Bladed balloon angioplasty for peripheral pulmonary artery stenosis

Ultra-high pressure balloon angioplasty for pulmonary artery stenosis in children with congenital heart defects: Short- to mid-term follow-up results from a retrospective cohort in a single tertiary center

Objective

Balloon angioplasty (BA) has been the treatment of choice for pulmonary artery stenosis (PAS) in children. There remains, however, a significant proportion of resistant lesions. The ultra-high pressure (UHP) balloons might be effective in a subset of these lesions. In this study, we analyzed the safety and efficacy with short- to mid-term follow-up results of UHP BA for PAS in children with congenital heart defects (CHD) in our center.

Methods

This is a retrospective cohort study in a single tertiary heart center. Children diagnosed with PAS associated with CHD were referred for UHP BA. All data with these children were collected for analysis with updated follow-up.

Results

A total of 37 UHP BAs were performed consecutively in 28 children. The success rate was 78.4%. A significantly (P = 0.005) larger ratio of the balloon to the minimal luminal diameter at the stenotic waist (balloon/waist ratio) was present in the success group (median 3.00, 1.64-8.33) compared to that in the failure group (median 1.94, 1.41 ± 4.00). Stepwise logistic regression analysis further identified that the balloon/waist ratio and the presence of therapeutic tears were two independent predictors of procedural success. The receiver operating characteristic curve revealed a cut-off value of 2.57 for the balloon/waist ratio to best differentiate success from failure cases. Signs of therapeutic tears were present in eight cases, all of whom were in the success group. Perioperative acute adverse events were recorded in 16 patients, including 11 pulmonary artery injuries, three pulmonary hemorrhages, and two pulmonary artery aneurysms. During a median follow-up period of 10.4 (0.1-21.0) months, nine cases experienced restenosis at a median time of 40 (4-325) days after angioplasty.

Conclusions

The UHP BA is safe and effective for the primary treatment of PAS in infants and children with CHD. The success rate is high with a low incidence of severe complications. The predictors of success are a larger balloon/waist ratio and the presence of therapeutic tears. The occurrence of restenosis during follow-up, however, remains a problem. A larger number of cases and longer periods of follow-up are needed for further study.

Pulmonary artery pathologies in Alagille syndrome: a meta-analysis

Alagille syndrome, caused by mutations in the gene encoding Jagged1 (JAG1), a ligand in the Notch signaling pathway, is an autosomal dominant disorder with developmental abnormalities affecting the liver, heart, eyes, face and skeleton. The aim of the present study is try to disclose the clinical features, management and outcomes of pulmonary artery stenosis associated with Alagille syndrome. By comprehensive literature retrieval, 38 articles involving 401 patients were recruited for this study. The pertinent variables closely related to pulmonary artery stenosis in patients with Alagille syndrome were comprehensively analyzed by following the PRISMA guidelines. The management of pulmonary artery pathologies, especially a severe type of pulmonary artery stenosis in Alagille syndrome, is a concerned matter. Publications of literature retrieval of recent 3 decades were the study material of this article. The pulmonary artery pathologies, especially the severe type of pulmonary artery stenosis in Alagille syndrome, warrant surgical or interventional treatments. After the procedures, the right ventricular to left ventricular pressure ratio was reduced by 25%. There were no intergroup differences in terms of recovery, reintervention and mortality rates between interventionally and surgically treated patients. Transcatheter treatment is preferable due to less trauma. Surgical treatment of pulmonary artery stenosis can be performed currently with intracardiac defect repair.

The treatment dilemma in adult patients with peripheral pulmonary artery stenosis of diverse etiologies

Background

Peripheral pulmonary artery stenosis (PPAS) is a rare and underdiagnosed phenomenon that is reported infrequently in adult patients. Most patients with PPAS have concomitant congenital heart diseases, a history of palliative surgical therapies during childhood, or syndromic characteristics. Acquired cases are rare, and they are underestimated in adulthood and managed inappropriately.

Case presentation

This case series describes 3 adult patients with PPAS of diverse etiologies and discusses their underlying causes, diagnostic modalities, and treatment strategies.

Conclusions

In patients with PPAS, sufficient heed should be paid to endovascular interventions such as balloon dilation and primary or bailout stenting, not least vis-à-vis the type and size of balloons or stents as well as complications and preventive strategies.

