Intra-arterial thrombolysis for early hepatic artery thrombosis after liver transplantation

BACKGROUND Early hepatic artery thrombosis(E-HAT)is a serious complication after liver transplantation(LT),which often results in graft failure and can lead to patient deaths.Treatments such as re-transplantation and re-anastomosis are conventional therapeutic methods which are restricted by the shortage of donors and the patient’s postoperative intolerance to re-laparotomy.Due to the advances in interventional techniques and thrombolytics,endovascular treatments are increasingly being selected by more and more centers.This study reviews and reports our single-center experience with intra-arterial thrombolysis as the first choice therapy for E-HAT after deceased donor LT.AIM To evaluate the feasibility and reasonability of intra-arterial thrombolysis for EHAT after deceased donor LT.METHODS A total of 147 patients who underwent deceased donor LT were retrospectively reviewed in our hospital between September 2011 and December 2016.Four patients were diagnosed with E-HAT.All of these patients underwent intraarterial thrombolysis with alteplase as the first choice therapy after LT.The method of arterial anastomosis and details of the diagnosis and treatment of EHAT were collated.The long-term prognosis of E-HAT patients was also recorded.The median follow-up period was 26 mo(range:23 to 30 mo).RESULTS The incidence of E-HAT was 2.7%(4/147).E-HAT was considered when Doppler ultrasonography showed no blood flow signals and a definite diagnosis was confirmed by immediate hepatic arterial angiography when complete occlusion of the hepatic artery was observed.The patients were given temporary thrombolytics(mainly alteplase)via a 5-Fr catheter which was placed in the proximal part of the thrombosed hepatic artery followed by continuous alteplase using an infusion pump.Alteplase dose was adjusted according to activated clotting time.The recanalization rate of intra-arterial thrombolysis in our study was 100%(4/4)and no thrombolysis-related mortality was observed.During the follow-up period,patient survival rate was 75%(3/4),and biliary complications were present in 50%of patients(2/4).CONCLUSION Intra-arterial thrombolysis can be considered first-line treatment for E-HAT after deceased donor LT.Early diagnosis of E-HAT is important and follow-up is necessary even if recanalization is successful.

Predictors of inaccurate coronary arterial stenosis assessment by CT angiography

ABSTRACT Objectives This study sought to investigate the clinical and imaging characteristics associated with diagnostic inaccuracy of computed tomography angiography （CTA） for detecting obstructive coronary artery disease （CAD） defined by quantitative coronary angiography （QCA）.

Angiographic Findings of Extrahepatic Branches Originating from Hepatic Artery and Its Clinical Significance

Objective： To observe the presentation and variation of extrahepatic branches originating from hepatic artery by hepatic arteriography. Methods： Hepatic arteriogram of 200 cases with unresectable hepatic primary or metastatic tumors before interventional therapy were retrospectively analyzed. Two interventional radiologists independently reviewed the type, originating artery, distribution and variation of extrahepatic artery. Results： Five types of extrahepatic artery were found, with the most common type of the right gastric artery （n=156, 78%）, followed by the cystic artery （n=126, 63%）, accessory left gastric artery （n=19, 9.5%）, hepatic falciform artery （n=5, 2.5%）, and accessory left inferior phrenic artery （n=4, 2%）. In 188 cases, there were extrahepatic arteries derived from hepatic proper artery or its branches, and the most frequent originating site was the right hepatic artery （130 extrahepatic branches）, followed by the proper hepatic artery （103 branches）, left hepatic artery （56 branches） and middle hepatic artery （3 branches）. The left hepatic artery was the arising site with the multiple types of extrahepatic branches including all above branches except the cystic artery. Conclusion： Many types of extrahepatic branches usually derive from the hepatic artery or its distal branches, and its originating sites are not constant. It is important to avoid damage of extrahepatic tissue during interventional therapy for liver tumors.

CLINICAL APPLICATION OF INTRACORONARY STENTING

Intracoronary stents were implanted in 61 patients(58 males and 3females,aged 52.1±8.3 years) with coronary heart disease in thishospital from June 1995 to May 1998.Seventy-two intracoronary stents (12Palmaz-Schatz.8 OR-I,45 Multilink,6 NIR and 1 Wiktor-i) were implanted,45 in LAD(62.5% ),22 in RCA(30.6%) and 5 in LCX(6.9%),Indications forstenting included 30 de novo(41.6%).4 bail-out(5.6%)and 38 Suboptimal(52.8%)stenting.The procedure success rate was 100%.Averagediameterstenosis decreased from 75-100% to -10-10% after stenting.There was one death from subacute stent thrombosis Two cases hadhematoma at the pancture site.There were no complication of acutethrombosis,cerebral hemorrhage and emergency CABG.During 1-36 monthsfollow-up,6 cases had relapse of chest pain,incinding 4 case ofrestenosis proved by argiography.Coronary stenting is a successfulmeans for atent"stand-by" and bail-out procedure for balloon angioplasty.Optimal angiographic results can be achieved in the majority ofpatients by proper stent sizing and deployment techniques.Anticoagulation should be given according to the characteristics oflesions and post-stenting angiographic findings so as to reducevascular and bleeding complications as well as hospital stay followingcoronary angioplasty.The results suggest that intracoronary stentinghas high success rate and low restenosis rate.It is an effective andsafe interventional therapy for acute coronary closure or selected denovo complex lesions following PTCA.

