Paraumbilical Vein Research Articles

Spontaneous porto-femoral shunting in long-standing portal hypertension.

Spontaneous portosystemic shunting is a compensation mechanism that is supposed to relieve the portal circulation from high pressures. Here we report an unusual shunt that originates from a patent paraumbilical vein and reaches the femoral vein via the inferior epigastric vein. Despite being merely anecdotal, this finding is fascinating from an anatomical point of view.

Paraumbilical vein aneurysm: case report

A 48-year-old female patient was found to have a paraumbilical vein saccular aneurysm, which is a rare consequence of portal hypertension. She presented with right upper quadrant pain and had a known diagnosis of alcoholic liver disease. This had progressed since her last admission. We discuss the multimodality images obtained, diagnosis and complications associated with this pathology.

Pseudolesion in the right parafissural liver parenchyma on CT: The base is found in embryology and collagen content.

Computed tomography (CT) images of livers may show a hypo-attenuated structure alongside the falciform ligament, which can be a focal fatty pseudolesion and can mimic a malignancy. The preferred location is on the right parafissural site, ventral in segment IVa/b. The etiology is not clear, nor is it known how the histology of this location develops. These are evaluated in this study. 40 adult cadavers with autopsy and / or postmortem CT in a university hospital and a forensic center were included. Liver biopsies were taken at the left side of the falciform ligament as control, and at the right side as the possible precursor of a pseudolesion; these were examined for collagen and fat content. Cadavers with steatotic (>5% fat) or fibrotic (>2% collagen) control samples were excluded. Significantly more collagen was present in the right parafissural liver parenchyma: median 0.68% (IQR: 0.32-1.17%), compared to the left side 0.48% (IQR: 0.21-0.75%) (p 0.008), with equal fat content and CT attenuation values. The etiophysiology goes back to the demise of the umbilical venes in the early embryonic and neonatal period. The right parafissural area contains more collagen and an equal amount of fat compared to the control left side. This supports the hypothesis of delayed, 'third' inflow: the postnatal change in blood supply from umbilical to portal leaves the downstream parafissural area hypoperfused leading to hypoxia which in turn results in collagen accumulation and the persistence of paraumbilical veins of Sappey.

Vascular and Parenchymal Alterations of the Liver and Liver Surveillance in Patients Who Received Inotuzumab Ozogamicin As the Standard of Care for Relapse/Refractory Acute Lymphoblastic Leukemia

Vascular and Parenchymal Alterations of the Liver and Liver Surveillance in Patients Who Received Inotuzumab Ozogamicin As the Standard of Care for Relapse/Refractory Acute Lymphoblastic Leukemia

Computed tomography evaluation of patent paraumbilical vein and its aneurysm in relation to other portosystemic collateral channels in patients with liver cirrhosis and portal hypertension

PurposeThe aim of the study was to evaluate the relationship between the diameter and aneurysmal dilatation of the paraumbilical vein (PUV) and the presence of portosystemic collateral shunts and their relationship with age and portal vein diameter.Material and methodsThe retrospective analysis, performed in the II Department of Radiology, Medical University Hospital in Warsaw, included 126 patients (77 males and 49 females) with patent umbilical vein and signs of portal hypertension due to liver cirrhosis. All patients underwent contrast enhanced abdominal CT. The average age was 54.7 ±12.98. We analysed the number and type of portosystemic collateral channels in respect of age, sex, presence of oesophageal varices, and the diameter of the paraumbilical vein and the portal vein.ResultsOur results disclosed statistically significant negative correlation between patient age and diameter of paraumbilical vein, number of portosystemic collateral channels and diameter of portal vein and positive correlation between diameter of paraumbilical vein and diameter of portal vein. A statistically significant difference in diameter of portal vein and number of collateral channels was found in groups with and without oesophageal varices. No significant difference in age and portal vein diameter was found in these groups.ConclusionsOur study showed that younger patients with liver cirrhosis are characterised by wider paraumbilical veins and higher number of portosystemic collateral channels. The presence of oesophageal varices does not correlate with age, sex, diameter of paraumbilical vein, and number of collateral portosystemic channels.

Portal hypertension – Paraumbilical vein collaterals causing a medusa head appearance

Portal hypertension – Paraumbilical vein collaterals causing a medusa head appearance

Portosystemic shunts and refractory hepatic encephalopathy: patient selection and current options.

