Comparing Survival After Resection, Ablation, and Radiation in Small Intrahepatic Cholangiocarcinoma

BACKGROUND

Hepatectomy is the cornerstone of curative-intent treatment for intrahepatic cholangiocarcinoma (ICC). However, in patients unable to be resected, data comparing efficacy of alternatives including thermal ablation and radiation therapy (RT) remain limited. Herein, we compared survival between resection and other liver-directed therapies for small ICC within a national cancer registry.

PATIENTS AND METHODS

Patients with clinical stage I-III ICC < 3 cm diagnosed 2010-2018 who underwent resection, ablation, or RT were identified in the National Cancer Database. Overall survival (OS) was compared using Kaplan-Meier and multivariable Cox proportional hazards methods.

RESULTS

Of 545 patients, 297 (54.5%) underwent resection, 114 (20.9%) ablation, and 134 (24.6%) RT. Median OS was similar between resection and ablation [50.5 months, 95% confidence interval (CI) 37.5-73.9; 39.5 months, 95% CI 28.7-58.4, p = 0.14], both exceeding that of RT (20.9 months, 95% CI 14.1-28.3). RT patients had high rates of stage III disease (10.4% RT vs. 1.8% ablation vs. 11.8% resection, p < 0.001), but the lowest rates of chemotherapy utilization (9.0% RT vs. 15.8% ablation vs. 38.7% resection, p < 0.001). In multivariable analysis, resection and ablation were associated with reduced mortality compared with RT [hazard ratio (HR) 0.44, 95% CI 0.33-0.58 and HR 0.53, 95% CI 0.38-0.75, p < 0.001, respectively].

CONCLUSION

Resection and ablation were associated with improved survival in patients with ICC < 3 cm compared with RT. Acknowledging confounders, anatomic constraints of ablation, limitations of available data, and need for prospective study, these results favor ablation in small ICC where resection is not feasible.

Utility of CBCT and AVD for intraprocedural diagnosis and treatment of lower GI bleeding

BACKGROUND

Intraprocedural Cone Beam CT (CBCT) is assessed to examine if use improves diagnosis and embolization rates of acute lower GI bleed (LGIB) and if automatic vessel detection (AVD) software can identify feeding vessels (FV) for embolization.

METHODS

Patients with inconclusive DSA findings had CBCT and retrospective analysis with AVD software (Innova 3100, GE Company, USA). Technical success was defined as the ability to detect a lower GIB site while clinical success was defined as successful embolization without evidence of rebleeding or death within 30 days. AVD technical success was defined by the ability to identify the FV on both CTA and CBCT upon independent review by 3 blinded IRs, who also assigned a degree of certainty on a 5-point Likert scale.

RESULTS

74 patients in total were treated for lower GI bleed of which 34 had indeterminate DSA. Of those, 10 patients received DSA only, of which 1 was super selective. 24 patients with GIB on pre-procedural CTA and inconclusive DSA underwent CBCT. Use of CBCT identified 9 bleeds not seen on DSA and an additional source artery in 1 case representing a 42% change in intraprocedural management as all findings were embolized. When a bleed could not be identified on CBCT, but the FV could be identified on CTA, the same suspected FV could be selected on AVD 62% of the time with an average certainty of 4.0.

CONCLUSION

CBCT is useful in the intraprocedural detection of GIB when DSA is indeterminate. Furthermore, AVD software can feasibly be utilized to accurately identify FVs for empiric treatment when intraprocedural imaging is inconclusive.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Intravascular Ultrasound-Guided Transvenous Biopsy of Abdominal and Pelvic Targets Difficult to Access by Percutaneous Needle Biopsy: Technique and Initial Clinical Experience

PURPOSE

To report initial clinical experience with intravascular ultrasound (US)-guided transvenous biopsy (TVB) for perivascular target lesions in the abdomen and pelvis using side-viewing phased-array intracardiac echocardiography catheters.

MATERIALS AND METHODS

In this single-institution, retrospective study, 48 patients underwent 50 intravascular US-guided TVB procedures for targets close to the inferior vena cava or iliac veins deemed difficult to access by conventional percutaneous needle biopsy (PNB). In all procedures, side-viewing phased-array intracardiac echocardiography intravascular US catheters and transjugular liver biopsy sets were inserted through separate jugular or femoral vein access sheaths, and 18-gauge core needle biopsy specimens were obtained under real-time intravascular US guidance. Diagnostic yield, diagnostic accuracy, and complications were analyzed.

