Talia Sasson

Shortening and Migration of Wallstents after Stenting of Central Venous Stenoses in Hemodialysis Patients

Purpose: To report our results for the placement of central venous stents in patients undergoing hemodialysis. Methods: Ten Wallstents (Schneider, Bülach, Switzerland) were placed in 10 patients with shunt thrombosis, shunt dysfunction or arm swelling associated with central vein stenosis or occlusion. Technical success, patency and complications were evaluated. Results: Stent deployment was successful in all cases. In seven cases (70%) there was significant delayed stent shortening. In two of these cases there was also stent migration. All these cases required additional stents. Primary patency rates at 6, 12 and 24 months were 66%, 25% and 0. Twenty-three additional procedures (percutaneous transluminal angioplasty or stenting) were required to achieve secondary patency rates at 6, 12 and 24 months of 100%, 75% and 57%. Conclusion: Stent placement in the central veins of dialysis patients has a high technical success rate resulting in symptomatic relief and preservation of access. Repeat interventions are required to maintain patency. Significant delayed shortening of the Wallstent occurred in 70% of patients which may have affected the patency rates. Strategies are suggested to avoid this problem.

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.

Vascular Access via Peripherally Inserted Central Venous Catheters (PICCs): Experience in 40 Patients with Acute Myeloid Leukemia at a Single Institute

Reliable long-term vascular access is essential for the treatment of patients with acute myeloid leukemia (AML). Although peripherally inserted central catheters (PICCs) have been in use for many years, little data exist on their use in patients receiving intensive chemotherapy. We retrospectively reviewed all AML patients who had a PICC inserted between July 95 and May 98. Fifty two PICCs were inserted in 40 patients with AML. Thirty three PICCs were inserted during severe thrombocytopenia (platelets < 50 × 109/L), and 31 during severe neutropenia (neutrophils < 0.5 × 109/L). Mean catheter duration was 82 (median 63, range 3–441) days fora total of 4274 catheter days. A mean of 1.8 chemotherapy courses were administered via each PICC. There were 5 early complications of PICC placement. Other mechanical complications occurred in 14 catheters and phlebitis in 12. Twenty blood stream infections (BSI) occurred in 17 patients. All BSIs occurred during neutropenia. Seventeen PICCs were removed due to the following complications - phlebitis (11), possible catheter related BSI (4), mechanical reasons in 3 (2 with concomitant phlebitis) and persistent fever (1). PICC duration was significantly shorter in these 17 catheters (52.9 v 96.4 days in the other 35, p=0.0289). We conclude that PICCs provide long-term vascular access with an acceptable complication rate in patients with AML. However, a randomised trial is required before PICCs can be considered an alternative to tunneled central venous catheters in these patients.

Intra-arterial catheter directed therapy for severe graft-versus-host disease

Summary. Graft‐versus‐host disease (GVHD) is a major complication of allogeneic bone marrow transplantation (BMT), resulting in death in the majority of steroid‐resistant patients. We assessed the efficacy of regional intra‐arterial treatment in patients with resistant hepatic and/or gastrointestinal (GI) GVHD. In total, 15 patients with steroid resistant grade 3–4 hepatic (n = 4), gastrointestinal (GI) (n = 8) GVHD or both (n = 3) were given intra‐arterial treatment. Patients with hepatic GVHD received methotrexate and methylprednisolone into the hepatic artery. Patients with GI GVHD were treated with infusions of methylprednisolone into the superior and inferior mesenteric arteries. Two patients with pronounced upper GI symptoms also received upper GI treatment. In total, 25 procedures were carried out (range 1–3 per patient). Hepatic response was observed in four out of seven (57%) patients with hepatic GVHD, three (43%) featuring good response. Complete responses were observed in nine (82%) GI GVHD patients, with median time to initial and complete response of 3 d (range 1–7) and 15·8 d (range 4–33) respectively. Regional treatment of severe GVHD with intra‐arterial treatment appears to be effective and safe. GI treatment maybe more effective than intrahepatic treatment. Early administration of isolated intra‐arterial therapy in high‐risk patients may further improve the outcome and reduce untoward effects of systemic immunosuppressive treatment.

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.

Liver± Spleen Infarcts Following Transcatheter Chemoembolization A Case Report and Review of the Literature on Adverse Effects

Even though liver biopsy is the gold standard for the diagnosis of HCC before commencing therapy, this is occasionally technically dif® cult, and rare complications include bleeding and disseminat ion of the tumor along the biopsy needle track. It is therefore acceptable to make a diagnosis of HCC based on a rising a -fetoprotein level in a patient with known liver disease, and, recently, through identi® cation of a focus of Lipiodol (iodized oil) retention (1). Lipiodol is a lymphographic contrast medium containing iodine that is retained selectively in foci of hepatocellular carcinoma (HCC) after injection into the hepatic artery (2). The uptake of Lipiodol in primary liver tumors is usually veri® ed by computerized tomography (CT) scan within 10 ± 21 days after selective intraarterial injection (3, 4). The mechanism of Lipiodol retention is not completely understood, and nonspeci® c retention may rarely occur in nontumorous areas including sites of previous liver biopsy (5), focal nodular hyperplasia (6), and hemangiomas (7). The af® nity of Lipiodol to HCC tissue may be utilized to improve targeting of conventional chemotherapy to the tumor. Chemotherapeutic agents, such as doxorubicin, mitomycin, or cisplastin, can be emulsi® ed with Lipiodol and injected directly into the hepatic artery supplying the tumor. Several noncontrolled clinical trials have indicated that ® ve-year survival rates have increased following Lipiodol chemotherapy combined with surgical resection for small tumors (8, 9). Occlusion of the hepatic artery after injection of the emulsion is thought to improve the ef® cacy of this procedure. The complete procedure is known as transcatheter oily chemoembolization (TOCE) (10), and various studies have shown prolongation of survival with a good quality of life (11± 13), whereas other studies have not shown any bene® t (14 ± 16). The procedure may be dif® cult to perform when there are anomalies of the arterial hepatic vasculature and is contraindicated when there is portal vein thrombosis. It is less effective in large tumors (17). We present a patient who developed a splenic infarction and hepatic infarction and abscess following TOCE.

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.

Combined transhepatic and endoscopic procedures in the biliary system.

Endoscopic biliary procedures are 89-97% successful in skilled hands. The commonest causes of failure are inability to cannulate the papilla of Vater due to difficult anatomy or tortuosity of the distal common bile duct and failure to cross a rigid biliary stricture. In nearly all of these cases, successful endoscopic procedures can be completed after percutaneous antegrade placement of a small catheter or guidewire to the duodenum. In 44 such combined procedures on 42 patients, the success rate was 43 (98%). There were two severe and eight mild complications. Combined procedures overcome the difficulties caused by tortuous biliary ducts and rigid strictures while obviating the need for more extensive percutaneous procedures and transhepatic tract dilatation.