Portosystemic shunt (PS) syndrome encompasses a spectrum of disease manifestations ranging from asymptomatic portal hypertension to recurrent and refractory hepatic encephalopathy, ultimately culminating in progressive hepatic failure in patients of cirrhosis and associated large PSs. PSs commonly seen in cirrhosis include splenorenal, gastrorenal, and dilated paraumbilical veins, all of which can present with recurrent or refractory hepatic encephalopathy. In this exhaustive review, we describe the anatomy of PSs, elucidate new theories on their pathophysiology, discuss the clinical implications of PSs in cirrhosis, provide details on different techniques (classical and novel) of shunt embolization, and explore all the pertinent current literature on shunt embolization for refractory and recurrent hepatic encephalopathy, all of which are enumerated with extensive images and illustrations.

Hepatic arterialization can predict the development of collateral veins in patients with HCV-related liver disease

PurposeArrival time parametric imaging (At-PI) using contrast-enhanced ultrasonography (CEUS) is a procedure for evaluating liver disease progression in chronic hepatitis C infection (CHC). We investigated At-PI diagnostic efficacy in predicting development of collateral veins.MethodsIn total, 171 CHC patients underwent CEUS and upper gastrointestinal (UGI) endoscopy before liver biopsy. Conventional US was performed before CEUS to identify paraumbilical veins (PV) or splenorenal shunts (SRS). After intravenous perflubutane, contrast dynamics of liver segments 5–6 and the right kidney were saved as raw data. At-PI image ratio of red (ROR) pixels to the entire liver was analyzed. Receiver operating characteristic (ROC) curves were generated to investigate the utility of At-PI for collateral vein identification.ResultsConventional US revealed PV in two patients and SRS in five patients; UGI endoscopy detected esophageal varices (EV) in eight patients. Diagnostic capability of At-PI for detecting PV, SRS, and EV was satisfactory, and high for PV and SRS [PV; area under the ROC curve (AUROC) 0.929, cutoff value 77.9%, SRS; AUROC 0.970, cutoff value 82.0%, EV; AUROC 0.883, cutoff value 66.9%].ConclusionsEvaluation of hepatic arterialization by At-PI was useful for predicting collateral vein development in CHC patients.

EP06.02: Prenatal visualisation of paraumbilical veins in a fetus with umbilical vein stricture

EP06.02: Prenatal visualisation of paraumbilical veins in a fetus with umbilical vein stricture

An Unfortunate Case of Dyspnea in Cryptogenic Cirrhosis

Portopulmonary hypertension is a type of pulmonary arterial hypertension associated with portal hypertension. It is a known complication of cirrhosis and can predict increased mortality after liver transplantation. A 35 year—old—female with suspected cirrhosis and acute dyspnea on exertion was transferred to our hospital for further management. Two weeks prior to transfer she had hematemesis; an upper endoscopy revealed medium—sized bleeding esophageal varices requiring banding. Cross—sectional imaging was concerning for a cirrhotic appearing liver. She had no past medical history and had an unknown family history as she was adopted. On admission she felt short of breath. Her physical exam was notable for scleral icterus, jugular venous distension to 10cm, right ventricular heave, and an abdominal fluid wave. Laboratory values included platelet 88x1000/uL (reference range 140—440), INR 1.4 (range 0.89—1.12), albumin 3.1g/dL (range 3.5—5.0), and total bilirubin 5.5mg/dL (range 0.1—1.2). She had an extensive laboratory workup for cirrhosis, of which the only remarkable finding was a positive anti—mitochondrial antibody at 73.8 units (range <20.0). She had an magnetic resonance imaging (MRI) liver which showed a cirrhotic—appearing liver with evidence of portal hypertension (Figure 1). A transjugular liver biopsy showed stage 4 fibrosis and areas of sinusoidal dilatation without signs of primary biliary cirrhosis. She had a hepatovenous pressure gradient (HVPG) of 11mmHg (reference range 0—5). Workup of her dyspnea included an echocardiogram which showed a dilated right ventricle (Figure 2) with an elevated right ventricular systolic pressure of 65mmHg (reference range 15—25). Subsequent right heart catheterization showed an elevated mean pulmonary artery pressure (mPAP) of 43mmHg (range 5—10) with a relatively normal pulmonary capillary wedge pressure of 12mmHg (range<10), indicative of pulmonary arterial hypertension. In the setting of cirrhosis a diagnosis of portopulmonary hypertension was made. Per consultation with pulmonology she was started on a prostacyclin analog and endothelin—receptor antagonist. Her case was discussed at the liver transplantation recipient review committee, but placed on hold pending improvements in her right—sided cardiac pressures. A diagnosis of pulmonary hypertension can be made via right heart catheterization indicating a mPAP >25mmHg. Per the 2013 AASLD liver transplant guidelines, a mPAP < 35mmHg is required for transplant.3052_A.tif Figure 1: MRI abdomen, T1—weighted; white arrow points to steatotic and echogenic liver consistent with cirrhosis; black arrow points to a recanalized paraumbilical vein, indicating portal hypertension3052_B.tif Figure 2: Transthoracic echocardiogram, short axis, showing dilated right atrium (RA) and right ventricle (RV)3052_C.tif Figure 3: Liver core biopsy, trichrome stain, blue area indicates fibrosis

