Endovascular management of portal vein obstruction in hepatobiliary cancer patients

BACKGROUND AND OBJECTIVES

The purpose of this article is to describe the procedural safety, technical success, and clinical success of endovascular management of portal and mesenteric venous obstruction in patients with hepatobiliary neoplasms.

METHODS

Institutional Review Board (IRB)-approved HIPAA compliant retrospective review of 21 consecutive patients with hepatobiliary malignancies who underwent endovascular portal vein recanalization and stent placement between January 2012 and March 2020. Clinical diagnoses were pancreatic cancer (n = 19), colon cancer metastatic to the liver (n = 1), and cholangiocarcinoma (n = 1). Presenting signs and symptoms included: ascites, abdominal pain, abnormal liver function tests, diarrhea, and gastrointestinal bleeding. Stent patency and patient survival are presented with Kaplan-Meier method.

RESULTS

The technical success rate was 100%. A transhepatic approach was used in 20 cases (95.2%); trans-splenic access in one. Primary stent patency was 95.2%, 84%, and 68% at 1, 3, and 6 months, respectively. All stent occlusions were caused by tumor progression. A total of 80% of patients reported symptomatic improvement. Patient survival at 10 months was 40%. The early death rate was 4.76%. There were no bleeding complications from the percutaneous tracts.

CONCLUSION

Endovascular recanalization with stent placement is safe with high technical and clinical success.

Transjugular Liver Biopsy with Hemodynamic Evaluation: Correlation between Hepatic Venous Pressure Gradient and Histologic Diagnosis of Cirrhosis

Objectives:

Measurement of hepatic vein pressures is the accepted gold standard for the evaluation of portal hypertension. This study was conducted to evaluate the correlation between hepatic vein pressure measurements and histologic findings from transjugular liver biopsies. The hypothesis was that higher hepatic venous pressure gradients would correlate with a histologic diagnosis of cirrhosis.

Material and Methods:

We identified all patients who underwent transjugular liver biopsies at our institution between January 2015 and December 2019. Of these, 178 patients who had undergone hemodynamic evaluations during the biopsy procedure were included in the study. Demographic information and laboratory data were extracted from the patients’ electronic medical records. The hepatic vein pressure gradient (HVPG) was determined by subtracting the free hepatic venous pressure from the wedged hepatic venous pressure (WHVP), and the portosystemic gradient (PSG) was determined by subtracting the right atrial pressure from the WHVP. HVPG and PSG were compared by linear regression analysis and by calculating their receiver operating characteristics (ROC).

Results:

HVPG and PSG measurements were significantly associated with cirrhosis, with area under the ROC curve of 0.79 and 0.78, respectively. At the optimal cutoff of 9 mmHg, sensitivity and specificity for HVPG were 71% and 83% for HVPG and 67 % and 81% for PSG, respectively. No statistical difference was observed between the two measurements.

Conclusion:

A transhepatic venous pressure gradient above a cutoff of 9 mmHg is predictive of histologic cirrhosis, regardless of whether it is expressed as HVPG or PSG, with acceptable to excellent performance characteristics.

Transjugular venous approach for endovascular intervention in upper-extremity dialysis access fistulae and grafts

A transjugular venous access is an alternative approach for endovascular intervention in upper-extremity dialysis arteriovenous fistulae and grafts. The transjugular access is recommended for patients who have an unfavorable anatomy for the direct arm access approach. Ultrasound evaluation of the arteriovenous access is essential before intervention and includes evaluation of the inflow artery and outflow vein diameters, arteriovenous anastomosis, and the entire outflow vein, specifically looking into potential problem areas. Patency of the ipsilateral internal jugular vein needs to be assessed. If patency of the ipsilateral internal jugular vein is confirmed, it can be used for access. Retrograde access into the outflow vein is obtained with a reverse-curve catheter and a Glidewire. In some cases, puncture of the outflow vein is necessary along with the use of snares to direct the catheter system into the outflow vein. The techniques for intervention are described. Successful access into the outflow vein is possible in >95% of cases. The technique is useful for fistula maturation, declotting procedure, and arteriovenous fistula and graft maintenance. If intervention is unsuccessful, the transjugular access offers the possibility of placement of a dialysis catheter for temporary or long-term dialysis.

