Predictors for Nonhome Patient Discharge following Lower Extremity Arterial Interventions

PurposeTo identify the variables associated with patient discharge disposition to optimize postprocedural care and discharge planning following lower extremity arterial interventions for peripheral artery disease (PAD).Materials and MethodsThe 2014–2017 American College of Surgeons National Surgical Quality Improvement Program database was queried using current procedural terminology codes for endovascular infrainguinal interventions for PAD. The main outcome variable of interest was nonhome discharge. Covariates included patient sociodemographic variables, age quartile (upper quartile, ≥77 years), comorbidities (diabetes, renal disease, bleeding disorder, congestive heart failure [CHF], and chronic obstructive pulmonary disease), presence of an open wound before a procedure, type of procedure, operative time, symptom severity, American Society of Anesthesiologists class, and baseline functional status. Univariate analysis and multivariate logistic regression were performed on Stata/SE 15.1.ResultsA total of 3,190 patients met the inclusion criteria, of whom 664 (20.8%) had nonhome discharge. Multivariate regression revealed that age (odds ratio [OR], 1.9 for the upper age quartile [>77 years]; 95% confidence interval [CI], 1.46–2.50), operative time (OR, 1.2 per increase in quartile; 95% CI, 1.09–1.30), preoperative wound (OR, 1.5; 95% CI, 1.24–1.90), renal failure (OR, 1.7; 95% CI, 1.30–2.14), CHF (OR, 2.2; 95% CI, 1.51–3.24), symptom severity (OR, 1.7; 95% CI, 1.46–1.98), and independent functional status (OR, 0.74; 95% CI, 0.59–0.92; P = .007) were associated with nonhome discharge. All P values were ≤.001 unless otherwise stated.ConclusionsProlonged procedural time, the presence of preprocedural wound and patient comorbidities, symptomatology, and baseline functional status may be used to identify patients who will require a nonhome discharge and early discharge planning.     

Factors Affecting Recurrent Deep Vein Thrombosis after Pharmacomechanical Thrombolysis and Left Iliac Vein Stent Placement in Patients with Iliac Vein Compression Syndrome

PurposeThis study evaluated the factors affecting contralateral and ipsilateral recurrent deep vein thrombosis (DVT) after iliac vein stent placement in patients with iliac vein compression syndrome (IVCS).Materials and MethodsData from 130 patients (95 female patients) who underwent catheter-directed thrombolysis and stent placement for IVCS with left lower leg thrombosis at a single institution were retrospectively analyzed. Mean patient age was 69.0 ± 14.0 years old. Median follow-up was 14 months (range, 3–164 months). Anticoagulation therapy was prescribed for 6 months, followed by lifelong antiplatelet therapy. Multivariate logistic regression analysis was performed to evaluate the factors affecting the development of contralateral and ipsilateral recurrent DVT.ResultsSeven patients (5.4%) developed contralateral DVT (median, 26 months; range, 2–61 months), and 11 patients (8.5%) developed ipsilateral DVT (median, 1 month; range, 0–53 months). Stent location (odds ratio [OR], 11.564; 95% confidence interval [CI], 1.159–115.417) and in-stent thrombosis during follow-up (OR, 15.142; 95% CI, 1.406–163.119) were predictors of recurrent contralateral DVT. Thrombophilia (OR, 47.560; 95% CI, 2.369–954.711), remaining inferior vena cava filter (OR, 30.552; 95% CI, 3.495–267.122), and in-stent thrombosis during follow-up (OR, 82.057; 95% CI, 2.915–2309.848) were predictors of ipsilateral DVT.ConclusionsContralateral DVT occurs late and is associated with extension of the iliac vein stent to the inferior vena cava and in-stent thrombosis. Ipsilateral DVT occurs relatively early and is associated with thrombophilia, remaining inferior vena cava filter, and in-stent thrombosis.     

Association of Aortic Arch Calcification with Acute Ischemic Stroke Subtypes and Endovascular Thrombectomy Outcomes

