Antonio Echenagusia

Clinical events after transjugular intrahepatic portosystemic shunt: Correlation with hemodynamic findings

BACKGROUND & AIMS Transjugular intrahepatic portosystemic shunt (TIPS) procedures are increasingly being used, but the relationship between the hemodynamic effects of TIPS and the clinical events on follow-up remains undefined. Hence, we have investigated the hemodynamic correlations of portal hypertension-related events after a TIPS procedure. METHODS Prospective follow-up of 122 cirrhotic patients who had a TIPS procedure performed because of variceal hemorrhage was conducted. RESULTS The portacaval pressure gradient (PPG) significantly decreased after the TIPS procedure (from 19.7 +/- 4.6 to 8.6 +/- 2.7 mm Hg; P > 0.001), but increased thereafter and at rebleeding (n = 25) was > 12 mm Hg in all patients (18.4 +/- 4.6 mm Hg). Twenty-six patients developed ascites; the PPG (measured in 19) was always > 12 mm Hg. Increasing the PPG to > 12 mm Hg occurred very frequently (83% at 1 year). Within 1 year, 77% of patients underwent balloon angioplasty or restenting. However, 80% had again a PPG of > 12 mm Hg 1 year after reintervention. Hepatic encephalopathy developed in 31% of patients at 1 year; 21 of 23 patients had a PPG of < 12 mm Hg. CONCLUSIONS Total protection from the risk of recurrent complications of portal hypertension after a TIPS procedure requires that the PPG be decreased and maintained < 12 mm Hg. However, reintervention will be required in most patients within 1 year and again the second year. On the other hand, such portal decompression is associated with an increased risk of hepatic encephalopathy.

Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure.

PURPOSE To compare the outcomes of embolotherapy and surgery as salvage therapy after therapeutic endoscopy failure in the treatment of upper gastrointestinal peptic ulcer bleeding. MATERIALS AND METHODS Retrospective analysis of 70 cases of refractory peptic upper gastrointestinal hemorrhage was performed. Thirty-one cases were managed with embolotherapy and 39 were managed surgically. Demographic variables, underlying conditions, clinical findings, endoscopic treatment, transfusion requirements before and after alternative therapeutic approach, length of hospital stay, and outcomes including recurrent bleeding, need for surgery after initial alternative treatment, and in-hospital death were recorded. RESULTS Patients who received embolotherapy were older (75.2 years +/- 10.9 vs 63.3 years +/- 14.5; P <.001) and had greater incidences of heart disease (67.7% vs 20.5%; P <.001) and previous anticoagulation treatment (25.8% vs 5.1%; P =.018). There were no differences in the rest of the pretreatment variables. No differences were found between the embolotherapy and surgery groups in the incidence of recurrent bleeding (29% vs 23.1%), need for additional surgery (16.1% vs 30.8%), or death (25.8% vs 20.5). CONCLUSIONS The lack of differences between these two treatment alternatives, despite the more advanced age and greater prevalence of heart disease in the embolotherapy group, provides support for future prospective randomized studies aimed to evaluate the role of embolotherapy in the management of refractory peptic ulcer bleeding.

Urgent Transjugular Intrahepatic Portosystemic Shunt for Control of Acute Variceal Bleeding

