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Novelli PM, Tublin JM, Orons PD. Correcting Coagulopathy for Image-Guided Procedures. Semin Intervent Radiol 2022; 39:428-434. [PMID: 36406020 PMCID: PMC9671671 DOI: 10.1055/s-0042-1758150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Patients with acquired coagulopathy often require percutaneous image-guided invasive procedures for urgent control of hemorrhage or for elective procedures. Routine preprocedural evaluation of coagulopathy previously focused on absolute prothrombin time, partial thromboplastin time, international normalized ratio, and platelet count values. Now viscoelastic testing and greater understanding of patient- and drug-specific changes in coagulation profiles can yield better coagulation profile data. More specific reversal agents and profiles combine for less generalized and more titrated transfusion or correction algorithms. This article reviews procedural and patient-specific factors for defining both hemorrhagic risk and correction strategies.
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Affiliation(s)
- Paula M. Novelli
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Philip D. Orons
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Novelli PM, Orons PD. The role of interventional radiology in the pre-liver transplant patient. Abdom Radiol (NY) 2021; 46:124-133. [PMID: 32840652 DOI: 10.1007/s00261-020-02704-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/11/2020] [Accepted: 08/08/2020] [Indexed: 11/25/2022]
Abstract
Each year approximately 8500 patients undergo liver transplantation in the USA for acute and chronic liver failure. Over the years, the success of liver transplantation has led to more clinical indications for liver transplantation. These expanded indications, without a proportionate increase in donors, result in increased competition for the limited pool of transplantable whole or partial grafts. The likelihood of receiving a deceased donor graft depends on many clinical variables, including the acute and chronic fitness of the candidate aligning with the timing of donor organ availability. Several types of patients are candidates for transplant: patients with acute fulminant hepatic failure who will die without a transplant, patients with decompensated cirrhosis, and patients with HCC and compensated cirrhosis. Interventional radiology can preserve equity between these subgroups and reduce patient dropout by increasing the physiologic and anatomic fitness of the candidate before and after formal listing. The primary determinants of candidacy fitness and dropout are the severity of clinical symptoms related to portal hypertension and the presence of hepatocellular cancer. There is a subgroup of patients whose disease severity is not accurately reflected by the Model for End-stage Liver Disease (MELD), such as patients with chronic cholestasis that also may benefit from IR management.
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Affiliation(s)
- Paula M Novelli
- Department of Radiology, UPMC, 200 Lothrop St, Pittsburgh, PA, 15213, USA.
| | - Philip D Orons
- Department of Radiology, UPMC, 200 Lothrop St, Pittsburgh, PA, 15213, USA
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Lindquester WS, Novelli PM, Amesur NB, Warhadpande S, Orons PD. A ten-year, single institution experience with percutaneous nephrostomy during pregnancy. Clin Imaging 2020; 72:42-46. [PMID: 33212305 DOI: 10.1016/j.clinimag.2020.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 10/27/2020] [Accepted: 11/08/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of percutaneous nephrostomy (PCN) in pregnancy. MATERIALS AND METHODS PCN tubes were placed during 52 pregnancies in 49 patients from 2008 to 2018. The medical records during pregnancies were retrospectively reviewed for imaging findings, procedural parameters, outcomes of delivery, and complications. RESULTS The mean gestational age on percutaneous nephrostomy placement was 27 weeks (range, 8-36 weeks). PCN catheters were placed for the following indications: 1) flank or lower abdominal pain (42%), 2) obstructing calculi (37%), 3) pyelonephritis (20%), and 4) obstructing endometrioma (2%). Prior to PCN, retrograde ureteric stenting was performed in 17 of 49 patients (34%) and attempted but failed in 4 patients (8%). Nephrostomy drainage relieved pain completely or significantly in all 12 patients without prior ureteral stenting, but in only 4 of 10 with retrograde ureteric stents. In one patient in whom the ureteral stent had been removed, PCN relieved her flank pain. The mean number of PCN catheter exchanges was 1.6, ranging from 0 to 9, with a mean time interval of 21.3 days between exchanges. There were 29 difficult exchanges due to encrustation in 15 patients with a mean of 20.5 days between exchanges. CONCLUSIONS PCN drainage is a safe and effective treatment for managing symptomatic hydronephrosis in pregnant patients but is less effective in treating pain when retrograde ureteral stents are in place. Rapid encrustation, seen more commonly in pregnancy, tends to recur in the same patients and requires more frequent exchanges than the general population.
