Back-table arterial reconstructions in liver transplantation: single-center experience

Anatomic variations of the arterial supply to donor liver grafts often require complex hepatic artery reconstructions on the back table. Therefore, because of the additional anastomoses, there is a greater risk of arterial thrombosis and graft loss. Among the 620 orthotopic liver transplantations (OLT) in 549 adult and pediatric patients performed from June 1983 through August 2004, the rates and types of donor hepatic artery variations (HAV) and the type of reconstructions were reviewed as well as the 1- and 5-year grafts and patient survival rates after OLT. At least 1 HAV was present in 133 liver grafts (21.4%). The most frequent variations were as follows: right hepatic artery (RHA) from superior mesenteric artery (SMA) (44 cases); RHA from aorta (4 cases); and RHA from SMA, combined with a left hepatic artery (LHA) from left gastric artery (3 cases). No graft was discarded. Fifty-six of 133 (42%) HAV required arterial reconstructions, generally a termino-terminal (TT) anastomosis between RHA and splenic artery (26 cases, 46.4%). Less frequently performed anastomoses were the "fold-over" technique (15 cases, 26.8%) and the anastomosis between the RHA and the gastro-duodenal artery (6 cases, 10.6%); rare reconstructions were performed in 9 cases (16.0%). The rate of hepatic artery thrombosis was 5.4% (3 of 56 OLT) in complex hepatic artery reconstructions and 2.2% in other grafts. One- and 5-years graft and patient actuarial survival rates have been respectively 73.2%- 71.4% in hepatic artery reconstructions and 78.6%-76.8% in the absence of an artery reconstruction, respectively.     

Traumatic and postoperative ischemic liver necrosis: causes, risk factors and treatment

BACKGROUND: To study the cause and outcome of ischemic liver necrosis and suggest treatment of these patients. METHODS: Retrospective study of 13 patients with ischemic liver necrosis treated at our departments from 1990 until 1997. RESULTS: Ischemic liver necrosis was caused by general hypoxia (n = 1) or acute arterial occlusion (n = 12) of the celiac and superior mesenteric artery (SMA, n = 3), proper hepatic artery (PHA, n = 1), right hepatic artery (RHA, n = 2), left hepatic artery (LHA, n = 2) and intrahepatic vessels (n = 4). Six of the cases were related to surgical procedures, 5 of these (38%) were unintended arterial injuries after biliary surgery. Ten patients (77%) had risk factors contributing to the development of liver necrosis: septicemia (n = 4), jaundice and septicemia (n = 2), shock and hypoxia (n = 3) and alcoholic cirrhosis (n = 1). Five patients (38%) needed resection of the liver necrosis due to infected necrosis. Three patients (23%) died; two of these had celiac/SMA occlusion. One died due to complete gastrointestinal ischemia and severe lactacidosis, two died of multiorgan failure after bile leakage and septicemia. CONCLUSION: Ischemic liver necrosis is mainly caused by arterial occlusion due to arteriosclerosis, arterial transection during biliary surgery or blunt liver trauma, and seldom occurs without additional risk factors. 50% of the patients develop infected necrosis and need liver resection. Patients with sterile necrosis may recover without surgical procedures of the liver. The mortality in patients with central (celiac/SMA) and peripheral (CHA, PHA, RHA, LHA, intrahepatic branches) occlusions was 67% (2/3) and 11% (1/9), respectively.     

动脉造影初步分析肝脏Ⅸ段肿瘤肝动脉血供

目的 研究肝脏Ⅸ段肿瘤的肝动脉血供方式.方法 回顾性分析8例肝脏Ⅸ段肿瘤病例的CT和DSA资料,由CT做出定位诊断,在DSA上观察肝脏Ⅸ段肿瘤的肝动脉血供情况.观察肝动脉的各级分支,统计这些分支向病灶供血的例数,分析肝脏Ⅸ段肿瘤的肝动脉血供来源.根据病灶染色情况,以积分法确定这些肝动脉分支向病灶供血的多少.结果 肝脏IX段肿瘤的肝动脉血供来源十分广泛,MHA、RPHA、RAHA、LMHA和CallA向病灶供血的例数分别是7、6、5、5和2例(X2=2.800,P=0.592,Chi-square test),积分分别是15、13、11、6和2分(X2=9.657,P=0.047,Kendall's W).RHA和LHA的积分分别是38和9分(Z=-2.243,P=0.025,Wilcoxon).未见CyA和LLHA向病灶供血的病例.结论 RHA和LHA系统都有可能向肝脏Ⅸ段肿瘤供血,RHA供血比LHA多.MHA、RPHA、RAHA、LMHA是主要的供血支.     

