Intrahepatic Portal Vein Branches Research Articles

Percutaneous Transsplenic Balloon-Assisted Transjugular Intrahepatic Portosystemic Shunt Placement in Patients with Portal Vein Obliteration for Portal Vein Recanalization: Feasibility, Safety and Effectiveness

PurposeTo assess the feasibility, safety and effectiveness of portal vein recanalization (PVR)–transjugular portosystemic shunt (TIPS) placement via splenic access using a balloon puncture technique.Materials and MethodsIn a single-center retrospective study from March 2017 to February 2021, 14 consecutive patients with portal hypertension, chronic liver disease and portal vein occlusion or near-complete (> 95%) occlusion were referred for PVR–TIPS placement. Feasibility, safety and effectiveness including procedural characteristics such as technical success, complication profile and splenic access time (SAT), balloon positioning time (BPT), conventional portal vein entry time (CPVET), overall procedure time (OPT), fluoroscopy time (FT), dose–area product (DAP) and air kerma (AK) were evaluated.ResultsTranssplenic PVR–TIPS using balloon puncture technique was technically feasible in 12 of 14 patients (8 men, 49 ± 13 years). In two patients without detectable intrahepatic portal vein branches, TIPS placement was not feasible and both patients were referred for further treatment with nonselective beta blockers and endoscopic variceal ligation. No complications grade > 3 of the Cardiovascular and Interventional Radiological Society of Europe classification system occurred. The SAT was 25 ± 21 min, CPVET was 33 ± 26 min, the OPT was 158 ± 54 min, the FT was 42 ± 22 min, the DAP was 167.84 ± 129.23 Gy*cm2 and the AK was 1150.70 ± 910.73 mGy.ConclusionsTranssplenic PVR–TIPS using a balloon puncture technique is feasible and appears to be safe in our series of patients with obliteration of the portal vein. It expands the interventional options in patients with chronic PVT.

Fluid dynamics analyses of the intrahepatic portal vein tributaries using 7-T MRI.

Assessing portal vein (PV) hemodynamics is an essential part of liver disease management/liver surgery, yet the optimal methods of assessing intrahepatic PV flow have not yet been established. This study investigated the usefulness of 7-Tesla MRI with hemodynamic analysis for detecting small flow changes within narrow intrahepatic PV branches. Flow data in the main PV was obtained by two methods, two-dimensional cine phase contrast-MRI (2D cine PC-MRI) and three-dimensional non-cine phase contrast-MRI (3D PC-MRI). Hemodynamic parameters, such as flow volume rate, flow velocity, and wall shear stress in intrahepatic PV branches were calculated before and after a meal challenge using 3D PC-MRI and hemodynamic analysis. The hemodynamic parameters obtained using 3D PC-MRI and 2D cine PC-MRI were similar. All intrahepatic PV branches were clearly depicted in eight planes, and significant changes in flow volume rate were seen in three planes. Average and maximum velocities, cross-sectional area, and wall shear stress were similar between before and after a meal challenge in all planes. 7-Tesla 3D PC-MRI combined with hemodynamic analysis is a promising tool for assessing intrahepatic PV flow and enables future studies in small animals to investigate PV hemodynamics associated with liver disease/postoperative liver recovery.

The Role of Spleen and Liver Elastography and Color-Doppler Ultrasound in the Assessment of Transjugular Intrahepatic Portosystemic Shunt Function

