Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy in the elective treatment of recurrent variceal bleeding.

The present study was designed to compare elective transjugular intrahepatic portosystemic shunts (TIPS) and endoscopic sclerotherapy (EST) in terms of their efficacy in preventing recurrent bleeding from gastro-oesophageal varices in patients with advanced liver cirrhosis and portal hypertension. Of 96 patients with at least three gastro-oesophageal variceal rebleeds, 50 were treated with elective TIPS and 46 with EST. Recurrent variceal bleeding was significantly more frequent in patients receiving EST treatment compared with those receiving TIPS (45.7% versus 6.3%, respectively). Cumulative 1- and 4-year survival in the TIPS group was 83.0% and 73.5%, respectively, compared with 69.8% and 39.8% in the EST group, respectively. The rate of portosystemic encephalopathy was 33.3% in the TIPS group and 37.0% in the EST group. Elective TIPS was more effective than EST in the prevention of gastro-oesophageal variceal rebleeding in cirrhotic patients, it improved survival and it was associated with a similar rate of portosystemic encephalopathy.

Infrapopliteal run-off and the outcome of femoropopliteal percutaneous transluminal angioplasty.

BACKGROUND: The outcome of percutaneous transluminal angioplasty (PTA) of peripheral arterial lesions is influenced by several factors, including the haemodynamic conditions. Our study tested: (a) whether infrapopliteal run-off after completed PTA influenced the time course of restenosis/reocclusion of the femoropopliteal arterial segment, and (b) whether worsening of infrapopliteal run-off influenced the long-term femoropopliteal patency after PTA. PATIENTS AND METHODS: Among 245 patients treated by femoropopliteal PTA we enrolled 176 patients who consented to regular follow-up. Concomitant infrapopliteal PTA was performed whenever feasible. The technical success of PTA and the patency of calf arteries were assessed by angiography. Infrapopliteal run-off was scored by a modification of the Society for Vascular Surgery criteria. The treated patients' limbs were divided into a group with good infrapopliteal run-off and a group with compromised run-off. Follow-up examination of the femoropopliteal arterial segment was performed by vascular ultrasonography (US) 1, 6 and 12 months after PTA, and an adverse outcome was defined by a > or = 50 % stenosis, i.e., at least doubling of the maximal systolic velocity, or occlusion - evidenced by the absence of flow. The patency of calf arteries was re-assessed by US 12 months after PTA. RESULTS: One month after femoropopliteal PTA 19 / 83 (23 %) of patients with compromised run-off developed the combined end-point of restenosis or reocclusion in comparison to 10 / 93 (11 %) with good run-off (p = 0.03). After 6 months the incidence of restenosis/reocclusion had increased in both groups at an approximately equal rate, but the differences were no longer significant: 39 / 80 (49 %) in the compromised run-off group vs. 36 / 83 (43 %) in the good run-off group after 6 months, p = 0.49, and 42 / 73 (57 %) vs. 38 / 73 (52 %) after 12 months, p = 0.51. However, in patients' limbs with good periprocedural run-off that deteriorated into compromised run-off in the year after PTA, femoropopliteal restenosis/reocclusion occurred more often than in limbs which retained good run-off: 10 / 14 (71 %) vs. 18 / 51 (35 %), p = 0.02. CONCLUSIONS: Compromised postprocedural infrapopliteal run-off predisposes to early restenosis/reocclusion after femoropopliteal PTA. Deterioration of infrapopliteal run-off in the year after femoropopliteal PTA is accompanied by worsening of long-term femoropopliteal patency.

The role of interventional radiology in management of patients with end-stage renal disease.

The aim of the paper is to review the role of interventional radiology in the management of hemodialysis vascular access and complications in renal transplantation. The evaluation of patients with hemodialysis vascular access is complex. It includes the radiology/ultrasound (US) evaluation of the peripheral veins of the upper extremities with venous mapping and the evaluation of the central vein prior to the access placement and radiological detection and treatment of the stenosis and thrombosis in misfunctional dialysis fistulas. Preoperative screening enables the identification of a suitable vessel to create a hemodynamically-sound dialysis fistula. Clinical and radiological detection of the hemodynamically significant stenosis or occlusion demands fistulography and endovascular treatment. Endovascular prophylactic dilatation of stenosis greater than 50% with associated clinical abnormalities such as flow-rate reduction is warranted to prolong access patency. The technical success rates are over 90% for dilatation. One-year primary patency rate in forearm fistula is 51%, versus graft 40%. Stents are placed only in selected cases; routinely in central vein after dilatation, in ruptured vein and elastic recoil. Thrombosed fistula and grafts can be declotted by purely mechanical methods or in combination with a lytic drug. The success rate of the technique is 89-90%. Primary patency rate is 8-26% per year and secondary 75% per year. The most frequently radiologically evaluated and treated complications in renal transplantation are perirenal and renal fluid collection and abnormalities of the vasculature and collecting system. US is often the method of choice for the diagnostic evaluation and management of the percutaneous therapeutic procedures in early and late transplantation complications. Computed tomography and magnetic resonance are valuable alternatives when US is inconclusive. Renal and perirenal fluid collection are usually treated successfully with percutaneous drainage. Doppler US, magnetic resonance angiography and digital subtraction angiography have a principle role in the evaluation of vascular complications of renal transplantation and management of the endovascular therapy. Stenosis, the most common vascular complication, occurs in 1-12% of transplanted renal arteries and represents a potentially curable cause of hypertension following transplantation and/or renal dysfunction. Treatment with percutaneous transluminal renal angioplasty (PTRA) or PTRA with stent has been technically successful in 82-92% of the cases, and graft salvage rate has ranged from 80 to 100%. Restenosis occurs in up to 20% of cases, but are usually amenable to repeated PTRA. Complications such as arterial and vein thrombosis are uncommon. Intrarenal A/V fistulas and pseudoaneurysms are occasionally seen after biopsy, the treatment requires superselective embolisation. Urologic complications are relatively uncommon, predominantly they consist of the urinary leaks and urethral obstruction. Interventional treatment consists of percutaneous nephrostomy, balloon dilation, insertion of the double J stents, metallic stent placement and external drainage of the extrarenal collections.

