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Predictors of need for endovascular intervention in hepatic trauma

Zhao, Ken; Mabud, Tarub S; Patel, Nihal; Bernstein, Mark P; McDermott, Meredith; Bryk, Hillel; Taslakian, Bedros
PURPOSE/OBJECTIVE:Non-operative management of hepatic trauma with adjunctive hepatic arterial embolization (HAE) is widely accepted. Despite careful patient selection utilizing CTA, a substantial proportion of angiograms are negative for arterial injury and no HAE is performed. This study aims to determine which CT imaging findings and clinical factors are associated with the presence of active extravasation on subsequent angiography in patients with hepatic trauma. MATERIALS AND METHODS/METHODS:The charts of 243 adults who presented with abdominal trauma and underwent abdominal CTA followed by conventional angiography were retrospectively reviewed. Of these patients, 49 had hepatic injuries on CTA. Hepatic injuries were graded using the American association for the surgery of trauma (AAST) CT classification, and CT images were assessed for active contrast extravasation, arterial pseudoaneurysm, sentinel clot, hemoperitoneum, laceration in-volving more than 2 segments, and laceration involving specific anatomic landmarks (porta hepatis, hepatic veins, and gallbladder fossa). Medical records were reviewed for pre- and post-angiography blood pressures, hemoglobin levels, and transfusion requirements. Angiographic images and reports were reviewed for hepatic arterial injury and performance of HAE. RESULTS:In multivariate analysis, AAST hepatic injury grade was significantly associated with increased odds of HAE (Odds ratio: 2.5, 95% CI 1.1, 7.1, p = 0.049). Univariate analyses demonstrated no significant association between CT liver injury grade, CT characteristics of liver injury, or pre-angiographic clinical data with need for HAE. CONCLUSION/CONCLUSIONS:In patients with hepatic trauma, prediction of need for HAE based on CT findings alone is challenging; such patients require consideration of both clinical factors and imaging findings.
PMID: 36520161
ISSN: 2366-0058
CID: 5382342

Clinical predictors of need for endovascular intervention in hepatic trauma [Meeting Abstract]

Zhao, K; Mabud, T; Patel, N; Bernstein, M; McDermott, M; Bryk, H; Taslakian, B
ISSN: 1535-7732
CID: 5192312

Extreme enhanced myometrial vascularity following cesarean scar pregnancy: a new diagnostic entity

Timor-Tritsch, Ilan E; McDermott, W Meredith; Monteagudo, Ana; Calί, Giuseppe; Kreines, Fabiana; Hernandez, Sasha; Stephenson, Courtney; Bryk, Hillel; D'Antonio, Francesco
OBJECTIVE/UNASSIGNED:To define, illustrate and to follow-up the diagnosis, pathophysiology and treatment of a subset of the known enhanced myometrial vascularity (EMV): its extreme form, associated with cesarean scar pregnancies (CSP) and with some cases pf placenta accreta spectrum being at increased risk of significant bleeding complications. We also aim to provide guidance to the management of such cases. MATERIAL AND METHODS/UNASSIGNED:This is an IRB-approved retrospective observational study of thirteen patients with an extreme form of EMV complicating CSPs. Patient's age, parity, number of cesarean deliveries, initial and time to negative serum hCG levels, primary and secondary diagnoses, blood flow peak systolic velocities, primary and secondary treatments, uterine artery embolization and outcomes were recorded. RESULTS/UNASSIGNED:Gestational ages ranged 6-11 weeks at initial presentation. Initial serum hCG was 20.0-102.48 mIU/L (mean 44.4 mIU/L). Diameter of EMV reached 20-75 mm (mean 46.8 mm). The mean peak systolic velocity (PSV) was 84.2 cm/s (range 46.7-118.0). Primary treatments were: systemic methotrexate (MTX) alone; D&C alone; MTX and D&C; local and systemic intra-gestational MTX injection; double cervical ripening balloon with systemic MTX; misoprostol and D&C; emergent UAE. UAE and hysterectomy were the two main secondary treatments in 10 women except 1 having a D&C after UAE, and in 1 the lesion regressed without secondary treatment. Mean time to nonpregnant hCG levels was 21-122 days (mean 67.2). Mean follow-up was 110.2 days (range 26-160). Ten women were treated with UAE, 6 had one, 3 had two embolizations. Two women had hysterectomies, one of these for persistent bleeding. Based upon the common denominators of the clinical and the US pictures, our definition of extreme EMV is sustained form of EMV associated with treated or untreated CSP, with peak systolic velocities of blood flow over 50 cm/s, slow return or plateauing serum hCG, with or without clinically significant vaginal bleeding, unresponsive to initial or secondary treatment requiring uterine artery embolization or hysterectomy. CONCLUSION/UNASSIGNED:differs following the normal regression of the physiologically re-modelled, dilated vascular bed from the faulty "disrepair" of the vessel wall in in treated or untreated CSPs. The "threatening" appearance of the above EMVs warranted the term "extreme", creating their separate new sub-category." Extreme forms of CSP-related EMV pose significant diagnostic and management challenges. Prompt recognition and intervention, the proactive use of UAE, can maximize the outcome of women affected by this "extreme" form of EMV enabling to preserve reproductive potential. Obstetricians, gynecologists and interventional radiologists should be aware of this form of severe vascular complication.
PMID: 33730990
ISSN: 1476-4954
CID: 4875282

