Anterior Segmental Branch Research Articles

Successful repair of transplant renal artery aneurysm (TRAA)

BackgroundTransplant renal artery aneurysm (TRAA) is rare. TRAA that develops post transplantation consists of 0.10% of the vascular complications post renal transplant (Transplant Proc 41:1609-1614, 2009; Indian J Urol 29:42-47, 2013).Case presentationWe report a case of TRAA in an asymptomatic young female. CT angiogram with detailed 3D reconstruction showed a 2.6 × 2.2 cm wide neck saccular TRAA arising from the anterior segmental branch of the graft renal artery (Figs. 2 and 3). A multidisciplinary team of interventional radiologists, vascular and urologist was involved for preoperative surgical planning and unique repair methods. Endovascular and percutaneous approaches were deemed not feasible, and an open in vivo approach with a saphenous vein graft was taken.ConclusionTRAA, albeit rare, is a complication that can occur post renal transplant. In-vivo surgical repair of TRAA is feasible with a multidisciplinary approach and careful preoperative planning. Saphenous vein graft is still a versatile graft and can be used as a conduit successfully.

Validity of using serum D-dimer titer in prefatory to computed Tomography pulmonary angiography scans in the early identification of pulmonary embolism amid emergency room patients: a single-center retrospective observational study

Background and aim Pulmonary embolism emerges when a thrombus forms in the veins or right heart and travels to the pulmonary arteries. The study aims to ascertain the robustness of D-dimer testing for PE compared with CTPA and identify the threshold values to support its use. Patients and methods The positivity threshold for D-dimer was above 250 ng/ml. CTPA was performed after performing blood sampling. Patients were managed in the ICU with anticoagulants by parenteral use. The most commonly used items were heparin, either unfractionated (UFH) or low-molecular-weight heparin (LMWH). Results Twenty-four patients of the total number of cases were positive for CTPA, while four patients were negative for PE by CTPA. Embolism was detected in the anterior, posterior, medial, and lateral basal segmental branches of the right lung, the lateral, posterior, and anterior basal segmental branches of the left lung, and the posterior segmental branch of the left lung. The D-dimer test and CTPA both provided similarly accurate PE diagnoses with no significant differences between them. There were 28 patients in total, three of those patients had D-dimer levels below the cutoff value of 250 ng/ml, whereas the remaining 25 had D-dimer levels over the diagnostic threshold. Those with a positive CTPA diagnosis of PE had greater levels of D dimers than those with a negative CTPA diagnosis of PE. Conclusion D-dimer levels can help in guiding the option of CTPA and the initiation of treatment for patients with suspected PE.

Long-term survival of an adult patient with undifferentiated embryonal sarcoma of the liver with multidisciplinary treatment: a case report and literature review

BackgroundUndifferentiated embryonal sarcoma of the liver (UESL) primarily occurs in children; it is rarely seen in adults and appears to have a poor prognosis. However, in recent years, some cases indicated that long-term survival was possible due to a combination of multiple surgeries, chemotherapy, and liver transplantation.Case presentationA 33-year-old female patient presented with a complaint of epigastric pain, for which she underwent a medical examination. Computed tomography (CT) and magnetic resonance imaging showed a cystic tumor in the right hepatic lobe, approximately 10 cm in size. During observation, the abdominal pain worsened, and a contrast-enhanced CT revealed that the tumor’s peripheral solid components increased in size and volume, suggesting a malignant tumor threatening hepatic rupture. Subsequently, transcatheter arterial embolization of the anterior and posterior segmental branches of the hepatic artery was performed, followed by right trisectionectomy. Histopathological and immunohistochemical examinations of the lesion revealed UESL. Two months after the surgery, we initiated sarcoma-directed chemotherapy with doxorubicin because of multiple metastases to the liver. After initiating the chemotherapy, she received another regimen using gemcitabine/docetaxel, eribulin, trabectedin, ifosfamide/mesna, pazopanib, and cisplatin. During the chemotherapy, she underwent palliative surgery twice due to the progressive disease. She lived for 49 months after the initial operation.ConclusionsImproved long-term survival was achieved in an adult patient with UESL after multidisciplinary therapy, involving a combination of three surgical procedures and several chemotherapies.

