Inger Keussen

Interventional Radiological Management of Prehepatic Obstruction the Splanchnic Venous System

PurposeThe purpose of this study was to retrospectively evaluate interventional radiological management of patients with symptomatic portal hypertension secondary to obstruction of splanchnic veins.Material and MethodsTwenty-four patients, 15 males and 9 females, 0.75 to 79 years old (mean, 36.4 years), with symptomatic portal hypertension, secondary to splanchnic venous obstruction, were treated by percutaneous methods. Causes and extent of splanchnic venous obstruction and methods are summarized following a retrospective evaluation.ResultsObstructions were localized to the main portal vein (n = 22), intrahepatic portal veins (n = 8), splenic vein (n = 4), and/or mesenteric veins (n = 4). Interventional treatment of 22 (92%) patients included recanalization (n = 19), pharmacological thrombolysis (n = 1), and mechanical thrombectomy (n = 5). Partial embolization of the spleen was done in five patients, in two of them as the only possible treatment. TIPS placement was necessary in 10 patients, while an existing occluded TIPS was revised in two patients. Transhepatic embolization of varices was performed in one patient, and transfemoral embolization of splenorenal shunt was performed in another. Thirty-day mortality was 13.6% (n=3). During the follow-up, ranging between 2 days and 58 months, revision was necessary in five patients. An immediate improvement of presenting symptoms was achieved in 20 patients (83%).ConclusionWe conclude that interventional procedures can be successfully performed in the majority of patients with obstruction of splanchnic veins, with subsequent improvement of symptoms. Treatment should be customized according to the site and nature of obstruction.

Prolonged chemotherapy impairs liver regeneration after portal vein occlusion – An audit of 26 patients

AIM The aim of the present retrospective study was to investigate the influence of neoadjuvant chemotherapy on liver regeneration after portal vein occlusion before major hepatectomy. METHOD Between 2003 and 2007, 26 patients underwent portal vein occlusion, of whom 22 had portal vein embolisation and 4 portal vein ligation. 15 of 23 patients with colorectal liver metastases had neoadjuvant chemotherapy. RESULTS After portal vein occlusion, the ratio of the future liver remnant volume to total parenchymal liver volume (FLR%) was reduced in patients receiving neoadjuvant chemotherapy (27 +/- 1% vs 32 +/- 1%, p = 0.03). A smaller future liver remnant before portal vein occlusion resulted in a greater degree of hypertrophy (r(2) = 0.18, p = 0.04). Patients with tumour size greater than 60 mm showed a decreased degree of hypertrophy (7 +/- 1)% as compared to patients with smaller tumours (13 +/- 1%, p = 0.01). There was one death shortly after portal vein embolisation. 19/26 patients were resected with zero operative mortality. CONCLUSION Prolonged neoadjuvant chemotherapy has a small negative effect on liver regeneration induced by portal vein occlusion. Liver regeneration induced by portal vein occlusion is relatively large when tumour burden is small.

Changes in the distribution of hepatic arterial blood flow following TIPS with uncovered stent and stent-graft: An experimental study

AbstractPurpose: To evaluate changes in distribution of hepatic arterial blood flow in the liver following insertion of an uncovered stent and subsequently a stent-graft in the transjugular intrahepatic portosystemic shunt (TIPS) channel. Methods: The experiments were performed in eight healthy pigs under general anesthesia. In a pilot study in one pig, scintigraphic evaluation of arterial perfusion to the liver was done before and after inflation of a balloon in the right hepatic vein. In the other pigs, outflow from the right liver vein was checked repeatedly by contrast injection through a percutaneously inserted catheter. The arterial perfusion through the liver was examined by scintigraphy, following selective injection of macro-aggregate of 99Tc m-labeled human serum albumin 99Tc m-HSA) into the hepatic artery. This examination was done before and after creation of a TIPS with an uncovered stent and subsequently after insertion of a covered stent-graft into the cranial portion of the shunt channel. Results: In the pilot study changes in the arterial perfusion to the liver were easily detectable by scintigraphy. One pig died during the procedure and another pig was excluded due to dislodgement of the hepatic artery catheter. The inserted covered stent obstructed venous outflow from part of the right liver lobe. The 99Tc m-HSA activity in this part remained unchanged after TIPS creation with an uncovered stent. A reduction in activity was seen after insertion of a stent-graft (p= 0.06). Conclusion: The distribution of the hepatic arterial blood flow is affected by creation of a TIPS with a stent-graft, in the experimental pig model.

