Downloaded from www.ajronline.org by 117.255.238.197 on 11/07/15 from IP address 117.255.238.197. Copyright ARRS. For personal use only; all rights reserved
1227
Case Report
Transcatheter Placement of a Metallic Stent for Treatment of an Occluded H-Graft Portacaval Shunt Juan
M. Pulido-Duque,1
Ellas
G#{244}rriz,1Ricardo
Reyes,1
Treatment of patients with portal hypertension and bleeding esophageal varices is one of the most complex problems in clinical medicine. The optimal therapeutic approach must be carefully selected, and detailed examination of the patient is of utmost importance [1 2]. Treatment options include both noninvasive and invasive (surgical and nonsurgical) procedures [1 -3]. The conventional end-to-side portacaval shunt was one of the first operations to be performed in such patients [4]. However, portacaval shunts are associated with a high risk of encephalopathy and hepatic failure caused by decreased portal flow [4]. In 1967, Warren et al. [5] described selective decompression of the portal system to preserve portal flow. In 1 980, Rypins and Sarfeh [6] reintroduced the concept of partial portal decompression; they used 1 0-mm portacaval grafts and ablation of portosystemic collateral vessels. Recently, the diameter of such “H grafts” has been decreased to 8 mm with good early hemodynamic results [2, 7]. However, early thrombosis of these smaller diameter grafts occurred in 1 5% of patients [7], and postoperative angiography and transcatheter recanalization of thrombosed grafts has become an important adjunctive procedure in these patients. We report a case of chronic occlusion of a small-diameter H-type portacaval shunt successfully treated with transcatheter recanalization and placement of a metallic stent. ,
Case Report A 47-year-old man had liver cirrhosis, portal hypertension, and esophageal varices grades IlI-IV. The patient had a history of recur-
Hector
Ferral,2
rent
upper
and
Manuel
gastrointestinal
recurred.
1992 0361 -803X/92/1596-1
227 © American
bleeding
that
had
been
treated
with
An angiogram
obtained
via a femoral
vein
approach
showed
severe stenosis in the proximal anastomosis of the portacaval shunt. The shunt was selectively catheterized and dilated with a 6-mm angioplasty balloon, with good results. After the procedure, the pressure gradient through the graft was less than 1 0 mm Hg. Eight months later, the patient had another episode of variceal bleeding. Because he was not considered a good candidate for surgery, the patient was referred for angiographic evaluation and possible percutaneous treatment of graft failure. The Gore-Tex portacaval shunt was occluded (Fig. 1A). Injection of contrast
material
into
the
superior
mesenteric
vein
showed
occlu-
sion of the portal vein with reconstitution of the intrahepatic portal branches via collaterals. Extensive gastric and esophageal varices were present. Recanalization of the thrombosed segment of the graft was achieved by using a Sidewinder catheter (Medi-tech Inc., Watertown, MA) and a Terumo guidewire (Terumo Corp., Tokyo, Japan). Subsequently, the stenosed segment was dilated by using 5- and 8-mm angioplasty balloons; however, the results were poor (Fig. 1 B). For this reason, it was decided to place a self-expandable metallic stent (Wallstent, Schneider Inc., Minneapolis, MN) 1 0 mm in diameter and 42 mm long. After the procedure, angiograms showed complete recanalization of the portacaval shunt and excellent flow of contrast material into the inferior vena cava (Fig. 1 C). The portosystemic gradient, which was 29 mm Hg before the procedure, decreased to 15 mm Hg after placement of the stent. No significant pressure gradient was found along the inferior vena cava.
Received March 16. 1992: accepted after revision May 27, 1992. 1 Department of Radiology, Hospital Nuestra Se#{241}ora del Pino, 35004 Las Palmas, Canary Islands, Spain. Department of Radiology, Box 292 UMHC, Room J2-564, The University of Minnesota Hospital and Clinic, December
tract
scierotherapy. He also had ascites and portal hypertensive gastropathy. Sclerotherapy was attempted unsuccessfully. A side-to-side portacaval shunt with a Gore-Tex interposition graft (10 mm in diameter, 5 cm long) was constructed. Five months after surgery, upper gastrointestinal tract bleeding
2
AJR 159:1227-1228,
Maynar1
Roentgen
Ray Society
420 Delaware
St. SE.,
Minneapolis,
MN 55455.
