David A. Kumpe

Dural sinus stent placement for idiopathic intracranial hypertension

OBJECT The use of unilateral dural sinus stent placement in patients with idiopathic intracranial hypertension (IIH) has been described by multiple investigators. To date there is a paucity of information on the angiographic and hemodynamic outcome of these procedures. The object of this study was to define the clinical, angiographic, and hemodynamic outcome of placement of unilateral dural sinus stents to treat intracranial venous hypertension in a subgroup of patients meeting the diagnostic criteria for IIH. METHODS Eighteen consecutive patients with a clinical diagnosis of IIH were treated with unilateral stent placement in the transverse-sigmoid junction region. All patients had papilledema. All 12 female patients had headaches; 1 of 6 males had headaches previously that disappeared after weight loss. Seventeen patients had elevated opening pressures at lumbar puncture. Twelve patients had opening pressures of 33-55 cm H(2)O. All patients underwent diagnostic cerebral arteriography that showed venous outflow compromise by filling defects in the transverse-sigmoid junction region. All patients underwent intracranial selective venous pressure measurements across the filling defects. Follow-up arteriography was performed in 16 patients and follow-up venography/venous pressure measurements were performed in 15 patients. RESULTS Initial pressure gradients across the filling defects ranged from 10.5 to 39 mm Hg. Nineteen stent procedures were performed in 18 patients. One patient underwent repeat stent placement for hemodynamic failure. Pressure gradients were reduced in every instance and ranged from 0 to 7 mm Hg after stenting. Fifteen of 16 patients in whom ophthalmological follow-up was performed experienced disappearance of papilledema. Follow-up arteriography in 16 patients at 5-99 months (mean 25.3 months, median 18.5 months) showed patency of all stents without in-stent restenosis. Two patients had filling defects immediately above the stent. Four other patients developed transverse sinus narrowing above the stent without filling defects. One of these patients underwent repeat stent placement because of hemodynamic deterioration. Two of the other 3 patients had hemodynamic deterioration with recurrent pressure gradients of 10.5 and 18 mm Hg. CONCLUSIONS All stents remained patent without restenosis. Stent placement is durable and successfully eliminates papilledema in appropriately selected patients. Continuing hemodynamic success in this series was 80%, and was 87% with repeat stent placement in 1 patient.

Angioplasty/Thrombolytic Treatment of Failing and Failed Hemodialysis Access Sites: Comparison With Surgical Treatment

Angioplasty is a valuable alternative to surgical revision of failing hemodialysis access sites and may be the treatment of choice because no further vein is compromised during the revision and because patency rates with repeat dilatations approach or equal those of surgical revision. Thrombolysis/angioplasty is a worthy substitute for surgical thrombectomy/revision in thrombosed access sites because dialysis can be resumed immediately, without the need of placement of a temporary subclavian vein access catheter, and lysis can be performed on an outpatient basis. Long-term secondary patency also approaches that of surgical therapy. Again, future access sites are not compromised. Either with percutaneous catheter or surgical therapy, it must be recognized that repeat treatment will be necessary to maintain patency of the access site after it has thrombosed. Close follow-up of these patients to observe for signs of recurring deterioration is mandatory. Because the number of vascular access sites is limited, the preservation of each site for as long as possible is important for the long-term management of these patients.

Role of TIPS as a Bridge to Hepatic Transplantation in Budd-Chiari Syndrome☆

PURPOSE To investigate the role of transjugular intrahepatic portosystemic shunt (TIPS) as a bridge to transplantation for patients with Budd-Chiari syndrome (BCS). MATERIALS AND METHODS Eight patients (five women, three men) with a mean age of 49.8 years (range, 20-61 years) were diagnosed with BCS by means of computed tomography, hepatic venography, and liver biopsy. One patient had acute liver failure, with subacute or chronic failure in seven. TIPS placement was attempted in all eight patients. Clinical follow-up and portograms were obtained in all patients until death or transplantation. RESULTS TIPS placement was completed in seven of eight patients (87.5%). During the follow-up period, TIPS occlusion occurred in four patients. TIPS revision in this patient, although successful, was complicated by hemorrhage and multiorgan failure, and the patient died. Assisted patency rate, excluding the technical failure, was 100%. Mean follow-up in the six survivors with TIPS was 342 days (range, 19-660 days). All six survivors had complete resolution of their ascites. Albumin levels improved an average of 0.43 g/dL (range, 0.3-1.4 g/dL). Bilirubin levels improved in five of six patients (83%), decreasing by an average of 5.6 mg/dL (range, 3.0-15.2 mg/dL). Of the six survivors, three underwent elective liver transplantation, one is awaiting transplantation, and one has been removed from the transplantation list because of clinical improvement. One patient was a candidate for transplantation but declined to be put on the list. CONCLUSION Hepatic synthetic dysfunction improves markedly after TIPS placement in patients with BCS. Significant improvement in ascites can also occur. TIPS can be an effective bridge to transplantation for patients with BCS.