The reference standard for assessing transjugular intrahepatic portosystemic shunt (TIPS) function is venography with portosystemic pressure gradient (PPG) measurement. This procedure is invasive and expensive; thus, we assessed the feasibility, reproducibility and diagnostic accuracy of color-Doppler ultrasound (CDUS) and spleen and liver stiffness (LS) measurements for identifying TIPS dysfunction. Twenty-four patients (15 undergoing TIPS placement and nine undergoing TIPS revision) consecutively underwent CDUS examination and LS and spleen stiffness (SS) determination by transient elastography (TE) and point shear-wave elastography (pSWE). All parameters were taken before TIPS placement/revision (1–15 d before) and 24 h after, just before revision by venography. pSWE inter-observer agreement was assessed by intra-class correlation coefficient (ICC). CDUS and elastographic data were correlated (Pearson coefficient) with pressure gradients (hepatic venous pressure gradient [HVPG], PPG). Main determinants of TIPS dysfunction were investigated by linear regression. Forty-nine paired examinations were performed in total: 49 (100%) SS reliable measurements by pSWE and 38 (88%) by TE. The ICC for pSWE values was 0.90 (95% confidence interval [CI] 0.81‒0.94). SS values significantly correlated with HVPG and PPG (R = 0.51, p = 0.01). The area under the Receiver-Operating Characteristic (AUROC) curve of SS for diagnosing TIPS dysfunction was 0.86 (95% CI 0.70‒0.96) using a 25 kPa cutoff. At multivariate analysis, the flow direction of the intrahepatic portal vein branches and SS values were independently associated to TIPS dysfunction. The intrahepatic portal vein branches flow direction and SS value are two simple, highly sensitive parameters accurately excluding TIPS dysfunction. SS measurement by pSWE is feasible, reproducible and both positively and significantly correlates with HVPG and PPG values.

2232 Peribiliary Cysts Mimicking Primary Sclerosing Cholangitis and Cholangiocarcinoma

INTRODUCTION: Peribiliary cysts are cystic dilatations resulting from obstruction of extramural peribiliary glands. They are usually benign, may arise from the intrahepatic and extrahepatic bile ducts and do not communicate with the biliary tree. They may, however, be confused with alternative diagnoses, resulting in unnecessary investigations with profound clinical implications. CASE DESCRIPTION/METHODS: A 42-year-old male was referred after recent diagnosis of cirrhosis, presumed secondary to primary sclerosing cholangitis (PSC), complicated by suspected cholangiocarcinoma. He presented with jaundice, weight loss and was noted to have nodular, cirrhotic liver with diffusely beaded appearance of the intra-hepatic biliary tree and central hilar prominence suggestive of mass lesion on outside imaging studies. ERCP was also interpreted as PSC with suspected cholangiocarcinoma. Brushing was negative for malignancy. Repeat MRI with MRCP showed multiple grape-like cystic structures surrounding the intrahepatic portal vein branches, resulting in compression of the intrahepatic bile ducts (Figure 1). These findings were consistent with peribiliary cysts. He subsequently underwent deceased donor liver transplantation. Gross examination of the explant revealed multiple benign bile duct cysts, which were focally multi-cystic with an exophytic semitranslucent cystic lesion in the hilum, which likely explains the prior imaging misdiagnosis as cholangiocarcinoma (Figure 2). Histologically, multiple cystic biliary structures were noted, lined by non-dysplastic cuboidal biliary type epithelium (Figure 3). DISCUSSION: Originally described in 1984, Peribiliary cysts are usually asymptomatic and often under- and misdiagnosed. The clinical importance of these structures arises from the fact that they may at times cluster together resembling multi-locular malignancy and mimic a dilated biliary tree. They may consequently be mistaken for entities such as biliary intraductal papillary mucinous neoplasm, cystic metastases, PSC, Caroli’s disease and importantly cholangiocarcinoma. In addition, they may also occasionally grow to compress the neighboring structures, resulting in biliary obstruction. High-resolution imaging with MRCP is a good modality for establishing the diagnosis. As highlighted by our case, given the prevalence of these lesions in patients with cirrhosis, awareness of this entity is critical to avoid misdiagnosis leading to inappropriate exclusion from transplantation in otherwise acceptable candidates.

