Inferior epigastric artery pseudoaneurysm: a complication of paracentesis.

Two patients had inferior epigastric artery pseudoaneurysms after therapeutic paracentesis for ascites caused by portal hypertension. The first patient, a 62-year-old man, had a two-week history of left lower quadrant pain, tenderness, and nonpulsatile mass after a paracentesis for ascites. A left inferior epigastric artery pseudoaneurysm measuring 10 cm in diameter and 20 cm in length was diagnosed by means of Duplex ultrasound and arteriography. The patient was treated with percutaneous embolization, with successful thrombosis of the pseudoaneurysm. The second patient, a 33-year-old woman, had a six-week history of left lower quadrant pain, tenderness, and nonpulsatile mass after a paracentesis for ascites. Computerized tomography and arteriography showed a left inferior epigastric artery pseudoaneurysm, measuring 7 cm in diameter and 9 cm in length. The patient was treated with percutaneous embolization with successful thrombosis of the pseudoaneurysm. Both patients were discharged in good condition 2 days after embolization. Inferior epigastric artery pseudoaneurysm is a complication of paracentesis, and percutaneous embolization may be preferable to surgical repair in patients with chronic liver failure and portal hypertension.

Transjugular intrahepatic portosystemic shunt patency and the importance of stenosis location in the development of recurrent symptoms.

PURPOSE: To analyze in detail the location and types of stenosis and occlusion that occur after transjugular intrahepatic portosystemic shunt (TIPS) creation and to determine the relative contribution of these various types of TIPS malfunction to recurrent symptoms of variceal bleeding or ascites. MATERIALS AND METHODS: In 116 of 217 patients who underwent TIPS creation between June 1990 and July 1995, follow-up portal venography was performed at 6-month intervals and for symptoms of recurrent variceal bleeding or ascites. RESULTS: Cumulative primary venographic patency by means of Kaplan-Meier survival analysis was 55% at 6 months and 5% at 2 years. Secondary patency was 92% at 2 years. Stenosis or occlusion occurred in 63 of 116 patients (54%). In 20 patients (17%), acute shunt occlusions developed less than 30 days after TIPS creation; in 24 patients (21%), tract abnormalities were detected after 30 days; and in 19 patients (16%), hepatic vein stenoses were detected after 30 days. Abnormalities of the parenchymal tract were more often correlated with recurrent variceal bleeding or ascites than were hepatic vein stenoses (odds ratio, 3.6; P = .02). Ten of 14 patients (71%) with detected biliary fistulas to their TIPS had symptoms, and all patients with biliary fistulas had tract abnormalities. CONCLUSION: Tract stenoses and occlusions were the major cause of symptomatic shunt failure after TIPS creation. Substantial bile duct transections are often associated with tract abnormalities and recurrent symptoms. Although common, hepatic vein stenoses were rarely associated with recurrent symptoms in our patient population.

Hepatic allograft abscess with hepatic arterial thrombosis.

BACKGROUND: Intrahepatic abscess (IA) is an uncommon complication after liver transplantation (OLTx) usually found in the setting of hepatic arterial thrombosis (HAT) often with associated biliary tree necrosis and/or stricture. Conventional treatment of IA in this setting has required retransplantation. METHODS: A retrospective review of 274 patients (287 OLTx) from September 1991 through September 1996 was performed. Median follow-up was 3.6 years. Diagnosis of HAT was confirmed by arteriography and IA was documented by computerized tomography. Percutaneous drainage of the abscess and stenting of biliary strictures, if present, was achieved using conventional interventional radiology techniques. RESULTS: The diagnosis of hepatic artery complication was made in 14 patients (5.1%), 2 of whom required retransplantation. Hepatic artery thrombosis associated with solitary IA was found in 3 patients (1%) who were transplanted in our center and in 1 additional patient followed up at our center but transplanted elsewhere. All 4 patients had complete resolution of IA using this approach. Three of the 4 patients are alive and well, with the fourth patient succumbing to recurrent hepatitis B infection resulting in allograft failure. CONCLUSIONS: Solitary hepatic allograft abscesses associated with HAT respond to percutaneous drainage and antibiotics, obviating the need for retransplantation in this setting.

