Long-term results of percutaneous biliary balloon dilation treatment for benign hepaticojejunostomy strictures: are repeated balloon dilations necessary?

PURPOSE: To determine the safety, efficacy, and long-term results of percutaneous biliary balloon dilation (PBBD) of benign hepaticojejunostomy strictures and evaluate the necessity of repeated PBBD in this setting. MATERIALS AND METHODS: PBBD was performed after traversing hepaticojejunostomy strictures in 89 patients (40 male, 49 female; age range, 19-84 y; mean age ± SD, 54.5 y ± 14.0), who were divided into three groups: group I (one satisfactory initial PBBD; n = 41), group II (two or more PBBDs with satisfactory initial PBBD; n = 33), and group III (two or more PBBDs without satisfactory PBBD; n = 15). Groups I and II were randomized. The primary outcome measure was the absence of clinical biliary obstruction symptoms at 24 months. Secondary outcome measures included technical and clinical success, primary and secondary patency, major complications, and mortality. Categoric variables were compared between groups I and II. RESULTS: Procedure-related mortality and major morbidity rates were 0% and 5.6%, respectively. Mean primary and secondary patency durations were 45.3 months ± 2.2 and 71.3 months ± 15.4, respectively. The follow-up period was 36.4 months ± 15.1. The primary outcome measure was achieved in 73% of patients. Technical and clinical success rates (secondary outcome measures) were 97.8% and 84.3%, respectively. Repeated PBBD procedures were not satisfactory in 16.9% of patients. No significant differences in categoric variables were observed between groups I and II. CONCLUSIONS: PBBD of benign hepaticojejunostomy strictures is a safe and effective procedure. Repeated PBBD is not required when the first procedure is successful.

Triple metallic stenting in hilar malignant biliary obstructions.

PURPOSE: To research the effects of triple stenting on primary patency rates and on clinical and biochemical findings in patients with high-level malignant biliary obstruction. MATERIALS AND METHODS: We analyzed eight patients who had undergone triple stenting for hilar malignant biliary obstruction, mainly with the percutaneous approach, between January 2009, and September 2009. Pre-interventional bilirubin levels and the existence of pruritus or cholangitis were recorded. Patients were examined 15 days and three months post-intervention. Procedure-related mortality and 30-day mortality rates were recorded. Changes in the serum bilirubin levels, pruritis and cholangitis were examined. Primary patency rates were calculated with the Kaplan-Meier method. RESULTS: Pruritis and cholangitis improved within 15 days. There was a significant decrease in serum bilirubin levels, which were very near to normal limits. Two patients died: one in the fourth month and the other in the eighth month. The mean patency rate was 179±18.81 days. There were no procedure-related or 30-day mortalities in the study group. CONCLUSION: Triple metallic stenting did not significantly improve primary patency rates in hilar malignant biliary obstructions. However, the beneficial effects of triple stenting included the rapid improvement in clinical and biochemical signs in select patients. Triple stenting will be beneficial in preventing isolation that might cause cholangitis. Malignant biliary obstruction in patients with a trifurcation anomaly in the hilar region may necessitate triple stenting.

Percutaneous management of malignant biliary disease: factors influencing the ability to overcome the stricture.

PURPOSE: To determine the factors affecting the ability to cross malignant biliary obstructions in percutaneous transhepatic interventions. MATERIALS AND METHODS: In this study, 256 patients with 310 obstructive malignant biliary lesions from May 2006 to January 2009 were analyzed retrospectively. All of the patients had undergone percutaneous transhepatic cholangiography and intervention. Obstructions crossed in two or fewer sessions were classified as technically easy obstructions, whereas obstructions that required more than two sessions for crossing were classified as technically difficult obstructions. Possible factors thought to affect the ability of malignant biliary obstructions to be crossed were compared according to the obstruction type (technically easy or difficult obstructions). RESULTS: Of the 310 malignant biliary obstructions studied, 79% (246) were technically easy to cross, and 21% (64) were technically difficult to cross. Lesions located between the hilum and the cystic duct and beak-shaped malignant biliary lesions were easily crossed, but suprahilar localized lesions and flat or ovoid-shaped lesions were difficult to cross. The histological nature of the malignant biliary obstruction, the direct-to-total bilirubin ratio, the entry segment for the intervention, the largest bile duct diameter proximal to the obstruction, and the length of the obstruction were not found to influence the ability of the stricture to be overcome. CONCLUSION: In patients with malignant biliary obstructions, the factors that can negatively affect obstruction crossing are lesions with suprahilar localization and flat or ovoid-shaped lesions. We also conclude that after five ineffective attempts have been made to pass the stricture, treatment of malignant biliary obstruction should proceed to external biliary drainage.

Internal thoracic artery-inferior epigastric artery as a collateral pathway in aortoiliac occlusive disease.

