Management of early hepatic arterial thrombosis after pediatric living-donor liver transplantation.

PURPOSE: Early hepatic arterial thrombosis after living-donor liver transplantation is a cause of graft loss and patient mortality. We analyzed early hepatic arterial thrombosis after pediatric living-donor liver transplantation. MATERIALS AND METHODS: Since September 2001, we performed 122 living-donor liver transplants on 119 children. Ten hepatic arterial thromboses developed in the early postoperative period. The 7 male and 4 female patients of overall mean age of 6.3±6.1 years underwent 5 left lateral segment, 3 right lobe, and 2 left lobe transplantations. RESULTS: Among 10 children with hepatic arterial thrombosis, 8 diagnoses were made before any elevation of liver function tests. One child displayed fever at the time of the hepatic arterial thrombosis. The median time for diagnosis was 5 days. Hepatic arterial thrombosis was treated with interventional radiologic techniques in 9 children, with 1 undergoing surgical exploration owing to failed radiologic approaches, and a reanastomosis using a polytetrafluoroethylene graft. Successful revascularization was achieved in all children, except 1. Four children died, the remaining 6 are alive with good graft function. During the mean follow-up of 52.7±18.8 months, multiple intrahepatic biliary stenoses were identified in 1 child. CONCLUSION: Routine Doppler ultrasonography is effective for the early diagnosis of hepatic arterial thrombosis. Interventional radiologic approaches such as arterial thrombolysis and intraluminal stent placement should be the first therapeutic choices for patients with early hepatic arterial thrombosis; if radiologic methods fail, one must consider surgical exploration or retransplantation.

Evaluation of failing hemodialysis fistulas with multidetector CT angiography: comparison of different 3D planes.

PURPOSE: To evaluate failing hemodialysis fistula complications using 16-detector MDCTA, and to assess the accuracies of different 3D planes. MATERIALS AND METHODS: Thirty patients (16 men, 14 women, aged 27-79 years) were referred for hemodialysis access dysfunction. Thirty-one MDCTA exams were done prior to fistulography. For MDCTA, contrast was administered (2mL/kg at 5mL/s) via a peripheral vein in the contralateral arm. Axial MIP, coronal MIP, and VRT images were constructed. Venous complications were evaluated on axial source images, on each 3D plane, and on all-planes together. Results were analyzed using McNemar test. RESULTS: Axial MIP, VRT and all-planes evaluations were most sensitive for fistula site detection (93%). Coronal MIP had the highest sensitivity, specificity and accuracy (35%, 96%, and 85%, respectively) for detecting venous stenosis. VRT and all-planes had the highest sensitivity and accuracy for detecting aneurysms (100%). All-planes and axial MIP were most sensitive for detecting venous occlusion (61% and 54%). Comparisons of detection frequencies for each venous pathology between the five categories of MDCTA revealed no significant differences (P>0.05). MDCTA additionally showed 3 partially thrombosed aneurysms, 4 anastomosis site stenosis and 12 arterial complications. CONCLUSION: MDCTA overall gives low sensitivity for detection of central vein stenosis and moderate sensitivity for occlusion. For most pathology, all-planes evaluation of MDCTA gives highest sensitivity and accuracy rates when compared to other planes. For venous stenosis and occlusion, MDCTA should be considered when ultrasonography and fistulography are inconclusive. MDCTA is helpful in identifying aneurysms, collaterals, partial venous thromboses and additional arterial, anastomosis site pathologies.

Prognostic value of the PAI-1 4G/5G polymorphism in invasive ductal carcinoma of the breast.

The study group was derived from the archive materials of 55 invasive ductal breast cancer (IDC) patients who had undergone breast-preserving surgery (partial mastectomy/ axillary dissection). All patients included in the study had clinically T(1)-2, N0-M0 invasive ductal carcinoma. Genomic DNA species were extracted from paraffin-embedded blocks, and plasminogen activator inhibitor type-1 (PAI-1) gene 4G/5G genotyping was done by polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP). Patient demographics, axillary metastasis status, metastatic lymph nodi/total dissected lymph nodes from axilla, histopathologic characteristics of tumors, local recurrences, and survival ratio were assessed. PAI-1 4G/5G genotype frequencies were 4G/4G (64%), 4G/5G (31%), and 5G/5G (5%) in the patient group. According to the results based on frequencies, the demographics were not different. Five-year local recurrence rate of 4G/5G patients was the lowest (2/17, 12%) (P = 0.02). Also five-year distant metastases ratio of 4G/5G patients was the highest (18%) (P = 0.01). Five- and 10-year disease-free survival rates for the 4G/4G, 4G/5G, and 5G/5G groups were 97% and 94%, 82% and 77%, and 100% and 94%, respectively (P = 0.004). The results of this study indicate that the 4G allele in the PAI 1 gene had a negative impact on local recurrence and disease-free survival of patients with clinical T(1)-2N0M0 IDC.

Case report: Jejuno-jejunal invagination from metastatic renal cell carcinoma.

