Incidence of important hemobilia following transhepatic biliary drainage: left-sided versus right-sided approaches.

Our purpose here is to describe our experience with important hemobilia following PTBD and to determine whether left-sided percutaneous transhepatic biliary drainage (PTBD) is associated with an increased incidence of important hemobilia compared to right-sided drainages. We reviewed 346 transhepatic biliary drainages over a four-year period and identified eight patients (2.3%) with important hemobilia requiring transcatheter embolization. The charts and radiographic files of these patients were reviewed. The side of the PTBD (left versus right), and the order of the biliary ductal branch entered (first, second, or third) were recorded. Of the 346 PTBDs, 269 were right-sided and 77 were left-sided. Of the eight cases of important hemobilia requiring transcatheter embolization, four followed right-sided and four followed left-sided PTBD, corresponding to a bleeding incidence of 1.5% (4/269) for right PTBD and 5.2% (4/77) for left PTBD. The higher incidence of hemobilia associated with left-sided PTBD approached, but did not reach the threshold of statistical significance (p = 0.077). In six of the eight patients requiring transcatheter embolization, first or second order biliary branches were accessed by catheter for PTBD. All patients with left-sided bleeding had first or proximal second order branches accessed by biliary drainage catheters. In conclusion, a higher incidence of hemobilia followed left-versus right-sided PTBD in this study, but the increased incidence did not reach statistical significance.

Abdominal aortic aneurysm in high-risk patients: short- to intermediate-term results of endovascular repair.

PURPOSE: To assess the safety and efficacy of endovascular repair of abdominal aortic aneurysm in high-risk patients during the short to intermediate term. MATERIALS AND METHODS: Endovascular aneurysm repair was performed in 50 patients considered too high risk for conventional repair. Stent-grafts were inserted through surgically exposed femoral arteries with fluoroscopic guidance. The anesthetic technique was epidural in 36 patients, general in 12, and local in two. Aortouniiliac stent-grafts were inserted in 42 patients and aortoaortic in eight. RESULTS: There were no deaths and no conversions to open surgical repair. The primary success rate (complete aneurysm exclusion according to CT criteria) was 88% (44 of 50). The secondary, clinical, and continuing success rates were all 98% (49 of 50). Surgical time was 196 minutes +/- 67 (mean +/- SD), blood loss was 284 mL +/- 386, and volume of contrast material administered was 153 mL +/- 64. The time from the end of the surgery to resumption of a normal diet was 0.58 days +/- 0.56, to ambulation was 1.22 days +/- 0.77, and to discharge from the hospital was 3.63 days +/- 1.60. Wound problems accounted for the majority of complications. There were no instances of pulmonary failure, renal failure, stent-graft migration, or late leakage. CONCLUSION: Endovascular repair of abdominal aortic aneurysm is feasible in two-thirds of high-risk patients, with a low mortality and high success rate during the short to intermediate term.

Transcatheter embolization of biopsy-related vascular injury in the transplant kidney: immediate and long-term outcome.

PURPOSE: To assess the effect of transcatheter embolization for treatment of biopsy-related vascular injury in renal allografts, specifically evaluating technical success, clinical benefit, and long-term effect on renal function. MATERIALS AND METHODS: A retrospective review was performed of all postbiopsy renal allograft vascular injuries referred for embolization during a 113-month period. The likelihood of a prolonged detrimental effect on allograft function was estimated from observed variation in serum creatinine levels before and after the procedure. RESULTS: Embolic therapy with use of metallic coils and superselective technique was performed in 21 renal transplant patients. Technical success was achieved in 95% of cases. There were no serious complications. Eradication of the clinical sign or symptom prompting referral was seen in 15 of 17 (88%) patients. Eleven of 19 (58%) patients analyzed demonstrated no evidence of a long-term detrimental effect on allograft function. A detrimental effect was possibly present in six of 19 (32%) patients, and probable in only two of 19 (10%) patients. CONCLUSIONS: Transcatheter embolization can be an appropriate and effective therapeutic choice for biopsy-related renal allograft vascular injury.

Ureteral obstructions and leaks after renal transplantation: outcome of percutaneous antegrade ureteral stent placement in 44 patients.