PurposeTo analyze the aortic arch calcification (AAC) on computed tomography (CT) scans, with the goal of predicting the subtypes of patients with ischemic stroke and endovascular thrombectomy (EVT) outcomes.Materials and MethodsAutomated analysis was used to quantify AAC on CT scans. From January 2020 to March 2021, 119 patients diagnosed with ischemic stroke were analyzed, and the feasibility of EVT was assessed; 43 underwent the procedure.ResultsAAC was present in 117 (98.3%) of 119 patients. There was a significant difference (P <.001) in AAC severity among all patients with ischemic stroke according to the Trial of ORG 10172 in Acute Stroke Treatment classification. In patients who underwent EVT, AAC severity was significantly related to the thrombolysis in cerebral infarction grade, thrombectomy procedure time, and modified Rankin scale at discharge (P =.002, P =.035 and P =.015, respectively). Multivariate logistic regression analysis also showed that severe AAC (volume, ≥1,000 mm³) (adjusted odds ratio [OR], 12.1; adjusted 95% confidence interval [CI]), 2.1–36.4; P =.001) and intracranial atherosclerotic disease (adjusted OR, 9.5; adjusted 95% CI, 2.3–33.7; P =.001) were both independently associated with poor thrombolysis reperfusion rate.ConclusionsA high proportion of patients with ischemic stroke have AAC, the severity of which is a potential imaging marker of ischemic stroke subtypes and the outcome of EVT.     

Comparison between Antegrade versus Retrograde Ureteral Stent Placement for Malignant Ureteral Obstruction

PurposeTo compare the technical success of antegrade uteral stent (AUS) and retrograde ureteral stent (RUS) placements in patients with malignant ureteral obstruction (MUO) and to determine the predictors of technical failure of RUS.Materials and MethodsThis study retrospectively included 61 AUS placements (44 patients) performed under fluoroscopic guidance and 76 RUS placements (55 patients) performed under cystoscopic guidance in patients with MUO from January 2019 to December 2020. Technical success rates of the 2 techniques were compared using inverse probability of treatment weighting (IPTW) analysis. Logistic regression was used to identify predictive factors for technical failures.ResultsTechnical success was achieved in 98.4% of the AUS group and 47.4% of the RUS group. After stabilized IPTW, the technical success rate was higher in the AUS group than in the RUS group (adjusted risk difference, 49.4%; 95% confidence interval [CI], 35.4%–63.1%). The independent predictors for technical failure of the RUS procedure were age of ≥65 years (odds ratio [OR], 5.56; 95% CI, 1.73–21.27), ureteral orifice invasion (OR, 4.21; 95% CI, 1.46–13.46), and extrinsic cancer (OR, 15.58; 95% CI, 2.92–111.81).ConclusionsThe technical success rate of AUS placement was higher than that of RUS placement in patients with MUO. RUS failure was associated with age of ≥65 years, cancer with ureteral orifice invasion, and extrinsic ureteral obstruction.     

Impact of membranous septum length on pacemaker need with different transcatheter aortic valve replacement systems: The INTERSECT registry

BackgroundNew permanent pacemaker implantation (new-PPI) remains a compelling issue after Transcatheter Aortic Valve Replacement (TAVR). Previous studies reported the relationship between a short MS length and the new-PPI post-TAVR with a self-expanding THV. However, this relationship has not been investigated in different currently available THV. Therefore, the aim of this study was to investigate the association between membranous septum (MS)-length and new-PPI after TAVR with different Transcatheter Heart Valve (THV)-platforms.MethodsWe included patients with a successful TAVR-procedure and an analyzable pre-procedural multi-slice computed tomography. MS-length was measured using a standardized methodology. The primary endpoint was the need for new-PPI within 30 days after TAVR.ResultsIn total, 1811 patients were enrolled (median age 81.9 years [IQR 77.2–85.4], 54% male). PPI was required in 275 patients (15.2%) and included respectively 14.2%, 20.7% and 6.3% for Sapien3, Evolut and ACURATE-THV(p ?< ?0.01).Median MS-length was significantly shorter in patients with a new-PPI (3.7 ?mm [IQR 2.2–5.1] vs. 4.1 ?mm [IQR 2.8–6.0], p ?= ?<0.01). Shorter MS-length was a predictor for PPI in patients receiving a Sapien3 (OR 0.87 [95% CI 0.79–0.96], p ?= ?<0.01) and an Evolut-THV (OR 0.91 [95% CI 0.84–0.98], p ?= ?0.03), but not for an ACURATE-THV (OR 0.99 [95% CI 0.79–1.21], p ?= ?0.91). By multivariable analysis, first-degree atrioventricular-block (OR 2.01 [95% CI 1.35–3.00], p = <0.01), right bundle branch block (OR 8.33 [95% CI 5.21–13.33], p = <0.01), short MS-length (OR 0.89 [95% CI 0.83–0.97], p ?< ?0.01), annulus area (OR 1.003 [95% CI 1.001–1.005], p ?= ?0.04), NCC implantation depth (OR 1.13 [95% CI 1.07–1.19] and use of Evolut-THV(OR 1.54 [95% CI 1.03–2.27], p ?= ?0.04) were associated with new-PPI.ConclusionMS length was an independent predictor for PPI across different THV platforms, except for the ACURATE-THV. Based on our study observations within the total cohort, we identified 3 risk groups by MS length: MS length ≤3 ?mm defined a high-risk group for PPI (>20%), MS length 3–7 ?mm intermediate risk for PPI (10–20%) and MS length > 7 ?mm defined a low risk for PPI (<10%). Anatomy-tailored-THV-selection may mitigate the need for new-PPI in patients undergoing TAVR.     

