Transvenous Biopsy Research Articles

A multiple variable index and extracardiac-Fontan associated hepatic fibrosis

BackgroundThe serial follow-up of Fontan-associated liver disease is challenging, as laboratory values are frequently normal, especially with mild to moderate liver disease. ObjectiveWe investigated a composite index's correlation with hepatic biopsy total fibrosis scores in extracardiac Fontan patients. MethodsWe identified extracardiac Fontan patients undergoing cardiac catheterization and transvenous hepatic biopsies between June 2013 and September 2023 and liver shear wave elastography between January 2017 and July 2023. We developed a composite index from the following: 1) elastography values, 2) sex, 3) history of a neonatal aortopulmonary shunt for pulmonary flow obstruction, 4) pacemaker, 5) Fontan duration, 6) bilirubin values, 7) univentricular dysfunction, 8) atrioventricular valvar regurgitation, 9) mean Fontan pressures, and 10) venovenous collaterals presence. We correlated the index with hepatic total fibrosis scores (0–8), the sum of pathology grading (0 to 4) performed for sinusoidal and portal fibrosis. We defined a hepatic total fibrosis score of 0–3 as none to mild and 4–8 as moderate to severe fibrosis. ResultsWe identified 62 patients who underwent 92 transvenous liver biopsies, with 30 patients undergoing 2 biopsies. The average age at biopsy was 15 ± 2 years. We found a strong correlation (rho = 0.8, p = .00001) between liver total fibrosis scores and composite index values. A receiver operating characteristic analysis demonstrated that an index cut-off value of ≥26 predicted a total fibrosis score of ≥4 with a sensitivity of 71 % and a specificity of 75 % (AUC = 0.73, 95 % CI 0.63, 0.83, p = .0001). ConclusionsWe developed a composite index with a moderate predictive ability to discriminate none to mild from moderate to severe hepatic fibrosis. Nevertheless, additional data is needed to assist further validation and determine its clinical utility in the serial follow-up of Fontan associated liver disease.

Multimodality Imaging in Right Heart Tumors: Proposed Algorithm towards an Appropriate Diagnosis.

A right heart tumor can be identified by transthoracic echocardiography during a routine examination or due to cardiac symptoms. The first step is the assessment by echocardiography, with its multiple techniques, and the obtained information must be judged in a clinical and biological context. The second step comprises one, sometimes even two, of the more complex modality imaging methods. The choice is driven not only by the advantages of each imaging technique but also by local expertise or the preferred imaging modality in the center. This step is followed by staging, follow-up, and/or imaging-guided excision or biopsy, which is performed in selected cases in order to obtain anatomopathological confirmation. In the presence of features suggestive of malignancy or causing hemodynamic impairment, a transvenous biopsy is essential before the more complex imaging modalities (which are still relevant in the staging process). Using a structured imaging approach, it is possible to reach an appropriate diagnosis without a biopsy. Frequently, these imaging techniques have a complementary role, so an integrated imaging approach is recommended. This proposed algorithm for appropriate diagnosis of right heart tumors could serve as a practical guide for clinicians (not only imaging specialists).

Liver Biopsy and Pressure Hemodynamics: IR Perspective

AbstractLiver biopsy is important for staging of liver disease and cirrhosis and can be performed by many techniques. While percutaneous biopsy is fast, safe, effective, and widely available, transvenous biopsy, most often performed from the transjugular approach, offers many advantages for selected patients. In the setting of suspected or confirmed portal hypertension, transjugular liver biopsy (TJLB), most commonly performed by interventional radiologists, can be used to simultaneously obtain core biopsies of the liver and measure hemodynamic pressures in the right atrium, hepatic vein, and portal vein to calculate a hepatic venous pressure gradient. TJLB can be performed safely when percutaneous biopsy is contraindicated, including in the setting of ascites, coagulopathy, anticoagulation, and other high-risk bleeding situations. The procedure can be performed in the outpatient setting in a short period of time for most patients and without the use of precious anesthesia resources. Hepatic venography also allows for variant anatomy evaluation that may be important in the diagnosis and planning of future procedures, such as transjugular intrahepatic portosystemic shunt.

