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PubMedDate not supplied

CO(2) wedged hepatic venography: technical considerations and comparison with direct and indirect portography with iodinated contrast.

BACKGROUND: We evaluated the efficacy and safety of CO(2) wedged hepatic venography (CO(2) WHV) by comparing it with direct transjugular (DP) and indirect arterial portography (IP). METHODS: Twenty-one CO(2) WHV and IP examinations were performed in 20 patients; 13 of them also underwent DP within 48 h of CO(2) WHV and IP. IP involved the injection of iodinated contrast into the superior mesenteric and splenic arteries. DP was performed from a transjugular approach, during transjugular intrahepatic portosystem shunt placement, with the injection of iodinated contrast into the superior mesenteric or splenic vein. The parameters evaluated were visualization of vessels and varices, portal vein thrombosis detection, and complications. RESULTS: CO(2) WHV depicted the splenic vein in 57%, the superior mesenteric vein in 62%, the main portal vein in 90%, the right portal vein in 95%, and the left portal vein in 90% of patients. It also demonstrated gastroesophageal varices in seven cases, a splenorenal shunt in one case, mesenteric varices in one case, and a recanalized umbilical vein in one case; other varices were also seen. CONCLUSION: CO(2) WHV is a good and safe technique for demonstrating the portal circulation. It may provide information not obtainable by IP and DP. However, IP provides better demonstration of the variceal network.

Adult↗
PubMed2003

Outcome of 28 split liver grafts.

UNLABELLED: Our aim is to present our experience with split liver transplantation. From 1992-2002, 14 livers were split to obtain 28 grafts that were transplanted to 12 adults and 16 children. Ex situ splitting was performed in all cases. The left graft consisted of the left lateral segment (segments II-III) in 11 cases and the left lobe in three, depending on the size of the pediatric recipient. Pediatric recipients were of mean age 3, 4 years; mean weight 13 kg; six emergency cases for fulminant hepatic failure or urgent retransplantation and seven of 10 elective cases for biliary atresia. Postoperative mortality rate was 31% (five cases), including four of six emergency cases and one elective case (10%). The main cause was multiorgan failure. Technical complications were: one arterial thrombosis, one portal vein thrombosis, and four biliary complications. Eleven patients are alive and well. Adult recipients were of mean age 53 years. The indications were hepatocellular carcinoma in six cases, liver cirrhosis of various etiologies in five, and one recurrence of hepatitis C in a graft. Two patients died during the postoperative period from sepsis after retransplantation for primary nonfunction of the split graft and multiorgan failure with sepsis. One-year actuarial survival was 84%. CONCLUSIONS: The results of split liver transplantation in elective cases are similar to whole liver transplantation, whereas patient survival among emergency cases is low due to the critical condition of the patients.

Adult↗
PubMed1994

Duplex Doppler sonography and angiography in the evaluation for liver transplantation.

Duplex Doppler sonography (DDS) and angiography were performed in a prospective study comprising 22 adult patients with hepatic failure. The ability of the 2 methods to visualize the different splanchnic vessels was compared, as well as any abnormality in the liver parenchyma and vessels. The purpose of the study was to decide if DDS could replace angiography in the pretransplantation work-up in these patients. The portal vein was correctly identified as open in 20 patients using DDS and in 21 patients at angiography. Portal vein thrombosis in one patient was correctly diagnosed by both methods. The identification of other vascular structures in the upper part of the abdomen, e.g., liver arteries and splenic vein, was demonstrated in 14 and 16 patients respectively at DDS. Hepatoma in one patient was correctly identified by both methods, as well as the presence of ascites. Splenic artery aneurysms were found in 4 patients at angiography, and in none of these was DDS able to show this abnormality. We conclude that abdominal angiography still seems superior to DDS in the evaluation of patients with hepatic failure prior to orthotopic liver transplantation, especially to demonstrate possible splenic artery aneurysms and detailed mapping of the hepatic arteries.

