Philip D. Orons

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.

Embolotherapy of Persistent Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysm with the Ancure-Endovascular Technologies Endograft System☆

PURPOSE Endoleak is a potential complication after endovascular repair of abdominal aortic aneurysm (AAA). It may result in continued growth of the aneurysm and potentially result in aneurysm rupture. The authors present their experience with embolotherapy in patients with persistent perigraft flow treated with the Ancure-Endovascular Technologies endograft system. MATERIALS AND METHODS Between February 1996 and August 1998, 54 patients underwent successful repair of AAA with use of the Ancure system. All underwent operative angiography and discharge computed tomography (CT). Follow-up included CT at 6, 12, and 24 months, and CT was also performed at 3 months if an endoleak was present on the discharge CT. Persistent endoleak was defined as perigraft flow still present on the 6-month CT. Seven of 21 initial endoleaks persisted at 6 months. Six patients returned for embolization of the perigraft space and outflow vessels including lumbar arteries and the inferior mesenteric artery (IMA). RESULTS Five of the six patients had leaks from the proximal (n = 1) or distal attachment sites (n = 4) of the Ancure system with outflow into lumbar arteries and/or the IMA; one leak was caused by retrograde IMA flow. The six patients underwent nine embolization procedures with only one minor complication. Follow-up CT showed complete resolution of endoleak and decrease in size of the aneurysm sac in all patients. CONCLUSIONS Although endoleak is commonly seen initially with the Ancure system, persistent leak occurred in 13% of the patients in the study. Persistent flow in most patients arises from a graft attachment site combined with patent outflow vessels such as the IMA or lumbar arteries. Persistent endoleaks can be effectively and safely embolized with use of a combination of coil embolization of the perigraft space and embolization of outflow vessels. Such intervention resulted in a decrease in size of the aneurysm sac.

Transjugular Liver Biopsy: A Prospective Study in 43 Patients with the Quick-Core Biopsy Needle

PURPOSE To evaluate the efficacy and complication rate of the Quick-Core biopsy needle system compared with traditional transjugular biopsy needle systems. MATERIALS AND METHODS Between January 1994 and April 1995, 43 patients underwent transjugular liver biopsy with the Quick-Core system; 18-, 19-, and 20-gauge needles were used in 28, 13, and two patients, respectively. Histologic diagnoses, specimen dimensions, and adequacy of the biopsy sample were determined. Immediate and delayed complications were recorded. RESULTS A total of 118 biopsy specimens were obtained with an average of 2.7 passes per patient. Biopsy was successful in 42 of 43 patients (98%); one specimen contained renal parenchyma. Of the specimens that contained liver tissue, 100% were adequate. Mean maximum sample lengths were 1.1 and 1.5 cm with the 18- and 19-gauge needles, respectively. The procedural complication rate of 2% was due to puncture of the liver capsule in one patient, but no clinical manifestations occurred. No delayed complications occurred in any patient. CONCLUSION The Quick-Core biopsy system produces consistently satisfactory, reproducible specimen cores with a very low complication rate.

Balloon Dilation and Endobronchial Stent Placement for Bronchial Strictures after Lung Transplantation