OBJECTIVE: In patients with aortoiliac occlusion, the internal thoracic artery-inferior epigastric artery (ITA-IEA) collateral is one of the collaterals supplying blood flow to the lower extremity, and the interruption of this collateral may cause severe leg ischemia. The aim of this study was to evaluate by color duplex ultrasonography scans the ITA-IEA pathway and its significance as a collateral in providing lower-extremity perfusion in aortoiliac occlusive disease. METHODS: Color duplex ultrasonography scans were prospectively performed in 64 consecutive patients with aortoiliac occlusion. Blood flow measurement in the ITA, IEA, and common femoral artery was done on both sides. The patients were stratified according to occlusion level (aorta, common iliac artery, external iliac artery), and the data obtained from such groups were compared. RESULTS: In 95% of patients with aortoiliac occlusion, the ITA-IEA pathway was functioning as a collateral, with mean collateral flow of 66 +/- 48 mL/min, and its average contribution to lower-extremity perfusion was 38% +/- 23%. Additionally, a moderately positive correlation was found between flows of ITA and IEA (r = 0.55, P < .0001). Depending on the level of occlusion, the collateral flow and its contribution to perfusion progressively decreased from the proximal to distal aortoiliac occlusion level. Furthermore, the difference in the ITA-IEA flow volume was statistically significant between occlusion levels (P = .009), but the differences in the perfusion contribution were not different among levels (P = .311). There was also no statistical difference between the groups concerning collateral flow volume and contribution to lower-extremity perfusion in relation to unilateral or bilateral occlusion of the iliac artery, the state of distal run-off being good or poor, or the clinical findings being mild or severe. CONCLUSION: In patients with aortoiliac occlusion, the ITA-IEA collateral pathway is an important route providing lower-extremity perfusion. Additionally, Doppler sonographic flow measurements of the contribution of the ITA-IEA route to lower-extremity perfusion may provide beneficial diagnostic information necessary for the pretreatment work-up of patients with aortoiliac occlusion, especially for whom the ITA is planned to be used as a coronary artery graft.

[Center specific duplex Doppler threshold values in carotid artery stenosis]. / Karotid arter stenozlarinda merkeze özgü dupleks Doppler esik degerleri.

PURPOSE: The traditional categorizations of color Doppler ultrasonography (CDUS) used for grading internal carotid artery stenosis are not consistent with the multicenter controlled randomized studies of carotid artery endarterectomy. The purpose of this study was to determine duplex Doppler threshold values specific to our center for classification of critical internal carotid artery stenosis which is determined according to the results obtained from multi-center clinical studies. MATERIALS AND METHODS: CDUS and digital subtraction angiography examinations were performed in 147 patients who were considered suitable for carotid endarterectomy. Using the values of peak systolic velocity (PSV), end diastolic velocity and peak systolic velocity ratio (PSV ICA/CCA), the optimum duplex Doppler threshold values were determined for internal artery carotid stenoses by ROC (receiver operating characteristics) analysis. RESULTS: The most accurate threshold levels for detection of ICA stenoses were found to be a PSV 133 cm/s for 50-99% stenosis, PSV ICA/CCA 2.6 for 60-99% stenosis and PSV ICA/CCA 3.6 for 70-99% stenosis. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy estimated using optimal duplex criteria for identification of ICA stenoses were 88%, 85% 78%, 91%, 86% for 50-69%, 94%, 87%, 71%, 98%, 89% for 60-99% stenosis, 92%, 92%, 65%, 99%, 92% for 70-99% stenosis, respectively. CONCLUSION: The duplex criteria established in our center have high accuracy. Every center should establish its own duplex criteria for the diagnosis of carotid artery stenosis.

Diagnosis of arterial occlusive disease of the upper extremities: comparison of color duplex sonography and angiography.

PURPOSE: The aim of this study was to assess the abilities of color duplex sonography (CDUS) to detect and characterize arterial occlusive disease of the upper extremities. METHODS: We prospectively compared the results of CDUS with those of intra-arterial digital subtraction angiography, which were considered definitive, in patients with symptomatic arterial occlusive disease of the upper extremities. In each extremity, we visualized 9 arterial segments, which were each evaluated for stenoses and occlusions. Each segment was categorized on each imaging modality as not significantly narrowed (narrowed by <50%), significantly narrowed (narrowed by > or =50% but <100%), or occluded (100%). RESULTS: We examined a total of 578 segments in 57 patients (34 men and 23 women) with a mean age of 50 years (range, 20-74 years). CDUS had a sensitivity, a specificity, a positive predictive value, a negative predictive value, and an accuracy of 98%, 99%, 97%, 99.5%, and 99%, respectively, for detecting occluded lesions and 79%, 100%, 100%, 99%, and 99%, respectively, for detecting hemodynamically significantly stenotic lesions. Notably, the sensitivity of CDUS for diagnosing significantly stenotic lesions (79%) was lower than that for diagnosing occlusive disease (98%). CONCLUSIONS: With high sensitivity and accuracy rates, CDUS is a reliable screening method for detecting arterial occlusive disease of the upper extremities. This modality efficiently provides anatomic and hemodynamic data that are useful in cases of such disease.