Arterioportal Shunt Research Articles

TACE Combined with Portal Vein Tumor Thrombus 125I Seed Implantation in the Treatment of HCC with Hepatic Arterioportal Shunts.

Transarterial chemoembolization (TACE) and 125I seed implantation are methods used to treat hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT), PVTT often associated with arterioportal shunts(APS), there are few reports on the combined use of TACE and 125I seed implantation for such patients. This study aimed to evaluate the efficacy and safety of TACE combined with PVTT 125I seed implantation in the treatment of HCC patients with APS. Forty-two patients diagnosed with HCC combined with PVTT and APS between January 2020 and December 2021 were included. Appropriate materials were selected to transarterial embolization of the APS, and 125I seeds were implanted into the PVTT. The occlusion effect was observed and recorded after 3 months, the efficacy of intrahepatic lesions and PVTT was evaluated, and the patient survival, prognostic factors affecting APS recanalization were analyzed. All 42 patients completed the follow-up three months after treatment. The immediate APS improvement rate was 100%, and the APS improvement rate at the three-month follow-up was 64.29%. The disease control rates of PVTT and intrahepatic lesions were 81.00% and 78.60%, respectively. The patients' 6-month and 12-month survival rates were 78.6% and 46.8%. The median OS for all patients was 11.90 months, and the median OS was 13.30 months in the APS effective treatment group and 8.30 months in the ineffective group. The PVTT type is the only independent factor affecting APS recanalization. (P=0.02). For HCC patients with PVTT and APS, TACE combine with 125I seed implantation in PVTT is a potentially effective and safe method that contributes to prolonging patient survival.

Drug-eluting beads transarterial chemoembolization combined apatinib/camrelizumab for advanced hepatocellular carcinoma with hepatic arterioportal shunts.

The objective of this study was to evaluate the efficacy and safety of drug-eluting beads transarterial chemoembolization (D-TACE) combined with apatinib/camrelizumab in advanced hepatocellular carcinoma (HCC) patients with hepatic arterioportal shunts (APS). From January 2021 to December 2022, consecutive medical records of advanced HCC patients with APS receiving D-TACE combined apatinib/camrelizumab were reviewed for eligibility. Overall survival (OS), progression-free survival (PFS), tumor response, and adverse events (AEs) were assessed. A total of 23 patients were included in this study, and the median follow-up time was 11 months (range, 2-26 months). In this study, 8 patients (34.8%) achieved PR, 13 patients (56.5%) achieved SD, and 2 patients (8.7%) developed PD. The objective response rate and disease controlled rate were 34.8% and 91.3%, respectively. OS and PFS were 11 months and 7 months, respectively. Multivariate analysis indicated that tumor number was an independent prognostic factor affecting PFS. AEs occurred in 19 patients after oral apatinib and in 8 patients after camrelizumab treatment. No treatment-related death occurred. D-TACE combined with apatinib/camrelizumab had meaningful efficacy and controllable AEs in advanced HCC patients with APS, which may be a promising treatment option. •1.We investigate a new treatment strategy for advanced HCC patients with hepatic arterioportal shunts；2.D-TACE combined with apatinib/camrelizumab had meaningful efficacy and controllable AEs in advanced HCC patients with APS, which may be a promising treatment option.

Hepatic Arterial Infusion Chemotherapy Combined with Lenvatinib and PD-1 Inhibitors for Managing Arterioportal Shunt in Hepatocellular Carcinoma with Portal Vein Tumor Thrombus: A Retrospective Cohort Study.

