Shunt Occlusion Research Articles

Utility of the turn-back supporting technique using a steerable intermediate catheter: illustrative case.

Selective shunt occlusion (SSO) for intracranial dural arteriovenous fistulas (DAVFs) is a safe and effective method that directly intercepts the shunted pouch from the affected sinus with minimal materials. However, it can be challenging to obliterate the shunted pouch if the microcatheter is not supported adequately. A 68-year-old woman presented with tinnitus and was diagnosed with multiple shunted DAVFs in the right transverse-sigmoid sinus (TSS) and the superior sagittal sinus (SSS). Although the entire sinus packing of the right TSS was performed, a follow-up angiography 7 months later revealed significant cerebral venous reflux due to occlusion of the left TSS and an increasing residual shunt flow in the venous pouch at the confluence of the SSS. A guiding catheter was introduced into the isolated sinus transvenously. Then, a steerable intermediate catheter (SIC) was manually steered into a hairpin shape and hooked on near the pouch prior to navigating a microcatheter into the fistula point. Finally, the fistula pouch was completely obliterated using only two coils under the adequate support of the turned-back intermediate catheter. The turn-back supporting technique using an SIC was useful in achieving SSO for DAVFs, providing both adequate support and guidance for the coaxial microcatheter. https://thejns.org/doi/10.3171/CASE24467.

Anesthetic management for aspiration thrombectomy using the Penumbra Indigo System® in pediatric patients with congenital heart disease

ObjectivesDescribe clinical characteristics and outcomes including transfusion requirements of pediatric patients with congenital heart disease undergoing aspiration thrombectomy DesignRetrospective chart review SettingQuaternary academic children's hospital ParticipantsPatients < 18yrs with congenital heart disease undergoing aspiration thrombectomy from November 2017-February 2022. Measurements and main results13 patients underwent mechanical thrombectomy with the Penumbra Indigo System®. Median age was 3.8 years and median weight was 15.2kg. Seven patients had palliated single ventricle and 6 had biventricular circulation. Nine patients were receiving ICU care pre-procedure and 12 required ICU care post-procedure. Indications for thrombectomy included systemic venous thrombus (n=7), pulmonary arterial thrombus (n=3), systemic arterial thrombus (n=2), and systemic to pulmonary shunt occlusion (n=1). Median estimated blood loss was 7.7ml/kg (interquartile range 1.4ml/kg-15.8ml/kg, range 0.5ml/kg-51.5ml/kg). Seven patients required intraoperative transfusion of pRBCs (n=4), FFP (n=2), platelets (n=3), and/or cryoprecipitate (n=1). In those requiring transfusion, median transfusion volume was 22ml/kg (interquartile range 15.5ml/kg-76.5ml/kg, range 9.3ml/kg-132.8ml/kg). Thrombectomy was successful in 8 of 13 patients, although 3 experienced recurrent thrombosis. ConclusionsMechanical aspiration thrombectomy is increasingly used to treat critically ill pediatric patients and presents unique anesthetic considerations particularly related to the need for volume and blood product resuscitation

Delayed recovery of consciousness from anesthesia due to exacerbation of hydrocephalus caused by a ventriculoperitoneal shunt malfunction during general anesthesia in the prone position: a case report

BackgroundDysfunction of ventriculoperitoneal (VP) shunts can lead to decreased levels of consciousness. We report a case of delayed emergence from anesthesia due to the malfunction of a VP shunt during neurosurgery in the prone position.Case presentationA 75-year-old male with a history of VP shunt for a fourth ventricle obstruction underwent cerebral vascular anastomosis in the prone position. His preoperative level of consciousness was clear. The surgery under general anesthesia was completed without any particular issues. After discontinuation of anesthesia, the patient did not awaken for over an hour. Postoperative CT revealed exacerbated hydrocephalus, likely from VP shunt occlusion. After pumping the reservoir of the VP shunt, the patient regained consciousness. He was extubated and discharged from ICU on the second postoperative day with no neurological issues.ConclusionFor surgical patients with a VP shunt, anesthesia management must consider the risk of shunt malfunction due to patient positioning.