PURPOSE To evaluate the effect of balloon dilation and endobronchial stent placement for bronchial fibrous stenoses and bronchomalacia after lung transplantation. MATERIALS AND METHODS Bronchial dilation and/or stent placement was performed on 25 lung transplant recipients. Indications included severe dyspnea with postobstructive pneumonia (n = 24) and respiratory failure (n = 1). All patients underwent pulmonary function testing (PFT) before and after bronchial dilation, the results of which were evaluated for changes. A total of 63 procedures were performed between February 1996 and December 1998. Thirty-five lesions were treated (18 were due to bronchomalacia, 17 were due to fibrosis). Areas treated included the left mainstem bronchus (n = 11), bronchus intermedius (n = 10), right mainstem bronchus (n = 7), left upper lobe bronchus (n = 4), right lower lobe bronchus (n = 2), and right middle lobe bronchus (n = 1). Bronchoscopic and/or bronchographic follow-up ranged from 1 to 34 months (mean, 15 months). RESULTS Six-month primary patency of stents placed for bronchomalacia was 71% (10 of 14), with three of the four occlusions caused by mechanical failure of Palmaz stents in the mainstem bronchi. Six-month primary patency for treatment of fibrous strictures was 29%. Secondary patency at 1 year was 100% for both bronchomalacia and fibrous strictures. After treatment, there was a significant improvement in mean PFT results (P = .01-.0001). There was one acute complication, obstruction of the left lower lobe bronchus by a Wallstent treated by dilating a hole in the side of the stent. CONCLUSIONS Balloon dilation and stent placement are safe and effective for bronchial strictures and bronchomalacia after lung transplantation, resulting in significant improvement in PFT results. However, there is almost universal restenosis in patients treated for fibrous strictures necessitating reintervention for prolonged patency.

Segmental nonanastomotic bronchial stenosis after lung transplantation

BACKGROUND Nonanastomotic distal bronchial stenosis has been observed in some patients after lung transplantation. We investigated its relationship with acute cellular rejection (ACR), infection, and ischemia. METHODS Between January 1994 and December 1997, 246 lung transplantations were performed at our hospital. These cases were retrospectively reviewed and evaluated to identify those patients with nonanastomotic bronchial stenosis. RESULTS Six patients had bronchial stenosis within the grafted airway distal to the uninvolved anastomotic site. The average ACR before stenosis was 1.9 compared with 1.6 in a control group. ACR at the time of first recognition of the stenosis ranged from A2 to A3.5, with an average value of A2.9. All 6 patients demonstrated alloreactive airway inflammation before and at the time of stenosis. Four patients had evidence of ischemic damage in the perioperative period. CONCLUSIONS Segmental nonanastomotic large airway stenosis after lung transplantation should be assessed separately from anastomotic complications. Although the pathogenesis is unclear, certainly one should consider alloreactive injury, ischemic damage, and infection as individual and coercive causes.

Endobronchial metallic stent placement for airway complications after lung transplantation: Longitudinal results

BACKGROUND In lung transplant recipients, bronchial stenosis (SB) and bronchomalacia (MB) result in obstructive airway disease and allograft dysfunction due to pulmonary infection. We hypothesized that endobronchial metallic stent placement for SB and MB would result in long-term improvement in respiratory function and rates of pulmonary infection. METHODS We studied symptomatic lung transplant recipients with bronchoscopic evidence of proximal airway complications (SB or MB) and a synchronous decline in forced expiratory volume in 1 second (FEV1) of at least 10% in the 6-month period before intervention. Stent placement was the primary intervention for SB and all focal MB lesions and for recurrent or refractory SB lesions failing a single initial attempt at balloon dilation. FEV1 and rates of pulmonary infection were assessed in the 12-month interval before and after stent placement. Spirometric evaluation was performed at 3-month intervals and compared with spirometry at the time of stent placement. The rates of pulmonary infection, determined by the number of antibiotics prescribed, was determined before and after endobronchial correction. RESULTS Thirty recipients underwent a total of 75 procedures (50 stent insertions and 25 balloon dilations). FEV1 improved significantly after stent placement compared with base line (1.29 +/- 0.43 L) as follows: 3 months, 1.45 +/- 0.50 L, p = 0.014; 6 months, 1.59 +/- 0.57 L, p = 0.002; 12 months 1.59 +/- 0.53 L, p = 0.006. The infection rate decreased from the 12-month period preceding stent insertion to the corresponding period after stent insertion (6.97/100 days +/- 6.33 versus 5.74/100 days +/- 7.76, p = 0.018). Recurrent SB occurred in 17.3%. No life-threatening complications occurred after stent placement and no deaths were attributed to stent malfunction or malposition. CONCLUSIONS In lung transplant recipients with SB and MB, maintenance of airway patency by stent placement is safe and resulted in improvements in lung function and reduced pulmonary infection rates for up to 1 year after their insertion.

