Susan D. Wall

Endoscopic Sclerotherapy Compared with Percutaneous Transjugular Intrahepatic Portosystemic Shunt after Initial Sclerotherapy in Patients with Acute Variceal Hemorrhage: A Randomized, Controlled Trial

During the past 15 years, endoscopic sclerotherapy and, more recently, band ligation and such pharmacologic agents as octreotide have eclipsed surgical shunting as the preferred method for controlling acute variceal hemorrhage. The status of sclerotherapy for the long-term management of patients with bleeding varices, however, remains controversial. In a previous controlled clinical trial comparing endoscopic sclerotherapy with surgical portacaval shunting [1], we enrolled 64 adult patients with Child class C cirrhosis and active hemorrhage from esophageal varices. At the index hospitalization, patients randomly assigned to sclerotherapy required less blood transfusion and fewer days of hospitalization than did those randomly assigned to shunt surgery. During the initial follow-up period, which extended for a mean of 530 days after randomization, 75% of the patients treated with sclerotherapy were hospitalized for recurrent variceal hemorrhage but none of the patients who had had shunt surgery were rehospitalized [1]. Although patients treated with sclerotherapy had longer hospital stays and received more blood transfusions during short-term follow-up, a longer follow-up study [2] showed no difference in survival or overall health care costs between patients treated with sclerotherapy and those treated with surgical shunt. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a nonsurgical procedure in which an expandable metal prosthesis is used to connect an intrahepatic portal vein with an adjacent hepatic vein [3, 4]. In our initial report on 100 patients having this procedure [3], TIPS stent placement was technically successful in 96 patients and variceal hemorrhage was controlled in 88 of 94 patients [3]. Furthermore, the 30-day mortality rate was only 13% in patients treated with TIPS. These data, as well as those of other researchers who used radiographically placed portosystemic stents, suggest that TIPS might be more cost-effective than sclerotherapy; however, data comparing the two procedures are limited [5-10]. Therefore, we did a randomized, controlled trial in patients with massive acute variceal hemorrhage in an effort to compare the two therapies for the prevention of recurrent variceal hemorrhage. Methods From November 1991 through December 1995, we enrolled 49 adults who had cirrhosis and endoscopically documented bleeding from esophageal varices. We excluded an estimated additional 250 patients with bleeding varices whom we had seen during the study period (vide infra). Our study protocol was approved by the Committee on Human Research of the University of California, San Francisco. Patients who were admitted to San Francisco General Hospital, University of California Medical Center, and Veterans Affairs Medical Center (all located in San Francisco, California) with massive or submassive acute gastrointestinal tract hemorrhage from large esophageal varices were approached for consent and randomization within 24 hours of admission. Massive hemorrhage was defined as bleeding associated with shock (systolic blood pressure < 80 mm Hg). Submassive hemorrhage was defined as hemorrhage associated with postural vital sign changes (upright pulse rate increased by 20 beats per minute compared with supine pulse rate; upright systolic blood pressure decreased by 20 mm Hg compared with supine blood pressure). The 250 excluded patients were excluded for the following reasons: They were prisoners; they were younger than 18 or older than 75 years of age; they had had a cerebrovascular accident within 3 months before the onset of bleeding; they refused to accept blood products; or they had gastric variceal hemorrhage, electrocardiographic changes compatible with acute myocardial infarction, a Po 2 less than 70 mm Hg or an arterial pH of 7.20 or less on room air at the time of evaluation for eligibility, a serum creatinine level of 221 mol/L or more, a prothrombin time at least 5 seconds longer than control (despite the use of fresh frozen plasma), a platelet count less than 50 109/L, stage IV hepatic encephalopathy, cancer other than skin cancer, the acquired immunodeficiency syndrome (AIDS) or advanced AIDS-related complex, sepsis, pneumonia, peritonitis, clinical evidence of alcoholic hepatitis, a serum bilirubin concentration of 7 mg/dL or more, thrombosis of the portal vein, thrombosis of the hepatic veins, or thrombosis of the inferior vena cava as determined by Doppler ultrasonography. All patients received endoscopic sclerotherapy at the time of the initial endoscopic procedure that established the source of hemorrhage as esophageal varices. Patients were deemed eligible for participation if they presented with hemodynamically submassive or massive hemorrhage and were found to have large (>1 cm across) distal esophageal varices with cherry red spots, hematocystic spots, or red wale signs. Before randomization, all patients had patency of the portal venous system (main, right, and left portal veins and the splenic vein) and hepatic veins determined by real-time color and pulse-wave Doppler ultrasonography. After we obtained informed consent, we used serially numbered, sealed, opaque envelopes to randomly assign patients either to repeated sclerotherapy or to TIPS. If neither the patient nor the patients next of kin was able to give informed consent, a patient advocate was designated to consider the invitation to participate. Patients randomly assigned to sclerotherapy received treatment every 2 to 7 days during the initial hospitalization; treatment consisted of 0.5- to 2.0-mL injections of ethanolamine oleate solution per varix. Repeated endoscopy and sclerotherapy treatments were done weekly after discharge from the initial hospitalization. As much as 30 mL of ethanolamine oleate solution was used per treatment session. All visible varices were injected within the distal 7 to 10 cm of the esophagus. In patients who developed sclerotherapy-associated ulcers, repeated endoscopy was scheduled to be done 2 to 7 days after the notation of ulcers to assess interval healing. Patients assigned to the TIPS group had the procedure within 48 hours of randomization; the procedure was performed by one of six radiologists skilled in this procedure, as described elsewhere [3]. Catheterization of the hepatic vein was done through the right internal jugular vein. A tract between a suitable hepatic vein and a suitable portal vein was established by needle set (Ring TIPS set, Cook, Inc., Bloomington, Indiana), dilated with a balloon over a guidewire, and then maintained by one or more expandable metal mesh stents (Wallstent, Schneider, Inc., Minneapolis, Minnesota). The adequacy of the portosystemic shunt was documented by contrast injection and manometric measurement at the time of the initial procedure. A target portal vein-to-hepatic vein pressure gradient of 12 mm Hg or less was achieved in all cases. Persistent varices opacified at portal venography after adequate stenting were occluded by using embolization coils. Preprocedural data recorded prospectively included sex, age, vital signs at admission, physical examination findings at admission (including presence of encephalopathy and ascites), nutritional status, results of laboratory tests, and Child-Pugh score [11]. Prospectively identified outcome variables after randomization included death, rebleeding, liver transplantation, total transfusion requirements, onset and presence of encephalopathy, cost of managing variceal hemorrhage after randomization, total duration of hospitalization for variceal hemorrhage and any related encephalopathy, and complications of therapy. Nutritional status was defined as malnourished if the patient had gross muscle wasting, had cachexia, or had lost at least 10% of body weight during the previous 6 months. Bleeding after randomization was defined as bloody or coffee grounds emesis (hemetemesis, melenemesis) or liquid black stools (melena) with a decrease in hematocrit sufficient to warrant transfusion. Hepatic encephalopathy was defined clinically by the presence of asterixis, gross disorientation or agitation, or frank somnolence or coma in the absence of another identifiable cause. Presence of ascites was determined by both ultrasonography and clinical assessment (shifting dullness, fluid wave, gross distention) for all patients initially and for patients in the TIPS group having follow-up Doppler ultrasonography. For patients assigned to sclerotherapy, presence of ascites was subsequently determined by clinical criteria alone. Follow-up information was obtained through face-to-face interviews, telephone interviews, or chart reviews and was obtained from the patient, family, physician, or all three sources. The total cost of health care per patient was calculated as the sum of all real costs for inpatient and outpatient hospital care, including hospital expenditures and costs for professional services from the day of randomization until death or the last follow-up visit. In addition, all outpatient costs for endoscopic sclerotherapy, Doppler ultrasonography, and stent revision during the follow-up period were included. We used the actual cost to the hospital or medical staff, or both, of providing a service or procedure (rather than billing charges or collections). For example, the cost of an endoscopic sclerotherapy session was determined by summating the following: 1 hour of a gastroenterologists time plus benefits (derived from personnel pay records); 2 hours of a registered nurses time plus benefits; the invoice cost of disposable sclerotherapy catheters, bite blocks, and intravenous tubing; the pharmacy costs of all drugs, including the sclerosant agent; the estimated depreciation of an Olympus GIT-IT100 videoendoscope (Lake Success, New York); endoscopic processing costs; 1 hour of recovery room personnel time; and costs of recovery supplies. Outcome variables were compared, using the intention-to-tre

