Complications of percutaneous transhepatic biliary interventions

Complications of percutaneous transhepatic biliary drainage procedures range from skin discomfort to life-threatening arterial hemobilia. A thorough understanding of biliary anatomy and postprocedure care is essential if such procedures are to be performed. This article summarizes the anatomic, technical, and clinical issues related to biliary interventions and assists the interventional radiologist in the management of complications encountered in patients undergoing biliary interventions.

Percutaneous management of benign biliary strictures

The interventional radiologist plays an increasing role in the management of patients with benign biliary disease. This article summarizes the percutaneous management of patients with benign biliary strictures and includes a discussion of currently available techniques. The techniques of percutaneous transhepatic cholangiography and biliary drainage will be reviewed. This includes anatomic and technical considerations of the right midaxillary and left subxyphoid percutaneous approaches, a review of percutaneous dilation of biliary strictures and the management of patients with chronic indwelling biliary drainage catheters. (ie, periodic catheter exchanges, catheter flushing, etc). The article concludes with a discussion of biliary drainage catheters and the clinical and physiologic parameters used in making a decision to remove the tube.

Advanced percutaneous transhepatic biliary access

Percutaneous transhepatic cholangiography and percutaneous biliary drainage are generally routine procedures in the majority of patients. However, when difficult clinical situations arise, advanced techniques for achieving biliary access may be required. Several advanced techniques for drainage are discussed.

Complications of percutaneous transhepatic biliary interventions

Complications of percutaneous transhepatic biliary drainage procedures range from skin discomfort to life-threatening arterial hemobilia. A thorough understanding of biliary anatomy and postprocedure care is essential if such procedures are to be performed. This article summarizes the anatomic, technical, and clinical issues related to biliary interventions and assists the interventional radiologist in the management of complications encountered in patients undergoing biliary interventions.

Percutaneous endoscopy for biliary radiologic interventions

Biliary endoscopy is an adjunct to percutaneous biliary interventions. Although there are technical and cost considerations, the interventional radiologist may apply this useful tool to patients with a wide range of biliary diseases (eg, patients with retained intrahepatic stones, patients with suspected lesions requiring biopsy, etc). Discussed in this article are advantages, disadvantages, patient preparation, technical advice, complications, and a review of the literature. Percutaneous biliary endoscopy, applied through a transhepatic tube tract or a mature T tube tract, reduces radiation exposure to the patient and health care personnel in the room. The procedure is generally performed on an outpatient basis under conscious sedation. Given access to a choledochofiberscope and familiarity with its use, percutaneous endoscopy for biliary radiologic interventions is a valuable technique and may be used to manage patients with complex biliary disease.

Budd-Chiari syndrome: current management options

OBJECTIVE

To assess the outcomes of current treatment strategies for Budd-Chiari syndrome.

SUMMARY BACKGROUND DATA

Budd-Chiari syndrome, occlusion or obstruction of hepatic venous outflow, is a disease traditionally managed by portal or mesenteric-systemic shunting. The development of other treatment options, such as catheter-directed thrombolysis, transjugular portosystemic shunting (TIPS), and liver transplantation, has expanded the therapeutic algorithm.

METHODS

The authors reviewed the medical records of all patients diagnosed with Budd-Chiari syndrome at the Johns Hopkins Hospital during the past 20 years.

RESULTS

A total of 54 patients were identified: 13 (24%) male patients and 41 (76%) female patients, ranging in age from 2 to 76 years (median 33 years). Twenty-one (39%) had polycythemia vera, 3 (5.6%) used estrogens, 11 (20%) had a myeloproliferative or coagulation disorder, and in 7 (13%) the cause remained unknown. Forty-three patients were treated with surgical shunting, 24 mesocaval and 19 mesoatrial. Actuarial survival rates at 1, 3, and 5 years after shunting were 83%, 78%, and 75%, respectively. Of 33 patients surviving more than 4 years, 28 (85%) had relief of clinical symptoms. Five patients required shunt revision and eight had radiologic procedures to maintain shunt patency. Primary and secondary shunt patency rates were 46% and 69% respectively for mesoatrial shunts and 70% and 85% respectively for mesocaval shunts. Clot lysis was successful as primary treatment in seven patients. TIPS was performed in three patients, one after a failed mesocaval shunt. During an average of 4 years of follow-up, these patients required multiple procedures to maintain TIPS patency. Six patients underwent liver transplantation. Of these, three had previous shunt procedures. Five of the transplant recipients are alive with follow-up of 2 to 9 years (median 6).

CONCLUSIONS

Both shunting and transplantation can result in a 5-year survival rate of at least 75%, and other treatment modalities may be appropriate for highly selected patients. Optimal management requires that treatment be directed by the predominant clinical symptom (liver failure or portal hypertension) and anatomical considerations and be tempered by careful assessment of surgical risk.

Chemoembolization of liver tumor in a rabbit model: assessment of tumor cell death with diffusion-weighted MR imaging and histologic analysis

PURPOSE

To assess the efficacy of chemoembolization of liver tumors by determining the fraction of viable tumor cells remaining after treatment with use of diffusion magnetic resonance (MR) imaging and histologic analysis.

MATERIALS AND METHODS

VX2 tumor was grown in the livers of 12 rabbits. Animals were divided into a chemoembolization group and an untreated group. Conventional, perfusion, and diffusion MR imaging was performed on all rabbits. Histopathologic analysis of explanted livers was performed to document tumor cell death and measure Bcl-2 levels (inhibitor of apoptosis).

RESULTS

Diffusion-weighted MR imaging delineated zones of tumor cell death as regions of lower signal intensity in both groups. Apparent diffusion coefficients were significantly greater in the area of tumor necrosis than in the area of viable tumor. Histologic analysis demonstrated a significantly lower percentage of viable cells in the treated group (<1%) than in the control group (55%). Bcl-2 expression detected within the viable areas of the tumor was greater in the treated group than in the control group.

CONCLUSIONS

Chemoembolization causes extensive tumor cell destruction. Diffusion MR imaging can detect tumor cell death and can be used to assess the efficacy of chemoembolization. Bcl-2 was expressed in the treated group, suggesting an apoptotic pathway of cell death.

Percutaneous deployment of a valved bovine jugular vein in the swine venous system: a potential treatment for venous insufficiency

PURPOSE

To develop a system for potential use in the treatment of chronic venous insufficiency by using percutaneous techniques.