Outcomes of Patients with Pulmonary Atresia and Major Aortopulmonary Collaterals Without Intervention in Infancy

Treatment of pulmonary atresia with major aortopulmonary collaterals (PA MAPCAs) remains a challenge. Despite variations in surgical technique, contemporary strategies all include initial intervention in the first year of life. However, a subset of patients presents later in life, and contemporary outcomes of this group have not been reported previously. We performed a retrospective case series of consecutive cases of PA MAPCAs who were seen at our center between January 2001 and February 2016, who had not undergone surgery before the age of 1 year. We describe their presenting characteristics, operative and transcatheter interventions, and outcomes. A total of eight cases were identified from 76 children with PA MAPCAs treated over the study period. Median age at presentation was 5.9 years. Seventy-five percent had confluent pulmonary arteries with a median Nakata index of 113 mm(2)/m(2). Operative intervention was performed in 5/6 cases. Two are awaiting intervention. The combination of operative and transcatheter interventions allowed for ventricular septal defect closure in 60 % of cases, all of whom had subsystemic right ventricular pressures. Operative intervention is possible in some older cases with PA and MAPCAs. Though multiple operations and transcatheter therapies are necessary, some can achieve operative correction of serial circulation with tolerable physiology. Subjects with ventricular hypoplasia and those without confluent pulmonary arteries are more challenging.

Peripheral pulmonary artery stenosis as a cause of pulmonary hypertension in adults

Peripheral pulmonary artery stenosis (PPAS) is an underrecognized condition in the adult population. PPAS can lead to pulmonary hypertension but is likely misdiagnosed as either idiopathic pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension. We retrospectively identified adult patients with PPAS either in its isolated form or related to other congenital defects from January 1998 to September 2012. We reviewed the patients' clinical data by using our hospital electronic medical records and/or their paper charts. We identified 6 adult patients with PPAS with an age range of 16-56 years (1 woman and the rest men). Presenting signs and symptoms were thoracic murmurs, progressive dyspnea, and syncope. Three patients had Williams-Beuren syndrome. Pulmonary angiography showed that PPAS was predominantly located in main branches or lobar pulmonary arteries in 5 patients, while in 1 patient the arterial narrowing was at the level of the segmental pulmonary arteries. Right heart catheterization showed a mean pulmonary artery pressure (PAP) ranging from 35 to 60 mmHg. Balloon dilation was performed in all patients, predominantly in the lobar arteries, and it caused a decrease in mean PAP that ranged from 16% to 46% in 5 patients. In 1 patient the mean PAP did not decrease. All but 1 patient had follow-up echocardiograms at 1 year that showed stable echocardiographic findings. Pulmonary hypertension due to PPAS continues to presents a diagnostic challenge. Therefore, a high index of suspicion during the initial evaluation of pulmonary hypertension is essential for its prompt diagnosis and adequate treatment.

Pulmonary artery stents in the recent era: Immediate and intermediate follow-up

BACKGROUND

Long-term follow-up after stent dilation of native and acquired pulmonary artery stenosis is scarce in the pediatric population. Most cohorts include a myriad of anatomies and associated conditions.

METHOD

In order to establish objective performance criteria, we performed a retrospective review of all patients who underwent unilateral pulmonary artery stenting in biventricular physiology at three centers from June 2006 to June 2011.

RESULTS

Fifty-eight patients received 60 stents with Palmaz Genesis stent used most commonly (78%). Average age at implantation was 10.4 ± 10.3 years and weight 31.6 ± 21.8 kg. The immediate success rate was 98%, with improvement in minimal diameter from 5.1 ± 2 cm to 10.6 ± 3 cm (P < 0.01). There were 10 complications (7 major and 3 minor) and no acute mortality. One-year follow-up studies were available in 48 patients (83%), including echocardiogram (60%), catheterization (28%), MRI (29%), and lung perfusion (31%). Follow-up echocardiogram showed mild increase in stent gradient, from 5.7 ± 6.7 mm Hg post-procedure to 17.1 ± 11.7 mm Hg. Follow-up catheterization showed no significant change in minimal stent diameter (8.8 ± 2.6 to 7.8 ± 2.3 mm), gradient (7.7 ± 8.4 to 12.6 ± 12.2 mm Hg), or right ventricular pressures (43.7 ± 9 to 47.7 ± 10.5 mm Hg). Nine patients (16%) underwent scheduled stent redilation over a period of 12 days to 25 months.

CONCLUSION

In conclusion, stent implantation shows excellent immediate and 1-year follow-up results with maintenance of improved caliber of the stented vessel and lowered right ventricular systolic pressures.

