Combined splenocaval or mesocaval C shunt and portoazygous devascularization in the treatment of portal hypertension: analysis of 150 cases

BACKGROUND: Portal hypertension is a common disease and its major surgical therapeutic approaches include devascularization and shunting. This study was undertaken to investigate the effects of combined splenocaval or mesocaval C shunt and portoazygous devascularization (combined procedures) on portal hypertension. METHODS: The clinical data of 150 patients with portal hypertension who had undergone combined procedures at the First Affiliated Hospital of Zhengzhou University from May1990 to May 2003 were analyzed retrospectively. RESULTS: The mean free portal pressure (FPP) was 25.6±1.83 mmHg, 18.0±2.07 mmHg and 18.4±2.19 mmHg before operation, after splenectomy plus splenocaval or mesocaval C shunt, and combined procedures, respectively. There was no operative death in all patients. The 1-7 year follow-up of 100 patients showed rebleeding in 3 patients, encephalopathy in 4, thrombosis of artificial vascular graft in 3, and dying from liver failure in 2. CONCLUSIONS: The combined procedures can not only decrease portal pressure but also preserve hepatic blood flow to some extent. It may be one of the best choices for treating portal hypertension in China.

Management of severe Budd-Chiari syndrome:report of 147 cases

BACKGROUND:Budd-Chiari syndrome (BCS) is an un- common disorder caused by the obstruction of hepatic ve- nous outflow and/or the inferior vena cava. Major thera- peutic approaches include operation and radiological inter- vention. This study was conducted to investigate the treat- ment of severe BCS. METHODS: The clinical data of 147 patients with severe BCS who had been treated at our hospital from November 1994 to December 2003 were retrospectively analyzed. RESULTS: One hundred twenty-one patients with BCS un- derwent surgery, including mesocaval C type shunt with ar- tificial graft (82 patients), splenojugular shunt (37), meso- jugular shunt (2), percutaneous transhepatic recanalization and dilatation and/or stent placement of the main hepatic vein (MHV) (12), and combined percutaneous transhepa- tic angioplasty (PTA) and stent placement of the inferior vena cava and mesocaval shunt (14). Follow-up for 6-108 months showed excellent results in 102 patients (69.4%), good results in 40 (27.2% ), and 5 deaths. CONCLUSION: Good results could be obtained in most of patients with BCS after different surgical treatments accord- ing to the pathological changes of the IVC and MHV.

Role of precoating in artificial vessel endothelialization

As the progress of vascular surgery, artificial vessels have become the substitute for large and middle diameter vessels but have not for small diameter ones owing to thrombogenesis and occlusion within a short period of time after being applied. Artificial vessel endothelialization is one of the ideal methods to resolve such issue and has been improved continuously since Herring in 1978 put forward this term in the first time and utilized vascular endothelial cells (ECs) harvested from living animals to perform the test of artificial vessel endothelialization. However, human endothelial cells show little adhesion to the currently available vascular graft materials and some expanded polytetrafluoroethylene (ePTFE) grafts have shown only 10%+/-7% endothelial cell attachment rate (ECA, ie, attachment of ECs when incubated in vitro). Moreover, when the graft is exposed to pulsatile blood flow, a high proportion of cells are washed off from the lumen. Maximum cell loss occurs in the first 30-45 min after exposure to pulsatile flow, with up to 70% of cells lost. After that, a slower exponential loss occurs over the next 24 h. The lack of retention of cells could be partly overcome by sodding, but other techniques, involving engineering the lumen to improve ECA and endothelial cell retention rate (ECR, ie, retention of ECs when the grafts are exposed to pulsatile flow) have been developed. These include shear stress preconditioning, electrostatic charging and, above all, most successfully to date, precoating with EC specific adhesive glues that are mostly found in the extracellular basement membrane of blood vessels. The commonest are chemical coatings, preclotting, chemical bonding, and surface modifications.