Abstract No. 583 Financial Analysis of Intravascular Ultrasound-Guided Transvenous Biopsy in an Outpatient Medicare Population

Abstract No. 583 Financial Analysis of Intravascular Ultrasound-Guided Transvenous Biopsy in an Outpatient Medicare Population

Abstract No. 223 Intravascular Ultrasound-Guided Transvenous Biopsy of Retroperitoneal Lymph Nodes: Efficacy and Safety Compared with Percutaneous CT-Guided Biopsy

Intravascular ultrasound-guided transvenous biopsy (IVUS-TVB) is a recently described technique using intracardiac echocardiography catheter visualization to sample targets adjacent to the IVC or iliac veins using a transjugular liver biopsy kit. Although IVUS-TVB has been shown to be technically feasible, the efficacy and safety have not been directly compared with conventional approaches such as CT-guided percutaneous needle biopsy (CT-PNB) for similar targets. Therefore, the purpose of this study was to compare diagnostic accuracy and adverse event rates for IVUS-TVB versus CT-PNB for retroperitoneal (RP) lymph nodes. A single-institution, retrospective study comparing IVUS-TVB to CT-PNB was conducted. From December 17, 2020, to August 10, 2022, 53 IVUS-TVBs were performed, of which 32 were of RP lymph nodes, a non-overlapping sample from that previously reported. For comparison, a search of CT reports from January 1, 2013, to January 1, 2022, using the terms “retroperitoneal and lymph and needle and biopsy,” was performed, yielding 191 CT-PNB procedures. Patient demographics, lymph node size/location, needle passes, procedure time, diagnostic accuracy, and adverse events were compared via t-tests for quantitative variables and chi-squared or Fisher’s exact tests for qualitative variables. The diagnostic accuracy and adverse event rate for IVUS-TVB were compared with CT-PNB as the reference standard using the Farrington-Manning non-inferiority test assuming a 10% non-inferiority margin. There was no significant difference in age, Charlson comorbidity score, or number of needle passes between groups. IVUS-TVB targets were slightly smaller (2.4 vs 2.7 cm, long-axis, P = 0.04, 1.7 vs 2.0 cm, short-axis, P = 0.04) and primarily precaval (34%) or aortocaval (47%) in location (vs predominantly left periaortic (80%) for CT-PNB, P< 0.001). Procedure time was approximately 33% longer for IVUS-TVB (64 vs 48 minutes, P< 0.001). Diagnostic accuracy, defined as diagnostic of malignancy or a clinically verifiable benign result, was 94% for IVUS-TVB compared with 88% for CT-PNB. Overall adverse event rate for IVUS-TVB was 3.1% compared with 3.7% for CT-PNB. IVUS-TVB was non-inferior to CT-PNB for both diagnostic accuracy (P = 0.02) and adverse event rate (P = 0.04). This study demonstrated non-inferiority of IVUS-TVB compared with CT-PNB with respect to diagnostic accuracy and adverse event rate for biopsy of RP lymph nodes adjacent to the IVC. These data suggest that IVUS-TVB is as safe and effective as a conventional biopsy approach such as CT-PNB for similar targets.

Intravascular Ultrasound-Guided Transvenous Biopsy of Retroperitoneal Lymph Nodes: Diagnostic Accuracy and Safety Compared with CT-Guided Percutaneous Biopsy

