Hepatic venous outflow obstruction after right lateral sector living-donor liver transplantation,treated by insertion of an expandable metallic stent

Hepatic venous outflow obstruction is a relatively uncommon but important and devastating complication occurring after liver transplantation. Recently, right lateral sector liver grafts have sometimes been used in living-donor liver transplantation (LDLT), but, to our knowledge, early hepatic venous outflow obstruction has never been reported in right lateral sector LDLT. A 58-year-old woman was diagnosed with liver cirrhosis and hepatocellular carcinoma and underwent right lateral sector LDLT. Postoperatively, she developed liver dysfunction. Doppler ultrasound examination revealed flat waveforms and low-flow velocity in the right hepatic vein (RHV). A computed tomography (CT) scan revealed a ventrally distorted RHV due to hypertrophy of the liver graft. Hepatic venous obstruction was suspected and a hepatic venogram was performed. The venogram revealed stenosis of the RHV due to the distortion of the vein. We performed percutaneous transfemoral balloon dilatation, but this was not effective. We then inserted an expandable metallic stent (EMS) into the RHV. After the EMS placement, the condition of the patient improved. Venogram and CT data suggested that the obstruction of the RHV developed because of distortion of the RHV to the ventral side during liver regeneration.     

Portal Vein Complications after Pediatric Liver Transplantation

Relatively few pediatric donors are available in relation to the number of children waiting for a liver transplant. This limited number of pediatric donor livers leads to the use of adult livers, usually requiring more complex portal vein (PV) anastomoses. These anastomoses are complicated by differences in PV caliber between donors and recipients, as well as by limitations of PV length, which may be inadequate to reach the recipient spleno-mesenteric junction. Three types of post-transplant complications result from these complexities: 1) anomalies of the portal flow; 2) stenosis of the PV anastomosis; and 3) PV thrombosis. Abnormal portal flow may rarely need a specific intervention, but persistent stenosis or appearance of signs of portal hypertension need to be corrected. Balloon dilatation and placement of a stent are usually successful to repair stenosis. Portal vein thromboses are in general diagnosed in the immediate post-operative period and frequently lead to re-transplantation; however, thrombolytic therapy should be attempted in children without major signs of liver necrosis. When intra-hepatic portal vein(s) are permeable, despite extrahepatic PV thrombosis, a Meso-Rex shunt may be the indicated therapy.     

Repair of total anomalous pulmonary venous connection in early infancy

From May 1995 through October 2001, 19 infants less than 90 days old underwent surgical correction of total anomalous pulmonary venous connection. In 15 babies with isolated total anomalous pulmonary venous connection, there was one operative death. In 4 with complex anomalies, there were 2 operative deaths. The vertical vein was not ligated in 6 cases for various reasons. Two patients died during reoperation for early pulmonary venous obstruction. In the late follow-up, 2 babies required reoperation for late anastomotic stricture; one needed additional balloon dilatation. Of the 14 surviving patients, one had a small residual gradient and infrequent supraventricular tachycardia, the others were asymptomatic and without gradients. Surgical correction of total anomalous pulmonary venous connection can be carried out in early infancy with low mortality and morbidity. However, associated complex cardiac anomalies and small caliber pulmonary arteries and veins carry higher risks. Recurrent pulmonary venous obstruction and diffuse pulmonary vein stenosis are causes of early reoperation and poor surgical outcome.     

Effect of a portal venous stent for gastrointestinal hemorrhage from jejunal varices caused by portal hypertension after pancreatoduodenectomy

We report herein the case of a 64-year-old man successfully treated by portal venous stent placement for repeated gastrointestinal bleeding associated with jejunal varices. He was admitted to our hospital with melena 8 years after having a pancreatoduodenectomy for carcinoma of the papilla of Vater. From portogram findings showing severe portal vein (PV) stenosis and dilated collaterals through the jejunal vein of the Roux-en-Y loop, jejunal varices resulting from PV stenosis were suspected as the cause of the melena. A metallic stent was placed in the PV following percutaneous transhepatic PV angioplasty. Although the cure of hemorrhagic jejunal varices caused by PV stenosis is difficult in patients who have undergone major abdominal surgery, patency of the stent in this patient has been maintained for 32 months without gastrointestinal hemorrhage. Metallic stent placement is recommended as a useful treatment for PV stenosis that is less invasive than open surgery.     

