Hepatic Arterial Blood Flow Research Articles

Hepatic artery restriction operation combined with ALPPS (HARO-ALPPS), a novel ALPPS procedure for the treatment of hepatocellular carcinoma with severe fibrosis: retrospective clinical cohort study.

Associating liver partition with portal vein ligation for staged liver resection (ALPPS) has been used in the treatment of patients with advanced or massive liver cancer without sufficient future liver remnant, but concerns remain regarding tumor outcomes and surgical safety. This study aims to evaluate the efficacy and safety of a new procedure, hepatic artery restriction operation combined with ALPPS (HARO-ALPPS), in the treatment of hepatocellular carcinoma (HCC) patients especially with severe fibrosis. This retrospective study analyzed 8 patients who underwent HARO-ALPPS for HCC and compared their outcomes with 64 patients who underwent conventional ALPPS. The primary outcomes assessed were liver regeneration ability (measured by relative and absolute kinetic growth rates), postoperative complications, and mortality. The secondary outcomes included overall survival and disease-free survival. HARO-ALPPS significantly restricted the blood supply of the hepatic artery. One week after surgery, the blood flow of the right hepatic artery dropped to 62.1%. At the same time, HARO-ALPPS shows superior liver regeneration ability, which is particularly prominent in the background of liver fibrosis. No serious complications occurred after HARO-ALPPS. The overall survival rate of HARO-ALPPS was 75%, which was higher than that of ALPPS (64%, P =0.816). Compared to conventional ALPPS, HARO-ALPPS exhibits a better liver regeneration ability, and favorable long-term outcomes. Further prospective studies are needed to validate these findings and evaluate the long-term oncologic outcomes of this novel procedure.

Hepatic infarction occurred after 125I particle stent treatment for hepatocellular carcinoma with portal vein tumor thrombus: A case report

BackgroundHepatic infarction is a rare liver condition. The purpose of this study is to report a case of hepatic infarction caused by thrombus formation following portal vein stent implantation in a patient with hepatocellular carcinoma and portal vein tumor thrombus, and to explore the underlying causes.Case reportThe patient in this study was a 52-year-old male admitted with diffuse hepatocellular carcinoma involving the right lobe and portal vein tumor thrombus. After undergoing portal vein stent implantation and 125I particle strand implantation treatment, the portal vein was patent, and the pressure decreased. However, multiple instances of hepatic artery chemoembolization combined with targeted immunotherapy resulted in gradual reduction in the diameter of the hepatic artery and affecting hepatic arterial blood flow. Two months post-stent implantation, thrombus formation within the stent was noted, and the patient’s condition did not improve with anticoagulant therapy, as evidenced by follow-up CT scans showing an increase in thrombi. Six months later, the patient suffered from gastrointestinal bleeding and, despite emergency esophagogastric variceal ligation and hemostatic treatment, developed hepatic parenchymal infarction and liver function failure.ConclusionsWe reveal the underlying cause is that (1) thrombus formation within the portal vein stent, leading to portal vein embolism and obstructed blood flow due to exacerbate portal hypertension after various treatments; and (2) the effect of hepatic artery chemoembolization, immunotherapy, and targeted therapy on tumor angiogenesis, causing reduced hepatic artery diameter and impaired arterial blood flow. These factors disrupt the liver’s dual blood supply system, ultimately contributing to hepatic infarction. To our knowledge, this is the first report of hepatic infarction as a complication following portal vein stent implantation for hepatocellular carcinoma with portal vein tumor thrombus, and it holds significant reference value for guiding the treatment of hepatocellular carcinoma with concurrent portal vein tumor thrombus in a clinical setting.

TWO PHASE SLIP FLOW OF BLOOD IN HEPATIC ARTERY WITH SPECIAL REFERENCE TO HEPATITIS B

In this paper, we have presented a model of two-phased arterial hepatic blood flow in hepaticarteries remote from the heart and proximate to the Liver keeping in view the nature of hepatic blood circulation in the human body. Blood is supposed to be non-Newtonian of the power-law type. Solutions of the constitutive equations are obtained in analytical as well as in numerical forms. The role of hematocrit is explicit in the determination of blood pressure drop in the case of Hepatic disease Hepatitis B.

