Klaus M. Bron

Complications of venous reconstruction in human orthotopic liver transplantation.

In 313 consecutive recipients of 393 orthotopic liver grafts, there were 51 (16.3%) and nine (2.9%) patients who had pre-existing portal vein and inferior vena cava abnormalities, respectively. These abnormalities required adjustments in the transplant operation and were a source of morbidity and mortality. The incidence of thrombosis of the reconstructed portal vein was 1.8%. Only three (0.8%) vena caval thromboses were seen after 393 liver replacements. Venous stenoses or disruptions were rare. Six women with the Budd-Chiari syndrome had liver replacement. Although this disorder is a veno-occlusive disease, five of the recipients achieved prolonged survival, only one had recurrence of disease, and three are alive after 2–6 years.

Oil embolism in lymphangiography. Incidence, manifestations, and mechanism.

Lymphangiography is proving to be an important diagnostic method in determining the anatomic integrity of the lymphatic network. This procedure permits direct visualization of nodes and lymph channels in areas of the body remote from the clinicians palpating fingers (5). It is particularly useful in studying the pelvic and retroperitoneal nodes which, short of surgery, were previously accessible to investigation by indirect methods only (15). Present evidence suggests that lymphangiography may enable the differentiation of metastatic deposits produced by carcinoma from those produced by lymphoma (2, 14, 21, 25). Furthermore, the precise site and extent of tumor spread may be demonstrated. Such information is essential to the therapist in evaluating the stage of disease, as well as in deciding upon the optimal mode of treatment. Although a number of reviews of the role of lymphangiography in diagnostic medicine have appeared (21, 25), there has been scant discussion of the complications following the use ...

Splanchnic Artery Stenosis and Occlusion

The observations and information available on stenosis and occlusion of the splanchnic arteries are primarily derived from surgical (1–4) and autopsy (5–7) studies. The clinical problem of splanchnic artery obstruction, however, extends beyond those patients who are either severely symptomatic or those with a fatal course. Undetermined from these studies is the incidence of asymptomatic or atypically symptomatic patients with splanchnic vessel lesions, since these vessels are not routinely palpated during exploratory laparotomy nor routinely described in autopsy reports (8). Knowledge of this incidence is necessary in evaluating the significance of the type and number of splanchnic vessel obstructions and the influence of collateral vessels in relation to the symptoms of intestinal angina. Abdominal arteriography, in contrast to autopsy and surgical studies, offers a unique opportunity to investigate these lesions in an in vivo population and thus to study their potential natural incidence and history. It...

Percutaneous Transluminal Angioplasty of Venous Anastomotic Stenoses Complicating Liver Transplantation: Intermediate-term Results☆

PURPOSE The authors evaluated the safety and efficacy of percutaneous transluminal angioplasty (PTA) for the treatment of venous stenoses in liver transplant recipients. PATIENTS AND METHODS Over a 5-year period, 15 venous stenoses were treated with PTA in 12 patients with liver transplants (seven children and five adults). PTA was performed for portal vein stenoses in five patients, inferior vena cava (IVC) stenoses (n = 6) in five patients, combined superior mesenteric vein-portal vein graft anastomosis and hepatic vein-IVC anastomosis in one patient, and combined IVC and hepatic vein-IVC anastomosis in one patient. PTA was repeated in three patients (five procedures) for recurrent IVC stenoses. RESULTS Initial technical and clinical success of PTA was achieved in 11 patients (92%); failure occurred in one patient (8%) with a portal vein anastomotic stenosis. No complications occurred in the immediate post-procedure period (up to 7 days). Nine patients (75%) are clinically well, with follow-up ranging from 7 to 33 months (mean, 18 months). Two of them required one or more repeated PTA procedures to maintain vessel patency. One patient required retransplantation for chronic rejection at 3 months, and another died of gastrointestinal tract bleeding from a gastric ulcer at 2 months after initially successful IVC PTA. CONCLUSIONS PTA is a safe procedure for the treatment of venous anastomotic stenoses in liver transplant recipients. PTA of portal vein anastomotic stenosis has favorable intermediate-term results. Repeat PTA may be necessary in some cases of IVC anastomotic stenoses to maintain vessel patency and avoid surgical revision or retransplantation.

Transhepatic Balloon Dilation of Biliary Strictures in Liver Transplant Patients: A 10-year Experience

PURPOSE The authors report their initial and long-term results using transhepatic balloon dilation to treat biliary strictures in liver transplant patients. PATIENTS AND METHODS Over a 10-year period, 72 liver transplant patients with biliary strictures underwent 81 balloon dilation treatments. Anastomotic strictures were present in 56 patients; nonanastomotic strictures were present in 16. RESULTS Initial technical success was achieved in 64 of 72 patients (89%). Balloon dilation failed in eight patients (11%), and they were treated surgically. Complications occurred in nine (12%) patients, and all were successfully treated. Within the first 6 months, five patients (6.9%) required surgical revision. Three patients (4.2%) underwent repeated liver transplantation; and five patients (6.9%) died. Fifty-one patients in whom balloon dilation was initially successful were available for at least a 6-month follow-up. Life-table analysis showed an overall 81% +/- 4.8 success rate at 6 months; it dropped to 70% +/- 6.2 at 6 years. For anastomotic strictures, it was 77% +/- 5.8 at 6 months and 66% +/- 7.3 at 6 years. For nonanastomotic strictures, it was 94% +/- 6.2 at 6 months, which dropped to 84% +/- 10 at 5 years. CONCLUSION Transhepatic balloon dilation represents an effective and relatively safe treatment for biliary stricture in liver transplant recipients.