PurposeTo compare the diagnostic accuracy and adverse event rates of intravascular ultrasound (US)-guided transvenous biopsy (TVB) versus those of computed tomography (CT)-guided percutaneous needle biopsy (PNB) for retroperitoneal (RP) lymph nodes. Materials and MethodsIn this single-institution, retrospective study, 32 intravascular US-guided TVB procedures and a sample of 34 CT-guided PNB procedures for RP lymph nodes where targets were deemed amenable to intravascular US-guided TVB were analyzed. Procedural metrics, including diagnostic accuracy, defined as diagnostic of malignancy or a clinically verifiable benign result, and adverse event rates were compared. ResultsThe targets of intravascular US-guided TVB were primarily aortocaval (47%, 15/32) or precaval (34%, 11/32), whereas those of CT-guided PNB were primarily right pericaval (44%, 15/34) or retrocaval (44%, 15/34) (P < .001). The targets of intravascular US-guided TVB averaged 2.4 cm in the long axis (range, 1.3–3.7 cm) compared with 2.9 cm (range, 1.4–5.7 cm) for those of CT-guided PNB (P = .02). There was no difference in the average number of needle passes (3.8 for intravascular US-guided TVB vs 3.9 for CT-guided PNB; P = .68). The diagnostic accuracy was 94% (30/32) and the adverse event rate was 3.1% (1/32) for intravascular US-guided TVB, similar to those of CT-guided PNB (accuracy, 91% [31/34]; adverse event rate, 2.9% [1/34]). ConclusionsIntravascular US-guided TVB had a diagnostic accuracy and adverse event rate similar to CT-guided PNB for RP lymph nodes, indicating that intravascular US-guided TVB may be as safe and effective as conventional biopsy approaches for appropriately selected targets.

Hepatic fibrosis gender differences in extracardiac Fontan patients.

We investigated possible gender differences for hepatic fibrosis in extracardiac-Fontan patients. We identified extracardiac Fontan, performed between 2000 and 2016, who underwent cardiac catheterizations with transvenous hepatic biopsies between April 2012 and June 2022. We divided the patients by gender for analysis. We identified 116 patients who underwent 145 transvenous biopsies, with 29 patients undergoing 2 biopsies at an average interval of 5 ± 1 years. We divided the 145 biopsies into two groups: 1) 98/145 (68%) males and 2) 47/145 (32%) females. For the 47 female liver biopsy specimens, the median total fibrosis score was 3 (0-8), and for the 98 male liver biopsy specimens, the median total fibrosis score was 2 (0-6), p = .007. The average age at surgery for females was 3 ± 1 years and for males 3 ± 1 years, p = .99. Average Fontan duration at biopsy for females was 11 ± 5 years and for males, 10 ± 4 years, p = .23. No other demographic, anatomic, echocardiographic, laboratory, or hemodynamic findings demonstrated statistically significant gender differences. Females had statistically significantly higher median total fibrosis scores than males for the similar average age at extracardiac Fontan and average Fontan duration.

Use of transvenous biopsy of tumor thrombus for the diagnosis of Wilms tumor

Wilms tumor (WT) accounts for 90% of renal malignancies in children. Surgical resection is the mainstay of treatment, but neoadjuvant chemotherapy is considered in certain cases of tumor thrombus [ 1 , 2 ]. In North America, tumor biopsies are generally performed prior to initiating neoadjuvant chemotherapy. This report describes a case of a 7-year-old boy who presented with an abdominal mass and gross hematuria. An abdominal ultrasound and CT scan revealed a 9 cm right-sided renal mass most consistent with Wilms tumor. A near obstructing tumor thrombus was identified in the inferior vena cava (IVC) from the right renal vein to the confluence of the hepatic veins. In consultation with oncology and according to Children's Oncology Group (COG) recommendations [2], a biopsy was performed prior to initiating neoadjuvant chemotherapy. An endovascular, transvenous biopsy of the tumor thrombus was performed. In this case, a transvenous biopsy of the IVC tumor thrombus was an alternative technique that yielded adequate tissue to establish the diagnosis of Wilms tumor including histologic sub-classification and LOH status. • Transvenous biopsy of Wilms tumor thrombus in the IVC is feasible. • This technique provided adequate tissue for diagnosis and tumor characterization. • This is an alternate biopsy technique for Wilms tumor with IVC thrombus.

Liver Decompensation after Bariatric Surgery in the Absence of Cirrhosis.

