RESUMEN

Sinistral portal hypertension, also known as left-sided portal hypertension, is a rare cause of gastric variceal bleeding which occurs secondary to occlusion of the splenic vein. We present a case of venous occlusion and sinistral portal hypertension secondary to distal pancreatic cancer requiring treatment of gastric variceal bleeding. After failing conservative management, transvenous intervention was attempted, but a venous communication with the gastric varices was unable to be identified on multiple venograms. A percutaneous trans-splenic approach using a 21-G needle and ultrasound guidance was successful in directly accessing an intraparenchymal vein feeding the gastric varices, and glue embolization was performed directly through the access needle with excellent results.

RESUMEN

PURPOSE: To assess the safety and effectiveness of percutaneous transsplenic access (PTSA) for portal vein (PV) interventions among patients with PV disease. MATERIALS AND METHODS: Adult patients with PV disease were enrolled if they required percutaneous catheterization for PV angioplasty, embolization, thrombectomy, variceal embolization, or transjugular intrahepatic portosystemic shunt (TIPS) placement for a difficult TIPS or recanalization of a chronically occluded PV. The procedures were performed between January 2018 and January 2023. Patients were excluded if they had an active infection, had a chronically occluded splenic vein malignant infiltration of the needle tract, had undergone splenectomy, or were under age 18 years. RESULTS: Thirty patients (15 women, 15 men) were enrolled. Catheterization of the PV through PTSA succeeded for 29 of 30 patients (96.7%). The main adverse effect recorded was flank pain in 5 of 30 cases (16.7%). No bleeding events from the spleen, splenic vein, or percutaneous access point were recorded. Two cases (6.7%) each of hepatic bleeding and rethrombosis of the PV were reported, and a change in hemoglobin levels (mean [SD], - 0.5 [1.4] g/dL) was documented in 14 cases (46.7%). CONCLUSION: PTSA as an approach to accessing the PV is secure and achievable, with minimal risk of complications. Minimal to no bleeding is possible by using tract closure methods.

Asunto(s)

RESUMEN

PURPOSE: This study aimed to assess the safety and efficacy of endovascular managements, including splenic vein recanalization (SVR), partial splenic embolization (PSE), and percutaneous transsplenic gastric varices embolization combined with PSE (PSE+GVE), for management of SPH-related variceal hemorrhage (VH). METHODS: A total of 61 patients with SPH-related VH from three hospitals were enrolled and classified into three groups: the SVR group (Group 1, n=24), the PSE+GVE group (Group 2, n=17), and the PSE group (Group 3, n=20). Baseline characteristics and clinical outcomes were compared among the groups. RESULTS: The technical success rates for transhepatic and transsplenic SVR were 27.8% and 34.6%, respectively. No major complications were observed during any of the procedures. The median follow-up period was 53.2 months. The 2-year GI rebleeding rates for Group 1, 2, and 3 were 0%, 5.9%, and 35%, respectively. Groups 1 and 2 have a lower GI rebleeding rate (p = 0.002, p = 0.048, respectively) and better results of the degree of GV (p = 0.003, p = 0.044, respectively) compared to Group 3. No significant differences were found in 2-year GI rebleeding rates and the degree of GV between Group 1 and 2 (p = 0.415, p = 0.352, respectively). CONCLUSION: SVR, PSE+GVE, and PSE seem safe and effective for management of SPH-related VH. SVR appears to be the superior treatment option. Transsplenic access may further increase the SVR success rate. PSE+GVE seems to have comparable outcomes in GV control and GI rebleeding rates compared to SVR, while superior to PSE.

