Louis Bouchard

Usefulness of transjugular intrahepatic portosystemic shunt in the management of bleeding ectopic varices in cirrhotic patients.

PurposeTo evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the control of bleeding from ectopic varices.MethodsFrom 1995 to 2004, 24 cirrhotic patients, bleeding from ectopic varices, mean age 54.5 years (range 15–76 years), were treated by TIPS. The etiology of cirrhosis was alcoholic in 13 patients and nonalcoholic in 11 patients. The location of the varices was duodenal (n = 5), stomal (n = 8), ileocolic (n = 6), anorectal (n = 3), umbilical (n = 1), and peritoneal (n = 1).ResultsTIPS controlled the bleeding in all patients and induced a decrease in the portacaval gradient from 19.7 ± 5.4 to 6.4 ± 3.1 mmHg. Postoperative complications included self-limited intra-abdominal bleeding (n = 2), self-limited hemobilia (n = 1), acute thrombosis of the shunt (n = 1), and bile leak treated by a covered stent (n = 1). Median follow-up was 592 days (range 28–2482 days). Rebleeding occurred in 6 patients. In 2 cases rebleeding was observed despite a post-TIPS portacaval gradient lower than 12 mmHg and was controlled by variceal embolization; 1 patient underwent surgical portacaval shunt and never rebled; in 3 patients rebleeding was related to TIPS stenosis and treated with shunt dilatation with addition of a new stent. The cumulative rate of rebleeding was 23% and 31% at 1 and 2 years, respectively. One- and 2-year survival rates were 80% and 76%, respectively.ConclusionThe present series demonstrates that bleeding from ectopic varices, a challenging clinical problem, can be managed safely by TIPS placement with low rebleeding and good survival rates.

Recovery G2 Inferior Vena Cava Filter: Technical Success and Safety of Retrieval

PURPOSE To assess the safety and technical success of the retrieval of the Recovery G2 filter when implanted for temporary protection against pulmonary embolism. MATERIALS AND METHODS The Recovery G2 inferior vena cava (IVC) filter was placed in 120 consecutive patients between September 2005 and September 2006 in a single center. Patients had deep venous thrombosis (DVT) (n = 63), pulmonary embolism and DVT (n = 55), and high risk for pulmonary embolism without recent thromboembolic disease (n = 2). Indications for filter placement included contraindication to anticoagulation (n = 106), failure of anticoagulation (n = 11), and prophylaxis in addition to anticoagulation (n = 3). In patients eligible for filter removal, the authors measured the mean implantation time, filter retrieval success rate, and retrieval procedure time. In addition, they assessed filter tilting, migration, caval penetration, thrombus within the filter, fracture, and caval injury or stenosis. RESULTS In the 51 patients who met the criteria for filter removal, filter tilting (>15 degrees ) was seen in six patients (12%), small thrombi were seen in filters of 15 patients (29%), presumed caval penetration was seen in nine patients (18%), and caudal filter migration was seen in two patients (3.9%). There were no fractures or cephalic migrations. Removal attempts were successful in all 51 patients (100%). The mean implantation time was 53.4 days (range, 7-242 days), and the retrieval procedure time averaged 16.8 minutes (range, 5-60 minutes). CONCLUSIONS Retrieval of the Recovery G2 filter is safe and can be performed successfully in patients who no longer need IVC filtration.

Transjugular intrahepatic portosystemic shunt before abdominal surgery in cirrhotic patients: A retrospective, comparative study

Surgery in cirrhotic patients is associated with high morbidity and mortality related to portal hypertension and liver insufficiency. Therefore, preoperative portal decompression is a logical approach to facilitate abdominal surgery and hopefully to improve postoperative survival. The present study evaluated the clinical outcomes of 18 patients (mean age 58 years) with cirrhosis (seven alcoholics and 11 nonalcoholics) who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement before antrectomy (n=5), colectomy (n=10), small-bowel resection (n=1), pancreatectomy (n=1) and nephrectomy (n=1). TIPS was performed a mean (+/-SD) of 72+/-21 days before surgery and induced a marked mean decrease in portohepatic gradient from 21.4+/-3.9 mmHg to 8.4+/-3.4 mmHg. Cirrhotic patients (n=17) who underwent elective abdominal surgery without preoperative TIPS placement were used as the control group. Both groups were matched for age, etiology of cirrhosis, indications for surgery, type of surgery and coagulation parameters. The mean Pugh score was significantly higher in the TIPS group (7.7 versus 6.2). No significant differences were observed for operative blood loss, postoperative complications, duration of hospitalization and one-month (83% versus 88%) or one-year (54% versus 63%) cumulative survival rate. Analysis using the Cox proportional hazards model showed that neither TIPS placement nor preoperative Pugh score were independent predictors for survival. The present study suggests that preoperative TIPS placement does not improve postoperative evolution after abdominal surgery in cirrhotic patients with good or moderately impaired liver function.

Stent-graft treatment of penetrating thoracic aortic ulcers.

Purpose: To evaluate the efficacy of stent-graft placement for the treatment of penetrating thoracic aortic ulcers. Methods: Ten patients (7 men; mean age 73.8 years, range 69–79) were treated for penetrating thoracic aortic ulcers using Talent or Excluder stent-grafts. Preoperative examinations included computed tomographic angiography (CTA), transesophageal echography, and digital subtraction angiography (DSA). Follow-up included predischarge multimodal imaging and periodic CTA scans after discharge. Endoleaks, aortic diameter changes, and clinical complications were tracked. Results: Technical success was achieved in 100%, but 1 major neurological complication led to death 3 months after the procedure. Radiological follow-up detected 4 early endoleaks (3 type I and a type II), all of which spontaneously regressed, and 1 secondary type II endoleak. The mean aortic diameter decreased by 22% over a mean 9-month follow-up. Conclusions: Aortic ulcers are potentially lethal lesions. Considering its low morbidity and mortality, endovascular repair could widen the treatment options for these lesions.

