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Purpose To retrospectively review the indications and outcomes of transjugular liver biopsy (TJLB) with the left internal jugular vein (IJV) approach. Materials and methods A retrospective review of all TJLBs performed at one institution was performed. From August 1995 to October 2004, 293 liver biopsies were performed. Nineteen of the 293 procedures (6.5%) were performed from the left IJV in 17 patients. There were 11 men and six women aged 36–59 years (mean, 49.3 years). All patients were suspected of having diffuse hepatic parenchymal disease and had contraindications to conventional percutaneous liver biopsy. The stiff metal biopsy cannula was advanced across the mediastinum and through the heart over a stiff guide wire. Biopsy was performed from the right hepatic vein in 15 procedures, the middle hepatic vein in two, and the intrahepatic IVC in two. Results The indications for using the left IJV approach were nonusable right IJV in 12 procedures, difficult previous catheterization of the hepatic veins from the right IJV due to distorted hepatic anatomy in six procedures, and the operator’s predilection for this approach in one procedure (the patient had previously undergone liver transplantation). All biopsies were successful, with diagnostic tissue obtained in 100% of cases. Two patients had chest pain during the procedure associated with placement of the rigid cannula through the mediastinal veins. One patient had a vaso-vagal episode that necessitated the use of intravenous atropine but subsequently underwent successful biopsy. All episodes of chest pain resolved after the cannula was removed. There were no recorded hemorrhagic or cardiac complications. Conclusion TJLB can be safely and repeatedly performed from the left IJV when the right IJV is not available or the hepatic anatomy prevents catheterization of the hepatic veins from the right IJV.

Proper positioning of inferior vena cava (IVC) filters is necessary for effective protection from pulmonary embolism (PE). This report describes a case of an IVC filter malpositioned partially in the right common iliac vein that resulted in risk of recurrent PE caused by thrombus emanating from the left common iliac vein. A new filter was placed in the IVC above the first device, followed by retrieval of the malpositioned filter through the new filter.

Purpose To prospectively evaluate the clinical efficacy of silicone-covered Gianturco-Rosch self-expandable Z (GRZ) stents in the treatment of malignant esophageal obstruction. Patients and Methods GRZ stents were placed in 52 patients (39 men, 13 women) with severe dysphagia due to high-grade malignant esophageal obstruction. Results Stent placement was technically successful, and immediate relief of dysphagia was achieved in 50 of 52 patients (96%), with long-term relief in 47 patients (90%). Fifty-one patients (98%) died during follow-up (range, 1 week to 33 months; mean, 4.3 months). Late complications were most prevalent and included stent migration ( n = 5), food impaction ( n = 2), chest pain ( n = 2), membrane disruption with tumor ingrowth ( n = 1), granulomatous reaction above the stent ( n = 1), esophageal perforation with mediastinitis ( n = 1), and upper gastrointestinal hemorrhage ( n = 4). Twelve complications were easily managed with medical, endoscopic, or radiologic intervention. Four deaths may have been related to stent placement (early mortality rate, 7.7%). Conclusion GRZ stents provide relatively safe and effective long-term palliation in patients with severe, malignant esophageal obstruction.

Purpose To prospectively evaluate the clinical efficacy of covered metallic Z stents in the treatment of esophagorespiratory fistulas (ERFs). Patients and Methods Twelve patients with severe aspiration symptoms from malignant ERFs were treated with silicone-covered, metallic, self-expanding Gianturco-Rosch Z (GRZ) stents. Results Fluoroscopically guided stent placement was successful and well tolerated in all patients. Immediate postprocedural endos-copy and esophagography showed excellent coverage of the fistulas in all cases. Aspiration symptoms were completely relieved in eight of 12 patients (67%). Four of 12 patients (33%) were improved and able to eat a soft diet. There were no stent-related deaths. Nine patients have died and three patients are alive. Mean follow-up for the entire group was 3.9 months (range, 1 week to 10.5 months). Nonfatal complications occurred in three of 12 patients (25%). Complications included one membrane disruption and one granulomatous reaction with a slight upward stent migration. Conclusion GRZ stents are an effective and safe means of palliation in patients with malignant esophagorespiratory fistulas.

P R O P E R entry into a large intrahepatic portal venous branch is the crucial part of successfully performing a transjugular intrahepatic portosystemic shunt (TIPS) procedure. The Brockenbrough or modified Ross transseptal needle, the Colapinto transjugular biopsy needle, and micropuncture coaxial needle have been used for liver puncture (1-4). In 1986, after traumatic experience with the modified Ross needle in experimental work, we designed a coaxial catheter-needle for an "atraumatic" transjugular portal vein entry in swine (5). We modified this set for clinical use in performing TIPS and describe our experience with it in 50 patients.

In an effort to more effectively use critical care facilities and to reduce costs, during a 2 1/2-year period, the condition of 32 patients who received 37 local intraarterial urokinase (UK) infusions was monitored in a non-intensive care unit (ICU) setting. Techniques of infusion, mean total dose of lytic agent used (1.7 million IU), and mean duration of infusion (22 hours) were similar to those reported previously in series of patients monitored in the ICU. Complete lysis (no angiographically detectable residual clot within the treated segment) was achieved in 28 of 37 infusions (76%). Major complications occurred during two infusions (5.4%). In 33 of the 37 cases, systemic heparin was administered during UK infusion. No cases of pericatheter thrombosis were encountered. At the authors' institution, patients can be safely monitored during local UK infusion in a non-ICU setting without compromising effectiveness of therapy. This approach has resulted in enhanced cost-effectiveness of thrombolytic therapy and more effective use of critical care facilities.