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so in this study that showed we're loaded forty patiently stuffer presentation
with a button selects norma n. we stumbled is i that new one set
well they can all this concurrently of two more and a cancer
we've clues sam because they uh some dropped out from that is eight with a school that because we fought
that this was an a plus it almost but fifteen what kept on the least because we
we're confident that that this patient had a bland for moses and
in all of them with the criteria that they showed you
uh which included the combination of ultrasound and i the city or i mean i see use
plus i that's it the other omitted or emmett i to be most as most
confident as possible all of them at bland portables importance so the
pause it the predictive value to state visit down through bosses
is extremely high demonstrated on the expand analysis
does that i've been also conferred by uh uh other studies that a cane previously
in which uh they uh these also these italian although two
different groups perform biopsy of troubles as it showed you
and they could even the most so they they the seals is more sensitive than net
city for tiny segment adventures in this is not strange
because the city and i'm alive the patient base
might be suboptimal lot position while you can repeat uh seals
but most importantly some of these to work almost every out of me causes or jazz components of
clocks so if you put the needle where the disney closes you don't find one says
so it's use is also useful when you want to perform a biopsy of the crown was
to show where to put the needle so combining all this situation these both these studies show that
so use is at least as articulate as it the as an ally
to check that i support of interim board this but when you speak
about in the button benches it is even more a sensitive
okay this one one example but that would go through very quickly is already did enough
uh they very good characterisation capability is not only for part
of interim was is in c. topic leave it
this was a patient always a single bypasses this but when she came
she had also portal vein from all these with some weekend visitation
this was the part then uh all the throng was in the late phase this was many years ago with initially
keep and so it's difficult to say whether this is devoid of signal out the facts or a confusion
what is important is is then it passes is you see hyper announcing that their face and washout
the same pattern of course also in the trouble so this means that the type of
the issue is the same here in the bay passes and in that from those
so it is important if you want to select the lies
the trauma was was says also they uh appear phase
so if you want to see the extension we look at the portal face if you
want to select the lies we have to pay attention also at that period phase
so these spends two also for me to static a
thrombosis okay go through quickly this is somewhat examples
okay so they take compliance going to the conclusion is there to to sound blast
doppler usually is the first imaging modality to detect the portal vein thrombosis
unless the patients can symptomatic because these are more huge in cases and is better to
go directly to c. d. or m. n. i. because in this equation more often
the supreme isn't very can they all be in film isn't very good may not involve any with ultrasound we're not sensitive enough
the additional seals helps to select that i supported him to moses distinguish
to work from non to waltz into the ten min is expand
if the findings adding come close if you we might also to buy i've seen all including all
into patty uh to moses not of x. the bathroom with these these it would be dangerous
because this is particularly important if we need to decide whether the patient can stay on the waiting list or not
city is recommended to us as part of an extension and the uh
yeah but because usually is more easily uh utilise the ball
and then i school but needs more corporation of the patients so if the patient is as paid off and is
unable to hold is bad so sleepy is better in this situation unless it is a a contra indicated
just a few slides to conclude how we do that's emerging to assess as possible treatment
uh and the combination is beneficial i hope these must it would be a set that we were able
to the most lately no respect to say this that and the glacial even improve survival instead occupations
so in the future because to make very still did it a
beta was discussing with um daily shake uh and he called
because of the study that the proposed he's it but always say how long we'll take your baby without
the population in the answer i don't it at glacier these vendors for our patients in the states
so clearly these the most ladies still not clear whether they have to be treated or not
hopefully in the future all this page you will be treated but given these big
around with them all for how long how strongly clunky cool aid them so
my in my view probably we need to monitor this patient basically because
maybe we'll start with the full article glacier only the patients vices
but if it does not improve in fifteen days probably have to go
to four and a little asian visit only speculations i don't know
but clearly does it not the situation was to perform c. p. so
often because of the has that so valuation high level conversations
so in my view there is a need in the monitoring of
different techniques city alumni for initial assessment and then probably
uh well the sound based techniques because we needed more strict uh
monitoring as short time interval and this is uh i conclude with these
events that i think is a taken from the man has it
been a seventy four because it illustrates very well the benefits and
the disadvantages of the big fat and techniques that they already
um mention to you and if you'd like to download these i think this is a really good overview
on the situation and the advantages and disadvantages of the different techniques that realise that
and all the fee is very really utilise only for diagnostic propose you could utilise when you need to
proceed with some to the political measures thank you very much for your
attention thank you very much for your presentation any questions or comments
you mentioned justification which which which function is to you when
images but what easy one for patients isa him
he sleeps functions not compete actually human
dynamic consultants he's almost to see
is a complete absorption what keys for you in terms
of even she completed function it must be completely
i would actually reasons smooth can oh of let's say ten percent
according to the was was real easy yeah in in our retrospective study we
did find that uh ninety percent of the rest of the need that
involved but strong was was held as a complete obstruction because in the end
i it's similar to what to say but there is no all
homage enters the finnish and this is uh what is clear is that once we have some degree of them was is
you want it to be skull portable pension regardless of whether
this is a limited or more expensive so that is
puerto letter bridge and then we have to keep in mind all the possible consequences supported attention
whether there is a certain degree percentage which creates a more c. news
uh the compensation difficulty then because like in the canopy yeah pretty you might have seventy
percent but if your cannot that that is lab that then what remains is enough
so clearly is difficult to state which part of the little man
is to be included to have them all see the other
ah complication so i don't have the answer if you have one place
ninety percent was seems to be the more just commenting on the committee now makes i
think yeah two situations when is this to look dictation um below that also take
a human and then we can be a significant huh just to know seasonal show closed an acceleration of blood flow
that possibly you can detected by the open and this will lead you
to the images of significant human a manic obstruction each these
knocks original but both to the the the idea of the ponytail
troubles probably is not significant from any point of view
and when you can she was use and establish prototype attention
to convert from goes in one place to another sometimes mitch makes very little difference because
you have already collectibles the composing the system and probably because of that
the significance of portability embassies insurers is easily match the beat it and then the data
uh showing that probably it can matters and the to showing that he
doesn't matter so it's it it depends on on on that
but even though i think that you should coming
on whether easy these acceleration through distances
because these ease by the finishing what defines
a significant distances causing portable station
and probably but in the say in the vendor system is more difficult to assess the acceleration
because the in the health care system you have more or less the same pressure
in the portal system uh you might not have a significant celebration because
you have not enough pressure and uh it is uh the asian
with the you know i wanted to me i think the question because it
it has nothing to do with this i think really at the moment
one of the major problems we open is really to differentiate between huh
plan to movie and an invasion from a two more impatient than in the waiting
list for the the transplantation and it is it's really a relevant topic
so the question is you showed us and we use it in the compacted that's use
is extremely sensitive we're assessing whether that's that's two more or or to who's
however there are cases in which is maybe i speak he
pizzas mulder movies close to an an opening my which
is the fruit of your difficult patients not you really always straight from youth maybe so the question is
when do you perform by you see so do you have click here mismatch between
emerging can or you just really trust on to some and that's all
because in that case we should never prefer mine to the little trouble is that uh usually if
uh with the sound can assess these it isn't very well really gives you a proper answer
the trouble is you mention is that when it is very deep but these
are also difficult location for biopsy so this guy was a situation
so basically should we try to stress other part like an i. part that um the why
uh i clearly you can perform live c. but usually a difficult location if
it is a limited portion of does not extend in the yeah
ideally this is this might be difficult even so this is really not a very common
but sometimes you can take bribes even over a a limited the portion but
are being c. t. m. n. i. n. c. use it is and yes we had to resort to biopsy less often then you pass
fifteen years ago the acquisition time over and then i was very long
so it was very difficult to to have a good images of
only need to portland maine uh combine not now it's better but uh in some
situation if you have no all and so what we do is the x.
