The majority of patients with acute liver failure (ALF) die waiting for orthotopic liver transplantation (OLT). No other treatment modality is shown to improve survival. This study was conducted to assess the safety and feasibility of hepatocyte transplantation (HT) and subsequent engraftment and function of donor cells. Functional and structural integrity of cryopreserved and thawed human hepatocytes were assessed by their morphological characteristics, induction of P-4501A1 transcription, and survival in vivo by xenotransplantation into rats. Five patients with severe ALF underwent intrasplenic (4 patients) and/or intrahepatic (2 patients) HT through angiography under cyclosporine immunosuppression. All patients had grade III to IV encephalopathy and factor V levels less than 0.5 U/mL, were ventilator and dialysis dependent, and were not OLT candidates. Three of the 5 patients who survived 48 hours after HT had substantial improvement in encephalopathy scores, arterial ammonia levels, and prothrombin times. Clinical improvement was paralleled by an increase in aminopyrine and caffeine clearances. All 3 patients lived substantially longer than expected based on clinical experience after HT (12, 28, and 52 days) but eventually died. Postmortem examination showed the presence of transplanted hepatocytes in liver and spleen by light microscopy and fluorescent in situ hybridization (FISH). Cryopreserved and thawed human hepatocytes can be transplanted into recipients with ALF with some acceptable but definite complications. Engraftment of donor hepatocytes was proven by histological examination and FISH by both transjugular biopsy and at autopsy. Improvement in brain edema, encephalopathy grade, and clearance of antipyrine and caffeine suggested function, albeit with a 24- to 72-hour delay posttransplantation.

PURPOSE: To investigate the role of transjugular intrahepatic portosystemic shunt (TIPS) as a bridge to transplantation for patients with Budd-Chiari syndrome (BCS),MATERIALS AND METHODS: Eight patients (five women, three men) with a mean age of 49.8 years (range, 20-61 years) were diagnosed with BCS by means of computed tomography, hepatic venography, and liver biopsy. One patient had acute liver failure, with subacute or chronic failure in seven. TIPS placement was attempted in all eight patients, Clinical follow-up and portograms were obtained in all patients until death or transplantation.RESULTS: TIPS placement was completed in seven of eight patients (87.5%). During the follow-up period, TIPS occlusion occurred in four patients. TIPS revision in this patient, although successful, was complicated by hemorrhage and multiorgan failure, and the patient died. Assisted patency rate, excluding the technical failure, was 100%. Mean follow-up in the six survivors with TIPS was 342 days (range, 19-660 days). All six survivors had complete resolution of their ascites, Albumin levels improved an average of 0.43 g/dL (range, 0.3-1.4 g/dL), Bilirubin levels improved in five of six patients (83%), decreasing by an average of 5.6 mg/dL (range, 3.0-15.2 mg/dL), Of the six survivors, three underwent elective liver transplantation, one is awaiting transplantation, and one has been removed from the transplantation list because of clinical improvement. One patient was a candidate for transplantation but declined to be put on the list.CONCLUSION: Hepatic synthetic dysfunction improves markedly after TIPS placement in patients with BCS, Significant improvement in ascites can also occur. TIPS can be an effective bridge to transplantation for patients with BCS.

PURPOSE: Arterial occlusions of the small vessels of the forearm and hand may have the same consequences as arterial occlusions in the distal lower extremity, There is limited reported experience with the regional thrombolytic therapy in this setting. The authors reviewed their experience with thrombolytic therapy in acute and subacute arterial occlusions of the distal upper extremity to further clarify its role.MATERIALS AND METHODS: Twelve patients with acute or subacute arterial occlusions of the forearm and hand who had ischemic digits and were treated with regional urokinase infusion were identified retrospectively. Their medical and radiology records were reviewed.RESULTS: All 12 patients demonstrated angiographic improvement and 11 patients demonstrated clinical improvement after treatment. Tissue necrosis in four patients led to partial amputation of one digit in two patients and three digits in two patients, Three of these patients had category III ischemia at presentation, The level of resulting amputation was altered in all but one patient. Vasospasm was noted frequently but responded to vasodilators. No significant complications occurred.CONCLUSIONS: When therapeutic alternatives are limited to anticoagulation and expectant amputation, regional urokinase infusion can optimize distal runoff, obviate or improve the options for distal surgical bypass, and limit tissue loss.

