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Abdominal Radiology (New York) Aug 2018Thrombosis of the portal venous system, although rare in the general population, is commonly diagnosed in patients with specific underlying conditions including... (Review)
Review
Thrombosis of the portal venous system, although rare in the general population, is commonly diagnosed in patients with specific underlying conditions including prothrombotic diseases, cirrhosis, hepatobiliary malignancy, and intraabdominal inflammation. Recent improvements in imaging have played a fundamental role in increased detection of portal vein thrombosis (PVT), frequently reported in asymptomatic patients as an incidental finding. Minimally invasive, endovascular therapy is a medically rational option to achieve recanalization of the portal vein as an adjunct to conservative medical management. This review focuses on the advances in imaging modalities to diagnose, stage and follow-up PVT, and gives a short overview of the available endovascular techniques in this field.
Topics: Diagnostic Imaging; Endovascular Procedures; Humans; Minimally Invasive Surgical Procedures; Portal Vein; Venous Thrombosis
PubMed: 28983654
DOI: 10.1007/s00261-017-1335-9 -
Journal of Pediatric Surgery Jul 2018Rex shunt (mesenteric-to-left portal vein bypass) is considered a more physiologically rational treatment for EHPVO than other portosystemic systemic shunts in children....
OBJECTIVE
Rex shunt (mesenteric-to-left portal vein bypass) is considered a more physiologically rational treatment for EHPVO than other portosystemic systemic shunts in children. However, about 13.6% of children with EHPVO do not have usable left portal veins and up to 28.1%. Rex operations in children are not successful. Hence, a Rex shunt in these children was impossible. This study reports a novel approach by portal-to-right portal vein bypass for treatment of children with failed Rex shunts.
MATERIAL AND METHODS
Eight children (age 6.1years, range 3.5-8.9years) who underwent Rex shunts developed recurrent gastrointestinal bleeding and hypersplenism 13months (11-30months) postoperatively. After ultrasound confirmation of blocked shunt, they underwent exploration. Three patients were found to have right portal vein agenesis. Five patients (62.5%) were found to have the patent right portal vein, with the diameter of 3-6mm. Four patients underwent bypass between the main portal vein in the hepatoduodenal ligament and the right portal vein by interposing an inferior mesenteric vein autograft, whereas the remaining patient underwent a bypass using ileal mesenteric vein autograft.
RESULTS
The operations took 2.3h (1.9-3.5h). The estimated blood loss was 50ml (30-80ml), with no complication. The portal venous pressure dropped from 34.6cmHO (28-45 cmHO) before the bypass to 19.6cmHO (14-24cmHO) after the bypass. The 5 patients were followed up for 10.2months (4-17months) and the post-operative ultrasound and CT angiography confirmed the patency of all the grafts and disappearance of the portal venous cavernova in all five patients.
CONCLUSION
The portal-to-right portal vein bypass technique is feasible and safe for treatment of children with EHPVO who have had failed Rex shunts. Our preliminary result indicates that this technique extends the success of Rex shunt from left portal vein to right portal vein and open a new indication of physiological shunt for some of the children who not only have had failed Rex shunts or but also are not suitable for the Rex shunts.
TYPE OF STUDY
Treatment study.
LEVEL OF EVIDENCE
Level IV.
Topics: Child; Child, Preschool; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Hypersplenism; Hypertension, Portal; Male; Portal Vein; Portasystemic Shunt, Surgical; Splenic Vein
PubMed: 29198895
DOI: 10.1016/j.jpedsurg.2017.10.059 -
HPB : the Official Journal of the... Jan 2021Portal vein aneurysms (PVAs) are rare, though clinically challenging with post-operative mortality approaching 20% and no evidence-based treatment guidelines. We aim to...
BACKGROUND
Portal vein aneurysms (PVAs) are rare, though clinically challenging with post-operative mortality approaching 20% and no evidence-based treatment guidelines. We aim to describe our experience with PVAs and recommend optimum management strategies.
METHODS
Demographics and clinical details of patients with PVAs admitted to our institution from 1984 to 2019 were reviewed. Clinical presentation, management and outcomes were analysed.
RESULTS
PVAs were identified in 18 patients (median age 56 years, range 20-101 years; 13 female); 10 were incidental and 8 diagnosed during abdominal pain work-up. Median aneurysm diameter at diagnosis was 3.4 cm (1.8-5.5 cm), remaining unchanged at 3.5 cm (1.9-4.8 cm) during a 3.2-year follow-up (4 months-31 years). Aneurysm sites were the main portal vein (n = 12), porto-splenic-junction (n = 3), splenic-SMV-junction (n = 2) and right portal vein (n = 1). Thrombosis occurred in 4 patients; 3 developed clinically insignificant cavernous transformation. Two patients underwent surgery for abdominal pain. Postoperatively, one developed PV thrombosis and PVA recurrence occurred in the second. No aneurysm ruptures or mortalities occurred during follow-up.