Metabolic dysfunction-associated fatty liver disease-related cirrhosis is possible at the time of bariatric surgery, complicated by further liver decompensation. Hepatic decompensation can also occur in the absence of cirrhosis but the presentation is less clear. We analyze the clinical characteristics, histological findings, and management of patients without cirrhosis who developed hepatic decompensation after bariatric surgery in our single tertiary-care hospital. From 2014 to 2019, 6 patients underwent a transvenous liver biopsy for liver decompensation after bariatric surgery. Mean age at diagnosis was 44 years. The time between bariatric surgery and the onset of symptoms varied widely (min. 8 months, max. 17 years). Mean % of weight loss was high at 43%. The clinical presentation was as follows: fatigue and jaundice (5/6), leg edema (3/6), and ascites (1/6). Blood test showed increased transaminases (mean ALT 53 UI/L, mean AST 130 UI/L), bilirubin (mean 6 mg/dL), and INR (mean 1.5) with a low albumin level (mean 27 mg/dL). The hepatic venous pressure gradient was high (mean 10 mmHg). Histology revealed steatosis, hepatocyte ballooning but also portal inflammation with polymorphonuclear cells, and bile duct alterations. Mean fibrosis score was 2. The clinical course was favorable with nutritional support with a mean follow-up of 36 months. Liver decompensation in the absence of cirrhosis can occur after bariatric surgery with a highly variable delay. A special histological signature is present with the coexistence of steatosis, bile duct alterations, and portal inflammation. Substantial clinical improvement with appropriate nutritional support seems to be effective.

Utility of transient elastography in evaluation and follow-up of Budd-Chiari syndrome patients after endovascular intervention

BackgroundLiver stiffness measurement (LSM) using transient elastography (TE) is a common noninvasive method for assessing hepatic fibrosis. The purpose of this study was to show the utility of LSM in the evaluation and short-term follow-up of Budd-Chiarri syndrome (BCS) patients as well as to investigate the relationships between LSM, hepatic venous pressure, and liver fibrosis. We conducted a prospective cohort study in which 25 patients with a confirmed diagnosis of primary BCS underwent endovascular intervention for BCS treatment. All patients had pressure gradient changes across the stenosed hepatic veins/inferior vena cava (HV/IVC) measured before and after the procedure, a transvenous liver biopsy during the procedure, and LSM (using Transient Elastography 3 days before and 3 months after the intervention as a short-term follow-up). Comparisons and correlations were made between liver stiffness, hepatic venous pressure, and fibrosis.ResultsThe HV/IVC pressure gradient measured immediately before and after the intervention had a direct proportionate correlation with the LS measured 3 days before and 3 months after the intervention (r = 0.41 & 0.44, p: 0.04 & 0.03, respectively). LSM drops significantly 3 months after intervention (from 51.62 ± 22 kPa to 28.80 ± 19.25 kPa (p: 0.001)). There is a significant improvement in LSM post-intervention among patients with moderate to severe fibrosis (METAVIR scores of ≥ F2 before intervention (p: 0.001).ConclusionsLSM in BCS patients reflects congestion rather than fibrosis stage. TE can be used for the short-term monitoring of patients with BCS following the endovascular intervention as a noninvasive tool.

Low discontinuity of care rate for adults with complex congenital heart disease: A single center's experience

BackgroundDiscontinuity of care between childhood and adulthood is an identified problem for those with congenital heart disease. ObjectiveThis study investigated our center's discontinuity of care rate during this transition period. MethodsThe study cohort included those post-Fontan performed in childhood; those post-pulmonary valve, mitral valve, or aortic valve replacements initially performed between birth and age 17 years; those post-atrial switch operations; and those with biventricular hearts and discordance of atrioventricular and ventriculoarterial connections. We included patients born between 1978 and 2000 and cared for at our center initially from a prenatal diagnosis, birth, infancy, or childhood. We defined discontinuity of care as lack of continuing care until a minimum of 20 years of age, after excluding those that died before 20 years old or had documented continuing care at another center. We also tabulated patients that underwent at least one adult invasive procedure during continuous care. ResultsWe identified 245 patients, of which 19 (7.8%) experienced discontinuity of care. Of the 226 in continuous care, 137 (60.6%) underwent 187 invasive procedures as adults: 36 cardiovascular surgeries, 82 surveillance cardiac catheterizations with or without transvenous liver biopsy, 32 interventional cardiac catheterizations, and 37 electrophysiology procedures with or without a pacemaker procedure. ConclusionWe found a low, 7.8% discontinuity of care rate for adults with complex congenital heart disease at our center. Further, for adults with complex congenital heart disease, most required additional invasive procedures as adults.

