Indigo Thrombectomy System for Hepatic Artery Thrombosis After Liver Transplantation: A Case Report.

INTRODUCTION: Hepatic artery thrombosis still represents a major complication after liver transplantation responsible for graft failure, possibly resulting in the need for retransplantation. CASE REPORT: We describe a case of a patient undergoing liver transplant complicated by hepatic artery thrombosis, successfully treated with an endovascular approach using the Indigo System. This new system allows mechanical fragmentation and aspiration of the thrombus, with no injection of any thrombolytic agents, thereby reducing the risk of bleeding. Hepatic artery flow was immediately restored, with no complications for the patient and the graft. DISCUSSION: The Indigo System appears to be a safe, affordable, and manageable technique for endovascular management of late hepatic artery thrombosis after liver transplant.

RESULTS FROM A NEW METHOD TO ASSESS THE OCCUPATIONAL LENS DOSE IN INTERVENTIONAL RADIOLOGY.

Interventional radiology procedures have always been of particular concern because of the potential high dose to the workers. Special attention has recently been given to the lens dose: in 2011 the ICRP issued the recommendation 'Statement on Tissue Reactions' where a new limit of 20 mSv in a year, averaged over defined periods of 5 years, is given. Due to the impossibility of measuring the dose directly on the eye, there is not still a general consensus on a standardized methodology to assess the lens dose, which should be at the same time reliable, robust and simple to implement in practice. The procedure described here aims to assess the lens dose using the Hp(0.07) equivalent dose measured with a dosimeter worn at chest level above the lead apron, through a correlation with the total KAP per procedure and considering the type of the protection tools used during each procedure: glasses (with lateral shields), ceiling screen, both or neither of them and the frequency of their use.

Splenic Artery Syndrome as a Possible Cause of Late Onset Refractory Ascites After Liver Transplantation: Management With Proximal Splenic Artery Embolization.

BACKGROUND: Portal hyperperfusion (PHP) is a hemodynamic condition which may develop after liver transplantation and cause refractory ascites (RA). The diagnosis is established by exclusion of other causes of increased sinusoidal pressure/resistance such as cellular rejection or toxicity and outflow obstruction. PHP as part of the pathogenesis of the splenic artery syndrome (SAS) can be treated with splenic artery embolization (SAE). METHODS: This is a retrospective study on a cohort of first-time whole-size liver transplant recipients diagnosed with RA due to PHP and treated by proximal SAE (pSAE) at the Liver Transplant Unit of the University Hospital of Udine between 2004 and 2014. RESULTS: For this study, 23 patients were identified (prevalence 8%) and treated. Preliminary clinical workup to diagnose SAS was based on exclusion of other possible causes of RA with graft biopsy, cavogram with hepatic venous pressure measurement, computed tomography scan, and angiography. The pSAE was performed 110 ± 61 days after transplantation, and no procedure-related complications occurred. pSAE resulted in a significant decrease of portal vein velocity (P = .01) and wedge hepatic venous pressure (P = .03). The diameter of the spleen showed a slightly significant reduction (P = .047); no modification of hepatic artery resistive index were encountered (P = .34). Moreover, pSAE determined the resolution of RA in all cases. CONCLUSIONS: pSAE is a safe and effective procedure to modulate the hepatic inflow and thus to treat RA secondary to SAS, with a low incidence of complications and a high rate of clinical response.

Necrosis percentage of radiologically treated hepatocellular carcinoma at hepatectomy for liver transplantation.

Among a cohort of 414 liver transplantations (OLT) performed form 1996 to 2009, we analyzed 86 patients (20.7%) who were affected by hepatocellular carcinoma (HCC) superimposed on cirrhosis, including 82 with a preoperative diagnosis of tumor; 4 cases had the diagnosis established upon histologic examination after hepatectomy. The gender of 75 patients was male (91.5%), and female in 7 cases (8.5%). The median Model for End-Stage Liver Disease score was 10 (range, 6-23). The underlying liver disease was hepatitis C virus (HCV)-related cirrhosis (41.46%), hepatitis B virus (HBV)-related cirrhosis (15.6%), or alcohol-related cirrhosis (29.3%); cryptogenic; HCV+HIV; HBV+HIV; or HCV+HBV+HIV cirrhosis were present in an other few patients. The diagnosis of HCC and the preoperative staging were defined through radiologic evaluations, without biopsy confirmation in any case. All patients underwent pretransplant radiologic treatments to reduce the drop-out risk while a waiting OLT; OLT was performed for HCC patients within the Milan criteria. Upon histologic examination, the median HCC necrosis was 57 ± 36%; in 22 cases (26.8%), there were no necrotizing effects. Forty patients (48.8%) display a satisfying degree of disease control with 26 patients (31.7%) downstaged effect; 15 patients (18.3%) showed neoplastic progression with advanced neoplastic disease exceeding the Milan criteria at hepatectomy. One patient had nonevaluable necrosis (1.2%). Our experience showed preoperative radiologic treatments to be not curative but serving as a bridge to OLT.