Use of colour duplex imaging to diagnose and guide angioplasty of lower limb arterial lesions.

BACKGROUND: The purpose of this study was to investigate whether colour duplex imaging alone could safely and effectively be used to diagnose lower limb arterial lesions and guide subsequent percutaneous transluminal angioplasty (PTA). METHODS: Patients with discrete lower limb arterial lesions, preferably stenoses, which could be visualized clearly by colour duplex imaging were selected for duplex-guided PTA. Duplex-guided PTA was performed in an operating theatre using conventional balloon catheters. RESULTS: Duplex imaging was used to diagnose and guide PTA of 55 arterial lesions in 50 legs of 45 patients. There were 53 stenoses and two occlusions. The median (range) ankle : brachial pressure index was 0. 86 (0.52-1.10) before dilatation and 1.00 (0.83-1.40) immediately after dilatation (P = 0.0001). There were no complications during or after any of the procedures and 46 of the 47 symptomatic legs were markedly improved at a median follow-up of 23 days. Radiographic imaging was not required for any of the procedures. CONCLUSION: It is possible to diagnose and angioplasty lower limb arterial lesions using colour duplex imaging alone.     

Outpatient treatment of arterial inflow stenoses of dysfunctional hemodialysis access fistulas by retrograde venous access puncture and catheterization

OBJECTIVE: To determine the feasibility of endovascular treatment of inflow stenoses in arteriovenous fistulae (AVFs) through retrograde venous access catheterization. METHODS: We included all 22 dysfunctional AVFs with arterial inflow stenoses at access imaging between January 2002 and September 2006. Following retrograde venous access puncture, an interventional radiologist intended to cross the arteriovenous anastomosis and advance a catheter into the aortic arch. After depiction of the complete vascular access tree, angioplasty and/or stent placement was aimed for stenoses with a >50% luminal diameter reduction at digital subtraction angiography (DSA). RESULTS: In one radiocephalic AVF, a catheter could not be positioned into the aortic arch after retrograde venous access puncture. DSA depicted 28 inflow stenoses in the remaining 21 patients (11 radiocephalic AVFs and 10 brachiocephalic AVFs). Clinical improvement was obtained in 18 out of 19 patients with a technically successful intervention (<30% residual stenosis after angioplasty or stent placement). Following endovascular therapy, access flow of 12 patients with a low flow access improved from 431 +/- 150 ml/min to 818 +/- 233 ml/min, and four patients with steal symptoms became symptom free. One nonmaturing fistula could be salvaged by angioplasty, and access cannulation problems were solved in another patient following angioplasty. Brachial artery stent placement did not reduce steal symptoms in one case, whereas two patients, in whom stent placement was not thought desirable, showed a >30% residual arterial stenosis after angioplasty. No complications were observed at DSA and endovascular intervention. CONCLUSION: Retrograde venous access puncture and catheterization, as an alternative to a potentially more hazardous brachial artery or more invasive femoral artery approach, should be considered for the visualization of the arterial inflow and endovascular treatment of inflow stenoses.     

