Hyun Ki Yoon

Endovascular treatment of hepatic venous outflow obstruction after living-donor liver transplantation.

PURPOSEnTo evaluate the effectiveness and safety of percutaneous interventional management of hepatic venous outflow obstruction after living-donor liver transplantation (LDLT).nnnMATERIALS AND METHODSnPercutaneous balloon angioplasty (n = 5) and stent placement (n = 22) were attempted in 27 patients with hepatic venous outflow obstruction. Patient follow-up included clinical and laboratory data collection, Doppler ultrasonography (US), hepatic venography, and computed tomography. The following parameters were documented retrospectively: technical success and complications, clinical improvement, and recurrence. Technical success was defined as elimination or successful reduction of pressure gradients across the stenosis and clinical success was defined as amelioration of presenting signs. Recurrence was defined as relapse of clinical signs with hepatic venous anastomotic restenosis on Doppler US.nnnRESULTSnTechnical success was achieved in all patients. The mean pressure gradients across the stenoses before and after the procedure were 10.6 mm Hg +/- 6.4 (range, 3-39 mm Hg) and 2.4 mm Hg +/- 2.6 (range, 0-8 mm Hg), respectively (P < .001). Three of the five patients who underwent balloon angioplasty developed recurrent stenosis 1-5 weeks after the procedure. These patients underwent repeat balloon angioplasty, and two of them eventually underwent stent placement (n = 1) or surgical repositioning (n = 1) of the graft. Three of the 22 patients who underwent stent placement required a second stent placement procedure because of malpositioning, partial migration, and acute angulation. During the mean follow-up period of 49 weeks +/- 47 (range, 3-214 wk), clinical success was achieved in 20 of 27 patients (73%).nnnCONCLUSIONnPercutaneous interventional management is an effective and safe adjunct for the treatment of hepatic venous outflow obstruction after LDLT.

Angiographic embolization for obstetrical hemorrhage: effectiveness and follow‐up outcome of fertility

Background. This study was undertaken to describe the results of angiographic embolization for obstetrical hemorrhage and the follow‐up outcome of fertility. Methods. Consecutive patients who received angiographic embolization for the management of obstetrical hemorrhage at a single tertiary center were included in this study. Medical records were reviewed to collect the clinical data and details on the procedure. Patients were interviewed by telephone to obtain the long‐term outcomes for complications, menstruation, desire for conception, and subsequent pregnancies. Results. Embolization was successful in 42 (86%) of 49 patients with obstetrical hemorrhage resulting from various causes. The main cause of hemorrhage was uterine atony (n=24). The success rate was significantly lower in cases with abnormal placentation than in other causes of hemorrhage (p<0.05). The procedure took an average of 45.6 min (range, 20–120 min). There were no major complications related to the procedure. We were able to follow‐up 48 patients. Among 37 patients with preserved uteri, menstruation resumed spontaneously in 36 patients. Nine patients became pregnant, of which six gave birth to healthy babies and three ended in early miscarriage. Conclusions. Angiographic embolization is an effective noninvasive method for the management of obstetrical hemorrhage and a useful technique for preserving fertility.

Tumor Response to Transcatheter Arterial Chemoembolization in Recurrent Hepatocellular Carcinoma after Living Donor Liver Transplantation

Objective To evaluate the tumor response and patient survival rate following transcatheter arterial chemoembolization (TACE) in recurrent hepatocellular carcinoma (r-HCC) after living donor liver transplantation (LDLT). Materials and Methods Twenty-eight patients with r-HCC underwent one or more cycles of TACE after LDLT (mean, 2.5 cycles). After a mixture of iodized oil and anti-cancer drugs was injected via the arteries feeding the tumors, these vessels were embolized with a gelatin sponge. Tumor response was determined by follow-up CT imaging on all patients four weeks after each TACE procedure. Patient survival was calculated using the Kaplan-Meier survival curve. Results After TACE, targeted tumor reduced in size by 25% or more in 19 of the 28 study patients (67.9%). However, intrahepatic recurrence or extrahepatic metastasis occurred in 21 of the 28 patients (75.0%) during the 3-month follow-up period and in 26 of the 28 patients (92.9%) during the 6-month period following TACE. Extrahepatic metastasis was noted in 18 of the 28 patients (64.3%). The 1-, 3- and 5-year survival rates following TACE were 47.9, 6.0 and 0%, respectively, with a mean survival of nine months in all patients. There were no significant complications related to TACE. Conclusion TACE produces an effective tumor response for targeted r-HCC after LDLT. However, the survival rate of patients with r-HCC after LDLT is poor due to extrahepatic metastasis and intrahepatic recurrence.