Asunto(s)

RESUMEN

BACKGROUND: To assess the feasibility and safety of a gelfoam torpedo plugging technique for embolization of the transsplenic access channel in adult patients following transvenous portal vein interventions. MATERIALS AND METHODS: Between 09/2016 and 08/2021, an ultrasound guided transsplenic portalvenous access (TSPVA) was established in twenty-four adult patients with a 21-G needle and 4-F microsheath under ultrasound guidance. Afterwards, sheaths ranging from 4-F to 8-F were inserted as needed for the procedure. Following portal vein intervention, the splenic access tract was embolized with a gelfoam-based tract plugging (GFTP) technique. TSPVA and GFTP were performed twice in two patients. Patients' pre-interventional and procedural characteristics were analyzed to assess the feasibility and safety of the plugging technique according Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system. Values are given as median (minimum;maximum). Subgroup analysis of intercostal vs. subcostal puncture site for TSPVA was performed using the two-sided Mann-Whitney-U test or Student's t-test and Fisher's exact test. Level of significance was p < 0.05. RESULTS: The study population's age was 56 (29;71) years and 54% were female patients. Primary liver disease was predominantly liver cirrhosis with 62% of the patients. Pre-interventional model for end-stage liver disease score was 9 (6;25), international normalized ratio was 1.15 (0.86;1.51), activated partial thromboplastin time was 33s (26s;52s) and platelet count was 88.000/µL (31.000;273.000/µL). Ascites was present in 76% of the cases. Craniocaudal spleen diameter was 17cm (10cm;25cm). Indication for TSPVA was assisted transjugular intrahepatic portosystemic shunt placement in 16 cases and revision in two cases, portal vein stent placement in five cases and variceal embolization in three cases. TSPVA was successfully established in all interventions; interventional success rate was 85% (22/26). The splenic access time was 33min (10min;133min) and the total procedure time was 208min (110min;429min). Splenic access was performed with a subcostal route in 11 interventions and with an intercostal route in 15 interventions. Final sheath size was 4-F in 17 cases, 5-F in three cases, 6-F in five cases, 7-F in two cases and 8-F in one case. A median of two gelfoam cubes was used for GFTP. TSPVA- and GFTP-related complications occurred in 4 of 26 interventions (15%) with a subcapsular hematoma of the spleen in two patients (CIRSE grade 1), access-related infection in one patient (CIRSE grade 3) and both in one patient (CIRSE grade 3). In detail, one access-related complication occurred in a patient with subcostal TSPVA (CIRSE grade 1 complication) and the other three complications occurred in patients with intercostal TSPVA (one CIRSE grade 1 complication and two CIRSE grade 3 complication) (p = 0.614). No patient required interventional or surgical treatment due to puncture tract bleeding. CONCLUSION: Gelfoam-based plugging of the puncture tract was feasible and safe for transsplenic access in adult patients undergoing percutaneous portal vein interventions. The lack of major bleeding complications and complete absorption of the gelatine sponge make it a safe alternative to transjugular and transhepatic access and re-interventions via the splenic route.

RESUMEN

PURPOSE: To evaluate the safety of ultrasound-guided percutaneous mesenteric vein access compared to transsplenic portal vein access for portosystemic shunt placement in patients with portal vein obstruction. MATERIALS AND METHODS: Eight patients underwent portosystemic shunt creation through either a transsplenic (n = 4) or transmesenteric (n = 4) approach. The superior or inferior mesenteric vein was percutaneously accessed under ultrasound guidance using a 21G needle and a 4F sheath. Hemostasis at the mesenteric access site was achieved with manual compression. For transsplenic access, sheath sizes between 6 and 8F were used and tract embolization with gelfoam was performed. RESULTS: Portosystemic shunt placement was successful in all patients. While there were no bleeding complications with transmesenteric access, hemorrhagic shock requiring splenic artery embolization occurred in one patient in which the transsplenic approach was used. CONCLUSION: Ultrasound-guided mesenteric vein access seems feasible and a valid alternative to the transsplenic access in case of portal vein obstruction. Level of Evidence Level 4, case series.

Asunto(s)

RESUMEN

Recent advances in chemotherapy and radiotherapy have led to an increase in the number of long-term survivors of pancreatic cancer. However, this has also increased the number of patients suffering from ectopic varices and bleeding owing to left-sided portal hypertension and thrombocytopenia caused by splenomegaly after pancreaticoduodenectomy combined with resection of the splenic vein. A 65-year-old woman with varices of the elevated jejunum due to left sided portal hypertension after pancreaticoduodenectomy had repeated melena, which started about 1 year before admission. We describe the first reported case of percutaneous transsplenic venous embolization using metallic coils, which successfully achieved hemostasis of refractory bleeding from the elevated jejunal varices after pancreaticoduodenectomy.