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Affiliation(s)
- Will S Lindquester
- Department of Radiology, University of Pittsburgh Medical Center, United States of America.
| | - Paula M Novelli
- Department of Radiology, University of Pittsburgh Medical Center, United States of America
| | - Nikhil B Amesur
- Department of Radiology, University of Pittsburgh Medical Center, United States of America
| | - Shantanu Warhadpande
- Department of Radiology, University of Pittsburgh Medical Center, United States of America
| | - Philip D Orons
- Department of Radiology, University of Pittsburgh Medical Center, United States of America
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Abstract
Optimal prenatal management of giant placental chorangioma (also known as chorioangioma, angiomyxoma, fibroangiomyxoma, or fibroma) has yet to be determined. Interventions intended to devascularize the tumor such as interstitial laser, bipolar coagulation, fetoscopic laser photocoagulation, and chemical embolization have met mixed results. We report a minimally invasive, extra-amniotic approach, technically similar to cordocentesis, of microcoil embolization of the feeding vessel. These percutaneously placed microcoils initiate clot formation at the site of insertion and are unable to migrate through the tumor, thereby minimizing fetal harm by downstream embolic phenomena. Intervention at 26 and 22 weeks resulted in intraoperative fetal loss in the former and vaginal delivery at term of a healthy neonate in the latter. Preoperative, intraoperative, and placental findings are highlighted. The ease and safety of this procedure may alter the risk-benefit equation toward earlier intervention with potentially better clinical outcomes.
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Affiliation(s)
- Stephen P Emery
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Philip D Orons
- Department of Interventional Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jeffrey F Bonadio
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Dhir M, Shrestha R, Steel JL, Marsh JW, Tsung A, Tublin ME, Amesur NB, Orons PD, Santos E, Geller DA. Initial Treatment of Unresectable Neuroendocrine Tumor Liver Metastases with Transarterial Chemoembolization using Streptozotocin: A 20-Year Experience. Ann Surg Oncol 2017; 24:450-459. [DOI: 10.1245/s10434-016-5591-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Chen JY, Agarwal V, Orons PD. Competitiveness of the Match for Interventional Radiology and Neuroradiology Fellowships. J Am Coll Radiol 2014; 11:1069-73. [PMID: 25156202 DOI: 10.1016/j.jacr.2014.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 06/11/2014] [Indexed: 10/24/2022]
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Amesur NB, Orons PD, Iacono AT. Interventional techniques in the management of airway complications following lung transplantation. Semin Intervent Radiol 2011; 21:283-95. [PMID: 21331140 DOI: 10.1055/s-2004-861563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The last four decades have seen tremendous advances in the field of pulmonary transplantation. Vast improvements in the areas of surgical transplantation techniques, immunosuppressive agents, and postoperative care have all contributed to improved survival of patients. Advances in noninvasive imaging and bronchoscopy have allowed the pulmonary transplant team to intervene early in patients presenting with airway complications, often using minimally invasive procedures such as endobronchial balloon dilation or stent placement, or both. Stent technology itself has also improved and stents may sometimes be customized for treatment of short airway lesions or to optimize continued airflow through the sides of stents by creating openings using balloons or bronchoscopically directed laser. Preliminary work with brachytherapy may be decreasing the need for secondary reinterventions. The authors present an overview of some of these conventional and novel approaches to the treatment of airway complications after lung transplantation.
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Affiliation(s)
- Nikhil B Amesur
- Assistant Professor of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Burns KEA, Orons PD, Dauber JH, Grgurich WF, Stitt LW, Raghu S, Iacono AT. Endobronchial metallic stent placement for airway complications after lung transplantation: longitudinal results. Ann Thorac Surg 2002; 74:1934-41. [PMID: 12643376 DOI: 10.1016/s0003-4975(02)04033-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In lung transplant recipients, bronchial stenosis (SB) and bronchomalacia (MB) result in obstructive airway disease and allograft dysfunction due to pulmonary infection. We hypothesized that endobronchial metallic stent placement for SB and MB would result in long-term improvement in respiratory function and rates of pulmonary infection. METHODS We studied symptomatic lung transplant recipients with bronchoscopic evidence of proximal airway complications (SB or MB) and a synchronous decline in forced expiratory volume in 1 second (FEV1) of at least 10% in the 6-month period before intervention. Stent placement was the primary intervention for SB and all focal MB lesions and for recurrent or refractory SB lesions failing a single initial attempt at balloon dilation. FEV1 and rates of pulmonary infection were assessed in the 12-month interval before and after stent placement. Spirometric evaluation was performed at 3-month intervals and compared with spirometry at the time of stent placement. The rates of pulmonary infection, determined by the number of antibiotics prescribed, was determined before and after endobronchial correction. RESULTS Thirty recipients underwent a total of 75 procedures (50 stent insertions and 25 balloon dilations). FEV1 improved significantly after stent placement compared with base line (1.29 +/- 0.43 L) as follows: 3 months, 1.45 +/- 0.50 L, p = 0.014; 6 months, 1.59 +/- 0.57 L, p = 0.002; 12 months 1.59 +/- 0.53 L, p = 0.006. The infection rate decreased from the 12-month period preceding stent insertion to the corresponding period after stent insertion (6.97/100 days +/- 6.33 versus 5.74/100 days +/- 7.76, p = 0.018). Recurrent SB occurred in 17.3%. No life-threatening complications occurred after stent placement and no deaths were attributed to stent malfunction or malposition. CONCLUSIONS In lung transplant recipients with SB and MB, maintenance of airway patency by stent placement is safe and resulted in improvements in lung function and reduced pulmonary infection rates for up to 1 year after their insertion.