Treatment of hepatic venous outflow stenosis after living donor liver transplantation by insertion of an expandable metallic stent

BACKGROUND:Hepatic venous outflow stenosis is an uncommon but serious complication after right lobe living donor liver transplantation(LDLT).Failure to recognize and treat this complication early can result in graft failure and even death.The early diagnosis and management of hepatic venous outflow stenosis has become an important issue. METHOD:We report a case with this complication treated by endovascular stent placement in the early period after right lobe LDLT and review related reports to explore the p...     

Successful transjugular balloon dilatation of the hepatic vein stenosis causing hypoalbuminemia after pediatric living-donor liver transplantation

Hepatic vein (HV) stenosis after liver transplantation is a rare but life-threatening complication that leads to graft loss. The incidence of HV stenosis after living-donor liver transplantation (LDLT) and split liver transplantation is not so rare, and is reported to range from 2 to 8.6%. Recently, the minimal invasiveness of radiologic interventions and the innovative techniques have led to their widespread adoption for the treatment of various complications after liver transplantation. We report a five-year-old boy with HV stenosis post-LDLT with only scarcity of clinical information including edema with hypoalbuminemia and elevated hyaluronic acid value. Doppler ultrasonography was effective to suggest stenosis, and angiography confirmed its diagnosis. The stenosis was successfully treated with balloon dilatation using interventional radiologic technique through the jugular vein. In conclusion, we suggest that if liver transplanted patients manifest ascites or/and edema with hypoalbuminemia and elevated hyaluronic acid in sera, HV stenosis should be suspected even if the other laboratory values are normal.     

Portal vein stenting as a significant risk factor for biliary stricture in adult living donor liver transplantation

BACKGROUND: Although perioperative portal vein(PV)stent implantation is an effective treatment for steno-occlusive disease in adult living donor liver transplantation(LDLT) re cipients, we experienced high incidence of biliary anastomotic strictures(BAS) after PV stenting. In this study, we sought to clarify the relation between BAS and PV stenting and to suggest the possible mechanism of BAS and measures to reduce its in cidence.METHODS: We retrospectively analyzed 44 LDLT recipients who underwent PV stent implantation across the line of PV anastomosis regardless of the location of steno-occlusion(stent group) and their matched controls(non-stented LDLT recipients,n=131).RESULTS:The incidence of BAS was higher in patients in the stent group than that in the control group(43.2% vs 17.6% P=0.001). Cumulative 6-month and 1-,2- and 5-year BAS rates were 31.8%, 34.1%, 41.4% and 43.2%, respectively, in the stent group and 13.0%, 13.8%, 16.1% and 17.8%, respectively, in the control group(P=0.001). Multivariate analysis revealed that PV stenting was an independent risk factor for BAS.CONCLUSIONS: Although PV stent implantation is a reliable treatment modality for steno-occlusive PV in adult LDLT recipients, innovative methods to prevent the PV stent from crossing the line of PV anastomosis may be necessary to reduce the incidence of postoperative BAS.     

Portal vein stenting as a signiifcant risk factor for biliary stricture in adult living donor liver transplantation

BACKGROUND: Although perioperative portal vein (PV) stent implantation is an effective treatment for steno-occlusive disease in adult living donor liver transplantation (LDLT) re-cipients, we experienced high incidence of biliary anastomotic strictures (BAS) after PV stenting. In this study, we sought to clarify the relation between BAS and PV stenting and to suggest the possible mechanism of BAS and measures to reduce its in-cidence.
METHODS: We retrospectively analyzed 44 LDLT recipients who underwent PV stent implantation across the line of PV anastomosis regardless of the location of steno-occlusion (stent group) and their matched controls (non-stented LDLT recipients, n=131).
RESULTS: The incidence of BAS was higher in patients in the stent group than that in the control group (43.2% vs 17.6%, P=0.001). Cumulative 6-month and 1-, 2- and 5-year BAS rates were 31.8%, 34.1%, 41.4% and 43.2%, respectively, in the stent group and 13.0%, 13.8%, 16.1% and 17.8%, respectively, in the control group (P=0.001). Multivariate analysis revealed that PV stenting was an independent risk factor for BAS.
CONCLUSIONS: Although PV stent implantation is a reliable treatment modality for steno-occlusive PV in adult LDLT recipients, innovative methods to prevent the PV stent from crossing the line of PV anastomosis may be necessary to reduce the incidence of postoperative BAS.     

