Opacification Of Hepatic Veins Research Articles

Combined Protein C and Protein S Deficiency Presenting as Primary Budd-Chiari Syndrome in a 23-Year-Old Filipino Woman

Budd - Chiari Syndrome (BCS) is an uncommon hepatic vascular disorder affecting approximately 1 in every 2.5 million people worldwide often presenting as a sub - acute to chronic hepatic failure. Primary BCS, an even rarer subset of BCS, is described as the presence of intrinsic hepatic venous compression and occurs in 1 in every 6 million population. Primary BCS has often been attributed to hematologic disorders, more commonly myeloproliferative disorders, such as Polycythemia Vera, and in fewer cases, inherited thrombophilias, such as Protein C (PC) and Protein S (PS) deficiency, of which such cases are noted to be exceedingly rare. The authors describe a case of a 23-year-old Filipino female who was admitted on multiple occasions at a tertiary private hospital for over the course of a year, initially for complaints of epigastric pain and increasing abdominal girth. A review of the patient's past medical history was largely unremarkable with no familial cancers nor hepatitis infections noted, with the absence of oral contraceptive use. Initial workup consisted of serum chemistries and serology which yielded non specific and unremarkable findings. A series of imaging studies were then conducted - an initial screening abdominal ultrasound revealed an unremarkable biliary system and non specific structural hepatic parenchymal changes. A biopsy of the liver was taken revealing non specific venous congestion. The patient was then subjected to serial abdominal CT scans over the course of 6 months, which finally revealed complete absence of opacification of hepatic veins with a pattern suspicious for the presence of a thrombus, further mottled enhancement of the liver and splenic parenchyma due to congestion, all of which werefindings compatible with a Budd - Chiari Syndrome. Referral to a hematologist was carried out with thrombophilia workup done revealing decreased Protein C (Results: 32.2%,[Ref. Range: 70-140%]) and decreased Protein S (Results: 56%[Ref. Range: 60-140%]) results. The patient was then appraised of the eventual need for hepatic transplantation with a DIPS procedure contemplated.However, the patient eventually died from complications. This clinical case report documents an ethnic Filipino patient diagnosed with Primary BCS secondary to combined PC and PS deficiency, a subset of BCS that is both extremely rare and is not known to have previously occured in this population group. The authors cite this case to highlight both the need for diagnostic suspicion in cases of fulminant hepatic failure in the young and intend for it to be an early contribution to potential population based studies on BCS.Figure 1Figure 2

Imaging Predictors of Elevated Lung Shunt Fraction in Patients Being Considered for Yttrium-90 Radioembolization

PurposeTo identify imaging findings associated with elevated lung shunt fraction (LSF) in patients being considered for yttrium-90 (90Y) radioembolization. Materials and MethodsDuring the period 2009–2014, 152 consecutive patients underwent planning hepatic arteriography with technetium-99m (99mTc) macroaggregated albumin (MAA) injection. Computed tomography (CT) or magnetic resonance imaging performed before the procedure for each patient was assessed for hepatic vein (HV) tumor thrombus or occlusion from external compression by tumor. When imaging was a multiphase CT scan (117 patients), the arterial phase was evaluated for evidence of early HV opacification (relative to unaffected HVs), indicating hepatic venous shunting. These factors were correlated with LSF determined by 99mTc-MAA imaging. ResultsMedian LSF was 6.7% (range, < 0.1%–71%), significantly higher for HCC (8.0% vs 6.3% for other tumors, P = .048). Larger tumor size was associated with higher LSF in univariate analysis (P = .001). There was high interobserver agreement for determining hepatic venous shunting (97%, κ = 0.847), which was associated with higher LSF (P < .001; 78% sensitivity, 93% specificity). Of 5 cases of HV tumor thrombus, all had high (> 20%) LSF (P < .001). HV occlusion was also associated with higher LSF (P = .039). Multivariate analysis confirmed that early HV opacification and either HV tumor thrombus or occlusion were associated with higher LSF. ConclusionsEarly HV opacification and HV tumor thrombus or occlusion on cross-sectional imaging performed before radioembolization are associated with elevated LSF, which may contraindicate or limit the dose delivered in 90Y radioembolization. This information could be helpful during patient counseling for anticipating the most appropriate mode of liver-directed therapy.