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Affiliation(s)
- Karen E A Burns
- Division of Pulmonary Transplantation, and Pulmonary, Critical Care Medicine, University of Pittsburgh Medical Center-Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
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Amesur NB, Zajko AB, Orons PD, Makaroun MS. Endovascular treatment of iliac limb stenoses or occlusions in 31 patients treated with the ancure endograft. J Vasc Interv Radiol 2000; 11:421-8. [PMID: 10787199 DOI: 10.1016/s1051-0443(07)61373-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The authors report their experience with treatment of iliac limb complications in patients treated with the Ancure endograft with Wallstents to provide additional support and thrombolysis when needed. MATERIALS AND METHODS From February 1996 to October 1999, 88 patients were treated for abdominal aortic aneurysm with use of the Ancure endograft. Of the 88 devices used, 20 were tube grafts and the remaining 68 devices had a total of 130 iliac limbs (bifurcated, n = 62; aortoiliac, n = 6). After graft deployment, all patients underwent intraoperative aortography; since July 1997, intravascular ultrasound (IVUS) has also been used. RESULTS Thirty-one patients (46%) required treatment of 47 (36%) limbs with Wallstents. Graft narrowing was observed in 41 limbs (27 patients) with IVUS immediately after graft deployment. All were successfully treated with placement of Wallstents. Before routine use of intraoperative IVUS, three patients presented between 2 and 6 weeks postoperatively with iliac limb thrombosis. All three limbs were successfully treated with thrombolysis and Wallstent placement to correct the underlying iliac problem. Additionally, two contralateral limbs in these three patients were also noted to have stenosis and were treated with use of Wallstents. The last patient required placement of a Wallstent to treat stenosis of surgical anastomosis of the iliac limb of an aortoiliac endograft at 3 days. All Wallstent-reinforced Ancure endografts remained patent from 1 to 36 months (mean, 14 months). CONCLUSION After placement of an Ancure bifurcated or aortoiliac endograft, iliac limb stenosis is easily detected with use of intraoperative IVUS. Such complications can be safely corrected with Wallstent placement. Postoperative limb occlusion at the authors' institution has been eliminated with such intervention.
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Affiliation(s)
- N B Amesur
- Division of Interventional Radiology, University of Pittsburgh Medical Center, PA 15213, USA
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Abstract
BACKGROUND Nonanastomotic distal bronchial stenosis has been observed in some patients after lung transplantation. We investigated its relationship with acute cellular rejection (ACR), infection, and ischemia. METHODS Between January 1994 and December 1997, 246 lung transplantations were performed at our hospital. These cases were retrospectively reviewed and evaluated to identify those patients with nonanastomotic bronchial stenosis. RESULTS Six patients had bronchial stenosis within the grafted airway distal to the uninvolved anastomotic site. The average ACR before stenosis was 1.9 compared with 1.6 in a control group. ACR at the time of first recognition of the stenosis ranged from A2 to A3.5, with an average value of A2.9. All 6 patients demonstrated alloreactive airway inflammation before and at the time of stenosis. Four patients had evidence of ischemic damage in the perioperative period. CONCLUSIONS Segmental nonanastomotic large airway stenosis after lung transplantation should be assessed separately from anastomotic complications. Although the pathogenesis is unclear, certainly one should consider alloreactive injury, ischemic damage, and infection as individual and coercive causes.
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Affiliation(s)
- T Hasegawa
- Department of Pathology, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pennsylvania 15213, USA
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Orons PD, Amesur NB, Dauber JH, Zajko AB, Keenan RJ, Iacono AT. Balloon dilation and endobronchial stent placement for bronchial strictures after lung transplantation. J Vasc Interv Radiol 2000; 11:89-99. [PMID: 10693719 DOI: 10.1016/s1051-0443(07)61288-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To evaluate the effect of balloon dilation and endobronchial stent placement for bronchial fibrous stenoses and bronchomalacia after lung transplantation. MATERIALS AND METHODS Bronchial dilation and/or stent placement was performed on 25 lung transplant recipients. Indications included severe dyspnea with postobstructive pneumonia (n = 24) and respiratory failure (n = 1). All patients underwent pulmonary function testing (PFT) before and after bronchial dilation, the results of which were evaluated for changes. A total of 63 procedures were performed between February 1996 and December 1998. Thirty-five lesions were treated (18 were due to bronchomalacia, 17 were due to fibrosis). Areas treated included the left mainstem bronchus (n = 11), bronchus intermedius (n = 10), right mainstem bronchus (n = 7), left upper lobe bronchus (n = 4), right lower lobe bronchus (n = 2), and right middle lobe bronchus (n = 1). Bronchoscopic and/or bronchographic follow-up ranged from 1 to 34 months (mean, 15 months). RESULTS Six-month primary patency of stents placed for bronchomalacia was 71% (10 of 14), with three of the four occlusions caused by mechanical failure of Palmaz stents in the mainstem bronchi. Six-month primary patency for treatment of fibrous strictures was 29%. Secondary patency at 1 year was 100% for both bronchomalacia and fibrous strictures. After treatment, there was a significant improvement in mean PFT results (P = .01-.0001). There was one acute complication, obstruction of the left lower lobe bronchus by a Wallstent treated by dilating a hole in the side of the stent. CONCLUSIONS Balloon dilation and stent placement are safe and effective for bronchial strictures and bronchomalacia after lung transplantation, resulting in significant improvement in PFT results. However, there is almost universal restenosis in patients treated for fibrous strictures necessitating reintervention for prolonged patency.
