[Liver transplantation, vascular complications, role of imaging, percutaneous therapeutic possibilities]. / Transplantation hépatique complications vasculaires place de l'imagerie possibilités thérapeutiques per-cutanées.

Duplex Doppler ultrasound should be the first investigation when a vascular complication is suspected. Serial examinations may increase sensitivity. Color imaging enhances identification of small vessels and increases specificity. Angiography is not necessary unless an pseudoaneurysm is suspected. When duplex Doppler ultrasound is abnormal, angiography is performed to evaluate the possibility of treatment. Endovascular therapeutic procedures appear to have a limited field of application in comparison to percutaneous biliary procedures. Hemostatic embolization or dilatation of vascular strictures can be used either as definitive treatment or while waiting for a new graft to be performed under better conditions.

Primary treatment of hepatocellular carcinoma by arterial chemoembolization.

Two hundred and ninety-one patients with hepatocellular carcinoma were treated by chemoembolization (CE), using ethiodized oil, doxorubicin, and a gelatin sponge. Patients with thrombosis of either the portal vein or a main branch were excluded. The mortality rate in the first 2 months after treatment was 7% in noncirrhotic patients, 2.8% in patients with class A cirrhosis, 8% in patients with class B cirrhosis, and 37% in patients with class C cirrhosis. The tumor diameter remained the same in 55.3% of patients, was reduced by up to 50% in 20% of the patients, was reduced by more than 50% in 7.3% of the patients, and almost completely disappeared in 1.8% of the patients. The diameter of the tumor increased in 15.6% of patients. Forty-three patients underwent a resection or transplantation after chemoembolization. Histologic examination of the specimens revealed significant necrosis of the tumor. The long-term survival rate at 2 years was 49% for class A cirrhotics, 29% for class B cirrhotics, and 9% for class C cirrhotics. Complications included cholecystitis (10%), vasculitis (14%), renal decompensation (13%), an increase in ascites (14%), and jaundice (12%). Chemoembolization is an effective and safe initial treatment for hepatocellular carcinoma. It is effective in producing tumor necrosis and reducing the size of the tumor. Improvement in survival was noted when patients who underwent chemoembolization were compared with an historical series of untreated patients, and resection and transplantation are kept as options.

[Use of a constant-flow 2-phase injector for abdominal scanners in 60 patients]. / Utilisation d'un injecteur biphasique à débit constant pour les scanners abdominaux chez 60 patients.

The intravenous injection of a contrast medium is carried out in more than 80% of all the patients undergoing abdominal CT. The use of a constant-flow two-phase injector has several advantages in practice: possibility to vary the injections, safety, easy use, reproducibility, overall quality of the results and possibility to reduce the dose of contrast medium. The routine use of such equipment seems to be indispensable at present.

[Imaging in the diagnosis of vascular complications after hepatic transplantation]. / Imagerie dans le diagnostic des complications vasculaires après transplantation hépatique.

Twenty-nine vascular complications which occurred after 388 hepatic transplantations performed over a 5 year period (14 arterial thromboses, 4 aneurysms and ruptures of the hepatic artery, 8 portal thromboses and 3 peri-anastomosis portal stenoses) were investigated retrospectively in order to determine the role of imagery in diagnosing these vascular complications. The best screening examination for the diagnosis of hepatic artery thrombosis appeared to be pulsed Doppler coupled with echography. It provides a means of selecting candidates for arteriography, the only investigation allowing certain diagnosis of thrombosis. False aneurysms, suspected in cases of severe post-operative sepsis should be investigated with arteriography even if CAT scans and echo-pulsed Doppler imagery is normal. The diagnosis of portal thrombosis and stenosis relies on echo-pulsed Doppler imagery. In these cases, arteriography is carried out before treatment to evaluate the extent of vascular involvement. Thus echography coupled with pulsed Doppler is the best first intention screening examination to be performed whenever a vascular complication is suspected after hepatic transplantation. Nevertheless, arteriography remains the key examination for the diagnosis and evaluation of these complications.

[Unresectable hepatic adenomas. Management by selective hepatic artery embolization]. / Adénomes hépatiques non résécables. Place de l'embolisation artérielle dans la conduite thérapeutique.

Four patients with unresectable hepatic adenoma underwent selective hepatic artery embolization. Non-operability was related to the size and the situation of the tumor, and the clinical background. The only subsequent postembolization syndrome was one case of acute renal failure, reversible after diuretic treatment. In 3 cases the decrease in tumoral size was delayed and appeared six months after the first embolization, allowing surgical resection in 2 cases. Because of lack of tumoral devascularization and presence of residual nodules on the resected specimen, this technique is not a satisfactory alternative to surgery, at least with the employed technique. However, preoperative selective hepatic artery embolization can play an important role in the management of hepatic adenomas as it may permit safer surgical resection.

