Preoperative portal vein embolization with Amplatzer(®) vascular plugs (AVP): a review of 17 cases

The purpose was to determine the efficacy and technical particularities related to the use of Amplatzer^® Vascular Plugs (AVP) for preoperative portal vein embolization. Between 2005 and 2009, a total of 48 type I AVP were embolized into the portal venous system of 17 patients (51–83 years) prior to extended hepatic resection where the residual liver volume (RLV) was deemed sufficient (RLV < 35–40% in patients with underlying hepatocellular disease, < 25–30% in patients with normal liver). AVP were used alone in seven patients and combined to other embolization agents in 10 patients (coils: n = 5, microparticles: n = 1, resorbable gel foam: n = 4). The procedure was technically successful in 100% of cases with immediate success rate of 94.1% (imcomplete embolization of a segmental branch of segment VIII). The procedure was well tolerated clinically in 94.1% of cases, and in 100% of cases based on laboratory values. The rate of recanalization on follow-up CT at 5 weeks (2–22) was 11.7%. The rate of complications, major (left portal vein thrombosis following right portal vein embolization) and minor (one case of portovenous fistula), was 11.7%. The rate of RLV growth was from +13 to +285 cm³ (mean at +122 cm³), or +4.98 to +78.51% (mean at +33.3%) (hepatocellular carcinoma: mean of +30.7%, metastases: mean of +19.7%). The rate of surgical candicacy was 94.1% (two patients were excluded: insufficient growth of RLV, development of peritoneal carcinomatosis). AVP appear to be reliable and effective for the preoperative embolization of the portal vein, with low morbidity and sufficient growth of RLV.     

肝癌合并肝动脉-门静脉分流影响门静脉血流动力学的定量研究

目的　通过门静脉系统置管直接测定肝动脉 门静脉分流 (APS)栓塞前后门静脉压力的改变 ;定量分析门静脉压力与门静脉高压症之间的变化关系。方法　对 18例肝癌合并中央型APS患者APS栓塞和肝动脉化疗栓塞术 (TACE) ,同时行经皮门静脉穿刺置管 ,测定APS分流道闭塞前后门静脉压力 ;术前及术后 2周行肝脏彩超及胃镜检查。结果　 18例患者术后门静脉主干压力显著降低 ,下降幅度为 5 .4 %～ 33.3% ,平均降幅为 2 0 .1% ;栓塞后门静脉直径缩小 ,血流速度加快 (P <0 .0 1) ;13例门静脉主干呈离肝血流患者 ,术后有 7例转为向肝方向。APS栓塞后 ,18例患者门静脉高压症状均有改善 ,在门静脉压下降幅度超过 2 0 %的 10例患者中 ,门静脉高压症有明显改善 ;门静脉压力下降在 2 0 %以下的8例患者中 ,门静脉高压症改善不明显。结论　栓塞APS能显著降低门静脉压力 ,平均降幅达 2 0 %以上 ;当门静脉压力降低 2 0 %及以上时可有效地改善腹水、上消化道出血和顽固性腹泻症等一系列门静脉高压症状     

Preoperative portal vein embolization with a new liquid embolic agent

PURPOSE: To evaluate the effectiveness and safety of a new liquid embolic agent in preoperative portal vein embolization. MATERIALS AND METHODS: Embol-78 was obtained by means of hydrolysis of polyvinyl acetate and was dissolved in a mixture of ethanol and nonionic water-soluble contrast medium. After percutaneous puncture of the portal vein, embolization of the right portal vein was performed in 22 patients with hepatocellular carcinoma and in 29 patients with nonhepatocellular carcinoma. In each group, changes in volume of the future liver remnant, portal venous pressure, and liver enzymes were evaluated both before and after embolization. Complications were also evaluated. RESULTS: Portal vein embolization was successful in all patients, without major complications. The mean volumes of the future liver remnant before and 2 weeks after embolization were 385 mL +/- 138 and 533 mL +/- 140, respectively, in the hepatocellular carcinoma group and 517 mL +/- 348 and 755 mL +/- 197, respectively, in the nonhepatocellular carcinoma group. There were only transient elevations in liver enzyme levels after embolization. Mean portal venous pressures before and after the procedure were 16.7 mm Hg +/- 3.8 and 20.3 mm Hg +/- 3.6, respectively, in the hepatocellular carcinoma group and 11.7 mm Hg +/- 3.5 and 14.6 mm Hg +/- 3.6, respectively, in the nonhepatocellular carcinoma group. In each group, changes in volume of the future liver remnant and portal venous pressure were statistically significant (P <.001). CONCLUSION: The liquid embolic material Embol-78 seems to be effective and safe for preoperative portal vein embolization.     

