Publications by authors named "Luigi Maruzzelli"

70 Publications

Portal vein puncture-related complications during transjugular intrahepatic portosystemic shunt creation: Colapinto needle set vs Rösch-Uchida needle set.

Radiol Med 2021 Aug 18. Epub 2021 Aug 18.

Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), via Tricomi 5, 90127, Palermo, Italy.

Transjugular portal vein puncture is considered the riskiest step in TIPS creation with possible incidence of portal vein puncture-related complications (PVPC). The Colapinto and the Rösch-Uchida needle sets are two different needle sets currently available. To date, there have been no randomized control trials or systematic reviews which compare the incidence of PVPC when using the two different needle sets. The aim of this literature review is to assess the rate of PVPC associated with the different needle sets used in the creation of TIPS. From the described search, 1500 articles were identified and 34 met the inclusion criteria. Outcome measured was the prevalence of PVPC using the different needle sets. Overall 212 (3.6%) PVPC were reported in 5865 patients; 142 (3.5%) reported in 4000 cases using the Rösch-Uchida set and 70 (3.7%) in 1865 patients using the Colapinto set (p = 0.69). PVPC in TIPS creation are not related to the choice of needle set used in the procedure. To our knowledge, this is the first review of its kind, the results of which support the theory that while the rate of PVPC is influenced by many factors, choice of needle set does not seem to be one of them.
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http://dx.doi.org/10.1007/s11547-021-01404-1DOI Listing
August 2021

Performance of the model for end-stage liver disease score for mortality prediction and the potential role of etiology.

J Hepatol 2021 Jul 30. Epub 2021 Jul 30.

Gastroenterology Unit, ASL Latina, Department of Translational and Precision Medicine, "Sapienza" University of Rome, Italy.

Background & Aims: Although the discriminative ability of the model for end-stage liver disease (MELD) score is generally considered acceptable, its calibration is still unclear. In a validation study, we assessed the discriminative performance and calibration of 3 versions of the model: original MELD-TIPS, used to predict survival after transjugular intrahepatic portosystemic shunt (TIPS); classic MELD-Mayo; and MELD-UNOS, used by the United Network for Organ Sharing (UNOS). We also explored recalibrating and updating the model.

Methods: In total, 776 patients who underwent elective TIPS (TIPS cohort) and 445 unselected patients (non-TIPS cohort) were included. Three, 6 and 12-month mortality predictions were calculated by the 3 MELD versions: discrimination was assessed by c-statistics and calibration by comparing deciles of predicted and observed risks. Cox and Fine and Grey models were used for recalibration and prognostic analyses.

Results: In the TIPS/non-TIPS cohorts, the etiology of liver disease was viral in 402/188, alcoholic in 185/130, and non-alcoholic steatohepatitis in 65/33; mean follow-up±SD was 25±9/19±21 months; and the number of deaths at 3-6-12 months was 57-102-142/31-47-99, respectively. C-statistics ranged from 0.66 to 0.72 in TIPS and 0.66 to 0.76 in non-TIPS cohorts across prediction times and scores. A post hoc analysis revealed worse c-statistics in non-viral cirrhosis with more pronounced and significant worsening in the non-TIPS cohort. Calibration was acceptable with MELD-TIPS but largely unsatisfactory with MELD-Mayo and -UNOS whose performance improved much after recalibration. A prognostic analysis showed that age, albumin, and TIPS indication might be used to update the MELD.

Conclusions: In this validation study, the performance of the MELD score was largely unsatisfactory, particularly in non-viral cirrhosis. MELD recalibration and candidate variables for an update to the MELD score are proposed.

Lay Summary: While the discriminative performance of the model for end-stage liver disease (MELD) score is credited to be fair to good, its calibration, the correspondence of observed to predicted mortality, is still unsettled. We found that application of 3 different versions of the MELD in 2 independent cirrhosis cohorts yielded largely imprecise mortality predictions particularly in non-viral cirrhosis. Thus, we propose a recalibration and suggest candidate variables for an update to the model.
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http://dx.doi.org/10.1016/j.jhep.2021.07.018DOI Listing
July 2021

Percutaneous Trans-Hepatic Embolization of an Iatrogenic Extra-Hepatic Pseudoaneurysm of the Right Hepatic Artery in a Patient With Previous Occlusion of the Proper Hepatic Artery: An Endovascular Procedure to Avoid a Difficult Surgical Repair.

Vasc Endovascular Surg 2021 Jun 7:15385744211022591. Epub 2021 Jun 7.

Department of Surgery, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy.

