RESUMEN
BACKGROUND: Surgical therapy is the most optimal treatment for hepatocellular carcinoma (HCC) combined with bile duct tumor thrombus (BDTT) patients. However, whether to perform bile duct resection (BDR) is still controversial. The purpose of this multicenter research is to compare the effect of BDR on the prognosis of extrahepatic BDTT patients. METHODS: We collected the data of 111 HCC patients combined with extrahepatic BDTT who underwent radical hepatectomy from June 1, 2004 to December 31, 2021. Those patients had either received hepatectomy with extrahepatic bile duct resection (BDR group) or hepatectomy without bile duct resection (NBDR group). Inverse probability of treatment weighting (IPTW) was used to reduce the potential bias between two groups and balance the influence of confounding factors in baseline data. Then compare the prognosis between the two groups of patients. Cox regression model was used for univariate and multivariate analysis to further determine the independent risk factors that influence the prognosis of HCC-BDTT patients. RESULTS: There were 38 patients in the BDR group and 73 patients in the NBDR group. Before and after IPTW, there were no statistical significance in OS, RFS and intraoperative median blood loss between the two groups (all P > 0.05). Before IPTW, the median postoperative hospital stay in the NBDR group was shorter (P = 0.046) and the grade of postoperative complications was lower than BDR group (P = 0.014). After IPTW, there was no difference in postoperative hospital stay between the two groups (P > 0.05). The complication grade in the NBDR group was still lower than that in the BDR group (P = 0.046). The univariate analysis showed that TNM stage and portal vein tumor thrombus (PVTT) were significantly correlated with OS (both P < 0.05). Preoperative AFP level, TNM stage and prognostic nutritional index (PNI) were significantly correlated with postoperative RFS (all P < 0.05). Multivariate analysis showed that tumor TNM stage was an independent risk factor for the OS rate (P = 0.014). TNM stage, PNI and AFP were independent predictors of RFS after radical hepatectomy (all P < 0.05). CONCLUSIONS: For HCC-BDTT patients, hepatocellular carcinoma resection combined with choledochotomy to remove the tumor thrombus may benefit more.
Asunto(s)
Conductos Biliares Extrahepáticos , Carcinoma Hepatocelular , Hepatectomía , Neoplasias Hepáticas , Humanos , Carcinoma Hepatocelular/cirugía , Carcinoma Hepatocelular/patología , Carcinoma Hepatocelular/mortalidad , Carcinoma Hepatocelular/complicaciones , Masculino , Femenino , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/complicaciones , Persona de Mediana Edad , Pronóstico , Conductos Biliares Extrahepáticos/cirugía , Conductos Biliares Extrahepáticos/patología , Trombosis/cirugía , Trombosis/etiología , Trombosis/patología , Estudios Retrospectivos , Neoplasias de los Conductos Biliares/cirugía , Neoplasias de los Conductos Biliares/patología , Neoplasias de los Conductos Biliares/complicaciones , Neoplasias de los Conductos Biliares/mortalidad , Anciano , AdultoAsunto(s)
Neoplasias Renales , Trombectomía , Humanos , Neoplasias Renales/cirugía , Neoplasias Renales/patología , Carcinoma de Células Renales/cirugía , Carcinoma de Células Renales/patología , Trombosis/cirugía , Trombosis/etiología , Masculino , Células Neoplásicas Circulantes/patología , Nefrectomía , Tomografía Computarizada por Rayos X , Venas Renales/cirugíaRESUMEN
OBJECTIVE: To summarize the clinical characteristics of patients with renal angiomyolipoma (RAML) combined with inferior vena cava (IVC) tumor thrombus, and to explore the feasibility of partial nephrectomy and thrombectomy in this series of patients. METHODS: The clinical data of patients diagnosed with RAML combined with IVC tumor thrombus in the Department of Urology of the Peking University Third Hospital from April 2014 to March 2023 were retrospectively analyzed, and demographic and perioperative data of RAML patients with IVC tumor thrombus were recorded and collected from Electronic Medical Record System, including age, gender, surgical methods, and follow-up time, etc. The clinical characteristics between classic angiomyolipoma (CAML) patients with IVC tumor thrombus and epithelioid angiomyolipoma (EAML) patients with IVC tumor thrombus were compared to determine the clinical characteristics of these patients. RESULTS: A total of 11 patients were included in this study, including 7 patients with CAML with IVC tumor thrombus and 4 patients with EAML with IVC tumor thrombus. There were 9 females (9/11, 81.8%) and 2 males (2/11, 18.2%), with an average age of (44.0±17.1) years. 