RESUMEN

An 81-year-old man with previously diagnosed cancer of the pancreatic body presented with melena and anemia. Upper gastrointestinal endoscopy showed gastric varices with bleeding in the entire stomach. Contrast-enhanced computed tomography identified a splenic vein occlusion resulting from invasion by the pancreatic body cancer and dilated collateral pathways from the splenic hilum to the gastric fundus. The patient was diagnosed with gastric varices associated with left-sided portal hypertension caused by obstruction of the splenic vein and underwent percutaneous transsplenic embolization with n-butyl-2-cyanoacrylate mixed with lipiodol. Splenic subcapsular hematoma occurred and was treated conservatively. The patient died of advanced cancer 5 months after the procedure, without experiencing rebleeding. Percutaneous transsplenic embolization was effective in treating gastric variceal bleeding caused by left-sided portal hypertension.

RESUMEN

We report two cases of chronic portal vein occlusion with jejunal varices successfully treated using percutaneous intervention with a combined transhepatic and transsplenic approach. Case 1 was a 60-year-old man with uncontrolled jejunal variceal bleeding, and case 2 was a 79-year-old man with anastomotic jejunal variceal bleeding and cholangitis. Single access via the transhepatic or transsplenic route failed to allow catheter advancement through the occlusion. After introducing pull-through access via the transhepatic and transsplenic routes, a metallic stent was could be used to dilate the occluded portal vein. Anastomotic jejunal varices functioning as hepatopetal collaterals were embolized after the establishment of antegrade portal flow. No symptom relapse was observed during the follow-up period (31 months for case 1 and 34 months for case 2).

RESUMEN

Rectal variceal bleeding is one of the rarer manifestations of portal hypertension caused by chronic liver disease. The management of these varices is very challenging. Our patient had portal vein thrombosis and presented with chronic recurrent rectal bleeding requiring transfusion secondary to rectal varices. The patient was treated from trans-splenic access with liquid embolics (sclerotherapy and glue) without balloon occlusion, leading to the successful cessation of his bleeding. Access hemostasis was achieved using a vascular plug in the access tract. There are no clear guidelines for the management of these patients. If rectal varices cannot be managed by colonoscopy, this approach to embolization with liquid embolic is an excellent minimally invasive alternative.

RESUMEN

PURPOSE: To assess the feasibility, safety and effectiveness of portal vein recanalization (PVR)-transjugular portosystemic shunt (TIPS) placement via splenic access using a balloon puncture technique. MATERIALS AND METHODS: In a single-center retrospective study from March 2017 to February 2021, 14 consecutive patients with portal hypertension, chronic liver disease and portal vein occlusion or near-complete (> 95%) occlusion were referred for PVR-TIPS placement. Feasibility, safety and effectiveness including procedural characteristics such as technical success, complication profile and splenic access time (SAT), balloon positioning time (BPT), conventional portal vein entry time (CPVET), overall procedure time (OPT), fluoroscopy time (FT), dose-area product (DAP) and air kerma (AK) were evaluated. RESULTS: Transsplenic PVR-TIPS using balloon puncture technique was technically feasible in 12 of 14 patients (8 men, 49 ± 13 years). In two patients without detectable intrahepatic portal vein branches, TIPS placement was not feasible and both patients were referred for further treatment with nonselective beta blockers and endoscopic variceal ligation. No complications grade > 3 of the Cardiovascular and Interventional Radiological Society of Europe classification system occurred. The SAT was 25 ± 21 min, CPVET was 33 ± 26 min, the OPT was 158 ± 54 min, the FT was 42 ± 22 min, the DAP was 167.84 ± 129.23 Gy*cm2 and the AK was 1150.70 ± 910.73 mGy. CONCLUSIONS: Transsplenic PVR-TIPS using a balloon puncture technique is feasible and appears to be safe in our series of patients with obliteration of the portal vein. It expands the interventional options in patients with chronic PVT.