Interventional Management of Variceal Bleeding: Techniques and Emerging Concepts

AbstractDespite technical advancements and disease understanding, variceal bleeding remains the leading cause of mortality in patients with cirrhosis. Endoscopic therapies are the main cornerstone of therapy in variceal bleeding. Interventional radiology (IR) plays a significant role in managing variceal bleeding, especially in cases where endoscopic therapies are not feasible or failed. Cross-sectional imaging is often critical to identify relevant anatomy before IR therapies. Transjugular intrahepatic portosystemic shunt (TIPS) is indicated as salvage therapy in patients with refractory variceal bleeding. Retrograde transvenous variceal embolization (RTO) procedures provide superior bleeding control in patients with gastric and ectopic varices, however, without increasing the risk of hepatic encephalopathy and liver function deterioration. Antegrade transvenous obliteration is a viable alternative when RTO is not feasible. Left-sided portal hypertension is a distinct entity resulting from splenic vein stenosis or occlusion, and variceal bleeding in left-sided portal hypertension does not respond to TIPS, requiring variceal embolization, partial splenic embolization, or splenic vein recanalization. Occasionally, endovascular splenorenal or mesorenal shunt and splenic vein occlusion with distal splenorenal diversion are performed to control variceal bleeding. This article entails the basic concepts and procedural aspects of various interventional radiological procedures performed in patients with variceal bleeding.

Additional outlet occlusion as an important factor in avoiding retreatment after transvenous embolization for cavernous sinus dural arteriovenous fistulas

BackgroundTransvenous embolization (TVE), such as selective shunt occlusion, is the first line treatment for cavernous sinus dural arteriovenous fistula (CSDAVF). Despite the favorable outcomes of TVE, some cases necessitating retreatment...

Hepatic myelopathy neurological complication of chronic liver disease: two case reports

BackgroundHepatic myelopathy is a very rare neurological complication of chronic liver disease. Patients habitually present with progressive pure motor spastic paraparesis. This neurological dysfunction is almost always due to cirrhosis and portocaval shunt, either surgical or spontaneous.Cases reportWe report two cases of a 57-year-old man and a 37-year-old woman with progressive spastic paraparesis linked to cirrhosis and portal hypertension. The two patients are of Tunisian origin (north Africa). Magnetic resonance imaging of the spinal cord of two patients was normal, while brain magnetic resonance imaging showed a T2 hypersignals of the pallidums. These signs, in favor of hepatic encephalopathy in the two patients with cirrhosis with isolated progressive spastic paraparesis without bladder or sensory disorders, help to retain the diagnosis of hepatic myelopathy.ConclusionHepatic myelopathy is a severe and debilitating neurological complication of chronic liver disease. The pathogenesis is misunderstood and seems to be multifactorial, including the selective neurotoxic role both of ammonia and other pathogenic neurotoxins. Usually a pathological brain magnetic resonance imaging showing a hepatic encephalopathy was documented, contrasting with a normal spinal cord magnetic resonance imaging that contributed to diagnosis of hepatic myelopathy. Conservative therapies such as ammonia-lowering measures, diet supplementation, antispastic drugs, and endovascular shunt occlusion show little benefit in improving disease symptoms. Liver transplantation performed at early stage can prevent disease progression and could probably allow for recovery.

Transcatheter Closure of Perimembranous Ventricular Septal Defect Using KONAR-MF™: A Multicenter Experience.

