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Background: Small-caliber plastic stents are sometimes placed across the hepaticojejunostomy in liver transplant recipients at the time of biliary reconstruction. These stents usually pass spontaneously, but they can be retained and, rarely, this may cause biliary obstruction., Objective: The purpose of this paper is twofold: to describe the appearance of biliary tract obstruction caused by retained surgical stents in pediatric liver transplants, and to report how these stents can be removed using interventional radiology techniques., Materials and Methods: Three pediatric patients presenting with biochemical and imaging evidence of biliary obstruction were encountered over a 6-month period. At percutaneous cholangiography all patients were found to have retained surgical stents which appeared to be causing biliary tract obstruction. Percutaneous snaring of the stents was undertaken., Results: All stents were successfully removed using interventional radiology techniques, and follow-up showed no evidence of recurrent obstruction., Conclusion: Surgical stents in children undergoing hepaticojejunostomy may be retained and cause biliary obstruction. Radiologists involved with imaging these patients should be aware of this potential cause of biliary obstruction. This complication is amenable to interventional radiology techniques with good long-term results. There is no easy endoscopic or surgical treatment option in these patients.

Background: Multivisceral transplantation has recently evolved to be a life-saving procedure for patients with intestinal failure and complex abdominal pathology. A composite aortic graft is always needed to restore the arterial flow to the transplanted organs. Accordingly, arterial complications can be life-threatening requiring prompt intervention. Herein, we describe innovative technical approaches in seven recipients who developed pseudo-aneurysm (PA) after transplantation., Methods: With a total of 285 composite visceral transplants, 15 (5.2%) patients experienced vascular complications. Of these, 7 were life-threatening PAs that were diagnosed 61 to 2677 days after transplantation. Due to the anatomic and technical complexity of the allograft vasculature, endovascular techniques were introduced alone (n=2) or in conjunction with surgical intervention (n=5) in an attempt to rescue patients and salvage the transplanted organs., Results: The endovascular and surgical technical approaches used for each of the 7 PA actively bleeding patients was successful in 5 (71%). Of these, 2 (40%) are alive 86 to 117 months after the intervention. The remaining 5 recipients died of recurrent hemorrhage (n=2), liver failure (n=1), and pneumonia (n=1). The cause of death was unknown in the remaining patient. Retransplantation and intra-abdominal infections were major risk factors. Candida was the most common isolated microorganism., Conclusions: Recipients of composite visceral allografts are at risk of developing life-threatening PAs, particularly in those with early posttransplantation abdominal infections. Prompt multidisciplinary diagnosis and therapeutic approaches are crucial management strategies.

Purpose: To evaluate our experience with the use of yttrium-90 ((90)Y) radioembolization in maintaining potential candidacy and, in some instances, downstaging hepatocellular carcinoma (HCC) that does not meet Milan criteria for liver transplantation., Materials and Methods: A retrospective review of 20 consecutive patients with HCC who were listed to receive a liver transplant and were treated with (90)Y radioembolization as a sole modality for locoregional "bridge" therapy was performed. Demographics, radiographic and pathologic response, survival, and recurrences were examined., Results: Twenty-two (90)Y treatments were performed in 20 patients before transplantation. Median time from first treatment to transplantation was 3.5 months. HCC in 14 patients met the Milan criteria at the time of the first (90)Y treatment, and HCC in six did not. All cases that originally met the Milan criteria remained within the criteria before transplantation, and two of six patients whose disease did not meet the criteria (33%) had their disease successfully downstaged to meet the criteria. Overall, nine patients (45%) had complete or partial radiologic response to (90)Y radioembolization according to modified Response Evaluation Criteria In Solid Tumors. Complete necrosis of tumor with no evidence of viable tumor on pathologic examination was observed in five patients (36%) whose disease met the Milan criteria., Conclusions: Particularly in regions with long wait list times, (90)Y treatment is effective in maintaining tumor size in potential liver transplantation candidates with HCC. In addition, it can also be considered as a downstaging therapy in select patients before transplantation., (© SIR, 2013.)

Purpose: To identify the diagnostic value of ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP) in diagnosing biliary strictures after liver transplantation., Materials and Methods: Sixty patients with clinically suspected biliary strictures after liver transplantation were retrospectively evaluated. All patients underwent US and MRCP before the standard of reference (SOR) procedure: endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Radiological images were analyzed for biliary dilatation and strictures., Results: By SOR, biliary dilatation was present in 55 patients, stricture in 53 (44 anastomotic, 4 intrahepatic, 5 both), and dilatation and/or stricture in 58. Dilatation was diagnosed by US and MRCP in 39 and 45, respectively (sensitivity 71% vs. 82%, p=0.18). Stricture was diagnosed by US and MRCP in 0 and 42, respectively (sensitivity 0% vs. 79%, p<0.0001). False positive stricture was diagnosed by MRCP in 2. Dilatation and/or stricture was diagnosed by US in 39 and MRCP in 50 (sensitivity 67% vs. 86%, p=0.01); however, using both techniques, sensitivity increased to 95%., Conclusions: MRCP is superior to US for diagnosing biliary strictures after liver transplantation primarily because MRCP can detect stricture. The combination of US and MRCP seems superior to either method alone. Our data suggest that in patients with normal US and MRCP, direct cholangiography could be avoided., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Hepatitis C virus (HCV) is the major cause of liver disease in haemophilia. Few data exist on the proportion with liver fibrosis in this group after long-term HCV and HIV co-infection. We conducted a cross-sectional multi-centre study to determine the impact of HIV on the prevalence and risk factors for fibrosis in haemophilic men with chronic hepatitis C. Biopsies were independently scored by Ishak, Metavir and Knodell systems. Variables were tested for associations with fibrosis using logistic regression and receiver operating curves (ROC). Of 220 biopsied HCV(+) men, 23.6% had Metavir ≥ F3 fibrosis, with higher mean Metavir fibrosis scores among HIV/HCV co-infected than HCV mono-infected, 1.6 vs. 1.3 (P = 0.044). Variables significantly associated with fibrosis included AST, ALT, APRI score (AST/ULN × 100/platelet × 10(9) /L), alpha-fetoprotein (all P < 0.0001), platelets (P = 0.0003) and ferritin (P = 0.0008). In multiple logistic regression of serum markers, alpha-fetoprotein, APRI and ALT were significantly associated with ≥ F3 fibrosis [AUROC = 0.77 (95% CI 0.69, 0.86)]. Alpha-fetoprotein, APRI and ferritin were significant in HIV(-) [AUROC = 0.82 (95% CI 0.72, 0.92)], and alpha-fetoprotein and platelets in HIV(+) [AUROC = 0.77 (95% CI 0.65, 0.88]. In a multivariable model of demographic and clinical variables, transformed (natural logarithm) of alpha-fetoprotein (P = 0.0003), age (P = 0.006) and HCV treatment (P = 0.027) were significantly associated with fibrosis. Nearly one-fourth of haemophilic men have Metavir ≥ 3 fibrosis. The odds for developing fibrosis are increased in those with elevated alpha-fetoprotein, increasing age and past HCV treatment., (© 2010 Blackwell Publishing Ltd.)

