Portal vein thrombosis: an unusual complication of laparoscopic cholecystectomy.

BACKGROUND: Complications following laparoscopic cholecystectomy are encountered infrequently due to increasing proficiency in laparoscopic surgery. The occurrence of portal venous thrombosis following laparoscopic cholecystectomy has not been previously described and forms the basis of this report. METHODS: A healthy, 32-year-old, female on oral contraceptives underwent an uneventful laparoscopic cholecystectomy for symptomatic gallbladder disease. Sequential compression devices and mini-dose unfractionated heparin were used before the procedure. The patient was discharged home on the first postoperative day without complaints. She returned 1 week later with nausea, bloating, and diffuse abdominal pain. RESULTS: Ultrasonography of the abdomen revealed thrombosis of the portal vein not seen in the preoperative ultrasound and the superior mesenteric vein. Computer tomography of the abdomen and pelvis on the same day confirmed this finding and showed a wedge-shaped infarction of the right lobe of the liver. The patient was anticoagulated with intravenous heparin. An extensive coagulation workup revealed elevation of the Immunoglobulin G anticardiolipin antibody. A percutaneous transhepatic portal vein thrombectomy was performed. A postprocedure duplex ultrasound of the abdomen demonstrated recannalization of the portal venous system with no flow voids. Anticoagulation therapy was continued, and the patient was discharged home with resolution of her ileus. She was maintained on a therapeutic dose of warfarin. CONCLUSIONS: This case demonstrates an unusual complication of laparoscopic cholecystectomy. It may have resulted from the use of oral contraceptives, elevation of the Immunoglobulin G anticardiolipin antibody, unrecognized trauma, and was accentuated by the pneumoperitoneum generated for the performance of the laparoscopic cholecystectomy. Our case report provides insight and poses questions regarding necessary perioperative measures for thromboprophylaxis in young females on oral contraceptives undergoing elective laparoscopic abdominal surgery.     

Portal vein thrombosis after laparoscopic splenectomy: an ongoing clinical challenge.

OBJECTIVES: Portal vein thrombosis (PVT) following open splenectomy is a potentially lethal complication with an incidence of up to 6%. The objective of this report is to describe our management of a recent laparoscopic case, discuss current therapies, and consider antiplatelet therapy for prophylaxis. METHODS: Medical records, laboratory studies, and imaging studies pertaining to a recent case of a laparoscopic splenectomy were examined. Current literature related to this topic was reviewed. RESULTS: A 16-year-old girl underwent laparoscopic splenectomy for idiopathic thrombocytopenic purpura. Her preoperative platelet count was 96K. She was discharged on postoperative day 1 after an uneventful operation including division of the splenic hilum with an endoscopic linear stapler. On postoperative day 20, she presented with a 5-day history of epigastric pain, nausea, and low-grade fevers without peritoneal signs. Her white blood cell count was 17.3; her platelets were 476K. Computed tomography demonstrated thrombosis of the splenic, superior mesenteric, and portal veins propagating into the liver. Heparinization was begun followed by an unsuccessful attempt at pharmacologic and mechanical thrombolysis by interventional radiology. Over the next 5 days, her pain resolved, she tolerated a full diet, was converted to oral anticoagulation and sent home. Follow-up radiographic studies demonstrated the development of venous collaterals and cavernous transformation of the portal vein. DISCUSSION: No standard therapy for PVT exists; several approaches have been described. These include systemic anticoagulation, systemic or regional medical thrombolysis, mechanical thrombolysis, and surgical thrombectomy. Unanswered questions exist about the most effective acute therapy, duration of anticoagulation, and the potential efficacy of routine prophylaxis with perioperative antiplatelet agents. PVT following splenectomy occurs with both the open and laparoscopic approach.     

Renal capsular tumors: the angiographic features.

Five masses of the renal capsule, which were studied angiographically, demonstrated a typical inward displacement of the renal parenchyma, and prominence and variable displacement of the renal capsular arteries. Benign lesions typically lacked malignant neovascularity and had a sharp interface with the renal parenchyma. The angiographic characterization of renal capsular lesions may help in identification of benign lesions and prevent unnecessary nephrectomy.     