Endovascular aneurysm repair in high-risk patients☆☆☆★★★

PURPOSE The purpose of this study was to evaluate the role of endovascular aneurysm repair in high-risk patients. METHODS The elective endovascular repair of infrarenal aortic aneurysm was performed in 116 high-risk patients with either custom-made or commercial stent grafts. The routine follow-up examination included contrast-enhanced computed tomography (CT) before discharge, at 3, 6, and 12 months, and annually thereafter. Patients with endoleak on the initial CT underwent re-evaluation at 2 weeks. Those patients with positive CT results at 2 weeks underwent endovascular treatment. RESULTS Endovascular repair was considered feasible in 67% of the patients. The mean age was 75 years, and the mean aneurysm diameter was 6.3 cm. The American Society of Anesthesiologists grade was II in 3.4%, III in 65.5%, IV in 30.1%, and V in 0.9%. There were no conversions to open repair. Custom-made aortomonoiliac stent grafts were implanted in 77.6% of the cases, custom-made aortoaotic stent grafts in 11.2%, and commercial bifurcated stent grafts in 11.2%. The 30-day rates of mortality, major morbidity, and minor morbidity were 3.4%, 20.7%, and 12%, respectively, in the first 58 patients and 0%, 3.4%, and 3.4%, respectively, in the last 58. The late complications included five cases of stent graft kinking, two cases of femorofemoral graft occlusion, and three cases of proximal stent migration, one of which led to aneurysm rupture. At 2 weeks after repair, endoleak was present in 10.3% of the cases. All the type I (direct perigraft) endoleaks underwent successful endovascular treatment, whereas only one type II (collateral) endoleak responded to treatment. The technical success rate at 2 weeks was 86.2%, and the clinical success rate was 96.6%. The continuing success rate was 87.9%. Seventeen patients died late, unrelated deaths. CONCLUSION Endovascular aneurysm repair is safe and effective in patients at high risk, for whom it may be the preferred method of treatment.