Small-diameter prosthetic H-graft portacaval shunts in the treatment of portal hypertension

Background Portasystemic shunts, especially total shunts, are effective tools for reducing portal pressure and controlling variceal bleeding but lead to high risk of encephalopathy and accelerating liver failure. The purpose of this study is to evaluate the clinical effects of small-diameter expanded polytetrafluoroethylene (ePTFE ) H-graft portacaval shunts in the treatment of portal hypertension.Methods Thirty-one patients with portal hypertension were treated with ePTFE small-diameter H-graft portacaval shunts from December 1995 to April 2002. Twenty-one had externally ringed grafts and 10 had non-ringed grafts; 20 had 10 mm diameter grafts and 11 had 8 mm grafts. The left gastric artery and coronary vein were ligated in 22 patients. Additionally, 6 patients underwent pericardial devascularization, and splenectomies were performed on 30 patients.Results An average decrease of free portal pressure (FPP) from (32. 13 ±4. 86) cmH2O before shunting to (12. 55 ±5. 57) cmH2O after shunting was observed. Portal blood flow was reduced by 1/3 compared with the levels measured before shunting. Twenty-eight patients survived after the operation, and no upper gastrointestinal rebleeding occurred in the follow-up period (40. 2 months on average). We lost contact with one patient. Color Doppler ultrasonography and/or portography revealed the shunts to be patent in 28 cases and occluded in 2 (6. 4%) cases. Encephalopathy developed in 4 patients (12. 9%).Conclusion Small-diameter ePTFE H-graft portacaval shunts can effectively reduce portal pressure. Moreover, the majority of the hepatopetal flow from the portal vein can be adequately maintained. The reinforced shunts may achieve a higher rate of patency. Morbidity from encephalopathy was less frequent than in pateints receiving total shunts. Small-diameter H-graft portacaval shunts are also effective in preventing recurrent variceal bleeding.

Aortic stent graft infection in a patient with Marfan syndrome

Endovascular repair of raptured abdominal aortic aneurysm （AAA） has been adopted clinically. It is especially suitable for the patients who are at high surgical risk or fulfil the technical requirements for endovascular therapy. The use of endoprostheses, however, may raise the risk of infection, as occurred in our AAA patient with Marfan syndrome who had stent-graft infection as a result of Salmonella choleraesuis.

Treatment of infrarenal abdominal aortic dissection concomitant with an aneurysm

Aortic dissection occurs when layers of the aortic ,walls are separated by the blood flow through an intimal tear. Dissection of the aorta most frequently originates in the ascending aorta （70%）, followed by the descending aorta （22%）, the aortic arch （7%） and the abdominal aorta （1/%）.1 The dissection limited to the abdominal aorta is rare.2 An isolated abdominal aortic dissection （IAAD） concomitant with an abdominal aortic aneurysm （AAA） is uncommon. We present here one patient with IAAD and AAA treated by endovascular therapy.

Partial portacaval shunt with H-grafts to treat portal hypertension

Partial portosystemic shunts have been popularized because of a reported low rate of mortality and morbidity(especially encephalopathy,liver failure and occlusion).The results of partial portacaval shunts[small-diameter expanded polytetrafluoroethylene(ePTFE)H-graft portacaval shunt]were retrospectively reviewed to evaluate the clinical efficacy in the treatment of portal hypertension.Forty-three patients with portal hypertension were treated by small-diameter H-graft of ePTFE portacaval shunt from May 1995 to April 2006.Thirty-three had externally ringed grafts and ten had non-ringed ones.Ten had grafts of 10 mm in diameter and 33 had grafts of 8 mm.The left gastric artery and coronary vein were ligated in all the cases.Six had pericardial devascularization and splenectomy was performed in 42.An average decrease of free portal pressure(FPP)from(33.24 P4.78)cmH2O before shunting and(13.65P5.65)cmH2O after shunting was observed.The portal blood flow was reduced by one-third of that before shunt.Thirty-eight patients survived and no upper gastro-intestinal rebleeding occurred in the follow-up period(50.5 months in average).Two were out of contact.Color Doppler ultrasonography and/or portography revealed the shunts were patent in 38 cases and were occluded in three cases(3/41,7.3%).Encephalopathy developed in five cases(5/41,12.2%).Partial(small-diameter ePTFE H-graft)portacaval shunting can reduce the portal pressure effectively.Majority of the hepatic flow from the portal vein can be maintained adequately.The shunts with reinforced grafts can keep a higher rate of patency.The morbidity of encephalopathy was lower than those with total shunt.The partial portacaval shunt is effective in preventing recurrent variceal bleeding.