Takashi Kitanosono

Transhepatic Dilation of Anastomotic Biliary Strictures in Liver Transplant Recipients with Use of a Combined Cutting and Conventional Balloon Protocol: Technical Safety and Efficacy

PURPOSE To determine the safety and technical efficacy of a transhepatic dilation protocol involving the use of a combined cutting and conventional balloon protocol in the management of anastomotic biliary strictures in adult liver transplant recipients. MATERIALS AND METHODS Retrospective review of adult transplant recipients undergoing transhepatic cutting balloon dilation for anastomotic biliary strictures was performed over a period of 8 months. Cutting balloon dilation was followed by conventional balloon dilation with use of a balloon with a diameter at least as large as that of the initial cutting balloon. Technically successful dilation was defined by improvement of the biliary stricture. A technically successful regimen was defined by a residual stenosis less than 30% after a maximum of three sessions. The technical results were stratified according to lesions treated for the first time and those with restenosis. Comparison among institutions in terms of published methods and technical results were made. RESULTS Twenty-two patients with liver transplants underwent 49 cutting balloon dilation sessions as part of 27 regimens (1.8 sessions per regimen): 12 cases of primary treatment, 10 cases of restenosis, four for intraprocedural failures of conventional balloon dilation, and one for the latter two indications. Technical success rates of regimens for primary stenoses, restenoses, and all cases were 100%, 90%, and 93%, respectively. These results compare favorably with historic intrainstitutional results, which are 89%, 73%, and 85% for primary stenoses, restenoses, and all cases, respectively. In addition, no biliary ruptures or cases of major hemobilia were encountered. Minor hemobilia was encountered in 10% of cases. CONCLUSIONS The use of commercially available cutting balloons augmented subsequently with larger conventional balloons is safe for transhepatic balloon dilation and can increase the technical success rate of percutaneous management of transplant biliary strictures.

Transhepatic balloon dilation of anastomotic biliary strictures in liver transplant recipients : The significance of a patent hepatic artery

PURPOSE To determine the significance of hepatic artery steno-occlusive disease on the patency of anastomotic biliary strictures in liver transplant recipients after transhepatic balloon dilation. MATERIALS AND METHODS A retrospective review of records of all patients undergoing transhepatic balloon dilation for anastomotic biliary strictures after orthotopic liver transplantation was performed over an 8-year period. Patency of the anastomosis was based on subsequent cholangiography. The presence of hepatic artery steno-occlusive disease was determined by Doppler ultrasound and/or angiography. The anastomotic biliary stricture patency rates were calculated by the Kaplan-Meier method. RESULTS Thirty-eight patients who had undergone liver transplants underwent 53 balloon dilations for anastomotic biliary strictures (nine patients for arterial disease, 26 patients had patent arteries and three patients had arteries of indeterminate patency). Eight of the 53 strictures treated (15%) were refractory to balloon dilation: 10.5% of first comers and 27% of restenotic lesions. Two of the 53 strictures treated (4%) had significant complications: hemobilia requiring blood transfusion and ductal rupture. One-year cumulative primary patency rates for anastomotic biliary strictures for patients with arterial disease, patent hepatic arteries, and all-comers were: 0%, 45% (P = .01), and 36%, respectively. One-year cumulative primary patency rates for choledocho-choledocal and choledocho-jejunal anstomoses in patients with patent arteries were 43% and 48%, respectively (P = .10). CONCLUSIONS In the presence of hepatic artery disease there is a lower patency of anastomotic biliary strictures after balloon dilation. Imaging of the hepatic artery should be considered to stratify patients who will have a successful outcome.

