Evaluation of the portal venous system before liver transplantation: value of phase-contrast MR angiography

OBJECTIVE

The purpose of this study was to assess the accuracy of phase-contrast MR angiography with gadolinium in evaluating the patency and blood flow direction of the portal venous system; the presence, extent, and type of varices; and the patency of surgical decompressive shunts in patients before liver transplantation. This information is essential in management and care of patients with chronic liver disease and portal hypertension and those who are candidates for liver transplantation.

SUBJECTS AND METHODS

Twenty-four patients with portal venous hypertension were evaluated with phase-contrast MR angiography. Two patients had surgical splenorenal shunts and one had a mesocaval shunt. Phase-contrast angiograms were acquired as a series of two-dimensional sequential coronal sections during breath-holding and after IV administration of gadopentetate dimeglumine. Correlative findings from color flow Doppler sonography, contrast-enhanced CT scanning, and conventional angiography were available in 23, 20, and 10 patients, respectively, and were used as standards. The images from each technique were analyzed independently for patency of and flow direction in the portal vein, splenic vein, superior mesenteric vein, and surgically created shunts, and for detection, distribution, and extent of five variceal groups.

RESULTS

Findings from phase-contrast MR angiography completely agreed with those of sonography, CT scanning, and conventional angiography. The main portal vein was patent in 18 patients, stenosed in one, partially thrombosed in one, and occluded in four. Phase-contrast MR angiography correctly showed hepatofugal flow in three patients and hepatopetal flow in 17 patients. Both the splenic and superior mesenteric veins were patent in 20, partially thrombosed in one, and occluded in three cases. Phase-contrast MR angiograms showed 85% of the variceal groups, and MR rating of variceal size was not significantly different from that of CT rating. Phase-contrast MR angiography correctly showed the patency of all three surgical decompressive shunts.

CONCLUSION

Phase-contrast MR angiography is accurate for evaluating the patency and flow direction of the portal venous system, detecting and determining the distribution and extent of varices, and assessing the patency of surgically created shunts. Therefore, it is a reliable and noninvasive technique that can provide crucial information in the preoperative workup of liver transplant recipients.

External jugular phlebectasia in children

The most common cause of a mass in the neck appearing only during straining is a laryngocele. On the other hand, the rare jugular phlebectasia may present in a similar manner. The cause of the jugular phlebectasia remains unclear. No treatment is indicated for this benign self-limiting condition. However, surgical removal for cosmetic purposes alone consists of a unilateral excision of the internal or external jugular vein; this produces no gross side-effects. Conclusion. Every patient with a swelling in the neck that enlarges in size after the Valsalva manoeuvre, straining, coughing or sneezing should be suspected of having jugular phlebectasia.

Orbital varix presenting as a subconjunctival mass

A 39-year-old woman presented with a vermiform superior conjunctival mass that progressively enlarged during 4 years of follow-up. Although magnetic resonance imaging suggested that the lesion was located in the superior forniceal conjunctiva, surgical exploration disclosed a vascular anomaly (varix) that extended deep into the orbit. The clinical features and management of orbital varices are discussed.

Idiopathic colonic varices: an unusual cause of massive lower gastrointestinal hemorrhage

We report a patient with massive lower gastrointestinal bleeding, probably from extensive colonic varices. Despite lengthy investigation, the etiology of the colonic varices was not determined. There are numerous reports in the literature of bleeding from colonic varices attributed to portal hypertension from cirrhosis or venous obstruction. However, bleeding from colonic varices located in the entire colon without demonstrable cause have only rarely been reported.

Intracardiac varices of the right atrium: a case report and review of the literature

Two broad-based masses arising along the right atrial septum in a 31-year-old man were detected by transesophageal echocardiography and were thought to represent partially calcified myxomas. However, at operation they were cystic structures filled with blood and calcific nodules. Microscopically, they represented varices with phleboliths. Angiography and ultrafast computed tomography may help distinguish this entity from myxomas and other right atrial intracavitary masses.