Hepatic Artery Angioplasty after Liver Transplantation: Experience in 21 Allografts

PURPOSE To assess whether percutaneous transluminal angioplasty (PTA) can help prolong allograft survival and improve allograft function in patients with hepatic artery stenosis after liver transplantation. PATIENTS AND METHODS Hepatic artery PTA was attempted in 19 patients with 21 allografts over 12 years. The postangioplasty clinical course was retrospectively analyzed. Liver enzyme levels were measured before and after PTA to determine if changes in liver function occurred after successful PTA. RESULTS Technical success was achieved in 17 allografts (81%). Retransplantation was required for four of 17 allografts (24%) in which PTA was successful and four of four allografts in which PTA was unsuccessful; this difference was significant (P = .03). Two major procedure-related complications occurred: an arterial leak that required surgical repair and an extensive dissection that necessitated retransplantation 14 months after PTA. Hepatic failure necessitated repeat transplantation in seven cases from 2 weeks to 27 months (mean, 8.4 months) after PTA. Six patients died during follow-up, three of whom had undergone repeat transplantation. Markedly elevated liver enzyme levels at presentation were associated with an increased risk of retransplantation or death regardless of the outcome of PTA. CONCLUSION PTA of hepatic artery stenosis after liver transplantation is relatively safe and may help decrease allograft loss due to thrombosis. Marked allograft dysfunction at presentation is a poor prognostic sign; thus, timely intervention is important.

LYMPHANGIOGRAPHY, CAVOGRAPHY, AND UROGRAPHY; COMPARATIVE ACCURACY IN THE DIAGNOSIS OF PELVIC AND ABDOMINAL METASTASES.

During the past few years, interest has been increasing in lymphangiography as a method of demonstrating abnormalities in lymph nodes and lymphatic channels (8, 10, 13, 14). Oncologists have exhibited a special enthusiasm for this new procedure since it affords a graphic representation of the site and extent of pelvic and abdominal cancer. Prior to the application of lymphangiography, the presence of retroperitoneal masses not detectable on physical examination was inferred from obliteration of the psoas shadows or delineation of a soft-tissue mass on the plain films of the abdomen; the secondary changes produced in the gastrointestinal tract during the course of a barium meal; displacement of either kidney or ureter during intravenous urography; the use of retroperitoneal air insufflation (2, 6); and, more recently, the displacement of the cava as shown by inferior vena cavography (5). The ease with which most of the above procedures can be performed enhances their appeal, particularly when compared with...

Arterial constrictor response in a diving mammal

Angiograms were obtained in the harbor seal, Phoca vitulina, in air and during diving. During diving there is arterial constriction of the vascular beds of muscle, skin, kidney, liver, spleen, and presumably of all vascular beds except those perfusing the brain and heart. There is sudden constriction and narrowing of muscular arteries close to their origin from the aorta. Constriction of small arterial branches is so intense that blood flow is essentially lost in all involved organs.

Percutaneous Transhepatic Cholangiography and Biliary Drainage After Liver Transplantation: A Five-Year Experience

Evaluation of the biliary tract by percutaneous transhepatic cholangiography (PTC) is often required in liver transplant patients with an abnormal postoperative course. Indications for PTC include failure of liver enzyme levels to return to normal postoperatively, an elevation of serum bilirubin or liver enzyme levels, suspected bile leak, biliary obstructive symptoms, cholangitis, and sepsis.Over a 5-year period 625 liver transplants in 477 patients were performed at the University Health Center of Pittsburgh. Fifty-three patients (56 transplants) underwent 70 PTCs. Complications diagnosed by PTC included biliary strictures, bile leaks, bilomas, liver abscesses, stones, and problems associated with internal biliary stents.Thirty-two percutaneous transhepatic biliary drainage procedures were performed. Ten transplantation patients underwent balloon dilatation of postoperative biliary strictures. Interventional radiologic techniques were important in treating other complications and avoiding additional surgery in many of these patients.

Hemobilia complicating transhepatic catheter drainage in liver transplant recipients: Management with selective embolization

Two liver transplantation patients are reported who experienced severe hemobilia following percutaneous placement of a transhepatic biliary drainage catheter. In both, hepatic angiography demonstrated the source of bleeding from a traumatic pseudoaneourysm of a right hepatic artery branch. Hemobilia in both patients was successfully treated using selective embolization techniques. Follow-up computed tomography of the liver showed no evidence of allograft necrosis or abscess formation. One patient developed an intrahepatic biliary stricture adjacent to the embolized branch artery nine months following the procedure. Hepatic artery embolization techniques are effective in the treatment of life-threatening hemobilia posttransplantation.