Janette D. Durham

Hepatic Artery Chemoembolization for Hepatocellular Carcinoma in Patients Listed for Liver Transplantation

We retrospectively analyzed all listed patients having hepatic artery chemoembolization (HACE) for hepatocellular carcinoma (HCC) stage T2 or less. Outcomes were transplantation, waiting list removal, death, and HCC recurrence. Twenty patients (mean age 55.7 years; 15 males) were identified. Twelve (60%) were transplanted, seven (35%) were removed from the list and one (5%) remains listed. Fourteen (70%) are alive. All 12 transplanted patients are alive (mean 2.94 years); one of seven removed from the list is alive (mean 1.45 years). Survival was significantly higher for those transplanted or listed vs. removed from the list (100% vs. 14.3%, p = 0.0002). No HCCs recurred. Three patients (15%) were removed from the list after prolonged waiting times before MELD. Hepatic artery chemoembolization induced deterioration and removal from the list of one (5%) patient. Survival for those transplanted was excellent(100%), but overall survival was significantly lower (61.3%) at a mean 5.48 years. Hepatic artery chemoembolization for listed patients with ≤€ T2 stage HCC is beneficial, but must be weighed against decreased waiting times and risk of HACE‐induced deterioration. This balance is influenced greatly by the MELD systems determination of waiting times for HCC 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.

The role of TIPS for portal vein patency in liver transplant patients with portal vein thrombosis

The purpose of this research was to study the efficacy and outcomes of transjugular intrahepatic shunt (TIPS) in end‐stage liver disease (ESLD) patients with portal vein thrombosis (PVT) eligible for orthotopic liver transplant. Nine consecutive patients with PVT underwent TIPS as a nonemergent elective outpatient procedure. The primary indication for TIPS was to maintain portal vein patency for optimal surgical outcome. Eight patients underwent contrast enhanced computed tomography (CT) and 1 magnetic resonance imaging diagnosing PVT. Shunt creation was determined by available targets at the time of TIPS and by prior imaging. Patients were followed with portography, ultrasound, CT, or magnetic resonance imaging, and the luminal occlusion was estimated before and after TIPS. Primary endpoints were transplantation, removal from the transplant list, or death. Stabilization, improvement, or complete resolution of thrombosis was considered successful therapy. Failures included propagation of thrombosis or vessel occlusion, and poor surgical anatomy due to PVT. Of 9 patients with PVT, TIPS was successfully placed in all patients without complication or TIPS‐related mortality. Eight of 9 patients (88.8%) had improvement at follow‐up. One patient failed therapy and re‐thrombosed. Two patients (22.2%) were transplanted without complication and had no PVT at the time of transplant. Eight of 9 patients were listed for transplant at the time of their TIPS. Eight of 9 PVTs were nonocclusive. Four of 9 patients (44%) had evidence of cavernous transformation. Two patients expired during follow‐up 42 and 44 months after TIPS. Three patients remain on the transplant list. One patient has not been listed due to nonprogression of disease. One patient has been removed from the transplant list because of comorbid disease. In conclusion, TIPS is safe and effective in patients with PVT and ESLD requiring transplant. Patients can be successfully transplanted with optimal surgical anatomy. Liver Transpt 12:1544–1551, 2006.

Percutaneous Mechanical and Pharmacomechanical Thrombolysis for Occlusive Deep Vein Thrombosis of the Proximal Limb in Adolescent Subjects: Findings from an Institution-based Prospective Inception Cohort Study of Pediatric Venous Thromboembolism