Catheter Interventions for Pulmonary Artery Stenosis: Matching the Intervention with the Pathology

Pulmonary artery (PA) stenosis represents a heterogeneous defect with a wide morphology and etiology. Interventions to treat PA stenosis should be based on the location, severity, and cause of stenosis as well as the size of the patient at presentation. Specialized dilation balloons, stents, and delivery techniques have been developed to treat a variety of PA stenoses in small infants through adulthood. Early and intermediate results of angioplasty and stenting are superior to surgical results, while long-term data on angioplasty and stenting are becoming available for these proven safe and effective techniques.

Randomized Trial of Cutting Balloon Compared With High-Pressure Angioplasty for the Treatment of Resistant Pulmonary Artery Stenosis

Background—

We sought to determine the safety and efficacy of Cutting Balloon therapy (CB) compared with conventional high-pressure balloon therapy (HPB) for the treatment of pulmonary artery stenosis.

Methods and Results—

This prospective, randomized, multicenter, investigational device exemption trial compared CB with HPB. Patient eligibility was determined at the precatheterization assessment; vessel eligibility was determined at catheterization. In all vessels, low-pressure balloon dilation to 8 atm was performed, and if it was not successful, the vessel was randomized to CB or HPB. The primary efficacy outcome was percent change in minimum lumen diameter. A core laboratory performed all vessel measurements and angiographic assessment of vessel damage. The primary safety outcome was any serious adverse event attributable to vessel dilation as assessed by the Data and Safety Monitoring Board. Seventy-three patients from 8 institutions were enrolled between 2004 and 2008. In these patients, 72 vessels responded to low-pressure balloon dilation. Of the 173 vessels that met eligibility criteria, 107 were randomized to CB and 66 to HPB. In randomized vessels, CB therapy was associated with greater percent increase in lumen diameter (85% versus 52%; P =0.004). After crossover was introduced, 26 of 47 vessels treated with HPB underwent CB therapy and experienced an additional 48% increase in lumen diameter; the final diameter after CB was 99% greater than the initial diameter. There were no serious adverse events related to treatment in a study vessel.

Conclusion—

CB therapy for pulmonary artery stenosis not responsive to low-pressure balloon is more effective than HPB therapy and has an equivalent safety profile.

Transcatheter rehabilitation of pulmonary arteries

Pulmonary arterial stenoses commonly occur in patients with congenital heart disease. Indications for treatment are based around reduction of right ventricular hypertension and equalization of flow to each lung and its constituent segments. There are many treatment approaches for these lesions depending on the anatomy, location and the age of the patient. Although surgical reconstruction remains an option, it is technically challenging and in many cases, the results are disappointing. In the modern era, the majority of these patients are treated with transcatheter therapy, including balloon angioplasty, and increasingly, the use of intravascular stents. In this article, we discuss these issues and deal with both the technical approach to transcatheter therapy and up-to-date results.

Management of large hepatocellular carcinoma in adult patients with Alagille syndrome: a case report and review of literature

BACKGROUND

Alagille syndrome is a multi-system developmental disorder associated with paucity of interlobular bile ducts and cholestasis, rarely associated with hepatocellular carcinoma. Associated syndromic co-morbidities may complicate surgical management. As such, we herein review the modern management of a large hepatocellular carcinoma in an adult patient with Alagille syndrome and review the literature of adult Alagille patients with hepatocellular carcinoma.

CASE PRESENTATION

A 29-year-old woman with a history of Alagille syndrome was referred with biopsy-proven 12 × 8 cm hepatocellular carcinoma replacing her right liver. Biopsy of the contralateral liver demonstrated findings consistent with Alagille syndrome, but no underlying cirrhosis. CT volumetrics demonstrated a future liver remnant of 40%. Extensive hematologic and cardiac work-up was performed pre-operatively, given the syndrome's associated bleeding dyscrasias and cardiac abnormalities. The patient underwent a margin-negative right hepatectomy using the "hanging" technique through a thoracoabdominal approach. The patient developed a transient hyperbilirubinemia but no hepatic insufficiency and did well post-operatively.

CONCLUSION

Since Alagille syndrome affects multiple organ systems, preoperative evaluation of cardiac, hematologic, and hepatic function should be considered. This case illustrates the peri-operative management of an Alagille patient, and highlights several key technical points that contributed to a successful resection.

