Shunt Embolization Research Articles

Percutaneous Transsplenic Access to the Portal Vein for Management of Vascular Complication in Patients with Chronic Liver Disease

To evaluate the safety and feasibility of percutaneous transsplenic access to the portal vein for management of vascular complication in patients with chronic liver diseases. Between Sept 2009 and April 2011, percutaneous transsplenic access to the portal vein was attempted in nine patients with chronic liver disease. Splenic vein puncture was performed under ultrasonographic guidance with a Chiba needle, followed by introduction of a 4 to 9F sheath. Four patients with hematemesis or hematochezia underwent variceal embolization. Another two patients underwent portosystemic shunt embolization in order to improve portal venous blood flow. Portal vein recanalization was attempted in three patients with a transplanted liver. The percutaneous transsplenic access site was closed using coils and glue. Percutaneous transsplenic splenic vein catheterization was performed successfully in all patients. Gastric or jejunal varix embolization with glue and lipiodol mixture was performed successfully in four patients. In two patients with a massive portosystemic shunt, embolization of the shunting vessel with a vascular plug, microcoils, glue, and lipiodol mixture was achieved successfully. Portal vein recanalization was attempted in three patients with a transplanted liver; however, only one patient was treated successfully. Complete closure of the percutaneous transsplenic tract was achieved using coils and glue without bleeding complication in all patients. Percutaneous transsplenic access to the portal vein can be an alternative route for portography and further endovascular management in patients for whom conventional approaches are difficult or impossible.

Transvenous Embolization of Intracranial Dural Arteriovenous Shunts through Occluded Venous Segments: Experience in 51 Patients

DAVFs with cortical venous reflux carry a high risk of morbidity and mortality. Endovascular treatment options include transarterial embolization with a liquid embolic agent or transvenous access with occlusion of the involved venous segment, which may prove difficult if the venous access route is thrombosed. The aim of this article is to describe the technique and results of the transvenous approach via thrombosed venous segments for occlusion of DAVFs. Our study was a retrospective analysis of 51 patients treated with a transvenous approach through an occluded sinus that was reopened by gentle rotational advancement of a 0.035-inch guidewire, which opened a path for a subsequently inserted microcatheter. Of 607 patients with DAVFs, the transvenous reopening technique was attempted in 62 patients in 65 sessions and was successful in 51 patients and 53 sessions. Immediate occlusion was seen in 42 patients; on follow-up, occlusion was seen in 49 patients, whereas 2 patients had reduced flow without cortical venous reflux. No permanent procedure-related morbidity was noted. The reopening technique to gain access to isolated venous pouches or the cavernous sinus for the treatment of DAVFs is a safe and effective treatment, which should be considered if transarterial approaches fail or are anticipated to result only in an incomplete anatomic cure.

Intracranial Dural Arteriovenous Shunts: Transarterial Glue Embolization—Experience in 115 Consecutive Patients

To evaluate the effectiveness and safety of transarterial glue embolization of intracranial dural arteriovenous shunts (DAVS). Institutional review board approval was obtained, with waiver of informed consent, for this retrospective study. From a single-center database of information on 371 intracranial DAVS, data in 115 consecutive patients treated with transarterial glue embolization were identified and assessed. Clinical and angiographic features, including cure rate, complications, and outcome, were evaluated. The treatment results were also compared between the patients in the first half of the consecutive series and those in the second half. The mean glue concentrations used were compared between the first and second halves of the patient series by using the Student t test. One hundred twenty-one lesions were treated with transarterial glue embolization. There were 31 (25.6%) Borden type I lesions, 39 (32.2%) Borden type II lesions, and 51 (42.1%) Borden type III lesions. Angiographic cure with glue embolization was achieved for 36 lesions (29.8%); 17 (14.0%) lesions were cured immediately, and 19 (15.7%) showed progressive thrombosis at follow-up. The angiographic cure rate for Borden type III lesions improved from 10% to 55% in the later group of patients as compared with the earlier group. The mean concentration of glue was significantly lower in the later group of patients. One (0.9%) of the 115 patients suffered permanent morbidity from aggravation of left extremity weakness due to venous thrombosis. Eight patients experienced nonpermanent morbidities, including transient worsening of neurologic status due to venous thrombosis (n = 4), alopecia (n = 2), scalp ulcer (n = 1), and pulmonary embolism (n = 1). Overall, improvement (n = 65) or stabilization (n = 32) of symptoms was seen in 84.3% of the patients. Transarterial glue embolization is a safe and effective method of primary treatment for intracranial DAVS, especially Borden type III lesions. Improvement of cure rates in the latter half of this study suggest that technical advances and experience may enhance outcomes.