Transjugular intrahepatic portosystemic shunt (TIPS) creation for refractory ascites: Post-TIPS gradient best predictor of clinical outcome [Meeting Abstract]

Wu, S; Farquharson, S; Gross, J S; Aaltonen, E T; Sridhar, D; Kovacs, S; Bryk, H; Teperman, L; Park, J S; Sigal, S; Charles, H; Deipolyi, A R
Purpose: TIPS creation fails to control ascites in 40% or more of patients, but the variables predicting outcome are unclear, with prior studies highlighting pre-TIPS portosystemic gradient (PSG) (Nair et al 2004; JVIR 15:1431). We studied which variables predict outcome of TIPS for refractory ascites. Materials and Methods: We retrospectively identified patients who underwent TIPS for refractory ascites between 1/12 and 5/14, yielding 40 patients. We excluded 17 patients due to insufficient peri-procedural documentation or technical failures, leaving 23 patients (16 men, 7 women, mean age 60 +/-2 yrs) for assessment of variables influencing osmotic (albumin and sodium levels) and hydrostatic (pre- and post- TIPS PSG and large varices) pressure. Responders were defined as those requiring fewer or no paracenteses; nonresponders had persistent ascites, with similar pre-TIPS frequency of therapeutic paracentesis. Complications within 1 month requiring hospitalization were noted. Multiple logistic regression, Mann-Whitney U tests, and one-tailed chi2 tests assessed group differences. Results: Ten patients (43%: responders) had documented improvement in ascites. Multiple logistic regression including pre- and post-TIPS PSG significantly impacted outcome (p=0.04). Post- but not pre-TIPS PSG predicted outcome (p=0.04 vs. p=0.84). Responders had significantly lower post- TIPS gradient (5.8) compared with non-responders (7.6) (p=0.02). In contrast, responders and non-responders did not differ in albumin (2.7 vs. 2.7) or sodium (136 vs. 134) levels, or pre-TIPS gradient (13.9 vs. 14.7 mmHg) (p>0.05). Similar numbers of responders (50%) had large varices compared to non-responders (61%) (p=0.3). Responders (50%) had significantly more complications compared to non-responders (15%) (p=0.04), mostly encephalopathy (85%) requiring hospitalization. Conclusion: Only post-TIPS PSG predicted which patients had significantly reduced ascites, in contrast to prior studies suggesting importance of pre-TIPS gradient. Findings suggest aggressively lowering the gradient below 6 mmHg may be the most reliable technique to improve outcomes, although with expected higher risk of complications
ISSN: 1051-0443
CID: 1514772

Denali, ALN, and Option/Option Elite filter retrieval: A single center experience [Meeting Abstract]