RESULTS

Intravascular US-guided TVB was diagnostic of malignancy in 40 of 50 procedures for a diagnostic yield of 80%. There were 5 procedures in which biopsy was correctly negative for malignancy, with a per-procedure diagnostic accuracy of 90% (45/50). Among the 5 false negatives, 2 patients underwent repeat intravascular US-guided TVB, which was diagnostic of malignancy for a per-patient diagnostic accuracy of 94% (45/48). There were 1 (2%) mild, 2 (4%) moderate, and 1 (2%) severe adverse events, with 1 moderate severity adverse event (venous thrombosis) directly attributable to the intravascular US-guided TVB technique.

CONCLUSIONS

Intravascular US-guided TVB performed on difficult-to-approach perivascular targets in the abdomen and pelvis resulted in a high diagnostic accuracy, similar to accepted thresholds for PNB. Complication rates may be slightly higher but should be weighed relative to the risks of difficult PNB, surgical biopsy, or clinical management without biopsy.

Proton pump inhibitor use is associated with increased rates of post-TIPS hepatic encephalopathy: Replication in an independent patient cohort

PURPOSE

Proton pump inhibitor (PPI) use is a potential risk factor for hepatic encephalopathy (HE), but few studies have examined the effect on post-TIPS HE. The purpose of this study was to determine whether PPIs are associated with increased rates of post-TIPS HE in an independent patient cohort.

MATERIALS AND METHODS

This single-institution retrospective study analyzed 86 patients (54 male, mean age 58.2) following TIPS from 1/1/2017 to 12/31/2019. Dates of PPI usage and episodes of new or worsening HE were recorded. Poisson regression with generalized estimating equations was used to test for association between PPI use and post-TIPS HE and to test for dose dependence. Post-TIPS HE was also analyzed using the Andersen-Gill survival model for recurrent events.

RESULTS

There were 1.88 episodes of new or worsening post-TIPS HE per person-year among 35 patients on uninterrupted PPIs therapy, 1.95 on PPIs and 0.94 off PPIs among 35 patients on intermittent therapy, and 0.47 among 16 patients never on PPIs. PPI use was significantly associated with post-TIPS HE in both univariable (incidence rate ratio (IRR) = 2.62; CI = 1.41-4.84; p = 0.002) and multivariable (IRR = 2.31; CI = 1.37-3.89; p = 0.002) regression. Analysis of only those patients on PPIs showed increased rates of HE with higher doses (IRR = 1.17 per 10 mg omeprazole equivalent; CI = 1.04-1.33; p = 0.011). Recurrent events survival analysis supported the association between PPI use and HE in univariable (hazard ratio (HR) = 2.17; CI = 1.19-3.95; p = 0.011) and multivariable (HR = 1.87; CI = 1.12-3.13; p = 0.017) analysis.

CONCLUSION

In an independent patient cohort PPI use was associated with increased rates of new or worsening post-TIPS HE.

Comprehensive Word-Level Classification of Screening Mammography Reports Using a Neural Network Sequence Labeling Approach

Radiology reports contain a large amount of potentially valuable unstructured data. Recently, neural networks have been employed to perform classification of radiology reports over a few classes at the document level. The success of neural networks in sequence-labeling problems such as named entity recognition and part of speech tagging suggests that they could be used to classify radiology report text with greater granularity. We employed a neural network architecture to comprehensively classify mammography report text at the word level using a sequence labeling approach. Two radiologists devised a comprehensive classification system for screening mammography reports. Each word in each report was manually categorized by a radiologist into one of 33 categories according to the classification system. Tagged words referencing the same finding were grouped into unique sets. We pre-labeled reports with a rule-based algorithm and then manually edited these annotations for 6705 screening mammography reports (25.1%, 66.8%, and 8.1% BI-RADS 0, 1, and 2, respectively). A combined convolutional and recurrent neural network model was used to label words in each sentence of the individual reports. A siamese recurrent neural network was then used to group findings into sets. Performance of the neural network-based method was compared to a rule-based algorithm and a conditional random field (CRF) model. Global accuracy (percentage of documents where all word tags were predicted correctly) and keyword accuracy (percentage of all words that were labeled correctly, excluding words tagged as unimportant) were calculated on an unseen 519 report test set. Two-tailed t tests were used to assess differences between algorithm performance, and p < 0.05 was used to determine statistical significance. The neural network-based approach showed significantly higher global accuracy compared to both the rule-based algorithm (88.3 vs 57.0%, p < 0.001) and the CRF model (88.3% vs. 75.8%, p < 0.001). The neural network also showed significantly higher keyword level accuracy compared to the rule-based algorithm (95.5% vs. 80.9% p < 0.001) and CRF model (95.5% vs. 76.9%, p < 0.001). We demonstrate the potential of neural networks to accurately perform word-level multilabel classification of free text radiology reports across 33 classes, thus showing the utility of a sequence labeling approach to NLP of radiology reports. We found that a neural network classifier outperforms a rule-based algorithm and a CRF classifier for comprehensive multilabel classification of free text screening mammography reports at the word level. By approaching radiology report classification as a sequence-labeling problem, we demonstrate the ability of neural networks to extract data from free text radiology reports at a level of granularity not previously reported.

