Venous Shunt Research Articles

Retrograde sclerotherapy of male varicocele with veno-venous shunts - incidence and management: a single-centre experience.

The aim of our study is to compare the incidence of veno-venous shunts in male varicocele and evaluate the possibility to exclude them with manual compression or/and scrotal ligation in order to carry out the procedure of retrograde sclero-embolization. In our retrospective study, all patients undergone retrograde sclerotherapy for varicocele in our Interventional Radiology Unit in the last four years were evaluated. Collaterals toward other venous shunts were identified and how many and which patients would be able to complete the procedure safely were considered. Of the 91 patients, as many as 22 (i.e., 24.17%) patients presented anatomical variants, consisting on shunting into left iliac vein (9 [9.89%]), lumbar left veins (3 [3.29%]), right iliac vein (1 [1.09%]), both iliac veins (1 [1.09%]), left femoral vein (1 [1.09%]) or a more proximal portion of the ISV itself without shunting (3 [3.29%]). Patients with duplication could benefit from a more distal injection in order to prevent back-flow; of the 19 left, nine successfully underwent sclerotherapy with manual compression or/and scrotal ligation, whereas in 10 flow through the collaterals could not be interrupted and patients were demanded for surgery. Many patients with abnormal communications between the internal spermatic vein and the iliac veins (that is, shunts towards the iliac veins) may as well undergo retrograde sclerotherapy safely if compression/ligation is applied. No large previous study highlighted the impact of veno-venous shunts in technical feasibility of retrograde sclerotherapy of varicocele.

Abstract Number ‐ 236: Pure Arterial Malformations: A Case Report

Introduction Pure arterial malformations are dilated, overlapping, and tortuous arteries forming a mass of arterial loops without a venous component. These malformations are rare, with limited cases reported in the literature. Affecting any of the intracranial arteries, they are usually found incidentally and often have a benign course. Methods We present a case of a pure arterial malformation in a young female with hyperprolactinemia. Furthermore, we review the literature and provide an updated summary of these malformations. Results A 28‐year‐old female with a history of infantile hemangiomas, polycystic ovary syndrome, and hyperprolactinemia presented with acne, mild hirsutism, and galactorrhea. Her neurological exam was normal. Magnetic Resonance Imaging (MRI) of the brain with and without contrast ruled out a prolactinoma but revealed a 3 cm vascular malformation at the margin of the left cavernous sinus extending posteriorly into the anterior left perimesencephalic cistern. Initial differentials included a pial arteriovenous malformation or less likely a dural arteriovenous fistula. She underwent a diagnostic cerebral angiogram which revealed a pure arterial malformation without arteriovenous shunting. This was composed of dysplasia of the left posterior communicating artery and anterior choroidal arteries. Stenosis of the left internal carotid artery distally with collateral support into the left anterior cerebral artery and middle cerebral artery was also noted. Lesser changes were noted in the right side with reconstitution of the right anterior cerebral artery from collaterals. Genetic testing for vascular malformation syndromes, including genes known to be associated with hereditary hemorrhagic telangiectasia, was negative. Repeat MRI/MRA done 8 months from the initial scan was stable with no abnormal large arterial venous shunting or definite saccular aneurysm formation noted. Conclusions Although rare, pure arterial malformations should be considered in the differential diagnosis for patients presenting with a cranial vascular malformation. Management of these lesions is usually conservative given their lack of arteriovenous shunting and low risk of rupture, with only a few cases undergoing surgery or endovascular treatment.

Abstract Number ‐ 91: A Case of Complex Giant Neck Arteriovenous Malformation Treated with Endovascular Embolization

