AIM: To determine utility of transplant liver biopsy in evaluating efficacy of percutaneous transluminal angioplasty(PTA) for hepatic venous obstruction(HVOO). METHODS: Adult liver transplant patients treated with PTA...AIM: To determine utility of transplant liver biopsy in evaluating efficacy of percutaneous transluminal angioplasty(PTA) for hepatic venous obstruction(HVOO). METHODS: Adult liver transplant patients treated with PTA for HVOO(2003-2013) at a single institution were reviewed for pre/post-PTA imaging findings, manometry(gradient with right atrium), presence of HVOO on prePTA and post-PTA early and late biopsy(EB and LB, < or > 60 d after PTA), and clinical outcome, defined as good(no clinical issues, non-HVOO-related death) or poor(surgical correction, recurrent HVOO, or HVOOrelated death). RESULTS: Fifteen patients meeting inclusion criteria underwent 21 PTA, 658 ± 1293 d after transplant.In procedures with pre-PTA biopsy(n = 19), no difference was seen between pre-PTA gradient in 13/19 procedures with HVOO on biopsy and 6/19 procedures without HVOO(8 ± 2.4 mm Hg vs 6.8 ± 4.3 mm Hg; P = 0.35). Post-PTA, 10/21 livers had EB(29 ± 21 d) and 9/21 livers had LB(153 ± 81 d). On clinical follow-up(392 ± 773 d), HVOO on LB resulted in poor outcomes and absence of HVOO on LB resulted good outcomes. Patients with HVOO on EB(3/7 good, 4/7 poor) and no HVOO on EB(2/3 good, 1/3 poor) had mixed outcomes. CONCLUSION: Negative liver biopsy greater than 60 d after PTA accurately identifies patients with good clinical outcomes.展开更多
The onset of hepatic decompensation in cirrhosis heralds an accelerated downhill course with poor outcome. The sole predictor of this decompensationin cirrhosis is increased hepatic vein to portal vein gradient hepati...The onset of hepatic decompensation in cirrhosis heralds an accelerated downhill course with poor outcome. The sole predictor of this decompensationin cirrhosis is increased hepatic vein to portal vein gradient hepatic venous pressure gradient(HVPG). Surrogate markers of liver function or hepatic reserve appear to be less relevant. The hepatic sinusoids become less elastic and more rigid as liver fibrosis and cirrhosis progress. We propose that the HagenPoiseuille's law,which applies to rigid,but not elastic vessels,determines the pressure-flow characteristics in the sinusoids. In the rigid cirrhotic liver,HVPG rises dramatically with any change in net surface area or radius,r4 of the vasculature that follows surgical resection. This review relates liver stiffness to the risk of decompensation in patients with cirrhosis. The liver has a unique dual blood supply comprising a low pressure portal vein and high pressure hepatic artery. We compare the complexity of autoregulation in the normal elastic liver with that in the rigid cirrhotic liver. Therapeutic modalities to reduce portal pressure may reduce the risk of hepatic decompensation and improve outcomes in cirrhosis.展开更多
文摘AIM: To determine utility of transplant liver biopsy in evaluating efficacy of percutaneous transluminal angioplasty(PTA) for hepatic venous obstruction(HVOO). METHODS: Adult liver transplant patients treated with PTA for HVOO(2003-2013) at a single institution were reviewed for pre/post-PTA imaging findings, manometry(gradient with right atrium), presence of HVOO on prePTA and post-PTA early and late biopsy(EB and LB, < or > 60 d after PTA), and clinical outcome, defined as good(no clinical issues, non-HVOO-related death) or poor(surgical correction, recurrent HVOO, or HVOOrelated death). RESULTS: Fifteen patients meeting inclusion criteria underwent 21 PTA, 658 ± 1293 d after transplant.In procedures with pre-PTA biopsy(n = 19), no difference was seen between pre-PTA gradient in 13/19 procedures with HVOO on biopsy and 6/19 procedures without HVOO(8 ± 2.4 mm Hg vs 6.8 ± 4.3 mm Hg; P = 0.35). Post-PTA, 10/21 livers had EB(29 ± 21 d) and 9/21 livers had LB(153 ± 81 d). On clinical follow-up(392 ± 773 d), HVOO on LB resulted in poor outcomes and absence of HVOO on LB resulted good outcomes. Patients with HVOO on EB(3/7 good, 4/7 poor) and no HVOO on EB(2/3 good, 1/3 poor) had mixed outcomes. CONCLUSION: Negative liver biopsy greater than 60 d after PTA accurately identifies patients with good clinical outcomes.
文摘The onset of hepatic decompensation in cirrhosis heralds an accelerated downhill course with poor outcome. The sole predictor of this decompensationin cirrhosis is increased hepatic vein to portal vein gradient hepatic venous pressure gradient(HVPG). Surrogate markers of liver function or hepatic reserve appear to be less relevant. The hepatic sinusoids become less elastic and more rigid as liver fibrosis and cirrhosis progress. We propose that the HagenPoiseuille's law,which applies to rigid,but not elastic vessels,determines the pressure-flow characteristics in the sinusoids. In the rigid cirrhotic liver,HVPG rises dramatically with any change in net surface area or radius,r4 of the vasculature that follows surgical resection. This review relates liver stiffness to the risk of decompensation in patients with cirrhosis. The liver has a unique dual blood supply comprising a low pressure portal vein and high pressure hepatic artery. We compare the complexity of autoregulation in the normal elastic liver with that in the rigid cirrhotic liver. Therapeutic modalities to reduce portal pressure may reduce the risk of hepatic decompensation and improve outcomes in cirrhosis.