[Endoscopic dissection of perforating veins]

Endoscopic subfascial sectioning (ESDP) is an effective method for the interruption of incompetent perforating veins. From March 1993 to April 1994 27 patients underwent ESDP in 35 legs. ESDP was performed in combination with Babcock's operation in 31 cases. Most patients demonstrated chronic venous insufficiency stage II or III (n = 25). A venous ulcer was found in 9 patients. Intraoperative complications were not seen. Postoperative complications were delayed wound healing (n = 1) and subfascial hematoma (n = 1). At follow-up examination after a mean interval of 8 months persistent insufficient perforating veins were seen in 3 of 88 Cockett veins (4%). A local dysesthesia of the saphenous nerve was found in 6 legs. Prior active venous ulcers had healed in 8 of 9 cases.

Varix occurring with cerebral venous angioma: a case report and review of the literature

We report a patient in whom a varix occurred with a venous angioma, a rare combination of cerebral vascular malformations. During our review of the 7 previously reported cases, we discovered that all 8 venous angiomas were relatively large and supratentorial, and that the varices involved the veins draining then.

Clinical examination of varicose veins

BACKGROUND

Little time is spent during medical school on evaluating varicose veins, although they are frequently seen in daily practice. The clinical exam is an important part of the workup.

OBJECTIVE

Clinical examination of patients with varicose veins is outlined. Special emphasis is given to the use of continuous wave Doppler ultrasound for the reflux diagnosis.

CONCLUSION

Treatment for varicose veins must be based on objective clinical and pathophysiological findings.

Primary varicose veins of the upper extremity: a report of three cases

Primary varicose veins of the upper extremity are extremely rare. We present three cases and discuss cause, diagnosis, and treatment. Three patients, a 23-year-old man, a 31-year-old woman, and a 39-year-old man, were referred with symptomatic varicose veins of the arm. None of the patients had lower extremity varicosities. Diagnosis was made by physical examination, noninvasive and invasive procedures, and excluded vascular malformations. Surgical treatment, similar to that for lower extremity varicose veins, entailed ligation and stripping of the varicose veins. Ligation and stripping were performed and successfully eliminated the varicosities with prevention of recurrence with a mean follow-up of 17 months. Although primary varicose veins of the upper extremity are extremely rare, they can be readily diagnosed and successfully treated, similar to lower extremity varicose veins. Although not proven, the cause is likely identical to lower extremity varicose veins. Excellent functional and cosmetic results can be obtained with surgical treatment.

Multiple vortex vein varices masquerading as choroidal secondaries

Images

Endoscopic ultrasonography with color Doppler function in the diagnosis of rectal variceal bleeding

Extraesophagogastric variceal bleeding in patients with portal hypertension is rare, but has been reported after endoscopic injection sclerotherapy (EIS) for esophageal varices. Here, we report rectal variceal hemorrhage following EIS. Endoscopic ultrasonography with color Doppler function (EUSCD) was useful for the diagnosis of rectal varices and complete hemostasis was obtained with EIS. A review of the literature since 1980 revealed a total of 15 patients, including ours, with extraesophagogastric variceal bleeding following EIS. This suggests EIS is the principal emergency treatment for bleeding rectal varices.

[Should the great saphenous vein be stripped in routine surgery for uncomplicated varicose veins?]

Stripping of the great saphenous vein is widely used in the surgical treatment for varicose veins. With the increasing demand of vein material in coronary- and femoro-distal bypass surgery, this routine creates a conflict. A review of the literature reveals the possibility of vein-saving procedures that do not increase the recurrence rates. By utilizing modern diagnostic methods, it is possible to make an exact preoperative diagnosis as to the extent of the varicose disease and thus make an individualized operation, that is just as radical as necessary, but at the same time as vein-preserving as possible.

Lumbar epidural varix as a cause of radiculopathy

STUDY DESIGN

Venous outflow obstruction or congestion has been implicated in the etiology of some lumbar radicular syndromes. Ten cases of epidural varices or variants manifesting themselves as masses within the lumbar spinal canal or adjacent foramina have been seen.

OBJECTIVES

Diagnosis was made by multiplanar cross-sectional magnetic resonance and computed tomography imaging and confirmed in five patients by operative findings. These venous abnormalities differ from cases of arteriovenous malformations described in the literature.

METHOD

Surgical treatment consisting of coagulative oblation and/or excision of the lesion was consistently successful in the five patients who underwent operations for recalcitrant symptoms. The other five patients experienced spontaneous resolution of symptoms. Three distinctly different types of these abnormalities have been identified.

