Anatomic Variation in Intrahepatic Bile Ducts: an Analysis of Intraoperative Cholangiograms in 300 Consecutive Donors for Living Donor Liver Transplantation

Objective

To describe the anatomical variation occurring in intrahepatic bile ducts (IHDs) in terms of their branching patterns, and to determine the frequency of each variation.

Materials and Methods

The study group consisted of 300 consecutive donors for liver transplantation who underwent intraoperative cholangiography. Anatomical variation in IHDs was classified according to the branching pattern of the right anterior and right posterior segmental duct (RASD and RPSD, respectively), and the presence or absence of the first-order branch of the left hepatic duct (LHD), and of an accessory hepatic duct.

Results

The anatomy of the intrahepatic bile ducts was typical in 63% of cases (n=188), showed triple confluence in 10% (n=29), anomalous drainage of the RPSD into the LHD in 11% (n=34), anomalous drainage of the RPSD into the common hepatic duct (CHD) in 6% (n=19), anomalous drainage of the RPSD into the cystic duct in 2% (n=6), drainage of the right hepatic duct (RHD) into the cystic duct (n=1), the presence of an accessory duct leading to the CHD or RHD in 5% (n=16), individual drainage of the LHD into the RHD or CHD in 1% (n=4), and unclassified or complex variation in 1% (n=3).

Conclusion

The branching pattern of IHDs was atypical in 37% of cases. The two most common variations were drainage of the RPSD into the LHD (11%) and triple confluence of the RASD, RPSD and LHD (10%).     

CT Findings of Completely Regressed Hepatocellular Carcinoma with Main Portal Vein Tumor Thrombosis after Transcatheter Arterial Chemoembolization

Objective

The objective of this study was to determine the sequential CT findings of controlled hepatocellular carcinoma (HCC) with main portal vein (MPV) thrombosis with the use of transcatheter arterial chemoembolization and additional intra-arterial cisplatin infusion.

Materials and Methods

From January 2004 to September 2006, 138 patients with HCC invading MPV were referred to the angiography unit of our institution for chemoembolization and additional intra-arterial cisplatin infusion. Until August 2008, seven (5%) of 138 patients were followed-up and found not to have tumor recurrence. CT scans were retrospectively reviewed by two radiologists, focusing on the following parameters: the extent of portal vein thrombosis, the diameter of the affected portal vein, and enhancement of portal vein thrombosis.

Results

The extent of portal vein thrombosis at the initial presentation was variable: left portal vein (LPV) and MPV (n = 1), right portal vein (RPV) and MPV (n = 3), as well as RPV, LPV and MPV (n = 3). The extent and diameter of the affected portal vein decreased during follow-up examinations. In addition, the degree of enhancement for tumor thrombi and serum alpha-feto-protein levels decreased after the transcatheter arterial chemoembolization. Portal vein thrombosis was found to be completely resolved in one patient, whereas residual thrombus without viability was persistent in six patients.

Conclusion

If chemoembolization is effective in patients with HCC that invades the portal vein, the extent and enhancement of portal vein thrombosis is reduced, but residual thrombosis frequently persists for months or years, without evidence of a viable tumor.     

Transcaval Transjugular Intrahepatic Portosystemic Shunt: Preliminary Clinical Results

Objective

To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins.

Materials and Methods

Transcaval TIPS, performed in six patients, was indicated by active variceal bleeding (n=2), recurrent variceal bleeding (n=2), intractable ascites (n=1), and as a bridge to liver transplantation (n=1). The main reasons for transcaval rather than classic TIPS were the presence of an unusually acute angle between the hepatic veins and the level of the portal bifurcation (n=3), hepatic venous occlusion (n=2), and inadequate small hepatic veins (n=1).

Results

Technical and functional success was achieved in all patients. The entry site into liver parenchyma from the inferior vena cava was within 2 cm of the atriocaval junction. Procedure-related complications included the death of one patient due to hemoperitoneum despite the absence of contrast media spillage at tractography, and another suffered reversible hepatic encephalopathy.

Conclusion

In patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins, transcaval TIPS creation is feasible.     