Interventional treatment of mesenteric venous occlusion.

Summary Background Mesenteric venous thrombus may be an incidental finding during imaging studies and asymptomatic patients are treated conservatively or with anticoagulant therapy only. Patients with symptomatic acute thrombosis causing bowel ischemia require urgent treatment, which frequently includes extensive surgery. Interventional treatment may be an alternative. Purpose: To present results of interventional treatment in patients with symptomatic occlusion of the mesenteric veins. Material/Methods Eight patients, four men and four women aged 24–74 years (mean 53 years) were treated due to symptomatic portomesenteric venous occlusion of thrombotic origin. Transhepatic (n=5), trans-splenic (n=2), and transjugular (n=4) accesses were used. Patients were treated with mechanical thrombus fragmentation (n=4), pharmacological thrombolysis (n=3) and stent placement (n=8). Additional transjugular intrahepatic portosystemic shunt (TIPS) was created to facilitate the outflow from the treated veins (n=4). Results The majority of the patients required combination of different treatment methods. Resolution of symptoms with initial clinical success was achieved in seven of the eight patients, and one patient died the day after the procedure due to sepsis. Two other patients had procedure-related complications; one of them required embolization. Two patients had documented long-term clinical success with patent stents and no symptoms at one year following intervention. Conclusions Endovascular treatment of portomesenteric occlusion in patients with acute symptomatology showed good short-term clinical success rate.

Hemorrhage after Major Pancreatic Resection: Incidence, Risk Factors, Management, and Outcome.

Background and Aims: Hemorrhage is a rare but dreaded complication after pancreatic surgery. The aim of this study was to examine the incidence, risk factors, management, and outcome of postpancreatectomy hemorrhage in a tertiary care center. Materials and Methods: A retrospective observational study was conducted on 500 consecutive patients undergoing major pancreatic resections at our institution. Postpancreatectomy hemorrhage was defined according to the International Study Group of Pancreatic Surgery criteria. Results: A total of 68 patients (13.6%) developed postpancreatectomy hemorrhage. Thirty-four patients (6.8%) had a type A, 15 patients (3.0%) had a type B, and the remaining 19 patients (3.8%) had a type C bleed. Postoperative pancreatic fistula Grades B and C and bile leakage were significantly associated with severe postpancreatectomy hemorrhage on multivariable logistic regression. For patients with postpancreatectomy hemorrhage Grade C, the onset of bleeding was in median 13 days after the index operation, ranging from 1 to 85 days. Twelve patients (63.2%) had sentinel bleeds. Surgery lead to definitive hemostatic control in six of eight patients (75.0%). Angiography was able to localize the bleeding source in 8/10 (80.0%) cases. The success rate of angiographic hemostasis was 8/8. (100.0%). The mortality rate among patients with postpancreatectomy hemorrhage Grade C was 2/19 (10.5%), and both fatalities occurred late as a consequence of eroded vessels in association with pancreaticogastrostomy. Conclusion: Delayed hemorrhage is a serious complication after major pancreatic surgery.Sentinel bleed is an early warning sign. Postoperative pancreatic fistula and bile leakage are important risk factors for severe postpancreatectomy hemorrhage.

Acute right ventricular failure caused by concomitant coronary and pulmonary embolism: successful treatment with endovascular coronary and pulmonary thrombectomy.

