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Aaberg MT, Marroquin CE, Kokabi N, Bhave AD, Shields JT, Majdalany BS. Endovascular Treatment of Venous Outflow and Portal Venous Complications After Liver Transplantation. Tech Vasc Interv Radiol 2023; 26:100924. [PMID: 38123283 DOI: 10.1016/j.tvir.2023.100924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Liver transplantation continues to rapidly evolve, and in 2020, 8906 orthotopic liver transplants were performed in the United States. As a technically complex surgery with multiple vascular anastomoses, stenosis and thrombosis of the venous anastomoses are among the recognized vascular complications. While rare, venous complications may be challenging to manage and can threaten the graft and the patient. In the last 20 years, endovascular approaches have been increasingly utilized to treat post-transplant venous complications. Herein, the evaluation and interventional treatment of post-transplant venous outflow complications, portal vein stenosis, portal vein thrombosis, and recurrent portal hypertension with transjugular intrahepatic portosystemic shunt (TIPS) are reviewed.
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Affiliation(s)
| | - Carlos E Marroquin
- Division of Transplant Surgery and Immunology, Department of Surgery, University of Vermont Medical Center, Burlington, VT
| | - Nima Kokabi
- Division of Interventional Radiology, Department of Radiology, University of North Carolina, Chapel Hill, NC
| | - Anant D Bhave
- Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, VT
| | - Joseph T Shields
- Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, VT
| | - Bill S Majdalany
- Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, VT.
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Agostini C, Buccianti S, Risaliti M, Fortuna L, Tirloni L, Tucci R, Bartolini I, Grazi GL. Complications in Post-Liver Transplant Patients. J Clin Med 2023; 12:6173. [PMID: 37834818 PMCID: PMC10573382 DOI: 10.3390/jcm12196173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/16/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Liver transplantation (LT) is the treatment of choice for liver failure and selected cases of malignancies. Transplantation activity has increased over the years, and indications for LT have been widened, leading to organ shortage. To face this condition, a high selection of recipients with prioritizing systems and an enlargement of the donor pool were necessary. Several authors published their case series reporting the results obtained with the use of marginal donors, which seem to have progressively improved over the years. The introduction of in situ and ex situ machine perfusion, although still strongly debated, and better knowledge and treatment of the complications may have a role in achieving better results. With longer survival rates, a significant number of patients will suffer from long-term complications. An extensive review of the literature concerning short- and long-term outcomes is reported trying to highlight the most recent findings. The heterogeneity of the behaviors within the different centers is evident, leading to a difficult comparison of the results and making explicit the need to obtain more consent from experts.
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Affiliation(s)
| | | | | | | | | | | | - Ilenia Bartolini
- Department of Experimental and Clinical Medicine, AOU Careggi, 50134 Florence, Italy; (C.A.); (S.B.); (M.R.); (L.F.); (L.T.); (R.T.); (G.L.G.)
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3
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Complete Endovascular Stenting of the Inferior Vena Cava Following Its Twisting After Liver Transplantation. Transplantation 2023; 107:e70-e71. [PMID: 36696523 DOI: 10.1097/tp.0000000000004432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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4
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Vayani OR, Patel MJ, Van Ha T, Leef JA, Lorenz JM, Millis M, Ahmed O. Endovascular thrombectomy and repair of suprarenal inferior vena cava thrombosis: A case series. Vascular 2022; 31:579-584. [PMID: 35034526 DOI: 10.1177/17085381211068233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The objective of this study is to document the combined use of catheter-based thrombectomy/thrombolysis with endovascular repair of high-risk segments of the inferior vena cava in the setting of iatrogenic and traumatic injuries. While the use of endovascular techniques to treat caval thrombosis is well documented and often preferred due to its minimally invasive nature, there is still little literature that focuses on the nuances related to injury of high mortality areas of the IVC as a result of major trauma, transplant, and other surgical interventions. METHODS An IRB-approved retrospective review of all patients undergoing IVC thrombectomy was performed at a single tertiary care academic center between January 2018 and July 2021. Cases were subsequently selected based on those who underwent primary mechanical thrombectomy followed by endovascular stenting (or angioplasty). Among this cohort, four patients who underwent this procedure in the context of iatrogenic and traumatic injuries were included. RESULTS All four patients undergoing primary mechanical thrombectomy followed by endovascular stenting (or angioplasty) due to IVC thrombus and/or stenosis were technically successful with immediate positive clinical outcomes. CONCLUSIONS Mechanical thrombectomy in conjunction with IVC recanalization via stenting may be a useful intervention with promising technical success and positive clinical outcomes for occlusive thrombosis and IVC stenosis.
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Affiliation(s)
- Omar R Vayani
- Pritzker School of Medicine, 12246The University of Chicago, Chicago, IL, USA
| | - Manish J Patel
- 12247University of Illinois College of Medicine, Chicago, IL, USA
| | - Thuong Van Ha
- Section of Vascular and Interventional Radiology, 21727University of Chicago Medical Center, Chicago, IL, USA
| | - Jeffrey A Leef
- Section of Vascular and Interventional Radiology, 21727University of Chicago Medical Center, Chicago, IL, USA
| | - Jonathan M Lorenz
- Section of Vascular and Interventional Radiology, 21727University of Chicago Medical Center, Chicago, IL, USA
| | - Michael Millis
- Section of Transplant Surgery, 2462University of Chicago Medical Center, Chicago, IL, USA
| | - Osman Ahmed
- Section of Vascular and Interventional Radiology, 21727University of Chicago Medical Center, Chicago, IL, USA
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L McDevitt J, T Goldman D, J Bundy J, N Hage A, K Jairath N, J Gemmete J, N Srinivasa R, Chick JFB. Gianturco Z-stent placement for the treatment of chronic central venous occlusive disease: implantation of 208 stents in 137 symptomatic patients. ACTA ACUST UNITED AC 2021; 27:72-78. [PMID: 33090095 DOI: 10.5152/dir.2020.19282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE To report the technical successes, adverse events, and long-term stent patency rates of Gianturco Z-stents for management of chronic central venous occlusive disease. METHODS Overall, 137 patients, with mean age 48.6±16.1 years (range, 16-89 years), underwent placement of Gianturco Z-stents for chronic central venous occlusions. Presenting symptoms included lower extremity edema (n=66, 48.2%), superior vena cava syndrome (n=30, 21.9%), unilateral upper extremity swelling (n=20, 14.6%), hemodialysis fistula or catheter dysfunction (n=11, 8.0%), ascites (n=8, 5.8%), and both ascites and lower extremity edema (n=2, 1.5%). Most common etiologies of central venous occlusion were prior central venous access placement (n=58, 42.3%), extrinsic compression (n=29, 21.2%), and post-surgical anastomotic stenosis (n=27, 19.7%). Number of stents placed, stent implantation location, stent sizes, technical successes, adverse events, need for re-intervention, follow-up evaluation, stent patencies, and mortality were recorded. Technical success was defined as recanalization and stent reconstruction with restoration of in-line venous flow. Adverse events were defined by the Society of Interventional Radiology Adverse Event Classification criteria. Primary and primary-assisted stent patencies were analyzed using Kaplan-Meier analysis. RESULTS In total, 208 Z-stents were placed. The three most common placement sites were the inferior vena cava (n=124, 59.6%), superior vena cava (n=44, 21.2%), and brachiocephalic veins (n=27, 13.0%). Technical success was achieved in 133 patients (97.1%). There were two (1.5%) severe adverse events (two cases of stent migration to the right atrium), one (0.7%) moderate adverse event, and one (0.7%) mild adverse event. Mean follow-up was 43.6±52.7 months. Estimated 1-, 3-, and 5-year primary stent patency was 84.2%, 84.2%, and 82.1%, respectively. Estimated 1-, 3-, and 5-year primary-assisted patency was 92.3%, 89.6%, and 89.6%, respectively. The 30- and 60- day mortality rates were 2.9% (n=4) and 5.1% (n=7), none of which were directly attributable to Z-stent placement. CONCLUSION Gianturco Z-stent placement is safe and effective for the treatment for chronic central venous occlusive disease with durable short- and long-term patencies.