Jejuno-jejunal invagination caused by metastatic renal cell carcinoma is a rare entity in the literature. We report a case of metastatic renal cell carcinoma that led to jejuno-jejunal invagination, which was diagnosed by multidedector CT examination.

Spleen size changes in pediatric liver transplant recipients with functioning grafts.

OBJECTIVE: Hypersplenism and splenomegaly are common pathologic conditions in patients with chronic liver failure. Herein we discuss the prognosis of these conditions after orthotopic liver transplantation (OLT) in pediatric patients with functional grafts. MATERIALS AND METHODS: Forty-eight pediatric patients with cirrhosis underwent OLT. Seven patients were excluded from the study because of death within 1 month. Patients were divided into 2 groups: group A consisted of patients with nonfunctioning grafts (n=9), and group B, patients with functioning grafts (n=32). We measured preoperative leukocytes, platelet counts, and spleen sizes. Postoperative measurements were performed at 1 week as well as at 1, 3, 6, and 12 months after grafting. Statistical analyses were performed to evaluate reversal of hypersplenism and splenomegaly after OLT. RESULTS: No change in hypersplenism and splenomegaly was seen in group A, whereas in group B, a statistically significant change was seen in spleen sizes with improvement in hypersplenism after OLT, although persistent splenomegaly was observed in 17 patients. CONCLUSIONS: Reversal of hypersplenism and improvement of splenomegaly can be expected after OLT in pediatric patients with functioning grafts. Although the literature points to the duration of chronic liver disease as a causative factor for persistent splenomegaly in adults, there must be other causes, as the condition is seen in pediatric patients as well.

Accuracy of multidetector computed tomographic angiography for detecting hepatic artery complications after liver transplantation.

AIMS: The aim of this study was to evaluate the accuracy of multidetector computed tomographic angiography (MDCTA) for detecting hepatic artery complications after liver transplantation. METHODS: Between July 2001 and September 2006, 212 patients underwent liver transplantation including 110 (41 female and 69 male patients); of mean age, 24 years (range=6 months to 66 years) who were assessed with MDCTA. First, arterial phase images obtained after intravenous injection of 150 mL of contrast at a rate of 4 mL/s were acquired using the bolus triggering technique. Then portal and late-phase images were obtained. Axial and coronal maximum intensity projection (MIP) images and volume-rendered images were produced from the axial image data. Arterial vascular complications were noted. Stenosis was defined as severe (>75%), moderate (>or=50%), or mild (<50%) according to its diameter. Twenty-nine of the 38 individuals with hepatic artery complications detected by MDCTA had correlative digital subtraction angiography (DSA). Seven of 110 patients with normal hepatic artery and venous pathologies in MDCTA also had DSA to investigate venous complications. RESULTS: MDCTA showed hepatic artery complications in 38 of the 110 patients who were assessed with this modality. DSA confirmed the MDCTA findings in all but 1 of the 29 patients assessed with catheter angiography. Fourteen of the 38 individuals also underwent percutaneous interventions and treatment. Fifteen patients had early hepatic artery complications, and 23 late hepatic artery complications. The most common early complications were thrombosis (66.6%) and stenosis (26.6%). The most common late complications were stenosis (56.5%) and thrombosis (26%). If we evaluate the early and late complications, the incidence of late complications was greater than that of the early complications (61% vs 39%). There was no statistically significant difference in cadaveric and living donor liver transplants for early versus late or for type of complications. CONCLUSIONS: MDCTA is noninvasive imaging modality that accurately shows a variety of vascular complications after liver transplantation. We suggest that if we suspect any vascular complication with Doppler ultrasound, we must perform MDCTA for diagnosis. If we detect severe/moderate stenosis, the patient must undergo DSA.

Abdominal computed tomography findings of malignant tumors in patients with solid organ transplants.

AIMS: Incidence of malignancy in solid organ transplant recipients is higher compared to the general population. The aim of this study was to characterize distribution and appearance of abdominal malignant tumors detected with spiral computed tomography (CT) examination in patients with solid organ transplantation. MATERIALS AND METHODS: Between July 1994 and April 2006, 198 patients underwent liver transplantation and 568 patients underwent renal transplantation in our center. The abdominal CT studies were reviewed to determine the presence or absence of abdominal malignancy. All abdominal CT examinations were performed prior to immunomodulation or chemotherapy. RESULTS: Eleven renal and one liver transplantation patient developed an abdominal malignancy. Among 11 renal transplantation patients eight were diagnosed as abdominal Kaposi's sarcoma (KS) and three as posttransplantation lymphoproliferative disorder (PTLD) upon spiral CT examination. In two patients the transplanted organ itself had malignant tumors: one patient had PTLD with Burkitt lymphoma in the transplanted liver and the other a renal cell carcinoma in the transplanted kidney. Abdominal PTLD and KS showed imaging findings and the site of organ involvement somewhat different from nontransplant patients. The most common pathologies in KS were liver lesions (n=6) and lymphadenopathy (n=6). But in abdominal PTLD, the spleen (n=3) was the most involved organ. CONCLUSIONS: The early diagnosis of abdominal malignancies after solid organ transplantation is crucial for the patient's prognosis, especially under immunosuppression. The abdominal spiral CT examination was an effective modality to depict a malignancy among patients with solid organ transplantation.