Percutaneous Angioplasty of Portal Vein Stenosis that Complicates Liver Transplantation: The Mid-Term Therapeutic Results

Objective

We wanted to valuate the mid-term therapeutic results of percutaneous transhepatic balloon angioplasty for portal vein stenosis after liver transplantation.

Materials and Methods

From May 1996 to Feb 2005, 420 patients underwent liver transplantation. Percutaneous transhepatic angioplasty of the portal vein was attempted in six patients. The patients presented with the clinical signs and symptoms of portal venous hypertension or they were identified by surveillance doppler ultrasonography. The preangioplasty and postangioplasty pressure gradients were recorded. The therapeutic results were monitored by the follow up of the clinical symptoms, the laboratory values, CT and ultrasonography.

Results

The overall technical success rate was 100%. The clinical success rate was 83% (5/6). A total of eight sessions of balloon angioplasty were performed in six patients. The mean pressure gradient decreased from 14.5 mmHg to 2.8 mmHg before and after treatment, respectively. The follow up periods ranged from three months to 64 months (mean period; 32 months). Portal venous patency was maintained in all six patients until the final follow up. Combined hepatic venous stenosis was seen in one patient who was treated with stent placement. One patient showed puncture tract bleeding, and this patient was treated with coil embolization of the right portal puncture tract via the left transhepatic portal venous approach.

Conclusion

Percutaneous transhepatic balloon angioplasty is an effective treatment for the portal vein stenosis that occurs after liver transplantation, and our results showed good mid-term patency with using this technique.     

Three-Dimensional Evaluation of the Anatomic Variations of the Femoral Vein and Popliteal Vein in Relation to the Accompanying Artery by Using CT Venography

Objective

We wanted to describe the three-dimensional (3D) anatomic variations of the femoral vein (FV) and popliteal vein (PV) in relation to the accompanying artery using CT venography.

Materials and Methods

We performed a retrospective review of 445 bilateral (890 limbs) lower limb CT venograms. After the 3D relationship between the FV and PV and accompanying artery was analyzed, the presence or absence of variation was determined and the observed variations were classified. In each patient, the extent and location of the variations and the location of the adductor hiatus were recorded to investigate the regional frequency of the variations.

Results

There were four distinct categories of variations: agenesis (3 limbs, 0.3%), multiplication (isolated in the FV: 190 limbs, 21%; isolated in the PV: 14 limbs, 2%; and in both the FV and PV: 51 limbs, 6%), anatomical course variation (75 limbs, 8%) and high union of the tibial veins (737 limbs, 83%). The course variations included medial malposition (60 limbs, 7%), anterior rotation (11 limbs, 1%) and posterior rotation (4 limbs, 0.4%). Mapping the individual variations revealed regional differences in the pattern and frequency of the variations.

Conclusion

CT venography helps to confirm a high incidence of variations in the lower limb venous anatomy and it also revealed various positional venous anomalies in relation to the respective artery.     

Percutaneous Unilateral Biliary Metallic Stent Placement in Patients with Malignant Obstruction of the Biliary Hila and Contralateral Portal Vein Steno-Occlusion

Objective

To investigate the outcomes of percutaneous unilateral metallic stent placement in patients with a malignant obstruction of the biliary hila and a contralateral portal vein steno-occlusion.

Materials and Methods

Sixty patients with a malignant hilar obstruction and unilobar portal vein steno-occlusion caused by tumor invasion or preoperative portal vein embolization were enrolled in this retrospective study from October 2010 to October 2013. All patients were treated with percutaneous placement of a biliary metallic stent, including expanded polytetrafluoroethylene (ePTFE)-covered stents in 27 patients and uncovered stents in 33 patients.

Results

A total of 70 stents were successfully placed in 60 patients. Procedural-related minor complications, including self-limiting hemobilia (n = 2) and cholangitis (n = 4) occurred in six (10%) patients. Acute cholecystitis occurred in two patients. Successful internal drainage was achieved in 54 (90%) of the 60 patients. According to a Kaplan-Meier analysis, median survival time was 210 days (95% confidence interval [CI], 135-284 days), and median stent patency time was 133 days (95% CI, 94-171 days). No significant difference in stent patency was observed between covered and uncovered stents (p = 0.646). Stent dysfunction occurred in 16 (29.6%) of 54 patients after a mean of 159 days (range, 65-321 days).

