Paul C. Lakin

Transjugular approach to liver biopsy and transhepatic cholangiography.

Abstract The percutaneous transjugular approach to liver biopsy and cholangiography (of Hanafee and Weiner) eliminates the necessity for traversing the peritoneal cavity and puncturing the liver capsule. The liver parenchyma is entered through the wall of a hepatic vein by a needle inserted into a catheter introduced percutaneously via the internal jugular vein. This approach offers a safe means for liver biopsy and transhepatic cholangiography in the patient with a bleeding tendency, high-grade obstructive jaundice or ascites. Acute cholangitis is the principal contraindication of this approach. The transjugular approach was used in 61 patients. Both biopsy and cholangiography were done in 36 patients, liver biopsy alone in eight patients, and cholangiography alone in 17 patients. Diagnostic biopsy specimens were obtained in 39 patients (89 per cent). Cholangiography succeeded in 29 of 31 patients (93 per cent) with enlarged intrahepatic ducts. There were no major complications. (N Engl J Med 289:227–231...

Blunt injuries to the carotid and vertebral arteries

A small series of patients with blunt injury to eigher a carotid or vertebral artery is presented. In three patients the injury was recognized relatively promptly. Two underwent surgery and one was observed with reasonably good results. In two patients the injury was unrecognized, resulting in death in one patient and in a severe, fixed, long-term neurologic deficit in the other. It appears likely that reconstruction may be the treatment of choice in any patient with angiographically proven injury unless coma or severe dense hemiplegia is present.

Treatment of Malignant Esophageal Obstructions with Covered Metallic Z Stents: Long-term Results in 52 Patients☆

PURPOSE To prospectively evaluate the clinical efficacy of silicone-covered Gianturco-Rösch self-expandable Z (GRZ) stents in the treatment of malignant esophageal obstruction. PATIENTS AND METHODS GRZ stents were placed in 52 patients (39 men, 13 women) with severe dysphagia due to high-grade malignant esophageal obstruction. RESULTS Stent placement was technically successful, and immediate relief of dysphagia was achieved in 50 of 52 patients (96%), with long-term relief in 47 patients (90%). Fifty-one patients (98%) died during follow-up (range, 1 week to 33 months; mean, 4.3 months). Late complications were most prevalent and included stent migration (n = 5), food impaction (n = 2), chest pain (n = 2), membrane disruption with tumor ingrowth (n = 1), granulomatous reaction above the stent (n = 1), esophageal perforation with mediastinitis (n = 1), and upper gastrointestinal hemorrhage (n = 4). Twelve complications were easily managed with medical, endoscopic, or radiologic intervention. Four deaths may have been related to stent placement (early mortality rate, 7.7%). CONCLUSION GRZ stents provide relatively safe and effective long-term palliation in patients with severe, malignant esophageal obstruction.

Treatment of Malignant Esophagorespiratory Fistulas with Silicone-covered Metallic Z Stents

PURPOSE To prospectively evaluate the clinical efficacy of covered metallic Z stents in the treatment of esophagorespiratory fistulas (ERFs). PATIENTS AND METHODS Twelve patients with severe aspiration symptoms from malignant ERFs were treated with silicone-covered, metallic, self-expanding Gianturco-Rösch Z (GRZ) stents. RESULTS Fluoroscopically guided stent placement was successful and well tolerated in all patients. Immediate postprocedural endoscopy and esophagography showed excellent coverage of the fistulas in all cases. Aspiration symptoms were completely relieved in eight of 12 patients (67%). Four of 12 patients (33%) were improved and able to eat a soft diet. There were no stent-related deaths. Nine patients have died and three patients are alive. Mean follow-up for the entire group was 3.9 months (range, 1 week to 10.5 months). Nonfatal complications occurred in three of 12 patients (25%). Complications included one membrane disruption and one granulomatous reaction with a slight upward stent migration. CONCLUSION GRZ stents are an effective and safe means of palliation in patients with malignant esophagorespiratory fistulas.

Injectable Flow-Guided Coaxial Catheters for Selective Angiography and Controlled Vascular Occlusion

Abstract The authors describe the use of Silastic tubing injected through conventional selective catheters by means of hydraulic propulsion. Such a technique extends the range of selective diagnostic catheterization and produces reversible, selective transluminal arterial occlusion for control of hemorrhage and for other purposes.

