Pranculis, Andrius

Introduction: Treatment of Hepatocellular carcinoma (HCC) is based on various guidelines and most often used criteria are the Barcelona Clinic Liver Cancer (BCLC) criteria. Transcatheter arterial chemoembolization (TACE) is recommended for patients with disease of intermediate stage (B), when surgery and ablation are not possible due to multimodal disease. Acute pancreatitis is one of the rarest complications after TACE with an incidence of 0.4%. Method: A retrospective analysis of data from a prospectively maintained database at the tertiary university hospital of the Lithuanian University of Health Sciences, Kaunas Clinics, in Kaunas, Lithuania, was performed. Patients diagnosed with hepatocellular carcinoma, who underwent transarterial chemoembolization (TACE) were included in the study. Data on patients demographic information, CT scan, HCC localization, number of lesions, number of TACE procedures, post-TACE abdominal pain, serum amylase and other complications was analyzed Results: Fifty-one (51) patient was included and most of them (34 (66.6%) had a single lesion. Most of the patients underwent transarterial chemoembolization once (64.7%) and one third - multiple times (35.3%). Post-TACE pancreatitis was diagnosed in 5 (9.8%) patients. All 5 patients had elevated amylase levels (1077±987 U/L) and abdominal pain. Two patients died of septic complications after TACE. Conclusion: Acute pancreatitis is rare complication after TACE. Routine monitoring of pancreatic enzymes after TACE are recommended, especially in symptomatic patients as complications of TACE might be lethal.

Background and objective: carotid artery stenosis contributes significantly to ischemic strokes, with management options including carotid endarterectomy (CEA) and carotid artery stenting (CAS) ischemic stroke risk can be reduced. Controversies persist regarding their efficacy and factors influencing complications, and understanding the relationship between atherosclerotic plaque characteristics and stent restenosis after CAS is crucial. Methods: we conducted a retrospective study involving 221 patients who underwent CAS for symptomatic or asymptomatic carotid artery stenosis. Comprehensive assessments of plaque morphology were performed using contrast-enhanced ultrasound (CEUS) before CAS. Patient demographics, including smoking status and diabetes, were also recorded. Stent restenosis was diagnosed using various imaging modalities, including ultrasound, angiography, and digital subtraction angiography (DSA). Results: plaque analysis using CEUS revealed a significant association between plaque grade and restenosis incidence (p < 0.001), particularly with grade 0 (11.1%) and grade 2 plaques (66.7%). Smoking was notably associated with plaque vascularization and restenosis (p < 0.001), while diabetes did not significantly impact plaque characteristics or restenosis risk (p > 0.05). The mean duration of restenosis was 17.67 months. Stenting was the most frequent treatment modality for restenosis (70.6%). However, no significant relationship was found between restenosis type and plaque morphology (p = 0.268). Furthermore, while no clear relationship was observed between plaque morphology and the type of restenosis, our findings underscored the importance of plaque characterization in predicting post-CAS outcomes. Conclusions: this study highlights the utility of CEUS in predicting stent restenosis following CAS. There was a significant association between stent restenosis within 12–24 months after the carotid stenting procedure and an elevated grade of plaque vascularization. Moreover, one of the main factors possibly determining the grade of plaque vascularization was smoking. Further research is warranted to elucidate the underlying mechanisms and refine risk stratification in this patient population.

Background and aim of the study: The incidence of stroke after on-pump cardiac surgery during the perioperative period can affect up to 4% of patients with significant unilateral carotid artery stenosis of 80-99. Between 3% to 10% of individuals who undergo coronary artery bypass grafting (CABG) display notable narrowing of the carotid arteries, which can be improved by either simultaneous or staged carotid endarterectomy and CABG. The aim of the study was to determine the association between the degree of plaque vascularization detected with contrast-enhanced ultrasound and postoperative complications. Methods and materials: A single center retrospective study of 62 patients was performed from 2019 to 2022 who underwent simultaneous CABG/CEA. Exclusion criteria: staged carotid endarterectomy and CABG procedures, off-pump CABG, urgent cases. The focus of our study was on patients who underwent elective CABG. These individuals were diagnosed with coronary artery disease (CAD) and exhibited either asymptomatic internal carotid artery stenosis greater than 70% or symptomatic ipsilateral carotid stenosis exceeding 50%. Before the procedure each patient underwent contrast enhanced ultrasound, the atherosclerotic lesions were classified based on Nakamura et al. classification. Results: Postoperative complications were analyzed within 30 days after surgery and type of plaque morphology detected by contrast-enhanced ultrasound, a statistically significant correlation was found between the presence of a higher grade plaque vascularization and ischemic stroke (r=0.329, p=0.008). Monte Carlo calculations of Chi-square test showed that higher grade of plaque vascularization was significantly associated with peripheral artery disease (χ2=15.175, lls=2 , p=0.003). Conclusions: Ischemic stroke after carotid endarterectomy following CABG within 30 days after surgery has a significant correlation with the presence of a higher grade of plaque vascularization detected by contrast-enhanced ultrasound.