Transcatheter closure of perimembranous ventricular septal defect (PmVSD) is an established procedure. However, the occurrence of complete heart block limits its scope. The newer KONAR-MF™ occluder has specific design characteristics that may improve the safety of PmVSD closure. The objective of the studywas to describe the efficacy and mid-term follow-up of transcatheter closure of PmVSD using KONAR-MF™. The study was conducted prospectively in 3 Indian centers (January 2018-December 2022). PmVSD closure was done by both antegrade and retrograde methods, and patients were followed up at 1, 3, 6, 12months, and annually after that. 121 out of 123 patients were included with the following characteristics: median age 4.4 (0.18-40) years; weight 15 (2.1-88) kg; mean Qp/Qs ratio 1.87 ± 0.52 and pulmonary artery mean pressure: 22 ± 6.9mmHg. The procedure was successful in all but 3; the device was removed due to significant residual shunt (n = 2) and new development of aortic regurgitation (AR) (≥ mild) in 1. The median defect size was 5.2 (2.5-12) mm. Device sizes from 6/4 to 14/12 were deployed (median fluoroscopy time 13.3min; range 3.6-47.8). Shunt occlusion rates were 90%-Immediate, 95%-pre-discharge, and 97%-1month, with no instances of complete heart block after the procedure and during follow-up. Six had new onset AR (mild: 2, trivial 4), and one had increased tricuspid regurgitation. All patients were well during follow-up (median: 20months; range: 6-46). The new KONAR-MF™ occluder appears to be a promising and safe alternative for the closure of the PmVSD; further long-term follow is merited.

Procedural outcomes of percutaneous closure of perimembranous and other ventricular septal defects using Konar-MF occluder and short-term follow-up.

The study aims to assess the procedural outcomes and follow-up after transcatheter closure of ventricular septal defects (VSDs) in children utilizing the Konar-MF™ occluder (Lifetech Scientific, Shenzhen, PRC) device. Clinical features, demographic characteristics, and follow-up findings of children undergoing percutaneous VSD device closure were retrospectively analyzed from the medical records. Fifty-seven patients underwent VSD closure using the Konar-MF occluder between January 2019 and April 2023. Median age and body weight of patients were 36 (5-216) months and 12.5 (3.8-42) kg, respectively. The mean size of the defect on the left ventricular side was 6.5 ± 2.4 mm on echocardiography; the mean pulmonary artery pressure was 19.1 ± 9.7 mmHg. Three patients with severe pulmonary hypertension had successful device closure. The most used device size was 8 mm × 6 mm. The initially chosen device was upsized in 4 (7.01%) patients and downsized in 1 (1.7%) patient. Forty-five patients (78.9%) had device closure through the retrograde route. The procedure was successful in 53 (93.0%) patients. Immediate shunt occlusion was achieved in 86.8% of patients. Major complications, namely, embolization (1) and moderate aortic regurgitation (1) in two patients were successfully managed by surgery. One patient with severe tricuspid regurgitation has been on close follow-up. There was no mortality. Late complications such as valve regurgitation or rhythm disturbance were not identified on a median follow-up of 6 (1.5-47) months. Transcatheter VSD closure using a Konar-MF occluder device is safe and effective, even in smaller children. The ability to deliver both anterogradely and retrogradely is a unique advantage.

Laparoscopic treatment of congenital portosystemic shunts with portal pressure measurement and portal angiography in 36 dogs.