Clinical Implications of an Aberrant Right Hepatic Artery in Patients Undergoing Pancreaticoduodenectomy

Background  Sometimes, it seems to be difficult to preserve the aberrant hepatic artery (HA) during pancreaticoduodenectomy (PD), with respect to en bloc lymph node dissection, especially in the case of aberrant right hepatic artery (RHA). Therefore, we evaluated the influence of incomplete en bloc lymph node (LN) dissection when aberrant RHA arises. Methods  We reviewed 103 patients with mid-to-distal common bile duct (CBD) cancers who underwent PD by one surgeon at Asan Medical Center from December 1994 to November 2005 (73 men, 30 women; mean age, 61.1 ± 9.4 (range: 40–84) years). The mean follow-up period was 32.7 months. We compared the normal RHA group with the aberrant RHA group. Results  Eighty-eight cases showed normal RHA anatomy, including nine cases (8.7%) of aberrant left hepatic artery (LHA) with normal RHA cases (normal HA group). RHA anomalies were observed in 15 cases (14.6%, aberrant HA group). In all cases, there was no direct invasion of cancer to aberrant HA. Among two groups, 43 cases (41.7%) showed recurrence and there was no significant difference in recurrence between two groups (p = 0.202). Three-year and 5-year overall survivals were 33.3% and 28.5% in the normal HA group, whereas 47.1% and 28.3% in the aberrant RHA group, respectively. There also was no statistically significant difference in survival (p = 0.763). Conclusions  When performing PD for CBD cancer, aberrant RHA should be preserved if there was no cancerous invasion and it does not seem to affect the recurrence of disease and overall survival of patients.     

肝动脉外科解剖在肝动脉置管术中的应用及意义

目的 目前术中肝动脉置管术(IHAC)已广泛应用于肝脏恶性肿瘤的综合治疗，但多采用盲目插管的方法，影响了IHAC的疗效。通过术中肝动脉的外科解剖结合肝动脉造影，了解肝总动脉及其主要分支的行径及相互关系，证明肝动脉外科解剖在IHAC中的意义。方法 采用电凝锐性解剖技术对116例肝脏或胆道疾病患者行肝动脉外科解剖，详细记录肝总动脉(CHA)、肝固有动脉(PHA)、肝左、右动脉(LHA、RHA)及胃十二指肠动脉(GDA)的位置和相互间的成角(锐角或钝角)，并在术中观察自然状态下导管经胃网膜右动脉插入后的走向。部分病例结合肝动脉造影资料进行分析。结果 (1)GDA与CHA呈水平或钝角72例(62％)。其中20例行IHAC，导管经胃网膜右动脉插入时全部进入CHA；(2)GDA与CHA呈锐角，而与PHA呈水平或钝角36例(31％)，13例行IHAC，导管或进入PHA或RHA；(3)PHA缺如8例(7％)。此外，116例中RHA起源于肠系膜上动脉9例(7．7％)，肝左动脉源于胃左动脉7例(6．0％)，肝左、右动脉之间在肝门部存在明显异常交通支2例(1．7％)。结论 影响IHAC准确性的关键是GDA与CHA的成角，以及肝动脉解剖异常。由于绝大多数GDA与CHA成角为钝角，加上一定比例的肝动脉解剖异常，因此，非肝动脉外科解剖的盲目插管其成功率不足25％，应引起临床的高度重视。     

Preexcisional artery reconstruction: A new strategy in multiple hepatic artery reconstruction for reducing ischemic injury of the liver

Multiple reconstructions of the hepatic arteries (HA) after cancer resection presents a surgical challenge, not only because it is technically demanding, but also because attention must be paid to potential ischemic injury to the liver caused by the prolonged ischemia. We present a novel “preexcisional artery reconstruction” method for minimizing ischemic injury of the liver. A 65‐year‐old woman presented with cholangiocarcinoma invading the HA. Pancreatoduodenectomy, resection, and multiple reconstruction of the HA were performed. First, the left hepatic artery (LHA) was reconstructed prior to the tumor resection. During this procedure, blood supply was maintained to most of the liver via the right hepatic artery (RHA). Then, resection of the tumor en bloc with the HA was performed, followed by reconstruction of the RHA. During this procedure, blood supply was maintained via the already‐reconstructed LHA, thereby limiting the ischemic area. Use of this method allowed the ischemia time and region to be divided and minimized, thereby leading to a reduced risk of ischemia‐related complications. We believe that this method may be one of the useful approaches in multiple HA reconstruction. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Anatomic variation of the right hepatic artery and its reconstruction for living donor liver transplantation using right lobe graft