Percutaneous transhepatic placement of a stent-graft to treat a delayed mesoportal hemorrhage after pancreaticoduodenectomy

Postoperative hemorrhage is one of the most severe complications after pancreaticoduodenectomy. While detection of bleeding from adjacent arteries via conventional angiography and treatment with endovascular arterial coil embolization has been well established, to date no reports of percutaneous therapy for mesoportal hemorrhage have been published. This article describes an unusual case of delayed post-pancreaticoduodenectomy hemorrhage detected on a fluoroscopic drain check and treated with percutaneous transhepatic covered stent placement.

Results With Viabahn-Assisted Subintimal Recanalization for TASC C and TASC D Superficial Femoral Artery Occlusive Disease

Objectives: Many investigators including TransAtlantic Inter-Society Consensus (TASC) recommend against primary endovascular treatment for severe (TASC C and D) superficial femoral artery (SFA) disease. Vein bypass is preferable but may not be appropriate due to comorbidities or lack of suitable vein. This study reviews our results with Viabahn stent graft-assisted subintimal recanalization (VASIR) for TASC C and D SFA atherosclerosis. Methods: In all, 13 males and 14 females, mean age 72 ± 11 years underwent 28 VASIR for severe (TASC C 8 of 28, TASC D 20 of 28, and 5 of 28 no continuous infrapopliteal runoff artery) SFA disease. Indications were claudication (14 of 28 limbs), ischemic rest pain (6 of 28), and tissue loss (8 of 28). Viabahn stent graft-assisted subintimal recanalization was chosen instead of bypass due to comorbidities or lack of vein. Patients received aspirin and, if not already taking warfarin, they also received clopidogrel. Patients were examined with Ankle-brachial Index (ABI) and duplex scan at 1 month, then every 3 months after VASIR. Results Viabahn stent graft-assisted subintimal recanalization was technically successful in all. Ankle-brachial Index averaged 0.47 ± 0.17 preprocedure, 0.89 ± 0.20 postprocedure, and increased by 0.15 or more in every case. Median follow-up is 20 months. There were 3 perioperative (<30 days) and 7 later failures including revision prior to any thrombosis. One patient required amputation. Four have died, 2 with patent grafts, none from causes related to VASIR, all more than 30 days post-VASIR. Estimated 1-year primary and secondary patency were 70% ± 11% and 73% ± 10%. Failure was not significantly associated with indications, comorbidities, or runoff status. There was a clear distinction between patients with early failure and the rest of the patients. None of the 8 patients with failure in the first 8 months after surgery has a patent graft. However, of 17 grafts primarily patent at 8 months, only 2 have failed (1 thrombosed and 1 required preemptive balloon angioplasty). There was a strong trend toward better patency with 6 and 7 mm diameter compared to 5 mm diameter stent grafts. Furthermore, although warfarin was not prescribed as part of the protocol, no patient taking warfarin before and who resumed warfarin after VASIR (n = 4) suffered failure. Conclusions: Despite significant early failures, we found VASIR to be durable in those who did not have early failure. Viabahn stent graft-assisted subintimal recanalization is an acceptable alternative to vein bypass in selected patients with severe SFA disease. Smaller arterial or stent graft diameter may be associated with poorer results. Warfarin may be valuable to reduce the risk of failure after VASIR.

Ectopic pregnancy in a cesarean section scar treated with intramuscular methotrexate and bilateral uterine artery embolization

We report a case of an ectopic pregnancy implanted in the myometrium at the site of a scar from a previous cesarean section that presented with vaginal bleeding and was successfully treated with bilateral uterine artery embolization and intramuscular administration of methotrexate. The combination of minimally invasive interventional techniques and medical therapies can preserve fertility.

Successful endovascular management of an acute iliac venous injury during lumbar discectomy and anterior spinal fusion

A 61-year-old woman experienced laceration of the left common iliac vein with significant hemorrhage during lumbar discectomy. An endovascular approach using stent grafts provided a minimally invasive and successful solution to the problem.