Laparoscopic surgery is used for canine congenital extrahepatic portosystemic shunts (CEHPSS). However, outcomes of laparoscopic surgery involving simultaneous portal vein angiography and portal pressure measurement to attenuate or completely occlude the shunt vessel in canines remain unclear. This study aimed to evaluate outcomes and complications of laparoscopic portosystemic shunt occlusion (LAPSSO) for CEHPSS. Between June 2014 and March 2021, data on dogs undergoing cellophane banding (CB) and complete occlusion of laparoscopically treated congenital extrahepatic port shunts were collected from hospital records. Cases in which complete occlusion was laparoscopically performed, or a CB was used for gradual occlusion were included. A total of 36 dogs (14 males; median age 32.5 months [range, 5-99] with median body weight, 4.2 kg [range, 1.5-7.9]) that underwent LAPSSO for CEHPSS were included. All the dogs underwent computed tomographic angiography (CTA), and data on blood and radiological examinations were collected. Shunt vessel morphology was categorized using CTA findings. Portal pressure measurements and portal angiography were performed by accessing mesenteric and splenic veins in 30 and 6 cases, respectively. The most common shunt types were spleno-phrenic shunts 16/36 (44.4%), followed by spleno-azygos 9/36 (25.0%), spleno-caval 4/36 (11.1%), right gastric-caval 6/36 (16.6%), and right gastric-caval with caudal loop shunts 1/36 (2.7%). The median portal pressure after complete occlusion was 11.5 mmHg (range, 4-16); portal pressures in the two dogs undergoing CB attenuation were 22 and 24 mmHg. The median operating time in the dogs with right (n = 25) and left (n = 11) recumbent positioning was 55 min (range, 28-120) and 54 min (range, 28-88), respectively. One dog had pneumothorax due to injury to the diaphragm. Another dog developed postoperative hypernatremia and succumbed 5 h post-procedure. Nevertheless, no other dogs exhibited signs of portal hypertension within 72 h. Blood tests and abdominal ultrasounds performed 1-2 months postoperatively revealed no residual shunts. LAPSSO, coupled with portal pressure measurement and portal angiography, was shown as safe and effective approach that facilitated successful occlusion of CEHPSS. Further large-scale prospective studies and analyses of perioperative complications are needed.

Occlusion of functional high-volume intra-atrial shunts in older patients after embolic stroke of undetermined source.

Intra-atrial shunts are associated with an elevated risk of embolic stroke of undetermined source (ESUS). Percutaneous occluder implantation is recommended as secondary prevention in younger patients. This study aims to compare the outcome after shunt occlusion between younger and older patients with a history of presumed paradox embolism and to evaluate the impact of high-volume shunting in an elderly population. We conducted a single-center, retrospective, observational study, involving 187 patients who underwent interventional percutaneous PFO or ASD occlusion at our center between 2013 and 2023. The mean age of participants was 51.8 ± 11.8 years, with 76 patients aged ≤50 years and 111 patients aged >50 years. Older patients presented more cardiovascular risk factors. The presence of atrial septum aneurysm or large shunting was evenly distributed (ASA 26.3% vs. 28.8%, p = 0.833, mean shunt defect size 6.67 vs. 7.23 mm, p = 0.151). There were no significant differences in procedural or intrahospital complications. The event rate during the 6-month follow-up was low. Recurrence of arterial embolism occurred in 1.6% of the younger and 3.8% of the older patients (p = 0.817). Comparison of high-volume shunts (defect size ≥10 mm or passage ≥20 bubbles during bubble study) with low-volume shunts in this elderly cohort with a mean age ≥50 years showed no significant difference in outcomes. There was a statistically non-significant trend toward a higher rate of residual shunt at the end of the procedure in the high-volume shunt group (2.9% vs. 9.8%, p = 0.0894). This difference was not observed at the 6-month follow-up anymore (14.5 vs. 12.1%, p = 0.628). Two unsuccessful implantation attempts were reported in the high-volume shunt group, while none were observed in the low-volume shunt group (p = 0.372). No intervention-related deaths occurred in this patient cohort during follow-up. Occlusion of relevant, intra-atrial shunting is a safe and effective option for secondary prevention of cryptogenic embolism in patients over 50 years of age. The beneficial outcome was irrespective of a high-volume shunting before implantation.

Evaluating the efficacy of the punch-out technique in systemic-to-pulmonary shunts: A computational fluid dynamics approach.