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Affiliation(s)
- Joseph L McDevitt
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA;Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Daryl T Goldman
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA;Department of Radiology, Icahn School of Medicine at Mount Sinai, Gustave L Levy Place, New York, USA
| | - Jacob J Bundy
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA;Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Anthony N Hage
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA;Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Neil K Jairath
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Joseph J Gemmete
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Ravi N Srinivasa
- Department of Interventional Radiology, University of California Los Angeles, Los Angeles, California, USA
| | - Jeffrey Forris Beecham Chick
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Washington Medical Center, Seattle, Washington, USA
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Ko GY, Sung KB, Gwon DI. The Application of Interventional Radiology in Living-Donor Liver Transplantation. Korean J Radiol 2021; 22:1110-1123. [PMID: 33739630 PMCID: PMC8236365 DOI: 10.3348/kjr.2020.0718] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/05/2020] [Accepted: 11/14/2020] [Indexed: 01/10/2023] Open
Abstract
Owing to improvements in surgical techniques and medical care, living-donor liver transplantation has become an established treatment modality in patients with end-stage liver disease. However, various vascular or non-vascular complications may occur during or after transplantation. Herein, we review how interventional radiologic techniques can be used to treat these complications.
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Affiliation(s)
- Gi Young Ko
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Kyu Bo Sung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Protein-losing Enteropathy Due to Inferior Vena Cava Stenosis in a Liver Transplant Recipient. Transplant Direct 2021; 7:e660. [PMID: 33521249 PMCID: PMC7838003 DOI: 10.1097/txd.0000000000001117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/13/2020] [Accepted: 11/18/2020] [Indexed: 11/26/2022] Open
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Morochnik S, Niemeyer MM, Lipnik AJ, Gaba RC. Immediate postoperative inferior vena cava stenting to improve hepatic venous outflow following orthotopic liver transplantation. Radiol Case Rep 2020; 16:224-229. [PMID: 33304431 PMCID: PMC7708766 DOI: 10.1016/j.radcr.2020.11.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/16/2020] [Indexed: 11/25/2022] Open
Abstract
Orthotopic liver transplantation can be a surgically complex undertaking, with hepatic venous outflow obstruction occurring at a rate of 1%-6% due to inferior vena cava (IVC) torsion, compression, or anastomotic stenosis. In this report, we present 2 cases of immediate postoperative hepatic venous outflow obstruction in the setting of Budd-Chiari syndrome successfully treated with immediate IVC stenting. Although IVC stenting has been reported for management of long-term IVC anastomotic stenosis after orthotopic liver transplantation, use of stenting to address immediate postoperative caval outflow obstruction is less commonly described. We describe the potential utility of immediate stenting to improve outflow from the transplanted liver and highlight the value of this approach in addressing early postsurgical IVC pathology
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Affiliation(s)
| | - Matthew M Niemeyer
- Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, 1740 West Taylor Street MC 931, Chicago, IL 60612, USA
| | - Andrew J Lipnik
- Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, 1740 West Taylor Street MC 931, Chicago, IL 60612, USA
| | - Ron C Gaba
- Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, 1740 West Taylor Street MC 931, Chicago, IL 60612, USA
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Gundlach JP, Günther R, Both M, Trentmann J, Schäfer JP, Cremer JT, Röcken C, Becker T, Braun F, Bernsmeier A. Inferior Vena Cava Constriction After Liver Transplantation Is a Severe Complication Requiring Individually Adapted Treatment: Report of a Single-Center Experience. Ann Transplant 2020; 25:e925194. [PMID: 32747619 PMCID: PMC7427346 DOI: 10.12659/aot.925194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Reports on vena cava occlusion after liver transplantation (LT) are rare, but this finding represents a severe complication in the early postoperative period. In the context of the complex presentation of a patient after LT, symptoms are often misinterpreted and can be subtle. Material/Methods In our cohort of 138 LTs performed between 2014 and 2017 at our University’s Transplantation Department, 117 transplantations were valid for further analysis after exclusion of pediatric transplantations and transplants with primary non-function grafts. In 101 cases (73%), patients received a deceased-donor full-size organ. Living-donor LT was performed in 8 patients (6.4%) and 8 patients (6.4%) received a split graft. We report on 6 patients who had inferior vena cava (IVC) occlusion and summarize the treatment choices. Results In our series, patients with positive findings (age 38–70 years) received an orthotopic full-size deceased-donor graft with end-to-end IVC anastomosis. In the subsequent period, imaging revealing IVC occlusion was done on a follow-up basis (n=2), due to dyspnea (n=1), and for progressive ascites (n=2). In 3 cases, a thrombus was found. We give detailed information on our treatment options from interventional treatment to transcardial thrombus removal and anastomosis augmentation. Conclusions IVC constriction and subsequent thrombosis are severe complications after LT that require individually adapted treatment in specialized centers. Since patients often present with subclinical symptoms, vascular diagnosis should be performed early to detect caval anastomosis pathologies. Despite regular ultrasonography, we favor CT and cavography for subsequent quantification. We also review the literature on IVC occlusion after LT.