CONCLUSION
PVAs follow a clinically indolent course with structural stability and minimal complications over time. Non-operative management is feasible for most patients. Abdominal pain, large size or thrombosis don't appear to confer additional risks and should not, in isolation, merit surgical intervention.
Topics: Adult; Aged; Aged, 80 and over; Aneurysm; Feasibility Studies; Female; Humans; Middle Aged; Portal Vein; Thrombosis; Treatment Outcome; Young Adult
PubMed: 32561177
DOI: 10.1016/j.hpb.2020.05.006 -
Journal of Visceral Surgery Aug 2021
Topics: Hepatectomy; Humans; Laparoscopy; Ligation; Liver Neoplasms; Portal Vein
PubMed: 33454308
DOI: 10.1016/j.jviscsurg.2020.11.014 -
Techniques in Vascular and... Mar 2016Catheter-based interventional therapy offers a safe and effective option for treatment of symptomatic portomesenteric venous thrombosis refractory to medical therapy.... (Review)
Review
Catheter-based interventional therapy offers a safe and effective option for treatment of symptomatic portomesenteric venous thrombosis refractory to medical therapy. Various techniques and approaches have been described for thrombolysis and thrombectomy and re-establishing the portal venous flow for select populations. Early diagnosis and prompt treatment based on clinical presentation, imaging, and underlying anatomy are necessary to prevent long-term complications. This article describes various catheter-based approaches for treatment of acute and subacute portal vein thrombosis.
Topics: Acute Disease; Aged; Anticoagulants; Combined Modality Therapy; Early Diagnosis; Female; Humans; Magnetic Resonance Angiography; Male; Middle Aged; Patient Selection; Phlebography; Portal Vein; Portasystemic Shunt, Transjugular Intrahepatic; Portography; Predictive Value of Tests; Risk Factors; Thrombolytic Therapy; Treatment Outcome; Ultrasonography, Doppler; Venous Thrombosis
PubMed: 26997088
DOI: 10.1053/j.tvir.2016.01.005 -
Transplantation Proceedings Mar 2023Herein, a different technique is presented describing complete dissection of the entire portal vein (PV), superior mesenteric vein (SMV), and splenic vein, thus enabling...
BACKGROUND
Herein, a different technique is presented describing complete dissection of the entire portal vein (PV), superior mesenteric vein (SMV), and splenic vein, thus enabling a complete thrombectomy without the risk of uncontrolled hemorrhage due to blind thrombectomy.
METHODS
In cases where a thrombectomy would not be an option because of extensive thrombosis involving the confluence of the PV and SMV, small branches of the SMV, including the inferior mesenteric vein, were divided. Both the SMV and splenic vein were encircled separately. Then, the side branches of the PV above the pancreas, left gastric vein on the left side, and superior pancreatoduodenal vein on the right side were divided. The lateral and posterior part of the PV were dissected within the pancreas both from above and below, allowing the main PV completely free from attachments. At this point, the splenic vein and SMV were clamped, and the main PV was divided above the pancreas and then pulled back through the pancreatic tunnel. The thrombus was easily dissected of the vein under direct visualization, and afterward the PV was redirected to its original position. Then, the liver transplant was carried out in a regular fashion.
RESULTS
This technique was applied to 2 patients. The first was a 43-year-old man who underwent a right lobe living donor liver transplant because of hepatitis B virus-related cirrhosis. The patient is still alive and well with stable liver function after 15 years of follow-up. The second was a 69-year-old woman who underwent a right lobe living donor liver transplant because of hepatitis C virus and hepatocellular carcinoma. She survived the procedure and her liver function was entirely normal afterward. She died of pneumonia and sepsis 5 months after transplant.
CONCLUSIONS
This technique enables complete dissection of the entire PV, SMV, and splenic vein. Thus, complete thrombectomy under direct visualization without the risk of uncontrolled hemorrhage can be performed.
Topics: Humans; Male; Female; Aged; Adult; Portal Vein; Liver Transplantation; Living Donors; Liver Diseases; Venous Thrombosis; Thrombectomy; Thrombosis
PubMed: 36959031
DOI: 10.1016/j.transproceed.2023.02.008 -
Journal of Digestive Diseases Apr 2021
Topics: Humans; Liver Cirrhosis; Liver Diseases; Portal Vein; Venous Thrombosis
PubMed: 33733596
DOI: 10.1111/1751-2980.12982 -
Hepatobiliary & Pancreatic Diseases... Jun 2024Despite advances in the diagnosis of patients with hepatocellular carcinoma (HCC), 70%-80% of patients are diagnosed with advanced stage disease. Portal vein tumor... (Review)
Review
BACKGROUND
Despite advances in the diagnosis of patients with hepatocellular carcinoma (HCC), 70%-80% of patients are diagnosed with advanced stage disease. Portal vein tumor thrombus (PVTT) is among the most ominous signs of advanced stage disease and has been associated with poor survival if untreated.