MATERIALS AND METHODS

A segment of a glutaraldehyde-fixed bovine external jugular vein with valves was trimmed and sutured to a nitinol stent. Animals were premedicated and anesthetized (n = 11). Venography of the right external jugular vein, inferior vena cava (IVC), and common iliac vein was performed. Deployment was accomplished via a sheath (12-24 F) with use of fluoroscopic guidance. Eleven bioprostheses were deployed in 11 animals. Bioprostheses were deployed in the IVC (n = 3) or right external iliac vein (n = 6). Animals were killed immediately after deployment (n = 7) at 1 week (n = 1) or at 2 weeks (n = 2). One animal was found dead in the cage. At necropsy, each bioprosthesis (n = 4) was explanted and histopathologic analysis was performed.

RESULTS

Deployments of the bioprostheses were successful in nine of 11 swine. Two deployments were unsuccessful (one accidental deployment in the right renal vein, one deployment in the IVC caused rupture of the vein). Postdeployment venography (n = 9) confirmed no reflux (in the recumbent position of the swine) of the valve leaflets and patency of the vein inferior to the level of the bioprostheses. in the first group of animals (n = 5), valve leaflets were normal and competent. In the survival animal group (n = 4), the bioprostheses remained patent without evidence of thrombus formation by ascending and descending venography. Gross inspection of the explanted bioprostheses (n = 4) demonstrated grossly normal valves that fully occluded the lumen. Complications included hemarthrosis (n = 1), death (n = 1), and bioprosthesis thrombosis immediately after deployment (n = 1). Histopathologic analysis showed endothelial cells covering the luminal surfaces. The wall of the bioprostheses had granulomatous response and foreign body reaction. Bacterial contamination was noted in one bioprosthesis.

CONCLUSIONS

Deployment of a glutaraldehyde-fixed bovine vein sutured to a self-expanding nitinol stent in the swine iliac vein or IVC is technically feasible. Development of a venous bioprosthesis that can be placed percutaneously may have important clinical applications as an endovascular treatment for chronic venous insufficiency when it is due to valvular incompetence.

Percutaneous replacement jejunostomy after esophagogastrectomy

A surgically placed jejunostomy tube is a safe and effective means of delivering nutritional support for the postesophagogastrectomy patient. We have previously described a method that permits percutaneous replacement of surgically placed jejunostomy feeding tubes, and now present our results with the use of this technique in 350 consecutive esophagogastrectomy patients. Replacement jejunostomy as required in 17 patients (4.9%). All patients had successful percutaneous jejunostomy replacement. There were no procedural complications or deaths. The timing of feeding tube replacement following esophagogastrectomy was predictive of the indication. Before 16 weeks, the indication for feeding tube replacement was intubation and inability to eat (1 patient) or anorexia with weight loss and dehydration (7 patients). At or after 16 weeks, the indications for feeding tube replacement were all related to symptoms resulting from recurrent carcinoma. We conclude that the technique of percutaneous jejunostomy allows the surgeon tremendous flexibility in the management of the postesophagogastrectomy patient as it preserves the advantages of an adjuvant surgically placed feeding tube over the lifetime of the patient. The technique is safe, and the success rate is excellent.

Isolated right segmental hepatic duct injury: a diagnostic and therapeutic challenge

Biliary leaks and injuries are not an uncommon occurrence following laparoscopic cholecystectomy. Bile leaks associated with the biliary anatomic variant of a low-inserting right segmental hepatic duct can be particularly difficult to diagnose in that results of endoscopic retrograde cholangiography (ERC) are usually interpreted as "normal" with no leaks demonstrated. The aim of this study was to describe a single institution's experience with nine patients with biliary leaks associated with this anatomic variant and to discuss their management. A retrospective analysis of the hospital records of all patients with bile duct injuries managed at a single institution between 1980 and July 1998, inclusive, was performed. Nine patients were identified as having an isolated right segmental hepatic duct injury associated with a biliary leak. Seven (78%) of the nine patients had undergone a laparoscopic cholecystectomy, whereas the remaining two patients (22%) had undergone an open cholecystectomy. All of the patients had undergone endoscopic retrograde cholangiography at outside institutions, the results of which had been interpreted as normal with no apparent leaks. The median interval from the time of cholecystectomy to referral was 1.4 months. All patients were managed with initial percutaneous access of the involved right segmental biliary system, with placement of a percutaneous transhepatic stent. After the biliary leak was controlled, all patients underwent Roux-en-Y hepaticojejunostomy to the isolated biliary segment. All patients had an uncomplicated postoperative course. There were no postoperative anastomotic leaks. Postoperative stenting was maintained for a mean of 8 months. Six (67%) of the nine patients had a long-term successful outcome with minimal or no symptoms. In three patients, recurrent symptoms with pain and/or cholangitis developed at a mean of 34 months. All three patients underwent percutaneous cholangiography, which demonstrated an anastomotic stricture, and all were managed with percutaneous balloon dilatation with a successful outcome. Currently eight (89%) of the nine patients are asymptomatic, with a mean follow-up of 70.4 months (range 12 to 226 months). One patient had intermittent right upper quadrant pain with normal liver function tests but has not required intervention. Isolated right segmental hepatic ductal injury with biliary leakage is an uncommon complication following laparoscopic cholecystectomy. A diagnostic dilemma is created by the presence of a bile leak with a normal endoscopic retrograde cholangiogram. Management begins with percutaneous access of the transected isolated ductal system followed by reconstruction as a Roux-en-Y hepaticojejunostomy.

How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement

OBJECTIVE

The introduction of excessive lengths of guidewire during placement of central venous catheters from the internal jugular vein (IJV) or the subclavian vein (SCV) can result in rare but significant complications. To identify a "safe" guidewire insertion length, the authors performed direct intravascular measurement of the distance from these venous access sites to the superior vena cava-atrial junction (CAJ), and evaluated these distances relative to the patients' height, weight, sex, and chest radiographs.

DESIGN

Prospective, nonrandomized observation.

SETTING

The Interventional Radiology Department of a tertiary care referral hospital.