Transvenous Biopsies – Technique, Pearls, and Pitfalls

Image-guided biopsies are one of the most common requests received by radiologists, and while most are straightforward, some lesions are not amenable to percutaneous sampling due to location or depth. Advances in intravascular ultrasound combined with the principles of non-targeted transvenous solid organ biopsy allow for direct visualization and successful targeted transvenous biopsies of solid organ and perivascular lesions. Here, we present our technique and three example cases of transvenous biopsies.

EUS-Guided versus Percutaneous Image-Guided Liver Biopsy: A Battle for Supremacy!

AbstractLiver biopsy has been the gold standard investigation for diagnosing and staging liver diseases. Image-guided percutaneous liver biopsy is a time-tested technique for obtaining the liver tissue in diffuse liver diseases. However, it is contraindicated in patients with ascites, altered mental status, skin infections, coagulopathy, and thrombocytopenia. It is associated with adverse events including postprocedure pain, bleeding, and pneumothorax. Transvenous liver biopsy can be performed in most cases with these contraindications, but it is an expensive technique and has its own inherent risks. Endoscopic ultrasound (EUS)-guided liver biopsy (EUS-LB) is a relatively new technique that has shown promising results and seems to have a potential of replacing percutaneous liver biopsy. In this news and views, we discuss the results of a randomized controlled trial (RCT) comparing EUS-guided and percutaneous techniques of liver biopsy. This RCT reported that percutaneous technique is superior in terms of diagnostic adequacy and total expenditure without any significant adverse effects compared with EUS-LB. EUS-LB is a promising technique that needs to be further explored in terms of appropriate situations in which it can be preferred over percutaneous or transvenous routes.

Intravascular Ultrasound-Guided Transvenous Biopsy of Abdominal and Pelvic Targets Difficult to Access by Percutaneous Needle Biopsy: Technique and Initial Clinical Experience

PurposeTo report initial clinical experience with intravascular ultrasound (US)-guided transvenous biopsy (TVB) for perivascular target lesions in the abdomen and pelvis using side-viewing phased-array intracardiac echocardiography catheters. Materials and MethodsIn this single-institution, retrospective study, 48 patients underwent 50 intravascular US-guided TVB procedures for targets close to the inferior vena cava or iliac veins deemed difficult to access by conventional percutaneous needle biopsy (PNB). In all procedures, side-viewing phased-array intracardiac echocardiography intravascular US catheters and transjugular liver biopsy sets were inserted through separate jugular or femoral vein access sheaths, and 18-gauge core needle biopsy specimens were obtained under real-time intravascular US guidance. Diagnostic yield, diagnostic accuracy, and complications were analyzed. ResultsIntravascular US-guided TVB was diagnostic of malignancy in 40 of 50 procedures for a diagnostic yield of 80%. There were 5 procedures in which biopsy was correctly negative for malignancy, with a per-procedure diagnostic accuracy of 90% (45/50). Among the 5 false negatives, 2 patients underwent repeat intravascular US-guided TVB, which was diagnostic of malignancy for a per-patient diagnostic accuracy of 94% (45/48). There were 1 (2%) mild, 2 (4%) moderate, and 1 (2%) severe adverse events, with 1 moderate severity adverse event (venous thrombosis) directly attributable to the intravascular US-guided TVB technique. ConclusionsIntravascular US-guided TVB performed on difficult-to-approach perivascular targets in the abdomen and pelvis resulted in a high diagnostic accuracy, similar to accepted thresholds for PNB. Complication rates may be slightly higher but should be weighed relative to the risks of difficult PNB, surgical biopsy, or clinical management without biopsy.

Transvenous Biopsy of a Primary Cardiac Lymphoma Guided by Real-Time 3-Dimensional Reconstructed Imaging From Intracardiac Echography.

Transvenous Biopsy of a Primary Cardiac Lymphoma Guided by Real-Time 3-Dimensional Reconstructed Imaging From Intracardiac Echography.

