Hemobilia and cystic artery stump pseudoaneurysm associated with liver abscess after a laparoscopic cholecystectomy: Report of a case

A 63-year-old woman was admitted for cholecystitis and underwent a laparoscopic cholecystectomy (LC). She experienced abdominal pain and hemobilia 11 days after the LC. Angiography was performed but it did not show any source of bleeding. Thereafter, at 27 days after LC, a repeat angiogram was performed which revealed a pseudoaneurysm (PA) arising from a cystic artery stump and an embolized PA sack. However, another PA arising from near the embolized PA and liver abscess was observed 4 days after embolization. The arterial collateral flow was evaluated by endovascular balloon occlusion of the right hepatic artery and it was embolized proximal and distal to the bleeding point. The embolization of the partial hepatic artery was effective for PA when packing the PA sack proved to be insufficient. In patients with liver cirrhosis or liver abscess who require an adequate arterial liver flow, it is important to evaluate the collateral arterial flow before hepatic artery embolization.     

Major resections of the liver in patients with high surgical risk

Experience with 75 major anatomic resections of the liver in patients with high surgical risk due to low functional reserve of the liver, spontaneous disruption of hepatic tumor, chronic purulent infection in patients with hepatic abscesses, posttraumatic sequestration of the liver with hemobilia, giant hepatic hemangiomas, old age and severe concomitant diseases was analyzed. General postoperative lethality was 14.7% which was determined mainly by unfavorable outcomes in postoperative patients in spontaneous disruption of tumor and massive intraabdominal bleeding, and also by severe postoperative hepatic insufficiency in patients after right-sided hemihepatectomy for hepatocellular carcinoma with postnecrotic cirrhosis of the liver. Immediate results of surgery in patients with obstructive jaundice and biliary hepatic cirrhosis were better that ones of patients with postnecrotic cirrhosis. There were no lethal outcomes in group of patients after surgery for giant hemangiomas, abscesses and posttraumatic sequestration of the liver. Thorough selection of patients based on detailed study of functional hepatic reserves and also volume of removed hepatic parenchyma is necessary for improvement of immediate results of surgical treatment. It is valid to perform portal venous embolization before right-sided hemihepatectomy in patients with postnecrotic, biliary cirrhosis, and also in old patients to decrease the risk of postresection hepatic insufficiency. Roentgenondovascular occlusion of the hepatic artery, Cell-Seiver use for intraoperative blood reinfusion and in some cases--use of methods of complete vascular isolation of the liver are indicated for patients with giant hepatic hemangiomas.     

Re-artelialization of the liver after intravascular occlusion and the possibilities of re-embolization of the arterial bed of the liver

Angiographic examinations were performed in 52 patients with portal cirrhosis and 6 patients with tumours of the liver in remote terms (1.5-38 months) after embolization of the hepatic artery. In 20 patients (34.5%) a considerable degree of reestablishment of the hepatic blood flow was noted which was considered to be an indication to a repeated endovascular intervention. Unlike the surgical operation, the intravascular occlusion can be performed repeatedly in the process of observation of the patient.     

Value of roentgenological embolization of the splenic artery in the complex treatment of liver cirrhosis

The authors share their experience with splenectomy, spleen artery ligation and its roentgen embolization in 110 patients with liver cirrhosis. Advantages of embolization ++ under roentgenological control are proved for the correction of hypersplenism, in preparing the patients to operations on the liver with using the methods of stimulation of reparative regeneration.     

肝动脉栓塞术后的肝内外胆道损毁性病变

目的 探讨经导管肝动态栓塞术后对胆道损伤的病因、治疗及预防。方法 总结５例因肝动脉栓塞引起的胆道损伤患者,其中４例为肝血管瘤经导管动脉栓塞术后,１例为手术时结扎肝动脉注射ＴＨ胶后。动物实验观察向大鼠肝动脉内注射乙醇复制血管栓塞剂对肝脏的损伤。结果 ５例患者均有胆道毁坏性病变,甚至造成胆汁性肝硬化,４例进行胆管空肠吻合及胆道支撑。实验结果证实肝动脉注射血管硬化剂无水乙醇后可以引起邻近汇管区肝脏局部坏     

Living donor liver transplantation as a means of rescuing post-embolization hepatic failure in a patient with idiopathic intrahepatic arteriovenous malformation in the liver

Interventional radiology used to be a first-line treatment for cardiac failure caused by idiopathic hepatic arteriovenous malformation (AVM). Here, we report a 64-year-old male patient treated by living donor liver transplantation (LDLT) following failed hepatic artery embolization for idiopathic hepatic AVM. Hepatic artery reconstruction in LDLT was very difficult in this case due to the adverse effects of the pre-transplant intervention. In the treatment of widespread AVM in the liver, arterial embolization should be avoided and primary liver transplantation should be considered.     