Novel approach to complex pulmonary arteriovenous malformation embolization using detachable coils and Amplatzer vascular plugs

Introduction

We evaluated the feasibility of a modified embolization technique of pulmonary arteriovenous malformations (PAVM) using venous sac embolization with detachable coils combined with the feeding artery embolization with the Amplatzer vascular plug (AVP).

Materials and methods

We retrospectively studied technical and clinical success in the treatment of 11 complexe PAVMs. We recorded number and size of feeding arteries and draining vein, the last prior and post treatment in the follow up CT, size of PAVMs; and the number of devices needed to occlude each PAVM.

Results

11 complexe PAVM were treated with detachable coils to venous sac embolization followed by AVP to embolize feeding arteries. In all but one case a complete occlusion of the PAVM was angiographically achieved. The mean number of feeding vessel was 2.64 ± 0.92 (2–5). The mean number of coils was 7.82 ± 5.09 (3–20 coils). CT-follow-up, that was possible in 8 patients, showed a significant reduction of the draining vein size. The mean diameter reduction of the draining vein was 62 ± 18% varying between 29% and 77%. In all but one case with the complexe angioarchitecture the reduction of draining vein size close to 70% was achieved.

Conclusions

Our study implies that the venous sac embolization using the detachable coils followed by occlusion of the large feeding arteries using the AVP is a highly efficient method for the treatment of the complex PAVMs with large out-flow vessels and short feeding arteries.     

Embolization with the Amplatzer Vascular Plug in TIPS Patients

Vessel embolization can be a valuable adjunct procedure in transjugular intrahepatic portosystemic shunt (TIPS). During the creation of a TIPS, embolization of portal vein collaterals supplying esophageal varices may lower the risk of secondary rebleeding. And after creation of a TIPS, closure of the TIPS itself may be indicated if the resulting hepatic encephalopathy severely impairs mental functioning. The Amplatzer Vascular Plug (AVP; AGA Medical, Golden Valley, MN) is well suited for embolization of large-diameter vessels and has been employed in a variety of vascular lesions including congenital arteriovenous shunts. Here we describe the use of the AVP in the context of TIPS to embolize portal vein collaterals (n = 8) or to occlude the TIPS (n = 2).     

Hepatoma, arterioportal shunting, and hyperkinetic portal hypertension: therapeutic embolization

Four patients with hepatocellular carcinoma, shunting of blood from the hepatic artery to the portal vein, and hyperkinetic portal hypertension were treated by transcatheter embolization of the hepatic artery. In three acutely bleeding patients variceal hemorrhage was controlled by the embolization. Following embolization hepatofugal portal venous flow became hepatopetal in all four patients. No serious complications were encountered. When hepatoma is complicated by arterioportal shunting and hyperkinetic portal hypertension, occlusion of the fistula by transcatheter embolotherapy can reduce the portal pressure.     

Percutaneous Transsplenic Access to the Portal Vein for Management of Vascular Complication in Patients with Chronic Liver Disease

Purpose

To evaluate the safety and feasibility of percutaneous transsplenic access to the portal vein for management of vascular complication in patients with chronic liver diseases.

Methods

Between Sept 2009 and April 2011, percutaneous transsplenic access to the portal vein was attempted in nine patients with chronic liver disease. Splenic vein puncture was performed under ultrasonographic guidance with a Chiba needle, followed by introduction of a 4 to 9F sheath. Four patients with hematemesis or hematochezia underwent variceal embolization. Another two patients underwent portosystemic shunt embolization in order to improve portal venous blood flow. Portal vein recanalization was attempted in three patients with a transplanted liver. The percutaneous transsplenic access site was closed using coils and glue.

