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Owing to improvements in surgical techniques and medical care, living-donor liver transplantation has become an established treatment modality in patients with end-stage liver disease. However, various vascular or non-vascular complications may occur during or after transplantation. Herein, we review how interventional radiologic techniques can be used to treat these complications.

Background More than 400 liver transplants were performed at Asan Medical Center (AMC) in 2011, and over 500 liver transplants including 420 living-donor liver transplants (LDLTs) were performed in 2019. Herein, we report the methodology of these procedures. Methods Since the first adult LDLTs at AMC using the left and right lobes were successfully performed, various innovative techniques and approaches have been developed: modified right lobe, dual graft, donor exchange for ABO incompatibility, expansion of indications and no-touch techniques for hepatocellular carcinoma, intraoperative cine-portogram and additional intervention for large collaterals, management of portal vein thrombosis (PVT) and stenosis, salvage LDLT after major hepatectomy, and timely LDLT for patients with acute-on-chronic liver failure. Results Four hundred twenty LDLTs in 403 adult and 17 pediatric patients and 85 deceased-donor liver transplants in 74 adult and 11 pediatric patients were performed. The number of deceased-donor liver transplants remained constant since 2011, but the number of LDLTs increased steadily. One hundred thirty patients (25.7%) required urgent liver transplantations and 24 patients with acute-on-chronic liver failure underwent LDLT. PVT including grade 1,2,3, and 4 was reported in 91 patients (18.0%), and Yerdel’s grade 2, 3, and 4 PVT was reported in 47 patients (51.6%); all patients with PVT were successfully treated. Adult LDLTs for hepatocellular carcinoma and ABO incompatibility accounted for 52.6% and 24.3% of the cases, respectively. In-hospital mortality in 2019 was 2.97%. Conclusion Continual efforts to overcome challenging problems in LDLT with various innovations and dedication of the team members during the perioperative period to improve patient outcomes were crucial in increasing the number of liver transplantations at Asan Medical Center.

Maintenance of adequate portal inflow is crucial for graft regeneration in adult living donor liver transplantation (ALDLT) to allow the recipients to meet their early metabolic demands. A persistent large spontaneous portosystemic shunt can divert portal flow away from the liver graft, leading to impaired or delayed graft regeneration and subsequent graft failure. The importance of obliterating huge portosystemic shunt during liver transplantation is obvious for successful ALDLT. However, in partial liver graft with a relatively small graft-to-recipient weight ratio (GRWR) (compared with deceased donor whole graft liver transplantation), even the persisting small portosystemic shunt may result in repeated portal flow steal when a liver graft faces increased intrahepatic vascular resistance caused by rejection or graft congestion with hepatic venous outflow stenosis. We present 2 complicated cases of reappearing portal flow steal that were derived from the remaining small portosystemic shunt under the increased vascular resistance of the liver graft, even after interruption of a large portosystemic shunt during ALDLT. Because ALDLT is always a partial liver graft, even when GRWR is over 1%, it is much more vulnerable to hemodynamic changes in portal flow by rejection or graft congestion by hepatic venous outflow obstruction. Therefore, a comprehensive understanding of complex portosystemic shunt and complete reinterruption of reappearing portosystemic shunt, even though small and insignificant, during ALDLT is important for graft salvage procedures before irreversible liver graft damage.

To evaluate the efficacy and safety of transjugular liver biopsy in pediatric patients with left lobe or lateral segment liver transplant. This was a retrospective study of data from 104 transjugular liver biopsies (57 children) using an 18- or 19-G biopsy needle. Transjugular liver biopsy was selected due to coagulopathy and/or ascites in 56 (54%) procedures. The median patient age, body weight, and interval from liver transplantation were 56 months, 16 kg, and 2 months, respectively. Technical success was defined as adequate liver specimens yield determined by the operator at the time of procedure. Complications, the longest length of obtained liver specimens according to needle type, and adequacy for histological diagnosis were analyzed. Biopsy using a biopsy needle was successfully achieved in 103 procedures (99%). In one procedure, liver samples were obtained using biopsy forceps following unsuccessful attempts with a biopsy needle. Major complication occurred in one procedure following biopsies using both a biopsy needle and biopsy forceps. The patient received transfusion to manage decreased blood pressure and hemoglobin levels although post-biopsy venography did not show extravasation. The median longest length of liver specimens using 18-G (n = 63) and 19-G (n = 40) needles were 10 mm (range, 5–20) and 10 mm (range, 5–20), respectively (p = 0.704). Liver specimens were adequate for histological diagnosis in all procedures. Transjugular liver biopsy using a biopsy needle appears to be a safe and effective method to obtain liver specimens for histological diagnosis in pediatric patients with left lobe or lateral segment liver transplant. Level 4, case series.

To compare the safety and efficacy of transjugular liver biopsy (TJLB) using a Quick-Core biopsy needle or a forceps biopsy in patients with liver transplantation (LT) who were suspected of having rejection. From June 2015 to January 2017, 98 TJLBs (60 patients) with the Quick-Core biopsy needle and 95 TJLBs (58 patients) with a forceps biopsy system were attempted in patients with LT suspected of having rejection. Technical success, adequacy for diagnosis, number of biopsy instrument passes, the maximum and mean length of the obtained samples, and the complications were retrospectively analyzed. TJLB was technically successful in all patients. Adequate specimens were obtained in 95.9% of the biopsy needle group and 91.6% in the forceps group (p = 0.246). The mean number of biopsies was 4.8 ± 1.8 in the biopsy needle group and 6.2 ± 1.7 in the forceps group. The mean size of the biopsy sample was 11.1 ± 3.0 mm in the biopsy needle group and 2.5 ± 1.2 mm in the forceps group. Only one minor complication (a subcapsular hematoma) occurred in the biopsy needle group. No major complication was observed in any patient. TJLB using a Quick-Core biopsy needle or forceps can be safely and effectively performed in LT patients. The adequacy of sampling for diagnosis was equivalent between the groups. Level 4, case series

Background Recent studies showed that sequential selective transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE) provided better future liver remnant (FLR) regeneration rate and disease-free survival following surgery compared with PVE alone. The present study aimed to clarify whether preoperative sequential TACE and PVE before right hemihepatectomy can reduce postoperative hepatocellular carcinoma (HCC) recurrence and improve long-term disease-free and overall survival. Methods Recurrence and survival outcomes were retrospectively evaluated in 205 patients with HCC who underwent right hemihepatectomy by a single surgeon from November 1993 to November 2017. Patients were divided into four groups according to the procedure performed before the surgery: sequential TACE and PVE (TACE-PVE), PVE-only, TACE-only, or naive control groups. The baseline patient and tumor characteristics, postoperative outcomes, recurrence-free survival and overall survival were analyzed. Results Baseline patient and tumor characteristics upon diagnosis were similar in all four groups, while sequential TACE and PVE were well tolerated. The TACE-PVE group had a higher mean increase in percentage FLR volume compared with that of the PVE-only group (17.46% ± 6.63% vs. 12.14% ± 5.93%; P = 0.001). The TACE-PVE group had significantly better overall and disease-free survival rates compared with the other groups (both P Conclusions Sequential TACE and PVE prior to surgery can be an effective therapeutic strategy for patients with HCC scheduled for major hepatic resection. The active application of preoperative sequential TACE and PVE for HCC would allow more patients with marginal FLR volume to become candidates for major hepatic resection by promoting compensatory FLR hypertrophy without the deterioration of basal hepatic functional reserve or tumor progression.

To evaluate the effectiveness and safety of transcatheter arterial embolization to control bleeding from the renal capsular artery (RCA).Embolization was performed in 28 patients (14 men; mean age, 49.7 y). Presence and type of previous invasive procedures, initial presentation, and coagulation profile were reviewed. Any preceding abdominal computed tomography (CT) findings were analyzed. Angiographic findings were categorized as active bleeding, suspicious for bleeding, or no bleeding. Technical and clinical success and clinical outcomes were evaluated. Changes in hemoglobin level and transfusion volume of packed red blood cells (pBRCs) before and after embolization were evaluated with the paired t test and Wilcoxon signed-rank test, respectively.Technical and clinical success rates of therapeutic embolization for active bleeding (n = 11) were 90.9% and 80%, respectively. One case of technical failure (5.9%) and 3 cases of postembolization bleeding (18.7%) were noted in the prophylactic embolization group in patients with suspicion of bleeding (n = 13) or no bleeding (n = 4). Transient renal insufficiency occurred in 4 patients (14.3%). The average hemoglobin level and volume of transfused pBRCs changed from 8.1 g/dL to 9.9 g/dL and from 871 mL to 543 mL, respectively (P.05). Extravasation of contrast media or acute hematoma in the right subhepatic or perirenal space on CT was noted in 21 patients (78%).Embolization can provide an effective and safe method to control RCA bleeding. Perirenal invasive procedures and signs of active or recent right subhepatic or perirenal hemorrhage should raise the suspicion of an RCA source.