Symptomatic focal nodular hyperplasia (FNH) of the liver can usually be treated safely with liver resection. However, in those patients in whom resection is not possible because of the location or size of the tumor or other patient factors, selective arterial embolization should be considered. Herein, the authors describe the use of arterial embolization to treat three women with symptomatic FNH and provide a review of the literature.

The purpose of this study was to evaluate the size responses and vascular responses to three different sizes of Embosphere (EMBS) embolization particles used for chemo-embolization in patients with unresectable hepatocellular carcinoma (HCC). Forty-seven patients with biopsy proven HCC treated with TACE using EMBS (Biosphere Medical, Rockland, MA, USA) were included in this study. EMBS are non-resorbable tris-acryl gelatin defined-size microspheres. Sixteen patients were treated with 40-120 micron (40-microm), 13 patients with 100-300 (100-microm), and 18 patients with 300-500 (300-microm) EMBS particles. We measured the two-dimensional area and vascularity of the tumor index lesion on initial and subsequent CTs after treatment. Lesions were classified into four grades based on the degree of vascularity measured in 25% increments. Size of tumor after one treatment decreased by an average (avg) of 18% for 40-120-microm particles, 38% for 100-300-microm particles, and 17% for 300-500-microm particles. After three treatments, size decreased by an avg of 46% for 40-120-microm particles, 76% for 100-300-microm particles, and 46% for 300-500-microm particles. Vascularity decrease was also measured after the first and third treatments, and defined as a decrease of one or more grades in tumor vascularity. Results were as follows (% of patients with decrease). For 40-120-microm particles: 1 and 3 treatments, 53% and 88% of patients. For 100-300-microm particles: 1 and 3 treatments, 60% and 88% of patients. For 300-500-microm particles: 1 and 3 treatments, 50% and 57% of patients. It was concluded the 100-300-microm EMBS particles produce slightly higher responses.

Liver transplantation has made many advances since its inception in the early 1970s. Despite volumes of basic science and clinical research related to liver transplantation, biliary complications continue to present the interventional radiologist with challenging cases in all transplant centers. Biliary complications can range from minor complications such as contained bile leaks to severe complications such as biliary necrosis resulting from hepatic artery thrombosis. Minor complications may require minimal or no intervention, whereas the more severe complications can require urgent surgery. To treat biliary complications such as anastomotic strictures, nonanastomotic strictures, biliary leaks, sludge or biliary necrosis, an accurate diagnosis must first be obtained. One must also be aware of how these complications can impair both allograft and transplant patient survival. With this information one can then plan a treatment knowing the potential success rates of specific treatments. Using proper technique with this information at hand can greatly increase the success rate in treating the spectrum of biliary complications. Interventional radiology serves a critical role in diagnosis and treatment of these liver transplant biliary complications and is important to the success of all transplant programs.

Background: Survival for patients with unresectable cholangiocarcinoma is reported to range from only 5-8 months without treatment. Systemic chemotherapy has not been shown to significantly improve survival, but newer regimens involving gemcitabine have shown increased response rates. Transcatheter arterial chemoembolization (TACE) has been shown to prolong survival in hepatocellular carcinoma patients, but experience using TACE in the treatment of cholangiocarcinoma is limited. We report our experience treating cholangiocarcinoma with TACE using chemotherapeutic regimens based on the well-tolerated drug gemcitabine., Methods: Forty-two patients with unresectable cholangiocarcinoma were treated with one or more cycles of gemcitabine-based TACE at our institution. Chemotherapy regimens used for TACE included: gemcitabine only (n=18), gemcitabine followed by cisplatin (n=2), gemcitabine followed by oxaliplatin (n=4), gemcitabine and cisplatin in combination (n=14), and gemcitabine and cisplatin followed by oxaliplatin (n=4)., Results: Patients were 59 years of age (range 36-86) and received a median of 3.5 TACE treatments (range 1-16). Thirty-seven patients (88%) had central cholangiocarcinoma, and five (12%) had peripheral tumors. Nineteen patients (45%) had extrahepatic disease. Grade 3 adverse events (AEs) after TACE treatments were seen in five patients, whereas grade 4 AEs occurred in two patients. No patients died within 30 days of TACE. Median survival from time of first treatment was 9.1 months overall. Results did not vary by patient age, sex, size of largest initial tumor, or by the presence of extra-hepatic disease. Treatment with gemcitabine-cisplatin combination TACE resulted in significantly longer survival (13.8 months) compared to TACE with gemcitabine alone (6.3 months)., Conclusions: Our report represents the largest series to date regarding hepatic-artery-directed therapy for unresectable cholangiocarcinoma and provides evidence in favor of TACE as a promising treatment modality in unresectable cholangiocarcinoma. Our results suggest that gemcitabine-based TACE is well tolerated and confers better survival when given in combination therapy (with cisplatin or oxaliplatin) for patients with unresectable cholangiocarcinoma.

The authors describe two cases in which Günther Tulip inferior vena cava filters migrated to the chest, necessitating open-heart surgery for retrieval. In the first case, a 52-year-old man was transferred to their hospital from an outside facility after the filter migrated to the main pulmonary artery during attempted filter placement. In the second case, a 72-year-old man, a Günther Tulip filter was found to have migrated to the tricuspid valve after cardiopulmonary arrest and subsequent resuscitation, including emergent central venous line placement. The authors present the relevant details of both cases, discuss possible preventive strategies, and review the available literature about migration of the Günther Tulip filter.