Adult↗
PubMed1990

Percutaneous transhepatic portal vein angioplasty and stent placement after liver transplantation: early experience.

In four patients who underwent liver transplantation, portal vein thrombosis was associated with esophageal varices and significant gastrointestinal bleeding. In a fifth liver transplant patient, portal vein stenosis was suspected when evidence of hepatic ischemia was revealed at liver biopsy. Four patients were treated with percutaneous transhepatic portal vein angioplasty. Percutaneous recanalization was precluded by technical factors in the remaining patient. Early in the series, one patient required surgical excision of what proved to be a thick cuff of fibrous tissue and lymph nodes after angioplasty failed to widen the stenosis significantly. Later, a patient with residual stenosis was treated successfully by means of intravascular stent placement. Of the four patients treated, three eventually died secondary to multiple problems unrelated to the percutaneous procedure. This early experience suggests that transhepatic portal vein interventions are feasible in patients who have received liver transplants and may prove useful at least in the early postprocedure period.

Adult↗
PubMed1991

Successful liver transplantation in a patient with a thrombosed portomesenteric system after multiple failed shunts.

Combined portal and mesenteric vein thrombosis preventing restoration of adequate portal venous flow has been considered a contraindication to liver transplantation. We report a patient with failed splenorenal (SR), portocaval (PC), and mesocaval (MC) shunts, who despite the absence of any obvious means for supplying portal venous inflow to a hepatic graft, successfully underwent orthotopic liver transplantation. A method of reconstruction of the portal vein with the use of vein grafts anastomosed to a large splanchnic venous collateral is described. This technique can be used in selected patients in whom orthotopic liver transplantation might otherwise be considered technically impossible.

Adult↗
PubMed2000

Surgical management of anatomical variations of the right lobe in living donor liver transplantation.

OBJECTIVE: To review the anatomical variations of the right lobe encountered in 40 living liver donors, describe the surgical management of these variations, and summarize the results of these procedures. SUMMARY BACKGROUND DATA: Anatomical variability is the rule rather than the exception in liver and biliary surgery. To make effective use of liver segments from living donors for transplantation, surgical techniques must be adapted to the anomalies. METHODS: Donor evaluation included celiac and mesenteric angiography with portal phase, magnetic resonance angiography, and intraoperative ultrasonography and cholangiography. Arterial anastomoses were generally between the donor right hepatic artery and the recipient main hepatic artery. Jump-grafts were constructed for recipients with hepatic artery thrombosis, and double donor arteries were joined to the bifurcation of the recipient hepatic artery. The branches of a trifurcated donor portal vein were isolated during the parenchymal transection, joined in a common cuff, and anastomosed to the recipient main portal vein. Significant accessory hepatic veins were preserved, brought together in a common cuff if multiple, and anastomosed to the recipient cava. The bile ducts were individually drained through a Roux-en-Y limb, and stents were placed in most patients. RESULTS: Forty right lobe liver transplants were performed between adults. No donor was excluded because of prohibitive anatomy. Seven recipients had a prior transplant and five had a transjugular intrahepatic portosystemic shunt (TIPS). Arterial anomalies were noted in six donors and portal anomalies in four. Arterial jump-grafts were required in three. Sixteen had at least one significant accessory hepatic vein, and one had a double right hepatic vein. There were no vascular complications. Multiple bile ducts were found in 27 donors. Biliary complications occurred in 33% of patients without stents and 4% with stents. CONCLUSIONS: Anatomical variations of the right lobe can be accommodated without donor complications or complex reconstruction. Previous transplantation and TIPS do not significantly complicate right lobe transplantation. Microvascular arterial anastomosis is not necessary, and vascular complications should be infrequent. Biliary complications can be minimized with stenting.

Adult↗
PubMed2003

[Living donor liver transplantation treatment of Wilson's disease complicated with neuropathy].

