Percutaneous management of benign biliary strictures.

The interventional radiologist plays an increasing role in the management of patients with benign biliary disease. This article summarizes the percutaneous management of patients with benign biliary strictures and includes a discussion of currently available techniques. The techniques of percutaneous transhepatic cholangiography and biliary drainage will be reviewed. This includes anatomic and technical considerations of the right midaxillary and left subxyphoid percutaneous approaches, a review of percutaneous dilation of biliary strictures and the management of patients with chronic indwelling biliary drainage catheters. (ie, periodic catheter exchanges, catheter flushing, etc). The article concludes with a discussion of biliary drainage catheters and the clinical and physiologic parameters used in making a decision to remove the tube.

Advanced percutaneous transhepatic biliary access.

Percutaneous transhepatic cholangiography and percutaneous biliary drainage are generally routine procedures in the majority of patients. However, when difficult clinical situations arise, advanced techniques for achieving biliary access may be required. Several advanced techniques for drainage are discussed.

Percutaneous endoscopy for biliary radiologic interventions.

Biliary endoscopy is an adjunct to percutaneous biliary interventions. Although there are technical and cost considerations, the interventional radiologist may apply this useful tool to patients with a wide range of biliary diseases (eg, patients with retained intrahepatic stones, patients with suspected lesions requiring biopsy, etc). Discussed in this article are advantages, disadvantages, patient preparation, technical advice, complications, and a review of the literature. Percutaneous biliary endoscopy, applied through a transhepatic tube tract or a mature T tube tract, reduces radiation exposure to the patient and health care personnel in the room. The procedure is generally performed on an outpatient basis under conscious sedation. Given access to a choledochofiberscope and familiarity with its use, percutaneous endoscopy for biliary radiologic interventions is a valuable technique and may be used to manage patients with complex biliary disease.

Complications of percutaneous transhepatic biliary interventions.

Complications of percutaneous transhepatic biliary drainage procedures range from skin discomfort to life-threatening arterial hemobilia. A thorough understanding of biliary anatomy and postprocedure care is essential if such procedures are to be performed. This article summarizes the anatomic, technical, and clinical issues related to biliary interventions and assists the interventional radiologist in the management of complications encountered in patients undergoing biliary interventions.

Budd-Chiari syndrome: current management options.

OBJECTIVE: To assess the outcomes of current treatment strategies for Budd-Chiari syndrome. SUMMARY BACKGROUND DATA: Budd-Chiari syndrome, occlusion or obstruction of hepatic venous outflow, is a disease traditionally managed by portal or mesenteric-systemic shunting. The development of other treatment options, such as catheter-directed thrombolysis, transjugular portosystemic shunting (TIPS), and liver transplantation, has expanded the therapeutic algorithm. METHODS: The authors reviewed the medical records of all patients diagnosed with Budd-Chiari syndrome at the Johns Hopkins Hospital during the past 20 years. RESULTS: A total of 54 patients were identified: 13 (24%) male patients and 41 (76%) female patients, ranging in age from 2 to 76 years (median 33 years). Twenty-one (39%) had polycythemia vera, 3 (5.6%) used estrogens, 11 (20%) had a myeloproliferative or coagulation disorder, and in 7 (13%) the cause remained unknown. Forty-three patients were treated with surgical shunting, 24 mesocaval and 19 mesoatrial. Actuarial survival rates at 1, 3, and 5 years after shunting were 83%, 78%, and 75%, respectively. Of 33 patients surviving more than 4 years, 28 (85%) had relief of clinical symptoms. Five patients required shunt revision and eight had radiologic procedures to maintain shunt patency. Primary and secondary shunt patency rates were 46% and 69% respectively for mesoatrial shunts and 70% and 85% respectively for mesocaval shunts. Clot lysis was successful as primary treatment in seven patients. TIPS was performed in three patients, one after a failed mesocaval shunt. During an average of 4 years of follow-up, these patients required multiple procedures to maintain TIPS patency. Six patients underwent liver transplantation. Of these, three had previous shunt procedures. Five of the transplant recipients are alive with follow-up of 2 to 9 years (median 6). CONCLUSIONS: Both shunting and transplantation can result in a 5-year survival rate of at least 75%, and other treatment modalities may be appropriate for highly selected patients. Optimal management requires that treatment be directed by the predominant clinical symptom (liver failure or portal hypertension) and anatomical considerations and be tempered by careful assessment of surgical risk.