Conclusion

Unilateral placement of ePTFE-covered and uncovered stents in the hepatic lobe with a patent portal vein is a safe and effective method for palliative treatment of patients with a contralateral portal vein steno-occlusion caused by an advanced hilar malignancy or portal vein embolization. No significant difference in stent patency was detected between covered and uncovered metallic stents.     

Percutaneous Access via the Recanalized Paraumbilical Vein for Varix Embolization in Seven Patients

Objective

To evaluate the feasibility of percutaneous access via the recanalized paraumbilical vein for varix embolization.

Materials and Methods

Between July 2008 and Jan 2014, percutaneous access via the recanalized paraumbilical vein for varix embolization was attempted in seven patients with variceal bleeding. Paraumbilical vein puncture was performed under ultrasonographic guidance, followed by introduction of a 5-Fr sheath. We retrospectively evaluated the technical feasibility, procedure-related complications, and clinical outcomes of each patient.

Results

Recanalized paraumbilical vein catheterization was performed successfully in all patients. Gastroesophageal varix embolization was performed in six patients, and umbilical varix embolization was performed in one patient. Embolic materials used are N-butyl cyanoacrylate (n = 6) and coil with N-butyl cyanoacrylate (n = 1). There were no procedure-related complications. One patient underwent repeated variceal embolization 6 hours after initial procedure via recanalized paraumbilical vein, due to rebleeding from gastric varix.

Conclusion

Percutaneous access via the paraumbilical vein for varix embolization is a simple alternative in patients with portal hypertension.     

The Accuracy of Ultrasonography for the Evaluation of Portal Hypertension in Patients with Cirrhosis: A Systematic Review

Objective

Studies have presented conflicting results regarding the accuracy of ultrasonography (US) for diagnosing portal hypertension (PH). We sought to identify evidence in the literature regarding the accuracy of US for assessing PH in patients with liver cirrhosis.

Materials and Methods

We conducted a systematic review by searching databases, including MEDLINE, EMBASE, and the Cochrane Library, for relevant studies.

Results

A total of 14 studies met our inclusion criteria. The US indices were obtained in the portal vein (n = 9), hepatic artery (n = 6), hepatic vein (HV) (n = 4) and other vessels. Using hepatic venous pressure gradient (HVPG) as the reference, the sensitivity (Se) and specificity (Sp) of the portal venous indices were 69-88% and 67-75%, respectively. The correlation coefficients between HVPG and the portal venous indices were approximately 0.296-0.8. No studies assess the Se and Sp of the hepatic arterial indices. The correlation between HVPG and the hepatic arterial indices ranged from 0.01 to 0.83. The Se and Sp of the hepatic venous indices were 75.9-77.8% and 81.8-100%, respectively. In particular, the Se and Sp of HV arrival time for clinically significant PH were 92.7% and 86.7%, respectively. A statistically significant correlation between HVPG and the hepatic venous indices was observed (0.545-0.649).

Conclusion

Some US indices, such as HV, exhibited an increased accuracy for diagnosing PH. These indices may be useful in clinical practice for the detection of significant PH.     

Tubular Foreign Body or Stent: Safe Retrieval or Repositioning Using the Coaxial Snare Technique

Objective

To evaluate the utility and advantages of the coaxial snare technique in the retrieval of tubular foreign bodies.

Materials and Methods

Using the coaxial snare technique, we attempted to retrieve tubular foreign bodies present in seven patients. The bodies were either stents which were malpositioned or had migrated from their correct position in the vascular system (n=2), a fragmented venous introducer sheath (n=1), fragmented drainage catheters in the biliary tree (n=2), or fractured external drainage catheters in the urinary tract (n=2). After passing a guidewire and/or a dilator through the lumina of these foreign bodies, we introduced a loop snare over the guidewire or dilator, thus capturing and retrieving them.