you wanted was we give and take out loans and we see what happens
if you get the souls it was not too well if it progresses
we we remove the patient from the least maybe it's not it's not cool whatever but uh we remove the vision from this
oh yes which we just we close the questions
it was rather naive question about the points again in my wish by one point six week lesions inside
the problem of the very low of the little not there no negative predictive value so if we
have indicated by so we don't know if it's actually sampling error or if it's not consumer
and i will ask if you're going to see from those things you
do get problems material into bikes are you confident that it
would you still be quick system with that you relative ms do you
go to force the mikes your remarks mister he can coexist
as i mentioned in some of the studies there was the table
janice appearance and so they tried to but from the biopsy
not in our study but in the study by seventy no they perform the by c. in there
areas and more enhancing and be a
doubtful but enhancing its use
usually if you take material and most importantly if you're confident that the needle wasn't gonna
take place so they open it or the pain you know usually when you
i'm not sure you you already when you take the biopsy if uh you have completely targeted delusion or you
are on the border so or even for their from by you know whether you crossed the chromosome all
it is sometimes they don't you don't get any material because it especially with aspiration needles
if the drum was not completely might has played the blah then you
lose b. and markham so it's uh these could be you know
right but then if you we we do not perform any by c. but that is a also that
performer are conceived and things considered cruel obvious and greater
competition was uh what is important is that
you all need all only when you are incident from was because usually you
can cross even the best as if we need to the scrolls
uh it does not them as when you really reflect the needle it close if you cross with the open needle
the the vessels and the bad that's then you can create the fees colour so
it is important that you open the needle only within the from those
usually we use the mindy
but you can use even we because it basically my impression the goal was movements
i believe that when is the two cat uh i've me for perusal
insisting eek huh vince composes u. k. and the user decide to just the time it's
you mentioned steffi to as a complement of like news is do we use the diamonds
spanking operators and this is part of the proposal eternally the for the prospective study
no usually not because the diamonds other very often elevated in
even in beijing without remorse is whether these are
related to the the school that opens it for that it was a nobody knows i don't know maybe so
maybe you know if you have more experience than myself but so far uh uh we don't know it
any other questions or
oh thank you very much it's really a great player for me to be here
as a we have a and longstanding an extensive fruitful cooperation with uh
the big bosses here in the first roll and i'm
really really pleased to be a hearing them
in uh i methodology student uh maybe seen so in a word
we see any type operation but we have a special
interest in uh only with disease and due to sound clinical
to sound and these is spending since about four years
and was started by my director prefers visible only an elisa but we got to draw in uh
our environment in our hospitals with multi number you need but uh the
something which is not specific our unit but is a a standard
or italy where most clinicians to perform with the sound and interventions
on the wrong and we have also a baby streak corporation
with the the radiologist that are in our same building so
we discuss the cases together we have meetings together
and uh since a year from now we'll start the about the ball
the boss will be with disease study group which is uh
cheered also by a professor the good to have the on an international basis but we discussed together
in a multi disciplinary by remember these difficult cases with the good but would be the surgeon
that indicated the radiologist peons all this for for protocol approaches
on the human toll does because often they have
on the levee underlying the with disease my talk today
will focus uh on imaging modalities with the uh
lot just part of the board to tool to sound because the this is something that you can perform
on your own personally and so i. e. uh to be time to sets many even this so that you can
uh collect them in our minds to maybe recall them when you see a uh cases but trying to
also apply this structure that we have when we approach
these patients so we'll touch base with the uh
shall i always better better show uh utilise the pointer or the mouse the
same for you okay if it works shouldn't where's the point about
so i would touch with a a very short big round about the frequency of composes
uh means heroes is because we have that onto roses and presupposes factors
and not to be over the portal windows big the beast it mainly to understand which techniques to apply
the detection extension of them was this shirt is racial portal been
from was and the assessment of the response to treatment
so the prevalence is a reported very valuable in different studies
and most importantly web all to always to keep in mind there
are two different types of what is called for moses
one is the uh caught and it's called also bland for for for more
just so when use here the word bland from was it means
this is not this is simply a the platelet opposition and the clocks
and the the best is can you stop but also because there there is an invasion from the two more
mainly observer 'cause you normal because this is the common is to to more which tends to invades
the the better brains but it can walk were also in panther punk about because you know my ah
and uh in a metal static a portal brain uh
two more invasion which uh whatever are quite rare
and uh we have to keep them in mind but they are not a very common
so just to have a an idea these was able to century study that was run
in a several units of internet maybe scene and propose bay that were national society
so all patient admitted to uh to these units was cleaned uh for having the uh
the portal vein thrombosis in c. forty patients and the overall prevalence was sixteen
point seven percent out of a nearly eight on the the patients
as you can see here this was the definition so the these clearly includes patient
who already have what the base imposes an uncanny again to the controls
as where a patient with the new a case of from poses as you can see here that portal basin trouble is is
in the study was suspected one solid and aluminium idea was detected
in the main franco the portal vein of these branches
by with the sound mean doppler examination so these are ready the clears which is usually the first
image modality uh to be uh utilise bases the prevalence so how many patients with zero these
coming into our lead have a portal been for moses and this is the incidence so how