Introduction Arteriovenous malformations (AVM) of the head and neck are vascular malformations composed of a cluster of connecting arteries and veins that form a central nidus without an intervening capillary network1. They make up 1.5% of vascular malformations and more than 90% of AVMs are located intracranially1. Extracranial AVMs are predominantly located in the head and neck and can manifest with pain, ulcerations, fatal hemorrhage, airway compromise, and cosmetic aberrations1,2. Methods We present a case of a 21 year old female with a medical history of multiple suspected neck hemangiomas status post microsurgical and laser resections, with a surrounding port wine stain, who presented to the hospital with growth of one of her posterior neck hemangiomas during and after pregnancy. In the postpartum period she reported increasing neck pain and persistent bleeding from the site. Initially, she was hemodynamically stable and her neurologic exam did not show any focal deficits. She underwent computed tomography angiogram of her neck which showed an extensive dorsal neck AVM with multiple arterial supplies frombranches of the bilateral subclavian, vertebral, and external carotid arteries.Her lesion continued to bleed with a precipitous drop in hemoglobin requiring blood transfusions. Subsequently, she underwent urgentpercutaneousN‐butyl‐2‐cyanoacrylate (n‐BCA) embolizationand endovascular onyx embolization of a left thyrocervical trunk branch.The procedure was completed without complications. Months later, she developed skin exfoliation and underwent successful elective embolization involving vertebral artery branches. This, to reduce profuse venous shunting in the paravertebral venous plexus, avoiding long term spinal cord injury. Results The management of complex head and neck AVMs is both challenging and complex. They may pose significant bleeding risk and can become infiltrative within surrounding tissue3. AVMs may be classified as either focal or diffuse. Focal lesions may be curable with resection, whereas diffuse lesions pose a significant challenge, with relapse in 90% of cases3. Head and neck AVMs require expert management and a multidisciplinary approach. The team may consist of neurosurgery, neuro‐endovascular,plastic surgery, and dermatology services. Treatment options include medical management, surgical resection, endovascular and percutaneous embolization. Percutaenous n‐BCA embolization is employed to prevent hemorrhage during surgical resection, or stabilization in acute hemorrhage4,5. This holds especially true when an endovascular approach is difficult; typically due to tortuous vasculature5. Treatment may require a staged target approach, with endovascular or percutaneous embolization prior to surgical excision. Conclusions This case highlights the complexities of AVM management and the multidisciplinary approach necessary, to provide optimal care. In this case, we believe that pregnancy could have contributed to the overall change in aggressive nature of the AVM. The patient underwent emergent percutaneous and endovascular embolization to prevent life threatening hemorrhage followed by palliative embolization to avoid long term cervical spinal cord injury due to venous hypertension.

Bile acid predicts congenital portosystemic venous shunt in patients with pulmonary arterial hypertension

The etiology of pulmonary arterial hypertension (PAH) is complex, especially the investigation of rare pathogeny is difficult. Congenital portosystemic venous shunt (CPSS) is a rare congenital anomaly in which the portal blood completely or partially bypasses the liver through a congenital portosystemic shunt, and drains directly into the inferior vena cava (IVC) (Howard and Davenport in J Pediatr Surg 32:494–497, 1997).CPSS is an uncommon cause of PAH (Christiane et al. in J Pediatr Gastroenterol Nutr 56:675–681, 2013), and often covered by other pathogenic factors. The clinical manifestations of CPSS-associated PAH are not specific, thus making it difficult to distinguish from PAH caused by other pathogenetic factors based on clinical presentations alone. This is a retrospective analysis of data from six patients with CPSS at a single center. Of these, five were diagnosed as PAH: four were also associated with other predisposing factors of pulmonary hypertension (PH). All patients had high serum bile concentration and high cardiac output. The aim of this retrospective study was to investigate the clinical recognition of PAH secondary to CPSS. The concentration of serum bile acid and cardiac output can be used as two important non-invasive indicators in clinical practice. Thus far, few studies have reported the clinical outcomes of CPSS-associated PAH specifically (Anna et al. in Hepatology 71:658–669, 2020;Franchi-Abella et al. in J Pediatr Gastroenterol Nutr 51:322–330, 2010;Uike et al. in Pediatr Pulmonol 53:505–511, 2018;). In the current study, such patients carried a poor prognosis if left untreated, or treated with pulmonary vasodilators alone.

