Impact of HIV on liver fibrosis in men with hepatitis C infection and haemophilia.

Hepatitis C virus (HCV) is the major cause of liver disease in haemophilia. Few data exist on the proportion with liver fibrosis in this group after long-term HCV and HIV co-infection. We conducted a cross-sectional multi-centre study to determine the impact of HIV on the prevalence and risk factors for fibrosis in haemophilic men with chronic hepatitis C. Biopsies were independently scored by Ishak, Metavir and Knodell systems. Variables were tested for associations with fibrosis using logistic regression and receiver operating curves (ROC). Of 220 biopsied HCV(+) men, 23.6% had Metavir ≥ F3 fibrosis, with higher mean Metavir fibrosis scores among HIV/HCV co-infected than HCV mono-infected, 1.6 vs. 1.3 (P = 0.044). Variables significantly associated with fibrosis included AST, ALT, APRI score (AST/ULN × 100/platelet × 10(9) /L), alpha-fetoprotein (all P < 0.0001), platelets (P = 0.0003) and ferritin (P = 0.0008). In multiple logistic regression of serum markers, alpha-fetoprotein, APRI and ALT were significantly associated with ≥ F3 fibrosis [AUROC = 0.77 (95% CI 0.69, 0.86)]. Alpha-fetoprotein, APRI and ferritin were significant in HIV(-) [AUROC = 0.82 (95% CI 0.72, 0.92)], and alpha-fetoprotein and platelets in HIV(+) [AUROC = 0.77 (95% CI 0.65, 0.88]. In a multivariable model of demographic and clinical variables, transformed (natural logarithm) of alpha-fetoprotein (P = 0.0003), age (P = 0.006) and HCV treatment (P = 0.027) were significantly associated with fibrosis. Nearly one-fourth of haemophilic men have Metavir ≥ 3 fibrosis. The odds for developing fibrosis are increased in those with elevated alpha-fetoprotein, increasing age and past HCV treatment.

Long-term fate of the aneurysmal sac after endoluminal exclusion of abdominal aortic aneurysms.

PURPOSE: Shrinkage of an abdominal aortic aneurysm (AAA) is the hallmark of successful endoluminal treatment. Our goal was to prospectively assess the midterm to long-term shrinkage of the AAA sac after endovascular repair. METHODS: A total of 123 patients with AAA underwent endoluminal treatment with the Ancure device at our institution between February 1996 and February 2000. At least a 1-year follow-up was available for 70 of the 123 patients. AAA sac size, presence of endoleaks, calcifications, and outcome data were collected on these patients at 6, 12, 24, and 36 months after repair and compared with the preoperative AAA size and characteristics. All endoleaks found at the 6-month follow-up visit were treated aggressively with embolotherapy. An AAA sac regression of 0.5 cm or more was considered the minimum measurable decrease. Regression of the sac diameter to 3.5 cm or less was considered a complete collapse of the sac. RESULTS: Successful endoluminal repair was accomplished in 119 of 123 patients. The mortality rate was 0.8% (1/123). There was a steady decrease in AAA sac size from baseline (5.56 +/- 0.1 cm), to 6 months (5.0 +/- 0.14 cm, P =.0006), to 12 months (4.65 +/- 0.13 cm, P =.04), and to 24 months (4.26 +/- 0.16 cm, P =.03). At 24 months, 74% (29/39) had a decrease in sac size of 0.5 cm or more, with 28% (11/39) complete collapse. Patients with initial endoleaks had the same likelihood of regression of sac size (> or = 0.5 cm) when compared with the group of patients with no endoleaks at the 24-month evaluation (64% vs 76%, P =.09). CONCLUSION: Endoluminal AAA repair resulted in a significant reduction in sac size that continues up to 2 years. Significant shrinkage occurs as early as 6 months after placement. The initial presence of endoleaks does not predict the lack of sac regression.

