Percutaneous Transhepatic Portal Embolization Research Articles

Intensive Multimodal Therapy Combined With Long-term Temozolomide and Etoposide Treatment for Recurrent Osteosarcoma to the Liver and Stomach.

The prognosis of patients with osteosarcoma recurring at extrapulmonary/extraosseous sites, especially those with unresectable tumors, is generally dismal due to high resistance to chemotherapy. The present study describes a pediatric patient with osteosarcoma recurring to the liver and stomach. Complete remission was achieved by long-term systemic chemotherapy with temozolomide+etoposide, local irradiation of the stomach, and radical surgical removal of multiple liver metastases following percutaneous transhepatic portal embolization. Second-line multimodal therapy, consisting of salvage chemotherapy and curative local treatment of metastases, may enhance disease-free survival of patients with osteosarcoma experiencing relapse to uncommon sites.

Safe perioperative management of major hepatectomy in a patient with portal hypertension after elimination of hepatitis C: a case report

BackgroundThe administration of direct-acting antiviral agents in patients with liver cirrhosis and hepatitis C has been shown to improve liver function and long-term prognosis after sustained virological response (SVR) is achieved. However, in patients with portal hypertension (PH) at the time of SVR, PH may persist despite improvement in liver function.Case presentationAn 82-year-old woman with liver cirrhosis due to hepatitis C was treated with direct-acting antiviral agents and achieved SVR. During follow-up, computed tomography revealed a low-density tumor in the left lateral region of the liver with dilation of the left intrahepatic bile duct. Considering the patient’s advanced age and PH persistence with a mild decrease in liver reserve function after SVR, preoperative percutaneous transhepatic portal embolization (PTPE) and partial splenic embolization (PSE) were performed concomitantly. Laparoscopic left hemihepatectomy was performed 8 days after the PTPE and PSE. The patient was discharged 8 days after surgery without any postoperative complications.ConclusionsLaparoscopic left hemihepatectomy after preoperative management of PH was performed safely in a patient after the elimination of hepatitis C.

A case of complete necrosis of a huge hepatocellular carcinoma after percutaneous transhepatic portal embolization

A case of complete necrosis of a huge hepatocellular carcinoma after percutaneous transhepatic portal embolization

Metastasis of ovarian cancer to the bile duct: a case report

BackgroundOvarian cancer typically spreads along the peritoneum or metastasizes through the blood or lymphatic stream. The bile duct is an extremely rare site of ovarian cancer-associated metastases.Case presentationA 55-year-old female underwent surgery for advanced left ovarian cancer 2 years ago. She was diagnosed with ovarian serous adenocarcinoma with multiple peritoneal metastases. She received chemotherapy for the residual peritoneal metastases. She achieved a clinical complete response and was followed up with imaging examinations for 1 year. She then complained of dark urine, yellowish discoloration of the eyes, and weight loss. Computed tomography showed an approximately 10-mm solid tumor at the hepatic hilum. Simultaneously, multiple peritoneal metastases were detected in the abdominal and pelvic cavity. Intraductal ultrasonography suggested that the hepatic hilum tumor was located in the bile duct wall. Tumor biopsy and brush cytology of the bile duct indicated atypical cells suspicious for carcinoma. After percutaneous transhepatic portal embolization, she underwent right hepatectomy and extrahepatic bile duct resection for the hepato-hilar tumor. The histopathological features were dysplastic cells with hyperchromatic nuclei and no dysplastic cells in the native biliary epithelium. Immunohistochemical staining revealed that the tumor cells were positive for CK-7 and WT-1 and negative for CK-20 and ER. These results suggested that the tumor was a metastasis of the ovarian serous adenocarcinoma.ConclusionThis may be the first case of ovarian cancer metastasis to the bile duct. While it is extremely rare, ovarian cancer may metastasize to the hepatic duct, mimicking hilar cholangiocarcinoma.