The combination of preoperative celiac axis stenting and neoadjuvant chemotherapy in an elderly patient with pancreatic cancer: a case report

BackgroundCeliac axis stenosis (CAS) is frequently observed in patients undergoing pancreaticoduodenectomy (PD). This poses challenges because of the potential disruption of the hepatic arterial blood flow.Case presentationWe present the case of an 81-year-old woman diagnosed with pancreatic head cancer and severe CAS caused by calcification. The patient received neoadjuvant chemotherapy (NAC) and underwent preoperative endovascular stenting of the celiac axis to restore blood flow. After two cycles of NAC, subtotal stomach-preserving PD was performed. An intraoperative assessment of the hepatic arterial blood flow determined that it was well maintained. PD was performed using the standard technique; specialized techniques were not necessary. Importantly, no ischemic complications were encountered.ConclusionThis case report describes the successful combination of preoperative celiac axis stenting, NAC, and surgical intervention for the management of CAS in an elderly patient with pancreatic cancer. This approach offers a potential solution for maintaining the hepatic arterial blood flow in the presence of CAS without vascular reconstruction, particularly in elderly individuals.

Laparoscopic median arcuate ligament section for median arcuate ligament compression syndrome initially detected as splenic infarction: a case report

BackgroundMedian arcuate ligament compression syndrome (MALS) causes upper abdominal pain and at times hemodynamic abnormalities in the pancreaticoduodenal region.Herein, we present a case of a 70 year-old man, initially diagnosed with splenic infarction and was successfully treated laparoscopically.Case presentationA 70-year-old man with abdominal pain admitted to our hospital. Abdominal-enhanced computed tomography revealed a poorly contrasted area in the spleen and stenosis at the root of the celiac artery. Arterial dilatation was observed around the pancreaticoduodenal arcade, however, no obvious aneurysm formation or arterial dissection was observed. Abdominal-enhanced magnetic resonance imaging indicated the disappearance of the flow void at the root of the celiac artery. The patient had no history of atrial fibrillation and was diagnosed with splenic infarction due to median arcuate ligament compression syndrome. We performed a laparoscopic median arcuate ligament section with five ports. Intraoperative ultrasonography showed a retrograde blood flow in the common hepatic artery and the celiac artery. After releasing the compression, the antegrade blood flow from the celiac artery to the splenic artery, and the common hepatic artery were visualized using intraoperative ultrasonography. The postoperative course of the patient was uneventful, and he was discharged on postoperative day 9. Postoperative computed tomography a month after surgery revealed no residual stenosis of the celiac artery or dilation of the pancreaticoduodenal arcade. Furthermore, the poorly contrasted area of the spleen improved.ConclusionsReports indicate that hemodynamic changes in the abdominal visceral arteries due to median arcuate ligament compression are related to the formation of pancreaticoduodenal aneurysms. In this case, median arcuate ligament compression syndrome caused splenic infarction by reducing blood flow to the splenic artery.

Enlargement of the hepatic artery is present in dogs with a congenital extrahepatic portosystemic shunt and is independent of shunt insertion into the systemic circulation.

