Hepatic Vein Stenosis Research Articles

Combined transhepatic and transvenous approach to hepatic vein stenosis after transjugular intrahepatic portosystemic shunt (TIPS).

We describe a simple technique for recatheterization of transjugular intrahepatic portosystemic shunts (TIPS) with severe hepatic vein ostial stenoses that are inaccessible to standard transvenous approaches. A small gauge needle is used to transhepatically introduce a guidewire into the shunt; the wire is passed through the hepatic vein stenosis, snared, and used to guide jugular or brachial catheters into the TIPS.

Klinische Erfahrungen mit dem transjugulären intrahepatischen portokavalen Shunt (TIPS)

Twenty-five patients with liver cirrhosis and portal hypertension were admitted for creation of a transjugular intrahepatic portosystemic shunt (TIPS). The procedure was successful in 22 patients (technical success 88%). The mean portal pressure gradient was lowered from 24.5 mmHg before to 11.4 mmHg after TIPS. Two early and three late occlusions were observed (primary patency rate 78%). The rate of secondary interventions was 41%. Five times a hepatic vein stenosis was dilated and stented, two times an occluded shunt was recanalized, two times a new shunt was created parallel to an occluded (secondary patency rate within a maximum of 16 months 95%). In two patients sepsis occurred which was effectively treated with antibiotics, two patients died shortly after TIPS due to hepatorenal syndrome and hepatic failure, respectively. There was no recurrent bleeding. Two patients developed hepatic encephalopathy; both improved after protein restriction. The authors conclude that TIPS is an alternative procedure to shunt surgery, especially for patients who cannot benefit from sclerotherapy.

Relief of hepatic vein stenosis by balloon angioplasty after living‐related donor liver transplantation

We have experienced 5 hepatic vein stenoses in 3 children (8 to 23 months old) after living‐related liver transplantation (total 48 liver transplants for 48 children between June 1990 and November 1992). The initial symptoms of hepatic vein stenosis were ascites and/or edema. The blood flow of hepatic vessels was monitored by duplex sonography. The mean velocity of the hepatic vein and the portal vein was decreased and flow wave pattern of the stenotic hepatic vein was flat. The patients were treated by percutaneous transhepatic balloon angioplasty. After a successful angioplasty, the mean velocity of the hepatic vein and portal vein increased and pulsatile waves returned to the hepatic vein. Arterial ketone body ratio (acetoacetate/3‐hydroxybutylate) increased, promptly followed by recovery of other liver function tests. In 1 patient, this complication occurred three times with intervals of 7 months and 3 months between episodes of hepatic vein stenosis. In conclusion, hepatic vein flow should be monitored routinely with duplex sonography after living‐related donor liver transplantation. Percutaneous transhepatic balloon angioplasty is a primary treatment for the stenosis.

Transjugular intrahepatic portosystemic shunt: early experience with a flexible trocar/catheter system.

The purpose of this study was to determine the feasibility of using a flexible trocar/catheter system to create a transjugular intrahepatic portosystemic shunt (TIPS). A flexible needle/trocar was used to connect the hepatic vein to the portal vein in 23 patients with portal hypertension and a history of bleeding gastroesophageal varices. Five patients had signs and symptoms of encephalopathy before shunting; in four, the disease was classified as Child's class C and in one, as Child's class B. Nine-millimeter self-expandable metallic stents were used in all patients. The procedure was technically successful in all patients. The mean portosystemic pressure gradient decreased from 26 to 16 mm Hg (range, 7-23 mm Hg). Eight patients have died. One patient in a hepatic coma with hepatorenal failure survived percutaneous portosystemic shunting, but died 2 days after the TIPS procedure was done. After creation of the shunt, three other patients died of unrelated disease without recurrence of bleeding from gastroesophageal varices. Two patients died of massive bleeding from esophageal varices, one 24 hr after shunting and one of disseminated intravascular coagulation after a second attempt to establish a shunt. One patient died of sepsis associated with infected ascitic fluid 2 months after the TIPS procedure was done, and one died of unknown causes 4 months after the procedure was done. The mean follow-up time in the surviving 15 patients was 12 months. Seven patients had recurrence of gastrointestinal bleeding; the recurrence was due to a thrombosed shunt in two, to hepatic vein stenosis in four, and to a high portosystemic pressure gradient (22 mm Hg) after creation of the shunt in one. Hepatic vein stenosis was noted on portal venograms in another three otherwise asymptomatic patients. In four of five patients, encephalopathy was adequately controlled after shunting. The fifth patient with encephalopathy (Child's class C) and an additional patient in whom encephalopathy (Child's class C) developed after the TIPS procedure have had two additional hospital admissions because of difficulty in controlling the encephalopathy. The amount of ascitic fluid decreased or totally disappeared after treatment in all cases. No severe complications associated with creation of a TIPS were observed. Use of a flexible trocar/catheter system to create a TIPS is a simple, safe, and moderately reliable means of decompressing the portal vein in patients with portal hypertension.