Coil Embolization of a Congenital Arteriovenous Fistula of the Saphenous Artery in a Dog

Coil Embolization of a Congenital Arteriovenous Fistula of the Saphenous Artery in a Dog

Initial experience of transcatheter arterial chemoembolization during portal vein occlusion for unresectable hepatocellular carcinoma with marked arterioportal shunts

The purpose of this study was to assess the clinical effects of transcatheter arterial chemoembolization (TACE) during the corresponding portal vein occlusion (TACE-PVO) in patients with hepatocellular carcinoma (HCC) and marked arterioportal (AP) shunts. This was a prospective, nonrandomized study of TACE-PVO in patients with HCC who had marked AP shunts. The subjects were 21 patients with unresectable HCC and marked AP shunts who underwent shunt embolization with the use of coils and/or gelatin-sponge particles (group A: n = 7) or by TACE-PVO (group B: n = 14). Clinical parameters and data on embolization of AP shunts and on tumor response were assessed prospectively. No major procedure-related complication occurred in either group. Effectiveness of AP-shunt treatment was significantly better in group B than in group A in terms of both immediate results (P = 0.009) and subsequent results (P = 0.028). Tumor response in the therapeutic target area was significantly (P = 0.002) better in group B than in group A. Survival was significantly better in group B than in group A (P = 0.008). TACE-PVO may be a safe and useful therapy for selected patients with unresectable HCC and marked AP shunts.

Interventional radiology in the management of portal hypertension

From being a mere (though important) diagnostic tool, radiology has evolved to become an integral part of therapy in portal hypertension today. Various procedures are currently available, the choice depending on the etiology and location of disease, the pathoanatomy, and the symptomatology. The main aim of any procedure is to reduce the portal pressure by either direct or indirect methods. This can be achieved with transjugular intrahepatic portosystemic shunt (TIPS), recanalization of the hepatic vein outflow, recanalization of the portal vein and its tributaries, recanalization of dysfunctional portosystemic shunts, partial splenic embolization, and embolization of arterioportal shunts. When any of these procedures cannot be performed due to anatomical or physiological reasons, the symptoms can often be controlled effectively with embolization of varices or balloon-occluded retrograde transvenous obliteration of varices (BRTO). This article briefly describes the procedures, their results, and their current status in the treatment of portal hypertension.

Treatment of chronic portosystemic encephalopathy in cirrhotic patients by embolization of portosystemic shunts

AIMS/BACKGROUNDS: Large spontaneous portal-systemic shunts can occasionally be the cause of chronic and disabling encephalopathy in cirrhotic patients. Shunt embolization has been proposed, however the clinical relevance of this technique remains uncertain. We report our results in seven patients treated by shunt embolization. Although the procedure was achieved and technically successful in all patients, the clinical results were poor as long-term improvement was obtained in only one patient. Three patients died within 3 months after the procedure from cirrhoses' end stage complications. We believe that optimal management of these patients with chronic spontaneous encephalopathy is liver transplantation.

Encefalopatía hepática secundaria a la existencia de un shunt portosistémico tratada satisfactoriamente mediante radiología intervencionista

Hepatic encephalopathy is a reversible state of altered cognition that may occur in patients with acute or chronic liver disease or porto-systemic shunt, and in which known neurological or psychiatric signs may develop. Nitrogenated substances from intestinal digestion reach the brain without being cleared by their passage through the liver due to the presence of porto-systemic shunt. We report two cases of patients with porto-systemic shunt diagnosed with recurrent chronic hepatic encephalopathy refractory to conventional medical treatment. They were satisfactorily treated with shunt embolization using interventionist radiology techniques.

Transvenous Removal of Glue from Obstructed Straight Sinus during Transarterial Embolization

Inadvertent embolization of the veins that drain arteriovenous intracranial shunts is likely to precipitate passive hyperemia with subsequent hemorrhage and brain edema. The mainstay of therapy for this complication is to decrease the flow through the shunt as much as possible and maintain the patient's blood pressure below baseline. We herein report our successful attempts at glue removal from partially obstructed straight sinus in two cases using a microsnare. This complication occurred during intracranial arteriovenous shunt embolization.

