Weight loss in a patient with polycystic kidney disease: when liver cysts are no longer innocent bystanders.

OBJECTIVE AND IMPORTANCE: Autosomal dominant polycystic kidney disease (ADPKD) is the most frequent inherited kidney disorder, and liver involvement represents one of its major extra-renal manifestations. Although asymptomatic in most patients, polycystic liver disease (PLD) can lead to organ compression, severe disability and even become life-threatening, thereby warranting early recognition and appropriate management. CLINICAL PRESENTATION: We report the case of a 56-year-old woman with ADPKD and severe weight loss secondary to a giant hepatic cyst compressing the pylorus. Partial hepatectomy was required after failure of cyst aspiration and sclerotherapy, and patient's condition improved rapidly. DISCUSSION AND CONCLUSIONS: We discuss the presentation and classification of compressing liver cysts, and the available therapeutic alternatives for this potentially severe complication of ADPKD.

Transjugular intrahepatic portosystemic shunt approach and local thrombolysis for treatment of early posttransplant portal vein thrombosis.

Early portal vein thrombosis is a rare but severe posttransplant complication that may lead to graft and/or patient loss. Transjugular intrahepatic portosystemic shunting and local thrombolysis may represent an easy solution to this major complication of liver transplantation.

Transjugular intrahepatic portosystemic shunt after adult liver transplantation: experience in eight patients.

BACKGROUND: Transjugular intrahepatic portosystemic shunting (TIPS) has become an effective treatment for the complications of portal hypertension. We assessed the feasibility and outcome of TIPS in liver transplant recipients. METHODS: During the period from December 1992 to January 1998, eight adults presenting recurrent hepatitis C virus (five patients) and hepatitis B virus (one patient) infection, veno-occlusive disease (one patient), and secondary biliary cirrhosis (one patient) had TIPS because of refractory ascites (five patients), bleeding esophageal varices (one patient), refractory hepatic hydrothorax (one patient), retransplantation (two patients), and redo-biliary surgery (one patient). RESULTS: In two patients, the procedure was difficult due to cavo-caval implantation. Ascites, hydrothorax, and variceal bleeding were controlled in all patients. Moderate to severe encephalopathy developed in four patients; two patients had worsening of their existing encephalopathy. Three of five patients treated with cyclosporine needed a drastic dose reduction due to the development of severe side effects. No long-term survivor developed shunt stenosis or occlusion. Two patients did moderately well at 6 and 14 months, respectively; the former died due to chronic rejection while waiting for a retransplantation. Three did well at 14, 36, and 28 months, respectively; the latter patient died of liver failure 32 months after TIPS. One jaundiced patient died after 1.5 months due to necrotic pancreatitis. Two patients died after 4 and 8.5 months, respectively, due to liver failure; the latter was doing well until 7 months after TIPS. CONCLUSIONS: TIPS is feasible in transplant recipients in cases of decompensated allograft cirrhosis, of allograft veno-occlusive disease or when retransplantation or redo-biliary surgery are scheduled in the presence of portal hypertension. At transplantation, the surgeon should keep in mind the eventuality of a later TIPS procedure. Close immunosuppression monitoring is warranted because modified metabolization of cyclosporine (and probably tacrolimus) may cause serious side effects.

Right gastroepiploic artery used as a pedicled graft in a retrograde fashion.

The right gastroepiploic artery is currently regarded as a most valuable arterial conduit for myocardial revascularization. We have documented a particular case wherein the proximal (pyloric) part of the right gastroepiploic artery could not be freed and was damaged because of previous cholecystectomy. The pedicle was divided at the pyloric side and raised up to be anastomosed to the posterior descending artery in a retrograde fashion. The purpose of this report is to emphasize the fact that a previous abdominal operation does not necessarily hamper the use of the gastroepiploic artery as a pedicled graft. It is also pointed out that retrograde flow in the pedicle was sufficient in this case to provide good revascularization.