many new cases they're up in patients who are not affected by from was before
this is a study run the my start study comparing
three man's that's just six months into about
for the assessment of the occurrence of it but also that 'cause you norma
but since the station received in emerging over the upper abdomen also all
they all chorus of portable for moses was recorded and a
again also in these cases the first technologies was made by with the sound
and conferred by contrast and has a city or i mean i
if you can see here the number where huge and partial obstruction was found in
eighty seven patients all cool really maybe six seven patients complete in seventeen
and it changes over time from partial to complete in a a
fourteen they also showed the the uh progression or not
of the only the disease and the compensation but what is
important is that overall the uh incidence was uh
five percent to one yeah eight percent that three years and ten percent of ideas
so these means is a quite common disease because out of five years
one of ten all our subtlety patient will develop a these
uh condition or a question is when it a lot
porter this imposes that's yours heroes he wasn't that the big compensate
and it you devalue can analysis there is a trend towards a
increase of leaving disease progression and the compensation so worsening of lot exams
or a over the compensation however these were not statistically significant it will
too but it analysis and in the end it is unclear whether
they portal they'd proposes a chorus wars and even
function or whatever that is a some
condition which wasn't even function and as a complication this
patient also develop a a portal the interim hoses
so there is actually no real situation where uh we can predict what
is going to happen at the time portal been to moses
accordance this is a prospective study and i would like to outline
uh that these were only tend to be in see patients
which are a as shown by these that that more often suffering by
a port of interim was you see that uh it two years
the rates of patients not receiving prophylactic uh and
the quiet ones because the study was aiming
it's showing the benefit that was the most slated of uh and the
quiet ones but the control group did not receive any profit axes
and as you can see the rate of development of a product that reported it from both these are
much bigger than intel eight pages because so variances applied usually instead a
patience and we've seen that it clears the rate is eighty percent
well he actually as is twenty seven percent because we're all prospective
studies so all that the weather core that does that
really so the data so if we have a patient with the lady instead
to be we have to be very careful looking for puerto vince importance
so that they come points of these big round is that a portal winter moses a
common find the is about impatience particularly if they have said b. or c.
and this should be kept in mind because that what patient you should undergo a
that is a variance in probably we out before being surveillance for these patients
therefore operators must be familiar with the findings imagine patents on port of interim
was is we have to keep in mind what is going to
the other but most importantly we must be actively impatiently search for the
nickel portable into more just because if if it goes undetected
any peas and treated you may progress doing been good about to the the next examination
and that it might become more longstanding more difficult to be resold it
so it is this is very important because uh as we will see part of
it imposes does not only cool in into the party portal vein branches
so we have to actively the look in the port is plenty
of blame to pay them isn't very contain important rank
as the older sum up later should we have an idea
whether some patients are at higher risk of uh
uh they're looking these finding apart from the the the dysfunction so if
the big background courses in nancy talking leave us we can call the
new normally that i plainly all conditions of local inflammation infection or
a trauma feel weak condition like milo probably for
the this or this hyper cognitive conditions
what is this effect less the situation is zero to patients because
you got the patient tend to have more local uh factors
that's a fair were the um occurrence of portal vein thrombosis
this is a another prospective study which uh excluded all patient with that with these
known causes of uh uh which favour portable from both zone operation with
cancer or uh other side all the the the most started this or there's no
previous pretty philbin stumbles this so after excluding all this patient with a
history of a high every scroll through moses the then started
and follow that for one yeah one hundred patients
out of this uh um the ultrasound was
performed every six man's as expected instead
of impatience the endpoint what the detection of puerto bins for moses and again
the technology was made by with a sound and doppler income for basically
and as you can see here after excluding patient who dropped from
the fall out because i that died or with transplanted
and they reportedly information whether that they had portal with remorse is but this could be the case
anyhow in the many patients sport of interim pauses according
a twelve out of thirteen so eighteen percent
in one yeah but is it relatively high percentage however as you
can see here fifty percent will sell to b. or
c. so it is consistent with the data or eighty can be less so this is the seems real data
and the the factors that were associated with the least
important ways from bodies where low platelet count
so this is important to keep in mind that that usually when you have
low platelet count we think only about three scroll the have mores
why the zeroes is low platelet count usually means higher portable pension and the uh high uh
hey more quite with the imbalance and this was associated with the occurrence of portal with through moses
abnormalities of from buffy factors and this was that
novel that of the study a slow
flow less than the portal vein flow velocity less than fifteen centimetres per second
i'm a bit proud of the study because i'm accustomed to doc okay i mean our centre
to learn when to summon doppler and when she went back she provided the study
so if we see a patient was low puerto from all we have to keep
in mind what he can so the next time to be sort valid for
uh an apple circus normal but is it diaries of portability moses
so this is the situation that we face and that when we use ultrasound we have to keep in mind
that that we had a very we are very good to uh investigate the internet patrick a basis
left puerto branch right proper brands segmented branches
and the dior and posted advances
fourth for and second segment dances the main portal thank is not
always very well visible sometimes that is intel pause i guess
uh from the gastrointestinal tract these one of the reason why we why the patient to four
be fasting for six eight hours because we want the store much to b. and b.