Chemoembolization of liver tumor in a rabbit model: assessment of tumor cell death with diffusion-weighted MR imaging and histologic analysis.

PURPOSE: To assess the efficacy of chemoembolization of liver tumors by determining the fraction of viable tumor cells remaining after treatment with use of diffusion magnetic resonance (MR) imaging and histologic analysis. MATERIALS AND METHODS: VX2 tumor was grown in the livers of 12 rabbits. Animals were divided into a chemoembolization group and an untreated group. Conventional, perfusion, and diffusion MR imaging was performed on all rabbits. Histopathologic analysis of explanted livers was performed to document tumor cell death and measure Bcl-2 levels (inhibitor of apoptosis). RESULTS: Diffusion-weighted MR imaging delineated zones of tumor cell death as regions of lower signal intensity in both groups. Apparent diffusion coefficients were significantly greater in the area of tumor necrosis than in the area of viable tumor. Histologic analysis demonstrated a significantly lower percentage of viable cells in the treated group (<1%) than in the control group (55%). Bcl-2 expression detected within the viable areas of the tumor was greater in the treated group than in the control group. CONCLUSIONS: Chemoembolization causes extensive tumor cell destruction. Diffusion MR imaging can detect tumor cell death and can be used to assess the efficacy of chemoembolization. Bcl-2 was expressed in the treated group, suggesting an apoptotic pathway of cell death.

Percutaneous replacement jejunostomy after esophagogastrectomy.

A surgically placed jejunostomy tube is a safe and effective means of delivering nutritional support for the postesophagogastrectomy patient. We have previously described a method that permits percutaneous replacement of surgically placed jejunostomy feeding tubes, and now present our results with the use of this technique in 350 consecutive esophagogastrectomy patients. Replacement jejunostomy as required in 17 patients (4.9%). All patients had successful percutaneous jejunostomy replacement. There were no procedural complications or deaths. The timing of feeding tube replacement following esophagogastrectomy was predictive of the indication. Before 16 weeks, the indication for feeding tube replacement was intubation and inability to eat (1 patient) or anorexia with weight loss and dehydration (7 patients). At or after 16 weeks, the indications for feeding tube replacement were all related to symptoms resulting from recurrent carcinoma. We conclude that the technique of percutaneous jejunostomy allows the surgeon tremendous flexibility in the management of the postesophagogastrectomy patient as it preserves the advantages of an adjuvant surgically placed feeding tube over the lifetime of the patient. The technique is safe, and the success rate is excellent.

Percutaneous deployment of a valved bovine jugular vein in the swine venous system: a potential treatment for venous insufficiency.

PURPOSE: To develop a system for potential use in the treatment of chronic venous insufficiency by using percutaneous techniques. MATERIALS AND METHODS: A segment of a glutaraldehyde-fixed bovine external jugular vein with valves was trimmed and sutured to a nitinol stent. Animals were premedicated and anesthetized (n = 11). Venography of the right external jugular vein, inferior vena cava (IVC), and common iliac vein was performed. Deployment was accomplished via a sheath (12-24 F) with use of fluoroscopic guidance. Eleven bioprostheses were deployed in 11 animals. Bioprostheses were deployed in the IVC (n = 3) or right external iliac vein (n = 6). Animals were killed immediately after deployment (n = 7) at 1 week (n = 1) or at 2 weeks (n = 2). One animal was found dead in the cage. At necropsy, each bioprosthesis (n = 4) was explanted and histopathologic analysis was performed. RESULTS: Deployments of the bioprostheses were successful in nine of 11 swine. Two deployments were unsuccessful (one accidental deployment in the right renal vein, one deployment in the IVC caused rupture of the vein). Postdeployment venography (n = 9) confirmed no reflux (in the recumbent position of the swine) of the valve leaflets and patency of the vein inferior to the level of the bioprostheses. in the first group of animals (n = 5), valve leaflets were normal and competent. In the survival animal group (n = 4), the bioprostheses remained patent without evidence of thrombus formation by ascending and descending venography. Gross inspection of the explanted bioprostheses (n = 4) demonstrated grossly normal valves that fully occluded the lumen. Complications included hemarthrosis (n = 1), death (n = 1), and bioprosthesis thrombosis immediately after deployment (n = 1). Histopathologic analysis showed endothelial cells covering the luminal surfaces. The wall of the bioprostheses had granulomatous response and foreign body reaction. Bacterial contamination was noted in one bioprosthesis. CONCLUSIONS: Deployment of a glutaraldehyde-fixed bovine vein sutured to a self-expanding nitinol stent in the swine iliac vein or IVC is technically feasible. Development of a venous bioprosthesis that can be placed percutaneously may have important clinical applications as an endovascular treatment for chronic venous insufficiency when it is due to valvular incompetence.