Ischemic gastric ulcer after coronary bypass using the right gastroepiploic artery.

The gastroepiploic artery has been widely used for complete arterial myocardial revascularization of young patients. Gastric complications related to the harvesting of this artery are exceptional. We describe here a case of ischemic gastric ulcer due to the use of a gastroepiploic artery in a patient with severe celiac trunk disease. The patient was cured by angioplasty completed by a stenting procedure.

Diagnosis of intracranial aneurysms: accuracy of MR angiography at 0.5 T.

PURPOSE: Our goal was to determine the accuracy of MR angiography at 0.5 T for the diagnosis of intracranial aneurysms. METHODS: We retrospectively studied 140 patients, 70 with acute subarachnoid hemorrhage, who were either at high or low risk for intracranial aneurysm. Three-dimensional time-of-flight MR angiography was typically performed to cover the circle of Willis, with a volume thickness of 30 mm. Conventional spin-echo MR images and MR angiograms were reviewed together, and the results were compared with those obtained at intraarterial cerebral angiography to determine the sensitivity and specificity of MR angiography. RESULTS: Eighty-nine aneurysms (size range, 2 to 27 mm; 25 aneurysms < 5 mm) were identified at intraarterial cerebral angiography. Six aneurysms were missed by MR angiography and two were doubtful (sensitivity, 91% to 93%; specificity, 100%). Missed aneurysms were located outside the MR angiographic acquisition volume (n = 3) or on the carotid siphon (n = 3; size = 2, 3, and 5 mm). CONCLUSION: Even if MR angiography presents some restrictions in acquisition volume and spatial resolution, the detection rate of intracranial aneurysms is excellent at 0.5 T in both asymptomatic patients and in those with subarachnoid hemorrhage. A midfield system is not a restriction to the detection of intracranial aneurysms by MR examination.

Local urokinase infusion for total occlusion of the lower abdominal aorta. Report of two cases and a review of the literature.

Two patients with acute occlusion of the lower abdominal aorta have been successfully treated with total of 7,425,000 and 8,850,000 units of urokinase infused locally over 93 and 86 hours, respectively, with restoration of flow. No complication occurred.

[Endovascular therapy of renal artery stenosis: technical results with the Palmaz-Corinthian stent]. / Endovaskuläre Therapie der Nierenarterienstenose: Technische Ergebnisse mit dem Palmaz-Corinthian-Stent.

OBJECTIVE: To evaluate the technical performance and delivery characteristics of the Palmaz-Corinthian stent for endovascular therapy of atherosclerotic renovascular disease. METHODS: 61 patients underwent implantation of 76 Palmaz-Corinthian (PC) stents in 72 arteries. 50 original PC and 26 PC stents with the modified IQ-design were employed. The indications comprised primary stenting of ostial (n = 49) or truncal (n = 1) stenosis or occlusion (n = 3), and selective stenting following complicated (dissection, n = 4) or unsuccessful (n = 8) angioplasty. The remaining stents were placed in patients with recurrent stenosis (n = 5) or acute aortic dissection (n = 2) involving the renal artery. Mean severity and length of stenosis were 81.3% and 9.8 mm, respectively. 39 lesions were rated eccentric or calcified. Data on technical success, complication rate, delivery characteristics and ease of placement compared to standard renal stents were retrieved from a prospective multicenter registry. RESULTS: Stent delivery was successful in all patients, major complications were not reported. Stent placement was suboptimal in 7 of 72 cases: 4 stents were located too distally in the renal artery, necessitating proximal coaxial overstenting in 2 cases. The distal part of the stenosis was incompletely covered and the orifice of a segmental branch inappropriately overstented in one case each. One stent was dislodged from the balloon, resulting in stent protrusion in the aortic lumen. Significant residual stenosis after stenting was not observed. Overall stent deliverability, trackability and potential repositioning inside the stenosis were rated positive, radio-opacity was rated superior for the IQ design. CONCLUSION: Technical performance and delivery characteristics of the Palmaz-Corinthian stent have been significantly improved compared to the Palmaz design, allowing mostly correct placement in renal artery stenoses with a low complication rate.