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Affiliation(s)
- Jan-Paul Gundlach
- Department of General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Rainer Günther
- Department of Internal Medicine I, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Marcus Both
- Institute of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Jens Trentmann
- Institute of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Jost Philipp Schäfer
- Institute of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Jochen T Cremer
- Department of Cardiovascular Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Christoph Röcken
- Department of Pathology, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Thomas Becker
- Department of General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Felix Braun
- Department of General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Alexander Bernsmeier
- Department of General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
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Intravascular Thrombolysis Followed by Stenting as Management of Retrohepatic Inferior Vena Caval Thrombosis due to a Twist in the Inferior Vena Cava after Deceased Donor Liver Transplant. Case Rep Surg 2019; 2019:7292974. [PMID: 31316858 PMCID: PMC6604350 DOI: 10.1155/2019/7292974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 02/19/2019] [Indexed: 11/17/2022] Open
Abstract
Inferior vena cava (IVC) occlusion due to acute thrombosis is a rare but important vascular complication after deceased donor liver transplantation (DDLT) that has been reported to occur up to 2% of recipients in a posttransplant period. This may be caused by direct instrumentation of the IVC stenosis at the anastomotic site, haematoma, and rarely by a twist in the retrohepatic IVC. The location of the thrombus, the timing after the surgery, and associated hemodynamic disturbances define the outcome of the patient. Without prompt diagnosis and timely intervention, the outcome after IVC thrombosis is usually dismal. Herein, we report a rare case of near-complete occlusion of the IVC secondary to intracaval thrombosis after DDLT associated with twisting of the IVC at the suprahepatic anastomosis which was successfully managed by intravascular thrombolysis and stenting.
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Thornburg B, Katariya N, Riaz A, Desai K, Hickey R, Lewandowski R, Salem R. Interventional radiology in the management of the liver transplant patient. Liver Transpl 2017; 23:1328-1341. [PMID: 28741309 DOI: 10.1002/lt.24828] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 02/06/2023]
Abstract
Liver transplantation (LT) is commonly used to treat patients with end-stage liver disease. The evolution of surgical techniques, endovascular methods, and medical care has led to a progressive decrease in posttransplant morbidity and mortality. Despite these improvements, a multidisciplinary approach to each patient remains essential as the early diagnosis and treatment of the complications of transplantation influence graft and patient survival. The critical role of interventional radiology in the collaborative approach to the care of the LT patient will be reviewed. Liver Transplantation 23 1328-1341 2017 AASLD.
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Affiliation(s)
- Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Nitin Katariya
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Kush Desai
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Ryan Hickey
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Robert Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL.,Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL
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Jang JY, Jeon UB, Park JH, Kim TU, Lee JW, Chu CW, Ryu JH. Efficacy and patency of primary stenting for hepatic venous outflow obstruction after living donor liver transplantation. Acta Radiol 2017; 58:34-40. [PMID: 27012279 DOI: 10.1177/0284185116637247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 02/07/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hepatic venous outflow is important for graft survival in living donor liver transplantation (LDLT). If hepatic venous outflow obstruction occurs, hepatic vein stenting is considered to restore the patency. PURPOSE To retrospectively evaluate the efficacy and patency of primary hepatic vein stenting for hepatic venous outflow obstruction (HVOO) after LDLT. MATERIAL AND METHODS Percutaneous interventions, including hepatic vein stent placement with or without balloon angioplasty, were performed in 21 patients who had undergone LDLT and had HVOO confirmed through hepatic venography or manometry, including the patients who had a structural abnormality. Two stents each were inserted in four patients; therefore, the total number of treated anastomoses was 25. Technical success, patency rates, and pressure gradients between hepatic veins and the right atrium were evaluated in 19 patients each. RESULTS Technical success was achieved in 25 of 26 vessels (96%). The mean interval between operation and stenting was 43 days. After the procedure, the follow-up period was a mean 530 days. The mean pressure gradient decreased from 8.5 mmHg to 2.1 mmHg after treatment (P < 0.01). The patency rates of the 25 vessels were 80% at 1, 2, and 3 years after stent placement. However, middle hepatic vein stenting revealed a low patency rate (all were 36%). Three of seven stents (43%) in the middle hepatic vein occluded during follow-up. CONCLUSION Percutaneous primary hepatic vein stent replacement is an effective treatment for HVOO after LDLT.