Hepatic hypertrophy and hemodynamics of portal venous flow after percutaneous transhepatic portal embolization

BackgroundPercutaneous transhepatic portal embolization (PTPE) is useful for safe major hepatectomy. This study investigated the correlation between hepatic hypertrophy and hemodynamics of portal venous flow by ultrasound sonography after PTPE.MethodsWe analyzed 58 patients with PTPE, excluding those who underwent recanalization (n = 10). Using CT volumetry results 2 weeks after PTPE, the patients were stratified into a considerable hypertrophy group (CH; n = 15) with an increase rate of remnant liver volume (IR-RLV) ≥ 40% and a minimal hypertrophy group (MH; n = 33) with an IR-RLV < 40%. We investigated the hemodynamics of portal venous flow after PTPE and the favorable factors for hepatic hypertrophy.ResultsUnivariate and multivariate analysis identified the indocyanine green retention rate at 15 min (ICGR15) and increase rate of portal venous flow volume (IR-pFV) at the non-embolized lobe on day 3 after PTPE as independent favorable factors of IR-RLV. Patients with IR-pFV on day 3 after PTPE ≥100% and ICGR15 ≤ 15% (n = 13) exhibited significantly increased IR-RLV compared with others (n = 35).ConclusionsCases with high IR-pFV on day 3 after PTPE exhibited better hepatic hypertrophy. Preserved liver function and increased portal venous flow on day 3 were important.

Successful treatment of isolated bile leakage after hepatectomy combination therapy with percutaneous transhepatic portal embolization and bile duct ablation with ethanol: a case report

BackgroundBile leakage after hepatectomy still causes relatively serious problems, and some types of bile leakage are intractable.Case presentationWe report a case of postoperative isolated bile duct leakage managed successfully by combination therapy of percutaneous transhepatic portal vein embolization (PTPE) and bile duct ablation with ethanol. A 61-year-old man diagnosed with hepatocellular carcinoma underwent partial hepatectomy. On postoperative day 1, bile leakage was detected at the drainage tube. Simple drainage treatment did not improve the situation. He was diagnosed with isolated bile leakage based on fistulogram from the drainage tube that showed the bile duct at segments V and VIII but not the common bile duct. A volume of drainage fluid of 200 mL/day was observed. Combination therapy with PTPE and bile duct ablation with ethanol was planned. After the percutaneous transhepatic cholangiography, the drainage tube was inserted into the bile duct, and PTPE was performed to segments V and VIII. The amount of drainage fluid decreased, and bile duct ablation with ethanol was performed to the isolated bile duct. No complication was found following combination therapy.ConclusionIn this case, we successfully treated a patient with isolated bile leakage by combination therapy with PTPE and bile duct ablation.

Liver atrophy after percutaneous transhepatic portal embolization occurs in two histological phases: Hepatocellular atrophy followed by apoptosis.

AIMTo clarify the histological changes associated with liver atrophy after percutaneous transhepatic portal embolization (PTPE) in pigs and humans.METHODSAs a preliminary study, we performed pathological examinations of liver specimens from five pigs that had undergone PTPE in a time-dependent model of liver atrophy. In specimens from embolized lobes (EMB) and nonembolized lobes (controls), we measured the portal vein to central vein distance (PV-CV), the area and number of hepatocytes per lobule, and apoptotic activity using the terminal deoxynucleotidyl transferase dUTP nick-end labeling assay. Immunohistochemical reactivities were evaluated for light chain 3 (LC3) and lysosomal-associated membrane protein 2 (LAMP2) as autophagy markers and for glutamine synthetase and cytochrome P450 2E1 (CYP2E1) as metabolic zonation markers. Samples from ten human livers taken 20-36 d after PTPE were similarly examined.RESULTSPV-CVs and lobule areas did not differ between EMB and controls at day 0, but were lower in EMB than in controls at weeks 2, 4, and 6 (P ≤ 0.001). Hepatocyte numbers were not significantly reduced in EMB at day 0 and week 2 but were reduced at weeks 4 and 6 (P ≤ 0.05). Apoptotic activity was higher in EMB than in controls at day 0 and week 4. LC3 and LAMP2 staining peaked in EMB at week 2, with no significant difference between EMB and controls at weeks 4 and 6. Glutamine synthetase and CYP2E1 zonation in EMB at weeks 2, 4, and 6 were narrower than those in controls. Human results were consistent with those of porcine specimens.CONCLUSIONThe mechanism of liver atrophy after PTPE has two histological phases: Hepatocellular atrophy is likely caused by autophagy in the first 2 wk and apoptosis thereafter.

Percutaneous transhepatic portal embolization using foam ethanolamine oleate and carbon dioxide (CO₂): a pilot study.