PULIDO-DUQUE
1228
ET AL.
AJR:159, December
1992
I
.
Downloaded from www.ajronline.org by 117.255.238.197 on 11/07/15 from IP address 117.255.238.197. Copyright ARRS. For personal use only; all rights reserved
‘t
I
Fig. 1.-Occlusion A, Superior
esophageal
‘‘
r’
of a surgical
mesenteric
portacaval
phlebogram
varices. Gore-Tex
shows
shunt in a 47-year-old occlusion
The
patient’s
clinical
examination
man.
vein with reconstitution
of intrahepatic
portal
vein branches.
Note extensive
gastric
and
graft did not opacity.
B, Superior mesenteric phlebogram obtained C, Phlebogram obtained after stent placement
At follow-up
of portal
condition
6 months
was
excellent
after balloon dilatation shows persistent narrowing of graft. shows excellent flow through stent into inferior vena cava.
after
later, the patient
the
procedure.
was still asymp-
tomatic.
Discussion Surgical portosystemic shunting plays a critical role in the treatment of patients with bleeding esophageal varices [8], and several surgical options are available. Different studies have found various degrees of operative mortality and postoperative shunt thrombosis, encephalopathy, and recurrent bleeding [8]. Recently, small-diameter H-graft shunts have been used with increasing frequency [2, 6, 7]. One of the most common early complications with this procedure is graft thrombosis, which occurs in 1 1 -1 5% of patients [2, 7]. This high prevalence has given the interventional radiologist an opportunity to have an active role in the diagnosis and treatment of this complication [2, 6, 7], because surgical correction of the problem is difficult and these patients are usually poor candidates for surgery [2]. Balloon dilatation of stenotic surgically created portacaval shunts has been performed with various degrees of success. Occluded shunts have been treated percutaneously by using fibrinolytic agents and balloon dilatation. Fibrinolytic therapy, however, must be monitored carefully in these patients because of the increased risk of bleeding from esophageal varices or retroperitoneal hemorrhage. In our case, balloon angioplasty was initially used to recanalize an occluded H graft, and, months later, because of reocclusion, a metallic stent was successfully placed across the H graft. We think that the placement of metallic stents through these surgically created portacaval shunts is an adequate treatment, as resuIts with these metallic stents in other areas of the vascular
system have been good [3, 9, 1 0]. The Wallstent prosthesis was chosen because of its flexibility and adaptability to tortuous blood vessels, which were an important feature in our case. The results in our case were extremely good, with establishment of blood flow across the portosystemic shunt and satisfactory portosystemic pressure gradient after stent placement. The long-term patency rate of the Wallstent prosthesis in this specific problem is unknown, and further clinical experience with similar cases will be needed in order to define the role of this technique in clinical practice.
REFERENCES 1 . Galambos JT. Evaluation of patients with portal hypertension. Am J Surg 1990;160:14-18 2. Rosemurgy AS, McAllister EW, Keamey RE. Prospective study of a prosthetic
H-graft
portocaval
shunt.
Am J Surg
1991
1 61 :159-164
3. Zemel G, Katzen BT, Becker GJ, Benenati JF, Sallee S. Percutaneous transjugular portosystemic shunt. JAMA 1991;266:390-393 4. Orozco H, Mercado MA, Takahashi T, et al. Role of the distal splenorenal shunt in management of variceal bleeding in Latin America. Am J Surg 1990;160:86-89 5. Warren WD, Zeppa A, Famon JJ. Selective transsplenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann Surg 1967: 166:437-455
6. Rypins EB, Sarfeh lJ. Influence
of portal hemodynamics
on long term
of alcoholic cirrhotic patients after small diameter portacaval Hgrafts. Am J Surg 1988:155:152-158 7. Rypins EB, Sarfeh lJ. Small diameter portacaval H-graft for variceal hemorrhage. Surg Clin North Am 1990:70:395-404 survival
8. Langer B, Taylor
BR, Greig PD. Selective or total shunts for variceal 1990;160:75-79 9. Gunther RW, Vorwerk D, Bohndorf K, Peters I, El-Din A, Messmer B. Iliac and femoral artery stenoses and occlusions: treatment with intravascular stents. Radiology 1989;172:725-730 10. Rees CR, Palmaz JC, Garcia 0, et al. Angioplasty and stenting of campletely occluded iliac arteries. Radiology 1989:172:953-959 bleeding.