Systemic-to-pulmonary shunt is a palliative procedure used to decrease pulmonary blood flow in congenital heart diseases. Shunt stenosis or occlusion has been reported to be associated with mortality; therefore, the management of thrombotic complications remains a challenge for most congenital cardiovascular surgeons. Despite its importance, the optimal method for shunt anastomosis remains unclear. The study investigates the clinical benefits of the punch-out technique over conventional methods in the anastomosis process of Systemic-to-pulmonary shunt, focusing on its potential to reduce shunt-related complications. Anastomotic models were created by two different surgeons employing both traditional slit and innovative punch-out techniques. Computational tomography was performed to construct three-dimensional models for computational fluid dynamics (CFD) analysis. We assessed the flow pattern, helicity, magnitude of wall shear stress, and its gradient. The anastomotic flow area was larger in the model using the punch-out technique than in the slit model. In CFD simulation, we found that using the punch-out technique decreases the likelihood of establishing a high wall shear stress distribution around the anastomosis line in the model. The punch-out technique emerges as a promising method in SPS anastomosis, offering a reproducible and less skill-dependent alternative that potentially diminishes the risk of shunt occlusion, thereby enhancing patient outcomes.

Endovascular Treatment With Targeted Embolization of Cavernous Sinus Dural Arteriovenous Fistulas: A Single-Center Study.

To assess the feasibility, efficacy, and safety of targeted embolization for cavernous sinus dural arteriovenous fistulas (CSDAVF). This retrospective study investigated patients with CSDAVF who underwent endovascular treatment at a tertiary hospital between October 1991 and March 2023. Treatment strategies were determined based on clinical symptoms and shunt characteristics. Targeted or non-targeted curative embolization was performed to achieve complete shunt occlusion. Initially, targeted embolization, selective occlusion of the shunted pouch while preserving the normal cavernous sinus lumen, was conducted, should that fail, non-targeted embolization was performed. In contrast, palliative embolization solely reduced shunt flow. Clinical signs, imaging characteristics, and outcomes were evaluated according to the agreed treatment strategy. In total, 198 patients with CSDAVF (mean age 59.0 ± 12.1 years, 23.2% male) participated in this study. Of which, 94 patients (47.5%) were treated with targeted embolization, 75 (37.9%) with non-targeted embolization, and 29 (14.6%) with palliative treatment. For patients undergoing curative embolization, 55.7% (94/169) successfully achieved targeted embolization; this procedure was usually used to treat focal fistulas (restrictive or late-restrictive types), whereas diffuse fistulas (proliferative type) often underwent non-targeted or palliative embolization. For patients that underwent targeted embolization, the rate of complete or near-complete occlusion on immediate post-treatment digital subtraction angiography was 93.6% (88/94), with a complication rate of 2.1% (2/94), symptom improvement rate of 96.8% (91/94), and retreatment rate of 5.3% (5/94). No serious complications were reported during follow-up. When successful, targeted embolization of CSDAVF causes low rates of cranial nerve palsy, retreatment, and good clinical outcomes.

Endoscopic Ultrasound-Guided Transgastric Shunt Obliteration for Recurrent Hepatic Encephalopathy.

Occlusion of spontaneous portosystemic shunts (SPSSs) in patients with cirrhosis may be required in recurrent or refractory hepatic encephalopathy. We describe a novel method for occlusion of SPSS using endoscopic ultrasound (EUS). EUS-guided transgastric shunt obliteration was performed by injecting glue and coils directly into SPSS. EUS-guided transgastric shunt obliteration was performed for 7 patients in 9 sessions. Complete cessation of Doppler flow was achieved in 6/7 cases. Adequate clinical response was observed in 6/7 patients. No procedure-related severe adverse events were seen. This novel technique is a potentially effective and efficient method for shunt obliteration.