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Affiliation(s)
- Joo Yeon Jang
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Ung Bae Jeon
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Jung Hwan Park
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Tae Un Kim
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Jun Woo Lee
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Chong Woo Chu
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Je Ho Ryu
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
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Treatment of Inferior Vena Cava Obstruction Following Pediatric Liver Transplantation: Novel Use of a Customized Endovascular Stent. J Pediatr 2017; 180:256-260. [PMID: 27793336 DOI: 10.1016/j.jpeds.2016.09.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 08/18/2016] [Accepted: 09/19/2016] [Indexed: 12/16/2022]
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Chun JM, Ha H, Choi YY, Kwon HJ, Kim SG, Hwang YJ, Ryeom H, Han YS. Late Hepatic Venous Outflow Obstruction Following Inferior Vena Cava Stenting in Patient with Deceased Donor Liver Transplantation Using Modified Piggyback Technique. KOREAN JOURNAL OF TRANSPLANTATION 2016. [DOI: 10.4285/jkstn.2016.30.2.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jae Min Chun
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Heontak Ha
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Young Yeon Choi
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyung Jun Kwon
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sang Geol Kim
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yoon Jin Hwang
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hunkyu Ryeom
- Department of Radiology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Young Seok Han
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
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Ingraham CR, Montenovo M. Interventional and Surgical Techniques in Solid Organ Transplantation. Radiol Clin North Am 2016; 54:267-80. [DOI: 10.1016/j.rcl.2015.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Fujimori M, Yamakado K, Takaki H, Nakatsuka A, Uraki J, Yamanaka T, Hasegawa T, Sugino Y, Nakajima K, Matsushita N, Mizuno S, Sakuma H, Isaji S. Long-Term Results of Stent Placement in Patients with Outflow Block After Living-Donor-Liver Transplantation. Cardiovasc Intervent Radiol 2015; 39:566-74. [DOI: 10.1007/s00270-015-1210-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 09/12/2015] [Indexed: 12/14/2022]
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Khorsandi SE, Athale A, Vilca-Melendez H, Jassem W, Prachalias A, Srinivasan P, Rela M, Heaton N. Presentation, diagnosis, and management of early hepatic venous outflow complications in whole cadaveric liver transplant. Liver Transpl 2015; 21:914-21. [PMID: 25907399 DOI: 10.1002/lt.24154] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 03/30/2015] [Accepted: 04/11/2015] [Indexed: 02/07/2023]
Abstract
Early hepatic venous outflow obstruction (HVOO) can be a devastating complication leading to graft loss after liver transplantation (LT). A retrospective study on 777 adult LT recipients over a 5-year period (August 2007 to August 2012) was undertaken to determine the incidence of early HVOO presenting within 3 months of transplant, its clinical features and management, and potential technical risk factors related to the implanting technique. Cases of early HVOO were screened for by identifying recipients with problematic ascites within 3 months of transplant. Definitive diagnosis for HVOO was based on a wedge pressure of >12 mm Hg. Considering only whole livers, the incidence of early problematic ascites was 3% (20/695) of which more than one-third (35%, 7/20) were then confirmed to have HVOO. Overall, the incidence of early HVOO was 1% (7/695). Two hepatic veins (HVs) with extension piggybacks (PBs; n = 423) were the dominant implanting technique in the time period of study rather than the 3 HV PB (n = 182) and caval replacement techniques (n = 82). Considering the implantation technique, all cases of HVOO occurred after 2 HVs when extension PBs had been used with an incidence of 1.7% (7/423). Institutionally, early HVOO was mainly managed surgically by either cavoplasty within a month of transplant (n = 4) or retransplant (n = 1), and the remainder (n = 2) were medically managed with diuretics. In conclusion, early HVOO is rare, and there is no evidence from this study that a given implantation technique is at a higher risk of developing HVOO (2 HV with extension versus 3 HV and caval replacement; P = 0.11). However, early revisional surgery for HVOO can preserve graft function with retransplantation being reserved for when surgical cavoplasty or radiological stenting is technically not possible.
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Affiliation(s)
| | - Anuja Athale
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | | | - Wayel Jassem
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Andreas Prachalias
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Parthi Srinivasan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Mohamed Rela
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
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Parvinian A, Gaba RC. Sequential venoplasty for treatment of inferior vena cava stenosis following liver transplant. J Clin Imaging Sci 2014; 4:50. [PMID: 25337436 PMCID: PMC4204234 DOI: 10.4103/2156-7514.141557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 08/15/2014] [Indexed: 01/20/2023] Open
Abstract
Obstruction of the inferior vena cava (IVC) is a rare complication of liver transplantation with significant consequences including intractable ascites and hepatic dysfunction. Although venoplasty and stenting are effective in many cases, patients who fail first-line treatment may require surgical intervention or re-transplantation. Scheduled sequential balloon dilation, an approach frequently used to treat fibrotic, benign biliary strictures, but less commonly vascular lesions, may avert the need for such high-risk alternatives while achieving favorable clinical and angiographic response. Herein, we report the case of a 36-year-old woman with transplant-related, initially angioplasty-resistant IVC stenosis that was successfully treated with sequential balloon dilation.
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Affiliation(s)
- Ahmad Parvinian
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Ron Charles Gaba
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
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Inferior Vena Cava Torsion and Stenosis Complicated by Compressive Pericaval Regional Ascites following Orthotopic Liver Transplantation. Case Rep Radiol 2014; 2013:576092. [PMID: 24386585 PMCID: PMC3872416 DOI: 10.1155/2013/576092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 11/06/2013] [Indexed: 11/18/2022] Open
Abstract
Inferior vena cava (IVC) stenosis and torsion are well-described rare complications following orthotopic liver transplantation (OLT). We present a case of inferior vena cava intermittent torsion and stenosis complicated by compressive regional ascites. To the best of our knowledge, this is the second case of post-OLT regional ascites related compressive IVC stenosis reported and the first reported case of torsion complicated by regional ascites compression.
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Ferro C, Andorno E, Guastavino A, Rossi UG, Seitun S, Bovio G, Valente U. Endovascular treatment with primary stenting of inferior cava vein torsion following orthotopic liver transplantation with modified piggyback technique. Radiol Med 2013; 119:183-8. [PMID: 24356944 DOI: 10.1007/s11547-013-0325-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 10/02/2012] [Indexed: 12/29/2022]
Abstract
PURPOSE This study was undertaken to evaluate primary stenting in patients with inferior vena cava torsion after orthotopic liver transplantation performed with modified piggyback technique. MATERIALS AND METHODS From November 2003 to October 2010, six patients developed clinical, laboratory and imaging findings suggestive of caval stenosis, after a mean period of 21 days from an orthotopic liver transplantation performed with modified piggyback technique. Vena cavography showed stenosis due to torsion of the inferior vena cava at the anastomoses and a significant caval venous pressure gradient. All patients were treated with primary stenting followed by in-stent angioplasty in three cases. RESULTS In all patients, the stents were successfully positioned at the caval anastomosis and the venous gradient pressure fell from a mean value of 10 to 2 mmHg. Signs and symptoms resolved in all six patients. One patient died 3 months after stent placement due to biliary complications. No evidence of recurrence or complications was noted during the follow-up (mean 49 months). CONCLUSIONS Primary stenting of inferior vena cava stenosis due to torsion of the anastomoses in patients receiving orthotopic liver transplantation with modified piggyback technique is a safe, effective and durable treatment.