PATIENTS

100 adults (45 women, 55 men) evaluated during fluoroscopically directed central venous catheter placement.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The distance from the IJV or SCV access site was directly measured using fluoroscopy and an intravascular guidewire. 40 right IJVs, 31 right SCVs, 16 left SCVs, and 13 left IJVs were studied. Comparative measurements from the postprocedure radiograph were made in 20 of these cases. All measurements were correlated with patient sex, height, and weight. The mean distance from all access sites to the superior vena cava-atrial junction was 18.0 cm. The right IJV distance was the shortest, averaging 16 cm. The left SCV distance was the longest, averaging 21.2 cm. Right SCV and left IJV distances were 18.4 and 19.1 cm, respectively, but this difference was not statistically significant. Weight and radiographic measurements did not correlate with the measured vascular distance, although there was a trend toward longer distances in taller patients and males.

CONCLUSIONS

Patient height, weight, and measurements from previous chest radiographs are less reliable in predicting a safe wire length than is the access site selected. In most cases, 18 cm should be considered the upper limit of guidewire introduced during central catheter placement in adults. The guidewires supplied in catheter kits should have lengths correlated to those of the catheters, and should have distance markings printed upon them.

Placement of a flexible endovascular stent across the femoral joint: an in vivo study in the swine model

PURPOSE

To investigate the effects of joint motion on the structural integrity of periarticular stents and on the development of neointimal hyperplasia within these devices.

MATERIALS AND METHODS

In four juvenile farm swine, Wall-stents were implanted in the common femoral arteries and contralateral common femoral veins, centered at the point of maximal conformational change during passive hip flexion. Control stents were placed in the aortae and iliac veins. Angiography and transcatheter blood pressure measurements were obtained across each stent, with periarticular stents studied in flexion and extension. Two animals underwent repeated evaluation after 1 month, the others after 3 months. Findings were correlated with gross and histopathologic findings in the harvested stents.

RESULTS

No stent fractures occurred. One femoral vein was injured during stent placement and was occluded 1 month later at follow-up. Hemodynamically significant stenoses were identified in one arterial stent and one venous stent at 3 months. The amount of neointimal hyperplasia was greater in periarticular stents than in controls and greater in animals studied at 1 month than in those studied at 3 months. The pattern of neointimal hyperplasia within mobile arteries was circumferentially asymmetric and thicker at the distal ends of the stents. Venous neointimal hyperplasia was thicker and markedly different in character than that seen in arterial stents from the same animals.

CONCLUSIONS

Periarticular Wallstents and the underlying vascular anatomy remained structurally intact despite the stresses of repetitive motion during a 3-month period. Stents deployed across joints or in venous locations may be at greater risk for neointimal hyperplasia development and eventual occlusion than those deployed in immobile vessels and arteries. Neointimal hyperplasia may decrease in thickness after an initial period of exuberant development. Additional studies are necessary to determine long-term outcomes.

TIPS placement in swine, guided by electromagnetic real-time needle tip localization displayed on previously acquired 3-D CT

PURPOSE

To determine the feasibility of guiding a transjugular intrahepatic portosystemic shunt (TIPS) procedure with an electromagnetic real-time needle tip position sensor coupled to previously acquired 3-dimensional (3-D) computed tomography (CT) images.

METHODS

An electromagnetic position sensor was placed at the tip of a Colapinto needle. The real-time position and orientation of the needle tip was then displayed on previously acquired 3-D CT images which were registered with the five swine. Portal vein puncture was then attempted in all animals.

RESULTS

The computer calculated accuracy of the position sensor was on average 3 mm. Four of five portal vein punctures were successful. In the successes, only one or two attempts were necessary and success was achieved in minutes.

CONCLUSION

A real-time position sensor attached to the tip of a Colapinto needle and coupled to previously acquired 3-D CT images may potentially aid in entering the portal vein during the TIPS procedure.

Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome)

Ovarian and pelvic (internal iliac) varices have long been recognized as a source of chronic pelvic pain in women. The technique of transcatheter embolotherapy for ovarian and pelvic varices requires selective catheterization of the ovarian and internal iliac veins, followed by contrast venography and embolization. The long-term effects of treatment are the subject of ongoing investigation. This article provides a concise background on ovarian and pelvic varices and reviews the recently published literature on their embolization for the treatment of pelvic venous incompetence (also known as pelvic congestion syndrome).

Real-time bronchoscope tip localization enables three-dimensional CT image guidance for transbronchial needle aspiration in swine

STUDY OBJECTIVE

To determine the feasibility of using real-time bronchoscope position technology coupled with previously acquired three-dimensional CT data to enhance transbronchial needle aspiration (TBNA).

DESIGN

Eight swine were given percutaneously created target lesions for TBNA. A miniature position sensor was placed at the tip of a bronchoscope, and real-time position information during bronchoscopy was presented on a monitor simultaneously displaying previously acquired three-dimensional CT data.

INTERVENTIONS

TBNA of target lesions and submucosal ink-spot injection of computer-generated targets.

MEASUREMENTS AND RESULTS

TBNA specimens revealed successful aspiration of target material. Distances between ink marks made at computer-generated tracheal targets varied, on average (+/- SD), 4.2 mm +/- 2.6 mm from predetermined computer-distance coordinates.

CONCLUSION

Real-time bronchoscope position technology coupled with previously acquired CT images may aid with TBNA of nonvisible extrabronchial lesions.

The biliary manometric perfusion test and clinical trial--long-term predictive value of success after treatment of bile duct strictures: ten-year experience

PURPOSE

To evaluate the long-term predictive value of the biliary manometric perfusion test and clinical trial for determining patency after treatment of bile duct strictures.

MATERIALS AND METHODS

One hundred four patients with benign biliary disease were treated with surgical (n = 59) or percutaneous (n = 45) techniques followed by intubation with large-caliber silicone stents. Prior to removal of the biliary stents, patients underwent a biliary manometric perfusion test (n = 168) and/or a clinical trial (n = 105) to objectively and subjectively evaluate the treated site for potential long-term patency. The patients were followed up for 1-87 months, and clinical outcomes were determined. Kaplan-Meier survival curves were generated for three patient groups, including those who (i) passed either test, (ii) failed either test, and (iii) failed either test, were re-treated, and passed either test.

