Patent ductus venosus in an adult presenting as pulmonary hypertension, right-sided heart failure, and portosystemic encephalopathy

Rates of Air Embolism in Pediatric Patients Undergoing Surgical Procedures of the Peritoneum

Background: Air embolism during laparoscopic surgery is a rare but feared complication in the pediatric population. The objective of this study was to identify rates of air embolus in pediatric patients during hospitalization for laparoscopic or open surgical procedures of the peritoneal cavity. Materials and Methods: Patients 0-18 years old within the Pediatric Health Information System who underwent a predefined, common inpatient laparoscopic or open surgical procedure involving the peritoneal cavity from 2015 to 2020 were studied. International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for air embolism were then searched among patients during the same admission. Firth logistic regression was used to compare rates of air embolism in open and laparoscopic cohorts and in patients >1 and ≤1 year. Results: Unadjusted rates of air embolism were higher in patients undergoing open compared with laparoscopic surgery (open: 9/45,080; 20.0/100,000 patients versus laparoscopic: 3/101,892; 2.9/100,000 patients). In patients ≤1 year (45,726), 2 patients undergoing open surgery (2/1,031; 9.5/100,000 patients) and all 3 patients undergoing laparoscopic surgery had an air embolism diagnosis (3/22,329; 13.4/100,000 patients). For laparoscopic surgery, a suggested lower relative risk (RR) of air embolism was demonstrated for children >1 year compared with children ≤1 year (RR: 0.05, P = .05). Conclusion: Air embolism associated with common pediatric surgical procedures of the peritoneum is rare and patients undergoing laparoscopic and open surgery have similar risks for air embolism. Although rare, the risk should be considered during surgical planning and abdominal access, especially in children ≤1 year old.

Patent ductus venosus presenting with cholestatic jaundice in an infant with successful trans-catheter closure using a vascular plug device

Persistent ductus venosus as a cause of cholestatic jaundice is very rare. Treatment varies, but is usually reserved for infants in whom complications develop. We report a 5-week-old female infant with cholestatic jaundice caused by a patent ductus venosus and subsequent successful treatment via a transcatheter occlusion using a vascular plug device.

Adult-onset portosystemic encephalopathy caused by patent ductus venosus successfully treated with endovascular coil embolization: a rare case report

Background

Patent ductus venosus (PDV) is a congenital shunt between the portal vein (PV) and inferior vena cava (IVC). However, there are few reports on symptomatic adult-onset PDV, and the appropriate management of this condition remains unknown. In particular, there are few reports on the use of endovascular therapy for the treatment of patients with symptomatic adult-onset PDV. However, the strategies, indications, long-term efficacy, and safety of this therapy remain poorly understood. Here we report a rare case of adult-onset PDV successfully treated via endovascular coil embolization using a retrievable IVC filter.

Case presentation

A 35-year-old man with a clinical course of progressive general fatigue and ataxia for 3 months was diagnosed with depressive personality disorder in another hospital 2 months ago and then referred to our hospital for detailed examination and further treatment. Blood test results showed hyperammonemia, indicating hepatic encephalopathy. Contrast-enhanced multidetector computed tomography and transarterial portography revealed a portosystemic shunt that connected the left PV to IVC. Endovascular coil embolization was successfully performed after temporary balloon occlusion testing and the placement of a retrievable IVC filter. After the procedure, ammonia levels gradually reduced, and his symptoms improved without any postoperative complications. No clinical symptoms were observed at the 6-year clinical follow up.

Conclusion

This report supports the findings of other studies and offers a less invasive therapeutic option, thereby aiding clinicians in making appropriate treatment decisions for these patients.

Patent ductus venosus and exercise related pulmonary hypertension: a case of a young adult with successful surgery closure

Abstract

The patent ductus venosus is an embryological portosystemic shunt that connects the umbilical vein to the inferior vena cava and it can be diagnosed incidentally or in subjects suffering from hepatic encephalopathy, hypoxemia or hypoglycaemia. Sometimes it can be found in patients with cardiac defects or hypoxia caused by pulmonary arteriovenous shunting.

Case presentation

A 34-year-old male patient was referred to our medical centre for further evaluation of abdominal pain and moderate exertional dyspnoea. An exercise stress echocardiogram was performed in order to understand the mechanism of the exertional dyspnoea. The test was interrupted due to dyspnoea and desaturation and an estimated pulmonary pressure value of 65 mmHg was detected. Exercise pulmonary hypertension (PH) seems to represent the hemodynamic manifestation of early pulmonary vascular disease, acting as a possible transitional phase anticipating resting PH.

An MRI of the abdomen showed the presence of a portosystemic shunt from a patent ductus venosus, associated with stenosis of the celiac tripod artery. A CT scan, of the pulmonary circulation, showed a normal pulmonary venous return,mediastinal vessel a normal pulmonary artery. Subsequently, taking into consideration the large size (> 25 mm) of the duct, treatment (closure) of the patent ductus venosus with the help of a detachable vascular plug device was not feasible and open surgery rather than a percutaneous invasive approach would be advisable.

