Main Portal Vein Research Articles

OBEZ ADOLESANLARDA YAĞLI KARACİĞER HASTALIĞININ PORTAL VEN AKIMINA ETKİSİ

Objective
 The increase in obesity in children has caused
 nonalcoholic fatty liver disease to become the most
 important chronic liver disease in the pediatric age
 group. In this study, we aimed to evaluate the portal
 diameter and blood flow velocity in obese children with
 fatty liver (NAFLD) and to compare them with normal
 healthy children.
 Material and Method
 71 obese adolescent patients aged 10-18 years were
 divided into two groups (NAFLD group and non-
 NAFLD group) according to the presence of elevated
 transaminases and the presence of hepatosteatosis
 on ultrasound. 30 healthy adolescents were included
 in the study as the control group. Blood samples
 were taken from each patient for fasting glucose,
 insulin, transaminases, and thyroid functions. Insulin
 resistance was calculated using the HOMA index.
 Portal vein measurements were performed from the
 main portal vein before bifurcation.
 Results
 The portal vein diameter (8.5 ± 0.9 mm) of the NAFLD
 group was statistically significantly wide compared
 to both the control group (7.8 ± 2.0 mm) and the
 non-NAFLD obese group (7.6 ± 1.1 mm) (p= 0.004)
 and (p= 0.002). There was no significant difference
 between the non-NAFLD obese group and the control
 group (p=0.460, p=0.214). There was no significant
 difference between the groups in terms of portal vein
 Vmax, Vmin, RI, S/D. Although there was no difference
 in portal vein diameter in the obese groups classified
 according to insulin resistance, Vmax (33.9 ± 10.3 and
 28.6 ± 10.6 cm/sec, p= 0.03) and Vmin (24.8 ± 6.2 and
 20.5 ± 5.5 cm/sec) were significantly different in the
 insulin resistance group.
 Conclusion
 In this study, it was determined that portal vein diameter
 and flow velocities (Vmax and Vmin) increased in
 obese adolescents with NAFLD. Thus, we suggest
 that resistance develops in hepatic venous flow due
 to hepatic portal vein steatosis, especially in obese
 patients with insulin resistance in adolescence. This
 finding suggests that when fatty liver continues, portal
 diameter will increase in adulthood, leading to portal
 hypertension.

Morphological Investigation of the Veins and Bile Vessels of Rabbit Liver

The focus was to investigate the anatomical specifics of v. portae, vv. hepaticae and ductus choledochus by corrosion. We investigated 10 sexually mature, clinically healthy New Zealand White rabbits, 8 months old, weighing 2.8 kg to 3.2 kg. To determine the veins and bile vessels, a cold-curing acrylic-based plastic (Duracryl +) was used. The main portal vessel was an intraorganic continuation of v. portae, after its branching into caudate lobe. The main portal vein was divided into v. portae dextra and v. portae sinistra, when entering lobus hepatis dexter and lobus hepatis sinister. V. portae sinistra caudalis was a branch of v. portae sinistra. The venous drainage of the rabbit liver in was carried out by v. hepatica sinistra caudalis, v. hepatica sinistra, v. hepatica dextra, v. hepatica media and venous vessel in lobus caudatus. V. hepatica sinistra and v. hepatica media had a common origin and took blood from lobus hepatis sinister medialis. V. hepatica dextra drained lobus hepatis dexter. V. hepatica sinistra caudalis was a direct tributary of the caudal vena cava. Ductus hepaticus communis was well developed and collected the bile from the main bile duct. Ductus hepaticus dexter drained lobus hepatis dexter and evacuated the bile into the main bile duct. Ductus hepaticus sinister caudalis flowed directly into ductus hepaticus communis. Ductus hepaticus sinister passed into the main bile duct.

Association of C-type lectin-like receptor 2 and galectin-1 with portal vein system thrombosis in HBV-related liver cirrhosis.