RESULTS

Final successful treatment outcomes were documented in 47 (92%) surgically and 31 (86%) percutaneously treated patients, respectively (P = .001). The Kaplan-Meier survival curves determined the probability of patency at 0, 2, 4, and 6 years after treatment to be 1.0, .96, .78, and .59, respectively, after passing a biliary manometric perfusion test; and 1.0, .91, .78, and .78, respectively, after passing a clinical trial (P > .10). The probability of patency at 4 years after treatment was .45 after failing a biliary manometric perfusion test, and at 6 months was zero after failing a clinical trial (P = .001 and .001, respectively, vs the same test in the passing group). Seventy-nine percent of patients who failed either test required an additional period of repeated stent placement or reoperation. After repeated treatment, the probability of patency at 0-4 years was .80 and .88, respectively, for the biliary manometric perfusion test and clinical trial (P > .05 and P > .10, respectively, vs same test in the group that passed).

CONCLUSION

Patients who initially pass either the biliary manometric perfusion test or clinical trial have a significantly increased probability of patency versus those who fail; however, patients who fail either test and who then receive definitive additional treatment have a similar probability of patency as those who initially pass. Although the log rank test demonstrated the Kaplan-Meier survival curves from the biliary manometric perfusion test and clinical trial not to be significantly different in any of the three groups (ie, passing, failing, re-treated), the biliary manometric perfusion test is recommended over the clinical trial because of its simplicity, immediate results, and predicted cost savings.

Entrapment of J-tip guidewires by Venatech and stainless-steel Greenfield vena cava filters during central venous catheter placement: percutaneous management in four patients

We present four patients in whom bedside placement of a central venous catheter was complicated by entrapment of a J-tip guidewire by a previously placed vena cava (VC) filter. Two Venatech filters were fragmented and displaced into the superior VC or brachiocephalic vein during attempted withdrawal of the entrapped wire. Two stainless-steel Greenfield filters remained in place and intact. Fluoroscopically guided extraction of both wires entrapped by Greenfield filters was successfully performed in the angiography suite.

Primary sclerosing cholangitis: resect, dilate, or transplant?

OBJECTIVE

The current study examines the results of extrahepatic biliary resection, nonoperative endoscopic biliary dilation with or without percutaneous stenting, and liver transplantation in the management of patients with primary sclerosing cholangitis (PSC).

SUMMARY BACKGROUND DATA

Primary sclerosing cholangitis is a progressive inflammatory disease leading to secondary biliary cirrhosis. The most effective management of sclerosing cholangitis before the onset of cirrhosis remains unclear.

METHODS

From 1980 to 1994, 146 patients with PSC were managed with either resection of the extrahepatic bile ducts and long-term transhepatic stenting (50 patients), nonoperative endoscopic biliary dilation with or without percutaneous stenting (54 patients), medical therapy (28 patients), and/or liver transplantation (21 patients).

RESULTS

Procedure-related morbidity and mortality rates were similar between surgically resected and nonoperatively managed patients. In noncirrhotic patients, the serum bilirubin level was significantly (p < 0.05) reduced from preoperative levels (8.3+/-1.5 mg/dL) 1 (1.7+/-0.4 mg/dL) and 3 (2.7+/-0.9 mg/ dL) years after resection, but not after endoscopic or percutaneous management. For noncirrhotic PSC patients, overall 5-year survival (85% vs. 59%) and survival until death or transplantation (82% vs. 46%) were significantly longer (p < 0.05) after resection than after nonoperative dilation with or without stenting. For cirrhotic patients, survival after liver transplantation was longer than after resection or nonoperative dilation with or without stenting. Five patients developed cholangiocarcinoma, including three (6%) of the nonoperatively managed patients but none of the resected patients.

CONCLUSIONS

In carefully selected noncirrhotic patients with PSC, resection and long-term stenting remains a good option. Patients with cirrhosis should undergo liver transplantation.

Portal venous system thrombosis: helical CT angiography before transjugular intrahepatic portosystemic shunt creation

PURPOSE

To evaluate the utility of helical computed tomographic (CT) angiography for depiction of thrombi in the portal venous system in patients under consideration for transjugular intrahepatic portosystemic shunt (TIPS) creation.

MATERIALS AND METHODS

Contrast material-enhanced helical CT was performed before TIPS creation in 25 patients. Axial, multiplanar, and three-dimensional images were evaluated to determine whether thrombus was present in the portal system and whether TIPS creation was contraindicated. CT findings were confirmed at visceral angiography (n = 3), direct portography (n = 20), or duplex ultrasonography (n = 2).

RESULTS

Ten (40%) of 25 patients, including 10 (56%) of 18 patients with refractory variceal hemorrhage, had thrombus in the portal venous system. Helical CT scans depicted thrombus in nine (90%) of 10 patients (95% confidence interval = 0.71, 1.00) and in 16 (94%) of 17 vessels (95% confidence interval = 0.83, 1.00), including the portal vein (eight of eight patients), splenic vein (three of four patients), and superior mesenteric vein (five of five patients). TIPS creation was canceled in four (16%) patients on the basis of CT findings.

CONCLUSION

Thrombi in the portal venous system are common in patients with refractory variceal hemorrhage. Helical CT angiography is sensitive and specific for portal venous system thrombosis and can provide information that alters treatment in these patients.

Cholangiocarcinoma: a review

Cholangiocarcinoma is associated with several etiological factors including cystic dilation of the bile duct, clonorchiasis, hepatolithiasis, and sclerosing cholangitis. Jaundice is the presenting symptom in over 90% of patients who present with cholangiocarcinoma. The disease is suspected on the basis of an abnormal ultrasound or computed tomography (CT). Tumor markers are often normal, but a significant elevation of carcinoembryonic antigen or CA 19-9 should alert the clinician of a possible diagnosis of cholangiocarcinoma. Cholangiogram is essential to dileneate the bile duct anatomy in hilar or distal cholangiocarcinoma. A tissue diagnosis can be obtained in 60 to 70% of patients using bile cytology, brush cytology, or percutaneous fine-needle aspiration. A multidisciplinary approach is essential for optimal management. Management is based on a number of factors, including age of the patient, performance status, other comorbid conditions, location of the tumor, and tumor resectability. Complete surgical resection offers the only chance for cure in patients with cholangiocarcinoma. Tumor resectability can be accomplished using a combination of CT or magnetic resonance imaging, cholangiography, and visceral angiography. The 5-year survival rate after a potentially curative resection for hilar cholangiocarcinoma ranges from 0 to 22% (mean 14%). By comparison, the 5-year survival rate for distal cholangiocarcinoma ranges from 0 to 39% (mean 25%). Symptomatic patients who are unsuitable for curative resection can have pallitive decompression performed using either percutaneously or endoscopically placed drainage catheters.