The experience of an academic medical center with endovascular treatment of abdominal aortic aneurysms

BACKGROUND Endovascular repair of abdominal aortic aneurysms (AAA) is gaining momentum although it is not yet approved in the United States by regulatory agencies. The Endovascular Grafting System (EGS), the first device to enter clinical trials in 1993, is now in phase III testing. METHODS We reviewed the first 50 patients to undergo an EGS repair of AAA over 24 months at our institution. Results were compared with 69 patients who underwent open repair during the same time period by the same surgeon. RESULTS Devices were successfully implanted in 47 of 50 (94%) patients. Three were converted to standard repair. Although length of stay was shorter, costs were similar. Follow-up was 3 to 24 months. Perigraft flow was noted in 33% at discharge; 73% of those stopped either spontaneously or with coiling. Three graft limbs occluded, requiring thrombolytic therapy. CONCLUSIONS The EGS repair of AAA is feasible and effective. Cooperation between surgery and radiology is important for the success of a new endovascular program.

Transjugular Intrahepatic Portosystemic Shunt in Patients Who Have Undergone Liver Transplantation

PURPOSE Transjugular intrahepatic portosystemic shunt (TIPS) placement is an accepted treatment for refractory variceal bleeding and/or ascites in end-stage liver disease and is an effective bridge to liver transplantation. The authors present their experience with TIPS in patients with a liver transplant, who subsequently developed portal hypertension. MATERIALS AND METHODS Thirteen TIPS were placed in 12 adult patients from 6 months to 13 years after liver transplantation for variceal bleeding that failed endoscopic treatment (n = 6) and intractable ascites (n = 6). All patients were followed to either time of retransplantation or death. RESULTS No technical difficulties were encountered in TIPS placement in any of the patients. Four of six patients treated for bleeding stopped bleeding and did not experience re-bleeding, two had functional TIPS at 3 and 36 months and two underwent retransplantation at 3 and 7 months. Two patients had recurrent bleeding within 1 week and required reintervention. In the ascites group, one is 32 months since TIPS placement with control of his ascites, two patients underwent retransplantation at 2 and 6 weeks with interval improvement in ascites. Two patients died within a week of TIPS of fulminant hepatic failure. The last patient died 1 month after TIPS subsequent to a splenectomy. CONCLUSION In conclusion, the placement of a TIPS in a transplanted liver, in general, requires no special technical considerations compared to placement in native livers. Although this series is small, the authors believe that TIPS should be considered a treatment option in liver transplant recipients who present with refractory variceal bleeding. TIPS may have a role in the management of intractable ascites.

Dissecting pseudoaneurysm of the hepatic artery: A delayed complication of angioplasty in a liver transplant

We report a 59-year-old female with a dissecting pseudoaneurysm of the allograft hepatic artery, as a delayed complication of percutaneous transluminal angioplasty (PTA). PTA of a severe anastomotic stenosis was successful, but complicated by a dissection involving the allograft hepatic artery. A large dissecting pseiidoaneurysm developed and was incidentally detected during routine sonographic evaluation 14 months after PTA. Because of the extent of the pseudoaneurysm, percutaneous repair or surgical reconstruction was considered impossible. The patient underwent successful retransplantation 1 week after diagnosis. Key words: Liver, transplantation-Hepatic arteries, stenosis or obstruction-Transluminal angioplasty-Aneurysm, hepatic

A Case-Based Approach to Common Embolization Agents Used in Vascular Interventional Radiology

OBJECTIVE The objective of this article is to familiarize the reader with the most commonly used embolic agents in interventional radiology and discuss an approach for selecting among the different embolic agents. This article reviews their properties and uses a case-based approach to explain how to select one. CONCLUSION A wide variety of embolic agents are available. Familiarity with the available embolic agents and selection of the most appropriate embolic agent is critical in interventional radiology to achieve optimum therapeutic response and avoid undesired, potentially disastrous complications such as nontarget embolization.