Results and hemodynamic changes after interposition mesocaval shunt.

Forty-seven patients have been treated by interposition mesocaval shunting for portal hypertension and variceal bleeding between December 1973 and March 1980. The average age was 55 years. The underlying diseases were alcoholic cirrhosis in 26 patients (56%), macronodular cirrhosis in 11 patients (23%), and other causes in 10 patients (21%). Thirty-five operations (75%) were performed on an emergency basis for patients who continued to bleed after failure of conservative management. In these patients, the early mortality rate was 43%. Overall survival, rebleeding, and postshunt encephalopathy rates are correlated with the preoperative Child's classification. These figures are similar to those reported for end-to-side portocaval shunts. The improvement in postshunt encephalopathy rates as reported by Drapanas is not borne out by our results. Postshunt angiography was performed in 31 patients and shunt patency was confirmed in 28 (90%). In 26 patients, selective studies to determine portal flow patterns were carried out, and in only three patients was there any evidence of hepatopedal flow. In each of these patients, some kinking of the shunt was noted. Mesocaval shunting is a reasonable alternative to end-to-side portocaval shunts and is associated with similar rates of patency, rebleeding, mortality, and late postoperative encephalopathy. A well-constructed, patent mesocaval shunt totally diverts portal flow.

Transluminal dilation. An alternative?

In a prospective study, 384 peripheral arterial transluminal dilations were evaluated, using clinical and vascular laboratory criteria, and analyzed by the life-table method. The overall cumulative success rate was 58.9 +/- 3.3% (mean +/- SEM) after two years but was higher if the iliac segment was dilated, only one site was dilated, the clinical indication was claudication, the distal vessels were normal, the ankle-brachial BP ratio was more than 0.35, or if the patient was younger than 55 years. The complication rate was 3.9%. If the dilation failed, the symptoms were worse in 8% and the ankle-brachial BP ratio fell in 23%. After successful dilation in patients with normal distal vessels, residual claudication persisted in 34%, and the ankle-brachial BP ratio remained abnormal in 40%. Although the overall success rate of transluminal dilation was lower than for a comparable surgical procedure, dilation does have a role in the management of localized peripheral vascular disease.

Percutaneous transluminal recanalization of complete iliac artery occlusions.

Percutaneous transluminal recanalization of ten complete iliac artery occlusions were attempted using the Grüntzig balloon catheter. The procedure was successful in eight of the ten occlusions, including all seven in which only one of the common or external iliac arteries was obstructed. Follow-up for periods of three to 13 months (average, eight months) showed continued patency in all cases. Although the long-term results remain to be determined, our preliminary results suggest that transluminal recanalization of complete obstruction of the iliac arteries is an alternative to surgery.

Hepatic venography in the surgical assessment of hepatic tumours.

Hepatic venography was performed on 80 patients with hepatic tumours for the pre-operative assessment of resectability. Sixty-six patients subsequently underwent laparotomy, 27 undergoing hepatic resection. Forty-two patients had metastases from colo-rectal primaries, 19 hepatocellular carcinoma and 19 a variety of other tumours. The type and frequency of the abnormalities shown on venography were noted for each tumour category and for their hepatic segmental distribution. The results of venography were compared with those of arteriography, computed tomography and ultrasound and with the findings at laparotomy. Displacement was the commonest abnormality seen while encasement or obstruction occurred less frequently and tumour invasion was rare. The sensitivity of venography in correctly identifying the segmental distribution of tumour deposits was 41%. Sensitivity was poorest with tumours in the left lobe (31%) and bilobar tumours (0%). Venography was most sensitive in detecting tumour involvement of the major segmental hepatic veins and inferior vena cava (100%). Peripheral colo-rectal metastases frequently produced no venographic abnormality. Hepatic venography provides no additional information to arteriography, computed tomography or ultrasound in patients with peripheral or bilobar tumour deposits. Some additional information may be obtained with central tumours and venography is the most accurate means of detecting tumour involvement of the major segmental hepatic veins.

Difficulty in assessing the severity of aorto-iliac disease by clinical and arteriographic methods.

Accurate hemodynamic assessment of the severity of aorto-iliac disease has important implications in the management of patients with symptomatic peripheral arterial occlusive disease. This study has documented that history, clinical examination, and single-plane angiography are often unsatisfactory for assessing the hemodynamic significance of an aorto-iliac lesion. The use of oblique angiographic views, certain noninvasive methods, such as quantitative Doppler waveform analysis, and direct pressure measurements will be of benefit in difficult cases and lead to a more accurate diagnosis.

Inadvertent percutaneous transluminal dilatation of a renal artery with a four-year follow-up.

The author presents a case of severe stenosis of the left renal artery with poststenotic dilatation. While performing a left arteriogram, a catheter was passed inadvertently through the stenosis, which resulted in the angiographic disappearance of the stenosis and the disappearance of an accompanying abdominal bruit. Dilatation was maintained when he returned four years later with hypertension and stenosis of the right renal artery. A left renal angiogram showed no stenosis. The long term result of this case suggests that deliberate dilatation of renal arteries may last for several years.