208 Medical therapy for Budd-Chiari syndrome (BCS) is ineffective in prolonging survival. The reported mortality rate is as high as 86% when BCS treated nonsurgically within six months of diagnosis. Purpose: To investigate the role of transjugular intrahepatic portosystemic shunt (TIPS) as a nonsurgical approach in the management of liver failure due to BCS. Methods: Between December 1995 and December 1997, eight patients(M:3 F:5) with a mean age of 50 years were diagnosed with BCS by CT, hepatic venography and liver biopsy. One patient had acute liver failure and 7 others had subacute or chronic failure. TIPS placement was attempted in all patients as the initial procedure. Clinical follow-up and portography were obtained in all patients until death or orthotopic liver transplantation (mean follow-up period 440 days). Results: TIPS placement was successful in 7 of 8 patients (88%), with a mean assisted patency of 303 days. One patient died during attempted recanalization of an occluded TIPS. All 6 survivors had near or complete resolution of ascites, cessation of further deterioration, and partial reversal of hepatic dysfunction. Outcomes include: urgent transplantation after failed TIPS (n=1), elective liver transplantation at 1 month and 18 months after the procedure (n=2), awaiting liver transplantation (n=2). One was not listed for transplantation due to clinical improvement and one was not considered a suitable transplant candidate. Conclusion: TIPS is a safe, effective treatment of liver failure due to BCS, providing sufficient time to allow for subsequent elective orthotopic liver transplantation, if needed.

Hepatic venoocclusive disease (VOD) is an often fatal disease which can occur during the first 100 days following bone marrow transplantation (BMT).To date multiple factors have been implicated; however, there is no clear cut study to identify the patients at increased risk before and after BMT.Thus, to identify the potential high risk groups and factors predisposing to VOD, we retrospectively reviewed the charts of patients who had BMT between 1990-96 at MD Anderson Cancer Center.Methods: In this case-control study patients' previous chemotherapy, medical and surgical history as well as hospital course, biochemical and histological data 100 days after BMT were extensively evaluated.Baltimore Clinical Diagnostic Criteria were applied to diagnose VOD within 21 days after BMT (Bilirubin _> 2 mg/dL, new onset ascites, 5% gain above admission weight, hepatomegaly and right upper quadrant pain) In addition to hyperbilirubinemia, presence of 2 out of 3 events was considered as diagnostic for VOD.Multiple stepwise logistic regression analysis was done and p<0.05 was considered as statistically significant.Results: There were 19 VOD patients and 99 controls who were age, gender and race matched.Use of pain medications, cyclosporin-A and methotrexate and presence of renal failure were the only significant independent risk factors for VOD (Table 1).

Mesenteric vein thrombosis (MVT) is a rare cause of intestinal ischemia. Because of its nonspecific symptoms, diagnosis is often delayed. We describe a patient with liver cirrhosis who developed acute MVT while waiting for liver transplantation. Surgical intervention carried a high risk because of her underlying cirrhosis. Mesenteric venous thrombectomy and thrombolysis were performed with an AngioJet (Possis Medical, Minneapolis, MN) thrombectomy device and streptokinase infusion through transjugular route. The patient subsequently received an orthotopic liver transplant. We also present a review of the literature about the occurrence and treatment options for MVT.

PURPOSE: In vitro and in vivo investigations were performed to evaluate the Irie retrievable inferior vena caval (IVC) filter.MATERIALS AND METHODS: The clot capturing performance of the Irie and five other IVC filters was assessed in both horizontal and vertical orientations within a pulsed-flow circuit with 240 clot challenges for each filter. Subjective comparisons of the flow disturbance characteristics of the Irie and three other filters were also performed. In vivo studies consisted of 13 Irie filter insertions and eight attempted retrievals in 11 pigs. Histologic evaluation of the IVC was performed with the Irie filter in situ and following retrieval.RESULTS: In vitro testing demonstrated the clot capturing capability and flow disturbance characteristics of the Irie filter to be similar to those of other IVC filters. Filter deployment problems occurred during three of the 13 insertions. Six of the eight retrieval procedures were successful; four filters were retrieved 1 month after insertion. Follow-up cavography demonstrated two tilted filters and three caval perforations.CONCLUSION: The performance of the Irie filter is similar to that of other currently available IVC filters. The filter can be retrieved after neointimal incorporation of the struts into the IVC wall.