Spinal dural arteriovenous fistula

To summarize clinical key points, diagnostic features, and results of imaging and therapy of spinal dural arteriovenous fistula (SDAVF). SDAVF accounts for 70% of spinal arteriovenous malformation with an annual incidence of 5-10 cases per million. At least 80% of patients are male, and more than 66% of patients are in the sixth and seventh decade of life indicating preponderance of gender and age. Thrombophilia is not a predisposing factor of disease. Clinical course is predominated by symptoms of congestive myelopathy, but subarachnoid hemorrhage may occur. Double SDAVF is a rare problem in the management of disease. Magnetic resonance imaging has replaced myelography as screening procedure. Contrast-enhanced magnetic resonance angiography and multislice computerized tomographic angiography may facilitate diagnostic procedure, however, spinal angiography is still required to confirm diagnosis. Treatment by permanent occlusion of fistula results in clinical improvement in 70% of cases. Microsurgical shunt interruption has proven secure and reliable. Endovascular shunt embolization has been established as a standardized procedure, but occlusion rates are still lower than in surgical treatment. Advances have been made in diagnosis and treatment of SDAVF, but the disease is still not completely understood.

Embolization of spinal cord arteriovenous shunts: morphological and clinical follow-up and results--review of 69 consecutive cases.

We sought to analyze the results of embolization in patients with intradural spinal cord arteriovenous shunts. The clinical and radiological files of 69 of a population of 155 patients treated with embolization between 1981 and 1999 were reviewed retrospectively. The patients' clinical status was evaluated according to Karnofsky Performance Scale score. Twenty-one (14%) of 155 patients were treated surgically because they were thought to be poor candidates for embolization. Twenty-four (15%) of 155 patients were considered untreatable with surgery or embolization; in these patients, follow-up was proposed, but only 8 of them were followed appropriately and remained stable after the first consultation. Forty-one (26%) of 155 patients consulted our group, but no follow-up could be obtained. In 69 (45%) of 155 patients, comprising 20 children and 49 adults, endovascular treatment was performed with the patients under general anesthesia and without provocative tests, mainly with acrylic glue, in 99% of these patients. The mean number of diagnostic and therapeutic sessions was 3.5 per patient, and the mean number of pure therapeutic sessions was 1.5 per patient. Follow-up ranged between 6 months and 18 years (mean, 5.6 yr). In 16% of patients, anatomic obliteration of spinal cord arteriovenous shunts was obtained. Embolization reduced more than 50% of the spinal cord arteriovenous shunts in 86% of cases. No recanalization was noted on follow-up angiograms. Good clinical outcomes were obtained in 83% of the patients: 15% of them were asymptomatic, 43% were improved, and 25% were stable. In 4% of patients, embolization failed to stabilize the disease. Transient deficits were seen after embolization in 14% of the patients, and permanent severe complications occurred in 4% of the patients (Karnofsky Performance Scale score <or=70). Mild worsening was seen in 9% of the patients (Karnofsky Performance Scale score, 80). No bleeding or rebleeding was seen after endovascular treatment was considered to have been completed. This study proves that embolization with acrylic glue is a therapeutic option that compares favorably with surgery or embolization with other agents (particles, coils, or balloons). It offers stable long-term clinical results, despite not necessarily achieving total cure. Studies of larger series with longer follow-up are necessary to confirm these encouraging therapeutic data.

Embolization of Seve re Arterioportal Shunts in the Patients with Hepatocellular Carcinoma: Safety and Influence on Patient Survival

Purpose : To evaluate the safety and the influence of embolization of severe arterioportal shunts, and the effect of the procedure on the survival rate of patients with hepatocellular carcinoma combined with portal vein tumor thrombosis. Materials and Methods : This study involved a total of 54 patients with hepatocellular carcinoma in whom he-patic arteriography revealed severe arterioportal shunt. From among this total, 34 patients (embolization group) underwent chemoinfusion after shunt embolization, while 19 (control group) underwent chemoinfu-sion only. The embolic materials included PVA particles and/or Gelfoam pieces. The frequency of postem-bolization symptoms (Chi-squared test) and changes in laboratory values (paired t-test) were compared be-tween the two groups, and shunt improvement was also evaluated. Patient survival was tested using the Kaplan-Meier method. Results : Fever and RUQ pain were more frequent in the embolization group (pweeks and weeks (p=0.0002), respectively. The best results were seen in the PVA particle group (p=0.01). Conclusion : The embolization of severe arterioportal shunts is relatively safe and increases patient survival rate.

