Hemorrhage risk with transjugular intrahepatic portosystemic shunt (TIPS) insertion at the main portal vein bifurcation with stent grafts

PURPOSE

The purpose of this study was to assess the incidence of major hemorrhage after transjugular intrahepatic portosystemic shunt (TIPS) insertion using a stent graft at the main portal vein bifurcation.

PATIENTS AND METHODS

TIPS insertion using stent grafts was performed in 215 patients due to non-variceal hemorrhage indications. There were 137 men and 78 women, with a mean age of 57 years±10.6 (SD) (range: 19-90 years). Based on retrospective review of portal venograms, TIPS inserted within 5mm from the portal vein bifurcation were considered "bifurcation TIPS", while those inserted 2cm or greater from the bifurcation were considered intrahepatic. Suspicion for acute major periprocedural hemorrhage were categorized as low, moderate, and high, based on the number of signs of hemorrhage.

RESULTS

Of 215 TIPS inserted for purposes other than hemorrhage, the TIPS was inserted at the portal bifurcation in 41 patients (29 men, 12 women; mean age, 55.9±11.7 (SD); range: 26-79 years) and intrahepatic in 62 patients (37 men, 25 women; mean age, 57.6±10.6 (SD), range: 34-82 years), whereas 112 were indeterminate in location. No active extravasations were identified on post-TIPS portal venograms. Suspicion for acute major hemorrhage was moderate or high in 3/41 (7%) of patients in the TIPS bifurcation group compared to 5/62 (8%) in the intrahepatic TIPS group (P>0.99). There were no significant differences in 30-day mortality rates (1/41 [2%] and 3/62 [5%] respectively; P> 0.99). No deaths or interventions were attributed to acute hemorrhage.

CONCLUSION

TIPS insertion at the portal bifurcation with stent grafts did not incur an elevated risk of hemorrhagic complications.

Direct percutaneous endoscopic jejunostomy with small bowel enteroscopy and fluoroscopy

BACKGROUND

Approaches to the creation of a percutaneous jejunostomy (PEJ) include enteroscopy with jejunal transillumination, fluoroscopy with small bowel distension and tract dilation, and jejunal enteral tube placement through a percutaneous endoscopic gastrostomy. Although all have been successful, the combination of enteroscopy and fluoroscopy may improve visualization and the success of PEJ placement. This is a description of such a technique and its successful use in 7 patients.

METHODS

The procedure was performed with the patient under conscious sedation in a manner similar to standard PEG placement. The proximal jejunum was visualized and a standard snare was passed though the enteroscope and was opened. A needle and guidewire were directed percutaneously though the snare by using fluoroscopic guidance. Under direct endoscopic visualization the snare was closed around the guidewire. A standard 20F push-type "gastrostomy" tube was passed over the guidewire and through the mouth and the dome seated in the jejunum. A bumper was passed externally over the tube and tightened at the skin.

RESULTS

PEJ placement was successful in all 7 patients. The average length of the procedure was 40 minutes (range 22-64 minutes). There were no major complications. Mean follow-up was 124 days (range 28-308 days). Feeding tubes remained functional until removal (2), death (1), or surgical removal for an unrelated reason (1). Three tubes are still in use.

CONCLUSIONS

Percutaneous endoscopic jejunostomy tube placement can be performed successfully with enteroscopy and fluoroscopy. This technique is safe and efficient and provides distal enteral nutritional support for patients in whom PEG cannot be used.

Biliary stricture secondary to donor B-cell lymphoma after orthotopic liver transplantation

Biliary complications after orthotopic liver transplantation (OLT) lead to considerable morbidity and occasional mortality after surgery. Bile duct strictures secondary to localized lymphoproliferative disorder of the porta hepatis is rare, with only 12 cases reported in the English literature. Posttransplant lymphoproliferative disorder develops in up to 9% of liver allograft recipients. We describe 2 adult patients who developed Epstein-Barr virus-associated localized B-cell lymphoma of donor-tissue origin confined to the porta hepatis 3 and 5 months after OLT. Both patients were administered cyclosporine (CyA) and prednisone as primary immunosuppression. One patient was administered basiliximab as induction therapy. Neither patient had CyA trough levels greater than 250 ng/mL. Both patients were treated with a hepatojejunostomy, 75% reduction in immunosuppression therapy, and acyclovir. One patient had complete involution of the tumor, and the second patient had an 80% reduction of the tumor at the 2-year follow-up visit. This report illustrates the need to consider localized lymphoma post-OLT as a cause of obstructive jaundice even within the first 6 months after surgery. Aggressive reduction of immunosuppression in conjunction with acyclovir remains a highly effective therapy.