Medical management of Alagille syndrome

Alagille syndrome is a highly variable, autosomal dominant disorder that affects the liver, heart, eyes, face, skeleton, kidneys, and vascular system. Much has been learned about the genetics of this disorder, which is caused primarily by mutations in the Notch signaling pathway ligand JAGGED1; however, the medical management of this condition is complex and continues to generate controversy. The significant variability of organ involvement requires the managing physician to have an understanding of the breadth and interplay of the variable manifestations. Furthermore, the liver disease in particular requires an appreciation of the natural history and evolution of the profound cholestasis.

How we approach peripheral pulmonary stenosis in Williams-Beuren syndrome

Williams-Beuren syndrome is associated with supravalvar aortic stenosis and peripheral pulmonary artery stenosis in the majority of affected individuals. Among patients in whom surgery for supravalvar aortic stenosis is contemplated, stenosis of the branch pulmonary arteries is common. For asymptomatic patients with subsystemic right ventricular pressure, the natural history is favorable and no intervention is necessary. For patients with important proximal branch pulmonary artery, stenoses patch arterioplasty can be accomplished at the time of surgery for supravalvar aortic stenosis. For patients with important peripheral pulmonary stenosis, preoperative catheter-based therapy is indicated. Surgical repair of peripheral pulmonary stenosis is indicated when preoperative intervention is unsuccessful and can include a combination of patch arterioplasty as well as intraoperative application of catheter-based techniques. This report will address the approach to this lesion with catheter-based approaches, surgical approaches, and their combination.

Ultra-high-pressure balloon angioplasty for treatment of resistant stenoses within or adjacent to previously implanted pulmonary arterial stents

BACKGROUND

Stents are essential tools in the management of pulmonary arterial (PA) stenosis in patients with congenital heart disease. Although stents can usually be reexpanded as children grow, resistant in-stent or peri-stent obstruction can complicate the management of PA stents. Angioplasty with ultra-high-pressure (UHP) balloons may facilitate successful treatment of stent-associated PA stenoses that are resistant to high-pressure dilation.

METHODS AND RESULTS

We reviewed patients who underwent UHP angioplasty of in-stent or peri-stent PA stenoses that were resistant to high-pressure redilation. A resistant stenosis was defined as a residual balloon waist during high-pressure redilation of the stent, along with a pressure gradient and/or angiographic stenosis. Thirty-four lesions in 29 patients, including 8 with multiple concentric, overlapping, or adjacent stents, were included. The median age at UHP angioplasty was 9 years, and a median of 4 years had elapsed since unsuccessful high-pressure angioplasty. Thirty-one of the 34 (91% [81% to 100%]) UHP angioplasty procedures were successful in relieving the resistant stenosis. Balloon:waist diameter ratios were conservative (median 1.26), reflecting the ability of UHP balloons to "fracture" nearly all obstructions. After UHP dilation, lesion diameter increased by a median of 3.1 mm (36%), significantly more than after previous high-pressure dilation (1.3 mm, 19%; P<0.001). In 5 lesions, UHP angioplasty fractured the stent, allowing further vessel expansion. There were no vascular or other complications.

CONCLUSIONS

UHP angioplasty was safe and effective for treatment of stent-related resistant PA stenosis in this series; the ability to fracture maximally expanded stents may extend the utility of stents in the pediatric population.

Balloon angioplasty for branch pulmonary artery stenosis--cutting balloons

Pulmonary artery stenosis can cause right ventricular strain but intrapulmonary lesions are inaccessible to surgery; moreover, some are also resistant to high pressure balloon angioplasty. An alternative is the use of microsurgical devices mounted on balloons for transvenous delivery, including cutting balloons. The current literature is sparse but seems to indicate a role for cutting balloons in specific situations. The higher cost of these devices does not merit routine use instead of high pressure balloons but a randomised controlled study is underway to address this issue. Until the results of this become available, the role of cutting balloons for pulmonary artery stenosis remains limited to specific situations. The recommendations for the safe use of these devices must be adhered to by all operators.