A novel model for in vivo quantification of immediate liver perfusion impairment after pancreatic islet transplantation

ABSTRACTInstant Blood-Mediated Inflammatory Reaction (IBMIR) is a major cause of graft loss during pancreatic islet transplantation, leading to a low efficiency of this treatment method and significantly limiting its broader clinical use. Within the procedure, transplanted islets obstruct intrahepatic portal vein branches and consequently restrict blood supply of downstream lying liver tissue, resulting typically in ischemic necrosis. The extent of ischemic lesions is influenced by mechanical obstruction and inflammation, as well as subsequent recanalization and regeneration capacity of recipient liver tissue. Monitoring of immediate liver perfusion impairment, which is directly related to the intensity of post-transplant inflammation and thrombosis (IBMIR), is essential for improving therapeutic and preventive strategies to improve overall islet graft survival. In this study, we present a new experimental model enabling direct quantification of liver perfusion impairment after pancreatic islet transplantation using ligation of hepatic arteries followed by contrast-enhanced magnetic resonance imaging (MRI). The ligation of hepatic arteries prevents the contrast agent from circumventing the portal vein obstruction and enables to discriminate between well-perfused and non-perfused liver tissue. Here we demonstrate that the extent of liver ischemia reliably reflects the number of transplanted islets. This model represents a useful tool for in vivo monitoring of biological effect of IBMIR-alleviating interventions as well as other experiments related to liver ischemia. This technical paper introduces a novel technique and its first application in experimental animals.

Iodine load reduction in dual-energy spectral CT portal venography with low energy images combined with adaptive statistical iterative reconstruction.

To study the application of using low energy images combined with adaptive statistical iterative reconstruction (ASiR) in dual-energy spectral CT portal venography (CTPV) to reduce iodine load. 41 patients for CTPV were prospectively and randomly divided into two groups. Group A ( n = 21) used conventional 120 kVp scanning protocol with contrast dose at 0.6 gI/kg while group B ( n = 20) used dual-energy spectral imaging with reduced contrast dose at 0.3 gI/kg. The 120 kVp images in Group A and 50 keV images in Group B were reconstructed with 40% ASiR. The contrast-to-noise ratio of portal vein was calculated. The image quality and the numbers of intrahepatic portal vein branches were evaluated by two experienced radiologists using a 5-point scoring system. Group B reduced iodine load by 52% compared to Group A (17.21 ± 3.30 gI vs 35.80 ± 6.18 gI, p < 0.001). All images in both groups were acceptable for diagnosis. CT values and standard deviations in portal veins of Group B were higher than Group A (all p < 0.05); There were no statistical differences in contrast-to-noise ratio, image quality score and the number of observed portal vein branches between the two groups (all p > 0.05), and the two observers had excellent agreement in image quality assessment (all κ > 0.75). The use of 50 keV images in dual-energy spectral CTPV with ASiR reduces total iodine load by 52% while maintaining good image quality. Spectral CT images combined with ASiR can be used in low contrast dose CTPV portal venography to maintain image quality and reduce contrast dose.

Evaluation of intrahepatic portal vascular system and its perfusion according to Doppler ultrasound and superb microvascular imaging in children with extrahepatic portal hypertension

Introduction: We aimed to study the features of intrahepatic portal vascular system and its perfusion using the Superb Microvascular Imaging (SMI) in children with extrahepatic portal hypertension. Method: Twenty pediatric patients with extrahepatic portal hypertension who underwent SMI with an Aplio 500 ultrasound system (Toshiba Medical Systems, Tokyo, Japan) were enrolled in this study. The subjects underwent conventional ultrasound examinations, including Doppler imaging followed by SMI. Standard imaging and SMI findings were compared. Result: The mean age of patients was 8.77±1,05 years. Before the shunt surgery, according to Doppler US hepatopetal flow on extrahepatic portion of portal vein was Vmpeak= 19.6 ± 1.51 cm/s. But it was impossible to determine patency of intrahepatic branches of portal vein. According to the SMI only in one case intrahepatic portal venous system, especially in the left lobe was irregular. In all other observations the intrahepatic branches of the portal vein and its segmental branches were patent. SMI characteristics of left portal vein in five patients were: d = 3±0.45 mm, the blood flow was Vmpeak = 7.25±0.16 cm/s. Conclusion: Superb microvascular imaging is especially useful for depicting the microvascular flow, and our initial experience shows that SMI was superior to Doppler imaging for depicting left portal vein at Rex recessus and estimating perfusion.

