Downloaded from www.ajronline.org by 119.252.120.187 on 11/03/15 from IP address 119.252.120.187. Copyright ARRS. For personal use only; all rights reserved
971
Case Report
Multiple Intrahepatic Portohepatic Venous Treatment with Steel-Coil Embolization Yoshitaka
Okada,1
Takashi
Endo,1
Shoichi
Kusano,1
and
Muneki
Large intrahepatic shunts between the portal vein and the hepatic vein are rare vascular abnormalities that frequently cause hepatic encephalopathy [1 -6]. Surgery for this condition is often associated with high morbidity and mortality rates [1 J. Angiographic intervention for treatment of intrahepatic portohepatic venous shunts has been limited. To our knowledge, only one case report has been published in the Englishlanguage literature [5]. We recently used steel-coil embolization through an angiographic catheter introduced from the ileocolic vein under minilaparotomy to treat a patient who had numerous large intrahepatic portohepatic venous shunts.
Case
into
finding
of tnphasic
waves
on EEG.
The
patient
subsequently
had
sonography and CT, both of which revealed multiple aneurysmal dilatations of the intrahepatic portal branches connecting with the hepatic veins (Fig. 1A). These findings were confirmed by arterial portography with selective injection of contrast material into the superior
mesenteric
artery.
Because
of the
number
venous shunts, the patient was not considered surgical repair. Therefore, transcatheter embolization The
procedure
of interventional administration and
a 7-French
was
performed
radiologists, of epidural sheath
in the angiography
surgeons,
anesthesia, introducer
(Cordis,
Miami,
November
1991 0361-803x/91/1575-0971
ileocolic
vein
and
A cobra-shaped,
(Cook,
through
then
advanced
6.5-French
Bloomington,
was introduced of a standard
IN;
size
into
the superior
long-tapered
of the
tapered
curved
tip,
5-French)
the sheath into the portal system by means
angiographic
technique.
The
portogram
was
obtained
with a direct injection of contrast material into the portal vein (Fig. 1 B). In order to evaluate the number, location, and size of the portohepatic
vanced
venous into
0.035-in.
the
shunts,
shunt
(0.89-mm)
the
catheter
channels
tip
as selectively
Radifocus
Glidewire
was
subsequently
as possible (Terumo,
ad-
by using
Tokyo)
for
a
guid-
ance, and the shunts were occluded one by one with Gianturco coils (Cook) 5 to 8 mm in diameter (Fig. 1 C). Because the abrupt closure of all the shunt channels might exacerbate
the
formed
in three
patient’s
portal
separate
first
and
the second
and
the
third.
channels.
At
end
of 59
and
coils
of the
the
Two
embolizations,
A total the
hypertension, sessions.
was
third
months
embolization elapsed
was
per-
between
the
6 months between the second used
to occlude
embolization
all the
session,
shunt
virtually
no
seen on the portogram, and uninvolved intrahepatic portal branches, which were unclear on the initial portograms because of the preferential flow of contrast medium to the large shunts, were visualized clearly (Fig. 1 D). No encephalopathy occurred during the shunts
were
1 5-months
of follow-up
exacerbation
after
the
of portal hypertension
third
embolization,
was observed
and
no
sign
of
clinically.
suite was FL)
Although intrahepatic portohepatic venous shunt had been thought to be a rare disorder, recent advances in sonography and CT have shown asymptomatic intrahepatic shunts in an increasing number of patients. Nevertheless, large intrahe-
by a team
After
performed,
was
Discussion
for
was attempted.
inserted
Received April 23, 1991: accepted after revision May 31 , 1991. 1Department of Radiology, Kitasato University East Hospital, 2-1 -1 Asamizodai, 2Department of Surgery, Kitasato University East Hospital, 2-1 -1 Asamizodai, AJR 157:971-973,
ofthe vein.
of portohepatic a candidate
and anesthesiologists.
minilaparotomy
a tributary
catheter
for
the
Yoshida2
mesentenc
Report
A 42-year-old man had had frequent disturbances in consciousness 8 years. He had had a liver biopsy, and alcoholic liver cirrhosis had been diagnosed. Hepatic encephalopathy was diagnosed on the basis of clinical signs and symptoms, results of laboratory tests, and
Shunts:
C American
Sagamihara, Kanagawa 228, Japan. Sagamihara, Kanagawa 228, Japan.
Roentgen
Ray Society
Address
reprint
requests
to Y. Okada.
972
OKADA
ET
AL.