Trans-Jugular Portosystemic Shunt (TIPSS): A Study of 31 Cases

This scientific report presents a retrospective analysis of 31 cases undergoing Transjugular Intrahepatic Portosystemic Shunt (TIPSS) placement. The study, conducted at a single center, aimed to evaluate the efficacy and safety of TIPSS in managing complications of portal hypertension. The main indications for TIPSS placement included variceal bleeding, refractory ascites, and Budd-Chiari syndrome. The procedural success rate was high, with only a small number of cases requiring re-intervention due to shunt occlusion. Significant improvements were observed in controlling ascites and variceal bleeding, although complications such as hepatic encephalopathy were noted. Despite these challenges, TIPSS emerged as a valuable intervention for patients with advanced liver disease and its associated complications. This study underscores the importance of TIPSS in the management of portal hypertension and highlights the need for further research to optimize patient selection and refine procedural techniques.

Is re-Rex shunt a better choice for patients with failed Rex shunt?

To review our single-center surgical outcomes of redo operations after failed Rex shunt procedures. From September 2017 to October 2021, a total of 20 patients (11 males, 9 females; median age: 8.6 years) with Rex shunt occlusions were admitted to our hospital. Two of these patients were previously operated on in our hospital, and the remaining 18 were from other centers. All patients underwent repeat operations after detailed preoperative evaluations. Preoperative wedged hepatic vein portography (WHVP) was conducted for 18 patients. Thirteen patients exhibited well-developed Rex recessus and intrahepatic portal vein during WHPV examination, consistent with the intraoperative exploration results. Fifteen patients (75%, 15/20) underwent redo-Rex shunt, four underwent Warren shunt and one underwent devascularization surgery. During the redo-Rex shunt operations, the left internal jugular veins (IJV) were used as bypass grafts in 11 patients; the intra-abdominal veins were used in 4 patients. The patients were followed up for 12-59 months (mean, 24.8 months). After redo Rex shunts, the grafts were patent in 14 patients (93.3%, 14/15), but 1 graft had thrombosis (6.7%, 1/15). Three patients suffered from postoperative anastomotic stenosis, and all of the stenosis was relieved with balloon dilatations. After re-Rex shunts, esophageal varices and spleen size were substantially reduced, and the platelet count significantly increased. Postoperative graft thrombosis was found in 1 patient after Warren shunt (1/4, 25%), and there was no graft stenosis. Compared with Warren surgery, patients who underwent re-Rex shunt had a significantly higher rate of platelet increase. Redo-rex shunts can be finished in most patients with failed Rex shunts. Re-Rex shunt is a preferred surgical choice after a failed Rex shunt when a good bypass graft is available, and the surgical success rate can reach more than 90%. A suitable bypass graft is essential for a successful redo Rex shunt. Preoperative WHVP is recommended for the design of a redo surgical plan preoperatively.

Evaluation of Serial Intra-Arterial Indocyanine Green Videoangiography in the Surgical Treatment of Cranial and Craniocervical Junction Arteriovenous Fistulae: A Case Series.

Intravenous indocyanine green (IV-ICG) videoangiography is commonly performed to detect blood flow in the microscopic view. However, intra-arterial ICG (IA-ICG) videoangiography provides high-contrast imaging, repeatability within a short period of time, and clear-cut separation of the arterial and venous phases compared with IV-ICG. These features are useful for detecting retrograde venous drainage (RVD) and shunt occlusion in arteriovenous fistulae (AVF) surgery. This study aimed to investigate whether IA-ICG videoangiography can be repeatable within a short period of time and be useful for detecting RVD and shunt occlusion in cranial- and craniocervical junction (CCJ)-AVF surgery. Between January 2012 and December 2022, 50 patients were treated with endovascular or surgical intervention for cranial- and CCJ-AVF at Tokushima University Hospital. Of these, 5 patients (6 lesions) underwent open surgery with IA-ICG videoangiography in a hybrid operating room. We analyzed the data of these 5 patients (6 lesions). There were 4/patient (median, range 2-12) and 3.5/lesion (median, range 2-10) intraoperative IA-ICG runs. IA-ICG videoangiography detected RVD in all patients. Clearance of IA-ICG-induced fluorescence was achieved within 30 seconds in all patients at each region of interest. After the disconnection of the fistulae, IA-ICG videoangiography and intraoperative digital subtraction angiography (DSA) confirmed the disappearance of RVD in all patients. There were no complications associated with IA-ICG videoangiography. This study showed that IA-ICG videoangiography is repeatable within a short period of time before and after obliteration and can be useful for detecting RVD and shunt occlusion in cranial- and CCJ-AVF surgery. IA-ICG videoangiography also allows intraoperative DSA studies in a hybrid operating room. Considering the recent advancements in hybrid operating rooms, combining IA-ICG videoangiography with intraoperative DSA is a useful strategy for cranial- and CCJ-AVF surgery.