ABERNETHY MALFORMATION AS A RARE INDICATION FOR LIVER TRANSPLANTATION: CASE REPORT

Abernethy malformation or congenital agenesis of the portal vein (CAPV) is a rare malformation of the abdominal splanchnic venous system. This malformation is commonly found in children and is often associated with other malformations such as congenital cardiac anomalies and skeletal system disorders, as well as liver tumors. There are two types of Abernethy malformation. In type I, portal blood bypasses the liver completely, with the superior mesenteric vein and the splenic vein draining into the inferior vena cava separately (type Ia), or together (type Ib). There are no intrahepatic portal vein branches in the liver. Type II is a partial portocaval shunt in which portal blood partially supplies the liver. There is no unified therapeutic approach for all patients with Abernethy malformation, however, liver transplantation is recommended in patients with liver disease (encephalopathy, poor liver function) and those with liver tumors. In this case report we present a case of Abernethy type Ib malformation in a 17-year-old patient with chronic malaise and uper abdominal pain. During diagnostic work-up, an unresectable liver tumor was found and the patient was successfully treated with orthotopic liver transplantation.

What makes non-cirrhotic portal hypertension a common disease in India? Analysis for environmental factors.

In India, an unexplained enteropathy is present in a majority of non-cirrhotic intrahepatic portal hypertension (NCIPH) patients. Small intestinal bacterial contamination and tropical enteropathy could trigger inflammatory stimuli and activate the endothelium in the portal venous system. Groundwater contaminated with arsenic is an environmental factor of epidemic proportions in large areas of India which has similar consequences. Von Willebrand factor (a sticky protein) expressed by activated endothelium may promote formation of platelet microthrombi and occlusion of intrahepatic portal vein branches leading to NCIPH. Environmental factors linked to suboptimal hygiene and sanitation, which enter through the gastrointestinal (GI) tract, predispose to platelet plugging onto activated endothelium in portal microcirculation. Thus, NCIPH, an example of poverty linked thrombophilia, is a disease mainly affecting the lower socio-economic strata of Indian population. Public health measures to improve sanitation, provide clean drinking water and eliminate arsenic contamination of drinking water are urgently needed. Till such time as these environmental factors are addressed, NCIPH is likely to remain 'an Indian disease'.

32. Histological differences between non-cirrhotic portal fibrosis and extra-hepatic portal vein obstruction

Background and Aims: Both non-cirrhotic portal fibrosis (NCPF) and extrahepatic portal venous obstruction (EHPVO) are important non-cirrhotic causes of portal hypertension (PH) in India. In this study we analyzed and documented the histopathological differences in liver biopsies from patients diagnosed with NCPF and EHPVO. Methods: Patients presented with PH were categorized as NCPF and EHPVO based on the Asia Pacific association for the study of liver (APASL) criteria. Minimum adequacy criteria were defined and 69 liver biopsies from patients with NCPF and 100 liver biopsies from EHPVO patients were included, over a period of twelve years (2004–2016). All histological parameters were pre- defined and three experienced pathologists analyzed the biopsies after reaching consensus on each finding. Institute ethics committee clearance was taken. Results: Though histological features were overlapping, phlebosclerosis of intra-hepatic branches of portal vein (PV), peri-portal aberrant vascular channels, remnant portal tracts and hepatic fibrosis beyond the portal tracts without formation of complete hepatic nodules were common findings in biopsies from patients with NCPF; while, in EHPVO lobular architecture of liver was mostly maintained and intra-hepatic phlebosclerosis, aberrant vascular channels and fibrosis beyond portal tracts were significantly less. Conclusions: Though most histological features between NCPF and EHPVO were overlapping, phlebosclerosis of the intrahepatic branches of PV with formation of peri-portal aberrant collateral channels, remnant portal tracts and fibrosis beyond portal tracts characterized NCPF over EHPVO. Correlation of suggestive histological features with clinico-radiological findings, hepatic venous pressure gradient, PV pressure or intra-splenic pressure would help to reach a conclusive diagnosis. The authors have none to declare.