Endovascular treatment of iliac limb stenoses or occlusions in 31 patients treated with the ancure endograft.

PURPOSE: The authors report their experience with treatment of iliac limb complications in patients treated with the Ancure endograft with Wallstents to provide additional support and thrombolysis when needed. MATERIALS AND METHODS: From February 1996 to October 1999, 88 patients were treated for abdominal aortic aneurysm with use of the Ancure endograft. Of the 88 devices used, 20 were tube grafts and the remaining 68 devices had a total of 130 iliac limbs (bifurcated, n = 62; aortoiliac, n = 6). After graft deployment, all patients underwent intraoperative aortography; since July 1997, intravascular ultrasound (IVUS) has also been used. RESULTS: Thirty-one patients (46%) required treatment of 47 (36%) limbs with Wallstents. Graft narrowing was observed in 41 limbs (27 patients) with IVUS immediately after graft deployment. All were successfully treated with placement of Wallstents. Before routine use of intraoperative IVUS, three patients presented between 2 and 6 weeks postoperatively with iliac limb thrombosis. All three limbs were successfully treated with thrombolysis and Wallstent placement to correct the underlying iliac problem. Additionally, two contralateral limbs in these three patients were also noted to have stenosis and were treated with use of Wallstents. The last patient required placement of a Wallstent to treat stenosis of surgical anastomosis of the iliac limb of an aortoiliac endograft at 3 days. All Wallstent-reinforced Ancure endografts remained patent from 1 to 36 months (mean, 14 months). CONCLUSION: After placement of an Ancure bifurcated or aortoiliac endograft, iliac limb stenosis is easily detected with use of intraoperative IVUS. Such complications can be safely corrected with Wallstent placement. Postoperative limb occlusion at the authors' institution has been eliminated with such intervention.

Endovascular repair of the abdominal aortic aneurysm with the ancure endograft: CT follow-up of perigraft flow and aneurysm size at 6 months.

PURPOSE: Perigraft flow--flow outside the graft lumen but contained within the abdominal aortic aneurysm (AAA)--is a potential complication after endovascular repair of AAA. Such flow may permit AAA growth and rupture. The purpose of this study is to evaluate with computed tomography (CT) the rate of spontaneous closure of perigraft flow and the effect of persistent flow on AAA diameter. MATERIALS AND METHODS: During a 30-month period, the authors evaluated all CT scans in 50 patients who underwent AAA repair using the Ancure endograft system. CT was performed at discharge, 6, 12, and 24 months, and at 3 months if there was perigraft flow at discharge. Scans were reviewed for the presence, size, and location of perigraft flow, and measurement of AAA diameter. Transcatheter embolization was performed on those patients with persistent leak at 6 months. RESULTS: Sixteen (32%) of 50 patients demonstrated perigraft flow on CT performed within 72 hours of placement. Resolution of perigraft flow by 6 months was found in nine (56%) of the 16 patients, in whom AAA size had decreased in five, had increased in none, and was unchanged in four. Seven patients had persistent leaks at 6-month CT; AAA size had decreased in one, had increased in one, and was unchanged in five. In 34 patients without leaks, AAA size had decreased in nine, had increased in one, and was unchanged on 24. There was no statistically significant difference for the relationship between resolution or persistence of perigraft flow and subsequent course of AAA diameter (P = .16). CONCLUSIONS: Although perigraft flow is frequently seen (32%) early after repair of AAA with the Ancure system, spontaneous resolution by 6 months occurs in 56% of cases. AAA size decreased in a larger percentage of patients in whom perigraft leak was absent or resolved by 6 months compared with those in whom perigraft leak persisted at 6 months.

Balloon dilation and endobronchial stent placement for bronchial strictures after lung transplantation.