One Case of Hilar Cholangiocarcinoma in which Extended Left Hepatectomy Was Carried Out with Combined Resection of the Anterior Segmental Branch of the Right Hepatic Artery Following Coil Embolization

One Case of Hilar Cholangiocarcinoma in which Extended Left Hepatectomy Was Carried Out with Combined Resection of the Anterior Segmental Branch of the Right Hepatic Artery Following Coil Embolization

2332 Large Hepatic Arteriovenous Fistula Leading to Non-Cirrhotic Portal Hypertension and Associated Complications

INTRODUCTION: Portal hypertension (and its complications including bleeding, ascites, encephalopathy) often occur in patients with liver cirrhosis as a result of intrahepatic resistance to portal blood flow and increased portal collateral blood flow. Non-cirrhotic portal hypertension (NCPH) is less common, but can also lead to similar complications. Arteriovenous fistulas are an uncommon presinusoidal intrahepatic cause of NCPH. We present a rare case of a patient with a remote history of a liver biopsy who presented with new onset ascites and found on imaging to have a large hepatic arteriovenous fistula which was subsequently treated with embolization. CASE DESCRIPTION/METHODS: A 61 year old male with no significant past medical history presented to clinic for evaluation of progressively worsening abdominal and lower extremity swelling. Laboratory findings on presentation were remarkable for hemoglobin 7.4 g/dL, platelets 59,000/microliter, INR 1.6, Na 137mmol/L, Cr 1.56 mg/dL T bilirubin 2.4 mg/dL. Paracentesis fluid studies showed high serum-ascites albumin gradient (SAAG) and high protein without evidence of heart failure on echocardiogram. Magnetic resonance imaging of the abdomen showed a 6.3 × 4 centimeters hepatic arteriovenous fistula within segment VIII of the liver; the portal vein was noted to be patent. Liver biopsy showed focal perivenular and subsinusoidal fibrosis without bridging (fibrosis stage 1/6) and nodular regenerative hyperplasia changes with bands of hepatocyte atrophy without any evidence of cirrhosis. Right hepatic arteriogram demonstrated a dilated and tortuous vessel with early filling of the portal venous system and a large aneurysm at the communication point between the arterial and venous fistula. Successful embolization of the anterior segmental branch of the right hepatic artery was achieved. The patient’s hospital course was also complicated by upper gastrointestinal bleeding secondary to esophageal varices which required banding x5. DISCUSSION: The presence of portal hypertensive changes with minimal hepatic fibrosis on liver biopsy is best categorized as non-cirrhotic portal hypertension (NCPH). This patient manifested complications of portal hypertension including variceal bleeding and recurrent ascites secondary to a large hepatic arteriovenous fistula which likely formed following his liver biopsy. Closure of large arteriovenous fistulas can be beneficial in preventing worsening portal hypertension and associated potentially fatal complications.

Endovascular treatment of visceral artery and renal aneurysms (VRAA) using a constant mesh density flow diverting stent

BackgroundFlow diverting stents have been used safely and effectively for the treatment of intracranial aneurysms, particularly for large and wide necked aneurysms that are not amenable to conventional endovascular treatment with coiling. The Surpass Streamline device (Stryker Neurovascular, MI, USA) is a relatively new and unique flow diverting stent which maintains constant device mesh density over varying vessel diameters. This may potentially provide advantages compared to other flow diverting stents in achieving aneurysmal occlusion.Case presentationTwo patients with VRAA were treated using the Surpass Streamline device. The first patient was a 65-year-old male with an incidental 2.4 cm aneurysm originating from the hepatic artery near the gastroduodenal artery (GDA). The second patient was a 56-year-old male with an incidental 1.9 cm renal aneurysm arising from an anterior inferior segmental branch of the left renal artery. A Surpass flow diverting stent was used to successfully exclude the aneurysm neck in both cases.Reduced flow was achieved in one patient (equivalent to O’Kelly-Marotta [OKM] Grade B1). Preserved flow and stagnation (equivalent to OKM Grade A3) was achieved in the other. There was preserved distal flow in the parent arteries. No immediate complications were encountered in either case. Complete occlusion of both aneurysms was seen on follow up CT angiographic imaging within 8-weeks.ConclusionsThe Surpass flow diverting stent can be used safely and effectively to treat VRAA. It should be considered in unruptured large and giant wide necked VRAAs aneurysms. Additional large prospective studies are required for further validation.