This study aimed to assess the effectiveness and safety of combining hepatic arterial infusion chemotherapy (HAIC) with lenvatinib (LEN) and PD-1 inhibitors in treating arterioportal shunt (APS) in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT). Conducted retrospectively, the study enrolled 54 HCC patients with APS and PVTT treated with HAIC, LEN, and PD-1 inhibitors at our center between January 2021 and October 2023. APS improvement, APS recanalization, tumor response, PVTT response rate, overall survival (OS), intrahepatic progression-free survival (InPFS), and adverse events were evaluated. APS improvement was observed in 42 patients (77.8%), with all improvement occurring within two treatment sessions. Complete APS occlusion was achieved in 40 patients (74.1%), and no recanalization occurred. The best objective response rate (ORR) and ORR after two HAIC sessions were 74.1% and 66.7%, respectively. The best PVTT response and PVTT response after two HAIC sessions were 98.1% and 94.4%, respectively. The median OS and InPFS were 10.0 months and 5.0 months, respectively. OS and InPFS were longer in patients with APS occlusion compared to those without (OS 12.1 vs 4.4 months, P<0.001, InPFS 6.2 vs 2.3 months, P=0.049). ALBI grade, extrahepatic spread, APS disappearance were potential prognostic factors for OS, while APS grade and extrahepatic spread being independently associated with InPFS. No treatment-related mortality occurred. Combining HAIC with LEN and PD-1 inhibitors proves to be both effective and safe in managing APS in HCC with PVTT, potentially improving patient survival.

Transcatheter Arterial Embolization with Bleomycin-Lipiodol of Hepatic Hemangiomas: Safety, Efficacy and Predictors of Response.

To evaluate the safety, efficacy and predictors of response of transcatheter arterial embolization (TAE) to treat hepatic hemangiomas (HHs). A retrospective analysis was conducted of consecutive HH patients who received TAE with bleomycin-Lipiodol emulsion and gelatin sponge particles at three institutions from January 2014 to January 2021. TAE effectiveness was defined as more than 50% reduction of tumor volume. The effectiveness, safety, and CT changes of hemangiomas after TAE were assessed. Factors affecting TAE efficacy on tumor size were analyzed with logistic regression analysis. A total of 102 patients with 109 HHs were included. After treatment, both the tumor diameter and volume were significantly reduced from 8.5 ± 3.9 to 5.9 ± 3.8cm (P < 0.001) and 412.6 ± 742.3cm3 to 102.0 ± 232.7cm3 (P < 0.001), respectively. TAE effectiveness was achieved in 80.7% (88/109) of hemangiomas, which was characterized by progressive reduction in tumor volume over time with Lipiodol retention. Atypical enhancement pattern (tiny enhancing dots in the hepatic arterial and portal venous phase) (p = 0.001) and central arterioportal shunt (APS) (p = 0.002) associated with the tumor were independent predictors of TAE ineffectiveness. Postembolization syndrome and transient increase in liver enzymes were common without severe complications and death. TAE was safe and effective in reducing HH size. Lesion enhancement pattern and APS type were associated with TAE efficacy on tumor shrinkage. Level 3, non-controlled retrospective cohort study.

Safety, efficacy, and survival of drug-eluting beads-transarterial chemoembolization vs. conventional-transarterial chemoembolization in advanced HCC patients with main portal vein tumor thrombus

ObjectivesTo compare the efficacy, overall survival (OS) and safety of drug-eluting beads-TACE (DEB-TACE) and C-TACE as initial treatment in advanced hepatocellular carcinoma (HCC) patients with main portal vein tumor thrombus (mPVTT).MethodsThe medical records of consecutive advanced HCC patients with mPVTT who underwent initial DEB-TACE or C-TACE from September 2015 to October 2021 were retrospectively evaluated. Treatment crossover was allowed in this retrospective research. The adverse events, disease control rate (DCR), time to tumor progression (TTP) and OS of patients who underwent DEB-TACE were compared with those of patients who underwent C-TACE.ResultsEighty-three patients were included: 42 patients in DEB-TACE group and 41 patients in C-TACE group. DEB-TACE could be safely performed in HCC patients with mPVTT, and they gained a better DCR than those submitted to the C-TACE (76.2% vs. 53.7%, P = 0.031), which might have resulted in longer TTP (median TTP: 9.0 months vs. 3.0 months, P < 0.001). Furthermore, DEB-TACE showed significant OS benefits compared with C-TACE (median OS: 12.0 months vs. 5.0 months, P < 0.001). DEB-TACE, absence of arterioportal shunts (APS), leisons with capsular non-infiltration were found to be independent prognostic factors for better OS. Furthermore, subgroup analysis proved that patients with good DCR gained longer OS in DEB-TACE group.ConclusionsDEB-TACE could be safely performed and improve the DCR of HCC patients with mPVTT, which resulting in longer TTP and OS, compared with C-TACE.