How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement.

OBJECTIVE: The introduction of excessive lengths of guidewire during placement of central venous catheters from the internal jugular vein (IJV) or the subclavian vein (SCV) can result in rare but significant complications. To identify a "safe" guidewire insertion length, the authors performed direct intravascular measurement of the distance from these venous access sites to the superior vena cava-atrial junction (CAJ), and evaluated these distances relative to the patients' height, weight, sex, and chest radiographs. DESIGN: Prospective, nonrandomized observation. SETTING: The Interventional Radiology Department of a tertiary care referral hospital. PATIENTS: 100 adults (45 women, 55 men) evaluated during fluoroscopically directed central venous catheter placement. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The distance from the IJV or SCV access site was directly measured using fluoroscopy and an intravascular guidewire. 40 right IJVs, 31 right SCVs, 16 left SCVs, and 13 left IJVs were studied. Comparative measurements from the postprocedure radiograph were made in 20 of these cases. All measurements were correlated with patient sex, height, and weight. The mean distance from all access sites to the superior vena cava-atrial junction was 18.0 cm. The right IJV distance was the shortest, averaging 16 cm. The left SCV distance was the longest, averaging 21.2 cm. Right SCV and left IJV distances were 18.4 and 19.1 cm, respectively, but this difference was not statistically significant. Weight and radiographic measurements did not correlate with the measured vascular distance, although there was a trend toward longer distances in taller patients and males. CONCLUSIONS: Patient height, weight, and measurements from previous chest radiographs are less reliable in predicting a safe wire length than is the access site selected. In most cases, 18 cm should be considered the upper limit of guidewire introduced during central catheter placement in adults. The guidewires supplied in catheter kits should have lengths correlated to those of the catheters, and should have distance markings printed upon them.

Isolated right segmental hepatic duct injury: a diagnostic and therapeutic challenge.

Biliary leaks and injuries are not an uncommon occurrence following laparoscopic cholecystectomy. Bile leaks associated with the biliary anatomic variant of a low-inserting right segmental hepatic duct can be particularly difficult to diagnose in that results of endoscopic retrograde cholangiography (ERC) are usually interpreted as "normal" with no leaks demonstrated. The aim of this study was to describe a single institution's experience with nine patients with biliary leaks associated with this anatomic variant and to discuss their management. A retrospective analysis of the hospital records of all patients with bile duct injuries managed at a single institution between 1980 and July 1998, inclusive, was performed. Nine patients were identified as having an isolated right segmental hepatic duct injury associated with a biliary leak. Seven (78%) of the nine patients had undergone a laparoscopic cholecystectomy, whereas the remaining two patients (22%) had undergone an open cholecystectomy. All of the patients had undergone endoscopic retrograde cholangiography at outside institutions, the results of which had been interpreted as normal with no apparent leaks. The median interval from the time of cholecystectomy to referral was 1.4 months. All patients were managed with initial percutaneous access of the involved right segmental biliary system, with placement of a percutaneous transhepatic stent. After the biliary leak was controlled, all patients underwent Roux-en-Y hepaticojejunostomy to the isolated biliary segment. All patients had an uncomplicated postoperative course. There were no postoperative anastomotic leaks. Postoperative stenting was maintained for a mean of 8 months. Six (67%) of the nine patients had a long-term successful outcome with minimal or no symptoms. In three patients, recurrent symptoms with pain and/or cholangitis developed at a mean of 34 months. All three patients underwent percutaneous cholangiography, which demonstrated an anastomotic stricture, and all were managed with percutaneous balloon dilatation with a successful outcome. Currently eight (89%) of the nine patients are asymptomatic, with a mean follow-up of 70.4 months (range 12 to 226 months). One patient had intermittent right upper quadrant pain with normal liver function tests but has not required intervention. Isolated right segmental hepatic ductal injury with biliary leakage is an uncommon complication following laparoscopic cholecystectomy. A diagnostic dilemma is created by the presence of a bile leak with a normal endoscopic retrograde cholangiogram. Management begins with percutaneous access of the transected isolated ductal system followed by reconstruction as a Roux-en-Y hepaticojejunostomy.

