Feasibility of morphologic assessment of vascular and biliary anatomy in pediatric liver transplantation: all-in-one protocol with breath-hold magnetic resonance

Background/Purpose

Noninvasive imaging for children with liver transplantation for possible sites of vascular and biliary complication remains a challenge. The aim of this study was to investigate the feasibility of magnetic resonance (MR) imaging as a comprehensive noninvasive test for the above purpose.

Methods

Thirteen children (age, 8-16 years) with biliary atresia and who received liver transplantation underwent a comprehensive MR study including MR cholangiography and gadolinium-enhanced MR angiography. Images were interpreted by 3 radiologists for liver parenchymal abnormalities; definition of hepatic arterial and venous, portal venous, and biliary anatomy; and detection of any complications. Findings were correlated with surgical records. Conventional angiography and percutaneous cholangiography were obtained for correlation in 2 patients. Confidence level scores (1-5) for depiction of anatomy were given for source, multiplanar, and 3-dimensional images.

Results

Hepatic artery anastomosis was visualized in 12 patients (92%) and the intrahepatic arteries were demonstrated in 10 (77%). The portal, hepatic venous, and biliary anastomoses were clearly demonstrated in all patients. Stenosis of hepatic artery anastomosis and multiple biliary strictures were detected in 1 patient each and confirmed by conventional imaging. High confidence scores (higher than 4) were obtained for all kinds of MR images.

Conclusions

Comprehensive MR imaging can be used in long-term follow-up of pediatric liver transplant recipients for depiction of hepatic structures and possible complications.     

Treatment of early hepatic artery thrombosis after liver transplantation

Introduction

Early hepatic artery thrombosis remains one of the major causes of graft failure and mortality in liver transplant recipients. It is the most frequent severe vascular complication after orthotopic liver transplantation (OLT) accounting for >50% of all arterial complications. Most patients need to be considered for urgent liver retransplantation.

Materials and Methods

Among 911 OLTs in 862 from 1989 to 2011, we observed 23 cases (2.6%) of acute early hepatic artery thrombosis. Seventeen patients were qualified immediately for liver retransplantation, and 6 underwent endovascular therapies, including intra-arterial heparin infusion or percutaneous transluminal angioplasty with stent placement.

Results

Among patients who were assigned to early liver retransplantation, 11/17 survived with 3 succumbling due to postoperative complications, including 1 portal vein thrombosis, and 3 succumbling on the waiting list. All patients who underwent endovascular therapy survived with an excellent result obtained in 1 who underwent treatment <24 hours after arterial thrombosis. In 2 patients we achieved a satisfactory result not requiring retransplantation, but 3 patients assigned to endovascular treatment >24 hours after arterial thrombosis needed to be reassigned to liver retransplantation because of poor results of endovascular treatment.

Conclusions

Endovascular treatment efforts should be made to rescue liver grafts through urgent revascularization depending on the patient's condition and the interventional expertise at the transplant center, reserving the option of retransplantation for graft failure or severe dysfunction.     

Vascular complications in hepatic transplantation: single-center experience in 14 years

Purpose

To evaluate the spectrum of liver transplantation-related vascular complications that occurred in a single center over the past 14 years.

Materials and methods

Vascular complications and their clinical outcomes were reviewed among 744 liver transplant recipients. All patients underwent Doppler ultrasound with findings correlated with conventional or computed tomography angiography (CTA) in 111 patients.

Results

Among 70 recipients with vascular complications (%0.9), 14/26 patients with hepatic artery thrombosis underwent thrombectomy and arterial reanastomosis; six were retransplanted and six died. Among hepatic artery stenoses, three of nine were treated with balloon angioplasty and six underwent reanastomosis. Among 20 portal vein thromboses, 16 underwent thrombectomy, two patients retransplantation and two died. Seven patients with portal vein stenosis were followed. Two of six hepatic vein stenosis were restored with balloon angioplasty and three patients with metallic stent placement; the one other died. One patient with hepatic vein thrombosis died while the other patient was retransplanted.

Conclusion

Transplantation related hepatic vascular complications diagnosed and managed in timely fashion showed a low mortality rate in our series.     