Deep Learning Based on MR Imaging for Predicting Outcome of Uterine Fibroid Embolization

PurposeTo develop and validate a deep learning model based on routine magnetic resonance (MR) imaging obtained before uterine fibroid embolization to predict procedure outcome.Materials and MethodsClinical data were collected on patients treated with uterine fibroid embolization at the Hospital of the University of Pennsylvania from 2007 to 2018. Fibroids for each patient were manually segmented by an abdominal radiologist on a T1-weighted contrast-enhanced (T1C) sequence and a T2-weighted sequence of MR imaging obtained before and after embolization. A residual convolutional neural network (ResNet) model to predict clinical outcome was trained using MR imaging obtained before the procedure.ResultsInclusion criteria were met by 727 fibroids in 409 patients. At clinical follow-up, 85.6% (n = 350) of 409 patients (590 of 727 fibroids; 81.1%) experienced symptom resolution or improvement, and 14.4% (n = 59) of 409 patients (137 of 727 fibroids; 18.9%) had no improvement or worsening symptoms. The T1C trained model achieved a test accuracy of 0.847 (95% confidence interval [CI], 0.745–0.914), sensitivity of 0.932 (95% CI, 0.833–0.978), and specificity of 0.462 (95% CI, 0.232–0.709). In comparison, the average of 4 radiologists achieved a test accuracy of 0.722 (95% CI, 0.609–0.813), sensitivity of 0.852 (95% CI, 0.737–0.923), and specificity of 0.135 (95% CI, 0.021–0.415).ConclusionsThis study demonstrates that deep learning based on a ResNet model achieves good accuracy in predicting outcome of uterine fibroid embolization. If further validated, the model may help clinicians better identify patients who can most benefit from this therapy and aid clinical decision making.     

Balloon Guide Catheter in Endovascular Treatment for Acute Ischemic Stroke: Results from the MR CLEAN Registry

PurposeTo compare outcomes after endovascular treatment (EVT) for acute ischemic stroke with and without the use of a balloon guide catheter (BGC) in clinical practice.Materials and MethodsData from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands (MR CLEAN) Registry were used, in which all patients who underwent EVT for anterior-circulation stroke in The Netherlands between 2014 and 2016 were enrolled. Primary outcome was modified Rankin scale (mRS) score at 90 days. Secondary outcomes included reperfusion grade (extended Thrombolysis In Cerebral Infarction [eTICI] score) and National Institutes of Health Stroke Scale (NIHSS) score 24–48 hours after intervention. The association between the use of a BGC and outcomes was estimated with logistic regression adjusted for age, sex, prestroke mRS score, NIHSS score, collateral grade, and time from onset to EVT.ResultsA total of 887 patients were included. Thrombectomy was performed with the use of a BGC in 528 patients (60%) and without in 359 patients (40%). There was no significant association between use of a BGC and a shift on the mRS toward better outcome (adjusted common odds ratio, 1.17; 95% confidence interval [CI], 0.91–1.52). Use of a BGC was associated with higher eTICI score (adjusted common OR, 1.33; 95% CI, 1.04–1.70) and improvement of ≥ 4 points on the NIHSS (adjusted OR, 1.40; 95% CI, 1.04–1.88).ConclusionsIn clinical practice, use of a BGC was associated with higher reperfusion grade and early improvement of neurologic deficits, but had no positive effect on long-term functional outcome.     