PURPOSE: To analyze the outcome of percutaneous antegrade ureteral stent placement for treatment of ureteral stenoses and leaks after renal transplantation. MATERIALS AND METHODS: Antegrade pyelography and percutaneous ureteral stent placement were performed in 45 patients with ureteral obstruction (n = 40), leak (n = 3), or both (n = 2). Obstructions were graded as mild, moderate, or complete, and as early (< or = 3 months after transplantation) or late (> 3 months). RESULTS: The outcome of stent placement was successful in 25 (57%) patients (average follow-up, 30 months). The ureteroneocystostomy (UNC) was the most common site of obstructions (22 of 41), leaks (four of five), and successful outcomes (16 of 22). Moderate obstructions were most common (29 of 41) and responded best to treatment (17 of 29). Eighteen (69%) of 26 early obstructions and five (33%) of 15 late obstructions were successfully managed percutaneously. All complications (12 of 45 patients) were minor, with infections the most common (n = 7). No mortality or allograft loss was attributable to stent placement. CONCLUSION: Ureteral stents are safe and effective for the treatment of obstructions and leaks and are particularly effective for early and UNC obstructions. These stents may also be useful for temporary drainage.

Endovascular repair of abdominal aortic aneurysm: getting out of trouble.

The standard techniques of endovascular aneurysm repair sometimes fail to produce atraumatic stent-graft delivery of hemostatic implantation, and additional maneuvers are required to avoid conversion to open repair. Between June 1996 and May 1997 elective endovascular aneurysm repair was performed in 33 high risk patients, using a Z-stent-based prosthesis. Challenging anatomic features included: short neck (< 15 mm) in four cases, angulated neck (> 60 degrees) in seven, iliac aneurysm in six, and iliac tortuosity (> 80 degrees) in 24. There were no deaths, no renal failure, no pulmonary failure, no graft thrombosis, no migration, and no conversions to open surgery. Deviations from standard technique were required to treat iliac artery dissection, iliac artery stenosis, and leaks resulting from proximal stent malalignment, proximal stent malposition, and distal stent malposition. The necessary adjunctive maneuvers included: additional stent placement, additional stent-graft placement, and balloon dilatation. Mean operating time was 191 +/- 72 min, mean contrast volume was 148 +/- 76 ml, and mean blood loss was 314 +/- 427 ml. Mean time from operation to discharge from the hospital was 3.5 +/- 1.67 days. These short-term results demonstrate that endovascular aneurysm repair is safe and effective in high risk patients, only if adjunctive maneuvers are available to supplement standard technique.

Bleomycin sclerosis of pelvic lymphoceles.

PURPOSE: To describe the results of postoperative pelvic lymphocele treatment by means of percutaneous drainage and sclerosis with bleomycin. MATERIALS AND METHODS: Four patients underwent treatment of pelvic lymphoceles by percutaneous tube drainage followed by instillation of bleomycin under fluoroscopic guidance at a concentration of 1 unit/mL. Bleomycin instillation was repeated at weekly intervals until the tube output was less than 10 mL per day. Three of four patients underwent unsuccessful sclerosis previously with alcohol, doxycycline, or povidone iodine. RESULTS: Lymphocele drainage was reduced to less than 10 mL per 24 hours after bleomycin sclerosis in all patients. Three patients required two sessions, and the fourth patient required three sessions. No patient developed recurrent symptoms suggesting reaccumulation of lymph during an average follow-up period of 11 months (range, 6-18 months). No complications related to percutaneous lymphocele drainage or sclerosant therapy were encountered. CONCLUSION: Percutaneous intracavitary instillation of bleomycin may be considered as an alternative to surgery in patients who have undergone unsuccessful lymphocele sclerosis with other agents.

Selective arterial embolization for the control of lower gastrointestinal bleeding.

BACKGROUND: Transcatheter embolization is accepted as a safe method for treating acute bleeding from the upper gastrointestinal (GI) tract. Hesitancy persists using this technique below the ligament of Treitz, based on the belief that the risk of intestinal infarction is unacceptably high, despite mounting clinical evidence to the contrary. METHODS: A series of 17 consecutive patients with angiographically demonstrated small intestinal or colonic bleeding was retrospectively reviewed. The success and complication rate of subselective embolization was assessed. RESULTS: Bleeding was stopped in 13 of 14 patients (93%) in whom embolization was possible, and in 13 of 17 patients (76%) where there was an intention to treat. Sufficiently selective catheterization to permit embolization could not be achieved in 3 patients. No clinically apparent bowel infarctions were caused. CONCLUSION: Subselective embolization is a safe treatment option for lower GI bleeding, suitable for many patients and effective in most. Careful technique and a readiness to abandon embolization when a suitable catheter position cannot be achieved are important.

Endoscopic sclerotherapy compared with percutaneous transjugular intrahepatic portosystemic shunt after initial sclerotherapy in patients with acute variceal hemorrhage. A randomized, controlled trial.