Purpose To evaluate the feasibility and safety of percutaneous transsplenic portal vein embolization (PVE) before major hepatectomy for patients with insufficient future liver remnant. Materials and Methods From May 2014 to June 2015, 27 transsplenic PVEs were attempted in 26 patients. In 16 patients, transsplenic PVE was indicated because of huge or multiple tumors in the trajectory of the puncture (n = 15) or a high-positioned liver (n = 1), which prevented safe ipsilateral transhepatic access. In the remaining 10 patients, transsplenic access was planned. A perihilar splenic vein was punctured using a 21-gauge Chiba needle under ultrasound and fluoroscopic guidance. Embolization of portal venous branches was performed using gelatin sponge particles followed by application of coils, an AMPLATZER Vascular Plug (AGA Medical Corporation, Golden Valley, Minnesota), or glue to prevent recanalization. Embolization of transsplenic routes was performed using coils followed by glue. Results Transsplenic PVE was successful in 24 (88.9%) of 27 sessions; 3 procedures failed because of splenic vein dissection (n = 1) and failed splenic vein puncture (n = 2). Major complications occurred in 1 patient (3.8%) with splenic vein dissection. Minor complications occurred in 2 patients: a small amount of fluid collection in the splenic hilar area in 1 patient and glue migration along the splenic vein in 1 patient. Planned liver resection was performed in 24 of 26 patients at 4.9 weeks ± 3.5 after PVE. Conclusions Transsplenic PVE is safe and feasible and can be an effective alternative treatment for patients with a challenging ipsilateral, transhepatic route.

To evaluate clinical impact of different intervals between multiple transarterial chemoembolization sessions in patients with unresectable hepatocellular carcinoma (HCC).A retrospective cohort study of 305 consecutive patients with HCC who underwent multiple sessions of on-demand transarterial chemoembolization by two independent physicians with different management policies in terms of transarterial chemoembolization interval was performed; 180 patients had intervals between the first and second transarterial chemoembolization session of60 days (short-interval group), and 125 patients had transarterial chemoembolization intervals of ≥ 60 days (conventional-interval group).The short-interval group had more cases of advanced-stage HCC, less favorable response to transarterial chemoembolization, and higher likelihood of having Child-Pugh class A. The short-interval group underwent more transarterial chemoembolization sessions (6.6 vs 5.5, P = .011), although the total number of admissions and total hospital stay were similar to the conventional-interval group. Overall survival was similar in the two groups in the full and the propensity score-matched cohorts. Although the overall survival of patients with Child-Pugh class A was comparable between the two groups in the full and propensity score-matched cohorts, the short-interval group showed inferior survival (P = .005) and a nonsignificant trend toward inferior survival (P = .117) in the full and propensity score-matched cohorts, respectively, for patients with Child-Pugh class B.Transarterial chemoembolization interval did not affect survival outcomes of patients with Child-Pugh class A. A shorter transarterial chemoembolization interval showed a nonsignificant trend of adversely affecting survival for patients with Child-Pugh class B.

Segmental arterial mediolysis (SAM) is a rare disease which can have catastrophic consequences due to massive hemorrhage or dissecting hematomas. The pathophysiology of this disease is not well-known, and the symptoms vary according to the organs involved. In many patients the diagnosis is based on the clinical and radiologic features rather than the pathologic confirmation. The catheter-based endovascular technique can be an interventional treatment option for SAM, as well as surgical management.

Objective To investigate the technical and clinical efficacy of the percutaneous insertion of a biliary metallic stent, and to identify the factors associated with biliary stent dysfunction in patients with malignant duodenobiliary obstruction. Materials and Methods The medical records of 70 patients (39 men and 31 women; mean age, 63 years; range, 38−90 years) who were treated for malignant duodenobiliary obstruction at our institution between April 2007 and December 2018, were retrospectively reviewed. Variables found significant by univariate log-rank analysis (p < 0.2) were considered as suitable candidates for a multiple Cox's proportional hazard model. Results The biliary stents were successfully placed in all 70 study patients. Biliary stent insertion with subsequent duodenal stent insertion was performed in 33 patients and duodenal stent insertion with subsequent biliary stent insertion was performed in the other 37 study subjects. The median patient survival and stent patency time were 107 days (95% confidence interval [CI], 78–135 days) and 270 days (95% CI, 95–444 days), respectively. Biliary stent dysfunction was observed in 24 (34.3%) cases. Multiple Cox's proportional hazard analysis revealed that the location of the distal biliary stent was the only independent factor affecting biliary stent patency (hazard ratio, 3.771; 95% CI, 1.157–12.283). The median biliary stent patency was significantly longer in patients in whom the distal end of the biliary stent was beyond the distal end of the duodenal stent (median, 327 days; 95% CI, 249–450 days), rather than within the duodenal stent (median, 170 days; 95% CI, 115–225 days). Conclusion The percutaneous insertion of the biliary metallic stent appears to be a technically feasible, safe, and effective method of treating malignant duodenobiliary obstruction. In addition, a biliary stent system with a distal end located beyond the distal end of the duodenal stent will contribute towards longer stent patency in these patients.

Background: The predisposing factors leading to transjugular intrahepatic portosystemic shunt (TIPS) dysfunction, other than the use of bare stents, which are often the only available options, have not been elucidated well to date. Objectives: To analyze clinical outcomes after TIPS created with bare stents and to assess risk factors for stent dysfunction. Patients and Methods: A total of 102 patients undergoing TIPS between January 1999 and December 2012 were retrospectively assessed. The incidence of stent dysfunction was evaluated, and associated risk factors were analyzed. Results: Symptom recurrence was observed in 51 (50%) patients, and TIPS revision was required in 37 (36%) during the mean follow-up period of 1889 days. The median stent patency and survival times were 470 and 1783 days, respectively. The only independent risk factor for stent dysfunction was portal trunk (right, left, or main portal trunk) access (P = 0.006). The median stent patency with segmental branch access (538 days) was significantly longer than that with portal trunk access (245 days) (P = 0.007). There were no significant differences in patient survival (P = 0.648), worsening of encephalopathy (P = .0742), or major complications (P = 1.000). Conclusion: TIPS created with segmental portal venous access has superior patency over that of TIPS with portal trunk access. However, we found no significant difference in patient survival, worsening of encephalopathy, or major complications between segmental access and portal trunk access.

PURPOSE The aim of this study was to assess the outcome of endovascular intervention for pancreatitis-related hemorrhage at a single institution. METHODS From January 2000 to October 2012, thirty-seven patients underwent endovascular intervention for the management of pancreatitis-related hemorrhage. The underlying etiology of the disease, clinical symptoms and laboratory findings, abnormalities seen on computed tomography, and details regarding the endovascular procedures were assessed, as were the outcome of each procedure and procedure-related complications. RESULTS A total of 41 endovascular procedures were performed in 37 patients. The splenic artery (34.8%) was the most commonly treated artery, and pseudoaneurysm was the most commonly detected abnormality on digital subtraction angiography (78.3%). Transcatheter embolization was performed in the majority of patients (95.1%), while two patients were treated with stent-grafts. Successful hemostasis without rebleeding was achieved in 34 patients (91.9%). Two cases of rebleeding were successfully treated by reintervention. Focal splenic infarction, which developed in eight patients, was either asymptomatic or accompanied by mild, transient fever. Splenic abscess was the only major complication occurring in three patients. Two of these patients died from resulting sepsis, while the third recovered after antibiotic treatment. CONCLUSION Endovascular management is effective for achieving hemostasis in patients with pancreatitis-related bleeding and demonstrates low recurrence and mortality rates.