Placement of a flexible endovascular stent across the femoral joint: an in vivo study in the swine model.

PURPOSE: To investigate the effects of joint motion on the structural integrity of periarticular stents and on the development of neointimal hyperplasia within these devices. MATERIALS AND METHODS: In four juvenile farm swine, Wall-stents were implanted in the common femoral arteries and contralateral common femoral veins, centered at the point of maximal conformational change during passive hip flexion. Control stents were placed in the aortae and iliac veins. Angiography and transcatheter blood pressure measurements were obtained across each stent, with periarticular stents studied in flexion and extension. Two animals underwent repeated evaluation after 1 month, the others after 3 months. Findings were correlated with gross and histopathologic findings in the harvested stents. RESULTS: No stent fractures occurred. One femoral vein was injured during stent placement and was occluded 1 month later at follow-up. Hemodynamically significant stenoses were identified in one arterial stent and one venous stent at 3 months. The amount of neointimal hyperplasia was greater in periarticular stents than in controls and greater in animals studied at 1 month than in those studied at 3 months. The pattern of neointimal hyperplasia within mobile arteries was circumferentially asymmetric and thicker at the distal ends of the stents. Venous neointimal hyperplasia was thicker and markedly different in character than that seen in arterial stents from the same animals. CONCLUSIONS: Periarticular Wallstents and the underlying vascular anatomy remained structurally intact despite the stresses of repetitive motion during a 3-month period. Stents deployed across joints or in venous locations may be at greater risk for neointimal hyperplasia development and eventual occlusion than those deployed in immobile vessels and arteries. Neointimal hyperplasia may decrease in thickness after an initial period of exuberant development. Additional studies are necessary to determine long-term outcomes.

Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome).

Ovarian and pelvic (internal iliac) varices have long been recognized as a source of chronic pelvic pain in women. The technique of transcatheter embolotherapy for ovarian and pelvic varices requires selective catheterization of the ovarian and internal iliac veins, followed by contrast venography and embolization. The long-term effects of treatment are the subject of ongoing investigation. This article provides a concise background on ovarian and pelvic varices and reviews the recently published literature on their embolization for the treatment of pelvic venous incompetence (also known as pelvic congestion syndrome).

TIPS placement in swine, guided by electromagnetic real-time needle tip localization displayed on previously acquired 3-D CT.

PURPOSE: To determine the feasibility of guiding a transjugular intrahepatic portosystemic shunt (TIPS) procedure with an electromagnetic real-time needle tip position sensor coupled to previously acquired 3-dimensional (3-D) computed tomography (CT) images. METHODS: An electromagnetic position sensor was placed at the tip of a Colapinto needle. The real-time position and orientation of the needle tip was then displayed on previously acquired 3-D CT images which were registered with the five swine. Portal vein puncture was then attempted in all animals. RESULTS: The computer calculated accuracy of the position sensor was on average 3 mm. Four of five portal vein punctures were successful. In the successes, only one or two attempts were necessary and success was achieved in minutes. CONCLUSION: A real-time position sensor attached to the tip of a Colapinto needle and coupled to previously acquired 3-D CT images may potentially aid in entering the portal vein during the TIPS procedure.