Major bile duct injuries during laparoscopic cholecystectomy. Follow-up after combined surgical and radiologic management

OBJECTIVE

The authors provide the results of follow-up evaluation after combined surgical and radiologic management of 89 patients with major bile duct injuries during laparoscopic cholecystectomy.

SUMMARY BACKGROUND DATA

The incidence and mechanism of injury of major bile duct injuries during laparoscopic cholecystectomy has been clearly defined. Furthermore, a number of series have described the management of these injuries by surgical, endoscopic, and radiologic techniques with excellent short-term results. Long-term follow-up data, however, are lacking in the management of these injuries.

METHODS

Data were collected prospectively on 89 patients treated at a single institution with major bile duct injuries after laparoscopic cholecystectomy managed between July 1, 1990, and July 1, 1996. Patients referred with injuries underwent early percutaneous transhepatic cholangiography and biliary drainage. Based on the cholangiographic appearance and clinical situation, patients were managed by either percutaneous balloon dilatation or surgical reconstruction with a Roux-en-Y hepaticojejunostomy with transanastomotic stenting. Follow-up was obtained by personal interview during October 1996.

RESULTS

Two patients died without an attempt at definitive therapy. Both deaths were caused by sepsis and multisystem organ failure present at the time of transfer to the authors' institution. The remaining 87 patients were managed initially by either balloon dilatation (N = 28) or surgical reconstruction (N = 59). Ten patients have not completed treatment and still have biliary stents in place. Evaluation of 25 patients completing treatment after balloon dilatation (mean follow-up, 27.8 months) showed a success rate of 64%. Evaluation of 52 patients completing treatment after surgical reconstruction (mean follow-up, 33.4 months) showed a success rate of 92%. All failures were managed successfully by either surgical reconstruction or balloon dilatation.

CONCLUSIONS

Major bile duct injuries can be managed successfully by combined surgical and radiologic techniques. This series provides, for the first time, significant follow-up on a large number of patients with overall success rates of 64% after balloon dilatation and 92% after surgical reconstruction. The combination of surgery and balloon dilatation resulted in a successful outcome in 100% of patients treated.

Laparoscopic cholecystectomy-related bile duct injuries: a health and financial disaster

OBJECTIVE

This study was designed to evaluate the total costs associated with repair of laparoscopic cholecystectomy (LC)-related bile duct injuries.

SUMMARY BACKGROUND DATA

The popularity of LC with both patients and surgeons is such that this procedure now exceeds open cholecystectomy by a ratio of approximately 4 to 10:1. However, costs associated with LC-related injuries, particularly regarding treatment patterns, have up to now not been explored fully.

METHODS

The complete hospital and interventional radiology (IR) billing records for 49 patients who have completed treatment for laparoscopic cholecystectomy-related bile duct injuries were divided into 8 categories. These records were totaled for comparison of costs between patient groups that experienced different injuries and treatment patterns.

RESULTS

Patients with LC-related bile duct injuries were billed a mean of $51,411 for all care related to repair of their bile duct injury. Patients incurred an average of 32 days of inpatient hospitalization and 10 outpatient care days. Postoperative treatment included long-term chronic biliary intubation averaging 378 days. Two patients (4%) died as a result of their LC-related complications. Patients with bile duct injuries that were recognized immediately at the time of the initial surgery ultimately experienced a total cost for their repair and hospitalization of 43% to 83% less than for patients in whom recognition of the injury was delayed (p < 0.019 to 0.070). In addition, the total hospitalization and outpatient care days was reduced by as much as 76% with early recognition of an iatrogenic injury.

CONCLUSIONS

Repair of cholecystectomy-related bile duct injuries can run 4.5 to 26.0 times the cost of the uncomplicated procedure and carries a significant mortality rate. Intraoperative recognition of such an injury with immediate conversion to an open procedure for definitive repair can result in significant cost savings and relates directly to a decreased morbidity, mortality, length of hospitalization, and number of outpatient care days.

Outcome of tunneled hemodialysis catheters placed by radiologists

PURPOSE

To compare the outcomes of hemodialysis catheters placed by interventional radiologists with those placed by surgeons.

MATERIALS AND METHODS

The outcomes were retrospectively analyzed of 237 hemodialysis catheters placed in 140 patients by a radiology service from January 1991 through December 1992. Follow-up data were available for 222 catheters (94%). Catheter secondary patency and freedom from infection were analyzed statistically and by means of life-table analysis.

RESULTS

Pneumothorax occurred after the placement of six catheters (2.5%); in two patients, a chest tube was required for decompression. Other short-term complications included air embolism with no clinical sequelae (two procedures) and prolonged oozing from the tunnel (two procedures). Long-term complications included infection and catheter failure. Infection occurred in 26 patients (18%) with 32 catheters (14%) and resulted in removal of 25 catheters. Ninety-three catheters (42%) failed, and 63 catheters (28%) were removed because of failure.

CONCLUSION

Hemodialysis catheters placed by radiologists do not have a higher rate of complications or failure than catheters placed by surgeons.

Subcutaneously tethered temporary filter: pathologic effects in swine

PURPOSE

To evaluate the histopathologic effects of the Tempo-filter, a temporary caval filter, on the caval wall and determine the feasibility of deployment and removal of the device in swine.

MATERIALS AND METHODS

Filters were placed in the infrarenal inferior vena cava of 11 swine. The tethering catheter was sutured in a subcutaneous pocket near the puncture site. The original tethering catheter used in humans and a stiffer catheter designed to prevent migration in swine were evaluated. Postplacement, mid-study, and preexplant vena cavography procedures were performed. Four swine underwent in situ dissection at 3-10 weeks. Filters were removed from seven animals just before they were killed at 1-6 weeks.

RESULTS

All filters were successfully placed. All seven filters were successfully removed at up to 6 weeks after placement. Cephalic migration of more than 1 cm was observed in 10 of 11 swine (100% of original catheters, 83% of stiff catheters). Other complications were more common with stiffer tethering catheters, including caval stenosis in 40% of original catheters and 100% of stiff catheters, filter cone thrombus in 0% and 67%, tethering catheter thrombus in 20% and 83%, pulmonary embolism in 0% and 50%, and death in 0% and 17%, respectively. There was mild vessel wall damage in the vena cava.