9 patients (9/11, 81.8%) experienced clinical symptoms, including local symptoms including abdominal pain, hematuria, abdominal masses, and systemic symptoms including weight loss and fever; 2 patients (2/11, 18.2%) with RAML and IVC tumor thrombus did not show clinical symptoms, which were discovered by physical examination. Among the 11 patients, 10 underwent radical nephrectomy with thrombectomy, of whom, 3 underwent open surgery (3/10, 30.0%), 2 underwent laparoscopic surgery (2/10, 20.0%), and 5 underwent robot-assisted laparoscopic surgery (5/10, 50.0%). In addition, 1 patient underwent open partial nephrectomy and thrombectomy. The patients with EAML combined with IVC tumor thrombus had a higher proportion of systemic clinical symptoms (100% vs. 0%, P=0.003), more intraoperative bleeding [400 (240, 3 050) mL vs. 50 (50, 300) mL, P =0.036], and a higher proportion of tumor necrosis (75% vs. 0%, P=0.024) compared to the patients with CAML combined with IVC tumor thrombus. However, there was no statistically significant difference in operation time [(415.8±201.2) min vs. (226.0±87.3) min, P=0.053] between the two groups. CONCLUSION: Compared with the patients with CAML and IVC tumor thrombus, the patients with EAML and IVC tumor thrombus had a higher rate of systemic symptoms and tumor necrosis. In addition, in the selected patients with CAML with IVC tumor thrombus, partial nephrectomy and tumor thrombectomy could be performed to better preserve renal function.
Asunto(s)
Angiomiolipoma , Neoplasias Renales , Nefrectomía , Trombectomía , Vena Cava Inferior , Humanos , Angiomiolipoma/cirugía , Angiomiolipoma/diagnóstico , Angiomiolipoma/patología , Angiomiolipoma/complicaciones , Neoplasias Renales/cirugía , Neoplasias Renales/patología , Neoplasias Renales/diagnóstico , Femenino , Masculino , Vena Cava Inferior/cirugía , Vena Cava Inferior/patología , Estudios Retrospectivos , Nefrectomía/métodos , Trombectomía/métodos , Adulto , Persona de Mediana Edad , Trombosis de la Vena/cirugía , Trombosis de la Vena/etiología , Laparoscopía/métodos , Trombosis/cirugía , Trombosis/diagnósticoRESUMEN
BACKGROUND: Hepatic artery thrombosis is the most common vascular complication of liver transplantation. When occurring late in the postoperative course, it may have no clinical repercussions, and conservative treatment may be implemented. Some patients, however, will develop severe biliary complications due to ischemic cholangiopathy and require retransplantation. The aim of this study is to report the outcomes of retransplantation in this population. METHODS: This is a single-center retrospective study involving all adult patients who underwent liver retransplantation due to late hepatic artery thrombosis from January/2010 to December/2022. RESULTS: During the study period, 1378 liver transplants were performed in our center; 147 were retransplantations, with 13 cases of late hepatic artery thrombosis (0.94%). All had symptomatic ischemic cholangiopathy. Twelve of them had already presented previous cholangitis, bilomas, or liver abscesses and had undergone biliary stenting or percutaneous drainage. The median time between the first liver transplant and late hepatic artery thrombosis diagnosis and between this diagnosis and retransplantation were 73 and 50 days, respectively. Arterial reconstruction using splenic artery, celiac trunk, or arterial conduit from the aorta was performed in 7 cases, whereas biliary reconstruction was mostly done with choledochojejunostomy (n = 8). There were 4 perioperative deaths, 2 due to primary non-function and 2 due to refractory shock after exceedingly complex retransplants. CONCLUSION: Liver retransplantation due to late hepatic artery thrombosis is a rare condition that should be offered to patients who develop severe biliary complications and recurrent infections. It is nonetheless a challenging procedure associated with significant perioperative mortality.