Outcomes in children with hypoplastic left heart syndrome undergoing open fundoplication

Background/Purpose

Some institutions recommend early fundoplication in patients with hypoplastic left heart syndrome (HLHS) with signs of gastroesophageal reflux disease because of the risk of reflux-related cardiac events. However, their cardiac physiology may impose high perioperative morbidity and mortality. Therefore, we reviewed our experience with fundoplication in this population to allow for assessment of the risk-benefit ratio.

Methods

A retrospective review of patients with a diagnosis of HLHS who underwent a fundoplication from January 1990 to July 7, 2009, was performed. All patients underwent open fundoplication between first and second stages of cardiac repair.

Results

Thirty-nine patients were identified. There were 3 intraoperative complications: hemodynamic instability (n = 2) and a pulmonary hypertensive crisis requiring extracorporeal membrane oxygenation and termination of the procedure (n = 1). There were 27 postoperative complications in 16 patients. There were 2 deaths (4%) within 30 days, and there were 9 deaths (23%) in patients between their first and second stage of cardiac repair during the study period.

Conclusions

Noncardiac surgical procedures in patients palliated for HLHS have a high morbidity and mortality. We recommend that routine fundoplication in this population should only be performed under prospective protocols until the relative risk of operation vs risk of reflux is delineated.     

Incidence, management, and results of vascular complications after liver transplantation

Introduction

Vascular complications show an 8%-15% incidence after liver transplantation and represent an important cause of mortality. An aggressive policy is necessary for an early diagnosis and treatment.

Patients and methods

From 2001 to 2009, we performed 240 liver transplantations in 232 patients. We employed Doppler ultrasonography on days 1 and 4 as well as before hospital discharge and always try a radiological approach.

Results

The incidence of vascular complications was 7.2% (n = 18) including arterial (n = 12, 4.8%) of early thrombosis (n = 4), late thrombosis (n = 4), and stenosis (n = 4) or portal (n = 3; 1.2%) of thrombosis (n = 2) or stenosis (n = 1); or caval complications (n = 3, 1.2%). Radiologic therapy was effective in 1 patient with arterial stenosis, in the 3 patients with portal complications, and in 2 patients with caval complications. All patients with early thrombosis and 2/4 with late thrombosis required retransplantation. Surgical treatment was effective in 1 patient with late thrombosis, 3 with stenosis, and 2 with caval complications. The overall mortality rate was 16.6%; 2 patients with arterial complications and 1 with a caval complications.

Conclusion

Vascular complications, mainly artery complications, represent serious problem after liver transplantation, which often requires retransplantation. With an aggressive policy of diagnosis and treatment, we can decrease the mortality rate from these adverse events.     

Pediatric splenic injuries with a contrast blush: successful nonoperative management without angiography and embolization

Background

The presence of a contrast blush on computed tomography (CT) in adult splenic trauma is a risk factor for failure of nonoperative management. Arterial embolization is believed to reduce this failure rate. The significance of a blush in pediatric trauma is unknown. The authors evaluated the outcome of children with blunt splenic trauma and contrast extravasation.

Methods

The trauma registry was queried for all pediatric patients with blunt splenic injuries. Admission CT was reviewed for injury grade and presence of an arterial blush by a radiologist blinded to patient outcome. Hospital and office charts were reviewed for success of nonoperative management, late splenic rupture, and other complications.

Results

One hundred seven children with blunt splenic trauma were identified over a 6-year period. Mean injury grade was 2.9. Six patients required emergency splenectomy. An additional 7 patients met hemodynamic criteria for surgical intervention (3 splenectomies, 4 splenorrhaphies). Admission CT was available in 63 patients. An arterial blush was identified in 5 (9.7%). Four remained stable and were treated conservatively. One underwent splenectomy for hemodynamic instability. There were no cases of delayed splenic rupture, failed nonoperative treatment, or long-term complications.

Conclusions

Contrast blush in children with blunt splenic trauma is rare, and its presence alone does not appear to predict delayed rupture or failure of nonoperative treatment. Based on this limited series, splenic artery embolization does not have a place in the management of splenic injuries in children.     

