Creation of a percutaneous mesocaval shunt to control variceal bleeding in a child.

Although transjugular intrahepatic portosystemic shunt (TIPS) placement is the standard procedure for the treatment of portal hypertension, it is often impossible to perform in patients with extrahepatic portal vein occlusion. In these patients, options for decompressing the liver are few. In this report, we present a novel solution for managing gastro-esophageal hemorrhage in a child with portal hypertension and extrahepatic portal vein occlusion, through the creation of a percutaneous mesocaval shunt.

The transjugular intrahepatic portosystemic shunt: an update.

OBJECTIVE: The purpose of this article is to review the indications, outcomes, complications, patient selection, and technical aspects of creating a transjugular intrahepatic portosystemic shunt (TIPS). CONCLUSION: The best available evidence supports the use of TIPS in secondary prevention of variceal bleeding and in refractory ascites, although TIPS is also commonly used for other indications such as Budd-Chiari syndrome, hepatic hydrothorax, and acute variceal hemorrhage. The TIPS procedure was revolutionized by the introduction of covered stents, which dramatically improved long-term shunt patency.

Intravenous vasopressin for the prevention of nontarget gastrointestinal embolization during liver-directed cancer treatment: experimental study in a porcine model.

PURPOSE: The aim of this study was to evaluate the potential for intravenous vasopressin to reduce the risk of nontarget gastrointestinal embolization during transcatheter liver-directed cancer therapies in a porcine model. MATERIALS AND METHODS: An angiographic catheter was used to select the celiac or common hepatic artery under fluoroscopic guidance in six anesthetized pigs. After angiography of the hepatic and splanchnic territories was performed, technetium-99m macroaggregated albumin ((99m)Tc-MAA) was injected through the catheter. Serial arteriograms were obtained before, every 5 minutes during, and after peripheral intravenous vasopressin infusion at 0.4 U/min for a minimum of 20 minutes. After 10 minutes of infusion, indium-111 ((111)In)-MAA was injected through the arterial catheter. Quantitative comparisons of liver and gastrointestinal activity using dual-isotope single-photon emission computed tomography (SPECT)/CT imaging were performed. RESULTS: Catheter angiography demonstrated reduced blood flow to the splanchnic vasculature while maintaining blood flow through the hepatic arteries during vasopressin infusion. Angiographic findings correlated with the relative distribution of (99m)Tc-MAA (before the vasopressin infusion) and (111)In-MAA (after the vasopressin infusion) on SPECT/CT. The increased ratio of liver to gastrointestinal tract activity during the vasopressin infusion was statistically significant (6.2:11.4, respectively; P = .018). CONCLUSIONS: Intravenous vasopressin reduces arterial blood flow to the splanchnic vasculature while preserving hepatic arterial blood flow in a healthy porcine model. Intraprocedural vasopressin administration has the potential to benefit liver-directed cancer therapies by enhancing tumor targeting as well as preventing the unintended delivery of bland embolic, chemoembolic, or radioembolic agents into the gastrointestinal vascular territories.

Hepatic arterial injuries after percutaneous biliary interventions in the era of laparoscopic surgery and liver transplantation: experience with 930 patients.

PURPOSE: To retrospectively determine if patients with a history of intraoperative bile duct injury or liver transplantation have an increased risk for arterial injury (AI) during percutaneous transhepatic cholangiography (PTC) and percutaneous transhepatic biliary drainage (PTBD) compared with the risk of AI established in the 1970s and 1980s. MATERIALS AND METHODS: This study was approved by the committee on human research and was deemed compliant with the Health Insurance Portability and Accountability Act. The informed consent requirement was waived. Records of 1394 procedures (307 PTCs, 1087 PTBDs) performed in 930 patients (445 male, 485 female; age range, 4 months to 99 years) over the past 13 years were retrospectively reviewed. The rate of AI was determined, and demographic, pathologic, technical, and laboratory variables were tested for association with increased risk of AI by using generalized estimating equation analysis. RESULTS: AIs were encountered after 30 (2.2%) biliary procedures. No significant difference in the rate of AI was seen among the groups of patients with malignant biliary obstruction (1.8%), history of bile duct injury (2.2%), or complications of liver transplantation (2.6%). Patients who underwent PTBD had a higher risk of AI than did patients who underwent PTC (2.6% vs 0.7%); however, this difference was not significant (P = .06). Ongoing hemobilia was seen in 26 (87%) of the patients, which made it the most common sign of AI, and it had a 94% positive predictive value for AI. A postprocedure decrease in the hematocrit level of more than 13% was seen only in the setting of AI, and it occurred in only three (10%) of patients with AIs. CONCLUSION: PTC and PTBD performed for management of bile duct injury and complications of liver transplantation are not associated with an increased risk of hepatic AIs compared with the risk of AI reported in the 1970s and 1980s.