Use of endovascular stents in congenital heart disease

BACKGROUND. Balloon expandable intravascular stents have been used to support vessel walls in coronary and peripheral arteries in adults. The purpose of this study was to examine the efficacy and safety of these stents in the treatment of congenital heart disease. METHODS AND RESULTS. Forty-five stents were placed in 30 patients, who were 0.2-30.2 years old (weight, 3.5-76 kg). Patients with areas of stenosis that were difficult to approach surgically were chosen. Stents were mounted over balloons and placed by standard catheterization techniques. Twenty-three patients had branch pulmonary artery stenosis. Thirty-six stents were placed successfully and had reduced pressure gradients from 50.6 +/- 24 to 15.9 +/- 13.4 mm Hg. Five patients had stents placed after atrial surgery: three in obstructed Fontan repairs, one at the superior vena cava-right atrial junction after sinus venous defect repair, and one at the site of a Glenn shunt. Atrial stents reduced pressure gradients from 9.8 +/- 8.2 to 2.0 +/- 2.6 mm Hg. One patient had a stent placed in the descending aorta after coarctation dilation, and the pressure gradient was reduced from 50 to 25 mm Hg. One patient had pulmonary vein dilation with stent placement. Two stents migrated at the time of placement; one required surgical removal, and one was anchored in place by balloon dilation. One patient died within 24 hours of catheterization because of thrombus obstruction of the Fontan repair. Nine patients have undergone recatheterization. All stented vessels have remained at the same caliber as at original stent placement. CONCLUSIONS. We conclude that balloon expandable stents are useful in selected postoperative stenoses in congenital heart disease.     

Protein-losing enteropathy caused by baffle obstruction after Mustard''s operation.

Three patients developed protein-losing enteropathy caused by intra-atrial obstruction of the systemic venous return after Mustard's operation. The enteropathy resolved in one case after reoperation and in the others after balloon dilatation of the stenosed caval pathways. Protein-losing enteropathy may occur as a complication of Mustard's operation. Balloon dilatation of the obstructed baffle is an effective alternative to reoperation.     

Protein-losing enteropathy caused by baffle obstruction after Mustard's operation

Three patients developed protein-losing enteropathy caused by intra-atrial obstruction of the systemic venous return after Mustard's operation. The enteropathy resolved in one case after reoperation and in the others after balloon dilatation of the stenosed caval pathways. Protein-losing enteropathy may occur as a complication of Mustard's operation. Balloon dilatation of the obstructed baffle is an effective alternative to reoperation.     

Transjugular approach to treat portal vein stenosis after liver transplantation--a case report

The authors present a case of portal vein stenosis that developed shortly after liver transplantation in a 48-year-old woman treated successfully with portal stent implantation by use of a transjugular approach to achieve portal vein access. To their knowledge, there are no other reports in the literature on the use of a transjugular approach with vein stent placement in the treatment of portal stenosis complicating orthotopic liver transplantation.     

Immunohistochemical evaluation for outflow reconstruction using opened round ligament in living donor right posterior sector graft liver transplantation: A case report

Utilizing the opened round ligament as venous grafts during liver transplantation is useful but controversial,and there are no pathological analyses of this procedure. Herein,we describe the first reported case of a pathological analysis of an opened round ligament used as a venous patch graft in a living donor liver transplantation(LDLT). A 13-year-old female patient with biliary atresia underwent LDLT using a posterior segment graft from her mother. The graft had two hepatic veins(HVs),which included the right HV(RHV; 15 mm) and the inferior RHV(IRHV; 20 mm). The graft RHV and IRHV were formed into a single orifice using the donor's opened round ligament(60 mm × 20 mm) as a patch graft during bench surgery; it was then anastomosed end-to-side with the recipient inferior vena cava. The recipient had no post-transplant complications involving the HVs,but she died of septic shock with persistent cholangitis and jaundice 86 d after LDLT. The HV anastomotic site had no stenosis or thrombus on autopsy. On pathology,there was adequate patency and continuity between the recipient's HV and the donor's opened round ligament. In addition,the stains for CD31 and CD34 on the inner membrane of the opened round ligament were positive. Hepatic venous reconstruction using the opened round ligament as a venous patch graft is effective in LDLT,as observed on pathology.     