Preoperative Evaluation of Living Kidney Donors With Multidetector Computed Tomography Angiography

Objective

The purpose of this study was to determinate the accuracy of multidetector computed tomography (MDCT) angiography for imaging evaluation of renal anatomic variants among potential living renal donors for surgical planning.

Materials and Methods

Two hundred twenty-three living kidney donors underwent MDCT angiography (MDCTA) in our institution over the last 2 years. The examination was performed with a 4-detector scanner, including scanning before and after power injection of nonionic contrast material during the arterial, nephrographic, and excretory phases. Scans were reconstructed for three-dimensional (3D) images using MIP, MPR, VRT, and CPR techniques.

Results

Arterial variants, including supernumerary renal arteries, were present in 140 subjects: 11 presented luminal stenosis; 10 had calcifications within the vessel wall; 3 had renal artery aneurysms; 2 had obstructions; and 1 had angulation of the renal artery. Calcifications were associated with luminal stenosis (4 subjects) or no pathology (6 subjects). Venous variants were present in 4 subjects, including 3 retroaortic renal veins and 1 left renal vein draining into the retrohepatic portion of the IVC. Incidental findings were 3 renal infarcts.

Conclusion

MDCTA and urography are a minimally invasive, fast method to detect and classify a variety of anatomic anomalies among potential living renal donors relevant to surgical planning.     

The risk factors for early infection in adult living donor liver transplantation recipients

Objective

The high rate of early major infections in liver transplantation recipients is due to their compromised immune-system. We examined the risk factors of early major infection in living donor liver transplantation (LDLT).

Materials and methods

From January 2004 to December 2010, 242 patients undergoing LDLT were enrolled in the prospective cohort. We prospectively collected their clinical and demographic variables, operative details, and posttransplant complications.

Result

One hundred thirty-nine patients (57.7%) experienced 252 episodes of early infection posttransplantation: bloodstream septicemia (n = 46, 18.3%), urinary tract (n = 34; 14.1%), pneumonia (n = 64; 25.4%), peritonitis (n = 62; 25.7%), and catheter related (n = 46; 19%). The most frequent Gram-positive bacteria were coagulase-negative staphylococci (n = 52; 16.9%), followed by Staphylococcus aureus (n = 32; 10.4%). The most common Gram-negative bacteria were Escherichia coli (n = 27; 8.8%); Acinetobacter baumannii (n = 29; 9.4%), Pseudomonas aureos (n = 18; 5.8%), and Sternotrophomonas maltophilia (n = 18; 5.8%). Upon multivariate logistic regression analysis, the risk factors for early major infection were a high creatinine level (odds ratio = 1.481), a long anhepatic arterial phase (1.01), a reoperation (6.417), young age (1.040), and non-hepatocellular carcinoma recipient (2.141).

Conclusion

Early major infection after LDLT was high with Gram-positive bacteria, the most common etiologies. Prolonged anhepatic arterial phase, renal insufficiency, and reoperation were risk factors for an early major infection.     

Diagnosis and interventional radiological treatment of vascular and biliary complications after liver transplantation in children with biliary atresia

Objective

Early diagnosis and appropriate management of vascular and biliary complications after living donor liver transplantation (LDLT) result in longer survival. We report our institutional experience regarding radiological management of these complications among patients with biliary atresia (BA) who underwent LDLT.

Methods

We analyzed the records of 116 children. All patients underwent Doppler ultrasound (US) at operation, daily for the first 2 postoperative weeks, and when necessary thereafter. After primary evaluation using US, the definite diagnosis of postoperative complication was confirmed using computed tomography, magnetic resonance imaging, and/or operation.