A Tumor Localized in the Portal Vein

Question: A 56-year-old man underwent annual abdominal ultrasonography (US) as a medical checkup and a mass was found in his portal vein. Further examination was required and he was admitted to our hospital. He had no significant chief complaints, family history, or past medical history. On physical examination, no significant findings were revealed. Laboratory data were as follows: aspartate aminotransferase of 57 IU/L, alanine aminotransferase of 42 IU/L, lactate dehydrogenase of 302 IU/L, and γ-glutamyltransferase of 248 IU/L. Tumor markers were as follows: carcinoembryonic antigen of 4.7 ng/mL carbohydrate antigen 19-9 of 0.9 U/mL, alpha-fetoprotein of 8.6 U/mL, DUPAN-2 of 155 U/mL, neuron-specific enolase of 17.74 ng/mL, and protein induced by vitamin K absence-2 of 18 mAU/mL. Serologic tests for hepatitis B virus and hepatitis C virus were negative. Abdominal US demonstrated a mass occupying the portal vein near the head of the pancreas (Figure A). Doppler examination demonstrated no blood flow in the portal vein. Early phase-enhanced computed tomography (CT) showed a homogenously enhanced mass occupying the portal vein and it elongated to secondary branches of the right intrahepatic portal vein and the superior mesenteric vein (Figure B). On CT and endoscopic US (EUS) examinations, there were no other detectable lesions suggesting primary tumors in the pancreas, liver or other organs. Positron emission tomography (PET) CT disclosed high enhancement in portal vein identical to the mass lesion (Figure C). How do you diagnose the tumor? What is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. To make a histologic diagnosis, we performed endoscopic ultrasound fine needle aspiration (Figure D). Microscopically, the tumor showed an alveolar growth pattern and cells were eosinophilic and some of them were amphophilic (Figure E). Immunohistochemical staining for both bcl-10 (Figure F) and trypsin (Figure G) was positive in the tumor. These microscopic features were consistent with acinar cell carcinoma of the pancreas. Because the tumor was invaded into secondary branches of both the right and left intrahepatic veins and the superior mesenteric vein, the tumor was considered to be unresectable. We started treating the tumor with chemotherapy. Acinar cell carcinoma is a rare malignant epithelial neoplasm and represents 1% to 2% of all exocrine pancreatic neoplasms.1Sun Y. Wasserman P.G. Acinar cell carcinoma arising in the stomach: a case report with literature review.Hum Pathol. 2004; 35: 263-265Crossref PubMed Scopus (41) Google Scholar We herein described an extremely rare case of pancreatic acinar cell carcinoma localized in the portal vein without any detectable primary lesions in the pancreas or other organs. In our patient, all the imaging studies including US, CT, PET-CT, and EUS could not detect any tumors in the pancreas. There are few case reports on pancreatic acinar cell carcinoma arising from non-pancreatic tissues, including the stomach,1Sun Y. Wasserman P.G. Acinar cell carcinoma arising in the stomach: a case report with literature review.Hum Pathol. 2004; 35: 263-265Crossref PubMed Scopus (41) Google Scholar the ampulla of Vater,2Kawakami H. Kuwatani M. Onodera M. et al.Primary acinar cell carcinoma of the ampulla of Vater.J Gastroenterol. 2007; 42: 694-697Crossref PubMed Scopus (10) Google Scholar and the jejunum.3Makhlouf H.R. Almeida J.L. Sobin L.H. Carcinoma in jejunal pancreatic heterotopia.Arch Pathol Lab Med. 1999; 123: 707-711Crossref PubMed Google Scholar In these cases, tumors were considered to arise from ectopic pancreatic tissue, because these tissues are derived from endoderm. However, in our patient, it is developmentally unlikely that acinar cell carcinoma arise from ectopic pancreatic tissue in the portal vein that is derived from mesoderm. Intraductal growth into the portal vein is also a rare feature for pancreatic acinar cell carcinoma. A few cases with portal tumor thrombus of acinar cell carcinoma have been reported. However, all of these cases had primary lesions in the pancreas and the tumor invaded directly to the portal vein. In conclusion, even though extremely rare, pancreatic acinar cell carcinoma should be included in the differential diagnosis of a tumor localized in the portal vein.