Systematic Review and Meta-Analysis of Drug-Coated Balloon Angioplasty for In-Stent Restenosis in Femoropopliteal Artery Disease

PurposeThe present meta-analysis evaluated the role of drug-coated balloon (DCB) angioplasty for in-stent restenosis (ISR) in femoropopliteal artery disease.Materials and MethodsCochrane Library, Embase, and PubMed were searched without language restrictions from inception to May 10, 2020. The endpoints included target lesion revascularization (TLR), recurrent ISR, clinical improvement, ankle-brachial index (ABI), and death. There were 5 randomized controlled trials with 425 patients (218 with DCB angioplasty and 207 with plain old balloon angioplasty [POBA]) were included in the meta-analysis.ResultsCompared with POBA, DCB angioplasty was associated with lower risk of TLR (odds ratio [OR], 0.21; 95% confidence interval [CI]: 0.09–0.49, P < .001 at 6 months and OR, 0.15; 95% CI, 0.08–0.30; P < .001 at 12 months) and recurrent ISR (OR, 0.22; 95% CI, 0.13–0.38; P < .001 at 6 months and OR, 0.31; 95% CI, 0.16–0.61; P < .001 at 12 months), and superior clinical improvement (OR, 1.98; 95% CI, 1.07–3.65; P = .03 at 6 months and OR, 2.84; 95% CI: 1.50–5.35; P = .001 at 12 months). There were no significant differences between groups in ABI and death. Subgroup analysis for patients with DCB angioplasty showed similar rates of TLR, recurrent ISR, clinical improvement, and death between the short lesion (<15 cm) and long lesion group (≥15 cm) (P > .05).ConclusionsThe current meta-analysis suggests that DCB angioplasty is an improvement over POBA for femoropopliteal ISR. Future studies about the effect of lesion length on DCB performance are still needed.     

Diagnostic Performance of CT-Guided Bone Biopsies in Patients with Suspected Osteomyelitis of the Appendicular and Axial Skeleton with a Focus on Clinical and Technical Factors Associated with Positive Microbiology Culture Results

PurposeTo assess diagnostic performance of CT-guided percutaneous needle bone biopsy (CTNBB) in patients with suspected osteomyelitis and analyze whether certain clinical or technical factors were associated with positive microbiology results.Materials and MethodsAll CTNBBs performed in a single center for suspected osteomyelitis of the appendicular and axial skeleton during 2003–2018 were retrospectively reviewed. Specific inclusion criteria were clinical and radiologic suspicion of osteomyelitis. Standard of reference was defined using outcome of surgical histopathology and microbiology culture and clinical and imaging follow-up. Technical and clinical data (needle size, comorbidities, clinical factors, laboratory values, blood cultures) were collected. Logistic regression was performed to assess associations between technical and clinical data and microbiology biopsy outcome.ResultsA total of 142 CTNBBs were included (46.5% female patients; age ± SD 46.10 y ± 22.8), 72 (50.7%) from the appendicular skeleton and 70 (49.3%) from the axial skeleton. CTNBB showed a sensitivity of 42.5% (95% confidence interval [CI], 32.0%–53.6%) in isolating the causative pathogen. A higher rate of positive microbiology results was found in patients with intravenous drug use (odds ratio [OR] = 5.15; 95% CI, 1.2–21.0; P = .022) and elevated white blood cell count ≥ 10 × 10⁹/L (OR = 3.9; 95% CI, 1.62–9.53; P = .002). Fever (≥ 38°C) was another clinical factor associated with positive microbiology results (OR = 3.6; 95% CI, 1.3–9.6; P = .011).ConclusionsCTNBB had a low sensitivity of 42.5% for isolating the causative pathogen. Rate of positive microbiology samples was significantly higher in patients with IV drug use, elevated white blood cell count, and fever.     

Image-Guided Ablation of Recurrent or Unresectable Intrahepatic Cholangiocarcinoma

PurposeTo assess the safety and effectiveness of image-guided ablation of recurrent or unresectable intrahepatic cholangiocarcinoma (ICC).Materials and MethodsIn this retrospective study, 25 patients (14 women; age, 36–84 years) underwent 37 image-guided liver tumor ablation procedures to treat 47 ICCs (May 2004 to January 2022). At initial diagnosis, 20 patients had Stage 1 or 2 disease and 5 had Stage 3 or 4 disease. Before ablation, 19 (76.0%) of the 25 patients had progressed through prior treatments, including resection (n = 11), chemotherapy (n = 11), transarterial embolization (n = 3), or radiotherapy (n = 1); 6 (24.0%) of the 25 patients were treatment naïve. Ablation modality selection was based on patient and tumor characteristics and operator preference. Primary outcomes included local progression–free survival (LPFS) and overall survival (OS) after ablation. Statistical analysis included Kaplan-Meier (KM) survival analyses and Cox proportional hazards models.ResultsThe mean ablated tumor size was 2.0 cm ± 1.2 (range, 0.5–5.0 cm). The 1-, 2-, and 5-year LPFS rates were 84.0% (95% CI, 72.9–96.8), 73.0% (95% CI, 59.0–90.4), and 59.5% (95% CI, 41.6–85.1), respectively. The 1-, 2-, and 5-year secondary LPFS rates were 89.5% (95% CI, 80.2–99.9), 81.9% (95% CI, 69.4–96.6), and 75.6% (95% CI, 60.2–94.9). The 1-, 2-, and 5-year LPFS rates for tumors ≤2 cm in size were all 95.8% (95% CI, 88.2–100.0). The 1-, 2-, and 5-year OS rates were 78.5% (95% CI, 63.5–97.2), 68.4% (95% CI, 51.3–91.1), and 43.5% (95% CI, 23.5–80.5). Larger tumor size was associated with decreased time to local progression (hazard ratio, 1.93; P = .012).ConclusionsPercutaneous ablation provided favorable intermediate to long-term disease control for patients with recurrent or inoperable cholangiocarcinoma.     