血管介入技术在严重肝外伤损伤控制中的应用

目的 探讨血管介入技术(肝动脉造影及栓塞)在损伤控制性处理严重肝外伤中的应用价值。方法 对13例损伤控制性处理后的严重肝外伤病人进行血管造影,观察是否有再出血的表现,并对出血动脉进行选择性的栓塞。观察止血效果。结果 13例肝动脉造影显示2例胆道出血,5例肝外伤创面出血,3例假性动脉瘤形成,3例无出血征象。10例进行了出血肝动脉分支栓塞均成功止血。随访3个月至2年,无再出血病例及死亡病例。结论 血管介入技术是诊断严重肝外伤行损伤控制性处理后是否再出血以及有效的止血方法。     

Blood supply of malignant tumors of the liver after embolization of the hepatic artery]

Repeated angiographic studies (10 arteriographies, 3 percutaneous transhepatic portography) were performed in 10 patients with malignant tumors of the liver 5-20 months after embolization of the hepatic artery. The ++roentgenological data obtained and results of 3 autopsies enabled the authors to make a conclusion that blood supply of malignant tumors of the liver after embolization of the hepatic artery remains mainly of arterial type.     

Embolization of the splenic artery in liver cirrhosis with portal hypertension and splenomegaly

Results of subacute embolization of the splenic artery with a metallic spiral obtained in 22 patients with cirrhosis of the liver with splenomegaly were studied at the stage of sub- and decompensation of the portal blood circulation. Results of the study and their clinical evaluation suggest that the subacute embolization of the splenic artery is a relatively safe, atraumatic and effective method of surgical treatment of splenomegaly, hypersplenism resulting from liver cirrhosis with portal hypertension. The method allows to decrease hypersplenism, splenomegaly, portal hypertension, to eliminate the pain syndrome due to splenomegaly.     

An experimental study of the basic properties of drug microspheres and target treatment of rats with liver tumor

This experimental hepatic artery embolization with Camptothecin (CPT) albumin microspheres was performed in normal rats and rats with liver tumor. The basic properties of the CPT albumin microspheres and the effects of target treatment on rats with liver tumor were studied. The results showed that the concentration of the drug released into hepatic vein was almost stable for over 3 hours after hepatic arterial infusion of CPT albumin microspheres, the partial and complete recovery of hepatic artery inflow occurred within 50-70 days after embolization. Pathological examination revealed many irreversible damages of the liver, and the tumor vessels and stains disappeared after hepatic arterial embolization, some of the tumor were decreased in size and had complete necrosis. Therefore, CPT albumin microspheres are peripheral biodegradable embolizatic substances with the property of slowly drug-releasing. It can exert the effect of chemoembolization in treating the hepatic malignant tumor, alleviating the toxic reaction of CPT and increasing the patient's tolerance to CPT.     

Mycotic pseudoaneurysms after liver transplantation

The most frequent etiology of visceral artery aneurysms is arteriosclerosis, but vascular manipulation during hepatic transplantation may also cause a mycotic pseudoaneurysm. Treatment with embolization, stents or percutaneous thrombin injection have been recommended but surgical revascularization is indicated when interventional techniques fail. A 43-year-old man with hepatitis C virus cirrhosis who underwent orthotopic liver transplantation from a cadaveric donor was treated with cyclosporine, mycophenolate, and steroids and was discharged from hospital at 35 days. Two months later he was readmitted with a febrile syndrome. Abdominal computed tomography showed necrosis of hepatic segments IV, V, and VI. Magnetic resonance imaging and angiography revealed partial thrombosis of the hepatic artery and stenosis of the portal anastomosis secondary to an aneurysm of the hepatic artery. A few hours after the radiological diagnosis, the patient suffered a bout of upper gastrointestinal bleeding and shock. Emergency surgery revealed a mycotic pseudoaneurysm of the common hepatic artery, which had ruptured into the bile tract with hemobilia. The liver graft was removed because of severe necrosis of the right liver. The patient died awaiting a new liver transplantation.     