PURPOSE: To evaluate the effect of balloon dilation and endobronchial stent placement for bronchial fibrous stenoses and bronchomalacia after lung transplantation. MATERIALS AND METHODS: Bronchial dilation and/or stent placement was performed on 25 lung transplant recipients. Indications included severe dyspnea with postobstructive pneumonia (n = 24) and respiratory failure (n = 1). All patients underwent pulmonary function testing (PFT) before and after bronchial dilation, the results of which were evaluated for changes. A total of 63 procedures were performed between February 1996 and December 1998. Thirty-five lesions were treated (18 were due to bronchomalacia, 17 were due to fibrosis). Areas treated included the left mainstem bronchus (n = 11), bronchus intermedius (n = 10), right mainstem bronchus (n = 7), left upper lobe bronchus (n = 4), right lower lobe bronchus (n = 2), and right middle lobe bronchus (n = 1). Bronchoscopic and/or bronchographic follow-up ranged from 1 to 34 months (mean, 15 months). RESULTS: Six-month primary patency of stents placed for bronchomalacia was 71% (10 of 14), with three of the four occlusions caused by mechanical failure of Palmaz stents in the mainstem bronchi. Six-month primary patency for treatment of fibrous strictures was 29%. Secondary patency at 1 year was 100% for both bronchomalacia and fibrous strictures. After treatment, there was a significant improvement in mean PFT results (P = .01-.0001). There was one acute complication, obstruction of the left lower lobe bronchus by a Wallstent treated by dilating a hole in the side of the stent. CONCLUSIONS: Balloon dilation and stent placement are safe and effective for bronchial strictures and bronchomalacia after lung transplantation, resulting in significant improvement in PFT results. However, there is almost universal restenosis in patients treated for fibrous strictures necessitating reintervention for prolonged patency.

Embolotherapy of persistent endoleaks after endovascular repair of abdominal aortic aneurysm with the ancure-endovascular technologies endograft system.

PURPOSE: Endoleak is a potential complication after endovascular repair of abdominal aortic aneurysm (AAA). It may result in continued growth of the aneurysm and potentially result in aneurysm rupture. The authors present their experience with embolotherapy in patients with persistent perigraft flow treated with the Ancure-Endovascular Technologies endograft system. MATERIALS AND METHODS: Between February 1996 and August 1998, 54 patients underwent successful repair of AAA with use of the Ancure system. All underwent operative angiography and discharge computed tomography (CT). Follow-up included CT at 6, 12, and 24 months, and CT was also performed at 3 months if an endoleak was present on the discharge CT. Persistent endoleak was defined as perigraft flow still present on the 6-month CT. Seven of 21 initial endoleaks persisted at 6 months. Six patients returned for embolization of the perigraft space and outflow vessels including lumbar arteries and the inferior mesenteric artery (IMA). RESULTS: Five of the six patients had leaks from the proximal (n = 1) or distal attachment sites (n = 4) of the Ancure system with outflow into lumbar arteries and/or the IMA; one leak was caused by retrograde IMA flow. The six patients underwent nine embolization procedures with only one minor complication. Follow-up CT showed complete resolution of endoleak and decrease in size of the aneurysm sac in all patients. CONCLUSIONS: Although endoleak is commonly seen initially with the Ancure system, persistent leak occurred in 13% of the patients in the study. Persistent flow in most patients arises from a graft attachment site combined with patent outflow vessels such as the IMA or lumbar arteries. Persistent endoleaks can be effectively and safely embolized with use of a combination of coil embolization of the perigraft space and embolization of outflow vessels. Such intervention resulted in a decrease in size of the aneurysm sac.

Transjugular intrahepatic portosystemic shunt in patients who have undergone liver transplantation.