Catheter Thrombolysis of Thrombosed Hepatic Arteries in Liver Transplant Recipients: Predictors of Success and Role of Thrombolysis

Hepatic artery thrombosis is an uncommon complication of liver transplantation. However, it is a major indication for re-transplantation. The use of transcatheter thrombolysis and subsequent surgical revascularization as a graft salvage procedure is discussed. Four of 5 cases (80%) were successful in re-establishing flow and uncovering underlying arterial anatomic defects. None were treated definitively by endoluminal measures due to an inability to resolve the underlying anatomic defects. However, 2 of 5 cases (40%) went on to a successful surgical revascularization and represent successful long-term outcome of transcatheter thrombolysis followed by definitive surgical revascularization. We conclude that, definitive endoluminal success cannot be achieved without resolving associated, and possibly instigating, underlying arterial anatomical defects. However, reestablishing flow to the graft can unmask underlying lesions as well as asses surrounding vasculature thus providing anatomical information for a more elective, better planned and definitive surgical revision.

The conventional balloon-occluded retrograde transvenous obliteration procedure: indications, contraindications, and technical applications.

Transvenous obliteration of gastric varices can be performed from the systemic venous side (draining veins or shunts) or from the portal venous side (portal afferent feeders). Balloon-occluded transvenous obliteration from the systemic veins is referred to as balloon-occluded retrograde transvenous obliteration (BRTO) and balloon-occluded transvenous obliteration from the portal veins is referred to as balloon-occluded antegrade (anterograde) transvenous obliteration (BATO). BRTO is the conventional balloon-occluded transvenous obliteration procedure and BATO is considered an alternative or adjunctive approach. This is because, from a technical standpoint, the least invasive choice of access or approach for balloon-occluded transvenous obliteration of gastric varices is the traditional or conventional transrenal route. The objective of BRTO or BATO or both is complete obliteration of the gastric varices with preservation of the anatomical hepatopetal flow of the splenoportal circulation. This article reviews the indications, contraindications, and technical considerations of the conventional BRTO procedure. The indications of concomitant portal venous modulators such as splenic embolization or the creation of a transjugular intrahepatic portosystemic shunt or both are also discussed.

Arc of Buhler: Incidence and Diameter in Asymptomatic Individuals

The purpose of this study was to determine the incidence and diameter of the Arc of Buhler by power injection digital subtraction angiography in asymptomatic patients. A retrospective evaluation of 120 combined celiac (CAx) and superior mesenteric artery (SMA) angiograms was carried out on potential live related liver transplant donors (asymptomatic patients) performed from January 1999 to May 2002. The diameter of the Arc of Buhler was calculated with reference to the 5 French catheters used to perform the diagnostic angiograms. It was considered hemodynamically significant if it preferential filled the branches of the other visceral vessel. An Arc of Buhler was identified in 4 patients (3.3%). All 4 patients had a patent gastroduodenal artery (GDA) and none of the 4 had a hemodynamically significant stenosis of either the SMA or the CAx. All Arcs of Buhler found measured less than 2.5 mm in diameter and half of them (2 of the 4) filled the CAx when power injecting the SMA and/or vice versa. There is a low incidence of Arc of Buhler in asymptomatic patients; however, 50% of those encountered were hemodynamically significant. When evaluating the Arc of Buhler by angiography in the setting of pathology, it is important to have a reference diameter and hemodynamic reference in the normal setting, particularly when the prospect of GDA ligation or embolization is entertained in the presence of CAx or SMA occlusion.

Endoluminal Management of Arterioportal Fistulae in Liver Transplant Recipients: A Single-Center Experience

Transcatheter embolization of arterioportal fistulae in liver transplant recipients is restricted to symptomatic arterioportal fistulae. Angiograms of liver transplant recipients from a single university medical center were retrospectively reviewed. Hemodynamically significant arterioportal fistulae were defined as those exhibiting opacification of the main portal vein of the transplanted hepatic graft or its first order branch with or without portal venous changes by Doppler ultrasound imaging. Six arterioportal fistulae were found. Doppler ultrasound imaging detected 50% of all arterioportal fistulae and all 3 hemodynamically significant arterioportal fistulae. Three successful embolizations were performed. Follow-up (37 to 67 months) demonstrated patent hepatic arteries and no parenchymal ischemic changes with graft preservation. High-throughput arterioportal fistulae may require larger intrahepatic artery branch embolization. There is a window of opportunity for embolizing significant arterioportal fistulae before their progression to large symptomatic, high through-put arterioportal fistulae with their added risk of ischemic changes before and after embolization.