BJTJ-1837, a novel FXI activation-blocking antibody

BackgroundFactor (F)XI contributes to thrombosis development while it plays a limited role in normal hemostasis. FXI targeting has the potential for preventing and treating thrombosis with little bleeding risk. ObjectivesThe aim of this study was to develop novel antibody therapeutics against FXI for the treatment of thrombosis-related diseases. MethodsMouse hybridoma technology was applied to screen for anti-FXI antibodies. Surface plasma resonance, enzyme inhibition, activated partial thromboplastin time, and prothrombin time assays were conducted to characterize the binding affinity and activity of antibodies. A cynomolgus monkey arterial venous shunt model was applied to validate the antithrombotic activities. ResultsA humanized antibody, BJTJ-1837, reported here bound to the protease domain of FXI and activated FXI with high affinity. BJTJ-1837 fully inhibited the activation of FXI by activated FXII and thrombin. BJTJ-1837 also demonstrated strong anticoagulant activity in human and cynomolgus monkey plasma as measured by activated partial thromboplastin time. Moreover, BJTJ-1837 showed favorable antithrombotic activity with a dose-dependent protection in an arterial venous shunt thrombosis model in cynomolgus monkeys without the bleeding adverse effect. Furthermore, BJTJ-1837 displayed favorable pharmacokinetic and pharmacodynamic properties and good developability. ConclusionAs a potential antithrombotic therapeutic agent with a safe profile, BJTJ-1837 is a very promising FXI activation-blocking antibody candidate.

Coagulopathy in cardiac surgery in the context of the COVID-19 pandemic: A review

Patients with concomitant cardiovascular diseases and traditional cardiovascular risk factors (age, male gender, arterial hypertension, diabetes mellitus and obesity) belong to a particularly vulnerable cohort characterized by progressive severe COVID-19 and high hospital mortality. Thorough screening strategies, standardized guidelines, and center-level protocols are needed to identify patients who are at greater risk of postoperative complications and mortality. Therefore, in this review, we consider the possible impact of COVID-19 on the patency of bypass vessels in the coronary arteries, mainly in relation to venous shunts. However, this hypothesis needs to be confirmed and further studied in the framework of clinical randomized trials.

Correlation of Prenatal and Postnatal Diagnosis in Umbilical-Portal-Systemic Venous Shunts.

Umbilical-portal-systemic venous shunts (UPSVS) are rare anomalies in the development of the fetal venous system. There are several postnatal and prenatal classifications of hepatic venous anomalies but the link between them is missing. We aimed to review the prenatal to postnatal diagnosis correlation in UPSVS at our center. It is a retrospective study of patients diagnosed with UPSVS between 2019 and 2021 at our institution. Demographic, obstetric, genetic, and neonatal data were reviewed with special focus on prenatal and postnatal ultrasounds. A total of seven patients were diagnosed with UPSVS at a median of 24 (20-34) weeks of gestational age. All patients were male and 62% were Caucasian. None of the patients had chromosomopathies or cardiac anomalies. One patient had renal ectopia, another one had a single umbilical artery, and a third one suffered from intrauterine growth retardation. An umbilico-systemic shunt (USS) was found in two patients and a ductus venosus-systemic shunt (DVSS) in the rest. Patients with USS were diagnosed postnatally with intrahepatic portosystemic shunts. One of the DVSS patients was transferred to another hospital and the other four had normal postnatal cardiac ultrasounds, with normal abdominal ultrasounds in two patients and lack of postnatally abdominal control in the other two. All babies were found to be doing well at a median follow-up of 1 month (0-24). There is a knowledge gap in the natural history of UPSVS between fetal and neonatal life. Building bridges between prenatal and postnatal research is mandatory in order to understand these rare anomalies.

Association Between Venous Homografts and Allosensitization After Norwood Procedure.

Right ventricle (RV) to pulmonary artery (PA) shunts have become the shunt of choice at many centers for use during the Norwood procedure for single ventricle palliation. Some centers have begun to use cryopreserved femoral or saphenous venous homografts as an alternative to polytetrafluoroethylene (PTFE) for shunt construction. The immunogenicity of these homografts is unknown, and potential allosensitization could have significant implications on transplant candidacy. All patients undergoing Glenn procedure at our center between 2013 and 2020 were screened. Patients who initially underwent Norwood procedure with either PTFE or venous homograft RV-PA shunt and had available pre-Glenn serum were included in the study. The primary outcome of interest was panel reactive antibody (PRA) level at the time of Glenn surgery. Thirty-six patients met inclusion criteria (N = 28 PTFE, N = 8 homograft). Patients in the homograft group had significantly higher median PRA levels at the time of Glenn surgery (0% [IQR 0-18] PTFE vs 94% [IQR 74-100] homograft, P = .003). There were no other differences between the two groups. Despite potential improvements in PA architecture, the use of venous homografts for RV-PA shunt construction at the time of Norwood procedure is associated with significantly elevated PRA level at the time of Glenn surgery. Centers should carefully consider the use of currently available venous homografts given the high percentage of these patients who may require future transplantation.