Asunto(s)
Arteria Hepática , Trasplante de Hígado , Reoperación , Trombosis , Humanos , Arteria Hepática/cirugía , Trasplante de Hígado/efectos adversos , Trombosis/etiología , Trombosis/cirugía , Estudios Retrospectivos , Masculino , Persona de Mediana Edad , Femenino , Adulto , Complicaciones Posoperatorias/cirugía , Resultado del Tratamiento , AncianoRESUMEN
Intra-cardiac thrombosis is a potentially devastating complication of extracorporeal membrane oxygenation (ECMO) mechanical circulatory support. We present here a patient who suffered complete thrombosis of a fresh mitral prosthesis and left atrium in the setting of ECMO with aortic insufficiency who was treated with repeat valve replacement and thrombectomy. To our knowledge, she is the only patient in the reported literature to have survived this complication.
Asunto(s)
Bioprótesis , Oxigenación por Membrana Extracorpórea , Atrios Cardíacos , Prótesis Valvulares Cardíacas , Válvula Mitral , Trombosis , Femenino , Humanos , Bioprótesis/efectos adversos , Oxigenación por Membrana Extracorpórea/métodos , Prótesis Valvulares Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Válvula Mitral/cirugía , Trombectomía/métodos , Trombosis/etiología , Trombosis/cirugía , AncianoAsunto(s)
Neoplasias Renales , Trombectomía , Humanos , Neoplasias Renales/cirugía , Neoplasias Renales/patología , Carcinoma de Células Renales/cirugía , Carcinoma de Células Renales/patología , Células Neoplásicas Circulantes/patología , Trombosis/cirugía , Trombosis/etiología , Masculino , Venas Renales/cirugía , NefrectomíaRESUMEN
CASE: A 71-year-old woman presented with post-traumatic arthritis 11 months after open reduction and internal fixation for a left proximal humerus fracture (PHF) dislocation. After revision to reverse total shoulder arthroplasty (rTSA), the patient's left upper extremity was found to be avascular. An emergent thrombectomy was performed with restoration of arterial flow after removal of an acute-on-chronic axillary artery thrombus. CONCLUSION: Although rare, as rTSA becomes more common for management of PHF, incidence of associated vascular injuries is likely to rise. Screening methods and clinical vigilance in diagnosis are advised for patients with anterior PHF dislocations and arterial injury risk factors.
Asunto(s)
Artroplastía de Reemplazo de Hombro , Arteria Axilar , Fracturas del Hombro , Trombosis , Humanos , Femenino , Anciano , Arteria Axilar/cirugía , Arteria Axilar/lesiones , Arteria Axilar/diagnóstico por imagen , Fracturas del Hombro/cirugía , Fracturas del Hombro/diagnóstico por imagen , Artroplastía de Reemplazo de Hombro/efectos adversos , Trombosis/etiología , Trombosis/diagnóstico por imagen , Trombosis/cirugía , Fijación Interna de Fracturas/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/diagnóstico por imagen , Reducción Abierta/efectos adversos , ReoperaciónRESUMEN
Hepatic abscesses are divided into bacterial and amoebic types. Although the prognosis of bacterial liver abscesses has improved owing to progress in drainage techniques and antimicrobial agents, poor outcomes remain common. While there have been some reports of amoebic liver abscesses complicated by thrombosis, bacterial liver abscesses and subsequent thrombus in the right atrium are very rare. We herein report the case of an 82-year-old man. He had suffered acute obstructive suppurative cholangitis 10 months previously, and bile culture yielded Enterococcus faecalis. In the present case, a right atrial thrombus caused by a bacterial liver abscess was observed and the causative organism was thought to be Enterococcus faecalis, for which was detected in a blood culture was positive. The patient was successfully treated with hepatic abscess drainage and surgical right atrial thrombectomy under cardiopulmonary bypass with a beating heart.