Diagnostic and monitoring value of ultrasound, computed tomography angiography, and portal venography in surgical ligation of congenital extrahepatic portosystemic shunts

PurposeTo investigate the diagnostic and monitoring value of ultrasound (US), computed tomography angiography (CTA), and portal venography in surgical ligation of congenital extrahepatic portosystemic shunts (CEPS) in children. MethodsWe retrospectively analysed different imaging examinations of 15 children with CEPS. Development of the portal vein before shunt occlusion, shunt location, portal vein pressure, main symptoms, diameter of the main portal vein, and location of secondary thrombosis after shunt occlusion were recorded. Final classification diagnosis was made by portal venography after shunt occlusion, and consistency with other imaging examinations in diagnosing development of the portal vein was calculated using Cohen’s kappa. ResultsCompared with portal venography after shunt occlusion, US, CTA, and portal venography before shunt occlusion had poor consistency in showing the development of hepatic portal veins (Kappa value 0.091–0.194, P > 0.05). Six cases developed portal hypertension (40–48 cmH2O) during the temporary occlusion test, and US showed that portal veins gradually expanded after shunt ligation. Eight patients with haematochezia had inferior mesenteric vein (IMV)-iliac vein (IV) shunts. After surgery, secondary IMV thrombosis was observed in eight cases and secondary splenic vein thrombosis in four cases. ConclusionPortal venography with occlusion testing is very important to accurately evaluate the development of the portal vein in CEPS. The portal vein needs to expand gradually, and partial shunt ligation surgery is necessary in cases diagnosed as portal vein absence or hypoplasia before occlusion testing to avoid severe portal hypertension. After shunt occlusion, US is effective in monitoring portal vein expansion, and both US and CTA can be used to monitor secondary thrombi. IMV-IV shunts can cause haematochezia and are prone to secondary thrombosis after occlusion.

Surgical outcome of extrahepatic portal venous obstruction: Audit from a tertiary referral centre in Eastern India.

Extra hepatic portal venous obstruction (EHPVO) is the most common cause of portal hypertension in Indian children. While endoscopy is the primary modality of management, a subset of patients require surgery. This study aims to report the short- and long-term outcomes of EHPVO patients managed surgically. All the patients with EHPVO who underwent surgery between August 2007 and December 2021 were retrospectively reviewed. Postoperative complications were classified after Clavien-Dindo. Binary logistic regression in Wald methodology was used to determine the predictive factors responsible for unfavourable outcome. Total of 202 patients with EHPVO were operated. Mean age of patients was 20.30 ± 9.96 years, and duration of illness, 90.05 ± 75.13 months. Most common indication for surgery was portal biliopathy (n = 59, 29.2%), followed by bleeding (n = 50, 24.8%). Total of 166 patients (82.2%) had shunt procedure. Splenectomy with esophagogastric devascularization was the second most common surgery (n = 20, 9.9%). Nine major postoperative complications (Clavien-Dindo > 3) were observed in 8 patients (4.0%), including 1 (0.5%) operative death. After a median follow-up of 56 months (15-156 months), 166 patients (82.2%) had favourable outcome. In multivariate analysis, associated splenic artery aneurysm (p = 0.007), isolated gastric varices (p = 0.004), preoperative endoscopic retrograde cholangiography and stenting (p = 0.015), and shunt occlusion (p < 0.001) were independent predictors of unfavourable long-term outcome. Surgery in EHPVO is safe, affords excellent short- and long-term outcome in patients with symptomatic EHPVO, and may be considered for secondary prophylaxis.

