Transhepatic Catheter Research Articles

Human AAT gene transfer to pig liver improved by using a perfusion isolated organ endovascular procedure.

The efficiency of endovascular liver gene transfer in pigs is evaluated by comparing two models of retrograde catheterization: single lobe catheterization with portal inflow (open procedure) versus whole liver isolation with portal and inferior vena cava blockage (close procedure). Percutaneous endovascular catheterization was performed in pigs. Open procedure (n = 3): 8Fr balloon catheter placement in a suprahepatic branch through the jugular vein. Closed procedure (n = 3): simultaneous catheterization of the intrahepatic portal vein (transhepatic catheterization, 10Fr balloon catheter), the supra- and infrahepatic cava veins (8Fr balloon catheters through the jugular and femoral veins). In both models, 200 ml of hAAT DNA solution (20 μg/ml) were retrogradely injected at 20 ml/s. Tissue samples (8 per liver) were obtained 14 days later and the exogenous DNA, RNA and protein per cell were quantified. Blood samples were collected periodically for transaminase determination in all the animals. The open procedure achieved lower (approx. 1000-fold) DNA delivery, resulting in a significantly lower (p < 0.001) gene transcription (> 100-fold). The closed model also achieved a higher translation index, although differences were smaller (p < 0.001). Portal inflow blockage increased the delivery, transcription and translation indexes, significantly improving the final procedure efficacy when compared with an open procedure. Endovascular hydrodynamic pig liver gene transfer: open procedure versus closed procedure. Open procedure resulted in much lower DNA delivery than closed model. Open procedure reached significantly lower gene transcription index. Translation index with closed model was higher than with the open.

Analysis of different ways of drainage for obstructive jaundice caused by hilar cholangiocarcinoma.

To evaluate the prognosis of different ways of drainage for patients with obstructive jaundice caused by hilar cholangiocarcinoma. During the period of January 2006- March 2012, percutaneous transhepatic catheter drainage (PTCD)/ percutaneous transhepatic biliary stenting (PTBS) were performed for 89 patients. According to percutaneous transhepatic cholangiography (PTC), external drainage was selected if the region of obstruction could not be passed by guide wire or a metallic stent was inserted if it could. External drainage was the first choice if infection was diagnosed before the procedure, and a metallic stent was inserted in one week after the infection was under control. Selection by new infections, the degree of bilirubin decrease, the change of ALT, the time of recurrence of obstruction, and the survival time of patients as the parameters was conducted to evaluate the methods of different interventional treatments regarding prognosis of patients with hilar obstruction caused by hilar cholangiocarcinoma. PTCD was conducted in 6 patients and PTBS in 7 (p<0.05). Reduction of bilirubin levels and ALT levels was obvious after the procedures (p<0.05). The average survival time with PTCD was 161 days and with PTBS was 243 days (p<0.05). With both drainage procedures for obstructive jaundice caused by hilar cholangiocarcinoma improvement in liver function was obvious. PTBS was found to be better than PTCD for prolonging the patient survival.

Complex central venous catheter insertion for hemodialysis.

Despite the introduction of payment by results in the UK, there has been no decrease in central venous catheter (CVC) use. In part, this may relate to a requirement to dialyse through a CVC while autogenous access matures. Mortality data have improved in parallel and patients on hemodialysis live longer, which may lead to an increased exposure to CVCs.Exposure to CVCs carries a significant risk of infection and occlusion requiring their repositioning or exchange. The mid to long-term sequelae of CVC use is central venous occlusion leaving clinical teams with an ever increasing challenge to find adequate venous access.In this article, we will discuss the challenges faced by operators inserting CVCs into the hemodialysis-dependent patient who has exhausted more tradition insertion sites. These include translumbar caval catheters, transocclusion and transcollateral catheters, transjugular Inferior Vena Cava catheter positioning, and transhepatic catheters. We will demonstrate the techniques employed, complications, and anticipated longevity of function.

Drainage Alone or Combined with Anti-tumor Therapy for Treatment of Obstructive Jaundice Caused by Recurrence and Metastasis after Primary Tumor Resection

To compare drainage alone or combined with anti-tumor therapy for treatment of obstructive jaundice caused by recurrence and metastasis after primary tumor resection. We collect 42 patients with obstructive jaundice caused by recurrence and metastasis after tumor resection from January 2008 - August 2012, for which percutaneous transhepatic catheter drainage (pTCD)/ percutaneous transhepatic biliary stenting (pTBS) were performed. In 25 patients drainage was combined with anti-tumor treatment, antineoplastic therapy including intra/postprodure local treatment and postoperative systemic chemotherapy, the other 17 undergoing drainage only. We assessed the two kinds of treatment with regard to patient prognosis. Both treatments demonstrated good effects in reducing bilirubin levels in the short term and promoting liver function. The time to reobstruction was 125 days in the combined group and 89 days in the drainage only group; the mean survival times were 185 and 128 days, the differences being significant. Interventional drainage in the treatment of the obstructive jaundice caused by recurrence and metastasis after tumor resection can decrease bilirubin level quickly in a short term and promote the liver function recovery. Combined treatment prolongs the survival time and period before reobstruction as compared to drainage only.