COLOR FLOW IMAGING OF HEPATIC CARCINOMA

Color flow imaging(CFI)ultrasound technique can discover the tumor vascularity and superimposed it to convontional B-mode ultrasonogram in real-time. The flow velocity on spectral Doppler sonogram can be measured by setting the sample volume to any selected site.One hundred and thirty-six patients with solid hepatic space-occupied lesions had been admitted and 113 cases were confirmed by operation and pathology,23 patients were strongly suspected by hepatic angiography (HAA).Ninety nine patients with 109 nodules were finally diagnosed as hepatic cellular carcinoma(HCC).According to color flow distribution pattern,3 kinds of color configuation had been nominated.Tumor vascularity discovered by CFI,especially the arterial blood flow was easy to be recognized,and its emerge rate was quite different between HCC group(94.5%)and hemangioma(HCH)group(17.07%)(P<0.01).Spectral Doppler studies were also carried out in these cases and the detectability of arterial flow in HCC group(95.41%)was much higher than that to HCH group (21. 95%) (P<0. 005).Resistant index(RI)and pulsatile index(PI)could be used to differentiate HCC (>0. 50 and >0.80 respectively)from HCH (P<0.001 and P<0.001 respectively).Arterial-portal(A-P) shunt could also be detected by CFI and spectral Doppler(mostly its Vmax>0.6m/s).The detection rate of A-P shunt was 64% in HCC group,but no case could be detected in HCH group.

Sirolimus-eluting Stent for the Treatment of Small Coronary Artery Lesions:Comparison between Cypher and Firebird Stent

Objectives To evaluate the effectiveness of firebird stent for the treatment of coronary de novo lesion compared with cypher stent. Methods Ninety-one consecutive patients with 156 lesions who underwent coronary cypher (n = 68 lesions) and firebird (n = 88 lesions) implantation, quantitative coronary angiography (QCA) was performed at the time of stent implantation and subsequently at 8 months post-stenting. Small vessel disease was defined as ≤2.5 mm of reference vessel diameter measured by QCA. Major adverse cardiac events (MACE) including death, thrombosis, nonfatal myocardial infarction and target lesion revascularization (TLR) were compared between the two groups. Results Baseline clinical characteristics and angiographic parameters were similar between the two groups. Seven-month angiographic follow-up, the late loss was not different between the two groups (0.14 ± 0.38 mm vs 0.13 ± 0.17 mm, P > 0.05). Similarly, overall thrombosis rate were similar in both groups (1.5% vs 1.1%, P > 0.05). However, in-stent restenosis as well as in-segment restenosis rate were significantly higher in cypher group than that in firebird group (4.4% vs 0% and 19.1% vs 3.4%, P = 0.047 and P = 0.001 respectively). TLR was also higher in the cypher group (10.3% vs 2.3%, P = 0.033) compared with firebird group. Conclusions In this small sample size, non-randomized study, the data indicated that implantation of firebird stent for the treatment of small coronary lesion showed more favorable results in respective of restenosis compared with cypher stent implantation. A multi-center, large-sample size, randomized study, therefore, may be warranted.

Study of Coronary Artery Disease in Single Aortic Valvular Disease

Objectives To analyze the results of coronary angiographies (CAG) in patients with single aortic valvular heart disease; To study the relationship between aortic valve diseases and coronary artery disease (CAD). Methods 105 patients with single aortic valvular heart disease before surgery underwent angiography. The data of clinical characteristics and angiographies were analyzed. Results 51 patients had symptoms of angina pectoris among 105 patients with single aortic valvular heart disease. Seven of them were confirmed coronary artery disease by angiographies. Although the incidence of angina in aortic valve stenosis group was significantly higher than that in aortic valve regurgitation, the probability of combination of CAD in aortic valve stenosis group was similar to the later. However, the probability of combination of CAD in degenerative aortic valve group was significantly higher than the groups of rheumatic, congenitally bicuspid aortic valves, and other causes (p < 0.01 ). Conclusions Angina pectoris is not sensitive for diagnosis of CAD in single aortic valve heart disease. The probability of combination of CAD in degenerative aortic valve disease is higher than that in aortic valve disease with other causes. Coronary angiography is strongly suggested for these patients.