PURPOSE: Transjugular intrahepatic portosystemic shunt (TIPS) placement is an accepted treatment for refractory variceal bleeding and/or ascites in end-stage liver disease and is an effective bridge to liver transplantation. The authors present their experience with TIPS in patients with a liver transplant, who subsequently developed portal hypertension. MATERIALS AND METHODS: Thirteen TIPS were placed in 12 adult patients from 6 months to 13 years after liver transplantation for variceal bleeding that failed endoscopic treatment (n = 6) and intractable ascites (n = 6). All patients were followed to either time of retransplantation or death. RESULTS: No technical difficulties were encountered in TIPS placement in any of the patients. Four of six patients treated for bleeding stopped bleeding and did not experience re-bleeding, two had functional TIPS at 3 and 36 months and two underwent retransplantation at 3 and 7 months. Two patients had recurrent bleeding within 1 week and required reintervention. In the ascites group, one is 32 months since TIPS placement with control of his ascites, two patients underwent retransplantation at 2 and 6 weeks with interval improvement in ascites. Two patients died within a week of TIPS of fulminant hepatic failure. The last patient died 1 month after TIPS subsequent to a splenectomy. CONCLUSION: In conclusion, the placement of a TIPS in a transplanted liver, in general, requires no special technical considerations compared to placement in native livers. Although this series is small, the authors believe that TIPS should be considered a treatment option in liver transplant recipients who present with refractory variceal bleeding. TIPS may have a role in the management of intractable ascites.

Thrombolysis and endovascular stent placement for inferior vena caval thrombosis in a liver transplant recipient.

BACKGROUND: Vascular complications remain an important cause of postoperative morbidity in liver transplant patients. Herein, we present an unusual case of nonanastomotic inferior vena cava (IVC) stenosis in a patient with a "piggyback" caval anastomosis. METHODS: A 59-year-old woman underwent liver transplantation using a piggyback IVC anastomosis. Her postoperative course was complicated by IVC thrombosis. Catheter-directed thrombolysis, followed by balloon angioplasty and intravascular stent placement, was used to recanalize the IVC and treat a severe retrohepatic IVC stenosis. RESULTS: After 46 hr of catheter-directed urokinase infusion, there was clot lysis and identification of a severe stenosis in the retrohepatic IVC. The lesion was extremely resistant to balloon dilatation alone and a 22-mm-diameter intravascular stent was placed. Simultaneous dilatation of three high-pressure balloons was necessary for maximal stent expansion. The patient remains asymptomatic with no evidence of IVC compromise through 20 months of follow-up. CONCLUSIONS: IVC stenosis and thrombosis after liver transplantation may be treated favorably in some patients using catheter-directed thrombolytic therapy followed by balloon dilatation and/or stent placement.

Cholangiographic features of biliary strictures after liver transplantation for primary sclerosing cholangitis: evidence of recurrent disease.

OBJECTIVE: Biliary strictures occur more frequently after liver transplantation for primary sclerosing cholangitis (PSC) than for other diseases. A hypothesized cause is recurrence of PSC in the liver graft. In our study, we compared cholangiographic features of biliary strictures after transplantation for PSC to those after transplantation for other diseases. MATERIALS AND METHODS: A study group of 32 PSC grafts in adults with biliary strictures was compared with a control group of 32 non-PSC grafts with strictures. Both groups were matched for the type of biliary anastomosis (choledochojejunostomy) and for the time interval between transplantation and stricture diagnosis. We then performed a blind retrospective review of cholangiograms in these 64 cases to evaluate for features of PSC. RESULTS: Location, number, and length of strictures and ductal dilatation were similar in the PSC and non-PSC groups. Mural irregularities of bile ducts were present in 15 of 32 (47%) PSC grafts compared with four of 32 (13%) in the control group (p=.005). Diverticulum-like outpouchings occurred in six of 32 (19%) PSC graft compared with one of 32 (3%) in the control group. An overall resemblance to PSC was observed in eight of 32 (25%) grafts in the PSC group compared with two of 32 (6%) in the control group. CONCLUSION: Mural irregularity and diverticulum-like outpouchings--findings suggestive of PSC--and an overall appearance resembling PSC occur more frequently in PSC transplants than in transplants for other diseases. These findings are consistent with the hypothesis that PSC may recur in liver transplants.