Outcome of 100 patients after transjugular intrahepatic portosystemic shunt for variceal hemorrhage.

OBJECTIVES: One hundred consecutive patients with recurrent or refractory acute variceal hemorrhage treated with a transjugular intrahepatic portosystemic shunt (TIPS) from June 1990 to June 1993 at Oregon Health Sciences University or the Portland Veterans Affairs Medical Center were evaluated to assess shunt patency and clinical outcome, including complications of TIPS, rebleeding, and survival. METHODS: Success of shunt placement, reduction in portal pressure, complications, survival, recurrent hemorrhage, severity of ascites, hepatic encephalopathy before and after TIPS, and shunt patency were assessed in each patient. RESULTS: The mean follow-up period was 17.7 months (range, 0.1-56.7 months). TIPS was successfully completed in all patients, with a mean reduction in portosystemic gradient from 24 to 11 mm Hg. Major complications occurred in 11 patients, including one death. Survival after TIPS was 85% at 30 days, 71% at 1 yr, and 56% at 2 yr. Variceal bleeding stopped within 24 hours after TIPS in all eight patients with active hemorrhage. Recurrent variceal hemorrhage occurred in 18 patients at a mean of 4.3 months (range, 1-713 days) after TIPS. The cumulative rate of recurrent variceal bleeding was 20% at 1 yr and 25% at 2 yr after TIPS. Recurrent variceal bleeding was associated with shunt stenosis or occlusion in all patients with endoscopically documented variceal hemorrhage, which was successfully managed by reopening obstructed shunts and performing variceal embolization. The prevalence of ascites was significantly reduced among surviving patients evaluated 3 months after TIPS (67 vs 25%, p < 0.005). Three months after TIPS, the incidence of new or worsening hepatic encephalopathy was 20%, but encephalopathy improved in an equal proportion of patients. Seventy-three of 77 (95%) shunts examined for patency were open at the last follow-up examination. However, most shunts required intervention to maintain patency, and only 48% (37 of 77) were primarily patent at a mean of 168 days (range, 2-538 days) of follow-up. Shunt stenosis or occlusion, as determined by venography, became increasingly frequent with longer follow-up (52% at 3-9 months and 70% at 9-15 months). CONCLUSIONS: TIPS is effective in lowering elevated portal pressures in patients with refractory variceal hemorrhage, has acceptable postprocedure complication and mortality rates, ameliorates ascites, and in, a minority of patients, worsens encephalopathy. Shunt stenosis occurs in the majority of patients but can be effectively treated by interventional techniques to maintain patency. The incidence of recurrent variceal hemorrhage is low and is associated with shunt stenosis or occlusion.

Malignant esophageal obstruction and esophagorespiratory fistula: palliation with a polyethylene-covered Z-stent.

PURPOSE: To prospectively evaluate the clinical efficacy of polyethylene-covered metallic Z-stents in treatment of dysphagia secondary to malignant esophageal obstruction and esophagorespiratory fistula. MATERIALS AND METHODS: Thirty-five patients with dysphagia due to malignant esophageal obstruction (n = 32) and esophagorespiratory fistula (n = 3) were treated with polyethylene-covered Gianturco-Rösch Z-stents. RESULTS: Thirty-nine stents were placed in 35 patients. Stent placement was technically successful in all patients. Improvement in dysphagia was achieved in 34 of 35 patients. The average dysphagia score decreased from 3.1 (dysphagia to liquids) to 0.6 (essentially normal diet). An esophagorespiratory fistula was completely sealed in two of three patients. All 35 patients were followed up clinically at 1 day and 1 week and at 3-month intervals (range, 1 week to 18 1/2 months; mean, 4.8 months). Recurrent dysphagia or aspiration occurred in only three of 34 (9%) patients whose disease was initially palliated and was easily treated in all cases. Nine complications occurred in eight patients (23%) and included chest pain that required analgesia (n = 3), food impaction (n = 1), stent migration (n = 2), and upper gastrointestinal tract hemorrhage (n = 3). CONCLUSION: Polyethylene-covered stents are a relatively safe and effective means of long-term palliation in patients with severe malignant esophageal obstruction and esophagorespiratory fistula. These stents are easily deployed, and the rate of stent migration is relatively low.

