Percutaneous Transhepatic Balloon Angioplasty Research Articles

Clinical Efficacy of Percutaneous Transhepatic Portal Vein Angioplasty for Late-onset Portal Vein Stenosis in Pediatric Liver Transplant Patients.

Stenosis of the portal vein (PV) is a rare complication after liver transplantation (LT) in pediatric patients, and it adversely affects outcomes. We reviewed the safety and efficacy of percutaneous transhepatic balloon angioplasty (PTBA) as a treatment for post-LT late-onset PV stenosis (PVS). Three hundred eighteen patients between the ages of 0 and 21 years received an LT from 2001 to 2016 at this tertiary center. Twenty-one children were evaluated for PVS using percutaneous portal venography. Of the 21, 19 patients (7 female, 12 male) with a median age of 12 years (7-15 years) were diagnosed with PVS and received PTBA. Two patients were excluded: one did not have PVS, and one received shunt surgery. Median time between LT and PTBA was 83 months (interquartile range, 49-138). For patients in whom pressure could be accurately measured (n = 9), mean PV pressure gradient was 6.3 mm Hg (SD, 5.0) preprocedure and 0.9 mm Hg (SD, 1.2) postprocedure. Mean percentage improvement in gradient across the stenotic region was 86.2% (SD, 15.9%; P < 0.01). At 12-month postprocedure, there was a mean improvement (pre-PTBA vs post-PTBA means) in bilirubin by 28.2% (0.6 mg/dL vs 0.4 mg/dL, P = 0.07), aspartate aminotransferase by 31.2% (116.3 IU/L vs 28.1 IU/L, P = 0.04), alanine aminotransferase by 40.7% (140.3 IU/L vs 28.6 IU/L, P = 0.07), γ-glutamyltransferase by 29.0% (337.2 IU/L vs 38.0 IU/L, P = 0.06) and platelets by 62.1% (128.3 vs 191.1 × 10/L, P = 0.03). The PV patency was successfully maintained in 18 of 19 patients for a median of 16 months (interquartile range, 5-35). One patient received a successful repeat procedure for restenosis at 6 weeks. Angioplasty for PVS after pediatric LT is a safe and effective treatment with good patency and improved clinical outcomes. Longer follow-up studies are required.

Long-Term Outcome of Portal Vein Stent Placement in Pediatric Liver Transplant Recipients: A Comparison with Balloon Angioplasty

PurposeTo evaluate the long-term efficacy of stent placement versus balloon angioplasty for portal vein (PV) stenosis in pediatric liver transplant (LT) recipients. Materials and MethodsFifty patients (<18 years old; median, 14 months) who underwent percutaneous transhepatic balloon angioplasty (n = 12), transhepatic stent placement (n = 18), or intraoperative transmesenteric stent placement (n = 20) between 1994 and 2015 were retrospectively analyzed. The median intervals from LT to percutaneous transhepatic angioplasty, stent, and intraoperative stent were 145 days (range, 27–2072), 98 days (range, 5–2289), and 0 days (range, 0–14), respectively. The primary study endpoint was the primary patency of each group. Secondary study endpoints included procedural complications, functional stent stenosis, and stent fractures. ResultsThe median clinical follow-up periods were 81 months (range, 13–179), 118 months (range, 65–181), and 112 months (range, 47–168) in each group, respectively. In the angioplasty group, the 1-, 5-, and 10-year primary patency rates were all 75% ± 13%. The corresponding rates were all 100% in the percutaneous transhepatic stent group and 90% ± 7%, 90% ± 7%, and 85% ± 8%, respectively, in the intraoperative transmesenteric stent group (P = .103). Major procedural complications occurred in 4 patients, including 1 case with PV tear after percutaneous transhepatic post-stent angioplasty, and 3 cases with acute PV thrombosis after intraoperative transmesenteric stent. Functional stent stenosis and stent fractures occurred in 1 and 2 patients, respectively. ConclusionsNo statistically significant difference was observed between the 3 groups in terms of the long-term primary patency rates. Therefore, angioplasty should be considered first to treat PV stenosis in pediatric LT recipients.

Abstract No. 645 - Long-term outcomes of percutaneous transhepatic balloon angioplasty with stent deployment for portal vein stenosis after liver transplantation

Abstract No. 645 - Long-term outcomes of percutaneous transhepatic balloon angioplasty with stent deployment for portal vein stenosis after liver transplantation

Long-Term Outcome of Percutaneous Transhepatic Balloon Angioplasty for Portal Vein Stenosis after Pediatric Living Donor Liver Transplantation: A Single Institute’s Experience