Pre-PTCA detection of chronic but reversible postischemic myocardial dysfunction by nicardipine.

The aim of the study was to find out whether in patients (n = 24) with one-vessel coronary artery disease, reversibility of related left ventricular (LV) wall motion abnormalities after successful percutaneous transluminal coronary angioplasty (PTCA) can be predicted by the immediate effect of calcium antagonist nicardipine. Dynamic quantitative left cineventriculography performed four times successively (as the control, 30 minutes after oral nicardipine, 10 minutes after PTCA, and 6 months after PTCA) and hemiaxis method (mean relative hemiaxis shortening or Xdeltar%) were used for wall motion analysis of 48 poststenotic LV myocardial segments divided into three groups: hypokinetic noninfarcted (PNHS, n = 25), infarcted (PIS, n = 12), and normokinetic noninfarcted (PNNS, n = 11) and of 24 normal LV myocardial segments (NS). In PNHS and PIS close correlation (r = 0.75, P < 0.0001 and r = 0.71, P < 0.005) was demonstrated between postnicardipine improvement (21 +/- 4% to 37 +/- 9%, P < 0.0001, and 16 +/- 7% to 20 +/- 8%, P < 0.0005) and 6 months after PTCA improvement (21 +/- 4% to 33 +/- 7%, P < 0.0001, and 16 +/- 7% to 19 +/- 9%, P < 0.0005) of wall motion. It was loose in PNNS and absent in all three groups immediately after PTCA. The sensitivity of the nicardipine test for 6 months after PTCA reversible LV segmental hypokinesia was high in PNHS (95%) and lower in PIS and PNNS (67% and 60%, respectively). The specificity was 100% in PIS, lower in PNNS (67%), and absent in PNHS (owing to lack of true nonresponders). Immediately after PTCA, contraction significantly improved only in PNHS; the nicardipine test was 100% sensitive but nonspecific. Significant improvement of contraction of all groups of poststenotic LV wall segments is expected 6 months after successful PTCA of related artery stenosis, being well predictable by the pre-PTCA effect of nicardipine, at least in PNHS and in PIS. Immediately after PTCA, only in PNHS can significant improvement of contraction be expected.

Asymmetric hypertrophic cardiomyopathy diagnosed by echocardiography and magnetic resonance imaging. Case reports.

The authors present 3 patients with asymmetric hypertrophic cardiomyopathy, which was diagnosed by echocardiography. Magnetic resonance imaging, however, proved superior in visualizing the cardiac anatomy of the left ventricle and enabled myocardial evaluation with determination of the location, severity, and extent of the abnormality. Magnetic resonance imaging can also differentiate unusual asymmetric hypertrophy from other pathologic states.

Risk of deterministic effects during endovascular aortic stent graft implantation.

Since the 1990s, stent graft implantation for aortic pathology has become an alternative to extensive surgical procedures in some patients. Indeed, many patients with such pathology are now treated endovascularly. Only limited data concerning the risk of a deterministic effect during aortic stent graft implantation are available Accordingly, 179 consecutive patients treated in our institute between October 2002 and July 2008 with endovascular aortic stent grafts were included in this study. Dosimetric data (kerma area product (KAP) and cumulative dose at the interventional reference point (CD(irp))) from radiograph reports were analysed for 172 patients. On a group of 19 patients, GAFCHROMIC XR type dosimetric films were also used to verify the automatic measurements. Readings from the integrated KAP meter were found to be too high and were therefore corrected - KAP to dose area product (DAP) and CD(irp) to entrance skin dose (ESD). Median DAP was 153 Gy cm² (35-700 Gy cm²) and median ESD was 0.44 Gy (0.12-2.73 Gy). Recorded dosimetric quantities were found to be good predictors of the skin dose and highlighted 4 patients (2.3%) who received skin doses that might cause possible deterministic effects. Endovascular stent graft implantation is less invasive than a surgical procedure and is widely used; mid-term results are encouraging. In a small number of patients, deterministic effects can occur even in departments with well-trained staff. Operators should inform the patients of possible skin injury after receiving high doses of ionising radiation and proper support must be available should that occur.