Treatment of esophageal obstruction from mediastinal compressive tumor with covered, self-expanding metallic Z-stents.

BACKGROUND: Mediastinal malignancies may involve the esophagus, leading to esophageal stenosis and dysphagia. Rigid and self-expanding esophageal stents have been used for effective palliation, but their use in extrinsic, compressive lesions is controversial. METHODS: A retrospective review of self-expanding Gianturco-Rösch Z-stents that were successfully placed in 13 patients with malignant esophageal obstruction due to extrinsic lesions. RESULTS: All patients had an improvement in dysphagia of at least two dysphagia grades. The mean dysphagia grade fell from 3.15 to 0.62. Mean survival was 2.2 months. Early (within 48 hours) procedure-related complications occurred in 4 of 13 patients and consisted of minor, transient chest pain that resolved within 6 hours (3 patients) and endoscopic stent dislodgment into the stomach (1 patient). Late complications (> 48 hours) occurred in 2 patients and consisted of a partial proximal stent migration and the development of a benign stricture proximal to the stent. There was no procedural or stent related mortality. CONCLUSIONS: Esophageal obstruction and malignant dysphagia from extrinsic, compressive mediastinal malignancies can be effectively and safely palliated with self-expanding Gianturco- Rösch Z-stents.

Gianturco-Rösch Z stents in tracheobronchial stenoses.

PURPOSE: To evaluate expandable metallic Gianturco-Rösch Z (GRZ) stents for treatment of benign and malignant tracheobronchial stenoses. PATIENTS AND METHODS: Six patients, ages 45-73 years, were treated for severe dyspnea with placement of GRZ stents. Three patients had benign tracheal lesions (one tracheomalacia, two postoperative) and received uncovered GRZ stents. Three patients had malignant stenoses at the level of the carina; one received an uncovered stent and the other two received silicone-covered GRZ stents. RESULTS: Two patients with benign lesions responded well to stent placement. One was asymptomatic for a year and then was lost to follow-up; the other improved substantially but died of end-stage lung disease 5 months after stent placement. A third patient with a benign high tracheal lesion did poorly; symptoms recurred secondary to inferior migration of a stent, which was removed surgically at 4 months. All patients with malignant lesions improved symptomatically after stent placement and remained without significant dyspnea until death (from 1 to 6 months). CONCLUSION: Expandable GRZ stents are promising devices for treatment of benign lesions and offer effective palliation of malignant tracheobronchial stenoses.

Treatment of malignant esophageal obstructions with covered metallic Z stents: long-term results in 52 patients.

PURPOSE: To prospectively evaluate the clinical efficacy of silicone-covered Gianturco-Rösch self-expandable Z (GRZ) stents in the treatment of malignant esophageal obstruction. PATIENTS AND METHODS: GRZ stents were placed in 52 patients (39 men, 13 women) with severe dysphagia due to high-grade malignant esophageal obstruction. RESULTS: Stent placement was technically successful, and immediate relief of dysphagia was achieved in 50 of 52 patients (96%), with long-term relief in 47 patients (90%). Fifty-one patients (98%) died during follow-up (range, 1 week to 33 months; mean, 4.3 months). Late complications were most prevalent and included stent migration (n = 5), food impaction (n = 2), chest pain (n = 2), membrane disruption with tumor ingrowth (n = 1), granulomatous reaction above the stent (n = 1), esophageal perforation with mediastinitis (n = 1), and upper gastrointestinal hemorrhage (n = 4). Twelve complications were easily managed with medical, endoscopic, or radiologic intervention. Four deaths may have been related to stent placement (early mortality rate, 7.7%). CONCLUSION: GRZ stents provide relatively safe and effective long-term palliation in patients with severe, malignant esophageal obstruction.

Improved transjugular intrahepatic portosystemic shunt patency with PTFE-covered stent-grafts: experimental results in swine.