Conclusion

Persistent ductus venous can lead to pulmonary arteriovenous shunt fistula and exercise related pulmonary hypertension. Percutaneous or surgical closure requires detailed planning and an anatomical and physiological evaluations.

Successful laparoscopic division of a patent ductus venosus: report of a case

Patent ductus venosus (PDV) is a rare condition of a congenital portosystemic shunt from the umbilical vein to the inferior vena cava. This report presents the case of an adult patient with PDV, who was successfully treated with laparoscopic shunt division. A 69-year-old male was referred with hepatic encephalopathy. Contrast-enhanced CT revealed a large connection between the left portal vein and the inferior vena cava, which was diagnosed as PDV. The safety of a shunt disconnection was confirmed using a temporary balloon occlusion test for the shunt, and the shunt division was performed laparoscopically. The shunt was carefully separated from the liver parenchyma with relative ease, and then divided using a vascular stapler. Portal flow was markedly increased after the operation, and the liver function of the patient improved over the 3-month period after surgery. Although careful interventional evaluation for portal flow is absolutely imperative prior to surgery, a minimally invasive laparoscopic approach can be safely used for treating PDV.

Pulmonary hypertension in patients with congenital portosystemic venous shunt: a previously unrecognized association

BACKGROUND

Pulmonary arterial hypertension has been reported to be observed in association with acquired portal hypertension. However, the contribution of congenital anomalies occurring in the portal system to the development of pulmonary arterial hypertension remains to be elucidated.

METHODS

Nine patients with congenital portosystemic venous shunt were studied from January 1990 through September 2005.

RESULTS

Patent ductus venosus was detected in 5 patients, including 3 patients with an absence of the portal vein. The presence of either a gastrorenal or splenorenal shunt was evident in another 4 patients. Six patients had a history of hypergalactosemia with normal enzyme activities, as seen during neonatal screening. Six (66.7%) of the 9 patients were identified to have clinically significant pulmonary arterial hypertension (mean pulmonary artery pressure: 34-79 mm Hg; pulmonary vascular resistances: 5.12-38.07 U). The median age at the onset of pulmonary arterial hypertension was 12 years and 3 months. Histologic studies of lung specimens, which were available in 4 of the 9 patients with congenital portosystemic venous shunt, showed small arterial microthrombotic lesions in 3 patients. This characteristic finding was recognized even in the congenital portosystemic venous shunt patients without PAH.

CONCLUSIONS

This study demonstrated thromboembolic pulmonary arterial hypertension to be a crucial complication in congenital portosystemic venous shunt, and this pathologic state may be latently present in patients with pulmonary arterial hypertension of unknown etiology.

Spontaneous occlusion of brainstem arteriovenous malformation following ligature of a hepatic patent ductus venosus. Case report and review of the literature

The authors describe the clinical and radiological findings in a case of brainstem arteriovenous malformation (AVM) associated with a hepatic patent ductus venosus (PDV) in a 12-year-old child. The AVM was discovered on magnetic resonance (MR) imaging performed because of slight mental retardation and headache. The malformation was otherwise asymptomatic and no treatment was proposed. An abdominal ultrasonography study performed 1 year later because of hyperammonemia revealed a PDV, which was surgically ligated. One year later, MR images and angiograms showed complete resolution of the brainstem AVM. This report is the first documentation of an association between these two entities in the same patient, and the possible pathophysiological interactions between them are discussed.

Auxiliary partial orthotopic living donor liver transplantation for a child with congenital absence of the portal vein

Congenital absence of the portal vein (CAPV) is a rare malformation of the mesenteric vasculature in which visceral venous blood bypasses the liver, completely draining into the systemic circulation through a congenital porto-systemic shunt. Liver transplantation has rarely been indicated for patients with this disease. We present a child with CAPV who was managed successfully by living donor auxiliary partial orthotopic liver transplantation (APOLT), while preserving the right lobe of the native liver. In conclusion, APOLT for patients with CAPV is a feasible and ideal procedure because portal vein (PV) diversion is not necessary.

Portal vein pulsatility index is a more important indicator than congestion index in the clinical evaluation of right heart function

AIM: To study the changes of portal blood flow in congestive heart failure.

METHODS: We studied the congestion index (CI) and portal vein pulsatility index (PI) in patients with varied degrees of congestive heart failure using ultrasonic Doppler. Ten patients with mean right atrial pressure (RA) < 10 mmHg were classified as group 1 and the remaining 10 patients with RA ≥ 10 mmHg as group 2.