Hypertensive Crisis during Microwave Ablation of Adrenal Neoplasms: A Retrospective Analysis of Predictive Factors

PurposeTo identify risk factors for hypertensive crisis (HC) during ultrasound-guided percutaneous microwave (MW) ablation of adrenal neoplasms.Materials and MethodsPatients who underwent MW ablation for adrenal tumors between April 2006 and November 2017 were retrospectively identified for this study (51 consecutive patients; 35 males, 16 females; mean age, 55 years; range, 15–85 years). A total of 77 MW ablation treatments were performed for 67 tumors (24 primary [9 pheochromocytomas, 8 adenomas, and 7 cortical carcinomas]; and 43 metastases [22 hepatocellular carcinoma, 8 renal cell carcinoma, 5 non-small cell lung cancer, 4 colorectal cancer, 3 liposarcoma, and 1 malignant fibrous histiocytoma]). The mean diameter of the adrenal tumors was 4.6 cm (range, 1.2–16.2 cm). Information about patient demographics, imaging studies, pathology and laboratory results, procedure records, and clinical outcomes was retrieved and analyzed. Statistical analysis was then performed to determine potential risk factors for HC.ResultsOf the 77 MW ablation procedures, HC occurred in 13 (16.9%). A significantly higher risk of HC was observed in patients with pheochromocytoma (odds ratio [OR], 9.037; 95% confidence interval [CI], 1.731–47.172; P = .009), body mass index <24 kg/m² (OR, 5.167; 95% CI, 1.060–25.194; P = .042), dominant tumor size ≤4.5 cm (OR, 4.023; 95% CI, 1.011–16.005; P = .048), and pre-procedural systolic blood pressure ≥130 mmHg (OR, 0.242; 95% CI, 0.068–0.861; P = .029).ConclusionHC can occur during MW ablation in patients with either primary or metastatic adrenal tumors. Pheochromocytoma, body mass index, tumor size, and pre-procedural systolic blood pressure appear to be significant risk factors for the occurrence of HC.     

Below-the-Ankle Angioplasty in Patients with Critical Limb Ischemia: A Systematic Review and Meta-Analysis

PurposeTo evaluate the safety and effectiveness of below-the-ankle (BTA) angioplasty and to assess whether additional BTA angioplasty after below-the-knee (BTK) angioplasty would improve clinical outcomes in patients with critical limb ischemia.Materials and MethodsTwo authors independently performed the search, study selection, assessment of methodological quality, and data extraction for this systematic review and meta-analysis. MEDLINE, Embase, and the Cochrane Database of Systematic Reviews were searched. Articles were eligible if it was reported that BTA angioplasty was performed and if the articles were published in English and had the full text available. Methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) score. The primary outcome was 12-month limb salvage rate. Secondary outcomes were 12-month amputation-free survival, technical success, complications, survival, and freedom from reintervention.ResultsTen articles met the inclusion criteria, reporting a total of 478 patients with BTA angioplasty performed in 524 legs. Three of the 10 included studies compared BTK angioplasty only to BTK angioplasty and additional BTA angioplasty. The pooled 12-month limb salvage rate was 92% (95% confidence interval [CI], 0.88–0.96). No statistically significant difference was found in limb salvage when additional BTA angioplasty was compared to BTK angioplasty only (odds ratio [OR], 1.23; 95% CI, 0.61–2.49). The pooled 12-month amputation-free survival was 78% (95% CI, 0.69–0.87). No statistically significant difference was found in amputation-free survival rate when additional BTA angioplasty was compared to BTK angioplasty only (OR, 1.58; 95% CI, 0.95–2.64). The methodological quality of the studies included was moderate, according to the MINORS score.ConclusionsThis systematic review and meta-analysis showed that additional BTA angioplasty is a safe and feasible procedure, with a 92% pooled proportion of limb salvage at 12 months.     