but even with empty storm uh sometimes the portal track is not very well visible so
we we can see doppler signals that is the bay might be difficult to detect
a tiny portions of a as for moses what as we must
re uh acknowledged that in the superior ms intelligent way apart from the distal track
in the infield missing page lane in the middle thought of this plainly bane
this is the t. v. deal with the sound is relatively port
x. spatially if we don't pay attention to explore these areas
so the easy to be kept in mind and if there is
any suspicion because maybe the patients become symptomatic we must
be aware that to the sound may not be enough alone and we have to resort to city or i mean i
so how and where to detect them was is uh it kinda
cool everywhere even is related so i mean that uh
uh in this planet vein thrombosis might oh cool regardless whether these from
was is even in the portal trunk or in been to partake
uh tracks or in the supreme isn't very being the commas place usually is here probably
because there is low vital items i cannot tell but this is the most common uh place so
we already mentioned that all the studies utilised ultrasound because this
is the tool that we utilised to investigate our patients
and fortunately with the sound is relatively actuate to
diagnose what exclude portal been for moses
at least as i mentioned when when exploring been to patty branches the
these that tract of the portal track as well because we can see then we
can seep through intercourse those can so avoiding been the pose a gas
well when we go to custody in some patients there is a lot of
gas and the some part of the portal tank might remain unix portable
what is a there's plenty plane is often what explore
the ball uh in it's the start part so
uh in front of the order that whereas in the middle part is the mansion
is not really a often visible and the sensitivity drops there so we
raise the suspicion of drum was when there is some it quite material within the portal been loon
the radical it should appeal black because bill's liquid so when there is a
a quite material we should think about uh from was i don't state
we diagnose long was because it quite materials might be happy fact from linda posing gas
so don't always want to see a collie is definitively from was
sometimes even very slow for all might be that cory so we have
to raise the suspicion and adopt other techniques to confirm that this is it from us
if the trial was is indeed in place the portal track can appear belated
usually when there is a complete occlusion but mainly when there is it to one
crumbles usually when there is a bland from was it occupies the little man
but does not expanded because usually it expands longitudinal d. after the
strongest and before the drums but it does not enlarge
they they still be on the the media that was present before the
thrombosis uh the cars in the city of the cloud is valuable
in the in the faces it is high point caloric then it tends to be
calm eyes though and then a hypothetical ache and over time each shootings
and we can see more and more high protocol can a
fibre optic however it is impossible to put a bait
in front of the drum was to tell whether these is the athens one day ten days
or one man's soul oh please refrain to date the strong
was based on that with the sound that bought them
colour doppler and spectral doppler flow battery improve sensitivity
inadequacy of baseline basically with the sound
but they do not always improve they might even sometimes overlook
uh the uh trauma was as i will show you because with the call
to be more sensibly we often put the game and so it might
extend over the throng was showing apparently the the scroll but before is the l.
by any does not be alec specially when the combos is body it out
is only the wall of the vessel and it does not all by the entire a
human however it is practically non that thirty to integrate the conventional grey scale
well the sound was call or and uh with a spectral
doctors so usually all these techniques are used in combination
these are some examples you see here there is equality material is the luminous
blake however as you can see apart from the dissolution of the images
even the the the the basis of not completely black where there is no uh flow
so this is why we need additional technique to confirm especially depends also on
the quality of the keep and if you have a point okay uh
but sound although some scan that often the best of them are completely back even when they're completely patent
differently in high end the scandalous usually they are more able to uh
polish to clear the image and to make black the spot that
doppler can comfort that there is no floor however to provide a very good and accurate
doppler examination probably is more difficult than you
to utilise qantas announce ultrasound because uh
in comparison to baseline grey scale to sound doppler
wallpaper sensitive uh you must uh um
said many different buttons curled up again frequency too
so the fifties the the provision frequency
and go obvious a nation all these things are not very relevant for grey scale
so before i use it for you had to help yourself
but if you're not they've experienced uh please consider i've been calling first whatever the
uh technique you will tell lies i the city or deny but uh uh
dublin is extremely useful but needs a bit
more expert uh operators than conventional ultrasound
so you scenes mm these examples that it's yeah but clearly there is a
drum was but the the strong most is partially they can allies
so it means that it is crossed by some for all and when
you add the doppler the flow tended to all the light
the the more images so you need some experience because if you
raise too high the gain here probably you will feel entirely the vessel any if you
rely on your the colour pattern you can state the these doctrine most here
clearly even in this case you see that that i have to fax these
are uh not this is noise it related to the movement so is
not always easy to define exactly the extension of the drum was small but you
know that with doppler you needed installation angle which should not be ninety degrees
so when you go all close to ninety degrees like in this case here
it is not an meg to all others is awful because there is
null for all these these absence of signal but probably the flow
is they out but simply this is it ninety degrees
be uh in summation angle the intonation beam and the the
axes of the vessel so you need more uh experience
he does for instance another example where the ninety degrees
effect might leave it to the possibility to detect
tiny um from by so you know the to work
and this imitation just uh some practical recommendation
to be as sensitive as possible lower the pull this week the petition frequency basically a
stylised think about that makes the doppler ball sensitive increases the doppler call again
never all the information and also try in the area of your interest like to
uh created the narrow waist angle between the vessel and your information be in
try with probably doppler and inject contests that can be utilised even to increase the signals
from doppler saw if you are a key pen is not a a key that
with qantas not with the sound in some situation if it is very
important you can add contest pages just to improve the doppler signal
so as you can see here the gain is high and you say that there is a quite material but it is
quite difficult to assess they a real the
exact extension of these uh uh material
and when you add doppler inexperience eyes you can see here the problem was
but uh at the this is on the it world for moses any bad
be overlooked if ya on how we understand the patient very quickly so
uh we must pay attention to our to our patient to
detect these tiny drum by because this can easily be
uh this all the that we've uh and the calculation before they become a bigger
and uh it if the thomas is partial clearly you
have it to serve the a portable a flow
this is a case of a recent trauma was because the
patient was the only fact the the disease without
a a and c. roses and a patient add count
to the hospital because she suddenly became symptomatic
so as you can see in this case they uh i'm
from was is quite high put caloric and you might
ms technology it for the patent portal bane unless you are the doppler which clearly
shows that there is no fuel in the in the basis and that these
tiny basis out at the high that topic up very compensating
the lack of the portable and this is not
a cat and mouse does formation this is important because
you differentiate the complete obstruction of the portal fuel
uh compared to where we can is a show which does not
resolve the portable pension but might improve the uh interpret profusion
so this is the appearance at the all the sound of uh
the trauma was how does it look at the city
if you start as it always is the case with non
enhance said se t. usually you don't see this roles
so because it is eyes advanced to the addition soft issue
only in the any phase it might be hyper bands if uh there is
the eh uh still him applauding inside so before female as completely
uh i said they are and there was a leases of the bible says
but based happens only in case of symptomatic complete occlusion by the patient can directly
to be off people because of the pain usually or buy whiskey yeah
so in this case you performed basically in the first hours or days after the occurrence of the