Results

There were 61 boys and 55 girls. The overall mean age was 2.69 years. The overall mean preoperative weight and height were 13.06 kg and 83.79 cm, respectively. There were 28 (24.13%) biliary and vascular complications. These were cases of biliary stricture (n = 5), bile leakage (n = 3), hepatic artery stenosis (n = 6), hepatic vein stenosis (n = 4), and portal vein thrombosis (n = 17). The diagnostic accuracy of US in detecting biliary complication, hepatic artery stenosis, hepatic venous stenosis, and portal vein thrombosis was 95.69%, 97.41%, 100%, and 100%, respectively. US in combination with multiple imaging modalities and clinical suspicion resulted in 100% diagnostic accuracy. Percutaneous transhepatic cholangiography, thrombolysis, balloon angioplasty, and stent placement were performed for the complications noted. There was an early mortality due to multiple-organ failure after failed radiological invention and subsequent surgical management.

Conclusions

Doppler US is accurate in detecting postoperative complications after pediatric LDLT for BA. Radiological interventions for vascular and biliary complications are effective and safe alternatives to reconstructive surgery.     

Biliary complications after 52 adult living donor liver transplantations: a single-center experience

Objective

The incidence of biliary complications after adult living donor liver transplantation (ALDLT) are still high even though various devices have been reported to overcome them.

Method

From October 2000 to April 2007, we performed 52 ALDLTs which included 15 ABO-incompatible grafts. Median follow-up was 565 days. In 49 procedures, we used duct-to-duct anastmosis with a stent inserted in the recipient duct and out through the common bile duct wall as an external stent, and in 3 procedures, we used duct-to-jejunostomy anastomosis. We investigated postoperative biliary complications and their management.

Results

Forty-four patients received right lobe grafts and 8 received left lobe grafts. Among patients in whom duct-to-duct anastomosis was used, nine (20.5%) developed biliary complications including bile leakage in five and biliary strictures in four. All bile leakage was treated with reoperation. Three biliary strictures were treated with stent placement, and one biliary stricture was treated with magnetic compression anastomosis. Among the three patients in whom duct-to-jejunostomy was used, two (66.7%) had bile leakage and stricture, respectively. Two of four ABO-incompatible patients (50%) had hepatic artery thrombosis with biliary complications, a high incidence.

Conclusion

In our series of ABO-incompatible patients undergoing ALDLT, those who developed hepatic artery thrombosis exhibited a high incidence of biliary complications.     

Vascular Complications Following Adult Piggyback Liver Transplantation With End-to-Side Cavo-Cavostomy: A Single-Center Experience

Background

Vascular complications remain a significant cause of morbidity, graft loss, and mortality following orthotopic liver transplantation (OLT). These problems predominantly include hepatic artery and portal vein thrombosis or stenosis. Venous outflow obstruction may be specifically related to the technique of piggyback OLT.

Materials and Methods

Between February 2002 and February 2009, we performed 200 piggyback OLT in 190 recipients. A temporary portacaval shunt was created in 44 (22%) cases, whereas end-to-side cavo-cavostomy was routinely performed for graft implantation. Pre-existent partial portal or superior mesenteric vein thrombosis was present in 17 (12%) cirrhotics in whom we successfully performed eversion thrombectomy, which was followed by a typical end-to-end portal anastomosis. The donor hepatic artery was anastomosed to the recipient aorta via an iliac interposition graft in 31 (16%) patients.

Results

The 14 (7%) vascular complications included hepatic artery thrombosis (n = 5), hepatic artery stenosis (n = 3), aortic/celiac trunk rupture (n = 2), portal vein stenosis (n = 2), and isolated left and middle hepatic venous outflow obstruction (n = 1). There was also 1 case of arterial steal syndrome via the splenic artery. No patient experienced portal or mesenteric vein thrombosis. Therapeutic modalities included re-OLT, arterial/aortic reconstruction and splenic artery ligation. Vascular complications resulted in death of 5 (36%) patients.

Conclusion

Our experience indicated that piggyback OLT with an end-to-side cavo-cavostomy showed a low risk of venous outflow obstruction. Partial portal or mesenteric vein thrombosis is no longer an obstacle to OLT; it can be successfully managed with the eversion thrombectomy technique.     

Chronic hepatic artery occlusion with collateral formation: imaging findings and outcomes

Objective

The imaging findings, clinical presentation, and outcome in post liver transplantation patients with hepatic arterial collaterals are reviewed.

