Rescue of a living donor with liver transplantation.

Postoperative liver failure is a rare complication after living donor liver resection. This is a case report of a 22-year-old healthy donor who was rescued with liver transplantation 11 days after right hemihepatectomy. Nine months later the patient is alive, and has fully recovered from his multiple organ failure. According to a review of the literature, there are four additional living liver donors, who received a liver transplant. Our own patient is the only survivor, so far. This case demonstrates that even in supposedly healthy living donors postoperative complications cannot be completely prevented. Although liver failure is rare in these patients, timely transplantation may need to be considered as the only life-saving treatment.

Hepatic artery-portal vein fistula formation after percutaneous liver biopsy in a living liver donor.

Percutaneous liver biopsy is a relatively safe method of assessing liver histology in living subjects. The current report depicts a case of arterioportal fistula in a living liver donor who underwent percutaneous liver biopsy as part of the routine transplant workup at our institution. The experience questions the utility of routine percutaneous liver biopsies as part of the living liver donor screening.

Facilitated coronary anastomosis using a nitinol U-Clip device: bovine model.

OBJECTIVE: The coronary anastomosis is the most difficult part of the coronary bypass procedure, particularly when using a minimally invasive technique. Methods to facilitate coronary anastomosis will make the minimally invasive approach to coronary bypass feasible. We sought preclinical validation and testing of the design and efficacy of a self-closing penetrating clip that can be used to facilitate the creation of graft-to-coronary end-to-side anastomosis. METHODS: The nitinol U-Clip device (Coalescent Surgical, Inc, Sunnyvale, Calif) was used in 13 consecutive calves (63-118 kg). In each animal, the device was (1) used to create an anastomosis of the right internal thoracic artery to a coronary artery with the heart beating and (2) compared to polypropylene suture when used to repair two carotid arteriotomies. Intraoperative, 1-week, 8-week, and 26-week postoperative angiograms and detailed histopathologic examinations were used to evaluate anastomotic patency and healing characteristics. RESULTS: The nitinol U-Clip device successfully created right internal thoracic artery-coronary artery anastomoses and repaired carotid arteriotomy sites in 13 consecutive calves. The clip was precisely placed by means of the integrated suture and needle in a fashion similar to that used for conventional suture. The clip met design specifications by reliable release and automatic closure, thereby eliminating knot tying and assisted suture management. At the time of harvest, angiography showed widely patent coronary anastomoses (FitzGibbon grade A criteria, n = 13) and carotid arteriotomy repair sites (n = 13). Histopathologic evaluation confirmed normal healing with smooth circumferential neointimal resurfacing at the anastomotic and repair sites. CONCLUSIONS: The nitinol U-Clip design and function was validated in the formation of bovine coronary anastomoses on the beating bovine heart with excellent graft patency and healing characteristics. The nitinol U-Clip device tests favorably when compared with conventional sutures in carotid artery repair.

Venography and vena cava filters.

Placement of inferior vena cava filters has become a standard part of a radiology practice. However, the number of filters on the market has increased dramatically. This paper attempts to discuss the various ramifications of the filters available. However, without a long term standardized study, we will not have the necessary information to adequately judge the effectiveness of these filters.

Chemoembolization for hepatocellular carcinoma.

Fifty-one patients with unresectable hepatocellular carcinoma (HCC) were treated with Gelfoam (absorbable gelatin sterile powder; The Upjohn Co, Kalamazoo, MI) chemoembolization. A mixture of Gelfoam powder, contrast media, and three drugs (doxorubicin, mitomycin, and cisplatin) was injected under fluoroscopic guidance via a percutaneous catheter into the hepatic artery until stagnation of blood flow was achieved. Of the 51 patients, 50 are assessable for response, and all are assessable for toxicity and complications. The median percent of liver replacement was 50% (range, 15% to 95%). By conventional response criteria, there were 12 partial responses (PRs) (24%), 13 minor responses (MRs) (26%), 12 stabilization of disease (SD) (24%), and 13 (26%) progressive disease (PD). Tumor liquefaction was noted on computed tomographic (CT) scan in 35 of 50 patients (70%). Of the 34 patients with elevated alpha-fetoprotein (AFP), 23 (68%) had a greater than 50% reduction following treatment. Responding patients were re-treated at the time of tumor progression if they still met the entry criteria. The median survival of assessable patients from the time of treatment was 207 days and from the diagnosis of the primary was 302 days. Fourteen patients remain alive at 3 months to 3 years following treatment. The vast majority of patients had transient pain, fever, nausea, and elevation in liver enzymes. Ascites developed in 14 patients. There were two treatment-related deaths: one from tumor hemorrhage and one from liver failure. Chemoembolization appears to have significant activity in patients with hepatocellular carcinoma and is relatively well tolerated.

