Endovascular Treatment of Venous Outflow and Portal Venous Complications After Liver Transplantation.

Liver transplantation continues to rapidly evolve, and in 2020, 8906 orthotopic liver transplants were performed in the United States. As a technically complex surgery with multiple vascular anastomoses, stenosis and thrombosis of the venous anastomoses are among the recognized vascular complications. While rare, venous complications may be challenging to manage and can threaten the graft and the patient. In the last 20 years, endovascular approaches have been increasingly utilized to treat post-transplant venous complications. Herein, the evaluation and interventional treatment of post-transplant venous outflow complications, portal vein stenosis, portal vein thrombosis, and recurrent portal hypertension with transjugular intrahepatic portosystemic shunt (TIPS) are reviewed.

Cholecystostomy as an Exclusive Access to Remove Cystic, Common Hepatic, and Common Bile Duct Stones.

OBJECTIVE. The purpose of this article was to evaluate the feasibility and efficacy of percutaneous fluoroscopic-guided stone retrieval from the cystic duct and antegrade common bile duct (CBD) stone advancement into the duodenum exclusively through a cholecystostomy tube. MATERIALS AND METHODS. Twenty-one patients with acute cholecystitis and choledocholithiasis or an impacted cystic duct stone who underwent percutaneous cholecystostomy tube placement were retrospectively enrolled in this study. The patients had a contra-indication for cholecystectomy (17 patients because of comorbidities and one who declined surgery) or had failed endoscopic retrograde stone removal attempts (three patients). RESULTS. The 21 patients underwent subsequent percutaneous CBD (17 patients) and cystic duct (nine patients) stone removal on follow-up sessions through the percutaneous cholecystostomy track using moderate sedation. A total of 32 stone removal procedures were performed. Seventeen patients underwent balloon dilatation sphincterotomy, after which the CBD stones were pushed forward into the duodenum using a compliant balloon. Seven patients also had stone removal from the cystic duct by a stone retrieval basket. The primary technical success rate for removal of all CBD and cystic duct stones was 76%. The secondary technical success rate was 100%. The clinical success rate was 74%. All patients tolerated the procedures well without major complication. The clinical follow-up interval ranged from 2 to 2310 days (median, 30 days), with no incidence of postprocedural complications. CONCLUSION. Percutaneous transcholecystic common bile and cystic duct stone removal through an existing cholecystostomy access is a safe and effective procedure that is well tolerated.

Hepatic venous pressure gradient correlates with advanced hepatic fibrosis: a retrospective review.

PURPOSE: To determine if hepatic venous pressure gradient (HVPG) correlates with advanced hepatic fibrosis, as a complement to transjugular (transvenous) core needle liver biopsy. MATERIALS AND METHODS: After institutional review board approval, a retrospective review was conducted on 340 patients who underwent transjugular (transvenous) core needle liver biopsy with concurrent pressure measurements between 6/1/2007 and 6/1/2013. Spearman correlation and linear regression were performed. A receiver operating characteristic (ROC) curve was created and sensitivity, specificity, predictive values and likelihood ratios were calculated. RESULTS: Indications included hepatitis C, abnormal liver function tests, non-alcoholic steatohepatitis, autoimmune hepatitis, and cirrhosis, among others. Biopsies showed stage 1 or 2 fibrosis in 15.6% each, stage 3 fibrosis in 21.6%, stage 4 fibrosis in 40.7%, and no fibrosis in 6.5%. Mean HVPG was 6.5 mm Hg (SD 5.0) with a range of 0-26 mm Hg. Spearman correlation coefficient for association between HVPG and fibrosis stage was 0.561 (p < 0.001). R2 on linear regression was 0.247 (p < 0.001). ROC curve for the prediction of stage 4 fibrosis had an area under the curve of 0.79 (95% CI 0.73-0.85). HVPG of ≥6 mm Hg had a sensitivity of 71.3%, specificity of 79.6%, positive predictive value of 70.5%, negative predictive value of 80.2%, positive likelihood ratio of 3.49 (95% CI 2.45-4.97) and negative likelihood ratio of 0.36 (95% CI 0.26-0.50) for diagnosis of stage 4 fibrosis. CONCLUSIONS: HVPG correlates with stage 4 (advanced) hepatic fibrosis.

A multidisciplinary quality improvement program increases the inferior vena cava filter retrieval rate.

Published reports indicate low retrieval rates for retrievable inferior vena cava (IVC) filters. We performed a historic-controlled study of a 5-year intervention (March 2007 to February 2012) to improve IVC filter retrieval rates at a university medical center serving a rural area. All adults with a retrievable filter placed were included, except those with a life expectancy <6 months. The intervention included initial verbal counseling and printed educational materials, correspondence after discharge, and a hematology consultation. The control group included patients with retrievable filters placed in the 15 months preceding study initiation. In the control group, 116 filters were placed and 27 (23%) were removed, compared to 378 filters placed and 169 (45%) removed during the intervention. Adjusting for patient characteristics, the odds ratio of retrieval during the intervention was 3.03 (95% CI 1.85-4.27) compared to the control period. An intervention including patient education and hematology follow-up appeared to significantly improve IVC filter retrieval rates.