Endovascular management of portal vein obstruction in hepatobiliary cancer patients.

Hector Ferral,Mark S Talamonti,Jewel Datri,Marc J Alonzo,Robert Marsh,Melissa E Hogg

doi:10.1002/jso.26713

Hector Ferral, Mark S Talamonti + Show 4 more

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https://doi.org/10.1002/jso.26713

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Abstract

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. Institutional Review Board (IRB)-approvedHIPAA 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. 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. Endovascular recanalization with stent placement is safe with high technical and clinical success.

Highlights

Obstruction of the splenoportal or mesoportal venous system occurs in approximately 15-25 % of patients with hepatobiliary malignancies
Diagnosis requires a high index of clinical suspicion because symptoms may be non-specific and directly attributed to the existing malignancy [2]; Cross-sectional imaging methods are key to diagnosis, but high suspicion by imaging professionals is important because description of imaging findings may be focused on the neoplastic process and vascular findings may be missed or under-reported [2, 5]
The trans-splenic access was used in a patient who presented with portal vein thrombosis after right lobectomy

Summary

Introduction

Obstruction of the splenoportal or mesoportal venous system occurs in approximately 15-25 % of patients with hepatobiliary malignancies. Obstruction of the splenoportal or mesoportal venous system occurs in approximately 15–25 % of patients with hepatobiliary malignancies [1, 2] These patients are prone to develop obstruction of the portal and mesenteric veins both because of local factors (tumor compression, stenosis after surgery) and systemic factors (hypercoagulability) [3]. Diagnosis requires a high index of clinical suspicion because symptoms may be non-specific and directly attributed to the existing malignancy [2]; Cross-sectional imaging methods (contrast-enhanced CT scan and MRI) are key to diagnosis, but high suspicion by imaging professionals is important because description of imaging findings may be focused on the neoplastic process and vascular findings may be missed or under-reported [2, 5]. Percutaneous recanalization followed by stent placement using a transhepatic or a trans-splenic approach has been described as safe and effective [1, 6, 7, 9,10,11,12]

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