Transcatheter arterial chemotherapy using doxorubicin, iodized oil and Gelfoam embolization in hepatocellular carcinoma.

Computed tomography (CT) was performed in 54 patients with hepatocellular carcinoma three weeks after transcatheter arterial chemotherapy using iodized oil and doxorubicin with or without gelfoam embolization. Patients with iodized oil retention in the tumor greater than 50 per cent of tumor size survived longer than patients with retention of less than 50 per cent. Differences were also found within Okuda stages I and II, but they were significant only in Okuda stage I (p less than 0.0001). These results suggest a possible relationship between iodized oil retention and survival. In addition to Okuda stage, several factors affected iodized oil retention: tumor vascularity, tumor size, portal thrombosis and Gelfoam embolization. These factors may thus influence the prognosis after transcatheter arterial chemotherapy.

[Pseudotumor nodules of the liver in cirrhotic patients. Study of 7 cases]. / Nodules pseudo-tumoraux du foie chez le cirrhotique. Etude de 7 cas.

Hepatocellular pseudotumor (HCP) occurs in cirrhotic liver and can resemble hepatocellular carcinoma. Liver ultrasonography shows a space-occupying lesion. The aim of this study was to describe the clinical, radiological and histologic features of HCP based on seven patients (3 women, 4 men), mean age 48 years (24 to 62), with histologically proven cirrhosis (alcoholic, 4 cases; autoimmune, 1 case; postnecrotic, 1 case, idiopathic, 1 case). Serum alphafetoprotein was below 16 ng/ml in 5 patients and remained over 120 ng/ml in the remaining 2. Desgammacarboxyprothrombin, performed in 3 cases, was below the upper limit of normal range. Real time ultrasonography of the liver showed a homogeneous parenchyma in 1 case and median size (20-48 mm) space-occupying nodular lesions in 6 cases. Sonography patterns of hepatocellular pseudotumor were as follows: anechoic lesions in 5 cases and mixed pattern (sonodense and hypoechogenic) in 1 case. Angiographic findings exhibited different patterns: hypervascular or hypovascular nodules, multinodular uptake after lipiodol bolus injection. Computed tomography showed iso- or hypodense space-occupying lesions. Lipiodol injection, performed in 3 cases, showed nodular lipiodol uptake. Fine needle biopsy always showed normal hepatocytes. At laparotomy, performed in 3 cases, an hyperplastic nodule was found in 1 case only. All patients were alive at 12 to 36 months. These findings are consistent with the fact that hepatocellular pseudotumor is a true entity. Differential diagnosis is difficult. Iodine oil nodular fixation on CT scan may be non specific for hepatocellular pseudotumor. Histologic data is mandatory before beginning a non surgical therapeutic regimen for suspected hepatocellular carcinoma.

[Is the focal echographic lesion of the liver in patients with cirrhosis always correlated with hepatocellular carcinoma? 217 cases]. / La lésion échographique focalisée du foie chez le cirrhotique correspond-t-elle toujours à un carcinome hépatocellulaire? 217 observations.

The value of ultrasonography and serum alpha foetoprotein assay in the detection of hepatocellular carcinoma was evaluated in a retrospective study of 217 patients, (135 men and 82 women; mean age 58 years) who had been hospitalized for 18 months. Cirrhosis was of alcoholic origin in 76 per cent of the cases and complicated by ascites in 54 per cent. Twenty-four patients (11 per cent) had hepatocellular carcinoma diagnosed at ultrasonography in 20 cases. The carcinoma was diffuse in 7 cases, focal in 13 cases and less than 3 cm in diameter in 3 cases. A second ultrasonography diagnosed hepatocellular carcinoma in 4 cases. In 25/217 patients (11.5 per cent) the focal lesion seen at sonography was obviously not a carcinoma. Among the 207 patients who had a serum alpha foetoprotein assay, the result was normal in 167 (81 per cent) and 4 of these had a carcinoma. Among the 40 patients with an abnormal level of alpha foetoprotein, 19 had a carcinoma. This study confirms the good sensitivity of ultrasonography in the detection of hepatocellular carcinoma, but it also shows its low specificity, especially in cases with focal lesions. Ultrasonography and serum alpha foetoprotein assay should be used to detect hepatocellular carcinomas in cirrhotic patients who may benefit from surgical treatment. In the other patients, ultrasonically-guided biopsy should provide a firm diagnosis of carcinoma before undertaking other treatments, such as chemoembolization.

