Life-threatening variceal bleeding after liver transplantation and extensive portal vein thrombosis: Desperate times call for desperate measures.

BACKGROUND: The management of complex, intra- and extrahepatic portal vein thrombosis (PVT) after liver transplantation (LT) is challenging. Although most of the patients remain asymptomatic or oligosymptomatic in the chronic setting, some of them may develop severe portal hypertension and related complications, notably gastrointestinal (GI) bleeding. In the emergency scenario, clinical and endoscopic treatments as well as intensive support constitute the bases of conservative management, while more definitive treatment options such as surgical shunting and retransplantation are related to high morbidity rates. Transjugular intrahepatic portosystemic shunt (TIPS) was largely considered of limited role due to technical difficulties arising from extensive PVT. Recently, however, new minimally invasive image-guided techniques emerged, allowing portal vein recanalization and TIPS creation simultaneously (TIPS-PVR), even in complex PVT pretransplant patients. METHODS: Herein, we describe a novel indication for TIPS-PVR in a post-LT adolescent presenting with life-threatening, refractory GI bleeding. RESULTS: The patient presented with complete resolution of the hemorrhagic condition after the procedure, with no deterioration of hepatic function or hepatic encephalopathy. Follow-up Doppler ultrasound after TIPS-PVR showed normal hepatopetal venous flow within the stents, and no evidence of complications, including intraperitoneal or peri splenic bleeding. CONCLUSIONS: This report describes the feasibility of TIPS-PVR in the post-LT scenario complicated by extensive PVT. In this case, a complete resolution of the life-threatening GI bleeding was achieved, with no major complications. Other patients with complex chronic PVT might benefit from the use of the described technique, but further studies are required to determine the correct timing and indications of the procedure, eventually before the occurrence of life-threatening complications.

Prostatic artery embolization using reflux-control microcatheter: prospective experience addressing feasibility.

PURPOSE: To evaluate the efficacy and safety of Prostatic Artery Embolization (PAE) using a reflux control microcatheter. MATERIALS AND METHODS: This is a prospective, single-center investigation that included 10 patients undergoing PAE for treatment of lower urinary tract symptoms (LUTS) attributed to benign prostate hyperplasia (BPH). Baseline, 3-month, and 12-month efficacy endpoints were obtained for all patients and included prostate-specific antigen (PSA), uroflowmetry, pelvic magnetic resonance imaging (MRI), and clinical assessment using the International Prostate Symptom Score (IPSS) questionnaire and the IPSS-Quality of life (QoL) item. Complications were assessed using the Cirse classification system. RESULTS: Ten patients entered statistical analysis and presented with significant LUTS improvement 12 months after PAE, as follows: mean IPSS reduction of 86.6% (2.8 vs. 20.7, - 17.9, P < 0.001), mean QoL reduction of 79.4% (1.1 vs. 5.4, - 4.3, P < 0.001), mean prostatic volume reduction of 38.4% (69.3 cm3 vs. 112.5 cm3, - 43.2 cm3, P < 0.001), mean peak urinary flow (Qmax) increase of 199.4% (19.9 mL/s vs. 6.6 mL/s, + 13.3 mL/s, P = 0.006) and mean PSA reduction of 50.1% (3.0 ng/mL vs. 6.1 ng/mL, - 3.0 ng/mL, P < 0.001). One patient (10%) needed transurethral resection of the prostate (TURP) after PAE due to a ball-valve effect. One microcatheter (10%) needed to be replaced during PAE due to occlusion. Non-target embolization was not observed in the cohort. CONCLUSION: This initial experience suggests that PAE using a reflux control microcatheter is effective and safe for the treatment of LUTS attributed to BPH.