Purpose To evaluate the safety and effectiveness of transcatheter arterial embolization (TAE) using N -butyl cyanoacrylate (NBCA) for the treatment of active postpartum hemorrhage (PPH) and compare the efficacy of NBCA with gelatin sponge particles. Materials and Methods From January 2004 to September 2013, 26 patients with PPH underwent TAE using NBCA as the primary embolic material. All patients were actively bleeding, and 12 (46.2%) had coagulopathy. TAE was performed using 1:2–1:4 mixtures of NBCA and ethiodized oil with or without use of a coil or gelatin sponge. To compare the efficacy of NBCA with conventional embolic material, 50 patients with active bleeding who underwent TAE using gelatin sponge were also analyzed. Results Angiograms demonstrated pseudoaneurysm or extravasation or both. The technical and clinical success rates were 100% and 92.3% (24 of 26 patients), respectively, for NBCA and 98% and 86.0% (43 of 50 patients), respectively, for gelatin sponge. In the NBCA group, one patient recovered with conservative management, and the other patient died because of multiorgan dysfunction. There were no major or minor procedure-related complications. Conclusions TAE using NBCA as the primary embolic agent is an effective method for treating PPH with extravasation or pseudoaneurysm; NBCA is comparable to gelatin sponge particles. TAE using NBCA seems to fill pseudoaneurysms and make devascularization more effective than using gelatin sponge.

Purpose: To assess the safety and efficacy of transcatheter arterial embolization (TAE) for the management of secondary postpartum hemorrhage (PPH) and to determine the factors associated with the clinical outcomes. Materials and Methods: A retrospective analysis of 52 patients (mean age, 31.6 y; range, 25–40 y) undergoing TAE for secondary PPH was performed. Clinical data, including maternal characteristics, delivery details, embolization details, and transfusion requirements, were obtained. Univariate analyses were performed to determine the factors related to clinical outcomes. Results: The major cause of bleeding was retained placental tissue (44.2%; 23 of 52). Actively bleeding foci were observed in 25 (48.1%) patients. Technical and clinical successes were achieved in 100% and 90.4% (47 of 52) of patients, respectively. Gelatin sponge particles with (n ¼ 10) or without (n ¼ 38) permanent embolic materials, such as microcoils or N-butyl cyanoacrylate, were most commonly used (92.3%; 48 of 52), whereas permanent embolic materials alone were used in 7.7% (4 of 52) of patients. In five patients, embolization failed, and these patients were managed by hysterectomy (n ¼ 3), repeat TAE (n ¼ 1), or conservative management (n ¼ 1). Bleeding control was eventually achieved in all five patients. No maternal risk factors were related to clinical results. The median and mean follow-up periods were 3 months and 12.6 months (range, 1–62 mo). Regular menstruation resumed in all 44 patients with available follow-up, and 5 of the patients became pregnant. Conclusions: TAE for secondary PPH is safe and effective and showed technical and clinical success in 100% and 90.4% of patients, respectively. Approximately half of these patients showed a positive bleeding focus, and the use of permanent embolic materials was also common.

To evaluate the long-term efficacy of stent placement versus balloon angioplasty for portal vein (PV) stenosis in pediatric liver transplant (LT) recipients.Fifty 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.The 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.No 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.

Objective To investigate the outcomes of percutaneous metallic stent placements in patients with malignant biliary hilar obstruction (MBHO). Materials and methods From January 2007 to December 2014, 415 patients (mean age, 65 years; 261 men [62.8%]) with MBHO were retrospectively studied. All the patients underwent unilateral or bilateral stenting in a T, Y, or crisscross configuration utilizing covered or uncovered stents. The clinical outcomes evaluated were technical and clinical success, complications, overall survival rates, and stent occlusion-free survival. Results A total of 784 stents were successfully placed in 415 patients. Fifty-five patients had complications. These complications included hemobilia (n = 19), cholangitis (n = 13), cholecystitis (n = 11), bilomas (n = 10), peritonitis (n = 1), and hepatic vein-biliary fistula (n = 1). Clinical success was achieved in 370 patients (89.1%). Ninety-seven patients were lost to follow-up. Stent dysfunction due to tumor ingrowth (n = 107), sludge incrustation (n = 44), and other causes (n = 3) occurred in 154 of 318 patients. The median overall survival and the stent occlusion-free survival were 212 days (95% confidence interval [CI], 186-237 days) and 141 days (95% CI, 126-156 days), respectively. The stent type and its configuration did not affect technical success, complications, successful internal drainage, overall survival, or stent occlusion-free survival. Conclusion Percutaneous stent placement may be safe and effective for internal drainage in patients with MBHO. Furthermore, stent type and configuration may not significantly affect clinical outcomes.

Background Despite conservative treatment, hemorrhage from an intrahepatic branch of the portal vein can cause hemodynamic instability requiring urgent intervention. Purpose To retrospectively report the outcomes of hemodynamically significant portal vein bleeding after endovascular management. Material and Methods During a period of 15 years, four patients (2 men, 2 women; median age, 70.5 years) underwent angiography and embolization for iatrogenic portal vein bleeding. Causes of hemorrhage, angiographic findings, endovascular treatment, and complications were reported. Results Portal vein bleeding occurred after percutaneous liver biopsy (n = 2), percutaneous radiofrequency ablation (n = 1), and percutaneous cholecystostomy (n = 1). The median time interval between angiography and percutaneous procedure was 5 h (range, 4–240 h). Common hepatic angiograms including indirect mesenteric portograms showed active portal vein bleeding into the peritoneal cavity with (n = 1) or without (n = 2) an arterioportal (AP) fistula, and portal vein pseudoaneurysm alone with an AP fistula (n = 1). Successful transcatheter arterial embolization (n = 2) or percutaneous transhepatic portal vein embolization (n = 2) was performed. Embolic materials were n-butyl cyanoacrylate alone (n = 2) or in combination with gelatin sponge particles and coils (n = 2). There were no major treatment-related complications or patient mortality within 30 days. Conclusion Patients with symptomatic or life-threatening portal vein bleeding following liver-penetrating procedures can successfully be managed with embolization.

The purpose of this study was to evaluate the efficacy and safety of transfemoral liver biopsy with a Quick-Core biopsy needle in select living donor liver transplantation (LDLT) recipients. Eight LDLT recipients underwent 9 transfemoral liver biopsy sessions. Six patients had undergone modified right lobe (mRL) LDLT, and 2 patients had undergone dual–left lobe LDLT. The indications for transfemoral liver biopsy were a hepatic vein (HV) at an acute angle to the inferior vena cava (IVC) on the coronal plane and a thin (

Objective To evaluate the safety and efficacy of transarterial nephrectomy, i.e., complete renal artery embolization, as an alternative to surgical nephrectomy. Materials and methods This retrospective study included 11 patients who underwent transarterial nephrectomy due to a high risk of surgical nephrectomy or their refusal to undergo surgery during the period from April 2002 to February 2013. Medical records and radiographic images were reviewed retrospectively to collect information regarding underlying etiologies, clinical presentations and embolization outcomes. Results The underlying etiologies for transarterial nephrectomy included recurrent hematuria (chronic transplant rejection [n = 3], arteriovenous malformation or fistula [n = 3], angiomyolipoma [n = 1], or end-stage renal disease [n = 1]), inoperable renal or ureteral injury (n = 2), and ectopic kidney with urinary incontinence (n = 1). The technical success rate was 100%, while clinical success was achieved in eight patients (72.7%). Subsequent surgical nephrectomy was required for three patients due to an incomplete nephrectomy effect (n = 2) or necrotic pyelonephritis (n = 1). Procedure-related complications were post-infarction syndrome in one patient and necrotic pyelonephritis in another patient. Of four patients with follow-up CT, four showed renal atrophy and two showed partial renal enhancement. No patient developed a procedure-related hypertension. Conclusion Transarterial nephrectomy may be a safe and effective alternative to surgical nephrectomy in patients with high operative risks.