Percutaneous transhepatic portal embolization (PTPE) can induce atrophy of the embolized- and hypertrophy of the residual area. These effects are advantageous in patients scheduled for extended hepatectomy. To evaluate the clinical safety and effectiveness of foam sclerotherapy with foam ethanolamine oleate (EO) and carbon dioxide (CO2) for PTPE before hepatectomy. We performed sclerotherapy for PTPE in 15 patients with: hepatocellular carcinoma (HHC; n = 9), bile duct carcinoma (n = 5), or metastatic liver tumor from colon cancer (n = 1). The foam contained 5% EO iopamidol (EOI) and CO2 at a 1:2 ratio. We compared the percentage of the pre- and post-PTPE future liver remnant (FLR) volumes and calculated the percent FLR volume (%FLR) increase after PTPE. The amount of EOI used (range, 14-20 mL; median, 16.8 mL) was based on the volume of the target portal vein. Technical success was achieved in 14 of 15 patients (93%); the other patient presented with computed tomography evidence of recanalization 1 week after PTPE. The FLR volume before and after portal vein embolization was 599 ± 342 and 691 ± 318 cm(3), respectively (P < 0.01); the mean %FLR volume increase was 29.5%. There was no significant difference in the mean platelet count, total bilirubin, total aspartate aminotransferase, and total creatinine before and after PTPE. One patient suffered intra-abdominal bleeding that required transcatheter arterial embolization. No other patients developed major complications higher than grade 3. Sclerotherapy using foam EOI and CO2 is clinically safe and effective for PTPE before hepatectomy.

4:33 PM, Abstract No. 223 - Use of celiac angiography immediately after percutaneous transhepatic portal interventional radiological procedure to confirm injury of the hepatic artery

The aim of this study is to evaluate usefulness of celiac angiography (CA) immediately after percutaneous transhepatic portal interventional radiological procedures (PTPIR) to confirm injury of the hepatic artery. Forty-two PTPIR (23 PTPE: percutaneous transhepatic portal embolization and 19 PTO: percutaneous transhepatic obliteration) were performed in 40 patients, 24 males and 16 females, with a median age of 69 years (range, 50-82) between April 2004 and May 2014. Nineteen PTPIR (7 PTPE and 12 PTO) were performed without CA (control group), and 23 PTPIR (16 PTPE and 7 PTO) was performed with CA (CA group). In all cases, intrahepatic portal vein was punctured using an 18 or 21 G needle with US guide, and a 4-, 5-, 6-, or 7-Fr. sheath was introduced. After the procedure, the transhepatic access route of the liver parenchyma was embolized using gelatin sponge. We reviewed medical records and images, and evaluated the rate of injury of the hepatic artery and mortality rate. Furthermore, the complication related to the celiac angiography was evaluated in the CA group. In the control group, the rate of injury was 5% (1/19). This one injury was intraabdominal bleeding after PTPE, and it was found after 12 hours with a drop of blood pressure. Contrast-enhanced CT confirmed the bleeding. Then, trasarterial embolization (TAE) was performed, but this patient died eventually. The mortality rate was 5% (1/19). In the CA group, the rate of injury was 9% (2/23). One of them was due to intraabdominal bleeding after PTO, but it was found immediately after the procedure with CA, and TAE was performed successfully. The other was arterioportal shunt after PTPE, and it was found with CA, and then coil embolization was immediately performed. The mortality rate was 0% (0/23). There was no complication related to the celiac angiography. The celiac angiography immediately after PTPIR appears to be useful to find complications earlier, and it contributes to decreasing mortality rate.

Efficacy and Safety of Percutaneous Transhepatic Portal Embolization with Dehydrated Ethanol

Purpose: The efficacy and safety of percutaneous transhepatic portal embolization (PTPE) with dehydrated ethanol was determined by measuring the liver lobe volume before and after the procedure. Materials and Methods: A total of 38 patients (25 men, 13 women; mean age: 62.0 ± 10.8 years) who underwent PTPE with dehydrated ethanol between April 2005 and March 2011 participated in this study. Dehydrated ethanol containing 17% lipiodol was injected into the target portal vein branch under balloon occlusion, and the portal vein was subsequently embolized. The liver lobe volume was measured via contrast-enhanced computed tomography, and the percent increase in the unembolized lobe volume was then calculated. In addition, PTPE-related complications were surveyed, and the procedural safety was evaluated. Results: The mean percent increase in the unembolized lobe volume after PTPE was 33.8% ± 20.2%. The procedure could not be completed in one patient because of an insufficient increase in the unembolized lobe volume. No serious post- PTPE complications were observed. Conclusion: These data suggest that PTPE with dehydrated ethanol is a safe and effective method for enlarging the planned residual liver volume before extensive liver resection.

