Venous Collaterals Research Articles

Percutaneous transhepatic treatment of a unique portal vein malformation with portal hypertension in a pediatric patient

BackgroundAnomalies of the portal venous system can be congenital or acquired, the latter being related to spontaneous thrombosis or iatrogenic alterations such as complications of perinatal catheterization of the umbilical vein. These conditions can be clinically silent for years and then manifest abruptly causing severe clinical emergencies.Case presentationThis case report describes the diagnosis and interventional management of a singular abnormality in the portal venous system of an 8-year-old female that led to severe portal hypertension and acute variceal bleeding. Peculiar imaging findings were not pathognomonic for any of the known congenital and acquired portal vein anomalies: absence of a normal extrahepatic portal vein; splenic and mesenteric veins merging into a dilated left gastric vein; presence of an aberrant mesenteric venous collateral with a stenotic connection with the intrahepatic right portal branch; and absence of porto-systemic shunt. The case was successfully managed with percutaneous transhepatic portography and angioplasty.ConclusionsPrompt non-invasive imaging characterization allowed to understand the singular vascular abnormality and mini-invasive interventional radiology management resolved portal hypertension and variceal bleeding.

Subclavian venoplasty: A second life to the upper limb

Venoplasty, a forgotten art now rescued the upper limb circulation and made the left brachial arteriovenous fistula for hemodialysis functional avoiding the long-time need of a femoral arteriovenous fistula for hemodialysis. We report a rare case of successful left subclavian venoplasty in a 43-year-old male with end-stage chronic kidney disease on alternate day hemodialysis therapy with critical chronic total occlusion of the left subclavian vein secondary to traumatic central line insertion 8 months back presenting with gross wet edema of the left upper limb with visible venous collaterals over the left neck and the left anterior chest wall. Due to acquired left subclavian stenosis, the left brachial arteriovenous fistula for hemodialysis became non-functional and the patient was on alternate day hemodialysis with right femoral arteriovenous fistula.

Chronic electrical performance of a new ultra-thin left ventricular quadripolar pacing lead

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): H2020-FTI [Fast Track to Innovation] Pilot-2016 and MicroPort CRM Background Left ventricular (LV) lead positioning is an important contributor to cardiac resynchronization therapy (CRT) response. Multiple additional LV sites could be stimulated by passing a new ultra-thin (1.2 Fr, 0.4 mm) quadripolar microlead from one LV vein into another via venous collaterals. Purpose Study the acute and chronic stability and electrical pacing performance of a novel 1.2 Fr quadripolar microlead ("Axone 4LV"). Methods Seven healthy adult dogs underwent CRT defibrillator implantation, including a right ventricular lead and the microlead. The microlead was advanced into the coronary sinus network using a dedicated microguide catheter. The animals were followed up at 1, 15, 30 and 90 days post-implant to evaluate chronic stability and electrical pacing performance. Results Successful uncomplicated implantation was achieved in all cases. Despite the small diameter of the distal veins and collaterals, placement of the pacing electrodes in two different LV veins was feasible via available collateral passages. Lead position was stable in all cases and over the entire study period. Capture threshold and pacing impedance at 90 days post-implant were 1.7 ± 0.5 V with 1323 ± 245 Ω, respectively, at 0.5 ms pulse width. The mean pacing energy to get capture was 1.1 ± 0.5 µJ and less than 2 µJ in all cases (2 µJ ≈ 1.4 V @500 Ω, 0.5 ms). No phrenic nerve stimulation was observed during pacing. Conclusions The novel 1.2 Fr quadripolar microlead demonstrated adequate stability and good electrical performance allied to low energy consumption. This quadripolar microlead may extend pacing options while increasing device longevity in CRT. Changes in pacing parameters over time Post-implant Follow-up Pacing Threshold Pacing Impedance Pacing Energy 1 day 1.4 ± 0.7 V 1294 ± 270 Ω 0.8 ± 0.7 µJ 15 days 1.9 ± 0.9 V 1336 ± 274 Ω 1.8 ± 1.8 µJ 30 days 1.8 ± 0.7 V 1187 ± 303 Ω 1.5 ± 1.2 µJ 90 days 1.7 ± 0.5 V 1323 ± 245 Ω 1.1 ± 0.5 µJ

Pulmonary-to-systemic venous collateral in obstructed supracardiac totally anomalous pulmonary venous connection: Blood finds a way!