Novel Ultrasonographic Scoring System of Sinusoidal Obstruction Syndrome after Hematopoietic Stem Cell Transplantation

Sinusoidal obstruction syndrome (SOS)/hepatic veno-occlusive disease (VOD) is a well-documented complication after hematopoietic stem cell transplantation (HSCT). Transabdominal ultrasonography (US) enables the visualization of blood flow abnormalities and is therefore useful for the diagnosis of SOS/VOD. We herein prospectively evaluated accuracy of a novel US diagnostic scoring system of SOS/VOD based on US findings. We carried out US in 106 patients on day 14 and when SOS/VOD was suspected after allogeneic HSCT. Among 106 patients, 10 patients (9.4%) were diagnosed as SOS/VOD by Baltimore or Seattle criteria. According to univariate analysis of 17 US findings (US-17 screening), we established a novel scoring system (HokUS-10) consisting of 10 parameters, such as gallbladder wall thickening, ascites, and blood flow signal in the paraumbilical vein. The sensitivity and specificity were 100% and 95.8%, respectively. Diagnostic performance of the HokUS-10 was significantly better than US-17 screening. In 4 of 10 patients US detection of SOS/VOD preceded to clinical diagnosis. The HokUS-10 scoring system is useful in the diagnosis of SOS/VOD; however, our results should be validated in other cohorts.

CT of the paraumbilical and ensiform veins in patients with superior vena cava or left brachiocephalic vein obstruction.

The purpose of this study was to elaborate on the anastomoses between the paraumbilical and systemic veins, particularly the ensiform veins. The connections with the ensiform veins have received little attention in the anatomical and radiological literature, and remain incompletely described. Too small to be reliably traced in normal CT scans, the paraumbilical veins can dilate in response to increased blood flow from systemic veins in superior vena cava obstruction (SVCO), allowing a study of their arrangement and connections. Collateral paraumbilical veins were therefore analyzed retrospectively in 28 patients with SVCO using CT. We observed inferior and superior groups of collateral vessels in 23/28 (82%) and 17/28 (61%) patients, respectively. Inferior veins ascended towards the liver and drained into portal veins (19/28, 68%) or the umbilical vein (8/28, 29%); superior veins descended and drained into portal veins. The inferior veins (N = 27) could be traced to ensiform veins in almost all of the cases (26/27, 96%), and a little over half (14/27, 52%) were also traceable to subcutaneous and deep epigastric veins. They were opacified by ensiform (25/27, 93%), deep epigastric (4/27, 15%) and subcutaneous (4/27, 15%) veins. The superior veins (N = 17) were supplied by diaphragmatic (13/17, 76%) and ensiform veins (4/17, 24%); the diaphragmatic veins were branches of collateral internal thoracic, left pericardiacophrenic and anterior mediastinal veins. Collateral ensiform veins were observed in 22 patients and anastomosed with internal thoracic (19/22, 86%), superior epigastric (9/22, 41%), diaphragmatic (4/22, 18%), subcutaneous (3/22, 14%) and anterior mediastinal veins (1/22, 5%). These observations show that the paraumbilical veins communicate with ensiform, deep epigastric, subcutaneous and diaphragmatic veins, joining the liver to the properitoneal fat pad, anterior trunk, diaphragm and mediastinum. In SVCO, the most common sources of collateral flow to the paraumbilical veins are the ensiform and diaphragmatic branches of the internal thoracic veins.

