Sandra J. Althaus

Critical appraisal of the angiographic portacaval shunt (TIPS)

The transjugular intrahepatic portacaval shunt (TIPS) is a novel angiographic method for achieving portal decompression without operation. Fifty-nine consecutive patients underwent a total of 80 consecutive TIPS procedures. The procedure was unsuccessful in 4 patients (7%) and initially succeeded in 55 (93%). Eighteen patients (30%) underwent 2 or more TIPS procedures during the same hospitalization due to technical difficulties, early rebleeding, shunt stenosis, or thrombosis. Early TIPS occlusion occurred in seven patients (12%) and led to recurrent variceal hemorrhage in five. Forty-two percent of the cases of persisting or recurrent bleeding were nonvariceal. Procedure-related complications occurred in 10% of TIPS procedures or 14% of patients. Twenty-three patients (39%) were actively bleeding at the time of the procedure, and, in 6 of these (26%), bleeding was never controlled. In-hospital mortality (25%) was related only to the presence of bleeding at the time of TIPS (56% for emergent versus 5.5% for non-emergent, p < 0.0001). Mortality was not related to the Child-Pugh classification. Hemodynamic stabilization, vasoconstrictor therapy, balloon tamponade, and sclerotherapy were underutilized in 30% to 40% of patients prior to TIPS. Aggressive medical management should be used to stop variceal hemorrhage prior to TIPS in all patients, regardless of the Child-Pugh classification. Prospective trials comparing TIPS with sclerotherapy and surgical shunt are required to demonstrate the proper role of this procedure in the management of portal hypertension and variceal hemorrhage.

Treatment of inferior vena cava anastomotic stenoses with the Wallstent endoprosthesis after orthotopic liver transplantation.

PURPOSE To evaluate the efficacy of the Wallstent endoprosthesis for treatment of stenotic or occlusive inferior vena cava (IVC) lesions refractory to balloon angioplasty in patients after orthotopic liver transplantation. MATERIALS AND METHODS Wallstent endoprostheses were implanted in six patients with IVC anastomotic stenoses or occlusions that were refractory to balloon angioplasty. Follow-up included both duplex ultrasound (US) and clinical evaluations. RESULTS Ten stents were successfully implanted in six patients. Five of six patients (83%) demonstrated primary patency on duplex US for a mean period of 11 months (range, 4-17 months). One patients symptoms recurred within 3 weeks after intervention. This patient underwent repeated stent placement. Follow-up duplex US in this patient demonstrated primary assisted patency at 7 months. Mean clinical follow-up was 12 months (range, 7-18 months). Other than the previously described case, no patient developed recurrent symptoms of IVC stenosis or occlusion. Two patients who experienced hemorrhagic complications secondary to anticoagulation were treated successfully. CONCLUSIONS The Wallstent endoprosthesis is a useful adjunct for treatment of IVC stenosis or occlusions in patients who have undergone orthotopic liver transplantation when these lesions are refractory to simple balloon angioplasty.

Use of a Wallstent in successful treatment of IVC obstruction following liver transplantation.

Obstruction of the IVC occurs in only 1-2% of patients after liver transplantation. The mortality of this complication can be as high as 66%. This case report describes the use of a Wallstent for an IVC obstruction that was unresponsive to conventional balloon angioplasty.

Cardiopulmonary consequences of transjugular intrahepatic portosystemic shunts: Role of increased pulmonary artery pressure