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Affiliation(s)
- Carlo Ferro
- Dipartimento di Radiologia e Radiologia Interventistica, IRCCS Azienda Ospedaliera ed Universitaria San Martino, IST-Istituto Nazionale per la Ricerca sul Cancro, Monoblocco 1-Fondi, Largo Rosanna Benzi 10, 16132, Genoa, Italy,
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Huber TJ, Hammer S, Loss M, Müller-Wille R, Schreyer AG, Stroszczynski C, Wohlgemuth WA, Uller W. Primary Stent Angioplasty of the Inferior Vena Cava After Liver Transplantation and Liver Resection. Cardiovasc Intervent Radiol 2013; 37:949-57. [DOI: 10.1007/s00270-013-0745-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 08/27/2013] [Indexed: 11/30/2022]
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Lorenz JM, van Beek D, Funaki B, Van Ha TG, Zangan S, Navuluri R, Leef JA. Long-term outcomes of percutaneous venoplasty and Gianturco stent placement to treat obstruction of the inferior vena cava complicating liver transplantation. Cardiovasc Intervent Radiol 2013; 37:114-24. [PMID: 23665862 DOI: 10.1007/s00270-013-0643-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 04/08/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE Evaluation of long-term outcomes of venoplasty and Gianturco stents to treat inferior vena cava (IVC) obstruction after liver transplantation. METHODS We retrospectively analyzed records from 33 consecutive adult patients referred with the intent to treat suspected IVC obstruction after liver transplantation. Treatment was performed for occlusion or stenosis with a gradient exceeding 3 mmHg. The primary treatment was venoplasty and, if refractory, Gianturco stent placement. Recurrence prompted repeat venoplasty or stent placement. RESULTS Of the 33 patients, 25 (aged 46.9 ± 12.2 years) required treatment at a mean of 2.3 years (14 days to 20.3 years) after transplantation. For technically successful cases, primary treatment was venoplasty alone (14) or with stent placement (10). Technical success was 96 % (24 of 25) reflecting failure to cross one occlusion. Clinical success was 88 % (22 of 25) reflecting the technical failure and two that died of unrelated complications within 5 weeks. Cumulative primary patencies were 57.1 % at 6 months (n = 21) and 51.4 % at 1 (n = 10), 3 (n = 7), 5 (n = 6), and 7 (n = 5) years. Cumulative primary assisted patency was 95.2 % at 6 months (n = 21) and at 1 (n = 15), 3 (n = 9), 5 (n = 8), and 7 (n = 8) years. The 17 patients stented for refractory (n = 10) or recurrent (n = 7) stenosis had cumulative primary and primary assisted patencies of 86.0 and 100 %, respectively, from 6 months (n = 14) to 7 years (n = 3). No major complications occurred; one fractured stent was observed after 11.6 years. CONCLUSION For IVC obstruction following liver transplantation, excellent long-term outcomes can be achieved by venoplasty and Gianturco stent placement.
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Affiliation(s)
- Jonathan M Lorenz
- University of Chicago, 5841 S Maryland Ave., MC2026, Chicago, IL, 60637, USA,
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24
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Aubuchon J, Maynard E, Lakshminarasimhachar A, Chapman W, Kangrga I. Intraoperative transesophageal echocardiography reveals thrombotic stenosis of inferior vena cava during orthotopic liver transplantation. Liver Transpl 2013; 19:232-4. [PMID: 23172844 DOI: 10.1002/lt.23576] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Accepted: 11/15/2012] [Indexed: 02/07/2023]
Affiliation(s)
- Jacob Aubuchon
- Department of Anesthesiology; Washington University School of Medicine; St. Louis; MO
| | - Erin Maynard
- Department of Surgery; Washington University School of Medicine; St. Louis; MO
| | | | - William Chapman
- Department of Surgery; Washington University School of Medicine; St. Louis; MO
| | - Ivan Kangrga
- Department of Anesthesiology; Washington University School of Medicine; St. Louis; MO
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Campsen J, Ray C, Zimmerman M, Mandell MS, Kaplan M, Kam I. Diagnosis and correction of hepatic vena caval obstruction following liver transplantation. INDIAN JOURNAL OF TRANSPLANTATION 2012. [DOI: 10.1016/s2212-0017(12)60108-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Roberts JH, Mazzariol FS, Frank SJ, Oh SK, Koenigsberg M, Stein MW. Multimodality imaging of normal hepatic transplant vasculature and graft vascular complications. J Clin Imaging Sci 2011; 1:50. [PMID: 22184543 PMCID: PMC3237000 DOI: 10.4103/2156-7514.86665] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Accepted: 09/29/2011] [Indexed: 12/31/2022] Open
Abstract
Orthotopic liver transplantation is an important treatment option for patients with end-stage liver disease. Advances in surgical technique, along with improvements in organ preservation and immunosuppression have improved patient outcomes. Post-operative complications, however, can limit this success. Ultrasound is the primary imaging modality for evaluation of hepatic transplants, providing real-time information about vascular flow in the graft. Graft vascular complications are not uncommon, and their prompt recognition is crucial to allow for timely graft salvage. A multimodality approach including CT angiography, MRI, or conventional angiography may be necessary in cases of complex transplant vascular anatomy or when sonography and Doppler are inconclusive to diagnose the etiologies of these complications. The purpose of this article is to familiarize radiologists with the normal post-transplant vascular anatomy and the imaging appearances of the major vascular complications that may occur within the hepatic artery, portal vein, and venous outflow tract, with an emphasis on ultrasound.
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Affiliation(s)
- Jeffrey H Roberts
- Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, 111 E. 210 St., Bronx, NY 10467, USA
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27
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Affiliation(s)
- Brian Funaki
- Associate Professor and Section Chief, Section of Vascular and Interventional Radiology, and Section of Abdominal Imaging, University of Chicago Hospitals, Chicago, Illinois
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28
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Abstract
Vascular complications (stenosis or thrombosis of the hepatic artery, portal vein or hepatic vein) are a relatively common occurrence following liver transplantation. Routine screening with ultrasound is critical to early detection of these complications. Careful application of standard interventional techniques (diagnostic catheter angiography, balloon angioplasty with selective stenting) may be used to confirm the ultrasound findings, treat the underlying lesions, and contribute to long-term graft survival.
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Affiliation(s)
- James C Andrews
- Division of Vascular and Interventional Radiology, Department of Radiology, Mayo Clinic, Rochester, Minnesota
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29
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Ikeda O, Tamura Y, Nakasone Y, Yamashita Y, Okajima H, Asonuma K, Inomata Y. Percutaneous transluminal venoplasty after venous pressure measurement in patients with hepatic venous outflow obstruction after living donor liver transplantation. Jpn J Radiol 2010; 28:520-6. [PMID: 20799017 DOI: 10.1007/s11604-010-0463-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Accepted: 05/10/2010] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to evaluate retrospectively the outcome of percutaneous transluminal venoplasty (PTV) after venous pressure measurement in patients with hepatic venous outflow obstruction following living donor liver transplantation (LDLT). MATERIALS AND METHODS We studied 24 consecutive patients suspected of having hepatic venous outflow obstruction after LDLT. Pressure gradients were measured proximal and distal to the lesion, and gradient values >3 mmHg were considered hemodynamically significant. We evaluated the technical success, complications, outcome of venoplasty and recurrence, and the patency rate. RESULTS In all, 11 female patients manifested a pressure gradient >3 mmHg across the anastomotic site; they underwent subsequent PVT. The initial balloon venoplasty procedure was technically successful in 10 of the 11 patients (91%), and the pressure gradient was reduced from 5.8 to 1.1 mmHg (P < 0.01). Clinical improvement was observed in 9 of these 10 patients; one patient failed to improve and underwent retransplantation. Recurrent obstruction occurred in four patients; they underwent PTV with (n = 2) or without (n = 2) stent placement. There were no major procedural complications. CONCLUSION PTV following venous pressure measurement is an effective and safe treatment for venous outflow obstruction in patients subjected to LDLT. In patients with recurrent obstruction, re-venoplasty is recommended.