Asunto(s)
Atrios Cardíacos , Cardiopatías , Absceso Piógeno Hepático , Trombosis , Humanos , Masculino , Absceso Piógeno Hepático/diagnóstico por imagen , Absceso Piógeno Hepático/complicaciones , Absceso Piógeno Hepático/cirugía , Anciano de 80 o más Años , Atrios Cardíacos/cirugía , Trombosis/cirugía , Trombosis/diagnóstico por imagen , Trombosis/complicaciones , Cardiopatías/complicaciones , Cardiopatías/cirugía , Cardiopatías/diagnóstico por imagen , Enterococcus faecalis , Infecciones por Bacterias Grampositivas/complicacionesRESUMEN
BACKGROUND: This study aimed to elucidate the methodology and assess the efficacy of the aortic arch inclusion technique using an artificial blood vessel in managing acute type A aortic dissection (ATAAD). METHODS: We conducted a retrospective review of 18 patients (11 males and 7 females, average age: 56.2 ± 8.6 years) diagnosed with ATAAD who underwent total aortic arch replacement (TAAR) using an artificial vascular "inclusion" between June 2020 and October 2022. During the operation, deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion (ACP) of the right axillary artery were employed for brain protection. The 'inclusion' total aortic arch replacement and stented elephant trunk (SET) surgery were performed. RESULTS: Four patients underwent the Bentall procedure during the study, with one additional patient requiring coronary artery bypass grafting (CABG) due to significant involvement of the right coronary orifice. Three patients died during postoperative hospitalization. Other notable complications included two cases of postoperative renal failure necessitating continuous renal replacement therapy (CRRT), one case of postoperative double lower limb paraplegia, and one case of cerebral infarction resulting in unilateral impairment of the left upper limb. Eleven patients underwent computed tomography angiography (CTA) examinations of the aorta three months to one-year post-operation. The CTA results revealed thrombosis in the false lumen surrounding the aortic arch stent in seven patients and complete thrombosis of the false lumen around the descending aortic stent in eight patients. One patient had partial thrombosis of the false lumen around the descending aortic stent, and another patient's false lumen in the thoracic and abdominal aorta completely resolved after one year of follow-up. CONCLUSIONS: Incorporating vascular graft in aortic arch replacement simplifies the procedure and yields promising short-term outcomes. It achieves the aim of total arch replacement using a four-branch prosthetic graft. However, extensive sampling and thorough, prolonged follow-up observations are essential to fully evaluate the long-term results.
Asunto(s)
Aneurisma de la Aorta Torácica , Disección Aórtica , Sustitutos Sanguíneos , Implantación de Prótesis Vascular , Trombosis , Masculino , Femenino , Humanos , Persona de Mediana Edad , Aorta Torácica/cirugía , Implantación de Prótesis Vascular/métodos , Disección Aórtica/cirugía , Stents , Aorta Abdominal/cirugía , Paraplejía , Trombosis/cirugía , Aneurisma de la Aorta Torácica/cirugía , Resultado del TratamientoRESUMEN
A 51-year-old male with a complicated medical history presented with shortness of breath. Preoperative workup confirmed the presence of a large atrial mass. However, delayed gadolinium enhancement CMR with long inversion time (TI 600) showed lack of enhancement, which was suggestive of a thrombus. During cardiac magnetic resonance imaging, delayed gadolinium enhancement sequences with long inversion time (TI 600) are commonly used to distinguish between an avascular thrombus versus a vascular tumor.