Materials and Methods

Adult post orthotopic liver transplantation patients who underwent an angiography at our institution for suspected hepatic arterial abnormality during an approximately 10-year period were included in our study. A retrospective review of all cases that had hepatic arterial collaterals detected on angiography was then performed. Angiographic findings were correlated with the findings on ultrasound and other imaging studies. Liver function at the time of angiography was recorded. Clinical outcomes were reviewed.

Results

Of the 129 angiographies performed in the approximately 10-year period, 24 (19.4%) were found to have collaterals on angiography. Maximum size of the collaterals seen on angiography was 3 mm. Twenty patients (83%) with collaterals are currently alive. Twelve patients (50%) had a normal outcome and did not develop any complications on follow-up; however, the rest developed complications. Eleven patients (41.7%) had complication related to the liver ischemia and 2 patients (8.3%) developed malignancy (posttransplant lymphoproliferative disease).

Conclusion

Collaterals seen in patients with chronic hepatic artery occlusion are usually small in caliber and their significance is unclear. Recognition and understanding of this phenomenon is important as this subset of patients may not need urgent surgical re-exploration/vascular intervention.     

Periprocedural complications by Child-Pugh class in patients undergoing transcatheter arterial embolization or chemoembolization to treat unresectable hepatocellular carcinoma at a VA medical center

Background

For patients with compensated cirrhosis, transcatheter arterial embolization with and without additive chemotherapy has been shown to improve survival. The aim of this study was to compare periprocedural complications in a population with hepatitis C virus-related hepatocellular carcinoma to evaluate for differences in complications by severity of liver disease.

Methods

Patients with unresectable hepatocellular carcinoma treated by transcatheter arterial embolization with or without additive chemotherapy procedures from 2003 to 2006 were retrospectively reviewed and compared by Child-Pugh (CP) class. A total of 141 embolizations were done in 76 patients.

Results

Complication rates were seen in 27% of CP class A and 17% of CP class B patients. There was no significant difference in the grade of complications between the 2 groups or between procedure types. Survival rate was dependent on the degree of liver dysfunction (3-year CP class A, 49%; CP class B, 13%; P = .0048).

Conclusion

Embolization procedures to treat hepatitis C virus-related hepatocellular carcinoma can be performed safely with low morbidity and mortality rates, even in patients with a compromised hepatic reserve.     

Early experience with the use of rhomboid excision and Limberg flap in 16 adolescents with pilonidal disease

Background

Rhomboid excision with Limberg flap (RELF) repair has been shown to be effective in the management of pilonidal disease (PD) in adults. Wide excision allows complete removal of diseased tissue, and the rotational flap allows tensionless coverage as well as helps flatten the natal crease, which is believed to contribute to the recurrence of PD.

Methods

This study is a retrospective review of all adolescents who underwent excision of pilonidal disease using RELF at a single institution for a period of 18 months.

Results

Sixteen adolescents with PD were treated with RELF during this period. All procedures were completed with no intraoperative complications. Mean operative time and hospital stay were 92 ± 30 minutes and 1.8 ± 0.29 days, respectively. Mean follow-up was 11 ± 6.0 months. One patient had recurrence of his disease, and one needed prolonged wound care after wound breakdown. Six others had minor complications including 4 patients (25%) who had superficial wound separation that resolved promptly with dressing change. One patient had a superficial wound infection. One patient had residual pain.

Conclusion

Rhomboid excision with Limberg flap is effective in the management of PD in adolescents. The 6% recurrence rate is similar to that reported in the adult literature. Despite the limitations of this study, the low morbidity, hospital stay, and recurrence rate noted with our initial experience are very encouraging.     

Biliary complications after orthotopic liver transplantation: a 5-year experience

Introduction

Biliary complications, particularly bile duct stenosis or leak, remain the “Achilles' heel” of orthotopic liver transplantation (OLT), significantly increasing the risk of graft loss and recipient death. The aim of the study was to retrospectively analyze biliary complications over a 5-year experience seeking to identify risk factors for these complications.