The accurate diagnosis of portovascular anomalies has been facilitated by improvements in diagnostic imaging technology. In humans, hepatic arterial blood flow changes in response to the reduction in portal blood flow. The hepatic arterial buffer response characterizes an intrinsic regulatory mechanism in response to reduced portal venous blood flow, which results in hepatic arterial enlargement. At the authors' institution, enlargement of the hepatic artery has been anecdotally observed in a population of dogs with extrahepatic portosystemic shunting, consistent with previous literature that documents variability in hepatic arterial size. In this retrospective, blinded, analytical study, a hepatic artery:aorta (Ha:Ao) ratio was assessed on CT studies from 112 dogs, with (n=43) and without (n=69) an extrahepatic congenital portosystemic shunt in order to compare the hepatic artery size independent of body weight between the two populations. A significant increase in the Ha:Ao ratio was documented in dogs with an extrahepatic portosystemic shunt (EHPSS) compared with those dogs with no EHPSS independent of the location of shunt insertion into the systemic circulation (P<.001). Three cases had repeat CT after surgery, and all had Ha:Ao ratio reductions following treatment. The authors propose that this may be an additional imaging feature observed in dogs with an EHPSS.

Low hepatic artery blood flow mediates NET extravasation through the regulation of PIEZO1/SRC signaling to induce biliary complications after liver transplantation.

Rationale: Biliary complications after liver transplantation persistently affect patient prognosis and graft survival. Neutrophil-mediated immune injury is an important factor leading to biliary injury. However, the mechanism by which neutrophils reach the periphery of the bile duct and further mediate bile duct injury is not fully understood. Methods: First, we obtained hepatic tissue samples from grafted rats subjected to warm and nonwarm ischemic injury. We constructed a protein map via proteomics and analyzed the correlations between neutrophil extracellular traps (NETs) and biliary injury. HuCCT1 cells were cocultured with NETs isolated from the peripheral blood of grafted rats in vitro to evaluate the role of NETs in bile duct injury. Next, we assessed NET extravasation through the PIEZO1/SRC pathway in liver samples from rats with liver grafts via proteomic analysis, immunohistochemical staining and immunofluorescence. Finally, we evaluated the correlations between hepatic arterial blood flow and the PIEZO1/SRC pathway in a liver graft model. Results: The results revealed a close correlation between NET formation by activated neutrophils and bile duct injury. Low hepatic arterial blood flow leads to NET extravasation through the activation of the mechanosensitive ion channel PIEZO1 and its downstream signaling events, including phosphorylation of tyrosine kinases sarcoma (SRC) protein. The extravasated NETs accumulate around the bile ducts and subsequently mediate biliary cell apoptosis. Verapamil was further used to increase hepatic artery blood flow to inhibit the PIEZO1/SRC axis, which reduced bile duct injury caused by extravasated NETs. Conclusions: Suppressing NET extravasation by increasing hepatic arterial blood flow is a potential strategy for the treatment of biliary complications after liver transplantation.

Effect of Somatostatin on hepatic blood flow: preliminary results

Background: Somatostatin (SOMATO) administration affects hepatic blood flow (HBF); however, its clinical effect remains ill-defined. The aim of this study is to assess the clinical effects of SOMATO administration on HBF during major abdominal surgery by comparing HBF in patients with and without intra-operative SOMATO admin-istration. Methods: This retrospective analysis used data from two separate prospective studies including patients undergoing pancreaticoduodenectomy and was approved by the Ghent University Hospital ethical committee. All patients received total intravenous an-esthesia, using target-controlled infusion, and guided by a depth of anesthesia monitor. Schnider model was used for propofol, and Minto model was used for remifentanil. All patients received goal-directed hemodynamic therapy guided and recorded by Pul-sioFlex monitoring (Getinge Group). Portal vein blood flow and arterial hepatic blood flow were measured using ultrasound transit time flow measurements (Medi-Stim®). Both PVF and HAF were indexed using cardiac index. Patients were divided in two groups, receiving SOMATO (group S) versus control group not receiving SOMATO (group C). The Shapiro-Wilk test was used for testing normal distribution. Statistical testing was done using a Welch T-test or a Wilcoxon test. Results: From 6/2017 to 10/2020, a total of thirty-seven patients were analyzed. Twenty-five patients received SOMATO (group S) whereas twelve patients did not (group C). In Group S, PVFi was significantly reduced in patients receiving SOMATO compared to the control group (p = 0.005). HAFi was similar in both groups. The net effect on total HBFi was significantly lower in group S (p = 0.027). Hemodynamic parameters did not differ between both groups. Conclusions: SOMATO significantly reduced PVFi in the surgical patients while HAFi remained similar in both groups. As a result, total HBFi was significantly lower in SO-MATO-treated patients.