Background Patent portal vein (PV) and adequate portal inflow is essential for successful living donor liver transplantation (LDLT). In extensive portal vein thrombosis (PVT) patients, however, complete PV thrombectomy is not feasible particularly at intrapancreatic portion, and subsequently portal flow steal through preexisting sizable collaterals or rethrombosis can occur. To overcome those problems, we introduced interruption of sizable collaterals and intraoperative cine-portogram (IOP), which is useful for diagnosis and treatment of residual PVT and sizable collaterals. Methods Fourteen percent of adult LDLT (188/1399) had PVT from February 2008 to December 2012 and were subdivided into Yerdel's grades 1, 2, 3, and 4 based on preoperative imaging and operative findings. Considering the severity of PVT and presence of sizable collaterals, the managements were as follows: thrombectomy alone, additional PV plasty, PV stenting, interposition graft, or additional interruption of collaterals. Results The Yerdel's grade of PVT patients were 1 (42%), 2 (54%), 3 (3%), and 4 (1%). One hundred one (77%) patients underwent interruption of sizable collaterals. The most common management for PVT was thrombectomy alone in grades 1 and 2, thrombectomy plus PV stenting and/or ballooning in grade 3, and interposition graft in grade 4. In LDLT for PVT patients, 1-year mortality was 9%, and PV-related complication occurred in 5%. The severity of PVT made no difference in the outcome. Conclusion Multi-disciplinary approaches including surgical correction of PVT, IOP, and interruption of sizable collaterals resulted in excellent outcome, and it was not affected by the severity of PVT.

This study was designed to evaluate the safety and effectiveness of transcatheter arterial embolization (TAE) for stopping bleeding following hip surgery.We performed a 12-year retrospective analysis of 13 patients (M:F = 6:7, median age 72 years) who underwent angiography for bleeding following hip surgery. The types of surgery, latency time, angiographic findings, TAE details, procedure-related complications, and clinical outcomes were analyzed. Technical success was defined as no further bleeding detected on angiography following embolization.Total hip replacement arthroplasty was the most common surgery performed for these patients (n = 10). Seven of the 13 study patients underwent angiography the same day as their surgery. Angiograms showed active (n = 11) or suspicious (n = 1) bleeding in 12 of the 13 patients. Gelatin sponge particles, coils, NBCA, PVA, and their combinations were used as the embolic material. For the one patient without obvious signs of bleeding, prophylactic TAE was done to achieve bleeding control. For the 11 patients with active bleeding, 10 underwent technically successful TAE, and 1 patient underwent surgery due to a large pseudoaneurysm located near the bifurcation of the common femoral artery. There were no major procedure-related complications or patient mortality. The 30-day mortality rate was 15% (2/13), and both of these patients died of multiorgan failure.Transcatheter angiography is useful for identifying bleeding arteries. TAE is safe and effective for managing bleeding after hip surgery.

Purpose To investigate the outcomes of percutaneous metallic stent placement in patients with malignant bilioenterostomy obstruction and to assess the risk factors influencing stent patency. Materials and Methods From August 2008 to January 2012, 53 patients with malignant bilioenterostomy obstructions were treated with percutaneous placement of biliary metallic stents; this included expanded polytetrafluoroethylene (ePTFE)–covered stent placement in 36 patients and uncovered stent placement in 17 patients. Results A total of 75 stents were successfully placed in 53 patients. No major complications occurred in any patients, and minor complications occurred in nine patients (17%). The mean serum bilirubin level, which was 3.6 mg/dL ± 0.7 before drainage, decreased significantly to 2.5 mg/dL ± 0.4 at 1 month after stent placement ( P = .041). Successful internal drainage was achieved in 44 of the 53 patients (83%). Kaplan–Meier analysis showed a median overall survival time of 145 days (95% confidence interval, 100–190 d), a median stent patency time of 313 days (95% confidence interval, 46–580 d), and cumulative stent patency rates at 1, 3, 6, 9, and 12 months of 91%, 75%, 64%, 56%, and 45%, respectively. Multivariate Cox regression analysis showed that the use of uncovered stents (odds ratio, 2.924; P = .033) was the only significant independent factor associated with stent occlusion. Conclusions Percutaneous metallic stent placement is a safe and effective method for the treatment of patients with malignant bilioenterostomy obstruction. Moreover, as uncovered stent placement is the only significant independent factor associated with stent occlusion, ePTFE-covered stent placement is preferable in these patients.

To evaluate technical safety, clinical safety, and effectiveness of vascular plug-assisted retrograde transvenous obliteration (RTO) for treatment of gastric varices (GV) and hepatic encephalopathy (HE).This retrospective study was approved by the institutional review board; written informed consent was waived. From April 2009 to December 2011, 20 patients (13, GV; seven, HE) who had undergone vascular plug-assisted RTO were retrospectively evaluated. After retrograde transvenous placement of a vascular plug in the left adrenal vein or gastrorenal shunt, subsequent gelatin-sponge embolization of both gastrorenal shunt and GV was performed. Follow-up computed tomography (CT) and upper gastrointestinal tract endoscopy were performed; clinical and laboratory data were collected to evaluate primary (technical success, complications, clinical success) and secondary (change of liver function by using the Child-Pugh score, worsening of esophageal varices) end points. Laboratory data before and after vascular plug-assisted RTO were compared (paired-sample t test).Placement of the vascular plug and subsequent gelatin-sponge embolization were technically successful in all 20 patients, with no procedure-related complications. Follow-up CT within 1 week after vascular plug-assisted RTO showed complete thrombosis of GV and gastrorenal shunts in all patients. Clinical symptoms of HE completely resolved in all seven patients with HE; mean serum NH3 level of 127.4 μmol/L ± 58 (standard deviation) before vascular plug-assisted RTO decreased significantly to 28.1 μmol/L ± 9.8 within 1 week after vascular plug-assisted RTO (P = .002). Eighteen patients who underwent follow-up longer than 2 months showed complete obliteration of GV and gastrorenal shunts at CT and endoscopy. There were no cases of variceal bleeding or HE during mean follow-up of 422 days. Improvement in Child-Pugh score was observed in 12 of 18 (67%) patients 1 month after vascular plug-assisted RTO. Worsening of esophageal varices was observed in four (22%) patients at mean follow-up of 9.4 months.Vascular plug-assisted RTO is technically simple and safe and seems to be clinically effective for treatment of GV and HE.

Background Thrombolysis and mechanical thrombectomy have been used to treat postoperative main portal vein and superior mesenteric vein thrombosis. Purpose To evaluate the safety and efficacy of balloon angioplasty and/or stent placement without thrombolysis or thrombectomy for treating such thromboses. Material and Methods 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. Results 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. Conclusion 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.

The purpose of this study is to investigate the technical and clinical efficacy of percutaneous bilateral stent-in-stent deployment using open cell-design stents and to compare the clinical outcomes of bilateral stent placement using T and Y configurations.From January 2006 to December 2010, 106 patients with malignant hilar biliary obstruction (Bismuth type II or higher) were included in this retrospective study. All patients were treated with percutaneous bilateral stent-in-stent deployment using open cell-design stents (64 in a T configuration and 42 in a Y configuration).Bilateral stent-in-stent deployment was technically successful in all patients. Seven patients (6.6%) had major complications, including one with severe hemobilia, two with acute cholecystitis, and four with cholangitis; seven (6.6%) patients had minor complications, including self-limiting hemobilia. Successful internal drainage was achieved in 94 patients (88.7%). Stent occlusion by tumor ingrowth, with or without overgrowth, occurred in 37 patients (34.9%). The median survival and stent patency times were 192 days (95% CI, 153.6-230.4 days) and 319 days (95% CI, 148.5-489.5 days), respectively. Stent configuration did not significantly affect technical success, complications, successful internal drainage, patient survival, or stent patency.Percutaneous bilateral stent-in-stent placement using open cell-design stents is effective for bilateral drainage in patients with malignant hilar biliary obstruction. In addition, there was no significant difference in technical and clinical outcomes between T and Y stent configurations.