Material and Methods

Eighty-seven OLT performed in 84 recipients were included in the analysis. In all cases but one, we performed an end-to-end hepatic duct anastomosis with a 7-0 running suture under 2.5× magnification.

Results

Biliary complications developed after 17.2% OLT: anastomosis site stenosis (10.3%), multiple stenoses (5.7%), or bile duct necrosis (1.1%). A bile leak was not observed. Two recipients died from biliary sepsis. Among the patients with biliary complications, there was an higher rate of hepatic artery problems (33.3% vs 2.7%; P < .01), and a longer anhepatic phase (85 vs 72 minutes; P < .01). We performed endoscopic treatment in 73% and percutaneous drainage in 6.6% of recipients. Good treatment results were achieved in 36.4% of cases with biliary complications whereas they were satisfactory in 27.3%. Five patients with biliary complications required re-transplantation.

Conclusions

A bile duct anastomosis performed end-to-end with a running suture under magnification decreased the risk of bile leakage after OLT. A prolonged anhepatic phase or an hepatic artery thrombosis or stenosis increased the risk of biliary complications after OLT.     

Should an infected Nuss bar be removed?

Background

The Nuss procedure is a minimally invasive procedure for correction of pectus excavatum. It involves insertion of a substernal metal bar. A feared complication of any implanted device is infection, which often necessitates removal. The purpose of this report is to describe the authors' experience with infectious complications after the Nuss procedure.

Methods

From February 2000 to July 2002, 102 patients underwent the Nuss procedure in 2 pediatric surgical centers. In a retrospective way, the files of those patients in whom a postoperative infection developed were studied.

Results

Seven patients suffered postoperative infectious complications. Only one bar needed to be removed.

Conclusion

The authors' experience indicates that there is no need for immediate removal of an infected Nuss bar. Most of these infections can be managed conservatively. However, early antibiotic treatment is warranted to ensure salvage of the bar.     

Early elective cesarean delivery before 36 weeks vs late spontaneous delivery in infants with gastroschisis

Purpose

The aim of this study is to assess the value of early elective cesarean delivery for patients with gastroschisis in comparison with late spontaneous delivery.

Methods

Analysis of infants with gastroschisis admitted between 1986 and 2006 at a tertiary care center was performed. The findings were analyzed statistically.

Results

Eighty-six patients were involved in the study. This included 15 patients who underwent emergency cesarean delivery (EM CD group) because of fetal distress and/or bowel ischemia. The remaining 71 patients born electively were stratified into 4 groups. The early elective cesarean delivery (ECD) group included 23 patients born by ECD before 36 weeks; late vaginal delivery (LVD) group included 23 patients who had LVD after 36 weeks; 24 patients had LCD after 36 weeks because of delayed diagnosis that resulted in late referral; and 1 patient had early spontaneous vaginal delivery (EVD group) before 36 weeks. The mean time to start oral feeding, incidence of complications, and primary closure were significantly better in the ECD group than in the LVD group. The duration of ventilation and the length of stay were shorter in ECD group, but the difference was not statistically significant.

Conclusion

Elective cesarean delivery before 36 weeks allows earlier enteral feeding and is associated with less complications and higher incidence of primary closure (statistically significant).     

Vascular Complications After Deceased and Living Donor Liver Transplantation: A Single-Center Experience

Introduction

Vascular complications (VC) after liver transplantation (OLT) are one of the most feared problems that frequently result in graft and patient loss. Herein we have reported our experience with VC after either deceased donor liver transplantation (DDLT) or living donor liver transplantation (LDLT).

Patients and Methods

Between April 2001 and September 2009, we performed 224 OLT: 155 DDLT and 69 LDLT. The overall male/female ratio was 136/88 and the adult/pediatric ratio was 208/16. We retrospectively identified and analyzed vascular complications in both groups.