Relationship Between Perioperative Factors and Splenic Artery Steal Syndrome After Orthotopic Liver Transplant: A Retrospective Clinical Study.

After orthotopic liver transplant, ischemia of biliary tract and graft loss may occur due to impaired hepatic arterial blood flow. This situation with hypersplenism and impaired hepatic arterial blood flowis defined as splenic artery steal syndrome.The aim of this study was to investigate the relationship between perioperative factors and splenic artery steal syndrome in orthotopic liver transplant patients. Forty-five patients who underwent orthotopic liver transplant between 2014 and 2022 were included in the study. The data for the patients were obtained from the hospital database, including the intraoperative anesthesiology and postoperative intensive care records. Eleven patients were diagnosed with splenic artery steal syndrome. Patients with splenic artery steal syndrome had higher need for intraoperative vasopressor agents (P = .016) and exhibited lower intraoperative urine output (P = .031). In the postoperative intensive care follow-up, patients with splenic artery steal syndrome had higher levels of C-reactive protein during the first 48 hours (P = .030). Intraoperative administration of vasopressor drugs, low urine output, and early postoperative high C-reactive protein levels were associated with the development of splenic artery steal syndrome in patients undergoing orthotopic liver transplant. Future studies should focus on investigation of biomarkers associated systemic hypoperfusion that may contribute to the development of splenic artery steal syndrome.

Pancreaticoduodenectomy combined gastroduodenal collateral reconstruction and preservation due to median arcuate ligament syndrome: technical notes with two surgical cases report (with video)

IntroductionPancreaticoduodenectomy in patients with CA stenosis due to median arcuate ligament often required carefully collateral pathways management to avoid hepatic ischemic complications.Cases presentationCase 1: A 63-year-old man was referred to our department because of jaundice with distal common bile duct tumor. Pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Case 2: A 48-year-old man was referred to our department because of right-upper-quadrant abdominal pain with Vater tumor. Laparoscopic pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Postoperatively, in all two cases, three-dimensional reconstruction images showed developed collateral pathways around the pancreatic head, and the CA was stenosis in 75% and 70% due to MAL, respectively. Intraoperatively, in all two cases, we confirmed poor blood flow in the common hepatic artery (CHA) by palpation and observation. So that in the first case, we have decided to proceed a no-touch technique of GDA segmental resection en bloc with the tumor and reconstructed with an end-to-end GDA anastomosis; in the second cases, we have decided to proceed gastroduodenal collateral preservation. When preserving these collateral pathways, we confirmed that the PHA flow remained pulsatile as an indicator that the blood flow was adequate.ConclusionCeliac axis stenosis was a rare but difficult-to-managed condition associated with pancreaticoduodenectomy. Collateral pathways management depends on variety of collateral pathways.

Four-dimensional imaging of umbilical-vein-to-right-atrium shunt in fetus with Type-I Abernethy malformation.

Videoclip S1: The four-chamber view showing dilated right atrium and significant herniation of the RFOA into the left atrium resulting in stretching of the primum septum resembling an ostium primum atrial septal defect. Videoclip S2: Four-chamber grayscale and color Doppler showing vigorous and bidirectional blood flow across the foramen ovale and reduced mitral inflow. Videoclip S3: Grayscale and color Doppler sweep from fetal upper abdomen to four-chamber view showing the umbilical vein draining directly into the right atrium. Videoclip S4: Sagittal color Doppler imaging of the fetal abdomen showing the anomalous extra-hepatic course of the umbilical vein draining directly into the right atrium. Videoclip S5: Axial four-chamber 4D STIC HD-live color silhouette volume rendering showing the extra-hepatic course of umbilical vein draining into the right atrium (hand symbol). Videoclips S6 and S7: Sagittal 4D STIC HD-live color silhouette volume rendering of the fetal abdomen showing the extra-hepatic course of the umbilical vein draining into the right atrium. The ductus venosus and intrahepatic portal venous system (right and left portal veins) were absent. Videoclip S8: Axial color Doppler examination of the fetal abdomen showing compensated liver perfusion by increased hepatic artery blood flow and end to side extrahepatic drainage of main portal vein to inferior vena cava. Videoclip S9: Oblique sagittal 4D STIC HD-live color silhouette volume rendering of the fetal abdomen showing the increased hepatic artery blood flow (hand symbol). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Full-Right Full-Left Split Liver Transplantation for Two Adult Recipients: A Single-Center Experience in China.