球囊导管扩张在良性气道狭窄Dumon支架置入中的应用评价

目的评价良性气道狭窄患者Dumon支架置入中应用球囊导管扩张的疗效和可行性。方法经硬质支气管镜置入Dumon支架治疗20例良性中心气道狭窄患者。支架置入前均予球囊扩张狭窄管腔,置入后再予球囊扩张使之完全膨胀。球囊压力3-5atm,每次持续1-3分钟,共进行3-4次。结果 20例Dumon支架均一次性放置成功,共置入支架20个,其中Y型6个,直筒型12个,沙漏型2个。支架刚释放时均存在完全或部分膨胀不良,予球囊扩张后完全扩张。术中、术后未见大出血、窒息、气道破裂、恶性心血管事件等严重并发症。结论球囊导管可以安全、快速的扩张良性狭窄的气道及膨胀不良的支架,为Dumon支架成功置入创造条件。     

28例次活体肝移植术后胆道并发症的内镜诊疗体会

目的 回顾性分析活体肝移植术后胆道并发症的临床特点,探讨内镜处置相关问题的有效方式.方法 21例活体肝移植胆道并发症患者接受ERCP诊疗,根据胆道造影所见给予相应治疗,观察内镜治疗的效果.结果 21例患者中43.8%处于术后早期,共接受28次内镜诊疗,其中发现胆管吻合口狭窄19例(90.4%),目.多数存在成角畸形;发现吻合口胆漏9例(42.9%).内镜治疗的操作成功率为85.7%,包括鼻胆管引流5例次、单支架引流10例次、气囊扩张和(或)多支架支撑9例次、胆漏腔引流2例次.随访中3例胆漏患者经治疗漏门已愈合,2例吻合口狭窄已基本消除.结论 活体肝移植术后胆道并发症发生率高且上发生早,吻合口严重狭窄伴成角畸形多见,合并胆漏的发生率较高;采用"先治漏,后治窄"的原则进行内镜治疗可取得满意的疗效.     

Difference in security of stent jail between Palmaz-Schatz, NIR, and Multi-Link stents: the effect of balloon inflation through stent struts.

After placing a stent in the main vessel of a bifurcation lesion, it is often necessary to perform further balloon inflation or stent placement through the stent struts in order to treat a lesion of the secondary vessel or side branch. This balloon inflation with dilatation through the cells of the stent in the main vessel results in stent strut disfigurement. This disfigurement causes various degrees of stenosis within the main vessel secondary to stent strut deformity. The degree of strut deformity, and therefore stenosis, may vary significantly depending on stent design and structure. A model of a bifurcation lesion with an angle of 45 degrees was created from acrylic resin. The diameters of the main vessel and the secondary vessel were both 3.5 mm. Deployment of the Palmaz-Schatz stent (PS, n = 5), NIR stent (n = 5), or Multi-Link stent (n = 5) was performed in the main vessel with a 3.5-mm balloon catheter inflated to 6 atm. A second 3.5-mm balloon catheter was then inflated to 6 atm through the stent struts of the main vessel and into the ostium of the secondary vessel. The minimal lumen diameter (MLD) and cross-sectional area (CSA) at the ostium of the side branch and the stenosis within the main vessel were then measured, taking into account the stent deformity that occurred. Kissing balloon dilatation with two 3.5-mm balloon catheters was then performed and the stenosis secondary to stent deformity in the main vessel was remeasured. The MLD of the Multi-Link stent at the side-branch ostium was greater compared with those of the Palmaz-Schatz stent or the NIR stent (2.4 +/- 0.1, 1.6 +/- 0.1, 1.7 +/- 0.1 mm, P < 0.01) and CSA (4.9 +/- 0.5, 2.7 +/- 0.3, 2.5 +/- 0.3 mm(2), P < 0.01). Balloon inflation through the stent struts caused stent deformity that resulted in some degree of stenosis within the stent of the main vessel in all three stent types. Kissing balloon inflation reduced, but never eliminated, this stenosis. The percent stenosis in the main vessel secondary to stent deformity (PS 34% +/- 9%, NIR 25% +/- 8%, Multi-Link 34% +/- 7%, NS) and residual stenosis postkissing balloon inflation (PS 12% +/- 1%, NIR 10% +/- 3%, Multi-Link 14% +/- 3%, NS) were not significantly different among these three stents. At the side-branch ostium, the MLD and CSA were significantly greater for the Multi-Link stent compared with those of the Palmaz-Schatz or NIR stent. Balloon inflation through the stent struts caused stent deformity that resulted in stenosis within the stent in the main vessel. Kissing balloon inflation reduced this stenosis, but some residual stenosis always remained. The stenoses within the main vessel did not differ among the three stent types. Cathet. Cardiovasc. Intervent. 48:230-234, 1999.     