Asunto(s)

Asunto(s)

RESUMEN

Portal vein thrombosis (PVT) is an important cause of noncirrhotic portal hypertension. Noncancerous extrinsic compression of portal vein to drive PVT formation is rare, but important to identify. A 64-year-old female with idiopathic hepatic artery pseudoaneurysm (HAPA) rupture 7 months prior presented with acute-onset hematemesis and melena and was found to have prehepatic portal hypertensive variceal bleeding. Her HAPA-related retroperitoneal hematoma had resulted in portal vein compression, thrombosis, and cavernous transformation despite prompt stent graft placement across the ruptured HAPA, and required definitive treatment by transjugular intrahepatic portosystemic shunt creation with portal vein reconstruction utilizing a trans-splenic access. This case highlights the importance of interval abdominal imaging and hypercoagulability screening for noncirrhotic patients at-risk for PVT, which identified the patient as a heterozygous carrier of Factor V Leiden.

RESUMEN

PURPOSE: To report a case of delayed splenic rupture after percutaneous transsplenic portal vein stent deployment. CASE REPORT: A 72-year-old male patient presented at a medical center with abdominal pain and reduced liver function according to laboratory tests. Due to a history of right hemihepatectomy and left portal vein occlusion, the percutaneous transhepatic approach was considered inappropriate. Instead, percutaneous transsplenic access was selected as a suitable procedure for portal vein catheterization. Eight days following the procedure, the patient developed abdominal pain, and a computed tomography scan showed a small splenic pseudoaneurysm that was underappreciated at the time. Patient suffered acute splenic rupture 32 days post-procedure. Subsequent embolization was performed, achieving complete hemostasis. CONCLUSION: The transsplenic approach should be considered when the transhepatic or transjugular approach is unfeasible or difficult to implement. A careful plugging of the puncture tract is necessary to prevent or minimize hemorrhage from the splenic access tract. In addition, careful serial follow-up computed tomography should be used to evaluate the splenic puncture tract.

Asunto(s)

RESUMEN

Portal venous thrombosis (PVT) is an uncommon complication in post-liver transplant recipients. The reported incidence is 1-4%. It may occur within a month, called early or after one month of transplantation, known as late PVT. Early PVT has a poor prognosis, leading to graft failure in most cases. Treatment of such cases is quite challenging because of difficult alternative portal inflow establishment. We performed successful thrombolysis of acute major PVT with a unique technique using ultrasound-guided percutaneous trans-splenic vein access in a post-liver transplant recipient. The per-cutaneous trans- splenic vein approach-based thrombolysis described here in this report might be very helpful in similar cases. This technique minimizes the potential risk of graft loss, avoids re-exploration, has a low risk of bleeding, and is cost-effective.

RESUMEN

Endovascular transshepatic access has limitations that can be exacerbated in the posttransplantation setting. Although several techniques are available for portal venous system catheterization, the transsplenic approach offers a direct pathway for accessing the portal venous system, as well as associated varices or shunts, while avoiding potential injury to the liver transplant. The purpose of this report is to present the diagnostic and interventional management of main portal vein occlusion in a 56-year-old female after liver transplantation. Endovascular transsplenic recanalization with stenting and shunt embolization is a viable method for treatment of main portal vein thrombosis in an adult liver transplant recipient.

RESUMEN

Hepatic encephalopathy (HE) is a significant symptom of decompensated liver cirrhosis. Occlusion of portosystemic shunts is used to treat refractory HE. Nevertheless, these treatments often cause adverse events, such as ascites and esophageal varices. We treated a 57-year-old man with refractory HE using shunt-preserving disconnection of the portal and systemic circulation (SPDPS). After SPDPS, there were no obvious complications, and the patient's ammonia level significantly decreased. To date, the patient has not experienced recurrent HE. SPDPS appears to be a safe and effective treatment method for portosystemic encephalopathy.