We describe a rare variant of obstructed supracardiac totally anomalous venous connection in a 7-day-old boy where the vertical vein was occluded and the entire pulmonary venous return was draining through a large tortuous pulmonary-systemic venous collateral. The case highlights the importance of computed tomography angiography in demonstrating such complex anatomies in congenital heart diseases.

Impact of transjugular intrahepatic portosystemic shunt creation on the central lymphatic system in liver cirrhosis

The puropse of this study was to evaluate associations of cisterna chyli (CCh) diameter with portal hemodynamics and the influence of TIPS-creation in cirrhotic patients. 93 cirrhotic patients (57 male, mean age 59 years) received CT prior to TIPS-creation. 38/93 additionally underwent post-interventional CT. CCh-diameter was measured. After categorization into patients with and without large venous collaterals (i.e. > 6 mm), data were analyzed regarding associations between CCh-diameter, clinical and portal-hemodynamic parameters and diameter-changes after TIPS-creation. Patient survival post-TIPS was analyzed. Median portosystemic pressure-gradient decreased from 20 to 9 mmHg after TIPS-creation. Large venous collaterals were observed in 59 patients. In 69/93 patients (74.2%) the CCh was detectable. Mean pre-interventional diameter was 9.4 ± 2.7 mm (large collaterals: 8.7 ± 2.0 mm, no large collaterals: 10.7 ± 3.2 mm, p = 0.003). CCh-diameter correlated strongly with pre-TIPS portal-pressure (Rs = 0.685, p = 0.0001), moderately with portosystemic-gradient (Rs = 0.524, p = 0.006), liver shear-wave-elastography (Rs = 0.597, p = 0.004) and spleen size (Rs = 0.501, p = 0.01) in patients without large collaterals, but not in patients with large collaterals. Post-TIPS CCh-diameter decreased significantly from 10.2 ± 2.8 mm to 8.3 ± 3.0 mm (p < 0.001). Patients without a detectable CCh on CT survived significantly shorter. The diameter of the CCh is associated with portal-pressure and decreases after TIPS-creation in cirrhotic patients, reflecting a portal decompression mechanism via the lymphatic system. Lack of larger central lymphatics detectable on CT may be associated with shorter survival.

Endovascular management of nutcracker syndrome in an adolescent patient population

Nutcracker syndrome is defined as left renal vein compression with concomitant clinical symptoms that include flank pain and hematuria. Historically, pediatric and adolescent patients with mild symptoms of nutcracker syndrome were simply observed while those with more severe symptoms underwent left renal vein transposition. Endovascular stenting of the left renal vein is a potentially efficacious and less invasive alternative for managing nutcracker syndrome in adolescents. The purpose of this study was to investigate the technical feasibility, efficacy and safety of left renal vein stenting in adolescents with nutcracker syndrome. We conducted a retrospective review of electronic medical records and imaging archives to identify adolescents undergoing endovascular stenting for nutcracker syndrome. We reviewed patient demographics including age, gender, presenting symptoms and diagnostic imaging findings. We compared pre- and post-stent deployment intravascular ultrasound (IVUS) and venography and evaluated patient symptoms in clinic up to 6months following stent placement. Ten patients (average age 16years, range 12-20years) underwent 13 procedures. Initial symptoms included pain (n=10) and gross hematuria (n=5). Diagnostic imaging studies included CT abdomen pelvis (n=8), retroperitoneal US (n=6), MRI abdomen/pelvis (n=4), scrotal US (n=2), pelvic US (n=1) and renal Doppler US (n=2). Venography and IVUS demonstrated venous collaterals, proximal blanching at the left-renal-vein-IVC junction, pre-stenotic dilation and intraluminal compression. Most patients (n=9) experienced symptomatic resolution; however, three patients required reintervention to achieve asymptomatic status. No periprocedural complications occurred. In this carefully selected adolescent cohort, left renal vein stenting for nutcracker syndrome was often technically feasible, safe and effective in symptom management.