3:00 PM Abstract No. 381 - Percutaneous transumbilical embolization of spontaneous portosystemic shunts for the treatment of hepatic encephalopathy

To evaluate the safety and efficacy of percutaneous transumbilical embolization (PTE) of spontaneous portosystemic shunts (SPSSs) for the treatment of hepatic encephalopathy (HE). The medical records of seven cirrhotic patients (sex, four men and three women; mean age, 63.2 ± 3.9 years) who underwent PTE of SPSSs for the treatment of HE at our institution between January 2012 and August 2016 were reviewed. The etiologies of cirrhosis were hepatitis B virus (n = 4), alcoholic liver disease (n = 2), and primary biliary cholangitis (n = 1). The mean Model for End-Stage Liver Disease score was 13.1 ± 3.4. All patients had overt HE. The median grade of HE was 2 (range, 2–3). Six (85.7%) patients had persistent HE and one (14.3%) had recurrent HE. The median number of episodes of overt HE within 6 months was 4 (range, 2–4). Technical success was achieved in 100% (7/7) of patients. All patients had complete resolution (n = 4) or improvement (n = 3) of signs and symptoms of HE within 3 days after procedure, rendering a clinical success rate of 100% (7/7). The median grade of HE 3 days after the procedure was 1 (range, 0–1). The grade of HE was significantly decreased 3 days after the procedure (p = 0.016). Development of new esophageal varices, a major complication, occurred in one (14.3%) patient 3 days after the procedure. The median follow-up period after the procedure was 43 (range, 5–111) months. Recurrence occurred in 71.4% (5/7) of patients in a median time of 13 (range, 1–49) months. Two (28.6%) patients had recurrence within 6 months. The remaining five (71.4%) patients remained free of recurrence for a median time of 37 (range, 10–49) months. The number of episodes of OHE within 6 months was significantly lower after the procedure (p > 0.017). PTE of SPSSs may be safe and effective for the treatment of HE. It may be considered for patients with recurrent and persistent HE in the setting of recanalized paraumbilical vein.

The Effectiveness of Noninvasive Transabdominal Ultrasound Evaluation in the Diagnosis of Sinusoidal Obstruction Syndrome after Hematopoietic Stem Cell Transplantation

Sinusoidal obstruction syndrome (SOS) is one of the complications after hematopoietic stem cell transplantation (HSCT). The widely used clinical criteria can efficiently diagnose SOS, but cannot determine the severity or assess the treatment response. To address the issues, we propose a new transabdominal ultrasound (US) scoring system of SOS. From 2008 to 2013, 113 patients underwent HSCT were enrolled in the study. The patients were scored by three factors in US findings: gall bladder wall thickness, existence of ascites, and appearance of blood flow signal in paraumbilical vein. We further assessed the effectiveness of the addition of some liver function tests to the US scoring. Statistical analysis was performed by t-test (P<0.05). Ten patients were diagnosed as SOS (7.5%) by clinical criteria. The US SOS score (mean±SD) of SOS-group and non-SOS-group were 3.6±1.1 and 0.6±0.8, respectively (P<0.01). The most effective cut off value was 3 (area under the receiver operating characteristic curve: 0.95). When total bilirubin level (no less than 1.0 mg/dl) was included in the score, specificity, accuracy, and negative predictive value were improved. Furthermore, the US scores were elevated prior to diagnosis in some cases, which suggests the US scoring system is useful for diagnosis in early stage. Other parameters didn’t contribute to SOS diagnosis in combination with US scoring. More analysis is needed to demonstrate the correlation with severity and outcomes. Our US SOS scoring system is effective in making a diagnosis of SOS, especially in combination with bilirubin levels.

Predictive value of CT for first esophageal variceal bleeding in patients with cirrhosis: Value of para-umbilical vein patency

PurposeTo evaluate if the presence/size of a para-umbilical vein (PUV) on computed tomography (CT) are associated with a first esophageal variceal hemorrhage (EVH) in patients with cirrhosis and whether imaging features can help identify patients at increased risk of EVH. Materials and methodsFrom January 2010 to June 2012 patients with cirrhosis who underwent CT and upper gastrointestinal endoscopy within six months were included. The presence/size of PUV was noted. PUV>5mm were considered large (LPUV). Association with a first EVH was searched for, and validated in a prospective cohort of 55 patients. Results172 patients (113 men, mean 60±12 yo) were included. Forty-three patients (25%) experienced a first EVH. LPUV were more frequent in the group without EVH (27% vs. 7%, p=0.005). At multivariate analysis, factors associated with a first EVH were spleen size>135mm (Odd Ratio [OR]=1.32 [95% confident interval [CI] 1.16–1.51], p<0.001), ascites (OR=4.07 [95%CI-1.84–9.01], p=0.001) and small/absent PUV (OR=3.06 [95%CI-1.86–5.05], p<0.001). An imaging score combining these factors was significantly associated with first EVH in the study and the validation cohorts (EVH in 0%, 19%, and 33% when score 0–1, 2–3, and 4–5, respectively). ConclusionsA simple imaging score combining the PUV and spleen size, and the presence of ascites could help to identify cirrhotic patients at high-risk for EVH.