Results

In all cases, it was possible to retrieve or reposition the various items, using a minimum-sized introducer sheath or a tract. No folding was involved. In no case were surgical procedures required, and no complications were encountered.

Conclusion

The coaxial snare technique, an application of the loop snare technique, is a useful and safe method for the retrieval of tubular foreign bodies, and one which involves minimal injury to the patient.     

Imaging of aberrant left gastric vein and associated pseudolesions of segments II and III of the liver and mimickers

We present imaging findings of aberrant left gastric vein (ALGV) and associated pseudolesions and mimickers including metastases and focal nodular hyperplasia. ALGV is formed due to interrupted involution of anastomotic omental veins, and it can drain into left portal vein or segments II and III of the liver as third inflow. Focal fat, focal fat sparing, and perfusion changes can be seen due to the presence of ALGV, which can mimic metastasis in cancer patients. ALGV may also serve as a pathway for direct tumor spread into the liver in patients with gastric cancer. Magnetic resonance imaging can be used as a problem solving tool in the presence of equivocal findings on ultrasonography and computed tomography.Pseudolesions of the liver are a well-known issue and have been reported in the literature. These pseudolesions are caused by aberrant hepatopedal venous flow other than portal venous system, also known as third inflow. Third inflow is most commonly due to aberrant right gastric, paraumbilical, and cholecystic veins (1–3). Pseudolesions caused by aberrant left gastric vein (ALGV) are considered to be a more rare entity (4).The purpose of this study is to illustrate ALGV drainage into the liver and associated pseudolesions of segments II and III of the liver. In addition, we illustrate imaging findings of the mimickers of these pseudolesions.     

Fluoroscopy-Guided Endovenous Sclerotherapy Using a Microcatheter Prior to Endovenous Laser Ablation: Comparison between Liquid and Foam Sclerotherapy for Varicose Tributaries

Objective

To compare the efficacy and adverse effects of endovenous foam sclerotherapy (EFS) and liquid sclerotherapy (ELS) using a microcatheter for the treatment of varicose tributaries.

Materials and Methods

From December 2007 to January 2009, patients with venous reflux in the saphenous vein were enrolled. The foam or liquid sclerosant was injected through a microcatheter just before endovenous laser ablation (EVLA). Patients were evaluated for the technical success, clinical success, and procedure-related complications during the procedure and follow-up visits.

Results

A total of 94 limbs were included: 48 limbs (great saphenous vein [GSV], 35; small saphenous vein [SSV], 13) were managed using EFS and EVLA (foam group; FG), and 46 limbs (GSV, 37; SSV, 9) were treated by ELS and EVLA (liquid group; LG). Varicose tributaries demonstrated complete sclerosis in 92.7% with FG and in 71.8% with LG (p = 0.014). Bruising (78.7% in FG vs. 73.2% in LG, p > 0.05), pain or tenderness (75.6% in FG vs. 51.2% in LG, p = 0.0237) were noted. Hyperpigmentation (51.2% in FG vs. 46.2% in LG, p > 0.05) was found.

Conclusion

Endovenous foam sclerotherapy using a microcatheter is more effective than ELS for eliminating remnant varicose tributaries prior to EVLA. However, EFS is more commonly associated with local complications such as pain or tenderness than ELS. Furthermore, both techniques seem to prolong the duration of hyperpigmentation along with higher costs.     

Efficacy and Safety of Balloon-Occluded Retrograde Transvenous Obliteration with Sodium Tetradecyl Sulfate Liquid Sclerotherapy

Objective

To evaluate the efficacy and safety of balloon-occluded retrograde transvenous obliteration (BRTO) with sodium tetradecyl sulfate (STS) liquid sclerotherapy of gastric varices.

