Mesenteric angioplasty in the treatment of chronic intestinal ischemia.

PURPOSE: This study was undertaken to determine the safety and efficacy of percutaneous transluminal angioplasty (PTA) in the treatment of chronic mesenteric ischemia (CMI) in very high-risk surgical patients. METHODS: Twenty-four focal mesenteric stenoses treated from 1984 to 1994 by PTA in 19 patients with CMI were reviewed. All 19 patients were considered poor surgical candidates. Seventeen patients had classic symptoms of CMI, and two patients had atypical abdominal complaints. Vessels dilated included the superior mesenteric artery (18), celiac artery (3), inferior mesenteric artery (1), aorta-superior mesenteric artery vein graft (1), and aorta-splenic artery vein graft (1). Complete follow-up was possible in all patients, with the exception of one patient who had no symptoms when last seen 17 months after the procedure. RESULTS: PTA was technically successful in 18 of 19 patients (95%) and 23 of 24 stenoses (96%). The lone technical failure resulted in superior mesenteric artery dissection with thrombosis and bowel infarction; the patient died despite emergent laparotomy and revascularization (mortality rate, 5%). Complete symptomatic relief was attained in 15 patients (79%), with follow-up showing continued relief of symptoms for a mean of 39 months (range, 4 to 101 months). Partial symptomatic relief was attained in three patients. Recurrent symptoms developed in three patients (20%) at a mean interval of 28 months (range, 9 to 43 months). Repeat PTA performed in two patients provided good technical results and relief from clinical symptoms. One patient had a symptomatic axillary sheath hematoma that required surgical decompression. CONCLUSIONS: Mesenteric PTA is a valuable treatment option in patients who have CMI and are considered very high operative risks. The initial technical success rate is excellent, with the majority of patients having complete symptomatic improvement and continued relief of symptoms at short-term follow-up.

Metallic stents for the treatment of intrahepatic biliary strictures after liver transplantation.

PURPOSE: The authors report their results with use of metallic stents for the treatment of intrahepatic biliary strictures occurring after liver transplantation. PATIENTS AND METHODS: Twenty-four patients with intrahepatic biliary strictures after liver transplantation were treated with metallic stents. Eleven had undergone prior unsuccessful percutaneous balloon dilation. Successful stent deployment occurred in all subjects. Gianturco, Wallstents, and Palmaz stents were used. Follow-up was obtained in all 24 patients. RESULTS: Initial technical success was obtained in all 24 patients. In 11 patients, long-term primary, primary assisted, or secondary stent patency was achieved with follow-up ranging from 17 to 58 months. Ten patients died or underwent retransplantation within 14 months for reasons unrelated to their stents. In three patients, stent placements failed because of stent obstructions that were refractory to attempts at secondary patency. By life-table analysis, cumulative primary, primary assisted, and secondary patency rates were 50%, 61%, and 80%, respectively, at 18 months. CONCLUSION: Metallic biliary stents offer promising results for intrahepatic strictures in the posttransplant patient, particularly in patients with widespread strictures. Stents can become partially or totally obstructed due to sludge and debris, but patency can often be restored with additional interventional techniques.

A comparison of treatment with transjugular intrahepatic portosystemic shunt or distal splenorenal shunt in the management of variceal bleeding prior to liver transplantation.

Recurrent variceal bleeding in liver transplant candidates with end-stage liver disease can complicate or even prohibit a subsequent transplant procedure (OLT). Endoscopic sclerotherapy and medical therapy are considered as first-line management with surgical shunts reserved for refractory situations. Surgical shunts can be associated with a high mortality in this population and may complicate subsequent OLT. The transjugular intrahepatic portosystemic shunt (TIPS) has been recommended in these patients as a bridge to OLT. This is a new modality that has not been compared with previously established therapies such as the distal splenorenal shunt (DSRS). In this study we report our experience with 35 liver transplant recipients who had a previous TIPS (18 patients) or DSRS (17 patients) for variceal bleeding. The TIPS group had a significantly larger proportion of critically ill and Child-Pugh C patients. Mean operating time was more prolonged in the DSRS group (P = 0.014) but transfusion requirements were similar. Intraoperative portal vein blood flow measurements averaged 2132 +/- 725 ml/min in the TIPS group compared with 1120 +/- 351 ml/min in the DSRS group (P < 0.001). Arterial flows were similar. Mean ICU and hospital stays were similar. There were 3 hospital mortalities in the DSRS group and none in the TIPS group (P = 0.1). We conclude that TIPS is a valuable tool in the management of recurrent variceal bleeding prior to liver transplantation. Intraoperative hemodynamic measurements suggest a theoretical advantage with TIPS. In a group of patients with advanced liver disease we report an outcome that is similar to patients treated with DSRS prior to liver transplantation. The role of TIPS in the treatment of nontransplant candidates remains to be clarified.

Microfibrillar collagen hemostat: a new transcatheter embolization agent.

Nine patients underwent transcatheter embolization with a suspension of microfibrillar collagen hemostat (MCH). Four of the patients had large vascular renal tumors, and two had bleeding bladder carcinomas. There was one case each of bleeding rectal tumor, bleeding esophageal varices, and arteriovenous malformation of the shoulder. MCH was highly thrombogenic and could be injected through very small catheters. It was highly effective as an occlusive agent and was able to penetrate the small end-arteries of a lesion. Its main disadvantage is that if normal tissues are inadvertently embolized, there is a risk of ischemic complication.