Endovascular repair of abdominal aortic aneurysm using a pararenal fenestrated stent-graft.

Purpose: To report an unusual case of endovascular abdominal aortic aneurysm (AAA) exclusion in which a fenestrated stent-graft was used to seal a proximal Type I endoleak. Methods and Results: An 84-year-old man with a 6.0-cm AAA underwent an aortomonoiliac aneurysm exclusion procedure that was complicated by a proximal endoleak. Because the patient had no right kidney, an additional stent-graft was designed to cover the right renal artery stump while preserving left renal perfusion through a fenestration in the graft material. This approach was successful in obliterating the endoleak around the proximal attachment site, but flow through the lumbar arteries remained. Conclusions: The use of a fenestrated stent-graft is feasible, but the type of fenestration in this case has limited applicability owing to the rarity of patients with suitable anatomy.

Computerized tomographic assessment of graft incorporation after aortic reconstruction

Computerized tomographic scanning is being used with increasing frequency for the detection of abdominal aortic prosthetic complications. Although computerized tomography remains a very precise method for direct imaging of the retroperitoneal space, the interpretation of a postoperative computerized tomographic scan is limited by the absence of any information on the normal appearance of the routine uncomplicated aortic graft. To study the normal tissue incorporation of aortic grafts, 29 patients were evaluated with periodic postoperative computerized tomographic scans. Seventeen patients had aortoiliac occlusive disease and 12 had aneurysmal disease. No patients who had reoperation were included and all patients had a normal postoperative course. Computerized tomographic scans were obtained in the early (mean 7 days), intermediate (mean 48 days), and late (mean 102 days) postoperative periods. A variable amount of perigraft hematoma was always present on the initial computerized tomographic scan. Perigraft air was seen in only four patients in the early study. Graft incorporation appeared complete in these patients by 48 days, although minimal hematoma persisted in one patient. This study provides baseline data on the appearance and timing of aortic graft incorporation which should facilitate subsequent computerized tomographic detection of aortic graft complications.

Value of computed tomography in detecting occult gastrointestinal perforation.

Five patients with clinically unsuspected gastrointestinal perforation were evaluated preoperatively with computed tomography (CT). In each case the CT demonstration of pneumoperitoneum established the diagnosis of a ruptured viscus and prompted early surgical intervention. The site of perforation was apparent on CT in four of the five patients. Plain radiographs including upright chest films (two patients) and supine radiographs of the abdomen (one patient) were interpreted as negative for free air prior to CT. The CT features of pneumoperitoneum and its clinical implications are reviewed.

Retrograde Catheterization of the Inferior Mesenteric Artery to Treat Endoleaks: Anatomic and Technical Considerations

Abbreviations: IMA inferior mesenteric artery, SMA superior mesenteric artery ENDOVASCULAR stent-graft placement is a promising new therapy for the treatment of infrarenal abdominal aortic aneurysm (1,2). The procedure can be successfully accomplished with low procedural morbidity in most cases. However, persistent aneurysm perfusion after stent-graft placement is an important complication of this new innovative therapy that is observed in 5%–40% of patients (3,4). The best method for managing patients with postimplantation perigraft perfusion (endoleak) is not yet known and, consequently, many approaches to the management of this problem are being explored (5–7). Some endoleaks are due to backbleeding from infrarenal aortic sidebranches (4). These sidebranches receive inflow from arterial collaterals. Blood typically flows in through one sidebranch, such as the inferior mesenteric artery (IMA), traverses the perigraft space, and then flows out through another sidebranch, such as a lumbar artery. Endoleaks of this type can be prevented by occluding the involved aortic sidebranches. Sidebranch vessels can be accessed for embolization in two ways: (i) via a systemic collateral (superior mesenteric artery [SMA] or iliolumbar arteries)—in this way, the sidebranch vessel and perigraft space are catheterized from an “outside-in” approach, or (ii) via the perigraft space, which can be entered directly, around the proximal or distal end of the stent-graft—in this way, the sidebranch vessel is catheterized from an “inside-out” approach. In the past few years, we have gained experience with retrograde catheterization of infrarenal aortic sidebranches for this purpose. The purpose of this article is to highlight the anatomic and technical considerations relevant to retrograde IMA catheterization used to treat endovascular stent-graft leaks.