i'm from all these other why usually you don't see these hyper dance
and appearance these means that that city without contrast is unable
to loud to moses so you cannot rule out
and these also is relevant because this means that a a
sickly is useless if you think about the ball
this if the patient cannot receive contest because of late
as insufficient see allergy hyper fatter the isn't it
so you know the situation uh we master the sort to other
techniques like doppler a and c. use or i mean i
so this is needed please keep in mind that uh often if that is the uh um
from both these which is especially into popular the inflow might be slow where
and so if you take the acquisitions too heavily
uh the same time but it is usually taken before the port
of roll which is slow down might not ever arrived yet
and so you might all that estimate with room was is simply because the portal bases have not be
he led by the contrast uh can mean through this planting supply consistent so the recommendation is to
i carry out these uh askance about eight ten seconds later then
usually which usually is about forty forty five seconds so
it is important that when you make the request to the the others is to outline
and whether you have a suspicion of puerto vein as from bosses
uh clearly after you inject the contrast the appearance is that
of a the fact of enhancement in the portal bases
so this is in a hanson lever and the uh this is uh from
the amount of sleep that i enjoyed reading it be recently published by
and then these uh and the crossover but they got it was a big daddy
and the you can see that the the appeal best as adam has saying
the putting camera isn't has seen but there is no enhancement in the portal
phase within the portal being the woman so this is a a complete
uh from was is this is a tiny a portal to moses you can see this
is divide portal vein and without conscious you are unable to recognise any thrombosis
whereas after that congress is actually that they'll face you see the all that is filled
with contrast the party cavities filled in contrast again we are not able to recognise
any trauma zia whereas these tiny thrombosis appears in the portal face
so it is important it all was it we we should we master got that
this situation a bit differently from public so that it's normal when we look for about the selectors to norma to
screen patient follicles circus animal that master relevant phase is yeah
pale face to detect hyper announcement when we look
for the port of interim was clearly the port of interface become the most uh relevant
these are uh other uh image this uh not from my centre but uh uh the uh they
were very nice so i prefer to to them this is a a panic attack this
complicated by explain it away in a tremble this you see here these no enhancement
and what you can see here is that there is also into patting strum was is of these segmented dances
and there's a compensatory effect you have a basic idea of
the lever which is confused only by the happy
because the portal vein is uh please be no clue is a cruel that now in this segment
so in the these uh uh time of a a position which is not delay time
these high paid enhancements here because this part of the lever will announce it beep
uh later when there is a full arrival of the contest uh there you can see from the clean is this is uh
and now the latent they'll phase and is not is not yet eh reported phase
this is not the example of our uh how when you will
have a extensive portal been from both the you have also
severance is can express a a severance of them is intake uh and i'm about would buttons
with a man i again you need contrast enhancement at
least with conventional and ice cannons because uh
and i have said that the one in teach away the sequences i'm not very good
with conventional scanners that uh uh do not work with the speed up already
gating and the they're not able to that
was properly tiny portion of thrombosis
what is the uh there are innovation in that place but
these are not present in a four centres yet
and with this new sick once it is claimed that
uh even this takes longer to be quiet because
but is it a speedup body gating but uh it it can uh the tech to be
peyton see all the rest of the longest in a good way this is not a logical
because clearly liquid material is very well depicted by him and i for instance east
what human dorm ah are easily and very precisely detected by
and then i so it means that a vessel which is filled with liquid should be
highly intense in some faces the problem is that uh to uh acquire the basis you need the
uh dating with the speed of body movements because it takes longer so probably in the future
even these big down but with the improvement of the technique will have this information
when want to select lies whether it ramos is made of the tool
more or a is made of a um fabian clots uh
uh we can assault also to the diffusion uh
water uh analysis because the water molecules
uh when i'm back in two more they move less and they created different signals in
this is being established to make it back knowledge is all about the circus norma
but when we have when you have it to what invasion i got this email about that also in the brain
uh in in the portal vein so these are uh the two different
uh uh acquisitions with the calculus they shut to with the
uh i'm an ally analyses of the pack them and this is the
y. and b. is the uh diffusion coefficient the a map
and they clearly show that in this case the a drum
was is made of packed cells on is uh
um malignant so this is invalid p. that can be utilised before
the stock into the contrast injection which is the weather today
no not really in the mm conventional m. n. i. scandals
so without the weeds conventional to sound adding doppler we have a says that
we have uh i represented how city and and then i work
as i mentioned m. at i. s. u. p. two date a quite
a contrast c. p. would require contest even in the future
in it i maybe but clearly needs more cooperation with the
patient while uh uh although somewhat in real time
so similarly to see the end and then i also to sound improves it that is accuracy
by using a qantas finance ultrasound these are some examples
when there is very slow for all it might be difficult to a state whether this is the
completely from was or not
this is a quite a a lawful p. l. f. for hand that
had for those of you with allies doctrinal that is probably
is the mini mall mean email valued the installation angle is the street so there is not
much more that we can do to assess whether there is partial to moses some out
this is how how it looks so and the so even said it best of
the doppler capabilities it is impossible to state whether there is some partial
from both this if we add instead contest to see the ulterior phase
the still the void the portal system allies some seconds later stalls fill the void of contrast this means
that there is a very slow in for all these patients as it means a lot to patient
and you can see that the that arise from here so probably they visited there so for all these area
in this explains also why there is such a slow for all of them tends to feel entirely
you can see here that if you wait some more time it is entirely
field and if you break the bubbles and let them be field again
it is very clear that there is no all i'm drawn by and this
is the main frank and it is basically less sensible that that
uh what we have seen in the previous images is uh
just loaf role in not portal been from all this
and the thing that these images highlight the quality of the real time modality
even for a glass of port of interim was this c. uses very useful because the the peaks
much more precisely the extension of the drum most part but it is
not the fused in case the bland portal been for moses
you can see here by doppler by of optimising doppler
we can measure this thickness of drum was
maybe its extension we can guess it even on be more even just
but this is much much clearer on a c. use emerges
this is the case i showed you the portal tantrum was is this is this
planning when from bosses you see these the the display make about because
but because i've been a ever gone last so there are a collateral
circulation at this planning hiram and we don't see uh the bases
if they come was is is longstanding over months of yeah
but it might be can classified like in this case
and the the technical suffocation uh i that's c. e. or
with the sound are a best that they work better then uh um and then i
in this situation uh although the long long time when you have chronic
portal interim was is that this past analogy can allies than
you can see that when you are doppler it tends to
call over these uh parts of the drum was because
there is some fuel event in between uh the drum was so
if you up to my is the game to be sensitive to stroll you might call over these images
and the again in this situation they uh when using c. use made things much easier
so this is why i was stating that a given base safety although contest analysis
with the sound because basically they save countless days as you don't even require
no need to look at the lab exams because there is no problem with the other insufficiently anything
the only requirement that even page annie's if we're
still really legit so yes several allergies
i would prefer to give steroids but for instance patient while
allergic to identity because the contras they'd enforce it p.