Materials and Methods

Between February 2012 and August 2014, STS liquid sclerotherapy was performed in 17 consecutive patients (male:female = 8:9; mean age 58.6 years, range 44–86 years) with gastric varices. Retrograde venography was performed after occlusion of the gastrorenal shunt using a balloon catheter and embolization of collateral draining veins using coils or gelfoam pledgets, to evaluate the anatomy of the gastric varices. We prepared 2% liquid STS by mixing 3% STS and contrast media in a ratio of 2:1. A 2% STS solution was injected into the gastric varices until minimal filling of the afferent portal vein branch was observed (mean 19.9 mL, range 6–33 mL). Patients were followed up using computed tomography (CT) or endoscopy.

Results

Technical success was achieved in 16 of 17 patients (94.1%). The procedure failed in one patient because the shunt could not be occluded due to the large diameter of gastrorenal shunt. Complete obliteration of gastric varices was observed in 15 of 16 patients (93.8%) with follow-up CT or endoscopy. There was no rebleeding after the procedure. There was no procedure-related mortality.

Conclusion

BRTO using STS liquid can be a safe and useful treatment option in patients with gastric varices.     

Development of Thrombus in a Systemic Vein after Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices

Objective

To retrospectively evaluate the frequency and risk factors for developing thrombus in a systemic vein such as the infrarenal inferior vena cava or the iliac vein, in which a balloon-occluded retrograde transvenous obliteration (B-RTO) catheter was indwelled.

Materials and Methods

Forty-nine patients who underwent B-RTO for gastric varices were included in this study. The B-RTO procedure was performed from the right femoral vein, and the B-RTO catheter was retained overnight in all patients. Pre- and post-procedural CT scans were retrospectively compared in order to evaluate the development of thrombus in the systemic vein in which the catheter was indwelled. Additionally, several variables were analyzed to assess risk factors for thrombus in a systemic vein.

Results

In all 49 patients (100%), B-RTO was technically successful, and in 46 patients (94%), complete thrombosis of the gastric varices was achieved. In 6 patients (12%), thrombus developed in the infrarenal inferior vena cava or the right common-external iliac vein. All thrombi lay longitudinally on the right side of the inferior vena cava or the right iliac vein. One of the aforementioned 6 patients required anticoagulation therapy. No symptoms suggestive of pulmonary embolism were observed. Prothrombin time-international normalized ratio and the addition of 5% ethanolamine oleate iopamidol, on the second day, were related to the development of thrombus.

Conclusion

Development of a thrombus in a systemic vein such as the inferior vena cava or iliac vein, caused by indwelling of the B-RTO catheter, is relatively frequent. Physicians should be aware of the possibility of pulmonary embolism due to iliocaval thrombosis.     

Trans-caval trans-jugular liver biopsy—a technical modification of trans-jugular liver biopsy

Objective:

To (a) describe the technical modification of trans-caval TJLB and (b) review our series of nine cases.

Methods:

We performed a retrospective review of all trans-caval TJLBs performed; we assessed indications for the procedure, technical success, complications, adequacy of specimen and histological positivity.

Results:

The technical success rate of the procedure was 9/9 (100%); the minor complication rate was 1/9 (11%), adequate specimen was obtained in all cases and a histological diagnosis was achieved in 8/9 (89%) cases.

Conclusion:

This preliminary report suggests that trans-caval modification of TJLB is a relatively safe procedure that may be useful in cases where conventional TJLB is infeasible.

Advances in knowledge:

(a) We describe the technique of trans-caval TJLBs and report our findings in the largest series of published cases. (b) Trans-caval TJLB is relatively safe and can be used to increase the success rates of conventional TJLB.Trans-jugular liver biopsy (TJLB) is an established technique in patients unsuitable for a percutaneous trans-abdominal liver biopsy. TJLB procedure involves biopsy of the liver parenchyma through trans-jugular venous access, with the biopsy needle placed in the right hepatic vein (commonly described) or the middle or left hepatic veins. However, a TJLB may be not technically feasible in a small subset of cases where hepatic venous cannulation is not possible, owing to unsuitable hepatic venous anatomy, occluded hepatic veins [Budd–Chiari syndrome (BCS)] or markedly shrunken liver. In such cases, a technical modification of TJLB, called a direct trans-caval TJLB, can be performed. In this study, we (a) describe the technical modification of the trans-caval TJLB and (b) review the results of a series of nine cases where the trans-caval TJLB was carried out.     