Conversion of indwelling chest port catheters to tunneled central venous catheters

PURPOSE

To determine the safety and efficacy of the conversion of subcutaneous chest wall infusion ports to tunneled central venous catheters.

MATERIALS AND METHODS

During a period of 34 months, 67 patients were referred for conversion of indwelling subcutaneous chest wall ports to tunneled central venous catheters as part of a bone marrow transplant protocol. Six patients were deemed unacceptable for conversion and the remaining 61 underwent successful conversion. All patients had functioning surgically placed single-lumen (n = 50) or double-lumen (n = 11) chest ports, which were removed to maintain the original venous access sites for placement of a tunneled central venous catheter, incorporating the chest wall pocket for tunneling, in 46 patients (75%). A new tunnel was created in the other 15 patients. There were no immediate complications and all patients were followed until catheter removal or patient demise with the catheter in place.

RESULTS

57 of 61 (93%) catheters were used without evidence of infection for 23-164 days (mean, 57 d) after placement. Two (3%) were removed (both at 26 days) because of persistent neutropenic fever without physical signs or laboratory evidence of catheter infection, and two (3%) were removed (at 11 and 77 days) because of proven catheter infection, yielding an overall infection rate of 1.2 per 1,000 catheter days. Two catheters required exchange and two required stripping because of decreased function, resulting in an overall catheter-related complication rate of 2.4 per 1,000 catheter days.

CONCLUSIONS

Indwelling subcutaneous chest wall infusion ports can be safely converted to tunneled central venous catheters, even in an immunocompromised patient population, with a low risk of complications such as infection.

Idiopathic splenic vein stenosis: a cause of gastric variceal hemorrhage

We report the case of a patient with isolated gastric variceal bleeding. Obesity precluded the use of noninvasive means for assessing splenic vein patency. Splenic vein stenosis was diagnosed by transhepatic portal and splenic venography with pressure measurements. A cause for the stenosis could not be found. Splenectomy was used as a curative measure.

Transjugular intrahepatic portosystemic shunts (TIPS): effects of respiratory state and patient position on the measurement of Doppler velocities

OBJECTIVE

The purpose of this prospective study was to examine the effects of patient position and respiratory state on the measurements of Doppler velocities in transjugular intrahepatic portosystemic shunts.

SUBJECTS AND METHODS

Thirty-eight transjugular intrahepatic portosystemic shunts in 34 consecutive patients were studied using Doppler sonography. Peak velocities were measured in the mid shunt with the patient in three positions (supine, sitting upright, and left lateral decubitus) and two respiratory states (deep inspiration and quiet respiration). A mixed linear regression model was used to assess statistically significant differences among the six velocity measurements.

RESULTS

Peak velocities in the mid stent averaged 22 cm/sec greater in quiet respiration than in deep inspiration, which was a significant difference (p < 0.00001). Differences in velocities in the three patient positions were not significant (p = 0.53). Using 90-190 cm/sec as the normal range, the peak velocity shifted from normal to abnormal levels by changing respiratory state in 17 (45%) of 38 studies. Using 60 cm/sec as the lower normal limit, the peak velocity fell below the normal range with inspiration in 10 (26%) of 38 studies. In 12 (32%) of 38 studies, a decline in peak velocity exceeding 50 cm/sec could be induced by inspiration.

CONCLUSION

Peak systolic velocity in transjugular intrahepatic portosystemic shunts is substantially altered by the respiratory state of the patient at the time of the measurement, but not by the patient position. Respiratory state must be taken into account in the interpretation of peak velocity for shunt stenosis.

