Anders Lunderquist

Transhepatic Catheterization and Obliteration of the Coronary Vein in Patients with Portal Hypertension and Esophageal Varices

Abstract For the management of esophageal varices complicating portal hypertension, we have developed a method that consists of (1) percutaneous transhepatic portal venipuncture, (2) manipulation of a catheter via the portal vein into the coronary vein, and, (3) if injection of contrast medium demonstrates retrograde flow through that vein as well as esophageal varices, injection of 30 ml of 50 per cent glucose solution followed by injection of a small amount of thrombin solution. Portography is used throughout to facilitate the procedure and assess results. Four patients have been treated, two of them with variceal bleeding. In all four, obliteration of the coronary vein by this method was successful. (N Engl J Med 291:646–649, 1974)

Therapeutic applications of catheter cholangiography.

Percutaneous transhepatic catheterization of the biliary tree was performed in 23 patients. In 21 the catheter was advanced past an obstructing lesion into the distal common bile duct and duodenum to establish antegrade biliary drainage. The catheter was left permanently in place as a form of endoprosthesis in 5 patients.

Percutaneous transhepatic intubation of bile ducts for combined internal-external drainage in preoperative and palliative treatment of obstructive jaundice

Percutaneous transhepatic intubation and combined internal-external drainage of the biliary system was performed in 15 patients with occlusion of the extrahepatic bile ducts due mainly to cholangiocarcinoma, metastases of the hepatoduodenal ligament, and tumors of the periampullary region. The technique is described and the value of the procedure in temporary decompression and combined internalexternal bile drainage prior to radical surgery is demonstrated. Its advantages as a palliative method are evident in far-advanced malignancy when extensive and complicated surgical procedures are ill-advised.

Evaluation of Splenic Embolization in Patients with Portal Hypertension and Hypersplenism

Twenty-five patients with hypersplenism caused by portal hypertension were treated by repeated partial splenic embolization. Fourteen surviving patients were followed for up to six years showing a good response on peripheral blood count and bleeding tendency. Three patients died in connection with the treatment and another eight died within half a year because of the underlying liver disease. The discomfort and complications of fever, pain, pleural effusion, and abscess formation and the possibility to avoid these by repeated partial embolization under antibiotic cover are discussed. The results are compared with reports in the reviewed actual literature and the splenic embolization is given a place among the means of a successful selective symptomatic treatment of partial hypertension.

Follow-up of Patients with Portal Hypertension and Esophageal Varices Treated with Percutaneous Obliteration of Gastric Coronary Vein

Percutaneous transhepatic catheterization of the portal vein was performed in 21 patients with liver cirrhosis and esophageal varices. Coronary and short gastric veins were selectively catheterized and obliterated. The examination was performed to stop bleeding in 6 patients and was successful in 5. Follow-up examination showed recanalization of previously obliterated veins in 13 of 16 patients.

Percutaneous cytodiagnosis of carcinoma of the pancreas and bile duct.

Fifty-one percutaneous fine-needle aspiration biopsies guided by selective angiography and 57 by percutaneous transhepatic cholangiography (PTC) were performed in 88 patients. Fifty-two of the patients had a tumor localized to the pancreas and 19 a tumor of the extrahepatic biliary tract. In 17 patients the suspicion of neoplasia was possible to rule out. In 60% of the patients with pancreatic carcinoma and in 53% of the patients with biliary duct carcinoma correct cytological diagnosis was obtained. No false positive results were found. The diagnostic reliability was the same under guidance of angiography as PTC. The experience of the examiner markedly influenced the accuracy of the method. Exact correlation between the cytologic and histologic reports was found in cases where representative material was obtained at the aspiration. None of the 108 punctions was followed by complications. Since the method is harmless and has a high success rate especially in experienced hands it is an important adjunct to the management of pancreatic and bile duct lesions.

Embolization of the spleen for treatment of splenomegaly and hypersplenism in patients with portal hypertension.

Splenectomy in cases of hypersplenism involves significant risk of serious complications, including infection, hemorrhage, portal systemic thrombosis, and necrosis of the stomach or small bowel. Alternative procedures such as transcatheter embolization have been associated with a high frequency of splenic or subphrenic abscess, preventing clinical use. We used partial splenic embolization under careful antibiotic protection to successfully treat thrombocytopenia in 18 patients, most of whom had hypersplenism and splenomegaly secondary to portal hypertension. Of the 30 embolizations performed, the only serious complications encountered were abscess in two patients (who had almost total infarction) and four cases of splenic vein thrombosis. We investigated the possible effect of splenic embolization on portal venous pressure in three patients and found no pressure change.

Obliteration of esophageal varices by PTP: a follow-up of 43 patients.

The percutaneous transhepatic portal vein catheterization (PTP) with selective obliteration of the coronary vein and/or the short gastric veins in treating bleeding esophageal varices was introduced in 1974. In order to prevent recanalization of the vessels Buerylate® (isobutyl-2-cyano-acrylate) has been used in 43 patients 55 times during a period of 34 months (October 1975 to July 1978). The obliterative treatment was followed by rebleeding in 35% of the cases and continued bleeding occurred in two patients. Fourteen patients were treated on 16 occasions during acute bleedings, and five of these (36%) died within two months from a portal vein thrombosis caused by the obliterative procedure. Because of these findings PTP with obliteration of the veins feeding the esophageal varices is not recommended as an elective way of treatment. It should only be used in the acute bleeding patient when transesophageal sclerosering therapy, continuous vasopressin infusion and balloon tamponade have failed. Fifty-six per cent of the patients acutely treated stopped bleeding for more than one week, thus avoiding an emergency shunt or devascularization operation which are associated with a high mortality rate.

Angiography in Renal Trauma

Renal rupture represents a fairly high percentage of abdominal Injuries. WILLIAMS & ZOLLINGER (1959) in a survey of 273 abdominal injuries in the period 1947-1958 found that 76 were in the urinary tract and that the kidney was involved in 58. Of62 cases of renal injury seen at our department, 27 were caused by traffic accidents (NILSSON & SANDBERG 1962). Examination by conventional roentgenography followed by urography are usually considered the methods of choice in the examination of cases of probable renal rupture. The predominant roentgenologic signs suggesting renal rupture are the loss of part or whole of the outline of the kidney, the failure to identify the lateral border of the psoas muscles, and the presence of a soft tissue mass. Urography may demonstrate a deformed renal pelvis, due to its rupture or compression by an intrarenal haematoma, and compression of the kidney or pelvis by an extrarenal haematoma. Deformation may also be caused by a blood clot or by two or more of these factors in combination. The demonstration of extravasation of contrast medium from the renal pelvis into the parenchyma or outside the kidney provides a conclusive sign of rupture. Such unequivocal evidence is seldom obtainable because the methods usually necessary to demonstrate these changes cannot be used. Pyelography is contraindicated, and the application of ureteric compression in association with

Percutaneous transhepatic portography.

The technique, indications, contraindications and complications of percutaneous transhepatic portography and selective catheterization of the major and minor veins draining the splanchnic organs based on the experience of 200 cases are described. The advantage of this method is discussed and compared with transjugular and transumbilical portography.