Objective:Endoscopic sclerotherapy and pharmacological therapy are widely used in the treatment of acute variceal hemorrhage. However, they fail at arresting acute bleeding in 20–30% of bleeding episodes. The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the prevention of recurrent variceal bleeding has been proved recently, but the effectiveness and safety of urgent TIPS in the treatment of acute variceal bleeding refractory to conventional therapy are still under evaluation.Methods:Over 4.5 yr, 358 variceal hemorrhage episodes were treated in our hospital. Pharmacological and endoscopic therapy failed to control hemorrhage in 93 episodes. Thirty-two patients died because of uncontrolled massive bleeding. In 56 patients, TIPS (Strecker stent) was performed after temporary control of the episode with balloon tamponade.Results:Eleven of 56 patients with urgent TIPS belonged to Child-Pugh class A, 22 to class B, and 23 to class C. The mean time between indication and insertion was 17 ± 10 h (range 4–24 h). Control of bleeding was achieved in 53 patients (95%). Eight patients had recurrent bleeding at 1 month after TIPS, seven of them during the first week after the procedure. The 1-month actuarial probability of rebleeding was 22%. The main complications of the procedure were massive hemoperitoneum (n = 1), cardiorespiratory arrest (n = 2), cardiac failure (n = 1), acute renal failure-(n = 2), and bacteremia (n = 7). Operative mortality (30 days) was 28%. The actuarial probability of survival at 30 days was significantly lower in Child-Pugh class C than in class A or B (48%vs 90%; p < 0.001). The presence of ascites, hepatic encephalopathy, and serum albumin level before TIPS were independent prognostic factors associated with the risk of operative mortality.Conclusions:Urgent TIPS is an effective alternative for the treatment of acute variceal bleeding refractory to endoscopic and pharmacological therapy, but sometimes is associated with major complications. Because of the high operative mortality rate in patients with severe liver failure, careful selection of patients is required before TIPS.

Stenosis of the inferior vena cava after liver transplantation: Treatment with gianturco expandable metallic stents

AbstractPurpose: Evaluate the efficacy of double Gianturco expandable metallic stents for stenosis of the inferior vena cava (IVC) after orthotopic liver transplantation (OLT). Methods: Three patients developed severe Budd-Chiari syndrome secondary to suprahepatic caval stenosis after OLT. Percutaneous angioplasty (PTA) of the stenoses was unsuccessful. Therefore double Gianturco expandable metallic stents, connected in tandem, were deployed at the site of the stenoses. Results: One double stent was successfully and definitively deployed in patient 1. Partial dislocation of the upper and lower stents comprising the double stent occurred in patient 2. The double stent initially implanted across the stenosis became displaced in patient 3. The Budd-Chiari syndrome resolved in all three patients who remained asymptomatic during follow-up from 3 to 32 months. Conclusions: Double Gianturco stent deployment is a viable option in patients with anastomotic stenosis of the IVC secondary to OLT when initial treatment with PTA fails. Certain modifications of the stents employed are suggested for the purpose of avoiding technical complications.

Randomized controlled trial of aspiration needle versus automated biopsy device for transjugular liver biopsy.

PURPOSE The efficacy and safety of transjugular liver biopsy used to obtain liver specimens in patients with coagulation disorders have been widely proven. However, histopathologic examination is not always possible because of fragmented samples provided by the aspiration technique. Recently, an automated device with a Tru-Cut-type needle was designed. In this randomized controlled trial, the use of this new device is compared with the traditional method in terms of efficacy and safety. METHOD Fifty-six patients were included in the study; 28 were randomized to undergo the aspiration technique and 28 were randomized to undergo the automated biopsy technique. RESULTS Correct positioning of the device was achieved in 93% of patients undergoing the aspiration technique and 96% of patients undergoing the automated biopsy technique (P = NS). Mean duration of the procedure and total number of passes were significantly higher in the aspiration needle group than in the automated device group (22.6 min +/- 12.6 vs 15.5 min +/- 9.4; P = .03, and 3.3 min +/- 1.9 vs 1.5 min +/- 0.63; P < .001, respectively). The number of portal tracts was significantly higher in the automated device group (4.7 +/- 2.5 vs. 2.7 +/- 3.4; P < .05). Adequate specimens for histopathologic evaluation were obtained in 26 patients in the automated device group and 24 patients in the aspiration needle group (92.8% vs 85.7%; P = NS), but a definite histopathologic diagnosis was more frequently obtained with the automated biopsy device (68% vs 43%; P = .05). No significant differences were observed in complication rates (7.14% vs. 10.7%; P = NS). CONCLUSION The automated biopsy device for transjugular liver biopsy is more effective than an aspiration needle in obtaining good samples for a definite histologic diagnosis.