Results

In the DDLT group, 11/155 recipients (7%) suffered vascular complications; hepatic artery thrombosis (HAT; n = 5; 3.2%), portal vein thrombosis occurred (n = 4; 2.6%); hepatic vein stenosis (n = 1; 0.6%), and severe postoperative bleeding due to a slipped splenic artery ligature (n = 1, 0.6%). In the DDLT group, 4/11 (36.4%) patients died as a direct result of the vascular complications. In the LDLT group, 9/69 recipients (13%) suffered vascular complications: HAT (n = 3; 4.3%), portal vein problems (n = 5; 7.2%), and hepatic vein stenosis (n = 1; 1.5%). Among LDLT, 3/9 (33.3%) patients died as a direct result of the vascular complications. In both groups vascular complications were associated with poorer patient and graft survival.

Conclusions

In our experience, the incidence of vascular complications was significantly higher among the LDLT group compared with the DDLT group. Vascular complications were associated with poorer graft and patient survival rates in both groups.     

Emergency endovascular stent-grafting for life-threatening acute type B aortic dissections

Background

There is still a considerable controversy regarding optimal treatment for patients with acute type B aortic dissection. Patients with complicated disease are particularly challenging for cardiovascular treatment. Early surgery for acute dissections of the descending aorta with life-threatening complications is known to carry a high mortality. Endovascular stent grafting is developing as an alternative treatment mainly for chronic stages of type B aortic dissection. It is not clear whether endovascular stent grafting is safe and effective in emergency treatment of acute type B aortic dissection.

Methods

In 10 patients (7 men, 3 women; mean age, 59.2 years; range, 46 to 65 years), endovascular stent grafting was performed within 11.0 ± 5.9 hours (range, 4 to 24 hours) of diagnosis of complications. Indications for acute intervention included contained rupture, hematothorax, life-threatening malperfusion, and refractory pain. Using a retrograde endovascular route after surgical exposure of the femoral artery, self-expanding stent prostheses consisting of polyester-covered Nitinol (Talent, World Medical; mean diameter, 40 ± 4 mm; length, 10 cm) were placed into the descending aorta distal to the subclavian artery. Before discharge and on follow-up visits, imaging of the aorta was performed using computed tomography.

Results

In 9 of 10 patients (90%), the primary entry could be completely occluded with the endovascular stent. Early mortality was 20% (2 of 10): 1 patient died after disruption of the intimal layer distal to the stent, and 1 patient died in hemorrhagic shock after surgical fenestration of the abdominal aorta for persistent malperfusion. Three patients (30%) required consecutive surgical treatment: indications included acute development of retrograde type A aortic dissection, acute stent dislocation by fractured wires and secondary leakage, and late formation of an aneurysm of the descending aorta 6 months after endovascular stent grafting. There were no surgical or late deaths.

Conclusions

Our experience provides some evidence that early mortality of life-threatening acute type B aortic dissection may be reduced by emergency endovascular stent grafting and that this form of treatment is a promising therapeutic option. Refinements, especially in stent design and application, may further improve the prognosis of patients in the life-threatening situation of complicated acute type B aortic dissection.     

Combined pharmacotherapy that increases proliferation and decreases apoptosis optimally enhances intestinal adaptation

Background

Adaptation after massive small bowel resection (SBR) is associated with increased rates of enterocyte proliferation (P) and apoptosis (A). In the present study, we sought to determine the effect of dual therapy designed to increase P and simultaneously reduce A.

Methods

C57Bl/6 mice underwent a 50% small bowel resection (SBR) or sham operation, and then received an inhibitor of apoptosis (pan-caspase inhibitor), a stimulus for proliferation (epidermal growth factor; EGF), a combination, or vehicle control. After 3 days, adaptive morphology (villus height, crypt depth) and rates of enterocyte turnover (proliferation and apoptosis) were measured in the remnant ileum.

Results

Adaptation in controls and treated with the inhibitor was similar. EGF-treated mice demonstrated an even greater adaptive response. Combined therapy with the inhibitor and EGF resulted in maximal adaptation as gauged by the greatest increases in villus height and crypt depth and ratio of rates of P to A.

Conclusion

The capacity for adaptation following massive SBR is maintained via tight regulation of cell production and death. Pharmacologic intervention directed at increasing enterocyte proliferation while simultaneously decreasing apoptosis augments adaptation greater than either intervention alone and may provide a useful strategy to clinically amplify adaptation.