Purpose: To prospectively evaluate whether ultrasonography (US)-guided vascular access can be learned and performed faster with the sonic flashlight than with conventional US and to demonstrate sonic flashlight-guided vascular access in a cadaver., Materials and Methods: Institutional review board approval and oral and written informed consent were obtained. The sonic flashlight replaces the standard US monitor with a real-time US image that appears to float beneath the skin and is displayed where it is scanned. In studies 1 and 2, participants performed sonic flashlight-guided needle insertion tasks in vascular phantoms. In study 1, 16 participants (nine women, seven men) with no US experience performed 60 simulated vascular access trials with sonic flashlight or conventional US guidance. With analysis of variance (ANOVA) and power-curve fitting, improvement with practice rate and mean differences between techniques and tasks were examined. In study 2, 14 female nurses (mean age, 50.1 years) proficient with conventional US performed simulated vascular access trials on three tasks with the sonic flashlight and conventional US. With random assignment, half the participants used the sonic flashlight first and half used conventional US first. Mean performance with each technique and that with each task were compared by using ANOVA. In study 3, feasibility of sonic flashlight guidance for access to internal jugular and basilic veins was demonstrated in a cadaver., Results: For study 1, learning rates (ie, decrease in access time over trials) did not differ for vascular access with sonic flashlight and conventional US. Overall, participants achieved faster vascular access times with sonic flashlight guidance (P < .007). In study 2, participants performed procedures faster overall with the sonic flashlight (P < .02) and found the sonic flashlight easier to use. In study 3, sonic flashlight-guided vascular access was gained in the cadaver., Conclusion: Learning and performance of vascular access were significantly faster with the sonic flashlight than with conventional US, and vascular access could be gained in a cadaver; the sonic flashlight is ready for clinical trials., ((c) RSNA, 2006.)

Improvements in surgical technique, advances in the field of immunosuppresion and the early diagnosis and treatment of complications related to liver transplantation have all led to prolonged survival after liver transplantation. In particular, advances in diagnostic and interventional radiology have allowed the Interventional Radiologist, as part of the transplant team, to intervene early in patients presenting with complications related to organ transplant with resultant increase in graft and patient survival. Such interventions are often achieved using minimally invasive percutaneous endovascular techniques. Herein we present an overview of some of these diagnostic and therapeutic approaches in the treatment and management of patients before and after liver transplantation., (Copyright 2006 AASLD)

Purpose: Shrinkage of an abdominal aortic aneurysm (AAA) is the hallmark of successful endoluminal treatment. Our goal was to prospectively assess the midterm to long-term shrinkage of the AAA sac after endovascular repair., Methods: A total of 123 patients with AAA underwent endoluminal treatment with the Ancure device at our institution between February 1996 and February 2000. At least a 1-year follow-up was available for 70 of the 123 patients. AAA sac size, presence of endoleaks, calcifications, and outcome data were collected on these patients at 6, 12, 24, and 36 months after repair and compared with the preoperative AAA size and characteristics. All endoleaks found at the 6-month follow-up visit were treated aggressively with embolotherapy. An AAA sac regression of 0.5 cm or more was considered the minimum measurable decrease. Regression of the sac diameter to 3.5 cm or less was considered a complete collapse of the sac., Results: Successful endoluminal repair was accomplished in 119 of 123 patients. The mortality rate was 0.8% (1/123). There was a steady decrease in AAA sac size from baseline (5.56 +/- 0.1 cm), to 6 months (5.0 +/- 0.14 cm, P =.0006), to 12 months (4.65 +/- 0.13 cm, P =.04), and to 24 months (4.26 +/- 0.16 cm, P =.03). At 24 months, 74% (29/39) had a decrease in sac size of 0.5 cm or more, with 28% (11/39) complete collapse. Patients with initial endoleaks had the same likelihood of regression of sac size (> or = 0.5 cm) when compared with the group of patients with no endoleaks at the 24-month evaluation (64% vs 76%, P =.09)., Conclusion: Endoluminal AAA repair resulted in a significant reduction in sac size that continues up to 2 years. Significant shrinkage occurs as early as 6 months after placement. The initial presence of endoleaks does not predict the lack of sac regression.

Purpose: The authors report their experience with treatment of iliac limb complications in patients treated with the Ancure endograft with Wallstents to provide additional support and thrombolysis when needed., Materials and Methods: From February 1996 to October 1999, 88 patients were treated for abdominal aortic aneurysm with use of the Ancure endograft. Of the 88 devices used, 20 were tube grafts and the remaining 68 devices had a total of 130 iliac limbs (bifurcated, n = 62; aortoiliac, n = 6). After graft deployment, all patients underwent intraoperative aortography; since July 1997, intravascular ultrasound (IVUS) has also been used., Results: Thirty-one patients (46%) required treatment of 47 (36%) limbs with Wallstents. Graft narrowing was observed in 41 limbs (27 patients) with IVUS immediately after graft deployment. All were successfully treated with placement of Wallstents. Before routine use of intraoperative IVUS, three patients presented between 2 and 6 weeks postoperatively with iliac limb thrombosis. All three limbs were successfully treated with thrombolysis and Wallstent placement to correct the underlying iliac problem. Additionally, two contralateral limbs in these three patients were also noted to have stenosis and were treated with use of Wallstents. The last patient required placement of a Wallstent to treat stenosis of surgical anastomosis of the iliac limb of an aortoiliac endograft at 3 days. All Wallstent-reinforced Ancure endografts remained patent from 1 to 36 months (mean, 14 months)., Conclusion: After placement of an Ancure bifurcated or aortoiliac endograft, iliac limb stenosis is easily detected with use of intraoperative IVUS. Such complications can be safely corrected with Wallstent placement. Postoperative limb occlusion at the authors' institution has been eliminated with such intervention.

Purpose: Perigraft flow--flow outside the graft lumen but contained within the abdominal aortic aneurysm (AAA)--is a potential complication after endovascular repair of AAA. Such flow may permit AAA growth and rupture. The purpose of this study is to evaluate with computed tomography (CT) the rate of spontaneous closure of perigraft flow and the effect of persistent flow on AAA diameter., Materials and Methods: During a 30-month period, the authors evaluated all CT scans in 50 patients who underwent AAA repair using the Ancure endograft system. CT was performed at discharge, 6, 12, and 24 months, and at 3 months if there was perigraft flow at discharge. Scans were reviewed for the presence, size, and location of perigraft flow, and measurement of AAA diameter. Transcatheter embolization was performed on those patients with persistent leak at 6 months., Results: Sixteen (32%) of 50 patients demonstrated perigraft flow on CT performed within 72 hours of placement. Resolution of perigraft flow by 6 months was found in nine (56%) of the 16 patients, in whom AAA size had decreased in five, had increased in none, and was unchanged in four. Seven patients had persistent leaks at 6-month CT; AAA size had decreased in one, had increased in one, and was unchanged in five. In 34 patients without leaks, AAA size had decreased in nine, had increased in one, and was unchanged on 24. There was no statistically significant difference for the relationship between resolution or persistence of perigraft flow and subsequent course of AAA diameter (P = .16)., Conclusions: Although perigraft flow is frequently seen (32%) early after repair of AAA with the Ancure system, spontaneous resolution by 6 months occurs in 56% of cases. AAA size decreased in a larger percentage of patients in whom perigraft leak was absent or resolved by 6 months compared with those in whom perigraft leak persisted at 6 months.