Lacrimal Canalicular Obstructions: Safety and Effectiveness of Balloon Dilation☆

PURPOSEnBalloon dilation of the lacrimal canaliculi has been considered contraindicated because of possible damage to the canaliculi. The purpose of this study was to assess the safety and effectiveness of balloon dilation in treatment of obstruction of the lacrimal canaliculus.nnnMATERIALS AND METHODSnFluoroscopically guided balloon dilation was performed in 26 eyes of 21 consecutive patients with epiphora due to lacrimal canalicular obstruction confirmed at dacryocystography. Nine of 26 eyes had complete obstruction and 17 eyes had incomplete obstruction.nnnRESULTSnTechnical failure occurred in one eye. Only one acute complication (punctal slitting) and no late complications occurred. At 7 days after balloon dilation, 14 of 17 eyes (82%) with incomplete obstruction and five of nine eyes (56%) with complete obstruction showed complete or partial resolution of epiphora with patency of the lacrimal drainage system. At 6-month follow-up, that improvement was maintained in seven of 17 eyes (41%) with incomplete obstruction and three of nine eyes (33%) with complete obstruction.nnnCONCLUSIONSnAlthough the 6-month recurrence rate is rather high, balloon dilation seems to be safe and valuable as an initial therapy for patients with obstruction of the lacrimal canaliculus.

Balloon Dacryocystoplasty: Results and Factors Influencing Outcome in 350 Patients

PURPOSEnTo evaluate the initial and long-term results of balloon dacryocystoplasty in the treatment of epiphora caused by obstruction of the lacrimal system with analysis of the procedures favorable effects.nnnMATERIALS AND METHODSnFour hundred thirty eyes of 350 patients with obstructions of the lacrimal system were enrolled. Dacryocystoplasty was performed with use of a balloon catheter and a ball-tipped guide wire. The lesions were categorized according to cause, severity, site of the obstruction, and diameter and inflation time of the balloon. The technical success, initial success (improvement of symptoms after 1 week), and long-term patency rates were calculated. These rates in each group were compared with the chi(2) test and the Kaplan-Meier method.nnnRESULTSnThe overall technical success rate was 95.3%. The overall initial success rate was 57.4%. There was no significant complication except for mild epistaxis in 12%. The 2-month, 1-year, and 5-year patency rates were 48.2%, 39.4%, and 36.9%, respectively. Initial success was influenced by the severity (P =.014) and the site (P <.001) of the obstruction, and the diameter of the balloon (P =.047). Long-term patency was affected by the site of the obstruction (P <.001) and the balloon inflation time (P <.001). Among the 183 initially ineffective and 88 recurrent cases, 62 underwent repeat balloon dacryocystoplasty, and the initial success rate was 38.7%.nnnCONCLUSIONSnThe initial success rate of balloon dacryocystoplasty is relatively low. However, long-term patency can be expected in cases with initial success. Some additional factors also should be considered for better results.

Percutaneous Transhepatic Stent Placement in the Management of Portal Venous Stenosis After Curative Surgery for Pancreatic and Biliary Neoplasms

OBJECTIVEnThe purpose of this study was to evaluate the efficacy and safety of stent placement in the management of portal venous stenosis after curative surgery for pancreatic and biliary neoplasms.nnnMATERIALS AND METHODSnFrom September 1995 to April 2007, percutaneous transhepatic portal venous stent placement was attempted in 19 patients with postoperative portal venous stenosis. Portal venous stenosis was a complication of surgery in 11 patients and caused by tumor recurrence in eight patients. The clinical manifestations were ascites, hematochezia, melena, esophageal varices, and abnormal liver function. Stents were placed in the stenotic or occluded lesions after percutaneous transhepatic portography. Technical and clinical success, stent patency, and complications were evaluated.nnnRESULTSnStent placement was successful in 18 patients (technical success rate, 95%). Clinical manifestations improved in 16 patients (clinical success rate, 84%). The mean patency period among the 18 patients with technical success was 21.3 ± 23.2 months. The mean patency period of the benign stenosis group (30.1 ± 25.6 months) was longer than that of the tumor recurrence group (7.3 ± 7.7 months), and the difference was statistically significant (p = 0.038). There were two cases of a minor complication (transient fever) and three cases of major complications (septicemia, liver abscess, and acute portal venous thrombosis).nnnCONCLUSIONnPercutaneous transhepatic stent placement can be safe and effective in relieving portal venous stenosis after curative surgery for pancreatic and biliary neoplasms. Patients with benign stenosis had more favorable results than did those with tumor recurrence.

Angiographically Negative Acute Arterial Upper and Lower Gastrointestinal Bleeding: Incidence, Predictive Factors, and Clinical Outcomes

Objective To evaluate the incidence, predictive factors, and clinical outcomes of angiographically negative acute arterial upper and lower gastrointestinal (GI) bleeding. Materials and Methods From 2001 to 2008, 143 consecutive patients who underwent an angiography for acute arterial upper or lower GI bleeding were examined. Results The angiographies revealed a negative bleeding focus in 75 of 143 (52%) patients. The incidence of an angiographically negative outcome was significantly higher in patients with a stable hemodynamic status (p < 0.001), or in patients with lower GI bleeding (p = 0.032). A follow-up of the 75 patients (range: 0-72 months, mean: 8 ± 14 months) revealed that 60 of the 75 (80%) patients with a negative bleeding focus underwent conservative management only, and acute bleeding was controlled without rebleeding. Three of the 75 (4%) patients underwent exploratory surgery due to prolonged bleeding; however, no bleeding focus was detected. Rebleeding occurred in 12 of 75 (16%) patients. Of these, six patients experienced massive rebleeding and died of disseminated intravascular coagulation within four to nine hours after the rebleeding episode. Four of the 16 patients underwent a repeat angiography and the two remaining patients underwent a surgical intervention to control the bleeding. Conclusion Angiographically negative results are relatively common in patients with acute GI bleeding, especially in patients with a stable hemodynamic status or lower GI bleeding. Most patients with a negative bleeding focus have experienced spontaneous resolution of their condition.