A226 INCIDENTAL FINDING OF A LARGE GASTRIC VARIX ASSOCIATED WITH NEONATAL UMBILICAL VEIN CANALIZATION

Abstract Results A 41-year old Asian male, who immigrated to Canada many years ago, and who had previously been successfully treated for Helicobacter pylori infection underwent gastroscopy for investigation of dyspepsia. His gastroscopy was normal except for a large subepithelial abnormality that was noted close to the gastroesophageal junction. Routine gastric biopsies from the antrum and body were normal. Subsequent endoscopic ultrasound revealed flow through the anechoic tortuous lesion and confirmed it was a very large isolated gastric varix type 1. Abdominal CT scan revealed chronic occlusion of the portal vein, splenic vein, and the portal confluence with extensive collateralization in the upper abdomen. There was complete cavernous transformation of the portal vein. Of the numerous varices in the upper abdomen, a very large varix drained into the left renal vein and indented into the posterior wall of the fundus of the stomach which accounted for the endoscopic finding. Multiple mesenteric veins were identified that connected to varices adjacent to the inferior aspect of the pancreas and duodenum. Notably, there was no evidence of cirrhosis or chronic pancreatitis. Liver enzymes, albumin, and INR were normal. Further collateral history revealed that he was hospitalized as a neonate for pneumonia with catheterization of the umbilical vein, which is known to be associated with thrombosis of the portal vein. Conclusions Detection of congenital absence of the portal vein (CAPV) is recognized more often due to advances in diagnostic imaging. Radiologically, the absence of the portal vein in CAPV is distinguished from portal vein thrombosis by the lack of venous collaterals or sequalae of portal hypertension, such as ascites or splenomegaly. A more gradual thrombosis of the portal vein may permit collaterals to develop without acute changes and is not equivalent to portal vein aplasia or agenesis as intrahepatic bile ducts are normal. The gold standard for diagnosis of CAPV is histologic absence of the portal vein in the liver on catheter angiography. CAPV is associated with abnormal embryologic development of the portal vein and frequently presents with complications of portal hypertension or portosystemic encephalopathy or the sequalae of venous shunts, hepatic or cardiac abnormalities found on imaging. Our case is an incidentally discovered absence of the portal venous system due to chronic thrombosis with extensive collateralization and an enlarged gastric varix protruding into the proximal stomach. It is well documented that canalization of the umbilical vein in infancy is associated with portal vein thrombosis, with incidences up to 68%. This case highlights the importance of eliciting a childhood hospitalization history in cases of non-cirrhotic portal hypertension. Funding Agencies None

Exploring a New Systematic Route for Left Ventricular Pacing in Cardiac Resynchronization Therapy.

Frequency and distribution of left ventricular (LV) venous collaterals were studied in vivo to evaluate the ease and feasibility of implanting a new ultra-thin LV quadripolar microlead for cardiac resynchronization therapy (CRT). Evaluable venograms were analyzed to define the prevalence of venous collaterals (>0.5 mm diameter) between: (1) different LV segments; and (2) different major LV veins in: unselected patients who underwent CRT from 2008 to 2012 at Rouen Hospital, France (retrospective); and CRT patients from the Axone Acute pilot study in 2018 (prospective). In prospective patients with evaluable venograms, LV microlead implantation was attempted. Thirty-six (21/65 retrospective, 15/20 prospective) patients had evaluable venograms with ≥1 visible venous collaterals. Collaterals were found between LV veins in all CRT patients with evaluable venograms. Regionally, prevalence was highest between: the apical inferior and apical lateral (42%); and mid inferior and mid inferolateral (42%) segments. Collateral connections were most prevalent between: the inferior interventricular vein (IIV) and lateral vein (64% [23/36]); and IIV and infero-lateral vein (36% [13/36]). Cross-vein microlead implantation was possible in 18 patients (90%), and single-vein implantation was conducted in the other 2 patients (10%). Venous collaterals were found in vivo between LV veins in all CRT patients with evaluable venograms, making this network an option for accessing multiple LV sites using a single LV microlead.

The spontaneous resolution of a vortex vein varix: case report

BackgroundThe natural course of a vortex vein varix, though not well understood, has been known to remain stable. However, here we report a novel case of a vortex vein varix that resolved after an extended period of monitoring.Case presentationAn asymptomatic 96-year-old Caucasian man was found to have a vortex vein varix. At his previous examination 13 months prior, his fundus was normal. At 13 months of observation, his vortex vein varix become clinically undetectable. Further follow-up confirmed continued absence of the varix.ConclusionThis case demonstrates the development then clinical resolution of a vortex vein varix with no clear identifiable factors for its evolution. This case is novel and offers new insight into the natural history of some vortex vein varices, implicating venous congestion as an instigator and venous collateralization as its alleviator, suggesting that vortex vein varices are likely more common than previously reported since some may be temporary and under-identified.