To evaluate outcomes of expanded polytetrafluoroethylene (ePTFE)-covered stents and compare them with outcomes of uncovered stents in patients with malignant superior vena cava (SVC) syndrome.This study was approved by the institutional review board and written informed consent was obtained. Thirty-seven consecutive patients (33 men, four women; mean age, 60.3 years; range, 35-81 years) who underwent ePTFE-covered stent placement for SVC syndrome were enrolled in a prospective study between January 2009 and September 2011. Their data were compared with retrospective data of 36 consecutive patients (31 men, five women; mean age, 62.3 years; range, 41-81 years) who underwent uncovered stent placement for SVC syndrome between January 2005 and December 2008. The causes of malignant SVC syndrome were squamous cell carcinoma (n = 27), adenocarcinoma (n = 25), small cell carcinoma (n = 15), thymic carcinoma (n = 3), invasive thymoma (n = 2), and breast cancer (n = 1). Stent patency and patient survival rates were calculated by using the Kaplan-Meier method, and groups were compared with the log-rank test.Stent placement was technically successful in all patients. Complications did not occur in either group. Kaplan-Meier analysis revealed that covered stents had higher cumulative patency (97%, 94%, 94%, and 94% at 1, 3, 6, and 12 months, respectively) than uncovered stents (97%, 79%, 67%, and 48% at 1, 3, 6, and 12 months, respectively; P = .038). Clinical success rates did not significantly differ (P = .674), nor did patient survival (P = .549). Median survival in the covered stent group was 141 days (95% confidence interval: 81, 201 days) and 100 days in the uncovered stent group (95% confidence interval: 60, 140 days).Endovascular placement of ePTFE-covered stents appeared to be a safe and effective method to treat patients with malignant SVC syndrome and seemed to be superior to uncovered stents in terms of stent patency.

The purpose of this article is to evaluate and compare the safety and efficacy of endovascular management of the portal vein (PV) via percutaneous transsplenic access versus percutaneous transhepatic access in liver transplantation (LT) recipients. A total of 18 patients who underwent endovascular management of PV via percutaneous transhepatic (n = 8) and transsplenic (n = 10) access were enrolled. Transsplenic access was chosen if the spleen was located in a normal position, the splenic vein (SpV) was preserved, and the target lesion did not involve confluence of the superior mesenteric and SpVs. Accessibility of the percutaneous transsplenic puncture was confirmed via ultrasound (US) in the angiography suite. All procedures were performed under local anesthesia. Percutaneous transhepatic or transsplenic access was performed using a 21-gauge Chiba needle under US and fluoroscopic guidance, followed by balloon angioplasty, stent placement, or variceal embolization. The access tract was embolized using coils and a mixture (1:2) of glue and ethiodized oil. Transhepatic or transsplenic access was successfully achieved in all patients. A total of 12 patients underwent stent placement; 3 had balloon angioplasty only; 2 had variceal embolization only; and 1 had variceal embolization followed by successful stent placement. Regarding major complications, 1 patient experienced a SpV tear with extravasation during transsplenic balloon angioplasty, which was successfully managed using temporary balloon inflation, followed by transfusion. Clinical success was achieved in 9 of 11 (82%) patients who exhibited clinical manifestations. The remaining 7 patients who underwent prophylactic endovascular management were healthy. In conclusion, endovascular management of PV via percutaneous transsplenic access is a relatively safe and effective alternative that does not damage the liver grafts of LT recipients. Liver Transplantation 23 1133-1142 2017 AASLD.

Background Arterial dissections during transcatheter arterial chemoembolization (TACE) procedures are not rare and can limit the successful treatment of unresectable hepatocellular carcinoma (HCC). Purpose To evaluate the incidence of arterial dissections during TACE procedures, the rate of spontaneous lumen recovery, and the predictive factors of dissecting stenosis during follow-up. Material and Methods Based on 69,651 TACE procedures from 1997 to 2016, patients who had procedure-related arterial dissections were identified by procedure report search. More than two months after the date of dissection, dissecting stenosis was evaluated using a three-grade scale: subclinical narrowing with diameter loss under 30%, overt stenosis with diameter loss over 30%, and occlusion. Pearson Chi-square and two-sample t-test were used to assess potential prognostic markers for dissecting stenosis. Results Eighty-four arterial dissections directly related to TACE were identified in 83 patients, resulting in an incidence of 0.12% (84/69651). After more than two months, normal or subclinical narrowing, overt stenosis, occlusion, and doubling were seen in 39 (46.4%), 26 (31.0%), 13 (15.5%), and one (1.2%) patients, respectively. No follow-up images were obtained for five (6.0%) patients. On univariate analysis, the dissection ratio (the ratio of the length to the diameter of the dissection) alone was related to dissecting stenosis ( P = 0.035). Conclusion The incidence of iatrogenic dissection during TACE was approximately 0.12%. Less than 50% of the iatrogenic dissections showed normal or subclinical narrowing during follow-up of at least two months. The dissection ratio alone was the predictive factor for dissecting stenosis during follow-up.

Pelvic arterial embolization for primary postpartum hemorrhage was safe and effective, although patients with disseminated intravascular coagulation and those who have received a massive transfusion should be carefully monitored during embolization because of the potential need for repeat embolization or additional surgery.

Background Despite its long history, the application of N-butyl cyanoacrylate (NBCA) has been limited compared to other materials such as particulate agents and coils. This possibly owes to a widespread misconception that NBCA is difficult to handle and carries a high risk of complications due to its liquid nature and rapid polymerization time. However, recent reports have shown that, with knowledge and experience, NBCA is safe and effective to use in visceral arteries. Purpose To review the outcome of transcatheter embolization of the renal artery using NBCA for varied etiologies in the kidney. Material and Methods Fourteen patients with varied etiologies in the kidney underwent renal artery embolization using NBCA as the sole embolic agent (64%) or in combination with an additional embolic material (36%). A review of medical charts and images were performed to gather information regarding underlying etiologies, clinical presentation, and outcome of embolization. Results Technical success was achieved in all patients (100%) while clinical success was achieved in 12 (85.7%). One failed case was managed by repeat embolization using microcoils, while the other underwent partial nephrectomy after failed reattempt at embolization. Three patients with recurrent bleeding after previously having undergone embolization using microcoils or gelatin sponge particles were successfully managed the second time using NBCA. NBCA embolization was also effective in three patients with hemostatic abnormality. Complications attributable to NBCA embolization were renal atrophy in one patient and microcatheter tip fracture in another. Conclusion The application of NBCA for transcatheter embolization of varied etiologies involving the renal artery is feasible and safe in the hands of an experienced interventional radiologist. It offers immediate and effective occlusion of the pathologic vessel and, while it can be used exclusively on its own, it can also be used to complement other embolic materials.

Aim To determine the efficacy of percutaneous transcatheter embolization in the management of patients with spermatic varicocoeles persisting or recurring after surgery. Materials and methods Over a period of 10 years, 28 patients (age range 13–55 years) were referred for percutaneous transcatheter embolization of postsurgical, recurrent varicocoeles. Medical documents were retrospectively reviewed to evaluate past surgical history, subjective symptoms, and results of scrotal examination, ultrasound, and semen parameters. Pre-embolization venograms were analysed to assess the anatomy of the testicular vein. The technical and clinical outcomes of embolization were then determined. Results The 28 patients included in the study had undergone laparoscopic varicocoelectomy (39.3%), high retroperitoneal ligation (25%), or inguinal ligation (25%). Subjective symptoms were scrotal pain (60.7%) and a palpable scrotal mass (50%) exclusively on the left side. Venograms revealed abnormalities of the left testicular vein in all cases. Embolization was technically successful in all but two cases, thus yielding an occlusion rate of 93%; a single case of suspected thrombophlebitis was the only complication. After excluding two, technically unsuccessful cases and one patient who was lost to follow-up, 25 patients underwent scrotal examination after embolization, which revealed complete resolution in 20 cases (80%), partial improvement in four cases (16%), and no improvement in a single case (4%). Among the follow-up group of patients, of the 12 who initially presented with scrotal pain, six (50%) were symptom-free and four (33.3%) had partial improvement. Conclusion Percutaneous transcatheter embolization of the testicular vein is technically feasible and effective for managing postsurgical recurrent varicocoeles.