Are saphenous sparing treatments beneficial to the hemodynamics of the venous system?

This short review analyzes first the hemodynamic changes that follow destructive procedures, such as stripping or endovascular techniques, and conservative procedures, such as the CHIVA Cure. Then, the effects of the hemodynamic changes resulting from conservative and destructive procedures are compared with respect to the course over time of the varicose disease, mainly focusing on the occurrence of recurrences and their different hemodynamic characteristics. The results show that both conservative and destructive procedures significantly improve the plethysmographic reflux parameters till their normalization. However, destructive procedures reduce the compliance of the lower limb, which expresses an impaired drainage of the superficial tissue, as documented by the typical occurrence of recurrent varicose veins without a detectable trans-compartmental reflux point that are never found after conservative procedures. On the contrary, conservative procedures, when appropriately performed based upon the type of the venous shunt, preserve the drainage of the superficial tissues making the incompetent venous system more hemodynamically stable, which results in a significantly less frequent occurrence of recurrences.

Simultaneous totally laparoscopic distal gastrectomy with distal splenorenal venous shunt in a patient with locally advanced gastric cancer and hepatitis C virus liver cirrhosis: a case report

Simultaneous totally laparoscopic distal gastrectomy with distal splenorenal venous shunt in a patient with locally advanced gastric cancer and hepatitis C virus liver cirrhosis: a case report

Acute Esophageal Necrosis Secondary to Cyanotic Spells Associated with Unrepaired Tetralogy of Fallot.

Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease. Cyanotic spells occur more frequently after infancy in unrepaired cases. Acute esophageal necrosis (AEN) is a rare disease that causes circumferential mucosal necrosis in the distal esophagus. We report the case of a 26-year-old man who was admitted due to coffee-ground emesis, black stools, and decreased oxygen saturations. The patient had an unrepaired ToF and a congenital portosystemic venous shunt. An upper gastrointestinal endoscopy revealed AEN, which could be due to unstable hemodynamics of cyanotic spells. This is the first adult case presenting these 2 conditions occurring simultaneously.

Retrograde venous coil embolization prior to transarterial chemoembolization in hepatocellular carcinoma with arterio-hepatic venous shunts.

PURPOSE This study explored the clinical efficacy of transcatheter retrograde shunt occlusion with coils to prevent pulmonary oil or particle embolization prior to transarterial chemoembolization (TACE) in patients with artero-hepatic venous shunts (AHVS) secondary to hepatocellular carcinoma (HCC). METHODS From July 2017 to January 2021, 6 patients with advanced, unresectable HCC were found to have an AHVS by hepatic arteriography at the time of attempted TACE. The AHVS was embolized ret rogradely with metal coils through a transfemoral or transjugular venous approach. After venous embolization and confirmation of the absence of the AHVS, TACE was performed using an emul sion of iodized oil and doxorubicin or drug-eluting beads. Follow-up computed tomography (CT) was performed within 1 month after the first TACE to evaluate the results and complications. RESULTS Hepatic angiography after venous embolization showed that AHVS had utterly disappeared in all patients during the operation. The immediate technical success of the retrograde venous embo lization was 100%. The AHVS had disappeared entirely during the follow-up period through triple-phase enhancement CT scanning. According to the modified response evaluation criteria in solid tumors, TACE in all 6 patients had a disease control response rate of 100% (6/6) with complete response in 2 patients and partial response in 4 patients. One patient died during the 6-month follow-up, and the other 5 were still alive. No complications related to pulmonary embolism occurred. CONCLUSION Retrograde venous coil embolization of AHVS via the draining hepatic vein appears to be a safe, feasible, and effective treatment to allow TACE treatment without pulmonary embolic events. This approach appears to provide better tumor control and effectively decreases the occurrence of pulmonary embolism.