Transjugular Intrahepatic Portosystemic Shunt Creation Using Intravascular Ultrasound Guidance

PURPOSE To describe the use of intravascular ultrasound (US) guidance for creation of transjugular intrahepatic portosystemic shunts (TIPSs) in humans. MATERIALS AND METHODS The initial 25 cases of intravascular US-guided TIPS were retrospectively compared versus the last 75 conventional TIPS cases during the same time period at the same institution in terms of the number of needle passes required to establish portal vein (PV) access, fluoroscopy time, and needle pass-related complications. RESULTS Intravascular US-guided TIPS creation was successful in all cases, and there was no statistically significant difference in number of needle passes, fluoroscopy time, or needle pass-related complications between TIPS techniques. Intravascular US-guided TIPS creation was successful in cases in which conventional TIPS creation had failed as a result of PV thrombosis or distorted anatomy. Intravascular US guidance for TIPS creation was additionally useful in a patient with Budd-Chiari syndrome and in a patient with intrahepatic tumors. CONCLUSIONS Intravascular US is a safe and reproducible means of real-time image guidance for TIPS creation, equivalent in efficacy to conventional fluoroscopic guidance. Real-time sonographic guidance with intravascular US may prove advantageous for cases in which there is PV thrombus, distorted anatomy, Budd-Chiari syndrome, or hepatic tumors.

Clinical Outcome after Intrahepatic Venous Stent Placement for Malignant Inferior Vena Cava Syndrome

We evaluated the clinical outcome of malignant inferior vena cava (IVC) syndrome after intrahepatic IVC stent placement by retrospective analysis of 50 consecutive patients (25 men, 25 women, age 32–83 years) with malignant IVC syndrome who were treated with intrahepatic stent placement. Gianturco-Rosch-Z (GRZ) stents (n = 45), and Wallstents (n = 5) were inserted. Clinical outcome was assessed from patients’ records using a score based on leg swelling, scrotal/vulvar edema, ascites and anasarca before and after stent placement, as well as at last follow-up visit before death. Clinical follow-up was supplemented by duplex sonography in 36 patients. Inferior venocavography was performed in 5 patients prior to re- intervention. Follow-up time ranged from 1 to 932 days (mean 62 days). Mean pressure gradient in the IVC was reduced from 14 ± 4.1 mmHg before to 2.9 ± 3.2 mmHg after stent placement (p < 0.001). Four patients had stent occlusion, 2 of whom were successfully re-stented. Primary and secondary patency was 59% and 100%, respectively at 540 days. Immediate clinical data were available in 44 patients: 38 improved; 6 did not respond. Last follow-up visit data were available in 36 patients: 24 showed persistent symptom relief till death. All symptom scores were significantly improved after stent placement (p < 0.001) and with the exception of ascites, remained significantly improved (p < 0.05) until the last follow-up. Increased serum bilirubin was a common characteristic of clinical failures and recurrences. Intrahepatic IVC stent placement resulted in significant symptomatic relief in patients with malignant IVC syndrome. Palliation was effective even in patients with a very short life expectancy.

Successful Endovascular Treatment of Aortoenteric Fistula Secondary to Eroding Duodenal Stent

Aortoenteric fistulas are characterized as either primary or secondary on the basis of their cause. Most aortoenteric fistulas occur between the aorta and duodenum and are a rare but well-known cause of catastrophic gastrointestinal hemorrhage. Conventional treatment of aortoenteric fistulas uses bypass grafting and aortic ligation, but endovascular treatments have become more common. The authors describe the successful endovascular repair of a primary aortoenteric fistula caused by eroding duodenal stent.

Percutaneous Transjugular Kidney Biopsy in Swine with Use of a Side-Cutting Needle with a Blunt-tipped Stylet

PURPOSE To evaluate a new 19-gauge blunt-tipped, side-cutting, single throw transjugular biopsy needle for transvenous kidney biopsies. MATERIALS AND METHODS Transjugular transvenous kidney biopsies were performed with a modified 70-cm biopsy needle utilizing fluoroscopic guidance in nine swine. Three tissue specimens were obtained with four biopsy device passes in five animals and three biopsy device passes in four animals. Renal arteriography and venography were performed immediately before and after renal biopsy. Five animals were killed immediately after biopsy. Four animals were allowed to recover and underwent arteriography and venography prior to being killed, which varied from 1 to 6 weeks. Gross and histologic examinations of the biopsied kidney were performed after euthanasia. A pathologist reviewed all biopsy specimens for quality based on the number of glomeruli present. RESULTS Results of immediate and delayed arteriography and venography were normal in all cases. Histologic evaluation of all biopsy specimens demonstrated a range of two to 13 glomeruli per sample (mean, 6.5), with successful acquisition of the cortex. In one animal killed immediately after biopsy, a small subcapsular hematoma was present. CONCLUSION The 19-gauge, side-cut biopsy needle with a blunt-tip stylet proved to be efficacious for obtaining renal cortical samples in right swine kidneys via a transjugular approach.