We report a case of successful percutaneous transhepatic, embolization of an iatrogenic extra-hepatic pseudoaneurysm (PsA) of the right hepatic artery (RHA) under combined fluoroscopic and ultrasonographic guidance. A 73-year-old man underwent percutaneous transhepatic biliary drainage placement in another hospital, complicated by haemobilia and development of a RHA PsA. Endovascular embolization was attempted, resulting in coil embolization of the proper hepatic artery, and persistence of the PsA. At this point, the patient was referred to our hospital. Computed tomography and direct angiography confirmed the iatrogenic extra-hepatic PsA of the RHA, refilled by small collaterals from the accessory left hepatic artery (LHA) and coil occlusion of the proper hepatic artery. Attempted selective catheterization of these vessels was unsuccessful due to the tortuosity and very small caliber of the intra-hepatic collaterals, the latter precluding endovascular treatment of the PsA. Percutaneous trans-hepatic combined fluoroscopic and ultrasound-guided embolization of the PsA was performed with Lipiodol® and cyanoacrylate-based glue (Glubran®2). Real time fluoroscopic images and computed tomography confirmed complete occlusion of the pseudoaneurysm. Surgical repair, although feasible, was considered at high risk. In our patient, we decided to perform a percutaneous trans-hepatic combined fluoroscopic and ultrasound-guided embolization of the PsA using a mix of Lipiodol® and Glubran®2 because of the fast polymerization time of the glue allowing the complete occlusion of the PsA in few seconds, thus eliminating the risk of coil migration, reducing the risk of PsA rupture and avoid a difficult surgical repair.
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http://dx.doi.org/10.1177/15385744211022591DOI Listing
June 2021

Transjugular Intrahepatic Portosystemic Shunt: A Single-Centre Mid-term Experience Using the Viatorr Controlled-Expansion Stent.

Dig Dis Sci 2021 Feb 27. Epub 2021 Feb 27.

Radiology Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via E. Tricomi 5, 90127, Palermo, Italy.

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http://dx.doi.org/10.1007/s10620-021-06867-wDOI Listing
February 2021

Imaging of calcified hepatic lesions: spectrum of diseases.

Abdom Radiol (NY) 2021 06 16;46(6):2540-2555. Epub 2021 Jan 16.

Radiology Unit, Department of Diagnostic and Therapeutic Services, IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), via Tricomi 5, 90127, Palermo, Italy.

Hepatic calcifications have been increasingly identified over the past decade due to the widespread use of high-resolution Computed Tomography (CT) imaging. Calcifications can be seen in a vast spectrum of common and uncommon diseases, from benign to malignant, including cystic lesions, solid neoplastic masses, and inflammatory focal lesions. The purpose of this paper is to present an updated review of CT imaging findings of a wide range of calcified hepatic focal lesions, which can help radiologists to narrow the differential diagnosis.
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http://dx.doi.org/10.1007/s00261-020-02924-6DOI Listing
June 2021

MELD calibration.

Am J Transplant 2021 01 27;21(1):438-439. Epub 2020 Aug 27.

Radiology Unit, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy.

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http://dx.doi.org/10.1111/ajt.16255DOI Listing
January 2021

A Right and a Left … With a Simple Needle….

Gastroenterology 2020 09 4;159(3):e3-e6. Epub 2020 Mar 4.

IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Department of Diagnostic and Therapeutic Services, Radiology Unit, Palermo, Italy.

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http://dx.doi.org/10.1053/j.gastro.2020.02.053DOI Listing
September 2020

Radiation exposure during transjugular intrahepatic portosystemic shunt creation in patients with complete portal vein thrombosis or portal cavernoma.

Radiol Med 2020 Jul 18;125(7):609-617. Epub 2020 Feb 18.

Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi, 5, 90127, Palermo, PA, Italy.

Background: This study aims to evaluate radiation exposure in patients with complete portal vein thrombosis (CPVT) or portal cavernoma (PC) undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation using real-time ultrasound guidance for portal vein targeting.

Materials And Methods: This is a single institution retrospective analysis. Between August 2009 and September 2018, TIPS was attempted in 49 patients with CPVT or PC. Radiation exposure (dose area product [DAP], air KERMA (AK) and fluoroscopy time [FT]), technical success, clinical success, complications and survival were analyzed.

Results: In total, 29 patients had CPVT and 20 patients had PC. 41/49 patients had cirrhosis. TIPS indications were refractory ascites (n =  25), variceal bleeding (n = 16) and other (n = 8). TIPS was successfully placed in 94% (46/49) of patients via a transjugular approach alone (n = 40), a transjugular/transhepatic approach (n = 5) and a transjugular/transsplenic approach (n = 1). Median DAP was 261 Gy * cm (range 29-950), median AK was 0.2 Gy (range 0.05-0.5), and median FT was 28.2 min (range 7.7-93.7). Mean portosystemic pressure gradient decreased from 16.8  ±  5.1 mmHg to 7.5  ±  3.3 mmHg (P <  0.01). There were no major procedural complications. Overall clinical success was achieved in 77% of patients (mean follow-up of 21.1 months). Encephalopathy was observed in 16 patients (34%), grade II-III encephalopathy in 7 patients (15%). TIPS revision was performed in 15 patients (32%). Overall survival rate was 75%.

Conclusion: In our experience, the use of real-time ultrasound guidance allowed the majority of the TIPS to be performed via a transjugular approach alone with a reasonably low radiation exposure considering the high technical difficulties of the selected cohort of patients with CVPT or PC.
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http://dx.doi.org/10.1007/s11547-020-01155-5DOI Listing
July 2020

OCCUPATIONAL RADIATION DOSE PERFORMING HEPATOBILIARY MINIMALLY INVASIVE PROCEDURES IN CHILDREN WEIGHING LESS THAN 20 kg.

Radiat Prot Dosimetry 2020 Jun;188(1):56-64

Radiology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi 5, 90127 Palermo, Italy.