Transjugular intrahepatic portosystemic shunt in patients with end-stage liver disease: results in 85 patients.

Transjugular intrahepatic portosystemic shunt (TIPS) is becoming an accepted procedure as a bridge to orthotopic liver transplantation (OLT) in patients with end-stage liver disease (ESLD) and bleeding from portal hypertension. It allows the immediate control of acute bleeding and decreases the risk of recurrent acute bleeding while the patient is awaiting OLT. We review in this report, our experience with 85 patients who underwent a TIPS procedure for gastrointestinal variceal bleeding from September 1991 until April 1994. All patients had liver cirrhosis and all had previous sclerotherapy before TIPS. Child-Pugh score was calculated at enrollment, and all patients were evaluated for possible OLT. Thirteen patients were Child A, 49 were Child B, and 23 were Child C. Fifty-three patients were candidates for OLT, and 32 were not. TIPS was performed urgently in 25 patients. At a median follow-up of 582 days (range, 1 to 1,095), 35 patients underwent transplantation, 21 patients died, and 29 patients are still alive and did not undergo transplantation. Technical complications were observed in 7% of patients and new onset of clinical encephalopathy in 37%. The 30-day mortality rate after TIPS was 13%. Actuarial survival was 60% at 1 and 3 years. Child class C and urgent TIPS were shown to be two independent predictor factors for mortality. TIPS was shown to be a valuable procedure, not only as a bridge to OLT but also as palliation for bleeding from portal hypertension in patients who were not candidates for either surgical shunt or OLT. However, its role in bleeding patients with acceptable liver function needs further investigation.

Transjugular liver biopsy: a prospective study in 43 patients with the Quick-Core biopsy needle.

PURPOSE: To evaluate the efficacy and complication rate of the Quick-Core biopsy needle system compared with traditional transjugular biopsy needle systems. MATERIALS AND METHODS: Between January 1994 and April 1995, 43 patients underwent transjugular liver biopsy with the Quick-Core system; 18-, 19-, and 20-gauge needles were used in 28, 13, and two patients, respectively. Histologic diagnoses, specimen dimensions, and adequacy of the biopsy sample were determined. Immediate and delayed complications were recorded. RESULTS: A total of 118 biopsy specimens were obtained with an average of 2.7 passes per patient. Biopsy was successful in 42 of 43 patients (98%); one specimen contained renal parenchyma. Of the specimens that contained liver tissue, 100% were adequate. Mean maximum sample lengths were 1.1 and 1.5 cm with the 18- and 19-gauge needles, respectively. The procedural complication rate of 2% was due to puncture of the liver capsule in one patient, but no clinical manifestations occurred. No delayed complications occurred in any patient. CONCLUSION: The Quick-Core biopsy system produces consistently satisfactory, reproducible specimen cores with a very low complication rate.

Arteriocholedochal fistula: an unusual cause of hemobilia.

We report an unusual cause of hemobilia in a patient with a transhepatic biliary catheter. Hemobilia was due to an extrahepatic fistula between the gastroduodenal artery and the common bile duct and was responsible for significant blood loss. The fistula was successfully treated with transarterial embolization that resulted in no further episodes of hemobilia during the following 12 months.

Biliary stones and sludge in liver transplant patients: a 13-year experience.