Prediagnostic CT findings of pancreatic cancer

We present a case of focal increased intrahepatic radiotracer activity on 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) in a patient with lymphoma and superior vena cava (SVC) obstruction, a false positive for malignancy. Contrast-enhanced computed tomography (CT) demonstrated an enhancing region of geographic focal hypoattenuation in the liver along the falciform, corresponding to the region of increased radiotracer activity on FDG-PET, with marked narrowing of the superior vena cava and resultant collateral venous pathways to the portal vein via paraumbilical veins. CT followup demonstrated stability of the hepatic abnormality, and no lesion was evident on ultrasound, suggesting that the finding on PET-CT represented a false positive for malignancy in this patient with known SVC obstruction. In patients with SVC obstruction, radiologists should consider this phenomenon of anomalous hepatic uptake along the falciform as a source of possible false positives for malignancy on PET.

The veno-venous bypass in liver transplantation: an unfinished product.

Veno-venous bypass (VVB) using a patent para-umbilical vein during liver transplantation (LT) has not been reported previously. Here, we report the decompression of the porto-mesenteric compartment via a patent para-umbilical vein in a patient needing a VVB during LT. Pre-transplant CT-scan showed a large patent para-umbilical vein. A femoro-axillary percutaneous VVB was installed prior to abdominal opening to decompress massive collateral veins in the abdominal wall. The para-umbilical vein was stapled and its proximal end was cannulated and connected to the VVB. The severe atrophy of the native liver allowed to place the whole liver graft in the "liver fossa" while maintaining the native liver pulled toward the left side and connected to the VVB. This maneuver maintained splanchnic venous decompression during latero-lateral cavo-caval anastomosis. The "portal" cannula was clamped and removed. The native portal vein was clamped and divided. Standard portal, arterial, and biliary reconstructions were then performed. A patent para-umbilical vein, present in one third of patients with portal hypertension could be used whenever VVB is indicated during LT in this setting.

Cruveilhier - Baumgarten syndrome with multiple splenic artery aneurysms: A case report

Cruveilhier - Baumgarten (CB) syndrome is a rare medical condition in which liver cirrhosis is associated with portal hypertension causing dilatation of the umbilical and the paraumbilical veins (giant paraumbilical vein). It is important to know about the dilatation of the portosystemic circulation to prevent inadvertent bleeding during any surgical procedure. There are only a few reported cases of CB syndrome and only one with associated multiple splenic artery aneurysms.

Computed Tomography Findings of Thrombosis and Aneurysm of the Portal Venous System

The portal venous system comprises all of the veins draining the abdominal part of the digestive tract, and tributaries of the portal vein are the splenic, superior mesenteric, left and right gastric vein, paraumbilical and cystic veins. The portal vein could be occluded in various clinical settings that may cause portal venous system thrombosis. And rarely aneurysms of the portal venous system may be presented. Multiphasic contrast enhanced computed tomography is a useful tool for both perfusion abnormalities and morphologic analysis of the portal venous system and the liver and it enables discrimination between bland and neoplastic portal vein thrombi. Key words: Portal vein; Thrombosis; Aneurysm; Tomography, X-ray computed; Liver

Predict esophageal varices via routine trans-abdominal ultrasound: A design of classification analysis model.

Upper gastrointestinal endoscopy remains the gold standard for diagnosis of esophageal varices. Trans-abdominal ultrasound, as a noninvasive routine examination for the follow-up of cirrhosis patient, is safe, cheap, easy to perform, and plays an important role. In this study, we attempt to design a practical classification analysis model to predict esophageal varices via ultrasound. Compared with endoscopy, the ultrasound qualitative signs (lower esophageal Doppler signals, left gastric vein hepatofugal flow, and paraumbilical vein recanalization) and quantitative parameters (spleen diameter, spleen vein diameter, portal vein diameter, and portal vein velocity) have been evaluated in 286 cirrhosis patients. The classification analysis model is designed as that: the patients are defined with esophageal varices high risk, who with any ultrasound qualitative signs or who with spleen diameter greater than 162 mm without qualitative parameters. The sensitivity for detecting esophageal varices is 97.5% and the specificity is 82.6%, while the positive predictive value is 96.7%, negative predictive value is 83.4%, and the omission diagnostic rate is 2.5%. This classification analysis model design includes ultrasound qualitative signs and spleen diameter, which can be detected easily via routine ultrasound without other auxiliary. The classification analysis model is useful in detecting esophageal varices, which may be a supplement for predicting of esophageal varices, and reducing the frequency of endoscopy in the follow-up of cirrhosis patients.