Stratification of portal vein-invaded hepatocellular carcinoma treated with transarterial chemoembolization monotherapy

Purpose:The study aimed to establish a prognostic prediction model and an artificial neural network(ANN)model to determine who will benefit from transarterial chemoembolization(TACE)monotherapy for patients with hepatocellular carcinoma(HCC)invading portal vein.Methods:Treatment-naive patients with HCC and portal vein invasion who were treated with TACE monotherapy at hospital A as training cohort and hospital B as validation cohort were included.The primary endpoint was overall survival(OS).In training cohort,independent risk factors associated with OS were identified by univariate and multivariate analysis.The prognostic prediction(PP)and ANN models based on the independent risk factors were established to find out who will benefit most from TACE monotherapy.The type of portal vein tumor thrombosis was classified based on the Cheng’s Classification.The accuracy of the models was validated in validation cohort.Results:Totally,242 patients(training cohort:n=159;validation cohort:n=83)were included.The median OS was 7.1 and 8.5 months in training and validation cohort,respectively.In training cohort,the PP model was established based on the following five independent risk factors:Cheng’s Classification,Eastern Cooperative Oncology Group score,maximum tumor size,number of HCC nodules,and Child-Pugh stage.PP score of 17.5 was identified as cut-off point and patients were divided into two groups by PP score<17.5 and>17.5 in survival benefit and prognostication(8.8 vs.5.5 months;P<0.001).These five factors were included and ranked based on the importance associated with OS in the ANN model.Both of the two models received high accuracy after validation.Conclusions:Portal vein invaded HCC patients with PP score<17.5 may benefit most from TACE monotherapy.For these patients,TACE monotherapy should be considered.

Comparison of embolic agents for varices during transjugular intrahepatic portosystemic shunt for variceal bleeding: Tissue gel or coil?

Purpose:We aimed to compare treatment efficacy,safety and material cost between tissue gel and coil regarding variceal embolization during transjugular intrahepatic portosystemic shunt(TIPS).Materials&Methods:This retrospective study including cirrhotic patients with variceal bleeding treated with TIPS combined with variceal embolization between January 2016 and August 2017.Patients were divided into three groups according to embolic agents used in variceal embolization:tissue gel group(Group A),combination group(Group B),and coil group(Group C).The primary endpoint was 1-year rebleeding rate after TIPS creation.The secondary endpoints included shunt dysfunction,overt hepatic encephalopathy,liver function,and embolic agents-related expense.Results:A total of 60 patients(30,10,and 20 in Group A,B,and C)were included.Variceal rebleeding occurred in3(10%),0(0%),and 4(20%)patients within one year after TIPS creation in Group A,B,and C,respectively.Stent dysfunction occurred in 2(3.3%)patients and 9(15.0%)patients experienced overt hepatic encephalopathy.No significant differences were observed between three groups regarding primary and secondary endpoints except embolic agents-related expense,with a significantly lower cost in Group A when compared to the other two groups.Stent dysfunction occurred in two patients,with one patient in Group A developed acute occlusion caused by thrombus and another patient in Group C underwent stent stenosis during follow-up.Conclusions:Compares to coil alone or combines with coil,tissue gel has similar treatment efficacy and safety,but with significantly lower cost for variceal bleeding during TIPS.

Percutaneous transhepatic intrahepatic portosystemic shunt for variceal bleeding: A series of six cases and literature review

