Portal Vein Stenting Research Articles

Portal vein stenting as a significant risk factor for biliary stricture in adult living donor liver transplantation

Although perioperative portal vein (PV) stent implantation is an effective treatment for steno-occlusive disease in adult living donor liver transplantation (LDLT) recipients, we experienced high incidence of biliary anastomotic strictures (BAS) after PV stenting. In this study, we sought to clarify the relation between BAS and PV stenting and to suggest the possible mechanism of BAS and measures to reduce its incidence. We retrospectively analyzed 44 LDLT recipients who underwent PV stent implantation across the line of PV anastomosis regardless of the location of steno-occlusion (stent group) and their matched controls (non-stented LDLT recipients, n=131). The incidence of BAS was higher in patients in the stent group than that in the control group (43.2% vs 17.6%, P=0.001). Cumulative 6-month and 1-, 2- and 5-year BAS rates were 31.8%, 34.1%, 41.4% and 43.2%, respectively, in the stent group and 13.0%, 13.8%, 16.1% and 17.8%, respectively, in the control group (P=0.001). Multivariate analysis revealed that PV stenting was an independent risk factor for BAS. Although PV stent implantation is a reliable treatment modality for steno-occlusive PV in adult LDLT recipients, innovative methods to prevent the PV stent from crossing the line of PV anastomosis may be necessary to reduce the incidence of postoperative BAS.

Portal vein stent placement with or without varix embolization of jejunal variceal bleeding after hepatopancreatobiliary surgery.

Background Extrahepatic portal hypertension after surgery involving the duodenum or jejunum might result in massive ectopic variceal bleeding. Purpose To report the results of portal vein stent placement with the addition of variceal embolization. Material and Methods Between January 2000 and June 2015, portal vein stent placement was attempted in 477 patients. Of these, 22 patients (age, 63 ± 10 years) with jejunal variceal bleeding caused by portal vein obstruction after surgery were included in this study. Computed tomography (CT) findings before and after treatment and the rates of technical and clinical success, complications, and clinical outcomes were retrospectively evaluated. Results Stent placement was successful in 19 of 22 patients. Additional variceal embolization was performed in five cases. Clinical success, defined as the cessation of bleeding without recurrence within 1 month, was achieved in 18 of 19 patients with technical success. One patient developed recurrent bleeding 4 days after stent placement and was successfully treated with additional variceal embolization. There were no procedure-related complications. A regression of the jejunal varices was noted in 14 of 19 patients on follow-up CT scans. During the follow-up period (258 days; range, 7-1196 days), stent occlusion and recurrent bleeding occurred in six and four patients, respectively, of the 19 patients who achieved technical success. Statistical analyses revealed no significant differences regarding stent patency between benign and malignant strictures. Conclusion Percutaneous, transhepatic, portal vein stent placement with or without jejunal variceal embolization appears to be a safe and effective treatment for jejunal variceal bleeding after surgery.

Refractory bleeding from ectopic varices stopped by percutaneous transhepatic portal vein recanalization and stenting

Ectopic varices is an uncommon cause of gastrointestinal bleeding. We reported a case of severe bleeding due to jejunal varices which arose as a complication of extrahepatic portal vein thrombosis. The patient was successfully treated by portal vein recanalization and percutaneous transhepatic stent placement.

Endovascular implantation of iodine-125 seeds strand and portal vein stenting followed by transcatheter arterial chemoembolization combined therapy with sorafenib for hepatocellular carcinoma with main portal vein tumor thrombus