CONCLUSION

Placement of the Tempofilter and removal at up to 6 weeks after placement is feasible.

Identification of the aberrant hepatic artery with axial spiral CT

PURPOSE

To determine whether axial spiral computed tomography (CT) allows detection of the replaced hepatic artery as part of preoperative planning for pancreatic tumor resection.

MATERIALS AND METHODS

Axial spiral CT scans (8-mm section thickness, 4-mm overlapping reconstructions) were obtained in 50 patients with periampullary tumor and were examined by three radiologists. Readers' interpretations were compared with angiographic results.

RESULTS

Eight patients had an aberrant hepatic artery. Two of the three readers detected or suspected all of these abnormalities (100% sensitivity), and one reader identified seven of eight aberrant arteries (88% sensitivity). However, readers requested angiographic confirmation in 14 of 24 tests. Sensitivity, specificity, and accuracy were 96%, 87%, and 88%, respectively, for all readers.

CONCLUSION

Axial spiral CT may simplify preoperative evaluation of periampullary tumors. However, angiographic support was necessary in most cases in this study. Improvements in CT techniques may eventually allow spiral CT to replace angiography in the examination of these patients.

Percutaneous jejunostomy replacement in patients who have undergone esophagectomy

PURPOSE

The authors expand their experience with a technique for the percutaneous replacement of a feeding jejunostomy tube in patients who have undergone esophagectomy, in which markers placed during the initial surgical jejunostomy are used.

PATIENTS AND METHODS

During esophagectomy in eight patients, a loop of jejunum was intubated with a surgical jejunostomy tube. This loop was then fixed to the anterior abdominal wall and marked with metal clips. In eight patients who required late nutritional support, the surgically placed metal clips on the fixed jejunal loop were used as fluoroscopic guides to mark the site for percutaneous access into the jejunum. Once access was obtained and verified with use of the Seldinger technique, a feeding jejunostomy tube was placed percutaneously after tract dilation.

RESULTS

Percutaneous replacement of a feeding jejunostomy tube was successful in all eight patients; in one patient, two placement attempts on successive days were required. No immediate complications occurred. Only one replacement jejunostomy tube has required replacement due to leakage around the tube (mean follow-up, 3.1 months).

CONCLUSION

Percutaneous replacement of a feeding jejunostomy tube with use of surgically placed clips as guides for access is a safe and effective method for providing late nutritional support in the postesophagectomy patient.

Percutaneous transluminal atherectomy of the superficial femoral and popliteal arteries: long-term results in 48 patients

PURPOSE

Evaluate retrospectively the long-term primary patency of directional atherectomy (DA) in the femoropopliteal arteries.

MATERIALS AND METHODS

DA was used alone in 59 patients (47%) or in combination with predilatation to allow passage of the device (43%) or after thrombolysis (10%) to treat 127 (93%) excentric atherosclerotic stenoses and nine (7%) occlusions of the femoropopliteal arteries. Forty-eight patients were followed by telephone interview, scheduled outpatient visits, color-flow Doppler evaluation, and angiography for 1-36 months (mean 16.9 months).

RESULTS

Technical success (reduction of the stenosis or occlusion to less than 30% luminal diameter) was achieved in 110 lesions (80.3%) during 48 procedures in 37 patients. Mean luminal diameter was increased 54% with a concomitant increase in mean ankle/brachial indices of 0.33. According to Kaplan-Meier survival curves, patency at 12 and 24 months was 88% and 75%, respectively. When patients who retained patency but developed restenosis were excluded, the probability of patency at 12, 24, and 36 months was 76%, 58%, and 32%, respectively. Major and minor complications occurred in 15 (21.4%) procedures each for a total complication rate of 42.8%.

CONCLUSION

Based on our results, DA is an effective method for percutaneous treatment of atherosclerotic disease involving the femoropopliteal arteries. It has similar patency but a relatively high complication rate compared with PTA.

Biliary manometry versus clinical trial: value as predictors of success after treatment of biliary tract strictures

PURPOSE

To evaluate the biliary manometric-perfusion test (BMPT) and clinical trial as predictors of long-term success after percutaneous and surgical treatment of biliary tract strictures.

PATIENTS AND METHODS

After percutaneous intervention or surgical repair of extrahepatic bile duct strictures, 43 patients underwent long-term biliary intubation (mean, 13 months) with 61 internal-external stents. Before removal of the stents, all 43 patients underwent a BMPT (n = 65) and 24 underwent a 2-3-week clinical trial (n = 27) with stents positioned above the treated region. Patients were followed up 1-46 months (mean, 16 months) after stent removal, with clinical outcome determined by means of physical examination, biochemical evaluation, chart review, and telephone interview.

RESULTS

With logistic regression analysis, the BMPT and clinical trial were shown to have equal predictive value in determining treatment success or failure. Eighty-four percent of the clinical outcomes were correctly predicted with BMPT, versus 88% for the clinical trial. Kaplan-Meier survival curve analysis demonstrated the probability of remaining stricture free at 1 year after passing a BMPT and after passing a clinical trial to be 90% and 86% (P = .55), respectively.

CONCLUSION

BMPT and clinical trial have similar capabilities in the prediction of long-term patency after treatment of benign biliary tract strictures, but the BMPT is less costly and time consuming for the patient.

Thrombosed dialysis access grafts: percutaneous mechanical declotting without urokinase

PURPOSE

To evaluate percutaneous declotting of dialysis access grafts with available catheters without urokinase.

MATERIALS AND METHODS

Thirty-four clotted grafts were treated in 24 patients. Clot was macerated and pushed into the central circulation with balloon catheters.

RESULTS

Successful mechanical declotting was performed in all but two patients (94%). The procedure was abandoned after successful declotting in four patients with poor venous outflow, resulting in a 24-hour success rate of 82%. Mean total procedure time was 116 minutes. Eight grafts clotted within 1 week. Using successful dialysis beyond 1 week as the measure of clinical success, the authors report a 59% clinical success rate with mean primary patency of 126 days (range, 16-322 days). Two complications, both emboli to the brachial artery, were successfully treated with urokinase. No symptomatic pulmonary emboli occurred.