Venous shunting and limb outcomes in military lower extremity combined arterial and venous injuries

Combined arterial and venous lower extremity (LE) injuries present complex management challenges. Temporary arterial shunting is widely accepted, but vein shunting is not well studied. We examined the influence of vein shunting on limb outcomes in military femoropopliteal arterial and venous combined injuries. A retrospective cohort study of Iraq and Afghanistan LE vascular injuries from 2004-2012 was performed and combined arterial and venous femoropopliteal injuries selected. Vein shunted and non-vein shunted groups were identified and pertinent variables compared. Of 135 arteriovenous injuries, 61 (45%) had vein ligation (5 after shunting), leaving 74 injuries undergoing venous repair (37 grafts (3 synthetic), 34 local repairs, 3 patches). The vein was shunted in 16 (22%). The shunt and no shunt cohorts had similar demographics, mechanism (70% blast), and ISS (median 18, IQR 10-26). Tourniquets and fasciotomy were used equally. Venous shunts were used almost exclusively in cases in which the artery was shunted (94% vs 22% no shunt, P<0.001) and more commonly in cases with bilateral LE vascular injuries (25% shunt vs 3.4% no shunt, P=0.01). Shunted veins more frequently underwent grafting (88% vs 40%, P<0.001). Median MESS was 8, IQR 7-9 in shunted vs. 6 (5-7) in unshunted limbs. Outcomes were similar, with amputation in 13% of shunted and 26% (P=0.33) unshunted and arterial repair complications in 44% and 28% (P=0.24). In combat casualties with combined arterial and venous femoropopliteal injury, vein shunting was used primarily in severely injured limbs in conjunction with arterial shunts and in injuries ultimately undergoing autologous grafting. Limb salvage was statistically equivalent with the use of venous shunts, suggesting equipoise in outcomes with and without venous shunting. Temporary venous shunting should be considered but does not appear to be mandatory in severe lower extremity combined arterial and venous injuries.

Perinatal Outcomes According to the Type of Prenatally Diagnosed Umbilical-Portal-Systemic Venous Shunt

Background: The abnormal course of the umbilical vein and the absence or displacement of the portal vein or ductus venosus may suggest the presence of other shunts. In recent years, an in utero classification of umbilical-portal-systemic venous shunts (UPSVS) has been introduced. This study aims to report our experience with the prenatal diagnosis of UPSVS and to evaluate the perinatal outcomes of fetuses with different types of UPSVS. Methods: This was a retrospective study of fetuses prenatally diagnosed with UPSVS between January 2005 and September 2020 at Asan Medical Center. UPSVS was prenatally classified into three types according to the anatomical origin of the shunt: type I, umbilical-systemic shunt; type II, ductus venosus-systemic shunt; and type III, portal-systemic shunt. Type III was further divided into two subtypes: type IIIa, intrahepatic shunt; type IIIb, extrahepatic shunt. Postnatal ultrasonography or abdominal computed tomography (CT) was performed to confirm UPSVS. Results: Out of 18 fetuses prenatally diagnosed with UPSVS, four were excluded. All four patients were confirmed to have portal vein variations without a shunt. The median gestational age at the diagnosis of the remaining 14 fetuses was 30.3 weeks (range, 23.1–37.3). The median gestational age at birth was 37.2 weeks (range, 31.0–39.3), and the median birth weight was 2105 g (range, 1350–2870), including nine (64%) who had body weights below the 10th percentile. Eleven patients (79%) had combined anomalies; cardiomegaly and fetal hydrops were observed in eight (57%) and two (14%) patients, respectively. Among the 11 patients who underwent chromosomal analysis, three had abnormal results. Two infants with abnormal karyotypes died. The most common type was type I (8, 57%), followed by type IIIa (4, 29%), type II (1, 7%), and type IIIb (1, 7%). In type I, all but one patient had structural anomalies; five (63%) showed cardiomegaly and five (63%) were associated with growth restriction. Nevertheless, half of the patients survived without major anomalies. In type IIIa, three (75%) patients were associated with growth restriction, but they showed catch-up growth after birth. All patients had mild transient hyperammonemia. One type II patient was associated with cardiomegaly, fetal hydrops, and an abnormal karyotype. One type IIIb patient had multiple anomalies and an abnormal karyotype. No surgical correction was required because of the UPSVS. Conclusions: Prenatal diagnosis of UPSVS is feasible. When an abnormal course of the umbilical or portal vein is detected on the transverse abdominal view, UPSVS should be suspected. UPSVS is commonly associated with structural anomalies, chromosomal anomalies, growth restriction, and cardiomegaly. UPSVS without associated anomalies may have a favorable prognosis. Our study can help predict the prognosis of UPSVS and assist in prenatal counseling.