To compare the therapeutic effect of portal vein stenting and endovascular implantation of iodine-125 seeds strand followed by transcatheter arterial chemoembolization combined with or without sorafenib in patients for hepatocellular carcinoma (HCC) with main portal vein tumor thrombus (MPVTT). A total of 53 patients with HCC complicated by MPVTT who received portal vein stenting and endovascular implantation of iodine-125 seeds strand followed by transcatheter arterial chemoembolization combined without (group A, n=38) or with (group B, n=15) sorafenib in Affiliated Yancheng Hospital of Southeast University Medical College during January 2010 and August 2015 were analyzed retropectively.Overal survival, progress free survival and procedure-related adverse event were compared between the two groups. The technical success rate was 100% for placement of (125)I seeds strand and stent in the obstructed main portal vein.No serious procedure-related adverse events occurred. Median survival time of group A and B were 12.1 and 14.8 months, respectively (P=0.037). Additionally, Median progress free survival time of group A and B were 2.8 and 4.0 months, respectively (P=0.002). Endovascular implantation of iodine-125 seeds strand and portal vein stenting followed by transcatheter arterial chemoembolization combined with sorafenib could improve the survival time, the progress free survival time of patients with HCC complicated by MPVTT.

Portal Vein Stent Placement in Five Patients with Chronic Portal Vein Thrombosis Prior to Pancreatic Surgery

Five patients with pancreatic tumors and chronic portal vein (PV) thrombosis underwent PV stent placement before surgery. The patients either had resectable tumors or locally advanced tumors with stable, partial, or complete response to neoadjuvant therapy. PV stent placement removed periportal collaterals in all cases, with no complications, in a mean time of 150 minutes. Patients received a daily dose of subcutaneous low-molecular-weight heparin until 12 hours before surgery, and low-molecular-weight heparin was resumed for 30 days after surgery. Surgery was performed 1 day to 3 months after PV stent placement, with no complications related to periportal collaterals.

Portal vein stenting is a significant risk factor for biliary stricture in adult living donor liver transplantation: matched case-control study

Portal vein stenting is a significant risk factor for biliary stricture in adult living donor liver transplantation: matched case-control study

The value of primary vascular stents in management of early portal vein stenosis after liver transplantation

If portal vein stenosis (PVS) occurs within 1 month after liver transplantation (LT), especially within 1 week, it can be catastrophic and result in rapid loss of the grafts and mortality. Although surgical treatments have been considered standard treatment for PVS, patients are usually unable to receive operations or re-transplantations, because of their critical conditions and a shortage of grafts. Recently, primary percutaneous transhepatic portal vein stents (PTPS) were suggested as alternative and less-invasive treatments of PVS. However, because lethal complications may follow these primary stent placements for patients in early stages after LT, primary PTPS placements for patients suffering PVS 1 month after LT has been suggested. From November 2009 to July 2015, 38 consecutive adult patients underwent LT at our institution. Among them, six recipients suffered PVS within 1 month after LT. Technical success was achieved in all six patients. Clinical success was obtained in two of the four patients suffering PVS within 1 week after LT, and in the other two patients suffering PVS>1 week after LT. All surviving patients and their grafts were in good condition, and their stents remained patent. Our experience showed that primary PTPS placements can be used to effectively treat patients with PVS encountered within 1 month, and even within 1 week, after LT with acceptable short-term results. However, possible fatal complications should be kept in mind. Long-term results of these procedures need further follow-up.

Therapeutic efficacy and stent patency of transhepatic portal vein stenting after surgery.

AIMTo evaluate portal vein (PV) stenosis and stent patency after hepatobiliary and pancreatic surgery, using abdominal computed tomography (CT).METHODSPercutaneous portal venous stenting was attempted in 22 patients with significant PV stenosis (> 50%) - after hepatobiliary or pancreatic surgery - diagnosed by abdominal CT. Stents were placed in various stenotic lesions after percutaneous transhepatic portography. Pressure gradient across the stenotic segment was measured in 14 patients. Stents were placed when the pressure gradient across the stenotic segment was > 5 mmHg or PV stenosis was > 50%, as observed on transhepatic portography. Patients underwent follow-up abdominal CT and technical and clinical success, complications, and stent patency were evaluated.RESULTSStent placement was successful in 21 patients (technical success rate: 95.5%). Stents were positioned through the main PV and superior mesenteric vein (n = 13), main PV (n = 2), right and main PV (n = 1), left and main PV (n = 4), or main PV and splenic vein (n = 1). Patients showed no complications after stent placement. The time between procedure and final follow-up CT was 41-761 d (mean: 374.5 d). Twenty stents remained patent during the entire follow-up. Stent obstruction - caused by invasion of the PV stent by a recurrent tumor - was observed in 1 patient in a follow-up CT performed after 155 d after the procedure. The cumulative stent patency rate was 95.7%. Small in-stent low-density areas were found in 11 (55%) patients; however, during successive follow-up CT, the extent of these areas had decreased.CONCLUSIONPercutaneous transhepatic stent placement can be safe and effective in cases of PV stenosis after hepatobiliary and pancreatic surgery. Stents show excellent patency in follow-up abdominal CT, despite development of small in-stent low-density areas.