Results

Percutaneous transsplenic splenic vein catheterization was performed successfully in all patients. Gastric or jejunal varix embolization with glue and lipiodol mixture was performed successfully in four patients. In two patients with a massive portosystemic shunt, embolization of the shunting vessel with a vascular plug, microcoils, glue, and lipiodol mixture was achieved successfully. Portal vein recanalization was attempted in three patients with a transplanted liver; however, only one patient was treated successfully. Complete closure of the percutaneous transsplenic tract was achieved using coils and glue without bleeding complication in all patients.

Conclusion

Percutaneous transsplenic access to the portal vein can be an alternative route for portography and further endovascular management in patients for whom conventional approaches are difficult or impossible.     

Altered hepatic hemodynamics caused by temporary occlusion of the right hepatic vein: evaluation with Doppler US in 14 patients

PURPOSE: To evaluate with Doppler ultrasonography (US) the altered hepatic hemodynamics caused by temporary occlusion of the right hepatic vein. MATERIALS AND METHODS: The study group consisted of 14 patients being considered for hepatic arterial infusion or transarterial embolization. In all patients, maximum peak velocity of the blood flow in the right portal vein was measured with Doppler US before and during the occlusion of the right hepatic vein. In 13 patients, color Doppler US was performed to evaluate Doppler signal in the portal venous branch in the occluded area before and during occlusion. Average peak velocity in the right hepatic artery in eight patients was measured by using a transducer-tipped guide wire before and during occlusion. RESULTS: Maximum peak velocity of the right portal vein significantly decreased with occlusion (P <.01). Hepatic venous occlusion changed the Doppler signal in the portal venous branch in the occluded area from hepatopetal to no signal in 10 patients; to weakened hepatopetal in two; and to hepatofugal in one. Average peak velocity of the right hepatic artery showed a decrease or plateau for 15-30 seconds after the start of occlusion and then a rapid increase to reach a plateau at around 75-90 seconds, with 1.5-2 times as much velocity as that before occlusion. CONCLUSION: Increase in hepatic arterial velocity is accompanied by a decrease in the portal velocity with temporary occlusion of the right hepatic vein; the expected increased drainage through the portal vein was almost undetectable.     

Preoperative portal vein embolization using an amplatzer vascular plug

The purpose was to evaluate the safety and efficacy of preoperative portal vein embolization (PVE) using an Amplatzer vascular plug (AVP). Forty-one patients who underwent PVE using gelatin sponge particles and the AVP were enrolled. The right portal branches were embolized using gelatin sponges (1–8 mm³) through a 5-F catheter, and the AVP was deployed at the first- or second-order right portal vein. Technical success and complications, recanalization, and changes of total estimated liver volumes (TELV), future liver remnant (FLR), and FLR/TELV were evaluated. Follow-up CT performed 6–43 days (median, 16 days) after PVE was used to evaluate volume parameters. PVE was technically successful in 40 of 41 patients. Major complications occurred in two patients, with one each having extensive portal vein thrombosis and liver abscess. Partial recanalization of the occluded portal vein was seen in one patient. The mean FLR volume (653 ± 174 ml vs. 532 ± 154 ml, p < 0.001) and mean FLR/TELV ratio (43 ± 8% vs 36 ± 7%, p < 0.001) were significantly higher after than before PVE. PVE using the AVP seems to be a relatively safe and effective technique for inducing hypertrophy of the FLR with minimal risk of recanalization.     

Percutaneous transumbilical portal vein embolization in a patient with a ruptured hepatocellular carcinoma supplied by the portal vein

We describe a case of a ruptured hepatocellular carcinoma supplied by the portal vein that was successfully treated with portal vein embolization via a percutaneous transumbilical approach. A contrast material-enhanced computed tomographic (CT) scan showed the presence of a large hypervascular tumor on portal venous phase as well as right hepatic vein thrombosis and hemoperitoneum that prevented portal vein embolization by the use of the percutaneous and transjugular transhepatic approach. The use of percutaneous transumbilical portal vein embolization can be an alternative option in this situation.     

Infantile hepatic hemangioendotheliomas: significance of portal venous and systemic collateral arterial supply.