Purpose: To evaluate the effect of balloon dilation and endobronchial stent placement for bronchial fibrous stenoses and bronchomalacia after lung transplantation., Materials and Methods: Bronchial dilation and/or stent placement was performed on 25 lung transplant recipients. Indications included severe dyspnea with postobstructive pneumonia (n = 24) and respiratory failure (n = 1). All patients underwent pulmonary function testing (PFT) before and after bronchial dilation, the results of which were evaluated for changes. A total of 63 procedures were performed between February 1996 and December 1998. Thirty-five lesions were treated (18 were due to bronchomalacia, 17 were due to fibrosis). Areas treated included the left mainstem bronchus (n = 11), bronchus intermedius (n = 10), right mainstem bronchus (n = 7), left upper lobe bronchus (n = 4), right lower lobe bronchus (n = 2), and right middle lobe bronchus (n = 1). Bronchoscopic and/or bronchographic follow-up ranged from 1 to 34 months (mean, 15 months)., Results: Six-month primary patency of stents placed for bronchomalacia was 71% (10 of 14), with three of the four occlusions caused by mechanical failure of Palmaz stents in the mainstem bronchi. Six-month primary patency for treatment of fibrous strictures was 29%. Secondary patency at 1 year was 100% for both bronchomalacia and fibrous strictures. After treatment, there was a significant improvement in mean PFT results (P = .01-.0001). There was one acute complication, obstruction of the left lower lobe bronchus by a Wallstent treated by dilating a hole in the side of the stent., Conclusions: Balloon dilation and stent placement are safe and effective for bronchial strictures and bronchomalacia after lung transplantation, resulting in significant improvement in PFT results. However, there is almost universal restenosis in patients treated for fibrous strictures necessitating reintervention for prolonged patency.

Purpose: Endoleak is a potential complication after endovascular repair of abdominal aortic aneurysm (AAA). It may result in continued growth of the aneurysm and potentially result in aneurysm rupture. The authors present their experience with embolotherapy in patients with persistent perigraft flow treated with the Ancure-Endovascular Technologies endograft system., Materials and Methods: Between February 1996 and August 1998, 54 patients underwent successful repair of AAA with use of the Ancure system. All underwent operative angiography and discharge computed tomography (CT). Follow-up included CT at 6, 12, and 24 months, and CT was also performed at 3 months if an endoleak was present on the discharge CT. Persistent endoleak was defined as perigraft flow still present on the 6-month CT. Seven of 21 initial endoleaks persisted at 6 months. Six patients returned for embolization of the perigraft space and outflow vessels including lumbar arteries and the inferior mesenteric artery (IMA)., Results: Five of the six patients had leaks from the proximal (n = 1) or distal attachment sites (n = 4) of the Ancure system with outflow into lumbar arteries and/or the IMA; one leak was caused by retrograde IMA flow. The six patients underwent nine embolization procedures with only one minor complication. Follow-up CT showed complete resolution of endoleak and decrease in size of the aneurysm sac in all patients., Conclusions: Although endoleak is commonly seen initially with the Ancure system, persistent leak occurred in 13% of the patients in the study. Persistent flow in most patients arises from a graft attachment site combined with patent outflow vessels such as the IMA or lumbar arteries. Persistent endoleaks can be effectively and safely embolized with use of a combination of coil embolization of the perigraft space and embolization of outflow vessels. Such intervention resulted in a decrease in size of the aneurysm sac.

Purpose: Transjugular intrahepatic portosystemic shunt (TIPS) placement is an accepted treatment for refractory variceal bleeding and/or ascites in end-stage liver disease and is an effective bridge to liver transplantation. The authors present their experience with TIPS in patients with a liver transplant, who subsequently developed portal hypertension., Materials and Methods: Thirteen TIPS were placed in 12 adult patients from 6 months to 13 years after liver transplantation for variceal bleeding that failed endoscopic treatment (n = 6) and intractable ascites (n = 6). All patients were followed to either time of retransplantation or death., Results: No technical difficulties were encountered in TIPS placement in any of the patients. Four of six patients treated for bleeding stopped bleeding and did not experience re-bleeding, two had functional TIPS at 3 and 36 months and two underwent retransplantation at 3 and 7 months. Two patients had recurrent bleeding within 1 week and required reintervention. In the ascites group, one is 32 months since TIPS placement with control of his ascites, two patients underwent retransplantation at 2 and 6 weeks with interval improvement in ascites. Two patients died within a week of TIPS of fulminant hepatic failure. The last patient died 1 month after TIPS subsequent to a splenectomy., Conclusion: In conclusion, the placement of a TIPS in a transplanted liver, in general, requires no special technical considerations compared to placement in native livers. Although this series is small, the authors believe that TIPS should be considered a treatment option in liver transplant recipients who present with refractory variceal bleeding. TIPS may have a role in the management of intractable ascites.

Background: Vascular complications remain an important cause of postoperative morbidity in liver transplant patients. Herein, we present an unusual case of nonanastomotic inferior vena cava (IVC) stenosis in a patient with a "piggyback" caval anastomosis., Methods: A 59-year-old woman underwent liver transplantation using a piggyback IVC anastomosis. Her postoperative course was complicated by IVC thrombosis. Catheter-directed thrombolysis, followed by balloon angioplasty and intravascular stent placement, was used to recanalize the IVC and treat a severe retrohepatic IVC stenosis., Results: After 46 hr of catheter-directed urokinase infusion, there was clot lysis and identification of a severe stenosis in the retrohepatic IVC. The lesion was extremely resistant to balloon dilatation alone and a 22-mm-diameter intravascular stent was placed. Simultaneous dilatation of three high-pressure balloons was necessary for maximal stent expansion. The patient remains asymptomatic with no evidence of IVC compromise through 20 months of follow-up., Conclusions: IVC stenosis and thrombosis after liver transplantation may be treated favorably in some patients using catheter-directed thrombolytic therapy followed by balloon dilatation and/or stent placement.