Portal Vein Stenting Combined with Iodine-125 Seeds Endovascular Implantation Followed by Transcatheter Arterial Chemoembolization for Treatment of Hepatocellular Carcinoma Patients with Portal Vein Tumor Thrombus.

Aim was to assess the therapeutic value of portal vein stenting (PVS) combined with iodine-125 seed (125I seed) strand endovascular implantation followed by transcatheter arterial chemoembolization (TACE) for treating patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT). This was a retrospective study of 34 patients aged 29–81 years, diagnosed HCC with PVTT, and treated with PVS combined with 125I seed strand endovascular implantation followed by TACE between January 2012 and August 2014. Survival, stent patency, technical success rate, complications related to the procedure, and adverse events were recorded. The technical success rate was 100%. No serious procedure-related adverse event was recorded. The median survival was 147 days. The cumulative survival rates and stent patency rates at 90, 180, and 360 days were 94.1%, 61.8%, and 32.4% and 97.1% (33/34), 76.9% (24/34), and 29.4% (10/34), respectively. PVS combined with 125I seed strand endovascular implantation followed by TACE is feasible for patients with HCC and PVTT. It resulted in appropriate survival and stent patency, with no procedure-related adverse effects.

Endoscopic ultrasonography-guided placement of a transhepatic portal vein stent in a live porcine model.

Background and Objectives:Percutaneous portal vein (PV) stent placement is used to manage PV occlusion or stenosis caused by malignancy. The use of endoscopic ultrasonography (EUS) has expanded to include vascular interventions. The aim of this study was to examine the technical feasibility and safety of EUS-guided transhepatic PV stent placement in a live porcine model.Materials and Methods:EUS-guided transhepatic PV stent placement was performed in six male miniature pigs under general anesthesia using forward-viewing echoendoscope. Under EUS guidance, the left intrahepatic PV was punctured with a 19-gauge fine-needle aspiration (FNA) needle and a 0.025 inch guidewire inserted through the needle and into the main PV. The FNA needle was then withdrawn and a needle-knife inserted to dilate the tract. Under EUS and fluoroscopic guidance, a noncovered metal stent was inserted over the guidewire and released into the main PV.Results:A PV stent was placed successfully in all six pigs with no technical problems or complications. The patency of the stent in the main PV was confirmed using color Doppler EUS and transhepatic portal venography. Necropsy of the first three animals revealed no evidence of bleeding and damage to intra-abdominal organs or vessels. No complications occurred in the remaining three animals during the 8 weeks observation period.Conclusions:EUS-guided transhepatic PV stent placement can be both technically feasible and safe in a live animal model.

Percutaneous transhepatic portal vein stenting for malignant portal vein stenosis secondary to recurrent perihilar biliary cancer.

Transhepatic portal vein (PV) stenting has been shown to be one of the most important treatments for patients with PV stenosis caused by hepatopancreatobiliary malignancy. Ten consecutive patients with PV stenosis caused by the recurrence of a perihilar biliary malignancy underwent transhepatic PV stenting. A self-expandable metallic stent was deployed at the stenosis site. The patients were retrospectively analyzed with regard to the procedure, complications, and survival after the stent placement. The median interval between the primary resection and the PV stenting was 22 months. The initial hepatic resection was a left trisectionectomy with caudate lobectomy in seven patients, a left hepatectomy with caudate lobectomy in one patient, a right anterior sectionectomy with caudate lobectomy following a left hepatectomy in one patient and a partial liver resection in one patient. The angle of the PV around the stenosis was greater in the patients with PV stenosis located in the right posterior PV. Eight patients with successful PV stent placement were able to receive anticancer treatment, with a median survival of 14 months. The remaining two patients without successful PV stent placement survived less than 6 months. Portal vein stenting might offer relief from the symptoms associated with PV hypertension and the opportunity for sustainable anticancer therapy in patients with recurrent perihilar biliary malignancy.