This report describes four infants with hepatic hemangioendotheliomas and cardiac failure who had extensive portal venous and systemic collateral arterial supply complicating hepatic arterial embolization. One patient with diffuse hepatic hemangioendothelioma and extensive portal vein supply but minimal systemic collateral arteries showed no improvement after technically successful hepatic artery embolization and died with disseminated intravascular coagulation and sepsis. A second infant with extensive portal vein and collateral supply died without undergoing embolization. Two patients had portal vein-hepatic vein fistulas as well as an extensive systemic arterial supply. Both infants tolerated staged hepatic and collateral artery embolization, although one patient died of congestive heart failure, probably related to pulmonary hemangiomas. The authors conclude that angiographic study of the potential collateral vessels and portal venous circulation should be performed before embolization. Patients with shunting from the portal vein to the hepatic vein and minimal systemic arterial collateral circulation should not undergo hepatic artery embolization.     

Embolization of percutaneous transhepatic portal venous access tract with N-butyl cyanoacrylate

Objective:

To evaluate the safety and feasibility of N-butyl cyanoacrylate (N-BCA) embolization of percutaneous transhepatic portal venous access tract and to establish an appropriate technique.

Methods:

40 consecutive patients underwent percutaneous transhepatic portal venous intervention for various reasons. Embolization of percutaneous transhepatic portal venous access tract was performed after the procedure in all of the patients using N-BCA and Lipiodol® (Lipiodol Ultra Fluide; Laboratoire Guerbet, Aulnay-sous-Bois, France) mixture. Immediate ultrasonography and fluoroscopy were performed to evaluate perihepatic haematoma formation and unintended embolization of more than one segmental portal vein. Follow-up CT was performed, and haemoglobin and haematocrit levels were checked to evaluate the presence of bleeding.

Results:

Immediate haemostasis was achieved in all of the patients, without development of perihepatic haematoma or unintended embolization of more than one segmental portal vein. Complete embolization of percutaneous access tract was confirmed in 39 out of 40 patients by CT. Seven patients showed decreased haemoglobin and haematocrit levels. Other complications included mild pain at the site of embolization and mild fever, which resolved after conservative management. 16 patients died during the follow-up period owing to progression of the underlying disease.

Conclusion:

Embolization of percutaneous transhepatic portal vein access tract with N-BCA is feasible and technically safe. With the appropriate technique, N-BCA can be safely used as an alternate embolic material since it is easy to use and inexpensive compared with other embolic materials.

Advances in knowledge:

This is the first study to investigate the efficacy of N-BCA for percutaneous transhepatic portal venous access tract embolization.Percutaneous transhepatic approach for portal venous intervention is used in various procedures, such as portal vein angioplasty, partial portal vein embolization before hemihepatectomy, variceal embolization for upper gastrointestinal bleeding and pancreatic islet cell transplantation.^1–6 After performing these procedures, life-threatening bleeding may occur from transhepatic tracts and, as a result, lead to morbidity and mortality. According to the literature, various embolic materials, including gelatin sponge particles, biological tissue adhesives, coils and plugs, have been utilized to prevent bleeding from the tracts.^7–13 Among these materials, gelatin sponge particles and coils are the two most commonly used embolic materials. However, most of these embolic materials have one or more drawbacks, such as incomplete tract embolization when using gelatin sponge particles, which may be the cause of delayed bleeding, and longer procedure time when using coils or plugs.^14,15 On the contrary, N-butyl cyanoacrylate (N-BCA) is a permanent, fast-acting and inexpensive embolic material, which is associated with a low possibility of rebleeding or migration. There are several reports on embolization of percutaneous biopsy tracts or biliary access tracts with N-BCA.^16–21 However, to the best of our knowledge, none of the studies has evaluated the outcome of embolization of portal venous access tracts with N-BCA. Therefore, the purpose of this study was to evaluate the safety and feasibility of N-BCA embolization of percutaneous transhepatic portal venous access tracts.     

Percutaneous Angioplasty of Portal Vein Stenosis that Complicates Liver Transplantation: The Mid-Term Therapeutic Results

Objective

We wanted to valuate the mid-term therapeutic results of percutaneous transhepatic balloon angioplasty for portal vein stenosis after liver transplantation.

Materials and Methods

From May 1996 to Feb 2005, 420 patients underwent liver transplantation. Percutaneous transhepatic angioplasty of the portal vein was attempted in six patients. The patients presented with the clinical signs and symptoms of portal venous hypertension or they were identified by surveillance doppler ultrasonography. The preangioplasty and postangioplasty pressure gradients were recorded. The therapeutic results were monitored by the follow up of the clinical symptoms, the laboratory values, CT and ultrasonography.