Morphologic and hemodynamic findings at sonography before and after creation of a transjugular intrahepatic portosystemic shunt.

The purpose of this study was to describe the morphologic and hemodynamic findings in the hepatic vasculature before and immediately after creation of a transjugular intrahepatic portosystemic shunt. We used gray-scale, duplex, and color Doppler sonography to prospectively examine 25 patients before and after percutaneous placement of a stent to create a transjugular intrahepatic portosystemic shunt. Patency and direction of flow were determined in the stent and in the main, right, and left portal veins. Flow velocity was measured in the stent and in the main portal vein. In all patients, the stent was easily identified as connecting branches of the portal and hepatic veins. Three thrombosed stents were correctly detected sonographically. One stent that was thought to be thrombosed at sonography was found to be patent at angiography. Flow velocities in the patent stents ranged from 73 to 185 cm/sec (mean, 130 +/- 33 cm/sec). Mean peak velocities in the main portal vein were 20 cm/sec before stent placement and 38 cm/sec after stent placement (p < .002). In 14 patients, flow direction in the left or right portal vein was hepatofugal after the stent was placed. In two of these 14 patients, long-term follow-up showed subsequent conversion of flow in the portal vein branches from hepatofugal to hepatopetal. One of these two patients had a thrombosed stent and the other had a hepatic vein stenosis above the stent. The second patient also had a proven decrease in flow velocity in the stent at the time of stenosis. We conclude that high flow velocities are expected in the main portal vein and in the stent immediately after the shunt is created and that flow in portal vein branches is usually hepatofugal. We recommend sonography soon after the shunt is created, so that baseline flow velocity in the stent and flow direction in portal vein branches can be established, because a subsequent decrease in flow velocity in the stent or a change in direction of flow in a portal branch may indicate stent malfunction.

Surgical Techniques and Innovations in Living Related Liver Transplantation

The authors successfully performed a series of 33 living related liver transplantations (LRLT) on children (15 males and 18 females, ranging from 7 months to 15 years of age) from June 1990 to May 1992, with the informed consent of their parents and the approval of the Ethics Committee of Kyoto University. Before operation, six of the children required intensive care, another 14 were hospitalized, and 13 were homebound. Donors (12 paternal and 21 maternal) were selected solely from the parents of the recipients on the basis of ABO blood group and graft/recipient size matching determined by computed tomography scanning. Procurement of graft was performed using ultrasonic aspirator and bipolar electrocautery without blood vessel clamping and without graft manipulation. All donors subsequently had normal liver function and returned to normal life. The left lateral segment (16 cases), left lobe (16 cases), or right lobe (one case) were used as grafts. The partial liver graft was transplanted into the recipient who underwent total hepatectomy with preservation of the inferior vena cava using a vascular side clamp. Twenty-seven of 33 recipients are alive and well with the original graft and have normal liver function. The patient survival rate was 89% (24/27) in elective cases and 50% (3/6) in emergent cases. The other six recipients had functioning grafts but died of extrahepatic complications. Complications of the graft were minimal in all cases. Hepatic vein stenosis, which occurred three times in two cases, was successfully treated by balloon dilatation. In cases with sclerotic portal vein, the authors anastomosed the portal vein of the graft to the confluence of the splenic vein and the superior mesenteric vein without a vascular graft, after experiencing a case of vascular graft thrombosis. After hepatic artery thrombosis occurred in one of the initial seven recipients whose arterial anastomosis was done with surgical loupe, microsurgery was introduced for hepatic artery reconstruction. There has been no occurrence of thrombosis since then. The current results with LRLT suggested that the meticulous management of surgical factors at each stage of the LRLT procedure is crucial for successful outcome. Living related liver transplantation is a promising option for resolving the graft shortage in pediatric liver transplantation and may be regarded as an independent modality to supplement cadaver donation.

Technical advances in transjugular intrahepatic portosystemic shunts.