Our objective is to retrospectively evaluate the effective dose (E) of operators performing pediatric Hepatobiliary Minimally Invasive Procedures (HMIP). Between October 2015 and December 2017, 58 consecutive HMIP were performed on 26 children weighing less than 20 kg (mean 12.3 kg, median 13 kg, range 2.4-20 kg). About 31 vascular procedures (n = 9 hepatic venograms with/without stenting; n = 9 retrograde wedge portography; n = 8 transhepatic portography with angioplasty and/or stenting and n = 5 hepatic arteriography/embolization) and 27 non-vascular procedures (n = 6 percutaneous transhepatic biliary drainage (PTBD); n = 3 bilioplasty; n = 15 biliary catheter change and n = 3 cholangiogram) were performed. Electronic personal dosimeters were used to measure radiation doses to the interventional radiologist, radiographer and anesthesia nurse. The results shows the highest mean effective dose: interventional radiologist's in PTBD (1.18 μSv); radiographer's in hepatic veins phlebography with/without stenting (0.25 μSv) and nurse's in hepatic arteriography/embolization (0.26 μSv). Operators' E can vary depending on the complexity of procedure performed and the position of the operators within the angiosuite.
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http://dx.doi.org/10.1093/rpd/ncz260DOI Listing
June 2020

Percutaneous recanalization of a segmental inferior vena cava occlusion in a patient with situs viscerum inversus and symptomatic Budd-Chiari syndrome.

Dig Liver Dis 2019 06 22;51(6):909. Epub 2019 Feb 22.

Radiology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy.

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http://dx.doi.org/10.1016/j.dld.2019.02.007DOI Listing
June 2019

Multimodality imaging of the Meso-Rex bypass.

Abdom Radiol (NY) 2019 04;44(4):1379-1394

Diagnostic and Therapeutic Services Department, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy.

Extrahepatic portal vein obstruction (EHPVO) is the most common cause of upper gastrointestinal bleeding in children. It is defined as thrombosis of the extrahepatic portal vein with or without extension to the intrahepatic portal veins. The Meso-Rex shunt is the gold standard treatment in children with favorable anatomy since it restores physiological portal liver reperfusion. This is achieved by rerouting the splanchnic venous blood through an autologous graft from the superior mesenteric vein (SMV) into the Rex recess of the left portal vein, curing portal hypertension by doing so. General and hepatobiliary radiologists must be familiar with multimodality imaging appearances of EHPVO and with the role of imaging in identifying suitable candidates for Meso-Rex bypass surgery. Imaging might also detect complications of this procedure, some of which might be treated via interventional radiology.
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http://dx.doi.org/10.1007/s00261-018-1836-1DOI Listing
April 2019

Transjugular Intrahepatic Portosystemic Shunt Using the New Gore Viatorr Controlled Expansion Endoprosthesis: Prospective, Single-Center, Preliminary Experience.

Cardiovasc Intervent Radiol 2019 Jan 2;42(1):78-86. Epub 2018 Aug 2.

Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy.

Objectives: To evaluate short-term clinical efficacy, complications and possible passive stent expansion of transjugular intrahepatic portosystemic shunt (TIPS) creation using the new controlled expansion ePTFE covered stent (VCX), for portal hypertension complications.

Methods: Between 7/2016 and 3/2018, 75 patients received TIPS using VCX. Thirty-nine patients with VCX dilated with an 8-mm angioplasty balloon underwent computed tomography (CT) study during follow-up and CT data were used to measure stent diameter. The CT measurement technique was validated by ex vivo experiment.

Results: TIPS indications were: refractory ascites (n = 45), variceal bleeding (n = 22), other (n = 8). Mean follow-up was 5.8 months (± 4.5, range 1-20). In 69 patients, TIPS was dilated to 8 mm of diameter reaching the hemodynamic target of a portosystemic pressure gradient (PSG) < 12 mmHg. In six patients, not reaching the hemodynamic target the stent was dilated to 10 mm of diameter during the same session with a final PSG < 12 mmHg. Overall clinical success was achieved in 66/75 (88%) patients (80% in refractory ascites, 95% variceal bleeding, 100% other). Grade II-III encephalopathy was observed in five patients (6%). TIPS revision with stent dilatation to 10 mm was performed in seven patients: in three patients with ascites persistence, without evidence of stent dysfunction and in four patients for stent stenosis. One patient underwent stent reduction. Fourteen patients (18%) died during follow-up of causes not related to TIPS. Five patients (6%) underwent liver transplant. No passive stent expansion was detected by CT measurements.

Conclusion: VCX for TIPS creation retains its diameter over a short-term period and is associated with a good clinical outcome with a reasonably low complication rate.
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http://dx.doi.org/10.1007/s00270-018-2040-yDOI Listing
January 2019

Hepatic vein stenting in a 7 week/old infant with Budd-Chiari syndrome using an anterograde approach from the inferior accessory hepatic vein.

Dig Liver Dis 2018 11 18;50(11):1246. Epub 2018 Jun 18.

Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy.

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http://dx.doi.org/10.1016/j.dld.2018.06.004DOI Listing
November 2018

Radiation Doses to Operators in Hepatobiliary Interventional Procedures.

Cardiovasc Intervent Radiol 2018 May 17;41(5):772-780. Epub 2018 Jan 17.

Radiology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy.

Purpose: The primary aim of this study is to provide a summary of operators' radiation doses during hepatobiliary fluoroscopic guided procedures. In addition, patient dose in these procedures was also documented.