Objectives:To present a case series of modified transjugular intrahepatic portosystemic shunts(TIPS) and percutaneous transhepatic intrahepatic portosystemic shunts(PTIPS) in cirrhotic patients with variceal bleeding(VB).In addition,the scientific literature pertaining to PTIPS was reviewed.Methods:This retrospective clinical case series included six cirrhotic patients with VB who were treated with PTIPS after the failure of endoscopic band ligation or endoscopic injection sclerotherapy combined with vasoactive drugs.The treatment was conducted between January 2017 and June 2019 at a single institution.Three patients suffered from severe atrophy of the right or left lobar of the liver as well as the main right or left branch of the portal vein.The remaining three patients showed severe atrophy of the whole liver and portal vein,resulting in widening of the liver fissure.A paired t-test was used to compare the changes in portal pressure gradient between before and after the PTIPS operation.The rebleeding rate,treatment efficacy,complications,and technical success rate were all assessed during follow-up.Results:All six PTIPS procedures were performed successfully,with no severe procedural-related complications observed.None of the patients experienced VB during a mean follow-up of 22.8(range,18.0-28.0) months.The mean portosystemic pressure gradient decreased from 28.3 ± 4.3 mmHg pre-procedure to 12.3 ± 2.6 mmHg immediately post-procedure(P <0.001).At follow-up,one patient was found to have developed grade 2 hepatic encephalopathy thrice during the first year,according to the West Haven criteria.However,this was resolved following medical treatment.Conclusions:When the patient’s portal venous anatomy is unconducive to the performance of TIPS using the transjugular approach,PTIPS can be considered as a safe,effective complementary surgical approach for patients with VB.

血管腔内介入治疗肾动脉瘤的临床疗效分析

目的探讨腔内治疗肾动脉瘤(renal artery aneurysm,RAA)的临床疗效及诊治体会。方法回顾性分析2016年3月至2023年2月苏州大学附属第一医院收治的14例采用腔内治疗的RAA患者手术资料和临床结果。记录术前与术后临床表现、影像学资料、肾功能变化以及术中与术后并发症的发生情况。结果14例患者中Ⅰ型RAA有2例,瘤体位于肾动脉主干;Ⅱ型RAA有7例,瘤体位于肾动脉分叉处;Ⅲ型RAA有5例,瘤体起源于肾内血管。瘤体平均最大径为11~57 mm,平均(21.8±11.4)mm;基底宽度为4.0~15.0 mm,平均(6.9±2.7)mm;载瘤动脉直径为1.8~5.1 mm,平均(3.9±1.0)mm。14例RAA患者均成功行腔内介入治疗,采用瘤腔栓塞12例,覆膜支架置入1例,载瘤动脉栓塞1例,手术成功率100%。腰腹痛患者术后症状缓解5例,高血压患者术后血压降至正常5例。术后平均随访时间为(20.1±18.4)个月,随访期间动脉瘤无复发,无严重并发症发生。结论腔内治疗RAA安全有效,弹簧圈栓塞可联合支架置入、球囊等手段治疗更为复杂的病例。

Transarterial chemoembolization refractoriness in hepatocellular carcinoma:Chinese College of Interventionalists definition and consensus statement

Transarterial chemoembolization(TACE)is recommended as the first-line approach for intermediate hepatocellular carcinoma(HCC),and it is the most widely applied method for advanced HCC in real-world clinical practice.[1,2]According to the China Liver Cancer(CNLC)staging system,TACE is recommended as the first-line therapy for stages IIb and IIIa,while it is also recommended as a major approach for stages Ib,IIa,and IIIb.[3]Despite its confirmed treatment efficacy and safety,repeated TACE is sometimes unbeneficial for some patients due to the high heterogenicity of HCC,manifesting as liver function deterioration and occupying the optimal occasion of other therapies.Accordingly,the concept of“TACE refractoriness”has been introduced by various societies around the world to avoid ineffective repeated TACE.[4]Nevertheless,there is no widely accepted consensus on the definitions of“TACE refractoriness”and some controversies have yet to be resolved.In addition,whether the existing definitions of“TACE refractoriness”are suitable for Chinese HCC patients is still doubtful.

Endovascular embolization for upper gastrointestinal bleeding due to portal hypertension caused by a superior mesenteric arteriovenous fistula

To the Editor,Upper gastrointestinal bleeding(UGIB)caused by portal hypertension is not uncommon in clinical practice,but UGIB caused by superior mesenteric arteriovenous fistula(SMAVF)is extremely rare.The primary etiologies of SMAVF are associated with traumatic or iatrogenic injury,and congenital lesions.1,2 Although many patients remain asymptomatic after unrecognized injury to the superior mesenteric artery(SMA)for many years,most previous studies reported delayed presentation of persistent epigastric pain,vomiting and nausea,ascites,mesenteric ischemia,or bleeding.The incidence of SMAVF is 0.09%,with a mortality rate of 39%–77%.3 Thus,prompt diagnosis and treatment are very important to prevent morbidity and mortality.