Congenital portosystemic shunts and AMPLATZER vascular plug occlusion in newborns

Intrahepatic portosystemic shunts, from prenatal diagnosis to postnatal outcome: a retrospective study

OBJECTIVE

Congenital intrahepatic portosystemic shunts (IHPSS) are rare vascular malformations resulting in blood bypassing the liver to the systemic circulation. Previous studies included symptomatic patients diagnosed postnatally, but the outcome of IHPSS diagnosed prenatally is rarely reported. We present a cohort of children prenatally diagnosed with IHPSS and report their natural course and outcome.

METHODS AND DESIGN

This was a retrospective study of all fetal cases diagnosed by ultrasound with IHPSS between 2006 and 2019 at a single tertiary centre which were prospectively followed up at the paediatric gastroenterology unit. The postnatal outcome was compared between patients with a single versus multiple intrahepatic shunts.

RESULTS

Twenty-six patients (70.3% boys) were included in the study, of them, eight (30.8%) patients had multiple intrahepatic shunts. The median gestational age at diagnosis was 29.5 weeks. Growth restriction affected 77% of the cohort. Postnatally, spontaneous shunt closure occurred in 96% of patients at a median age of 7.5 months (IQR 2.2-20 months). Failure to thrive (FTT) and mild developmental delay were observed in eight (30.8%) and seven (26.9%) patients, respectively. FTT was significantly more prevalent in patients with multiple shunts compared with patients with a single shunt (62.5% vs 16.7%, p=0.02); however, the rate of shunt closure and age at time of closure were similar between these groups. All patients survived with limited to no sequelae.

CONCLUSIONS

IHPSS usually close spontaneously by 2 years of age. Children with prenatally detected IHPSS may develop FTT and mild developmental delay. Close surveillance at a paediatric gastroenterology unit may be beneficial.

Pre and postnatal diagnosis of congenital portosystemic shunt: Impact of interventional therapy

INTRODUCTION

Congenital portosystemic shunts (CPSS) are rare vascular malformations that can lead to severe complications. With advanced imaging techniques, diagnosis is becoming more feasible occurring in fetal life. Different approaches have been adopted to manage these cases, with an increased utilization of interventional therapy recently. This cohort aims to describe the course of children diagnosed with CPSS and the impact of interventional therapy on the outcome.

METHODS

Retrospective chart review was done for all patients who were diagnosed with CPSS in our institution between January 2006 and December 2015.

RESULTS

Six patients were diagnosed with CPSS. During this period, 8,680 mothers carrying 9548 fetuses underwent fetal ultrasound examinations. Three patients were diagnosed antenatally at a median [IQ] gestational age of 33 [26-33] weeks, and three patients were diagnosed postnatally at 0, 2, and 43 months, respectively. At a median follow-up of 87 [74-110] months, 5 patients are alive; 4 of whom had received transcatheter closure for different indications, and one who had spontaneous resolution of her CPSS. One infant died at the age of 6 weeks secondary to sepsis.

CONCLUSION

CPSS can result in significant complications in children. Interventional therapy is feasible at any age group, but long-term follow-up is warranted.

Appreciation of the treatment in adult patients with congenital portosystemic connections in relation with their symptoms

BACKGROUND

portosystemic intrahepatic venous connections (Abernethy syndrome) are rare anatomical variants, which are classified according to the type of union between the portal venous circulation and the central venous system. In adults, the diagnosis is often incidental, although some cases can be presented with an encephalopathy without associated liver disease.

CASE REPORTS

here we present two cases of portosystemic shunt, one with encephalopathy development, and the other casually caught. Its treatment by interventionist radiology, was decided in function of clinic symptoms. Both patients were asymptomatic at controls in the outpatient consultation. No complications derived from the therapeutic decision. The control is carried out annually with image tests and blood analysis.

DISCUSSION

given the low prevalence of malformation and its usual diagnosis at younger ages (associated with important cognitive alterations) its treatment in adults is not protocolized. In these cases the decision of the treatment would be conditioned to the associated symptomatology, being the minimally invasive treatment (by interventional radiology) a therapeutic option in the symptomatic adult. Observation by imaging tests and control in outpatient consultation (without associated treatment) would be a choice in asymptomatic adults.

Endovascular Transjugular Occlusion of Congenital Intrahepatic Portosystemic Venous Shunt Using Simultaneous Fluoroscopy and Transabdominal Ultrasound Guidance: Report of 2 Cases

Congenital intrahepatic portosystemic venous shunts (CIPVS) are rare anomalies that can be detected before birth or in early infancy or later in life. Symptomatic shunts are treated as they carry high risk of complications like hepatic encephalopathy. Various treatment options include surgery, endovascular embolization, and percutaneous closure devices. We treated 2 infants with CIPVS successfully by endovascular embolization of the shunt using vascular plug through transjugular route. Transabdominal ultrasound guidance in addition to fluoroscopy was used at the time of vascular plug placement. We emphasize that the use of transabdominal ultrasound during endovascular occlusion enhances the safety and technical success rate.