in our centre they receive a micro bubbles for seals without any pain medication so busy we
found it very safe where that for more than a ten thousand the examination so
as you can see here hopefully
it is easily easy is the visible and this is important if you want
to manage out over time the changes induced by a anti calculation
these images have to show that you can detect
even tiny fee in portions of a um
one of them was is that go undetected by conventional grey scale images these clearly of
not the convention like the scale because below men is filled with contrast which generates
he has even conventionally more so don't don't refer to these left hand images
but this is to show that even for instance cross sectional images which
doppler does not walk because this is it ninety degrees estimation
seals works a very well so this is really a
useful just if you want example this is there
patient with a non dilated portal they in this was about to ten millimetres
but if you are doppler you immediately see that this is a vessel for all
and when you put a put a doppler you see that it
tend to have a physique um but then uh likely
representing the annotator phase so we go all in the right lobe in in the last two all
in the light all these other vets of puerto floor but we have to be at the base
and putting the float here we see that uh this is the most likely
a pity for the feast a lot because you have their data flow
and that they then as fuel is that a vested but
with the physique updated appearance and finally we detected the
feasibility of so there is no night low level so full which goals outcome believe that in the portal thank
then moving to the left logo we were unable heaving using low p. i have
and uh a good insulation angles to take whether this was completely crumbles or not
i wanted to show it again now okay so here
clearly the something moving so the idea the spatial
was the fed with the backing all this base on be more of a portal they come moses
but in the this could be a fresh
from was but as i mentioned city uh sorry
seals might be useful this is to show the appeal phase button
ram of these computers probably is not be yes strong enough
but this is the representative emails so you can see that in their late
at the interface that is only partial profusion so if we stop here
clearly he is seeing that i portal part part this is feel but we have to think that this patient as
a feast allow so clearly does not unexpected that here we have a feel for the main tank
but to explain the back then we uh but from seals
and i think these shows very clearly the advantage of the ideal time modality
because we understand that this is only the the the the scroll scroll
you see how slow is the fuel in the left
portal system not just keeping patiently observing the patient
uh we could the mustard whether these the traumas of not and as you can see here this is
the the fuel is extremely slow nearly standing but
it is completely patent because he feels entirely
the looming of the best and so this is the benefit of the uh on sales because you
could avoid the city was before because she uh was a fair to us and uh
clearly seals in this situation can immediately uh
clarify the a complete patton c. of
the situation would indeed can be shown even in the portal phase where
i'm sorry one that to show
oh the the the one part of the of the vessel is less field with contest
so this is an overview or how we can use the different technologies to
assess the presence of portal been from was is all too loud
both of islam bosses
once they to moses is longstanding always mm longstanding is not correct
is uh in places yes at least a few days
you might have what is called the cover most over cover models transformation
which is selected eyes by the code and so small totals basis with about a bit of role in the
side or around that is out portal track affected by that on the base is a way to bypass
the abstract that track starts radially between six and twenty days
after nick to onset of them all these all complete symbols is clearly parts of them was is
wars and portable pension but does not generate the collateral circulation
and one is the patient have uh the cavernous transformation that are
gonna get that as having and the the crone stage
uh since some of these uh portal they must option might be
stand in the l. c. is the time of infancy uh these uh terminology is being applied
for patient that dustin without zero this with the
longstanding s. that patti porter the abstraction
and this is uh the definition and over time
this might use also changes in the better
these are some examples you see this is a cover number two transformation
you see the portal puerto collateral seen big outlet there was
uh please take care not to define these is inflamed got that that because sometimes is
seen the thickening of the down rather watch which is related to portable pension
with the blood vessels inside so to to be eh i should call this
is tied this this is only report that it opens in condition
and the u. v. c. they profusion these are all uh then as vessels
this is the cover normal clothes transformation of the troubles right portal
vein in the courses can this is more fully can allies
in other location these another situation but i've seen technologies of a a
is the pancreatic uh e. p. and and tried to defuse because if you don't have
the doppler you can see that many sees any be patient as not several this
i remember it is one patient it well the fact that was for pancreatic disease
and the the portal they long spending part of infirm pauses as being overlooked
but if you had the doppler you clearly see the these analyses
on a collateral bases so it is very important that you either doppler whenever
you find an equality uh lesions so what happens here is that uh
as collateral us there is a a enlargement of these that tiny basis
it equally local vendors lexus and the particle it all goes a bit inspectors
uh all of the long term the labs meant of these vessels tend to compress the bile ducts
and the is is they unfortunately a complication which is call the puerto below but the
because inclusive behaviour changes it'll distract obstruction of that by that's
due to the compression of the the elated portal collateral it's
at the uh patty hi loom clearly even for you have any
can alleviation with the government was transformation this does not
completely restore the normal portal pleasures so the patient over
time they block all the conditions of portable pension
which means puerto collapse else including batteries but um
but i says i'm split omega lee
and potentially hyper topic changes of the of databases to compensate
they interrupt but floor and the enlargement of the uh spleen
clearly if you have a suspicion of the situation this
might be tricky because you see many an equality
things at the high low sam might be but that's and some might be collateral so
this is situation with is very very important to perform very good doppler examination
because if you have a suspicion this some of these anechoic
lesions and not basis but are violated but that's
you have to ask what a and then i uh i call runs open photography
to the most late like in this case busy they indentation due to the
but that's that cause you to stop shown the parcels trash on
in the the elation of the inter party but that's
this has been classified into two three different
uh seventy degree of severity delayed one
smile delegation great shoe in grade three with the most of the the
location and abstraction due to the compression of the uh but that's
please note that seem tom's you to call it stays is our core only in grade three powerful
or they can be delayed three uh cases of portable uh uh colours up at the
this is a quite important busted that that underlies the portal columns up at the
con sequel to portal with moses saw how we should approach by emerging
so clearly the recommendation is to proceed with him and i columns of the three