Hepatitis B virus (HBV) infection is the most common cause of liver cirrhosis. Portal venous system thrombosis (PVST) is a major complication of liver cirrhosis. Recently, it has been shown that C-type lectin-like receptor 2 (CLEC-2) and galectin-1 participate in the activation and aggregation of platelets, thereby promoting the development of thrombosis. This cross-sectional study aims to evaluate the association of serum CLEC-2 and galectin-1 levels with PVST in patients with HBV-related liver cirrhosis. Overall, 65 patients with HBV-related liver cirrhosis were included, of whom 23 had PVST and 42 did not have. Serum CLEC-2 and galectin-1 levels were measured using enzyme-linked immunosorbent assay kits. PVST was assessed by contrast-enhanced computed tomography and/or magnetic resonance imaging scans. Subgroup analyses were conducted according to the degree and location of PVST. Patients with PVST had significantly higher serum CLEC-2 (p = 0.006) and galectin-1 (p = 0.009) levels than those without. Patients with partial/complete PVST or fibrotic cord (p = 0.007; p = 0.002), but not those with mural PVST (p = 0.199; p = 0.797), had significantly higher serum CLEC-2 and galectin-1 levels than those without PVST. Patients with superior mesenteric vein thrombosis had significantly higher serum CLEC-2 (p = 0.013) and galectin-1 (p = 0.025) levels than those without PVST. Patients with main portal vein thrombosis had higher serum CLEC-2 (p = 0.020) and galectin-1 (p = 0.066) levels than those without PVST, but the difference in serum galectin-1 level was not significant between them. Serum CLEC-2 and galectin-1 levels may be associated with the presence of PVST in HBV-related cirrhotic patients, but this association should be dependent upon the degree of PVST.

Portal Venous Pulsatility Index: A Novel Biomarker for Diagnosis of High-Risk NonAlcoholic Fatty Liver Dise

Objective: To assess the accuracy of portal vein pulsatility (VPI) for non-invasive diagnosis of high-risk non-alcoholic fatty liver disease (NAFLD).
 Study Design: Cross-sectional study.
 Place and Duration of Study: Pakistan Institute of Medical Science, Islamabad Pakistan, from Jan to May 2022.
 Methodology: Duplex Doppler ultrasound was used to examine the main portal vein in patients with a biopsy-proven Nonalcoholic fatty liver disease (NAFLD) diagnosis. Patients were evaluated by Doppler ultrasonography after fasting for four hours in accordance with standard methodology. The maximum (Vmax) and minimum (Vmin) blood velocities in the portal veins were measured using the spectral waveform. 
 Results: Out of 240 NAFLD patients, 102(42.50%) were males, and 138(57.50 %) were females. According to the Non-alcoholic Steatohepatitis clinical research network (NASH CRN) scoring system, 95(39.58%) patients had F0 disease, 80(33.33%) had F1, 30(12.5%) patients F2, 24(10%) patients had F3 and 11(4.58%) had F4. 50(53.76%) patients in the low-risk group and 43(46.24%) patients in the high-risk group had diabetes. Of 102 males, 73(71.56%) had low risk, and 29(28.44%) had high risk. While out of 138 females, 79(57.24%) females had low risk, and 59(42.76%) females had a high risk of NAFLD. Venous pulsatility index, NAFLD fibrosis score, FIB-4, BARD score, and APRL had statistically significant differences (p<0.05).
 Conclusion: Venous pulsatility index is a reliable marker for detecting high-risk NAFLD. It is a readily available non-invasive investigation and can be reliably used as a screening tool for detecting NAFLD in high-risk patients, avoiding invasive investigation.

Successful Liver Transplantation From a Deceased Donor With Congenital Extrahepatic Portosystemic Shunt: A Case Report

Congenital extrahepatic portosystemic shunt belongs to a family of rare vascular abnormalities. We present a case of congenital extrahepatic portosystemic shunt occurring in a 42-year-old man who died of cerebral hemorrhage and donated his liver. His portal vein angiography revealed that the main portal vein communicated with the left renal vein, suggesting a portosystemic shunt. A liver biopsy showed that the liver tissue structure was normal. His liver was not involved, and the transplantation was carried out smoothly. The recipient recovered smoothly, and the function of the transplanted liver was good.

Addition of transarterial chemoembolization improves outcome of tyrosine kinase and immune checkpoint inhibitors regime in patients with unresectable hepatocellular carcinoma.