Embolization of percutaneous transhepatic portal venous access tract with N-butyl cyanoacrylate.

To evaluate the safety and feasibility of N-butyl cyanoacrylate (N-BCA) embolization of percutaneous transhepatic portal venous access tract and to establish an appropriate technique. 40 consecutive patients underwent percutaneous transhepatic portal venous intervention for various reasons. Embolization of percutaneous transhepatic portal venous access tract was performed after the procedure in all of the patients using N-BCA and Lipiodol® (Lipiodol Ultra Fluide; Laboratoire Guerbet, Aulnay-sous-Bois, France) mixture. Immediate ultrasonography and fluoroscopy were performed to evaluate perihepatic haematoma formation and unintended embolization of more than one segmental portal vein. Follow-up CT was performed, and haemoglobin and haematocrit levels were checked to evaluate the presence of bleeding. Immediate haemostasis was achieved in all of the patients, without development of perihepatic haematoma or unintended embolization of more than one segmental portal vein. Complete embolization of percutaneous access tract was confirmed in 39 out of 40 patients by CT. Seven patients showed decreased haemoglobin and haematocrit levels. Other complications included mild pain at the site of embolization and mild fever, which resolved after conservative management. 16 patients died during the follow-up period owing to progression of the underlying disease. Embolization of percutaneous transhepatic portal vein access tract with N-BCA is feasible and technically safe. With the appropriate technique, N-BCA can be safely used as an alternate embolic material since it is easy to use and inexpensive compared with other embolic materials. This is the first study to investigate the efficacy of N-BCA for percutaneous transhepatic portal venous access tract embolization.

Infusion of 50 % glucose solution to occlude an intrahepatic portosystemic venous shunt before percutaneous transhepatic portal embolization: report of a case

A 68-year-old man with cholangiocarcinoma underwent percutaneous transhepatic portal embolization to expand the indication for hepatic resection. Selective right posterior portography revealed an intrahepatic portosystemic venous shunt (IPSVS) connecting the segment VII branch to the right hepatic venous branch. An infusion of 50% glucose solution was given to occlude the shunt. This is novel management for IPSVSs when they are numerous, small, or torturous, and makes the subsequent procedures simpler, shorter, and less expensive.

Ultrasound-guided thrombin injection for the treatment of an iatrogenic hepatic artery pseudoaneurysm: a case report

IntroductionPercutaneous transhepatic portal embolization is often performed to expand the indications for hepatic resection. Various etiologies of hepatic artery pseudoaneurysm have been reported, but regardless of the etiology, hepatic artery pseudoaneurysm is usually managed with an endovascular approach or open surgery, depending on the location and clinical symptomatology. However, it is difficult to manage hepatic artery pseudoaneurysm after percutaneous transhepatic portal embolization, since embolization of the hepatic artery may cause hepatic infarctionCase presentationA 58-year-old Japanese man with hilar bile duct cancer underwent percutaneous transhepatic portal embolization to expand the indication for hepatic resection. Two days after percutaneous transhepatic portal embolization, our patient suddenly complained of abdominal pain. Contrast-enhanced computed tomography confirmed a pseudoaneurysm arising from a segmental branch of his right hepatic artery. Since embolization of the hepatic arterial branches may cause hepatic infarction, ultrasound-guided thrombin injection therapy was successfully performed for the pseudoaneurysm.ConclusionWe performed a thrombin injection instead of arterial embolization to avoid hepatic infarction. The rationale of this choice may be insufficient. However, ultrasound-guided percutaneous thrombin injection therapy may be considered as an alternative to percutaneous transarterial embolization or surgical intervention for an iatrogenic hepatic artery pseudoaneurysm.