Graft vessel wall pathology in a case of hepatic artery pseudo-aneurysm in a liver transplant recipient.

Pseudo-aneurysms (PAs) of the hepatic artery are rare complications of liver transplantation, which are characterized by a high mortality rate. The majority occur within the first 2 months after orthotopic liver transplantation. They become clinically manifest with sudden hypotension, gastrointestinal bleeding, and abnormal liver function test results. Early diagnosis and treatment are essential to prevent life-threatening hemorrhage. Conventional treatment consists of surgical resection and vascular reconstruction, but a feasible treatment option involves an angiographic approach with the positioning of a stent or transarterial coil embolization followed by revascularization. We report a case of posttransplantation hepatic artery PA (HA-PA) with bleeding into the duodenum, diagnosed using abdominal computed tomography (CT). Arterial kinking prevented a covered stent graft from being inserted successfully using X-ray angiography, so the patient underwent emergency surgery in an attempt to exclude the PA and revascularize the organ via an aorto-hepatic bypass with an iliac vascular graft obtained from the donor. The surgical procedure failed due to progressive macroscopic dissection of the HA wall up to the bifurcation. The patient underwent retransplantation but died 25 days later due to multiple-organ failure. Histopathology of the first liver graft confirmed arterial graft dissection and pathological changes in the donor HA wall.

Intraperitoneal Tenckhoff catheter for the treatment of recurrent lymphoceles after kidney transplantation: our early experience.

Lymphoceles may occur as frequently as 16% of the time after kidney transplantation, becoming clinically evident between 18 and 180 days after surgery. The management of lymphoceles is unclear. Percutaneous needle aspiration and external drainage are associated with high recurrence and complications. Surgical intraperitoneal marsupialization of lymphocele is considered the treatment of choice, but requires hospital admission, general anesthesia, and sometimes extensive surgical dissection. We discuss our experience in the treatment of recurrent symptomatic lymphocele intraperitoneally drained using a Tenckhoff catheter in 7 consecutive patients. Clinical manifestations became evident between 26 and 90 days after transplantation. The diagnosis was obtained with abdominal ultrasound in all cases; mean lymphocele diameter was 14 +/- 6 cm. After percutaneous drainage, performed to differentiate urinoma/lymphocele and to rule out infections, the lymphocele recurred within 1 month. Thereafter, we decided to treat recurrent lymphatic collection using a Tenckhoff catheter. The lymphocele was located during the operative procedure using a sterile 3.5-MHz ultrasound probe. With the patient under local anesthesia, we performed 2 vertical 1-cm incisions to the lymphocele and peritoneum, respectively. The Tenckoff catheter was first positioned into the lymphocele and the tunneled inside the peritoneal cavity. One cuff of the Tenckhoff was fixed to the fascia to avoid possible delocalization. The patients were discharged the same day. The catheter was removed 6 months later with no evidence of lymphocele recurrence.

Successful minimally invasive management of late portal vein thrombosis after splenectomy due to splenic artery steal syndrome following liver transplantation: a case report.

Portal vein thrombosis (PVT) after liver transplantation (OLT), which occurs in 1% to 2.7% of cases, can compromise patient and graft survival. Percutaneous transhepatic portal vein angioplasty offers an option to treat PVT, diminishing surgically related morbidity and the need for retransplantation. We describe a case of late PVT after OLT, which was successfully treated by a minimally invasive percutaneous transhepatic approach using both mechanical fragmentation and pharmacologic lysis of the thrombus followed by anticoagulation. The patient has had a good clinical course with normal graft function and patent portal blood flow at 6-month follow-up. This case report confirms the possibility of successful recanalization of the portal vein in a patient with late PVT after liver transplantation. Sustained anticoagulation/antiaggregation therapy for at least 6 months after the procedure is advisable.

Percutaneous mechanical fragmentation and stent placement for the treatment of early posttransplantation portal vein thrombosis.