BACKGROUND: Hemorrhage from esophageal varices remains a substantial management problem. Endoscopic sclerotherapy was preferred for more than a decade, but fluoroscopically placed intrahepatic portosystemic stents have recently been used with increasing frequency. OBJECTIVE: To compare sclerotherapy with transjugular intrahepatic portosystemic shunt (TIPS) in patients with bleeding from esophageal varices. DESIGN: Randomized, controlled clinical trial. SETTING: Three teaching hospitals. PATIENTS: 49 adults hospitalized with acute variceal hemorrhage from November 1991 to December 1995: 25 assigned to sclerotherapy and 24 assigned to TIPS. INTERVENTION: Patients assigned to repeated sclerotherapy had the procedure weekly. In those assigned to TIPS, an expandable mesh stent was fluoroscopically placed between an intrahepatic portal vein and an adjacent hepatic vein. MEASUREMENTS: Pretreatment measures included demographic and laboratory data. Postrandomization data included index hospitalization survival, duration of follow-up, successful obliteration of varices, rebleeding from varices, number of variceal rebleeding events, total days of hospitalization for variceal bleeding, blood transfusion requirements after randomization, prevalence of encephalopathy, and total health care costs. RESULTS: Mean follow-up (+/-SE) was 567 +/- 104 days in the sclerotherapy group and 575 +/- 109 days in the TIPS group. Varices were obliterated more reliably by TIPS than by sclerotherapy (P < 0.001). Patients having TIPS were significantly less likely to rebleed from esophageal varices than patients receiving sclerotherapy (3 of 24 compared with 12 of 25; P = 0.012). No other follow-up measures differed significantly between groups. A trend toward improved survival, which was not statistically significant, was noted in the TIPS group (hazard ratio, 0.53 [95% CI, 0.18 to 1.5]). CONCLUSIONS: In obliterating varices and reducing rebleeding events from esophageal varies, TIPS was more effective than sclerotherapy. However, TIPS did not decrease morbidity after randomization or improve health care costs. It seemed to produce better survival, but the increase in survival was not statistically significant.

Transjugular intrahepatic portosystemic shunts (TIPS) in children.

The transjugular intrahepatic portosystemic shunt procedure is an accepted treatment for adults with complications of portal hypertension. We performed a retrospective review of all pediatric TIPS placements performed at the University of California, San Francisco between 1990 and 1996. Twelve procedures were attempted in nine children, with a mean age (+/- SD) of 9.4 +/- 3.9 years (range, 5 to 15 years) and a mean weight of 31 +/- 18 kg (range, 16 to 70 kg). The indications for TIPS placement were portal hypertension complicated by chronic variceal hemorrhage not controlled with sclerotherapy (n = 7) and hypersplenism with thrombocytopenia (n = 2). TIPS placement was successfully completed initially in seven of nine (78%) patients. Unfavorable vascular anatomy was the cause of failure in two cases. The seven patients who underwent successful TIPS placement were followed up for an average of 136 days (range, 1 to 800 days); two still have patent shunts, three underwent liver transplantation, one had a splenorenal shunt after stenosis, and one died of underlying liver disease. Variceal bleeding was controlled in four of five patients who successfully underwent TIPS placement. Shunt occlusion occurred in four patients; patency was restored by transjugular shunt revision in three, and a splenorenal shunt was performed in one.

Failure patterns of cryopreserved vein grafts in liver transplantation.

Reports of early success with cryopreserved saphenous veins (CSV) as arterial conduits led us to develop cryopreserved iliac veins (CIV) as interposition grafts for portal vein reconstruction in living-related liver transplantation (LRLT). Despite encouraging short-term results, retrospective analysis of long-term cryopreserved vein graft performance in LRLT at our institution has revealed a high rate of late graft failures. Between July 1992 and JUly 1994, interposition grafts (CIV for portal vein interposition n=4, CSV for portal vein interposition n=3, and CSV for hepatic artery interposition n=2) were utilized in 7 LRLT. (Two transplanted organs had both CIV and CSV grafts.) Recipients included 5 children and two small adults (median: 3.5 years, range: 0.5--59 years). Posttransplant follow-up in excess of 36 months revealed portal vein (PV) and hepatic artery (HA) complications of cryopreserved grafts in each patient. PV complications included aneurysm (n=4) diagnosed at 28, 24, 18, and 1.5 mo, stricture (n=1) diagnosed at 11 mo, and thrombosis (n=1) diagnosed at 18 mo posttransplantation. All portal vein complications have been managed without retransplantation, but one (PV thrombosis) necessitated surgical shunt therapy. Each CSV hepatic artery interposition graft has been complicated by thrombosis (diagnosed at 11 days and 24 mo posttransplant) necessitating retransplantation. Based on these observations, we have adopted alternative strategies for HA and PV reconstruction. At present, 11 LRLT have been performed without cryopreserved vein conduits over 17 mo with no vascular complications. While this study does not permit statistical analysis, these results discourage the use cryopreserved iliac veins for portal interposition and cryopreserved saphenous veins for arterial interposition in liver transplantation.