CONCLUSION

Mechanical thrombolysis of clotted grafts with currently available catheters yields results similar to those reported with mechanical devices and urokinase. The procedure is relatively inexpensive, safe, and well tolerated.

Intrahepatic stones. The transhepatic team approach

OBJECTIVE

The authors reviewed the combined interventional radiologic and surgical management of 54 patients with intrahepatic stones at the Johns Hopkins Hospital. The team approach used large-bore transhepatic stents to access the intrahepatic ducts until they were stone free.

SUMMARY BACKGROUND DATA

Intrahepatic stones are uncommon in western countries. As a result, few American institutions have had much experience, and multiple management algorithms have been suggested. Nonoperative, operative, and combination surgical and nonoperative approaches have been advocated. At Johns Hopkins, combined surgical and percutaneous management has been used for 18 years.

METHODS

This team approach includes (1) percutaneous placement of transhepatic access catheters, (2) surgery for underlying biliary disease and stone removal, and, when necessary (3) postoperative percutaneous choledochoscopy and stone removal through the transhepatic stents.

RESULTS

The median age of the 54 patients was 50 years, and 32 were men. Biliary disease included 27 benign strictures, 7 sclerosing cholangitis, 5 choledochal cysts, 5 parasitic infections, 5 choledocholithiasis, and 5 biliary tumors. Fourteen patients (26%) were treated exclusively with percutaneous techniques. Forty patients (74%) had surgery, including 36 Roux-en-Y hepatico- or choledochojejunostomies with large-bore transhepatic stents. Eighteen of these 40 patients (45%) with multiple intrahepatic stones, strictures, or both required additional procedures after operation. No hospital deaths occurred after any of the percutaneous or surgical procedures. With a mean follow-up of 60 months, 94% of patients were stone free, 87% of patients were symptom free, and 73% have had their transhepatic stents removed.

CONCLUSIONS

A combined radiologic and surgical approach with transhepatic stents is a safe and effective method for managing intrahepatic stones.

Unresectable hilar cholangiocarcinoma: percutaneous versus operative palliation

BACKGROUND

Several nonoperative and operative options are available for palliation of patients with unresectable hilar cholangiocarcinoma. This retrospective analysis compares the results of nonoperative percutaneous stenting and operative palliation in 65 patients.

METHODS

Twenty-one patients were managed with percutaneous biliary stents (group A), and 44 patients underwent laparotomy (group B) with placement of large-bore silicone rubber transhepatic stents in 33. The two groups were similar with respect to age, gender, mean laboratory data, and cholangiographic extent of tumor.

RESULTS

Group A and group B patients were comparable in hospital morbidity (67% vs 61%), hospital mortality (14% vs 7%), and mean initial hospital stay (27 vs 31 days). Survival was greater in group B laparotomy patients at 1, 3, and 6 months (p < 0.01), and median survival was 5 months for group A compared with 8 months for group B patients (p = 0.06). Group A patients who were managed with percutaneous stents required more stent changes per month of survival (0.5 vs 0.3, p = 0.06). However, group B patients who underwent operative palliation were more likely to undergo a second operation (0% vs 21%, p = 0.05), most often for duodenal or small-bowel obstruction.

CONCLUSIONS

Operative placement of large-bore transhepatic stents may reduce cholangitis, delay hepatic failure, and prolong survival. We conclude that patients with unresectable hilar cholangiocarcinoma who are fit for surgery may benefit from operative palliation.

Percutaneous varicocele occlusion: long-term follow-up

PURPOSE

The authors summarize their 11-year experience with percutaneous varicocele occlusion at the Johns Hopkins Hospital.

PATIENTS AND METHODS

Data were obtained from the patients' medical records and from a mailed questionnaire. Most of the data analysis is based on the 182 patients who responded to the questionnaire.

RESULTS

Most of the occlusions were performed for infertility. The mean length of time couples had been attempting to conceive was approximately 44 months. Occlusion was technically successful in 95.7% of cases. Patients were followed up for a mean period of 59 months. Success is difficult to define because many patients and/or their wives received additional infertility treatment. Fifty-seven percent of all couples and 60% of a subgroup of couples who received no other treatment eventually conceived.

CONCLUSION

Percutaneous occlusion is a well-established treatment for varicoceles. Pregnancy rates and recurrence rates are comparable to those following surgical varicocelectomy. It is unlikely that resultant pregnancies occur from random chance alone.

Percutaneous embolotherapy of adolescent varicocele: results and long-term follow-up

PURPOSE

The authors evaluated the technical success and immediate and long-term results of percutaneous varicocele embolotherapy in the adolescent population.

PATIENTS AND METHODS

Fifty-nine adolescent patients were referred for outpatient spermatic venography and possible varicocele embolotherapy. Embolization was attempted with use of detachable balloons, coils, "sandwiched" dextrose, or a combination of these techniques. Data regarding follow-up were obtained through telephone interviews or mailed questionnaires.

RESULTS

The technical success rate for spermatic vein occlusion was 90%. Follow-up, obtained in 79% of the patients, ranged from 6 months to 8.75 years (mean, 4 years). Thirty-nine of 42 patients (93%) reported disappearance (n = 31) or only a slight, asymptomatic residual varicocele (n = 8). Three patients reported a recurrence of their varicocele. Complications occurred in three of 59 cases (5%), none had any long-term sequelae. In six cases, embolization was not feasible because of multiple collateral vessels or venous spasm.

CONCLUSIONS

Given the convenience of performing the procedure on an outpatient basis, the rapid recovery time, and long-term success and complication rates comparable to those with surgical ligation, we believe spermatic venography and percutaneous embolization is the treatment modality of choice for adolescent varicocele.

Preoperative spinal artery localization and its relationship to postoperative neurologic complications

PURPOSE

To evaluate the risk of spinal cord revascularization and ascertain the relationship between preoperative spinal arteriography and the frequency of postoperative neurologic injury and overall morbidity and mortality in patients who require surgical repair of thoracoabdominal aortic aneurysms.

MATERIALS AND METHODS

Fifty patients scheduled for surgical repair of a thoracoabdominal aortic aneurysm underwent spinal arteriography. All patients were divided into a positive spinal artery group (in which the spinal artery was identified) or negative spinal artery group (in which the spinal artery was not identified) and further divided based on extent of disease.