The most effective treatment for end-stage liver diseases is liver transplantation, which is impeded by the shortage of donor livers. Split liver transplantation (SLT) is important for addressing the donor liver shortage. However, full-right full-left SLT for two adult recipients is globally rarely conducted. This study aimed to investigate the clinical outcomes of this technique. We retrospectively analyzed the clinical data of 22 recipients who underwent full-right full-left SLT at Shulan (Hangzhou) Hospital between January, 2021 and September, 2022. The graft-to-recipient weight ratio (GRWR), cold ischemia time, operation time, length of the anhepatic phase, intraoperative blood loss, and red blood cell transfusion amount were all analyzed. The differences in liver function recovery after transplantation were compared between the left and right hemiliver groups. The postoperative complications and prognosis of the recipients were also analyzed. The livers of 11 donors were transplanted into 22 adult recipients. The GRWR ranged from 1.16-1.65%, the cold ischemia time was 282.86 ± 134.87 min, the operation time was 371.32 ± 75.36 min, the anhepatic phase lasted 60.73 ± 19.00 min, the intraoperative blood loss was 759.09 ± 316.84 mL, and the red blood cell transfusion amount was 695.45 ± 393.67 mL. No significant difference in the levels of liver function markers, total bilirubin, aspartate aminotransferase, or alanine aminotransferase between left and right hemiliver groups at 1, 3, 5, 7, 14, and 28 d postoperatively was observed (both p > 0.05). One recipient developed bile leakage 10 d after transplantation, which improved with endoscopic retrograde cholangiopancreatography-guided nasobiliary drainage and stent placement. Another developed portal vein thrombosis 12 d after transplantation and underwent portal vein thrombectomy and stenting to restore portal vein blood flow. A color Doppler ultrasound performed 2 d after transplantation revealed hepatic artery thrombosis in one patient, and thrombolytic therapy was administered to restore hepatic artery blood flow. The liver function of other patients recovered quickly after transplantation. Full-right full-left SLT for two adult patients is an efficient way to increase the donor pool. It is safe and feasible with careful donor and recipient selection. Transplant hospitals with highly experienced surgeons in SLT are recommended to promote using full-right full-left SLT for two adult recipients.

Longitudinal ultrasound imaging and network modeling in rats reveal sex-dependent suppression of liver regeneration after resection in alcoholic liver disease.

Liver resection is an important surgical technique in the treatment of cancers and transplantation. We used ultrasound imaging to study the dynamics of liver regeneration following two-thirds partial hepatectomy (PHx) in male and female rats fed via Lieber-deCarli liquid diet protocol of ethanol or isocaloric control or chow for 5-7weeks. Ethanol-fed male rats did not recover liver volume to the pre-surgery levels over the course of 2weeks after surgery. By contrast, ethanol-fed female rats as well as controls of both sexes showed normal volume recovery. Contrary to expectations, transient increases in both portal and hepatic artery blood flow rates were seen in most animals, with ethanol-fed males showing higher peak portal flow than any other experimental group. A computational model of liver regeneration was used to evaluate the contribution of physiological stimuli and estimate the animal-specific parameter intervals. The results implicate lower metabolic load, over a wide range of cell death sensitivity, in matching the model simulations to experimental data of ethanol-fed male rats. However, in the ethanol-fed female rats and controls of both sexes, metabolic load was higher and in combination with cell death sensitivity matched the observed volume recovery dynamics. We conclude that adaptation to chronic ethanol intake has a sex-dependent impact on liver volume recovery following liver resection, likely mediated by differences in the physiological stimuli or cell death responses that govern the regeneration process. Immunohistochemical analysis of pre- and post-resection liver tissue validated the results of computational modeling by associating lack of sensitivity to cell death with lower rates of cell death in ethanol-fed male rats. Our results illustrate the potential for non-invasive ultrasound imaging to assess liver volume recovery towards supporting development of clinically relevant computational models of liver regeneration.