Objective: Biliary strictures occur more frequently after liver transplantation for primary sclerosing cholangitis (PSC) than for other diseases. A hypothesized cause is recurrence of PSC in the liver graft. In our study, we compared cholangiographic features of biliary strictures after transplantation for PSC to those after transplantation for other diseases., Materials and Methods: A study group of 32 PSC grafts in adults with biliary strictures was compared with a control group of 32 non-PSC grafts with strictures. Both groups were matched for the type of biliary anastomosis (choledochojejunostomy) and for the time interval between transplantation and stricture diagnosis. We then performed a blind retrospective review of cholangiograms in these 64 cases to evaluate for features of PSC., Results: Location, number, and length of strictures and ductal dilatation were similar in the PSC and non-PSC groups. Mural irregularities of bile ducts were present in 15 of 32 (47%) PSC grafts compared with four of 32 (13%) in the control group (p=.005). Diverticulum-like outpouchings occurred in six of 32 (19%) PSC graft compared with one of 32 (3%) in the control group. An overall resemblance to PSC was observed in eight of 32 (25%) grafts in the PSC group compared with two of 32 (6%) in the control group., Conclusion: Mural irregularity and diverticulum-like outpouchings--findings suggestive of PSC--and an overall appearance resembling PSC occur more frequently in PSC transplants than in transplants for other diseases. These findings are consistent with the hypothesis that PSC may recur in liver transplants.

Transjugular intrahepatic portosystemic shunt (TIPS) is becoming an accepted procedure as a bridge to orthotopic liver transplantation (OLT) in patients with end-stage liver disease (ESLD) and bleeding from portal hypertension. It allows the immediate control of acute bleeding and decreases the risk of recurrent acute bleeding while the patient is awaiting OLT. We review in this report, our experience with 85 patients who underwent a TIPS procedure for gastrointestinal variceal bleeding from September 1991 until April 1994. All patients had liver cirrhosis and all had previous sclerotherapy before TIPS. Child-Pugh score was calculated at enrollment, and all patients were evaluated for possible OLT. Thirteen patients were Child A, 49 were Child B, and 23 were Child C. Fifty-three patients were candidates for OLT, and 32 were not. TIPS was performed urgently in 25 patients. At a median follow-up of 582 days (range, 1 to 1,095), 35 patients underwent transplantation, 21 patients died, and 29 patients are still alive and did not undergo transplantation. Technical complications were observed in 7% of patients and new onset of clinical encephalopathy in 37%. The 30-day mortality rate after TIPS was 13%. Actuarial survival was 60% at 1 and 3 years. Child class C and urgent TIPS were shown to be two independent predictor factors for mortality. TIPS was shown to be a valuable procedure, not only as a bridge to OLT but also as palliation for bleeding from portal hypertension in patients who were not candidates for either surgical shunt or OLT. However, its role in bleeding patients with acceptable liver function needs further investigation.

We report an unusual cause of hemobilia in a patient with a transhepatic biliary catheter. Hemobilia was due to an extrahepatic fistula between the gastroduodenal artery and the common bile duct and was responsible for significant blood loss. The fistula was successfully treated with transarterial embolization that resulted in no further episodes of hemobilia during the following 12 months.

Purpose: To determine the prevalence, radiologic features, and clinical significance of bile duct filling defects (BDFDs) in liver transplant recipients studied with cholangiography., Materials and Methods: During 13 years, 4,100 cholangiograms were obtained in 1,650 patients. All studies showing BDFD suggestive of stones, sludge, cast, or necrotic debris were retrospectively evaluated., Results: The prevalence of BDFD was 5.7% (n = 94). On the basis of cholangiographic appearance, BDFDs were categorized as sludge or cast in 53 grafts (56%), stones in 32 (34%), and necrotic debris in nine (10%). Forty-three patients (46%) underwent surgical biliary reconstruction, while 14 (15%) underwent interventional radiologic treatments. Twenty-four of 32 stones (75%) were treated with surgical reconstruction, compared with 31% (19 of 62 grafts) of other BDFDs (P < .0001). Necrotic debris and sludge were associated with hepatic artery occlusion in seven of nine (78%) and 16 of 53 (30%) grafts, respectively., Conclusion: Stones and sludge are relatively infrequent after liver transplantation but are associated with high morbidity. Surgical or interventional radiologic treatments are usually performed. Bile duct stones are usually treated with surgical biliary reconstruction. While debris and bile duct necrosis are due to ischemia from hepatic artery occlusion, sludge may also have an ischemic pathogenesis in some cases.

Purpose: To evaluate the efficacy and complication rate of the Quick-Core biopsy needle system compared with traditional transjugular biopsy needle systems., Materials and Methods: Between January 1994 and April 1995, 43 patients underwent transjugular liver biopsy with the Quick-Core system; 18-, 19-, and 20-gauge needles were used in 28, 13, and two patients, respectively. Histologic diagnoses, specimen dimensions, and adequacy of the biopsy sample were determined. Immediate and delayed complications were recorded., Results: A total of 118 biopsy specimens were obtained with an average of 2.7 passes per patient. Biopsy was successful in 42 of 43 patients (98%); one specimen contained renal parenchyma. Of the specimens that contained liver tissue, 100% were adequate. Mean maximum sample lengths were 1.1 and 1.5 cm with the 18- and 19-gauge needles, respectively. The procedural complication rate of 2% was due to puncture of the liver capsule in one patient, but no clinical manifestations occurred. No delayed complications occurred in any patient., Conclusion: The Quick-Core biopsy system produces consistently satisfactory, reproducible specimen cores with a very low complication rate.

Objective: The occurrence of biliary strictures or bile duct necrosis in liver transplant recipients with hepatic artery stenosis has been well documented. This study was done to determine the prevalence and cholangiographic appearance of biliary complications in liver transplant recipients with hepatic artery stenosis and to determine if such complications occur with increased frequency compared with transplant recipients with patent hepatic arteries., Materials and Methods: The study population consisted of 33 patients (17 male, 16 female; 1-65 years old) with angiographically proven significant hepatic artery stenosis after liver transplantation. All patients had T-tube or percutaneous transhepatic cholangiography performed within 4 months of hepatic arteriography. A retrospective review of radiographs was done to determine the prevalence and appearance of biliary complications in the study group compared with a control group of 58 patients with angiographically patent hepatic arteries who had liver transplants during the same period., Results: Biliary complications were significantly more prevalent in patients with hepatic artery stenosis, with 22 (67%) showing cholangiographic abnormal findings compared with 16 (28%) in the control group (p = .001). The most significant abnormalities in patients with arterial stenosis were nonanastomotic biliary strictures seen in 16 (49%), compared with 13 (22%) in the control group (p = .04). Other findings (intraductal filling defects, anastomotic biliary stricture, and anastomotic bile leak) showed no statistically significant difference between the study and control groups., Conclusion: Biliary complications are significantly more prevalent in liver transplant recipients with hepatic artery stenosis. The most common complication seen on cholangiography was nonanastomotic biliary stricture.

