Membranous Obstruction Research Articles

Image-guided treatment of Budd-Chiari syndrome: a giant leap from the past, a small step towards the future.

Budd-Chiari syndrome (BCS) is a relatively rare vascular disease characterized by hepatic outflow tract obstruction, and image-guided endovascular treatment, namely percutaneous angioplasty, stenting, and transjugular intrahepatic portosystemic shunt (TIPS), has proven to be effective treatment modalities to alleviate symptoms and markedly improve the prognosis of the disease. Specifically, a step-wise approach is recommended, i.e., angioplasty and stenting are the prioritized choice for patients with membranous obstruction and short-length stenosis, whereas TIPS is the option for patients who fail this treatment. Currently, 5-year survival with the step-wise approach is about 75%, and the most promising way to further improve this value is to identify candidates who are at high risk of failing angioplasty, and perform pre-emptive TIPS in these patients.

Use of the Masterka for complex nasolacrimal duct obstruction in children

The Masterka stent has been recommended solely for treatment of simple distal membranous nasolacrimal duct obstruction (NLDO). The purpose of this study was to evaluate the Masterka stent as a primary treatment in complex forms of NLDO, including bony ductal stenosis and proximal and serial membranous obstruction. The medical records of patients who underwent treatment for congenital nasolacrimal duct obstruction with the monocanalicular Masterka stent were reviewed retrospectively. Both simple and complex forms of NLDO were primarily treated with probing and irrigation, followed by placement of the Masterka stent. A total of 72 eyes (53 patients) were included: 17 cases were simple forms of NLDO; and 55 were complex. Success was achieved in 15 of 17 simple cases (88%) and 39 of 55 complex cases (71%); the overall success rate was 75%. In patients <24months of age, success rates were 100% for simple and 78% for complex forms. The Masterka stent can be useful in a younger subset of patients with more complex forms of congenital NLDO. A lower success rate is noted in children >2years of age and complex forms of NLDO, especially those with bony stenosis.

Probing for congenital nasolacrimal duct obstruction.

Probing for congenital nasolacrimal duct obstruction.

Endoscopic treatment of adult idiopathic obstruction of the foramen of Monro

Adult idiopathic membranous obstruction of the foramen of Monro is an extremely rare condition that can be effectively treated with endoscopic foraminoplasty. A unilateral or bilateral foraminoplasty is performed if one or both of the foramina of Monro are obstructed, respectively. Endoscopic septum pellucidotomy is usually used in combination with the foraminoplasty. The operative chart and video of one of our patients undergoing endoscopic treatment for adult idiopathic membranous obstruction of the foramen of Monro were retrieved from our database and reviewed. A description of the surgical technique was then formulated. The surgical technique of endoscopic foraminoplasty plus septum pellucidotomy for adult idiopathic membranous obstruction of the foramen of Monro is described.

Hepatic vena cava syndrome: New concept of pathogenesis.

Hepatic vena cava syndrome, also known as membranous obstruction of inferior vena cava (IVC), was considered a rare congenital disease and classified under Budd-Chiari syndrome. It is now recognized as a bacterial infection-induced disease related to poor hygiene. Localized thrombophlebitis of the IVC at the site close to hepatic vein outlets is the initial lesion which converts on resolution into stenosis or complete obstruction, the circulatory equilibrium being maintained by development of cavo-caval collateral anastomosis. These changes persist for the rest of the patient's life. The patient remains asymptomatic for a variable period until acute exacerbations occur, precipitated by bacterial infection, resulting in deposition of thrombi at the site of the lesion and endophlebitis in intrahepatic veins. Large thrombus close to hepatic vein outlets results in ascites from hepatic venous outflow obstruction, which is followed by development of venocentric cirrhosis. Endophlebitis of intrahepatic veins results in ischemic liver damage and development of segmental stenosis or membrane. Acute exacerbations are recognized clinically as intermittent jaundice and/or elevation of aminotransferase or ascites associated with neutrophil leukocytosis and elevation of C-reactive protein; sonologically, they are recognized as the presence of thrombi of different ages in IVC and thrombosis of intrahepatic veins. Development of liver cirrhosis and hepatocellular carcinoma is related to severity or frequency of acute exacerbations and not to duration or type of caval obstruction. Hepatic vena cava syndrome is a common co-morbid condition with other liver diseases in developing countries and it should be considered in differential diagnosis in patient with intermittent elevation serum bilirubin and or aminotransferase or development of ascites and cirrhosis.