Multimodality imaging of primary extrahepatic portal vein obstruction (EHPVO): what every radiologist should know.

Portal vein thrombosis (PVT) is a frequent complication of liver cirrhosis, but it can also occur as a primary vascular disorder amid absent liver disease. Extrahepatic portal vein obstruction (EHPVO) refers to the obstruction of the extrahepatic portal vein with or without involvement of the intrahepatic portal vein branches, splenic and/or superior mesenteric vein. It is a distinct disorder that excludes PVT occurring in concurrence with liver cirrhosis or hepatocellular carcinoma. The term "EHPVO" implies chronicity and is principally reserved for a long-standing condition characterized by cavernous transformation of the portal vein. The most characteristic imaging manifestation is the formation of portoportal collaterals (via the venous plexi of Petren and Saint) that allow hepatopetal flow. However, this collateral circulation is insufficient resulting in clinically significant pre-hepatic portal hypertension, wherein the liver function and structure remain preserved until late. Although the long-term (more than 10 years) survival with controlled variceal bleeding is up to 100%, affected individuals have an impaired quality of life owing to portal cavernoma cholangiopathy, hypersplenism, neurocognitive dysfunction and growth retardation. Imaging diagnosis is not always straightforward as the collaterals can also present as a tumour-like solid mass that can be inadvertently biopsied. Moreover, EHPVO has its implications for the biliary tree, arterial circulation, liver/splenic volumes and stiffness, which merit proper understanding but have not been so well described in literature. In this review, we present the complete spectrum of the vascular, biliary and visceral changes with a particular emphasis on what our medical/surgical hepatology colleagues need to know from us in the pre-operative and post-operative settings.

Multimodality imaging of obliterative portal venopathy: what every radiologist should know.

Obliterative portal venopathy (OPV) is an important cause of non-cirrhotic portal hypertension, which is often erroneously misdiagnosed as cryptogenic cirrhosis. It has a worldwide distribution with majority of cases hailing from the Asian subcontinent. However, recently the disease has gained global attention particularly because of its association with human immunodeficiency virus infection and use of antiretroviral drug therapy (didanosine). As the name suggests, the disorder is characterized by sclerosis and obliteration of the intrahepatic portal vein branches (with attendant periportal fibrosis) leading to portal hypertension amid intriguingly little liver dysfunction. It primarily affects young adults who present with clinically significant portal hypertension in the form of episodes of variceal bleed; however, contrasting liver cirrhosis, the liver function and liver structure remain normal or near normal until late in the disease process. Radiological findings during advanced disease are often indistinguishable from cirrhosis often warranting a liver biopsy. Nevertheless, recent studies have suggested that certain imaging manifestations, if present, can help us to prospectively suggest the possibility of OPV. At imaging, OPV is characterized by a wide range of intrahepatic and/or extrahepatic portal venous abnormalities with attendant changes in liver and splenic volume and stiffness. We shall, through this pictorial review, appraise the literature and illustrate the germane radiological manifestations of OPV that can be seen using different imaging modalities including ultrasonography, CT, MRI, elastography and hepatic haemodynamic studies.

Abernethy Malformation and the Spectrum of Imaging Findings: A Case Report

Congenital extrahepatic porto systemic shunt (CEPS) is a rare condition in which the porto mesenteric blood drains into a systemic vein, bypassing the liver through a complete or partial shunt. It is commonly associated with multiple congenital anomalies. A diagnosis of Abernethy malformation is made by non-invasive cross-sectional imaging techniques such as Doppler ultrasound, CT or MRI, which show the shunt and intrahepatic portal vein branches. We report a case presenting with psychological issues, systemic hypertension, upper extremity deformities, liver lesions and portal hypertension. Usually the patients are diagnosed in childhood, in our case the patient is a middle aged woman. This case report shows the importance of imaging in diagnosis of this condition and presentation of the patient with portal hypertension which is rare.DOI: http://dx.doi.org/10.3126/njr.v3i2.9622 Nepalese Journal of Radiology Vol.3(2)July-Dec, 2013: 97-102