球囊扩张与临时性金属支架置入治疗良性气道狭窄的疗效分析

目的观察和分析经支气管镜球囊扩张与临时性金属支架置入治疗良性气道狭窄的疗效。方法将30例良性气道狭窄的患者随机分为两组,球囊扩张组(A组,n=15例)和临时性金属支架置入组(B组,n=15例),疗程均为2个月,随访共6个月,观察两组治疗前后气促评分、狭窄段管腔直径等指标的变化。结果观察6个月末时,两组患者的狭窄段管腔直径均较治疗前增加,差异有统计学意义,气促指数均较治疗前降低,差异有统计学意义;临时性金属支架置入组与球囊扩张组相比,气促评分显著降低,狭窄段管腔直径显著升高,差异均有统计学意义,同时临时性金属支架置入组再狭窄发生率低于球囊扩张组。结论临时性金属支架置入治疗良性气道狭窄疗效优于球囊扩张,且术后再狭窄率较低。     

Therapeutic efficacy and stent patency of transhepatic portal vein stenting after surgery

AIM To evaluate portal vein(PV) stenosis and stent patency after hepatobiliary and pancreatic surgery, using abdominal computed tomography(CT).METHODS Percutaneous portal venous stenting was attempted in 22 patients with significant PV stenosis( 50%)-after hepatobiliary or pancreatic surgery- diagnosed by abdominal CT. Stents were placed in various stenotic lesions after percutaneous transhepatic portography. Pressure gradient across the stenotic segment was measured in 14 patients. Stents were placed when the pressure gradient across the stenotic segment was 5 mm Hg or PV stenosis was 50%, as observed on transhepatic portography. Patients underwent followup abdominal CT and technical and clinical success, complications, and stent patency were evaluated.RESULTS Stent placement was successful in 21 patients(technical success rate: 95.5%). Stents were positioned through the main PV and superior mesenteric vein(n = 13), main PV(n = 2), right and main PV(n = 1), left and main PV(n = 4), or main PV and splenic vein(n = 1). Patients showed no complications after stent placement. The time between procedure and final follow-up CT was 41-761 d(mean: 374.5 d). Twenty stents remained patent during the entire follow-up. Stent obstruction-caused by invasion of the PV stent by a recurrent tumor- was observed in 1 patient in a follow-up CT performed after 155 d after the procedure. The cumulative stent patency rate was 95.7%. Small in-stent low-density areas were found in 11(55%) patients; however, during successive follow-up CT, the extent of these areas had decreased.CONCLUSION Percutaneous transhepatic stent placement can be safe and effective in cases of PV stenosis after hepatobiliary and pancreatic surgery. Stents show excellent patency in follow-up abdominal CT, despite development of small in-stent low-density areas.     

Management of balloon rupture during rigid stent deployment

Balloon rupture may occur during stent placement and will only become apparent when the stent has been manouvered across the target stenosis and deployment is attempted. Withdrawal may be complicated by displacement of the stent off the balloon. We describe two cases in which a power injector was used to momentarily inflate the balloon and partially expand the stent in place. The punctured balloon could then be withdrawn and the stent fully deployed, using a new balloon. © 1995 Wiley-Liss, Inc.     

Immediate stent recoil in an anastomotic vein graft lesion treated by cutting balloon angioplasty

Saphenous vein graft (SVG) anastomotic lesions can have significant fibromuscular hyperplasia and may be resistant to balloon angioplasty alone. Stents have been used successfully to treat these lesions. There are no reports of immediate stent recoil following such treatment in the literature. We describe immediate and persistent stent recoil in an anastomotic SVG lesion even after initial and post-deployment complete balloon dilatation of the stent and its successful treatment by cutting balloon angioplasty.