Midterm Outcomes of Thoracic Aortic Stent-Grafts: Complications and Imaging Techniques

Purpose: To evaluate the midterm outcomes of thoracic aortic stent-grafting and the performance of computed tomographic angiography (CTA), radiography, and magnetic resonance angiography (MRA) in endograft surveillance. Methods: Forty-seven patients with traumatic thoracic aortic ruptures (n=16), aneurysms (n=14), false aneurysms (n=3), penetrating ulcers (n=3), and dissections (n=11) treated with stent-grafts were monitored in follow-up using chest radiography and CTA in all patients and MRA in 23 patients. Two perpendicular maximal aortic diameters, the sum of these diameters, and the elliptical cross-sectional area were determined and compared to baseline for the entire group and in subgroup analyses according to lesion type. CTA, MRA, and radiography were compared for their ability to detect endoleak, monitor stent-graft configuration, and measure aortic diameters. Results: The mortality rate was 8.5%. Severe complications were observed in 14.8% (6% neurological complications); 12 (25.5%) patients had primary endoleaks. Over a mean 11-month follow-up (range 0.25–46 months), the aortic diameters decreased for all patients without endoleak (p<0.001). In the diameter/area subgroup analyses, only the traumatic rupture cohort demonstrated significant decreases in all 4 measurements. CTA and MRA measurements correlated well, but chest radiography was superior to both for visualizing stent-graft shape. In terms of endoleak detection, MRA missed only 1 (12.5%) endoleak (type II) seen on CTA; there were no false positive results with MRA. Conclusions: Morbidity and mortality observed after thoracic stent-grafting are acceptable. Radiography is better for monitoring stent-graft conformation, while CTA provides the best overall morphological information. The performance of MRA in endoleak detection is encouraging.

Endovascular Treatment of Aberrant Systemic Arterial Supply to Normal Basilar Segments of the Right Lower Lobe: Case Report and Review of the Literature

We report the case of a 17-year-old man with acute chest pain due to a partial thrombosis of a pseudosequestration. Unlike a true sequestration, there was a normal bronchial distribution and the involved lung parenchyma was normal on CT scan. A therapeutic transarterial embolization of the aberrant systemic artery from the proximal abdominal aorta was performed successfully. The patient did not suffer from further chest pain during the follow-up of 12 months. A contrast-enhanced CT scan 4 months later demonstrated complete occlusion of the embolized aberrant artery. Our case represents an alternative treatment to surgery for this rare abnormality.

The Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Portal Hypertension: Current Status

The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients.

Transcatheter arterial chemoembolization of hepatocellular carcinoma as a bridge to liver transplantation: a retrospective study.

Background. Transcatheter arterial lipiodol chemoembolization (TACE) can be used in cirrhotic patients with hepatocellular carcinoma to avoid tumor progression before transplantation. Objective. To evaluate the efficacy and safety of TACE used as a bridge to liver transplantation. Methods. TACE was performed in 30 cirrhotic patients with hepatocellular carcinoma. Milan criteria were used to select patients for transplant. Patients had a good or moderately impaired liver function, no arterioportal fistulae, and a good portal perfusion. Results. 48 TACE were performed in 30 patients. Before transplantation, 4 patients were dropped off the list due to tumor extension or liver failure. Complete necrosis of the tumor was observed in 11 patients and partial necrosis in 15 patients. After transplantation, 6 patients died and tumor recurrence was observed in 5 patients with a tumor beyond Milan criteria or no response to TACE. Conclusion. TACE is useful as a bridge to liver transplantation in a selected group of cirrhotic patients with hepatocellular carcinoma. A combined therapeutic approach before surgery might improve the prognosis in these patients.

Percutaneous embolization of iatrogenic arterial kidney injuries: safety, efficacy, and impact on blood pressure and renal function.

PURPOSE To evaluate the efficacy and safety of percutaneous renal artery embolization (RAE) of iatrogenic vascular kidney injuries and the effects of RAE on renal function and arterial blood pressure (BP). MATERIALS AND METHODS Over a 12-year period, 50 consecutive patients with severe hemorrhage after iatrogenic arterial kidney injuries underwent RAE. Technical success was defined as occlusion of the bleeding site, and clinical success was defined as complete bleeding cessation. The effects on renal function and arterial BP were assessed by comparing the estimated glomerular filtration rate (eGFR), renal function stage (National Kidney Foundation scale), systolic BP, and BP stage (European Society of Hypertension classification) before and after RAE. RESULTS RAE was technically successful in 49 patients (98%). Two patients were lost to follow-up after RAE. Clinical success was obtained in 40 (83%), 45 (94%), and 47 patients (98%), respectively, at 24, 48, and 96 hours after RAE. Three patients (6%) had minor complications, and one patient (2%) died within 30 days after RAE. Follow-up renal function data (mean, 4 mo) were available for 33 patients (66%). No statistically significant differences in eGFR (P = .186) or renal function stage (P = .183) were apparent after RAE. Follow-up BP data (mean, 3 mo) were available for 28 patients (56%). There were no significant differences in systolic BP (P = .233) or BP stage (P = .745) after RAE. CONCLUSIONS Embolization of iatrogenic renal artery injuries is safe and associated with high technical and clinical success rates. It is not associated with a significant worsening of renal function or increase in BP.

Hepatic hemodynamics in 24 patients with nodular regenerative hyperplasia and symptomatic portal hypertension.

Background and Aim:  To evaluate hepatic hemodynamics in patients with nodular regenerative hyperplasia of the liver (NRH) with portal hypertension (PHT).