Direct splenic vein reconstruction combined with resection of the portal vein/superior mesenteric vein confluence during pancreaticoduodenectomy.

Splenic vein (SV) ligation combined with portal vein (PV)/superior mesenteric vein (SMV) confluence resection during pancreaticoduodenectomy (PD) is reported to cause left-side portal hypertension (LPH). The purpose of this study was to present our technique of the SV reconstruction and to evaluate the surgical outcomes with/without SV ligation during PD. Twenty-four patients undergoing PD with PV and/or SMV resection and being followed over 4 months after surgery between March 2013 and December 2019 in our hospital were evaluated. Resection of the PV/SMV confluence were performed in 14, and SV reconstruction was successfully performed in 3. Presence of LPH was assessed by examining changes in splenic volume, newly venous collateral formation, and platelet counts before and 4-8 months after PD. Surgical technique is the direct anastomosis between SV and PV. Splenic volume ratio was significantly higher in the SV ligation group (n = 11) than in the SV preservation group (n = 13) (median (range) 1.11 (0.57-1.62) vs. 1.68 (1.05-2.22), p < 0.01), but no significant differences were found in the incidence of newly formed venous collaterals or platelet counts between groups. SV ligation may represent the cause of LPH after PD combined with resection of PV/SMV confluence. Our simple procedure may help decrease the incidence of LPH.

COLATERAL BLOOD FLOW AT THROMBOSIS IN THE FEMORAL VENOUS COLLECTOR

Anatomical features of collateral circulation of a hip influence on the severity of a clinical picture at deep thromboses and play a role in the prevention of complications. This necessitates the assessment of collateral blood flow.&#x0D; The aim of research: to evaluate the compensatory possibilities of the collateral blood flow in the femoral venous collector in the acute venous thrombosis.&#x0D; Methods. The analysisis made of results examination and treatment of 790 patients with the acute thrombosis in the vena cava inferior system and being treated at the Transcarpathian Regional Clinical Hospital named after A. Novak and the Transcarpathian Regional Clinical Oncology Center during 2006–2016. The laboratory methods and the instrumental ones (ultrasound duplex scanning, X-ray phlebography, computed tomography, radionuclide flebo scintigraphy and ultrasound scanning of heart) were used for investigation of patients,&#x0D; Results of research. Deep vein thrombosis in the popliteal-femoral segments was observed in 322 (40.8%) of 790 patients. At the occlusion of the popliteal-femoral segments in the collateral blood flow take part the next vessels: superficial (large subcutaneous vein, small subcutaneous vein, posterior cutaneous femoral vein) and deep (deep femoral vein, vein-satellites of the main arteries, popliteal-femoral-sciaticpath, v. articularis genusuprema, vv. comitans n. ischiadici and abnormal femoral collateral), which quickly off set violations.&#x0D; At the spread of thrombosis to general femoral vein, the clinical picture of the disease becomes more pronounced, due to the exclusion from the blood flow of deep femoral vein and most superficial venous collaterals (posterior cutaneous femoral vein and large subcutaneous vein), which leads to a sharp decompensation of venous outflow.&#x0D; Conclusions. At the deep vein thrombosis in the popliteal-femoral segment the venouscollaterals, whichin 98.4% of cases occur secondarily, quickly compensate for hemodynamicdisorders, but at progression of thrombosis and exclusion of deep femoral and large subcutaneous veins in popliteal-femoral segments the decompensation of venous blood flow rapidly.&#x0D; Thrombosis of deep veins in the popliteal-femoral segment occurs secondarily, due to the spread of thrombotic masses from the tibial veins. The jugular vein share the source of thrombosis in only 1.6% of patients.&#x0D; At occlusion of a popliteal-femoral venous segment in collateral blood flow the following vessels participate: superficial (LSV, SSV, a back cutaneousvein of a hip) and deep (DFV, veins-satellites of the main arteries, popliteal-femoral-sciatic way, v. Articularis us vv. comitans n. Ischiadici and abnormal femoral collaterals), which quickly eliminate hemodynamic disturbancesin the popliteal-wall segment.&#x0D; The most pronounced clinical symptoms of deep vein thrombosis in the popliteal-femoral segment are observed when excluding from the collateral blood flow of the deep femoral and great saphenous veins.