Aaltonen, E T; Obele, C; Bryk, H; Deipolyi, A R; Farquharson, S; Gross, J S; Kovacs, S; Sridhar, D; Charles, H W
Purpose: To evaluate if there is a significant difference in retrieval difficulty as determined by fluoroscopy time and equipment use when comparing three different filters: Denali, ALN, and Option/Option Elite. Materials and Methods: Retrospective analysis was performed of 33 filter retrievals performed over a 24 month period (12 men, 21 women; mean age 60). There were 8 Denali (Bard Peripheral Vascular), 9 ALN (ALN Implants), and 16 Option/ Option Elite (Argon Medical Devices) filter retrievals. Demographics, filter dwell time, fluoroscopy time during retrieval, and equipment used for retrieval were collected for each case. One Option case was excluded due to unsuccessful retrieval. Kruskal-Wallis H, two sample t-test and Chi-square analysis were used to determine significant differences in fluoroscopy time and equipment use between the three filter groups. Results: There were no significant differences between groups based on demographics or filter dwell time. Mean retrieval times were 4.9 min (SD: 3.6, range 1.2-10.3) for Denali, 9.9 min (SD: 5.5, range 2.9-18.6) for ALN, and 23.9 min (SD: 20.0, range 2.5 - 58) for Option/Option Elite. A Kruskal-Wallis H test showed a significant difference in these times (chi2=7.17, p=0.028), subsequent post-hoc analysis showed a significant difference only between Denali and Option but not between Denali and ALN or ALN and Option. Given normal distribution of fluoroscopy times for Denali and ALN, a separate t-test comparing these two filters did demonstrate a significant difference in fluoroscopy time (p=0.023). None of the Denali retrievals required additional equipment beyond a snare and sheath, 1/9 (11%) of ALN and 10/15 (67%) of Option retrievals required at least a tip deflecting wire or angled catheter (chi2=11.07, p=0.004). Sub-analysis separating Option and Option Elite filters did not change any results significantly. Conclusion: Denali filter retrieval involves significantly less fluoroscopy time than ALN or Option/Option Elite filter retrieval. In this series, Option/Option Elite retrieval also required significantly more equipment to achieve technical success compared to Denali and ALN retrieval. A larger sample size is required to corroborate these early results. (Table Presented)
ISSN: 1051-0443
CID: 2664492

Late presentation of a hepatic pseudoaneurysm with hemobilia after angioembolization for blunt hepatic trauma [Case Report]

Moreno, Ricardo D; Harris, Marsha; Bryk, Hillel B; Pachter, H Leon; Miglietta, Maurizio A
PMID: 17426568
ISSN: 0022-5282
CID: 72732

Arm exercise testing with myocardial scintigraphy in asymptomatic patients with peripheral vascular disease

Goodman S; Rubler S; Bryk H; Sklar B; Glasser L
Arm exercise with myocardial scintigraphy and oxygen consumption determinations was performed by 33 men with peripheral vascular disease, 40 to 74 years of age (group 2). None had evidence of coronary disease. Nineteen age-matched male control subjects (group 1) were also tested to determine the normal endurance and oxygen consumption during arm exercise in their age group and to compare the results with those obtained during a standard treadmill performance. The maximal heart rate, systolic blood pressure, pressure rate product, and oxygen consumption were all significantly lower for arm than for leg exercise. However, there was good correlation between all these parameters for both types of exertion. The maximal heart rate, work load and oxygen consumption were greater for group 1 subjects than in patients with peripheral vascular disease despite similar activity status. None of the group 1 subjects had abnormal arm exercise ECGs, while six members of group 2 had ST segment changes. Thallium-201 scintigraphy performed in the latter group demonstrated perfusion defects in 25 patients. After nine to 29 months of follow-up, three patients who had abnormal tests developed angina and one of them required coronary bypass surgery. Arm exercise with myocardial scintigraphy may be an effective method of detecting occult ischemia in patients with peripheral vascular disease. Those with good exercise tolerance and no electrocardiographic changes or 201T1 defects are probably at lower risk for the development of cardiac complications, while those who develop abnormalities at low exercise levels may be candidates for invasive studies
PMID: 2924603
ISSN: 0012-3692
CID: 32304