Asunto(s)

RESUMEN

OBJECTIVE: The aim of this article is to focus on etiology, risk factors, clinical presentation and classification systems of acute and chronic PVT as well as focusing on current diagnostic and therapeutic options for the management of acute and chronic PVT. RESULTS: PVT represents a serious clinical concern in cirrhotic patients and in those with specific local or systemic risk factors. The rate and extent of thrombus formation can significantly impact patient presentation and the resulting clinical outcomes. The presentation of acute PVT can range from abdominal pain to intestinal ischemia/infarction and even death, while chronic PVT can remain clinically silent. A number of imaging modalities including US, CT and MRI can be used to confirm the diagnosis. In addition to addressing underlying risk factors, AC therapy forms a cornerstone of treatment and has demonstrated efficacy in both acute and chronic settings. Proper caution should be used when initiating AC therapy in cirrhotic patients given their underlying coagulopathic status with attention now being paid to NOACs and LMWH. For patients with bowel ischemia, extensive thrombosis, contraindications or poor response to AC, or for those with co-morbidities that preclude AC, minimally invasive endovascular techniques offer alternative treatment options. CONCLUSION: Familiarity with the etiology, clinical presentation and classification of PVT optimize early detection and incorporate effective therapeutic options, the management of these complex patients should be undertaken by a multidisciplinary team. Minimally invasive catheter-based therapies and endovascular portosystemic shunt creation demonstrated efficacy in the treatment of AC-resistant patients and for patients with extensive or complicated disease.

Asunto(s)

RESUMEN

A 72-year-old male presented with refractory ascites secondary to portal vein occlusion with cavernomatous transformation following pancreaticoduodenectomy (Whipple procedure). Due to the unfavorable anatomy, transjugular intrahepatic portosystemic shunt was not an option. However, given patency of the spleno-mesenteric confluence and absence of the pancreatic head after the Whipple procedure, a splenomeso-caval shunt was successfully created using a transjugular-transsplenic rendezvous technique.

Asunto(s)

RESUMEN

Recently, new techniques and devices in transjugular intrahepatic portosystemic shunt (TIPS) placement have emerged that can improve upon the standard procedure. Ultrasound guidance during TIPS with intracardiac echocardiography (ICE), placement of controlled expansion (CX) stents, and portal vein recanalization (PVR) via transsplenic access are three techniques with new data supporting their implementation. ICE guidance can improve the technical success of difficult cases, decrease procedure time, and decrease complications such as capsular puncture, hemobilia, and hepatic artery injury. CX stents offer the operator better control over the final portosystemic gradient, which is particularly useful in patients with a high risk of post-TIPS hepatic encephalopathy. Finally, transsplenic access provides a stable, antegrade route for PVR, which can be used to optimize transplant candidacy as well as treat the sequelae of portal hypertension in patients with portal vein thrombosis. This article will describe the benefits, technical parameters, and patient selection criteria for each of these new techniques.

RESUMEN

BACKGROUND: Data regarding transsplenic portal venous access for diagnostic imaging and endovascular intervention in children are limited, possibly due to concerns regarding high bleeding risks and resultant underutilization. OBJECTIVE: To investigate the safety and utility of transsplenic splenoportography and portal venous interventions in children. MATERIALS AND METHODS: A retrospective review was performed of all pediatric patients undergoing percutaneous transsplenic portal venous access and intervention at two large tertiary pediatric institutions between January 2012 and April 2017 was performed. Parameters assessed included procedural indications, procedural and relevant prior imaging, technical details of the procedures, laboratory values and clinical follow-up. RESULTS: Transsplenic portal venous access was achieved in all patients. Diagnostic transsplenic splenoportography was performed in 22 patients and was 100% successful at providing the desired anatomical and functional information. Four transsplenic portal venous interventions were performed with 100% success: meso-Rex shunt angioplasty, snare targeted transjugular intrahepatic portosystemic shunt (TIPS) creation through cavernous transformation, pharmacomechanical thrombectomy for acute thrombosis, and transplant portal vein angioplasty. Intraperitoneal bleeding occurred in 2/26 (7.7%) and one case required transfusion (3.8%). No cases of hemorrhage were observed when transsplenic access size was 4 Fr or smaller. CONCLUSION: Transsplenic splenoportography in children is safe and effective when noninvasive imaging methods have yielded incomplete information. Additionally, a transsplenic approach has advantages for complex portal interventions. Bleeding risks are proportional to tract access size and may be mitigated by tract embolization.

Asunto(s)