Long-term Histopathologic Follow-up of a Spherical Embolic Agent; Observation of the Transvascular Migration of HepaSphereTM.

Very few studies have been published on the long-term histopathologic follow-up of spherical embolic agents after their injection. To our knowledge, there are no reports in the literature regarding pathological analysis of the transvascular migration of HepaSphere particles. We here report a case of a patient with hepatocellular carcinoma (HCC) who underwent liver transplantation 12 months after drug eluting microsphere transcatheter arterial chemoembolization (DEM-TACE), and long-term histopathologic follow-up of the microspheres was performed. Furthermore, to our knowledge, this is the first report in which transvascular migration of a HepaSphere particle was confirmed histologically. A 60-year-old male with chronic hepatitis B was treated with entecavir and seroconversion was obtained. The patient had decompensated cirrhosis, and desired to undergo living donor liver transplantation (LDLT). However, 2 HCC tumors of 3 cm or less were detected in his liver. The transplantation surgeon proposed DEM-TACE as a bridge therapy. The HCCs were located in the right lobe and lateral segment of the liver. A 1.9 F preshaped microcatheter (ProgreatΣ, Terumo, Japan) was selectively inserted into the A3 and anterior segmental branch, 10 mg of epirubicin was injected into each artery, and the arteries were embolized with 7 mg and 13 mg of HepaSphere loaded with epirubicin, respectively. Two months later, contrast-enhanced CT displayed a complete response. At that time, lung metastasis was suspected, but after partial lung resection, the patient was diagnosed as having inflammatory granuloma. One year after DEM-TACE treatment, LDLT was performed. No cancerous cells were detected in the area where the tumor was present, but 22 HepaSphere particles were detected. All particles were present in the interstitium. Furthermore, the transvascular migration of a HepaSphere particle was histologically confirmed. The largest and smallest HepaSphere diameters were 241.6 ± 52.5 µm and 186.5 ± 41.4 µm, respectively, and deformity was 22.6% ± 13.0 %. All the HepaSpheres detected in the examined pathological specimen were noted to be extravascular.

Living-Donor Liver Transplantation With the Use of a Left-Lobe Graft From a Donor With Anomalous Biliary Anatomy in Which B4 Joins the Right Anterior Sectional Duct: A Case Report

When there is an anatomic anomaly in the biliary tract of the donor for living-donor liver transplantation, the risk of postoperative biliary tract complications increases in both the donor and the recipient. We studied a case of living-donor liver transplantation with a left hepatic lobe graft that had anatomic anomalies, in which the medial segmental branch (B4) joined the anterior segmental branch and the posterior segmental branch formed a common trunk with the lateral segmental branch. A 40-year-old man visited our institution as a candidate organ donor for his mother, who had end-stage liver failure. An anomaly of B4 connecting the anterior segmental branch was suspected on magnetic resonance cholangiopancreatography. On intraoperative cholangiography, confluence of B4 with the anterior segmental branch and connection of the posterior and lateral segmental branches forming a common trunk were confirmed. Accordingly, individual anastomoses of the lateral segmental branch and B4 with the recipient jejunum were planned, and a left-lobe graft was excised. The postoperative recovery was smooth, and the donor was discharged with no complications. Even when an anatomic anomaly is present in the donor bile duct, in urgent cases, accurate evaluation through the use of various modalities may enable living-donor liver transplantation with the use of a graft with an anatomic anomaly.