PurposeTo evaluate retrospectively the long-term outcomes of percutaneous transhepatic balloon angioplasty performed for portal vein stenosis (PVS) after pediatric living donor liver transplantation (LDLT). Materials and MethodsBetween October 1997 and December 2013, of 527 pediatric patients (age < 18 y) who underwent LDLT in a single institution, 43 patients (19 boys, 24 girls; mean age, 4.1 y ± 4.1) were confirmed to have PVS at direct portography with or without manometry and underwent percutaneous interventions, including balloon angioplasty with or without stent placement. Technical success, clinical success, laboratory findings, manometry findings, patency rates, and major complications were evaluated. Follow-up periods after initial balloon angioplasty ranged from 5–169 months (mean, 119 mo). ResultsTechnical success was achieved in 65 of 66 sessions (98.5%) and in 42 of 43 patients (97.7%), and clinical success was achieved in 37 of 43 patients (86.0%). Platelet counts improved significantly. Of 32 patients undergoing manometry, 19 showed significant improvement of pressure gradient across the stenosis after percutaneous transhepatic balloon angioplasty. At 1, 3, 5, and 10 years after balloon angioplasty, the rates of primary patency were 83%, 78%, 76%, and 70%, and the rates of primary-assisted patency were 100%, 100%, 100%, and 96%. Two major complications subsequent to balloon angioplasty were noted: severe asthma attack and portal vein thrombosis. ConclusionsPercutaneous transhepatic balloon angioplasty is a safe and effective treatment with long-term patency for PVS after pediatric LDLT.

Treatment of postoperative main portal vein and superior mesenteric vein thrombosis with balloon angioplasty and/or stent placement

Thrombolysis and mechanical thrombectomy have been used to treat postoperative main portal vein and superior mesenteric vein thrombosis. To evaluate the safety and efficacy of balloon angioplasty and/or stent placement without thrombolysis or thrombectomy for treating such thromboses. Fourteen patients with postoperative main portal vein or superior mesenteric vein thrombosis underwent percutaneous transhepatic balloon angioplasty and/or stent placement without thrombolysis or thrombectomy. The rates of technical and clinical success, major complications, and recurrence were evaluated retrospectively. Initial technical success was achieved in 13 of the 14 patients (93%). After the procedures, these 13 patients showed brisk portal inflow, without a significant amount of residual thrombus in the stented lumen or embolism. One patient was considered to be a technical failure despite showing a brisk portal inflow because 50% stenosis and partial residual thrombus remained in the stented lumen. Initial clinical success was achieved in 13 patients. One patient with technical success died of acute respiratory distress syndrome 8 days after the procedure, whereas one patient with technical failure achieved clinical success. One patient experienced acute rethrombosis 8 days after the procedure. During the median follow-up period of 16.3 months, rethrombosis occurred in six patients (43%), including one patient with acute rethrombosis. Balloon angioplasty and/or stent placement without thrombolysis or thrombectomy may be a safe and effective treatment modality for postoperative main portal vein and superior mesenteric vein thrombosis.

Outcome of Percutaneous Transhepatic Balloon Angioplasty ( PTBA ) with Stenting in Egyptian Patients with Budd - Chiari Syndrome

Outcome of Percutaneous Transhepatic Balloon Angioplasty ( PTBA ) with Stenting in Egyptian Patients with Budd - Chiari Syndrome

Feasibility and midterm outcomes of percutaneous transhepatic balloon angioplasty for symptomatic Budd-Chiari syndrome secondary to hepatic venous obstruction

This study evaluated the feasibility and outcomes of percutaneous transhepatic balloon angioplasty (PTBA) of the hepatic vein in the management of Budd-Chiari syndrome (BCS) secondary to hepatic venous outflow obstruction. From September 1996 to October 2008, 101 patients (52 males, 49 females) with BCS secondary to occlusion of the hepatic veins were prospectively treated using PTBA of the hepatic vein. Average age was 31.3 years (range, 15-57 years). Nineteen had concurrent inferior vena cava (IVC) obstruction. All the patients presented with symptomatic portal hypertension. PTBA, with or without stenting, was performed after hepatovenography. PTBA was successfully performed in 92 of the 101 patients. Sixty-eight patients underwent PTBA of right hepatic vein, followed by stent placement in two. PTBA was performed in 11 patients with left hepatic vein occlusion and in 13 patients with dominant accessory hepatic vein occlusion. The technical success rate was 92 of 101 (91%). Hepatic venous pressure was significantly decreased after balloon angioplasty/stenting (P < .01, paired t test). Symptoms were significantly improved in the 92 patients who had successful PTBA. Three patients had acute hepatic vein thrombosis during or after PTBA. Two patients sustained intraperitoneal bleeding from the transhepatic puncture track, and one had intrahepatic hematoma. Pulmonary embolism developed in one patient during the operation. All complications were managed nonoperatively. There were no perioperative deaths. Within 1 year, 74 of the 101 patients returned for follow-up, and 51 patients had follow-up at 2 years. The primary patency rates were 84% (62 of 74), 78% (58 of 74), and 76% (39 or 51) at 6, 12, and 24 months after PTBA, respectively. The secondary patency rates were 95% (70 of 74), 92% (68 of 74), and 84% (43 of 51) at 6, 12, and 24 months. PTBA of the hepatic vein is a safe and effective treatment of BCS. It is currently the most physiologic procedure, and the risk of postoperative encephalopathy is minimized because portal flow is not diverted. Midterm outcomes are satisfactory. Further investigation of the long-term outcomes is needed.