Transarterial chemoembolization (TACE) is the standard treatment for hepatocellular carcinoma (HCC); the value of its combination with systemic therapy is worthy of further exploration. This study aimed to investigate the efficacy and safety of TACE combined with tyrosine kinase inhibitor (TKI) and immune checkpoint inhibitor (ICI) in the treatment of unresectable HCC. In this retrospective observational, single-center study, 147 patients with unresectable HCC were divided into a TACE group (n=98) and a non-TACE group (n=49) based on whether TACE was performed during TKI plus ICI therapy. The survival outcomes and adverse events (AEs) of the two groups were compared. Data from patients with unresectable HCC who received TKI plus ICI treatment between July 2017 and April 2020 were collected. The median intrahepatic tumor size was 8.7 cm [interquartile range (IQR), 5.9-12.4 cm]. At data cut-off, overall survival (OS) of the TACE group was significantly longer than that of the non-TACE group (19.5 and 10.8 months, respectively, P=0.005). In the high-risk cohort (with main or contralateral portal vein tumor thrombi and/or bile duct invasion and/or a tumor burden >50% of liver), the OS of the TACE group was still longer than that of the non-TACE group (14.9 and 8.7 months, respectively, P=0.031). Major AEs were tolerated in both groups, and there was no significant difference in their incidence (34.7% and 30.6%, respectively, P=0.621). TACE treatment combined with TKI plus ICI regime resulted in longer OS than treatment with TKI plus ICI alone for patients with unresectable HCC.

Do the stent blind insertion into the main portal vein (MPV) and stent diameter influence the surgical outcome of the transjugular intrahepatic portosystemic shunt (TIPS)?

Transjugular intrahepatic portosystemic shunt (TIPS) surgery is a clinical intervention to treat portal hypertension (PH) by deploying a covered stent to establish a shunt path for the portal vein (PV) system, and proper surgical strategy is of great importance to balance the shunt effect and the risk of complications. To understand the clinical strategies of the stent blind insertion and stent selection in clinic, this study investigated the effects of varying stent insertion positions and diameters on the PV hemodynamics and the shunt effect by computational fluid dynamics (CFD) analysis of five post-TIPS subjects. The results showed that the successful TIPS surgeries of the five PH subjects were confirmed by quantifying their pressure drops. The stent insertion positions at the main portal vein (MPV) slightly affected the clinically concerned hemodynamic indexes (i.e., MPV pressure, stent-outlet velocity) and the shunt index (SI). This indicated that the position of the stent going into the MPV may not need to be deliberately selected. Moreover, the covered stents with 6 mm and 8 mm diameters slightly influenced the hemodynamics as well, but the large-diameter stent better improved the shunt effect compared to the small-diameter one. Despite this, the 6 mm stent was suggested thanks to the higher risk of the hepatic encephalopathy (HE) observed in clinic, which indicated the excessive shunt of the 8 mm stent. The current work revealed the effects of different TIPS strategies on the surgical outcome, and could be useful for potential clinical practices.

A systematic review and meta-analysis of portal vein morphometry in pediatric and adult populations: Drawing the line between normal and abnormal findings

PurposeThe morphometry of the hepatic portal vein is of clinical importance, particularly in pre-operative assessments, surgical management, and diagnoses of liver conditions. This systematic review and meta-analysis aimed to characterize the morphometry of the normal portal vein in both pediatric and adult patients. MethodsThe study, conducted using the PRISMA guidelines and registered with PROSPERO, utilized the MEDLINE, EMBASE, SCOPUS and Web of Science databases up to May 2020, and updated to May 2023. All studies reporting extractable data on diameter, length, and cross-sectional area (CSA) of the main, left, and right portal veins (PV, LPV, RPV, respectively) were included. The AQUA Tool was used to assess the quality of the included studies. Data analysis included subgroup analyses based on geographical location, sex, age, and imaging modality. ResultsA total of 122 studies with 11,637 subjects were eligible for inclusion. Overall, the pooled mean diameter of the PV (PVD) was 10.09 mm (95% CI: 9.56–10.62). Significant differences in diameter were found between pediatric (6.60 mm; 95% CI: 5.38–7.82) and adult (10.72 mm; 95% CI: 10.25–11.19) subjects. Additionally, there was a significantly larger PVD measurement from computed tomography (CT) than other imaging modalities: CT, 13.28 mm (95% CI: 11.71–14.84); magnetic resonance imaging (MRI), 10.50 mm (95% CI: 9.35–11.66) and ultrasound (US), 9.81 mm (95% CI: 9.47–10.16). The mean diameters of the LPV and RPV were 8.27 mm (95% CI: 6.78–9.77) and 8.33 mm (95% CI: 6.70–9.95), respectively. Mean PV length in adults is 48.63 mm (95% CI: 35.63–61.64). Mean CSA of the PV was 1.09 cm2. ConclusionsThe study obtained aim to improve the understanding of portal vein anatomy, especially with relevance to surgical interventions of the liver in both pediatric and adult patients. Measurements from ultrasound imaging closely approximates the generated pooled PVD mean for pediatric and adult patients. CT imaging, however, significantly exceeded the established 13 mm threshold for adults. For pediatric patients, a threshold of 8 mm is proposed as a diagnostic upper limit for a normal PVD. Although not significant, the PVD decreased from the portal confluence towards its bifurcation.