Transhepatic venous catheters for hemodialysis

PurposeTo describe our experience with the technique of transhepatic venous access for hemodialysis and to evaluate its functionality and complications. Patients and methodsFrom March 2012 till October 2012, 23 patients with age ranging from 12 to 71years old having end-stage renal disease (ESRD) were included in our study and were subjected to transhepatic venous catheter insertion. In 21 patients there were not any remaining patent peripheral venous accesses. In 2 patients there were only a last one venous access needed to be preserved. Thus, it was decided to make THVA. In all the 23 patients the indication was palliative due to inoperability which was because of inability to insert an arterio-venous graft or making another arterio-venous fistula. Complications were evaluated and calculated in terms of number of procedures, infection, dislodgement and outcome; in terms of disfunctionality of the catheter.Follow-up was performed by monitoring the catheter dialysis rate in each session, abdominal ultrasonography, fluoroscopy or CT. Mean survival time and median survival time from the start of treatment were calculated using Kaplan–Meier method. ResultsTwenty-three patients required a single transhepatic access procedure. Because of catheter dislodgment, two patients required a second access placement procedure, which resulted in a total of 25 separate transhepatic access sites in 23 patients. Technical success was achieved in 22 procedures. Functionality success was achieved in 20 patients. Functionality failure occurred in 3 patients.The trans-hepatic catheters stayed in place between 90 and 300days. Complications occurred in 14 patients. ConclusionBased on our findings, transhepatic hemodialysis catheters have proven to achieve good long-term functionality. A high level of maintenance is required to preserve patency, although this approach provides remarkably durable access for patients who have otherwise exhausted access options.

Ray-casting based evaluation framework for haptic force feedback during percutaneous transhepatic catheter drainage punctures

Development of new needle insertion force feedback algorithms requires comparison with a gold standard method. A new evaluation framework was formulated and tested on needle punctures for percutaneous transhepatic catheter drainage (PTCD). Needle insertion is an established procedure for minimally invasive interventions in the liver. Up-to-date, needle insertions are precisely planned using 2D axial CT slices from 3D data sets. To provide a 3D virtual reality and haptic training and planning environment, the full segmentation of patient data is often a mandatory step. To lessen the time required for manual segmentation, we propose direct haptic volume-rendering based on CT gray values and partially segmented patient data. The core contribution is a new force output evaluation method driven by a ray-casting technique that defines paths from the skin to target structures, i.e., the right hepatic duct near the juncture with the common hepatic duct. A ray-casting method computes insertion trajectories from the skin to the duct considering no-go structures and plausibility criteria. A rating system scores each trajectory. Finally, the best insertion trajectories are selected that reach the target. Along the selected paths, force output comparison between a reference system and the new haptic force output algorithm is carried out, quantified and visualized. The evaluation framework is presented along with an exemplary study of the liver using the atlas data set from a reference patient. In a comparison of our reference method to a newer algorithm, force outputs are found to be similar in 99% of the paths. The proposed evaluation framework allows reliable detection of problematic PTCD trajectories and provides valuable hints to improve force feedback algorithm development.

Radiation Exposure in Biliary Procedures Performed to Manage Anastomotic Strictures in Pediatric Liver Transplant Recipients: Comparison Between Radiation Exposure Levels Using an Image Intensifier and a Flat-Panel Detector-Based System