BACKGROUND: Early portal vein thrombosis is a rare but severe complication of liver transplantation requiring retransplantation or at least surgical thrombectomy, both hampered by high morbidity and mortality. METHODS: We describe of a case of successful long-term recanalization of early posttransplantation portal vein thrombosis by a minimally invasive percutaneous transhepatic angiographic approach using both mechanical fragmentation and pharmacological lysis of the thrombus followed by stent placement. RESULTS: Mechanical fragmentation and contemporaneous local urokinase administration resulted in complete removal of the clot; the use of a vascular stent after balloon dilatation allowed restoration of normal blood flow to the liver after 9 months of follow-up. CONCLUSIONS: This case report confirms the possibility of successful recanalization of the portal vein after early posttransplantation thrombosis by a minimally invasive angiographic approach. Balloon dilatation and placement of a vascular stent could help to decrease the risk of recurrent thrombosis.

Treatment options in Western hepatocellular carcinoma: a prospective study of 224 patients.

BACKGROUND/AIMS: Though hepatocellular carcinoma (HCC) is one of the most frequent malignant tumors in the world, the optimal therapeutic strategy is still poorly defined. This is mainly due to geographic differences in HCC which may affect the validity of treatment regimens in differents areas of the world. The aim of the present study was to analyze the natural course of the disease as well as to assess the efficacy of different therapeutical schemes in HCC observed in Ljubljana (Slovenia) and Trieste (Italy), two cities in Western Europe situated close to each other. METHODS: During the period from January 1988 to December 1993, 224 consecutive patients (132 in Trieste and 92 in Ljubljana) with HCC were enrolled in the study. Patients were treated with the following 3 schemes: surgery 39 (17.4%), transcatheter chemoembolization (TACE) 116 (51.8%), and no treatment 69 (30.8%). The tumor was classified by Okuda staging and the liver disease by Child-Pugh score. Patients were followed up for 12-60 months, with an average of 40 months. The response rate to TACE and recurrence following surgery were evaluated. Comparative analysis of survival between different treatment groups was performed. RESULTS: The natural course of the disease, and other characteristics of the HCC, showed a typical Western type of tumor. Liver disease was scored as Child A in 58%, Child B in 30% and Child C in 12%, and the tumor was staged as Okuda I in 52%, Okuda II in 37% and Okuda III in 11%, respectively. Treatment with TACE was followed by an objective response in 27%, with a median survival of 31 months. Surgery was followed by a recurrence rate of 77% within 19.5 months and median survival of 49 months. The overall median survival of nontreated patients was 8 months. Survival in each group of patients differed significantly between all three consecutive stages of Okuda (p<0.001). In contrast, the differences in survival were significant only between Child A and B (p<0.02). The differences between Child B and C were not significant. CONCLUSIONS: This study emphasizes the importance of staging in the choice of treatment modality and diffusion of HCC in affecting an overall response to treatment and survival. Surgery is highly effective in monofocal HCC of Okuda I and II without cirrhosis. TACE is effective in Okuda I and II and Child A cirrhosis only. The treatment of HCC in Child B cirrhosis needs further studies. In Child C and/or Okuda stage III of HCC, any treatment except pure symptomatic relief is detrimental and should not be used.

[Diagnostic imaging and interventional therapy in hepatocarcinoma. Multicenter study of 290 cases]. / La diagnostica mediante immagini e la terapia interventistica dell'epatocarcinoma. Studio multicentrico su 290 casi.