We analyzed the anatomy and reconstruction of the right hepatic artery (RHA) in 96 cases of adult-to-adult living donor right liver transplantations, during 2002. Most right livers had a single orifice (n = 185, 96%). Seven right livers (4%) showed multiple arteries, namely a replaced artery in five cases and accessory arteries in two cases. Three liver grafts had two separate orifices: both arterial stumps were reconstructed in one case, and accessory arteries were ligated in two cases because of sufficient back bleeding. The mean diameter of the graft RHA was 2.4 mm (1-4). More than 60% (59 of 96) of graft arteries were anastomosed with distal branches of recipient RHA for size matching. Eleven graft arteries were anastomosed to vessels other than the RHA, namely the left hepatic artery [LHA] in eight right gastroepiploic artery in three: for size matching in five and due to previous injury of RHA in six. Five cases showed significant size-mismatches of more than twofold. The median follow-up period was 270 days. In one patient, an intramural thrombus developed on postoperative day 3 requiring a revision of the anastomosis. In another patient, arterial stenosis occurred on postoperative day 16 a time when collateral arteries had developed. The overall complication rate related to arterial reconstruction was 2%. In conclusion, with precise knowledge of the anatomy, an adequate selection of recipient arterial stump, and an experienced technique, a desirable result may be achieved in right lobe transplantation.     

肝移植供体切取中变异肝动脉的保护

目的 探讨在肝移植供体切取过程中如何避免损伤变异肝动脉。资料与方法 分析123例供肝切取资料，统计变异肝动脉发生率。结果 肝动脉解剖变异32例（26．02％），其中仅肝右动脉（RHA）变异11例（8．94％），仅肝左动脉（LHA）变异10例（8．13％），左右肝动脉均变异3例（2．44％），肝总动脉（CHA）起于肠系膜上动脉7例（5．69％），其它少见类型1例（0．81％），为肝固有动脉（PHA）来源于胃左动脉。结论 肝动脉解剖复杂，熟悉肝动脉解剖变异可减少供肝切取过程中的肝动脉损伤。     

Angioscopy before and after percutaneous transluminal angioplasty

Background: Reports of endoscopic visualization of the vascular lumen date back to the 1970s. While angioscopy is already used as a routine intraoperative technique in a variety of therapeutic procedures, there are only few reports on the use of percutaneous angioscopy in the course of radiologic interventions. Methods: Fifty two angioscopies before and after percutaneous transluminal angioplasty (PTA) were performed in 30 patients. A 1.4 mm angioscope was used together with a roller-pump (n=42) or a pressure infusion set (n=10) for fluid irrigation. Results: Angiographically, 24 stenoses and 6 occlusions of the superficial femoral artery (SFA) were diagnosed. Angioscopically, circular stenoses were visualized in 14 patients, eccentric stenoses in 7 patients. 6 angiographically diagnosed occlusions were identified angioscopically as high-grade stenoses in 3 cases and fresh thromboses in the remaining 3 patients. In 5 patients (17%) the therapeutic management was modified as a result of the angioscopic findings. After PTA angioscopy showed partly dissected plaques and freely floating intimal flaps which were not visualized angiographically. Conclusions: Thus a direct angioscopic view made a more accurate diagnosis possible. Consequently angioscopy may aid in the selection of the appropriate interventional modality and it may serve as an immediate quality control after PTA.      

Improved detection of renal vascular anatomy using multidetector CT angiography: Is 100% detection possible?