RESULTS: There were no difference on cardiac index (HI, P = 0.28), aortic pressure (AO, P  = 0.78), left ventricular end-diastolic pressure (LVED, P  = 0.06), maximum portal blood velocity (V_max, P  = 0.17), mean portal blood velocity (V_mean, P = 0.15) and portal blood flow volume (PBF, P  = 0.95) between the two groups. Group 2 patients had higher pulmonary wedge pressure (PW, 29.9 ± 9.3 mmHg vs 14.6 ± 7.3 mmHg, P = 0.002), pulmonary arterial pressure (PA, 46.3 ± 13.2 mmHg vs 25.0±8.2 mmHg, P =0.004), RA (17.5±5.7 mmHg vs 4.7 ± 2.4 mmHg, P  < 0.001), right ventricular end-diastolic pressure (RVED, 18.3 ± 5.6 mmHg vs 6.4 ± 2.7 mmHg, P < 0.001), CI (8.7 ± 2.4 vs 5.8 ± 1.2, P  = 0.03), and PI (87.8 ± 32.3% vs 27.0 ± 7.4%, P  < 0.001) than Group 1. CI was correlated with PI (P  < 0.001), PW (P  < 0.001), PA (P  < 0.001), RA (P  = 0.043), RVED (P  = 0.005), HI (P  < 0.001), AO (P  < 0.001), CO (P  < 0.001), LVED (P  < 0.001), V_max (P  < 0.001), V_mean (P  < 0.001), cross-sectional area of the main portal vein (P  < 0.001) and PBF (P  < 0.001). CI could be as high as 8.3 in patients with RA < 10 mmHg and as low as 5.9 in those with RA ≥ 10 mmHg.

CONCLUSION: Our data show that RI is a more significant indicator than CI in the clinical evaluation of high RA ≥ 10 mmHg, whereas CI is better than PI in the assessment of left heart function.

Remnants of Fetal Circulation: Appearance on MDCT in Adults

OBJECTIVE

The objective of our study was to describe the appearance of the remnants of the fetal circulation in adults on MDCT.

CONCLUSION

The use of MDCT allows frequent visualization of the remnants of the umbilical vein, ductus venosus, foramen ovale, ductus arteriosus, and umbilical arteries.

Doppler ultrasonographic assessment of closure of the ductus venosus in neonatal Irish wolfhounds

The normal appearance and closure time of the ductus venosus of 22 neonatal Irish wolfhounds from three unrelated litters were determined by repeated two-dimensional, grey-scale and colour-flow Doppler ultrasound examinations. A left intercostal approach was used to identify the ductus venosus, which appeared as a parallel-sided or cone-shaped vessel connecting a left-sided intrahepatic branch of the portal vein with a confluence of veins on the cranial aspect of the liver. Doppler signals indicative of patent ductus venosus were obtained in nine of nine puppies on day 2, 11 of 17 on day 4, five of 22 on day 6, none of nine on day 9 and none of eight on day 10.

Percentage of peak-to-peak pulsatility of portal blood flow can predict right-sided congestive heart failure

AIM: To study the change of portal blood flow for the prediction of the status of right-sided heart failure by using non-invasive way.

METHODS: We studied 20 patients with rheumatic and atherosclerotic heart diseases. All the patients had constant systemic blood pressure and body weight 1 week prior to the study. Cardiac index (CI), left ventricular end-diastolic pressure (LVEDP), mean aortic pressure (AOP), pulmonary wedge pressure (PWP), mean pulmonary arterial pressure (PAP), mean right atrial pressure (RAP), right ventricular end-diastolic pressure (RVEDP) were recorded during cardiac catheterization. Ten patients with RAP < 10 mmHg were classified as Group 1. The remaining 10 patients with RAP ≥ 10 mmHg were classified as Group 2. Portal blood velocity profiles were studied using an ultrasonic Doppler within 12 h after cardiac catheterization.

RESULTS: CI, AOP, and LVEDP had no difference between two groups. Patients in Group 1 had normal PWP (14.6 ± 7.3 mmHg), PAP (25.0 ± 8.2 mmHg), RAP (4.7 ± 2.4 mmHg), and RVEDP (6.4 ± 2.7 mmHg). Patients in Group 2 had increased PWP (29.9 ± 9.3 mmHg), PAP (46.3 ± 13.2 mmHg), RAP (17.5 ± 5.7 mmHg), and RVEDP (18.3 ± 5.6 mmHg) (P < 0.001). Mean values of maximum portal blood velocity (Vmax), mean portal blood velocity (Vmean), cross-sectional area (Area) and portal blood flow volume (PBF) had no difference between 2 groups. All the patients in Group 1 had a continuous antegrade portal flow with a mean percentage of peak-to-peak pulsatility (PP) 27.0% ± 8.9% (range: 17% - 40%). All the patients in Group 2 had pulsatile portal flow with a mean PP 86.6 ± 45.6 (range: 43%-194%). One patient had a transient stagnant and three patients had a transient hepatofugal portal flow, which occurred mainly during the ventricular systole. Vmax, Vmean and PBF had a positive correlation with CO (P < 0.001) but not with AOP, LVEDP, PWP, PAP, RAP, and RVEDP. PP showed a good correlation (P < 0.001) with PWP, PAP, RAP, and RVEDP but not with CI, AOP, and LVEDP. All the patients with PP > 40% had a right-sided heart failure with a RAP = 10 mmHg.

CONCLUSION: The measurement of PP change is a simple and non-invasive way to identify patients with right heart failure.