Clinical Significance of the Transitional Phase at Gadoxetate Disodium–Enhanced Hepatic MRI for the Diagnosis of Hepatocellular Carcinoma

To investigate the clinical significance of the "transitional phase" at gadoxetate disodium (Gd-EOB)-enhanced magnetic resonance imaging for diagnosing hepatocellular carcinoma (HCC). We studied 54 patients with 70 histologically diagnosed HCC. Transitional- and hepatobiliary-phase (TP, HBP) images were acquired 3 and 20 minutes after Gd-EOB injection, respectively. Radiologists measured the size of the hepatic tumors on images and surgical specimens and qualitatively evaluated the signal intensity of the hepatic tumors during TP and HBP independently. In 4 patients with portal tumor embolism who had undergone percutaneous transhepatic portal embolization and who manifested arterioportal (AP) shunts, the low-intensity area was larger during HBP than TP. Of the 70 HCCs, 4 were of high signal intensity during HBP and 2 were of slightly low intensity during TP. Tumor extension seen during TP rather than HBP more accurately reflected histological findings in patients with HCC with portal tumor thrombi, percutaneous transhepatic portal embolization, or AP shunt.

A new approach to percutaneous transhepatic portal embolization using ethanolamine oleate iopamidol

We aimed to examine the therapeutic efficacy of ethanolamine oleate iopamidol (EOI) as an embolic material for percutaneous transhepatic portal embolization (PTPE). Eighty-two patients with liver tumors were treated with PTPE. Fifty-eight patients had hepatocellular carcinomas, 11 had liver metastases, and 13 had other liver tumors. A total of 55 patients (group E) were treated with 5% ethanolamine oleate after gelatin sponge administration. As a control, we evaluated 27 patients (group F) who were treated with fibrin glue and iodized oil. PTPE was mainly indicated before hepatic resection, for patients with high nontumorous volumetric resection ratios (the nontumorous volumetric resection ratio was estimated to be greater than 65% in patients with an indocyanine green retention ratio of 15 min (ICG R15) of 10% or less, and the nontumorous volumetric resection ratio was estimated to be greater than 40% in the patients with an ICG R15 of 10-20%). All patients were successfully treated percutaneously under local anesthesia. Balloon-occluded and ipsilateral approaches were used in 81 patients (99%) and 62 (75%) patients, respectively. The rate of insufficient embolization or recanalization was significantly lower in group E (7.3%) in comparison to group F (25.9%; p < 0.05). The volumetric resection ratios, before and after PTPE, decreased from 60 to 45% in group E and from 63 to 55% in group F. The post-PTPE resection ratio was significantly decreased in group E. Before and after PTPE, average ICG R15 values changed from 17 to 27% in group E and from 18 to 26% in group F. The complication rates in groups E and F were similar (7.3 vs. 7.4%). EOI is a safe embolic material that can be used to induce greater liver hypertrophy, in comparison to fibrin glue, in PTPE for liver tumors.

Percutaneous transhepatic portal embolization for persistent bile leakage after hepatic resection: Report of a case

Bile leakage is a relatively common complication after hepatic resection. We report a case of intractable bile leakage after hepatectomy, which was successfully treated by percutaneous transhepatic portal embolization (PTPE). A 58-year-old Japanese man underwent anterior resection of the rectum followed by central bisegmentectomy of the liver (S4 + S5 + S8) for rectal cancer with liver metastasis. Bile leakage from the cut surface of the posterior segment developed on postoperative day 2. Conservative management with simple drainage and ethanol injections into the fistula proved ineffective. Thus, we performed PTPE in the posterior portal branch to eliminate the production of bile from the posterior segment and to block the enterohepatic circulation to that segment. His post-treatment course was uneventful and the bile leakage resolved immediately.