BACKGROUND AND PURPOSE: Multidetector CT angiography (MDCTA) is being used increasingly to evaluate vascular anatomy prior to donor nephrectomy. To improve the ability of MDCTA to predict donor renal anatomy, a novel protocol including four-phase imaging with three-dimensional reconstruction and maximum intensity projections (MIPs) was incorporated into the standard donor evaluation. The purpose of this study was to determine the results of this protocol. PATIENTS AND METHODS: Seventy consecutive patients who underwent hand-assisted laparoscopic donor nephrectomy between January 2003 and September 2004 were reviewed. All MDCTA studies were examined initially by a radiologist alone, after which, a second preoperative reading was performed by a radiologist and the operating surgeon together. The two reviews were compared with the operative findings. RESULTS: Using this protocol to detect the total number of renal arteries, veins, and ureters, the sensitivity of the initial radiologist was 97%, 100%, and 96%, respectively. These values increased to 100%, 100%, and 99% when the films were reviewed by a radiologist together with the surgeon who would operate on the donor. The sensitivity, specificity, and accuracy in predicting supernumerary arteries, including early (< or =1-cm) arterial branching was 89%, 100%, and 97%, respectively after the single reading but increased to 100%, 100%, and 100% with the combined reading. CONCLUSIONS: An MDCTA study with this protocol provides excellent anatomic detail prior to donor nephrectomy. Its ability to predict renal-arterial and ureteral anatomy is enhanced when the films are reviewed simultaneously by a radiologist and the operating surgeon.     

Accuracy of multidetector computed tomographic angiography for detecting hepatic artery complications after liver transplantation

Aims

The aim of this study was to evaluate the accuracy of multidetector computed tomographic angiography (MDCTA) for detecting hepatic artery complications after liver transplantation.

Methods

Between July 2001 and September 2006, 212 patients underwent liver transplantation including 110 (41 female and 69 male patients); of mean age, 24 years (range = 6 months to 66 years) who were assessed with MDCTA. First, arterial phase images obtained after intravenous injection of 150 mL of contrast at a rate of 4 mL/s were acquired using the bolus triggering technique. Then portal and late-phase images were obtained. Axial and coronal maximum intensity projection (MIP) images and volume-rendered images were produced from the axial image data. Arterial vascular complications were noted. Stenosis was defined as severe (>75%), moderate (≥50%), or mild (<50%) according to its diameter. Twenty-nine of the 38 individuals with hepatic artery complications detected by MDCTA had correlative digital subtraction angiography (DSA). Seven of 110 patients with normal hepatic artery and venous pathologies in MDCTA also had DSA to investigate venous complications.

Results

MDCTA showed hepatic artery complications in 38 of the 110 patients who were assessed with this modality. DSA confirmed the MDCTA findings in all but 1 of the 29 patients assessed with catheter angiography. Fourteen of the 38 individuals also underwent percutaneous interventions and treatment. Fifteen patients had early hepatic artery complications, and 23 late hepatic artery complications. The most common early complications were thrombosis (66.6%) and stenosis (26.6%). The most common late complications were stenosis (56.5%) and thrombosis (26%). If we evaluate the early and late complications, the incidence of late complications was greater than that of the early complications (61% vs 39%). There was no statistically significant difference in cadaveric and living donor liver transplants for early versus late or for type of complications.

Conclusions

MDCTA is noninvasive imaging modality that accurately shows a variety of vascular complications after liver transplantation. We suggest that if we suspect any vascular complication with Doppler ultrasound, we must perform MDCTA for diagnosis. If we detect severe/moderate stenosis, the patient must undergo DSA.     

Treatment of "swing point stenoses" in hemodialysis arteriovenous fistulae

AIM: This is a retrospective study of percutaneous transluminal balloon angioplasty (PTA) efficacy for treatment of surgical vein mobilization site ("swing point") stenoses in hemodialysis arteriovenous fistulae (AVF) that fail to mature or are poorly functioning. METHOD: Between February 1, 1999, and February 28, 2001, 65 non-maturing or poorly functioning AVF were studied in 63 consecutive hemodialysis patients (30 male, 33 female, aged 26-92 years). All AVF underwent contrast angiography to study the inflow artery, AVF, outflow and central veins. PTA of stenotic sites was performed to initiate or restore AVF function. RESULTS: Seventy-eight venous and 2 arterial stenoses were found and treated with PTA in the 65 AVF. All PTA were technically successful. A total of 55 stenoses were identified in the vein at the site of surgical mobilization ("swing point"). Additionally, 19 cephalic and 4 central venous stenoses were found. During the study, 13 AVF underwent repeat PTA at the "swing point". Of the 65 AVF treated, 50 were being successfully used as an access site, 4 AVF were lost during follow-up (34-688 days; mean: 258 days) and 8 patients died within the study period. The duration of functional patency of the treated AVF was 39-660 days (mean: 280 days). CONCLUSION: Non-maturing or poorly functioning AVF frequently have stenoses in the outflow vein at the original site of surgical vein mobilization. These "swing point stenoses" are amenable to PTA, which is a safe and effective treatment for prolonging AVF patency and function.     