Етапна хірургічна корекція гастрошизису з вираженою вісцеро-абдомінальною диспропорцією, ускладненого мембранозною обструкцією тонкої кишки

Етапна хірургічна корекція гастрошизису з вираженою вісцеро-абдомінальною диспропорцією, ускладненого мембранозною обструкцією тонкої кишки

Rare Case of Membranous Obstruction at the Origin of Left Pulmonary Artery: Role of Perioperative Echocardiography to Evaluate the Anatomy of Pulmonary Artery

ABSTRACT Branch pulmonary artery (PA) stenosis may occur as an isolated finding or in conjunction with other cardiac malformations; it may be congenital or acquired postoperatively. Branch PAs need to be assessed individually to determine the adequacy of their size, whether they are confluent or nonconfluent, any stenosis at origin or distally, and severity of stenosis. Certain lesions, such as supravalvar pulmonary stenosis, or stenosis at the branch PAs bifurcation, are better dealt with at surgery. Thus, perioperative transthoracic and transesophageal echocardiography (TEE) assume a very important role in precisely evaluating the anatomy of main and branch PAs. How to cite this article Bhat IH, Damodaran S, Mandal B. Rare Case of Membranous Obstruction at the Origin of Left Pulmonary Artery: Role of Perioperative Echocardiography to Evaluate the Anatomy of Pulmonary Artery. J Perioper Echocardiogr 2017;5(2):74-76.

Non-contrast-enhanced MR angiography in the diagnosis of Budd-Chiari syndrome (BCS) compared with digital subtraction angiography (DSA): Preliminary results

Non-CE MRA techniques (true steady-state free-precession, SSFP) have been used effectively for the selective visualization of the portal venous system and inferior vena cava. Budd-Chiari Syndrome (BCS) encompasses a number of conditions that cause the obstruction of the hepatic outflow tract from the small hepatic veins to the junction of the inferior vena cava (IVC) and right atrium. The purpose of this study was to diagnose BCS with IVC obstruction using respiratory triggered three-dimensional (3D) true SSFP with T-SLIP and compare to digital subtraction angiography (DSA). The image acquisition of 3D true SSFP scans was successfully performed in 108 patients (≧2 score). The mean and SDs of the relative SNR and CNR were 55.96±2.32 and 30.72±1.56, respectively. Intergroup agreement for the detection of the 4 types (membranous obstruction, segmental occlusion, and membranous obstruction with a hole and segmental stenosis) of BCS with IVC obstruction was excellent between the Time-SLIP and the DSA. In conclusion, Time-SLIP for the detection of IVC obstruction BCS does not require the use of contrast. This procedure can achieve a high success rate, high accuracy rate and fine image quality for the diagnosis of IVC obstruction BCS.

Idiopathic bilateral occlusion of the foramen of Monro: An unusual entity with varied clinical presentations

We review our experience with four patients who presented to our Medical Center from 2005–2015 with adult idiopathic occlusion of the foramen of Monro (FM). All patients underwent CT scanning and MRI. Standard MRI was performed in each patient to rule out a secondary cause of obstruction (T1-weighted without- and with gadolinium, T2-weighted, fluid-attenuated inversion recovery [FLAIR] and diffusion-weighted imaging [DWI] protocols). When occlusion of the FM appeared to be idiopathic, further high-resolution MRI with multiplanar reconstructions for evaluation of stenosis or an occluding membrane at the level of the FM was performed (T1-weighted without- and with gadolinium, T2-weighted 3D turbo spin-echo). Occlusion of the FM was due to unilateral stenosis and septum pellucidum deviation in two patients, to an occluding membrane in one, and to bilateral stenosis in one patient. Urgent surgical intervention is mandatory when there are signs of increased intracranial pressure while asymptomatic patients may be managed conservatively. In this patient series, truly bilateral stenotic obstruction of the FM was best managed with ventriculoperitoneal shunt and patients with membranous obstruction or unilateral stenosis with septum deviation were treated endoscopically.

Outcomes of nasolacrimal duct probing in older children

There is limited literature regarding the success rate of surgery for older children with nasolacrimal duct (NLD) obstruction. The current study investigated the outcomes of primary NLD probing in patients four years of age or older with simple membranous NLD obstruction.

Cause and Management of Patients With Failed Endonasal Dacryocystorhinostomy.