PURPOSE: To evaluate the ability of stent-grafts made with polytetrafluoroethylene (PTFE) graft material to improve transjugular intrahepatic portosystemic shunt (TIPS) patency. MATERIALS AND METHODS: TIPS were created in 13 swine by using PTFE-covered stent-grafts. Uncovered TIPS were placed in 13 other swine. Twenty-one of 26 animals were followed up with portal venography for 3 months or until the shunt became severely stenotic. Five animals without severe stenosis were sacrificed before 3 months because of illness. RESULTS: At 4 weeks after TIPS placement, nine of 13 stent-graft TIPS were patent (< 50% diameter narrowing) compared with only one patent stent in 13 uncovered TIPS. Six of 13 stent-graft TIPS remained patent until the animals were sacrificed. In 11 of 12 uncovered TIPS, stenosis was most prominent in the parenchymal tract. In five of seven stent-graft TIPS, stenosis was most prominent in the hepatic vein above the end of the graft material. Bile leaks were discovered in six occluded uncovered TIPS and in two of the stent-graft TIPS. CONCLUSION: PTFE-covered stent-grafts significantly improved TIPS patency in swine (P < .01). However, stenosis in the hepatic vein led to late shunt malfunction in selected cases.

Treatment of malignant esophagorespiratory fistulas with silicone-covered metallic Z stents.

PURPOSE: To prospectively evaluate the clinical efficacy of covered metallic Z stents in the treatment of esophagorespiratory fistulas (ERFs). PATIENTS AND METHODS: Twelve patients with severe aspiration symptoms from malignant ERFs were treated with silicone-covered, metallic, self-expanding Gianturco-Rösch Z (GRZ) stents. RESULTS: Fluoroscopically guided stent placement was successful and well tolerated in all patients. Immediate postprocedural endoscopy and esophagography showed excellent coverage of the fistulas in all cases. Aspiration symptoms were completely relieved in eight of 12 patients (67%). Four of 12 patients (33%) were improved and able to eat a soft diet. There were no stent-related deaths. Nine patients have died and three patients are alive. Mean follow-up for the entire group was 3.9 months (range, 1 week to 10.5 months). Nonfatal complications occurred in three of 12 patients (25%). Complications included one membrane disruption and one granulomatous reaction with a slight upward stent migration. CONCLUSION: GRZ stents are an effective and safe means of palliation in patients with malignant esophagorespiratory fistulas.

Silicone-covered self-expanding metallic stents for the palliation of malignant esophageal obstruction and esophagorespiratory fistulas: experience in 32 patients and a review of the literature.

Esophagogastric malignancies often are manifested with progressive dysphagia or esophagorespiratory fistulas. Palliative modalities currently available have significant limitations. A modified Gianturco-Rösch silicone-covered self-expanding metallic Z stent was used in 32 consecutive patients with malignant esophageal obstruction (n = 24) or esophagorespiratory fistulas (n = 8). The stent was placed successfully in all patients. Dysphagia improved by at least two grades in 21 of the 24 patients (87.5%); the mean dysphagia grade fell from 3.21 to 1.08. Six of the 8 patients with fistulas were able to resume a normal diet, and the other 2 were able to eat solids without symptoms of aspiration. Complications occurred in 10/32 patients (31%) and included stent migration (4 patients), food impaction (2 patients), membrane disruption with tumor ingrowth (1 patient), tumor overgrowth (1 patient), early pressure necrosis with hemorrhage (1 patient), and late pressure necrosis with sepsis (1 patient). The latter 2 patients died, giving a mortality rate of 6.3%. Many complications were managed with endoscopic or interventional radiologic techniques. Although randomized prospective clinical trials are needed, the silicone-covered Gianturco-Rösch Z stent offers promise for the effective palliation of malignant esophageal obstruction and esophagorespiratory fistulas.

Aortoiliac disease: two-dimensional inflow MR angiography with lipid suppression.

