Surgical shunts and TIPS for variceal decompression in the 1990s

BACKGROUND

In the 1990s, liver transplantations and transjugular intrahepatic portosystemic shunts (TIPS) have become the most common methods to decompress portal hypertension. This center has continued to use surgical shunts for variceal bleeding in good-risk patients who continue to bleed through endoscopic and pharmacologic treatment. This article reports this center's experience with surgical shunts and TIPS shunts from 1992 through 1999.

METHODS

Sixty-three patients (Child A, 43 patients; Child B, 20 patients) received surgical shunts: distal splenorenal, 54 patients; splenocaval, 4 patients; coronary caval, 1 patient; and mesocaval, 4 patients. Sixty-two patients had refractory variceal bleeding, and 1 patient had ascites with Budd-Chiari syndrome. Two hundred patients (Child A, 24 patients; Child B, 62 patients; Child C, 114 patients) received TIPS shunts. One hundred forty-nine patients had refractory variceal bleeding, and 51 patients had ascites, hydrothorax, or hepatorenal syndrome. Data were collected by prospective databases, protocol follow-up, and phone contact.

RESULTS

The 30-day mortality rate was 0% for surgical shunts and 26% for TIPS shunts; the overall survival rate was 86% (median follow-up, 36 months) for surgical shunts and 53% (median follow-up, 40 months) for TIPS shunts. For surgical shunts, the portal hypertensive rebleeding rate was 6.3%; the overall rebleeding rate was 14.3%. For TIPS shunts, the overall rebleeding rate was 25.5% (30-day, 9.4%; late, 22.4%). There were 4 reinterventions for surgical shunts (6.3%); the reintervention rate for TIPS shunts in the bleeding group was 33%, and the reintervention rate in the ascites group was 9.5%. Encephalopathy was severe in 3.1% of the shunt group and mild in 17.5%; this was not systematically evaluated in the TIPS shunts patients.

CONCLUSIONS

Surgical shunts still have a role for patients whose condition was classified as Child A and B with refractory bleeding, who achieve excellent outcomes with low morbidity and mortality rates. TIPS shunts have been used in high-risk patients with significant early and late mortality rates and have been useful in the control of refractory bleeding and as a bridge to transplantation. The comparative role of TIPS shunts versus surgical shunt in patients whose condition was classified as Child A and B is under study in a randomized controlled trial.

Role of angiography and embolization for massive gastroduodenal hemorrhage

The role of mesenteric angiography and embolization for massive gastroduodenal bleeding is unclear. We reviewed the records of patients who underwent angiography for acute, nonmalignant, and nonvariceal gastric or duodenal hemorrhage that was documented but not controlled by endoscopy. Fifty patients were identified over a 7-year period ending in March 1998. Only 17 patients (34%) were originally admitted to the hospital with gastrointestinal bleeding. All required treatment in the intensive care unit (mean 15 days) with a mean APACHE III score of 79 (29% predicted hospital mortality), and 32 (64%) had organ failure. A mean of 2.1 endoscopies were performed to locate the source of acute duodenal bleeding in 37 (74%) and gastric bleeding in 13 (26%). An average of 24.3 units of packed red blood cells were transfused per patient. Twenty-five patients (50%) were found to have active bleeding at angiography; all were treated by embolization as were 22 who underwent empiric embolization. Twenty-six patients (52%) were successfully treated by embolization and thus spared imminent surgery. Multiple variables were compared between those who were successfully treated by embolization and those considered failures. Time to angiography was considerably shorter (2.5 vs. 5.8 days, P<0. 017) and fewer total units of packed red blood cells were used (14.6 vs. 34, P<0.003) in those who were successfully treated. There was also a strong trend toward using fewer units of packed red blood cells for transfusion prior to angiography (11.2 vs. 17.1, P<0.08). No differences were found that could be attributed to gastric vs. duodenal sources, number of comorbid diseases, organ failure, APACHE score, age, or whether active bleeding was found at angiography. A total of 20 patients (40%) died including 9 of 17 patients operated on in an attempt to salvage angiographic failure. In summary, angiographic embolization should be performed early in the course of bleeding in otherwise critically ill patients.

Transjugular core liver biopsy with a 19-gauge spring-loaded cutting needle

One hundred and five sequential transjugular core liver biopsies (TJLBx) were performed in 101 patients with coagulopathy and/or ascites using the 19-gauge Quick-Core Biopsy (QCB) needle. Two-hundred and seventy-three cores were obtained in 295 passes (92. 5%). One-hundred and two of the 105 procedures (97.1%) led to a histopathologic diagnosis. One of the three nondiagnostic biopsies was done because of severe autolysis of the liver. There was one subcapsular hematoma, one hepatic arteriovenous fistula, and one liver capsular puncture. Two minor neck hematomas occurred. One death was reported (unrelated to the procedure). QCB needle TJLBx is an effective and relatively safe way to obtain core liver samples.

Post-transplant renal artery stenosis: impact of therapy on long-term kidney function and blood pressure control

PURPOSE

We assessed the long-term outcome of different treatment methods for transplant renal artery stenosis.

MATERIALS AND METHODS

Outcome data for 23 patients with transplant renal artery stenosis treated during a 16-year period were reviewed and analyzed.

