Stenosis of the inferior vena cava after liver transplantation: treatment with Gianturco expandable metallic stents.

PURPOSE: Evaluate the efficacy of double Gianturco expandable metallic stents for stenosis of the inferior vena cava (IVC) after orthotopic liver transplantation (OLT). METHODS: Three patients developed severe Budd-Chiari syndrome secondary to suprahepatic caval stenosis after OLT. Percutaneous angioplasty (PTA) of the stenoses was unsuccessful. Therefore double Gianturco expandable metallic stents, connected in tandem, were deployed at the site of the stenoses. RESULTS: One double stent was successfully and definitively deployed in patient 1. Partial dislocation of the upper and lower stents comprising the double stent occurred in patient 2. The double stent initially implanted across the stenosis became displaced in patient 3. The Budd-Chiari syndrome resolved in all three patients who remained asymptomatic during follow-up from 3 to 32 months. CONCLUSIONS: Double Gianturco stent deployment is a viable option in patients with anastomotic stenosis of the IVC secondary to OLT when initial treatment with PTA fails. Certain modifications of the stents employed are suggested for the purpose of avoiding technical complications.

Two-clamp method to avoid portal anastomotic stenosis in liver transplantation.

We developed a two-clamp technique to avoid stenoses in portal anastomoses during liver transplantation. A portal anastomosis is created with a continuous polypropylene suture. A second vascular clamp is placed on the donor portal vein before release of the recipient vein clamp. After release of the proximal clamp, the vein is allowed to distend to its maximal diameter, and the suture is gently tied. This technique was used in both portal and arterial anastomoses in 43 consecutive liver transplant recipients. No cases of postoperative stenosis or thrombosis were observed.

Salvage of angioaccess after late thrombosis of radiocephalic fistulas for hemodialysis.

A retrospective study of 44 surgical procedures performed in 39 patients with late occlusions of radiocephalic fistulas for hemodialysis is reported. In 6 cases (13.6%) no apparent anatomical cause was found, and a simple thrombectomy was performed as a corrective procedure. Some sort of arterial and/or venous stenosis was present in the other 38 cases. In 11 cases with evidence of mild localized vascular stenosis we performed a thrombectomy and then an endoluminal angioplasty with a balloon catheter and Bakes dilators. In 26 cases, with more severe degrees of stenosis, we made a proximal new fistula in the distal portion of the forearm, bypassing the vascular stenosis, either end-to-end radiocephalic or with interposition of a short segment of PTFE graft. The best results were achieved with the creation of a proximal new fistula, which resulted in almost 50% cumulative patency rates at 2 years, with no immediate failures. We think that an attempt at angioaccess salvage should be made in every case of late thrombosis of radiocephalic fistulas.