Open hepatic artery flow with portal vein clamping protects against bile duct injury compared to pringles maneuver

Background Conventional hepatic artery and portal vein clamping strategies can prevent blood loss and ischemia-reperfusion liver injury, and such preventative measures are the key to successful liver surgery. However, ischemic-induced damage to cholangiocytes is rarely considered. Here, we aimed to investigate the effect of different hepatic inflow interruption methods on bile duct injury. Methods Forty rats were randomly grouped as sham, Pringle maneuver (PM) and hepatic arterial blood flow open (HAFO) groups. We evaluated liver histology and function in liver sections, and biliary histology, cholangiocyte apoptosis and proliferation, cytokine production, and bile composition. RNA sequencing is performed to explore possible molecular mechanisms. The Blood-biliary barrier permeability and tight junctions were analyzed by HRP injection, immunofluorescence staining and analysis of ZO-1 expression by immunoblotting. Results HAFO significantly attenuated ischemia-induced liver injury and decreased ALT, ALP, TBIL, and DBIL levels in serum. The histopathological observations showed that bile duct injury in the PM group was more serious than that in the HAFO group. The numbers of apoptotic biliary epithelial cells in HAFO-treated rat bile ducta were lower than those in the PM group. RNA-seq showed that tight junctions may be related to the mechanism underlying the protective effect of HAFO, as shown by the reduced HRP levels and increased ZO-1 and claudin-1/3 expression in the HAFO group compared to the PM group. Conclusion Compared with PM, HAFO alleviated the ischemic injury to the biliary system, which was characterized by decreased biliary epithelial cell apoptosis, reduced inflammatory responses and decreased blood-biliary-barrier permeability.

Fontan-associated liver disease current status and transplantation consideration

Fontan-associated liver disease (FALD) is one of the main complications after the Fontan procedure, manifesting mostly as liver fibrosis and even cirrhosis, with a high incidence rate and a lack of typical clinical symptoms that seriously affect patient prognosis. The specific cause is unknown, although it is considered to be associated with long-term elevated central venous pressure, impaired hepatic artery blood flow, and other relevant factors. The absence of association between laboratory tests, imaging data, and the severity of liver fibrosis makes clinical diagnosis and monitoring difficult. A liver biopsy is the gold standard for diagnosing and staging liver fibrosis. The most important risk factor for FALD is time following the Fontan procedure; therefore, it is recommended to do a liver biopsy 10 years after the Fontan procedure and to be cautious for the presence of hepatocellular carcinoma. Combined heart-liver transplantation is a recommended choice with favorable outcomes for patients with Fontan circulatory failure and severe hepatic fibrosis.

Роль комплексной эхографии печени в ранней диагностике преэклампсии и HELLP-синдрома