肝血管瘤的介入治疗(37例疗效观察)

目的观察经皮肝动脉超选插管栓塞治疗肝血管瘤的临床疗效。方法对37例确诊肝血管瘤患者,超选至肝动脉后以超液化碘油和平阳霉素栓塞硬化治疗。结果31例1次栓塞,6例行2次栓塞。随访2~12个月,瘤体缩小>50%者21例,缩小20%~50%者9例,<20%以下者7例,均无严重并发症发生。结论超液化碘油和平阳霉素经皮肝动脉超选插管栓塞治疗肝血管瘤疗效确切。     

Transcatheter treatment of splenic artery aneurysms (SAA). Report of two cases

Splenic artery embolization with steel coils was performed in two patients who both had large splenic artery aneurysms and hepatic cirrhosis complicated by hypersplenism. A good clinical effect was noticed after the procedure. It was concluded that this treatment is safe and effective and decreases the risk of splenic artery rupture. It also corrects hypersplenism. Transcatheter embolization appears to be a preferable alternative to surgery in such cases.     

Sequential Preoperative Ipsilateral Portal and Arterial Embolization in Patients with Colorectal Liver Metastases

Background Preoperative portal vein embolization (PVE) induces ipsilateral atrophy of the hepatic parenchyma to be resected, as well as contralateral compensatory hypertrophy of the residual liver. However, there are two potential problems with this technique: inadequate contralateral hypertrophy and tumor progression while waiting for the non-embolized liver to hypertrophy. We devised a strategy to deal with these two problems by performing an ipsilateral hepatic artery embolization 6 weeks after an unsatisfactory PVE in an effort to accelerate the hypertrophy of the remnant liver. Materials and Methods Two patients with colorectal liver metastases underwent to this sequential preoperative treatment in order to achieve resectability of their metastatic disease. Results Both patients successfully underwent major hepatic resection. Conclusions In our experience sequential ipsilateral portal vein and hepatic artery embolization extended the indications for liver resection for metastatic colorectal cancer.     

部分脾动脉栓塞术后肝脏血流改变的CT灌注成像

目的观察肝硬化门静脉高压伴脾脏功能亢进患者部分脾动脉栓塞术（PSE）后的肝脏血流改变。方法肝硬化门静脉高压伴脾脏功能亢进患者20例,肝功能A级16例,B级4例;脾肿大轻度5例,中重度15例。分别在脾脏栓塞前2d及术后1个月接受肝脏CT灌注成像,测量以下参数：肝总血流灌注量（HBF）、肝总血容量（HBV）,肝动脉灌注指数（HPI）,门静脉灌注量（PVP）,肝动脉灌注量（HAP）,平均通过时间（MTT）,毛细血管表面通透性（PS）。对术前、术后参数进行统计学分析。结果PSE前、后的各项灌注参数为：HBF129.30/116.30ml/（min.100ml）（P〉0.05）,HBV18.50/19.90ml/100ml（P〉0.05）,HPI0.23/0.45（P〈0.05）,PVP102.80/67.80ml/（min.100ml）（P〈0.05）,HAP27.46/48.53ml/（min.100ml）（P〈0.05）,MTT15.40/14.60s（P〉0.05）,PS36.10/37.30ml/（min.100ml）（P〉0.05）。结论肝硬化门静脉高压伴脾脏功能亢进患者在PSE术后HPI升高,PVP降低。研究肝脏CT灌注成像参数可对制定个体化治疗方案、选择治疗手段和评价疗效提供帮助。     