Median Arcuate Ligament in Orthotopic Liver Transplantation: Relevance to Arterial Reconstruction

Median arcuate ligament (MAL) syndrome results from luminal narrowing of the celiac artery by the insertion of the diaphragmatic muscle fibers or by fibrous bands of the celiac nervous plexus. In 10% to 50% of cases it is responsible for significant angiographic celiac trunk compression. In orthotopic liver transplantation (OLT), the presence of celiac compression by MAL is considered to be a risk factor for hepatic arterial thrombosis (HAT); it may lead to graft loss. Various surgical procedures have been proposed to overcome the impact of MAL in OLT, but their impact is still ill defined. The aim of our study was to compare standard hepatic artery reconstruction and graft reconstruction (aortohepatic bypass) in terms of HAT among patients with MAL undergoing OLT. We retrospectively reviewed 168 adult recipients of OLT performed from January 1991 to December 1998. Ten cases (5.6%) of celiac compression by MAL were identified after celiomesenteric arteriography. There was no significant difference in terms of HAT incidence when aortohepatic bypass was performed compared to a standard anastomosis; moreover, this was greater in the graft reconstruction group (25% vs 17%; P = .67). In our opinion, the presence of an arcuate ligament should not contraindicate a routine hepatic artery reconstruction.     

Carcinoma of Papilla Vater with celiac axis stenosis--application of percutaneous transluminal angioplasty

In a case of carcinoma of Papilla of Vater with angiographically proved celiac axis stenosis, PTA (Percutaneous transluminal angioplasty) was performed to restore sufficient blood flow, followed by standard pancreaticoduodenectomy. This would be the first case to have PTA applied to the cancer-bearing celiac axis stenosis. The patient was 58 year old female, presented with acute abdominal pain and vomiting. DIC revealing protruding defect in the choledochus and hypotonic duodenography showed elevated tumor at Papilla of Vater. Aortography revealed 75% circumferential stenosis at the celiac artery and superior mesenteric angiography visualized all the branches of the celiac axis via dilated pancreaticoduodenal arcades. PTA with Grüntzig Dilaca (4.3Fr), 5 atm for 60 seconds serially every two min for 4 times was performed with the immediate relief of the stenosis down to 25%. Intraoperatively 70-80ml/sec flow confirmed, pancreaticoduodenectomy was done without sacrificing curability. PTA would be superior strategy to restore sufficient blood flow in cases with GI anastomoses, compared with other bypass or reimplantation surgery.     

长段股胭动脉硬化闭塞的腔内治疗

目的 评价血管腔内治疗长段股腘动脉硬化闭塞的临床效果.方法 2006年4月～2009年1月采用血管腔内治疗长段股胭动脉硬化闭塞10例,10条肢体术中同时行股胭动脉血管腔内球囊扩张成及支架植入术.结果 手术技术成功率是90%,放置10个支架,术后12个月通畅率为70%,术后血管再狭窄率30%.结论 血管腔内成形治疗长段股胭动脉硬化闭塞是一种安全有效的治疗方法.     

Laser irradiation and balloon dilatation in experimental transluminal angioplasty