Abstract No. 530 - Hepatic vein imaging findings associated with elevated lung shunt fraction in patients being considered for yttrium-90 radioembolization

No. 530 Hepatic vein imaging findings associated with elevated lung shunt fraction in patients being considered for yttrium-90 radioembolization O.G. Olorunsola, N. Fidelman, S. Behr, M. Kohi, K. Kolli, A.G. Taylor, R. Tong, J. LaBerge, R.K. Kerlan, Jr.; Radiology, University of California, San Francisco, San Francisco, CA Purpose: To identify hepatic vein (HV) morphologic and flow abnormalities associated with elevated lung shunt fraction (LSF) determined by Technetium-99m (Tc) macroaggregated albumin (MAA) imaging in patients being considered for yttrium-90 (Y) radioembolization. Materials and Methods: This single-center retrospective study included 152 consecutive patients who underwent mapping arteriography with Tc-MAA injection from 2009 to 2014 (50 with hepatocellular carcinoma [HCC], 102 with other tumors; 103 men, 49 women; median age 62). Each preprocedure imaging examination (CT or MRI) was assessed for HV tumor thrombus or HV occlusion from external compression by tumor. In addition, two readers separately evaluated the mapping arteriograms and the arterial phase from multiphase CTs (117 patients) for evidence of early HV opacification (relative to unaffected HVs), with consensus determined by a third reader. These factors were correlated with LSF categories (low [o10%], intermediate [10-20%], and high [420%]) determined by Tc-MAA imaging using uniand multivariate analysis. Results: Median LSF was 6.7% (range 0-71%; 74.3% low, 18.4% intermediate, 7.2% high). There was high interobserver agreement for determining early HV opacification (97%, kappa1⁄40.847). Early HV opacification at CT and angiography each were associated with higher LSF category (po.001 for both modalities). This finding at CT was 78% sensitive and 93% specific for predicting high (420%) LSF (64% sensitive and 95% specific at angiography). Of five cases of HV tumor thrombus (3 HCC, 2 other tumors), all had high (420%) LSF (po.001). HV occlusion due to external tumor compression was also associated with higher LSF category (p1⁄4.04). Multivariate analysis confirmed that early HV opacification at CT and either HV tumor thrombus or occlusion were associated with higher LSF category. Conclusion: Early HV opacification and HV tumor thrombus or occlusion on pre-procedure cross-sectional imaging are associated with elevated LSF, which may contraindicate or limit the dose delivered in Y radioembolization. This information could be helpful during patient counseling for anticipating the most appropriate mode of liver-directed therapy.

Abstract No. 385 - Clinical correlation between hepatic vein opacification and hepatopulmonary shunt fraction for 90Y evaluation

Purpose Hepatopulmonary shunt (HPS) fraction ≥20% is one of the occasional criteria preventing 90Y therapy. This study aimed to identify if there is clinical correlation between hepatic vein (HV) opacification and HPS during initial evaluation for 90Y therapy. Materials and Methods We collected 90Y candidates from 2004 to 2011. Patient’s underlying disease, imaging, arteriograms, and HPS calculations were retrospectively reviewed. If the HV was opacified during visceral arteriogram, the time between contrast injection and HV visualization was recorded. Statistical analysis with unpaired t-test compared the time of HV visualization in patients with and without an elevated HPS fraction. Results Total of 151 initial 90Y work up studies in 149 patients were included. The diagnoses included 75 HCC, 53 neuroendocrine tumor metastases, 14 colorectal metastases, 3 cholangiocarcinoma and 4 other metastases. Imaging revealed multifocal disease(n=117, 77%), bilobar disease(102, 68%) and macrovascular invasion (41, 27%). Macrovascular invasions included 4 HV and IVC, 2 HV and portal vein (PV), 1 IVC, 11 main PV, 1 right main PV, 16 right PV branch, 2 left main PV and 4 left PV branch. Mean maximum tumor diameter was 6.9±3.6 cm. Twenty-nine patients (19%) did not complete Y90 therapy; due to (18) high HPS, (5) unfavorable vascular anatomy, (2) declining liver function, (1) gastric uptake, (1) extrahepatic tumor, (1) poor tumor localization and (1) misdiagnosis. HV opacification was noted in 15 studies. Nine out of 15 studies showed HPS fraction ≥20%. PPV and NPV of HV opacification as a predictor of high HPS fraction were 60% and 94%. Average time until visualized HV in patients whom HPS fraction ≥20% and Conclusion The results demonstrated that visualization of the HV during initial arteriogram alone may not be sufficient to predict high HPS. We found that HV opacifications were seen on arteriograms earlier in the patients with high HPS (≥20%) than the patients with shunt

Abstract No. 367: Hepatic vein opacification as an early predictor of pulmonary shunt fraction in radioembolization cases

To determine if early visualization of the hepatic venous return in the arterial phase injections of Y90 mapping arteriograms correlates with high pulmonary shunt fraction and screening failures in radioembolization cases.

