George Behrens

Budd-Chiari Syndrome

OBJECTIVE Budd-Chiari syndrome (BCS) is an uncommon condition characterized by obstruction of the hepatic venous outflow tract. Presentation may vary from a completely asymptomatic condition to fulminant liver failure. BCS is an example of postsinusoidal portal hypertension. The management can be divided into three main categories: medical, surgical, and endovascular. The purpose of this article is to present an overall perspective of the problem, diagnosis, and management. CONCLUSION BCS requires accurate, prompt diagnosis and aggressive therapy. Treatment will vary depending on the clinical presentation, cause, and anatomic location of the problem. Patients with BCS are probably best treated in tertiary care centers where liver transplantation is available.

Vacuum-assisted thrombectomy device (AngioVac) in the management of symptomatic iliocaval thrombosis.

Three patients with complete iliocaval thrombosis causing symptomatic leg swelling failed initial treatment with standard pharmacomechanical techniques. The occluded segments of the inferior vena cava and iliac veins were subsequently treated with the AngioVac Cannula (AngioDynamics, Latham, New York) and extracorporeal venous bypass circuit. In each patient, symptoms improved after treatment. This report discusses potential benefits and ancillary techniques of using the AngioVac device for iliocaval venous thrombosis.

Transjugular Liver Biopsy

Liver biopsy is considered the gold standard for the evaluation of acute and chronic liver disorders. Transjugular liver biopsy (TJLB) was described by Dotter in 1964 and clinically performed for the first time by Hanafee in 1967. TJLB consists of obtaining liver tissue through a rigid cannula introduced into one of the hepatic veins, typically using jugular venous access. The quality of the TJLB specimens has improved so much that the samples obtained by this method are comparable with those obtained with the percutaneous technique. TJLB is indicated for patients with coagulopathy, ascites, peliosis hepatis, morbid obesity, liver transplant, or in patients undergoing a transjugular intrahepatic portosystemic shunt procedure. The technical success rate for a TJLB procedure ranges from 87 to 97%. Sample fragmentation has been reported in 14 to 25% of the TJLB samples. The complication rates are low and range between 1.3% and 6.5%. The purpose of this article is to provide a review of the fundamental aspects of the TJLB procedure, including technique, indications, contraindications, results, and complications.

Occlusion of a Rapidly Expanding Hemodialysis Graft Pseudoaneurysm with Placement of a Stent Graft

We describe a 44-year-old man with end-stage renal disease who underwent insertion of a stent graft to repair a hemodialysis graft pseudoaneurysm. The indication for stent graft placement was an acute and rapidly enlarging intragraft pseudoaneurysm. The patient experienced no complications following the procedure, but he presented with two graft occlusions within the 2 months following the procedure.

Venous Thromboembolic Disease: The Use of the Aspiration Thrombectomy Device AngioVac

Central venous thrombosis is a complex problem, particularly in cases where the thrombus burden is large. Several interventional techniques and devices have been developed over the past 15 to 20 years to manage this entity, but the vast majority of them still need the concomitant use of thrombolytics to achieve an optimal result. AngioVac (AngioDynamics, Latham, NY) is the first aspiration thrombectomy device capable to remove a larger burden of undesired intravascular material such as thrombus, tumor, and foreign bodies without the need of lytics. This review focuses on the AngioVac device in the management of iliocaval thrombosis and pulmonary embolism.

Transjugular Liver Biopsy: Comparison of Sample Adequacy with the Use of Two Automated Needle Systems

PURPOSE To compare the adequacy of transjugular liver biopsy (TJLB) specimens with use of the 18-gauge Quick-Core and Flexcore needles. MATERIALS AND METHODS The records of 233 patients who underwent a TJLB procedure from January 2005 to December 2006 were retrospectively reviewed. Tissue samples from a total of 194 procedures were available for review; 117 TJLB procedures were performed with a Quick-Core needle and 77 were performed with a Flexcore needle. A single pathologist reviewed all the liver biopsy specimens in a blinded fashion. The χ(2), Fisher exact, and Student t tests were used to analyze differences between groups. RESULTS The TJLB procedure was technically successful in 232 of 233 cases (99.6%). Histologic diagnosis was possible in 96% of cases. Sample fragmentation rates were 24.9% with the Quick-Core needle and 14.3% with the Flexcore needle (P = .1). The mean numbers of complete portal tracts (CPTs) per submitted tissue per procedure were 10.0 ± 4.6 for the Quick-Core needle and 12.2 ± 6.1 for the Flexcore needle (P = .003). The mean numbers of CPTs per liver sample were 2.63 ± 1.8 for the Quick-Core needle and 3.28 ± 3.3 for the Flexcore needle (P = .00004). Complications were more common in patients with multiple comorbidities such as renal failure and coagulopathy and those who had received a liver transplant. CONCLUSIONS This study demonstrates that the 18-gauge Flexcore TJLB system provided better liver biopsy specimens compared with the 18-gauge Quick-Core needle system.