Comparison of efficacy of medium-sized cutting balloons versus standard balloons for dilation of peripheral pulmonary stenosis

The efficacy of medium-sized cutting balloons (CBs) 5 to 8 mm in diameter was compared with that of standard balloons (SBs) in the dilation of peripheral pulmonary stenosis (PPS). Nine vascular lesions in 7 patients were primarily dilated by CBs, and 13 vascular lesions in 11 patients were dilated by SBs alone. The efficacy of balloon dilation was evaluated by angiography and intravascular ultrasound (IVUS). There was no significant difference between the 2 groups in the success rate (66% vs 62%), the percentage increase in minimal lesion diameter (MLD; median 71% vs 52%) on angiography, and the number of new tears (2 vs 1) on IVUS. However, in the subgroup of vascular lesions with MLDs of <4.0 mm, for which CBs with diameters >200% of the MLD could have been applied, the percentage increase in MLD (95% vs 53%, p <0.05) and the number of tears (2 vs 1, p <0.05) with CBs were significantly greater than with SBs, requiring significantly smaller maximum balloon pressure (10 vs 13 atm, p <0.05). CBs are as effective as conventional balloons in the dilation of PPS and may be more effective when larger balloons are available.

Expanding indications for the treatment of pulmonary artery stenosis in children by using cutting balloon angioplasty

OBJECTIVES

To evaluate the role of cutting balloon angioplasty in children with pulmonary artery stenosis.

BACKGROUND

Pulmonary artery stenoses can be either congenital or secondary to postoperative scar formation. Isolated multiple small-vessel pulmonary artery stenoses are very rare. No surgical procedures for their treatment are currently available.

METHODS

We report on four patients in whom standard and high-pressure balloon angioplasty had failed. Three of the four (2.5-, 3-, and 3.5-years-old; two girls) had isolated multiple peripheral pulmonary artery stenosis. The fourth patient was an 11-month-old girl (8 kg) with tetralogy of Fallot and hypoplastic pulmonary artery branches treated with the implantation of two stents in the pulmonary arteries. During the follow-up this patient developed severe intrastent restenosis and showed severely hypoplasic distal left pulmonary artery.

RESULTS

We treated 11 vessels. The mean vessel diameter increased by 81% (P<0.0001) and RV/LV pressure ratio decreased from 1.15 to 0.75 (P=0.05). Patient treated for intrastent restenosis underwent successful complete tetralogy of Fallot repair. None of the patients suffered procedure-related complications. At a median follow-up of 18 months, results were stable and no late complications had occurred.

CONCLUSIONS

Cutting balloon angioplasty is a promising technique for the treatment of highly challenging pathologies such as small vessel pulmonary artery stenoses and intrastent restenosis.

Recent results of pulmonary arterial angioplasty: the differences between proximal and distal lesions

INTRODUCTION

We sought to establish a modern understanding of the safety and efficacy of trans-catheter pulmonary arterial angioplasty.

METHODS

A review of records in a sample of 104 dilations, out of a total of 711 procedures undertaken between January, 1996 and December, 2000, provided descriptive information regarding technique, adverse events, and changes achieved in luminal diameter. Because evidence during the review of angiograms suggested substantial differences according to whether the stenotic lesions were positioned proximally or distally within the pulmonary arterial tree, all analyses incorporated this classification.

RESULTS

We reviewed stenoses in 203 pulmonary arteries, 38% located proximally and 62% distally, with follow-up available concerning dilation in 92 vessels. Proximal dilations frequently involved a prior surgical site, and appeared more compliant and amenable to conventional angioplasty, as evidenced by more common elimination of the waist, but also more recoil, then requiring placement of stents. In contrast, distal lesions frequently required balloons capable of sustaining high pressures of inflation, and larger balloons relative to the size of the vessels. The proportional increase in diameter was greater for distal sites, at 90 plus or minus 77%, compared to proximal, at 64 plus or minus 70%, p equal to 0.002. Serious adverse events occurred in 3 of 104 procedures, giving a rate of serious adverse events of 2.9%. At follow-up, 9 of 92 vessels (10%), 95% confidence intervals from 5% to 18%, returned to their diameters prior to dilation, with no difference in the rate of restenosis according to the site of dilation.

CONCLUSION

Our findings indicate the need to distinguish, and to consider, the important differences in technical issues and outcomes, when performing dilations at proximal as opposed to distal sites. Although angioplasty is effective therapy for pulmonary arterial stenosis, a subset of vessels, more often distal, remain resistant to conventional techniques.

Follow-up results of Cutting Balloon angioplasty used to relieve stenoses in small pulmonary arteries

BACKGROUND

We sought to determine if the acute gains in pulmonary arterial diameter achieved by using Cutting Balloons to dilate stenoses in small arteries are maintained at follow-up.

METHODS

A search of our database identified all patients who underwent dilation with Cutting Balloons for pulmonary arterial stenosis between June 2001 and September 2003. We reviewed the procedural and angiographic data obtained at the initial and follow-up procedures.