Outcome of intrahepatic portosystemic shunt diagnosed prenatally

We analyzed the characteristics of the population with congenital portosystemic shunt diagnosed during the antenatal period and the organization of their perinatal care. This multicentric retrospective study included all the patients with a prenatal diagnosis of congenital portosystemic shunt. Between 1999 and 2015, 12 patients were included. Prenatal diagnosis was done at a median 26.5 weeks of gestation (21-34). All the patients presented intrahepatic CPSS, three of them had associated congenital cardiopathy, and one a Bannayan-Zonana syndrome. Ten patients had simple outcome on conservative treatment, eight of them having a spontaneous closure of their portosystemic shunt within the first 2 years of life. One patient had surgical treatment which failed and he developed a focal nodular hyperplasia. Another patient had radiological interventional closure of his shunt which was complicated by a venal portal thrombosis.

CONCLUSION

Outcome of intrahepatic portosystemic shunt diagnosed prenatally is good in the majority of cases. What is known: • Multiples studies exist on congenital porto systemic shunt but when the diagnosis is done after birth. • The evolution, management, and complication are well known. What is new: • There is very few studies with only patients diagnosed in antenatal and it is a large series of cases. • Outcome of intrahepatic portosystemic shunt diagnosed prenatally is good in the majority of cases.

The Amplatzer Vascular Plug: Review of Evolution and Current Applications

The Amplatzer Vascular Plug (AVP) was created for peripheral embolization as a modification of the family of Amplatz septal occluders used in the treatment of congenital heart malformations. The device has evolved over the years and multiple versions have been launched into the market. Each of the versions of the device has some important modifications in terms of the size of the introducer's system, number of layers, and resultant thrombogenicity. It is very important for the operator to become familiar with the unique features of the AVP, and to understand the advantages and limitations of each model in the AVP family to achieve an optimal embolic result. The purpose of this article is to review the evolution and current clinical applications of the AVP in the field of interventional radiology, with emphasis on the advantages and limitations of this device in comparison with other embolization agents.

Predisposing Factors for Spontaneous Closure of Congenital Portosystemic Shunts

In a review of 382 cases of congenital portosystemic shunt, we found that presentation with neonatal cholestasis strongly predicts spontaneous closure of intrahepatic shunts (OR 8.3, 95% CI 3.4-20.2). Spontaneous closure before the 24th month of age is more likely for distal or multiple shunts, but rare for patent ductus venosus.

Amplatzer vascular plugs in congenital cardiovascular malformations

BACKGROUND

Amplatzer vascular plugs (AVPs) are devices ideally suited to close medium-to-large vascular communications. There is limited published literature regarding the utility of AVPs in congenital cardiovascular malformations (CCVMs).

AIMS

To describe the use of AVPs in different CCVMs and to evaluate their safety and efficacy.

MATERIALS AND METHODS

All patients who required an AVP for the closure of CCVM were included in this retrospective review of our catheterization laboratory data. The efficacy and safety of AVPs are reported.

RESULTS

A total of 39 AVPs were implanted in 31 patients. Thirteen (33%) were AVP type I and 23 (59%) were AVP type II. AVP type III were implanted in two patients and type IV in one patient. The major indications for their use included closure of pulmonary arteriovenous malformation (AVM) (n = 7), aortopulmonary collaterals (n = 7), closure of a patent Blalock-Taussig shunt (n = 5), systemic AVM (n = 5), coronary AVM (n = 4), patent ductus arteriosus (PDA) (n = 3), pulmonary artery aneurysms (n = 3), and venovenous collaterals (n = 2). Deployment of the AVP was done predominantly via the 5 - 7F Judkin's right coronary guide catheter. Overall 92% of the AVPs could be successfully deployed and resulted in occlusion of the target vessel in all cases, within 10 minutes. No procedure-related or access site complication occurred.

CONCLUSIONS

AVPs are versatile, easy to use, and effective devices to occlude the vascular communications in a variety of settings. AVP II is especially useful in the closure of tubular structures with a high flow.

Early experience on peripheral vascular application of the vascular plugs

BACKGROUND

Transcatheter closure of various congenital and acquired vascular malformations with Amplatzer Vascular plugs I and II has been established. Here we present our experience with device closure.

MATERIALS AND METHODS

Between October 2006 and August 2012, nine (three males and six females) patients aged between 11 months and 62 years (mean age 19 years) underwent percutaneous device closure with AVP I and II vascular plugs for congenital and acquired arteriovenous malformation and cardiac diverticulum are presented here.

RESULTS

One case of coronary cameral fistula, four cases of pulmonary arteriovenous fistula, one case of large major aortopulmonary collaterals (in tetralogy of Fallot closed before intracardiac repair), one case of congenital cardiac diverticulum, one case of fistula between external carotid artery and internal jugular vein and one case of iatrogenic carotid jugular fistula were successfully closed with AVP I and II plugs. Overall in nine cases, 16 AVP I and II plugs were deployed to occlude feeding vessels and one cardiac diverticulum. The technical success rate was 100%. No major complications were observed.