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Affiliation(s)
- Osamu Ikeda
- Department of Diagnostic Radiology, Kumamoto University Graduate School of Medical and Pharmaceutical Sciences, Kumamoto, Japan.
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Tasse J, Borge M, Pierce K, Brems J. Safe and Effective Treatment of Early Suprahepatic Inferior Vena Caval Outflow Compromise Following Orthotopic Liver Transplantation Using Percutaneous Transluminal Angioplasty and Stent Placement. Angiology 2010; 62:46-8. [DOI: 10.1177/0003319710369795] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jordan Tasse
- Department of Radiology, Loyola University Medical Center,
Maywood, IL, USA
| | - Marc Borge
- Department of Radiology, Loyola University Medical Center,
Maywood, IL, USA,
| | - Kenneth Pierce
- Department of Radiology, Loyola University Medical Center,
Maywood, IL, USA
| | - John Brems
- Department of Surgery, Loyola University Medical Center,
Maywood, IL, USA
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31
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Lee JM, Ko GY, Sung KB, Gwon DI, Yoon HK, Lee SG. Long-term efficacy of stent placement for treating inferior vena cava stenosis following liver transplantation. Liver Transpl 2010; 16:513-9. [PMID: 20213830 DOI: 10.1002/lt.22021] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aims of this study were to evaluate both the efficacy of stent placement for treating inferior vena cava (IVC) stenosis and the patency of hepatic veins (HVs) following IVC stent placement. Fourteen hepatic transplant recipients underwent stent placement to treat IVC stenosis. The median interval between transplantation and stent placement was 32 days. Stents varied from 20-36 mm in diameter and were 60-120 mm long. We retrospectively analyzed the technical and clinical success, changes of hepatic venous flow, and the patency of the IVC stents. Stent placement was successful in all patients. Clinical success was achieved in 12 patients. Four patients underwent HV balloon angioplasty or stent placement through IVC stent meshes either immediately (n = 1) or 12-110 days after (n = 3) IVC stent placement. Nine of the 12 patients were healthy when this manuscript was completed, and the last follow-up computed tomography scan obtained at a median of 65.3 months after IVC stent placement revealed the patency of the stent-placed IVC and HVs. IVC stent placement seems to be an effective treatment with an excellent, long-term patency for treating posttransplant stenosis, although the possibility of hepatic venous outflow abnormalities following IVC stent placement should also be considered.
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Zamboni F, Sampietro R. Conversion to termino-terminal cavo-cavostomy as a rescue technique for infrahepatic obstruction after piggyback liver transplantation. Transpl Int 2008; 21:1008-10. [PMID: 18564987 DOI: 10.1111/j.1432-2277.2008.00715.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Darcy MD. Management of venous outflow complications after liver transplantation. Tech Vasc Interv Radiol 2008; 10:240-5. [PMID: 18086429 DOI: 10.1053/j.tvir.2007.09.018] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Liver transplantation can be complicated by stenosis of the hepatic venous or inferior vena cava outflow. Venous outflow stenosis occurs at rates of 1 to 6% depending on the type of anastomosis. Stenoses can develop acutely as a result of technical problems or can present much later after the transplant due to intimal hyperplasia or perianastomotic fibrosis. Common clinical presentations include hepatic dysfunction, liver engorgement, ascites, abdominal pain, and occasionally variceal bleeding. Treatment can generally be accomplished via a transjugular approach, but percutaneous transhepatic access may be needed when the anastomosis cannot be catheterized from the jugular access. Angioplasty can achieve technical success in restoring anastomotic patency in close to 100% of cases, but restenosis is frequent. Repeat angioplasties may be needed. In adults and pediatric patients with adult sized hepatic veins, stenting may be a better option. Resolution of clinical signs and symptoms is seen in 73 to 100% of cases. Major complications are uncommon, with stent migration being one of the more difficult complications to manage.
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Affiliation(s)
- Michael D Darcy
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University, St Louis, MO 63110, USA.
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Abstract
Transplantation has become the method of choice for treatment of patients with irreversible severe liver dysfunction. Vascular thrombosis or stenosis, biliary obstruction, hemorrhage, posttransplantation neoplasm, and rejection are some of the most common potential complications. Most complications cause significant morbidity and mortality after liver transplantation. The appearance of vascular complications in posttransplantation patients is illustrated in this article.
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Grams J, Teh SH, Torres VE, Andrews JC, Nagorney DM. Inferior vena cava stenting: a safe and effective treatment for intractable ascites in patients with polycystic liver disease. J Gastrointest Surg 2007; 11:985-90. [PMID: 17508255 DOI: 10.1007/s11605-007-0182-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We performed a retrospective study of seven patients with polycystic liver disease who underwent stenting of the inferior vena cava for intractable ascites. All patients had symptomatic ascites and inferior vena cava stenosis demonstrable by venography. The mean pressure gradient across the inferior vena cava stenosis before stenting was 14.5 mm Hg (range 6-25 mm Hg) and significantly decreased to a mean pressure gradient of 2.8 mm Hg (range 0-6 mm Hg, p = 0.008) after stenting. Two patients also had stenting of hepatic venous stenoses after unsuccessful inferior vena cava stenting. After a mean follow-up of 12.2 months (range 0.5-39.1 months), five of the seven patients have had maintained clinical improvement, defined as decreased symptoms, diuretic requirements, and frequency of paracentesis. Four patients have required no further intervention. The other patient was lost in follow-up. Patients with clinical improvement had an overall larger mean pressure gradient before stenting (19.2 vs. 9.8 mm Hg) and a larger Delta pressure gradient (15.8 vs. 7.8 mm Hg) compared to those in whom stenting was unsuccessful. These results suggest inferior vena cava stenting is safe and effective and should be considered as a first-line intervention in the treatment of medically intractable ascites in select patients with polycystic liver disease.