Balloon-Occluded Antegrade Transvenous Obliteration With or Without Balloon-Occluded Retrograde Transvenous Obliteration for the Management of Gastric Varices: Concept and Technical Applications

Alternative routes for transvenous obliteration are sometimes resorted in the management of gastric varices. These alternative routes can be classified into A, portal venous access routes and B, systemic venous access routes. The portal venous approach to transvenous obliteration is called balloon-occluded antegrade transvenous obliteration (BATO) and is a collective definition, including 1-percutaneous transhepatic obliteration (PTO), 2-through an existing transjugular intrahepatic portosystemic shunt [(Trans-TIPS), and 3-trans-iliocolic vein obliteration (TIO)]. PTO is usually out of necessity; however, trans-TIPS approach is usually used out of serendipity (because the low-risk access route is there). The TIPS for the trans-TIPS BATO is not formed for mere access, but is done to create a TIPS or is done when there is a preexisting TIPS. The trans-TIPS approach can be resorted to in the United States in up to 19% of balloon-occluded retrograde transvenous obliteration (BRTO) cases. PTO is resorted to, out of necessity, in the United States and Japan in 10% of BRTO cases (2%-19% of BRTO cases) and can increase the technical and obliterative success rate of the transvenous obliteration procedure from 84%-98% to 98%-100%. The advantage of BATO as an adjunct to BRTO (combining a BRTO and BATO approach to obliterate the gastric varices) is not only limited to increasing the technical success rate of the obliterative procedure. BATO reduces the risk of overspill of the sclerosant from the gastric variceal system into the portal vein. Moreover, if the BATO is performed from a trans-TIPS approach, any overspill of the sclerosant mixture will partly (if not mostly) go through the patent TIPS to the systemic circulation (lung) rather than the intrahepatic portal vein branches (prevent portal vein embolization). This article discusses the clinical and technical applications, technical considerations, and the outcomes of BATO.

Incidence of cholangitis and sepsis associated with percutaneous transhepatic biliary drain cholangiography and exchange: A comparison between liver transplant and native liver patients

OBJECTIVE The purpose of our study was to determine the rate of sepsis and cholangitis associated with percutaneous biliary drain cholangiography and subsequent drain exchanges and to compare the incidence of these complications between patients with liver transplants and those with native livers. MATERIALS AND METHODS A retrospective review of 154 consecutive patients (100 with liver transplants and 54 with native livers) who underwent a total of 910 percutaneous biliary drain cholangiography examinations and exchanges (January 2005 to July 2008) was performed. Cholangitis was defined as fever (> 38.5°C) within 24 hours after the intervention, and sepsis included cholangitis in addition to hemodynamic instability. RESULTS The overall incidence of cholangitis and sepsis after percutaneous biliary drain exchanges was 2.1% (n = 19/910 exchanges) and 0.4% (n = 4/910 exchanges), respectively. There was no statistically significant difference in complications between liver transplant patients versus nontransplant patients (p = 0.34 for cholangitis and p = 1.00 for sepsis). The mean hospital stay due to postprocedural complications was 2.4 days for observation and supportive treatment. None of these patients required an intensive care stay. Mean percutaneous biliary drain dwell time in liver transplant and nontransplant patients was 6.2 and 1.5 months, respectively. Transplant patients were significantly younger (54 versus 67 years; p << 0.05), male predominant (70% vs 52%, p = 0.035), and had more severe liver disease (12.2 vs 8.0 Model for End-Stage Liver Disease [MELD] scores; p << 0.05). CONCLUSION Percutaneous biliary drain cholangiography and exchange is associated with a low rate of postprocedure cholangitis and sepsis. These complications require brief hospitalizations. Liver transplant patients do not have an increased risk of complications despite higher MELD scores and longer intubation periods.