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Affiliation(s)
- P D Orons
- Department of Radiology, University of Pittsburgh Medical Center, Pennsylvania 15213, USA.
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Amesur NB, Zajko AB, Orons PD, Makaroun MS. Embolotherapy of persistent endoleaks after endovascular repair of abdominal aortic aneurysm with the ancure-endovascular technologies endograft system. J Vasc Interv Radiol 1999; 10:1175-82. [PMID: 10527194 DOI: 10.1016/s1051-0443(99)70217-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Endoleak is a potential complication after endovascular repair of abdominal aortic aneurysm (AAA). It may result in continued growth of the aneurysm and potentially result in aneurysm rupture. The authors present their experience with embolotherapy in patients with persistent perigraft flow treated with the Ancure-Endovascular Technologies endograft system. MATERIALS AND METHODS Between February 1996 and August 1998, 54 patients underwent successful repair of AAA with use of the Ancure system. All underwent operative angiography and discharge computed tomography (CT). Follow-up included CT at 6, 12, and 24 months, and CT was also performed at 3 months if an endoleak was present on the discharge CT. Persistent endoleak was defined as perigraft flow still present on the 6-month CT. Seven of 21 initial endoleaks persisted at 6 months. Six patients returned for embolization of the perigraft space and outflow vessels including lumbar arteries and the inferior mesenteric artery (IMA). RESULTS Five of the six patients had leaks from the proximal (n = 1) or distal attachment sites (n = 4) of the Ancure system with outflow into lumbar arteries and/or the IMA; one leak was caused by retrograde IMA flow. The six patients underwent nine embolization procedures with only one minor complication. Follow-up CT showed complete resolution of endoleak and decrease in size of the aneurysm sac in all patients. CONCLUSIONS Although endoleak is commonly seen initially with the Ancure system, persistent leak occurred in 13% of the patients in the study. Persistent flow in most patients arises from a graft attachment site combined with patent outflow vessels such as the IMA or lumbar arteries. Persistent endoleaks can be effectively and safely embolized with use of a combination of coil embolization of the perigraft space and embolization of outflow vessels. Such intervention resulted in a decrease in size of the aneurysm sac.
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Affiliation(s)
- N B Amesur
- Division of Interventional Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Amesur NB, Zajko AB, Orons PD, Sammon JK, Casavilla FA. Transjugular intrahepatic portosystemic shunt in patients who have undergone liver transplantation. J Vasc Interv Radiol 1999; 10:569-73. [PMID: 10357482 DOI: 10.1016/s1051-0443(99)70085-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Transjugular intrahepatic portosystemic shunt (TIPS) placement is an accepted treatment for refractory variceal bleeding and/or ascites in end-stage liver disease and is an effective bridge to liver transplantation. The authors present their experience with TIPS in patients with a liver transplant, who subsequently developed portal hypertension. MATERIALS AND METHODS Thirteen TIPS were placed in 12 adult patients from 6 months to 13 years after liver transplantation for variceal bleeding that failed endoscopic treatment (n = 6) and intractable ascites (n = 6). All patients were followed to either time of retransplantation or death. RESULTS No technical difficulties were encountered in TIPS placement in any of the patients. Four of six patients treated for bleeding stopped bleeding and did not experience re-bleeding, two had functional TIPS at 3 and 36 months and two underwent retransplantation at 3 and 7 months. Two patients had recurrent bleeding within 1 week and required reintervention. In the ascites group, one is 32 months since TIPS placement with control of his ascites, two patients underwent retransplantation at 2 and 6 weeks with interval improvement in ascites. Two patients died within a week of TIPS of fulminant hepatic failure. The last patient died 1 month after TIPS subsequent to a splenectomy. CONCLUSION In conclusion, the placement of a TIPS in a transplanted liver, in general, requires no special technical considerations compared to placement in native livers. Although this series is small, the authors believe that TIPS should be considered a treatment option in liver transplant recipients who present with refractory variceal bleeding. TIPS may have a role in the management of intractable ascites.