Vascular complications in biliary atresia patients undergoing living donor liver transplantation: Analysis of 110 patients over 10 years.

Introduction:Vascular complications are very common in pediatric living donor liver transplants. We present our experience in vascular complications in biliary atresia patients undergoing liver transplantation.Materials and Methods:All the patients who have undergone living donor liver transplant for biliary atresia from January 2003 to March 2013 were retrospectively analyzed. P value < 0.05 was considered to be statistically significant.Results:Total 110 patients have undergone living donor liver transplantation for biliary atresia between January 2003 and March 2013. There were 56 males and 54 females. Median age at transplant was 13.5 months. Eleven were primary transplants and 99 were post KASAI procedure. One hundred left lateral, four left lobe, and four right lobe grafts were used. Twenty-two patients developed vascular complications. Twelve patients developed hepatic artery thrombosis. Eleven patients of hepatic artery thrombosis were managed with redo hepatic artery anastomosis and one patient managed with radial artery interposition graft. Five patients developed portal vein stenosis and were managed by portal vein stenting. Five patients developed portal vein thrombosis and portal vein thrombectomy and re-anastomosis were done. One patient developed stenosis at the site of venous anastomosis and was managed by stenting. One patient developed both hepatic artery thrombosis and portal vein thrombosis and eventually succumbed to these complications. Out of five cases who died in this study, two had vascular complications. Graft/recipient weight ratio (GRWR) greater than 2.5 was significantly associated with vascular complications (P = 0.017).Conclusion:Vascular complications are frequently seen in liver transplantation for biliary atresia. Large for size grafts, weight less than 10 kg, age less than 1 year, and prolonged warm ischemia time is significantly associated with vascular complications.

Assessment of percutaneous transhepatic portal vein embolization with portal vein stenting for perihilar cholangiocarcinoma with severe portal vein stenosis.

The aim of the present study was to assess the clinical efficiency of portal vein (PV) stenting when performed with preoperative percutaneous transhepatic portal vein embolization (PTPVE) in patients with severe PV stenosis due to tumor invasion. Between 2007 and 2013, four consecutive patients (one male, three females; mean age, 52 years; age range, 25-73 years) with perihilar cholangiocarcinoma and PV stenosis underwent PTPVE and PV stenting. Patients were analyzed with regard to the procedure, hypertrophy of the future remnant liver (FRL), and plasma clearance rate of indocyanine green by the FRL (ICGK-F). Further, the %FRL volume increase in PTPVE was compared between the stenting group and the usual PTPVE group who have perihilar cholangiocarcinomas without PV stenosis. Preoperative PTPVE with PV stenting was successfully performed and portal flow to the FRL improved after stenting in all four patients. The %FRL volume increase was 18-60% (mean, 34%) in the stenting group and was 12-51% (mean, 21%) in the usual PTPVE group. The ICGK-F value after PTPVE exceeded 0.05 in all four patients. All patients achieved R0 resection. Preoperative PTPVE with PV stenting appears to be feasible in cases of severe PV tumor invasion and stenosis. This procedure may allow a broader indication for surgery.

Transcatheter embolotherapy with N-butyl cyanoacrylate for ectopic varices.