Splenic embolization in liver transplant recipients: early outcomes

Clinical improvement has been reported following splenic embolization for a wide variety of indications. Improvement following splenic embolization has been described in cirrhotic patients awaiting hepatic transplantation who are not candidates for surgical splenectomy. Occasionally, patients who have undergone hepatic transplantation have conditions that may also benefit from nonsurgical intervention with splenic embolization. Indications include persistent hypersplenism and pancytopenia precluding optimal treatment with antiviral therapy or chemotherapy, risk for persistent gastroesophageal variceal hemorrhage, and splenic artery steal syndrome attenuating hepatic arterial perfusion. Limited data is available on the outcome of splenic embolization in liver transplant recipients. We present the early outcomes of liver transplant recipients who were treated with splenic embolization. A retrospective chart review of all liver transplant recipients who underwent splenic embolization between 1997 and 2006 was performed, under minimal-risk study approval by the institutional review board. Five liver transplant recipients received splenic embolization: 3 for persistent hypersplenism, 1 for increased risk of gastroesophageal variceal hemorrhage, and 1 for splenic artery steal syndrome. The patients with hypersplenism demonstrated hematologic improvement, the patient with gastroesophageal varices did not experience any hemorrhage on follow-up, and the patient with splenic artery steal experienced resolution of the steal phenomenon. Postembolization syndrome was observed but no splenic abscess or death occurred. Mean follow-up was 20.2 months. In conclusion, splenic embolization is a safe and effective nonsurgical alternative for a variety of indications in liver transplant recipients.     

Management of bleeding liver tumours in Hong Kong

A retrospective study was undertaken of 41 patients diagnosed as having suffered spontaneous liver rupture over a 4-year period to identify the clinical features, treatment and outcome of this complication in an area in which hepatocellular carcinoma is endemic. Two patients were excluded with a revised diagnosis of haemorrhagic malignant ascites. Of the remaining 39 patients, 37 bled from ruptured hepatocellular carcinoma, one from peliosis hepatis and multiple liver cell adenomas, and one from a malignant hepatic epithelioid haemangioendothelioma. Analysis showed that 59 per cent of patients were in shock on admission and that all but two of the 37 patients with ruptured hepatocellular carcinoma were men with cirrhosis. The association with cirrhosis was significantly higher than in a series of 45 patients with hepatocellular carcinoma undergoing elective resection during the same period (P less than 0.05). Treatment consisted of supportive care only in two patients, angiographic embolization in four, emergency liver resection in 11 of whom six died, hepatic artery ligation in 12 of whom eight died, and suture and/or packing in eight of whom six died. One patient died at laparotomy and in another patient bleeding was successfully arrested by intratumoural injection of absolute alcohol. Because of the high operative mortality of emergency surgery in these poor risk patients, prospective evaluation of emergency angiographic embolization is required.     

Changes in hemodynamics and angioarchitecture of the hepatolienal basin after embolization of the splenic artery in liver cirrhosis

Complex investigations of regional hemodynamic changes in the spleno-hepatic basin in 72 patients with cirrhosis of the liver after the embolization of the splenic artery have shown that in most patients the embolization of the splenic artery is followed by pronounced alterations in the portal system, decreased portal pressure, inversed blood flow in the main trunk of the splenic vein. The ESA used in the complex surgical treatment of patients facilitates the compensation of the portal blood circulation.     

Hepatectomy in patients with advanced hepatocellular carcinoma after hepatic artery chemotherapy/embolization or hepatic artery embolization/ligation]

Eight patients with advanced hepatic cancer underwent hepatectomy after repeated hepatic artery chemotherapy/embolization (HACE) or hepatic artery embolization/ligation (HAEL). Seven of the 8 patients survived for more than one year after operation, the longest being up to 73 months. The results showed that both HACE and HAEL are effective for the treatment of liver cancer, and in some patients they can make large tumors resectable.     

Portal embolization (an experimental-morphological study)

Results of experimental-morphological study of influence of unilobar portal embolization by biologic occlusive material RABROM on the liver of 6 laboratory animals are presented. It is shown that portal venous embolization leads to focal necrosis of parenchyma of embolized hepatic lobe, it atrophy and formation of portal cirrhosis. In non-embolized hepatic lobe the distinct signs of increased regeneration and hypertrophy of hepatocytes were revealed. RABROM didn't lead to damage and inflammatory changes of vascular wall that testifies to it biologic inertia. It is recommended to use the method of portal venous embolization for preparation of patients with low functional hepatic reserve for extensive resections.