A magnetic resonance (MR) imaging strategy, SLIP (spatially separated lipid presaturation), which can be incorporated into existing MR imaging and MR angiographic techniques, has been developed to suppress lipid signal. The authors report the clinical application of this technique, with a triple comparison of two-dimensional inflow MR angiography, with and without SLIP, and x-ray angiography in patients with aortoiliac disease. SLIP improved visualization of arterial segments, with 50 of 63 (79%) arterial segments visualized versus 41 of 63 (65%) for non-SLIP MR angiography. The SLIP strategy aids in the depiction of slow or turbulent flow, because the lipid signal is suppressed while the intravascular signal is left undisturbed. Image quality improves because of the combination of decreased background lipid signal intensity and use of the maximum-intensity-projection algorithm. Compared with x-ray arteriography, non-SLIP MR angiography had a sensitivity and specificity of 60% and 56%, respectively, for detection of lesions with 50%-100% diameter reduction, while SLIP MR angiography had a sensitivity and specificity, respectively, of 53% and 67%.

Activation of the adrenergic beta-receptor stimulates prolactin release from primary cultured pituitary cells.

Prolactin release from primary cultured pituitary cells was investigated using a dynamic perifusion system. Although epinephrine (1 mumol/l) produced an elevation in the mean value of the prolactin concentration at the onset of the perifusion, the elevation was not statistically significant, and the overall effect of the epinephrine was to produce an inhibition of prolactin release. The alpha- and D2-receptors of the primary cultured cells were functionally removed by a pretreatment with phenoxybenzamine (0.1 or 1 mumol/l). Since phenoxybenzamine irreversibly inactivates both the adrenergic alpha- and the D2-receptors but does not block the beta-receptors, the enhanced stimulatory action of the epinephrine (1 mumol/l) on the phenoxybenzamine pretreated cells suggests the involvement of adrenergic beta-receptors in prolactin release. Perifusion of isoproterenol (1 mumol/l), a beta-receptor agonist, stimulated prolactin release. This stimulation was blocked by beta-receptor antagonism with propranolol (1 mumol/l) supporting the implication of the beta-receptor in prolactin release. In order to differentiate between beta 1- and beta 2-receptor involvement, we investigated the effects of ICI 118,551 (1 mumol/l) on isoproterenol-induced prolactin release. ICI 118,551, a selective beta 2-receptor antagonist, blocked the stimulatory action of isoproterenol on prolactin release indicating that the beta-receptor responsible for the stimulation of prolactin release belongs to the beta 2-receptor family. Moreover, the demonstration that salbutamol, a selective beta 2-receptor agonist, stimulated prolactin secretion offers further evidence in support of the role of the beta 2-receptor in the stimulation of prolactin release.(ABSTRACT TRUNCATED AT 250 WORDS)

Gianturco-Rösch expandable Z-stents in the treatment of superior vena cava syndrome.

Gianturco-Rösch expandable Z-stents were used in 22 patients with superior vena cava syndrome (SVCS). Stents were placed in all patients in the SVC and in 17 patients, also into the innominate veins. Stent placement resulted in complete relief of symptoms in all patients. Twenty-one patients had no SVCS recurrence from 1 to 16 months, to their death, or to the present time. SVCS recurred only in 1 patient 9 months after stent placement due to tumor ingrowth and secondary thrombosis. Based on ours and on other reported experiences, expandable metallic stents are effective devices for treatment of the SVCS which is difficult to manage by other means.

Urokinase infusion: feasibility of monitoring for complications in a non-intensive care setting.

In an effort to more effectively use critical care facilities and to reduce costs, during a 2 1/2-year period, the condition of 32 patients who received 37 local intraarterial urokinase (UK) infusions was monitored in a non-intensive care unit (ICU) setting. Techniques of infusion, mean total dose of lytic agent used (1.7 million IU), and mean duration of infusion (22 hours) were similar to those reported previously in series of patients monitored in the ICU. Complete lysis (no angiographically detectable residual clot within the treated segment) was achieved in 28 of 37 infusions (76%). Major complications occurred during two infusions (5.4%). In 33 of the 37 cases, systemic heparin was administered during UK infusion. No cases of pericatheter thrombosis were encountered. At the authors' institution, patients can be safely monitored during local UK infusion in a non-ICU setting without compromising effectiveness of therapy. This approach has resulted in enhanced cost-effectiveness of thrombolytic therapy and more effective use of critical care facilities.