AJR:157,
November
Fig. 1.-Steel-coil embolization multiple intrahepatic portohepatic nous shunts. A, contrast-enhanced c
1991
of ye-
scan
Downloaded from www.ajronline.org by 119.252.120.187 on 11/03/15 from IP address 119.252.120.187. Copyright ARRS. For personal use only; all rights reserved
shows multiple abnormal serpentine intrahepatic vessels. B, Portogram obtained before treatment shows multiple enlarged intrahepatic portal branches communicating with hepatic veins. uninvolved portal branches are scarcely seen because of preferential flow into large shunt channels. C, Portogram obtained after selec-
tive catheterization
into shunt vessel in
right lobe shows communication between portal branch and right hepatic vein more clearly. This vessel was subsequently occluded with coils. Other shunt vessels were treated likewise. D, Portogram obtained after third embolization procedure shows absence of shunts. Uninvolved portal branches in right lobe are clearly depicted.
patic shunts that cause hepatic encephalopathy are still uncommon; fewer than 20 cases have been reported [1 -7]. The cause is thought to be a congenital vascular anomaly in some patients [1 2, 4], and an acquired event is suspected in others [3]. The cause of the shunts in our patient was unknown. We speculate, however, that the acquired changes due to liver cirrhosis may have contributed somewhat to the development of the patient’s large shunts. It is uncertain whether there were any underlying congenital abnormalities. Unlike small asymptomatic shunts, large shunts causing hepatic encephalopathy require appropriate therapeutic intervention. Because of the rarity of this disorder, however, the choice of treatment is controversial. To our knowledge, three patients, each of whom had a single shunt channel, have been treated successfully by surgical intervention, including shunt ligation and hepatic resection [2-4]. As far as multiple large intrahepatic shunts are concerned, however, only one case, a patient who had surgery, has been reported [1], and the patient died 2 days after surgery. Creation of the alternative portosystemic shunt by surgery, such as the distal splenorenal shunt (Warren’s operation), also may be considered. The splenorenal shunt would reduce the portal inflow and therefore diminish the size of intrahepatic shunt channels. ,
Because of the large size and number of the intrahepatic shunts, however, complete disappearance of all the shunts seemed unlikely in this patient. Had some shunt channels remained patent, the patient might still have suffered from encephalopathy. The first patient with intrahepatic portohepatic venous shunts treated with angiographic intervention was reported by Ohtomo et al. in 1 986 [5]. That patient had multiple large intrahepatic shunts throughout the liver and was treated with steel-coil embolization through a catheter introduced from the ileocolic vein, a technique we used with our patient. The transileocolic vein approach was first described by Ueda et al. [7] as an access to the portal system for the embolotherapy of gastroesophageal varices. This method, although admittedly more invasive than the percutaneous transhepatic approach, makes it possible to manipulate a catheter more easily and to avoid inadvertent hemorrhage associated with the transhepatic route [7, 8]. These factors were critical in our patient because the catheterization into the complicated intrahepatic shunt vessels was technically demanding and required better catheter maneuverability. Furthermore, the unusual intrahepatic vasculature could increase the risk for hemorrhagic complication of the transhepatic approach.
Downloaded from www.ajronline.org by 119.252.120.187 on 11/03/15 from IP address 119.252.120.187. Copyright ARRS. For personal use only; all rights reserved
AJR:157,
November
1991
EMBOLIZATION
OF
PORTOHEPATIC
Potential complications of steel-coil embolization may indude exacerbation of portal hypertension caused by abrupt changes in the portal hemodynamics and dislodgement of coils into the systemic circulation. Although neither was observed in our patient, the long-term outcome of this treatment still needs to be evaluated. When the difficulty of surgical repair is considered, transcatheter steel-coil embolization is a promising treatment for the management of multiple large intrahepatic portohepatic venous shunts that cause hepatic encephalopathy.
rysmal
3.
4.
5.
6.
7.
REFERENCES 1 . Raskin NH, Price JB, Fishman RA. Portal-systemic encephalopathy due to congenital intrahepatic shunts. N EnglJ Med 164;270:225-229 2. Chagnon SF, Vallee CA, Barge J, Chevalier U, Gal JL, Blery MV. Aneu-
American Residents’
VENOUS
8.
973
SHUNTS
portohepatic
venous
fistula:
report
of
two
cases.