Hepatic Venous Outflow Obstruction in Polycystic Liver Disease

Background: The development of prolonged ascites in posthepatectomy polycystic liver disease (PCLD) patients is not well understood. The pathology may be related to hepatic vein outflow obstruction (HVOO). Herein we describe posthepatectomy patients with preoperative hepatic venous collateralization who developed prolonged ascites in the setting of polycystic liver disease. Methods: A single institution cohort of 183 patients with PCLD undergoing partial hepatectomy between 1987 and 2014 was retrospectively reviewed. Of those, 90 patients had preoperative imaging available for analysis. Prolonged ascites was defined as greater than 200 cc of intraperitoneal drain (IP) output per day after postoperative day 5 or the need for an IP drain greater than 2 weeks. HVOO was defined as non-thrombotic obstructive involvement of the large HVs and or IVC. Results: A total of 90 patients with preoperative imaging underwent liver resection. No patients presented with clinically significant ascites preoperatively. Among this cohort 88% were female and the mean age was 49 years. Posthepatectomy liver failure occurred in 8 (9%) of patients and was not significant in patients with prolonged ascites. All 90 patients demonstrated non-thrombotic HVOO (60% IVC, 94% HV and 76% IVC+HV involvement) on preoperative imaging. Prolonged postoperative ascites was seen in 71% of patients; this was significantly higher in those with hepatic venous collateralization (52 vs 12 p=0.001). Conclusions: Patients with PCLD also had HVOO and frequently developed venous collateralization. Operative disruption of this may result in prolonged postoperative ascites. Collateralization is a strong parameter to be considered when electing a surgical intervention.

Successful Endovascular Treatment for Recanalized Post-Traumatic Carotid-Cavernous Fistula

Carotid-cavernous fistulas (CCFs) are spontaneous or acquired communications between the internal carotid artery (ICA) and the cavernous sinus, which can be classified as direct or indirect. Direct fistulas between the ICA and the cavernous sinus can arise from injury, rupture of intracavernous carotid aneurysm, collagen deficiency syndrome, artery dissection, fibromuscular dysplasia, and direct surgical trauma. The symptoms caused by CCF are related to their size, duration, location, the direction of venous outflow, and the presence of arterial and venous collaterals. The goal of treatment for direct CCFs is to close the defect between the ICA and the cavernous sinus while maintaining the patency of the ICA. This goal can be achieved either by transarterial fistula occlusion using a removable balloon, transarterial or transvenous occlusion of the ipsilateral cavernous sinus with coils or other embolic material, or by implanting a covered stent in the fistula area. The choice of a method for CCF treatment remains relevant. The paper describes a clinical case of successful endovascular treatment for post-traumatic recanalized CCF in a patient with obvious ophthalmic manifestations as pulsating exophthalmos, conjunctival chemosis, and ischemic optic neuropathy of the right eye. Previously, the patient had undergone endovascular CCF embolization with coils and ICA reconstruction with flow diverting stents. Fistula embolization was performed with coils via transvenous access. In the opinion of the authors, the use of venous access in this case allowed them to perform total occlusion of the recanalized fistula and to achieve good angiographic and clinical results in the long-term period.

Prognostic Imaging Biomarkers for Pancreatic Ductal Adenocarcinoma Extracted from Structured Radiologist Reports