ObjectivesEndonasal dacryocystorhinostomy (DCR) is a well-established treatment method in patients with nasolacrimal duct obstruction. However, there are a few reports about the overall management of failed endonasal DCR. We investigated the causes and management strategies of failed endonasal DCR.MethodsThis retrospective review included 61 patients (61 eyes) who had undergone revision surgery by the same surgeon after failed endonasal DCR between January 2008 and December 2012. The appropriate revision method was determined after analysis of the etiology of failure by the fluorescein dye disappearance test, nasal endoscopy, lacrimal irrigation, and probing. The criteria for success of the revision surgery were defined by the passage of fluid without resistance upon lacrimal irrigation and normalization of the tear meniscus height.ResultsThe mean duration between the primary endonasal DCR and revision surgery was 15.3 months. The average follow-up period after revision surgery was 12.2 months. The most common cause of endoscopic revision surgery was membranous obstruction. Endoscopic revision surgery was performed in 48 patients, while lacrimal silicone tube intubation under endoscopy was performed in 13 patients. The most common indication for lacrimal silicone tube intubation was functional epiphora. The overall success rate of the revision surgery was 89%.ConclusionThe most common cause of failed endonasal DCR was membranous obstruction. When patients with failed endonasal DCR presented at the clinic, it is important to identify the cause of the failure. Revision surgery could increase the final success rate of endonasal DCR.

Percutaneous Transluminal Angioplasty for Complete Membranous Obstruction of Suprahepatic Inferior Vena Cava: Long-Term Results.

To determine the long-term results of percutaneous transluminal angioplasty (PTA) for a complete membranous obstruction of the suprahepatic inferior vena cava. Patients (n=65) who were referred to the interventional unit for PTA for a complete membranous obstruction of the suprahepatic inferior vena cava between January 2006 and October 2014 were included in the study. Thirty-two patients (18 males, 14 females, mean age 35±10.7, range 20-42years) were treated. The patients presented with symptoms of ascites (88%), pleural effusion (53%), varicose veins (94%), hepatomegaly (97%), abdominal pain (84%), and splenomegaly (40%). Transjugular liver access set and re-entry catheter were used to puncture and traverse the obstruction from the jugular side. PTA balloon dilations were performed. The mean follow-up period was 65.6±24.5months. The objective was to evaluate technical success, complications, primary patency, and clinical improvement in the symptoms of the patients. The technical success rate was 94%. In two patients, obstruction could not be traversed. These patients underwent cavoatrial graft bypass surgery. There were no procedure-related complications. Clinical improvements were achieved in all patients within 3months. The primary patency rate at 4years was 90%. There was no primary assisted patency. There was no need for metallic stent deployment in the cohort. The secondary patency rate at 4years was 100%. Percutaneous transluminal angioplasty for a complete membranous obstruction of the suprahepatic inferior vena cava is safe and effective, and the long-term results are excellent.

A Simple Technique to Avoid Restenosis for Dacryocystorhinostomy.

The most common reason for failure in dacryocystorhinostomy has been proven to be the granuloma or membranous obstruction of scar tissue formation on lacrimal opening in the nasal cavity during the healing process. In this article, the authors suggest an easy maneuver to avoid the risk of scarring and collapsing of the knot in bony window by using a piece of an aspiration catheter. Using this easy maneuver, the authors can manage to reduce the risk of scarring and stenosis, and when the authors take out the tubes after 2 months, removing the silicone tube was easier with our technique. Moreover with the present technique the authors observed there was no embedding of the knot in the scar.

A prospective outcome study of membranous and solid distal common canalicular obstructions.

To prospectively evaluate the surgical outcomes of membranous and solid distal common canalicular obstructions (CCOs) following endoscopic dacryocystorhinostomy (EnDCR) and lacrimal intubation combined with either membranotomy or trephination. This was a prospective, non-randomized, consecutive interventional case series. Inclusion criteria included patients undergoing EnDCR with evidence of a membranous block or more solid obstruction of the distal common canaliculus, treated with membranotomy or canalicular trephination. Complete CCO was confirmed pre-operatively using dacryocystography and dacryoscintigraphy. All patients received bicanalicular intubation for 3 months with a minimum follow-up of 12 months. Functional and anatomical success was assessed at 4 weeks, 3 months, and 12 months following surgery. Functional success was defined as subjective improvement of epiphora and anatomical success as the presence of a patent ostium and a positive dye test on nasal endoscopy. Twenty-nine patients were included in the study with a mean age of 58 years. Twenty-one patients (72%) received a membranotomy and eight (28%) required trephination. At 12 months, the functional and anatomical success rate in the membranotomy group was 90% (19/21) and 100% (21/21), respectively, and in trephination group the functional and anatomical success rate was 63% (5/8). There were no intra-operative or lacrimal stent-related complications. Identifying and excising distal CCOs in association with EnDCR and lacrimal intubation is associated with a high degree of functional (83%) and anatomical (90%) success. The success of membranous obstructions appear be superior to outcomes for solid obstructions of the distal common canaliculus that require trephination.