CONCLUSION

Amplatzer vascular plugs can be used successfully for closure of various congenital and acquired vascular malformations with good result.

Evolution of congenital malformations of the umbilical-portal-hepatic venous system

OBJECTIVE

The objective of this study is to describe the evolution of 8 cases of congenital malformations of the umbilical-portal-hepatic venous system diagnosed before the first month of life.

MATERIALS AND METHODS

All cases of congenital malformation of the portal and hepatic venous system diagnosed prenatally or during the first month of life in our institution were systematically reviewed since November 2000. Clinical features, imaging, and anatomical findings were reviewed, focusing primarily on clinical and radiologic evolution.

RESULTS

Eight cases of congenital malformation of the umbilical-portal-hepatic venous system were studied. Fifty percent of these malformations were diagnosed prenatally. We report 4 portosystemic shunts. Three involuted spontaneously, and the fourth one required surgical treatment. We report a variation of the usual anatomy of portal and hepatic veins that remained asymptomatic, an aneurysmal dilatation of a vitelline vein causing portal vein thrombosis that needed prompt surgical treatment with good result, a complex portal and hepatic venous malformation treated operatively, and a persistent right umbilical vein that remained asymptomatic.

CONCLUSION

Prenatal diagnosis of malformations of the umbilical-portal-hepatic venous network is uncommon. Little is known about the postnatal prognosis. Clinical, biologic, and radiologic follow-up by ultrasonography is essential to distinguish pathologic situations from normal anatomical variants.

Clinical features of congenital portosystemic shunt in children

Clinical features, images, complications, treatments, and prognosis of 10 children with congenital portosystemic shunt (CPSS) were reviewed. Nine children were diagnosed with intrahepatic shunts while one presented with extrahepatic shunt. CPSS was detected by prenatal ultrasonography in four infants. Three infants presented with galactosemia without an enzyme deficiency. Two children presented with mental retardation and attention deficit hyperactivity disorder. Pulmonary hypertension developed in two patients. Spontaneous closure occurred in four infants with intrahepatic shunts including patent ductus venosus. The shunts were closed using transcatheter embolizations in four patients with intrahepatic shunts.

CONCLUSION

Intrahepatic shunts may close spontaneously. Transcatheter embolization is effective for the treatment of symptomatic intrahepatic shunts.

Stenosis of alternative umbilical venous pathways in absence of the ductus venosus

OBJECTIVE

We evaluated fetuses with absence of the ductus venosus (ADV) and restricted alternative umbilical venous pathways.

METHODS

We identified 3 cases that fit our objective. The angles of insonation for spectral Doppler ultrasound interrogation were less than 20 degrees in all cases. We used commercially available ultrasound systems with a curved array transducer.

RESULTS

In all 3 cases, we noted mild cardiac volume overload without fetal hydrops.

CONCLUSIONS

We speculate that the fetus with ADV and a restrictive alternative umbilical venous pathway may have a more benign clinical course than fetuses previously reported with unrestricted alternative pathways.

Intravascular occlusion for the correction of extrahepatic portosystemic shunts in dogs

BACKGROUND

Congential extrahepatic portosystemic shunts (EHPSS) are common in dogs. An effective minimally invasive technique for correction of EHPSS could result in reduced morbidity, reduced costs, and reduced hospitalization times.

HYPOTHESIS

Use of an intravascular occlusion device can effectively and safely result in acute complete occlusion of EHPSS in dogs.

ANIMALS

Seven dogs with naturally occurring EHPSS that presented to the Purdue University Veterinary Teaching Hospital.

METHODS

Prospective, clinical trial. The 7 dogs were consecutively enrolled over a 2-year period. Results of serum biochemistry, total serum bile acids, fasting plasma ammonia, abdominal radiography, and ultrasonography suggested the diagnosis of portosystemic shunts in all dogs. Definitive diagnosis of EHPSS was achieved with cranial mesenteric arterial portography and acute occlusion was attempted by the deployment of the Amplatzer vascular plug (AVP).

RESULTS

EHPSS were identified in all dogs consisting of 5 portocaval and 2 portoazygous variants; 1/7 dogs (14%) were intolerant to temporary complete occlusion of the EHPSS. Of the remaining 6 dogs, 5 (83%) had complete occlusion of the EHPSS by the AVP. There were no complications and resolution of abnormal clinical signs and laboratory values was achieved in 4/5 (80%) dogs with complete occlusion.

CONCLUSIONS AND CLINICAL IMPORTANCE

Intravascular correction of EHPSS by the AVP is a viable option to surgical correction while larger studies will be required to determine the clinical applicability of this procedure in the broader portosystemic shunt population.