Treatment of hepatocellular carcinoma with arterioportal shunting using balloon-assisted transarterial yttrium-90 radiation segmentectomy: A case report

Portal vein tumor thrombus (PVTT) is a common finding associated with hepatocellular carcinoma (HCC) often further complicated by arterioportal shunting. While radioembolization with Yttrium-90 (Y-90) is the preferred treatment for HCC with PVTT, shunting can complicate particle delivery. Here, we describe a case of a 65-year-old man with HCC and significant shunting from the segment IV hepatic artery into the left and right portal veins due to a PVTT. We performed a balloon-assisted radiation segmentectomy by occluding the hepatic artery supplying the PVTT to minimize arterioportal shunting and promote redistribution of particles into the tumor bed. Post Y-90 bremsstrahlung scan correlated with appropriate uptake. One-month follow-up magnetic resonance imaging demonstrated response to treatment with decreased tumor thrombus in the left portal vein. Here, we demonstrate that balloon-occlusion-assisted transarterial radiation segmentectomy could be a beneficial approach for improving tumor response and reducing complications in individuals with HCC and arterioportal shunting.

DEM-TACE as the initial treatment could improve the clinical efficacy of the hepatocellular carcinoma with portal vein tumor thrombus: a retrospective controlled study

BackgroundConventional-transarterial chemoembolization (C-TACE) was proven to improve overall survival (OS) in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT), drug-eluting microsphere-TACE (DEM-TACE) was supposed to provide more benefit than C-TACE in this respect.PurposeTo compare the safety and efficacy between DEM-TACE and C-TACE as the initial treatment in HCC patients with PVTT and to identify prognostic factors of OS.MethodsThe medical records of advanced HCC patients with PVTT who underwent DEM-TACE or C-TACE as the initial thearpy from September 2015 with mean follow-up time 14.9 ± 1.2 (95% CI 12.6–17.2) months were retrospectively evaluated. A total of 97 patients were included, 49 patients in the DEM-TACE group and 48 in the C-TACE group. Adverse events (AEs) related to TACE were compared. Tumor and PVTT radiologic response, time to tumor progression (TTP) and OS were calculated and compared in both groups.ResultsPatients in DEM-TACE group had a better radiologic response (Tumr response: 89.8% vs. 75.0%; PVTT response: 85.7% vs. 70.8%; overall response: 79.6% vs. 58.3%, P = 0.024) and longer TTP (7.0 months vs. 4.0 months, P = 0.040) than patients in C-TACE group. A lower incidence of abdominal pain was found in the DEM-TACE group than in C-TACE group (21 vs. 31, P = 0.032), but there were no significant differences between DEM-TACE and C-TACE patients in any other AEs reported. When compared to C-TACE, DEM-TACE also showed significant OS benefits (12.0 months vs. 9.0 months, P = 0.027). DEM-TACE treatment, the absence of arterioportal shunt (APS), lower AFP value and better PVTT radiologic response were the independent prognostic factors for OS in univariate/multivariate analyses, which provided us with a guide for better patient selection.ConclusionsBased on our retrospective study, DEM-TACE can be performed safely and might be superior to C-TACE as the initial treatment for HCC patients with PVTT.Trial registrationRetrospectively registered.

Intrahepatic arterioportal shunt with portal-hypertension caused by liver biopsy after living-donor liver transplantation: a case report

Intrahepatic arterioportal shunt with portal-hypertension caused by liver biopsy after living-donor liver transplantation: a case report

Liver Metastases: Correlation between Imaging Features and Pathomolecular Environments.