Hepatocellular carcinoma with portal vein tumor thrombus: embolization of arterioportal shunts.

To evaluate transcatheter arterial embolization in patients with hepatocellular carcinoma, portal vein tumor thrombus, and arterioportal shunts. Ten patients with hepatocellular carcinoma, portal vein tumor thrombus, and severe arterioportal shunting were identified; in these patients, portal blood flow before embolization was hepatofugal. Embolization of arterioportal shunts was performed with steel coils that were introduced through a catheter during arteriography. After embolization, changes in portal hemodynamics and clinical signs and performance status of patients were evaluated; survival rates of patients with and patients without severe arterioportal shunting were compared. In all patients after embolization, angiography showed resolution of arterioportal shunting, and portography showed hepatopetal blood flow in the portal vein trunk. After embolization, performance status of five patients with initial scores of 2 or 3 improved. Ascites resolved in four patients and improved in four patients. One patient died of hepatic failure caused by rupture of esophageal varices 7 days after embolization. Median survival was 4.3 months, and the 6-month and 1-year survival rates were 45% and 12%, respectively. There were no significant differences between survival rates in patients with and patients without severe arterioportal shunting. Transcatheter arterial embolization of arterioportal shunts is a useful treatment for improving quality of life in patients with hepatocellular carcinoma.

Embolization of portal-systemic shunts in cirrhotic patients with chronic recurrent hepatic encephalopathy.

To evaluate the efficacy of embolization of portal-systemic shunts in cirrhotic patients with chronic recurrent hepatic encephalopathy (CRHE). Seven cirrhotic patients with CRHE refractory to medical treatment (3 men and 4 women, mean age 66 years) were studied. Five patients had splenorenal shunts, 1 had a gastrorenal shunt, and 1 had an intrahepatic portal vein-hepatic vein shunt. Shunt embolization was performed using stainless steel coils, with a percutaneous transhepatic portal vein approach in 4 patients and a transrenal vein approach in 3 patients. After embolization, the shunt disappeared in 4 patients on either ultrasound pulsed Doppler monitoring or portography. Complications observed in the 7 patients were fever, transient pleural effusion, ascites, and mild esophageal varices. For 3-6 months after embolization, the 4 patients whose shunts disappeared showed minimal or no reappearance of a shunt, and had no recurrence of encephalopathy. The serum ammonia levels decreased and electroencephalograms also improved. One of the 4 patients, who developed mild esophageal varices, required no treatment. Treatment was effective in 3 of the 4 patients (75%) who underwent embolization via a transhepatic portal vein. Transvascular embolization of shunts improved the outcome in 4 of 7 patients. The most effective embolization was achieved via the percutaneous transhepatic portal vein approach.

Case report: Percutaneous transhepatic portographic embolization (PTPE) for recurrent hepatic encephalopathy derived from intrahepatic portal-systemic shunts

In 1964, Raskin et al. described portal-systemic encephalopathy due to congenital intrahepatic shunts [1]. Only 20 or so cases of this rare disease have been reported [2,3], and only eight of these concern hepatic encephalopathy [1,4-8]. Medical treatment and surgery with medication have been used in these patients [1,3,5], but there is no report of shunt embolization without abdominal incision. We treated a patient with hepatic encephalopathy due to acquired intrahepatic shunts, complicated by hepatic cirrhosis.

Combined transjugular intrahepatic portosystemic shunt and segmental Lipiodol hepatic artery embolization for the treatment of esophagogastric varices and hepatocellular carcinoma in patients with cirrhosis: preliminary report.

