Arterial constrictor response in a diving mammal.

Angiograms were obtained in the harbor seal, Phoca vitulina, in air and during diving. During diving there is arterial constriction of the vascular beds of muscle, skin, kidney, liver, spleen, and presumably of all vascular beds except those perfusing the brain and heart. There is sudden constriction and narrowing of muscular arteries close to their origin from the aorta. Constriction of small arterial branches is so intense that blood flow is essentially lost in all involved organs.

Postprandial rest pain and claudication of the lower extremity: A case report.

Postprandial rest pain and claudication in the lower extremities may occur in arteriosclerotic aortic occlusion when mesenteric and systemic collateral pathways provide inadequate blood flow to the extremity. The symptoms occur as a result of vasodilation of the distal mesenteric vascular bed with a concomitant increase in mesenteric blood flow which leads to a decrease in mesenteric artery to extremity collateral blood flow. This normal physiologic phenomenon, increase in mesenteric blood flow, causes the extremity pain. Such symptoms indicate a quite significant decrease in blood flow to the extremity, and prompt surgical correction is indicated. Aortofemoral reconstruction yields total reflief of the symptom complex.

Aneurysms in renal oncocytoma.

Renal oncocytoma is a nonaggressive lesion of the kidney that only recently has been defined as a separate entity pathologically. Clinically they are usually silent and are incidental findings on excretory urography. Sonography and computerized tomography demonstrate that it is a solid lesion, but it is only with angiography that a preoperative diagnosis can be suggested. The angiographic signs are summarized, and it is proposed that aneurysms in or associated with a mass now be included in the angiographic spectrum of oncocytoma.

Cystic mesoblastic nephroma.

Mesoblastic nephroma is the most common solid renal neoplasm in the first few months of life. It has been recognized only recently as a distinct entity, having been classified previously as Wilms tumor. There are relatively few ultrasonic descriptions of this entity in the literature. We present an additional case featuring a large peripheral cystic component with a solid central core demonstrated on ultrasonograhy. This feature is not specific for mesoblastic nephroma and occurs in cystic Wilms tumor.

Repositioning catheters in surgically drained abscesses.

Primary percutaneous drainage of intraabdominal abscesses under local anesthesia is an accepted method of treatment, with low morbidity and mortality. This technique was extended to patients with recurrent or secondary abscesses after initial primary surgical drainage. Four patients had abscesses drained operatively but were reevaluated several weeks later for recurrent fever. Sinography demonstrated an inadequately drained abscess cavity. Under fluoroscopic control and using local anesthesia, new drains were inserted and repositioned to provide better drainage. Resolution of the abscess cavity was documented radiographically, with improvement in the patients' clinical status.

Retroperitoneal malignant fibrous histiocytoma: the angiographic and computed tomographic features of an unusual tumor.

Malignant fibrous histiocytomas are uncommon retroperitoneal soft tissue tumors. We report a case of a malignant fibrous histiocytoma of the retroperitoneum that was anmgiographically hypervascular and indistinguishable from renal cell carcinoma. Computerized tomography of the abdomen demonstrated extensive psoas muscle infiltration by tumor. This feature may be useful in differentiating a renal cell carcinoma from a primary retroperitoneal sarcoma.

Hepatopetal collaterals after portal vein thrombosis following liver transplantation.

Two liver transplant patients with hepatopetal collaterals after portal vein thrombosis are described. Angiographically, the appearance is similar to cavernous transformation of the portal vein. The demonstration of hepatopetal collaterals is diagnostic of portal vein occlusion from whatever cause. After portal vein occlusion, collaterals develop from preexisting periportal vessels which undergo compensatory enlargement and reconstitute the intrahepatic portal vessels. In liver transplant patients, the collateral communications must arise de novo, since all potential collateral pathways are severed at the time of transplantation.

Treatment of iatrogenic biliary obstruction by balloon dilatation of a biliary jejunal fistula.

Biliary obstruction and multiple hepatic abscesses occurred in a patient after ligation of a segmental branch of the right hepatic duct. The patient was successfully managed by transhepatic biliary drainage and balloon dilatation of an internal fistula that developed between the ligated duct and a Roux limb of jejunum. Internal biliary fistulas may be dilated using interventional radiologic techniques to permit nonobstructed bile flow. Implications for the nonsurgical treatment of biliary strictures are discussed.

Transhepatic balloon dilation of biliary strictures in liver transplant patients: a 10-year experience.

PURPOSE: The authors report their initial and long-term results using transhepatic balloon dilation to treat biliary strictures in liver transplant patients. PATIENTS AND METHODS: Over a 10-year period, 72 liver transplant patients with biliary strictures underwent 81 balloon dilation treatments. Anastomotic strictures were present in 56 patients; nonanastomotic strictures were present in 16. RESULTS: Initial technical success was achieved in 64 of 72 patients (89%). Balloon dilation failed in eight patients (11%), and they were treated surgically. Complications occurred in nine (12%) patients, and all were successfully treated. Within the first 6 months, five patients (6.9%) required surgical revision. Three patients (4.2%) underwent repeated liver transplantation; and five patients (6.9%) died. Fifty-one patients in whom balloon dilation was initially successful were available for at least a 6-month follow-up. Life-table analysis showed an overall 81% +/- 4.8 success rate at 6 months; it dropped to 70% +/- 6.2 at 6 years. For anastomotic strictures, it was 77% +/- 5.8 at 6 months and 66% +/- 7.3 at 6 years. For nonanastomotic strictures, it was 94% +/- 6.2 at 6 months, which dropped to 84% +/- 10 at 5 years. CONCLUSION: Transhepatic balloon dilation represents an effective and relatively safe treatment for biliary stricture in liver transplant recipients.