Spinal Arterial Blood Supply Does Not Arise from the Bronchial Arteries: A Detailed Analysis of Angiographic Studies Performed for Hemoptysis

PURPOSE

To determine the angiographic prevalence of spinal arteries originating directly from the bronchial arteries in the setting of embolization for hemoptysis.

MATERIALS AND METHODS

Over a 14-year interval, 205 patients underwent angiography for hemoptysis. Twenty-five patients were excluded because their bronchial arteries were not visualized. The remaining 180 patients underwent a total of 254 angiographic procedures (range, 1-8 per patient). Images were reviewed jointly by 2 interventional radiologists with formal fellowship training in both peripheral and neurological interventional radiology. All catheterized arteries were evaluated for arterial contribution to the spinal cord. For patients with multiple studies, each unique artery was reported only once. Embolization was performed during at least 1 procedure in 158 patients (88%). Electronic record review was used to assess neurological sequelae after the procedure.

RESULTS

One or 2 bronchial arteries originating from the aorta were identified in 57 patients (32%) on the right and in 75 patients (42%) on the left. Conjoined bronchial arteries were found in 76 patients (42%). Spinal arterial supply was absent in all. A total of 102 patients (57%) had at least 1 right and 11 patients (6%) at least 1 left intercostobronchial artery. Spinal arterial supply from the intercostal portion of an intercostobronchial artery was found in 6 patients (5 right, 1 left). Medical record review revealed no postprocedure symptoms referable to spinal cord injury in any patient.

CONCLUSIONS

Spinal arterial supply does not originate directly from the bronchial artery but can originate from the intercostal portion of an intercostobronchial artery.

CT Fluoroscopy-Guided Blood Patching of Ventral CSF Leaks by Direct Needle Placement in the Ventral Epidural Space Using a Transforaminal Approach

BACKGROUND AND PURPOSE

Epidural blood patch treatment of spontaneous intracranial hypotension arising from ventral CSF leaks can be difficult secondary to challenges in achieving ventral spread of patching material. The purpose of this study was to determine the technical success rates and safety profile of direct needle placement into the ventral epidural space via a posterior transforaminal approach.

MATERIALS AND METHODS

We retrospectively reviewed consecutive CT fluoroscopy-guided epidural blood patches from June 2013 through July 2015. Cases were included if a posterior transforaminal approach was taken to place the needle directly in the ventral epidural space. Rates of technical success (defined as contrast in the spinal canal ventral epidural space) and optimal epidurogram (defined as contrast spreading into or beyond the middle third of the spinal canal ventral epidural space) were determined. Factors influencing these rates were assessed. All complications, inadvertent intravascular injections, and intrathecal punctures were recorded.

RESULTS

A total of 72 ventral epidural blood patches were identified; immediate technical success was achieved in 95.8% and an optimal epidurogram in 47.2%. Needle position within the spinal canal ventral epidural space was associated with obtaining an optimal epidurogram (P = .005). Inadvertent intravascular injection was identified in 29.3% of cases, but all were venous. There were no inadvertent intrathecal punctures or complications.

CONCLUSIONS

Direct needle placement in the ventral epidural space via a transforaminal approach for treatment of ventral CSF leaks has an excellent technical success rate and safety profile. This technique can be considered as a treatment option in selected patients with ventral CSF leaks for whom traditional techniques are unsuccessful.