Introduction Up to 20% of ST-elevation myocardial infarction (STEMI) patients who undergo primary percutaneous coronary intervention (PCI) continue to have persistent angina, which is considered to be a significant side effect of reperfusion therapy and is associated with coronary microvascular dysfunction (CMD).

Purpose To determine if there is a correlation between the technique employed in primary PCI in STEMI patients and the prevalence of CMD after reperfusion.

Methods This is a prospective single-blinded observational cohort study conducted in a tertiary cardiac care center in the republic of Lithuania. The study enrolled STEMI patients with multivessel coronary artery disease who underwent primary PCI. Three months later, participants underwent staged PCI of their non-culprit vessels and evaluation for CMD. CMD was defined as an index of microcirculatory resistance (IMR) value ≥ 25 U and a coronary flow reserve (CFR) value < 2.5 U. PCI technique, such as direct stenting or conventional stenting (balloon angioplasty followed by stenting), aspiration thrombectomy, and intracoronary glycoprotein IIb/IIIa inhibitor administration, were prospectively documented. We tested for overall differences in patient characteristics and outcomes between groups using Chi-Square (or Kruskal-Wallis) tests and used the Holm-Bonferroni adjustment (or Dunn's tests) for subsequent pairwise tests. We also performed logistic regression.

Results 200 patients were enrolled, with 96 (48%) and 104 (52%), respectively, undergoing direct and conventional stenting. The median age was 65.5 [58, 76] years, most patients were men (59.5%) and 46 patients (23%) met criteria for CMD. Baseline characteristics and risk factors were similar between those with and without CMD. Patients who underwent direct stenting were less likely to suffer from CMD compared to those who underwent conventional stenting (10 (10.4%) vs 36 (34.6%); p < 0.001). In the logistic multivariable analysis, direct stenting, aspiration thrombectomy, and administrations of glycoprotein IIb/IIIa had a ROC AUC of 0.765, indicating good predictive ability. In this particular model, direct stenting, aspiration thrombectomy, and the administration of an intracoronary glycoprotein IIb/IIIa inhibitor were associated with decreased odds of the presence of CMD (OR: 0.193, 95% CI: 0.087-0.430, p < 0.001), (OR: 0.243, 95% CI: 0.086-0.688, p = 0.008), and (OR: 0.200, 95% CI: 0.065-0.620, p = 0.005), respectively.

Conclusion In STEMI patients undergoing primary PCI, direct stenting is associated with reduced prevalence of CMD compared with conventional stenting. Furthermore, performing aspiration thrombectomy and administering a glycoprotein IIb/IIIa inhibitor was also associated with a lower prevalence of CMD.

Background Despite significant progress in cardiopulmonary resuscitation (CPR), outcomes remain relatively poor. Epinephrine administration remains a cornerstone in the treatment of in-hospital cardiac arrest. Various routes of administration, including intravenous, intramuscular, intraosseous, and endotracheal routes have been studied; however, the optimal route is debated. Purpose The purpose of this study was to compare patient outcomes following peripheral intravenous (IV), central IV, or arterial intracoronary (IC) epinephrine administration in patients undergoing CPR in the catheterization laboratory. Methods This was a prospective two-center pilot cohort study conducted in high-volume percutaneous coronary intervention (PCI) facilities in the republic of Lithuania. The study enrolled patients with acute myocardial infarction (AMI) who suffered a cardiac arrest in the cardiac catheterization laboratory during PCI. Cardiac resuscitation was performed according to the European Resuscitation Council Guidelines. Central IV was the first choice for epinephrine administration if it was available. However, in cases without central access, the route of epinephrine administration (peripheral IV or arterial IC) was at the discretion of the physician. The primary endpoint was the rate of return of spontaneous circulation (ROSC). We tested for overall differences in patient characteristics and outcomes between groups using Chi-Square (or Kruskal-Wallis) tests and used the Holm-Bonferroni adjustment (or Dunn's tests) for subsequent pairwise tests. We also performed logistic regression. Results There were 158 participants in this study, with 48 (30.4%), 50 (31.6%), and 60 (38.0%) receiving epinephrine via central IV, IC, and peripheral IV routes, respectively. The median age was 71 [61, 80] years and 56% of participants were men. Patient characteristics were similar across routes, except for age (higher for peripheral IV than IC), serum potassium (although no significant post-hoc differences), hemoglobin (lowest in peripheral route), and heart rhythm before CPR (higher rates of electromechanical dissociation in peripheral route). There were 111 (70%) patients who achieved the primary outcome of ROSC (Table 1). Peripheral IV administration was associated with 7-fold decreased odds of achieving ROSC (odds ratio = 0.14, 95% confidence interval = 0.05–0.36, p<0.0001) compared to central IV (no difference between central IV and IC; p=0.9343). By itself, adrenaline route yielded an area under the receiver operating characteristic curve of 0.73, indicating good predictive ability. Conclusion Epinephrine administration route was a significant predictor of ROSC for patients with AMI undergoing CPR in the catheterization laboratory. ROSC rates for patients who received epinephrine via IC or central IV were superior to those who received it via peripheral IV.

