Interventional Radiology

Project 1: Interventional Radiology survey and assembly: Development and implementation of a national registry for Interventional Radiology (IR)

Responsible: Rickard Nyman and Charlotte Ebeling Barbier

Interventional radiology (IR) is constantly and rapidly evolving. Since IR techniques are minimally invasive, entailing fast patient recovery and short hospital stays, its use spreads faster than scientific evidence can be provided. The fact that IR evolution is guided by clinical requests and that treatments are largely individualized complicates scientific evaluation. Hence, we lack convincing scientific evidence for many recommended and widely used IR treatments.

A national IR registry has been built and implemented and is currently being modernised and adjusted. This enables accumulation and evaluation of the national IR experience and performance, which has not been done before. The registry entails a much-warranted opportunity for qualitative and quantitative assessment as well as for prospective randomized studies.

Project 2: Steatosis – cirrhosis – portal hypertension: Identifying non-invasive imaging biomarkers of non-alcoholic steatohepatitis (NASH)

Responsible: Charlotte Ebeling Barbier

Co-operation with: Håkan Ahlström, Fredrik Rorsman, Johan Vessby

PhD student: Salem Alsaqal

The prevalence of non-alcoholic fatty liver disease (NAFLD) increases with increasing obesity worldwide. Its progressive inflammatory state, non-alcoholic steatohepatits (NASH), may further progress to cirrhosis causing portal hypertension, and potentially develop into liver failure and/or hepatocellular carcinoma. Since NASH is amenable to prevention and treatment, it is important to identify persons who progress from NAFLD to NASH. This is currently performed with liver biopsy, an invasive method with high costs, limited availability and risk of complications. With an increasing prevalence of NAFLD the need for non-invasive diagnostic tools intensifies.

Non-invasive imaging biomarkers are sought for using various PET/MRI techniques in a prospective, exploratory observational study.

Project 3: Steatosis – cirrhosis – portal hypertension: The effects of transjugular intrahepatic portosystemic shunt (TIPS) treatment of portal hypertension

Responsible: Charlotte Ebeling Barbier, Ulf Johnson, Rickard Nyman

Co-operation with: Fredrik Rorsman

Severe portal hypertension (PHT) caused by liver cirrhosis can be successfully treated with the insertion of a transjugular intrahepatic portosystemic shunt (TIPS). Early TIPS has been proved to increase survival in PHT patients presenting with variceal bleeding. We are currently evaluating whether early TIPS has similar benefits in PHT patients presenting with refractory ascites.

A potential important complication to TIPS is hepatic encephalopathy (HE), which is difficult to predict and partly seems to be correlated to the pressure gradient over the TIPS (i.e. the gradient between portal blood pressure and central venous blood pressure in the right atrium/inferior vena cava). We are investigating possible predictors of HE in TIPS patients in a retrospective and a prospective study.

TIPS may also be used when PHT is caused by acute or chronic portomesenteric thrombosis – and then combined with transjugular thrombectomy. This approach has been used for a few years. It has saved the lives of several patients and is currently evaluated.

Project 4: Interventional oncology in liver tumours: Exploring the effects of preoperative portal vein occlusion potentiating curative liver tumour resection

Responsible: Charlotte Ebeling Barbier

Co-operation with: Håkan Ahlström, Bengt Isaksson, Jozef Urdzik

PhD-student: Marijela Moreno Berggren

Patients in whom liver tumours are to be surgically removed may risk postoperative liver insufficiency if the volume of the remaining liver, the future liver remnant (FLR), is too small. In these patients hypertrophy of the FLR can be achieved by occluding the portal vein in the part of the liver that is to be removed allowing for a more extensive surgery and increasing the chances for cure. Portal vein occlusion (PVO) can be performed surgically, but it is more commonly achieved by portal vein embolization (PVE). The exact mechanisms leading to atrophy of the embolized lobe and hypertrophy of the FLR are largely unknown. Even though the function of the FLR must be what matters, only the size of the FLR and its degree of hypertrophy has been associated with postoperative liver insufficiency.

A retrospective evaluation of PVE effects has been performed and a prospective study, Prospective Evaluation of preoperative Portal vein ocklusion with PET/MRI (PEPP), is being performed, exploring metabolic and functional changes in the FLR with PET/MRI, intravasal pressure measurements, and biopsies.

Project 5: Interventional oncology in liver tumours: Exploring and enhancing transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC)

Responsible: Charlotte Ebeling Barbier

Co-operation with: Fredrik Rorsman, Hans Lennernäs, Mikael Hedeland, Femke Hendryckx, Jonas Bergquist, Ulrika Simonsson, Erik Sjögren

PhD-student: Sofi Sennefelt Nyman

Patients with hepatocellular carcinoma (HCC) who cannot be operated on can be treated with transarterial chemoembolisation (TACE), where a catheter is advanced under flouroscopy through a sheath in the common femoral artery. The catheter is placed in the liver artery supporting the tumour and the chemotherapeutic agent is administered through the catheter (embolized) into the tumour. This treatment option allows for higher doses of chemotherapy than when systemic treatment is performed, since there are fewer systemic side effects. The TACE technique varies greatly over the world and there is no completely standardized approach. The drug formulation has limited effectiveness, there are handling disadvantages and no effort has been made to improve the lipiodol emulsion during the past 30 years.

A prospective translational cross-diciplinary study involving various pre-clinical and clinical experts is currently performed, the TransArterial Chemoembolization Therapy with idarubicin (TACTida) study, aiming to improve the currently unsatisfactory effect TACE, to identify biomarkers for treatment response, and enable early detection of HCC.

Project 6: Gastrointestinal and venous access: Post Market Clinical Follow-Up study on the T-Port® Enteral Access System

Responsible: Rickard Nyman

Co-operation with: Teus van der Laar, Dag Nyholm

A multicenter, non-randomized, open label, observational study is performed where Parkinson patients who have been prescribed the T-Port as the access system for delivery of Duodopa to the jejunum will be monitored carefully and systematically the first year following the implantation.

Project 7: Gastrointestinal and venous access: Pilot Study on the Use of a Novel Hemodynamic Access System for patient on Haemodialysis. The HAS-01 Study

Responsible: Rickard Nyman and Allina Dimopoulou Creusen

Co-operation with: Bengt Fellström, Hans Furuland

A hemodynamic access port (HAS-port) for hemodialysis has been developed based on the experience from the clinical use of the CE-marked product T-Port© Enteral Access System (T-Port), which was developed for catheter access to the stomach and small intestine. The HAS-port has a specially designed mechanism to open and close the port without interference with the skin which is believed to reduce the risk of serious infection. If functional problems occur the port can easily be opened for inspection, catheter exchange or procedures such as thrombolysis, balloon dilation or stripping of fibrous sheath.

The hypothesis is that the port will heal in uneventfully during the first month and that the central venous catheter (CVC) will maintain an acceptable blood flow (> 300 ml/min) during dialysis for 6 months. The number of complications (inflectional or functional) that results in hospitalization or intervention and the incidence of bacteremia during this period will be analyzed and compared with historical data of conventional CVCs.