The aim of this study was to estimate radiation exposure in pediatric liver transplants recipients who underwent biliary interventional procedures and to compare radiation exposure levels between biliary interventional procedures performed using an image intensifier-based angiographic system (IIDS) and a flat panel detector-based interventional system (FPDS). We enrolled 34 consecutive pediatric liver transplant recipients with biliary strictures between January 2008 and March 2013 with a total of 170 image-guided procedures. The dose-area product (DAP) and fluoroscopy time was recorded for each procedure. The mean age was 61 months (range 4-192), and mean weight was 17 kg (range 4-41). The procedures were classified into three categories: percutaneous transhepatic cholangiography and biliary catheter placement (n = 40); cholangiography and balloon dilatation (n = 55); and cholangiography and biliary catheter change or removal (n = 75). Ninety-two procedures were performed using an IIDS. Seventy-eight procedures performed after July 2010 were performed using an FPDS. The difference in DAP between the two angiographic systems was compared using Wilcoxon rank-sum test and a multiple linear regression model. Mean DAP in the three categories was significantly greater in the group of procedures performed using the IIDS compared with those performed using the FPDS. Statistical analysis showed a p value = 0.001 for the PTBD group, p = 0.0002 for the cholangiogram and balloon dilatation group, and p = 0.00001 for the group with cholangiogram and biliary catheter change or removal. In our selected cohort of patients, the use of an FPDS decreases radiation exposure.

Metastasis to the skin at the drain site after complete resection of the lower bile duct cancer: report of a case

There are extremely few reports of metastases from a lower cholangiocarcinoma to the skin except for metastatic seeding in a percutaneous transhepatic biliary drainage catheter tract. This report presents a rare case of metastases to the skin after the removal of a drain following curative pancreaticoduodenectomy for lower bile duct cancer (LBDC). A 73-year-old female had undergone subtotal stomach-preserving pancreaticoduodenectomy. Skin metastasis was noted at the site where the drain from the lower border at pancreaticojejunostomy had been removed 22 weeks postoperatively, and it was en bloc resected with the abdominal wall without exposing the carcinoma. Multiple nodules were confirmed in the axilla and chest wall 40 weeks after the initial operation. Careful discussion is necessary to avoid this mode of metastasis. The surgical field should not be exposed to pancreatic juice, even with LBDC. Nevertheless, this case is rare. Therefore, the risks and benefits of using such drains must be considered.

A Cyclic Guanosine Monophosphate–Dependent Pathway Can Regulate Net Hepatic Glucose Uptake in Vivo

We previously showed that hepatic nitric oxide regulates net hepatic glucose uptake (NHGU), an effect that can be eliminated by inhibiting hepatic soluble guanylate cyclase (sGC), suggesting that the sGC pathway is involved in the regulation of NHGU. The aim of the current study was to determine whether hepatic cyclic guanosine monophosphate (cGMP) reduces NHGU. Studies were performed on conscious dogs with transhepatic catheters. A hyperglycemic-hyperinsulinemic clamp was established in the presence of portal vein glucose infusion. 8-Br-cGMP (50 µg/kg/min) was delivered intraportally, and either the glucose load to the liver (CGMP/GLC; n = 5) or the glucose concentration entering the liver (CGMP/GCC; n = 5) was clamped at 2× basal. In the control group, saline was given intraportally (SAL; n = 10), and the hepatic glucose concentration and load were doubled. 8-Br-cGMP increased portal blood flow, necessitating the two approaches to glucose clamping in the cGMP groups. NHGU (mg/kg/min) was 5.8 ± 0.5, 2.7 ± 0.5, and 4.8 ± 0.3, whereas the fractional extraction of glucose was 11.0 ± 1, 5.5 ± 1, and 8.5 ± 1% during the last hour of the study in SAL, CGMP/GLC, and CGMP/GCC, respectively. The reduction of NHGU in response to 8-Br-cGMP was associated with increased AMP-activated protein kinase phosphorylation. These data indicate that changes in liver cGMP can regulate NHGU under postprandial conditions.

A Catheter-Based Suture-Free Approach to Bilioenteric Anastomosis

Bilioenteric anastomoses are commonly performed during liver transplantation, reconstruction following tumor resection, and repair of bile duct injury. Ischemia plays an important role in both short- and long-term complications related to biliary anastomoses. The authors describe a catheter-based, suture-free approach to bilioenteric anastomosis that aims to reduce or eliminate tissue trauma and foreign material that contribute to anastomotic ischemia. The device uses a novel "umbrella" anchoring mechanism to approximate bowel to the transected bile duct over a percutaneously placed transhepatic catheter. The authors performed an open choledochojejunostomy using the device in 7 pigs. The anastomosis was assessed with cholangiography, gross inspection, and histology at the time of necropsy. The procedure was well tolerated, with no evidence of anastomotic leak in any of the study animals. This alternative catheter-based approach to bilioenteric anastomoses is safe and effective, offers potential advantages over traditional approaches, and can be easily adapted to a minimal access surgery.