Radiology
1986:159:693-695 Kitami V. Usui Y, Rai F, Torninaga S. Hashino H. A surgical case of portal systemic encephalopathy due to an enormous portahepatic venous shunt. Nippon Rinsho Geka !gakukai Zasshi(J Jpn Soc C/in Surg) 1985:46:10001005 [in Japanese] Nakatsuji Y, Kiyosawa K, Furuta K, et al. A case of hepatic encephalopathy and pulmonary hypertension due to intrahepatic portacaval shunt. Kanzo (Acta Hepato! Jpn) 1991:32: 197-204 [in Japanese] Ohtorno K, Furui 5, Saito M, Kokubo T, Itai V. ho M. Case report: enormous intrahepatic communication between the portal vein and the hepatic vein. Clin Radio! 1986:37:513-514 Mon H, Hayashi K, Fukuda T, et al. Intrahepatic portosysternic venous shunt: occurrence in patients with and without liver cirrhosis. AJR 1987:149:711-714 Ueda T, Isobe V. Tsutsui T, Aoki Y, Ando M, Ishibashi T. Trans-ileocolic vein obliteration of the gastroesophageal varices. Rinsho Geka 1979:34:685-694 [in Japanese] Goldman ML, Philip PK, Shah DM, Sarrafizadeh MS. Minilaparotomy for occlusion of coronary veins and control of varices. Radiology 1982:144:924-926
Roentgen Ray Society Award Papers, 1992
The ARRS announces competition for the 1 992 President’s Award papers concerning the clinical application of the radiologic sciences.
and two
Executive
Council
Awards
for the best
Awards The winner of the President’s Award will receive a certificate and a $2000 prize. The winners of the two Executive Council Awards will each be given a certificate and a prize of $1 000. The winners will be announced on March 1 6, 1992. Winning papers will be presented at the ARRS annual meeting at Marriott’s Orlando World Center, Orlando, FL, May I 0-i 5, 1992. Winning papers will be submitted for early publication in the American Journal of Roentgenology. All other papers will be returned to the authors. Regulations Eligibility is limited to residents or fellows in radiology who have not yet completed 4 years of approved training in a radiologic discipline. A letter from the resident’s department chairman attesting to this Status must accompany the manuscript. The resident must be the sole or senior author and be responsible for all or most of the project. Submitted manuscripts must not exceed 5000 words and have no more than 1 0 illustrations. Four copies of the manuscript and illustrations are required. Submitted manuscripts should not contain previously presented or published material and should not be under consideration for publication elsewhere. Deadline for submissions is February 14, 1 992. Send papers to Nancy 0. Whitley, M.D. Chairman, Committee on Education & Research American Roentgen Ray Society Department of Radiology University of Maryland Medical Systems Hospital 22 S. Greene St. Baltimore, MD 21201
971
Case Report
Multiple Intrahepatic Portohepatic Venous Treatment with Steel-Coil Embolization Yoshitaka
Okada,1
Takashi
Endo,1
Shoichi
Kusano,1
and
Muneki
Large intrahepatic shunts between the portal vein and the hepatic vein are rare vascular abnormalities that frequently cause hepatic encephalopathy [1 -6]. Surgery for this condition is often associated with high morbidity and mortality rates [1 J. Angiographic intervention for treatment of intrahepatic portohepatic venous shunts has been limited. To our knowledge, only one case report has been published in the Englishlanguage literature [5]. We recently used steel-coil embolization through an angiographic catheter introduced from the ileocolic vein under minilaparotomy to treat a patient who had numerous large intrahepatic portohepatic venous shunts.
Case
into
finding
of tnphasic
waves
on EEG.
The
patient
subsequently
had
sonography and CT, both of which revealed multiple aneurysmal dilatations of the intrahepatic portal branches connecting with the hepatic veins (Fig. 1A). These findings were confirmed by arterial portography with selective injection of contrast material into the superior
mesenteric
artery.
Because
of the
number
venous shunts, the patient was not considered surgical repair. Therefore, transcatheter embolization The
procedure
of interventional administration and
a 7-French
was
performed
radiologists, of epidural sheath
in the angiography
surgeons,
anesthesia, introducer
(Cordis,
Miami,
November
1991 0361-803x/91/1575-0971
ileocolic
vein
and
A cobra-shaped,
(Cook,
through
then
advanced
6.5-French
Bloomington,
was introduced of a standard
IN;
size
into
the superior
long-tapered
of the
tapered
curved
tip,
5-French)
the sheath into the portal system by means
angiographic
technique.
The
portogram
was
obtained
with a direct injection of contrast material into the portal vein (Fig. 1 B). In order to evaluate the number, location, and size of the portohepatic
vanced
venous into
0.035-in.
the
shunts,
shunt
(0.89-mm)
the
catheter
channels
tip
as selectively
Radifocus
Glidewire
was
subsequently
as possible (Terumo,
ad-
by using
Tokyo)
for
a
guid-
ance, and the shunts were occluded one by one with Gianturco coils (Cook) 5 to 8 mm in diameter (Fig. 1 C). Because the abrupt closure of all the shunt channels might exacerbate
the
formed
in three
patient’s
portal
separate
first
and
the second
and
the
third.
channels.