A wide range of imaging manifestations of liver metastases can be encountered, as various primary cancers preferably metastasize to the liver (organ-specific metastases), with the imaging characteristics largely depending on various primary tumor-specific factors such as histopathologic category, degree of tumor differentiation, histologic behavior, and intratumor alterations. Characteristic imaging features potentially can help provide a more precise diagnosis in some clinical settings. These settings include those of (a) primary cancers of hollow organs such as gastrointestinal organs, the lungs, and the bladder, owing to the appearance of metastases that cannot be applied to the liver, which is a parenchymal organ; (b) unknown primary tumors; (c) more than one primary tumor; (d) another emergent malignancy; and (e) transformation to a different histopathologic tumor subtype. The characteristic features include the target sign on T2-weighted MR images or during the hepatobiliary phase of hypovascular metastasis, the peripheral rim washout sign on delayed phase images, peritumor hyperintensity during the hepatobiliary phase, hypervascular metastasis, a cystic appearance with marked hyperintensity on T2-weighted images, marked hyperintensity on T1-weighted images, calcification, capsular retraction, absence of the vessel-penetrating sign, distribution of liver metastases, and rare intraductal forms of metastases. In addition to various factors associated with the primary cancer, desmoplastic reactions around the tumor-which can be observed in adenocarcinomas with peripheral and peritumor enhancement, distinct arterioportal shunts with metastases from pancreatic ductal carcinoma, and pseudocirrhosis-also can affect these findings. The authors review the characteristic imaging findings of liver metastases from various primary cancers, with a focus on the mechanisms that underlie organ-specific liver metastases. Online supplemental material is available for this article. ©RSNA, 2022.

Balloon-Occluded Radiofrequency Ablation as Bridge to TACE in the Treatment of Advanced HCC with Arterioportal Shunt.

Transarterial chemoembolization is the most widely used palliative treatment for unresectable hepatocellular carcinoma; however, arterioportal shunt represents a contraindication to this treatment. The study aims to assess the feasibility of balloon-occluded radiofrequency ablation in the transitory resolution of an extensive arterioportal shunt in patients with advanced hepatocellular carcinoma as a bridge to safe and effective transarterial chemoembolization. 12 consecutive patients advanced multinodular unilobar unresectable hepatocellular carcinoma with a target lesion larger than 5 cm (mean diameter 7.7 ± 1.4 cm), not suitable to transarterial chemoembolization due to extensive arterioportal shunt, were recruited. Balloon-occluded radiofrequency ablation of the hepatic area surrounding the shunt during occlusion of the artery supplying the shunt was performed, followed by lobar conventional chemoembolization. Intra/periprocedural complications were evaluated. Technical success was defined by the result of radiofrequency ablation in terms of immediate disappearance, reduction, or persistence of the shunt. Local efficacy of chemoembolization was evaluated at 1-month computed tomography according to m-RECIST criteria. Technical success was achieved in all patients. No major complications were observed. 1- month follow-up showed a mean necrotic diameter of 6.3 cm (range: 3.8-8.7 cm), with an acceptable procedural result and persistence of the shunt. An overall response rate was obtained in all patients, with 25% complete response and 75% partial response. Balloon-occluded radiofrequency ablation of an arterioportal shunt in patients with advanced hepatocellular carcinoma can temporarily reduce shunting, allowing to perform safe and therapeutically useful chemoembolization, with satisfactory control of tumor growth.

Hepatic Encephalopathy in Osler-Weber-Rendu Syndrome

Hereditary hemorrhagic telangiectasia or Osler-Weber-Rendu syndrome is a rare condition that leads to multiple vascular malformations. We describe the interesting patient case of a woman with recurrent epistaxis secondary to Osler-Weber-Rendu syndrome, who presented with confusion, and was ultimately found to have a hepatic arteriovenous malformation leading to hepatic encephalopathy. Computed tomography angiography images are provided, which highlight the extensive hepatic arterioportal shunting that caused elevated serum ammonia levels in the setting of gastrointestinal breakdown of blood products.