Hepatic Hereditary Hemorrhagic Telangiectasia

A 31-year-old woman underwent an exploratory laparoscopy for evaluation of chronic pelvic pain. She was found to have mild endometriosis; however, an incidental finding was that intraoperatively the liver was noted to be abnormal, with nodularity and discrete telangiectasias noted throughout the entire surface (Figure A). A triphasic computed tomography scan of the abdomen showed heterogeneous enhancement of hepatic parenchyma, premature opacification of hepatic veins (striped arrows), and dilated tortuous arterial branches (solid arrow) in the arterial phase (Figure B).

Clinical Relevance of Retrograde Inferior Vena Cava or Hepatic Vein Opacification During Contrast-Enhanced CT

The purpose of this investigation was to explore the clinical relevance of retrograde inferior vena cava or hepatic vein opacification during contrast-enhanced CT. We retrospectively identified 127 patients who underwent contemporaneous contrast-enhanced CT of the chest or abdomen and echocardiography. On CT, the presence of retrograde inferior vena cava or hepatic vein opacification and the rate of IV contrast injection (> 3 mL/sec, high; < or = 3 mL/sec, low) were recorded. On echocardiography, the presence of tricuspid regurgitation, pulmonary hypertension, or right ventricular systolic dysfunction was recorded. Retrograde inferior vena cava or hepatic vein opacification was more common in studies performed with a high rather than a low contrast injection rate (28/56 vs 6/71 patients, respectively; p < 0.01). This finding was 31% sensitive (5/16) and 98% specific (54/55) for right-sided heart disease at low contrast injection rates, and 81% sensitive (17/21) and 69% specific (24/35) at high injection rates. Multivariate logistic regression models showed that high injection rate, tricuspid regurgitation, pulmonary hypertension, and right ventricular systolic dysfunction were independent predictors of retrograde inferior vena cava or hepatic vein opacification (p < 0.05 for each). Retrograde opacification of the inferior vena cava or hepatic veins on CT is a specific but insensitive sign of right-sided heart disease at low contrast injection rates, but the usefulness of this classic sign decreases with high injection rates. This realization is important because many centers increasingly use high-injection-rate CT.

The prevalence and variations of inferior right hepatic veins on contrast-enhanced helical CT scanning

Purpose: To present the prevalence and variations of inferior right hepatic veins (IRHVs) on contrast-enhanced helical computed tomography (CEHCT) scans. Materials and methods: The routine abdominal CEHCT scans of 349 patients were reviewed. Three hundred and eight patients (88.2%) were included in the study. Of the 349 patients, 41 (11.8%) were excluded from the study because of improper opacification of hepatic veins and right hepatic lobe lesions which made difficult the optimal visualization and assessment of IRHVs. The mean age of 308 patients was 43 years (range 3–97 years). One hundred and forty-three patients (46.4%) were men and 165 (53.6%) women. Scans were examined whether the IRHVs were demonstrated or not and classified according to their numbers, levels, diameters, and joinings to inferior vena cava (IVC). Results: Of the 308 patients, 65 (21.1%) had one or two IRHVs. Fifty-four patients (83.1%) had only one IRHV and 11 (16.9%) patients had two. More than two IRHVs were not seen in any patient. Eight (72.7%) of 11 double IRHVs joined the IVC at the same level and others (27.3%) did not. There was no truncal opening to the IVC. In five patients (7.7%) the IRHV were large (≥0.5 cm). Conclusion: The presence of IRHVs is common and routine CEHCT scanning is efficacious in assessment of IRHVs.

Opacification of Hepatic Veins During Celiac and Hepatic Angiography

When the hepatic veins are opacified during celiac or hepatic arteriography, a hemodynamic abnormality in the hepatic arterial or portal venous system should be suspected. The hepatic veins were opacified in only 3 of 50 patients with normal hepatic and portal hemodynamics. Hepatic veins were frequently opacified, however, when pancreatic masses compressed the splenic or portal vein and when vascular tumors caused increased hepatic arterial blood flow. Although hepatic arterial blood flow is often increased in cirrhosis, hepatic veins were not opacified in any of the 33 cases, presumably because of a hepatic venous blockage peculiar to cirrhosis.