Incidental fibromuscular dysplasia in potential renal donors: long-term clinical follow-up.

The clinical natural history of renal arterial fibromuscular dysplasia (FMD) in patients with normal blood pressure is unknown, to the authors' knowledge. The authors reviewed the results of 1,862 renal angiograms obtained in potential renal donors. FMD was present in 71 patients (3.8%). The average age at which FMD was discovered was 50.8 years. Seventy-five percent of the patients with FMD were female. Of 30 patients who did not undergo nephrectomy, eight (26.6%) developed hypertension over a mean followup interval of 7.5 years. Of 19 patients who underwent nephrectomy, despite the presence of FMD, five (26.3%) developed hypertension over a mean follow-up interval of 4.4 years. In comparison, three subjects (6.1%) (from a randomized control group of 49 age- and sex-matched healthy individuals) developed hypertension over a mean follow-up period of 7.1 years. The authors conclude that asymptomatic middle-aged individuals with renal FMD develop hypertension at a rate greater than that of age-matched control subjects with normal blood pressure.

Role of interventional radiology in the management of major esophageal leaks.

Six patients with major esophageal leaks associated with pleural and mediastinal abscesses were treated by means of fluoroscopically placed drainage tubes. In each patient, large-bore sumps were positioned in the esophagus to obtain optimal diversion of enteric contents. Mediastinal and pleural collections were drained percutaneously or with catheters passed through the esophagus and across the esophageal rent. Closure of the esophageal disruption without further surgery was achieved in all patients.

Management of incurable urinary fistulas by percutaneous ureteral occlusion.

Women with large urinary tract fistulas in the presence of advanced incurable gynecologic cancer are a difficult problem. In the past, treatment has usually been either inadequate or highly morbid. We have palliated three women with large incurable urinary tract fistulas by occluding the distal ureters with isobutyl-2-cyanoacrylate (Bucrylate) and implanting permanent bilateral percutaneous nephrostomies. This technique is easily performed and effective, and has few complications.

Treatment of urinary conduit fistula by antegrade ureteral stent catheter.

Two women with urinary conduit fistulas are presented. Both patients developed a conduit fistula postoperatively after total pelvic exenteration. The fistulas were managed successfully by inserting an antegrade ureteral stent catheter via a percutaneous nephrostomy. The details of the method used to perform this procedure are described in detail, and risks and benefits are reviewed.

Percutaneous transjejunal catheterization of Roux-en-Y biliary-jejunal anastomoses.

Percutaneous transjejunal biliary interventions were performed in 11 patients with Roux-en-Y jejunobiliary anastomoses that had not been specially constructed for percutaneous puncture. These procedures were performed to evaluate the utility of this approach in patients with complex biliary abnormalities. Catheterization from the jejunal loop into the biliary tree was successful in each case. In three cases, long-term stents were placed; eight other catheters were removed after the intervention. No complications were encountered. This preliminary experience suggests that this approach can provide safe access for biliary intervention.

Thrombosed dialysis grafts: efficacy of intrathrombic deposition of concentrated urokinase, clot maceration, and angioplasty.

Forty-one thrombosed polytetrafluoroethylene hemodialysis grafts in 26 patients were treated by a modified method of fibrinolytic therapy and transluminal angioplasty. The modifications included the use of highly concentrated urokinase, intrathrombic injection of urokinase into mechanically macerated thrombi, use of a crossed two-catheter technique, observation of the patient in the angiography suite during the entire procedure, and transluminal angioplasty to correct underlying stenosis immediately after partial or complete thrombolysis. Lysis was initially successful in 37 (90%) of 41 procedures. Successful treatment, defined as a functional graft for longer than 6 months without intervening surgery, was achieved in 16 (62%) of 26 patients. In comparison with previous transluminal or surgical regimens, this modified method permits marked acceleration of thrombolysis, immediate transluminal angioplasty, and sparing of potential future graft sites.