Results

The overall technical success rate was 100%. The clinical success rate was 83% (5/6). A total of eight sessions of balloon angioplasty were performed in six patients. The mean pressure gradient decreased from 14.5 mmHg to 2.8 mmHg before and after treatment, respectively. The follow up periods ranged from three months to 64 months (mean period; 32 months). Portal venous patency was maintained in all six patients until the final follow up. Combined hepatic venous stenosis was seen in one patient who was treated with stent placement. One patient showed puncture tract bleeding, and this patient was treated with coil embolization of the right portal puncture tract via the left transhepatic portal venous approach.

Conclusion

Percutaneous transhepatic balloon angioplasty is an effective treatment for the portal vein stenosis that occurs after liver transplantation, and our results showed good mid-term patency with using this technique.     

Diagnosis of an accessory portal vein and its clinical implications for portosystemic shunts

Purpose To present a peculiar anatomic portal veins variant and evaluate its clinical implications. Methods Among 118 consecutive patients undergoing transjugular intrahepatic portosystemic shunting (TIPS), six male patients were found to have an accessory portal vein, which was seen during direct portography. Results In all six patients, portograms showed an accessory small-caliber vein parallel to the trunk of the main portal vein ending in the right lobe of the liver. Two of the six accessory portal veins drained blood from coronary veins, precluding access to coronary vein embolization during TIPS. Conclusion An accessory portal vein is a rare anatomical variation with clinical significance for both surgical shunt placement and TIPS, as well as for transportal embolization of coronary veins.     

Embolization of portal-systemic shunts in cirrhotic patients with chronic recurrent hepatic encephalopathy

Purpose To evaluate the efficacy of embolization of portal-systemic shunts in cirrhotic patients with chronic recurrent hepatic encephalopathy (CRHE). Methods Seven cirrhotic patients with CRHE refractory to medical treatment (3 men and 4 women, mean age 66 years) were studied. Five patients had splenorenal shunts, 1 had a gastrorenal shunt, and 1 had an intrahepatic portal vein-hepatic vein shunt. Shunt embolization was performed using stainless steel coils, with a percutaneous transhepatic portal vein approach in 4 patients and a transrenal vein approach in 3 patients. Results After embolization, the shunt disappeared in 4 patients on either ultrasound pulsed Doppler monitoring or portography. Complications observed in the 7 patients were fever, transient pleural effusion, ascites, and mild esophageal varices. For 3–6 months after embolization, the 4 patients whose shunts disappeared showed minimal or no reappearance of a shunt, and had no recurrence of encephalopathy. The serum ammonia levels decreased and electroencephalograms also improved. One of the 4 patients, who developed mild esophageal varices, required no treatment. Treatment was effective in 3 of the 4 patients (75%) who underwent embolization via a transhepatic portal vein. Conclusion Transvascular embolization of shunts improved the outcome in 4 of 7 patients. The most effective embolization was achieved via the percutaneous transhepatic portal vein approach.     

Portal hemodynamics in patients with hepatocellular carcinoma

The protal blood flow was assessed in 46 patients with hepatocellular carcinoma, 81 with cirrhosis, and 110 control subjects using an ultrasonic B-mode pulsed Doppler duplex system. The cross-sectional area of the portal vein was increased, and the velocity of portal blood flow was decreased in hepatocellular carcinoma and cirrhosis, whereas the blood flow volume was not significantly different. A significant decrease in portal blood flow was found in hepatocellular carcinoma only when at least three of the four major branches of the portal vein were occluded. The change in portal hemodynamics before and after transcatheter arterial embolization (TAE) was investigated. Immediately after TAE, neither portal venous pressure nor portal blood flow showed any constant trend. The portal blood flow reached a peak 1 week after TAE and then returned to its former value after 3-4 weeks, while all cases with poor prognoses showed a drop in portal blood flow after TAE.     