the weather number of patients with acute part of it from pauses at the time
of first detections so symptomatic and sam had chronic portal been for moses
and clearly acute port of interim was it at the shot the
time from technologies to uh from um accordance to technologies
so less than one yeah that and you can see the moss it and all puerto colour job but the
whereas when legal longstanding chronic portal vein thrombosis
meantime for black ball this about a a five yes
you can see that half of the patient had a lady grade three
so these clearly shows that columns up but we of course over time and we must not
forget this patient even when they have a baby with a look at the moment because
apart from the portal it'd bessie complications unfortunately this patient might even they're up
other complication which uh which are the by that's in this is the portal uh columns up but it's so
uh this is a proposal of the um how how to follow up this patient is is not
being and also the fully by everybody so i deportees dust uh uh as a proposal
but uh it in case you have a primary complete reprimand visitation after that you don't
said there is no need for a a an eye colours of the fee
whereas in case that you have a better band all covered norma or there is a chronic portal of interim bosses
there is a need to put for an ally not with contrast specifically with contest for the
sorry for the portal with proposes but it was as the by that's uh
uh and to assess whether they had ballet to them out just where standpoint
to compare with future acquisitions and they recommend to perform
in use can in the second yep to confer
the lack of probation really that there is not enough information on how well fed to perform it
amanda commendation would be to that that would astound is enough for these patients
so we have detected part of it for moses we have the tech
the complications we know that by the coding several uh locations
so one recommendation is how to classify a this page and
this is something i discussed also with the with about
that because i think this could be relevant now that we're starting more beauty lies and the choir glance
to to assess how we declare that there is any improvement and not an improvement from
maybe on the you will tell us uh later how to says this but
you might you this is not been enough um standardised so we must report the location
the degree of occlusion the presence of a cam cover most transformations in the
science of puerto little attention portal of protests in colour job but the
and possible signs about whisky name cases of extensive oh prudential
all this information should be present in the report
and therefore should stay also in the classification this at all anatomical finding
so there are the all this can be bought all this information
but probably they are not enough because it is important also to mull the symptom
of the patient this is why their ideology on his alone is not enough
the initial sorry not the ninja but one of the most adopted classification was this one
it was proposed to classify patients candidate for the there's been page on this is that yeah bill classification
you can see it is a non complete um
portal they important black hole displayed one complete um or
more than fifty percent of the portal been planned
then process now supreme is intelligent main issue the involvement of
this opinion isn't bathing is very relevant really because basing
use in terms of buy whisky you know so it's very important to applebee's is probably the the main
paid for all the all the sound which is not very good
to assess disappeared um isn't very rainy especially the bees objects
you realise that this is quite good but in uh besides it is not very good how well this
is only anatomically this is mainly the van was
sees this article choices so from is not
uh optimal i like maybe more much more this classification which is a
adopted from that but the anal propose above in a six a
and the slightly about that there was a report to the by the uh um your by the band group
as i mentioned so this is anatomical the location an extension of the
a tomboy this only the portal been flank or only the branches one
or two branches into party dances or whether it involves both conditions
backward you have here a point for spanish brain as intelligent being or both so put into guys that
point one point four you have a very thorough
uh at analysis of the extension through moses
whether the thrombosis is completely all cruise your martin this is the
recommended the crowning all clues eve what normal cruise if
the duration whether this can be always assess so that not
is uh not easy but what what can be easily
essays is whether these governments as formation in in this case
clearly we must be clear is is chronic and
it has also functional presentation whether it is symptomatic or of symptomatic
so this is important especially in a time now without the calculation is counting
if you want to compare the fantasy it is from different centres
we have to have a standardisation of a patient to assess whether they
patiently tennis centre ah are compatible with one that are compatible to patient incentive be
with a different and so i think that that is absolutely a need
for these uh classification to be standardised and adopted a worldwide
one of the that probably the last point because these would be only three slides but this is a very relevant one
what does it mean to tell lies as i mentioned we have too much invasion and the uh brown trouble is is
when they believe they can so the data go goals in the main cities quite easy but sometimes
it is only the danes any this situation it might
be the key to distinguish blanton was this from
two more a presence i would say the other that infiltration
and it is highly relevant because clearly no plastic pot of interim bosses mean sport problem all this
in very limited on call logical treatment possibilities only systemic that's already been decision
while any few cases says it but these the availability needed when on the plastic bottle bit of houses he's
not so relevant on the outcome and some bible and can be completely the call that so it is
very important to this thing with this whole situation because they require completely different ads
and that the presence of two well they invasion is present
in all to most asian system diseases japanese one this
is one does what not it is not the it is still kept but it was propose many years ago
and you see that this is one of the three main factors and also
in the uh western counties the present of puerto they've invasion a long
means advances days where that if ever blunder was this
you can belong to any of these condition
so all it is a completely different situation and it is very important to direct advice probably
properly the patient this is particularly that banned in the stepping all
leave it has been patient because uh now at least in volunteer with aspen patients
more than half of the patient at least in front of the silicon sonoma
they have zero this and we've seen that in basically don't zero this the incidence of portal
been from was is is between eighteen twenty percent so the patient weight one yeah but
even those with a purpose other cancer norma one out of five with el portal with both so it is
eyes is too worried invasion based band from those is can the patient remain on
the list or market in in in the so this is a very
talk question any in the past we prospectively assesses the situation in uh uh the study
and that we defined arbitrarily this pattern as
associated with two what of invasion
so the throng most as a mass for me aspect this is quite
subjective is related to experience of the paper but it is
might be relevant this adoption of the portal was this is a very valid well it
can be seen only by with the sound because the c. p. and that i
i'm not very good too because they have not enough uh