We report the results of a multicenter study on the diagnosis and interventional therapy of hepatocellular carcinoma (HCC). The first aim--diagnosis--was to evaluate the sensitivity of 4 imaging techniques, namely ultrasonography (US), Computed Tomography (CT), digital arteriography (DSA) and Lipiodol CT (LCT), in HCC detection. The accuracy of these techniques was also investigated in tumor staging, which is important for treatment planning. Two hundred ninety patients underwent this imaging protocol. The patients were classified by tumor spread into three groups, namely group 1 (single HCCs < 5 cm), group 2 (multifocal HCCs with max. 3 nodules or tumor volume < 80 cc), group 3 (multifocal HCCs with more than 3 nodules and/or tumor volume > 80 cc). US and CT diagnosed more cases as group 1 and fewer cases as group 3 than DSA and LCT; the latter two techniques gave a similar classification. With LCT as the gold standard, US and CT understaged 27.9% and 26.5% of cases, respectively. Even though LCT is known to have 53% sensitivity, it is currently the most sensitive preoperative investigation and therefore the best tool for treatment planning. In surgical patients, however, intraoperative US, with its nearly 100% sensitivity, is suggested. The second aim--treatment--consisted in assessing the therapeutic efficacy of intraarterial chemoembolization (CEAT) versus percutaneous ethanol injection (PEI) in non advanced HCC and of CEAT versus no treatment (NT) in advanced HCC. Treatment efficacy was evaluated with the following randomized protocols: PEI versus CEAT in group 1, PEI versus CEAT in group 2 and CEAT versus NT in group 3. The data were analyzed relative to 215 patients for 6 to 30 months. The Kaplan-Meier method was used to calculate survival rates, which were, at 24 and 30 months, 72% and 72% for PEI and 72% and 52% for CEAT in group 1, 52% and 28% for PEI and 70% and 50% for CEAT in group 2 and finally 30% and 20% for NT and 45% and 30% for CEAT in group 3. In group 1, PEI appeared markedly superior to CEAT. In group 2, the difference between PEI and CEAT was not statistically significant; the results in this group indicate that CEAT should be considered when three nodules are present because of PEI invasiveness in these cases. In group 3, CEAT results were definitely better in the first two years, but there was no difference with NT patients at the end of the third year. Therefore, CEAT is indicated in advanced HCC because it improves the survival rate in the first 24 months. After this period, the survival time is not modified by treatment.

[Role of Doppler color ultrasonography and of flowmetric analysis in the diagnosis and follow-up of Grave's disease]. / Ruolo dell'eco color Doppler e dell'analisi flussimetrica nella diagnosi e nel follow-up della malattia di Graves.

Hyperthyroidism in Graves' disease is caused by the presence of circulating autoantibodies to the THS receptors on the thyroid cells. Thyroid-suppression therapy prevents hormone production directly, without affecting the pathogenetic process. We performed color Doppler US of the thyroid gland and pulsed Doppler analysis of thyroid artery flow in 21 patients with Graves' disease before and during medical treatment. US results were compared with those of a control group of 40 healthy subjects and correlated with the values of thyroid hormones, TSH, and thyroid microsomal and thyroglobulin antibodies. The thyroid gland was hypovascularized in the control group. Pulsed Doppler examination of the thyroid arteries exhibited peak systolic velocity of PSV 20 +/- 4 cm/s, diastolic velocity of 8 +/- 1 cm/s, and resistive index of 0.60 +/- 0.04. The thyroid gland of Graves' disease patients was hypervascularized. Pulsed Doppler examination of the thyroid arteries exhibited peak systolic velocity (PSV = 51 +/- 12 cm/s), end diastolic velocity (VD = 15 +/- 4 cm/s), and resistive index (RI = 0.71 +/- 0.04) significantly higher than in normal subjects (p < 0.001). Circulating thyroid hormones and flow parameters normalized after 6-8 months of medical therapy (PSV = 20 +/- 6 cm/s, VD = 9 +/- 3 cm/s, RI = 0.58 +/- 0.07). Conversely, the color Doppler patterns normalized only in a patient with normal TSH and antibodies. Sampling of the thyroid arteries proved more repeatable than sampling of parenchymal vessels.

[Comparative evaluation of ultrasonography, computerized tomography, angiography and lipiodol CT in defining extent of hepatocarcinoma. A multicenter study]. / Valutazione comparativa dell'ecografia, della Tomografia Computerizzata, dell'angiografia, della Lipiodol TC nel bilancio di estensione dell'epatocarcinoma. Studio multicentrico.

The authors report the results of a multicentric trial on hepatocellular carcinoma (HCC) patients, whose lesions were confirmed with biopsy or by high (> 400 ng/ml) alpha-fetoprotein levels. The series consisted of 149 patients examined in 8 different centers and submitted to ultrasonography (US), Computed Tomography (CT) before and after contrast agent administration, angiography and Lipiodol CT. According to lesion size and number, the patients were divided with each imaging modality into three groups: a) group 1: unifocal HCC < 5 cm diameter; b) group 2: multifocal HCC with 2-3 nodules and/or tumor mass < 80 ml; c) multifocal HCC with more than 3 nodules (with total tumor mass not exceeding 40% of liver volume) or with total tumor mass > 80 ml. In 77 patients all the examinations were available for comparison. US and CT diagnosed more patients as belonging to group 1 than angiography and Lipiodol CT, while more patients were classified as groups 2 and 3 with angiography and Lipiodol CT, meaning that US and CT may understage some HCC cases (about 15%) because they show a lower number of nodules. This observation was confirmed by the direct comparison between US and Lipiodol CT (in 114 patients), CT and Lipiodol CT (in 103 patients) and angiography and Lipiodol CT (in 116 patients). US and Lipiodol CT were in disagreement in 18 cases, CT and Lipiodol CT in 16 cases and angiography and Lipiodol CT in 13 cases. In most of these cases, Lipiodol CT showed more lesions than the other techniques. The size of the undetected lesions was small, ranging few mm to 2 cm in nearly all cases. To conclude, the results of this multicentric trial show that Lipiodol CT is a fundamental tool to evaluate HCC extent. In contrast, conventional CT appeared not to add any significant piece of information and can therefore be excluded from the diagnostic protocol of HCC.