Asunto(s)
Mixoma , Trombosis , Masculino , Humanos , Persona de Mediana Edad , Medios de Contraste , Gadolinio , Imagen por Resonancia Magnética , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/cirugía , Mixoma/complicaciones , Mixoma/diagnóstico por imagen , Mixoma/cirugía , Trombosis/diagnóstico por imagen , Trombosis/cirugíaAsunto(s)
Estenosis de la Válvula Aórtica , Atrios Cardíacos , Estenosis de la Válvula Mitral , Derrame Pleural , Cardiopatía Reumática , Trombosis , Humanos , Estenosis de la Válvula Mitral/cirugía , Estenosis de la Válvula Mitral/complicaciones , Estenosis de la Válvula Mitral/diagnóstico por imagen , Trombosis/diagnóstico por imagen , Trombosis/etiología , Trombosis/cirugía , Trombosis/complicaciones , Atrios Cardíacos/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Cardiopatía Reumática/complicaciones , Cardiopatía Reumática/cirugía , Derrame Pleural/etiología , Derrame Pleural/diagnóstico por imagen , Femenino , Cardiopatías/etiología , Cardiopatías/complicaciones , Cardiopatías/diagnóstico por imagen , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: The gold standard treatment for renal cell carcinoma (RCC) with tumor thrombus (TT) is complete surgical excision. The surgery is complex and challenging to the surgeon, especially with large tumor thrombus extending into the inferior vena cava (IVC) and right atrium. Traditionally, these difficult cases required the use of cardiopulmonary bypass (CPB) with or without deep hypothermic cardiac arrest, but in recent years, different surgical techniques derived from the field of liver transplantation have been used in efforts to avoid CPB. CASE PRESENTATION: We present a case of RCC with TT level IIIc (extending above major hepatic veins) that "uncoiled" intraoperatively into the right atrium after division of the IVC ligament, transforming into a level IV TT. Despite the new TT extension, the surgery was successfully completed exclusively through an abdominal approach without CPB and while using intraoperative transesophageal echocardiography (TEE) monitoring and a cardiothoracic team standby. CONCLUSIONS: This case highlights the need for a multidisciplinary approach and the utility of intraoperative continous TEE monitoring which helped to visualize the change of the TT venous extension, allowing the surgical teamto modify their surgical approach as needed avoiding a catastrophic event.
Asunto(s)
Carcinoma de Células Renales , Neoplasias Renales , Células Neoplásicas Circulantes , Trombosis , Humanos , Carcinoma de Células Renales/diagnóstico por imagen , Carcinoma de Células Renales/cirugía , Carcinoma de Células Renales/patología , Neoplasias Renales/diagnóstico por imagen , Neoplasias Renales/cirugía , Neoplasias Renales/patología , Nefrectomía/métodos , Trombosis/diagnóstico por imagen , Trombosis/etiología , Trombosis/cirugía , Vena Cava Inferior/diagnóstico por imagen , Vena Cava Inferior/cirugía , Vena Cava Inferior/patología , Trombectomía/métodos , Células Neoplásicas Circulantes/patologíaRESUMEN
A 67 years old male had underwent left upper division segmentectomy. On the sixth day after surgery, he had developed unconsciousness, aphasia and unilateral spatial neglect. Brain MRI revealed a cerebral infarction, and percutaneous cerebral thrombectomy was performed. Enhanced computed tomography revealed thrombus formation in the remnant superior pulmonary vein (SPV), left renal infarction and right acute limb ischemia. After starting anticoagulant therapy with apixaban the thrombus reduced and neurological symptoms improved. A thrombus in the SPV may cause serious whole body organ infarction in the same way as a left atrial thrombus. It was suggested that left upper division segmentectomy was associated with the risk of remnant pulmonary vein thrombosis.
Asunto(s)
Neoplasias Pulmonares , Venas Pulmonares , Tromboembolia , Trombosis , Humanos , Masculino , Anciano , Venas Pulmonares/diagnóstico por imagen , Venas Pulmonares/cirugía , Neumonectomía/métodos , Neoplasias Pulmonares/cirugía , Tromboembolia/cirugía , Trombosis/cirugía , InfartoRESUMEN
A 74-year-old woman had been on hemodialysis for about 2 months using a short-term indwelling dialysis catheter due to chronic kidney disease. A 20 mm-diameter left atrial neoplastic lesion was noted during a screening echocardiogram performed at the time of induction of hemodialysis. The lesion rapidly increased to 30 mm 2 months later and was referred to our hospital for surgical resection. Under cardiopulmonary bypass and cardiac arrest, tumor resection was performed. Although the lesion was myxomatous with a thin stalk on the left atrial ceiling, the pathological diagnosis was thrombus. After the initiation of anticoagulation, the patient was discharged.