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

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

Assessment of hepatic veno-occlusive disease/sinusoidal obstruction syndrome using different scanning approaches for the ultrasonographic evaluation of portal vein blood flow and hepatic artery resistive index in hematopoietic stem cell transplant recipients.

Sinusoidal obstruction syndrome (SOS) is a fatal complication of hematopoietic stem cell transplantation (HSCT). Previously, we established a scoring system (Hokkaido ultrasound-based scoring system-10; HokUS-10) comprising 10 ultrasound parameters for SOS diagnosis. In HokUS-10, the portal vein time-averaged flow velocity (PV TAV) and hepatic artery resistive index (HA RI) are measured using subcostal scanning. However, measurement errors and delineation difficulties occur. Therefore, we aimed to prospectively evaluate PV TAV and HA RI measurements obtained via intercostal scanning as an alternative method to subcostal scanning and determine their cutoff values. HokUS-10 was administered before and after HSCT. PV TAV and HA RI were measured on subcostal and right intercostal scans. We performed 366 scans on 74 patients. The median value (range) of PV TAV in the main and right portal veins was 15.0cm/s (2.2-49.6cm/s) and 10.5cm/s (1.6-22.0cm/s), respectively. A low correlation was observed between the two values (r = 0.39, p < 0.01). The highest diagnostic value of the right portal vein was less than 8.0cm/s. The median value (range) of HA RI in the proper and right hepatic arteries was 0.72 (0.52-1.00) and 0.70 (0.51-1.00), respectively. A strong correlation was observed between the two values (r = 0.65, p < 0.01). The highest diagnostic value of the right HA RI was 0.72 or higher. Quantitative measurement of PV TAV and HA RI using intercostal scanning can be appropriately performed as an alternative method to using subcostal scanning.

Early Onset Portal Hypertension Due to Silent Extensive Portal Vein Thrombosis Following Umbilical Vein Catheterization

Background: Umbilical vein catheterization is a routine procedure in neonatal intensive care units. This invasive procedure, though easy and useful, can result in disastrous complications. Clinical Description: A 28 day old baby boy presented with umbilical sepsis along with multiple skin abscesses. He had a history of double volume exchange transfusion for Glucose 6 Phosphate deficiency induced hyperbilirubinemia, during the postnatal period. Ultrasound whole abdomen done to look for intra-abdominal abscesses revealed extensive portal vein thrombosis including the main portal vein and its branches with cavernoma formation. Upper gastrointestinal endoscopy revealed Grade II esophageal varices suggestive of the development of portal hypertension. Management and Outcome: Baby was started on subcutaneous enoxaparin which continued for 3 months. Follow up ultrasound showed complete obliteration of portal vein, replaced by cavernomas with development of grade II esophageal varices seen on upper gastrointestinal endoscopy. Conclusion: This case highlights how umbilical vein catheterization in the neonatal period can lead to catastrophic complications such as obliteration of the entire main portal vein and its branches, formation of portal cavernoma, portal hypertension, and esophageal varices, all of which can develop silently, at a very early age.

Diagnostic and monitoring value of ultrasound, computed tomography angiography, and portal venography in surgical ligation of congenital extrahepatic portosystemic shunts