OBJECTIVE: To investigate living donor liver transplantation for Wilson disease with neurologic features. METHODS: From Jan 2001 to Mar 2003, fifteen cases of living donor liver transplantation were performed for Wilson Disease (WD), five of those were complicated with neurologic features. A retrospective analysis was given for cooper metabolism and neurologic features. RESULTS: All operation were living related liver transplantation and donors were mothers. Four left lobes with hepatic middle vein and one right lobe without hepatic middle vein were harvested from donors, and graft volume to recipient body weight ratio was 0.79 approximately 1.08. One patient occurred hepatic artery thrombosis and performed retransplantation later, the other recipients recovered satisfactorily. All patients showed Extrapyramidal sign and three patients companying with language handicap and dyskinesia alleviated postoperation follow-up between 2 and 16 months. All recipients are alive and remain well, and none have developed signs of recurrent WD. CONCLUSION: Living donor liver transplantation is effective treatment for WD complicated with nervous system symptom, ceruloplasmin is normal and Kayser-Fleischer ring and nervous system symptom are to various extents.

Adolescent↗
PubMed1985

[Partial Budd-Chiari syndrome with Zahn infarct of the liver in venous transmitted tumor thrombosis of a uterine cancer].

Aspects of a patient's case are reported in which tumorogenic thrombosis, originating from a clinically occult uterine carcinoma, was transmitted via the ovarian vein into the inferior vena cava, thus leading to hepatic vein occlusion (partial Budd-Chiari syndrome) with hepatic infarct. The specific angiographic signs of Zahn's infarct are described and interpreted.

Adenocarcinoma↗
PubMed1990

[Technics of arterial and venous reconstruction in liver transplantation].

In liver transplantation, the quality of the immediate postoperative period depends on a perfect surgical technique and, notably, on the quality of the hepatic arterial blood flow. In case of arterial abnormality, the reconstruction resulting from a donor's right hepatic artery is performed either by Gordon's technique or by reimplantation of the patch on splenic artery. An insufficient hepatic arterial blood flow requires the installation of an iliac artery graft between the recipient's aorta and the donor's coeliac patch. The presence of portal thrombosis, parietal defect or portocaval anastomosis requires the use of an interposed iliac vein graft. Direct implantation on the superior mesenteric vein suppresses the need for dissection of a portocaval shunt or resection of the thrombotic vein.

Anastomosis, Surgical↗
PubMed1984

Hepatic tumors induced by sex steroids.

Our study of more than 250 women with hepatic tumors, accessioned in our tumor registry at the University of Louisville, disclosed three types of tumor: FNH , HCA, and HCC. The ingestion of sundry kinds of sex steroids by the majority of these women, chiefly for purposes of preventing conception, warrants the suspicion that such hormones induced these different types of hepatic tumors. Publications by others reporting similar hepatic tumors in men using male sex steroids lends support to this hypothesis. Rupture of the hepatic tumor and consequent hemorrhage, producing hemoperitoneum, is a major risk factor. Other presenting symptoms are pain and palpable mass. Symptomatic women using OCs should be subjected to a CT or technetium hepatic scan as an initial screening assessment. Because of the imminent possibility of rupture, large turgid vascular tumors should be resected without biopsy. Biopsy-proved HCC should also be removed surgically. All other tumors, including small multiple tumors, will usually regress when exogenous sex steroids are withdrawn and pregnancy avoided. Other significant hepatic changes observed in this study are peliosis hepatis, periportal sinusoidal dilation, and vascular lesions. The branches of the hepatic artery and the tributaries of the portal vein show combinations of intimal and smooth muscle proliferation, vascular thickening, occlusive intimal thickening, and, at times, obstructing thrombosis. Similar smooth muscle proliferation in the afferent vessels of the livers of animals treated with sex steroids suggests that there is a cause and effect relationship in women using OCs.

Adolescent↗
PubMed1995

Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome after failure of surgical shunting.