A feasibility study to evaluate splanchnic arterial and venous hemodynamics by flow-sensitive 4D MRI compared with Doppler ultrasound in patients with cirrhosis and controls

To evaluate the feasibility of time-resolved flow-sensitive four-dimensional (4D) MRI for the visualization and quantification of splanchnic arterial and portal venous hemodynamics in patients with cirrhosis and in controls. We applied flow-sensitive 4D MRI to evaluate arterial and portal venous three-dimensional blood flow in patients with advanced liver cirrhosis (n=5) and in healthy controls (n=10) using 3T MRI (spatial resolution=1.7×2.1×2.4 mm, temporal resolution=62.4 ms). The qualitative flow was analyzed using three-dimensional streamlines and time-resolved particle traces. Retrospective flow was quantified in nine predefined anatomic regions evaluating maximum and mean velocities, the flow volume, the vessel lumen area, pulsatility indices, and resistance indices. Doppler ultrasound (US) was our reference standard. Flow-sensitive 4D MRI visualized liver hemodynamics successfully in 91% of patients and 96% of volunteers with limitations for the patients' extrahepatic vessels (one case of splenic and superior mesenteric veins each) and intrahepatic portal vein branches (in five vessels). Healthy control individuals revealed reduced velocities and larger vessel areas in MRI than in Doppler US. We found no significant differences in the flow volume, pulsatility indices, and resistance indices on comparing MRI with US. Regional flow quantification within the splanchnic system of healthy volunteers and liver cirrhosis patients revealed an increase in the inflow (up to 65%), but a decrease in the patients' outflow (up to 37%). Flow-sensitive 4D MRI is feasible for profound evaluation of arterial and portal venous hemodynamics in liver cirrhosis patients, providing additional information on the pathophysiology of the altered splanchnic system.

Abstract No. 412 - CT spectrum of findings in liver parenchyma after transarterial chemoembolization with DC-beads

Purpose To describe MDCT findings and parenchymal changes after transarterial chemoembolization (TACE) with DC-beads in the treatment of primary and metastasic liver tumors. Materials and Methods Baseline and follow-up CT scans obtained in 93 patients with TACE DC-bead treatment between September 2009 and March 2012 were reviewed retrospectively to evaluate changes in biliary ducts, adjacent portal vein branches and hepatic parenchyma. Clinical data including etiology and correlation with CT findings were analyzed using the Fischer test. A p Results 93 patients, 55 men and 38 women (21-78 years) were evaluated. Etiologies included 44 hepatocellular carcinomas (38 with cirrhosis), 17 neuroendocrine metastases, 10 colorectal metastases and 22 others. The average time between TACE and follow-up CT was 50 days (r6-172). The most frequent findings at follow-up were bile duct dilatation (41.9%, n 39), obliteration of adjacent intrahepatic portal vein branches (31.1%, n 29), bilomas (26.8%, n 25), parenchymal hypodense ill-defined areas (44%, n 41), parenchymal infarcts (6.4%, n 6), periportal edema (35.4%, n 33) and perilesional parenchymal enhancement (23.6%, n 22). One patient (1.07%) had an abscess. The first 4 findings showed significant negative association with cirrhosis. In spite of these findings, there were no clinical relevant manifestations in these patients. There were no mayor complications reported. Only one patient required a percutaneous drainage catheter to drain an abscess. Conclusion The spectrum of MDCT findings we report after transarterial chemoembolization with DC-beads were not related with clinical manifestations of mayor complications in most cases. It is important for the radiologist to be familiar with these changes in order to distinguish collateral findings from complications and residual or recurrent tumor.

Thrombolysis of portal vein thrombosis after splenectomy following liver transplantation

Thrombolysis of portal vein thrombosis after splenectomy following liver transplantation

MDCT findings after hepatic chemoembolization with DC-beads: What the radiologist needs to know

Transcatheter arterial chemoembolization with drug-eluting beads (TACE-DC-beads) is a new local treatment for primary or metastatic liver tumors. Despite technical efforts to achieve highly selective embolization of the tumor-supplying vessels, small, or large insults to the non-tumorous parenchyma are inevitably induced by the embolic materials or procedure itself. Parenchymal changes following TACE-DC-beads include bile duct injuries (bile duct dilatation, periportal edema, and bilomas), obliteration of intrahepatic portal vein branches, hypodense ill-defined areas, and perilesional parenchymal enhancement. The radiologist must be familiar with the changes induced by this treatment in order to distinguish therapeutic effect and collateral findings from complications and residual or recurrent tumor.