Circulating microRNA profile in patients with membranous obstruction of the inferior vena cava.

Membranous obstruction of the inferior vena cava (MOVC) is a common type of Budd-Chiari syndrome. However, the pathogenesis of MOVC has not been fully elucidated. Recent studies demonstrated that microRNAs (miRNAs or miRs) are involved in multiple diseases. To the best of our knowledge, specific changes in the expression of miRNAs in MOVC patients have not been previously assessed. The present study used a microarray analysis, followed by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) validation, with the aim to access the miRNA expression levels in the plasma of 34 MOVC patients, compared with those in healthy controls. The results revealed a total of 16 differentially expressed miRNAs in MOVC patients. Subsequently, RT-qPCR analysis verified the statistically consistent expression of 5 selected miRNAs (miR-125a-5p, miR-133b, miR-423-5p, miR-1228-5p and miR-1266), in line with the results of the microarray analysis. These 5 miRNAs, which were described as crucial regulators in numerous biological processes and vascular diseases, may play an important role in the pathogenesis of MOVC. Bioinformatics analysis of target genes of the differentially expressed miRNAs revealed that these predicted targets were significantly enriched and involved in several key signaling pathways important for MOVC, including the ErbB, Wnt, MAPK and VEGF signaling pathway. In conclusion, miRNAs may involve in multiple signaling pathways contributing to the pathological processes of MOVC. The present study offers an intriguing new perspective on the involvement of miRNAs in MOVC; however, the precise underlying mechanisms require further validation.

Redefining Budd-Chiari syndrome: A systematic review.

To re-examine whether hepatic vein thrombosis (HVT) (classical Budd-Chiari syndrome) and hepatic vena cava-Budd Chiari syndrome (HVC-BCS) are the same disorder. A systematic review of observational studies conducted in adult subjects with primary BCS, hepatic vein outflow tract obstruction, membranous obstruction of the inferior vena cava (IVC), obliterative hepatocavopathy, or HVT during the period of January 2000 until February 2015 was conducted using the following databases: Cochrane Library, CINAHL, MEDLINE, PubMed and Scopus. Of 1299 articles identified, 26 were included in this study. Classical BCS is more common in women with a pure hepatic vein obstruction (49%-74%). HVC-BCS is more common in men with the obstruction often located in both the inferior vena cava and hepatic veins (14%-84%). Classical BCS presents with acute abdominal pain, ascites, and hepatomegaly. HVC-BCS presents with chronic abdominal pain and abdominal wall varices. Myeloproliferative neoplasms (MPN) are the most common etiology of classical BCS (16%-62%) with the JAK2V617-F mutation found in 26%-52%. In HVC-BCS, MPN are found in 4%-5%, and the JAK2V617-F mutation in 2%-5%. Classical BCS responds well to medical management alone and 1(st) line management of HVC-BCS involves percutaneous recanalization, with few managed with medical management alone. Systematic review of recent data suggests that classical BCS and HVC-BCS may be two clinically different disorders that involve the disruption of hepatic venous outflow.