Purpose: To assess whether percutaneous transluminal angioplasty (PTA) can help prolong allograft survival and improve allograft function in patients with hepatic artery stenosis after liver transplantation., Patients and Methods: Hepatic artery PTA was attempted in 19 patients with 21 allografts over 12 years. The postangioplasty clinical course was retrospectively analyzed. Liver enzyme levels were measured before and after PTA to determine if changes in liver function occurred after successful PTA., Results: Technical success was achieved in 17 allografts (81%). Retransplantation was required for four of 17 allografts (24%) in which PTA was successful and four of four allografts in which PTA was unsuccessful; this difference was significant (P = .03). Two major procedure-related complications occurred: an arterial leak that required surgical repair and an extensive dissection that necessitated retransplantation 14 months after PTA. Hepatic failure necessitated repeat transplantation in seven cases from 2 weeks to 27 months (mean, 8.4 months) after PTA. Six patients died during follow-up, three of whom had undergone repeat transplantation. Markedly elevated liver enzyme levels at presentation were associated with an increased risk of retransplantation or death regardless of the outcome of PTA., Conclusion: PTA of hepatic artery stenosis after liver transplantation is relatively safe and may help decrease allograft loss due to thrombosis. Marked allograft dysfunction at presentation is a poor prognostic sign; thus, timely intervention is important.

Interventional techniques play key roles in the management of the renal transplant donor and recipient. With prompt diagnosis and intervention, postoperative vascular and urologic complications frequently may be treated by nonsurgical means. Current concepts in percutaneous intervention for renal transplant patients are discussed. Topics include transluminal angioplasty of arterial stenoses, treatment of arterial or venous occlusion, embolization of intrarenal arteriovenous fistula or pseudoaneurysm, management of periallograft fluid collections, and therapy for urinary obstruction or leak.

Objective: Recent reports have shown that a high percentage of patients with transjugular intrahepatic portosystemic shunts (TIPS) have postprocedural shunt complications, including thrombosis of the stent, stenosis of the stent, or stenosis of the hepatic vein draining the stent. We did a prospective study to determine the utility of Doppler sonography as a screening technique for the detection of these complications., Subjects and Methods: From September 1991 to September 1992 we placed TIPS in 45 patients. After the procedure, patients were routinely evaluated with both Doppler sonography and angiography. The sonographic protocol consisted of insonation of the stent, portal vein, and hepatic vein to determine the presence of flow, peak velocity, and direction of flow. The angiograms were evaluated for stenoses of the stent or hepatic vein that caused an increase in the portosystemic pressure gradient greater than 15 mm Hg, increased intrahepatic portal venous filling, retrograde filling of the draining hepatic vein, or opacification of varices. The sonographic findings were statistically evaluated to determine if sonography could demonstrate the complications shown by angiography., Results: Adequate follow-up was obtained in 29 of the 45 patients. Sixteen of the 29 patients had shunt complications that consisted of one stent thrombosis, three stent stenoses, nine hepatic vein stenoses, and three concomitant stenoses of the stent and hepatic vein. Flow was not detected by sonography in the stent of the patient with thrombosis. There was a significant difference (p = .003) between the temporal change in peak stent velocity in patients with stenoses versus those without. Use of a change (increase or decrease) in peak stent velocity greater than 50 cm/sec from the post-TIPS baseline sonogram as the diagnostic criterion for the detection of shunt stenoses resulted in a 93% sensitivity and 77% specificity. Five patients with stenosis had reversed flow in the draining hepatic vein. Only one patient with a stenosis had a peak stent velocity less than 50 cm/sec., Conclusion: Our results suggest that Doppler sonography is an excellent noninvasive screening technique for the detection of complications of TIPS. We have found a temporal change in peak stent velocity greater than 50 cm/sec to be a more sensitive sonographic sign of TIPS stenosis than the previously reported low-velocity parameters. Our experience suggests that nearly all complications of TIPS can be detected by using three criteria: (1) no flow for thrombosis, (2) a temporal change in peak stent velocity greater than 50 cm/sec for stent and/or hepatic vein stenosis, and (3) reversed flow in the hepatic vein draining the stent for hepatic vein and, rarely, stent stenosis.

Over the past several years, operative techniques, postoperative care, and immunosuppressive therapy have advanced steadily, allowing 5-year survival for liver transplantation to increase from 20% 15 years ago to 65% today. Biliary and vascular complications, however, remain causes of significant morbidity and mortality to the liver transplant patient. The interventional radiologist is an integral part of the multidisciplinary team necessary for optimization of care of the liver transplant patient. In this article, interventional techniques in the management of the liver transplant patient are addressed. Topics discussed include preoperative evaluation, methods of vascular and biliary reconstruction, and diagnosis and management of postoperative complications.

We report a 59-year-old female with a dissecting pseudoaneurysm of the allograft hepatic artery, as a delayed complication of percutaneous transluminal angioplasty (PTA). PTA of a severe anastomotic stenosis was successful, but complicated by a dissection involving the allograft hepatic artery. A large dissecting pseudoaneurysm developed and was incidentally detected during routine sonographic evaluation 14 months after PTA. Because of the extent of the pseudoaneurysm, percutaneous repair or surgical reconstruction was considered impossible. The patient underwent successful retransplantation 1 week after diagnosis.

Purpose: The authors report their initial and long-term results using transhepatic balloon dilation to treat biliary strictures in liver transplant patients., Patients and Methods: Over a 10-year period, 72 liver transplant patients with biliary strictures underwent 81 balloon dilation treatments. Anastomotic strictures were present in 56 patients; nonanastomotic strictures were present in 16., Results: Initial technical success was achieved in 64 of 72 patients (89%). Balloon dilation failed in eight patients (11%), and they were treated surgically. Complications occurred in nine (12%) patients, and all were successfully treated. Within the first 6 months, five patients (6.9%) required surgical revision. Three patients (4.2%) underwent repeated liver transplantation; and five patients (6.9%) died. Fifty-one patients in whom balloon dilation was initially successful were available for at least a 6-month follow-up. Life-table analysis showed an overall 81% +/- 4.8 success rate at 6 months; it dropped to 70% +/- 6.2 at 6 years. For anastomotic strictures, it was 77% +/- 5.8 at 6 months and 66% +/- 7.3 at 6 years. For nonanastomotic strictures, it was 94% +/- 6.2 at 6 months, which dropped to 84% +/- 10 at 5 years., Conclusion: Transhepatic balloon dilation represents an effective and relatively safe treatment for biliary stricture in liver transplant recipients.