HomeRadiology: Imaging CancerVol. 2, No. 6 PreviousNext Research HighlightsFree AccessPrognostic Imaging Biomarkers for Pancreatic Ductal Adenocarcinoma Extracted from Structured Radiologist ReportsNikita ConsulNikita ConsulNikita ConsulPublished Online:Nov 27 2020https://doi.org/10.1148/rycan.2020209032MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked InEmail Take-Away Points■ Major Focus: Use of a structured reporting template for pancreatic ductal adenocarcinoma to extract potential prognostic and predictive imaging biomarkers.■ Key Result: Tumor-arterial contact, portal vein deformity, larger tumor size, and presence of venous collaterals were found to be associated with decreased overall survival in patients with pancreatic ductal adenocarcinoma.■ Impact: Routine use of the structured reporting template could allow for increased imaging data extraction and preoperative stratification of patients with pancreatic ductal adenocarcinoma based on imaging biomarkers.In this era of precision medicine, biomarkers are instrumental to prognosticate and predict survival in our patients with cancer. Such biomarkers could be advantageous in preoperative cases of pancreatic ductal adenocarcinoma, an aggressive epithelial cell malignancy associated with extremely poor prognosis. While CA-A-19 is a widely recognized serum marker for pancreatic ductal adenocarcinoma, levels of this protein do not have prognostic value alone (1). However, preoperative CT in conjunction with CA-A-19 levels and the physician’s subjective assessment have exhibited predictive value for 2-year survival (2). Consequently, many studies have evaluated the role for imaging in measuring preoperative tumor extent and posttherapy treatment response, recognizing that imaging biomarkers could be used for noninvasive prognostication.In a retrospective study of patients with pancreatic ductal adenocarcinoma who underwent preoperative CT imaging and curative intent surgical resection between 2006 and 2017, Dickinson et al describe multiple imaging features that were associated with decreased overall survival in patients who underwent surgery either with or without neoadjuvant therapy, including tumor contact with the common hepatic artery or other arteries, portal vein deformity, larger tumor size, and the presence of venous collaterals. These features were extracted from the structured American Pancreatic Association (APA)/Society of Abdominal Radiology (SAR) reporting template (3), and therefore the authors conclude that the use of this template may identify imaging features that predict survival. Furthermore, widespread use of the APA/SAR reporting template will equip future studies of imaging biomarkers for the preoperative stratification of patients with pancreatic ductal adenocarcinoma.Highlighted ArticleDickinson SM, McIntyre CA, Schilsky JB, et al. Preoperative CT predictors of survival in patients with pancreatic ductal adenocarcinoma undergoing curative intent surgery. Abdom Radiol 2020. doi: https://doi.org/10.1007/s00261-020-02726-w

Assessment of collateral venous flow using temporary clip placement at ICG videoangiography.

As there are many collateral pathways between venous systems, intraoperative venous injury rarely induces venous infarction. In some patients, however, venous injury during microsurgical manipulation may cause acute and/or delayed serious complications. Although intraoperative evaluation using indocyanine green (ICG) videoangiography is very useful, it is difficult to assess the flow direction using this technique. A simple technique using temporary clips and ICG videoangiography was applied to assess the collateral venous pathway in 4 cases of surgical manipulation-related injury or occlusion of the main superficial Sylvian vein in patients with aneurysm. The flow direction and collateral pathway can be easily visualized after release of temporary occlusion. A collateral venous pathway can be evaluated with the present simple technique described here.

Inferior Vena Cava Syndrome: A Rare Complication.

Inferior vena cava syndrome is rare and often difficult to diagnose because of its rarity and consequent low suspicion.We describe the case of a 28-year-old female patient with a history of nephroblastoma of the right kidney, stage IV, with a favourable histology with epidural metastasis (D5–D9), diagnosed at 3 years of age. The patient underwent treatment with surgery, chemotherapy and radiotherapy.The patient suffered from sudden low back pain worsening over 2 weeks, with progressive inability to walk. The pain radiated to the front of the thighs. Concomitantly, oedema of the lower limbs with cephalocaudal progression was observed. At admission to our institution, the physical examination showed peripheral oedema, abdominal wall venous collaterals, an inability to walk due to low back pain in the supine position, with no neurological deficits. Lumbar MRI showed exuberant epidural venous congestion. The hypothesis of inferior vena cava thrombosis (IVCT) was considered and confirmed by angio-CT.IVCT is prevalent in patients with congenital anomalies of the inferior vena cava, occurring in approximately 60–80% of these cases, and most published series on inferior vena cava syndrome refer to thrombotic complications in this subgroup of patients. There are currently no guidelines defined or validated to guide the diagnosis and approach to IVCT. With this case, we would like to draw attention to a rare disease that should be suspected in all patients with inferior vena cava disease, whether resulting from congenital disease or after surgical procedures.LEARNING POINTSDiagnosing IVCT can be challenging and a high index of suspicion is needed in presence of abnormalities of the inferior vena cava.In rare instances, IVCT can present with severe lumbar pain due to epidural venous congestion.

Feasibility of Retrohepatic Inferior Vena Cava Resection Without Reconstruction for Hepatic Alveolar Echinococcosis.