The purpose of this study was to investigate the outcome of biliary metallic stent placement in patients with contralateral portal vein occlusion caused by advanced hilar malignancy and to compare the outcomes of unilateral and bilateral stent placement.From January 2007 to December 2009, 41 patients with unilobar portal vein occlusion due to advanced hilar malignancy were enrolled in this retrospective study. All patients were treated with percutaneous placement of biliary metallic stents: unilateral stent placement in 23 patients, bilateral stent placement in 18 patients.There were no significant differences in technical success (p0.999), successful drainage (p0.999), early cholangitis (p = 0.734), stent occlusion (p = 0.713), stent patency (p = 0.653), or patient survival (p = 0.493) between the two groups. In the patients who underwent unilateral stent placement, a slight decrease in diameter (mean diameter, 7.2 ± 3 mm before drainage, 6.2 ± 3 mm after stent placement) (p = 0.058) was observed in the intrahepatic bile duct of the undrained lobe with portal vein occlusion. Four of the patients who underwent unilateral stent placement had stent malfunctions, but the other 19 patients did not experience cholangitis or jaundice before death or the end of the study.Unilateral biliary metallic stent placement in the lobe with a patent portal vein seems to be a safe and effective palliative treatment of patients with contralateral portal vein occlusion caused by advanced hilar malignancy, obviating bilateral stent placement in these patients.

Purpose To compare retrospectively percutaneous transhepatic primary placement of a retrievable self-expanding metallic stent with percutaneous balloon dilation for the treatment of benign biliary strictures. Materials and Methods From 2005–2009, 66 patients with benign biliary strictures in whom an endoscopic approach failed or in whom such an approach was inaccessible were evaluated. Of 66 patients, 31 underwent balloon dilation, and 35 underwent temporary metallic stent placement. The etiologies of the benign strictures were anastomotic stricture after surgery (n = 54), stricture secondary to intraoperative injury (n = 9), inflammatory stricture (n = 2), and stricture secondary to trauma (n = 1). Results The primary patency rates were significantly better in the stent group (87% at 3 years) than in the balloon group (44% at 3 years; P = .022). The indwelling period of percutaneous transhepatic biliary drainage (PTBD) catheters after the initial procedure was able to be significantly reduced in the stent group (median 2.5 months) compared with the balloon group (median 4.5 months; P = .001). Significant bleeding (associated with PTBD) occurred in one patient in the balloon group. In the stent group, stent migration occurred in two patients, and one patient underwent surgery for stent removal after failure of removal under fluoroscopic guidance. Conclusions Percutaneous primary placement of a retrievable self-expanding metallic stent showed superior intermediate-term results compared with percutaneous balloon dilation for the treatment of benign biliary strictures. In addition, the indwelling period of PTBD catheters can be significantly reduced using temporary stent placement.

Purpose To estimate the effect of splenic artery embolization (SAE) on blood flow in orthotopic liver transplantation (OLT) recipients with splenic artery steal syndrome (SASS) based on changes in caliber of related arteries upon serial computed tomography (CT) scans. Methods Between 2004 and 2007, nine OLT recipients with SASS underwent SAE. They had CT scans before and after SAE: short-, mid-, and long-term, ie, approximately 1 week, 1 month, and 1 year, respectively. The diameters of the celiac axis (CA), common hepatic artery (CHA), and splenic artery (SA) were measured with arterial phase of each CT scan and the ratios of SA to CHA diameter (SA/CHA) calculated to analyze their changes during the follow-up period. Results The diameters of celiac axis, CHA, and SA and SA/CHA changed most rapidly during the short-term period. The CHA diameter significantly increased short-term post-SAE by CT and slightly decreased thereafter. However, the mid-term and long-term post-SAE CT values were still significantly greater than those on the pre-SAE CT. The SA diameter steadily decreased throughout the follow-up. The SA/CHA decreased until the mid-term. The SA diameter and SA/CHA were significantly smaller upon mid-term and long-term post-SAE CT compared with those at pre-SAE CT. Conclusions The effect of SAE to improve hepatic arterial flow in OLT recipients with SASS might be expected for at least approximately one year. The effect maximally occurred during the short-term after SAE on the basis of changes in the caliber of related arteries upon CT.

The objective of our study was to analyze the technical and clinical outcomes of endovascular treatment of patients with extrahepatic artery hemorrhage after pancreatobiliary surgery.From January 2000 to September 2009, 27 patients who had undergone pancreaticobiliary surgery had an extrahepatic artery hemorrhage with or without a pseudoaneurysm were enrolled in this retrospective study. All patients underwent diagnostic angiography and endovascular treatment-either transcatheter arterial embolization (TAE) (n = 20) or stent-graft placement (n = 7).Bleeding sites were located in the gastroduodenal artery stump (n = 14), proper hepatic artery (n = 10), and common hepatic artery (n = 3). In the TAE group, the initial technical and clinical success rates were 100% and 90%, respectively. Two patients died of hepatic failure and multiorgan failure within 7 days after TAE. Hepatic ischemia and infarction were observed in six (33.3%, 6/18) and eight (44.4%, 8/18) patients, respectively. Hepatic abscess was observed in one patient (5.6%, 1/18) with hepatic infarction. The development of hepatic infarction was significantly associated with a serum aspartate aminotransferase (AST) level of more than 700 IU/L and a serum alanine transferase (ALT) level of more than 500 IU/L (p = 0.031 for both, Fisher exact test). In the stent-graft group, the initial technical and clinical success rates were 100% for both. Early stent thrombosis with bile duct necrosis was observed in one patient (14.3%). During the mean follow-up period of 22.8 months (range, 8-43 months), the intrahepatic arteries were patent on follow-up CT.The endovascular treatments of TAE and stent-graft placement can be performed safely in most patients and are effective treatment options for extrahepatic artery hemorrhage after pancreatobiliary surgery. Moreover, stent-graft placement is better than TAE for preserving intrahepatic arterial flow without rebleeding from the extrahepatic artery.

This study was designed to retrospectively compare the effectiveness of combined transarterial chemoembolization (TACE) plus radiofrequency ablation (RFA) with that of RFA alone in patients with medium-sized (3.1–5.0 cm) hepatocellular carcinoma (HCC). From March 2000 to April 2010, 57 patients, each with a single medium-sized HCC, were treated with combined TACE and RFA, and 66 were treated with RFA alone. During follow-up (mean, 42.5 ± 33.2 months; range, 2.6–126.2 months), local tumor progression was observed in 40% of treated lesions in the combined treatment group and in 70% in the RFA-alone group. The 1-, 3-, 5-, and 7-year local tumor progression rates were significantly lower in the TACE + RFA group (9%, 40%, 55%, and 66%, respectively) than in the RFA-alone group (45%, 76%, 86%, and 89%, respectively; P

The purpose of this study was to evaluate the results of percutaneous transhepatic management of anastomotic biliary strictures using the dual catheter placement technique (2 drainage catheters inserted via single percutaneous tract). The protocol of this retrospective study was approved by the institutional review board of our institution and written informed consent was waived. Percutaneous transhepatic biliary drainage and subsequent balloon dilation of anastomotic strictures were performed in 79 patients. Serial exchanges of drainage via catheter with larger diameters up to 14-French were performed at 1-month intervals followed by 3 exchanges of dual catheters at 2 month intervals. Drainage catheters were removed when follow-up cholangiography revealed improved strictures without recurrence of symptoms or elevation of biochemical findings. Technical success was achieved in all 79 (100%) patients after percutaneous transhepatic treatment. The mean period of dual catheter placement was 6.5 ± 1.1 months (range, 5.5-14.2 months). Clinical success was achieved in 78 (98.7%) of 79 patients and drainage catheters were removed 23.8 ± 8.8 months (range, 11.4-43.3 months) after the initial percutaneous transhepatic biliary drainage. Procedure-related complications occurred in 14 (17.8%) patients. During the mean follow-up period of 34.5 ± 3 months (range, 24.4-38.5 months) in the 78 patients, the primary patency rates were 96%, 92%, and 91% at 1, 2, and 3 years, respectively. Seven (9%) of the 78 patients experienced recurrent symptoms at a mean of 15.4 ± 8.9 months (range, 6.1-26.2 months) after catheter removal. In conclusion, the dual catheter placement technique seems to be an easy, safe, and effective method with an acceptable catheter intervention period for the treatment of anastomotic strictures following LDLT.

