Plinio Rossi

Arteriovenous malformation management

Arteriovenous malformations (AVM) are rare vascular lesions that can present with a myriad of clinical presentations. In our institutions, initial workup consists of a clinical exam, color Doppler imaging, and magnetic resonance imaging. After the initial nonivasive workup, arteriography, at times closed system venography, and ethanol endovascular repair of the AVM is performed under general anesthesia. Depending on the size of the lesion, additional Swan-Ganz line and arterial line monitoring are performed. Patients are usuallay observed overnight and uneventfully discharged the following day if no complication occurs. Patients are followed at periodic intervals despite cure of their lesion. Long-term follow-up is essential in AVM management.

MELD score is better than Child-Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt

BACKGROUND/AIMS Patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) are at risk of early death due to end-stage liver failure. The aim of this study was to compare model of end-stage liver disease (MELD) and Child-Pugh scores as predictors of survival after TIPS. METHODS We studied 140 cirrhotic patients treated with elective TIPS. Concordance (c)-statistic was used to assess the ability of MELD or Child-Pugh scores to predict 3-month survival. The prediction of overall survivals was estimated by comparing actuarial curves of subgroups of patients stratified according to either Child-Pugh scores or MELD risk scores. RESULTS During a median follow-up of 23.7 months, 55 patients died, 14 underwent liver transplantation and seven were lost to follow-up. For 3-month survival, the discrimination power of MELD score was superior to Child-Pugh score (0.84 vs. 0.70, z=2.07; P=0.038). Unlike Pugh score, MELD score identified two subgroups of Child C patients with different overall survivals (P=0.027). The comparison between observed and predicted survivals showed that MELD score overrates death risk. CONCLUSIONS MELD score is superior to Child-Pugh score as predictor of short-term outcome after TIPS. Its accuracy, however, decreases for long-term predictions.

Percutaneous transluminal angioplasty versus surgery for subclavian artery occlusive disease

Twenty-one patients who underwent percutaneous transluminal angioplasty (PTA) for proximal stenosis of the subclavian artery were compared with 15 patients who underwent carotid subclavian reconstruction. This represents the first attempt to directly compare the two procedures. All patients had routine Doppler examination during follow-up. Mean follow-up was 30 +/- 24 months after PTA and 40 +/- 25 months after surgery. The incidences of procedural complications were similar (PTA one complication, surgery two complications). Although better early results were achieved in patients who underwent PTA (actuarial patency: PTA 91 percent, surgery 87 percent), after dilatation, we observed a continuous deterioration of the hemodynamic status of the artery, which led to a high rate of late restenosis (actuarial patency: PTA 54 percent, surgery 87 percent). There were no significant changes postoperatively. The specific role of each procedure is analyzed in view of the new acknowledgment of the clinical importance of proximal subclavian artery disease.

New ePTFE/FEP-covered stent in the palliative treatment of malignant biliary obstruction

PURPOSE To determine the technical efficacy and safety of an expanded polytetrafluoroethylene and fluorinated ethylene propylene (ePTFE/FEP)-covered metallic stent in the management of malignant biliary obstruction and to evaluate its clinical efficacy by estimating stent patency and patient survival rates. MATERIALS AND METHODS Twenty-six patients with common bile duct stricture caused by malignant disease were treated by placement of 29 stents. The stent consists of an inner ePTFE/FEP lining and an outer supporting structure of nitinol wire. Multiple wire sections elevated from the external surface provide anchoring. Stents are available in two versions, with or without holes in the proximal stent lining. Holes should provide drainage of the cystic duct or biliary side branches when covered by the proximal stent end. Clinical evaluation and assessment of serum bilirubin and liver enzyme levels were done before stent placement and at 1, 3, 6, and 9 months. Average follow-up duration was 5.4 months (range, 5 d to 12.5 mo). RESULTS Placement was successful in all cases. The 30-day mortality rate was 11.5%. The survival rates were 40% and 15% at 6 and 12 months, respectively. Eighty-four percent of patients had adequate palliative drainage during their lifetime. The stent patency rates were 91%, 77%, and 77% at 3, 6, and 12 months, respectively. Four patients (16%) presented with stent occlusion and needed repeat intervention. No migration occurred. Complications other than stent occlusion occurred in five patients (19%); among these, acute cholecystitis was observed in three patients (12%). CONCLUSION Preliminary results suggest that placement of this ePTFE/FEP-covered stent is feasible and effective in achieving biliary drainage. The percentage of patients undergoing lifetime palliation and the midterm patency are promising. However, the incidence of acute cholecystitis is high. Treatment of a larger group of patients is mandatory to validate these long-term results.