Transjugular biopsy of the liver.

Percutaneous liver biopsy is the procedure of choice for most patients because of its simplicity and the high percentage of adequate biopsies obtained. It is a bedside procedure that does not require specialized equipment or the services of a highly trained angiographer. Nevertheless, complications are not uncommon unless strict contraindications are observed. It is usually recommended that patients be excluded who present with ascites, a prothrombin time less than 50%, a partial thromboplastin time greater than 10 s, or a platelet count less than 50 000. Mahal et al (1979) cite lack of attention to the contraindications as the most important factor in 22 bleeding episodes which occurred following 3800 percutaneous biopsies (0.7%). It is these contraindications that are the main indication for transjugular biopsy. Despite the highly selective nature of the patients who have undergone transjugular biopsy, the frequency of post-biopsy bleeding is only 0.35% and of death 0.13% (Table 1). These figures include the earliest experiences with this technique and can be expected to improve with increased experience and the development of new instruments that make the procedure safer and easier. Transjugular liver biopsy should be an essential procedure in every hospital that is involved in treating patients with liver disease. Unfortunately, although Lebrec et al (1982) estimated that approximately 30% of patients are rejected for percutaneous biopsy because of the presence of contraindications, relatively few centres have adopted this technique. This may be in part due to the reluctance of clinicians to subject their patients to a procedure they perceive as stressful, although a study by Poynard and Lebrec (1982) showed patients rated transjugular biopsy as less painful and inconvenient than percutaneous biopsy.

Femoral artery compression device for outpatient angiography.

To avoid late bleeding from the femoral artery puncture site after outpatient femoral angiography, a compression device was designed to exert continuous pressure over the groin, even when the patient is upright. It has been successfully used in more than 2,000 arterial catheter procedures. The device can also help prevent bleeding in patients who are at increased risk because of hypertension or anticoagulant therapy.

Liver biopsy through the transjugular approach. Modification of instruments.

Two modifications of the needle to facilitate transjugular biopsy of the liver are described. The bevel is reversed to prevent perforation of the catheter by the needle, and a stylet is placed within the needle to prevent aspiration of fragmented specimens into the syringe.

Transluminal dilatation in the management of mesenteric angina: a report of two cases.

Two patients with typical clinical and angiographic findings of mesenteric angina are reported. Both remain asymptomatic seven and 11 months respectively, after transluminal dilatation of superior mesenteric artery stenoses.

Peripheral arterial transluminal dilatation: early results.

Over a 3-year period, 275 transluminal dilatations were performed for the treatment of peripheral arterial occlusive disease. The results have been evaluated prospectively using radiologic, clinical and noninvasive criteria. The cumulative success rates for all dilatations were 63 +/- 4% (mean +/- 1 standard error) at 1 year and 53 +/- 5% at 2 years, but varied depending upon the site of the dilatation and the extent of the arteriosclerosis. The results are best in patients who have short, localized stenoses or occlusions, especially in the iliac arteries.

Transluminal angioplasty of complete iliac obstructions.

Of 64 complete iliac obstructions, 50 (78%) were recanalized using the Gruntzig balloon catheter. Life-table analysis of the patency rate over a 4-year period gives a cumulative success rate of 78%. Only three of eight obstructions that involved both the common and external iliac arteries were successfully dilated. The only serious complication was distal embolization, which occurred in two cases (3.1%). Although the procedure is difficult, with a relatively low technical success rate, the high cumulative patency rate should make it an option in the treatment of all patients with totally occluded iliac artery segments.

Intestinal angina: percutaneous transluminal angioplasty of the celiac and superior mesenteric arteries.

Percutaneous transluminal angioplasty (PTA) was performed in ten patients with chronic ischemia of the mesenteric arteries and stenoses of the celiac artery and/or the superior mesenteric artery (SMA). PTA was performed on 14 occasions, with attempted dilation of 19 arteries. PTA was technically unsuccessful in two patients. Seventeen of 19 arteries (90%) were successfully dilated in eight patients, resulting in relief of symptoms that lasted from 6 to 24 months. Symptoms recurred in five patients, and redilation in three of them relieved the symptoms. Three patients, one of them following redilation, remained asymptomatic 7-9 months following PTA. An asymptomatic intimal dissection of the SMA was the only complication attributable to the procedure. PTA of celiac and SMA stenoses is an alternative to surgical revascularization and can be repeated if symptoms recur.

Percutaneous transluminal angioplasty of abdominal aortic stenoses.