Percutaneous Transluminal Aortic Angioplasty: Techniques and Results

Percutaneous transluminal angioplasty of the infrarenal abdominal aorta has been reported by a few authors. In the present series, aortic stenoses in 32 patients were treated with various percutaneous angioplasty techniques. Isolated aortic stenoses and primary aortic stenoses extending into the iliac arteries were successfully dilated. The initial success rate was 100%, without evidence of rupture, thrombosis, dissection, or distal embolization. In only three of the 28 patients who returned for follow-up did symptoms recur or noninvasive vascular laboratory indexes deteriorate (mean follow-up, 25 months). Percutaneous transluminal aortic angioplasty has proved safe and efficacious in the treatment of atherosclerotic aortic stenoses.

Embolization of an intrahepatic arterioportal fistula: case report and review of the literature.

An intrahepatic arterioportal fistula causing portal hypertension was successfully palliated with steel coils. The patient remains well 2 1/2 years after embolization. The 13 previously reported cases of transcatheter embolization of large intrahepatic arterioportal fistulae are reviewed. Percutaneous transcatheter embolization with suitable embolic material should be preferred to surgery in the treatment of these fistulae.

Obstructive Cholangitis Secondary to Mucus Secreted by a Solitary Papillary Bile Duct Tumor

A middle-aged woman had repeated episodes of common bile duct obstruction and cholangitis caused by profuse secretion of mucus by a solitary papillary tumor in the left hepatic duct. This complication usually occurs only with papillomatosis. The tumor initially appeared to be benign but subsequently was proven to be an invasive adenocarcinoma. Although the tumor recurred after surgical resection, her course remained uneventful without spread of the neoplasm for 3 yr.

Planned Delayed Nephrectomy after Ethanol Embolization of Renal Carcinoma

Planned delayed nephrectomy after preoperative ethanol infarction was done in 6 patients with renal carcinoma. Three patients had intracaval extension of tumor, 2 had renal vein but no vena caval extension and 1 had no renal vein or vena caval involvement. Nephrectomy was delayed 22 to 44 days after embolization. In the patients with inferior vena caval extension shrinkage of tumor thrombus after embolization allowed for easier surgical resection. Furthermore, delay of nephrectomy after preoperative infarction was of value in improving the clinical status of high risk patients.

Management of major bile duct injury associated with laparoscopic cholecystectomy.

BackgroundBile duct injury is a major complication of laparoscopic cholecystectomy. The purpose of this study was to evaluate our management strategy and outcomes for the treatment of such injuries.MethodsWe studied 54 consecutive patients who had de novo bile duct injury (n = 20) or prior biliary injury repair (n = 34) associated with laparoscopic cholecystectomy. All patients were managed using a multidisciplinary approach.ResultsDefinitive operation, almost always Roux-en-Y hepaticojejunostomy, was required in 85% of patients. We inserted external percutaneous biliary catheters in 98% of cases prior to surgery. There were no operative deaths, and the 30-day complication rate was 20%. Eight patients (15%) were managed nonoperatively. Overall, 96% of patients had no long-term, objectively definable biliary sequelae.ConclusionsTreatment of bile duct injury associated with laparoscopic cholecystectomy is optimally done using a multidisciplinary approach. Surgical reconstruction is required in most cases and can be safely accomplished with minimal morbidity and excellent long-term outcomes.

Course of thrombocytopenia of chronic liver disease after transjugular intrahepatic portosystemic shunts (TIPS). A retrospective analysis.

Thrombocytopenia associated with chronic liver disease presents a difficult management issue. Most reports conclude that portocaval and distal splenorenal shunts do not improve platelet counts in this setting. The response of thrombocytopenia after transjugular intrahepatic portosystemic shunt placement has not been studied. All platelet counts of 21 patients undergoing intrahepatic shunt placement were determined retrospectively to accumulate values at one month prior to procedure, weekly for the first month after the procedure, and monthly thereafter to six months. Comparison of pre- and postshunt platelet means showed a significant increase in counts in patients with a postshunt portal pressure gradient <12 mm Hg, with the increment evident by one week after the procedure. This response was not seen when preshunt thrombocytopenia was used as the lone variable. This study suggests that the transjugular intrahepatic portosystemic shunt may improve the thrombocytopenia associated with liver cirrhosis when these pressure gradients are attained.

Popliteal artery entrapment: findings at MR imaging.

Magnetic resonance (MR) imaging can noninvasively demonstrate the anatomic relationships between the popliteal artery and the muscles within the popliteal fossa, making it an ideal screening test for popliteal artery entrapment prior to angiography or surgery. The authors describe a patient with bilateral type II popliteal artery entrapment in whom the anomaly was diagnosed in the asymptomatic extremity with MR imaging.