English

The renal vasculature was always a subject of variations both in the number and pattern of portal of entry into kidney and Perihilar placement of the artery, vein and pelvis. Good anatomical insight is an essential prerequisite besides the surgical expertise. The cadaveric dissection revealed a Right Kidney supplied by Quadruple renal arteries & Drained by two renal veins. The main renal artery (MRA) was arising from antero lateral aspect and the accessory renal artery was arising from anterior aspect of aorta 1cm distal to the former vessel. Only the MRA showed Fork Pattern Branching with four anterior segmental arteries and one posterior segmental artery in the pre hilar region. The first and fourth segmental arteries showed a small subsidiary branch and a large tortuous subsidiary branch respectively. The later along with the branch running downwards and lateral from lower renal artery formed a common trunk and pierced the capsule and entered into the substance of the kidney anteriorly about 2cm lateral to the hilum, thus forming an aberrant artery. The upper polar artery was seen arising from the lower supra renal artery. The main renal vein (MRV), was formed by two formative tributaries of which one is larger and other being smaller. The later was seen just anterior to the third anterior segmental branch of MRA. Accessory renal vein was formed by only one tributary encircled by the fourth anterior segmental artery and posterior segmental artery. There was crowding of structures seen with altered hilar anatomy in both vertical and horizontal disposition. Such a rare combination of extra renal multiple arterio-venous variation is of worth concern to the urologists harvesting kidneys from the live donors for performing transplantation procedures. Partial nephrectomies for the hilar tumors and for Radiologists during interpretation of the angiograms.

Successful Treatment Using Coil Embolization of a Symptomatic Intrahepatic Portosystemic Venous Shunt Developing through a Patent Ductus Venosus in a Noncirrhotic Adult

The patient was a 60-year-old man with encephalopathy without liver cirrhosis. CT angiography revealed a patent ductus venosus between the anterior segmental branch of the portal vein and the middle hepatic vein. Coils were framed in the patent ductus venosus and then used to fill in the frame. After treatment, transarterial portography showed that the shunt flow of the ductus venosus had decreased significantly. After one day, the patient's disturbance of consciousness disappeared. Our case involved the adult-onset of a patent ductus venosus, which is extremely rare. This case is the first in which coil embolization was successfully achieved in a noncirrhotic elderly patient with a patent ductus venosus.

Anatomic Variations of the Right Hepatic Duct: Results and Surgical Implications from a Cadaveric Study

Purpose. Thorough understanding of biliary anatomy is required when performing surgical interventions in the hepatobiliary system. This study describes the anatomical variations of right bile ducts in terms of branching and drainage patterns, and determines their frequency. Methods. We studied 73 samples of cadaveric material, focusing on the relationship of the right anterior and posterior segmental branches, the way they form the right hepatic duct, and the main variations of their drainage pattern. Results. The anatomy of the right hepatic duct was typical in 65.75% of samples. Ectopic drainage of the right anterior duct into the common hepatic duct was found in 15.07% and triple confluence in 9.59%. Ectopic drainage of the right posterior duct into the common hepatic duct was discovered in 2.74% and ectopic drainage of the right posterior duct into the left hepatic duct in 4.11%. Ectopic drainage of the right anterior duct into the left hepatic ductal system and ectopic drainage of the right posterior duct into the cystic duct was found in 1.37%. Conclusion. The branching pattern of the right hepatic duct was atypical in 34.25% of cases. Thus, knowledge of the anatomical variations of the extrahepatic bile ducts is important in many surgical cases.

A Case of a 32 Year Old Immunocompetent Female with a Portal Vein Thrombosis Secondary to Cytomegalovirus Hepatitis