晚期肝癌伴门脉癌栓的介入治疗

本文回顾性分析了１９例晚期肝癌伴门脉癌栓病人的介入治疗疗效和肝动脉栓塞的安全性。结果显示１９例中有１３例肿瘤不同程度的缩小，全部是经加用碘油或明胶抽栓塞肝动脉的病例。在抗癌药物加碘油，明胶海棉栓塞的肝动脉组中，９例门脉显像者仅１例ＡＬＴ和ＡＳＴ升高，而３例门脉未显影者全部升高。因此作者认为：对伴有门脉癌栓的晚期肝癌，只要间接门脉造影显示门静脉，亦应加用碘油和明胶海绵栓塞肝动脉，但对门脉未显影者，用     

经皮脾穿刺门静脉插管技术及临床应用

目的 探讨经皮脾穿刺门静脉插管(PTSPC)技术的可行性.方法 30例门静脉高压症患者接受经PTSPC行食管胃底曲张静脉栓塞术,其中2例同时接受门静脉支架植入术.病例纳入标准:门静脉主干阻塞(癌栓或血栓)和肝硬化严重肝萎缩患者;排除标准:凝血酶原时间(PT)＞20 s的严重凝血功能不良患者.17例患者为原发性肝癌合并门静脉主干癌栓、13例为肝硬化合并严重肝萎缩和(或)小至中量腹水.30例患者术前均有食管胃底静脉曲张破裂出血病史;术前凝血功能正常(PT＜14 s)16例,轻度降低(PT 14～17 s)10例,中度降低(PT 18～20 s)4例;均接受上腹部CT增强检查,并依据CT结果确定脾静脉分支的穿刺位置、方向及深度.术后回顾性分析PTSPC要点、并发症及临床应用价值.结果 30例患者,28例成功应用PTSPC进行门静脉插管;2例插管未成功者均为脾静脉脾内分支细小.发生与PTSPC相关并发症6例(20.0%),均为不同程度血红蛋白浓度下降(15～50 g/L);其中4例需要输血治疗,包括1例腹腔大出血,在术后2 h出现血压严重下降,经输入4个单位红细胞和补充血容量后好转.PTSPC成功的28例均行食管胃底曲张静脉栓塞术,其中2例在栓塞曲张静脉的基础上放置门静脉覆膜支架.28例患者术后中位随访时间6个月(1～42个月),死亡16例,其中14例为肝癌患者在术后1～12个月死亡,2例肝硬化患者分别在术后14、23个月死于肝功能衰竭.随访期间,发生静脉曲张再出血4例,累积再出血率为14.3%.结论 PTSPC是可行的,为经导管门静脉腔内治疗提供了一条新路径,但穿刺部位出血应引起足够重视.     

经皮门静脉栓塞治疗肝癌的临床应用

目的探讨经皮选择性门静脉右支栓塞(PVE)在肝癌治疗中的应用价值。方法12例无手术切除指征的中晚期肝癌患者,在电视透视引导下经导管行经皮穿肝或穿脾行PVE。栓塞前、后用CT测量左侧肝叶的体积,并测量栓塞前后的门静脉压力、肝功能。结果12例患者均成功行经皮PVE,栓塞术后左肝叶代偿增生明显,其中3例PVE后顺利实行右肝切除术。PVE后未出现门静脉高压,肝功能损害轻,均未发现并发症。结论经皮选择性PVE能诱导非栓塞侧肝叶代偿性增生及栓塞侧肝叶萎缩,增加肿瘤手术切除机会,提高手术切除的安全性,对于无法手术切除的肝癌患者重新获得手术切除的机会,具有潜在的临床应用价值。     

Embolization of the spleen for treatment of splenomegaly and hypersplenism in patients with portal hypertension

Splenectomy in cases of hypersplenism involves significant risk of serious complications, including infection, hemorrhage, portal systemic thrombosis, and necrosis of the stomach or small bowel. Alternative procedures such as transcatheter embolization have been associated with a high frequency of splenic or subphrenic abscess, preventing clinical use. We used partial splenic embolization under careful antibiotic protection to successfully treat thrombocytopenia in 18 patients, most of whom had hypersplenism and splenomegaly secondary to portal hypertension. Of the 30 embolizations performed, the only serious complications encountered were abscess in two patients (who had almost total infarction) and four cases of splenic vein thrombosis. We investigated the possible effect of splenic embolization on portal venous pressure in three patients and found no pressure change.