A Palmaz stent had dislodged into the left pulmonary artery after TIPS. After transfemoral catheterization of the left pulmonary artery, the stent was retrieved into the right femoral vein employing an angioplastic balloon catheter and finally extracted after surgical venotomy.
Sonographic angiography can improve characterization and staging of hepatic tumors. Low cost and the simplicity of the technique should encourage further experimentation.
Angiographic visualization of the hepatic vascular bed by selective angiography can be profitably complemented with the evaluation of functional portal‐systemic shunting by D‐sorbitol bioavailability. Seventeen patients requiring diagnostic arterial catheterization were studied: most of them had biopsy‐proven liver cirrhosis. Patients were studied at rest and after overnight fasting on two subsequent days, in which a sterile pyrogen‐free solution (1.5%) of D‐sorbitol was administered by direct infusion (15 mg/min for 20 min) into the superior mesenteric artery and an antecubital vein, respectively. The fractional bioavailability (Fma) of Dsorbitol was calculated as the ratio between the net cumulative urinary outputs obtained after infusion through the catheter into the superior mesenteric artery and the systemic vein, respectively. A good correlation was found between the estimated fractional portal‐systemic shunting, which in the present study ranged between 1.4% and 96.7%, and a suitable index scoring the clinical evidence of collateral circulation. Since the hepatic removal of D‐sorbitol is not affected by sinusoidal capillarization and its hepatic extraction ratio is quite high and only slightly modified by reduction in the number or functional activity of hepatocytes, the measured Fma can be assumed as a parameter reflecting the entity of portal‐systemic shunting. The test is safe and inexpensive, and appears potentially useful in several situations in which portal‐systemic shunting is pathophysiologically relevant.
— Aims/Background: TIPS, an effective procedure applied for the treatment of complications of portal hypertension, is potentially followed by worsening of the hyperdynamic circulation of cirrhosis and the impairment of liver function. The aim of the present study was to evaluate short‐term changes of functional liver plasma flow after application of TIPS, using the hepatic (extrarenal) clearance of D‐sorbitol (S‐HCl). Methods: Twenty‐five cirrhotic patients submitted to TIPS for prevention of variceal rebleeding entered the study. At steady‐state, during constant infusion of a solution of D‐sorbitol (25 mg/min), appropriate blood and urine samples were collected in order to calculate S‐HCl before and 120 min after TIPS opening. In addition, the hepatic extraction ratio of D‐sorbitol was directly measured at the level of the right (Er), where TIPS was applied, and of the left (El) hepatic veins; meanwhile the portocaval gradient (PCG) was registered, before and after stent dilation. A comparison of values obtained before and after TIPS application was performed by Student's t‐test for paired data. Results: After application of TIPS, a substantial reduction was observed in PCG (12.1 ± 4.2 vs 24.8 ± 4.3 mmHg; p<0.001) and Er values (20.6 ± 14.8 vs 57.5 ± 22.3%; p<0.001) but not El values (47.4 ± 22.0 vs 53.4 ± 21.4%; p=0.178). S‐HCl measured 120 min after TIPS opening was not statistically different from pre‐TIPS values (389.2 ± 212.1 vs 394.6 ± 152.7 ml/min; p=0.892), although S‐HCl variations in Child‐Pugh class B patients were positively correlated with portal pressure variations (r=0.63, p=0.016). Conclusion: Our results demonstrate that in patients with advanced cirrhosis, TIPS procedure, while effective in reducing portal hypertension, does not lead to alterations in the functional liver plasma flow within the first 2 h.
Controversial data exist in the literature about the presence and clinical relevance of hepatic arterial-venous shunting. An interesting opportunity for reconsidering the problem has been provided by the use, in the study of liver function, of D-sorbitol, a substance whose first-pass hepatic extraction is very high in normal subjects, while being directly related to circulatory alterations in liver cirrhosis. Because of this property, the systemic bioavailability of D-sorbitol during hepatic arterial infusion can be assumed to reflect arterial-venous shunting. Thirteen biopsy-proven cirrhotic patients (ages 35-66 years), who required diagnostic arterial catheterization, entered the study. Patients were studied on two subsequent days, in which a sterile pyrogen-free solution (1.5%) of D-sorbitol was administered by direct low-rate infusion (15 mg/min for 20 min) into the hepatic artery and the systemic circulation, respectively. Urine samples were spontaneously collected for 8-hr periods before and during/after each infusion. The hepatic arterial bioavailability of D-sorbitol was calculated as the ratio between the net cumulative urinary outputs of D-sorbitol after infusions into the hepatic artery and the systemic vein. Observed values confirm the existence and the large variability (0-88.7%) of hepatic arterial-venous shunting in cirrhotic patients.
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