Hypereosinophilic Syndrome: CT Findings in Patients with Hepatic Lobar or Segmental Involvement

Objective

The purpose of this study was to describe the CT findings of hepatic hypereosinophilic syndrome in which hepatic lobes or segments were involved.

Materials and Methods

Seven patients with hypereosinophilic syndrome with hepatic lobar or segmental involvement were included in our study. In all seven, diagnosis was based on liver biopsy and the results of corticosteroid treatment. CT findings were retrospectively reviewed by three radiologists, who reached a consensus. Biopsy specimens were examined, with special reference to portal and periportal inflammation.

Results

CT demonstrated well-defined, homogeneous or heterogeneous low attenuation with a straight margin limited to a hepatic lobe (n = 2), segments (n = 3), or subsegments (n = 2), particularly during the portal phase. Where there was subsegmental involvement, lesions were multiple, ovoid or wedge-shaped, and showed low attenuation. In two patients with lobar or segmental involvement, segmental portal vein narrowing was observed. Histopathologic examination disclosed eosinophilic infiltration in the periportal area, sinusoids and central veins, as well as portal phlebitis.

Conclusion

Hypereosinophilic syndrome may involve the presence of hepatic lobar, segmental, or subsegmental low-attenuated lesions, as seen on CT images. Their presence may be related to damage of the liver parenchyma and to portal phlebitis.     

Role of CT Venography in the Diagnosis and Treatment of Benign Thoracic Central Venous Obstruction

Objective

To evaluate the role of CT venography in the diagnosis and treatment of benign thoracic central venous obstruction.

Materials and Methods

Eighteen patients who had undergone both CT venography and digital subtraction venography were prospectively enrolled in this study. The following features were analyzed by two observers: the cause, degree, and extent of venous obstruction; associated thrombosis; and implications for the planning of treatment. CT venography and digital subtraction venography were compared in defined venous segments, and the degree of obstruction, and correlation was expressed using Spearman''s rank correlation coefficient.

Results

In all patients, CT venography depicted the causes of obstruction, including extrinsic compression of the left brachiocephalic vein, and mediastinal inflammatory pseudotumor. Interobserver agreement regarding classification of the degree of obstruction was judged as good for CT venography (κ=0.864), and in evaluating this, there was significant correlation between CT venography and digital subtraction venography (reader 1: Rs = 0.58, p < 0.01; reader 2: Rs = 0.56, p < 0.01). In evaluating the status of central veins proximal to long segmental obstruction, and associated thrombosis, CT venography was superior to digital subtraction venography. In half of all patients, the findings of CT venography led to changes in the treatment plan.

Conclusion

The findings of CT venography correlated closely with those of digital subtraction venography, and the former accurately depicted the degree and extent of benign venous obstruction.     

Stent Extension below the Common Femoral Vein in Extensive Chronic Iliofemoral Venous Obstructions

Purpose

To analyze whether primary venous stent placement into 1 dominant inflow vein peripheral to the common femoral vein (CFV) confluence is feasible.

Migrating Lobar Atelectasis of the Right Lung: Radiologic Findings in Six Patients

Objective

To describe the radiologic findings of migrating lobar atelectasis of the right lung.

Materials and Methods

Chest radiographs (n = 6) and CT scans (n = 5) of six patients with migrating lobar atelectasis of the right lung were analyzed retrospectively. The underlying diseases associated with lobar atelectasis were bronchogenic carcinoma (n = 4), bronchial tuberculosis (n = 1), and tracheobronchial amyloidosis (n = 1).

Results

Atelectasis involved the right upper lobe (RUL) (n = 3) and both the RUL and right middle lobe (RML) (n = 3). On supine anteroposterior radiographs (n = 5) and on an erect posteroanterior radiograph (n = 1), the atelectatic lobe(s) occupied the right upper lung zone, with a wedge shape abutting onto the right mediastinal border. On erect posteroanterior radiographs (n = 6), the heavy atelectatic lobe(s) migrated downward, forming a peri- or infrahilar area of increased opacity and obscuring the right cardiac margin. Erect lateral radiographs (n = 4) showed inferior shift of the anterosuperiorly located atelectatic lobe(s) to the anteroinferior portion of the hemithorax.