Objective. To study the possibilities of comprehensive ultrasound imaging with pulsed wave mode and Doppler color flow mapping in evaluation of hepatic blood flow and its compensatory capabilities in pre-eclampsia (PE) of different severity. Patients and methods. Complex liver ultrasonography combined with Doppler assessment of arterial and venous blood flow was performed in 87 pregnant women at 28–40 weeks’ gestation. The study group comprised 59 women with PE of varying severity and 12 women with HELLP syndrome. The control group included 30 women with normal pregnancy. Results. Doppler assessment of blood flow in the hepatic artery and in the maternal-placental-fetal system arteries in patients with moderate and severe PE revealed similar changes, which were manifested by elevated vascular resistance in these vessels and correlated with the severity of PE. The maximum values of pulsatility index and resistance index in the hepatic artery were observed in patients with HELLP syndrome – 1.6 ± 0.11 and 0.74 ± 0.08, respectively. Qualitative and quantitative characteristics of blood flow in the portal vein in patients with moderate PE did not statistically differ from those in the control group, while patients with severe PE and HELLP syndrome showed statistically significant disturbances of portal vein blood flow manifested by an increase in portal vein diameter and a decrease in maximum linear velocity of blood flow in the portal vein. Changes in hepatic arterial blood flow were found in patients with moderate PE in the absence of clinical and laboratory manifestations of liver dysfunction. Already in the early stages of PE, a shift of hemodynamic indices toward an increase in peripheral vascular resistance was determined. The increase in hepatic artery vascular resistance was observed in parallel with the increase of similar indices in the uterine-placental-fetal blood flow. Disturbance of blood flow in the portal vein was determined only in patients with severe PE and HELLP syndrome. Conclusion. Vascular disorders of the liver can serve as an additional diagnostic method for early diagnosis of liver involvement in the pathological process, while the signs of portal vein blood flow disorders are a criterion of extremely severe PE course, prognostically unfavorable regarding HELLP syndrome development. Key words: resistance index, liver dysfunction, hepatic artery, pre-eclampsia, hepatic blood flow, pulsatility index, HELLP syndrome

S3162 Subcapsular Hepatic Hematoma: A Rare Complication of Hemolysis, Elevated Liver Enzymes, and Low Platelet Count (HELLP) Syndrome in Pregnancy

Introduction: Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is seen in 0.1-1.0% of pregnant people overall, with the risk increased by preeclampsia. Common complications of HELLP include bleeding, disseminated intravascular coagulation (DIC), and abruptio placentae. Here we present a rare case of subcapsular liver hematoma that occurs in only 1% of HELLP patients. Case Description/Methods: A 29-year-old woman, gravida 4, para 3 with a history of preeclampsia during prior pregnancies presents with acute onset epigastric and pelvic pain for one day at 27th-week gestation. The severe, intermittent epigastric pain radiates laterally down to the pelvis and is aggravated with laying down. The review of systems and vitals were normal. Mild tenderness in the right upper quadrant (RUQ) was noted. Labs showed high ALT 233 U/L, AST 378 U/L, low platelet 108,000/microL, and high LDH 519 IU/L. The rest of the labs were normal. She underwent an emergent C-section at admission for HELLP syndrome. An ultrasound showed two complex hypoechoic hepatic mass-like areas measuring 9.3cm and 3.5 cm in the setting of hepatomegaly and diffuse hepatic steatosis suggestive of focal fatty sparing or cavernous hemangioma. Biliary sludge without cholecystitis or cholelithiasis was also noted. An MRI with IV contrast with the liver mass protocol was obtained which showed hepatic subcapsular hematoma of dimensions 24 cm x 9.2 cm x 3.9 cm at the level of the right hepatic lobe. The pain continued to worsen with a drop in hemoglobin from 12.8 gm/dl at admission to 7.1 gm/dl on day 4. IR was consulted for rupture concern and recommended CT angiography of abdomen and pelvis with and without arterial/venous phase that showed similar appearing subcapsular hematoma without an active bleed. Underwent image-guided hepatic angiography that showed large perihepatic hematoma along the right lateral abdominal wall without active contrast extravasation. Right hepatic artery embolization was done with a reduction in peripheral hepatic arterial blood flow by 25%. Later hemoglobin stabilized, liver enzymes improved, and the patient was discharged home 6 days later in a clinically stable state (Figure). Discussion: Early diagnosis of subcapsular hematoma is challenging due to nonspecific signs and symptoms but crucial for improved outcomes. Physicians should evaluate for a subcapsular hematoma in patients with HELLP and RUQ pain or hypotension. Therapeutic options for ruptured hematomas include laparotomy and hepatic artery embolization.Figure 1.: Coronal section of MRI with IV contrast (Liver mass protocol) of abdomen and pelvis demonstrates subcapsular hepatic hematoma involving the hepatic dome and right hepatic lobe approximately measuring 24 cm in craniocaudal dimension.

