PERCUTANEOUS MANIPULATIONS OF THE BILIARY TRACT

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Metal Stent Outcomes • Clinical success – Serum bilirubin decreases 63-100% • Quality of survival – Solves hydration and K + loss problems – Physiological antegrade bile flow – Shortens hospitalization time • Stent patency — 58 to 93% over 3 - 12 months • Reintervention rate decreased vs plastic • Nitinol (78%) better 6 mo patency than Z- stents (30%) and tantalum (20%) – (Rossi P, JVIR, 1994) Lee KH. et al. Biliary intervention for cholangiocarcinoma. Abdominal Imaging. 29(5):581-9, 2004 Sep-Oct. PTFE COVERED STENTS FOR MALIGNANT <strong>BILIARY</strong> OBSTRUCTION • Prospective multicenter safety and efficacy trial in Europe • 42 pts -- 38 unilateral - 4 bilateral stents • Technical success 100% • 4/42 (10%) branch obstruction • 2/42 (5%) complications – Entry site bile leak (1) and hematoma (1) – Only 1 mild case of lab pancreatitis (not complication) • 8/41 (20%) 30 day mortality - none biliary • Median primary patency 138 days • 6/41 (15%) obstruction mean 106 days • 3, 6,12 mo primary patency 90%, 76%, 76% – Schoder M et al, Radiol 2002; 225:35-42 COVERED VS UNCOVERED STENTS DOES CANCER TYPE MATTER? • 73 patients with cancer – Covered stents (CS) 42, Uncovered stents (US) 31 • Cholangio ca 12, gb ca 22, pancreas ca 12 – 6 mo patency CS US • Overall 81% 50% – Mean time of patency CS US • Cholangio ca 15 mo 28 mo • Gb ca 13 mo 3 mo • Pancreas ca 12 mo 10 mo – Kawamoto H, Hepato-gastroenterology, 2005; 52(65): 1351-6 IR Management of Liver Transplant Complications • Most recipients will have a complication – Arterial • Thrombosis 6.8% (high mortality) • Steal 5.9% – Portal 1.8% – Caval
Biliary Complications of Liver Transplants Improvements in Dilation Technique • Possibly better with cutting balloon – 12 pts, 49 dilations with technical success of 100%, 90% 93% for primary, recurrent, and fail non-cutting balloon • Saad, WEA, JVIR, 2006 • Success much less at 12 months with arterial stenosis or occlusion – 0% with arterial problem – 45% with patent artery • Saad WEA, JVIR, 2005 Late Biliary Complications of LIVER TRANSPLANTS • Mechanisms – Ischemia • 85% associated with arterial problems – CMV infection – Cold ischemia >12 h • Lesions are diffuse, extensive – Chronic repeated dilations • Sludge, debris – Treatment: Flushing (percutaneous) or lithotripsy (endoscopic) or rheolytic (Loehr SP, AJR 2002) – Risks: Infection, sepsis Denys A, IR in the Management of Complications after Liver Transplantation Eur Radiol (2004) 14:431 TREATING REFRACTORY TRANSPLANT STENOSES JS – Age 1-12 LFTs always a little elevated • 8 patients -- 9 stenoses – 33 previous interventions • Dilation 27 • Prolonged catheters 3, surgery 1, metal stent 1, atherectomy 1 – 11 home made “Z-stent” plus gortex stent-grafts with gortex “tethers” • 2 left in 1 pt due to clinical deterioration, patent at autopsy • 9 planned for retrieval in 7 patients -- 8 stenoses – 9/9 retrieved successfully -- 2 with difficulty – 4/8 stenoses recur in 7 patients (40,90,90,90 %) » 1/7 to surgery » 6/7 observed, all still asymptomatic mean 12 mo later • 5 migrate or removed 1-3 months with reocclusion in all – Petersen B, JVIR 2000; 11:919-20 Dr J. Garcia Says Be a team, Play together, Forget yourself. Remember, Patients First Or maybe, Second After Love We are nothing If we do not Sacrifice Some part Of ourself To every song We sing
Page 1 and 2: Cancer of the Pancreas PERCUTANEOUS
Page 3 and 4: Percutaneous Transhepatic Cholangio
Page 5 and 6: GG - PSC Progressive worsening LFTs
Page 7 and 8: 11/13/03 Laparoscopic cholecystecto
Page 9: PTCB DOING THE ERCP THING • Stone

PERCUTANEOUS MANIPULATIONS OF THE BILIARY TRACT

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