Purpose: To assess the value of resistive index (RI) and systolic acceleration time (SAT) for diagnosis of stenoses and thromboses of the hepatic artery in liver transplant recipients., Materials and Methods: Doppler sonograms and angiograms in 125 liver transplant recipients were correlated and analyzed for any statistically significant difference in the RI or SAT of patients with and without arterial stenosis or thrombosis. Sensitivity and specificity were calculated for RI, SAT, peak arterial systolic velocity, and absence of arterial flow., Results: Forty-seven patients had a marked stenosis; 16 had thrombosis. There was a statistically significant difference (P < .05) in the RI and SAT of patients with stenosis or thrombosis versus those with normal arteries but not in patients with stenosis versus thrombosis. RI and SAT parameters allowed detection of abnormalities not found with peak velocity and no-flow parameters. Combined parameters produced 97% sensitivity and 64% specificity for marked arterial disease., Conclusion: Doppler spectral wave form analysis provides excellent screening for detection of hepatic allograft arterial stenosis or thrombosis.

Purpose: To evaluate cholangiographic features and prevalence of bile duct leaks in liver transplant recipients and correlate the different types of leaks with clinical outcomes., Materials and Methods: For 6 years, 3,242 cholangiograms were obtained in 1,363 liver allografts in 1,306 patients. All cholangiograms with definite or suspected bile duct leaks, per the radiology reports, were retrospectively reviewed., Results: Leaks were diagnosed in 59 allografts in 59 patients. The prevalence of leaks after liver transplantation, as depicted on cholangiograms, was 4.3% (59 of 1,363 grafts). Sixteen of 21 patients with anastomotic leaks needed 17 surgical repairs, four leaks were surgically drained without repair, and one was treated with percutaneous biliary catheter drainage. Twelve of 21 patients with T-tube exit-site leaks underwent T-tube drainage. Seven underwent surgical repair or drainage, one died, and one underwent retransplantation. Nine of 13 patients with leaks from bile duct necrosis required retransplantation., Conclusion: Bile duct leaks at biliary anastomoses and those resulting from bile duct necrosis have high morbidity, mortality, and graft loss rates and usually require surgical intervention. Most T-tube exit-site leaks heal with conservative treatment.

Purpose: To evaluate the prevalence, cholangiographic features, causes, and management of intrahepatic biliary strictures in hepatic transplants., Materials and Methods: Over a 12-year period, cholangiography was performed in 1,590 liver allografts. Confirmed cases of stricture were evaluated and correlated with clinical variables., Results: Intrahepatic biliary strictures occurred in 130 of 1,590 grafts (8.2%). Strictures were multiple in 99 grafts (76.2%) and single in 31 (23.8%). Locations were the common hepatic duct bifurcation in 46 grafts (35.4%), the peripheral ducts in 44 (33.8%), and both in 40 (30.8%). Strictures caused mild to moderate bile duct dilatation in 72 grafts (55.4%), marked dilatation in 11 (8.5%), and obstruction in four (3.1%). Hepatic artery occlusion, pretransplantation primary sclerosing cholangitis, choledochojejunostomy, use of Euro-Collins organ preservation solution, cholangitis at liver biopsy, and young age were statistically significantly associated with strictures (P < .001)., Conclusion: Strictures have multiple causes and may be an important indicator of underlying abnormalities. They often require interventional radiologic or surgical treatment.

Purpose: The authors evaluated the safety and efficacy of percutaneous transluminal angioplasty (PTA) for the treatment of venous stenoses in liver transplant recipients., Patients and Methods: Over a 5-year period, 15 venous stenoses were treated with PTA in 12 patients with liver transplants (seven children and five adults). PTA was performed for portal vein stenoses in five patients, inferior vena cava (IVC) stenoses (n = 6) in five patients, combined superior mesenteric vein-portal vein graft anastomosis and hepatic vein-IVC anastomosis in one patient, and combined IVC and hepatic vein-IVC anastomosis in one patient. PTA was repeated in three patients (five procedures) for recurrent IVC stenoses., Results: Initial technical and clinical success of PTA was achieved in 11 patients (92%); failure occurred in one patient (8%) with a portal vein anastomotic stenosis. No complications occurred in the immediate post-procedure period (up to 7 days). Nine patients (75%) are clinically well, with follow-up ranging from 7 to 33 months (mean, 18 months). Two of them required one or more repeated PTA procedures to maintain vessel patency. One patient required retransplantation for chronic rejection at 3 months, and another died of gastrointestinal tract bleeding from a gastric ulcer at 2 months after initially successful IVC PTA., Conclusions: PTA is a safe procedure for the treatment of venous anastomotic stenoses in liver transplant recipients. PTA of portal vein anastomotic stenosis has favorable intermediate-term results. Repeat PTA may be necessary in some cases of IVC anastomotic stenoses to maintain vessel patency and avoid surgical revision or retransplantation.

Background: Transjugular intrahepatic portosystemic shunt (TIPS) has proved to be a successful bridge to liver transplantation in the management of variceal bleeding. The safety and ease of this technique has now challenged standard surgical approaches to portal hypertension. To define the role of TIPS, we prospectively studied patients undergoing this procedure for variceal bleeding and/or ascites., Methods: From September 1991 to September 1992, 45 patients entered a protocol that included assessment of liver chemistries, ammonia levels, coagulation profiles, liver synthetic function by caffeine-antipyrine clearance, ultrasonographic evaluation of hepatic and portal veins, portogram and direct measurement of portal vein pressures, upper endoscopy, computed tomography for liver volume and ascites, and formal neuropsychiatric evaluation. These studies were repeated at 3-month intervals or more frequently if bleeding or complications occurred., Results: Technical success and control of bleeding were achieved in all patients with only three (7%) variceal rebleeds from recurrent portal hypertension. Complete and permanent control of clinical ascites was noted in all patients with this complication. Five of six deaths occurred from sepsis and multiorgan failure in intensive care unit-bound patients with Child class C liver disease. No serial changes were noted in liver chemistries; however, progressive loss of liver volume and prolongation of caffeine-antipyrine clearance was observed in most patients. In addition, hepatic vein stricture or shunt stenosis seen in nine patients (20%) required TIPS revision, whereas the frequent appearance of symptomatic encephalopathy was a main indication for transplantation in 11 of 14 patients., Conclusions: TIPS successfully controls variceal bleeding and may serve as a novel approach to control of diuretic resistant ascites. The uncertain long-term patency and progressive decline in synthetic function emphasize the importance of initiating proper trials comparing TIPS with other management strategies before indiscriminant use of this technique is seen.