Imaging findings in Takayasu's arteritis.

OBJECTIVE: The objective of our study was to evaluate the clinical usefulness of cross-sectional imaging for establishing the diagnosis of Takayasu's arteritis (TA), an inflammatory vascular disorder that produces arterial stenoses and aneurysms primarily involving the thoracoabdominal aorta and its branches and the pulmonary arteries. CONCLUSION: CT and MRI findings of TA include vascular wall thickening and enhancement early in the disease, and arterial stenoses, occlusions, and aneurysms later in the disease. Cross-sectional imaging is useful for establishing the diagnosis of TA and for showing response to nonsurgical therapy or for planning a surgical intervention.

Integrated fellowship in vascular surgery and intervention radiology: a new paradigm in vascular training.

OBJECTIVE: To evaluate an integrated fellowship in vascular surgery and interventional radiology initiated to train vascular surgeons in endovascular techniques and to train radiology fellows in clinical aspects of vascular diseases. SUMMARY BACKGROUND DATA: The rapid evolution of endovascular techniques for the treatment of vascular diseases requires that vascular surgeons develop proficiency in these techniques and that interventional radiologists develop proficiency in the clinical evaluation and management of patients who are best treated with endovascular techniques. In response to this need the authors initiated an integrated fellowship in vascular surgery and interventional radiology and now report their interim results. METHODS: Since 1999 vascular fellows and radiology fellows performed an identical year-long fellowship in interventional radiology. During the fellowship, vascular surgery and radiology fellows perform both vascular and nonvascular interventional procedures. Both vascular surgery and radiology-based fellows spend one quarter of the year on the vascular service performing endovascular aortic aneurysm repairs and acquiring clinical experience in the vascular surgery inpatient and outpatient services. Vascular surgery fellows then complete an additional year-long fellowship in vascular surgery. To evaluate the type and number of interventional radiology procedures, the authors analyzed records of cases performed by all interventional radiology and vascular surgery fellows from a prospectively maintained database. The attitudes of vascular surgery and interventional radiology faculty and fellows toward the integrated fellowship were surveyed using a formal questionnaire. RESULTS: During the fellowship each fellow performed an average of 1,201 procedures, including 808 vascular procedures (236 diagnostic angiograms, 70 arterial interventions, 59 diagnostic venograms, 475 venous interventions, and 43 hemodialysis graft interventions) and 393 nonvascular procedures. On average fellows performed 20 endovascular aortic aneurysm repairs per year. There was no significant difference between the vascular surgery and radiology fellows in either the spectrum or number of cases performed. Eighty-eight percent (23/26) of the questionnaires were completed and returned. Both interventional radiologists and vascular surgeons strongly supported the integrated fellowship model and favored continuation of the integrated program. Vascular surgery and interventional radiology faculty members wanted additional training in clinical vascular surgery for the radiology-based fellows. With the exception of the radiology fellows there was uniform agreement that vascular surgery fellows benefit from training in nonvascular aspects of interventional radiology. CONCLUSIONS: Integration of vascular surgery and interventional radiology fellowships is feasible and is mutually beneficial to both disciplines. Furthermore, the integrated fellowship provides exceptional training for vascular surgery and interventional radiology fellows in all catheter-based techniques that far exceeds the minimum requirements for credentialing suggested by various professional societies. There is a clear need for cooperation and active involvement on the parts of the American Board of Radiology and the American Board of Surgery and its Vascular Board to create hybrid training programs that meet mutually agreed-on criteria that document sufficient acquisition of both the cognitive and technical skills required to manage patients undergoing endovascular procedures safely and effectively.

Transjugular Intrahepatic Portosystenlic Shunts: TIPS.

The emergency management of patients with acute variceal bleeding has evolved dramatically over the past 20 years. Initially, bleeding was controlled by supportive medical measures in conjunction with surgical portal decompression procedures. However, the high operative mortality and the significant incidence of post-operative encephalopathy associated with emergency portal decompression led to the development of alternative therapeutic techniques. Injection sclerotherapy has been used in large numbers of patients for the past 10 years with considerable success and is now advocated by many authors as the treatment of choice for acute variceal hemorrhage. While sclerotherapy controls bleeding in approximately 70 per cent of patients, repeat sessions are necessary in 20 per cent and sclerotherapy may be unsuccessful in 10 per cent. When sclerotherapy fails, most authors recommend surgical shunting. While the side-side portacaval shunt is still the most popular operation in this setting, other types of shunts have been advocated by some authors. A small mesocaval or portacaval H-graft, or a distal splenorenal shunt may he performed in an attempt to reduce the incidence of post-operative encephalopathy and liver failure.