PurposeTo investigate the diagnostic and monitoring value of ultrasound (US), computed tomography angiography (CTA), and portal venography in surgical ligation of congenital extrahepatic portosystemic shunts (CEPS) in children. MethodsWe retrospectively analysed different imaging examinations of 15 children with CEPS. Development of the portal vein before shunt occlusion, shunt location, portal vein pressure, main symptoms, diameter of the main portal vein, and location of secondary thrombosis after shunt occlusion were recorded. Final classification diagnosis was made by portal venography after shunt occlusion, and consistency with other imaging examinations in diagnosing development of the portal vein was calculated using Cohen’s kappa. ResultsCompared with portal venography after shunt occlusion, US, CTA, and portal venography before shunt occlusion had poor consistency in showing the development of hepatic portal veins (Kappa value 0.091–0.194, P > 0.05). Six cases developed portal hypertension (40–48 cmH2O) during the temporary occlusion test, and US showed that portal veins gradually expanded after shunt ligation. Eight patients with haematochezia had inferior mesenteric vein (IMV)-iliac vein (IV) shunts. After surgery, secondary IMV thrombosis was observed in eight cases and secondary splenic vein thrombosis in four cases. ConclusionPortal venography with occlusion testing is very important to accurately evaluate the development of the portal vein in CEPS. The portal vein needs to expand gradually, and partial shunt ligation surgery is necessary in cases diagnosed as portal vein absence or hypoplasia before occlusion testing to avoid severe portal hypertension. After shunt occlusion, US is effective in monitoring portal vein expansion, and both US and CTA can be used to monitor secondary thrombi. IMV-IV shunts can cause haematochezia and are prone to secondary thrombosis after occlusion.

Hepatic Artery and Portal Vein Hemodynamics in Nonalcoholic Fatty Liver Disease in Adult Saudi Patients: A Doppler Ultrasound Study

Background: Nonalcoholic fatty liver disease (NAFLD) is a growing public health problem. With the growing severity of NAFLD, there are considerable alterations in the hemodynamics of the hepatic circulation that might affect the prognosis of the condition, according to numerous reports written to assess the vasculature of the liver in patients affected with fatty liver disease. The aim of the study was to examine hemodynamic alterations in the hepatic artery (HA) and portal vein (PV) in NAFLD patients and determine how they relate to the severity of the condition, and to classify patients into various categories of NAFLD and connect the results to liver size and body mass index (BMI). Methods and Results: One hundred and six diagnosed NAFLD patients who attended the Imaging department at King Fahad Hospital from December 2019 to January 2020 were retrospectively studied. The mean age of the patients was 45.75±15.6 years, with a range of 10-79 years. The patients were examined by a TOSHIBA Xario, SSA-660A ultrasound system utilizing a multifrequency convex transducer (2–5 MHz) for all sonographic exams. B-mode assessed the liver parenchyma, and spectral Doppler estimated the HA and PV. The US appearance of hepatosteatosis, according to the severity of echogenicity, was graded (0-3). Most participants were asymptomatic (76.4%), and diabetes and diabetes with hypertension were diagnosed in 12.3% and 11.3%, respectively. It was observed that grade 1 hepatosteatosis was more prevalent than the other grades: 54 cases versus 41 cases for grade 2 and 11 cases for grade 3. The mean values of liver size and BMI in grade 3 were higher than in grade 1 (P=0.0033 and P=0.0054, respectively). A Spearman test found that the liver size (R=0.19, P=0.05) and BMI (R=0.26, P=0.01) had weak positive, but statistically significant, correlations with the severity of the hepatosteatosis grade. Doppler indices of the HA and PV in NAFLD patients did not differ significantly in hepatosteatosis grades 1-3. Only the PSV and EDV of the main PV showed a significant decrease in the hepatosteatosis grade 2 compared to grade 1 (P=0.0065 and P=0.0234, respectively). Despite the insignificant differences, the Doppler flow parameters of the HA decreased with the severity of hepatic steatosis; for example, the hepatic artery resistive index (HARI) was 0.77±0.16 in grade 1, 0.72±0.16 in grade 2, and 0.75±0.10 in grade 3, respectively. The hepatic artery pulsatility index (HAPI) was 1.62±49 in grade 1, 1.63±.68 in grade 2, and 1.74±0.77 in grade 3. There was also a trend toward a decrease in PSV and end-diastolic velocity (EDV) of HA with the severity of hepatosteatosis. Conclusion: The severity of hepatic steatosis is significantly correlated with liver size and BMI. The blood flow parameters of PV and HA decrease with the severity of hepatic steatosis except for the pulsatility index.