A case of acute Budd-Chiari syndrome in a 26-year-old woman is reported. After a mesocaval shunt, the patient remained asymptomatic for 21 months, but ascites and hepatomegaly reappeared due to inferior vena cava stenosis subsequently treated by balloon dilation. Recurrence of stenosis indicated the need for a cavoatrial shunt with an expanded polytetrafluoroethylene prosthesis, which was followed by a complete recovery during the next 29 months. Radiological follow-up with magnetic resonance imaging demonstrated progressive hepatomegaly, thrombosis of the cavoatrial shunt, and stenosis of the mesocaval shunt. A transjugular intrahepatic portosystemic shunt was carried out, despite the absence of any patent residual hepatic vein at the usual level, by perforating the inferior vena cava and liver up to the right portal vein. An expandable 12-mm stent was successful in decreasing liver congestion. Dilation of the transjugular intrahepatic portosystemic shunt was done 15 months later, and the patient remains asymptomatic after a follow-up of 18 months.

Adult↗
PubMed1998

Donor factor V Leiden mutation and vascular thrombosis following liver transplantation.

The most commonly detected hypercoagulable state involves an abnormal factor V protein synthesized by the liver in which arginine at position 506 is replaced by glutamine as a result of a single-point mutation in the factor V gene (factor V Leiden). Liver transplantation is complicated by hepatic vascular thrombosis in up to 15% of cases, resulting in graft loss in most instances. This retrospective study examined the effect of the factor V Leiden mutation on the risk of hepatic vessel thrombosis after liver transplantation. The mutation was sought by polymerase chain reaction and Mnl I digestion of DNA where available from 214 recipients and 276 donors receiving 319 liver transplants. No donors or patients were homozygous for the factor V Leiden mutation. The prevalence of the heterozygous mutation was 19 of 276 (6.9%) in donors and 19 of 214 (8.9%) in recipients. Forty-one thrombotic episodes occurred after transplantation in the 276 transplants in which donor DNA was available for analysis; 22 involved the hepatic artery, 9 involved the portal vein, and 10 were deep venous thromboses. A donor factor V Leiden mutation was detected in the donor in 6 of 41 (14.6%) with any thrombotic event compared with 13 of 235 (5.5%) without (P = 0.03). The relative risk of any thrombosis with this mutation was therefore 2.32 (95% confidence interval [CI], 1.12-4.81). The factor V Leiden mutation was present in the donor in 4 of 31 (12.9%) cases complicated by hepatic vessel thrombosis (which always led to graft loss or death) and 15 of 245 (6.1%) cases without (P = 0.16). The relative risk of hepatic vessel thrombosis in the presence of this allele was therefore 2.00 (95% CI, 0.78-5.14). As anticipated, the presence of this allele in the recipient was not associated with deep venous or hepatic vessel thrombosis. The factor V Leiden mutation in the donor liver is not a major risk factor for hepatic vessel thrombosis and subsequent graft loss after liver transplantation.

Adolescent↗
PubMed2002

Auxiliary liver transplantation with portal arterialization in the rat: description of a new model.

In recent years, portal arterialization has been used in liver transplantation to increase the portal flow, as a solution for singular technical problems. We have developed a new auxiliary liver transplantation model in the rat with portal arterialization, so the native hepatic hilium remains untouched, consisting on a graft with a previous 70% hepatectomy. It is sited on the right renal bed, joining the infrahepatic inferior vena cava (IVC) of the graft with the recipient IVC. With an abdominal aortic graft, we connect the recipient aorta with the portal vein from the auxiliary liver. All the animals survived at the seventh day. No thrombosis was seen in any graft and an important rejection was observed in all the fields. We have developed a new experimental model of an auxiliary liver with portal arterialization, avoiding the utilisation of the native hepatic hilium, necessary for the possible recovering of the proper liver in the case of a reversible fulminant hepatitis.

