Carlo Ferro

Recurrent acute Budd–Chiari syndrome after right hepatectomy: US color-Doppler vascular pattern and left hepatic vein stenting for treatment

After extended right hepatectomy remnant liver can be affected by outflow obstruction due to torsion of the inferior vena cava or kinking of the left hepatic vein. Remnant liver fixation is therefore suggested to avoid postoperative acute Budd–Chiari syndrome. Despite remnant liver reposition during surgery, a 76-years-old woman developed complete outflow obstruction. This clinical situation, due to left hepatic vein kinking, was suspected by US examination and confirmed by CT scan that showed a pathological intrahepatic vascular pattern. Patient required urgent relaparotomy and the liver was replaced in normal position. However, recurrence of outflow obstruction occurred and it was ultimately treated by inferior vena cava angiogram with left hepatic vein stenting.

A Nearly Missed Catastrophic Aortic Injury After Reduction of a Thoracic Spine Fracture Managed by Prompt Endovascular Treatment

Fig 3. Tcedures are rare. Delayed diagnosis and the clinical complexity may result in a catastrophic outcome. Moreover, in such circumstances a conventional surgical approach might be impeded by the need to keep the patient in a supine position to avoid spinal injuries. A 48-year-old man was transferred to our hospital for emergency treatment of an aortic intramural hematoma after an open reduction of a traumatic thoracic spine fracture. Routine computed tomography of the chest performed after the orthopedic procedure had revealed the lower screw impinging on the descending thoracic aorta (Fig 1A), thus producing an intramural hematoma that extended to the concavity of the aortic arch and ascending aorta (Fig 1B, arrow). In the hybrid room under direct fluoroscopic guidance, a single Gore Tag 31/31/100 mm thoracic endoprosthesis (Gore, Flagstaff, AZ) was introduced through the right femoral artery and deployed into the proximal descending thoracic aorta (Fig 2A; arrow indicates impinging screw). Within the same procedure, the screw was removed (Fig 2B, insert), and the aorta was rechecked (Fig 2B). Follow-up computed tomography of the chest (Fig 3) and the clinical outcome showed an uneventful recovery.

Nongated vs electrocardiography-gated CT imaging of blunt aortic root rupture in a trauma patient.

An 18-year-old male, involved in a car accident, underwent a non-gated contrast enhanced CT with apparently no evidence of significant abnormalities of the thoracic aorta. The later onset of aortic valve regurgitation prompted a prospectively ECG-triggered high-pitch spiral acquisition using a dual-source CT system which showed a tear with a huge pseudoaneurysm of the aortic root. The patient underwent successful urgent conservative surgical repair. CT is the primary screening modality for aortic injuries. Cardiac motion artifacts may hamper sensitivity at the root/ascending aorta level when a non ECG-gated technique is used, thus masking a potentially life-threatening condition. ECG-gated-CT should be mandatorily performed in patients with a high suspicion for an aortic root trauma thus allowing timely repair and avoiding a catastrophic event.

Radiologic Percutaneous Gastrostomy in Nondistended Stomach: A Modified Approach

AbstractIntroductionGastrostomy tube placement for patients requiring long-term nutritional support may be performed using different techniques including endoscopic, surgical, and percutaneous radiologically guided methods. Radiologically inserted gastrostomy (RIG), typically performed when percutaneous endoscopic gastrostomy is not possible, requires proper gastric distension that is achieved by insufflating air through a nasogastric tube. We describe a simple technique to prevent air escape from the stomach during gastrostomy tube placement. To the best of our knowledge, this technique has not yet been described in the literature.Materials and MethodsFour patients with unsuccessful percutaneous endoscopic gastrostomy were referred for fluoroscopic-guided gastrostomy. One patient had a pyriform sinus tumor and three had an ischemic stroke causing dysphagia. Gastric distention was not achieved in the patients due to air escaping into the bowel during the standard RIG procedure. A modified approach using a balloon catheter inflated in the pylorus to avoid air passing into the duodenum permitted successful RIG.ResultsThe modified RIG procedure was successfully carried out in all cases without complications.DiscussionInadequate air distension of the stomach is an unusual event that causes a failure of gastrostomy tube placement and an increased risk of both major and minor complications. The use of a balloon catheter inflated in the first part of the duodenum prevents the air passage into the bowel allowing the correct positioning of the gastrostomy.

P.1.308: ACUTE ALCOHOLIC HEPATITIS IN CIRRHOSIS PATIENTS WITH HEPATORENAL SYNDROME TYPE I: ROLE OF TRANSJUGULAR PORTO-SYSTEMIC STENT SHUNT

P.1.307 – Table 1. Endoscopic spectrum of ulcerative colitis with diverticulosis (UCD), segmental colitis associated with diverticulosis (SCAD), and acute uncomplicated diverticulitis (AUD) UCD (25 pts.) SCAD (129 pts) AUD (130 pts.) Endoscopic spectrum Mild Moderate Severe A B C D Mild Moderate Severe (8 pts.) (10 pts.) (7 pts.) (72 pts.) (36 pts.) (13 pts.) (8 pts.) (67 pts.) (42 pts.) (21 pts.) Diffuse inflammation 7 (87.5) 9 (90.0) 7 (100) – – – 8 (100) 1 (1.5) 1 (2.4) 7 (33.3) Inflammation of inter-diverticular mucosa 1 (12.5) 1 (10.0) – 71 (98.6) 34 (94.4) 11 (84.6) – 2 (3.0) 12 (28.6) 13 (61.9) Inflammation of peri-diverticular mucosa – – – 1 (1.4) 2 (5.6) 2 (15.4) – 64 (95.5) 29 (69.0) 1 (4.8) Data are given as number (percentage) of patients (pts.). tive pts (4 males, mean age 50) affected by AAH (HCV-RNA and HBV-DNA negative) and presenting type 1 HRS. 4 patients had refractory ascites before the development of HRS. All patients had AAH on cirrhosis. HRS and RA (non responders to common therapy) has been diagnosed according to International Ascites Club (1996). Patients were studied after a minimun of 7 days on a 40 mEq/die sodium diet and without diuretics. During this period of observation renal function continued to worsen despite the administration of plasma expanders and vasocostrictors: patients were submitted to TIPS (stent diameter 10 mm) after a written informed consent. In all patients we compared laboratory parameters before intervention and 4 weeks after TIPS. Results: All stents were successfully established, 4 patients presenting minor complications. Function parameters in the table. Before TIPS After TIPS Serum Creatinine (mg/dl) 5.1±0.8 1.6±0.7* Serum Sodium (mEq/L) 124±3 135±3 Sodium Excretion (mEq/L) 6.6±3 65.0±17* Urine Volume (ml/d) 250±4.1 1040±181* *Paired t-test p<0.001. 3-6 months after 4 patients were listed for liver transplantation (status 2A), 2 patients progressively recovery liver function with abstinence, 1 patient presented a abuse alcholic relapse. Conclusions: Even in presence of AAH TIPS allows a satisfactory treatment of functional renal impairment and it is a valid bridge to liver transplantation.