Percutaneous transluminal balloon angioplasty (PTA) is being currently used in patients with coronary artery disease. Laser irradiation (LI) has been effective in vaporizing atherosclerotic plaques. The purpose of this work was twofold: to compare PTA and LI techniques in the recanalization of experimental obstructive arterial lesions, and to evaluate the possibility of reducing the failures and local complications and increasing the success rate of PTA by the combined use of LI. Atherosclerotic iliac stenoses were induced in 27 rabbits; lesions were evaluated angiographically before and after intervention and were studied histologically and by electron microscopy. Argon-ion LI delivered through microlens-tip optic fibers reduced the stenotic area from 64.2 +/- 21.8% to 40.3 +/- 10.7% (n = 10, P less than .01) and PTA from 60.7 +/- 15.9% to 30.4 +/- 7.7% (n = 9, P less than .01). However, percentage reduction was higher in PTA-treated stenoses (48.4 +/- 10.1% vs 34.5 +/- 13.5%, P less than .0125). In eight more rabbits, low power LI (4.55 +/- 1.25 J) was delivered after PTA in dilated segments. Post-PTA LI further decreased stenoses (from 31.2 +/- 7.8% to 29.1 +/- 8.1%, P less than .0125); laser-irradiated segments showed diffuse carbonization of the disrupted intimal layer. The normalized transtenotic pressure gradient decreased significantly in all groups: LI reduced the gradient from .40 +/- .25 to .17 +/- .07 (P = .005); PTA from .37 +/- .14 to .11 +/- .04 (P = .001); LI after PTA from .40 +/- .16 to .12 +/- .06 (P = .001). Thus, LI is effective (less than PTA) in relieving experimental atherosclerotic stenoses and seems useful when combined with PTA.     

Asymptomatic celiac and superior mesenteric artery stenoses are more prevalent among patients with unsuspected renal artery stenoses

The prevalence of unsuspected renal artery stenosis among patients with peripheral vascular disease has been reported to be as high as 40%, but the prevalence of asymptomatic celiac and superior mesenteric artery stenoses in these patients is not known. The biplane aortograms of 205 male patients who were military veterans and had aneurysms or occlusive disease were independently reviewed, and medical records were studied to determine associated coronary disease, risk factors, and patient outcome. Fifty-six patients (27%) had a 50% or greater stenosis in the celiac or superior mesenteric artery, and seven patients (3.4%) had significant stenoses in both mesenteric arteries. Patients with celiac or superior mesenteric artery stenoses were older (p = 0.002) and had a higher prevalence of hypertension (p = 0.029) than those without significant mesenteric stenoses. Fifty of the 205 patients had significant renal artery stenoses, and 20 had advanced (greater than 75% diameter loss) renal stenoses. Ten of the 20 patients (50%) with advanced renal stenoses had a concomitant celiac artery stenosis, compared to 40 of the 185 patients (22%) who did not have advanced renal stenoses (p = 0.011). In the present study asymptomatic celiac or superior mesenteric artery stenoses were common among male veterans evaluated for peripheral vascular disease, but the prevalence of significant stenoses in both the celiac and superior mesenteric arteries was low. The prevalence of significant celiac stenosis was higher in patients with advanced (greater than 75%) renal artery stenoses who might be considered for prophylactic renal revascularization. Lateral aortography with evaluation of the celiac artery is always appropriate in these patients.     

Stenting for localised arterial stenoses in the aorto-iliac segment.

OBJECTIVE: to determine complications and patency following angioplasty (PTA) and stenting of aorto-iliac stenoses. Setting: District General Hospital in U.K. Design: prospective observational study. PATIENTS AND METHODS: between December 1994 and June 2000, 50 patients (38 men), median age 64 (41-89) years underwent aorto-iliac stenting. A total of 61 stents were placed. Indications were intermittent claudication in 38 and rest pain, ulceration or gangrene in 12. Sites stented were aorta 11, common iliac artery 32, external iliac artery 14, common and external iliac arteries two. Bilateral iliac procedures were carried out in nine. Two stents were used to correct residual stenoses after aortic stenting. Some 11 recurrent stenoses were treated. The other reasons for stenting were residual stenoses greater than 30% after PTA, tight calcified stenoses or when a stenosed iliac artery was being used as a donor prior to crossover or femoropopliteal bypass. RESULTS: two immediate technical failures occurred due to malposition. Residual stenoses were corrected by PTA. Two further patients sustained minor complications. None of the aortic stents occluded through two required secondary procedures. Primary-assisted patency was thus 100% at three years. Primary patency following iliac stenting for claudication and critical ischaemia were 97% and 86% at three years respectively. CONCLUSION: PTA and stenting of aorto-iliac stenoses can be safely achieved with durable results.