Late complications and shape changes of the endografts after gigantic thoracic aortic aneurysm repair over a 7-year follow-up.

This report details a 7 years follow up observations in a 71-year-old patient treated with custom made endograft for gigantic thoracic aortic aneurysm (TAA). Progressive changes of the thoracic aorta and aneurysm after endograft placement led to two late complications including proximal stent graft prolapse into the aneurysm and extreme kinking of the endograft and aorta 28 and 51 months after treatment, respectively. Both complications were successfully treated with new endografts placement. Percutaneous endovascular repair is a promising, minimally invasive alternative to exclude TAA. This technique allows long-term treatment of patients who are unsuitable for conventional surgical procedures.

Percutaneous drainage of pancreatic pseudocyst into the stomach.

BACKGROUND: We present our experience with percutaneous ultrasonographically guided internal cystogastric drainage of pancreatic pseudocysts using a double pigtail catheter. METHODS: In nine patients, the pancreatic pseudocysts following acute pancreatitis were drained percutaneously into the stomach with the double pigtail catheter under ultrasonographical (US) control. The needle insertion through both gastric walls and the final position of the proximal curve of the catheter were monitored with a gastroscope. The position of the distal curve of the catheter was checked by US. There were no procedure-related complications. The patients were followed up monthly by clinical and US examination. RESULTS: At first follow-up 1 month after the intervention, none of the patients had evidence of the pseudocyst. The patients were not aware of the catheter and functioned normally throughout the procedure and catheter removal. The catheter was removed endoscopically after 5-8 months. CONCLUSIONS: The method is minimally invasive and also feasible in high-risk surgical patients. It requires a team consisting of an interventional radiologist, an ultrasonographer, and an endoscopist. In properly selected patients, the results are excellent.

Transfemoral intraluminal stent graft implanted for thoracic aortic aneurysm.

We describe two patients with inoperable descending thoracic aortic aneurysm. The first patient had complained of severe back pain for at least thirteen years. Radiological examination revealed a large posterior mediastinal mass that was misdiagnosed in 1981. Follow-up studies in 1992 revealed this mass to be a large descending thoracic aortic aneurysm, eroding the vertebral bodies of T3 through T6 and entering the spinal canal. Because of the high risk, thoracic aortic surgery was not performed. The second patient had an acute descending thoracic aortic aneurysm. There was contraindication to a second surgical approach due to previous thoracotomy. Both patients underwent an intraluminal bypass of the descending thoracic aorta with a stent graft. Postplacement aortogram and follow-up studies showed that aneurysm was effectively excluded. We believe that this type of therapy should be offered to selected individuals who are considered by cardiovascular surgeons to be a high risk for thoracic aneurysm surgery.

Treatment options in Western hepatocellular carcinoma: a prospective study of 224 patients.

BACKGROUND/AIMS: Though hepatocellular carcinoma (HCC) is one of the most frequent malignant tumors in the world, the optimal therapeutic strategy is still poorly defined. This is mainly due to geographic differences in HCC which may affect the validity of treatment regimens in differents areas of the world. The aim of the present study was to analyze the natural course of the disease as well as to assess the efficacy of different therapeutical schemes in HCC observed in Ljubljana (Slovenia) and Trieste (Italy), two cities in Western Europe situated close to each other. METHODS: During the period from January 1988 to December 1993, 224 consecutive patients (132 in Trieste and 92 in Ljubljana) with HCC were enrolled in the study. Patients were treated with the following 3 schemes: surgery 39 (17.4%), transcatheter chemoembolization (TACE) 116 (51.8%), and no treatment 69 (30.8%). The tumor was classified by Okuda staging and the liver disease by Child-Pugh score. Patients were followed up for 12-60 months, with an average of 40 months. The response rate to TACE and recurrence following surgery were evaluated. Comparative analysis of survival between different treatment groups was performed. RESULTS: The natural course of the disease, and other characteristics of the HCC, showed a typical Western type of tumor. Liver disease was scored as Child A in 58%, Child B in 30% and Child C in 12%, and the tumor was staged as Okuda I in 52%, Okuda II in 37% and Okuda III in 11%, respectively. Treatment with TACE was followed by an objective response in 27%, with a median survival of 31 months. Surgery was followed by a recurrence rate of 77% within 19.5 months and median survival of 49 months. The overall median survival of nontreated patients was 8 months. Survival in each group of patients differed significantly between all three consecutive stages of Okuda (p<0.001). In contrast, the differences in survival were significant only between Child A and B (p<0.02). The differences between Child B and C were not significant. CONCLUSIONS: This study emphasizes the importance of staging in the choice of treatment modality and diffusion of HCC in affecting an overall response to treatment and survival. Surgery is highly effective in monofocal HCC of Okuda I and II without cirrhosis. TACE is effective in Okuda I and II and Child A cirrhosis only. The treatment of HCC in Child B cirrhosis needs further studies. In Child C and/or Okuda stage III of HCC, any treatment except pure symptomatic relief is detrimental and should not be used.