Interventional Radiology

Interventional Radiology survey and assembly:

Steatosis – cirrhosis – portal hypertension:

Interventional oncology in liver tumours:

Gastrointestinal and venous access:

Members of the group 2020:
Charlotte Ebeling Barbier, Associate Professor, Research group leader
Rickard Nyman, Professor emeritus
Pär Gerwins, Professor
Lars-Gunnar Eriksson, MD, PhD
Alina Dimopoulou Creusen, MD, PhD
Ulf Johnson, MD, PhD
Salem Alsaqal, MD, PhD student
Marijela Moreno Berggren, MD, PhD student
Niclas Hegerius, PhD student (not registered yet)
Sofi Sennefelt Nyman, PhD student (not registered yet)
Kerstin Rosenqvist, MD, PhD
Hampus Eklöf, MD, PhD

Co-operation with:
Håkan Ahlström, Professor, Radiology
Fredrik Rorsman, Associate Professor, Hepatology
Per Sangfelt, MD, PhD, Hepatology
Reza Sheikhi, MD, Hepatology
Johan Vessby, MD, Hepatology
Bengt Isaksson, Professor, Surgery
Jozef Urdzik, MD, PhD, Surgery
Hans Lennernäs, Professor, Pharmacology
Mikael Hedeland, Professor, Analytical and Pharmaceutic 
Femke Hendryckx, PhD, Medical Cell Biology
Magnus Sundbom, Professor, Surgery
Mikael Ljungdahl, MD, PhD, Surgery
Bengt Fellström, Professor, Nephrology
Hans Furuland, MD, Nephrology
Johan Rydén, Transcutan AB

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.

By building a national IR registry we will be able to accumulate and evaluate the national IR experience and performance, which is not done today. The registry will create 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 will be 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 and Rickard Nyman
Co-operation with: Fredrik Rorsman, Per Sangfelt
PhD-student: Reza Sheikhi

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 we are now evaluating the technique.

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 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
(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 (commonly doxorubicin) 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 retrospective evaluation of TACE effects is being performed and we are investigating ways to improve drug delivery and effectiveness of TACE in a cross-diciplinary project involving various pre-clinical and clinical experts.

Project 6: Interventional oncology in liver tumours: Monitoring and augmenting image-guided treatments of liver tumours
Responsible: Charlotte Ebeling Barbier
Co-operation with: Håkan Ahlström, Fredrik Rorsman, Bengt Isaksson, Hans Lennernäs, Mikael Hedeland, Femke Hendryck
(PhD-student): Niclas Hegerius

Unresectable liver tumours have been treated with individualised strategies including percutaneous thermal ablation and transarterial chemoembolization (TACE) for several decades. Although imaging techniques have evolved to become increasingly sophisticated during this time, patient selection for ablation and TACE is still based on rudimentary tumour characterization. Several TACE studies report good tumour response and survival, but most of them have a number of non-responders. This is most likely explained by the known phenotype heterogeneity of HCC tumours.

Image-based phenotyping will be attempted using PET/MRI and radiomics, possibly directing improvements and augmentation of TACE and ablation techniques.

Project 7: Gastrointestinal and venous access: Prospective randomized comparison between percutaneous endoscopic gastrostomy (PEG) and radiologically inserted gastrostomy (RIG)
Responsible: Rickard Nyman
Co-operation with: Magnus Sundbom, Mikael Ljungdahl
PhD student: Eladio Cabrera

Patients who are unable to take food orally due to stroke, malignancies or neuromuscular disorders benefit from a gastrostomy for enteral nutrition. Even though gastrostomies have been inserted endoscopically (PEG) or radiologically (RIG) for several decades, no randomized comparisons between the two techniques have been published.

A randomized study is currently being performed.

Project 8: 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 9: 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 Alina Dimopoulou Creusen
Co-operation with: Bengt Fellström, Hans Furuland, Johan Rydén

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.