RESULTS

Over the period of study, 29 patients with a median age of 3.7 years, and a range from 0.4 to 46.6, underwent treatment with Cutting Balloons at 41 procedures for one or more pulmonary arterial obstructions resistant to conventional angioplasty. At the initial procedure, we enlarged 79 vessels, with an initial minimal luminal diameter of 1.5 plus or minus 0.8 millimetres, to a diameter of 3.0 plus or minus 1.1 millimetres (p smaller than 0.001). Angiographic data indicated that 49% of the vessels showed evidence of vascular damage not requiring intervention, while stents were placed in 9 vessels. Follow-up angiography was available for 39 of the vessels, evaluated at a median of 6 months, with a range from 3 to 24 months, after the initial procedure. In these vessels, there was a mean loss of 10 plus or minus 25% in luminal diameter, p not significant. Of the 39 vessels, 8 had returned to a diameter within half of the initial diameter, giving a failure rate at follow-up of 21%, with 95% confidence intervals from 9% to 36%. All complications were identified within 24 hours of the catheterization procedure, and there were no late complications or deaths during the period of follow-up. Placement of stents produced both greater increases in diameter at the initial procedure (p smaller than 0.001), and greater losses at follow-up (p equal to 0.01).

CONCLUSIONS

Despite the frequent identification of intravascular trauma, initial gains in luminal diameter after use of Cutting Balloons to dilate stenotic pulmonary arteries are maintained at follow-up.

Pulmonary vein stenosis: initial experience with cutting balloon angioplasty

OBJECTIVE

To determine the safety and effectiveness of cutting balloon angioplasty for pulmonary vein stenosis (PVS).

DESIGN AND SETTING

Retrospective review of case notes and cardiac catheterisation data at the Royal Brompton Hospital.

MAIN OUTCOME MEASURES

Diameter of pulmonary vein, tricuspid regurgitant jet velocity on echocardiogram, and percutaneous oxygen saturation before and after cutting balloon angioplasty.

RESULTS

Three patients had congenital PVS and three had PVS associated with total anomalous pulmonary venous drainage. A total of 27 PVSs were treated during 12 catheterisation procedures. Median patient age at the time of procedure was 12.5 months (range 1.5-36 months) and weight was 7.1 kg (range 2.8-11.1 kg). Minimum pulmonary vein diameter increased significantly on angiography after cutting balloon angioplasty, from mean (SD) 2.3 (0.7) mm to 4.2 (1.9) mm, mean of differences 1.9 mm (95% confidence interval (CI) 0.9 to 2.9 mm, p = 0.0013). Mean (SD) oxygen saturation rose from 79.6 (12.9)% to 83.9 (9.0)%, mean of differences 4.3% (95% CI 0.7% to 8.0%, p = 0.0238). All children's symptoms improved subjectively. Tricuspid regurgitant jet velocity did not change significantly. The longest time interval before repeat intervention was six months. There were no acute deaths; one patient had a small pulmonary haemorrhage and developed a small aneurysm adjacent to the site of angioplasty.

CONCLUSION

Cutting balloon angioplasty is safe in the palliation of PVS in children. It gives some acute relief but often needs to be repeated, as improvement is rarely sustained.

Orthotopic liver transplantation for alagille syndrome

Alagille syndrome (AS) is a dominantly inherited, multisystem disorder involving the liver, heart, eyes, face, and skeleton. From October 1997 through July 2004, 260 pediatric orthotopic liver transplantations (OLTx) were performed in 231 patients. This report describes 21 patients of median age 1.95 years (range, 0.7-16.7) who had alagille syndrome. We present the technical features of the OLTx, incidence and type of complications, medical conditions related to the syndrome, need for retransplantation, as well as patient and graft survival rates. A split liver technique was used in 16 patients (76%) who received a left lateral segment (LLS) graft whereas 7 patients (33%) received a whole liver. Only cadaveric donors were used. The major surgical complications requiring reintervention in 11 patients (52%) included biliary problems (19%) and vascular complications (17%). One case of hepatic artery thrombosis required retransplantation. Three recipients (14%) died. All other patients are alive with an actuarial survival rate of 90% at 1 year and 80% at 5 years. The actuarial graft survival rate is 85% at 1 year and 75% at 5 years. Patients with AS, despite the associated cardiovascular anomalies, can be treated successfully by a combined approach between cardiologist, radiologist, cardiothoracic, and liver transplant surgeons. With careful planning and operative management, the results are comparable with those obtained with other more common cholestatic diseases.