Physician self-referral and imaging use appropriateness: negative cervical spine MRI frequency as an assessment metric

BACKGROUND AND PURPOSE

Imaging self-referral is increasingly cited as a contributor to diagnostic imaging overuse. The purpose of this study was to determine whether ownership of MR imaging equipment by ordering physicians influences the frequency of negative cervical spine MR imaging findings.

MATERIALS AND METHODS

A retrospective review was performed of 500 consecutive cervical spine MRIs ordered by 2 separate referring-physician groups serving the same geographic community. The first group owned the scanners used and received technical fees for their use, while the second group did not. Final reports were reviewed, and for each group, the percentage of negative study findings and the frequency of abnormalities were calculated. The number of concomitant shoulder MRIs was recorded.

RESULTS

Five hundred MRIs meeting inclusion criteria were reviewed (250 with financial interest, 250 with no financial interest). Three hundred fifty-two had negative findings (190 with financial interest, 162 with no financial interest); there were 17.3% more scans with negative findings in the financial interest group (P = .006). Among scans with positive findings, there was no significant difference in the mean number of lesions per scan, controlled for age (1.90 with financial interest, 2.19 with no financial interest; P = .23). Patients in the financial interest group were more likely to undergo concomitant shoulder MR imaging (24 with financial interest, 11 with no financial interest; P = .02).

CONCLUSIONS

Cervical spine MRIs referred by physicians with a financial interest in the imaging equipment used were significantly more likely to have negative findings. There was otherwise a highly similar distribution and severity of disease between the 2 patient samples. Patients in the financial interest group were more likely to undergo concomitant shoulder MR imaging.

Abstract P139: Heart Failure Is Initiated By and Progresses Because of Normal Responses of Energy Metabolism to Stress

Objectives The mechanism underlying heart failure (HF) after an index cardiac event is unknown but should have several characteristics. HF is a modern problem, so it will likely be a general response and be able to encompass the variety of initiating cardiac lesions as well as significant stress (e.g. exertion). The consequences should lead to the many alterations found in HF.

[ATP] falls when energy demand outstrips supply (e.g. ischemia) but do not recover promptly with reperfusion because AMP is quickly catabolized and unavailable for recharging. [ATP] recovery is slow and limited by the availability of ribose-5-P. Ribose is not used as fuel and is channeled into nucleotide (ATP) synthesis allowing the effects of [ATP] recovery on function to be studied. Our hypothesis was that HF results from these responses of energy metabolism to stress which lower [ATP[ and affect the numerous myocardial reactions whose activity depends on [ATP]. The ability of ribose to quickly increase [ATP] allows these effects to be studied.

Methods The effects of ribose infusion on two models of myocardial stress were studied. (1) An intact canine model of global ischemia which allowed serial myocardial biopsies and detailed function analysis. (2) A rat myocardial infarction model which allowed ECHO analysis of the remote myocardium.

Results Table 1. Global ischemia (20') [ATP] recovery control w/ ribose infusion 9.9 ± 1.4 days
 2.8 ± 0.6 days Diastolic compliance recovery control w/ ribose infusion 9.4 ± 1.1 days
 2.4 ± 0.9 days Myocardial infarction Pre MI 2 weeks post MI LV systolic diameter (cm) control w/ ribose infusion 0.40 ± 0.03
 0.39 ± 0.06 0.73 ± 0.10
 0.47 ± 0.22 Remote LV wall thickness (cm) control w/ ribose infusion 0.13 ± 0.03
 0.13 ± 0.02 0.10 ± 0.01
 0.18 ± 0.12 LV ejection fraction control w/ ribose infusion 74 ± 5.9%
 76 ± 2.3% 22 ± 6.3%
 52 ± 5.0%

Conclusions 1) When energy demand outstripped supply (either from ischemia or increased work) myocardial [ATP] falls and recovery was slow. 2) Ribose is the limiting precursor for [ATP] recovery and infusion allowed the relationship between [ATP] and function to be studied. 3) In both myocardial ischemia recovery and increased load (from MI) ribose enhanced [ATP] and improved function. 4) The response of myocardial energy metabolism response to stress results in lower [ATP] which will decrease the activity of many function related reactions. 5) HF could begin and progress from these reactions of energy metabolism to cardiac stress.