The Role Of Biliary Percutaneous Transhepatic Angioplasty In The Management Of Biliary Structures Following Liver Transplantation

139 This study evaluated the efficacy of a protocol of balloon dilation for biliary strictures following liver transplantation. The outcome parameter measured was biliary drainage tube independence. Methods: Complete records from 96 patients with biliary strictures were retrospectively reviewed. Strictures were classified by location in the biliary tree, and by whether single or multiple. Follow-up ranged from 6 months to 7 years. All patients were initially evaluated for biliary percutaneous transhepatic angioplasty (BPTA). Three dilations were performed four to eight weeks apart in a majority of cases. Groups were compared using Student's t test and Fisher's exact test. Results: One hundred three strictures were identified in 96 patients. BPTA was attempted in 80 cases, with three technical failures. BPTA successfully treated strictures in 38 of the remaining 77 cases (48.6%), resulting in tube independence in 36. In 23 cases, no BPTA was performed; 12 strictures resolved spontaneously and 2 were surgically revised. Factors favoring successful BPTA included older age at transplant (43 ± 17 vs. 32 ± 19, p<0.01), shorter cold ischemic time (10.6 ± 2.5 hours vs. 12.2 ± 3.6 hours, p<0.03), and single strictures (61% success vs. 36%, p<0.05). BPTA was successful in only 5/17 attempts in pediatric patients (29%) vs. 33/60 in adult patients (55%, p=0.09). There was no association between BPTA success and stricture location (intra vs extrahepatic), gender, warm ischemic time, intraoperative blood loss, bile leak, type of reconstruction (duct-duct vs Roux), acute or chronic rejection, vascular complications, or bile duct stones. There were five recurrent strictures, all of which were successfully treated by BPTA. Of the 39 BPTA failures, 15 underwent subsequent surgical revision. Twelve of the patients undergoing revision had single common duct or anastomotic strictures. When both angiographic and surgical modalities were considered, ultimate tube independence was associated with less cold ischemic time (13.3 ± 3.4 hours vs. 10.5 ± 2.7 hours, p<0.002), shorter operative time (7.4 ± 2.1 hours vs. 8.7 ± 2.2 hours, p<0.05), and less intraoperative transfusion (10.1 ± 6.4 units PRBC vs. 14.8 ± 9.7, p<0.02). Other significant risk factors are shown. (Table)TableTwo strictures recurred following surgical revision, one of which was treated successfully by BPTA. Utilizing this combined approach, tube independence was achieved in 51 of 77 patients (66%). Conclusions: Biliary percutaneous transhepatic balloon angioplasty is an effective initial modality for treating post-transplant biliary strictures. Prolonged cold ischemic and operative times, young patient age, stones, and multiple or peripheral strictures predispose to treatment failure. Solitary extrahepatic strictures that fail BPTA are salvageable with subsequent surgical revision