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Affiliation(s)
- N B Amesur
- Department of Radiology, University of Pittsburgh Medical Center, PA 15213, USA
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Orons PD, Hari AK, Zajko AB, Marsh JW. Thrombolysis and endovascular stent placement for inferior vena caval thrombosis in a liver transplant recipient. Transplantation 1997; 64:1357-61. [PMID: 9371680 DOI: 10.1097/00007890-199711150-00020] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Vascular complications remain an important cause of postoperative morbidity in liver transplant patients. Herein, we present an unusual case of nonanastomotic inferior vena cava (IVC) stenosis in a patient with a "piggyback" caval anastomosis. METHODS A 59-year-old woman underwent liver transplantation using a piggyback IVC anastomosis. Her postoperative course was complicated by IVC thrombosis. Catheter-directed thrombolysis, followed by balloon angioplasty and intravascular stent placement, was used to recanalize the IVC and treat a severe retrohepatic IVC stenosis. RESULTS After 46 hr of catheter-directed urokinase infusion, there was clot lysis and identification of a severe stenosis in the retrohepatic IVC. The lesion was extremely resistant to balloon dilatation alone and a 22-mm-diameter intravascular stent was placed. Simultaneous dilatation of three high-pressure balloons was necessary for maximal stent expansion. The patient remains asymptomatic with no evidence of IVC compromise through 20 months of follow-up. CONCLUSIONS IVC stenosis and thrombosis after liver transplantation may be treated favorably in some patients using catheter-directed thrombolytic therapy followed by balloon dilatation and/or stent placement.
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Affiliation(s)
- P D Orons
- Department of Radiology, University of Pittsburgh Medical Center, Pennsylvania 15213, USA.
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Affiliation(s)
- P C Pretter
- Department of Radiology, University of Pittsburgh Medical Center, PA 15213, USA
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Jabbour N, Zajko AB, Orons PD, Irish W, Bartoli F, Marsh WJ, Dodd GD, Aldreghitti L, Colangelo J, Rakela J, Fung JJ. Transjugular intrahepatic portosystemic shunt in patients with end-stage liver disease: results in 85 patients. Liver Transpl Surg 1996; 2:139-47. [PMID: 9346640 DOI: 10.1002/lt.500020210] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is becoming an accepted procedure as a bridge to orthotopic liver transplantation (OLT) in patients with end-stage liver disease (ESLD) and bleeding from portal hypertension. It allows the immediate control of acute bleeding and decreases the risk of recurrent acute bleeding while the patient is awaiting OLT. We review in this report, our experience with 85 patients who underwent a TIPS procedure for gastrointestinal variceal bleeding from September 1991 until April 1994. All patients had liver cirrhosis and all had previous sclerotherapy before TIPS. Child-Pugh score was calculated at enrollment, and all patients were evaluated for possible OLT. Thirteen patients were Child A, 49 were Child B, and 23 were Child C. Fifty-three patients were candidates for OLT, and 32 were not. TIPS was performed urgently in 25 patients. At a median follow-up of 582 days (range, 1 to 1,095), 35 patients underwent transplantation, 21 patients died, and 29 patients are still alive and did not undergo transplantation. Technical complications were observed in 7% of patients and new onset of clinical encephalopathy in 37%. The 30-day mortality rate after TIPS was 13%. Actuarial survival was 60% at 1 and 3 years. Child class C and urgent TIPS were shown to be two independent predictor factors for mortality. TIPS was shown to be a valuable procedure, not only as a bridge to OLT but also as palliation for bleeding from portal hypertension in patients who were not candidates for either surgical shunt or OLT. However, its role in bleeding patients with acceptable liver function needs further investigation.
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Affiliation(s)
- N Jabbour
- Pittsburgh Transplantation Institute, University of Pittsburgh Medical Center, PA, USA
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Abstract
We report an unusual cause of hemobilia in a patient with a transhepatic biliary catheter. Hemobilia was due to an extrahepatic fistula between the gastroduodenal artery and the common bile duct and was responsible for significant blood loss. The fistula was successfully treated with transarterial embolization that resulted in no further episodes of hemobilia during the following 12 months.
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Affiliation(s)
- P D Orons
- Department of Radiology, University of Pittsburgh Medical Center, PA 15213, USA
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Abstract
PURPOSE To evaluate the efficacy and complication rate of the Quick-Core biopsy needle system compared with traditional transjugular biopsy needle systems. MATERIALS AND METHODS Between January 1994 and April 1995, 43 patients underwent transjugular liver biopsy with the Quick-Core system; 18-, 19-, and 20-gauge needles were used in 28, 13, and two patients, respectively. Histologic diagnoses, specimen dimensions, and adequacy of the biopsy sample were determined. Immediate and delayed complications were recorded. RESULTS A total of 118 biopsy specimens were obtained with an average of 2.7 passes per patient. Biopsy was successful in 42 of 43 patients (98%); one specimen contained renal parenchyma. Of the specimens that contained liver tissue, 100% were adequate. Mean maximum sample lengths were 1.1 and 1.5 cm with the 18- and 19-gauge needles, respectively. The procedural complication rate of 2% was due to puncture of the liver capsule in one patient, but no clinical manifestations occurred. No delayed complications occurred in any patient. CONCLUSION The Quick-Core biopsy system produces consistently satisfactory, reproducible specimen cores with a very low complication rate.