Endovascular Salvage of a Right Brachial Artery-Right Atrium Hemodialysis Graft Using a Covered Endoprosthesis

Creation of a functional hemodialysis access in patients with exhausted peripheral access sites and concomitant central venous occlusive disease (CVOD) is a multifaceted challenge; often requiring complex, innovative solutions, not without their own complications. We present a 57-year-old hemodialysis patient with a history of hypercoagulable disorder and multiple failed arteriovenous accesses. Because of inadequate peripheral access sites and chronic occlusions in superior vena cava, brachiocephalic veins and inferior vena cava, in addition to multiple transhepatic catheter related issues; we decided to perform a right brachial artery to right atrium (RA) hemodialysis graft. The access was used without complications for 18 months at which point he had his first episode of thrombosis; open thrombectomy and percutaneous balloon angioplasty (PTA) at the atrial anastomosis were done with success. The following three months, he endured two more thrombectomies and PTAs. During the last intervention we performed an intravascular Ultrasound (IVUS) through the atrial anastomosis, which demonstrated stenosis; and the decision was made to extend the outflow anastomosis with a covered stent into the atrium. Therefore a 10 cm x 10 mm Viabahn stent-graft (W. L. Gore and Associates, Flagstaff, Ariz.) was deployed and post dilated with 8 mm balloon within the graft component. Repeat injection and Intravascular Ultrasound (IVUS) demonstrated significant improvement and free outflow. The brachial-RA hemodialysis graft could be use immediately and at 5 months has remained fully functional and no reinterventions have been necessary.

Catheter-Free Survival After Primary Percutaneous Stenting of Malignant Bile Duct Obstruction

The purpose of this article is to review the outcomes of patients with malignant biliary obstruction treated by immediate placement of a metallic stent at the time of percutaneous biliary drainage. By a search of our PACS, we retrospectively identified all patients who underwent biliary stent placement at our interventional radiology section between January 2003 and December 2008. Of 564 biliary stent procedures, 71 primary percutaneous stents were placed at the time of biliary drainage; the other 493 were secondary percutaneous stents, placed at various durations after biliary drainage. Medical records and procedure reports were reviewed for the primary percutaneous stent group recording time to removal of the percutaneous catheter, periprocedural complications, subsequent biliary interventions, overall survival, and catheter-free survival. After placement of primary percutaneous stents, 97% of patients were able to have their transhepatic catheter removed, and in 73% of patients, this 5-French catheter was removed within 24 hours. Major complications after placement of primary percutaneous stents included bile peritonitis requiring IV analgesia for less than 48 hours (5.6%) and fever with leukocytosis treated with IV antibiotics (8.5%) for 48-72 hours. Median overall survival was 165 days, and 90% of patients had 100% catheter-free survival. Overall, 94% of survival days were catheter free. Placement of primary percutaneous stents when clinically appropriate has the advantage of avoiding an externalized drainage catheter and its attendant lifestyle limitations and complications. Most patients with malignant biliary obstruction, for whom expected survival is short, will experience 100% catheter-free survival after placement of a primary percutaneous stent.

Intrapleural Migration of a Percutaneous Transhepatic Hemodialysis Catheter

Percutaneous transhepatic catheters are a form of nonconventional access for patients requiring hemodialysis. We report a complication of these catheters which has not been previously described in the literature. The mechanism for intrapleural migration and a way to avoid this potential complication are discussed.

Abstract No. 47: Percutaneous transhepatic tunneled catheter for long term venous access in children with short gut syndrome

Retrospective review of trans-hepatic catheters placed in children with short gut syndrome in our institution in the past two years. Three males and one female (age 2–12 years, mean 6.75 years) with short gut syndrome and poor venous access had 22 trans-hepatic catheters for TPN (7 new trans-hepatic placements, 12 over the wire exchanges, three replacements through the tract. The success rate and complications of trans-hepatic catheter placement were assessed. Trans-hepatic catheters were placed through right (n=4) or middle hepatic vein (n=2) in right upper quadrant. Left hepatic vein was used in one patient who developed collection around the right lobe of liver. All patients had successful placement, replacement through existing tract or exchange of catheters. The primary functionality of trans-hepatic catheter was 50.4 days and secondary functional rate was 24.93 days. Catheter related infection was the cause of over the wire exchange in 7 instances, and malfunction in 5 instances. The infection rate was 9.6/1000 catheter days and malfunction rate was 20.63/1000 catheter days. One of the patients had three episodes of fungemia in the catheters placed in Right hepatic vein approach n=1, left hepatic vein approach n=1 which was successfully managed with antifungal and over the wire exchanges. Complications associated with trans-hepatic catheter placement included transperitoneal migration of the catheter leading inadvertent spillage and collection of TPN into peritoneal cavity (n=1) which was managed by collection drainage and placement of new left sided transhepatic catheter. Seroma in subcutaneous tissues (n=1) was noted in one patient. Transhepatic central venous catheter can be placed with a high success rate. However catheter related infection rate is high and mechanical problems like clogging, dislodgement rates are high. Replacement of the catheter through existing mature tract is possible without complications. Catheter migration into peritoneum can occur. In patients with fungemia successful exchange of catheter over the wire can be performed after treatment with antifungal agents.