RESULTS

The described entity may account for some previously unexplained or spontaneously resolving cases of lumbar radiculitis.

CONCLUSIONS

Knowledge of the existence of this condition, its possible etiologies, and its imaging characteristics may assist in its recognition and improved management of patients with it.

Diagnosis and treatment of varicose veins: a review

Varicose veins are superficial vessels that are abnormally twisted, lengthened, or dilated and are usually caused by inefficient or defective valves within the vein. They represent a medical condition accompanied by symptoms deserving treatment. Varicose veins are a manifestation of venous disease that may precede later severe complications. Varicosities cause cutaneous disease in addition to complications specific to the venous system. This article reviews the epidemiology, adverse sequelae, anatomy, pathophysiology, evaluation, and treatment of varicose veins.

Epidemiology of varicose veins. A review

Disease of the venous system is a major problem affecting western societies, resulting in considerable morbidity in the population and cost to the health service. In many countries "varicose veins are probably the commonest disorder presenting to general surgeons" and an average of 30% of district nursing time is estimated to be spent caring for patients with venous ulcers. For the patient with varicose veins or leg ulceration, there is often persistent discomfort and disability extending over long periods of time. Despite this, little epidemiological research has been carried out on venous disease, perhaps partly because of society's perception that venous disease is not a major problem and it is not normally a cause death. More recently however, efforts have been made to conduct structured epidemiological studies to identify risk factors and to clarify the geographical variations suggested in the past by anecdotal evidence. This article reviews recent epidemiological studies, discusses the prevalence of varicose veins and presents evidence for and against the differing theories of causation.

Hemoptysis secondary to bronchial varices associated with alcoholic liver cirrhosis and portal hypertension

End-stage liver disease is associated with systemic changes involving many organs. Several pulmonary, tracheal, bronchial, and pleural abnormalities have been described. In this report we describe the first case of hemoptysis secondary to bronchial and lower tracheal varices in a patient with end-stage alcoholic liver disease and portal hypertension, and explore the relationship between tracheobronchial varices and portal hypertension.

Embolisation of orbital varix

A 34-year-old man with intermittent exophthalmos, found to have a large varix in the right orbit, was treated by endovascular surgery. Percutaneous transfemoral venous catheterisation and embolisation of the orbital varix was performed on two occasions. A Tracker 18 microcatheter was introduced through the right inferior petrosal sinus, cavernous sinus, superior ophthalmic vein and then into the varix, following a guidewire. Superselective venography of the right ophthalmic vein showed the varix. A total of 204 platinum microcoils was used to pack the varix. At the time of discharge, the exophthalmos had largely resolved. As this technique is much less invasive than surgical resection, we recommend an attempt at endovascular embolisation of orbital varices prior to surgical removal.

Cystic lesions around the knee joint: MR imaging findings

A wide variety of cystic lesions may be encountered in the soft tissues and bones during routine MR imaging of the knee. These lesions represent encapsulated fluid collections and exhibit low signal intensity on T1-weighted images and high signal intensity on T2-weighted images because of their high content of free water. Many lesions produce clinical features suggestive of internal derangement of the knee, so correct MR diagnosis is needed to avoid unnecessary arthroscopy and to guide specific therapy. The purpose of this essay is to illustrate the MR appearance of cystic lesions that can be found around the knee and to explain the clinical features and significance of these lesions.

Massive and recurrent gastrointestinal hemorrhage due to jejunal varices in an afferent loop--diagnosis and management

Bleeding from "ectopic" varices outside the gastroesophageal region is an uncommon complication of portal hypertension. Although the high mortality rate of bleeding duodenal varices has been emphasized (1-4), an awareness of the condition and its characteristic presentation may enable diagnostic and therapeutic procedures to be performed rapidly with an increased likelihood of a successful outcome. This report describes a patient with recurrent, frequent and massive hemorrhage from jejunal varices in the afferent loop after a Billroth II resection, chronic pancreatitis and portal hypertension; the diagnosis and management of this unusual case of recurrent gastrointestinal bleeding are discussed.

Duodenal varices causing intractable gastrointestinal bleeding in a 12-year-old child

Duodenal varices complicating extrahepatic portal hypertension in a 12-year-old girl resulted in her presentation with massive upper gastrointestinal bleeding. This unusual occurrence resulted in delay in correctly localizing the bleeding varices.