PURPOSE Young individuals with occlusive, proximal-limb deep vein thrombosis (DVT) who have acutely increased plasma levels of factor VIII and D-dimer are at high risk for postthrombotic syndrome (PTS) when treated with conventional anticoagulation alone. The present report is an evaluation of experience with adjunctive percutaneous mechanical thrombolysis (PMT) and/or percutaneous pharmacomechanical thrombolysis (PPMT) in such patients. PATIENTS AND METHODS Among 95 children 11-21 years of age enrolled in a prospective cohort of venous thromboembolism between March 1, 2006, and November 1, 2009, 16 met eligibility criteria and underwent PMT/PPMT, typically with adjunctive catheter-directed thrombolytic infusion (CDTI) of tissue-type plasminogen activator given after the procedure. RESULTS Median age was 16 years (range, 11-19 y). Thirteen cases (81%) involved lower limbs. Underlying stenotic lesions were disclosed in 53%, with endovascular stents deployed in all cases of May-Thurner anomaly. There were no periprocedural major bleeding events and one symptomatic pulmonary embolism. Technical success rate was 94%. Early (< 30 days) locally recurrent DVT developed in 40% of cases, of which 83% were successfully treated with repeat lysis. Late recurrent DVT rate (median follow-up duration, 14 months; range, 1-42 mo) was 27%. Cumulative incidence of physically and functionally significant PTS at 1-2 years was 13%. CONCLUSIONS This experience provides preliminary evidence that PMT/PPMT with adjunctive CDTI can be used safely and effectively in adolescent subjects with DVT at high risk for PTS.

Pelvic Congestion Syndrome

Patients with pelvic congestion syndrome present with otherwise unexplained chronic pelvic pain that has been present for greater than 6 months, and anatomic findings that include pelvic venous insufficiency and pelvic varicosities. It remains an underdiagnosed explanation for pelvic pain in young, premenopausal, usually multiparous females. Symptoms include noncyclical, positional lower back, pelvic and upper thigh pain, dyspareunia, and prolonged postcoital discomfort. Symptoms worsen throughout the day and are exacerbated by activity or prolonged standing. Examination may reveal ovarian tenderness and unusual varicosities-vulvoperineal, posterior thigh, and gluteal. Diagnosis is suspected by clinical history and imaging that demonstrates pelvic varicosities. Venography is usually necessary to confirm ovarian vein reflux, although transvaginal ultrasound may be useful in documenting this finding. Endovascular therapy has been validated by several large patient series with long-term follow-up using standardized pain assessment surveys. Embolization has been shown to be significantly more effective than surgical therapy in improving symptoms in patients who fail hormonal therapy. Although there has been variation in approaches between investigators, the goal is elimination of ovarian vein reflux with or without direct sclerosis of enlarged pelvic varicosities. Symptom reduction is seen in 70 to 90% of the treated females despite technical variation.

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.

Metaanalysis of survival, complications, and imaging response following chemotherapy-based transarterial therapy in patients with unresectable intrahepatic cholangiocarcinoma.

PURPOSE Unresectable intrahepatic cholangiocarcinoma represents a devastating illness with poor outcomes when treated with standard systemic therapies. Several smaller nonrandomized outcomes studies have been reported for such patients undergoing transarterial therapies. A metaanalysis was performed to assess primary clinical and imaging outcomes, as well as complication rates, following transarterial interventions in this patient population. MATERIALS AND METHODS By using standard search techniques and metaanalysis methodology, published reports (published in 2012 and before) evaluating survival, complications, and imaging response following transarterial treatments for patients with unresectable intrahepatic cholangiocarcinoma were identified and evaluated. RESULTS A total of 16 articles (N = 542 subjects) met the inclusion criteria and are included. Overall survival times were 15.7 months ± 5.8 and 13.4 months ± 6.7 from the time of diagnosis and time of first treatment, respectively. The overall weighted 1-year survival rate was 58.0% ± 14.5. More than three fourths of all subjects (76.8%) exhibited a response or stable disease on postprocedure imaging; 18.9% of all subjects experienced severe toxicities (National Cancer Institute/World Health Organization grade ≥ 3), and most experienced some form of postembolization syndrome. Overall 30-day mortality rate was 0.7%. CONCLUSIONS As demonstrated by this metaanalysis, transarterial chemotherapy-based treatments for cholangiocarcinoma appears to confer a survival benefit of 2-7 months compared with systemic therapies, demonstrate a favorable response by imaging criteria, and have an acceptable postprocedural complication profile. Such therapies should be strongly considered in the treatment of patients with this devastating illness.

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.