Animals↗
PubMed1994

Beware the anomalous portal vein.

Portal vein thrombosis is an unusual potential complication of liver resection. In our case it was due to ligation of the right branch of the portal vein during right hepatectomy in a patient without portal vein bifurcation. Hepatic angiography can delineate this abnormality and influence the choice of surgical management.

Cholangitis↗
PubMed1994

[A case of hepatoblastoma using intraarterial hepatic chemotherapy with THP-ADR].

The patient was a 2-year-old who was admitted with the diagnosis of liver tumor. The diagnosis at admission was stage III A hepatoblastoma complicated with tumor thrombosis of portal vein. Soon after the admission, the patient's general condition became deteriorated with increased ascites and severer jaundice. As the patient was considered to be in oncogenic emergency, chemotherapy with systemic administration of ADR and CDDP was started. Despite decreases in tumor marker and tumor shrinkage on imaging examinations, tachycardia and arrythmia occurred from the end of the second course of chemotherapy, suggesting ADR-induced cardiomyopathy, when the systemic administration of ADR was switched to less cardiotoxic hepatic arterial infusion of THP-ADR. Following 13 courses of intra-arterial infusion with the total dose of THP-ADR of 200 mg/m2, the tumor was found to have reduced markably in size and thus surgical resection of the tumor was performed. Our experience of this case indicates that, considering the pharmacokinetics and side effects, THP-ADR should be a very effective anti-tumor agent for intra-arterial hepatic infusion. The patient died 10 months after surgery because of multiple metastases into the brain and lungs.

Antibiotics, Antineoplastic↗
PubMed2005

Comparative analysis of the results of orthotopic liver transplantation in patients with and without portal vein thrombosis.

INTRODUCTION: Portal vein thrombosis (PVT), which had been considered an absolute contraindication to orthotopic liver transplantation (OLT), is currently considered a risk factor that increases morbi-mortality. The objective of this study was to compare OLT outcomes in patients with vs without PVT. MATERIALS AND METHODS: Between April 1986 and December 2003, a sample of 83 patients with PVT was compared with another sample of 83 patients without PVT among 962 OLT performed in our department. RESULTS: Both groups were homogeneous in terms of epidemiological variables, surgical technique, immunosuppression, and donor-related variables. There were no differences with respect to graft function during the first week following surgery. Surgical time and anhepatic phase duration was longer in the PVT group, albeit the differences were not significant. PVT patients also required more transfusions; a strong statistical association was observed with respect to blood (P = .12) and plasma (P = .11) transfusions and statistically significant differences regarding platelet transfusions (P = .02). Time on mechanical ventilation and the length of stay in the ICU were longer but not significant among PVT patients. The only statistically significant difference was the incidence of portal rethrombosis (P = .02). With respect to mean and global patient and graft actuarial survivals after 1, 3, 5, and 10 years, we have observed no significant intergroup differences, although both patient (P = .48; NS) and graft (P = .96, NS) survivals were lower among PVT cases. CONCLUSIONS: PVT should not only cease to be considered a contraindication for OLT, but there were no significant differences between the outcomes despite this finding.

Adolescent↗
PubMed1987

Protein C deficiency in splanchnic venous thrombosis.

Deficiencies of protein C activity and antigen were observed in eight consecutive patients with splanchnic venous thrombosis. There was a significant reduction in the ratio of protein C to factor X. Six of the eight patients had a decrease in antithrombin III, but free protein S antigen was within normal limits in all but two subjects. It is proposed that a thrombogenic stimulus such as stasis, altered hormonal milieu, or failure of hepatic clearance of activated coagulants results in consumption of protein C and antithrombin III, predisposing to splanchnic venous occlusion. This further impairs hepatic function, prevents restitution of protein C and antithrombin levels, and promotes continuing venous thrombosis. Thus, a vicious cycle of thrombosis and hepatic damage is perpetuated.

Adult↗