Transjugular Intrahepatic Portosystemic Shunts in Liver Transplant Recipients: Technical Considerations and Review of the Literature

Transjugular intrahepatic portosystemic shunt (TIPS) is an accepted therapeutic option for the treatment of complications of portal hypertension, such as refractory variceal bleeding, refractory ascites, refractory hepatic hydrothorax and Budd-Chiari syndrome, in cirrhotic livers. However, portal hypertension is uncommon after liver transplantation, and when it occurs, it has been related to hepatic vein outflow obstruction, small liver donor size, rejection, or recurrence of the original disease. There are few reports in the literature addressing TIPS experience in liver transplant patients. This review will address the published experience of TIPS procedures in liver transplant patients, including indications, technical issues, complications, and outcomes.

Endovascular Diagnosis and Management of Chronic Cerebrospinal Venous Insufficiency: Retrospective Analysis of 30-Day Morbidity and Mortality in 95 Consecutive Patients

OBJECTIVE The purpose of this study is to report the 30-day morbidity and mortality associated with the endovascular diagnosis and management of chronic cerebrospinal venous insufficiency. MATERIALS AND METHODS The medical records of 95 consecutive patients (60 women and 35 men) with a mean age of 48 years (age range, 25-66 years) who underwent diagnostic endovascular evaluation and intervention for chronic cerebrospinal venous insufficiency between June 2010 and September 2011 were reviewed retrospectively. All patients had a diagnosis of multiple sclerosis by McDonald criteria. Endovascular evaluation of the internal jugular and azygos veins was performed with digital subtraction venography and intravascular ultrasound. Indications for percutaneous transluminal angioplasty (PTA) were venographic findings of a greater than 50% diameter stenosis, the presence of reflux on digital subtraction venography, greater than 50% cross-sectional area stenosis by intravascular ultra-sound, or a finding of abnormal thick valves or webs by either method. The primary endpoint of this study was the 30-day mortality, and the secondary endpoint was the presence of major complications. Results are presented as means and percentages. RESULTS A total of 107 procedures were performed in 95 patients. Endovascular evaluation showed venous lesions requiring intervention in 90 of 95 patients (94.7%) and was negative in five of 95 patients (5.3%). A total of 193 venous lesions were treated; angioplasty was technically successful in 188 of 193 (97.4%) lesions. Internal jugular vein thrombosis after PTA was identified in three of 95 (3.2%) of the treated patients. Bleeding at the puncture site not requiring transfusion occurred in four of 95 patients (4.2%). There were no reported procedure-related deaths. CONCLUSION The results of the current study suggest that endovascular evaluation and management of chronic cerebrospinal venous insufficiency is safe, with low morbidity and no procedure-related mortality.

Splenic Artery Embolization and Balloon Occlusion Retrograde Alcohol Embolization in a Patient with Bleeding Gastric Varices

We present a patient with a large spontaneous splenorenal shunt secondary to isolated splenic vein thrombosis who developed severe bleeding from fundal gastric varices. The patient was managed emergently with splenic artery embolization and balloon occlusion retrograde embolization of the varices with alcohol. We discuss the clinical presentation, embolization techniques, and a potential complication of the use of alcohol for this purpose.

A case of complete resolution of gastric varices.

Background. A 49-year-old woman with hepatitis C and peptic ulcer disease presented to the emergency department after an onset of sudden massive hematemesis. She had a history of alcohol abuse, but denied any recent excessive drinking.Investigations. Physical examination, laboratory investigations including complete blood cell counts and liver function tests, esophagogastroduodenoscopy, abdominal angiography and venography, CT scans of the abdomen and pelvis.Diagnosis. Gastric variceal hemorrhage, severe portal hypertensive gastropathy, splenic vein thrombosis.Management. Blood transfusion, splenic artery embolization and balloon-occluded retrograde transvenous obliteration of gastric varices. Immediate postprocedural CT scans of the abdomen, with repeat imaging 30 months later.