CT demonstration of extension of renal angiomyolipoma into the inferior vena cava in a patient with tuberous sclerosis.

The authors present a case of tumor thrombus in the inferior vena cava produced by angiomyolipoma in a young woman with tuberous sclerosis. Diagnosis was made by computed tomography (CT) by measuring the attenuation values of the tumor thrombus. The values obtained were characteristic of fat, demonstrating that tumoral invasion was the cause of the thrombus. To our knowledge, this is the first description of such an association shown by CT in the literature.

Percutaneous nephrostomy in pyonephrosis.

A series of 76 pyonephrotic kidneys in 73 patients were drained by percutaneous nephrostomy (PN) tube and examined to evaluate the contribution of this technique to the treatment of pyonephrosis. In 71 patients, clinical symptoms disappeared 24–48 h after the procedure. Two patients died from sepsis subsequent to anuria and underlying malignancy.Once the acute phase had remitted, interventional procedures were carried out in 39 cases, and constituted the definitive therapy in 36. In 32 cases, elective surgery was the definitive therapy, including the 3 cases not resolved after interventional procedures. Three patients in whom the obstruction cleared spontaneously following PN needed no additional treatment. Major complications included 6 cases of sepsis, all of which resolved satisfactorily with proper medical therapy.

Patients with cirrhosis and bare‐stent TIPS may have increased risk of hepatocellular carcinoma

A trend toward a higher incidence of hepatocelullar carcinoma (HCC) in patients with cirrhosis treated with bare‐stent transjugular intrahepatic portosystemic shunt (TIPS) has been observed in previous studies. To assess the influence of TIPS as a risk factor for developing HCC, we have compared the incidence of HCC in two retrospective cohorts of patients. The TIPS cohort (n = 138) included patients with cirrhosis who underwent TIPS placement for the treatment of portal hypertension–related complications; the non‐TIPS cohort was composed of patients admitted at the hospital at the same time of TIPS insertion who were individually matched 1:1 according to age, sex, Child‐Turcotte‐Pugh class, and cause of cirrhosis. A stratified Cox model was used to assess risk of HCC development. The median time of follow‐up was similar in TIPS and non‐TIPS cohorts (30.3 [range, 7.8‐119.5] and 31.4 [range, 7.8‐110.8] months, respectively). The cumulative probability of developing HCC at 1, 3, and 5 years was 3%, 24%, and 34% for the TIPS cohort and 1%, 6%, and 25%, for the non‐TIPS cohort, respectively (Breslow test = 5.23, P = .022). The adjusted hazard ratio was 1.52 (95% confidence interval, 1.06‐2.19; P = .02). Hepatitis C virus infection and age were independent predictors of HCC development in patients without TIPS. In conclusion, patients with cirrhosis who are treated with TIPS may have a higher incidence of HCC. This observation suggests the need for a strict HCC surveillance program for these patients, especially if they are not expected to undergo a short‐ or medium‐term liver transplantation. (HEPATOLOGY 2005;41:566–571.)

Percutaneous treatment of benign portal vein stenosis after liver transplantation.

O SCVIR, 1996 PORTAL vein stenosis at the site of anastomosis is a relatively uncommon complication following liver transplantation (1). Although such complications have traditionally been managed surgically, percutaneous transluminal angioplasty (PTA) and placement of vascular endoprostheses have increasingly been used as therapeutic alternatives in selected patients (2,3). We present two cases of anastomotic stenosis of the portal vein in liver transplant recipients. One patient was treated with PTA and the other was managed with balloon dilation and subsequent implantation of a vascular stent.

Ultrasound diagnosis of ruptured hydatid cyst of the liver with biliary obstruction

Communication between a hydatid cyst of the liver and biliary tract results in a clinical picture of obstructive jaundice because of occupation of the extrahepatic biliary tract by intracystic material. Five cases of this complication are presented. Ultrasound criteria for diagnosis are analyzed, based on previous publications as well as our own experience.