RESULTS

There was a higher incidence of renal artery stenosis in cadaveric donor kidneys compared to living donor kidneys (2% versus 0.3%, p < 0.02), and in cadaveric kidneys from pediatric donors less than 5 years old compared to those from adults (13.2% versus 1.3%, p < 0.01). Six patients underwent primary medical treatment for renal artery stenosis, with a successful outcome in 4 (mean followup plus or minus standard error 57 +/- 22 months) and failure in 2. Of the patients 16 were treated with percutaneous transluminal angioplasty, including 12 who were cured or improved with respect to hypertension (followup 44.7 +/- 7.6 months). Five patients underwent surgical revascularization for renal artery stenosis with postoperative improvement of hypertension (followup 18.8 +/- 11.6 months). Overall, 21 of 23 patients (91%) were treated successfully for transplant renal artery stenosis with cure or improvement of associated hypertension. Posttreatment renal function was stable or improved in 18 patients, while renal function deteriorated due to parenchymal disease in 3.

CONCLUSIONS

Most patients with transplant renal artery stenosis can be treated successfully. Percutaneous transluminal angioplasty is the initial interventive treatment of choice for high grade renal artery stenosis. Surgical revascularization is indicated if percutaneous transluminal angioplasty cannot be done or is unsuccessful.

Experience with percutaneous transluminal angioplasty for renal artery stenosis at the Cleveland Clinic

From April 1979 to June 1985 percutaneous transluminal angioplasty was attempted in 68 patients at our clinic to treat renovascular hypertension and/or to preserve renal function. The etiology of renal artery disease was atherosclerosis in 55 patients, fibrous dysplasia in 6, renal transplant arterial stenosis in 5 and postoperative saphenous vein graft stenosis in 2. A successful clinical outcome, defined as a decrease in blood pressure and/or improvement in renal function, was achieved in 12 patients (26.1 per cent) with atherosclerotic renal artery disease, 3 (75 per cent) with fibrous dysplasia, 2 (100 per cent) with saphenous vein graft stenosis and all 5 with transplant renal arterial stenosis (100 per cent). Improved results were observed in patients with nonostial atherosclerotic lesions compared to ostial lesions. There were 23 complications (33.8 per cent) after percutaneous transluminal angioplasty and all but 1 occurred with atherosclerosis. Of these complications 13 (19 per cent) were considered major. Since the beginning of 1983, however, only 3 complications occurred among 32 procedures (9.4 per cent) and only 1 of these was of major significance. When technically feasible, percutaneous transluminal angioplasty can provide effective treatment for selected patients with renal artery stenosis.

Intra-arterial chemotherapy as an adjuvant to surgery in transitional cell carcinoma of the bladder

Regional chemotherapy with intra-arterial cis-platinum and doxorubicin as an adjuvant to total cystectomy and urinary diversion has been evaluated in a phase I to II study. In the first 17 patients chemotherapy consisted of 40 to 75 mg. per m. cis-platinum intra-arterially during 30 minutes, 30 to 40 mg. per m. doxorubicin intra-arterially during 60 minutes (11 patients) or 12 hours (6 patients) and 400 to 500 mg. per m. cyclophosphamide intravenously. The remaining 8 patients received 70 to 100 mg. per m. cis-platinum intra-arterially during 30 minutes. Intra-arterial chemotherapy was administered through a percutaneous catheter placed in the hypogastric artery before each course. Courses were repeated at 4-week intervals. A total of 25 patients received 58 courses (median 2 per patient). Clinical stages of disease in the patients entering the protocol were T3aNxMo (8), T3bNx-2Mo (12) and T4a-bNxMx-1 (5). Clinical response was assessed in 24 of 25 patients: 6 achieved a complete clinical response, 12 had a partial response and 7 had no response. Of 25 patients 16 underwent total cystectomy and urinary diversion with pathological staging as follows: ToNoMo in 3, T1NoMo in 1, T3aNoMo in 5, T3bNo-2Mo in 6 and T4NoMo in 1. Intra-arterial chemotherapy can produce a complete pathological response in patients with locally advanced bladder cancer and is tolerated well by most patients.

Volume and planar gated cardiac magnetic resonance imaging: a correlative study of normal anatomy with thallium-201 SPECT and cadaver sections

Magnetic resonance (MR) gated cardiac imaging was performed in ten subjects using a prototype 0.15-T resistive magnet imaging system. Volume and planar imaging techniques utilizing saturation recovery, proton Tl-weighted relaxation time pulse sequences produced images of the heart and great vessels with exquisite anatomic detail that showed excellent correlation with cadaver sections of the heart. The left ventricular myocardial segments also showed excellent correlation with the thallium-201 cardiac single photon emission computed tomography images. Volume acquisition allowed postprocessing selection of tomographic sections in various orientations to optimize visualization of a particular structure of interest. The excellent spatial and contrast resolution afforded by MR volume imaging, which does not involve the use of ionizing radiation and iodinated contrast material, should assure it a significant role in the diagnostic assessment of the cardiovascular system.

The effects of nuclear magnetic resonance on patients with cardiac pacemakers

The effect of nuclear magnetic resonance (NMR) imaging on six representative cardiac pacemakers was studied. The results indicate that the threshold for initiating the asynchronous mode of a pacemaker is 17 gauss. Radiofrequency levels are present in an NMR unit and may confuse or possibly inhibit demand pacemakers, although sensing circuitry is normally provided with electromagnetic interference discrimination. Time-varying magnetic fields can generate pulse amplitudes and frequencies to mimic cardiac activity. A serious limitation in the possibility of imaging a patient with a pacemaker would be the alteration of normal pulsing parameters due to time-varying magnetic fields.