Ultrasound-Guided Human Islet Transplantation: Safety, Feasibility, and Efficacy Analysis

We aimed to analyze the safety, feasibility, and efficacy of human islet transplantation (IT) using ultrasound (US) throughout the entire procedure. A total of 22 recipients (18 males; mean age 42.6±17.5years) with 35 procedures were retrospective included. Under US guidance, percutaneous transhepatic portal catheterization was successfully performed through a right-sided transhepatic approach, and islets were infused into the main portal vein. Color Doppler and contrast-enhanced ultrasound were used to guide the procedure and monitor the complications. After infusion of the islet mass, the access track wasembolized by embolic material. If hemorrhage persisted, US-guided radiofrequency ablation (RFA) was performed to stop bleeding. Factors that could affect the complication were analyzed. After transplantation, primary graft function was evaluated with a β-score 1month after the last islet infusion. The technical success rates were 100% with a single puncture attempt. Six (17.1%) abdominal bleeding episodes were immediately stopped by US-guided RFA. No portal vein thrombosis were encountered. Dialysis (OR (Odd Ratio): 32.0; 95% CI: 1.561-656.054; and P=.025) was identified as a significant factor associated with bleeding. Primary graft function was optimal in eight patients (36.4%), suboptimal in 13 patients (59.1%), and poor in one patient (4.5%). In conclusion, whole-procedure US-guided IT is a safe, feasible, and effective method for diabetes. Complications are either self-limiting or manageable with noninvasive treatment.

The Fetal Liver Afferent Venous Flow Volumes in Fetuses With Appropriate for Gestational Age Birth Weight.

The present study aimed: 1) to simultaneously investigate the relationship between blood flow volumes of the two fetal liver afferent venous systems of normally appropriate for gestational age newborns. 2) to establish the normal reference range centiles values that will serve as a basis for future investigations. A cross-sectional, prospective study of singleton low obstetric risk pregnancies. Doppler examination included the measurement of the umbilical and the main portal vein vessels' diameters and time-averaged maximum velocity. The absolute and per kilogram of estimated fetal weight flow volumes and the ratio between the placental and portal blood volume flow were calculated from these data. Three hundred and sixty-three pregnant women were included in the study. The umbilical and portal flow volumes' capacity to provide blood flow per kilogram of fetal weight, in the period of maximum fetal growth, was diverse. The placental flow decreased continuously from a mean of 121.2 mL/min/kg at the 20th week of gestation to 64.1 mL/min/kg at the 38th week of gestation. Meanwhile, the portal flow volume per kilogram of fetal weight increased from 9.6 mL/min/kg at 32 weeks of gestation to 10.3 at the 38th week of gestation. This resulted in a decrease in the umbilical to portal flow volume ratio from 13.3 to 9.6 during this period. Our results indicate that in the period of maximum fetal growth, the placental/portal ratio diminishes emphasizing the portal flow's predominance with low oxygen and nutrient supply to the liver.

Hepatic artery infusion chemotherapy combined with donafenib and camrelizumab in patients with unresectable hepatocellular carcinoma presenting portal vein tumor thrombus: A prospective, single-arm study.

e16134 Background: Rational and effective treatment strategies for patients with unresectable hepatocellular carcinoma (uHCC) presenting portal vein tumor thrombus (PVTT) are lacking, and hepatic artery infusion chemotherapy (HAIC) combined with tyrosine kinase inhibitors and immune checkpoint inhibitors could be an effective therapy. Herein, we evaluated the efficacy and safety of HAIC combined with donafenib and camrelizumab in patients with uHCC presenting PVTT. Methods: This prospective, single-arm, single-center study enrolled patients with uHCC presenting PVTT (distant metastases were allowed), BCLC stage C, Child-Pugh scores ≤ 7, ECOG PS ≤1, and no previous local or systemic treatment. Patients received mFOLFOX6-HAIC (every 3 weeks, no more than 6 cycles), followed by peroral donafenib (200 mg BID every day) and intravenous camrelizumab (200 mg every 3 weeks). The primary endpoint was the objective response rate (ORR; per RECIST1.1 and mRECIST). Secondary endpoints included surgical conversion rate, disease control rate, progression-free survival (PFS), overall survival (OS), duration of response, and safety. Results: Between November 2021 and September 2022, we enrolled 15 eligible patients with a median age of 53 years (range, 36-76), including 12 (80%) males. Considering enrolled patients, 14 (93.3%) were HBV+, 13(86.7%) presented with PVTT invasion into the main portal vein, Child-Pugh scores 5/6/7: 9/5/1, ECOG PS 0/1: 10/5, median tumor size was 8.4 cm (range, 5.2-13.6), and 5 (33.3%) had extrahepatic metastases. The median number of HAIC procedures was 5 (range, 1-6). The median follow-up time was 338.0 days (95% CI, 298.7-377.4). Considering the 15 evaluable patients (completed at least one cycle of treatment), the ORR was 66.7% (10/15) according to RECIST 1.1, with 0 complete response (CR) and 10 partial responses (PR). According to mRECIST, the ORR was 73.3% (11/15), with 2 CR and 9 PR. Three patients (20%) became eligible for surgical resection, with one undergoing surgical resection (two refused surgery for financial reasons). Median PFS and OS were insufficient. All 15 (100%) patients experienced treatment-related adverse events (TRAEs). Common TRAEs included hand-and-foot skin reaction (HFSR; 93.3%), abdominal pain (73.3%), hypoalbuminemia (60.0%), platelet count decreased (60.0%), nausea (60%), aspartate aminotransferase increased (53.3%), and vomiting (53.3%). Grade 3/4 TRAEs included platelet count decreased (13.3%), HFSR (13.3%), hepatic function abnormal (6.7%), and ascites (6.7%). No grade 5 TRAEs were observed. TRAEs led to drug reduction in 8 patients (53.3%). Conclusions: HAIC combined with donafenib and camrelizumab afforded promising efficacy and safety in patients with uHCC presenting PVTT. Longer follow-up is required for further evaluation. Clinical trial information: ChiCTR2100051714 .