Transjugular liver biopsy in patients with living donor liver transplantation: Comparison with percutaneous biopsy

Transjugular liver biopsy (TJLB) is an alternative method of pathological diagnosis in patients with an established contraindication to percutaneous biopsy. Between November 2005 and July 2007, 111 TJLBs were attempted in 67 patients and 95 percutaneous liver biopsies (PCLBs) were attempted in 51 patients with living donor liver transplantation suspected of having rejection. Indications of TJLB included classic contraindications to PCLB and a postoperative period of less than 30 days. TJLB was performed a mean of 111.1 ± 292.6 days after transplantation (range: 6–2478 days, median: 35 days), and PCLB was performed a mean of 534.7 ± 591.6 days after transplantation (range: 6–2555 days, median: 299 days). Technical success was 99.1% in TJLB and 100% in PCLB, and there was no significant difference between these 2 groups (P = 0.354). A clinical suspicion of rejection was confirmed by histopathology in 38 (34.2%) of 111 TJLBs and 38 (40.0%) of 95 PCLBs. The overall complication rates related to the procedure were 1.8% (2/111) in TJLB and 5.3% (5/95) in PCLB. Although there was no significant difference in complication rates between TJLB and PCLB (P = 0.172), the patients who underwent TJLB showed significantly higher incidence of ascites, coagulopathy, and thrombocytopenia, given its indication. TJLB seems to be a safe and effective procedure for pathological diagnosis of rejection in patients with living donor liver transplantation when there is a high risk of complication with PCLB. Liver Transpl 14:971–979, 2008.

Transvenous Variceal Embolization during or after Living-donor Liver Transplantation to Improve Portal Venous Flow

PURPOSEnDiversion of portal vein (PV) flow from the partial liver graft in living-donor liver transplantation (LDLT) can be life-threatening and warrant interruption of large collateral vessels. The purpose of this study is to evaluate the clinical efficacy of percutaneous or intraoperative transvenous embolization of portosystemic collateral vessels to improve PV inflow during or after LDLT.nnnMATERIALS AND METHODSnFrom 2000 to 2007, 105 of 1,435 patients (7%) who had undergone LDLT underwent percutaneous (n = 17) or intraoperative (n = 88) venography to evaluate the status of PV inflow and portosystemic collateral vessels. Among these 105 patients, 19 underwent percutaneous (n = 6) or intraoperative (n = 13) transvenous embolization of portosystemic collateral vessels to improve PV inflow. This included 12 men and seven women with a mean age of 46.5 years.nnnRESULTSnSuccessful embolization of the portosystemic collateral vessels with subsequently improved PV inflow was achieved in all 13 patients (100%) treated with the intraoperative approach and in four of six (67%) patients treated with the percutaneous approach. During follow-up (median, 8 months), Doppler ultrasonography showed adequate PV inflow in 17 of 19 patients, and follow-up computed tomography showed that collateral flow to the varices disappeared in 13 patients and decreased in four patients. One patient died of acute reactivated hepatitis 2 months after the procedure. Overall clinical success was achieved in 16 of the 19 study patients (84%).nnnCONCLUSIONSnTransvenous embolization of varices may be an effective method to improve PV inflow in LDLT recipients.

Covered Stent Placement for the Treatment of Malignant Superior Vena Cava Syndrome: Is Unilateral Covered Stenting Safe and Effective?

Objective To evaluate the safety and efficacy of unilateral covered stent placement in patients with malignant superior vena cava (SVC) syndrome. Materials and Methods Between October 2008 and November 2012, expanded polytetrafluoroethylene-covered stent placement for malignant SVC syndrome was performed in 40 consecutive patients (35 men and five women; mean age, 61.4 years; range, 35-81 years). All covered stents were unilaterally placed within the SVC or across the venous confluence when needed to relieve venous obstruction and prevent tumor overgrowth, regardless of patency of contralateral brachiocephalic veins. Results Stent placement was technically successful in all patients. There were no major complications. Of the 37 patients symptomatic prior to stent placement, 34 (92%) experienced complete symptomatic relief 1-8 days after stent placement. Of the 29 patients who underwent covered stent placement across the venous confluence, nine patients had patent contralateral brachiocephalic veins prior to stent placement. However, no sign of SVC obstruction or contralateral upper extremity venous thrombosis was observed during the follow-up period. Kaplan-Meier analysis revealed median patient survival of 163 days. Stent occlusion occurred in four (10%) of 40 patents. Cumulative stent patency rates at 1, 3, 6, and 12 months were 95%, 92%, 86%, and 86%, respectively. Conclusion Unilateral covered stent placement appears to be a safe and effective method for treating malignant SVC syndrome, despite the location of SVC occlusion.