Balloon-Occluded Antegrade Transvenous Obliteration With or Without Balloon-Occluded Retrograde Transvenous Obliteration for the Management of Gastric Varices: Concept and Technical Applications

Alternative routes for transvenous obliteration are sometimes resorted in the management of gastric varices. These alternative routes can be classified into A, portal venous access routes and B, systemic venous access routes. The portal venous approach to transvenous obliteration is called balloon-occluded antegrade transvenous obliteration (BATO) and is a collective definition, including 1-percutaneous transhepatic obliteration (PTO), 2-through an existing transjugular intrahepatic portosystemic shunt [(Trans-TIPS), and 3-trans-iliocolic vein obliteration (TIO)]. PTO is usually out of necessity; however, trans-TIPS approach is usually used out of serendipity (because the low-risk access route is there). The TIPS for the trans-TIPS BATO is not formed for mere access, but is done to create a TIPS or is done when there is a preexisting TIPS. The trans-TIPS approach can be resorted to in the United States in up to 19% of balloon-occluded retrograde transvenous obliteration (BRTO) cases. PTO is resorted to, out of necessity, in the United States and Japan in 10% of BRTO cases (2%-19% of BRTO cases) and can increase the technical and obliterative success rate of the transvenous obliteration procedure from 84%-98% to 98%-100%. The advantage of BATO as an adjunct to BRTO (combining a BRTO and BATO approach to obliterate the gastric varices) is not only limited to increasing the technical success rate of the obliterative procedure. BATO reduces the risk of overspill of the sclerosant from the gastric variceal system into the portal vein. Moreover, if the BATO is performed from a trans-TIPS approach, any overspill of the sclerosant mixture will partly (if not mostly) go through the patent TIPS to the systemic circulation (lung) rather than the intrahepatic portal vein branches (prevent portal vein embolization). This article discusses the clinical and technical applications, technical considerations, and the outcomes of BATO.

Recanalized umbilical vein as a conduit for mesenterico/porto-Rex bypass for patients with extrahepatic portal vein obstruction

Mesenterico-left portal vein (meso-Rex) bypass is as an effective modality for restoring intrahepatic portal perfusion in patients with extrahepatic portal vein obstruction. Achieving sufficient patency is difficult with end-to-side anastomosis of a bypass graft to a small or hypoplastic left portal vein in the Rex recessus. Here, we describe the use of a recanalized umbilical vein in the round ligament as a conduit for bypass construction in two patients. Case 1 was an 11-year-old boy diagnosed with rupture of the esophageal varices and hypersplenism due to congenital extrahepatic portal hypertension. Because of persistent hypersplenism and thrombocytopenia, he underwent meso-Rex bypassing with a left iliac vein graft interposed between the umbilical vein and the superior mesenteric vein. Case 2 was a neonate with a large hepatic tumor (mesenchymal hamartoma) that developed abdominal compartment syndrome at birth. The tumor was removed by right hepatectomy with excision of the portal vein bifurcation at 3days of age. Porto-Rex bypassing was accomplished by end-to-end anastomosis between the portal vein trunk and the umbilical vein. Sufficient hepatopetal portal flow through the umbilical vein was achieved in both patients and maintained for over 16 and 13months, respectively. Although hypersplenism remained in Case 1, intrahepatic portal vein branches gradually widened and the cavernoma in the hepatic hilum disappeared within 2months. Neither patient had symptoms or signs of portal hypertension at the most recent follow-up. Using the umbilical vein as a vein conduit may facilitate construction of a meso/porto-Rex bypass and restore intrahepatic portal vein perfusion in patients with extrahepatic portal vein obstruction.