Hepatic adenoma associated with portasystemic shunting in a young woman.

The development of a hepatic adenoma is described in a young female of reproductive age who had documented portasystemic shunting and hyperestrogenemia. The intrinsic hyperestrogenemia and the increased hepatic arterial blood flow, both of which occurred as a result of the portasystemic shunting secondary to portal venous obstruction, may have been important factors in the development of her hepatic tumor. We would postulate that prolonged endogenous hyperestrogenemia, like exogenous sex steroids, may predispose to hepatic adenoma formation.

Vascular complications after liver transplantation: a 5-year experience.

During the past 5 years, 104 angiographic studies were performed in 87 patients (45 children and 42 adults) with 92 transplanted livers for evaluation of possible vascular complications. Seventy percent of the studies were abnormal. Hepatic artery thrombosis was the most common complication (seen in 42% of children studied, compared with only 12% of adults) and was a major complication that frequently resulted in graft failure, usually necessitating retransplantation. In six children, reconstitution of the intrahepatic arteries by collaterals was seen. Three survived without retransplant. Arterial stenosis at the anastomosis or in the donor hepatic artery was observed in 11% of patients. Portal vein thrombosis or stenosis occurred in 13% of patients. Two children and one adult with portal vein thrombosis demonstrated hepatopetal collaterals that reconstituted the intrahepatic portal vessels. Uncommon complications included anastomotic and donor hepatic artery pseudoaneurysms, a hepatic artery-dissecting aneurysm, pancreaticoduodenal mycotic aneurysms, hepatic artery-portal vein fistula, biliary-portal vein fistula, hepatic vein occlusion, and inferior vena cava thrombosis.

Pediatric liver transplantation. Part I. Standardization of preoperative diagnostic imaging.

The preoperative radiologic imaging workups of 44 pediatric liver transplantation patients were reviewed. Biliary atresia (43%) and metabolic disorders (33%) with end-stage liver disease were the leading indications for pediatric liver transplantation at our institution. The radiologic imaging examinations included chest and skeletal radiography, upper gastrointestinal tract series, abdominal ultrasonography (US), computed tomography, angiography, and contrast echocardiography. Abdominal US (performed in 38 of 44 patients) was the pivotal screening imaging examination; it was invaluable in determining the patency and size of the extrahepatic portal vein and inferior vena cava. Angiography is mandatory if this vascular anatomy is not established with certainty on sonograms or if malrotation is seen on the upper gastrointestinal tract series. Congenital malrotation should be differentiated from small bowel malposition caused by portoenterostomy in patients with biliary atresia. Vascular anomalies, especially absent portal vein and/or inferior vena cava, in patients with biliary atresia and polysplenia syndrome may preclude liver transplantation.

Low-dose streptokinase for occluded Hickman catheters.

In 14 patients, 16 episodes of occluded Hickman catheters were evaluated by contrast venography. In 13 instances, a fibrin sheath occluding the distal catheter was observed. A mechanical problem was responsible for occlusion in three catheters. Low-dose streptokinase effectively restored lumen patency in 12 catheters (92%) occluded by a fibrin sheath.

Percutaneous transhepatic balloon dilatation of benign biliary strictures.

Between February 1981 and June 1984, 15 patients with benign biliary strictures were treated with percutaneous transhepatic balloon dilatation. Three of these patients had received liver transplants. The treatment began with a course of balloon dilatation therapy, after which a stent catheter was left across the stricture. Six weeks later, after duct patency had been shown by cholangiography, the stent catheter was removed from all but two patients, both of whom had intrahepatic sclerosing cholangitis. After this procedure, six patients (40%), including two liver-transplant patients, were stricture-free after one treatment for periods ranging from 27 to 56 months, and were considered to be treatment successes. Nine patients (60%) suffered stricture recurrences. In eight of these patients, the stricture was heralded by symptoms of either cholangitis or jaundice; in one patient, who was on permanent catheter drainage, the stricture was discovered only on follow-up cholangiography. All successfully treated patients had only one stricture, while all patients with more than one stricture suffered recurrences. Our data also suggest a greater responsiveness for anastomotic strictures than for non-anastomotic strictures. Of the patients with recurrences, five had symptom-free intervals of 23 months or more (up to 31 months). The fact that strictures recurred after such long periods of time underscores the importance of long-term follow-up. In view of the number of patients helped, the favorable experience with post-liver-transplantation strictures, and the lack of any major complications in our series, percutaneous biliary balloon dilatation offers a viable alternative to surgical management of benign biliary strictures.

Recurrent cholangiocarcinoma in the biliary tree after liver transplantation.

Four liver transplant recipients with recurrent cholangiocarcinoma (CCA) within the allograft biliary tree are described. One patient received a transplant for known CCA and three received transplants for end-stage primary sclerosing cholangitis, in which CCA was found within the hepatectomy specimen. All four developed biliary obstruction due to malignant stricture at the bile duct anastomosis 9-15 months after transplantation. Diagnosis of recurrent CCA was made by means of transhepatic brush biopsy in two patients. Recognition that the biliary tract, especially the anastomosis, is a site of recurrence of CCA should facilitate prompt diagnosis by means of transhepatic brush biopsy in patients with biliary obstruction due to stricture. In addition, because of an association between CCA and primary sclerosing cholangitis, preoperative bile duct biopsy should be considered for liver transplantation candidates with the latter condition. Positive biopsy findings may preclude transplantation.