Change in Platelet Count after Transjugular Intrahepatic Portosystemic Shunt Creation: An Advancing Liver Therapeutic Approaches (ALTA) Group Study

PurposeTo evaluate recovery of platelet count after transjugular intrahepatic portosystemic shunt (TIPS) creation and patient factors predicting platelet recovery after TIPS creation.Materials and MethodsAdults with cirrhosis who underwent TIPS creation at 9 U.S. hospitals from 2010 to 2015 were included in this retrospective analysis. Change in platelets from before TIPS to 4 months after TIPS creation was characterized. Logistic regression was used to assess factors associated with top quartile percentage platelet increase after TIPS. Subgroup analyses were performed among patients with a pre-TIPS platelet count of ≤50 ×10⁹/L.ResultsA total of 601 patients were included. The median absolute change in platelets was 1 × 10⁹/L (−26 × 10⁹/L to 25 × 10⁹/L). Patients with top quartile percent platelet increase experienced ≥32% platelet increase. In multivariable analysis, pre-TIPS platelet counts (odds ratio [OR], 0.97 per 10⁹/L; 95% CI, 0.97–0.98), age (OR, 1.24 per 5 years; 95% CI, 1.10–1.39), and pre-TIPS model for end-stage liver disease (MELD) scores (OR, 1.06 per point; 95% CI, 1.02–1.09) were associated with top quartile (≥32%) platelet increase. Ninety-four (16%) patients had a platelet count of ≤50 × 10⁹/L before TIPS. The median absolute platelet change was 14 × 10⁹/L (2 × 10⁹/L to 34 × 10⁹/L). Fifty-four percent of patients in this subgroup were in the top quartile for platelet increase. In multivariable logistic regression, age (OR, 1.50 per 5 years; 95% CI, 1.11–2.02) was the only factor associated with top quartile platelet increase in this subgroup.ConclusionsTIPS creation did not result in significant platelet increase, except among patients with a platelet count of ≤50 × 10⁹/L before TIPS. Lower pre-TIPS platelet counts, older age, and higher pre-TIPS MELD scores were associated with top quartile (≥32%) platelet increase in the entire cohort, whereas only older age was associated with this outcome in the patient subset with a pre-TIPS platelet count of ≤50 × 10⁹/L.     

Stent Graft Placement for the Treatment of Hepatic Artery Injury in Patients with Cancer: Primary Patency and Clinical Outcomes

PurposeTo evaluate the safety, primary patency, and clinical outcomes of hepatic artery stent graft (SG) placement for vascular injuries.Materials and MethodsPatients treated with hepatic arterial SG placement for vascular injuries between September 2018 and September 2021 were reviewed. Data on demographic characteristics, indication, stent graft characteristics, antiplatelet/anticoagulant use, clinical success rate, complications, and type of follow-up imaging were collected. Follow-up images were reviewed by 2 independent reviewers to assess primary patency. A time-to-event analysis was performed. The median duration of stent graft patency was estimated using Kaplan-Meier curves. A Cox proportional hazard model was used to evaluate factors related to stent graft patency.ResultsThirty-five patients were treated with hepatic arterial SG placement, 11 for postoperative bleeds and 24 for hepatic artery infusion pump catheter–related complications. Clinical success was achieved in 32 (91%) patients (95% CI, 77–98). The median primary patency was 87 days (95% CI, 73–293). Stent grafts of ≥6-mm diameter retained patency for a longer duration than that with stent grafts of smaller diameters (6 mm vs 5 mm; hazard ratio, 0.35; 95% CI, 0.14–0.88; P = .026; and 7+ mm vs 5 mm; hazard ratio, 0.27; 95% CI, 0.09–0.83; P = .023). Anticoagulation/antiplatelet regimen was not associated with increased stent graft patency duration (P > .05). Only minor complications were reported in 2 (5.7%) patients.ConclusionsStent grafts can be used safely and effectively to treat injuries of the hepatic artery. Stent graft diameters of ≥6 mm seem to provide more durable patency.     