Purpose: The patient is a 32 year old female who presented with right upper quadrant abdominal pain, nausea and vomiting. Prior to presentation she had cough with fever and nausea for 2 weeks. She had been seen by her primary care physician who had put her on a course of azithromycin for a presumed bronchitis with no improvement. In the emergency department, the patient was found to have abnormal liver function tests with an aspartate aminotransferase level of 243, alanine aminotrasferase level of 478, and alkaline phosphatase level of 116 and total bilirubin level of 0.8. A CT scan of the abdomen and pelvis revealed a thrombus of the anterior segmental branch of the right portal vein. The patient denied any significant past medical history. She used ibuprofen on an as needed basis and was on an oral contraceptive pill. The patient was evaluated by hematology and underwent an extensive work-up for an underlying hypercoagulable state which was negative. The patient's only risk factor was felt to be the use or oral contraception. The patient was also evaluated by the infectious diseases team and underwent an extensive viral work up including viral hepatitis panel, EBV, HIV, Influenza A and B, RSV, Parvovirus, and CMV. The only positive test was CMV PCR. An ultrasound with doppler showed partially occlusive thrombus extending from the main portal vein into several braches of the anterior right portal vein. The patient was started on anticoaguation with a heparin drip transitioned to coumadin given concern of extension of the clot. Given a high viral load and the thrombus the patient was also started on valganciclovir for treatment of CMV hepatitis. A month after discharge the patient's liver function tests had returned to normal. Follow up ultrasounds have shown improvement in the thrombus. CMV hepatitis leads to local inflammation as well as systemic responses that can increase the risk of portal vein thrombosis. Patients with CMV hepatitis are at risk for forming portal vein clots especially when there are other underlying pro-coagulant risk factors. CMV should also be considered in cases of portal vein thrombosis without a known cause.

Congenital absence of the horizontal portion of the left portal vein.

The adult portal vein and hepatic veins are the descendants of the vitelline and umbilical veins in embryo. Early in intrauterine life there are many anatomic channels between the vitelline and umbilical veins. As the embryo matures, certain channels regress and others become more prominent. The anatomic channels connecting the caudal portion of the right vitelline vein and the left umbilical veins form the horizontal portion of the left portal vein. If this anastomosis fails to develop normally, another venous channel maintains the communication. Clinically, this event is represented by the congenital absence of the horizontal portion of the left portal vein and the development of an aberrant vessel feeding the left lobe. As a result, the left lobe is suffi ciently fed by this aberrant vessel and does not atrophy. US demonstrates this anomaly as an echogenic line in the usual location of the horizontal portion of the left portal vein, the undeveloped horizontal portion, and a large aberrant vessel communicating between the anterior segmental branch of the right portal vein and the vertical portion of the left portal vein. The fl ow direction of the aberrant vessel is always from the former toward the latter. If the entire course of the portal vein is carefully observed with US and color Doppler US, there is very little room for ambiguity in diagnosing this extremely rare congenital anomaly.

3D contrast-enhanced MR portography and direct X-ray portography: a correlation study

Our objective was to compare 3D contrast-enhanced MR portography (3D CE MRP) on a 1.5-T MR imager with direct X-ray portography. Twenty-six consecutive patients underwent 3D CE MRP with in-plane resolution of 1.4 or 1.8 mm, and direct X-ray portography. The findings of these two methods were evaluated and compared. The main portal vein (PV), right PV with its anterior and posterior segmental branches, and left PV including its sagittal segment were shown clearly without diagnostic problem in all cases on MRP. The main PV appearance was accordant with MRP and X-ray. For intrahepatic PVs, the results agreed in 21 patients but disagreed in 5 patients. In 1 patient with a huge tumor in right liver, the right posterior PV was classified as occluded at MRP, but diffusely narrowed at X-ray. The findings of left intrahepatic PV were discordant in 3 patients with hepatocelluar carcinoma in the left lobe. The MRP demonstrated complete occlusion of the left PVs, whereas X-ray showed proximal narrowing and distal occlusion. In another patient with hepatocelluar carcinoma, a small non-occlusive thrombus involving the sagittal segment of the left PV was seen on MRP but not on X-ray. With demonstration of varices and portosystemic shunts, MRP showed results similar to those of X-ray, except one recanalized para-umbilical vein was excluded from the field of view at MRP due to the patient's limited ability of breathholding. The 3D CE MRP correlated well with direct X-ray portography in most cases, it was limited in distinguishing narrowing of an intrahepatic PV from occlusion, but it showed advantage in demonstrating small thrombus within PV.