Superselective arterial embolization in the liver transplant recipient: a safe treatment for hemobilia caused by percutaneous transhepatic biliary drainage.

Transcatheter arterial embolization is widely used to treat life-threatening iatrogenic hemobilia, although in the transplanted liver its use has only been reported in two cases. To evaluate more fully whether transcatheter embolization is safe and effective in transplant recipients, we retrospectively reviewed eight cases of severe hemobilia. These occurred after 128 percutaneous transhepatic biliary drainage procedures performed during a 6-year period. In each case, angiography localized the bleeding to a specific intrahepatic branch that was then subselectively catheterized and occluded by transcatheter embolization. Bleeding was successfully controlled by this method in all eight patients with no immediate complications. The main, right, and left hepatic arteries were shown to be patent immediately after embolization by angiography in all patients. Duplex sonography performed in each case (1 to 4 months) after the procedure confirmed that patency was maintained in all patients. No patients developed liver abscesses, sepsis, or clinical liver infarctions after the embolization. No patients underwent retransplantation after embolization. Our experience shows that superselective transcatheter embolization is a safe, effective therapy to correct iatrogenic hemobilia in the liver transplant recipient without threatening the patency of the major hepatic arteries, the viability of the liver, or the integrity of the biliary tree.

Percutaneous transhepatic hepatic venography in the delineation and treatment of Budd-Chiari syndrome.

PURPOSE: To assess the usefulness of percutaneous transhepatic hepatic venography (PTHV) in planning interventional radiologic treatment of Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: Six patients aged 14-56 years underwent examination for BCS. After preliminary transfemoral inferior vena cavography and selective hepatic venography failed in determining the extent of venous obstruction, PTHV was performed. RESULTS: PTHV completely depicted the proximal and distal extent of hepatic venous occlusion. Intraluminal thrombus in the right and middle hepatic veins shown in one patient was treated with fibrinolytic infusion and balloon thrombectomy. Central obstruction of the right hepatic vein shown in two patients was treated with venoplasty or venoplasty and stent placement. In three patients. PTHV showed a "spider web" appearance of diffuse obliteration of the normal intrahepatic venous architecture; a transjugular intrahepatic portosystemic shunt was placed in two of these patients. CONCLUSION: PTHV provides information not available with conventional venography that is useful in planning the treatment of BCS.

Successful reversal of hepatic encephalopathy with intentional occlusion of transjugular intrahepatic portosystemic shunts.

PURPOSE: To establish a safe and effective method for occluding a transjugular intrahepatic portosystemic shunt (TIPS) in patients who develop uncontrollable, disabling encephalopathy. PATIENTS AND METHODS: The study population consisted of five patients who developed refractory encephalopathy following TIPS. The indication for TIPS was bleeding in four patients and ascites in one. Wallstents that were 10 mm in diameter and 68 mm long were used to bridge the hepatic parenchyma in all patients. The onset of encephalopathy from the time of the TIPS procedure ranged from 24 hours to 210 days. Because encephalopathy was not responsive to conventional medical management, shunt thrombosis was induced by means of temporary inflation of an 11.5-mm-diameter latex occlusion balloon within the midportion of the stent. RESULTS: All shunts were successfully thrombosed when the balloon was inflated for 12 hours or more. Encephalopathy resolved in four patients and improved in the remaining patient. One patient experienced recurrent bleeding within 24 hours of the TIPS occlusion that was controlled medically. CONCLUSION: Temporary occlusion of a TIPS with latex balloons successfully induces shunt thrombosis and improves encephalopathy. However, the patient is again exposed to risks related to complications of portal hypertension.

Three-dimensional transabdominal ultrasound identification of aortic plaque.