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Affiliation(s)
- A F Little
- Department of Radiology, University of Pittsburgh Medical Center, PA 15213, USA
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Orons PD, Sheng R, Zajko AB. Hepatic artery stenosis in liver transplant recipients: prevalence and cholangiographic appearance of associated biliary complications. AJR Am J Roentgenol 1995; 165:1145-9. [PMID: 7572493 DOI: 10.2214/ajr.165.5.7572493] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The occurrence of biliary strictures or bile duct necrosis in liver transplant recipients with hepatic artery stenosis has been well documented. This study was done to determine the prevalence and cholangiographic appearance of biliary complications in liver transplant recipients with hepatic artery stenosis and to determine if such complications occur with increased frequency compared with transplant recipients with patent hepatic arteries. MATERIALS AND METHODS The study population consisted of 33 patients (17 male, 16 female; 1-65 years old) with angiographically proven significant hepatic artery stenosis after liver transplantation. All patients had T-tube or percutaneous transhepatic cholangiography performed within 4 months of hepatic arteriography. A retrospective review of radiographs was done to determine the prevalence and appearance of biliary complications in the study group compared with a control group of 58 patients with angiographically patent hepatic arteries who had liver transplants during the same period. RESULTS Biliary complications were significantly more prevalent in patients with hepatic artery stenosis, with 22 (67%) showing cholangiographic abnormal findings compared with 16 (28%) in the control group (p = .001). The most significant abnormalities in patients with arterial stenosis were nonanastomotic biliary strictures seen in 16 (49%), compared with 13 (22%) in the control group (p = .04). Other findings (intraductal filling defects, anastomotic biliary stricture, and anastomotic bile leak) showed no statistically significant difference between the study and control groups. CONCLUSION Biliary complications are significantly more prevalent in liver transplant recipients with hepatic artery stenosis. The most common complication seen on cholangiography was nonanastomotic biliary stricture.
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Affiliation(s)
- P D Orons
- Department of Radiology, University of Pittsburgh Medical Center, PA 15213, USA
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Orons PD, Zajko AB, Bron KM, Trecha GT, Selby RR, Fung JJ. Hepatic artery angioplasty after liver transplantation: experience in 21 allografts. J Vasc Interv Radiol 1995; 6:523-9. [PMID: 7579858 DOI: 10.1016/s1051-0443(95)71128-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
PURPOSE To assess whether percutaneous transluminal angioplasty (PTA) can help prolong allograft survival and improve allograft function in patients with hepatic artery stenosis after liver transplantation. PATIENTS AND METHODS Hepatic artery PTA was attempted in 19 patients with 21 allografts over 12 years. The postangioplasty clinical course was retrospectively analyzed. Liver enzyme levels were measured before and after PTA to determine if changes in liver function occurred after successful PTA. RESULTS Technical success was achieved in 17 allografts (81%). Retransplantation was required for four of 17 allografts (24%) in which PTA was successful and four of four allografts in which PTA was unsuccessful; this difference was significant (P = .03). Two major procedure-related complications occurred: an arterial leak that required surgical repair and an extensive dissection that necessitated retransplantation 14 months after PTA. Hepatic failure necessitated repeat transplantation in seven cases from 2 weeks to 27 months (mean, 8.4 months) after PTA. Six patients died during follow-up, three of whom had undergone repeat transplantation. Markedly elevated liver enzyme levels at presentation were associated with an increased risk of retransplantation or death regardless of the outcome of PTA. CONCLUSION PTA of hepatic artery stenosis after liver transplantation is relatively safe and may help decrease allograft loss due to thrombosis. Marked allograft dysfunction at presentation is a poor prognostic sign; thus, timely intervention is important.
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Affiliation(s)
- P D Orons
- Department of Radiology, University of Pittsburgh Medical Center, PA 15213, USA
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Orons PD, Zajko AB. Angiography and interventional procedures in liver transplantation. Radiol Clin North Am 1995; 33:541-58. [PMID: 7740110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Over the past several years, operative techniques, postoperative care, and immunosuppressive therapy have advanced steadily, allowing 5-year survival for liver transplantation to increase from 20% 15 years ago to 65% today. Biliary and vascular complications, however, remain causes of significant morbidity and mortality to the liver transplant patient. The interventional radiologist is an integral part of the multidisciplinary team necessary for optimization of care of the liver transplant patient. In this article, interventional techniques in the management of the liver transplant patient are addressed. Topics discussed include preoperative evaluation, methods of vascular and biliary reconstruction, and diagnosis and management of postoperative complications.