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Affiliation(s)
- Jayleen Grams
- Department of Surgery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905, USA
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36
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Kubo T, Shibata T, Itoh K, Maetani Y, Isoda H, Hiraoka M, Egawa H, Tanaka K, Togashi K. Outcome of percutaneous transhepatic venoplasty for hepatic venous outflow obstruction after living donor liver transplantation. Radiology 2006; 239:285-90. [PMID: 16567488 DOI: 10.1148/radiol.2391050387] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate retrospectively the outcome of percutaneous transhepatic venoplasty of hepatic venous outflow obstruction after living donor liver transplantation (LDLT). MATERIALS AND METHODS The institutional Human Subjects Research Review Board approved the interventional protocol and the retrospective study, for which informed consent was not required. Before treatment, informed consent was obtained from the patient or the patient's parents in all cases. Of 26 consecutive patients (nine male, 17 female; median age, 9 years) suspected of having hepatic venous outflow obstruction after LDLT, 20 patients confirmed to have anastomotic outflow stenosis at percutaneous hepatic venography and manometry underwent venoplasty. Pressure gradients before and after venoplasty were evaluated by using a paired t test. Patients in whom obstruction recurred during follow-up were re-treated with venoplasty with or without expandable metallic stents. Patency was analyzed by using Kaplan-Meier analysis. RESULTS The initial balloon venoplasty was technically successful in all 20 patients, all of whom had improved clinical findings. The pressure gradient +/- standard deviation was reduced from 14.6 mg Hg +/- 8.6 to 2.2 mg Hg +/- 2.4 (P < .001). Eleven patients had recurrent obstruction and were treated with balloon venoplasty; one of them underwent stent placement, as well as venoplasty. The primary (event-free) patency and 95% confidence interval (CI) at 3, 12, and 60 months after venoplasty were 0.80 (95% CI: 0.62, 0.98), 0.60 (95% CI: 0.38, 0.81), and 0.60 (95% CI: 0.38, 0.81), respectively. The primary assisted patency, maintained with repeated venoplasty and expandable metallic stents, was 1.00 at 60 months. CONCLUSION Percutaneous venoplasty is an effective treatment for hepatic venous outflow obstruction after LDLT.
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Affiliation(s)
- Takeshi Kubo
- Department of Radiology, Kyoto University Graduate School of Medicine, 54-Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan
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37
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Gemmete JJ, Mueller GC, Carlos RC. Liver transplantation in adults: postoperative imaging evaluation and interventional management of complications. Semin Roentgenol 2006; 41:36-44. [PMID: 16376170 DOI: 10.1053/j.ro.2005.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Joseph J Gemmete
- Department of Radiology, University of Michigan Medical Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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38
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Guimarães M, Uflacker R, Schönholz C, Hannegan C, Selby JB. Stent Migration Complicating Treatment of Inferior Vena Cava Stenosis after Orthotopic Liver Transplantation. J Vasc Interv Radiol 2005; 16:1247-52. [PMID: 16151067 DOI: 10.1097/01.rvi.0000167586.44204.c8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A case of inferior vena cava (IVC) stenosis after orthotopic liver transplantation was treated with balloon angioplasty and Wallstent placement. There was stent migration into the right atrium (RA), and percutaneous removal of the stent was attempted without success. Open cardiac surgery was required for stent removal and repair of aortic/RA fistula. Months later, recurrent IVC stenosis was successfully treated with placement of large Z stents after additional failed surgical repair. At 2 years follow-up, the patient is asymptomatic and Doppler ultrasonography demonstrated the stent to be patent and well-positioned.
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Affiliation(s)
- Marcelo Guimarães
- Division of Interventional Radiology, Department of Radiology, Medical University of South Carolina, 169 Ashley Ave., Box 250322, Charleston, South Carolina 29425, USA.
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Stecker MS, Casciani T, Kwo PY, Lalka SG. Percutaneous stent placement as treatment of renal vein obstruction due to inferior vena caval thrombosis. Cardiovasc Intervent Radiol 2005; 29:147-50. [PMID: 15886939 DOI: 10.1007/s00270-004-0198-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A patient who had undergone his third orthotopic liver transplantation nearly 9 years prior to presentation developed worsening hepatic and renal function, as well as severe bilateral lower extremity edema. Magnetic resonance imaging demonstrated vena caval thrombosis from the suprahepatic venous anastomosis to the infrarenal inferior vena cava, obstructing the renal veins. This was treated by percutaneous placement of metallic stents from the renal veins to the right atrium. At 16 months clinical follow-up, the patient continues to do well.
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Affiliation(s)
- Michael S Stecker
- Department of Radiology, Vascular and Interventional Radiology Section, Indiana University School of Medicine, Indianapolis, IN 46202-5253, USA.
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40
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Funaki B. Percutaneous Treatment of Vascular Complications Following Liver Transplantation. J Vasc Interv Radiol 2004. [DOI: 10.1016/s1051-0443(04)70134-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Joshi A, Carr J, Chrisman H, Omary R, Resnick S, Saker M, Nemcek A, Vogelzang R. Filter-related, thrombotic occlusion of the inferior vena cava treated with a Gianturco stent. J Vasc Interv Radiol 2003; 14:381-5. [PMID: 12631645 DOI: 10.1097/01.rvi.0000058419.01661.01] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The authors report a case of complete thrombotic occlusion of the inferior vena cava (IVC), which occurred 4 weeks after placement of an IVC filter (TrapEase; Cordis, Miami FL). Initial treatment with suction thrombectomy and thrombolysis was ineffective. Percutaneous removal of the filter was unsuccessful because of the long period of implantation. TrapEase filters (Cordis) are easily collapsible because of their symmetric design and composition (nitinol). An expandable metallic Gianturco Z stent (Cook, Bloomington, IN) was used to exclude the filter from the vessel lumen. In cases of persistent filter-related, thrombotic occlusion of the IVC, in which initial treatment has failed, the use of a Gianturco stent (Cook) to exclude the filter from the vessel lumen is a viable treatment option if the filter has a collapsible design.
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Affiliation(s)
- Akash Joshi
- Department of Radiology, Northwestern Memorial Hospital, Chicago, IL 60611, USA.