Abstract No. 76 ▪ FEATURED ABSTRACT Intravascular ultrasound-guided transvenous biopsy of retroperitoneal targets inaccessible by percutaneous iopsy: technique and initial clinical experience

Retroperitoneal lymph nodes and masses adjacent to the inferior vena cava (IVC) or iliac veins can be inaccessible by a conventional percutaneous needle biopsy (PNB) approach due to surrounding vascular and osseous structures. The purpose of this study was to report initial clinical experience with the use of intravascular ultrasound-guided transvenous biopsy (IVUS-TVB) of difficult to access extravascular lymph nodes and masses. From October 2018 to August 2020, 41 IVUS-TVB procedures were performed under fluoroscopy in 38 patients (n = 19 males, mean age = 63) using side viewing intracardiac echocardiography IVUS catheters (ViewFlex Xtra, St. Jude Medical) and 18-gauge transjugular liver biopsy kits (Argon) through separate 10 French sheaths. All cases were initially reviewed for feasibility by PNB but were deemed unacceptably high risk. Patient demographics, target locations and sizes, success rates, and 30-day complications were recorded. Forty biopsies were performed, and 1 lesion was determined to be a vascular malformation by IVUS. Lymph nodes were interaortocaval (n = 11), porta hepatis (n = 5), right paracaval (n = 3), retrocaval (n = 3), iliac chain (n = 3), and retrocrural (n = 2), and masses were in liver (caudate n = 2, dome n = 2, segment 6 n = 2), right adrenal (n = 3), pancreas (n = 2), aortic wall (n = 1) and IVC (n = 1). The average short axis size was 2.6 cm (range 1.0-6.8). IVUS access was jugular (n = 27) or femoral (n = 13), and biopsy access was jugular (n = 28), femoral (n = 11), or portal (n = 1) with passes made from the IVC (n = 37), iliac (n = 2), or portal vein (n = 1). In 32 procedures (80%) IVUS visualization was good. Final pathology was diagnostic of malignancy in 29 procedures (73%), correctly excluded malignancy in 4 (10%), and was non-diagnostic in 7 (18%) with subsequent diagnosis made via repeat IVUS-TVB (n = 3) or surgical biopsy (n = 2) or remaining unknown (n = 2). There were 3 minor complications requiring no treatment (hyperbilirubinemia attributed to hemobilia; contrast induced acute kidney injury; small non-occlusive IVC thrombus at the biopsy site). There was 1 major complication directly related to the biopsy (bleeding at the femoral vein access site requiring transfusion) and 1 other major complication (aortic pseudoaneurysm in a patient with preexisting salmonella aortitis). IVUS-TVB achieves high diagnostic yields similar to accepted thresholds for PNB. Complications rates may be higher but should be weighed relative to the risks of difficult PNB, surgical biopsy, or clinical management without biopsy.

Fontan-associated liver disease and total cavopulmonary anatomical flow effectors.

We investigated a relationship between a composite index comprised of Fontan-circuit anatomical features and hepatic fibrosis scores from biopsy. We identified living extracardiac Fontan patients, ≥7 years old and ≥5 but <20 years postoperative, that underwent cardiac catheterization and transvenous liver biopsy between March 2012 and September 2020. We divided patients into anatomical groups and applied a risk score to each patient. We compared average anatomical risk scores with average hepatic total fibrosis scores by group. We identified 111 patients that met inclusion criteria. After excluding four patients, we assigned 107 to one of 12 anatomical variant groups (n ≥ 3). For the 107, the average age at liver biopsy was 14 ± 6 years old. Of the 107, 105 (98%) were New York Heart Association Class 1. We found average anatomical risk scores by group correlated with average total fibrosis scores by group (R = 0.8; p = .005). An average Fontan duration to biopsy of 10 ± 1 years was similar for all 12 anatomical groups. We found no other clinical variables, laboratory, or hemodynamic values that trended with anatomical risk scores or hepatic total fibrosis scores. In a cohort of relatively young, stable extracardiac Fontan patients, average composite anatomical risk scores strongly correlated with average hepatic total fibrosis scores by anatomical group. These findings suggest that some anatomical variants in extracardiac Fontan patients are associated with higher Fontan-associated liver disease (FALD)-related hepatic total fibrosis scores than others, despite similar Fontan durations.