C45 MULTI–INSTITUTIONAL ITALIAN EXPERIENCE OF ATRIAL FLOW REGULATOR DEVICE IN CONGENITAL AND ACQUIRED HEART DISEASE

Abstract The Atrial Flow Regulator is a self–expandable nitinol device implanted into the interatrial septum to establish a communication with a predetermined diameter.The creation of such shunt is advisable in several cardiovascular diseases.In pediatric population,the experience is limited to a few case reports describing patients with failing Fontan,pulmonary hypertension,or severe heart failure.We aim to report the preliminary data of Italian registry of AFR implantation in children with heart failure in congenital and acquired heart disease.The goal is to create a local and national register,to monitoring the safety and efficacy of the AFR in pediatric population.The register is prospective and multi–institutional, with 2 centers involved: Pediatric Cardiology department of Padova Hospital and of Bambino Gesù Hospital in Rome,started on the 27/11/2021 and ongoing.AFR implantation was proposed for all patients with symptomatic heart failure,not responding to maximal medical therapy and a history of complex congenital or acquired cardiac diseases.We enrolled 8 patients (median age 124 months)indications were LV systolic dysfunction in 4 patients,restrictive cardiomyopathy with pulmonary hypertension in one, post–operative RV dysfunction after surgical repair of a native TOF and 2 patients with failing Fontan.AFR implantation was successfully reached in all 8 patients.In one case,it was performed a hybrid procedure during pulmonary artery surgical banding, with peratrial approach through the right atrial free wall.Atrial septostomy was needed in 5 cases, in the other 3 cases pre–existing PFO and ASD were used.Balloon pre–dilation was performed in 4 cases.Mean time of procedure was 50 minutes and median radiation exposure dose was 3 Gy/cm2.No complications were reported during the procedure.No acute or sub–acute shunt occlusion or stroke was observed.One patient died of sepsis not related to the procedure;one patient presented a cardiac arrest due to a cerebral ischemia 24 hours after the procedure.Heparin or aspirin were administered to all patients for at least 6 months.Clinical improvement was observed in all patients with an increase in ejection fraction (p=0.02), reduction in LA dilation(p&amp;lt; 0.05)and in HF symptoms(62% of patients improved their NYHA class).AFR implantation is safe and feasible in children with specific congenital and acquired heart diseases,allowing right/left cavities unloading and improvement of hemodynamics and symptoms.

Prenatal ultrasound, magnetic resonance imaging and therapeutic options for fetal thoracic anomalies: a pictorial essay.

Congenital thoracic anomalies are uncommon malformations that require a precise diagnosis to guide parental counseling and possible prenatal treatment. Prenatal ultrasound (US) is the gold standard imaging modality to first detect and characterize these abnormalities and the best modality for follow-up. Fetal magnetic resonance imaging (MRI) is a complementary tool that provides multiplanar assessment and tissue characterization and can help estimate prognosis. Prenatal treatment is increasingly being used in fetuses with signs of distress and to potentially decrease morbidity and mortality. In this essay, the authors illustrate side-by-side US, MRI and therapeutic options for congenital thoracic anomalies in cases that presented to a tertiary pediatric hospital during the 7-year period 2014-2021. Entities included are congenital diaphragmatic hernia, congenital pulmonary airway malformation, bronchopulmonary sequestration, hybrid lesions, foregut duplications cysts and congenital lobar overinflation. Treatment options include maternal steroids, thoraco-amniotic shunt and fetal endotracheal occlusion. Recognition of typical findings in congenital thoracic anomalies is helpful to establish diagnosis, predict prognosis and plan perinatal treatment.