Objective: The purpose of this study was to determine the prevalence and types of biliary strictures seen in liver allografts transplanted for primary sclerosing cholangitis and other end-stage liver diseases and to determine if such strictures occur more often in the allografts transplanted for primary sclerosing cholangitis than in the others., Materials and Methods: During a 10-year period, 643 liver transplantation patients (687 allografts) with choledochojejunostomy biliary anastomoses underwent 1728 cholangiographic studies. Three hundred six cholangiograms were obtained in 100 transplant recipients who had primary sclerosing cholangitis (112 allografts) and 1422 cholangiograms were obtained in 543 recipients who had other liver diseases (575 allografts). We retrospectively reviewed all cholangiograms of transplant recipients who had primary sclerosing cholangitis and 909 cholangiograms of the recipients who had other liver diseases and a diagnosis of biliary strictures, possible biliary strictures, or duct irregularity based on radiologic reports. The presence, number, and locations of strictures were recorded. The remaining 513 cholangiograms of recipients with other liver diseases without strictures were not reviewed. Biliary strictures were classified as intrahepatic (including bifurcation), anastomotic, and nonanastomotic extrahepatic., Results: Cholangiograms showed intrahepatic biliary strictures in 105 allografts (15%), anastomotic strictures in 105 allografts (15%), and nonanastomotic extrahepatic biliary strictures in 17 allografts (2%). Intrahepatic biliary strictures were diagnosed in 27% (30/112) of the allografts transplanted for primary sclerosing cholangitis and in 13% (75/575) of the allografts transplanted for other end-stage liver diseases (p = .0005). Anastomotic strictures developed in 18% (20/112) of the allografts transplanted for primary sclerosing cholangitis and in 15% (85/575) of the others (p = .381). Nonanastomotic extrahepatic strictures were seen in 6% (7/112) of the allografts transplanted for primary sclerosing cholangitis and in 2% (10/575) of the others (p = .008)., Conclusion: Intrahepatic and nonanastomotic extrahepatic biliary strictures are significantly more common in patients who have liver transplantation for primary sclerosing cholangitis than in patients who receive allografts for other end-stage liver diseases. However, strictures at the choledochojejunostomy anastomosis occur with equal frequency in both groups of patients.

A 41-year-old liver transplant patient had severe hemobilia from an intrahepatic pseudoaneurysm secondary to a liver biopsy. Selective intra-arterial embolization was not technically possible due to marked redundancy and tortuosity of the allograft hepatic artery. The pseudoaneurysm was localized by ultrasound and embolized using a direct percutaneous transhepatic approach. This is a novel way of approaching hemobilia in liver transplant patients after liver biopsy and may avoid the risks of arterial embolization.

Four liver transplant recipients with intrahepatic bile duct leakage following liver biopsy are described. Two patients were clinically suspected of having a bile leak, one of whom had bile peritonitis. All four patients had elevated liver enzyme levels. In three patients, cholangiography showed contrast media leakage into the peritoneum through the needle biopsy tract; one leak was totally intraparenchymal. All patients had varying degrees of biliary obstruction. The differential diagnosis of bile leakage post-transplantation should include recent liver biopsy.

Objective: Cadaveric kidneys from donors less than 5 years old, previously considered inferior graft material, are now being successfully transplanted en bloc into children and adults. On the basis of our experience with 132 patients, we describe the general principles of the procedure and review the spectrum of normal and abnormal imaging findings in patients who have undergone this promising transplantation procedure., Materials and Methods: Paired cadaveric kidneys obtained from donors less than 5 years old (mean age, 24 months) were transplanted en bloc to 132 patients (mean age, 37 years) at our institution between 1981 and 1991. All available medical, surgical, pathologic, and imaging records were retrospectively reviewed to define the surgical technique, 1-year survival rate of the graft, appearance of the transplant on postoperative imaging studies, and the prevalence of and imaging findings caused by vascular, urinary, infectious, and neoplastic complications after transplantation. Complications were confirmed by a definitive imaging study, surgical exploration, or study of a pathologic specimen., Results: Paired donor kidneys were transplanted en bloc extraperitoneally into the recipient's right or left iliac fossa, with intact portions of the donor aorta and inferior vena cava anastomosed to the recipient's external iliac artery and vein. One-year graft survival was 70% during the first 8 years of the study and 78% during the last 2 years. Postoperative imaging, particularly sonography and scintigraphy, clearly depicted the normal individual kidneys, urinary collecting systems, and en bloc vasculature. Postoperative complications were vascular (arterial stenoses and thromboses, venous thromboses, and pseudoaneurysms) in 18%, urinary (obstruction and anastomotic leak) in 11%, infectious (caliceal fungal balls) in 1%, and neoplastic (posttransplant lymphoma) in 1%. The complications involved one kidney in 60% of the patients and both kidneys in 40%. The imaging findings caused by these complications were similar to those caused by complications occurring after transplantation of single cadaveric kidneys; however, their detection was more difficult because of the complexity of the en bloc graft., Conclusion: Because of the shortage of available donor organs, en bloc renal transplantation will most likely become increasingly popular. Familiarity with the imaging appearance of the normal transplant and of posttransplantation complications will allow radiologists to perform effective postoperative imaging evaluations.

Pseudoaneurysm (PA) is a rare but life-threatening complication of liver transplantation. The authors present their experience on 7 patients treated by ligation of a post-OLT PA. Hepatic artery ligation or embolization was performed from 10 to 70 days after liver transplantation. Of the seven patients, four survived, one developed a biliary stricture, treated by percutaneous balloon dilatation, two died of a complication not related to treatment, and one died of multiple organ failure.

To better understand changes in the size of the extrahepatic bile duct after liver transplantation, we retrospectively studied the luminal diameter of the extrahepatic bile duct on serial cholangiograms in 40 liver transplant recipients with choledochocholedochostomy biliary anastomoses and without biliary complications. Forty operative and 105 postoperative cholangiograms were reviewed. The average interval between operative and last postoperative cholangiogram was 5 weeks (range, 1-17 weeks). The mean diameter of the donor common hepatic duct increased from 5.5 +/- 2.1 mm to 6.3 +/- 2.4 mm (p = .015). The mean diameter of the native common bile duct increased from 5.1 +/- 1.4 mm to 6.8 +/- 2.4 mm (p less than .001). The diameter of the donor common hepatic duct increased by 3 mm or more in six patients (15%); the diameter of the native common bile duct increased by 3 mm or more in nine (23%). Increased diameter of the native common bile duct was associated with T-tube migration into the duct in four cases. The size of the extrahepatic bile duct on cholangiograms is stable or increases slightly in most liver transplant recipients. Mild increases unassociated with a specific cause of obstruction or hepatic dysfunction do not portend biliary obstruction and are clinically benign.