Patent foramen ovale (PFO) is present in approximately 25% of the general population. PFO is characterized by intermittent shunting of blood from the right to the left atrium, especially in the context of increased right-sided filling pressures, with risk of paradoxical embolism. We describe a 69-year-old woman presenting with acute chest pain, severe dyspnoea, and acute inferolateral ST-segment elevation on the electrocardiogram. The patient was diagnosed with myocardial infarction and failure of the right cardiac ventricle, which was considered to be secondary to extensive pulmonary embolism leading to increased filling pressures and paradoxical coronary embolism. The patient underwent emergent percutaneous interventions with coronary thrombus extraction and pulmonary thrombus fragmentation and local thrombolysis. The patient was free of symptoms at follow up 6 months later and echocardiography showed substantially improved right ventricular function. We discuss issues related to the diagnosis, treatment, and secondary prevention for patients with concomitant pulmonary and coronary arterial thrombosis.

Positron emission tomography in malignancies of the liver, pancreas and biliary tract - indications and potential pitfalls.

Abstract Malignancies of the hepato-pancreatico-biliary (HPB) system are relatively common and generally characterized by a dismal prognosis. Positron emission tomography (PET) is a functional imaging technique that has emerged as an important modality in oncological decision-making. The principal radiopharmaceutical in PET imaging is the glucose analog 18F-fluorodeoxyglucose, which is able to detect altered glucose metabolism in malignant tissue. PET is typically used in conjunction with computed tomography (CT), and previous studies have supported several uses of PET/CT in HPB malignancies, including staging, differential diagnostics and monitoring of treatment response and progress of disease. A review of PET/CT in the context of HPB malignancies will be presented, including indications and potential pitfalls.

Endovascular Treatment of Two Pseudoaneurysms Originating From the Left Ventricle

A 67-year-old woman resented with an acute type A aortic dissection, which was treated surgically with aortic valve replacement as a composite graft with reimplantation of the coronary arteries. At the end of surgery, a left-ventricular venting catheter was placed through the apex and closed with a buffered suture. Consecutive computed tomography (CT) examinations verified a growing apex pseudoaneurysm. Communication between the ventricle and the pseudoaneurysm was successfully closed with an Amplatz septal plug by the transfemoral route. Follow-up CT showed an additional pseudoaneurysm, which also was successfully closed using the same method.

Endovascular Removal of the Viatorr Stent-Grafts. Report of Two Cases.

Summary Background The dysfunction of misplaced or dislodged endovascular endoprostheses, may be a serious complication, and endovascular removal may be attempted in some cases. Case Report A Viatorr® stent-graft (Gore, Flagstaff, AR, USA) is an endoprosthesis designed and commonly used for creation of a transjugular intrahepatic portosystemic shunt (TIPS). Two Viatorrs were accidentally dislodged during TIPS procedure. In another patient, the Viatorr was malpositioned, with its distal end being placed in the bile duct. All endoprostheses were successfully removed without serious complications. Conclusions Removal of a misplaced or dislodged Viatorr endoprosthesis is possible using interventional methods.

Concurrent biliary drainage and portal vein embolization in preparation for extended hepatectomy in patients with biliary cancer.

Background Patients with perihilar cholangiocarcinoma and gallbladder cancer extending into the hilum often present with jaundice and a small future liver remnant (FLR). If resectable, preoperative biliary drainage and portal vein embolization (PVE) are indicated. Classically, these measures have been performed sequentially, separated by 4–6 weeks. Purpose To report on a new regime where percutaneous transhepatic biliary drainage (PTBD) and PVE are performed simultaneously, shortening the preoperative process. Material and Methods Six patients were treated with concurrent PTBD and PVE under general anesthesia. Results Surgical exploration followed the combined procedure after 35 days (range, 28–51 days). The FLR ratio increased from 22% to 32%. Three patients developed cholangitis after the procedure. Conclusion The combined approach of PTBD and PVE seems feasible, but more studies on morbidity are warranted.