Comparison of Technical Success and Complications of Percutaneous Transhepatic Cholangiography and Biliary Drainage Between Patients With and Without Transplanted Liver

OBJECTIVE The purpose of this study is to compare technical success and complications of percutaneous transhepatic cholangiography (PTC) and percutaneous transhepatic biliary drainage (PTBD) between patients with and without transplanted liver. MATERIALS AND METHODS Between 2007 and 2011, 89 PTCs, including 34 PTBDs, in 87 patients with transplanted liver were attempted, and 131 PTCs, including 118 PTBDs, in 126 patients without transplanted liver were attempted. Technical success, diameters of the bile ducts, fluoroscopy time, and complications were statistically compared between the two groups. RESULTS The technical success rate of PTC for transplanted liver was significantly lower than that for nontransplanted liver (88.8% vs 98.5%; p = 0.004). Consequently, the technical success rate of PTBD for transplanted liver was also significantly lower than that for nontransplanted liver (75.0% vs 95.8%; p < 0.001). The average diameters of the first branches and second branches of the bile ducts of transplanted liver were significantly smaller than those of nontransplanted liver (5.8 ± 3.4 mm vs 8.7 ± 3.9 mm for the first branches [p < 0.001]; and 3.7 ± 1.7 mm vs 5.8 ± 2.4 mm for the second branches [p < 0.001]). No significant difference of fluoroscopy time of unilateral successful PTBD was observed (21.8 ± 11.7 vs 19.3 ± 12.9 min; p = 0.372), and no significant difference of overall complication rates was observed (8.0% vs 8.7%; p = 1.000) between transplanted and nontransplanted liver. CONCLUSION The technical success rates of PTC and PTBD for transplanted liver are slightly lower than those for nontransplanted liver because the bile ducts are smaller. There is no significant difference in complication rate.

Elective Transjugular Intrahepatic Portosystemic Shunt Creation for Portal Decompression in the Immediate Pretransplantation Period in Adult Living Related Liver Transplant Recipient Candidates: Preliminary Results

PURPOSE To evaluate (i) the efficacy of purposeful creation of transjugular intrahepatic portosystemic shunts (TIPS) before transplantation to optimize potential living related liver transplantation (LRLTx) and (ii) the efficacy of TIPS creation in this setting in reducing perioperative resource utilization. MATERIALS AND METHODS Retrospective review was performed of the records of patients who underwent adult LRLTx with or without preoperative TIPS creation from October 2003 through April 2005. Patients were evaluated for preoperative parameters (Child-Pugh class, Model for End-stage Liver Disease score, Acute Physiology and Chronic Health Evaluation [APACHE] II score, and coagulation parameters), intraoperative parameters (blood transfusion requirements and operative time), and postoperative parameters (intensive care unit stay, hospital stay, and 30-day repeat operation and mortality rates). Comparison between the two treatment groups was made with the Mann-Whitney U test. Within the TIPS group, comparison of blood transfusion requirements was performed by one-way analysis of variance based on the degree of portosystemic gradient reduction after TIPS creation. RESULTS Sixteen patients were included in the TIPS group, and 12 patients were included in the group without TIPS. Median time between TIPS and transplantation was 2 days. There was no statistical difference in the preoperative, intraoperative, and postoperative parameters between groups except for the APACHE II score (P<.002), which was higher in the TIPS group. Despite this, the outcome and postoperative hospital resource utilization were similar between groups. Intraoperative blood transfusion based on the degree of portosystemic gradient reduction after TIPS creation was not significantly different between groups. CONCLUSIONS Newly created TIPS do not interfere with the intraoperative technical and perioperative clinical aspects of adult LRLTx. Preoperative TIPS creation before transplantation may reduce the postoperative morbidity and mortality seen in liver transplant recipients who have a greater APACHE II score at the outset of treatment.