At
end
of 59
and
coils
of the
the
Two
embolizations,
A total the
hypertension, sessions.
was
third
months
embolization elapsed
was
per-
between
the
6 months between the second used
to occlude
embolization
all the
session,
shunt
virtually
no
seen on the portogram, and uninvolved intrahepatic portal branches, which were unclear on the initial portograms because of the preferential flow of contrast medium to the large shunts, were visualized clearly (Fig. 1 D). No encephalopathy occurred during the shunts
were
1 5-months
of follow-up
exacerbation
after
the
of portal hypertension
third
embolization,
was observed
and
no
sign
of
clinically.
suite was FL)
Although intrahepatic portohepatic venous shunt had been thought to be a rare disorder, recent advances in sonography and CT have shown asymptomatic intrahepatic shunts in an increasing number of patients. Nevertheless, large intrahe-
by a team
After
performed,
was
Discussion
for
was attempted.
inserted
Received April 23, 1991: accepted after revision May 31 , 1991. 1Department of Radiology, Kitasato University East Hospital, 2-1 -1 Asamizodai, 2Department of Surgery, Kitasato University East Hospital, 2-1 -1 Asamizodai, AJR 157:971-973,
ofthe vein.
of portohepatic a candidate
and anesthesiologists.
minilaparotomy
a tributary
catheter
for
the
Yoshida2
mesentenc
Report
A 42-year-old man had had frequent disturbances in consciousness 8 years. He had had a liver biopsy, and alcoholic liver cirrhosis had been diagnosed. Hepatic encephalopathy was diagnosed on the basis of clinical signs and symptoms, results of laboratory tests, and
Shunts:
C American
Sagamihara, Kanagawa 228, Japan. Sagamihara, Kanagawa 228, Japan.
Roentgen
Ray Society
Address
reprint
requests
to Y. Okada.
972
OKADA
ET
AL.
AJR:157,
November
Fig. 1.-Steel-coil embolization multiple intrahepatic portohepatic nous shunts. A, contrast-enhanced c
1991
of ye-
scan
Downloaded from www.ajronline.org by 119.252.120.187 on 11/03/15 from IP address 119.252.120.187. Copyright ARRS. For personal use only; all rights reserved
shows multiple abnormal serpentine intrahepatic vessels. B, Portogram obtained before treatment shows multiple enlarged intrahepatic portal branches communicating with hepatic veins. uninvolved portal branches are scarcely seen because of preferential flow into large shunt channels. C, Portogram obtained after selec-
tive catheterization
into shunt vessel in
right lobe shows communication between portal branch and right hepatic vein more clearly. This vessel was subsequently occluded with coils. Other shunt vessels were treated likewise. D, Portogram obtained after third embolization procedure shows absence of shunts. Uninvolved portal branches in right lobe are clearly depicted.
patic shunts that cause hepatic encephalopathy are still uncommon; fewer than 20 cases have been reported [1 -7]. The cause is thought to be a congenital vascular anomaly in some patients [1 2, 4], and an acquired event is suspected in others [3]. The cause of the shunts in our patient was unknown. We speculate, however, that the acquired changes due to liver cirrhosis may have contributed somewhat to the development of the patient’s large shunts. It is uncertain whether there were any underlying congenital abnormalities. Unlike small asymptomatic shunts, large shunts causing hepatic encephalopathy require appropriate therapeutic intervention. Because of the rarity of this disorder, however, the choice of treatment is controversial. To our knowledge, three patients, each of whom had a single shunt channel, have been treated successfully by surgical intervention, including shunt ligation and hepatic resection [2-4]. As far as multiple large intrahepatic shunts are concerned, however, only one case, a patient who had surgery, has been reported [1], and the patient died 2 days after surgery. Creation of the alternative portosystemic shunt by surgery, such as the distal splenorenal shunt (Warren’s operation), also may be considered. The splenorenal shunt would reduce the portal inflow and therefore diminish the size of intrahepatic shunt channels. ,
Because of the large size and number of the intrahepatic shunts, however, complete disappearance of all the shunts seemed unlikely in this patient. Had some shunt channels remained patent, the patient might still have suffered from encephalopathy. The first patient with intrahepatic portohepatic venous shunts treated with angiographic intervention was reported by Ohtomo et al. in 1 986 [5]. That patient had multiple large intrahepatic shunts throughout the liver and was treated with steel-coil embolization through a catheter introduced from the ileocolic vein, a technique we used with our patient. The transileocolic vein approach was first described by Ueda et al. [7] as an access to the portal system for the embolotherapy of gastroesophageal varices. This method, although admittedly more invasive than the percutaneous transhepatic approach, makes it possible to manipulate a catheter more easily and to avoid inadvertent hemorrhage associated with the transhepatic route [7, 8]. These factors were critical in our patient because the catheterization into the complicated intrahepatic shunt vessels was technically demanding and required better catheter maneuverability. Furthermore, the unusual intrahepatic vasculature could increase the risk for hemorrhagic complication of the transhepatic approach.