A transjugular intrahepatic portosystemic shunt (TIPS) can be created percutaneously with the Palmaz balloon-expandable stent. This article describes a transjugular-only approach with a 16-gauge needle. A functional and efficacious shunt can be achieved in most cases with stent diameters of 8-10 mm. Occasionally, a 12-mm-diameter shunt is necessary for effective variceal decompression. The procedure is considered successful when the portosystemic gradient is lowered to 12 mm Hg or less after stent placement. Hepatic vein stenosis in the shunt outflow can develop after the TIPs procedure. This complication has been treated successfully with additional stent placement. TIPS can undoubtedly be performed successfully and safely with a transjugular-only approach; however, the full impact of TIPS on the treatment of portal hypertension remains to be determined.

Percutaneous Placement of a Hepatic Vein Stent in the Treatment of Budd-Chiari Syndrome

The authors describe the first reported use, to their knowledge, of an intravascular stent to relieve hepatic vein stenosis causing the Budd-Chiari syndrome. A patient with severe stenosis of the left hepatic vein is described. Multiple balloon angioplasty procedures were performed over a period of several months and provided only transient relief of symptoms. As an alternative to surgical management, an intravascular stent was placed, with complete resolution of symptoms. Intravascular stent placement may play an important role in treatment of the Budd-Chiari syndrome.

Angiography of liver transplantation patients.

Over 45 months, 119 angiographic examinations were performed in 95 patients prior to liver transplantation, and 53 examinations in 44 patients after transplantation. Transplantation feasibility was influenced by patency of the portal vein and inferior vena cava. Selective arterial portography, wedged hepatic venography, and transhepatic portography were used to assess the portal vein if sonography or computed tomography was inconclusive. Major indications for angiography after transplantation included early liver failure, sepsis, unexplained elevation of liver enzyme levels, and delayed bile leakage, all of which may be due to hepatic artery thrombosis. Other indications included gastrointestinal tract bleeding, hemobilia, and evaluation of portal vein patency in patients with chronic rejection who were being considered for retransplantation. Normal radiographic features of hepatic artery and portal vein reconstruction are demonstrated. Complications diagnosed using results of angiography included hepatic artery or portal vein stenoses and thromboses and pancreaticoduodenal aneurysms. Intrahepatic arterial narrowing, attenuation, slow flow, and poor filling were seen in five patients with rejection.

Hepatic pathology of a primary experimental infection of Fasciola hepatica in sheep

Four hundred metacercariae of Fasciola hepatica were administered orally to 11 parasite-free sheep and the lesions they induced were studied over a 30-weekperiod. Flukes migrated principally in the ventral lobe where they produced an extensive system of necrotic and haemorrhagic tracks which organized to form post-necrotic scars. Portal and hepatic vein stenosis developed in veins traversed by flukes and in portal veins around tracks where collagen fibres replaced eosinophils and oedematous fluid. Arterial medial hyperplasia and convolutions were observed together with vascular channels in collagen septa. Around triads, bile ductules were numerous, and many hepatocytes became enveloped by collagen fibres to form pericellular fibrosis while others were seen to degenerate. A distinctive type of fibrosis, monolobular fibrosis, developed in areas of minimal fluke damage at a time when hepatocyte regeneration was prominent. A chronic cholangitis was induced and fluke eggs were involved with a granulomatous lesion which resulted in the destruction of the bile duct containing the eggs.

A Family with Protein-Losing Enteropathy

This a report of a family of two sibships resulting from consanguineous matings of first cousins once removed. Eight of 28 children in the two sibships were affected by edema, growth retardation, diarrhea, abdominal pain, or clubbing, in varying combinations. In 4 patients, ascites developed and all 4 died. Autopsies performed in 2 of the cases revealed hepatic vein stenosis which caused a Budd-Chiari syndrome. Laboratory examinations revealed iron-deficiency anemia and low serum albumin and globulin in all affected family members. In some cases, mild eosinophilia was present. All patients had normal lymphocyte counts. Five patients were investigated in detail, and a protein-losing enteropathy was demonstrated. In some patients, the intestinal biopsy showed slight to marked dilation of mucosal lymphatics. Lymphangiography was normal in all 5 cases, and 3 patients formed antibodies in response to immunization with TAB vaccine. Three patients were treated with prednisone. In 2 cases, abdominal pain and edema disappeared, and the patients gained a considerable amount of weight. Serum proteins returned to normal levels in all 3 prednisone-treated patients, their polyvinylpyrrolidone excretion decreased, and the parameters of protein metabolism returned to normal in the 1 patient in which they were reinvestigated. The cause of this familial protein-losing enteropathy is unknown.