Materials And Methods: A total of 283 transarterial chemoembolisation (TACE) and 302 biliary procedures, including 52 percutaneous transhepatic cholangiogram (PTC), 36 bilioplasty and 214 biliary catheter changes (BCC) performed over 14 months, were included. Electronic personal dosimeters were used to measure operator radiation doses. Effective dose (E) was calculated using modified Niklason algorithm. Patient dose was measured as dose area product (DAP) and fluoroscopy time (FT).

Results: For TACE, E for radiologist ranged between 0 and 9.96 µSv, for radiographer 0-0.99 µSv and for nurse 0-4.65 µSv. The patient DAP and FT ranged between 1.5 and 421.9 Gy cm and 1.91-67.25 min. For PTC, E for the radiologist ranged between 0.33 and 55.89 µSv, for radiographer 0-38.61 µSv and for nurse 0-3.18 µSv. Patient DAP and FT ranged between 1.7 and 218.4 Gy cm and 2.07-71.53 min. For bilioplasty, E ranged between 0.09 and 9.24 µSv for radiologist, 0-0.84 µSv for radiographer and 0-1.38 µSv for nurse. The patients' DAP and FT ranged from 0.7 to 52.54 Gy cm and 1.13-24.47 min. For BCC, E ranged from 0 to 12.78 µSv for radiologist, 0-8.43 µSv for radiographer and 0-4.05 µSv for nurse. Patient DAP and FT ranged between 0.12 and 117.3 Gy cm and 0.57-15.83 min.

Conclusions: This study shows that doses to all operators performing hepatobiliary interventional procedures can be very low.
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http://dx.doi.org/10.1007/s00270-017-1870-3DOI Listing
May 2018

Transjugular intrahepatic portosystemic shunt in a patient with Caroli's disease and portal cavernoma.

Dig Liver Dis 2017 Dec 25;49(12):1375. Epub 2017 May 25.

Radiology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Tricomi 5, 90127 Palermo, Italy.

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http://dx.doi.org/10.1016/j.dld.2017.05.013DOI Listing
December 2017

Transjugular Intrahepatic Portosystemic Shunts in Patients with Cirrhosis with Refractory Ascites: Comparison of Clinical Outcomes by Using 8- and 10-mm PTFE-covered Stents.

Radiology 2017 07 25;284(1):281-288. Epub 2017 Jan 25.

From the Department of Diagnostic and Therapeutic Services (R.M., L.M., M.D., A.L.), Research Office (F.T.), and Hepatology Unit (I.P.), IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Tricomi 5, 90127 Palermo, Italy.

Purpose To compare the efficacy and complications of transjugular intrahepatic portosystemic shunt (TIPS) creation performed by using a 10-mm or an 8-mm-diameter polytetrafluoroethylene (PTFE)-covered stent in a consecutive series of patients with cirrhosis with refractory ascites (RA). Materials and Methods The institutional review board approved this retrospective study and informed consent was waived. One hundred seventy-one patients with RA (mean age, 58.7 years ± 10.3; 95% confidence interval [CI]: 57.2 years, 60.3 years) had undergone TIPS placement by using 10-mm (60 patients) or 8-mm (111 patients) covered stent between January 2004 and December 2012. Median follow-up time was 16.8 months (range, 3.4-84.8 months). Hemodynamic changes, incidence of hepatic encephalopathy, and long-term (>3 months) need for paracentesis after TIPS placement were evaluated and calculated by using the Kaplan-Meier method and were compared by using the log-rank test. Results Pre-TIPS demographics and clinical characteristics of the two groups were comparable. The portosystemic gradient before TIPS was 17.0 mm Hg ± 4.2 (95% CI: 15.9 mm Hg, 18.1 mm Hg) in the 10-mm group versus 16.1 mm Hg ± 3.7 (95% CI: 15.4 mm Hg, 16.8 mm Hg) in the 8-mm group (P = .164). After TIPS, the portosystemic gradient was 6.5 mm Hg ± 3.4 (95% CI: 5.7 mm Hg, 7.4 mm Hg) in the 10-mm group versus 7.5 mm Hg ± 2.6 (95% CI: 6.9 mm Hg, 7.9 mm Hg) in the 8-mm group (P = .039). The long-term need for paracentesis was greater in the 8-mm group (64 of 111 patients [58%] vs 18 of 60 patients [31%], P = .003). Overall, hepatic encephalopathy was similar in both groups (45 of 111 patients [41%] vs 26 of 60 patients [44%], P = .728). Conclusion A10-mm PTFE-covered stent leads to better control of RA secondary to portal hypertension in patients with cirrhosis, compared with an 8-mm stent, without increasing the incidence of hepatic encephalopathy. RSNA, 2017.
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http://dx.doi.org/10.1148/radiol.2017161644DOI Listing
July 2017

Radiation doses to operators performing transjugular intrahepatic portosystemic shunt using a flat-panel detector-based system and ultrasound guidance for portal vein targeting.

Eur Radiol 2017 May 25;27(5):1783-1786. Epub 2016 Aug 25.

Radiology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy.

Objectives: The aim of this study was to prospectively evaluate effective dose (E) of operators performing transjugular intrahepatic portosystemic shunts (TIPS) in a single centre. Patients' radiation exposure was also collected.