To address technical feasibility and clinical outcome of transcatheter embolotherapy with N-butyl cyanoacrylate (NBCA) for bleeding ectopic varices. The institutional review board approved this retrospective study and waived informed consent. From January 2004 to June 2013, a total of 12 consecutive patients received transcatheter embolotherapy using NBCA for bleeding ectopic varices in our institute. Clinical and radiologic features of the endovascular procedures were comprehensively reviewed. Preprocedural computed tomography images revealed ectopic varices in the jejunum (n = 7), stoma (n = 2), rectum (n = 2), and duodenum (n = 1). The 12 procedures consisted of solitary embolotherapy (n = 8) and embolotherapy with portal decompression (main portal vein stenting in 3, transjugular intrahepatic portosystemic shunt in 1). With regard to vascular access, percutaneous transhepatic access (n = 7), transsplenic access (n = 4), and transjugular intrahepatic portosystemic shunt tract (n = 1) were used. There was no failure in either the embolotherapy or the vascular accesses (technical success rate, 100 %). Two patients died within 1 month from the procedure from preexisting fatal medical conditions. Only one patient, with a large varix that had been partially embolized by using coils and NBCA, underwent rebleeding 5.5 months after the procedure. The patient was retreated with NBCA and did not undergo any bleeding afterward for a follow-up period of 2.5 months. The remaining nine patients did not experience rebleeding during the follow-up periods (range 1.5-33.2 months). Transcatheter embolotherapy using NBCA can be a useful option for bleeding ectopic varices.

Section 8. Management of portal venous complications in pediatric living donor liver transplantation.

Portal vein (PV) complications after living donor liver transplant (LDLT) have been a major concern in pediatric liver transplantation. The incidence of PV complications is more in pediatric (0%-33%) than in adult recipients. Early diagnosis and treatment of PV complications may ensure optimal graft function and good recipient survival. Small preoperation PV size (<4 mm) and slow portal flow (<10 cm/s) combined with lower hepatic artery resistance index (<0.65) are strong warning signs that may predict the development of post LDLT PV complications. Portal vein angioplasty/stenting is conventionally performed through the percutaneous transhepatic approach; however, this can also be performed through transjugular, trans-splenic, and intraoperative approaches. Depending on the situation, using optimal method is the key point to minimize complication (5%) and gain high success rate (80%). PV occlusion of greater than 1 year with cavernous transformation seems to be a factor causing technical failure. Good patency rate (100%) with self-expandable metallic stents was noted in long-term follow-up. In conclusion, PV stent placement is an effective, long-term treatment modality to manage PV complications after pediatric LDLT. Early diagnosis and treatment are essential to maximize the use of stent placement and achieve good success rates.

Portal vein stenting combined 125I particle implanted followed by transarterial chemoembolization in the treatment of hepatocellular carcinoma with portal vein tumor thrombus

Objective To assess the clinical value of portal vein stenting (PVS) combined 125I particle implanted followed by transcatheter arterial chemoembolization (TACE) in the treatment of hepatocellular carcinoma (HCC) with main portal vein tumor thrombus (MPVTT).Methods The clinical data of 26 patients with HCC accompanied with MPVTT were retrospectively analyzed.All the patients received PVS combined 125I particle implanted first and TACE treatment later.The patients were followed-up and the cumulative survival rate was calculated.Results There were 25 male,one female and the median age was 49 years.Sixteen cases had multiple lesions in the liver and 10 cases had single lesion.Among those,the lesion of eight cases was in right lobe and two in left lobe.A total of six patients with right portal vein tumor thrombus,three with left portal vein tumor thrombus,13 with main and right portal vein tumor thrombus and four with main and left portal vein tumor tbrombus.The liver function grading of 20 patients was Child-Pugh A and six was Child-Pugh B.All the patients received PVS combined 125I particle implanted followed by TACE treatment successfully,the success rate of operation was 100％.A total of 26 stents and 28 125I particle chains (520 125I particles) were implanted and 55 TACE were operated.In all the patients,no severe complications,such as puncture bleeding,bile leak complicated by infection,liver abscess,abdominal bleeding,tumor rupture bleeding and gastrointestinal bleeding occurred.After operation,patients were followed-up for 6 to 15 months.The survival rates at 3th,6th,9th,12thand 15thmonth were 100.0％ (26/26),61.5％ (16/26),53.8％ (14/26),30.8％ (8/26) and 15.4％ (4/26),respectively.The stent patency rates were 96.2％ (25/26),76.9％ (20/26),57.7％ (15/26),23.1％ (7/26) and 7.7％ (2/26),respectively.Among 16 dead patients,two died of lung metastasis,five died of gastrointestinal bleeding,six died of liver failure,and one died of brain metastases,one died of vertebral metastases,one died of heart failure for tumor invasion in atrial.Conclusion Treated by PVS combined 125I particle implanted followed by TACE,HCC patients with MPVTT complication may obtain a long stent patency and survival time. Key words: Carcinoma, hepatocellular; Portal vein; Neoplasm circulating cells; Stents; Iodine radioisotopes; Chemoembolization, therapeutic