FRI560 - Focal nodular hyperplasia: a response to portal vein thrombosis followed by a sequence of arterio-portal shunting, hyperperfusion, focal retrograde sinusoidal blood and Wnt flow, and Wnt-induced activation of the bud maturation sequence

FRI560 - Focal nodular hyperplasia: a response to portal vein thrombosis followed by a sequence of arterio-portal shunting, hyperperfusion, focal retrograde sinusoidal blood and Wnt flow, and Wnt-induced activation of the bud maturation sequence

Radioembolization for Hepatocellular Carcinoma: The Effects of Arterioportal Shunts on Nontargeted Liver Hypertrophy

PurposeTo determine whether arterioportal shunting to the contralateral lobe attenuates liver function and hypertrophy of the nontargeted liver after radioembolization in patients with hepatocellular carcinoma (HCC). Materials and MethodsThe current retrospective study included 46 patients who received radioembolization for HCC contained within the right lobe between 2012 and 2020. The patients were divided into the following groups on the basis of the presence and extent of arterioportal shunting: patients with retrograde arterioportal shunting to the left lobe (contralateral group) and patients with arterioportal shunt limited to the right lobe or no arterioportal shunt (control group). Safety profiles, including adverse events, tumor response, and overall survival, were compared. With the volume of the left lateral segment used as a surrogate marker for nontarget liver, the degree of hypertrophy was compared between the 2 groups at 3 and 6 months. ResultsLiver function significantly deteriorated in the contralateral group in a month (P ≤ .05). Tumor response and overall survival did not significantly differ between the 2 groups. The degree of hypertrophy was significantly higher in the control group than in the contralateral group at 3 months (10.6% vs 3.5%; P = .008) and 6 months (20.7% vs 2.4%; P < .001). ConclusionsIn patients with arterioportal shunting to the contralateral lobe, hypertrophy of the nontarget liver may not occur and the liver function may be worsened.

Transarterial chemoembolization for hepatocellular carcinoma with vascular invasion.

Although the global guidelines only recommend systemic therapy for hepatocellular carcinoma with vascular invasion, various treatments are performed for it. Among them, transarterial chemoembolization (TACE) is the most frequent option; however, standard techniques have not been established. Conventional TACE (cTACE) has also been frequently performed for tumors invading the portal vein (PVTT), hepatic vein (HVTT), and bile duct (BDTT). In cTACE for PVTT, selective catheterization into the tumor-feeder is essential to avoid adverse effects. However, if it is unsuccessful, injection of embolic agents under balloon occlusion of the hepatic artery can improve the therapeutic effects and avoid hepatic infarction. When marked arterioportal shunts are demonstrated, embolization with gelatin sponge particles soaked with a chemotherapeutic solution is another option. Arteriovenous shunts accompanied by HVTT may cause systemic embolization due to migration of embolic agents, and occlusion of a shunt-draining hepatic vein using a balloon catheter can reduce the risk. BDTT is often accompanied by obstructive jaundice; therefore, endoscopic or percutaneous biliary drainage is required when the serum total bilirubin concentration is ≥3 mg dl-1. TACE should be performed as selectively as possible and attention should also be paid to the risk of obstructive jaundice and/or pancreatitis caused by sloughing of necrotized BDTT.

Morphological, dynamic and functional characteristics of liver pseudolesions and benign lesions.

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related deaths worldwide and one of the most common causes of death among patients with cirrhosis, developing in 1-8% of them every year, regardless of their cirrhotic stage. The radiological features of HCC are almost always sufficient for reaching the diagnosis; thus, histological confirmation is rarely needed. However, the study of cirrhotic livers remains a challenge for radiologists due to the developing of fibrous and regenerative tissue that cause the distortion of normal liver parenchyma, changing the typical appearances of benign lesions and pseudolesions, which therefore may be misinterpreted as malignancies. In addition, a correct distinction between pseudolesions and malignancy is crucial to allow appropriate targeted therapy and avoid treatment delays.The present review encompasses technical pitfalls and describes focal benign lesions and pseudolesions that may be misinterpreted as HCC in cirrhotic livers, providing the imaging features of regenerative nodules, large regenerative nodules, siderotic nodules, hepatic hemangiomas (including rapidly filling and sclerosed hemangiomas), segmental hyperplasia, arterioportal shunts, focal confluent fibrosis and focal fatty changes. Lastly, the present review explores the most promising new imaging techniques that are emerging and that could help radiologists differentiate benign lesions and pseudolesions from overt HCC.

Atypical Manifestation of Primary Hepatocellular Carcinoma and Hepatic Malignancy Mimicking Lesions.