Methods: Between 8/2015 and 6/2016, 45 consecutive TIPS were performed in adult patients using a flat-panel detector-based system (FPDS) and real-time ultrasound guidance (USG) for portal vein targeting. Electronic personal dosimeters were used to measure radiation doses to the primary and assistant operators, anaesthesia nurse and radiographer. Patients' radiation exposure was measured with dose area product (DAP); fluoroscopy time (FT) was also collected.

Results: Mean E for the primary operator was 1.40 μSv (SD 2.68, median 0.42, range 0.12 - 12.18), for the assistant operator was 1.29 μSv (SD 1.79, median 0.40, range 0.10 - 4.89), for the anaesthesia nurse was 0.21 μSv (SD 0.67, median 0.10, range 0.03 - 3.99), for the radiographer was 0.42 μSv (SD 0.71, median 0.25, range 0.03 - 2.67). Mean patient DAP was 59.31 GyCm (SD 56.91, median 31.58, range 7.66 - 281.40); mean FT was 10.20 min (SD 7.40, median 10.40, range 3.8 - 31.8).

Conclusion: The use of FPDS and USG for portal vein targeting allows a reasonably low E to operators performing TIPS.

Key Points: • The operators' E vary according to the complexity of the procedure. • FPDS and USG allow a reasonably low E to TIPS operators. • FPDS and USG have an important role in reducing the occupational exposure.
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http://dx.doi.org/10.1007/s00330-016-4558-1DOI Listing
May 2017

Early Liver Failure after Transjugular Intrahepatic Portosystemic Shunt in Patients with Cirrhosis with Model for End-Stage Liver Disease Score of 12 or Less: Incidence, Outcome, and Prognostic Factors.

Radiology 2016 08 14;280(2):622-9. Epub 2016 Mar 14.

From the Department of Diagnostic and Therapeutic Services (A.L., R.M., L.M., M.D.) and Research Office (F.T.), IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Via Tricomi 5, 90127 Palermo, Italy.

Purpose To evaluate the incidence, outcomes, and prognostic factors of early liver failure (ELF) after transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with cirrhosis with Model for End-Stage Liver Disease (MELD) score of 12 or less. Materials and Methods Institutional review board approved this retrospective study, with waiver of written informed consent. Two-hundred sixteen consecutive patients with cirrhosis (140 men, 76 women; mean age, 55.9 years; virus-related cirrhosis, 67.6% [146 of 216 patients]) with baseline MELD score of 12 or less who underwent TIPS placement between September 1999 and July 2012 were followed until last clinical evaluation, liver transplantation, or death. The Kaplan-Meier method, log-rank test, area under the receiver operating characteristic curve, and univariate and multivariate analyses were used, as appropriate. Results Twenty of 216 patients (9.2%) developed ELF within 3 months of TIPS (10 patients died, one required liver transplantation, and nine increased the MELD score to >18). ELF was associated with lower survival, 37% versus 95% at 6 months, and 24% versus 86% at 12 months (P < .001) compared with patients without ELF. ELF occurred in 16 of 95 (16.8%) patients with refractory ascites and in four of 121 (3.3%) patients with other indications for TIPS. Multivariate analysis confirmed MELD scores of 11 or 12 (odds ratio, 3.96 [95% confidence interval: 1.07, 14.67]; P = .040), decreased hemoglobin level (odds ratio, 0.68 [95% confidence interval: 0.49, 0.95]; P = .022), and decreased platelet count (odds ratio, 0.99 [95% confidence interval: 0.99, 0.99]; P = .024) as predictors for ELF in patients with refractory ascites. Conclusion ELF is not uncommon in cirrhotic patients with a MELD score of 12 or less who undergo TIPS placement for refractory ascites (especially in patients with MELD of 11 or 12) and decreased hemoglobin level and platelet count. (©) RSNA, 2016.
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http://dx.doi.org/10.1148/radiol.2016151625DOI Listing
August 2016

Endovascular Embolization of a Large High-Flow Splenic Arteriovenous Fistula and Aneurysm Using the Amplatzer Vascular Plug II.

Ann Vasc Surg 2016 Feb 26;31:210.e1-3. Epub 2015 Nov 26.

Department of Diagnostic and Therapeutic Services, Radiology Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy.

We describe the use of an Amplatzer Vascular Plug (AVP) II for embolizing a large high-flow splenic arteriovenous fistula and an aneurysm in a young patient. This patient presented to our center with persistent mild abdominal discomfort, 5 years after open splenectomy. Contrast-enhanced computed tomography angiography showed the presence of a fistula between the splenic arterial and splenic venous remnants and a resultant fusiform aneurysmal dilatation of the residual splenic vein. We decide to embolize the splenic artery with a 12-mm diameter AVP II with an oversizing by 70% of the vessel diameter. Celiac angiography performed 5 min postembolization revealed complete obliteration of the splenic artery and closure of the arteriovenous fistula. The overall procedure time was 40 min, and overall radiation exposure was 32 Gy cm(2) (dose-area product).
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http://dx.doi.org/10.1016/j.avsg.2015.09.012DOI Listing
February 2016

Successful Recanalization of a Complete Lobar Bronchial Stenosis in a Lung Transplant Patient Using a Combined Percutaneous and Bronchoscopic Approach.