Safety and Effectiveness of Yttrium-90 Radioembolization around the Time of Immune Checkpoint Inhibitors for Unresectable Hepatic Metastases

PurposeTo assess the safety and effectiveness of yttrium-90 radioembolization and checkpoint inhibitor immunotherapy within a short interval for the treatment of unresectable hepatic metastases.Materials and MethodsThis single-institution retrospective study included 22 patients (12 men; median age, 65 y ± 11) with unresectable hepatic metastases and preserved functional status (Eastern Cooperative Oncology Group performance status 0/1) who received immunotherapy and radioembolization within a 15-month period (median, 63.5 d; interquartile range, 19.7–178.2 d) from February 2013 to March 2018. Primary malignancies were uveal melanoma (12 of 22; 54.5%), soft tissue sarcoma (3; 13.6%), cutaneous melanoma (3; 14%), and others (4; 18.2%). Studies were reviewed to March 2019 to assess Common Terminology Criteria for Adverse Events grade 3/4 toxicities, disease progression, and death.ResultsThere were no grade 4 toxicities within 6 mo of radioembolization. Grade 3 hepatobiliary toxicities occurred in 3 patients (13.6%) within 6 months, 2 from rapid disease progression and 1 from a biliary stricture. Two patients (9.1%) experienced clinical toxicities, including grade 4 colitis at 6 months and hepatic abscess at 3 months. Median overall survival (OS) from first radioembolization was 20 mo (95% confidence interval [CI], 12.5–27.5 mo), and median OS from first immunotherapy was 23 months (95% CI, 15.9–30.1 mo). Within the uveal melanoma subgroup, the median OS from first radioembolization was 17.0 months (95% CI, 14.2–19.8 mo). Median time to progression was 7.8 months (95% CI, 3.3–12.2 mo), and median progression-free survival was 7.8 mo (95% CI, 3.1–12.4 mo).ConclusionsCheckpoint immunotherapy around the time of radioembolization is safe, with a low incidence of toxicity independent of primary malignancy.     

Transjugular Intrahepatic Portosystemic Shunts in Pediatric Portal Hypertension: A Systematic Review and Meta-Analysis

PurposeTo investigate the technical outcome, clinical outcome, and patency of transjugular intrahepatic portosystemic shunt (TIPS) in pediatric portal hypertension (PHT).MethodsA systematic search of MEDLINE/PubMed, EMBASE, Cochrane databases, ClinicalTrials.gov, and WHO ICTRP registries was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An a priori protocol was registered at the PROSPERO database. Original full-text articles on pediatric patients (sample size of ≥5 patients with upper age limit of 21 years) with PHT who underwent TIPS creation for any indication were included.ResultsSeventeen studies with 284 patients (average-weighted age of 10.1 years) were included, with an average-weighted follow-up of 3.6 years. TIPS was technically successful in 93.3% (95% confidence interval [CI], 88.5%–97.1%) of patients, with a major adverse event rate of 3.2% (95% CI, 0.7–6.9) and adjusted hepatic encephalopathy rate of 2.9% (95% CI, 0.6–6.3). The pooled 2-year primary and secondary patency rates were 61.8% (95% CI, 50.0–72.4) and 99.8% (95% CI, 96.2%–100.0%), respectively. Stent type (P = .002) and age (P = .04) were identified as a significant source of heterogeneity for clinical success. In subgroup analysis, the clinical success rate was 85.9% (95% CI, 77.8–91.4) in studies with a majority of covered stents, and 87.6% (95% CI, 74.1–94.6) in studies with a median age of 12 years or older.ConclusionsThis systematic review and meta-analysis demonstrates that a TIPS is a feasible and safe treatment for pediatric PHT. To improve clinical outcome and patency on the long term, the use of covered stents should be encouraged.     

Clinical Utility of Transient Elastography in the Management of Patients with Budd-Chiari Syndrome Undergoing Endovascular Intervention

PurposeTo quantify liver stiffness measurement (LSM) changes after endovascular intervention for Budd-Chiari syndrome (BCS) and evaluate whether LSM changes predict restenosis after endovascular intervention.Materials and MethodsPatients with BCS who underwent endovascular intervention and had at least 2 LSM values available after the intervention were included. ΔLSM was the difference between LSMs estimated at the last and second last hospital visits. In patients with restenosis, 2 LSM values before restenosis were included. ΔLSM% was calculated as the ratio of ΔLSM to the LSM at the second last visit and expressed as a percentage. Odds ratio (OR) with confidence interval (CI) and area under the receiver operating characteristic curves (AUROCs) were calculated for the predictors of restenosis.ResultsThe median baseline and postinterventional 1-week, 3-month, 6-month, and 12-month LSM values were 47.2 kPa (33.8–68.4 kPa), 29.2 kPa (24.5–43.0 kPa), 26.2 kPa (18.6–38.9 kPa), 20.9 kPa (13.3–29.8 kPa), and 17.3 kPa (11.8–25.4 kPa), respectively. Of the 118 patients, including 67 men, restenosis developed in 10 patients after a median (interquartile range) duration of 19 months (11–46 months). ΔLSM% was higher (more positive) in patients with restenosis than in those without restenosis (44.7 [8.3–134.3] vs ?6.6 [?19.4 to 14.9], P = .001). ΔLSM% was a significant predictor of restenosis with an OR of 1.032 (95% CI, 1.015–1.050; P < .001). The AUROC for ΔLSM% was 0.831 (95% CI, 0.750–0.893; P = .001), and a ΔLSM% increment of 13.2% predicted restenosis with a sensitivity and specificity of 80.0% and 74.1%, respectively.ConclusionsLSM gradually decreases after endovascular intervention, and transient elastography is a promising test for detecting restenosis after the endovascular treatment of patients with BCS.     