Background and Aims: The therapeutic efficacy of transarterial chemoembolization (TACE) has not been evaluated in hepatocellular carcinoma (HCC) patients with extrahepatic metastasis. We investigated the efficacy of TACE with/without systemic chemotherapy (s-chemo) in these patients. Methods: We performed a survival analysis of consecutive HCC patients with extrahepatic metastasis, diagnosed at initial presentation according to treatment modality after stratification, using the Child–Pugh classification and intrahepatic HCC T stage, retrospectively. Results: Between 2005 and 2007, 251 patients were newly diagnosed with HCC involving extrahepatic metastasis at our institution. Among those, 226 were classified as Child–Pugh A–B and the other 25, Child-Pugh C. Within the Child–Pugh A–B group, repeated TACE or transarterial chemoinfusion (TACI) was performed with/without s-chemo in 171 patients. Eight of 226 received s-chemo alone, and 47, conservative management (CM) alone. The median survival time of patients treated with TACE/TACI with s-chemo, TACE/TACI alone, and CM was 10, 5, and 2.9 months in patients classified as Child–Pugh A and T3-stage HCC (TACE/TACI with s-chemo vs CM, P = 0.0354; TACE/TACI alone vs CM, P = 0.0553) and 7.1, 2.6, and 1.6 months in Child–Pugh B and T3-stage patients, respectively (TACE/TACI with s-chemo vs CM, P = 0.0097; TACE/TACI alone vs CM, P

Purpose To evaluate outcomes of transcatheter arterial embolization (TAE) for gastric cancer–related gastrointestinal (GI) bleeding and factors associated with successful TAE and improved survival after TAE. Materials and Methods This retrospective study included 43 patients (34 men; age 60.6 y ± 13.6) with gastric cancer–related GI bleeding undergoing angiography between January 2000 and December 2015. Clinical course, laboratory findings, and TAE characteristics were reviewed. Technical success of TAE was defined as target area devascularization, and clinical success was defined as bleeding cessation with hemodynamic stability during 72 hours after TAE. Student t test was used for comparison of continuous variables, and Fisher exact test was used for categorical variables. Univariate and multivariate analysis were performed to identify predictors of successful TAE and 30-day survival after TAE. Results TAE was performed in 40 patients. Technical and clinical success rates of TAE were 85.0% and 65.0%, respectively. Splenic infarction occurred in 2 patients as a minor complication. Rebleeding after TAE occurred in 7 patients. Death related to bleeding occurred in 5 patients. Active bleeding ( P = .044) and higher transfusion requirement (3.3 U ± 2.6 vs 1.8 U ± 1.7; P = .039) were associated with TAE failure. Successful TAE predicted improved 30-day survival after TAE on univariate and multivariate analysis ( P = .018 and P = .022; odds ratio, 0.132). Conclusion TAE for gastric cancer–associated GI bleeding may be a lifesaving procedure. Severe bleeding with a higher transfusion requirement and active bleeding on angiography predicted TAE failure.

Background: Complete resection of hypervascular metastatic tumors is often complicated by massive intraoperative blood loss. Purpose: To assess the technical success and clinical effectiveness of transcatheter arterial embolization (TAE) of hypervascular metastatic tumors of long bones to reduce blood loss during orthopedic surgery. Material and Methods: From January 2000 to September 2009, 25 patients (M:F=13:12; mean age 58.3 years) were treated with TAE of metastatic bone tumors before elective, orthopedic surgery. In all cases, the indication for TAE was preoperative devascularization. Technical success, defined as obliteration of tumor staining to 70% or more, requirement for red blood cell transfusion within 24 h following surgery, and hematologic parameters, i.e. the hemoglobin, hematocrit, and erythrocyte counts before and after surgery, were obtained. Results: The technical success rate was 96% (24/25 patients). Gelatin sponge particles ( n=21) or polyvinyl alcohol particles ( n=4) were used as embolic materials. The mean amount of red blood cell transfusion within the 24 h following surgery was 1.91 units (range 0–6) in the 23 patients with technically successful TAE and who underwent surgery within 3 days after TAE. In 22 patients with technically successful TAE and available hematologic data, the mean gaps in the hemoglobin, hematocrit, and erythrocyte counts before and after operation were 1.22 g/dl, 4.07%, and 0.45×106/mm3, respectively. Conclusion: Preoperative TAE is technically successful and clinically effective to minimize intraoperative and postoperative bleeding in patients with hypervascular metastasis to long bones.

The incidence of clinically significant right hepatic vein (RHV) stenosis after adult living donor liver transplantation has been higher than expected. In this study, an assessment of the risk factors for the development of RHV stenosis in this context was undertaken. Hepatic anatomy, surgical techniques, and the incidence of RHV stenosis 1 year after transplantation were evaluated retrospectively in 225 recipients of right lobe grafts. These patients underwent independent RHV reconstruction, which was facilitated by the application of computed tomography morphometry and computational simulation analyses. Three types of preparation of the orifice of the graft RHV and 7 types of preparation for venoplasty of the recipient RHV were used. The frequency of high, middle, and low sites of RHV insertion into the inferior vena cava (IVC) was 56.0%, 36.4%, and 7.6%, respectively, for donors, and 26.7%, 58.7%, and 14.7%, respectively, for recipients. Nine patients (4%) developed RHV stenosis of early onset that required stent insertion during the first 2 postoperative weeks; in 12 patients (5.3%), RHV stenosis of delayed onset occurred. Inappropriate matching of RHV sites of insertion correlated with the incidence of stenosis of early onset (P = 0.039). Technical refinements to avoid adverse consequences of inappropriate ventrodorsal matching of RHV sites of insertion include making the recipient RHV orifice wide and enlarging the recipient IVC by a customized incision and patch venoplasty after anatomical assessment of the RHV and IVC of the graft and recipient. Liver Transpl 16:639-648, 2010. © 2010 AASLD.

Objective To investigate the technical safety and clinical efficacy of a double-stent system with long duodenal extension in patients with malignant extrahepatic biliary obstruction. Materials and methods This prospective study enrolled 48 consecutive patients (31 men, 17 women; mean age, 61 years; age range, 31-77 years) with malignant extrahepatic biliary obstructions from May 2013 to December 2015. All patients were treated with a double-stent system with long duodenal covered extension (16 cm or 21 cm). Results The stents were successfully placed in all 48 patients. There were five (10.4%) procedure-related complications. Minor complications were self-limiting hemobilia (n = 2). Major complications included acute pancreatitis (n = 1) and acute cholecystitis (n = 2). Successful internal drainage was achieved in 42 (87.5%) patients. Median patient survival and stent patency times were 92 days (95% confidence interval [CI], 61-123 days) and 83 days (95% CI, 46-120 days), respectively. Ten (23.8%) of the 42 patients presented with stent occlusion due to food impaction with biliary sludge, and required repeat intervention. Stent occlusion was more frequent in metastatic gastric cancer patients with pervious gastrectomy, but did not reach statistical significance (p = 0.069). Conclusion Percutaneous placement of a double-stent system with long duodenal extension is feasible and safe. However, this stent system does not completely prevent stent occlusion caused by food reflux.

The aims of this study were to evaluate both the efficacy of stent placement for treating inferior vena cava (IVC) stenosis and the patency of hepatic veins (HVs) following IVC stent placement. Fourteen hepatic transplant recipients underwent stent placement to treat IVC stenosis. The median interval between transplantation and stent placement was 32 days. Stents varied from 20-36 mm in diameter and were 60-120 mm long. We retrospectively analyzed the technical and clinical success, changes of hepatic venous flow, and the patency of the IVC stents. Stent placement was successful in all patients. Clinical success was achieved in 12 patients. Four patients underwent HV balloon angioplasty or stent placement through IVC stent meshes either immediately (n = 1) or 12-110 days after (n = 3) IVC stent placement. Nine of the 12 patients were healthy when this manuscript was completed, and the last follow-up computed tomography scan obtained at a median of 65.3 months after IVC stent placement revealed the patency of the stent-placed IVC and HVs. IVC stent placement seems to be an effective treatment with an excellent, long-term patency for treating posttransplant stenosis, although the possibility of hepatic venous outflow abnormalities following IVC stent placement should also be considered.