Hepatocellular carcinoma (HCC) can be diagnosed noninvasively on multiphasic CT and MRI based on its distinctive imaging findings. These features include arterial phase hyperenhancement and washout on portal or delayed phase images. However, radiologists face significant diagnostic challenges because some HCCs exhibit atypical imaging characteristics. In addition to many HCC-mimicking lesions, such as arterioportal shunts, combined HCC-cholangiocarcinoma, intrahepatic cholangiocarcinoma, and hemangioma present a challenge for radiologists in actual clinical practice. The ability to distinguish HCCs from mimickers on initial imaging examinations is crucial for appropriate management and treatment decisions. Therefore, this pictorial review presents the imaging findings of atypical HCCs and HCCs mimicking malignant and benign lesions and discusses important clues that may help narrow down the differential diagnosis.

S2747 Hereditary Hemorrhagic Telangiectasia: A Rare Disease Diagnosed From Incidental Liver Lesions

Introduction: Hereditary hemorrhagic telangiectasia (HHT) is a rare, autosomal dominant syndrome characterized by mucocutaneous telangiectasias and AVMs. Epistaxis and GI bleeding are the most common presenting features. HHT-related visceral AVMs have also been well-described and when identified without a prior diagnosis of HHT can present a significant diagnostic challenge. Case Description/Methods: A 60-year-old male with prior history of prior tobacco and alcohol use was referred to GI clinic for two years of chronic diarrhea and dyspepsia. No unintentional weight loss although he reported intermittent episodes of epistaxis every 2-3 months for past 40 years. Physical examination and family history was unremarkable. CT A/P showed a heterogeneous liver with innumerable liver lesions. (Figure 1) An EGD was performed for dyspepsia which revealed an 8mm gastric body ulcer and biopsy negative for H.pylori. The patient’s diarrhea resolved with probiotics and changes to diet. Hepatology recommended a liver biopsy which was suggestive of an arteriovenous or vascular malformation with scarring. Follow up EGD revealed a healed stomach ulcer and a 5mm gastric AVM. Chart review revealed a prior CT chest with a small pulmonary vascular malformation. The patient was referred to genetics for evaluation of HHT. A HHT genetic panel was positive for a pathogenic heterozygous variant in the ACVRL1 gene and the diagnosis of HHT was confirmed. Discussion: HHT is a clinically heterogenous disorder and diagnosis requires at least three of the following Curaçao criteria: epistaxis, mucocutaneous telangiectasias, visceral AVMs and family history of HHT. HHT-related AVMs can involve the brain, lung or liver. Hepatic involvement is common ranging from 32% up to 95%. Hepatic AVMs, are rarely symptomatic and routine screening is not recommended. Symptomatic hepatic AVMs can present with three distinct clinical presentations – high output heart failure from AV shunting, portal hypertension from arterioportal shunting and biliary disease from chronic ischemia. In the absence of routine screening, follow-up of these patients requires close attention to the development of these complications. In these cases, multi-phasic CT may be the preferred imaging modality. In conclusion, hepatic AVMs should be included in the differential for hepatic lesions and genetic evaluation should be considered with concomitant history of epistaxis, GI bleeding and/or evidence of other visceral AVMs.Figure 1.: CT abdomen and pelvis without contrast revealed several liver lesions, largest lesion 3.3cm in diameter.

Revascularization of iatrogenic intraoperative injury to a major artery during hepatobiliary-pancreatic surgery: a single-center experience in China

Although uncommon during hepatobiliary-pancreatic (HBP) surgery, iatrogenic intraoperative injury to a major artery requires prompt and appropriate repair. Here, we outline our surgical experience with the repair of this injury and compare our experience to findings garnered from a selective review of the literature. We retrospectively analyzed the clinical diagnoses, surgical methods, sites of arterial injury, operative repair, intra-operative blood loss, blood transfusion requirements, postoperative management and outcome of 17 consecutive patients who sustained iatrogenic intra-operative injuries to major arteries during HBP surgery between January 2008 and December 2013. Depending on the location and extent of injury, suture repair, primary end-to-end anastomosis, artery transposition, interposition grafting, or arterio-portal shunting were used. Postoperative morbidity occurred in three cases and there was only one case of in-hospital mortality (5.9%). No arterial thrombosis or other repair-related complications were found after the operation with a follow-up duration of 6 months. The use of an optimal repair method for injured arteries based on their location and extent resulted in a satisfactory outcome.