RESULTS

The complication rate of spinal arteriography was 4.6%; no patient had a permanent neurologic injury. No significant difference existed between the positive and negative spinal artery groups in occurrence of neurologic injury (P = .88) or combined morbidity and mortality (P = 51).

CONCLUSION

Patients who require spinal cord revascularization do not have greater frequency of neurologic injury or overall morbidity and mortality than those without this requirement. Spinal arteriography enables definitive spinal cord revascularization and thereby reduces the risk of neurologic injury.

Complications of interventional radiology: an imaging overview

The growth of interventional radiology has contributed to the development of more complex procedures applicable to an increasing patient population, with maintenance of low complication rates. However, due to its invasive nature, potential complications will always be associated with each procedure. Prompt recognition of these complications allows for rapid treatment with decreased patient morbidity and mortality. This overview provides detailed statistics and diagnostic imaging for evaluation of a wide spectrum of complications from hepatobiliary, renal, and vascular interventional procedures.

Randomized double-blind clinical trial of celiac plexus block for percutaneous biliary drainage

PURPOSE

This study was undertaken to determine the efficacy of celiac plexus block (CPB) as a method of providing analgesia for percutaneous biliary drainage (PBD).

PATIENTS AND METHODS

Thirty-two patients scheduled to undergo PBD were prospectively assigned randomly into placebo (30 mL of normal saline) and treatment (30 mL of 0.25% bupivacaine) CPB groups. Each patient received .03 mg/kg of midazolam for premedication before PBD and had access to a patient-controlled analgesia pump during the procedure. The pump was set to deliver 0.2 mg of midazolam and 25 micrograms of fentanyl per dose with a 3-minute lockout time. Vital signs, including heart rate and blood pressure, were continuously monitored during the procedure and recorded for comparison with baseline values. Patients completed a 10-point visual analogue pain scale following completion of their procedure.

RESULTS

Patients in the placebo and treatment groups self-administered a mean of 2.0 and 1.85 mg of midazolam, respectively (P = .40), and a mean of 247 and 231 micrograms of fentanyl, respectively (P = .40). On a 10-point pain scale, the mean postprocedure versus preprocedure elevation in pain was 2.1 points in the placebo group versus 1.6 points in the treatment group (P = .60). Overall, the degree of satisfaction with the analgesia was equal in both groups.

CONCLUSION

This study indicates that CPB is not an effective means of providing additional visceral pain relief over and above that which can be accomplished with self-administered intravenous medication for patients who undergo PBD.

Giant pseudoaneurysm of the hepatic artery--CT demonstration. Case report

Noninvasive imaging studies, particularly computed tomography (CT), are the first step in evaluation of patients with suspected hepatic trauma. Iatrogenic injury, accounting for up to one-third of cases, may commonly result in hepatic artery pseudoaneurysm formation. We present a case in which a giant hepatic artery pseudoaneurysm was misinterpreted as an intrahepatic hematoma on sequential CT scans due to the failure to employ dynamic contrast-enhanced scan techniques.

Biliary tract complications following laparoscopic cholecystectomy: imaging and intervention

Radiologic studies and interventional procedures were performed in a series of 13 patients with biliary complications following laparoscopic cholecystectomy, and the results were evaluated. Two categories of ductal complication--minor and major--were found. Minor complications (n = 6) included bile leaks and bilomas; these were managed with percutaneous techniques or simple surgical repair. Major complications (n = 8), consisting primarily of common hepatic duct injuries or strictures, were markedly resistant to percutaneous therapy, requiring major surgical repair (hepaticojejunostomy). Percutaneous treatment of recurrent strictures after primary repair was undertaken in three patients. Diagnostically, radionuclide imaging appeared most helpful in screening for biliary complications of laparoscopic cholecystectomy, supplemented by endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic cholangiography for definitive diagnosis.

Interventional radiology in the biliary tract

Numerous papers have appeared in the past year outlining the expanded role of the radiologist in the treatment of patients with biliary disease, including papers describing palliative treatment of patients with obstructive jaundice due to malignant disease using self-expanding metallic biliary endoprostheses placed percutaneously, extracorporeal shock-wave lithotripsy used to treat patients with gallstones and intrahepatic stones, percutaneous rotational contact biliary lithotripsy, pulsed dye laser biliary lithotripsy, percutaneous biliary intervention via a minicholecystotomy, conventional percutaneous fluoroscopic management of bile duct stones, and percutaneous management of biliary strictures including transluminal biopsy. Percutaneous evaluation and treatment of patients with biliary disease using cholangioscopy as an adjuvant to biliary intervention, radionuclide imaging for improved evaluation of suspected biliary injury after laparoscopic cholecystectomy, and percutaneous treatment of the critically ill patient with cholecystitis or the patient with a perforated gallbladder are also discussed. Diagnostic and therapeutic options available to radiologists for treating patients with biliary disease are summarized.

Interventional radiology in the liver and pancreas

The application of interventional radiographic procedures in the management of patients with liver and pancreatic pathology continues to expand. Percutaneous hepatobiliary interventional procedures that have received considerable attention in the past year include technical refinements of the transjugular intrahepatic portosystemic shunt procedure used in patients with portal hypertension and esophageal varices, transshunt embolotherapy of persistent varices in patients with small-caliber mesocaval shunts, percutaneous and transcatheter embolotherapy of hepatic malignancies in patients with primary or metastatic lesions, and MR angiography in the preoperative evaluation of patients awaiting liver transplantation. Other topics reviewed include percutaneous and transvenous biopsy of orthotopic liver transplants, management of bile leaks and strictures after liver transplantation, use of a biopsy gun and larger gauge needles to obtain specimens for histologic analysis in patients with orthotopic liver and pancreatic transplants, percutaneous treatment of caval and hepatic venous stenoses in patients with Budd-Chiari syndrome using self-expanding stainless steel stents, percutaneous treatment of patients with hepatic Echinococcus granulosus cysts, and percutaneous managements of iatrogenic hepatic vascular injuries. General diagnostic evaluation and interventional procedures highlighted include using selective intra-arterial injection of calcium to localize small insulinomas. Recent review papers describing complications of percutaneous transabdominal fine-needle biopsy are analyzed. The diagnostic and therapeutic options available for treating patients with hepatic and pancreatic diseases are summarized in greater detail.