Hepatic Tract Plug-Embolisation After Biliary Stenting. Is It Worthwhile?

Bleeding anorectal varices treated by a direct puncture approach through the greater sciatic foramen: The utility of a steerable microcatheter for reverse catheterization

Bleeding is less common from anorectal varices than from esophageal varices, but it is potentially life-threatening. Here, we present a case of a woman in her 70s with critical hemorrhage from anorectal varices. The endoscopic approach could not be performed due to the huge variceal formation and the transhepatic approach was also unsuitable due to the presence of portal vein thrombosis and ascites. A direct puncture to the right superior rectal vein was performed through the greater sciatic foramen under computed tomography fluoroscopic guidance. Using a steerable microcatheter, superior rectal veins were bilaterally embolized with a mixture of n-butyl cyanoacrylate and ethiodized oil, and microcoils. Endoscopy and contrast-enhanced computed tomography performed after the procedure confirmed a marked shrinkage of anorectal varices. When endoscopic or any other approaches are difficult, this technique can be a useful alternative therapeutic option.

Preventive Transhepatic Tract Embolisation after Percutaneous Biliary Interventions: A Systematic Review

Preventive transhepatic tract embolisation (PTTE) after percutaneous biliary intervention (PBI) may reduce adverse events. The aim of this systematic review was to analyse feasibility, safety, and efficacy of PTTE with different embolic agents. A systematic literature research was performed according to the PRISMA guidelines. The identified studies were analysed concerning study quality, number of cases, indication, embolic agent, embolisation technique, success, and embolisation-related adverse events. Out of 62 identified records, 7 studies of mainly moderate study quality published through 2019 were included for further analysis. Cyanoacrylate (n = 4), gelatin sponge (n = 2), and coils (n = 1) were used as embolic agents in a total number of 314 patients. Technical success was 96-100%. Embolisation-related adverse events (glue migration, pain) occurred in 10/314 (3.2%) patients. Reduction of PBI-related pain was approved by one controlled study; haemorrhage events were reduced but not clearly significant. Overall, biliary leak, transhepatic bleeding, and PBI-related pain occurred in 7/201 (3.5%), 1/293 (0.3%), and 17/46 (36.9%) documented patients after PTTE. Adverse events which likely could not have been prevented by PTTE occurred in 23/180 (12.8%) patients. Embolic agents were not compared. In conclusion, PTTE is feasible and safe. It is effective concerning the prevention of PBI-related pain, and it may be effective concerning haemorrhage. Prevention of biliary leak is not proven. It remains unclear which embolic agent should be preferred. A prospective randomised trial including all preventable adverse events is lacking.

Transhepatic Tract Embolisation After Biliary Intervention Using n-Butyl Cyanoacrylate and Autologous Blood: A Retrospective Analysis of 42 Patients

PURPOSE

We evaluated the safety and efficacy of transhepatic tract embolisation after a biliary intervention using n-butyl cyanoacrylate (NBCA) and autologous blood.

MATERIALS AND METHODS

Between January 2017 and December 2018, 42 consecutive patients (mean age: 71 ± 15 years, 24 men) with malignant (n = 26) or benign (n = 16) biliary obstructions underwent percutaneous biliary intervention followed by tract embolisation within 2 weeks. Forty-six transhepatic tracts (4 bilateral) in 42 patients were embolised using a NBCA and lipiodol mixtures (1:1-1:2 ratios) after intraductal infusion of peripherally obtained autologous blood. The indwelling catheter diameters were 8.5-14 Fr. The median interval between percutaneous biliary drainage and tract embolisation was 10 days (range 3-14 days). Glue-cast formation via fluoroscopy and immediate complications were reviewed retrospectively in medical records. Follow-up data (median: 135, range 11-720 days) including computed tomography (CT) images (n = 17) were evaluated for delayed complications and glue-cast formation.

RESULTS

Successful glue-cast formations were achieved in all 46 tracts. No patients experienced haemorrhage, and only one patient had external bile leakage. Eight patients complained of abdominal pain (numerical scale ≤ 5) immediately after embolisation, which was controlled by analgesics. Two patients had transient fever. Segmental (n = 11) or sub-segmental (n = 6) glue-cast patterns were identified along the transhepatic tract by follow-up CT. No biliary obstructions were caused by inadvertent glue spread. Fragmented glue was detected outside the stent in one patient.

CONCLUSION

Transhepatic parenchymal tract embolisation with NBCA and autologous blood is a safe and feasible method for preventing bile leakage.

LEVEL OF EVIDENCE

Level 4, Case Series.