Value of precontrast and portal venous phases for evaluating atypical hepatocellular carcinoma mimicking arterioportal shunt

PurposeTo evaluate the value of precontrast phase (PP) and portal venous phase (PVP) for differentiation of small hypervascular hepatocellular carcinomas (HCCs) without delayed washout from arterioportal (AP) shunts in high-risk patients of HCC. MethodsA total of 122 lesions (73 AP shunts and 49 HCCs) detected on quadriphasic CT in 101 patients with chronic liver disease were analyzed. All lesions (≤2 cm) showed arterial enhancement and isodensity on delayed phase (DP) with exclusion of typical features of AP shunts. Lesion morphologic features (size, location, shape, margin) on biphasic CT (arterial phase and DP), Alpha-fetoprotein (AFP) values and coexistent HCC were evaluated. The qualitative and quantitative analyses of lesion attenuation on quadriphasic CT were performed. Diagnostic performances for prediction of AP shunts over HCC were compared among the biphasic CT, triphasic CT (adding PP or PVP) and quadriphasic CT. ResultsIn multivariate analysis, the presence of concomitant HCC (p = 0.0005, odds ratio [OR] = 0.11), visual hypodensity on PP (p = 0.0004, OR = 17.72) and visual hyperdensity on PVP (p = 0.0003, OR = 0.051) were independent predictors for HCCs rather than AP shunts. Additional review of PP and PVP revealed significantly improved diagnostic performance yielding the highest diagnostic performance. ConclusionsHypodensity on PP and hyperdensity on PVP are significant predictive features in differentiating atypical small hypervascular HCC from AP shunts in patients with high-risk of HCC. Careful evaluation of the PP and PVP may reduce underdiagnosis and lead to earlier diagnosis of atypical small HCCs.

Vascular Involvements in Cholangiocarcinoma: Tips and Tricks.

Simple SummaryCholangiocarcinoma (CCA) is the second most common liver primary malignancy and its gold-standard treatment is surgery. Unfortunately, CCA is seldom amenable to curative resection due to late-stage diagnosis and frequent major vascular invasion. Major vascular invasion has historically been considered a contraindication to resection, but lately aggressive surgeries for CCA with vascular involvement have been shown to improve outcomes. The purpose of this review is to provide a comprehensive and up to date summary of the strategies for CCA resection, focusing on the surgical techniques and results of complex procedures with tumour vascular involvements. The current review shows that satisfactory results can be achieved in patients with CCA and tumoral vascular invasion by aggressive surgical resection and challenging vascular reconstruction, ensuring a meticulous evaluation of patients in a multidisciplinary setting by experienced hepatobiliary surgeons.Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract. To date, surgical treatment remains the only hope for definitive cure of CCA patients. Involvement of major vascular structures was traditionally considered a contraindication for resection. Nowadays, selected cases of CCA with vascular involvement can be successfully approached. Intrahepatic CCA often involves the major hepatic veins or the inferior vena cava and might necessitate complete vascular exclusion, in situ hypothermic perfusion, ex situ surgery and reconstruction with autologous, heterologous or synthetic grafts. Hilar CCA more frequently involves the portal vein and hepatic artery. Resection and reconstruction of the portal vein is now considered a relatively safe and beneficial technique, and it is accepted as a standard option either with direct anastomosis or jump grafts. However, hepatic artery resection remains controversial; despite accumulating positive reports, the procedure remains technically challenging with increased rates of morbidity. When arterial reconstruction is not possible, arterio-portal shunting may offer salvage, while sometimes an efficient collateral system could bypass the need for arterial reconstructions. Keys to achieve success are represented by accurate selection of patients in high-volume referral centres, adequate technical skills and eclectic knowledge of the various possibilities for vascular reconstruction.