The biliary manometric perfusion test and clinical trial--long-term predictive value of success after treatment of bile duct strictures: ten-year experience.

PURPOSE: To evaluate the long-term predictive value of the biliary manometric perfusion test and clinical trial for determining patency after treatment of bile duct strictures. MATERIALS AND METHODS: One hundred four patients with benign biliary disease were treated with surgical (n = 59) or percutaneous (n = 45) techniques followed by intubation with large-caliber silicone stents. Prior to removal of the biliary stents, patients underwent a biliary manometric perfusion test (n = 168) and/or a clinical trial (n = 105) to objectively and subjectively evaluate the treated site for potential long-term patency. The patients were followed up for 1-87 months, and clinical outcomes were determined. Kaplan-Meier survival curves were generated for three patient groups, including those who (i) passed either test, (ii) failed either test, and (iii) failed either test, were re-treated, and passed either test. RESULTS: Final successful treatment outcomes were documented in 47 (92%) surgically and 31 (86%) percutaneously treated patients, respectively (P = .001). The Kaplan-Meier survival curves determined the probability of patency at 0, 2, 4, and 6 years after treatment to be 1.0, .96, .78, and .59, respectively, after passing a biliary manometric perfusion test; and 1.0, .91, .78, and .78, respectively, after passing a clinical trial (P > .10). The probability of patency at 4 years after treatment was .45 after failing a biliary manometric perfusion test, and at 6 months was zero after failing a clinical trial (P = .001 and .001, respectively, vs the same test in the passing group). Seventy-nine percent of patients who failed either test required an additional period of repeated stent placement or reoperation. After repeated treatment, the probability of patency at 0-4 years was .80 and .88, respectively, for the biliary manometric perfusion test and clinical trial (P > .05 and P > .10, respectively, vs same test in the group that passed). CONCLUSION: Patients who initially pass either the biliary manometric perfusion test or clinical trial have a significantly increased probability of patency versus those who fail; however, patients who fail either test and who then receive definitive additional treatment have a similar probability of patency as those who initially pass. Although the log rank test demonstrated the Kaplan-Meier survival curves from the biliary manometric perfusion test and clinical trial not to be significantly different in any of the three groups (ie, passing, failing, re-treated), the biliary manometric perfusion test is recommended over the clinical trial because of its simplicity, immediate results, and predicted cost savings.

Entrapment of J-tip guidewires by Venatech and stainless-steel Greenfield vena cava filters during central venous catheter placement: percutaneous management in four patients.

We present four patients in whom bedside placement of a central venous catheter was complicated by entrapment of a J-tip guidewire by a previously placed vena cava (VC) filter. Two Venatech filters were fragmented and displaced into the superior VC or brachiocephalic vein during attempted withdrawal of the entrapped wire. Two stainless-steel Greenfield filters remained in place and intact. Fluoroscopically guided extraction of both wires entrapped by Greenfield filters was successfully performed in the angiography suite.

Real-time bronchoscope tip localization enables three-dimensional CT image guidance for transbronchial needle aspiration in swine.

STUDY OBJECTIVE: To determine the feasibility of using real-time bronchoscope position technology coupled with previously acquired three-dimensional CT data to enhance transbronchial needle aspiration (TBNA). DESIGN: Eight swine were given percutaneously created target lesions for TBNA. A miniature position sensor was placed at the tip of a bronchoscope, and real-time position information during bronchoscopy was presented on a monitor simultaneously displaying previously acquired three-dimensional CT data. INTERVENTIONS: TBNA of target lesions and submucosal ink-spot injection of computer-generated targets. MEASUREMENTS AND RESULTS: TBNA specimens revealed successful aspiration of target material. Distances between ink marks made at computer-generated tracheal targets varied, on average (+/- SD), 4.2 mm +/- 2.6 mm from predetermined computer-distance coordinates. CONCLUSION: Real-time bronchoscope position technology coupled with previously acquired CT images may aid with TBNA of nonvisible extrabronchial lesions.