Sequential treatment of hepatorenal syndrome and posthepatic cirrhosis by intrahepatic portosystemic shunt (TIPSS) and liver transplantation.

The results of liver transplantation are compromised in cirrhotic patients presenting with renal insufficiency from hepatorenal syndrome. A case of cirrhosis and hepatorenal syndrome, treated sequentially with transjugular intrahepatic porto-systemic stent shunting (TIPSS) and liver transplantation, is discussed. TIPSS may be useful for correcting renal dysfunction and/or hepatorenal syndrome in end-stage cirrhotics, thus permitting subsequent elective liver transplantation under good conditions.

[Treatment of massive arterial thrombosis caused by thrombocytopenia induced by heparin with local thrombolysis]. / Traitement par thrombolyse locale d'une thrombose artérielle massive par thrombopénie induite par l'héparine.

The authors report the case of a patient treated by subcutaneous injection of calcium heparin after deep vein thrombosis with floating thrombus and pulmonary embolism. She was readmitted to hospital after 16 days' treatment because of a massive aorto-iliac thrombosis due to heparin-induced thrombocytopenia (platelet count = 29.000). This thrombosis was treated by local injection of Urokinase (total dose = 7.425.000 U) over 93 hours without any major complications. The aorto-iliac circulation was completely restored to normal after treatment. Thrombotic complications secondary to immuno-allergic heparin-induced thrombocytopenia are relatively common because of the widespread use of heparin. From the therapeutic point of view, it is imperative to stop the heparin, which makes surgery very difficult, and the platelet-fibrin composition of these thrombi suggests that local thrombolysis with Urokinase is the treatment of choice in this syndrome.

[The role of embolization and chemo-embolization in the emergency treatment of hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma]. / Apport de l'embolisation et de la chimio-embolisation au traitement en urgence des hémopéritoines par rupture spontanée de carcinome hépatocellulaire.

Twelve caucasian patients with intraperitoneal hemorrhage due to spontaneous rupture of hepatocellular carcinoma were treated by emergency transcatheter arterial embolization (n = 9) or chemoembolization (n = 3). Pretreatment angiography showed active bleeding (extravasation of contrast medium) in two patients only. Successful hemostasis was initially achieved in all patients. Early recurrence of hemorrhage was noted in 3 patients with large tumors; two were successfully treated by a second embolization and one died immediately after the first embolization. Of the 12 patients, two underwent subsequent chemoembolization while two had surgical resection of their tumors. The mean length of survival was 7 months from the time of rupture. No serious complications related to embolization or chemoembolization were noted. Our data suggest that emergency embolization or chemoembolization is an effective treatment in caucasian patients with intraperitoneal hemorrhage from hepatocellular carcinoma. Prognosis of ruptured hepatocellular carcinoma in those patients, however, remains poor.

Early diagnosis of acute intestinal ischaemia: contribution of colour Doppler sonography.

The aim of this study was to evaluate the contribution of colour Doppler sonography in the diagnosis of acute intestinal ischaemia. In a two years experience, all patients admitted for acute abdominal pain in our emergency department were evaluated with colour Doppler sonography of the abdomen. The final diagnosis based on clinical evolution, endoscopic or surgical findings and further radiological investigations was compared to the sonographic results. Therapy and final outcome of the patients with acute intestinal ischaemia were also evaluated. In twenty-one patients a final diagnosis of acute intestinal ischaemia (mesenteric ischaemia (n = 13) and ischaemic colitis (n = 8)) was made. Intestinal ischaemia was correctly diagnosed by initial clinical and biological data and further confirmed by sonography in eight cases (mesenteric ischaemia (n = 2) and ischaemic colitis (n = 6)). Eleven other cases were detected by suggestive colour Doppler sonography features (mesenteric ischaemic (n = 10) and ischaemic colitis (n = 1)). Sixteen of the 21 patients had a final favourable outcome (mesenteric ischaemia (10/ 13) and ischaemic colitis (6/8)). We conclude that sonography has a place in the diagnosis of acute intestinal ischaemia and has to be integrated in the diagnostic algorithm of this acute condition. By this way, this diagnosis may be suspected earlier and may allow a prompt and adapted treatment with possible improvement in survival rate.