Assessment of liver blood flow regulation mechanism by ultrasound

The constancy of hepatic blood flow is important for several homeostatic roles. This paper reviews studies related to liver blood flow regulation mechanism. The liver has mechanism maintain a constant hepatic blood flow and compensate for portal flow changes. A reduction in portal flow leads to reduced intrahepatic distending pressure, resulting the hepatic arterial buffer response causes dilation of the hepatic artery, thus buffering the Portal flow change. This mechanism is exclusive to this specific vascular bed and offer a great illustration of multiple integrative regulation of a significant homeostatic organ. Ultrasound provides noninvasive accurate information on the liver hemodynamic and assess the flow in the hepatic artery and the portal vein specially diameter of vessels. Aim: The aim of this study was to evaluate the dual hepatic blood supply in normal individual and compared altered in the hepatic artery buffer response with chronic hepatic diseases. Materials and methods: The current review focuses on researches that evaluate the mechanisms involved in maintaining a steady hepatic arterial buffer response (HBF), such as the impact of portal blood flow on hepatic artery flow, or assessing the intrinsic regulation of hepatic arterial blood flow by measure the hepatic arterial buffer response intraoperative in patients with or without cirrhosis using an ultrasound transit-time flowmetry, or by duplex ultrasound, Moreover studies to understand the role of hepatic flow in liver atrophy.

Effects of endoscopic injection sclerotherapy for esophagogastric varices on portal hemodynamics and liver function

ObjectivesTo identify patients suitable for endoscopic injection sclerotherapy (EIS) by evaluating their portal hemodynamics and liver function.MethodsWe selected 58 patients with esophagogastric varices (EGV) and liver cirrhosis (LC) related to either hepatitis C virus (C) (n = 19), hepatitis B virus (n = 2), alcohol (AL) (n = 20), C + AL (n = 6), non-alcoholic steatohepatitis (n = 6), others (n = 3), or non-LC (n = 2). All patients underwent EIS. We measured their portal venous tissue blood flow (PVTBF) and hepatic arterial tissue blood flow (HATBF) using xenon computed tomography before and after EIS. We classified them into increased group and decreased group according to the PVTBF to identify the predictors that contribute to PVTBF increase post-EIS.ResultsLow value of indocyanine green retention at 15 min (ICG-R15), the absence of paraesophageal veins, and low baseline PVTBF/HATBF (P/A) ratio predicted increased PVTBF in the multivariate logistic analysis (odds ratio (OR) 10.46, p = 0.0391; OR 12.45, p = 0.0088; OR 13.57, p = 0.0073). The protein synthetic ability improved 1 year post-EIS in increased group. Cox proportional hazards regression identified alcohol drinking (hazard ratio; 3.67, p = 0.0261) as an independent predictor of EGV recurrence.ConclusionsPatients with low ICG-R15, low P/A ratio, and the absence of paraesophageal veins were probable predictors of PVTBF improvement post-EIS. In addition, the improvement of hepatic hemodynamics likely enhanced liver function following EIS.

Isolated cavaportal hepatic chemoperfusion using melphalan in the treatment of uveal melanoma liver metastases

A rare clinical observation of using hyperthermic isolated hepatic chemoperfusion is considered in the setting of a pathologically altered hepatic arterial blood flow in focal hepatic lesions caused by uveal melanoma metastases. The technical feasibility and safety of performing hyperthermic isolated hepatic chemoperfusion through the portal vein against the background of the altered hepatic arterial bed were demonstrated.