Percutaneous Angioplasty of Portal Vein Stenosis that Complicates Liver Transplantation: The Mid-Term Therapeutic Results

ObjectiveWe wanted to valuate the mid-term therapeutic results of percutaneous transhepatic balloon angioplasty for portal vein stenosis after liver transplantation.Materials and MethodsFrom May 1996 to Feb 2005, 420 patients underwent liver transplantation. Percutaneous transhepatic angioplasty of the portal vein was attempted in six patients. The patients presented with the clinical signs and symptoms of portal venous hypertension or they were identified by surveillance doppler ultrasonography. The preangioplasty and postangioplasty pressure gradients were recorded. The therapeutic results were monitored by the follow up of the clinical symptoms, the laboratory values, CT and ultrasonography.ResultsThe overall technical success rate was 100%. The clinical success rate was 83% (5/6). A total of eight sessions of balloon angioplasty were performed in six patients. The mean pressure gradient decreased from 14.5 mmHg to 2.8 mmHg before and after treatment, respectively. The follow up periods ranged from three months to 64 months (mean period; 32 months). Portal venous patency was maintained in all six patients until the final follow up. Combined hepatic venous stenosis was seen in one patient who was treated with stent placement. One patient showed puncture tract bleeding, and this patient was treated with coil embolization of the right portal puncture tract via the left transhepatic portal venous approach.ConclusionPercutaneous transhepatic balloon angioplasty is an effective treatment for the portal vein stenosis that occurs after liver transplantation, and our results showed good mid-term patency with using this technique.

THE ROLE OF BILIARY PERCUTANEOUS TRANSHEPATIC ANGIOPLASTY IN THE MANAGEMENT OF BILIARY STRICTURES FOLLOWING LIVER TRANSPLANTATION

139 This study evaluated the efficacy of a protocol of balloon dilation for biliary strictures following liver transplantation. The outcome parameter measured was biliary drainage tube independence. Methods: Complete records from 96 patients with biliary strictures were retrospectively reviewed. Strictures were classified by location in the biliary tree, and by whether single or multiple. Follow-up ranged from 6 months to 7 years. All patients were initially evaluated for biliary percutaneous transhepatic angioplasty (BPTA). Three dilations were performed four to eight weeks apart in a majority of cases. Groups were compared using Student's t test and Fisher's exact test. Results: One hundred three strictures were identified in 96 patients. BPTA was attempted in 80 cases, with three technical failures. BPTA successfully treated strictures in 38 of the remaining 77 cases (48.6%), resulting in tube independence in 36. In 23 cases, no BPTA was performed; 12 strictures resolved spontaneously and 2 were surgically revised. Factors favoring successful BPTA included older age at transplant (43 ± 17 vs. 32 ± 19, p<0.01), shorter cold ischemic time (10.6 ± 2.5 hours vs. 12.2 ± 3.6 hours, p<0.03), and single strictures (61% success vs. 36%, p<0.05). BPTA was successful in only 5/17 attempts in pediatric patients (29%) vs. 33/60 in adult patients (55%, p=0.09). There was no association between BPTA success and stricture location (intra vs extrahepatic), gender, warm ischemic time, intraoperative blood loss, bile leak, type of reconstruction (duct-duct vs Roux), acute or chronic rejection, vascular complications, or bile duct stones. There were five recurrent strictures, all of which were successfully treated by BPTA. Of the 39 BPTA failures, 15 underwent subsequent surgical revision. Twelve of the patients undergoing revision had single common duct or anastomotic strictures. When both angiographic and surgical modalities were considered, ultimate tube independence was associated with less cold ischemic time (13.3 ± 3.4 hours vs. 10.5 ± 2.7 hours, p<0.002), shorter operative time (7.4 ± 2.1 hours vs. 8.7 ± 2.2 hours, p<0.05), and less intraoperative transfusion (10.1 ± 6.4 units PRBC vs. 14.8 ± 9.7, p<0.02). Other significant risk factors are shown. (Table)TableTwo strictures recurred following surgical revision, one of which was treated successfully by BPTA. Utilizing this combined approach, tube independence was achieved in 51 of 77 patients (66%). Conclusions: Biliary percutaneous transhepatic balloon angioplasty is an effective initial modality for treating post-transplant biliary strictures. Prolonged cold ischemic and operative times, young patient age, stones, and multiple or peripheral strictures predispose to treatment failure. Solitary extrahepatic strictures that fail BPTA are salvageable with subsequent surgical revision

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.