Transluminal angioplasty of a stenotic surgical splenorenal shunt.

A stenosis of a side-to-side splenorenal shunt was treated by percutaneous angioplasty two years after the performance of the shunt. After dilatation, there was a fall of the splenorenal pressure gradient from 28 to 17 cm H2O and good transanastomotic flow was re-established. As in other arterial and venous territories, angioplasty may be an interesting alternative to surgery.

Intrahepatic calculi: imaging by MR.

The magnetic resonance (MR) examinations of six patients with intrahepatic calculi were reviewed retrospectively to 1) determine the ability of MR to demonstrate intrahepatic calculi and 2) assess the MR appearance of the stones. In five out of six cases, MRI demonstrated intrahepatic calculi. In three cases, stones exhibited a low intensity signal on the different spin echo (SE) sequences, as previously described by in vitro and in vivo studies. However in two other cases, a significant signal with short T1 and relatively long T2 relaxation times was noticed. These different features are discussed in relation to chemical and physical differences in intrahepatic calculi and compared with variable CT attenuation values of stones. MRI seems to provide complementary information concerning intrahepatic calculi.

[Vascular malformations of the cecum: treatment by embolization. Apropos of 2 cases]. / Malformations vasculaires du caecum: traitement par embolisation. A propos de deux cas.

Two cases of arteriovenous malformations of the cecum treated by transcatheter embolization are presented. In both cases, treatment resulted in improvement of the clinical and biological signs. In general, there is a high risk of ischemic complications associated with this treatment. Embolization of arteriovenous malformations should be considered rarely and in the following cases: single lesion, high blood output, feasibility of superselective catheterization. The risk of colonic ischemia calls for preparation of the colon as if the patient were undergoing colonic surgery, as well as thorough clinical follow-up (for at least 10 days).

[Pseudo-aneurysm in acute necrotico-hemorrhagic pancreatitis: direct transcutaneous embolization. Apropos of 2 cases]. / Pseudo-anévrysme au cours d'une pancréatite aiguë nécrotico-hémorragique: embolisation directe transcutanée. A propos de deux observations.

Massive hemorrhage associated with pancreatitis is rare but frequently lethal complication. We report two patients with gastrointestinal hemorrhage related to pseudo-aneurysms, the control of these lesions was not possible without risk by vascular selective embolization. The technique we reported for clotting aneurysms by direct injection (Ethibloc) stopped hemorrhage temporary in one case and permanently in the other.

[Mediastinal pseudotumors in cirrhosis. Diagnostic value of nuclear magnetic resonance in 3 cases]. / Pseudo-tumeurs médiastinales au cours de la cirrhose. Intérêt diagnostique de la résonance magnétique nucléaire dans 3 cas.

We report 3 cases of mediastinal pseudotumours in cirrhotic patients. In the 3 cases, plain chest X-ray showed regular homogeneous radiolucency superposed on cardiac shadow. Computerized tomography bolus injection, performed in 2 cases, was poorly contributive in one case. On the other hand, magnetic resonance imaging ensured the diagnosis in all 3 patients showing significant dilatation of the azygos vein and prominent esophageal varices connected with spontaneous abdominal portacaval shunts. These vascular mediastinal structures were well documented by frontal and sagittal spin echoes. Knowledge of such neovascular mediastinal pseudotumours may prevent the use of invasive investigations such as direct puncture or thoracotomy.

[Unusual echographic aspects of hepatic distomiasis]. / Aspect échographique singulier d'une distomatose hépatique.

The authors report, a pediatric case of hepatic fascioliasis with an unusual ultrasonographic aspect; that is a hypoechoic intrahepatic nodule with an extrahepatic prolongation through a thickened capsule. This ultrasonographic appearance, which has not been reported in the literature to our knowledge, seems to reflect the parasite migration.

[Metastases of breast angiosarcoma. Apropos of 2 cases]. / Métastases d'angiosarcome mammaire. A propos de deux observations.

Two patients with breast angiosarcoma and hepatic and splenic metastases developed a hemoperitoneum confirmed by ultrasound and CT scan imaging. This complication has further adverse effects on the already extremely poor prognosis of this disease.

[Are there specific echographic signs of cortical necrosis of a grafted kidney?]. / Existe-t-il des signes échographiques spécifiques de la nécrose corticale du rein greffé?

The authors report three cases in which echotomographic findings were suggestive of cortical necrosis in a grafted kidney (cortical hypoechogenic border). This proved to actually be the diagnosis in one case only.