Conclusion

Atelectatic lobe(s) can move within the hemithorax according to changes in a patient''s position. This process involves the RUL or both the RUL and RML.     

Ultrasound and Fluoroscopy-Guided Placement of Central Venous Ports via Internal Jugular Vein: Retrospective Analysis of 1254 Port Implantations at a Single Center

Objective

To assess the technical success and complication rates of the radiologic placement of central venous ports via the internal jugular vein.

Materials and Methods

We retrospectively reviewed 1254 central venous ports implanted at our institution between August 2002 and October 2009. All procedures were guided by using ultrasound and fluoroscopy. Catheter maintenance days, technical success rates, peri-procedural, as well as early and late complication rates were evaluated based on the interventional radiologic reports and patient medical records.

Results

A total of 433386 catheter maintenance days (mean, 350 days; range 0-1165 days) were recorded. The technical success rate was 99.9% and a total of 61 complications occurred (5%), resulting in a post-procedural complication rate of 0.129 of 1000 catheter days. Among them, peri-procedural complications within 24 hours occurred in five patients (0.4%). There were 56 post-procedural complications including 24 (1.9%, 0.055 of 1000 catheter days) early and 32 (2.6%, 0.074 of 1000 catheter days) late complications including, infection (0.6%, 0.018 of 10000 catheter days), thrombotic malfunction (1.4%, 0.040 of 1000 catheter days), nonthrombotic malfunction (0.9%, 0.025 of 1000 catheter days), venous thrombosis (0.5%, 0.014 of 1000 catheter days), as well as wound problems (1.1%, 0.032 of 1000 catheter days). Thirty six CVPs (3%) were removed due to complications. Bloodstream infections and venous thrombosis were the two main adverse events prolonging hospitalization (mean 13 days and 5 days, respectively).

Conclusion

Radiologic placement of a central venous port via the internal jugular vein is safe and efficient as evidenced by its high technical success rate and a very low complication rate.     

Catheter-Directed Thrombolysis with a Continuous Infusion of Low-Dose Urokinase for Non-Acute Deep Venous Thrombosis of the Lower Extremity

Objective

We wanted to evaluate the feasibility of catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for treating non-acute (less than 14 days) deep venous thrombosis of the lower extremity.

Materials and Methods

The clinical data of 110 patients who were treated by catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for lower extremity deep venous thrombosis was analysed. Adjunctive angioplasty or/and stenting was performed for the residual stenosis. Venous recanalization was graded by pre- and post-treatment venography. Follow-up was performed by clinical evaluation and Doppler ultrasound.

Results

A total of 112 limbs with deep venous thrombosis with a mean symptom duration of 22.7 days (range: 15-38 days) were treated with a urokinase infusion (mean: 3.5 million IU) for a mean of 196 hours. After thrombolysis, stent placement was performed in 25 iliac vein lesions and percutaneous angioplasty (PTA) alone was done in five iliac veins. Clinically significant recanalization was achieved in 81% (90 of 112) of the treated limbs; complete recanalization was achieved in 28% (31 of 112) and partial recanalization was achieved in 53% (59 of 112). Minor bleeding occurred in 14 (13%) patients, but none of the patients suffered from major bleeding or symptomatic pulmonary embolism. During follow-up (mean: 15.2 months, range: 3-24 months), the veins were patent in 74 (67%) limbs. Thirty seven limbs (32%) showed progression of the stenosis with luminal narrowing more than 50%, including three with rethrombosis, while one revealed an asymptomatic iliac vein occlusion; 25 limbs (22%) developed mild post-thrombotic syndrome, and none had severe post-thrombotic syndrome. Valvular reflux occurred in 24 (21%) limbs.

Conclusion

Catheter-directed thrombolysis with a continuous infusion of low-dose urokinase combined with adjunctive iliac vein stenting is safe and effective for removal of the clot burden and for restoration of the venous flow in patients with non-acute lower extremity deep venous thrombosis.