Asunto(s)
Apéndice Atrial , Trombosis , Femenino , Humanos , Anciano , Trombosis/diagnóstico por imagen , Trombosis/cirugía , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/cirugía , EcocardiografíaRESUMEN
BACKGROUND: Morphologically, the risk of aortic aneurysm rupture is mainly evaluated based on its type (e.g., fusiform or saccular) and diameter. Based on the finite element analysis, peak wall stress has been identified as a more sensitive and specific predictor of rupture in recent years. Moreover, in finite analysis, the neck of aneurysm is the highest peak wall stress and is associated with the rupture point. CASE PRESENTATION: A saccular aortic aneurysm (84 mm) was incidentally detected during preoperative examination for chronic empyema in a 74-year-old male patient with a history of polycythemia. Aortic arch graft replacement using an open stent was performed. CONCLUSIONS: Morphologically, this case was associated with a very high risk of rupture; nevertheless, it did not rupture. In this case, a mural thrombus (likely formed due to polycythemia) covered the neck of aneurysm that is experiencing the highest peak wall stress and is associated with the rupture point. The mural thrombus decreased peak wall stress and could reduce the risk of rupture even for huge saccular aneurysms. Furthermore, the mural thrombus was fully occupied in aneurysms, such as during coil embolization. Thus, polycythemia could decrease the risk of rupture of huge saccular aneurysms.
Asunto(s)
Aneurisma de la Aorta Abdominal , Aneurisma de la Aorta , Rotura de la Aorta , Policitemia , Tromboembolia , Trombosis , Masculino , Humanos , Anciano , Policitemia/complicaciones , Aneurisma de la Aorta/complicaciones , Rotura de la Aorta/complicaciones , Trombosis/complicaciones , Trombosis/cirugía , Tromboembolia/complicaciones , Aneurisma de la Aorta Abdominal/complicacionesRESUMEN
BACKGROUND: Surgical pulmonary artery thrombectomy is a well-established emergency treatment for massive pulmonary embolism (PE) in which fibrinolysis or thrombolysis are not effective. However, surgery for massive PE that requires peripheral pulmonary artery thrombus removal remains challenging. We established a simple and secure pulmonary artery thrombectomy method using cardiopulmonary bypass and cardiac arrest. In this procedure, the surgical assistant arm, typically used for coronary artery bypass grafting, is used to obtain a feasible working space during thrombectomy. CASE PRESENTATION: We present seven consecutive massive PE cases that were treated with the present surgical method and successfully weaned from cardiopulmonary bypass or extracorporeal membrane oxygenation postoperatively. CONCLUSIONS: This procedure can be used to prevent right ventricular failure after surgery as surgeons can remove the peripheral thrombus with clear vision up to the second branch of the pulmonary artery.
Asunto(s)
Paro Cardíaco , Embolia Pulmonar , Trombosis , Humanos , Resultado del Tratamiento , Trombectomía/métodos , Embolia Pulmonar/cirugía , Paro Cardíaco/etiología , Paro Cardíaco/cirugía , Arteria Pulmonar/cirugía , Trombosis/cirugíaRESUMEN
BACKGROUND: Portal vein embolization (PVE) is often performed prior to right hemihepatectomy (RH) to increase the future liver remnants. However, intraoperative removal of portal vein thrombus (PVT) is occasionally required. An algorithm for treating the right branch of the PV using laparoscopic RH (LRH) after PVE is lacking and requires further investigation. METHODS: In our department, after the confirmation of a lack of extension of PVT to the main portal trunk or left branch on preoperative examination (ultrasound and contrast-enhanced computed tomography), a final evaluation was performed using intraoperative ultrasonography (IOUS). Here we present the cases of eight patients who underwent LRH after PVE and examine the safety of our treatment strategies. RESULTS: IOUS revealed PVT extension into the main portal trunk in two cases. For the other six patients without PVT extension, we continued the laparoscopic procedure. In contrast, in the two cases with PVT extension, we converted to laparotomy after hepatic transection and removed the PVT. The median operation time for hepatectomy was 562 min (421-659 min), the median blood loss was 293 mL (85-1010 mL), no liver-related postoperative complications were observed, and the median length of stay was 10 days (6-34 days). CONCLUSIONS: PVT evaluation and removal are important in cases of LRH after PVE. Our strategy is safe and IOUS is particularly useful for laparoscopically evaluating PVT extension.