Multidetector computed tomography angiography in detection of active bleeding in renal and liver transplant recipients.

OBJECTIVES: The aim of this study was to evaluate the effectivity of multidetector computed tomography angiography (MDCT-A) to detect active bleeding in transplant patients. MATERIALS AND METHODS: Between 1999 and 2006, 532 patients underwent renal or liver transplantation. MDCT-A was performed on recipients who displayed decreased hemoglobin levels or who had a hematoma during abdominal ultrasound imaging. The MDCT-A used a 16-detector CT device (Siemens, Sensation) with slices 0.75 mm thick after injection of nonionic contrast media (4 mL per second). A multiple intensity projection (MIP) technique was used to maintain angiographic images in the axial and coronal planes. RESULTS: MDCT-A detected active bleeding among 23 posttransplant patients: 10 of arterial origin and 13 venous, as proven either by angiography or during operation. Among 8 of the 11 patients who underwent angiographic imaging the arterial origin was embolized. For three patients the angiographic evaluation was not helpful to find the bleeding point. A cohort of 5 of 12 patients did not undergo angiographic evaluation and were followed by clinical and ultrasonographic findings. Seven patients underwent re-operating. DISCUSSION: Management of the patients who were suspected to have active bleeding after renal or liver transplantation was benefitted by MDCT-A as an accurate and feasible screening modality.

Comparison of hemodynamic changes associated with two different polytetraflouroethylene arteriovenous fistulae in hemodialysis patients.

The aim of this prospective study was to identify hemodynamic factors associated with two different types of polytetrafluroethylene (PTFE) AV grafts. The study was conducted on 46 hemodialysis patients over a 3-year period. The subjects were randomly assigned to one of two study groups: Group 1 patients (n = 24) underwent a brachiocephalic loop PTFE fistula; Group 2 patients (n = 22), a brachioaxillary PTFE fistula. Preoperatively, we recorded each individual's subclavian catheter history, hemodialysis frequency, and serum levels of parathormone (PTH), calcium (Ca)-phosphorus (P) product, homocysteine, protein C, and protein S. Doppler ultrasonography was used to evaluate vascular hemodynamic changes in the proximal and distal portions of the AV fistula at 48 hours and 1 week postoperatively. Group 1 showed a significantly greater number of ipsilateral subclavian catheter interventions prior to AV graft surgery than Group 2 (14 versus 7, respectively; P = .05; chi-square). The mean peak systolic velocity in the brachial artery in Group 1 was significantly higher than that in Group 2 at 1-week postoperatively (P = .04, paired t-test). The mean radial artery diameter in Group 1 was greater than that of Group 2 at 1 week postoperatively (P = .05, Student t-test). At 48 hours postoperatively the observed change in cephalic vein diameter in Group 1 was significantly greater than the change in axillary vein diameter in Group 2 (P = .08, paired t-test). Preoperatively, the mean serum protein C and protein S levels in Group 1 were higher than those in Group 2 (P = .03 and P = .04, respectively; Mann-Whitney U test). The total numbers of dialysis sessions per week in each group were significantly different (P = .001, chi-square). Six Group 1 patients exhibited graft thrombosis at 48 hours after AV graft surgery. None of the patients in Group 2 exhibited thrombosis at 48 hours or 1 week postoperatively. The results indicate that patients with brachiocephalic PTFE AV grafts show more significant changes in the cephalic vein and brachial artery than patients with brachioaxillary PTFE AV grafts. The findings also suggest that more ipsilateral subclavian catheter interventions and a higher weekly frequency of hemodialysis prior to AV graft surgery are risk factors for early thrombosis of PTFE AV grafts.

Chondromyxoid fibroma of the temporal bone: CT and MRI findings.

We present the case of a 44-year-old woman with chondromyxoid fibroma of temporal bone origin. Since this is the least common bone tumor of cartilaginous origin, it is highly unusual to find this tumor in the skull. In fact, the literature describes 18 cases of this form of neoplasia arising in the skull, only 4 of these having originated in the temporal bone. To date, the radiological features of these tumors, and especially features detected using the latest imaging modalities, have not been described in detail. This report is unique in that it is the first to present a case of chondromyxoid fibroma of the temporal bone accompanied by detailed CT and MRI findings.

Pachymeningitis and optic neuritis in rheumatoid arthritis: MRI findings.

Rheumatoid arthritis is a systemic disease in which cerebral and eye involvement is neither common nor fully understood. Although it is rarely the cause of pachymeningitis and optic neuritis, rheumatoid arthritis should always be kept in mind in these two conditions. We present a 52-year-old male with an 8 month history of rheumatoid arthritis who was referred to the neurology department with headache and decreasing vision and was diagnosed as having rheumatoid pachymeningitis and optic neuritis on the basis of MRI findings.