Fontan-Associated Anatomical Variants and Hepatic Fibrosis.

We hypothesized that a relationship between post-Fontan hepatic fibrosis and anatomical variants might exist. Attempting to limit confounding variables, we analyzed data from living, stable, post-extracardiac Fontan patients who underwent cardiac catheterization and transvenous hepatic biopsy procedures between March 2012 and June 2020. We identified 120 patients who met the inclusion criteria. Of the 120, 35 (29%) had pulmonary artery stents. For the 35 with pulmonary artery stents, the average total fibrosis score was 3.2 ± 1.9 and the fibrosis progression rate was 0.36 ± 0.33, and for those with no pulmonary artery stents, the total fibrosis score was 2.6 ± 1.8 and the fibrosis progression rate was 0.27 ± 0.33 (P = .13 and P = .11, respectively). Of the 120, 65 had functional univentricles of right ventricular type. Of these 65, 27 had pulmonary artery stents. For the 27 with pulmonary artery stents, the average total fibrosis score was 3.4 ± 1.8 and the average fibrosis progression rate was 0.39 ± 0.30, and for the 38 without pulmonary artery stents, the average fibrosis score was 2.3 ± 1.5 and the average fibrosis progression rate was 0.23 ± 0.21 (P = .01 for comparison of both values). This study's findings suggest that a post-extracardiac Fontan with a functional univentricle of right ventricular type plus a pulmonary artery stent may have more advanced liver pathology than those without a pulmonary artery stent at similar Fontan duration years and ages at liver biopsy.

Secondary Cardiac Lymphoma Presenting as Sick Sinus Syndrome and Atrial Fibrillation Which Required Leadless Pacemaker Implantation.

Cardiac involvement of malignant lymphoma is relatively common, although such a phenomenon has subclinical manifestations that are difficult to detect. We herein describe a patient with atrial fibrillation and sick sinus syndrome as the main symptoms. Computed tomography showed a mass in the right atrium extending into the superior vena cava (SVC). We implanted the patient with a leadless pacemaker. Transvenous biopsy revealed a diffuse large B-cell lymphoma. The patient was treated successfully with chemotherapy including rituximab. This case suggested that cardiac lymphoma may cause sick sinus syndrome, and leadless pacemaker implantation is a safe treatment option in patients with partial SVC obstruction.

Transjugular versus Transfemoral Transcaval Liver Biopsy: A Single-Center Experience in 500 Cases

PurposeTo compare the safety and efficacy of transfemoral transcaval liver biopsies (TFTC) with that of transjugular liver biopsies (TJLB) at a single tertiary-care institution. Materials and MethodsA retrospective review was performed of 500 consecutive transvenous liver biopsies between December 2010 and December 2018. The cases included 286 TFTC patients at a median age of 54 years old (interquartile range [IQR], 42–63 years of age), 37.4% were female; and 214 TJLB patients at a median age of 55 years old (IQR, 46–61 years of age), 45.4% female. Patient demographic and laboratory data and technical and histopathological success, fluoroscopy times, and complications were recorded. Comparative statistical analyses were performed using a 2-sample test or a Wilcoxon ranked sum test for continuous variables and a chi-square test or Fisher exact test for categorical variables when appropriate. ResultsTFTC and TJLB data are presented as: technical success rates of 99.3% (283 of 286) and 100% (214 of 214), respectively; histopathologic success rates of 96.5% (275 of 285) and 95.8% (205 of 214), respectively; and major complication rates of 1.4% (4 of 284) and 5.6% (12 of 214), respectively (P = .009). There were no hepatic injuries in the TFTC group, whereas the TJLB group included 6 significant hepatic injuries requiring intervention. Median fluoroscopic times were 5.5 minutes (IQR, 3.9–8.6 minutes) for TFTC and 8.1 minutes (IQR, 5.2–13.1) for TJLB (P < .001). ConclusionsIn this single-institution study, TFTC was associated with a lower major complication rate and lower fluoroscopy times than conventional TJLB with similar technical and histopathologic successes.