Effects of Hypoxic Hypoxia on Cerebral Phosphate Metabolites and pH in the Anesthetized Infant Rabbit

The effects of hypoxic hypoxia on high-energy phosphate metabolites and intracellular pH (pHi) in the brain of the anesthetized infant rabbit were studied in vivo using 31P nuclear magnetic resonance spectroscopy. Five 10- to 16-day-old rabbits were anesthetized with 1.5% halothane. Ventilation was controlled to maintain normocarbia. Inspired O2 fraction was adjusted to produce three states of arterial oxygenation: hyperoxia (Pao2 > 250 mm Hg), normoxia (Pao2 ∼ 100 mm Hg), and hypoxia (Pao2 25–30 mm Hg). During hypoxia, blood pressure was kept within 20% of control values with a venous infusion of epinephrine. During hyperoxia, the phosphocreatine-to-ATP ratio was 0.86, a value that is 2–2.5 times less than that reported for adults. During normoxia, ATP decreased by 20% and Pi increased by 90% from hyperoxia values. During 60 min of hypoxia, the concentrations of high-energy phosphate metabolites did not change, but intracellular and arterial blood pH (pHa) decreased significantly. When hyperoxia was reestablished, pHi returned to normal and pHa remained low. These results suggest that during periods of hypoxemia, the normotensive infant rabbit maintains intracellular concentrations of cerebral high-energy phosphates better than has been reported for adult animals.

Aortic stent-grafts in patients with renal transplants.

Purpose: To report the endovascular treatment of abdominal aortic aneurysms (AAA) in 2 patients with pelvic renal transplants. Methods and Results: Two men with multiple comorbidities and pelvic transplant kidneys underwent endovascular AAA repair using an aortomonoiliac system with femorofemoral bypass grafting. The arterial end-to-side anastomosis in both patients was to the external iliac artery. Tapered aortomonoiliac grafts were fashioned from Gianturco Z-stents covered with Dacron graft material and implanted with the distal attachment site in the iliac system ipsilateral to the transplant kidney arterial anastomosis. The body of the stent-graft was reinforcement with a Wallstent in each case before the contralateral common iliac artery was occluded and the cross-femoral bypass constructed. Both patients recovered uneventfully from the procedure and are free of endoleak or other complications related to their aneurysm repair at 7 and 34 months. Conclusions: The presence of a pelvic renal transplant in a patient undergoing endovascular AAA repair increases the complexity of procedural planning and endograft implantation, but a good outcome can be achieved.

Hepatic Infarction: Unusual Complication of a Transjugular Intrahepatic Portosystemic Shunt

O SCVIR, 1997 THE transjugular intrahepatic portosystemic shunt (TIPS) procedure has been used with increasing frequency as a safe and effective method for treating variceal bleeding and ascites in patients with portal hypertension. The technical aspects and success rates of the procedure have been well delineated in several reports (1-3). Most short-term and long-term followup reports have focused on the wellknown problems of postprocedural shunt stenosis or occlusion, and new or worsening encephalopathy. Less common ( ~ 1 0 % ) procedure-related complications that have been reported include semis. contrast material. , related nephropathy, puncture site hematoma, cardiac arrhythmia, stent malposition, and extracapsular needle puncture with associated bleeding (2-5). TIPS-related hepatic artery injury and associated traumatic hepatic artery occlusion are distinctly uncommon, with TIPS-associated hepatic infarction being extremely rare (6-9). Hepatic infarction, in general, is unusual because of the dual vascular supply to the liver via the portal vein and hepatic artery. We describe a patient who developed hepatic infarction after TIPS, which was not initially identified with ultrasound (US) but was seen a t computed tomography (CT). The infarction was noted to resolve almost completely over the course of 3 weeks without clinical consequence.

Mr Imaging of Pathologic Abdominal Fluid Collections

A retrospective comparison was made of the capability of magnetic resonance (MR) imaging and CT to display and characterize pathologic abdominal fluid collections. Fluid collections in 41 patients were analyzed: ascites (seven patients), hematoma (five), pancreatic pseudocyst (four), biloma (two), abscess (four), simple renal cyst (nine), hemorrhagic renal cyst (two), hydronephrosis (four), hemonephrosis (two), and cystic metastases (two). Most fluid collections were equally demonstrated by the two modalities. Walls around fluid collections were better demonstrated CT. Six fluid collections appeared heterogeneous on MR but were homogeneous or nearly so on CT.