DATA SOURCES
A systematic search of MEDLINE (PubMed), Embase, Cochrane Library and Database for Systematic Reviews (CDSR), Google Scholar, and National Institute for Health and Clinical Excellence (NICE) databases until December 2022 was conducted using free text and MeSH terms: hepatocellular carcinoma, portal vein tumor thrombus, portal vein thrombosis, vascular invasion, liver and/or hepatic resection, liver transplantation, and systematic review.
RESULTS
Centers of surgical excellence have reported promising results related to the individualized surgical management of portal thrombus versus arterial chemoembolization or systemic chemotherapy. Critical elements to the individualized surgical management of HCC and portal thrombus include precise classification of the portal vein tumor thrombus, accurate identification of the subgroups of patients who may benefit from resection, as well as meticulous surgical technique. This review addressed five specific areas: (a) formation of PVTT; (b) classifications of PVTT; (c) controversies related to clinical guidelines; (d) surgical treatments versus non-surgical approaches; and (e) characterization of surgical techniques correlated with classifications of PVTT.
CONCLUSIONS
Current evidence from Chinese and Japanese high-volume centers demonstrated that patients with HCC and associated PVTT can be managed with surgical resection with acceptable results.
Topics: Humans; Carcinoma, Hepatocellular; Liver Neoplasms; Portal Vein; Treatment Outcome; Retrospective Studies; Hepatectomy; Systematic Reviews as Topic; Thrombosis; Chemoembolization, Therapeutic
PubMed: 37903712
DOI: 10.1016/j.hbpd.2023.10.009 -
Digestive and Liver Disease : Official... Feb 2017Portal vein thrombosis is an infrequent condition occurring in several different clinical scenarios. In the last years it has been increasingly recognised due to the... (Review)
Review
Portal vein thrombosis is an infrequent condition occurring in several different clinical scenarios. In the last years it has been increasingly recognised due to the broad use of radiological methods. In this review we underline the central role of imaging in diagnosing portal vein thrombosis, in clarifying its etiology, choosing the best therapeutic approach and screening possible complications. Special attention is given to the role of imaging to differentiate portal vein thrombosis from neoplastic invasion of the portal vein, and to new diagnostic methods available for clinical practice in this field.
Topics: Humans; Hypertension, Portal; Liver Cirrhosis; Liver Neoplasms; Magnetic Resonance Imaging; Portal Vein; Tomography, X-Ray Computed; Ultrasonography; Venous Thrombosis
PubMed: 27965037
DOI: 10.1016/j.dld.2016.11.013 -
Updates in Surgery Jun 2022Patients with advanced hepatocellular carcinoma (HCC) and macrovascular invasion (MVI) have dismal prognosis and are referred to systemic treatment or palliation. To...
Patients with advanced hepatocellular carcinoma (HCC) and macrovascular invasion (MVI) have dismal prognosis and are referred to systemic treatment or palliation. To investigate the outcomes of patients with HCC and MVI undergoing the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure. Demographics and operative data were retrospectively reviewed. All types of hepatectomies and all types of ALPPS modifications were included. MVI was categorized according to the Japanese Liver Cancer Study Group classification. 28 patients were included. Viral aetiology was the most common cause of chronic liver disease (89.3%). 85.7% of patients were cirrhotic, with a median MELD score of 9 (7-10). MVI of the hepatic veins or inferior vena cava was diagnosed in 46.4% of patients while portal vein involvement was present in 64.2% of cases. Four patients (14.2%) were diagnosed with bile duct involvement. No patients died after Step 1 while complications occurred in 21.4% of cases. Following step 2, 3 patients (11.5%) died and 20 (69.2%) developed complications. Grade B and C post-hepatectomy liver failure occurred in 57.6% and 11.5% of patients, respectively. After a median follow-up of 18 months (7-35), median survival was 22 months (3-40). Eleven patients (39.3%) recurred. Median disease-free survival was 15 months (5-26). The ALPPS procedure is an extreme rescue approach in otherwise inoperable advanced HCC with MVI. The procedure is associated with high morbidity and mortality and patients' selection is pivotal. Oncological outcomes are safe and should be further investigated.
Topics: Carcinoma, Hepatocellular; Hepatectomy; Humans; Ligation; Liver; Liver Neoplasms; Neoplasm Recurrence, Local; Portal Vein; Retrospective Studies; Treatment Outcome
PubMed: 35305261
DOI: 10.1007/s13304-022-01277-7