Clinical Experience with Covered Wallstents for Biliary Malignancies: 23-Month Follow-Up

AbstractPurpose: To evaluate the effectiveness of partially covered metallic Wallstents to prevent tumoral ingrowth in patients with neoplastic obstruction of the biliary tract. Methods: Twenty-one patients with malignant obstructive jaundice have been treated with Wallstents partially covered with a polyurethane polymer. In total, 36 covered stents (8 and 10 mm in diameter, 70 and 90 mm long) were deployed. All the stents were free from covering at both ends. Results: Jaundice was successfully treated in 100% of cases. There were no problems related to the releasing system during stent positioning, no major complications, and no incompatibility reactions to the materials composing the endoprostheses. At 23-month follow-up, 6 patients are still alive and 15 are dead; of these 15 patients, 11 died in the first 6 months and the last 4 died between 6 and 23 months. Seven patients had an obstructed stent; in four of these, cholangioscopy showed the presence of tumoral ingrowth and in one it showed necrotic tissue with biliary pigments and inflammatory cells. No biopsy specimen was obtained in the remaining two patients with stent obstruction. The follow-up, ranging from 7 to 23 months, showed a primary patency of 46.8% and 24.6% and an assisted patency of 66.3% and 59% at 6 months and 23 months, respectively. Conclusions: Covered metallic stents are effective and may produce improved survival in patients with malignant biliary obstruction (27.8% at 23 months). Stent patency, however, is similar to that of uncovered stents. Modifications in the design of the covering membrane may reduce stent obstruction resulting from disruption of the plastic covering.

Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Incidence and risk factors

Forty-seven consecutive patients were prospectively evaluated to study the incidence of hepatic encephalopathy as well as modifications in the PSE index after TIPS. Various clinical, laboratory, and angiographic parameters were also recorded to identify risk factors for the development of post-TIPS hepatic encephalopathy (HE). Mean follow-up was 17±7 months. During follow-up, six patients died and one underwent transplantation. All other patients were followed for at least a year. Fifteen patients (32%) experienced 20 acute episodes of precipitated HE (hospitalization was necessary in 10 instances), and five patients (11%) presented a continuous alteration in mental status with frequent spontaneous exacerbation during follow-up. Both precipitated and spontaneous HE occurred more frequently during the first three months of follow-up. Moreover the PSE index was significantly worse than basal values one month after TIPS, thereafter returning to near basal values. HE was successfully treated in all patients but one who required a reduction in the stent/shunt diameter. Increasing age (>65 years) and low portacaval gradient (<10 mm Hg) were predictors of HE after TIPS. A gradual dilation of the stent/shunt should be performed to obtain a portacaval gradient >10 mm Hg to avoid an unacceptable rate of HE after TIPS.

The Value of Total Aortography in the Diagnosis of Takayasu's Arteritis

The arteriographic and clinical spectrum of Takayasus arteritis in a series of 23 cases is reviewed. The incidence of the disease appears to be much higher than is generally suspected. Although it primarily afflicts young women, children are frequently affected. Two clinical stages of the disease are recognized: an early systemic and a late occlusive phase. The signs and symptoms of both stages are protean and variable. The pathological appearance varies with the activity and duration of the disease. Total aortography is of primary diagnostic importance in demonstrating the characteristic appearance of the diseased aorta.

Transcatheter therapeutic arterial embolization.

Transcatheter therapeutic arterial embolization was employed in 11 patients with gastrointestinal hemorrhage and 8 patients with bleeding from other sites. Hemorrhage was stopped successfully in all of the patients with gastrointestinal bleeding and 6 of the 7 patients with active bleeding from other sites. There were no significant complications or sequelae, although ischemia msy cause problems in such patients. Embolization is of considerable value when pharmacological therapy fails or is not appropriate due to the site of bleeding. In some cases it may represent the definitive treatment, as in pelvic trauma or renal hemorrhage; in others, embolization may serve to halt bleeding long enough to permit surgery. Therapeutic embolization should be considered whenever active extravasation of contrast material is demonstrated.

Self-expandable Nitinol Stent for the Management of Biliary Obstruction: Long-term Clinical Results

PURPOSE Technical characteristics and clinical efficacy of a new metallic stent for the management of biliary obstruction were investigated in a clinical study. PATIENTS AND METHODS From February 1991 to January 1993, 35 self-expandable, nickel-titanium alloy wire-mesh stents (diameter, 10 mm; length, 6 cm) were placed in 19 patients with obstructive jaundice due to cholangiocarcinoma (n = 6), pancreatic carcinoma (n = 5), lymph node metastasis to the liver hilum (n = 5), gallbladder carcinoma (n = 2), and intraductal papillary mucosal hyperplasia (n = 1). RESULTS Stent placement was successful in 18 of 19 patients. In one patient, stent dislodgement occurred after correct release; no other procedure-related complications or deaths occurred within 30 days following the procedure. Two (11%) of the remaining 18 patients are alive at 11 months; 16 (89%) died after a mean survival of 7.4 months. Two of three patients with stent obstruction underwent repeated intervention. Adequate palliation from jaundice was achieved without further intervention in 83% of cases. The mean stent patency was not less than 7 months. CONCLUSION Use of these metallic stents reestablished bile flow in the occluded biliary tree. Their efficacy and patency rate were also adequate.

Protection and revascularization of bronchial anastomoses by the intercostal pedicle flap

We used an improved method for preparation of the intercostal pedicle flap for encircling bronchial anastomoses, and we studied its vascular supply after the operation. The flap was used in 56 patients undergoing various types of sleeve resection and in three patients undergoing single lung transplantation. The technique is simple, fast, and causes neither extra surgical trauma nor complications. It allows satisfactory isolation and sealing of the bronchial anastomosis. Even if complete anastomotic dehiscence occurs (one case), the flap preserves the continuity of the airway, thus avoiding bronchopleural fistulas or other complications. The postoperative arteriographic study of the intercostal artery supplying the flap (performed in 14 patients) demonstrated the full patency of the vessel in all cases. It also showed that a fine vascular network develops around the anastomosis early in the postoperative period.