Successful Surgical Management of Cervical Esophageal Membranous Obstruction and Stricture in a Cattle Calf

Copyright: © 2016 Ali MM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. *Corresponding author: Ahmed Ibrahim, Faculty of Veterinary Medicine, Assiut University, Assiut, Postal Code: 70155, Egypt, Tel: +201062204009; Fax: 088-208050; E-mail: elgrah38@gmail.com

Membranous obstruction of hepatic Inferior Vena Cava: A rare finding in the workup of ascites and oedema

44 years old Caucasian female presented with new-onset ascites with extremity edema and work up indicated absence of hepatic, cardiac or hematologic diseases. Imaging suggested Budd-Chiari (Image 1), abdominal venography demonstrated a blunt occlusion of the Inferior Vena Cava (IVC) prior to junction with suprahepatic IVC (Image 2). Attempts to cannulate thick web-like segment with a Kumpe and Cobra style catheter over flexible Glidewire by femoral approach were unsuccessful. It was thus decided to position an endovascular snare at the level of the occlusion via jugular approach, a Kumpe catheter was advanced after carefully piercing the occlusion with the back end of a stiff Glidewire which was then snared successfully. Sequential balloon dilatation was then performed using 8/10/12, and 14 mm catheters. Post-completion venography showed no restriction to IVC flow and disappearance of collaterals (Image 2). She was started on anticoagulation with resolution of ascites and edema subsequently. Hepatic IVC obstruction remains a rare cause of hepatic outflow obstruction, and development of IVC collaterals may delay presentation. The diagnosis and prompt treatment can prevent development of advanced liver disease and portal hypertension. Endovascular treatment without stent placement has diverse long-term outcomes data, however is shown to be safe and well tolerated with no immediate technical complications i.e. embolization, bleeding, infection, or hematoma. Patients mostly require anticoagulation to prevent IVC thrombosis.

Value of combined three dimensional constructive interference in steady state with phase-contrast MR in diagnosis of hydrocephalus children

Objective To investigate the value of combined 3D-constructive interference in steady state(3D-CISS) with phase-contrast MR(PC-MR) in diagnosis of hydrocephalus children. Methods We collected retrospectively 28 children with hydrocephalus who caused by obstructive membranes.They all underwent MR imaging examination with a 1.5 T consisting of 3D-CISS, conventional sequences and PC-MR. With the result of surgery and CT cisternography as gold standard,we analysised different sequence in the diagnosis of membranous obstruction. The results of obstructive were analysed by χ2 test between 3D-CISS combined with PC-MR and conventional sequences. Results The study included 28 children, of whom 16 showed obstructive membranes in CSF pathways of ventricle and 12 displayed obstructive membranes in CSF pathways of cistern. Conventional sequences diagnosed obstructive membranes of 15 children, and obstructive membranes of 11 children were consistent with gold standard, and 4 cases were false positive. The 3D-CISS diagnosed obstructive membranes of 40, and 12 cases were false positive.There were significant difference between 3D-CISS combined with PC-MR and conventional sequence about obstructive membranes diagnosis of CSF pathways(χ2=24.410, P=0.001). Conclusions Making use of jointing 3D-CISS sequence and PC-MR sequence successively, and we can diagnose the position of obstructive membrane for hydrocephalus, which can be helpful to select a perfect surgical approach. Key words: Hydrocephalus; Magnetic resonance imaging

Prognostic value of metal–metal contact during nasolacrimal duct probing

ObjectiveTo evaluate the prognostic value of metal–metal contact during nasolacrimal duct (NLD) probing in patients with simple membranous versus complex congenital NLD obstructions (CNLDO). DesignRetrospective case series. ParticipantsInfants diagnosed with CNLDO. MethodsSeventy-nine eyes of 70 infants with CNLDO who underwent probing were recruited. Metal–metal contact was sought during probing in every patient. CNLDO was classified into simple membranous versus complex type of obstruction. Complete resolution of epiphora, increased tear meniscus, and mucous discharge were defined as successful outcome. ResultsThe mean age of patients at the time of probing was 21.0 ± 8.3 (range 1–42) months. Postoperative evaluations were performed in all patients between the first and second postoperative months. Overall success rate of probing was 84.9%. A higher success rate was obtained in membranous (89.7%) versus complex (54.5%) obstructions (p = 0.01). A metal–metal contact could be established in 62 (78.5%) eyes. Treatment success was achieved in 93.5% of cases in which metal–metal contact was detected versus 52.9% of cases without metal–metal contact (p < 0.001). Among cases with metal–metal contact, a trend toward successful outcomes was observed with membranous as compared with complex obstructions (96.4% vs 71.4%, p = 0.059). Logistic regression analysis revealed the presence of metal–metal touch (odds ratio [OR] 13.3, p = 0.001) and membranous type obstruction (OR 7.7, p = 0.019) as significant factors for a successful outcome. ConclusionsEstablishment of metal–metal contact is an important prognostic sign for surgical success in both the membranous and the complex type of CNLDO.