Goals: To determine whether increased pulmonary artery pressure (PAP) following transjugular intrahepatic portosystemic shunting (TIPSS) results in short-term mortality or cardiorespiratory complications. Background: TIPSS is frequently performed for complications of cirrhosis. PAP increases following TIPSS; however consequences of this phenomenon are unknown. Study: Demographics, disease severity and etiology were recorded among patients undergoing TIPSS. PAP before and following TIPSS were measured and the relationship between PAP before and after TIPSS, and subsequent cardiorespiratory complications and mortality was examined. Results: Thirty-one patients were enrolled (mean age 53 years, 74% men, 55% Child-Pugh class C cirrhosis). TIPSS was performed for variceal bleeding in 84% of cases. Ten patients (32%) died 5–20 days following TIPSS. PAP increased significantly following TIPSS (mean 20.8 mm Hg pre-TIPSS (95% CI 18.2–23.4) to 26.9 mm Hg post-TIPSS (95% CI 24.2–29.6, P = 0.0016). Congestive heart failure developed in 4 patients (13%), sepsis in 4 (13%), and ARDS in 8 (26%). Increased PAP following TIPSS was not associated with early mortality (P = 0.13), CHF (P = 0.31), or ARDS (P = 0.43). ARDS was the only significant predictor of short-term mortality following TIPSS (OR 18.7, P = 0.02 (95% CI: 1.5–232). Conclusion: PAP increases after TIPSS and cardiorespiratory complications are common, yet unrelated to increased PAP. ARDS is independently associated with increased risk of mortality after TIPSS.

Transcatheter arterial embolization of two symptomatic giant cavernous hemangiomas of the liver

Cavernous hemangiomas are usually asymptomatic; however, a small percetage may cause symptoms. This case report discusses palliation by transcatheter arterial embolization with polyvinyl alcohol particles.

Percutaneous placement of self-expanding stent for acute traumatic arterial injury

The frequency of arterial injury continues to rise primarily urban violence and invasive interventional procedures. 1,2 Becker et al. described the use of a silicone-coated balloon-expandable intraluminal stent to control a life-threatening subclavian iatrogenic arterial hemorrhage. 3 Although the use of intraluminal arterial stents in peripheral vascular occlusive disease has been described in the treatment of both spontaneous and angioplasty-induced dissections, 4-11 their use in the management of traumatic vascular injuries has not been previously noted. The two cases described are the first report of the use of self-expanding, noncoated stents in the emergent treatment of acute noniatrogenic arterial trauma.

Transluminal Treatment of a Celiac Artery Pseudoaneurysm with a Stent Graft Occlusion Device

Abstract This report describes the transluminal placement of a stent graft occlusion device to treat a celiac bypass graft pseudoaneurysm which was causing biliary and duodenal obstruction.

Effects of Transjugular Intrahepatic Portosystemic Shunts on Hepatic Metabolic Function Determined with Serial Monitoring of Arterial Ketone Bodies

PURPOSE To investigate the effects of transjugular intrahepatic portosystemic shunt (TIPS) on hepatic metabolic function by measuring serial arterial ketone body ratio (acetoacetate/-hydroxybutyrate; AKBR). MATERIAL AND METHODS The arterial blood of 30 TIPS patients was assayed before TIPS, 30 minutes after TIPS, and 24 hours after TIPS for acetoacetate, beta-hydroxybutyrate, and glucose. The authors compared the AKBR values to clinical outcome stratified by Child class, emergent versus elective TIPS, and before-TIPS AKBR value < or = 0.5 versus before-TIPS AKBR value > 0.5. RESULTS A significant change was noted between the AKBR values obtained before TIPS and values 30 minutes after TIPS (0.76 +/- 0.09 vs 0.61 +/- 0.05, P < .05) and between 30 minutes and 24 hours after TIPS (0.81 +/- 0.10, P < .001), but not between the value obtained before TIPS and that obtained 24 hours after TIPS. The 30-day mortality rate in emergency TIPS patients was 50% compared to 7% in the elective TIPS patients (P < .01). The pre-TIPS AKBR values were significantly suppressed in the emergency TIPS patients compared to the elective TIPS patients (0.56 +/- 0.04 vs 0.99 +/- 0.17, P < .005). The 30-day mortality rate in patients with a pre-TIPS AKBR value < or = 0.5 was 75%, which was significantly higher than the 14% rate in patients with a pre-TIPS AKBR value > 0.5 (P < .01). CONCLUSION A low pre-TIPS AKBR may be predictive of poor outcome after TIPS. Furthermore, AKBR may be of value in determining the timing for performing an elective TIPS.