PURPOSE: To determine the prevalence, radiologic features, and clinical significance of bile duct filling defects (BDFDs) in liver transplant recipients studied with cholangiography. MATERIALS AND METHODS: During 13 years, 4,100 cholangiograms were obtained in 1,650 patients. All studies showing BDFD suggestive of stones, sludge, cast, or necrotic debris were retrospectively evaluated. RESULTS: The prevalence of BDFD was 5.7% (n = 94). On the basis of cholangiographic appearance, BDFDs were categorized as sludge or cast in 53 grafts (56%), stones in 32 (34%), and necrotic debris in nine (10%). Forty-three patients (46%) underwent surgical biliary reconstruction, while 14 (15%) underwent interventional radiologic treatments. Twenty-four of 32 stones (75%) were treated with surgical reconstruction, compared with 31% (19 of 62 grafts) of other BDFDs (P < .0001). Necrotic debris and sludge were associated with hepatic artery occlusion in seven of nine (78%) and 16 of 53 (30%) grafts, respectively. CONCLUSION: Stones and sludge are relatively infrequent after liver transplantation but are associated with high morbidity. Surgical or interventional radiologic treatments are usually performed. Bile duct stones are usually treated with surgical biliary reconstruction. While debris and bile duct necrosis are due to ischemia from hepatic artery occlusion, sludge may also have an ischemic pathogenesis in some cases.

Hepatic artery stenosis in liver transplant recipients: prevalence and cholangiographic appearance of associated biliary complications.

OBJECTIVE: The occurrence of biliary strictures or bile duct necrosis in liver transplant recipients with hepatic artery stenosis has been well documented. This study was done to determine the prevalence and cholangiographic appearance of biliary complications in liver transplant recipients with hepatic artery stenosis and to determine if such complications occur with increased frequency compared with transplant recipients with patent hepatic arteries. MATERIALS AND METHODS: The study population consisted of 33 patients (17 male, 16 female; 1-65 years old) with angiographically proven significant hepatic artery stenosis after liver transplantation. All patients had T-tube or percutaneous transhepatic cholangiography performed within 4 months of hepatic arteriography. A retrospective review of radiographs was done to determine the prevalence and appearance of biliary complications in the study group compared with a control group of 58 patients with angiographically patent hepatic arteries who had liver transplants during the same period. RESULTS: Biliary complications were significantly more prevalent in patients with hepatic artery stenosis, with 22 (67%) showing cholangiographic abnormal findings compared with 16 (28%) in the control group (p = .001). The most significant abnormalities in patients with arterial stenosis were nonanastomotic biliary strictures seen in 16 (49%), compared with 13 (22%) in the control group (p = .04). Other findings (intraductal filling defects, anastomotic biliary stricture, and anastomotic bile leak) showed no statistically significant difference between the study and control groups. CONCLUSION: Biliary complications are significantly more prevalent in liver transplant recipients with hepatic artery stenosis. The most common complication seen on cholangiography was nonanastomotic biliary stricture.

Hepatic artery angioplasty after liver transplantation: experience in 21 allografts.

PURPOSE: To assess whether percutaneous transluminal angioplasty (PTA) can help prolong allograft survival and improve allograft function in patients with hepatic artery stenosis after liver transplantation. PATIENTS AND METHODS: Hepatic artery PTA was attempted in 19 patients with 21 allografts over 12 years. The postangioplasty clinical course was retrospectively analyzed. Liver enzyme levels were measured before and after PTA to determine if changes in liver function occurred after successful PTA. RESULTS: Technical success was achieved in 17 allografts (81%). Retransplantation was required for four of 17 allografts (24%) in which PTA was successful and four of four allografts in which PTA was unsuccessful; this difference was significant (P = .03). Two major procedure-related complications occurred: an arterial leak that required surgical repair and an extensive dissection that necessitated retransplantation 14 months after PTA. Hepatic failure necessitated repeat transplantation in seven cases from 2 weeks to 27 months (mean, 8.4 months) after PTA. Six patients died during follow-up, three of whom had undergone repeat transplantation. Markedly elevated liver enzyme levels at presentation were associated with an increased risk of retransplantation or death regardless of the outcome of PTA. CONCLUSION: PTA of hepatic artery stenosis after liver transplantation is relatively safe and may help decrease allograft loss due to thrombosis. Marked allograft dysfunction at presentation is a poor prognostic sign; thus, timely intervention is important.