Background. The Coronavirus disease 2019 (COVID-19) pandemic has changed the way patients seek medical attention and have medical services are provided. We sought to compare characteristics, clinical course, and outcomes of patients presenting with acute myocardial infarction (AMI) during the pandemic compared to before it. Methods. This is a multicenter, retrospective cohort study of consecutive COVID-19 negative patients with AMI in Lithuania from March 11,2020 to April 20,2020 compared to patients admitted with the same diagnosis during the same period in 2019. All patients under went angiography. Six month follow-up was obtained for all patients. Results. A total of 269 patients were included in this study, 107 (40.8%) of whom presented during the pandemic. Median pain-to-doot times were significantly longer (858 [quartile 1-360, quartile 3-2600] vs. 385.5 [200,745] mins, p<0.00001) and post-revascularization ejection fractions were significantly lower (35 [30,45] vs. 45 [40,50], p<0.0001) for patients presenting during vs. prior to the pandemic. While the in-hospital mortality rate did not differ, we observed a higher rate of six-month major adverse cardiovascular events (MACE) for patients whe presented during vs. prior to the pandemic (30.8% vs 13.6%, p=0,0006). Conclusion. In conclusion, 34% fewer patients with AMI presented to the hospital during the COVID 19 pandemic, and those who did waited longer to present and experienced more 6-month MACE compared to patients admitted before the pandemic.

Post-operative biliary complications for pediatric liver transplantation recipients are usually treated with a surgery. However we present a very successful case of an invasive radiology treatment. The 4-year-old patient underwent urgent liver transplantation from a living donor at University Hospital of Warsaw due to acute liver failure of unknown origin in 2016. Drug-resistant epilepsy developed after transplantation due to a history of severe hepatic encephalopathy and implantation of a nerve Vagus stimulator (NVS) was performed because of ineffective treatment with anti-epileptic drugs. The patient continued immunosuppressive therapy according to liver transplant protocol. On March 2019 an acute graft rejection was diagnosed and patient was treated at Warsaw transplant center, after which the condition improved. 5 years after liver transplantation the cholestatic symptoms appeared: jaundice, loss of appetite, diarrhea up to 6 times per day with acholic stools and marked pruritus. Repeated blood tests showed marked cholestasis (GGT> 1000 IU/l, bilirubin - 180 µmol/l, conjugated bilirubin - 99 µmol/l), expanded graft bile ducts were detected by ultrasound. Due to the NVS magnetic resonance cholangiopancreatography (MRCP) was contraindicated. Percutaneous transhepatic cholangiography (PTC) with contrast of the bile ducts was performed two strictures, enlargment of billiary tree were found - stricture of the graft and intestine biliary junction and intestinal stricture due to the bent of access loop.a Cholangioplasty of the strictures and stenting with self-expanding stents were performed.b The patient's condition improved immediately after procedure - jaundice and pruritus disappeared, defecation decreased, appetite improved. After one month the signs of cholestasis disappeared: GGT - 19 IU/l, bilirubin - 10.46 µmol/l, cojugated bilirubin - 2.63 µmol/l). According to our data for the first time PTC with stenting was performed in the pediatric liver transplant patient in Lithuania. Successful cholangioplasty with self-expanding stents was completed and clinical symptoms regressed.