Cardiovasc Intervent Radiol 2016 Mar;39(3):462-6

Airway stenosis is a major complication after lung transplantation that is usually managed with a combination of interventional endoscopic techniques, including endobronchial debridement, balloon dilation, and stent lacement. Herein, we report a successful case of recanalization of a complete stenosis of the right middle lobe bronchus in a lung transplant patient, by using a combined percutaneous–bronchoscopic approach after the failure of endobronchial debridement.
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http://dx.doi.org/10.1007/s00270-015-1219-8DOI Listing
March 2016

Long-Term (>5 Years) Clinical and Histological Follow-up of Pediatric Liver Transplant Recipients After Successful Radiological Percutaneous Treatment of Biliary Strictures.

Cardiovasc Intervent Radiol 2016 Feb 17;39(2):313-4. Epub 2015 Sep 17.

Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy.

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http://dx.doi.org/10.1007/s00270-015-1206-0DOI Listing
February 2016

Real-time ultrasound-guided placement of a pigtail catheter in supine position for draining pleural effusion in pediatric patients who have undergone liver transplantation.

J Clin Ultrasound 2016 Jun 2;44(5):284-9. Epub 2015 Sep 2.

Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy.

Purpose: Ultrasound (US) guidance is currently used for placement of wire-guided thoracic drains, and its use is associated with a decreased risk of complications. However, most studies conducted to date in this field have been performed on adult patients. The aim of this study was to report the technical success and complication rates observed during real-time US-guided placement of a thoracic pigtail catheter in pediatric liver-transplant recipients with symptomatic pleural effusion.

Methods: This was a single-center retrospective review of the clinical records and images from pediatric liver-transplant patients with symptomatic pleural effusion who had undergone real-time US-guided pleural-space puncture followed by placement (via the Seldinger technique) of a pigtail catheter for drainage, between May 2006 and June 2014.

Results: We identified 25 patients who had undergone 41 pigtail catheter-placement procedures during the study period. The patients' mean age (± SD) was 4.2 ± 3.9 years (range, 2 months to 16 years), and their mean weight was 14.2 ± 7.2 kg (range, 4.5-33 kg). Seventeen procedures had been performed in the intensive care unit, and 8, in patients undergoing mechanical ventilation. Twelve of the 41 procedures had been performed in patients with altered hemostasis (ie, platelet count < 50 × 10(3) /μl and/or international normalized ratio > 1.5). The size of the pigtail catheters ranged from 5 F to 8.5 F. The technical success rate was 100%, with no major complications such as pneumothorax or hemothorax. Accidental dislocation of the catheter occurred in four patients (9%) over 3-10 days after the first procedure.

Conclusions: In our experience, real-time US-guided pleural-space puncture, performed at bedside, with the patient in the supine position, followed by placement of a pigtail catheter for drainage of effusion, is safe to use and has a high rate of technical success in pediatric patients. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound 44:284-289, 2016.
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http://dx.doi.org/10.1002/jcu.22294DOI Listing
June 2016

Radiation Exposure in Transjugular Intrahepatic Portosystemic Shunt Creation.

Cardiovasc Intervent Radiol 2016 Feb 1;39(2):210-7. Epub 2015 Jul 1.

Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy.

Purpose: Transjugular intrahepatic portosystemic shunt (TIPS) creation is considered as being one of the most complex procedures in abdominal interventional radiology. Our aim was twofold: quantification of TIPS-related patient radiation exposure in our center and identification of factors leading to reduced radiation exposure.

Materials And Methods: Three hundred and forty seven consecutive patients underwent TIPS in our center between 2007 and 2014. Three main procedure categories were identified: Group I (n = 88)-fluoroscopic-guided portal vein targeting, procedure done in an image intensifier-based angiographic system (IIDS); Group II (n = 48)--ultrasound-guided portal vein puncture, procedure done in an IIDS; and Group III (n = 211)--ultrasound-guided portal vein puncture, procedure done in a flat panel detector-based system (FPDS). Radiation exposure (dose-area product [DAP], in Gy cm(2) and fluoroscopy time [FT] in minutes) was retrospectively analyzed.

Results: DAP was significantly higher in Group I (mean ± SD 360 ± 298; median 287; 75th percentile 389 Gy cm(2)) as compared to Group II (217 ± 130; 178; 276 Gy cm(2); p = 0.002) and Group III (129 ± 117; 70; 150 Gy cm(2) p < 0.001). The difference in DAP between Groups II and III was also significant (p < 0.001). Group I had significantly longer FT (25.78 ± 13.52 min) as compared to Group II (20.45 ± 10.87 min; p = 0.02) and Group III (19.76 ± 13.34; p < 0.001). FT was not significantly different between Groups II and III (p = 0.73).

Conclusions: Real-time ultrasound-guided targeting of the portal venous system during TIPS creation results in a significantly lower radiation exposure and reduced FT. Further reduction in radiation exposure can be achieved through the use of modern angiographic units with FPDS.
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http://dx.doi.org/10.1007/s00270-015-1164-6DOI Listing
February 2016

Successful Portal Vein Stent Placement in a Child with Cavernomatous Replacement of the Portal Vein After Partial Liver Transplantation: The Importance of a Recognizable Portal Vein Remnant.

Cardiovasc Intervent Radiol 2015 Dec 26;38(6):1658-62. Epub 2015 Mar 26.

Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via Ernesto Tricomi 5, 90127, Palermo, Italy.

Late portal vein thrombosis with cavernomatous replacement has been reported in 4.5% of pediatric patients who have undergone partial liver transplantation. In such cases, minimally invasive radiological treatments have a high failure rate. We report a successful case of percutaneous recanalization of the portal vein remnant, and subsequent stent placement, in a pediatric patient who underwent left lateral split liver transplantation with cavernomatous replacement of the portal vein.
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http://dx.doi.org/10.1007/s00270-015-1084-5DOI Listing
December 2015

Digital subtraction angiography during transjugular intrahepatic portosystemic shunt creation or revision: data on radiation exposure and image quality obtained using a standard and a low-dose acquisition protocol in a flat-panel detector-based system.

Abdom Imaging 2015 Aug;40(6):1808-12

Diagnostic and Therapeutic Services Department, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via Tricomi 5, 90127, Palermo, Italy,

Purpose: To determine whether the use of a low-dose acquisition protocol (LDP) in digital subtraction angiography during transjugular intrahepatic portosystemic shunt (TIPS) creation/revision results in significant reduction of patient radiation exposure and adequate image quality, as compared to a default reference standard-dose acquisition protocol (SDP).

Methods: Two angiographic runs were performed during TIPS creation/revision: the first following catheterization of the portal venous system and the second after stent deployment/angioplasty. Constant field of view, object to image-detector distance, and source to image-receptor distance were maintained in each patient during the two angiographic runs. 17 consecutive adult patients who underwent TIPS creation (n = 11) or TIPS revision (n = 6) from December 2013 to March 2014 were considered eligible for this single centre prospective study. In each patient, the LDP and the SDP were used in a random order for the two runs, with each patient serving as his/her own control. The dose-area product (DAP) was calculated for each image and compared. Image quality was graded by two interventional radiologists other than the operator.

Results: In all runs acquired with the LDP, image quality was considered adequate for a successful procedural outcome. The DAP per image of the LDP was numerically inferior as compared to the DAP per image of the SDP in all patients. The mean reduction in DAP per image was 75.24% ± 5.7% (p < 0. 001).

Conclusion: Radiation exposure during TIPS creation/revision was significantly reduced by selecting a LDP in our flat-panel detector-based system, while maintaining adequate image quality.
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http://dx.doi.org/10.1007/s00261-014-0313-8DOI Listing
August 2015

Comparison between radiation exposure levels using an image intensifier and a flat-panel detector-based system in image-guided central venous catheter placement in children weighing less than 10 kg.

Pediatr Radiol 2015 Feb 10;45(2):235-40. Epub 2014 Sep 10.

Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via Tricomi 5, 90100, Palermo, Italy,

Background: Ultrasound-guided central venous puncture and fluoroscopic guidance during central venous catheter (CVC) positioning optimizes technical success and lowers the complication rates in children, and is therefore considered standard practice.

Objective: The purpose of this study was to compare the radiation exposure levels recorded during CVC placement in children weighing less than 10 kg in procedures performed using an image intensifier-based angiographic system (IIDS) to those performed in a flat-panel detector-based interventional suite (FPDS).

Materials And Methods: A retrospective review of 96 image-guided CVC placements, between January 2008 and October 2013, in 49 children weighing less than 10 kg was performed. Mean age was 8.2 ± 4.4 months (range: 1-22 months). Mean weight was 7.1 ± 2.7 kg (range: 2.5-9.8 kg). The procedures were classified into two categories: non-tunneled and tunneled CVC placement.

Results: Thirty-five procedures were performed with the IIDS (21 non-tunneled CVC, 14 tunneled CVC); 61 procedures were performed with the FPDS (47 non-tunneled CVC, 14 tunneled CVC). For non-tunneled CVC, mean DAP was 113.5 ± 126.7 cGy cm(2) with the IIDS and 15.9 ± 44.6 cGy · cm(2) with the FPDS (P < 0.001). For tunneled CVC, mean DAP was 84.6 ± 81.2 cGy · cm(2) with the IIDS and 37.1 ± 33.5 cGy cm(2) with the FPDS (P = 0.02).

Conclusion: The use of flat-panel angiographic equipment reduces radiation exposure in small children undergoing image-guided CVC placement.
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http://dx.doi.org/10.1007/s00247-014-3119-5DOI Listing
February 2015

Liver regeneration after liver resection: clinical aspects and correlation with infective complications.

World J Gastroenterol 2014 Jun;20(22):6953-60

Duilio Pagano, Marco Spada, Fabio Tuzzolino, Davide Cintorino, Luigi Maruzzelli, Giovanni Vizzini, Angelo Luca, Alessandra Mularoni, Paolo Grossi, Bruno Gridelli, Salvatore Gruttadauria, Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center in Italy, 90127 Palermo, Italy.

Aim: To investigate whether early liver regeneration after resection in patients with hepatic tumors might be influenced by post-operative infective complications.

Methods: A retrospective analysis of 27 liver resections for tumors performed in a single referral center from November 2004 to January 2010. Regeneration was evaluated by multidetector computed tomography at a mean follow-up of 43.85 d. The Clavien-Dindo classification was used to evaluate postoperative events in the first 6 mo after transplantation, and Centers for Disease Control and Prevention definitions were used for healthcare associated infections data. Generalized linear regression models with Gaussian family distribution and log link function were used to reveal the principal promoters of early liver regeneration.