additional specialist solution to see the uh puerto vessels
when they don't want to almost stick the locate the close to that of the circus norman
these are all signs these particularly basis what specific for the big
noses to one of the invasion this is only suggested
while doppler low impedance elevator cygnus yes and the throng was
enhancements of the troubles both indicate disease activity issue
because blanton was this does not have appeal lessons inside it might
have been a signals because that is they can isolation
but not appear signals when all these lack
then we messages this is in on a plastic drum was and also
when there is longstanding cannot cover models transformation every can isolation
clearly these out signs of a bland from was so just to show images
so this is the mass forming you see that the vessel here is lab
that then yeah you see that the vessel wall he's is interrupted
he's as well so mass forming and is an option of the vessel was and this can be seen only by with the sound
this is the tool or this is the portal vein branch these they are thirty when it this is next
this is also highly suggestive this is it previously treated the too well
you see expanding drum was because the messages lab that here they need
you know you need cross the part that i think you should be can now where a narrow uh as
long as big all the study so this is the mail so that mass forming
this option of the vessel was because here it is very
clear the vessel wall when he added this goes last
and after injection or contest it is enhancing already and get paid a phase
while it washout the late face so you can see more of a very well
that this is the previously the the tool more which is exactly crawls
to these portable and so this was a patient on the waiting list and
when we see these appearance clearly he was immediately removed from the list
updated cygnus inside the trauma was see this is again this adoption of the so was
bit mass forming aspect but this is not so clear mass forming
but importantly if you go to pick up with puts a
doctor the signals you see updated floor was low impedance
these are different from normal uh i've seen other licensees high impedance
and what duty lies in the past to make it back noses away to see by doppler
while here probably because the out for all those immediately the bane of low impedance
so please don't make the mistake that easy low impedance mean means
benign leisure no this is it to whatever drum was
you see you see the of the helpful inside the
the traumas itself this is from was portable
does this for and so was the patient with hepatitis b. and there can be no surveillance
and he's on several counts that was only inside the a
portal they system so there was no all focal lesion
and they clearly when you see the spot that does is it too much to want promos
well the sound in the in the patent and this is very sensitive because the
the text even tiny lesions this is if you millimetre lesion drum was
go with contrast eighteen seconds twenty two seconds you see that it is diffuse mass before the
profusion of the portal brain so this is not a refusal of the portal woman
but is at they'll profusion of it issue and now even the portal vein
is feel was qantas thirty four seconds we don't see any more thrombosis
because the thrombosis diffuse by the out pretty and the luminous feet was contrast of
the patent portal brain also this patient wasn't with at least an was removed
this was another patient uh it's seventy eight yes
all but still very fit should winced was
maybe often something she cooks so we are happy to people have very well and that
and when she came to their usual control we detected these tiny uh
thomas here
so this is not clearly mass forming it seems that is it is
it optional the vessels so this can be seen only by ultrasound
it is not only a partial to moses not complete room was is so it's uh
not soul mass for mean also expensive and they have a fit
approaching was normal soul by this once a long it
is not enough to the clear the this is it to what the issue also very suspicious this is the button
because as i mentioned this but then i highly suggestive uh
whereas outfit the protein is not so relevant so we
have to put more than one of the spartan together so what was lacking is the and hasn't bought them
and when you see here didn't get pale face it feels before the
contrast allies in the portal buses so this is a fatally enhancing
and it was is out you see that there is now less enhancements
then the the budding time uh and clearly less than in
the portal branches but most importantly it is a portion
all the uh from was which is diffuse so that out micro
bubbles inside inside the drum was you see here very well
so the spatial was fortunately this is the sickly appearance you see india pale face
um later they'll face these enhancing any washes out in the portal face
so the station was the take the very end is so she could go all undergo all successfully about improvisation
so this is signal up back there potentially mass forming no there's an option unless it was not signals
but clearly there is no i'll signal it all inside so if you see this patient if
this page in is on the waiting list especially would be kept on the waiting list
because this is that non uh plastic drum was all you see how relevant it is the addition of contrast agents
if there is any doubt don't forget that we can take by steel
drum some sorry for the uh the solution but we had to
uh so we because of the clip you see the needle here coming down
at that time we were still working freehand with a biopsy
and that that is not clearly there are some risk of uh creating a belated fees to learn
but if you for the spatial was very important to be kept on the list to the most it really was not it tomorrow crumbles
so you can perform the biopsy even in tiny
promises is fine need those not so difficult
this is a basic ways to agency dissipation still alive on the waiting list
any developed is is part of the study from most of this part
i'll say the was outgoing but you see there was devoid of any signal
and uh uh clearly that there might be some active like this is not come basically about the
uh in area time in this image of it is not working
uh there was no mike about what's equating was kept on
the least and finally at the x. plant analysis is the strongest was bland from was is it not too well they
uh sometimes we need to take by so that almost even
to do a rotation the trials or if if they
almost is eve the vessel is drum was then there is also all the weather is completely because there are there
is an awful so you can put the needle inside the throng balls and a tape there and the biopsy
see when distracting the scan through all the the throngs
okay this is uh just some more and last example
says yeah again when the strong by i. p. it is difficult to state whether they are no
plastic or not because they look mass forming they have a a collie a difficult to say
and the in the situation see use is really extremely extremely useful because it
it working real time you see the mike about will seek liquidating
even with c. t. is not so easy sometimes to spell whether thrombosis diffuse them off
well here you clearly the most laid the that is null see quality meant about was
this was what signals that would present before the conference injections so this is
clearly not they'll announce interim was not portal vein phase and
as interim was and this is the plan for moses

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Conference program

Imaging modalities to assess splanchnic vein thrombosis
Prof. Fabio Piscaglia, University of Bologna, Italy
21 June 2018 · 6 p.m.
Anticoagulation treatment for portal vein thrombosis in patients with cirrhosis: DOACs – are we still far from using them?
Prof. Dr. med. Andrea De Gottardi, Hepatology, Inselspital, University Hospital Bern
21 June 2018 · 7:30 p.m.

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