[Thin-section computerized tomography of the kidney in the differential diagnosis of small tumor and cystic hypodensities]. / La tomografia computerizzata con strato sottile del rene nella diagnostica differenziale delle ipodensità tumorali e cistiche di piccole dimensioni.

Small hypodense renal lesions with a round shape are frequently detected on CT scans of the upper abdomen after contrast medium administration. In nearly all cases these round hypodensities are simple small cysts with no clinical significance. However, the fluid density of these cysts cannot be always defined, due to the partial volume averaging which occurs on CT when 10-mm-thick slices and contrast enhancement are used. Therefore, a malignant tumor--i.e., small renal tumors or metastatic lesions--cannot be ruled out in some cases. Since the limitations of CT are related to partial volume averaging, the authors used both 5-mm and 10-mm slices to reduce this artifact. Forty-eight small hypodensities (< 15 mm) were studied after contrast agent administration: 42 of them were simple cysts and 5 were tumoral lesions--i.e., 3 renal cell carcinomas and 2 lymphomatous lesions. The results showed that, with 5-mm slices, the density of the fluid hypodensities decreased in nearly all cases and in 81.3% of cases it was below 30 HU. The difference in densities between 10-mm and 5-mm slices was about 50 HU (75 +/- 30 to 21 +/- 16 HU). In the 5 tumoral hypodensities, lesion density was still in the soft tissue range also with 5-mm slices, with no major decrease. These results show that this technique is simple and effective in the differential diagnosis of small renal hypodensities since it requires only a short additional examination time.

[Arterial anatomy of the celiac trunk and the superior mesenteric artery with computerized tomography]. / Anatomia arteriosa del tripode celiaco e dell'arteria mesenterica superiore con la tomografia computerizzata.

A hundred patients with different conditions underwent CT and the results were retrospectively reviewed to evaluate the visibility of the celiac trunk, of its branches and of the superior mesenteric artery. Thirty-six patients underwent angiography too, which allowed the anatomical variants suspected on CT to be demonstrated, according to Kuhns' criteria. The other 64 patients were consecutively selected and only aneurysmal changes were not included. All examinations were performed using a General Electric 9800 Advantage scanner, with 2 second scanning time and 10 mm-thick contiguous scans. In 20 patients 5 mm contiguous scans were performed. All examinations followed i.v. injections of contrast agents which were given with an automatic injector. The cases with suspected anatomical variants on CT but with no angiographic confirmation were not considered. A hundred CT exams were retrospectively reviewed: the celiac trunk and the common hepatic artery were demonstrated in all of them. Visibility of the other branches was 40% for the hepatic artery, 53% for the right branch of the hepatic artery and 39% for its left branch, 70% for the gastroduodenal artery, 82% for the left gastric artery, 97% for the splenic artery and 100% for the superior mesenteric artery. As for the 36 patients who underwent both CT and angiography, right hepatic artery from the superior mesenteric artery was seen in 19% of cases with both modalities; common hepatic artery arising from the superior mesenteric artery was detected in 2% of cases. In both instances, these anatomical variants appeared as a vessel running posterior to the portal vein. The careful investigation of axial CT scans showed the level of origin of the artery from the superior mesenteric artery. These results are in agreement with the angiographic data reported in the literature. Our study demonstrated that the celiac trunk and its variants are always depicted by the new CT scanner. The knowledge of these variants may be useful in the patients to submit to liver surgery. The celiac trunk and its variants are demonstrated with conventional 10 mm slices. The use of 5 mm slices improves the visibility of thin anatomical branches but is not essential to recognize the major vessels and anatomical variants.