Percutaneous transhepatic biliary drainage catheter tract recurrence in cholangiocarcinoma (Br J Surg 2010; 97: 1860–1866)

Percutaneous transhepatic biliary drainage catheter tract recurrence in cholangiocarcinoma (<i>Br J Surg</i> 2010; 97: 1860–1866)

Authors' reply: Percutaneous transhepatic biliary drainage catheter tract recurrence in cholangiocarcinoma (Br J Surg 2010; 97: 1860–1866)

Authors' reply: Percutaneous transhepatic biliary drainage catheter tract recurrence in cholangiocarcinoma (<i>Br J Surg</i> 2010; 97: 1860–1866)

Transhepatic Hemodialysis Catheters: Functional Outcome and Comparison Between Early and Late Failure

Purpose To describe the authors' experience with transhepatic placement of catheters, highlighting early and late complications, and to determine if this procedure is a viable option in patients in whom central venous occlusions present a significant challenge. Materials and Methods The records of all the patients who underwent placement of transhepatic hemodialysis from January 2003 to October 2008 were retrospectively reviewed. Selected patients were dialysis-dependent, having undergone multiple access procedures and revisions. Kaplan-Meier analysis was used to estimate primary and secondary patency. Results Twenty-two patients (mean age 42 years, range 22–70 years, 59% women) underwent a total of 127 transhepatic catheter placements at 24 transhepatic access sites; technical success was achieved in all cases. There were no hepatic injuries (bleeding or fistula formation). There were 105 exchanges in 14 patients, with a mean of 7.5 exchanges, a median of 5 exchanges (range 1–18 exchanges), and a catheter migration rate of 0.39 per 100 catheter-days. The sepsis rate was 0.22 per 100 catheter-days, and the catheter thrombosis rate was 0.18 per 100 catheter-days. The mean cumulative catheter duration in situ was 506.2 days, and the mean time catheter in situ was 87.7 days. The mean total access site interval was 1,046 catheter-days (range of 423–1,413 catheter-days). Conclusions Transhepatic hemodialysis catheter placement is associated with low rates of morbidity. In this series, transhepatic catheters provided the possibility of long-term functionality, despite associated high rates of catheter-related maintenance, provides a potentially viable access for patients with exhausted access options.

Transhepatic Hemodialysis Catheters: Functional Outcome and Comparison Between Early and Late Failure

Transhepatic Hemodialysis Catheters: Functional Outcome and Comparison Between Early and Late Failure

Multiple Hemodialysis Access Failures Due to Recurrent Thrombosis in a Patient with Antiphospholipid Antibody Syndrome

Introduction: The most common complication of permanent hemodialysis (HD) vascular access is thrombosis, with some cases being related to a hypercoagulable state. Antiphospholipid antibody syndrome (APAS) is a cause of increased thrombotic tendency, and this may complicate the management of such patients on HD. Case report: We describe a 48-year-old man with end stage renal disease (ESRD) of undetermined cause who was referred to our tertiary care center for urgent renal transplantation. He was maintained on regular HD, but his dialysis care was complicated by recurrent vascular access thrombosis to the extent that no further access site was available for his routine renal replacement treatment. A thorough thrombophilia screen confirmed the presence of antiphospholipid antibodies. A diagnosis of APAS was made and he was anticoagulated with warfarin. A transhepatic dialysis catheter was inserted and HD was resumed, but this was complicated by a large intra-abdominal hematoma. His anticoagulation was reversed and he improved, but his transhepatic catheter got clotted. This catheter was removed and a translumbar dialysis catheter was inserted as a last resort. Within a week of his arrival to our hospital, he recieved a kidney transplant. Graft function was delayed, but eventually improved, though he has never regained normal renal function. Conclusion: The presence of APAS can complicate HD management by causing recurrent vascular access thrombosis and failure, and nephrologists must remain alert to this possibility. Anticoagulation management of these patients must be handled with extra care to avoid bleeding complications.

A case of ascariasis in the gallbladder successfully treated with an anthelmintic injection into the gallbladder via a percutaneous transhepatic catheter

A case of ascariasis in the gallbladder successfully treated with an anthelmintic injection into the gallbladder via a percutaneous transhepatic catheter