Am J Surg
1227
Case Report
Transcatheter Placement of a Metallic Stent for Treatment of an Occluded H-Graft Portacaval Shunt Juan
M. Pulido-Duque,1
Ellas
G#{244}rriz,1Ricardo
Reyes,1
Treatment of patients with portal hypertension and bleeding esophageal varices is one of the most complex problems in clinical medicine. The optimal therapeutic approach must be carefully selected, and detailed examination of the patient is of utmost importance [1 2]. Treatment options include both noninvasive and invasive (surgical and nonsurgical) procedures [1 -3]. The conventional end-to-side portacaval shunt was one of the first operations to be performed in such patients [4]. However, portacaval shunts are associated with a high risk of encephalopathy and hepatic failure caused by decreased portal flow [4]. In 1967, Warren et al. [5] described selective decompression of the portal system to preserve portal flow. In 1 980, Rypins and Sarfeh [6] reintroduced the concept of partial portal decompression; they used 1 0-mm portacaval grafts and ablation of portosystemic collateral vessels. Recently, the diameter of such “H grafts” has been decreased to 8 mm with good early hemodynamic results [2, 7]. However, early thrombosis of these smaller diameter grafts occurred in 1 5% of patients [7], and postoperative angiography and transcatheter recanalization of thrombosed grafts has become an important adjunctive procedure in these patients. We report a case of chronic occlusion of a small-diameter H-type portacaval shunt successfully treated with transcatheter recanalization and placement of a metallic stent. ,
Case Report A 47-year-old man had liver cirrhosis, portal hypertension, and esophageal varices grades IlI-IV. The patient had a history of recur-
Hector
Ferral,2
rent
upper
and
Manuel
gastrointestinal
recurred.
1992 0361 -803X/92/1596-1
227 © American
bleeding
that
had
been
treated
with
An angiogram
obtained
via a femoral
vein
approach
showed
severe stenosis in the proximal anastomosis of the portacaval shunt. The shunt was selectively catheterized and dilated with a 6-mm angioplasty balloon, with good results. After the procedure, the pressure gradient through the graft was less than 1 0 mm Hg. Eight months later, the patient had another episode of variceal bleeding. Because he was not considered a good candidate for surgery, the patient was referred for angiographic evaluation and possible percutaneous treatment of graft failure. The Gore-Tex portacaval shunt was occluded (Fig. 1A). Injection of contrast
material
into
the
superior
mesenteric
vein
showed
occlu-
sion of the portal vein with reconstitution of the intrahepatic portal branches via collaterals. Extensive gastric and esophageal varices were present. Recanalization of the thrombosed segment of the graft was achieved by using a Sidewinder catheter (Medi-tech Inc., Watertown, MA) and a Terumo guidewire (Terumo Corp., Tokyo, Japan). Subsequently, the stenosed segment was dilated by using 5- and 8-mm angioplasty balloons; however, the results were poor (Fig. 1 B). For this reason, it was decided to place a self-expandable metallic stent (Wallstent, Schneider Inc., Minneapolis, MN) 1 0 mm in diameter and 42 mm long. After the procedure, angiograms showed complete recanalization of the portacaval shunt and excellent flow of contrast material into the inferior vena cava (Fig. 1 C). The portosystemic gradient, which was 29 mm Hg before the procedure, decreased to 15 mm Hg after placement of the stent. No significant pressure gradient was found along the inferior vena cava.
Received March 16. 1992: accepted after revision May 27, 1992. 1 Department of Radiology, Hospital Nuestra Se#{241}ora del Pino, 35004 Las Palmas, Canary Islands, Spain. Department of Radiology, Box 292 UMHC, Room J2-564, The University of Minnesota Hospital and Clinic, December
tract
scierotherapy. He also had ascites and portal hypertensive gastropathy. Sclerotherapy was attempted unsuccessfully. A side-to-side portacaval shunt with a Gore-Tex interposition graft (10 mm in diameter, 5 cm long) was constructed. Five months after surgery, upper gastrointestinal tract bleeding
2
AJR 159:1227-1228,
Maynar1
Roentgen
Ray Society
420 Delaware
St. SE.,
Minneapolis,
MN 55455.
PULIDO-DUQUE
1228
ET AL.
AJR:159, December
1992
I
.