Partial Nephrectomy versus Percutaneous Cryoablation of Small Renal Cell Carcinomas: A Comparison of Adverse Events in a Prospective Multicenter Cohort Study

PurposeTo assess and compare complications and readmissions after partial nephrectomy and percutaneous cryoablation of cT1 renal cell carcinoma (RCC).Materials and MethodsPatients treated for cT1 RCC between 2019 and 2021 were prospectively and consecutively enrolled. Complications recorded within 30 and 90 days were graded according to the Clavien-Dindo classification, and percutaneous cryoablation was graded according to the Society of Interventional Radiology classification of adverse events. Major complications were defined as complications with a grade of ≥3 based on the Clavien-Dindo classification. Readmission within 30 days was recorded.ResultsThe cohort included 86 partial nephrectomies and 104 cryoablations. The complication rate within 90 days was 23% after partial nephrectomy and cryoablation (P = .98), with major complication rates of 3% after partial nephrectomy and 10% after cryoablation (P = .15). The readmission rates were 14% and 11% after partial nephrectomy and cryoablation, respectively (P = .48). Double-J stents were associated with overall complications (odds ratio [OR], 9.88; 95% confidence interval [CI], 2.18–44.68; P = .003) and readmissions (OR, 5.39; 95% CI, 1.37–21.06; P = .015) after cryoablation. A high versus low radius-endophytic-nearness-anterior-location score (OR, 5.86; 95% CI, 1.08–31.81; P = .040) and endophytic location (OR, 7.70; 95% CI, 1.72–34.50; P = .008) were associated with a higher complication rate after cryoablation. The Charlson Comorbidity Index (CCI) was associated with major complications after partial nephrectomy (OR, 2.12; 95% CI, 1.05–4.30; P = .036).ConclusionsPartial nephrectomy and cryoablation are comparable regarding complications within 90 days after treatment. Tumor complexity and double-J stents were associated with complications after cryoablation, and a high CCI was associated with complications after partial nephrectomy.     

Prognostic Factors for Local Recurrence after Cryoablation of Desmoid Tumors

PurposeTo determine the risk factors for local of adult patients treated for desmoid tumors by cryoablation.Materials and MethodsEighty-four patients treated for nonabdominopelvic desmoid tumors by cryoablation from July 2012 to July 2020 were included in a retrospective study. The population was composed of 64 women (76.19%) and 20 men (23.81%), aged from 16 to 75 years (median, 35 years ± 14.25). Each patient underwent preprocedural gadolinium-enhanced magnetic resonance imaging and was followed up to 36 months with the same technique. Clinical features, such as tumor size and previous treatment, epidemiological features, and the technical parameters of cryoablation, were studied.ResultsLocal relapse was found in 19 (22.62%) of 84 patients. The 12-, 24-, and 36-month progression-free survival rates were 89% (95% confidence interval [CI], 79–94), 74% (95% CI, 60–83), and 68% (95% CI, 53–79), respectively. In univariate analysis, significant prognostic factors associated with local recurrence were non–abdominal wall location (P = .042), debulking strategy (P = .0105), risk of visceral injury (P = .034) or peripheral nerve injury during cryoablation (P = .033), previous radiation therapy (P = .043), and treatment before 2016 (P = .008). In multivariate analysis, abdominal wall tumors displayed the best outcome, whereas the neck and trunk showed a high rate of recurrence (hazard ratio, 7.307 [95% CI, 1.396–38.261]).ConclusionsThe local recurrence of desmoid tumors after cryoablation depends on a number of prognostic factors, in particular, a non–abdominal wall location of the tumor and previous local treatment such as surgery or radiation therapy.