Onyx in an experimental aneurysm model: histological and angiographic results

OBJECT: The use of liquid embolic agents for endovascular treatment of cerebral aneurysms is evolving. The authors' aim was to evaluate the use of Onyx HD-500 in an experimental aneurysm model and to obtain histological and angiographic long-term results. METHODS: Ten aneurysms were created using an elastase model in rabbits. The aneurysms were embolized using Onyx in combination with an inflated balloon. One animal died 1 day after embolization. The animals were divided into 2 different groups. The animals in the first group (4 rabbits) were killed at 3 months and those in the second group (5 rabbits) were killed at 6 months after embolization. A venous control angiogram was obtained, and the aneurysms were examined histologically. RESULTS: In both groups control angiograms demonstrated that all aneurysms were completely occluded. There were no signs of recanalization. Migration of Onyx was seen in 4 animals, leading to the death of 1. Histological examination not only proved the aneurysms to be occluded but also demonstrated a thin layer of endothelium at the neck of the aneurysm. The histological result was identical in both groups. CONCLUSIONS: This is the first study reporting the formation of a neointima over the neck of aneurysms embolized with Onyx in a rabbit model. Although the technique is challenging and migration of the liquid embolic agent cannot always be prevented, Onyx has a great potential to achieve a durable occlusion of aneurysms.     

Global and regional left ventricular function in heart transplant patients: an angiographic follow-up study.

We studied the global and regional left ventricular function, its determinants and its modification with time, in orthotopic heart transplant recipients. We reviewed the left ventricular cineangiography performed 1 (50 patients), 2 (33 patients), 3 (18 patients), and 4 (seven patients) years after operation. Regional wall motion was quantitatively evaluated by the area method. All patients had angiographically normal coronary arteries and no evidence of acute rejection at the time of the study. One year after heart transplantation, cardiac index and left ventricular ejection fraction were mildly but significantly lower than normal. Cardiac index was more than 2.5 L/min/m2 in all but one patient, and ejection fraction was more than 50% in all patients. Only previous acute cardiac rejection necessitating therapy and arterial hypertension showed some influence on the left ventricular function. Two years after operation, the left ventricular end-diastolic volume was increased, and left ventricular mass-volume ratio decreased compared with year 1. Three years after operation, an increase of left ventricular end-diastolic pressure and of left ventricular ejection fraction was also evident. Four years after operation, the heart rate was higher, compared with previous years. Even if the changes in the parameters of left ventricular function were significant, they were small in terms of absolute value. Regional hypokinesia was detected 1 year after heart transplantation in eight patients, involving one segment in six patients and two segments in two patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Colour-coded carotid Doppler imaging: an angiographic comparison of 324 bifurcations

The accuracy of a colour-coded Doppler ultrasound imaging system in the assessment of the extracranial carotid tree is presented. A series of 162 consecutive patients (324 bifurcations) were assessed with angiographic control. Doppler frequency shifts of between 3600 and 5000 Hz, corresponding to yellow on the colour code, detected carotid arteries that were stenosed greater than or equal to 50% with a sensitivity of 95%, a specificity of 72% and an overall accuracy of 81%. At frequency shifts of over 5000 Hz corresponding to the blue code, the sensitivity was 83%, specificity 90% and accuracy 87%. With highly stenosed lesions (90-99%), 24% were incorrectly diagnosed as occlusion by the imager. In those cases with a haemodynamically significant lesion on one side there is no evidence of a compensatory increase in velocity on the other side. The technique is readily learnt but an awareness of its pitfalls is essential for accurate scanning and these are discussed. Carotid Doppler imaging has superseded phono-angiography and peri-orbital Doppler examination in our laboratory and is used with the oculoplethysmograph in the routine assessment of patients with suspected carotid bifurcation disease.     

Portal vein injuries.

Wounds of the portal vein are caused most commonly by penetrating trauma and carry a very high mortality rate. Most deaths are caused by exsanguination, occurring intraoperatively as surgeons struggle to control the hemorrhage from the portal vein and associated vascular injuries. A thorough knowledge of the anatomy of the area and of the likely patterns of wounding is important. At surgery, surgeons must be prepared to deal with multiple vessel wounding. Although most investigators have advocated lateral repair of the portal vein when it can be accomplished, portal ligation seems to be a safe alternative. Complex repairs are justified only when a contraindication to ligation exists. Postoperative care must recognize the need for extraordinary fluid replacement and the small risk for postoperative bowel infarction after repair or ligation of the portal vein.     

Tuberous sclerosis: emphasis on the angiographic findings.

Two cases of angiomyolipoma of the kidney are reported. Specific emphasis is placed on the angiographic findings that distinguish this disease from malignant and polycystic renal disease.     

Portal embolization (an experimental-morphological study)

Results of experimental-morphological study of influence of unilobar portal embolization by biologic occlusive material RABROM on the liver of 6 laboratory animals are presented. It is shown that portal venous embolization leads to focal necrosis of parenchyma of embolized hepatic lobe, it atrophy and formation of portal cirrhosis. In non-embolized hepatic lobe the distinct signs of increased regeneration and hypertrophy of hepatocytes were revealed. RABROM didn't lead to damage and inflammatory changes of vascular wall that testifies to it biologic inertia. It is recommended to use the method of portal venous embolization for preparation of patients with low functional hepatic reserve for extensive resections.     

Essential hypertension associated with neurovascular compression: angiographic findings.