Percutaneous transluminal angioplasty (PTA) was performed on 25 patients with localized distal abdominal aortic stenoses. All patients were smokers and all complained of bilateral lower limb claudication. Eleven patients had small distal aortas and iliac vessels. Technically successful dilatation was achieved in all patients. Long-term follow-up was available on 17 of the patients. The mean follow-up period was 38 months. Cumulative patency at 5 years was 70%. Thirteen patients remain asymptomatic 15-83 months following PTA. Late failure occurred in 4 patients, 1-38 months following PTA. No complications related to PTA were experienced. PTA of localized aortic stenoses is a safe alternative to surgery and should be the treatment of choice in this condition.

Percutaneous transluminal angioplasty of peripheral vascular disease: a two-year experience.

Over a 23-month period, 172 successful peripheral angioplasties were performed. Life-table analysis gave a two-year patency rate for the total series of 80%. The patency rate for aorto-iliac and femoral-popliteal lesions was 86% and 70%, respectively. Only one late failure occurred in the group of 44 arteries followed for longer than eight months.

Percutaneous transluminal dilatation and recanalization in the treatment of peripheral vascular disease.

Ninety-four successful transluminal angioplasties were followed up for as long as 15 months, during which time 15 failures occurred. Life-table analysis of this series gave a cumulative patency rate of 64%. The patency rate of 70% for iliac lesions, compared to 50% for the femoral-popliteal group, suggests that the former are likely to have a better long-term prognosis. In selected cases, transluminal angioplasty is a viable alternative to surgery that should be available to both patient and physician.

Pheochromocytoma in the modern context.

The hypertensive patient faces an uncertain future. Therefore a search for those cases in which the condition is potentially curable is eminently worth while and has become increasingly productive because of the specific diagnostic aids now available and because of the present safety of surgical intervention. Detection and localization of a pheochromocytoma allows a planned surgical approach. Correction of hypovolemia preoperatively ensures a safe course postoperatively. The use of blocking agents pre- and peroperatively prevents the hazardous hypertensive crises and arrhythmias that were a part of early surgical experience. Monitoring of central venous and arterial pressures as well as the electrocardiographic tracing during the operation permits prophylactic therapy when necessary. On the basis of a series of 31 patients the authors compare many aspects of the current management with earlier experience of pheochromocytoma in the same institution. The incidence of extra-adrenal lesions (3.8%), multicentric tumours (3.8%) and malignant change (11.5%) was lower in this group of patients than that usually reported. Abdominal exploration remains the approach of choice in most cases. Treatment of the solitary pheochromocytoma has become straightforward. However, management of the familial syndromes and the malignant from of the disease still requires careful scrutiny.

Renal and hemodynamic effects of the peritoneovenous shunt. II. Long-term effects.

The long-term renal and hemodynamic effects of the peritoneovenous shunt for intractable ascites were studied in 11 patients to elucidate the mechanism of its persistent beneficial effect. Sodium balance studies were performed in 7 patients. All had patent shunts and no clinically detectable ascites. On a 20-mEq sodium diet, the mean sodium excretion was 17.2 +/- 5.3 mEq/day which was increased over the preoperative mean of 2.4 +/- 0.4 (p < 0.025) on the same diet. There was a 100% increase in creatinine clearance over the preoperative level (p < 0.0005). The mean plasma renin activity and serum aldosterone levels were within normal limits in most patients, and the sodium excretion correlated inversely with the levels of each. During 100-mEq sodium challenge diet, the sodium excretion ranged from 4 to 130 mEq/day with a mean of 56.1 +/- 16.5 and with 6 of the 7 patients displaying sodium retention. On this diet the mean creatinine clearance was 104.3 +/- 6.4 ml/min, and the mean plasma renin activity and serum aldosterone levels had decreased physiologically with the higher sodium intake. Again the sodium excretion correlated inversely with the serum aldosterone on the 100-mEq sodium diet. In 8 patients, the portal pressure, as reflected by the wedge hepatic vein pressure, had decreased by a mean of 37% (p < 0.0005). But, despite this, 2 of the 8 patients had major variceal hemorrhages postoperatively. There was a significant inverse correlation between the increase in sodium excretion and the fall in portal pressure in 4 patients. Thus, sodium retention in cirrhosis is multifactorial with the reninaldosterone system and, possibly, portal hypertension per se both playing a role. Peritoneovenous shunting in carefully selected patients partially reverses the sodium retention and renders patients more manageable over the long term.

Scintigraphy and arteriography in the diagnosis of diseases of the liver.

Arteriograms and scans performed over a five-year period on 60 patients with suspect hepatic disease have been reviewed. The diagnosis was proved in every case by biopsy, autopsy or laparotomy. Scintigraphy correctly predicted the presence or absence of disease in 75% and arteriography in 75% of cases. Fifty-four of the patients had hepatic disease. In 81% of these the accurate diagnosis of diffuse or localized disease was made by one or both techniques. Arteriography is preferred for the detection of localized lesions, but diffuse processes are more readily demonstrated by scintigraphy.