Tree-dimensional (3-D) reconstruction of acquired tomographic images in adults has recently been described. With an adaptation of this technique, we performed 3-D reconstruction of transabdominal images of the abdominal aorta to test the hypotheses that 3-D reconstruction of the abdominal aorta is feasible and that 3-D images have incremental value over 2-D in the detection of atheromatous plaque. Twenty-one patients undergoing contrast aortography (Aogram) for clinical indications (1 abdominal aorta (AA) aneurysm, 5 peripheral vascular disease, 1 renal artery stenosis, 14 renal donors) were studied using a 5-MHz annular array probe fitted to a mechanical registration device. In 13 of 21 patients, adequate 2-D ultrasound slices were acquired around a 180 degrees rotation and stored as a volumetric data set using a dedicated computer and 3-D images were reconstructed off-line. Three-dimensional and planar images were blindly compared with Aograms using the following scale: grade 1, normal; grade 2, increased echodensity of the intimal surface; grade 3, local intimal thickening and/or luminal irregularity; and grade 4, protruding mass. Analogous 3-D images were produced in all 13 patients with branching vessels visible in 3 of 13. In 10 patients, the Aogram was interpreted as normal. Compared with Aogram, blindly interpreted 3-D images were compared and correctly identified normal AA in 8 of 10 and atherosclerotic plaque (grade 3 or 4) in 2 of 3. Discordant results were present in 2 of 10 normal aortas and 1 of 3 disease aortas. When 2-D (planar) images were compared with Aograms, 8 of 10 identified normal AA and 3 of 3 aortas with grade 3 or 4 plaque. Thus, in 2 patients, 3-D and planar images suggested atherosclerotic changes not seen by Aogram. Transabdominal 3-D imaging of the abdominal aorta is a feasible technique. Early data suggest that 3-D imaging may distinguish normal from moderate to severe disease, but currently has no demonstrable incremental value over conventional 2-D images. These early results in a small number of patients suggest that this promising technique warrants further evaluation.

Liver transplantation complicated by malpositioned transjugular intrahepatic portosystemic shunts.

PURPOSE: To report the surgical problems encountered during orthotopic liver transplantation as a result of a malpositioned transjugular intrahepatic portosystemic shunt (TIPS). PATIENTS AND METHODS: Three patients are described in whom TIPS stents were malpositioned in the following locations: extending into the main portal vein, extending into the suprahepatic inferior vena cava, and extending into the right atrium. RESULTS: Malpositioning of TIPS stents altered and prolonged the operation in all of these patients by interfering with cross-clamping at the usual vascular sites during liver transplantation. Incorporation of the stents into the vascular wall prevented transcatheter retrieval and increased the difficulty of intraoperative removal. CONCLUSION: Awareness of hepatic vascular anatomy is necessary in avoiding stent malpositioning. If malpositioning is identified, transcatheter approaches may be helpful in repositioning the stent. Otherwise, the transplant surgery team must be made aware of the problem for proper surgical planning prior to liver transplantation.

Multicenter investigation of the role of transjugular intrahepatic portosystemic shunt in management of portal hypertension.

PURPOSE: To determine the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) placement, a prospective multicenter trial was undertaken. MATERIALS AND METHODS: In eight institutions, 96 patients underwent TIPS placement after failed sclero-therapy (Child-Pugh class A [n = 24], class B [n = 38], and class C [n = 34]), with follow-up for 6 months (with ultrasonography and angiography and clinical and laboratory studies). RESULTS: TIPS placement was successful in all patients (mean initial portosystemic pressure gradient, 22.8 mm Hg + 6.7 [standard deviation]; mean decrease after placement, 12.8 mm Hg + 5.2), with variceal embolization in 25 patients. Complications included liver capsule puncture (n = 12), hepatic artery puncture (n = 3), main portal vein puncture (n = 1), and increased encephalopathy (n = 28). The 30-day mortality rate was 0% for patients with Child class A disease, 18% for class B, and 40% for class C. At 6 months, primary patency was 88% and assisted patency was 94%. CONCLUSION: The risk associated with TIPS placement is reasonable, and it is an effective procedure for the treatment of portal hypertension.

Transjugular intrahepatic portosystemic shunts: current status.

The management of acute variceal hemorrhage from portal hypertension has traditionally included pharmacologic agents, mechanical compression with tamponading balloons, and endoscopic techniques including sclerotherapy and variceal banding. The role of operative portosystemic shunting has diminished in the past several years because of unpredictable postoperative morbidity from hepatic failure or encephalopathy [1-8]. Although orthotopic liver transplantation provides a unique and effective solution to these problems, it is often impractical in the emergent setting and may not be necessary if the hemorrhage can be reliably controlled by other means. The transjugular intrahepatic portosystemic shunt (TIPS) was developed to relieve portal hypertension without the mortality and morbidity of an open surgical procedure. This review summarizes the salient history, technique, and results of this procedure. The evolving role of TIPS in the management of portal hypertension, including indications, contraindications, and the durability of the procedure, is assessed.