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Affiliation(s)
- P D Orons
- Department of Radiology, University of Pittsburgh School of Medicine, Pennsylvania, USA
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Dodd GD, Zajko AB, Orons PD, Martin MS, Eichner LS, Santaguida LA. Detection of transjugular intrahepatic portosystemic shunt dysfunction: value of duplex Doppler sonography. AJR Am J Roentgenol 1995; 164:1119-24. [PMID: 7717217 DOI: 10.2214/ajr.164.5.7717217] [Citation(s) in RCA: 84] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Recent reports have shown that a high percentage of patients with transjugular intrahepatic portosystemic shunts (TIPS) have postprocedural shunt complications, including thrombosis of the stent, stenosis of the stent, or stenosis of the hepatic vein draining the stent. We did a prospective study to determine the utility of Doppler sonography as a screening technique for the detection of these complications. SUBJECTS AND METHODS From September 1991 to September 1992 we placed TIPS in 45 patients. After the procedure, patients were routinely evaluated with both Doppler sonography and angiography. The sonographic protocol consisted of insonation of the stent, portal vein, and hepatic vein to determine the presence of flow, peak velocity, and direction of flow. The angiograms were evaluated for stenoses of the stent or hepatic vein that caused an increase in the portosystemic pressure gradient greater than 15 mm Hg, increased intrahepatic portal venous filling, retrograde filling of the draining hepatic vein, or opacification of varices. The sonographic findings were statistically evaluated to determine if sonography could demonstrate the complications shown by angiography. RESULTS Adequate follow-up was obtained in 29 of the 45 patients. Sixteen of the 29 patients had shunt complications that consisted of one stent thrombosis, three stent stenoses, nine hepatic vein stenoses, and three concomitant stenoses of the stent and hepatic vein. Flow was not detected by sonography in the stent of the patient with thrombosis. There was a significant difference (p = .003) between the temporal change in peak stent velocity in patients with stenoses versus those without. Use of a change (increase or decrease) in peak stent velocity greater than 50 cm/sec from the post-TIPS baseline sonogram as the diagnostic criterion for the detection of shunt stenoses resulted in a 93% sensitivity and 77% specificity. Five patients with stenosis had reversed flow in the draining hepatic vein. Only one patient with a stenosis had a peak stent velocity less than 50 cm/sec. CONCLUSION Our results suggest that Doppler sonography is an excellent noninvasive screening technique for the detection of complications of TIPS. We have found a temporal change in peak stent velocity greater than 50 cm/sec to be a more sensitive sonographic sign of TIPS stenosis than the previously reported low-velocity parameters. Our experience suggests that nearly all complications of TIPS can be detected by using three criteria: (1) no flow for thrombosis, (2) a temporal change in peak stent velocity greater than 50 cm/sec for stent and/or hepatic vein stenosis, and (3) reversed flow in the hepatic vein draining the stent for hepatic vein and, rarely, stent stenosis.
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Affiliation(s)
- G D Dodd
- Department of Radiology, University of Pittsburgh Medical Center, PA 15238, USA
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Orons PD, Zajko AB. Angiography and interventional aspects of renal transplantation. Radiol Clin North Am 1995; 33:461-71. [PMID: 7740106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Interventional techniques play key roles in the management of the renal transplant donor and recipient. With prompt diagnosis and intervention, postoperative vascular and urologic complications frequently may be treated by nonsurgical means. Current concepts in percutaneous intervention for renal transplant patients are discussed. Topics include transluminal angioplasty of arterial stenoses, treatment of arterial or venous occlusion, embolization of intrarenal arteriovenous fistula or pseudoaneurysm, management of periallograft fluid collections, and therapy for urinary obstruction or leak.
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Affiliation(s)
- P D Orons
- Department of Radiology, University of Pittsburgh School of Medicine, Pennsylvania, USA
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Orons PD, Zajko AB. ANGIOGRAPHY AND INTERVENTIONAL PROCEDURES IN LIVER TRANSPLANTATION. Radiol Clin North Am 1995. [DOI: 10.1016/s0033-8389(22)00306-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Sheng R, Orons PD, Ramos HC, Zajko AB. Dissecting pseudoaneurysm of the hepatic artery: a delayed complication of angioplasty in a liver transplant. Cardiovasc Intervent Radiol 1995; 18:112-4. [PMID: 7773992 DOI: 10.1007/bf02807234] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We report a 59-year-old female with a dissecting pseudoaneurysm of the allograft hepatic artery, as a delayed complication of percutaneous transluminal angioplasty (PTA). PTA of a severe anastomotic stenosis was successful, but complicated by a dissection involving the allograft hepatic artery. A large dissecting pseudoaneurysm developed and was incidentally detected during routine sonographic evaluation 14 months after PTA. Because of the extent of the pseudoaneurysm, percutaneous repair or surgical reconstruction was considered impossible. The patient underwent successful retransplantation 1 week after diagnosis.