Prenatal ultrasonographic features and follow-up outcomes of 19 cases of congenital intrahepatic portosystemic venous shunts diagnosed during the foetal period

BackgroundTo investigate the prenatal ultrasonographic features and case characteristics of the congenital intrahepatic portosystemic venous shunt (IHPSS) diagnosed during the foetal period and analyse its prognosis.MethodsWe conducted a retrospective cohort study of patients diagnosed with IHPSS between 2016 and 2021. IHPSS was defined as an abnormal connection between the foetal intrahepatic portal and the hepatic veins.ResultsIn this study, 19 foetuses were identified, including 12 cases of single shunt and 7 cases of multiple shunts, with a gestational age of 33.8 ± 4.5 (range 25–40) weeks at diagnosis. In the single-shunt group, the origin position of the shunts was all from the left branch of the portal vein (LPV), whereas in the multiple-shunt group, the origin position of the shunts was from the LPV in six cases. Common concomitant intrauterine abnormalities of IHPSS include foetal growth restriction (47.4%) and foetal cardiac enlargement (21.1%). The postnatal manifestations of IHPSS include biochemical abnormalities (increased gamma-glutamyl transferase and bilirubin levels), neonatal hypoglycaemia, neonatal hyperammonaemia, pulmonary hypertension, multiple intrahepatic hyperechoic nodules, and cutaneous haemangiomas. Spontaneous closure of shunts occurred in ten cases, and the mean time to shunt closure was 8.1 months (1–28 months).ConclusionsMost IHPSS found during the foetal period is located in the left branch of the portal vein, and the gestational age at diagnosis is usually in the late second or third trimester. Spontaneous closure of shunts can occur in most live births, and the prognosis is good.

S3320 An Intrahepatic Portosystemic Shunt Masquerading as a Tumor

Introduction: Portosystemic shunts can be congenital or acquired and are divided into extrahepatic and intrahepatic shunts. Intrahepatic portosystemic venous shunts (IPSVSs) are abnormal intrahepatic connections that occur between branches of the portal vein (PV) and hepatic veins (HV) or IVC. Patients with IPSVSs can be symptomatic or asymptomatic as most of the cases are detected incidentally on imaging. However, they can potentially lead to long term complications by allowing bypass of mesenteric venous return into systemic circulation without going through the liver. We herein describe the case of a 58-year-old woman who was incidentally found to have an IPSVS on imaging for which she was recommended periodic surveillance imaging. Case Description/Methods: A 58-year-old woman was undergoing workup for weight loss and was noted to have a 2.3 x 2.0 cm hyperdense nodular lesion in the posterior segment of the right hepatic lobe suspicious for hemangioma or a hypervascular neoplasm on CT abdomen pelvis. She was referred to the hepatobiliary clinic and a CTA abdomen pelvis was then performed and showed a lobulated 2.2 x 2.1 x 2.9 cm lesion in segment 6 consistent with an intrahepatic portosystemic shunt (figure 1). The patient was otherwise asymptomatic and therefore was advised to continue with periodic imaging surveillance. Discussion: IPSVSs are divided into 4 types depending on their morphology. In type 1, a single large vessel connects the PV or its right branch to the IVC. Type 2 involves a localized peripheral shunt within one hepatic segment that has one or more communications between peripheral branches of the PV and HV. In type 3, an aneurysmal connection exists between PV and HV. And finally, multiple communications between PV and HV in multiple lobes are present in type 4. In patients without a history of liver disease or trauma, the origin of the IPSVS is presumed to be congenital. CT scan, MRI and even color Doppler sonograms should provide visualizations of the feeding portal vein and draining hepatic vein. For symptomatic IPSVSs, endovascular closure is the standard of care. However, no consensus exists for asymptomatic cases and surveillance is an appropriate option in asymptomatic patients.Figure 1.: Axial CTA abdomen venous phase showing aneurysmal communication (red arrow) between right portal vein (yellow arrow) and middle hepatic vein (green arrow) in segment 6 of the liver.