[Imaging of intestinal ischemia]. / Imagerie des ischémies intestinales.

Ischemic bowel disease includes acute and chronic mesenteric ischemia, and colon ischemia. Cross-sectional imaging, and more particularly computed tomography, has an increasing role in the detection of acute and chronic mesenteric ischemia. Vascular obstructions or stenoses and changes in the bowel wall can be observed. Functional information can be added with MRI by using sequences that are sensitive to oxygen saturation in the superior mesenteric vein. Arteriography remains the reference examination in patients with acute mesenteric ischemia.

[Cardiac imaging by means of four-detector row computed tomography and cardiac gating]. / Imagerie cardiaque en tomodensitométrie à quatre canaux d'acquisition et synchronisation cardiaque.

Electrocardiographically-assisted imaging is a recent development in multislice spiral computed tomography. In this article, we summarize the principles of four-detector row CT for cardiac applications. Following is an overview of the potential of this technique to evaluate the heart, the thoracic aorta, and the paracardiac pulmonary parenchyma. Technical considerations for optimal imaging are highlighted.

[True isolated atherosclerotic aneurysm of the axillary artery]. / Anévrisme vrai isolé d'origine athéromateuse de l'artère axillaire.

The true atherosclerotic aneurysm of the axillary artery is a rare condition. It either presents as a pulsatile axillary mass or arterial emboli in the hand and fingers. We report the case of a 70-year-old man with a 5 cm aneurysm of the axillary artery presenting with embolic disease to the hand. Angiography is helpful and provides valuable preoperative anatomic details. Surgery remains the treatment of choice but endovascular treatment can also be considered.

[Chronic arterial mesenteric ischemia: Doppler color ultrasonography demonstration of collateral flow]. / Ischémie mésentérique chronique d'origine artérielle: mise en évidence de réseaux de vicariance par échographie Doppler couleur.

Two cases of atypical mesenteric ischemia where color Doppler US demonstration of the underlying arterial abnormality and collateral supply was possible are presented. Significant stenosis of the celiac axis and thrombosis of the SMA were clearly depicted, along with the presence of collateral arterial supply. Endovascular treatment was successful in both cases. These cases confirm the possibility of detecting collateral flow at Doppler imaging in patients with mesenteric ischemia, both for diagnosis of mesenteric ischemia and endovascular treatment planning.

[Follow-up of TIPS: evaluation of signs of dysfunction with Doppler ultrasonography]. / Suivi des TIPS: evaluation des signes de dysfonctionnement en echographie doppler.

PURPOSE: to assess the signs of TIPS dysfunction at Doppler sonography. MATERIALS AND METHODS: retrospective study of signs observed in 106 TIPS including 31 TIPS with dysfunction (portoauricular pressure gradient > 12 mmHg). RESULTS: the signs of TIPS dysfunction were a decrease in the mean velocity in the TIPS (for a velocity < 40 cm/sec, 90% sensitivity, 96%), a hepatopetal intrahepatic portal flow (on the right 90% sensitivity, 100% specificity, on the left 95% sensitivity, 92% specificity), a lack of cardiac modulation of the signal in the TIPS (93% sensitivity, 65% specificity), a hepatic vein flow reversal (30% sensitivity, 100% specificity), and, the only direct sign of stenosis, an increase of the mean velocity in the stenosis (42% sensitivity, 95% specificity for a velocity > or = 1 m/sec). CONCLUSION: the most sensitive Doppler signs of tips dysfunction are the indirect signs of stenosis.