Asunto(s)
Embolización Terapéutica , Laparoscopía , Neoplasias Hepáticas , Trombosis , Humanos , Hepatectomía/métodos , Vena Porta/cirugía , Neoplasias Hepáticas/cirugía , Embolización Terapéutica/métodos , Trombosis/cirugíaRESUMEN
BACKGROUND: Hepatic artery thrombosis (HAT) is one of the critical conditions after an orthotopic liver transplant (OLT) and leads to severe problems if not corrected promptly. However, multiple treatments have been proposed for HAT, in which surgical revascularization with either auto-hepatic conduit interposition (AHCI) or revision of the anastomosis is more familiar indeed indicated for some patients and in specific situations. In this study, we want to evaluate the success and outcomes of treating early HAT (E-HAT), which defines HAT within 30 days after OLT with either of the surgical revascularization techniques. METHOD: In this retrospective study, we collected information from the medical records of patients who underwent either of the surgical revascularization procedures for E-HAT after OLT. Patients who needed early retransplantation (RT) or died without surgical intervention for E-HAT were excluded. Demographic data, OLT surgery information, and data regarding E-HAT were gathered. The study outcomes were secondary management for E-HAT in case of improper inflow, biliary complications (BC), RT, and death. RESULTS: A total of 37 adult patients with E-HAT after OLT included in this study. These E-HATs were diagnosed within a mean of 4.6 ± 3.6 days after OLT. Two patients had their HA revised for the initial management of E-HAT; however, it changed to AHCI intraoperatively and finally needed RT. Two and nine patients from the AHCI and revision groups had re-thrombosis (12.5% vs. 47.3%, respectively, p = 0.03). RT was used to manage rethrombosis in all patients of AHCI and two patients of the revision group (22.2%). In comparison to the AHCI, revision group had statistically insignificant higher rates of BC (47.4% vs. 31.2%); however, RT for nonvascular etiologies (12.5% vs. 5.3%) and death (12.5% vs. 10.5%) were nonsignificantly higher in AHCI group. All patients with more than one HA exploration who were in the revision group had BC; however, 28.5% of patients with just one HA exploration experienced BC (p < 0.001). CONCLUSION: Arterial conduit interposition seems a better approach for the initial management of E-HAT in comparison to revision of the HA anastomosis due to the lower risk of re-thrombosis and the number of HA explorations; indeed, BC, RT, and death remain because they are somewhat related to the ischemic event of E-HAT than to a surgical treatment itself.
Asunto(s)
Arteria Hepática , Trombosis , Adulto , Humanos , Arteria Hepática/cirugía , Estudios Retrospectivos , Hígado/cirugía , Trombosis/etiología , Trombosis/cirugía , Anastomosis Quirúrgica/efectos adversosRESUMEN
BACKGROUND: Calcified right atrial thrombus is rare and commonly occurs secondary to atrial fibrillation and long-term central venous catheterization which present risk for embolization. Treatment typically involves anticoagulation and antiplatelet therapy but rarely surgical excision can be performed, especially in patients with venous obstruction or concomitant valvular dysfunction. CASE PRESENTATION: We present the case of a 69 year old symptomatic female with a history of atrial fibrillation and long-term venous catheterization found to have a large calcified right atrial thrombus causing inferior vena cava obstruction and severe tricuspid regurgitation. Patient underwent full median sternotomy with ascending arterial cannulation with superior vena cava and femoral venous cannulation. Intraoperatively, extensive right atrial calcified thrombus was found extending into the inferior vena cava and involving the septal portion of the tricuspid valve annulus causing regurgitation. The calcified thrombus was removed which resolved the inferior vena cava obstruction and the tricuspid valve was repaired by transecting septal leaflet chordae, commissuroplasty, and ring annuloplasty. Postoperative course was uncomplicated and pathology confirmed a calcified right atrial thrombus. At 6 month follow up, the patient was asymptomatic with echocardiogram showing no inferior vena cava stenosis and trivial tricuspid regurgitation. CONCLUSIONS: Surgical excision of calcified right atrial thrombus is rare and is often indicated for symptomatic patients with extensive involvement causing venous inflow obstruction or valvular dysfunction. Sufficient preoperative imaging and a multi-disciplinary approach are essential for accurate diagnosis to guide targeted treatment. When the tricuspid valve is involved, repair is preferred over replacement in this patient population given their propensity for calcification and thrombus formation which may result in an increased risk of early bioprosthetic valve degeneration or mechanical valve thrombosis.