Portal venous variations. Prevalence with contrast-enhanced helical CT.

To review the distribution of intrahepatic portal venous branching in order to determine the prevalence of variations. We made a retrospective review of 655 contrast-enhanced helical CT (CECT) images of patients referred to our department for upper abdominal CT examination during an 8-month period. Of the 655 patients, 70 were eliminated from the study because of improper opacification of the portal venous system. Variations of portal venous branching in the remaining 585 patients were classified. Of 585 patients, 504 (86.2%) had classical bifurcation of the main portal vein (MPV); 72 (12.3%) had a trifurcation of the MPV, 5 (0.9%) had a right anterior segmental branch originating from the left portal vein (LPV), 2 (0.3%) had an LPV originating from the right anterior segmental branch and 2 (0.3%) had a right posterior segmental branch arising from the MPV. Variations of portal venous branching are common and helical CT is efficacious in identifying these variations.

Portal venous variations. Prevalence with contrast-enhanced helical CT

Purpose: To review the distribution of intrahepatic portal venous branching in order to determine the prevalence of variations. Material and Methods: We made a retrospective review of 655 contrast-enhanced helical CT (CECT) images of patients referred to our department for upper abdominal CT examination during an 8-month period. Of the 655 patients, 70 were eliminated from the study because of improper opacification of the portal venous system. Variations of portal venous branching in the remaining 585 patients were classified. Results: Of 585 patients, 504 (86.2%) had classical bifurcation of the main portal vein (MPV); 72 (12.3%) had a trifurcation of the MPV, 5 (0.9%) had a right anterior segmental branch originating from the left portal vein (LPV), 2 (0.3%) had an LPV originating from the right anterior segmental branch and 2 (0.3%) had a right posterior segmental branch arising from the MPV. Conclusion: Variations of portal venous branching are common and helical CT is efficacious in identifying these variations.

Anatomy of the Intrahepatic Ramification of the Portal Vein in the Right Hemiliver

The ramification of the portal vein in the right hemiliver was studied by anatomic dissection in 36 formalin-fixed human livers. In 28/36 (77.8%) cases, the portal vein bifurcated into a right branch and a left branch and the right branch bifurcated into anterior and posterior segmental branches. The anterior segmental branch terminated in the anterosuperior subsegment (S₈) in two types: bifurcated when it divided into anterior P₈ and posterior P₈branches towards the respective regions of S₈ (24/28 cases) and monopodal when it had a single pedicle (4/28 cases). The maximum anteroinferior subsegmental branch (P₅maximum) originated either from the anterior segmental branch (16/28 cases) or from the anterior P₈ branch (12/28 cases). The posterior segmental branch vascularized the posteroinferior (S₆) and the posterosuperior (S₇) subsegments, and was terminated in three types: fan-shaped (16/28), bifurcated (9/28) and tripodal (3/28). In 4/36 (11.1%) cases the portal vein bifurcated into a right branch and a left branch but the posterior segmental branch was not present. In 4/36 (11.1%) the right branch of the portal vein was not present. These anatomical variations are explained separately and finally all cases are considered as a whole.

Role of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension in pediatric patients.

Role of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension in pediatric patients.

Identification of segments VI and VII of the liver based on the ramification patterns of the intrahepatic portal and hepatic veins.