Downloaded from www.ajronline.org by 117.255.238.197 on 11/07/15 from IP address 117.255.238.197. Copyright ARRS. For personal use only; all rights reserved
‘t
I
Fig. 1.-Occlusion A, Superior
esophageal
‘‘
r’
of a surgical
mesenteric
portacaval
phlebogram
varices. Gore-Tex
shows
shunt in a 47-year-old occlusion
The
patient’s
clinical
examination
man.
vein with reconstitution
of intrahepatic
portal
vein branches.
Note extensive
gastric
and
graft did not opacity.
B, Superior mesenteric phlebogram obtained C, Phlebogram obtained after stent placement
At follow-up
of portal
condition
6 months
was
excellent
after balloon dilatation shows persistent narrowing of graft. shows excellent flow through stent into inferior vena cava.
after
later, the patient
the
procedure.
was still asymp-
tomatic.
Discussion Surgical portosystemic shunting plays a critical role in the treatment of patients with bleeding esophageal varices [8], and several surgical options are available. Different studies have found various degrees of operative mortality and postoperative shunt thrombosis, encephalopathy, and recurrent bleeding [8]. Recently, small-diameter H-graft shunts have been used with increasing frequency [2, 6, 7]. One of the most common early complications with this procedure is graft thrombosis, which occurs in 1 1 -1 5% of patients [2, 7]. This high prevalence has given the interventional radiologist an opportunity to have an active role in the diagnosis and treatment of this complication [2, 6, 7], because surgical correction of the problem is difficult and these patients are usually poor candidates for surgery [2]. Balloon dilatation of stenotic surgically created portacaval shunts has been performed with various degrees of success. Occluded shunts have been treated percutaneously by using fibrinolytic agents and balloon dilatation. Fibrinolytic therapy, however, must be monitored carefully in these patients because of the increased risk of bleeding from esophageal varices or retroperitoneal hemorrhage. In our case, balloon angioplasty was initially used to recanalize an occluded H graft, and, months later, because of reocclusion, a metallic stent was successfully placed across the H graft. We think that the placement of metallic stents through these surgically created portacaval shunts is an adequate treatment, as resuIts with these metallic stents in other areas of the vascular
system have been good [3, 9, 1 0]. The Wallstent prosthesis was chosen because of its flexibility and adaptability to tortuous blood vessels, which were an important feature in our case. The results in our case were extremely good, with establishment of blood flow across the portosystemic shunt and satisfactory portosystemic pressure gradient after stent placement. The long-term patency rate of the Wallstent prosthesis in this specific problem is unknown, and further clinical experience with similar cases will be needed in order to define the role of this technique in clinical practice.
REFERENCES 1 . Galambos JT. Evaluation of patients with portal hypertension. Am J Surg 1990;160:14-18 2. Rosemurgy AS, McAllister EW, Keamey RE. Prospective study of a prosthetic
H-graft
portocaval
shunt.
Am J Surg
1991
1 61 :159-164
3. Zemel G, Katzen BT, Becker GJ, Benenati JF, Sallee S. Percutaneous transjugular portosystemic shunt. JAMA 1991;266:390-393 4. Orozco H, Mercado MA, Takahashi T, et al. Role of the distal splenorenal shunt in management of variceal bleeding in Latin America. Am J Surg 1990;160:86-89 5. Warren WD, Zeppa A, Famon JJ. Selective transsplenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann Surg 1967: 166:437-455
6. Rypins EB, Sarfeh lJ. Influence
of portal hemodynamics
on long term
of alcoholic cirrhotic patients after small diameter portacaval Hgrafts. Am J Surg 1988:155:152-158 7. Rypins EB, Sarfeh lJ. Small diameter portacaval H-graft for variceal hemorrhage. Surg Clin North Am 1990:70:395-404 survival
8. Langer B, Taylor
BR, Greig PD. Selective or total shunts for variceal 1990;160:75-79 9. Gunther RW, Vorwerk D, Bohndorf K, Peters I, El-Din A, Messmer B. Iliac and femoral artery stenoses and occlusions: treatment with intravascular stents. Radiology 1989;172:725-730 10. Rees CR, Palmaz JC, Garcia 0, et al. Angioplasty and stenting of campletely occluded iliac arteries. Radiology 1989:172:953-959 bleeding.
Am J Surg