OBJECTIVE: To describe the ultrasonographic appearance of collagen injected periurethrally to treat urinary stress incontinence. PATIENTS AND METHODS: Transvesical and transvaginal ultrasonography IUS) was performed 26 times in 23 patients 3 to 36 months after periurethral injection of collagen to treat symptomatic urinary stress incontinence. The patients ranged in age from 23 to 86 (median 54) years. The appearance, location and volume of the collagen were recorded. Clinical data were also obtained. RESULTS: Transvesical US demonstrated the collagen in 17 of the patients, whereas transvaginal US demonstrated the collagen in all of them. The collagen collections appeared as circumscribed masses at the bladder base and showed various levels of echogenicity with both techniques. However, in patients with more than one deposit of collagen, the collections had similar echogenicity, and echogenicity increased over time in the two patients who underwent serial imaging. In 21 of the patients, the collagen collections were located posterior or lateral to the urethra, and these patients recorded complete or moderate resolution of incontinence. In two of the patients the collections were exophytic, projecting into the bladder lumen; these patients experienced little improvement in their continence, CONCLUSIONS: US provides a rapid, noninvasive method of assessing collagen after periurethral injection. Transvaginal US is the best method of visualizing such collections.

OBJECTIVES:To compare the clinical, bacteriologic, and radiologic features of pulmonary and pleural tuberculosis in young adults and the elderly and determine if any differences exist between both groups.DESIGN:Prospective recruitment of all patients diagnosed as having pulmonary and pleural tuberculosis in British Columbia, Canada.SETTING:A population-based sample from a provincial control program TB registry.PATIENTS:A total of 218 consecutive patients whose conditions were diagnosed between January 1990 and May 1991. We excluded 15 HIV-positive patients whose conditions were diagnosed during this study.INTERVENTION:Standardized data collection of symptoms, bacteriology, and review of radiology by two readers blind to the clinical and epidemiologic data.MAIN RESULTS:There were 142 young adult patients and 76 elderly patients. The young adults had a mean age of 41.2 years and the elderly group had a mean age of 75 years of age. Fever (p = 0.002) and night sweats (p = 0.02) were more common in young adults. In culture-proven disease, hemoptysis, fever, and cough were more common in young adult (p = 0.03, 0.02, and 0.01, respectively). There was no difference in the duration of symptoms between the two groups. The odds ratio for cancers other than lung cancer, 3.98 (confidence interval, 1.49, 10.65) in the elderly group was the only significant risk factor to differ between the two groups. Skin test responses to 5TU PPD were positive in 86.2 percent of young adults and 67.6 percent of elderly patients tested (p = 0.03). A total of 79.6 percent of young adults and 88.15 percent of the elderly patients (not significant) were culture positive. Comparison of radiologic findings in young adults vs elderly patients showed no significant differences apart from those with miliary TB 0.7 percent vs 6.7 percent (p = 0.04).CONCLUSIONS:In this population-based study, young adults were more likely to have hemoptysis, fever, and cough and to have a positive PPD response. Cancer was significantly associated as a risk factor in the older age group. There was no difference in bacteriologically proven disease or radiologic findings between the two groups, apart from the more common occurrence of miliary TB in the elderly.

To assess the radiologic patterns of presentation of active pulmonary tuberculosis, the authors studied all patients with active, culture-proven pulmonary tuberculosis who presented in British Columbia between May 1989 and May 1991. The chest radiographs were assessed by two observers. Epidemiologic data were collected to allow examination of differences among ethnic groups. The 188 patients ranged in age from 1 to 96 (median 54) years; only 2 were less than 20 years of age. Thirty of the 188 patients (16%) presented with clinical and radiologic findings consistent with primary tuberculosis; the other 158 (84%) had postprimary disease. Of the second group, typical upper lobe infiltrates were seen in 126 (80%). Less common manifestations included lymphadenopathy (in 14 cases), isolated nodular tuberculoma (in 10), isolated involvement of the lower lung zones (in 10), cavities with air-fluid levels (in 6) and isolated pleural effusion (in 2). The authors conclude that the characteristic upper lobe infiltrates of postprimary disease remain the most common form of presentation of active tuberculosis in adults. However, atypical presentation, due to either an unusual pattern of post-primary tuberculosis or to primary tuberculosis, may be seen in up to 30% of patients.

Duplex spectral or color Doppler sonography demonstrated major abdominal vessel blocks affecting 18 vessels in 16 infants aged between 23 and 56 weeks postconceptional age. The portal vein was affected in 8 infants, the renal vein in 3, the renal vein and inferior vena cava in 1, the renal artery in 1, the inferior vena cava and hepatic vein in 1, and the aorta in 2 infants. Doppler sonography confirmed the grey-scale findings and often demonstrated the extent of vascular flow, providing functional information not available from the grey-scale scan. It facilitated the follow-up of thrombosis during therapy. Most important of all, in many instances it enabled a rapid and reliable specific diagnosis often not possible on the grey-scale study alone and hence altered patient management.