Incarceration of umbilical hernia following transjugular intrahepatic portosystemic shunt for the treatment of ascites

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for patients with medically refractory ascites. Many patients with refractory ascites have umbilical herniation. Incarceration of umbilical hernia has been reported following diuresis, paracentesis, and peritoneovenous shunting. We report 2 cases of umbilical hernia incarceration following resolution of ascites after TIPS.

Injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay

OBJECTIVE

The purpose of this study was to determine the prevalence of injured aberrant bile ducts in a population with complications after cholecystectomy and to determine whether such injury resulted in significant delay in the diagnosis and treatment of bile duct injuries.

MATERIALS AND METHODS

The cholangiograms of 82 patients who sustained bile duct injury during cholecystectomy were reviewed. Prevalence of aberrant bile duct anatomy in the injured ducts was noted. The time periods from injury to diagnosis and treatment of bile duct leaks in patients with aberrant bile duct anatomy were compared with those in patients with normal anatomy.

RESULTS

Seventeen percent (14/82) of the patients were found to have aberrant bile duct anatomy. Fifteen percent (12/82) were found to have had an aberrant bile duct involved in the injury. Eleven of the patients had an aberrant bile duct leak, and one patient had an aberrant bile duct clipping injury. The time period required for diagnosis and treatment of a leaking aberrant bile duct was significantly longer (p < .005) than that required for a bile leak in an anatomically normal bile duct.

CONCLUSION

Aberrant bile ducts are present in a significant number of patients who sustain bile duct injuries during cholecystectomy. Diagnosis of an aberrant bile duct leak may be delayed because of nonfilling of the bile duct during standard cholangiographic techniques. Careful examination of cholangiograms for nonfilling segments and contrast material injection of biloma drains and T tubes may shorten the time to definitive treatment for this group of patients.

Transjugular intrahepatic portosystemic shunt (TIPS) in patients with refractory ascites: effect on body weight and Child-Pugh score

OBJECTIVE

This study suggests that patients with medically refractory ascites treated with transjugular intrahepatic portosystemic shunt (TIPS) may have improved in overall clinical status.

METHODS

We performed a retrospective study of 35 patients with medically refractory ascites treated with TIPS. Body weight, ascites, and Child-Pugh score were assessed at baseline, at 2 months, and after a mean 8.8-month follow-up interval.

RESULTS

After TIPS, there was significant improvement in Child-Pugh score from 9.7+/-1.5 to 8.2+/-2.3. Ascites completely resolved or improved in 23 of 24 patients (96%) who had long term follow-up. Two months after TIPS, there was a significant decrease in weight of 6.1 kg corresponding to a loss of ascites. Between 2 and 8.8 months, there was a significant mean weight gain of 5.5 kg.

CONCLUSION

This study suggests that patients treated with medically refractory ascites with TIPS may have improvement in overall clinical status, as measured by increase in lean body mass and improvement in Child-Pugh score.

Hereditary hemorrhagic telangiectasia causing high output cardiac failure: treatment with transcatheter embolization

We report a case of hereditary hemorrhagic telangiectasia complicated by high output heart failure caused by intrahepatic arteriovenous malformations. This patient was treated using transcatheter embolization of the intrahepatic arteriovenous malformations with concurrent measurement of cardiac output to monitor progress of the embolization.

Percutaneous cholecystostomy: who responds?

OBJECTIVE

Our purpose was to identify clinical or radiologic features predictive of response to percutaneous cholecystostomy performed for the treatment of acute cholecystitis.

MATERIALS AND METHODS

The clinical records and radiologic images of patients who underwent percutaneous cholecystostomy for suspected acute cholecystitis between January 1987 and July 1994 were retrospectively reviewed. A response to percutaneous cholecystostomy was defined as an improvement in clinical symptoms and signs or reduction in fever and WBC to normal within 72 hr of percutaneous cholecystostomy. The number and type of radiologic investigations were reviewed by two radiologists. The presence of gallstones, gallbladder wall thickening, distention, and pericholecystic fluid was recorded. The clinical and radiologic findings were analyzed for their relationship to response to percutaneous cholecystostomy.