This study evaluates the feasibility of retrohepatic inferior vena cava (RHIVC) resection without reconstruction in patients with end-stage hepatic alveolar echinococcosis (AE). Four hundred and fifty-seven patients diagnosed with hepatic AE and who underwent surgical resections between January 2010 and October 2018 were retrospectively analyzed. Nine patients receiving RHIVC resection without reconstruction were included in this study. Among the patients, 5 were male and 4 female. Mean follow-up time was 64.4 months (18-95). In this series, adequate collateral circulation was formed before operation in all patients, and 7 cases underwent ex vivo liver resection and autotransplantation (ELRA) and 2 cases underwent extended right hemi-hepatectomy. Average standard liver volume, graft volume, surgical time, and anhepatic phase in ELRA group patients was 1144 ± 127 cm3, 740 ± 235 cm3, 16.8 ± 4.1 hours, and 337.4 ± 108.65 minutes respectively. Average hospital stay time for all patients was 45 ± 36.4 days. There were no intraoperative deaths. The 30-day mortality rate was 11.1%, and total mortality rate was 22.2%. Postoperative complications occurred in 4 patients. During follow-up, no relapsed AE lesions were found. RHIVC resection without reconstruction is a feasible way for hepatic AE patients with adequate collateral circulation. Careful protection of collateral venous is the key factor for successful operation.

Preoperative CT predictors of survival in patients with pancreatic ductal adenocarcinoma undergoing curative intent surgery.

To evaluate the associations between computed tomography (CT) imaging features extracted from the structured American Pancreatic Association (APA)/Society of Abdominal Radiology (SAR) template and overall survival in patients with resected pancreatic ductal adenocarcinoma (PDAC). This retrospective analysis included consecutive patients with PDAC who consented to genomic tumor testing and underwent preoperative imaging and curative intent surgical resection from December 2006 to July 2017. Two radiologists assessed preoperative CT imaging using the APA/SAR PDAC-reporting template. Univariable associations between overall survival and imaging variables were evaluated using Cox proportional hazards regression. The study included 168 patients (66years ± 11; 91 women). 126/168 patients (75%) received upfront surgical resection whereas 42/168 (25%) received neoadjuvant therapy prior to surgical resection. In the entire cohort, features associated with decreased overall survival were tumor arterial contact of any kind (hazard ratio (HR) 1.89, 95% CI 1.13-3.14, p = 0.020), tumor contact with the common hepatic artery (HR 2.33, 95% CI 1.35-4.04, p = 0.009), and portal vein deformity (HR 3.22, 95% CI 1.63-6.37, p = 0.003). In the upfront surgical group, larger tumor size was associated with decreased overall survival (HR 2.30, 95% CI 1.19-4.42, p = 0.013). In the neoadjuvant therapy group, the presence of venous collaterals was the only feature associated with decreased overall survival (HR 2.28, 95% CI 1.04-4.99, p = 0.042). The application of the APA/SAR pancreatic adenocarcinoma reporting template may identify predictors of survival that can aid in preoperative stratification of patients.

Colonic varices: a rare complication of pancreatic cancer

A 55-year-old man was diagnosed with pancreatic cancer of the uncus and received chemotherapy (modified FOLFIRINOX). Ten months later, he was admitted to our hospital with massive lower gastrointestinal bleeding. Contrast-enhanced CT showed ascending colon varices caused by the occlusion of the superior mesenteric vein (SMV) due to pancreatic cancer invasion. Colonoscopy revealed tortuous varices with red spots in the ascending colon. The patient received blood transfusions and was discharged; however, he was hospitalized for recurrent massive lower gastrointestinal bleeding 3 months later. During this readmission, we performed the transileocolic vein obliteration method due to SMV stenosis and the absence of an obvious shunt. He experienced an uneventful post-operative recovery, and contrast-enhanced CT after 2months revealed no recurrence of colonic varices. Ectopic varices are portosystemic venous collaterals resulting from portal hypertension occurring in any locations other than the esophagogastric region. Colonic varices have rarely been reported before. Patients with pancreatic cancer may present with gastrointestinal bleeding caused by tumor bleeding or esophagogastric varices; however, ectopic varices such as colon varices, a rare complication of pancreatic cancer, should be considered in patients with obscure gastrointestinal bleeding.

Contrast-Enhanced Endoscopic Ultrasound for Evaluation of Common Bile Duct in Presence of Portal Cavernoma

AbstractEndoscopic ultrasound (EUS) is an excellent imaging modality for the evaluation of common bile duct (CBD) because of its close proximity to the transducer placed in duodenum. However, in the presence of portal cavernoma, identification and proper evaluation of CBD become difficult because of presence of numerous venous collaterals. In these circumstances, the evaluation of CBD is more difficult if it is nondilated. In these difficult situations, contrast-enhanced EUS can provide better and clear images of CBD and therefore seems to be an excellent modality to evaluate nondilated CBD in the presence of portal cavernoma.