To evaluate the feasibility of combining placement of a transjugular intrahepatic portosystemic shunt (TIPS) and transcatheter hepatic segmental artery chemoembolization with Lipiodol (Seg-Lp-TAE) in patients with cirrhosis, esophagogastric varices, and hepatocellular carcinoma (HCC). Five patients with bleeding or large, high-flow esophagogastric varices and HCC were treated by TIPS and Seg-Lp-TAE. The mean portosystemic pressure gradient decreased from 20.8 cm H2O to 7.8 cm H2O after TIPS. The direct portogram and endoscopic examination revealed reduction of varices. At 6 months, one shunt had functionally occluded and could not be reopened; the other TIPS remained functional. Follow-up CT and the changes of alpha fetoprotein indicated effective therapy of Seg-Lp-TAE for HCC. Four patients are in stabile clinical condition at 9, 6, 1, and 1 months after the combined therapy; one died after 14 months due to decompensated liver cirrhosis. The combined therapy of TIPS and Seg-Lp-TAE will become a new interventional approach for patients with HCC and esophagogastric varices.

Transcatheter Occlusion of Blalock-Taussig Shunts: Technical Options

This review of findings in children undergoing transcatheter shunt occlusion was carried out to describe and compare the results of four different embolization techniques. A retrospective review of clinical, radiologic, and cardiac catheterization records was carried out for 18 consecutive pediatric patients referred for Blalock-Taussig shunt occlusion at one institution. Technical aspects included the use of three devices--steel wire/fiber coils, detachable latex balloons, and ductal occlusion devices--and four techniques--direct transarterial placement, transarterial placement with proximal or with distal flow control, and transvenous delivery. Occlusion of the shunt was attempted in 17 patients (mean age, 6.2 years). Shunt occlusion was successful in 14 patients. Embolization of a device into the pulmonary circulation occurred in five patients, and was most frequent with transarterial delivery without flow control or with proximal flow control (in four of six). Transarterial occlusion with distal flow control and transvenous delivery of ductal occluder devices were the most reliable methods of occluding shunts without distal stenosis, with success in eight of nine cases with the former technique and all of three with the latter technique. Transarterial embolization of Blalock-Taussig shunts carries a risk of device embolization to the pulmonary circulation; this is best avoided by the use of distal flow control or transvenous placement of a ductal occlusion device.

巨大胃腎短絡路を有する肝性脳症を経皮経肝的短絡路塞栓術により治癒せしめた１例

巨大胃腎短絡路を有する肝性脳症を経皮経肝的短絡路塞栓術により治癒せしめた１例

Treatment of post-shunt portal systemic encephalopathy by embolization of the shunt.

Operative ligation of portosystemic shunts is effective in controlling chronic portosystemic encephalopathy (CPSE) but is associated with significant mortality. Review of the records of five patients with CPSE treated with radiologic occlusion procedures showed that these are suitable alternatives to surgery. Three patients had alcoholic cirrhosis, one had hepatic fibrosis from schistosomiasis, and one had post-necrotic cirrhosis. All had CPSE with progressive, severe cerebral impairment refractory to clinical treatment. Four patients had a spontaneous splenorenal shunt, and one had a surgically created mesocaval shunt (MCS). Partial splenic embolization was performed in two patients, direct shunt embolization was performed via percutaneous transhepatic portography in two other patients, and an MCS embolization was performed in one patient through the inferior vena cava. In four patients embolization controlled the CPSE. In the remaining patient it could not be evaluated because of his premature death from intraabdominal bleeding, a late complication of the procedure. Interventional radiologic procedures are effective in the control of CPSE in selected patients.

Interventional catheterization in pediatric congenital and acquired heart disease

The present status of catheter-directed therapy in pediatric congenital and acquired heart disease is reviewed. Balloon pulmonary valvotomy, established as the procedure of choice for children and adults with isolated pulmonary stenosis, has now been extended to neonates with critical pulmonary stenosis. Balloon mitral and aortic valvotomy are being performed for congenital and acquired stenoses, although indications and optimal techniques remain to be established. Balloon angioplasty of coarctation effectively relieves obstruction in native and post-operative aortic arch stenoses, but remains controversial due to late aneurysm formation. Balloon angioplasty of branch pulmonary artery hypoplasia and stenosis, despite a relatively low success rate and significant complications, remains the procedure of choice due to lack of better therapeutic options. Transcatheter closure of congenital and acquired vessels and defects is being performed with increasing frequency. Embolization of aortopulmonary collaterals and shunts using Gianturco coils is safe and effective in selected patients. Although Rash-kind umbrellas are most commonly used for closure of a patent ductus arteriosus, their use, especially in closing intracardiac defects, remains investigational.