RESULTS

Sixty-one percutaneous cholecystostomies were performed in 37 male and 24 female patients and were technically successful in 59. Thirty-one patients had gallstones, 28 did not. Thirty-one patients were in the intensive care unit, and 15 were ventilated. Complications occurred in six (10%): misplacement of the percutaneous cholecystostomy catheter in the colon (one), exacerbation of sepsis (three), and bile leakage (two). The mortality rate was 2%--one of the patients with septic shock succumbed to a cardiac arrest 3 days after the procedure. Forty-three patients (73%) responded to percutaneous cholecystostomy. Patients with gallstones and symptoms and signs localized to the right upper quadrant of the abdomen were more likely to respond (p = .006). The only individual radiologic feature predictive of a positive response was the presence of pericholecystic fluid in patients with gallstones (p = .03). The presence of all four radiologic findings was also associated with a positive response (p = .039). The results of bile cultures were not predictive of response. Of the 16 nonresponders, six had documented biliary sepsis and cholecystitis.

CONCLUSION

Clinical symptoms and signs referable to the gallbladder, the presence of pericholecystic fluid in patients with gallstones, and the presence of an increasing number of radiologic findings in any one patient are predictive of a positive response to percutaneous cholecystostomy.

Silastic cuffed catheters for hemodialysis vascular access: thrombolytic and mechanical correction of malfunction

Silastic cuffed catheters are assuming a greater role in providing long-term vascular access for hemodialysis patients. However, catheter thrombosis, fibrin sheath formation, and catheter malposition are recurrent problems that reduce extracorporeal flow rates and shorten catheter life. We reviewed 163 consecutive episodes of catheter malfunction that occurred in 121 catheters in 88 patients over a 3.5-year period. Intraluminal instillation of urokinase was successful in reestablishing an extracorporeal flow rate of > or = 300 mL/min in 74% of episodes. The 42 remaining episodes (26%) were radiologically evaluated. Two catheters required replacement for catheter kinking or insufficient catheter length. Two additional catheters were malpositioned; both were successfully repositioned with percutaneous techniques. A fibrin sheath was detected encasing the catheter in 38 instances. The fibrin sheath was successfully stripped from the distal portion of the catheter in 36 of the 38 instances. Using endoluminal thrombolytic therapy and percutaneous mechanical techniques, we have extended the mean survival for catheters intended for permanent vascular access to 12.7 months and have allowed 95% of the catheters inserted for temporary use to reach their use goal. Tunnel tract infection and catheter-mediated bacteremia were the primary reasons for catheter removal.

CT during arterial portography: comparison of injection into the splenic versus superior mesenteric artery

PURPOSE

To determine whether the diagnostic quality of computed tomography (CT) during arterial portography (CTAP) performed via the splenic artery (SA) is better than that performed via the superior mesenteric artery (SMA).

MATERIALS AND METHODS

The authors evaluated CTAP images obtained in 98 patients from 1991 to 1994; 47 examinations were performed via the SA and 51 were performed via the SMA. Images were reviewed, by consensus, by three radiologists blinded to catheter location. Hepatic enhancement was quantitatively assessed in 53 patients (31 in the SA group, 22 in the SMA group).

RESULTS

The numbers of low-attenuation non-tumor-related perfusion defects (19 in the SA group, 17 in the SMA group), high-attenuation non-tumor-related perfusion defects (six in the SA group, six in the SMA group), diffuse mottled perfusion abnormalities (six in the SA group, five in the SMA group), and portal venous flow defects (20 in the SA group, 20 in the SMA group) were similar in both groups (P > .05). Peak hepatic enhancement was similar in both groups (SMA group = 111 HU; SA group = 112 HU) (P > .05).

CONCLUSION

There is no difference in quality between CTAP performed via the SA versus CTAP performed via the SMA.

Percutaneous transhepatic liver biopsy with tract embolization

PURPOSE

To determine the success and safety of percutaneous transhepatic liver biopsy with tract embolization (PBTE) in patients at risk for standard transhepatic biopsy.

