of the circumference (OR, 7.9; 95% CI, 2.1-29.4; P=.002). Neither previous femoral cutdown (44 accesses [23%]) nor percutaneous closure with VCDs (38 accesses [20%]) affected the closure success rate in the large-sheath group. Closure failure did not significantly increase the need for postoperative blood transfusions or hospital length of stay.
Conclusions: Off-label use of VCDs and the pre-close technique for percutaneous approach with large-bore sheaths needed for complex aortic endovascular procedures is safe and feasible. Closure success rate is not significantly different from that obtained with on-label application of VCDs with smaller sheaths.
Hepatology. 2020 Sep;72(3):1043-1055. doi: 10.1002/hep.31071.
Paracentesis-induced circulatory dysfunction with modest-volume paracentesis is partly ameliorated by albumin infusion in acute-on-chronic liver failure
Vinod Arora, Rajan Vijayaraghavan, Rakhi Maiwall, Amrish Sahney, Sherin Sarah Thomas, Rehmat Ali, Priyanka Jain, Guresh Kumar, Shiv Kumar Sarin
Background and aims: Paracentesis-induced circulatory dysfunction (PICD) is a serious complication of large- volume (>5 L) paracentesis in cirrhosis and is reduced with albumin infusion. There is a lack of data on PICD in acute- on-chronic liver failure (ACLF). Because ACLF patients have greater hemodynamic derangements than patients with decompensated cirrhosis, we investigated whether PICD could develop with modest-volume paracentesis (MVP) and the role of albumin infusion.
Approach and results: A total of 80 ACLF patients undergoing <5 L paracentesis were randomized to receive albumin (8 g/dL of ascitic fluid; n = 40) or no albumin (n = 40) and serially followed to detect PICD. Baseline characteristics were comparable between groups, including volume of ascitic tap (4.16 ± 0.23 versus 4.14 ± 0.27 L; P=0.72) and plasma renin activity (PRA; 20.5 ± 7.03 versus 23.2 ± 8.24 ng/mL/hour; P = 0.12). PICD was more frequent in the no-albumin group than the albumin group (70% versus 30%; P = 0.001), with higher incidence of hepatic encephalopathy (50% versus 27.5%; P = 0.04), hyponatremia (67.5% versus 22.5%; P < 0.001), acute kidney injury (62.5% versus 30%; P = 0.001), and in-house mortality (62.5% versus 27.5%; P = 0.003). PRA of 25.15 ng/ mL at day 3 had sensitivity and specificity of 71% and 68%, respectively, for development of PICD at day 6. Albumin infusion decreased the incidence of PICD at day 6 (odds ratio, 0.068; 95% confidence interval, 0.011-0.43; P = 0.005).
Conclusions: PICD is common and develops even with MVP in ACLF patients. Albumin infusion decreases the incidence of PICD and mortality in patients with ACLF. Clinical trial identifier: NCT02467348.
Hepatology. 2020 Mar 2. doi: 10.1002/hep.31210.
Liver transplantation outcomes in a U.S. multicenter cohort of 789 patients with hepatocellular carcinoma presenting beyond Milan criteria
Ani Kardashian, Sander S. Florman, Brandy Haydel, Richard M. Ruiz, Goran B. Klintmalm, David D. Lee, C. Burcin Taner, Federico Aucejo, Amit D. Tevar, Abhinav Humar, Elizabeth C. Verna, Karim J. Halazun, William C. Chapman, Neeta Vachharajani, Maarouf Hoteit, Matthew H. Levine, Mindie H. Nguyen, Marc L. Melcher, Alan N. Langnas, Carol A. Carney, Constance Mobley, Mark Ghobrial, Beth Amundsen, James F. Markmann, Debra L. Sudan, Christopher M. Jones, Jennifer Berumen, Alan W. Hemming, Johnny C. Hong, Joohyun Kim, Michael A. Zimmerman, Trevor L. Nydam, Abbas Rana, Michael L. Kueht, Thomas M. Fishbein, Daniela Markovic, Ronald W. Busuttil, Vatche G. Agopian
Methods: The Organ Procurement and Transplantation Network recently approved liver transplant (LT) prioritization for patients with hepatocellular carcinoma (HCC) beyond Milan Criteria (MC) who are downstaged (DS) with locoregional therapy (LRT). We evaluated post-LT outcomes, predictors of downstaging, and the impact of LRT in beyond-MC HCC patients from the U.S. Multicenter HCC Transplant Consortium (20 centers, 2002–2013). Clinicopathologic characteristics, overall survival (OS), recurrence-free survival (RFS), and HCC recurrence (HCC-R) were compared between patients within MC (n=3,570) and beyond MC (n=789) who were downstaged (DS, n=465), treated with LRT and not downstaged (LRT-NoDS, n=242), or untreated (NoLRT-NoDS, n=82). Five-year post-LT OS and RFS was higher in MC (71.3% and 68.2%) compared to DS (64.3% and 59.5%), and lowest in NoDS (n=324; 60.2% and 53.8%; overall P<0.001). DS patients had superior RFS (60% vs 54%, P=0.043) and lower 5-year HCC-R (18% vs 32%, P<0.001) compared to NoDS, with further stratification by maximum radiologic tumor diameter (5-year HCC-R of 15.5% in DS/< 5cm and 39.1% in NoDS/>5cm, P<0.001). Multivariate predictors of downstaging included alpha-fetoprotein response to LRT, pathologic tumor number and size, and wait time >12 months. LRT-NoDS had greater HCC-R compared to NoLRT- NoDS (34.1% vs 26.1%, P<0.001), even after controlling for clinicopathologic variables (HR=2.33, P<0.001) and inverse probability of treatment weighted propensity matching (HR=1.82, P<0.001).
Conclusion: In LT recipients with HCC presenting beyond MC, successful downstaging is predicted by wait time, alpha- fetoprotein response to LRT, and tumor burden, and results in excellent post-LT outcomes, justifying expansion of LT criteria. In LRT-NoDS patients, higher HCC-R compared to NoLRT- NoDS cannot be explained by clinicopathologic differences, suggesting a potentially aggravating role of LRT in patients with poor tumor biology that warrants further investigation.
32 IRQ | SPRING 2021
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40