The Evaluation of the Safety and Efficacy of Transradial Coronary Procedures

Objectives To evaluate the safety and efficacy of transradial coronary procedures （TRCP）. Methods The data of 83 cases who accepted transradial coronary angiography （CAG） and transradial percutaneous coronary intervention （PCI） in our department were summarized. The success rates, proximal coronary complications, peripheral vascular complications, severe vagal reflex, mean operation time （MOT）, mean recumbent time （MRT）, mean hospital-staying time （MHT） were analyzed. The data were compared with that of 420 cases of transfemoral coronary procedures （TFCP） in the same period. Results Success rates and proximal coronary complications were similar in both groups. Severe vagal reflexes were less in TRCP group than in TFCP group. MOT was longer in TRCP group. MRT and MHT were shorter in TRCP group. 12（14.5%） radial artery spasm, 3（3.6%） radial artery obstruction, 1 sudden respiratory arrest caused by jugular hematoma were observed in TRCP group. Conclusions The efficacy and safety of TRCP are definite. TRCP is more economical. For the purpose of properly evaluate the peripheral vascular complications of TRCP, it is necessary to pay special attention to radial artery occlusion, radial artery stenosis, and jugular hematoma.

Randomized study on the safety and efficacy of dual-axis rotational versus standard coronary angiography in the Chinese population

Background Dual-axis rotational coronary angiography （DARCA） was developed as an innovative adaptation of rotational angiography （RA）, but it requires a longer coronary injection compared to standard coronary angiography （SA）. As the body of the average Chinese patient is smaller than that of most western patients, with the same contrast injection time, the risk of complications from the contrast agent is increased in this population. The purpose of this study was to assess the clinical safety and efficacy of DARCA in the diagnosis of coronary artery disease （CAD） in the Chinese population by directly comparing it to SA. Methods Two hundred Chinese patients were randomized to either the SA group （n=100） or DARCA group （n=100）. Contrast utilization, radiation exposure and procedure time were recorded for each modalities. Blood pressure （BP）, heart rate （HR） pre and post injection symptoms and any arrhythmias were recorded. Results Compared to the SA group, there was a 42% reduction in contrast utilization, 55% reduction in radiation exposure and a 31% shorter procedure time in the DARCA group. In both groups, there were slight declines in the systolic BP values in the left coronary artery （LCA） post injection （P 〈0.01）. Moreover, post injection HRs for the LCA were also reduced in the DARCA group （P 〈0.01）. But all of these changes were small, transient and without clinical importance. Only one patient （1%） in the DARCA group had an attack of ventricular tachycardia immediately post injection and it resolved by itself during LCA angiography. No arrhythmias occurred in the SA group. Conclusion DARCA is a safe, efficient, and clinically comparable alternative to SA in the diagnosis of coronary artery disease in the Chinese population with less contrast utilized, which is less radiation exposure and a shorter procedure

Correlation among obstructive sleep apnea syndrome,coronary atherosclerosis and coronary heart disease

Epidemiologic investigations have shown that the morbidity of obstructive sleep apnea syndrome （OSAS） among adults is 2%-4%, among the population aged 30 years and over is 4.63%, and among patients with hypertension or coronary atherosclerostic disease （CAD） is as high as 30%-50%.1 Many studies have indicated that OSAS may be closely associated with the development of CAD since increased incidence and mortality of CAD were found in OSAS patients. However, although it has been confirmed that OSAS is an independent risk factor for hypertension, its exact correlation with CAD has not been entirely elucidated. The aim of the present study was to explore the correlation between the degrees of OSAS and CAD with the application of coronary artery angiography （CAA）, Gensini scoring evaluation system, and other risk factors which may contribute to CAD.

Coronary angiographies of patients with recurrent acute coronary syndrome following coronary artery bypass grafting

Coronary artery bypass grafting (CABG) is considered as a more complete means of revascularization than percutaneous coronary intervention (PCI). However, acute coronary syndrome (ACS) can still occur after CABG. The culprit vessel can be the graft vessel or the native vessel. Many questions remain unanswered in the Chinese literature regarding this topic: what are the short- and long-term pathological changes that induce ACS? Is there any difference between arterial and venous grafts with respect to the frequency of restenosis? Are there any patterns of ACS-related vessels in different periods after CABG? We aim to answer these fundamental questions by analyzing coronary angiographies of patients with recurrent ACS following CABG and provide evidence for reducing post-CABG restenosis.