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Affiliation(s)
- R Sheng
- Department of Radiology, University of Pittsburgh Medical Center, PA 15213, USA
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Little AF, Baron RL, Peterson MS, Confer SR, Dodd GD, Chambers TP, Federle MP, Oliver JH, Orons PD, Sammon JK. Optimizing CT portography: a prospective comparison of injection into the splenic versus superior mesenteric artery. Radiology 1994; 193:651-5. [PMID: 7972803 DOI: 10.1148/radiology.193.3.7972803] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate whether computed tomographic arterial portography (CTAP) is best performed with injections in the superior mesenteric artery (SMA) or the splenic artery. MATERIALS AND METHODS Seventy-one studies were performed with injection into the SMA (n = 37) or splenic artery (n = 34) of 150 mL of contrast material at 1.5 mL/sec and 20-second delay for both groups. Images were reviewed for location and type of nontumoral perfusion abnormalities. The degree of liver parenchymal enhancement with each technique was compared. RESULTS Fewer nontumoral perfusion defects were seen with splenic artery (65%) versus SMA (78%) injection. Visual differences in contrast enhancement with greater attenuation in dependent portions of the liver were seen with greater frequency with SMA (41%) than with splenic artery (24%) injection. Contrast enhancement that obscured detail in the right lobe was seen only with SMA injections (16%). Greater parenchymal enhancement (up to 18 HU) at all time intervals was seen with splenic artery injection. CONCLUSION Because of greater parenchymal enhancement and fewer nontumoral perfusion abnormalities, splenic artery catheterization is the preferred technique for CTAP.
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Affiliation(s)
- A F Little
- Department of Radiology, University of Pittsburgh Medical Center, PA 15213-2582
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Orons PD, Jabbour N, Zajko AB, Marsh JW. Embolized portal vein catheter fragment in a liver transplant recipient: intraoperative removal using a snare. J Vasc Interv Radiol 1994; 5:839-41. [PMID: 7873862 DOI: 10.1016/s1051-0443(94)71619-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- P D Orons
- Department of Radiology, University of Pittsburgh Medical Center, PA 15213
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Orons PD, Zajko AB, Jungrels CA. Arterioportal fistula causing portal hypertension and variceal bleeding: treatment with a detachable balloon. J Vasc Interv Radiol 1994; 5:373-6. [PMID: 8186610 DOI: 10.1016/s1051-0443(94)71505-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- P D Orons
- Department of Radiology, University of Pittsburgh Medical Center, PA 15213
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Martin M, Zajko AB, Orons PD, Dodd G, Wright H, Colangelo J, Tartar R. Transjugular intrahepatic portosystemic shunt in the management of variceal bleeding: indications and clinical results. Surgery 1993; 114:719-26; discussion 726-7. [PMID: 8211686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) has proved to be a successful bridge to liver transplantation in the management of variceal bleeding. The safety and ease of this technique has now challenged standard surgical approaches to portal hypertension. To define the role of TIPS, we prospectively studied patients undergoing this procedure for variceal bleeding and/or ascites. METHODS From September 1991 to September 1992, 45 patients entered a protocol that included assessment of liver chemistries, ammonia levels, coagulation profiles, liver synthetic function by caffeine-antipyrine clearance, ultrasonographic evaluation of hepatic and portal veins, portogram and direct measurement of portal vein pressures, upper endoscopy, computed tomography for liver volume and ascites, and formal neuropsychiatric evaluation. These studies were repeated at 3-month intervals or more frequently if bleeding or complications occurred. RESULTS Technical success and control of bleeding were achieved in all patients with only three (7%) variceal rebleeds from recurrent portal hypertension. Complete and permanent control of clinical ascites was noted in all patients with this complication. Five of six deaths occurred from sepsis and multiorgan failure in intensive care unit-bound patients with Child class C liver disease. No serial changes were noted in liver chemistries; however, progressive loss of liver volume and prolongation of caffeine-antipyrine clearance was observed in most patients. In addition, hepatic vein stricture or shunt stenosis seen in nine patients (20%) required TIPS revision, whereas the frequent appearance of symptomatic encephalopathy was a main indication for transplantation in 11 of 14 patients. CONCLUSIONS TIPS successfully controls variceal bleeding and may serve as a novel approach to control of diuretic resistant ascites. The uncertain long-term patency and progressive decline in synthetic function emphasize the importance of initiating proper trials comparing TIPS with other management strategies before indiscriminant use of this technique is seen.
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Affiliation(s)
- M Martin
- Department of Surgery, University of Pittsburgh Medical Center, Pa
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