Portal Vein Stenting to Treat Portal Vein Stenosis in a Patient With Malignant Tumor and Gastrointestinal Bleeding

This report describes the successful use of portal venous stent placement for a patient with recurrent melena secondary to jejunal varices that developed after subtotal stomach preserved pancreatoduodenectomy (SSPPD). A 67-year-old man was admitted to our hospital with tarry stool and severe anemia at 2 years after SSPPD for carcinoma of the head of the pancreas. Abdominal computed tomography examination showed severe stenosis of the extrahepatic portal vein caused by local recurrence and showed an intensely enhanced jejunal wall at the choledochojejunostomy. Gastrointestinal bleeding scintigraphy also revealed active bleeding near the choledochojejunostomy. Based on these findings, jejunal varices resulting from portal vein stenosis were suspected as the cause of the melena. Portal vein stenting and balloon dilation was performed via the ileocecal vein after laparotomy. Coiling of the jejunal varices and sclerotherapy of the dilate postgastric vein with 5% ethanolamine oleate with iopamidol was performed. After portal stent placement, the patient was able to lead a normal life without gastrointestinal hemorrhage. However, he died 7 months later due to liver metastasis.

Percutaneous transhepatic portal vein stenting in a patient with benign non-transplant postoperative portal vein stenosis: A case report

Extrahepatic portal vein stenosis is caused by a variety of benign and malignant diseases and results in development of symptoms due to portal hypertension. Benign post-surgical adhesions causing portal vein stenosis in non-transplant population is an uncommon etiology of portal hypertension. Endovascular treatment of such patients with angioplasty and stenting is uncommonly reported in literature. We report a case of portal hypertension caused by benign postoperative portal vein fibrosis, successfully treated by self-expandable metallic stent.

A bidirectional approach for portal vein stent placement in a child with complete portal vein occlusion after living donor liver transplantation

Delayed PV complications are not rare in pediatric liver transplantation. Although PTPV offers a treatment and minimizes surgical revision, in case of complete PV thrombosis (PVT), the failure rate of PTPV is high. Herein, we report a successful technique of PTPV in a case of complete PVT with a stent placement using a bidirectional approach in a child with living donor liver transplantation.

More Than 300 Consecutive Living Donor Liver Transplants a Year at a Single Center

BackgroundLiving donor liver transplantation (LDLT) has been the first option for the patients requiring liver transplantation in East Asia because of the scarcity of cadaveric grafts. We have performed consecutively more than 300 LDLTs per year, and herein report our methods. MethodsIn 1997, the first successful adult LDLTs used a left and subsequently a right lobe. However, congestion in the anterior segment of right-lobe grafts prompted us to initiate reconstruction of middle hepatic venous tributaries in 1998. Dual LDLT grafts using 2 left lobes were developed in 2000 to solve graft-size insufficiency and minimize donor risk. The indications for adult LDLT were broadened to near complete obstruction of the portal vein by application of intraoperative cine-portography and portal vein stenting in 2004. ABO-incompatible adult LDLT was initiated in 2008 to overcome the blood group barrier between recipient and donor. ResultsWith various innovations at our institution, 317 LDLTs were performed yearly in 2010 and 2011: 301 in 2010 and 298 in 2011. The most common primary diseases was hepatitis B virus-related liver cirrhosis with or without hepatocellular carcinoma (64.3%). The most common graft types were right hemiliver (82.6%). There has been no donor mortality. ABO-incompatible LDLT cases were 11.0% of the total. In-hospital mortality in 2011 was 2.5% (n = 8; adult 6, pediatric 2). ConclusionInnovations in operative techniques and perioperative care as well as dedicated team members have made it possible to perform more than 300 LDLTs per year consecutively with excellent outcomes.