According to the hypothesis of Jannetta, an arterial compression of the left root entry zone (REZ) of cranial nerves IX and X by looping arteries could play an important role in the pathogenesis of essential hypertension. In an initial anatomical study, the positions of the left vagus and glossopharyngeal nerves in the skull were radiographically determined in 10 cadavers. By using a pattern of REZ topography developed from this information, the angiographic findings in 107 hypertensive and 100 normotensive patients were then compared retrospectively. In 80% of the angiograms of the hypertensive patients that could be evaluated, an artery crossed the left REZ of cranial nerves IX and X. Most frequently, this was the posterior inferior cerebellar artery (35.3% of cases), followed by the vertebral artery (29.4% of cases) and the anterior inferior artery (19.1% of cases). In 9 cases (13%), both the posterior inferior cerebellar artery and the vertebral artery appeared in the REZ. Frequently, a larger diameter of the left vertebral artery was found. The angiograms of normotensive patients that could be evaluated revealed an artery in the REZ in only 34.5% of cases. Our results support the hypothesis that essential hypertension may be associated with neurovascular compression of the left REZ of cranial nerves IX and X.     

The development of vascular supply of normal rat prostate during the sexual maturation: an angiographic study.

Vascular distribution of small blood vessels and capillaries using India ink angiography was studied in normal rat prostate from puberty up to full sexual maturation. The study included both macroscopic observation of the lobular vascular irrigation and the histological assessment of the periacinar capillary network. The topographical distribution of the main prostate branches was found to be different among the rat prostate lobes. The ventral lobe seems to be better irrigated than the dorsal one. The former being supplied by two parallel vascular systems, one irrigating the median two-thirds of the ventral lobe, whereas the remaining external one-third was found to be conjointly irrigated from the pericapsular branches of the fat pads. The blood vessels of the dorsal and lateral lobes emerged radially from a periurethral circle, with the dorsal branches ending blindly in the connective tissue of the pelvic cavity, whereas the lateral prostate was also conjointly irrigated by a dual vascularization from the pericapsular fat pad and the periurethral circle branch. The histological study revealed quantitative differences between the periacinar capillaries of both ventral and dorsal lobes. The capillary density was found to be age dependent and directly proportional to the acinar size. Small acini were less well irrigated by capillaries than were the larger ones. The number of capillaries per acinar area increased progressively toward the maturation (day 90); thereafter, their number remained constant. Both prostate lobes showed identical patterns. The heterogeneous vascular networks among the rat prostatic lobes might offer an additional clue for their distinctive morphophysiological characteristics, which most probably play a role in various pathogenetic processes.     

Spontaneous angiographic disappearance of an intracranial arteriovenous malformation

A deep right hemisphere AVM was demonstrated by angiography in an 8-year-old girl soon after her presentation with a subarachnoid haemorrhage. Eight years later the AVM was no longer visible on angiography. During the interval she had been completely asymptomatic and had received no treatment. There was no residual neurological deficit or epilepsy. A similar case has previously been described and is discussed briefly along with other cases of complete AVM regression.     

Sequential angiographic studies demonstrating delayed development of an acute epidural hematoma. Case report

A case is presented in which the delayed development of an acute epidural hematoma within 12 hours of a head injury was documented by serial cerebral angiography. A possible mechanism for the delayed evolution of the epidural hematoma is discussed.     

Composite lengthened arterial conduits: long-term angiographic results of an uncommon surgical strategy

BACKGROUND: We sought to evaluate the long-term patency rate of composite lengthened conduits. METHODS AND RESULTS: From December 1991 to April 2000, 43 patients had a composite lengthened arterial conduit. There was a mean of 2.83 +/- 1.23 anastomoses per patient. No 30-day mortality occurred. Five patients died from 3 to 84 months after the operation (mean, 38.6 +/- 34.6 months). After a mean follow-up of 57.0 +/- 32.3 months (range, 3-99 months), all the survivors are asymptomatic. The only cardiac major events recorded were 2 (4.6%) late acute myocardial infarctions in the patients who died. Eight-year survival and event-free survival were both 80.4% +/- 9.1% (range, 3%-93%). In the early period (13.5 +/- 4.8 days) in 26 patients, 26 arterial composite lengthened conduits and 37 distal anastomoses had postoperative angiographic control; all the anastomoses were rates as grade A, according to Fitzgibbon classification. In the late period (29 +/- 30 months) in 23 patients, 23 arterial composite lengthened conduits and 34 distal anastomoses were checked; the patency rate was 22 (95.6%) of 23 for the composite lengthened conduits and 33 (97%) of 34 for the distal anastomoses. CONCLUSIONS: In particular situations, when the length of an arterial conduit is not enough to allow a correct use of the graft, lengthening of an arterial conduit can be a safe and effective technique.