Downloaded from www.ajronline.org by 119.252.120.187 on 11/03/15 from IP address 119.252.120.187. Copyright ARRS. For personal use only; all rights reserved
AJR:157,
November
1991
EMBOLIZATION
OF
PORTOHEPATIC
Potential complications of steel-coil embolization may indude exacerbation of portal hypertension caused by abrupt changes in the portal hemodynamics and dislodgement of coils into the systemic circulation. Although neither was observed in our patient, the long-term outcome of this treatment still needs to be evaluated. When the difficulty of surgical repair is considered, transcatheter steel-coil embolization is a promising treatment for the management of multiple large intrahepatic portohepatic venous shunts that cause hepatic encephalopathy.
rysmal
3.
4.
5.
6.
7.
REFERENCES 1 . Raskin NH, Price JB, Fishman RA. Portal-systemic encephalopathy due to congenital intrahepatic shunts. N EnglJ Med 164;270:225-229 2. Chagnon SF, Vallee CA, Barge J, Chevalier U, Gal JL, Blery MV. Aneu-
American Residents’
VENOUS
8.
973
SHUNTS
portohepatic
venous
fistula:
report
of
two
cases.
Radiology
1986:159:693-695 Kitami V. Usui Y, Rai F, Torninaga S. Hashino H. A surgical case of portal systemic encephalopathy due to an enormous portahepatic venous shunt. Nippon Rinsho Geka !gakukai Zasshi(J Jpn Soc C/in Surg) 1985:46:10001005 [in Japanese] Nakatsuji Y, Kiyosawa K, Furuta K, et al. A case of hepatic encephalopathy and pulmonary hypertension due to intrahepatic portacaval shunt. Kanzo (Acta Hepato! Jpn) 1991:32: 197-204 [in Japanese] Ohtorno K, Furui 5, Saito M, Kokubo T, Itai V. ho M. Case report: enormous intrahepatic communication between the portal vein and the hepatic vein. Clin Radio! 1986:37:513-514 Mon H, Hayashi K, Fukuda T, et al. Intrahepatic portosysternic venous shunt: occurrence in patients with and without liver cirrhosis. AJR 1987:149:711-714 Ueda T, Isobe V. Tsutsui T, Aoki Y, Ando M, Ishibashi T. Trans-ileocolic vein obliteration of the gastroesophageal varices. Rinsho Geka 1979:34:685-694 [in Japanese] Goldman ML, Philip PK, Shah DM, Sarrafizadeh MS. Minilaparotomy for occlusion of coronary veins and control of varices. Radiology 1982:144:924-926
Roentgen Ray Society Award Papers, 1992
The ARRS announces competition for the 1 992 President’s Award papers concerning the clinical application of the radiologic sciences.
and two
Executive
Council
Awards
for the best
Awards The winner of the President’s Award will receive a certificate and a $2000 prize. The winners of the two Executive Council Awards will each be given a certificate and a prize of $1 000. The winners will be announced on March 1 6, 1992. Winning papers will be presented at the ARRS annual meeting at Marriott’s Orlando World Center, Orlando, FL, May I 0-i 5, 1992. Winning papers will be submitted for early publication in the American Journal of Roentgenology. All other papers will be returned to the authors. Regulations Eligibility is limited to residents or fellows in radiology who have not yet completed 4 years of approved training in a radiologic discipline. A letter from the resident’s department chairman attesting to this Status must accompany the manuscript. The resident must be the sole or senior author and be responsible for all or most of the project. Submitted manuscripts must not exceed 5000 words and have no more than 1 0 illustrations. Four copies of the manuscript and illustrations are required. Submitted manuscripts should not contain previously presented or published material and should not be under consideration for publication elsewhere. Deadline for submissions is February 14, 1 992. Send papers to Nancy 0. Whitley, M.D. Chairman, Committee on Education & Research American Roentgen Ray Society Department of Radiology University of Maryland Medical Systems Hospital 22 S. Greene St. Baltimore, MD 21201