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Frazer CK, Gupta A. Stenosis of the hepatic vein anastomosis after liver transplantation: treatment with a heparin-coated metal stent. AUSTRALASIAN RADIOLOGY 2002; 46:422-5. [PMID: 12452917 DOI: 10.1046/j.1440-1673.2002.01097.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Delayed-onset fibrotic stenosis of the hepatic-vein anastomosis following liver transplantation resulted in ascites and abnormal liver-function tests. The stenosis was treated with balloon dilatation resulting in a clinical improvement; however, this had to be repeated four times in the 9 months after transplantation due to recurrent stenosis. The stenosis was eventually successfully treated with percutaneous insertion of a metal stent. Aspirin 50 mg daily was prescribed for 1 month. The patient was not anticoagulated. The patient remains clinically well at follow up after 18 months.
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Affiliation(s)
- C K Frazer
- Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia.
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Ko GY, Sung KB, Yoon HK, Kim JH, Song HY, Seo TS, Lee SG. Endovascular treatment of hepatic venous outflow obstruction after living-donor liver transplantation. J Vasc Interv Radiol 2002; 13:591-9. [PMID: 12050299 DOI: 10.1016/s1051-0443(07)61652-2] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To evaluate the effectiveness and safety of percutaneous interventional management of hepatic venous outflow obstruction after living-donor liver transplantation (LDLT). MATERIALS AND METHODS Percutaneous balloon angioplasty (n = 5) and stent placement (n = 22) were attempted in 27 patients with hepatic venous outflow obstruction. Patient follow-up included clinical and laboratory data collection, Doppler ultrasonography (US), hepatic venography, and computed tomography. The following parameters were documented retrospectively: technical success and complications, clinical improvement, and recurrence. Technical success was defined as elimination or successful reduction of pressure gradients across the stenosis and clinical success was defined as amelioration of presenting signs. Recurrence was defined as relapse of clinical signs with hepatic venous anastomotic restenosis on Doppler US. RESULTS Technical success was achieved in all patients. The mean pressure gradients across the stenoses before and after the procedure were 10.6 mm Hg +/- 6.4 (range, 3-39 mm Hg) and 2.4 mm Hg +/- 2.6 (range, 0-8 mm Hg), respectively (P < .001). Three of the five patients who underwent balloon angioplasty developed recurrent stenosis 1-5 weeks after the procedure. These patients underwent repeat balloon angioplasty, and two of them eventually underwent stent placement (n = 1) or surgical repositioning (n = 1) of the graft. Three of the 22 patients who underwent stent placement required a second stent placement procedure because of malpositioning, partial migration, and acute angulation. During the mean follow-up period of 49 weeks +/- 47 (range, 3-214 wk), clinical success was achieved in 20 of 27 patients (73%). CONCLUSION Percutaneous interventional management is an effective and safe adjunct for the treatment of hepatic venous outflow obstruction after LDLT.
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Affiliation(s)
- Gi-Young Ko
- Departments of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap-Dong, Songpa-Ku, Seoul 138-736, Korea
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Yamagami T, Nakamura T, Kato T, Iida S, Nishimura T. Hemodynamic changes after self-expandable metallic stent therapy for vena cava syndrome. AJR Am J Roentgenol 2002; 178:635-9. [PMID: 11856689 DOI: 10.2214/ajr.178.3.1780635] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We examined changes in hemodynamics after self-expandable metallic stent placement in the vena cava. CONCLUSION The rapid increase in venous return immediately after expandable metallic stent placement influenced the hemodynamics of the circulatory system.
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Affiliation(s)
- Takuji Yamagami
- Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan
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Weeks SM. Hepatic Venous/Caval Complications. J Vasc Interv Radiol 2002. [DOI: 10.1016/s1051-0443(02)70047-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Petersen B, Uchida BT, Timmermans H, Keller FS, Rosch J. Intravascular US-guided direct intrahepatic portacaval shunt with a PTFE-covered stent-graft: feasibility study in swine and initial clinical results. J Vasc Interv Radiol 2001; 12:475-86. [PMID: 11287535 DOI: 10.1016/s1051-0443(07)61887-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
PURPOSE To determine the feasibility of the creation of a direct intrahepatic inferior vena cava (IVC)-to-portal-vein shunt with puncture guided by a transfemorally placed intravascular ultrasound (IVUS) probe and use of a polytetrafluoroethylene (PTFE)-covered stent-graft. MATERIALS AND METHODS In five swine, transjugular access was used to perform a direct puncture from the IVC to the portal vein with use of a modified Rosch-Uchida Portal Access set directed with real-time IVUS (9 MHz) introduced from a transfemoral venous approach. The direct intrahepatic portocaval shunt (DIPS) was then created with single or overlapping PTFE-covered Palmaz stents placed through a 10-F sheath and dilated to a diameter of 8 mm. Follow-up was performed with transhepatic portography at 2, 4, and 8 weeks. Animals were killed when shunts occluded or at the termination of the study at 8 weeks. Gross and microscopic histologic study was performed on sacrificed animals. A similar technique was used to create DIPS in five patients with intractable ascites, with follow-up by US and venography. RESULTS All experimental DIPS created in swine were created without complications. Portal vein punctures were achieved in four of five swine on the first or second pass of the needle. Follow-up transhepatic portography at 2 weeks demonstrated occlusion of two shunts, both explained by technical reasons at sacrifice. At 4 and 8 weeks, the remaining three shunts were patent on portography. Histology showed a thin neointimal lining with no significant tissue ingrowth or hyperplasia. Clinically, in five patients, successful puncture of the portal vein from the IVC was achieved in one to three passes. Creation of DIPS led to a reduction of mean portosystemic gradient from 18-29 mm Hg (mean, 24 mm Hg) to 9-10 mm Hg (mean, 9 mm Hg). One patient died of liver failure 2 days after creation of DIPS. The other four patients were doing well 2-15 months (mean, 8 months) after the procedure, with patency confirmed by US and venography. CONCLUSION Creation of DIPS is technically feasible, and the direct IVC-to-portal-vein puncture can be done accurately with real-time IVUS guidance. Further studies and longer follow-up are necessary to determine if the short length of the PTFE-covered stent-graft and avoidance of the hepatic vein will increase the long-term patency compared to standard transjugular intrahepatic portosystemic shunt creation.
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Affiliation(s)
- B Petersen
- Dotter Interventional Institute, Oregon Health Sciences University L342, 3181 SW Sam Jackson Park Rd., Portland, OR 97201, USA.
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