The safety and efficacy of donafenib combined with anti-PD-1 antibody as adjuvant therapy for patients (pts) with hepatocellular carcinoma (HCC): Updated results of a phase 2 study.

e16202 Background: Adjuvant therapy may have an important role in decreasing recurrence rates and improve survival in selected pts with HCC following surgical resection. However, there is no standard treatment options or strategies. This study aimed to investigate the safety and efficacy of donafenib combined with anti-PD-1 antibody as adjuvant therapy for HCC pts with high risks of recurrence. Methods: This prospective, open-label, single-arm study planned to enroll 30 pts who had undergone radical surgery and were diagnosed as HCC confirmed by histology or cytology with any of the following risk factors: a) Microvascular invasion (MVI); b) Satellite nodules in specimens; c) &gt;3 tumor nodules; d) Portal vein tumor thrombosis (excluded main portal vein invasion). Donafenib combined with anti-PD-1 antibody was initiated at 4 to 8 weeks after surgical resection and continued for up to six months. The primary endpoint was the cumulative 1-year recurrence-free survival rate (RFSR). The secondary endpoints were recurrence-free survival (RFS), overall survival, and safety. Results: As of December 31st, 2022, a total of 23 pts received donafenib plus anti-PD-1 antibody (toripalimab) with a mean follow-up of 7.6 months (safety set). The most common risk factor was MVI (91%). 20 pts were included in efficacy set (three pts were excluded due to ineligibility), of whom 16 pts had one risk factor and four had two. Intrahepatic recurrence occurred in 3 pts (15%) and no extrahepatic metastasis or death was reported. The RFSR at one year was 83.0% (90%CI, 61.6%-93.1%) in all the pts from efficacy set, 81.9% (90%CI, 59.6%-92.6%) and 92.3% (90%CI, 66.0%-98.5%) in pts with MVI and MVI-low risk, and 85.1% (90%CI, 59.6%-95.1%) in pts with only one risk factor. The median RFS was not reached. The incidence of grade 3 adverse events related to donafenib and/or toripalimab was 52.2% (12/23). No pts had grade 4/5 adverse events. Adverse events leading to withdrawal of any and both treatments occurred in six (26.1%) and one (4.3%) pts, respectively. The most common grade 3 treatment-related adverse events (occurred in more than one patient) were palmar-plantar erythrodysesthesia syndrome (17.4%), rash (17.4%), alanine aminotransferase increased (13.0%), and aspartate aminotransferase increased (8.7%). Conclusions: These results were consistent with earlier reports. The combination of donafenib and toripalimab may be a promising adjuvant therapy for pts with MVI, satellite nodules or multiple tumor after hepatectomy. No safety issues were noted. Clinical trial information: NCT04418401 . [Table: see text]

Real-world multicentre analysis of patients with hepatocellular carcinoma (HCC) treated with atezolizumab and bevacizumab (A+B): Efficacy, esophagogastroduodenoscopy (EGD) uptake and bleeding complications.