Complete necrosis of a giant tumor in liver by transcatheter arterial embolization and percutaneous transhepatic portal embolization before liver resection

Complete necrosis of a giant tumor in liver by transcatheter arterial embolization and percutaneous transhepatic portal embolization before liver resection

Preoperative Portal Vein Embolization for Major Liver Resection

Preoperative portal vein embolization (PVE) is used clinically to prevent postoperative liver insufficiency. The current study examined the impact of portal vein embolization on liver resection. A comprehensive Medline search to identify all registered literature in the English language on portal vein embolization. Meta-analysis was performed to assess the result of PVE and its impact on major liver resection. A total of 75 publications met the search criteria but only 37 provided data sufficiently enough for analysis involving 1088 patients. The overall morbidity rate for PVE was 2.2% without mortality. Four weeks following PVE, 85% patients underwent the planned hepatectomy (n = 930). Twenty-three patients had transient liver failure following resection after PVE (2.5%) but 7 patients developed acute liver failure and died (0.8%). The reason for nonresection following PVE (n = 158, 15%) included inadequate hypertrophy of remnant liver (n = 18), severe progression of liver metastasis (n = 43), extrahepatic spread (n = 35), refusal to surgery (n = 1), poor general condition (n = 1), altered treatment to transcatheter artery embolization or chemotherapy (n = 24), complete remission after treatment with 3 cycles of fluoracil and interferon alpha in a patient with hepatocellular carcinoma (n = 1), incomplete pre- or postembolization scanning (n = 8). Of those who underwent laparotomy without resection, (n = 27) reasons included intraoperative finding of peritoneal dissemination (n = 15), portal node metastasis (n = 2), severe invasion of the tumor to the hepatic artery and portal vein (n = 1), and gross tumoral extension precluding curative resection (n = 9). Two techniques were used for portal vein embolization: percutaneous transhepatic portal embolization, (PTPE) and transileocolic portal embolization, (TIPE). The increase in remnant liver volume was much greater in PTPE than TIPE group (11.9% vs. 9.7%; P = 0.00001). However, the proportion of patients who underwent resection following PVE was 97% in TIPE and 88% PTPE, respectively (P = <0.00001). Although there was no significant difference in patients who had major complications post-PVE, the rate for minor complications was significantly higher among patients who had PTPE (53.6% vs. 0%, P = <0.0001). PVE is a safe and effective procedure in inducing liver hypertrophy to prevent postresection liver failure due to insufficient liver remnant.

Successful complete resection of biliary cystadenocarcinoma after percutaneous transhepatic portal embolization

An 82-year-old woman was admitted to our hospital with a full sensation in the abdomen and weight loss. On admission, a huge tumor without tenderness was palpated in the right upper abdomen. Laboratory evaluation revealed elevated serum levels of alkaline phosphatase (621 units/L), γ-guanosine triphosphate (169 units/L), aspartate aminotransferase (45 units/L), and carbohydrate antigen 19-9 (43 units/mL), but serum levels of total bilirubin and carcinoembryonic antigen were within normal ranges.

Physical hemodynamic interaction between portal venous and hepatic arterial blood flow in humans

The hepatic arterial end-diastolic velocity (HAEDV) is normally equal to portal vein peak velocity (PVPV). However, there is no report of quantitative measurement that HAEDV was equal to PVPV. We investigated the interaction in PVPV and HAEDV in both chronic and acute hepatic hemodynamic changes. One hundred and nineteen patients (54 with cirrhosis, 23 with chronic hepatitis, and 42 with no diffuse liver disorder) were enrolled. We investigated the differences in PVPV and HAEDV among the patients with and without liver disorder. In addition, we measured the intraindividual changes in HAEDV when PVPV was mechanically changed by percutaneous isolated hepatic perfusion in six patients and by percutaneous transhepatic portal embolization (PTPE) in six more. HAEDV was nearly equal to PVPV not only in patients with both normal and hepatitis but also in those with cirrhosis (PVPV-HAEDV = 3.0 +/- 5.2, 2.2 +/- 5.4, 2.3 +/- 6.5 cm/s, respectively). In the intraindividual study, both PVPV and HAEDV decreased during hepatic mechanical perfusion and HAEDV was equal to PVPV (8.2 +/- 2.8, 10.5 +/- 1.5 cm/s, respectively). After PTPE, PVPV was increased and hepatic arterial peak systolic velocity was reciprocally decreased. However, HAEDV was nearly equal to PVPV 7 days after PTPE (PVPV-HAEDV = 5.9 +/- 5.1 cm/s). Since arterial end-diastolic velocity depends on the downstream vascular resistance, lower HAEDV in patients with cirrhosis was considered to reflect a high outflow resistance. If there is no collateral pathway, we consider that HAEDV may actually reflect sinusoidal resistance to the same degree as PVPV.