MATERIALS AND METHODS

Eighty biopsies were performed in 76 patients with diffuse liver disease: 57 biopsies in patients with coagulopathy (11 of whom also had ascites), 16 in patients with mild coagulopathy and ascites, and seven in patients with ascites only. Biopsy was performed with a cutting needle placed through a 10-cm vascular sheath. Gelatin sponge was the embolization agent.

RESULTS

All 80 biopsy specimens (100%) were adequate for histopathologic diagnosis. Six complications (8%) resulted from the procedure: one bleeding complication due to incomplete tract embolization, two bowel injuries, one hemobilia, one intercostal artery injury, and one posterior liver capsule perforation with bleeding. All complications occurred in patients with coagulopathy and with the operator's first or second PBTE.

CONCLUSION

PBTE produces excellent diagnostic specimens. The high complication rate empirically appears to be related to the degree of coagulopathy and operator experience.

Prospective evaluation of pulmonary artery pressures during pulmonary angiography performed with low-osmolar nonionic contrast media

PURPOSE

To determine the effects of pulmonary angiography performed with low-osmolar, nonionic contrast media on pulmonary artery pressures.

PATIENTS AND METHODS

In a prospective, uncontrolled clinical trial, pulmonary artery pressures (systolic, diastolic, mean) of 116 patients referred for pulmonary angiography were recorded before and 1 and 5 minutes after injection of contrast material.

RESULTS

There was a statistically significant rise in systolic, diastolic, and mean pulmonary artery pressure at 1 minute (4.6, 3.4, 4.1 mm Hg, respectively) and 5 minutes (3.8, 2.7, 3.4 mm Hg, respectively) after the initial contrast material injection (P < .05). Increases were smaller with additional injections. Systolic pressure changes at 1 and 5 minutes after the first injection were linearly dependent on the volume of contrast material injected (P < .05). There was no statistically significant difference in the increase in pulmonary artery pressure between patients with pulmonary embolus or pulmonary arterial hypertension and those without.

CONCLUSION

There is a small but statistically significant rise in pulmonary artery pressure after injection of low-osmolar, nonionic contrast material for pulmonary angiography; it is unlikely to be of clinical significance.

Pulmonary angiography performed with iopamidol: complications in 1,434 patients

PURPOSE

To evaluate the safety of pulmonary angiography performed with iopamidol compared with pulmonary angiography performed with ionic contrast media.

MATERIALS AND METHODS

The data in 1,434 patients who underwent pulmonary angiography with iopamidol 76% were retrospectively reviewed. Complications that occurred within 48 hours were identified with review of hospital charts and/or computer records.

RESULTS

Pulmonary arterial hypertension was present in 402 patients and was severe in 99. Pulmonary embolus was diagnosed in 357 patients (24.9%). Major complications occurred in four patients (0.3%). Respiratory insufficiency occurred in two of these patients. Catheterization was not completed in two patients due to catheter-induced cardiac arrhythmia that was refractory to treatment. No procedure-related deaths occurred. During the periprocedural period, eight patients required intubation and 10 patients died; all patients previously were critically ill.

CONCLUSION

Pulmonary angiography is a safe procedure, and the margin of safety is enhanced by the use of iopamidol.

Non-operative management of a common bile duct injury sustained during cholecystectomy in a morbidly obese patient. (Non-operative repair of CBD injury)

A 29 year old morbidly obese patient suffered injury to his common bile duct during cholecystectomy. Subsequent access to the biliary tree was obtained by using a long heavy gauge needle after first opacifying the system with contrast injection through a nasobiliary tube. It is now twenty six months after initial percutaneous biliary drainage placement and eighteen months after removal of all biliary access. The patient is asymptomatic and has normal liver function tests. This technique can be useful in morbidly obese patients who are at increased risk from surgical repair of biliary duct injuries.

Superselective gelfoam embolotherapy using a highly visible small caliber catheter

A new, highly visible and flexible 3F catheter has become available for superselective catheterization and embolization. We describe the first reported series of cases in which this catheter was used for superselective Gelfoam embolization of bleeding visceral arteries.