EP30.03: Prenatal diagnosis and outcome of umbilical‐portal‐systemic venous shunts: experience of a tertiary centre and proposal for a new complex type

EP30.03: Prenatal diagnosis and outcome of umbilical‐portal‐systemic venous shunts: experience of a tertiary centre and proposal for a new complex type

542 Laparoscopic Division of a Congenital Splenogonadal Portosystemic Shunt: A Case Report

Abstract We describe a rare congenital portosystemic shunt. A 37-year-old woman was found to have a previously unreported congenital shunt following investigations into secondary causes of hypertension. The abnormal venous shunt connected the splenic vein to the left ovarian vein. The patient underwent a laparoscopic procedure to successfully divide the shunt. She made a full recovery without complications. To our knowledge, this is the first presentation of a congenital portosystemic shunt involving the splenic and ovarian veins to be reported. This case demonstrates that such a shunt can be amenable for laparoscopic management. The case report shows preoperative scans and intraoperative images.

Fetal intrahepatic Umbilical-Porto-Systemic venous shunts (IHUPSVS): In-utero anatomic classification

ObjectiveCongenital intrahepatic shunts divert highly oxygen and nutrients rich placental blood flow from the liver into the systemic flow having a negative influence on normal fetal growth and postnatal development. The ability to recognize this anomaly helps assess the possible clinical impact, counseling, and management of pregnancy. The present study aimed to propose in utero classification for the Intrahepatic Umbilical-Porto-Systemic Venous Shunt (IHUPSVS) based on our experience. Study DesignA prospective study. Grayscale ultrasound with two and three-dimensional high-definition Doppler modalities was used. IHUPSVS was defined as a diversion of blood from the liver tissue by abnormal communication between a branch of the intrahepatic Umbilical vein or the Portal veins with the systemic circulation (the Hepatic veins or the Sub-Diaphragmatic Vestibulum). ResultsTwenty-five fetuses were diagnosed with IHUPSVS. We identified three main anatomic types: I) Porto-hepatic shunt which was divided into Ia) regular single shunt (15/25, 60%) and Ib) regular multiple shunts, (6/25, 24%) II) Umbilical-Porto-Hepatic shunt divided into a) Umbilical or b) Umbilical combined with Portal hepatic shunt (2/25, 8%) and III) Cavernous- aneurysmatic shunt (2/25, 8%). All the shunts were verified by postnatal targeted sonography. ConclusionsThis study creates the anatomic basis for common nomenclature and future probable updating for this anomaly.

An update on the management algorithms of priapism during the last decade.

Priapism is a persistent penile erection lasting longer than 4 hours, that needs emergency management. This disorder can induce irreversible erectile dysfunction. There are three subtypes of priapism: ischemic, non-ischemic, and stuttering priapism. If the patient has ischemic priapism (IP) of less than 24-hours (h) duration, the initial management should be a corporal blood aspiration followed by instillation of phenylephrine into the corpus cavernosum. If sympathomimetic fails or the patient has IP from 24 to 48h, surgical shunts should be performed. It is recommended that distal shunts should be attempted first. If distal shunt failed, proximal, venous shunt, or T-shunt with tunneling could be performed. If the patient had IP for 48 to 72h, proximal and venous shunt or T-shunt with tunneling is indicated, if those therapies failed, a penile prosthesis should be inserted. Non-ischemic priapism (NIP) is not a medical emergency and many patients will recover spontaneously. If the NIP does not resolve spontaneously within six months or the patient requests therapy, selective arterial embolization is indicated. The goal of the management of a patient with stuttering priapism (SP) is the prevention of future episodes. Phosphodiesterase type 5 (PDE5) inhibitor therapy is considered an effective tool to prevent stuttering episodes but it is not validated yet. The management of priapism should follow the guidelines as the future erectile function is dependent on its quick resolution. This review briefly discusses the types, pathophysiology, and diagnosis of priapism. It will discuss an updated approach to treat each type of priapism.