4105 Background: The IMbrave150 trial established A+B as a standard of care for HCC and an EGD within 6 months (mos) of starting treatment to detect esophagogastric varices and prevent bleeding complications was advised. However, the value of performing EGD in all patients (pts) is unknown. Methods: We conducted a retrospective analysis of all HCC pts treated with A+B between July 2020 to August 2022 at 5 cancer centres from the Canadian provinces of Ontario, Alberta and Manitoba (members of the HCC-CHORD Consortium). Pts characteristics and treatment history including efficacy, EGD details and bleeding events were collected. Overall survival (OS), progression-free survival (PFS) and response rate (RR) were calculated. A comparative analysis was conducted to compare the correlation between the EGD uptake and bleeding events. Results: A total of 112 pts were identified (median age 66 years, 87% male, 24% East Asian, 67% liver cirrhosis, 33% HCV, 25% HBV, 15% NASH, 23% BCLC B, 71% BCLC C, 91% Child-Pugh A, 29% main portal vein invasion, 45% ALBI grade 1 and 54% ALBI grade 2). Prior to systemic, 61% had locoregional therapies. 90% received A+B as first-line therapy, while 9% received it as second-line and 1% as third-line. Outcomes of pts treated with A+B are shown. Before starting A+B, 78 pts (70%) had completed an EGD within 6 mos. Of these, 32 pts (41%) had evidence of varices on EGD, and 15 (20%) required treatment with either banding or beta-blockers. All bleeding events in this population was 15% (n=17). Bleeding rates in the EGD and non-EGD groups were 18% (n=14) and 9% (n=3), respectively. Bleeding adverse events were 5%(n=6) gastrointestinal vs 10%(n=11) non-gastrointestinal (6 epistaxis, 1 ecchymosis, 1 periodontal and 3 unspecified). The GI bleeding rates in the EGD and non-EGD groups were 6% (n=5) and 3% (n=1). Conclusions: Outcomes of HCC pts treated with A+B in Canada are comparable to those observed in the IMbrave150 trial. Our study detected and treated varices at twice the rate of the IMbrave150 trial among the EGD group, reflecting real-world treatment of a high-risk population. Yet, pts who had no EGD before starting A+B, presumably due to a low risk of portal hypertension based on physicians’ judgement, did not experience more bleeding/GI bleeding than those who had an EGD. This supports the approach of selective EGD prior to A+B, and more guidelines are needed in this area. Outcomes and response rate of patients(pts) treated with Atezolizumab with Bevacizumab in this study. [Table: see text]

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.

Transjugular Intrahepatic Portosystemic Shunt and Thrombectomy (TIPS-Thrombectomy) for Symptomatic Acute Noncirrhotic Portal Vein Thrombosis

PurposeTo report the safety and effectiveness of transjugular intrahepatic portosystemic shunt and mechanical thrombectomy (TIPS-thrombectomy) for symptomatic acute noncirrhotic portal vein thrombosis (NC-PVT). Materials and MethodsPatients with acute NC-PVT who underwent TIPS-thrombectomy between 2014 and 2021 at a single academic medical center were retrospectively reviewed. Thirty-two patients were included (men, 56%; median age, 51 years [range, 39–62 years]). The causes for PVT included idiopathic (n = 12), prothrombotic disorders (n = 11), postsurgical sequelae (n = 6), pancreatitis (n = 2), and Budd-Chiari syndrome (n = 1). The indications for TIPS-thrombectomy included refractory abdominal pain (n = 14), intestinal venous ischemia (n = 9), ascites (n = 4), high-risk varices (n = 3), and variceal bleeding (n = 2). Variables studied included patient, disease, and procedure characteristics. Patients were monitored over the course of 1-year follow-up. ResultsSuccessful recanalization of occluded portal venous vessels occurred in all 32 patients (100%). Compared with pretreatment patency, recanalization with TIPS-thrombectomy resulted in an increase in patent veins (main portal vein [28% vs 97%, P < .001], superior mesenteric vein [13% vs 94%, P < .001], and splenic vein [66% vs 91%, P < .001]). Three procedure-related adverse events occurred (Society of Interventional Radiology grade 2 moderate). Hepatic encephalopathy developed in 1 (3%) of 32 patients after TIPS placement. At 1-year follow-up, return of symptoms occurred in 3 (9%) of 32 patients: (a) ascites (n = 1), (b) variceal bleeding (n = 1), and (c) intestinal venous ischemia (n = 1). The intention-to-treat 1-year portal vein and TIPS primary and secondary patency rates were 78% (25/32) and 100% (32/32), respectively. Seven patients required additional procedures, and the 1-year mortality rate was 3% (1/32). ConclusionsTIPS-thrombectomy is a safe and effective method for treating patients with symptomatic acute NC-PVT.