Results: Ten of the 27 patients (37%) underwent chemotherapy prior to surgery, with a statistically significant prevalence of patients with metastasis (P = 0.007). Eight patients (30%) underwent embolization, 3 with primary tumors, and 5 with secondary tumors. Twenty patients (74%) experienced complications, with 12 (60%) experiencing Clavien-Dindo Grade 3a to 5 complications. Regeneration ≥ 100% occurred in 10 (37%) patients. The predictors were smaller future remnant liver volume (-0.002; P < 0.001), and a greater spleen volume/future remnant liver volume ratio (0.499; P = 0.01). Patients with a resection of ≥ 5 Couinaud segments experienced greater early regeneration (P = 0.04). Nine patients experienced surgical site infections, and in 7 cases Clavien-Dindo Grade 3a to 4 complications were detected (P = 0.016). There were no significant differences between patients with primary or secondary tumors, and either onset or infections or severity of surgical complications.

Conclusion: Regardless of the onset of infective complications, future remnant liver and spleen volumes may be reliable predictors of early liver regeneration after hepatic resection on an otherwise healthy liver.
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http://dx.doi.org/10.3748/wjg.v20.i22.6953DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4051937PMC
June 2014

Quantification of hepatic steatosis: a comparison of computed tomography and magnetic resonance indices in candidates for living liver donation.

Acad Radiol 2014 Apr;21(4):507-13

Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via Tricomi 5, Palermo, 90127 Italy.

Rationale And Objectives: To evaluate, in a group of candidates for liver donation, the role of unenhanced computed tomography (CT) and magnetic resonance (MR) as noninvasive means to measure hepatic steatosis (HS).

Materials And Methods: Sixty-one consecutive candidates underwent CT and MR evaluation for liver donation within 3 weeks of liver biopsy. On CT, three methods of HS quantification were evaluated: the measurement of hepatic attenuation (CT L), the ratio of hepatic attenuation to splenic attenuation (CT L/S), and the difference between the hepatic and splenic attenuation (CT L-S). On MR, HS was reported in terms of fat signal fraction (FSF) using in-phase/opposed-phase and fat/non-fat- saturated images, with and without normalization with the spleen (T1W IP/OP FSF, T1W IP/OP FSF spleen and T2W ± FS FSF, TW2 ± FS FSF spleen). The accuracy of each imaging index in the diagnosis of HS, according to various thresholds, was assessed using receiver operating characteristic analysis.

Results: On biopsy, 35 donors showed no significant HS (<5%); the remaining 26 showed HS ranging from 5% to 40%. With all CT and MR indices, there was a trend toward increasing diagnostic accuracy as the threshold levels of HS increased. When comparing all the indices, TW2 ± FS FSF(spl) showed higher accuracy at threshold levels of 5% and 10% of steatosis but without reaching statistical significance.

Conclusions: In candidates for living donation, MR and CT indices are similar in estimating liver-fat content; however, MR with T2W ± FS FSF(spl) sequences shows higher accuracy when low threshold levels of steatosis (≤5% and ≤10% HS) are selected.
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http://dx.doi.org/10.1016/j.acra.2014.01.007DOI Listing
April 2014

US-guided percutaneous liver biopsy in pediatric liver transplant recipients.

J Pediatr Gastroenterol Nutr 2014 Jun;58(6):756-61

*Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA †Diagnostic and Therapeutic Services ‡Department of Information Technology §Transplantation Surgery ||Pediatric Hepatology, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy.

Objectives: The present study assesses the safety of ultrasound (US)-guided percutaneous liver biopsies (PLBs) within pediatric liver allograft recipients, describes the pathological results according to early (≤12 months) and late (>12 months) posttransplantation periods, and analyzes the value of liver function tests (LFTs) and Doppler US variables in determining these results.

Methods: A total of 219 US-guided PLBs in 85 pediatric patients with liver transplant (mean age 7 ± 5 years, range: 6 months to 18 years) performed between March 2005 and May 2012 were retrospectively evaluated at a single institution. Doppler US and LFT evaluation (including total bilirubin, alanine aminotransferase, aspartate aminotransferase, γ-glutamyl transferase, alkaline phosphatase) occurred within 1 day of early (n = 92, 42%) and late term (n = 127, 58%) posttransplantation biopsies.

Results: The rate of major complications (hemorrhage requiring blood transfusion) was 0.91% (n = 2). The early versus late term biopsy results, respectively, included: cholestasis at 36% versus 18% (P = 0.003), minimal changes 16% versus 24% (not significant [NS]), acute rejection 13% versus 5% (P = 0.027), inflammatory diseases 15% versus 15% (NS), indeterminate acute rejection 11% versus 7% (NS), chronic rejection 4% versus 14% (P = 0.017), fibrotic diseases 4% versus 12% (NS), and other 0% versus 5% (NS). Neither LFT nor US variables were correlated with pathological outcomes.

Conclusions: The rate of complications in pediatric patients after US-guided liver biopsy is low. A range of pathological results exists between early and late posttransplantation liver biopsies. LFT and Doppler US findings are not predictors of pathological results.
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http://dx.doi.org/10.1097/MPG.0000000000000328DOI Listing
June 2014
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