We describe the pattern of intrahepatic vessel ramification in the right posterior hepatic sector in a population of 197 adults. Each specimen was dissected from its visceral (inferior) surface in order to demonstrate variations in the distribution of the portal vein branches to the hepatic segments of the right lobe, especially to segments VI (S6) and VII (S7) as described by Couinaud. We also examine whether three hepatic veins, i.e., the right hepatic vein (RHV), middle hepatic vein (MHV), and the short hepatic vein (SHV), aid the identification of segmental portal branches in the lower posterior sector. Four major patterns of branching of the posterior sectorial trunk of the portal vein system are described. In group A (32.0%) a single posterior trunk formed an arch-like pattern sending multiple branches to S6 and S7 (P6 and P7). We named the multiple branches to the apparent S6 the inferoposterior portal branches. It was difficult to identify which of these branches were equivalent to P6. In group B (27.9%), the posterior sectorial trunk bifurcated to form P6 and P7. In most of the specimens in this group, therefore, we were able clearly to identify both S6 and S7 based on the portal vein system. In group C (6.6%), the trunk trifurcated to form P6, P7, and an intermediate branch, which supplied both segments or a gray zone between them. Group D (33.5%) included variations of the anterior segmental branches, and in specimens of this group, the anteromedial border of the sector was difficult to identify. Notably, the three-dimensional interdigitating topographical relationship of the hepatic veins and the portal branches was not evident in the lower posterior sector, since tributaries of the RHV and the portal branches followed similar courses and paralleled each other in the region and since the territory of the SHV was usually restricted to the superficial parenchyma near the inferior surface. In group A, tributaries of the RHV/SHV (>3 mm in diameter) passed between the inferoposterior portal branches in only 22.2%/14.3% of the specimens. Thus the hepatic veins often did not reveal which of the multiple inferoposterior branches was P6. Moreover, in the subset of Group B in which the segments were identified based on the portal vein ramification, tributaries of the RHV/SHV (>3 mm in diameter) showed the intersegmental interdigitating arrangement in only 32.0%/6.0% of the specimens. In addition, a thick tributary of the MHV, sometimes arising from S6, did not run along, but penetrated the S5/S6 border plane from the lateral to the medial side. Therefore, the three hepatic veins (RHV, SHV, MHV) often did not aid the identification of the liver segments in the region. Consequently, the less than ideal combinations of irregular configurations of the portal and hepatic venous systems suggest that the right posterior segments cannot be conclusively identified anatomically in 30-40% of cases. Other means of identification, such as the conventional proportional manner (the upper and lower halves of the posterior sector roughly correspond to S6 and S7) may be required.

Thrombo-endartériectomie pulmonaire sous vidéo-angioscopie et arrêt circulatoire: une alternative à la transplantation cardiopulmonaire dans l'hypertension artérielle pulmonaire postembolique

The best predictor of poor or suboptimum outcome from pulmonary thromboendarterectomy (PTE) is insufficient relief of obstruction, especially in the lower lobes. The aim of this study is to emphasize that the use of video-assisted angioscopy may increase the quality of PTE and thus improve outcome. PTE included a median sternotomy, intrapericardial dissection limited to the superior vena cava, institution of cardiopulmonary bypass, deep hypothermia and sequential circulatory arrest periods. PTE was always bilateral and performed through two separate arteriotomies of both main intrapericardial pulmonary arteries. A rigid 5 mm angioscope connected to a video camera was introduced through the arteriotomy into the lumen to increase the visibility and perform the video-assisted endarterectomies of all obstructed segmental branches, including normally inaccessible anterior segmental branches. Between January 1996 and December 1997, 48 patients with severe postembolic pulmonary hypertension had PTE. Patients were in New York Heart Association (NYHA) class II ( n = 2), III ( n = 28) or IV ( n = 18) with the following hemodynamics: mean pulmonary arterial pressure (PAP) 53 ± 13 mmHg, cardiac index 2.16 ± 0.5 L/min/m 2, pulmonary vascular resistances (PVR): 1,152 ± 414 dyne·s −1·cm −5. Six patients died from alveolar hemorrhage ( n = 1), high residual pulmonary pressure and rethrombosis ( n = 4) and hypoxic cardiac arrest ( n = 1). The functional outcome in surviving patients was as follows: (NYHA) class I ( n = 24), II ( n = 16) or III ( n = 2) with improved hemodynamics: mean pulmonary arterial pressure: 30 ± 9 mmHg, cardiac index: 2.78 ± 0.5 L/min/m 2, pulmonary vascular resistances (PVR): 484 ± 159 dyne·s −1·cm −5. Video-assisted angioscopy allows much improved quality and degree of pulmonary endarterectomy. This expands the indications to include patients with previously inaccessible distal disease and candidates for heart-lung transplantation.