Portal hypertension (PH) in liver cirrhosis leads to increased gut permeability and the translocation of bacteria across the gut-liver axis. Microbial DNA has recently been detected in different blood compartments; however, this phenomenon has not been thoroughly analyzed in PH. This study aimed to explore circulating bacterial DNA signatures, inflammatory cytokines, and gut permeability markers in different blood compartments (peripheral and hepatic veins) of patients with cirrhosis and PH. The 16S rRNA blood microbiome profiles were determined in 58 patients with liver cirrhosis and 46 control patients. Taxonomic differences were analyzed in relation to PH, liver function, inflammatory cytokines, and gut permeability markers. Circulating plasma microbiome profiles in patients with cirrhosis were distinct from those of the controls and were characterized by enrichment of Comamonas, Cnuella, Dialister, Escherichia/Shigella, and Prevotella and the depletion of Bradyrhizobium, Curvibacter, Diaphorobacter, Pseudarcicella, and Pseudomonas. Comparison of peripheral and hepatic vein blood compartments of patients with cirrhosis did not reveal differentially abundant taxa. Enrichment of the genera Bacteroides, Escherichia/Shigella, and Prevotella was associated with severe PH (SPH) in both blood compartments; however, circulating microbiome profiles could not predict PH severity. Escherichia/Shigella and Prevotella abundance was correlated with IL-8 levels in the hepatic vein. In conclusion, we demonstrated a distinct circulating blood microbiome profile in patients with cirrhosis, showing that specific bacterial genera in blood are marginally associated with SPH, Model for End-Stage Liver Disease score, and inflammation biomarkers; however, circulating microbial composition failed to predict PH severity.

Introduction: COVID-19 pandemic has changed the way patients seek medical attention and the manner medical service is provided. Purpose: To examine the changes in patient characteristics, clinical course and rates of rehospitalization due to decompensated heart failure for patients admitted with acute myocardial infarction (AMI) during the COVID-19 pandemic compared to the corresponding period in the previous year. Methods: This is a region-wide, multicenter, retrospective cohort study of consecutive COVID-19 negative patients with AMI from March 11, 2020 to April 20, 2020 compared to patients admitted with the same diagnosis during the same period in the previous year. Six-month follow-up was obtained for all patients included in the study. Results: A total of 269 AMI patients were evaluated in this study. Pain-to-door times (858 [360, 2600] vs. 385.5 [200, 745] min, p < 0.0001) and troponin I levels (7.8 [2.6, 37.2] vs. 4.5 [1.1, 25.4] µg/l, p = 0.013) were significantly higher for AMI patients presenting during the pandemic. Similarly, NSTEMI patients had a significantly prolonged pain-to-door time during the pandemic than prior to it (2021 [960, 5746] vs 558 [369, 882.5] min, p < 0.0001) and there is evidence to suggest a trend toward longer door-to-wire times, as well (302.5 [179, 600] vs 200.5 [98, 434.5] min, p = 0.0948). furthermore, STEMI patients waited significantly longer before presenting to the hospital during the pandemic (582 [180, 1212] vs 262 [120, 525] min, p = 0.0003). However, door-to-wire times were similar (75 [53.5, 106.5] vs 71 [43, 119] min, p = 0.2257). Additionally, Post-revascularization ejection fraction was significantly lower for AMI patients during the pandemic (35 [30, 45] vs. 45 [40, 50] %, p < 0.0001). During follow-up we observed a significantly higher rate of re-hospitalization due to decompensated heart failure in patients admitted with NSTEMI and STEMI during the pandem[...].

Background. Acute myocardial infarction (AMI) is a stress-inducing situation, which triggers a cascade of physiological and physiopathological events, leading to the activation of the hypothalamic-pituitaryadrenal axis. Biological effects of local earth magnetic fields (LEMF) and their consequences on human health have become the subject of important and recurrent public debate. Aim. The aim of the current study was to determine the correlation between LEMF and serum cortisol levels in patients diagnosed with AMI. Methods. The prospective, observational study was conducted in the Lithuanian University of Health Sciences Kaunas Clinics, including all patients admitted in 2017 to the CCU with a diagnosis of AMI. Total serum cortisol levels were measured on admission. The intensity of the time varying LEMF intensity was measured by the Global Coherence Monitoring Network magnetometer located in Lithuania. The LEMF was observed in five frequency intervals obtained from Schumann resonances: SDelta [0–3.5], STheta [3.5– 7], SAlpha [7–15], SBeta [15–32], SGamma [32–65]. We formed [0–65] group, where all frequency intervals were combined together. The electromagnetic fields frequencies average during week days was assigned as [0–3.5], [3.5–7], [7–15], [15–32], [32–65], [0–65]. The strength of the magnetic field is measured in two directions: north-south (NS) and east-west (EW) axis. Results. 94 patients were included. The mean age of the patients was 63.9±11.6 years and 65% were males. Average of plasma cortisol level for patients admitted during the day time (5–12:59 hours) (n=37) showed no significant difference in comparison with patients admitted during the evening time (13–4:59 hours) (n=86) [743.9±309.7 vs. 715.2±374.9; p=0.683]. Table. Correlation of studied LEMF frequency with plasma cortisol level for patients admitted during the day [...].