RESUMEN
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.
Asunto(s)
Trasplante de Hígado , Derivación Portosistémica Intrahepática Transyugular , Trombosis , Humanos , Constricción Patológica , Trasplante de Hígado/efectos adversos , Vena Porta/diagnóstico por imagen , Vena Porta/cirugía , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Resultado del TratamientoRESUMEN
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.
Asunto(s)
Conductos Biliares Extrahepáticos , Colecistitis Aguda/cirugía , Colecistostomía , Coledocolitiasis/cirugía , Conducto Cístico , Cálculos Biliares/cirugía , Anciano , Anciano de 80 o más Años , Colecistostomía/métodos , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosAsunto(s)
Anticoagulantes/administración & dosificación , Prótesis Valvulares Cardíacas/efectos adversos , Válvula Mitral , Complicaciones Cardiovasculares del Embarazo/diagnóstico por imagen , Trombosis/diagnóstico por imagen , Adulto , Angiografía por Tomografía Computarizada , Ecocardiografía , Femenino , Humanos , Imagenología Tridimensional , Embarazo , Complicaciones Cardiovasculares del Embarazo/terapia , Trombosis/terapiaRESUMEN
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.
Asunto(s)
Hipertensión Portal/patología , Cirrosis Hepática/patología , Adulto , Anciano , Anciano de 80 o más Años , Biopsia con Aguja Gruesa , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sensibilidad y EspecificidadRESUMEN
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.
Asunto(s)
Remoción de Dispositivos/métodos , Grupo de Atención al Paciente , Evaluación de Procesos, Atención de Salud , Implantación de Prótesis/instrumentación , Mejoramiento de la Calidad , Indicadores de Calidad de la Atención de Salud , Filtros de Vena Cava , Centros Médicos Académicos , Adulto , Anciano , Remoción de Dispositivos/normas , Femenino , Conocimientos, Actitudes y Práctica en Salud , Hematología , Estudio Históricamente Controlado , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Grupo de Atención al Paciente/normas , Educación del Paciente como Asunto , Evaluación de Procesos, Atención de Salud/normas , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Derivación y Consulta , Estudios Retrospectivos , Servicios de Salud Rural , Factores de Tiempo , Resultado del Tratamiento , VermontAsunto(s)
Cateterismo Venoso Central/efectos adversos , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Remoción de Dispositivos/métodos , Complicaciones Intraoperatorias/diagnóstico , Venas Yugulares/anatomía & histología , Ultrasonografía/métodos , Humanos , Complicaciones Intraoperatorias/cirugía , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: : Angiographic embolization (AE) is used to control hemorrhage in adult blunt liver, spleen, and kidney (ASO) injuries. Pediatric experience with AE for blunt ASO injuries is limited. We reviewed our use of AE to control bleeding pediatric blunt ASO injuries for efficacy and safety. METHODS: : A 5-year review (trauma registry and charts) of children (age < or = 16 years) who had AE for hemorrhage from blunt ASO injuries. Nonoperative management was attempted in all stable children with blunt ASO injuries. Children with ongoing hemorrhage underwent AE. The success of AE and complications were evaluated. Data were reviewed on injury type and grade, injury severity score, length of intensive care unit stay (LOS-ICU) and length of hospital stay (LOS), and complications. RESULTS: : One hundred twenty-seven patients with 149 blunt ASO injuries were identified (72 spleen, 51 liver, and 26 renal). Two children had immediate splenectomies. Seven children underwent AE: two spleen (grades IV and V), two liver (grades III and IV), and three grade IV renal injuries. Three children received blood before embolization. Mean age and injury severity score were 12.3 years +/- 3.7 years and 22.4 +/- 10.0,respecyively. Mean intensive care unit stay was 4.8 days +/- 5.5 days with a mean length of hospital stay of 12.8 days +/- 5.5 days. Embolization was successful in all children; there were no procedure-related complications. Four minor complications occurred; two pleural effusions and two patients with transient hypertension. A nephroblastoma was later found in one renal injury requiring nephrectomy. CONCLUSIONS: : AE is a safe and an effective technique for controlling hemorrhage from blunt ASO injuries in select pediatric patients.
Asunto(s)
Traumatismos Abdominales/terapia , Embolización Terapéutica , Riñón/lesiones , Hígado/lesiones , Bazo/lesiones , Heridas no Penetrantes/terapia , Traumatismos Abdominales/diagnóstico por imagen , Adolescente , Angiografía , Niño , Estudios de Cohortes , Femenino , Humanos , Masculino , Estudios Retrospectivos , Resultado del Tratamiento , Heridas no Penetrantes/diagnóstico por imagenRESUMEN
OBJECTIVE: The purpose of this study was to document the initial experience, indications, technical success, and complications with an optional vena caval filter at a Level I trauma center. METHODS: The trauma registry and interventional radiology database were reviewed for all venal caval filters placed during a 15-month period. Records were reviewed for age of patient, indication, type of filter, and duration between placement and removal of the filter. RESULTS: One hundred thirty-six filters were placed into 130 patients (55 trauma patients), and the most frequently placed filter was the Günther Tulip (n = 58, 29 in trauma patients). Forty-five of 1,257 trauma patients received a prophylactic vena cava filter, for a rate of 4%. Twenty-two repositioning (n = 8) or removal procedures (n = 14, 9 in trauma patients) were performed in 15 patients, with a technical success rate of 93%. No minor complications and one major complication occurred. The average duration between placement and removal was 19 days (range, 11-41 days). The mean age of patients selected prospectively for filter removal (29 years; range, 18-71 years) was significantly lower than the mean age (49 years; range, 19-82 years) of trauma, surgical, and intracranial hemorrhage patients selected for placement of prophylactic permanent filters (p < 0.002; 95% confidence interval, 18.0-22.4). CONCLUSION: The Günther Tulip filter is commonly used at this Level I trauma center as an optional filter that can be left in place as a permanent filter or removed up to 41 days after placement. Without an intervening repositioning procedure, the manufacturer suggests that the Günther Tulip filter can be safely removed within 14 days of implantation, or it can remain in place as a permanent filter.
Asunto(s)
Traumatismos Craneocerebrales/terapia , Tratamiento de Urgencia/tendencias , Sistemas de Atención de Punto/estadística & datos numéricos , Embolia Pulmonar/prevención & control , Filtros de Vena Cava/estadística & datos numéricos , Vena Cava Superior/diagnóstico por imagen , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Traumatismos Craneocerebrales/epidemiología , Femenino , Humanos , Masculino , Registros Médicos , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Prospectivos , Radiografía , Sistema de Registros , Estudios Retrospectivos , Centros Traumatológicos , Vermont/epidemiologíaRESUMEN
Radiofrequency (RF) ablation is a feasible option for treatment of renal tumors when definitive tumor resection is not performed. Renal hilar and ureteral masses are generally more difficult than peripheral renal tumors to approach with RF ablation because of the higher associated risks of injury to the hilar vessels and the collecting system. This report presents a case of RF ablation of transitional cell carcinoma of the ureteropelvic junction, performed successfully for intractable hematuria. Significant injury to the uroepithelium was avoided by the concomitant use of a cold saline infusion into the collecting system of the kidney.