Purpose Diversion of portal vein (PV) flow from the partial liver graft in living-donor liver transplantation (LDLT) can be life-threatening and warrant interruption of large collateral vessels. The purpose of this study is to evaluate the clinical efficacy of percutaneous or intraoperative transvenous embolization of portosystemic collateral vessels to improve PV inflow during or after LDLT. Materials and Methods From 2000 to 2007, 105 of 1,435 patients (7%) who had undergone LDLT underwent percutaneous ( n = 17) or intraoperative ( n = 88) venography to evaluate the status of PV inflow and portosystemic collateral vessels. Among these 105 patients, 19 underwent percutaneous ( n = 6) or intraoperative ( n = 13) transvenous embolization of portosystemic collateral vessels to improve PV inflow. This included 12 men and seven women with a mean age of 46.5 years. Results Successful embolization of the portosystemic collateral vessels with subsequently improved PV inflow was achieved in all 13 patients (100%) treated with the intraoperative approach and in four of six (67%) patients treated with the percutaneous approach. During follow-up (median, 8 months), Doppler ultrasonography showed adequate PV inflow in 17 of 19 patients, and follow-up computed tomography showed that collateral flow to the varices disappeared in 13 patients and decreased in four patients. One patient died of acute reactivated hepatitis 2 months after the procedure. Overall clinical success was achieved in 16 of the 19 study patients (84%). Conclusions Transvenous embolization of varices may be an effective method to improve PV inflow in LDLT recipients.

Splenic artery aneurysms (SAAs), occurring in 7% to 17% of patients with cirrhosis, often result in catastrophic rupture after liver transplantation. We had experienced 3 cases of ruptured SAAs after adult living donor liver transplantation (LDLT), and we then performed this study to find risk factors for coexisting SAAs in liver transplant candidates with cirrhosis and to propose ideal approaches for them. Preoperative and postoperative computed tomography angiograms and axial views were reviewed for 310 adult LDLT recipients who had cirrhosis from January 2004 to August 2005. The recorded variables were the preoperative diagnosis, the presence of SAA and its characteristics, the splenic artery (SA) diameter, and the presence and size of portosystemic collaterals. Devastating SAA rupture accompanied by hypovolemic shock occurred on postoperative days 6, 82, and 8, respectively, and it was treated emergently by embolization in cases 1 and 2 and by splenectomy in case 3. Cases 1 and 3 recovered well, but case 2 died of an unrelated cause with a long hospital stay. The incidence of SAA during the study period was 14.2% (44/310), and the size was 16.6 ± 5.7 mm. Most SAAs were single (70.6%, 31/44) and were located in the distal one-third of the SA (82.4%, 36/44). Large portosystemic collaterals demonstrating longstanding severe portal hypertension were significantly correlated with the occurrence of SAAs. Nine patients with SAAs were preventively treated by proximal ligation (n = 4) intraoperatively and by embolization (n = 5) 1 day before or after LDLT. No patient showed severe postembolization syndrome. In conclusion, a careful preoperative evaluation of SAAs by high-resolution 3-dimensional computed tomography in liver transplant candidates, especially in those showing large portosystemic collaterals, is merited. Preventive treatment should be encouraged regardless of the size in order to avoid severe morbidity and mortality related to SAA rupture, and methods such as radiological and surgical interventions need to be individualized according to the location and number of SAAs. Liver Transpl 15:1535–1541, 2009. © 2009 AASLD.

Aim To describe the image findings and results of transcatheter arterial chemoembolization (TACE) or transcatheter arterial embolization (TAE) for treating primary hepatic angiosarcoma. Materials and methods A retrospective review of the electronic medical database from 2002 to 2007, revealed six patients with primary hepatic angiosarcoma confirmed by percutaneous liver biopsy. The computed tomography (CT) and angiography imaging findings, the TACE or TAE results, and the post-procedure course were evaluated in all patients. Results On CT and angiography, each tumour appeared as a solitary mass or as multiple nodules or masses with heterogeneously early and progressive enhancement. One of the two patients with tumour response to TACE died 8 months after initial presentation, and the remaining patient was still alive at the last follow-up 12 months after initial presentation. However, two patients with no response to TACE and two patients who underwent emergent TAE for tumour rupture died 1 week to 5 months (mean 2.1 months) after initial presentation. Conclusions Primary hepatic angiosarcoma appears as a solitary or multiple, hypervascular lesions with heterogeneously early and progressive enhancement on CT and angiography. Although TAE may be the primary procedure for achieving emergent bleeding control caused by the rupture of hepatic angiosarcomas, TACE may be effective for treating patients with a dominant hepatic angiosarcoma with or without intrahepatic metastases.

Objective: To evaluate the incidence, predictive factors, and clinical outcomes of angiographically negative acute arterial upper and lower gastrointestinal (GI) bleeding. Materials and Methods: From 2001 to 2008, 143 consecutive patients who underwent an angiography for acute arterial upper or lower GI bleeding were examined. Results: The angiographies revealed a negative bleeding focus in 75 of 143 (52%) patients. The incidence of an angiographically negative outcome was significantly higher in patients with a stable hemodynamic status (p < 0.001), or in patients with lower GI bleeding (p = 0.032). A follow-up of the 75 patients (range: 0-72 months, mean: 8 14 months) revealed that 60 of the 75 (80%) patients with a negative bleeding focus underwent conservative management only, and acute bleeding was controlled without rebleeding. Three of the 75 (4%) patients underwent exploratory surgery due to prolonged bleeding; however, no bleeding focus was detected. Rebleeding occurred in 12 of 75 (16%) patients. Of these, six patients experienced massive rebleeding and died of disseminated intravascular coagulation within four to nine hours after the rebleeding episode. Four of the 16 patients underwent a repeat angiography and the two remaining patients underwent a surgical intervention to control the bleeding. Conclusion: Angiographically negative results are relatively common in patients with acute GI bleeding, especially in patients with a stable hemodynamic status or lower GI bleeding. Most patients with a negative bleeding focus have experienced spontaneous resolution of their condition.

Objective To assess the effect of ipsilateral hepatic vein embolization (HVE) performed after portal vein embolization (PVE) on liver regeneration. Summary background data PVE induces shrinkage of the embolized lobe and compensatory enlargement of the non-embolized lobe, but it does not always induce sufficient liver regeneration. There was no effective method to accelerate liver regeneration in addition to PVE yet. Methods During a 1-year study period, preoperative HVE were performed on 12 patients who had shown limited liver regeneration after PVE awaiting right hepatectomy. The right hepatic vein was embolized with multiple coils after insertion of vena cava filters or vascular plugs. Results No HVE procedure-related complications occurred, but embolization of the wrong hepatic vein trunk occurred in 1 patient. The increase in blood liver enzymes after HVE was comparable with that after PVE alone. In 9 patients who underwent hepatectomy, the proportions of future liver remnant volume to total liver volume were 34.8% +/- 1.5% before PVE, 39.7% +/- 0.6% 1 to 2 weeks after PVE, 44.2% +/- 1.1% 2 weeks after HVE, and 64.5% +/- 6.2% 1 week after right hepatectomy. Cirrhotic livers showed lower regeneration rates following HVE after PVE and 1 patient underwent hepatectomy 17 months after HVE. Immunohistochemistry showed that apoptosis occurred more in the liver area affected by both PVE and HVE than in that affected by PVE alone. Conclusions Preoperative sequential application of PVE and HVE seems to be safe and effective in facilitating contralateral liver regeneration by inducing more severe liver damage than PVE alone.

Purpose To evaluate long-term outcomes of patients receiving percutaneous stent placement for cancer recurrence at the anastomotic hepaticojejunostomy site after curative or palliative biliary surgery. Materials and Methods Fourteen patients (mean age, 60.1 years; range, 43–81 years) who received stent placement for malignant biliary anastomotic recurrence were enrolled. The median interval between biliary surgery and stent placement was 21 months (range, 0.7–54 months). Technical success, complications, clinical success (ie, >30% decrease in serum bilirubin level 1 week after stent placement vs baseline), stent malfunction and management, stent patency, and patient survival were evaluated. Results The 14 patients received a total of 20 stents without procedure-related complications at the time of initial stent placement. Six patients each required two stents to drain both lobes of the liver. Clinical success was achieved in 10 patients (71%), and an additional two patients showed a decrease in total bilirubin level that was less than 30% versus baseline measurement. Stent malfunction occurred in 10 stents in seven patients (50%) and was managed with interventional procedures such as percutaneous transhepatic biliary drainage, balloon dilation, or a second biliary stent placement. Median overall stent patency was 5.0 months (range, 0.7–60 months), and median survival time was 10.0 months (range, 0.7–60 months). Conclusion Stent placement was feasible, safe, and effective in patients with cancer recurrence at the anastomotic hepaticojejunostomy site.