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HPB : the Official Journal of the... Feb 2021The therapeutic effect of portal vein (PV) stenting for PV stenosis following nontransplant hepato-pancreato-biliary (HPB) surgery has not been fully investigated.
BACKGROUND
The therapeutic effect of portal vein (PV) stenting for PV stenosis following nontransplant hepato-pancreato-biliary (HPB) surgery has not been fully investigated.
METHODS
Changes in portal venous pressure (PVP) gradient before and after stenting, complications, symptomatic improvement, and stent patency were evaluated.
RESULTS
We identified 14 consecutive patients undergoing PV stenting for malignant (n = 8) and benign (n = 6) PV stenosis. Signs of PV stenosis were composed of refractory ascites in 6 patients, varices with hemorrhagic tendencies in 5, and abnormal liver function in 5. The median PVP gradient after PV stenting was 3.0 cm HO (range, 1.5-3.0), which was significantly smaller than that before PV stenting (median, 15 cm HO [range, 2.5-25]; P < 0.01). Thirteen out of 14 (93%) achieved clinical success with symptomatic improvement, except one patient with sustained refractory ascites because of peritoneal seeding. During the median follow-up time of 7.3 months (range, 1.0-87), stent occlusion occurred in two patients (14%) because of intrastent tumor growth. The 1-year cumulative stent patency rate was 76% in the entire cohort.
CONCLUSIONS
Based on durable effect on patency, we deemed PV stenting for PV stenosis after HPB surgery to be safe and beneficial for improving symptoms.
Topics: Constriction, Pathologic; Humans; Portal Pressure; Portal Vein; Retrospective Studies; Stents; Treatment Outcome
PubMed: 32600950
DOI: 10.1016/j.hpb.2020.06.003 -
World Journal of Gastroenterology Jun 2020Portal vein thrombosis (PVT) is currently not considered a contraindication for liver transplantation (LT), but diffuse or complicated PVT remains a major surgical... (Review)
Review
Portal vein thrombosis (PVT) is currently not considered a contraindication for liver transplantation (LT), but diffuse or complicated PVT remains a major surgical challenge. Here, we review the prevalence, natural course and current grading systems of PVT and propose a tailored classification of PVT in the setting of LT. PVT in liver transplant recipients is classified into three types, corresponding to three portal reconstruction strategies: Anatomical, physiological and non-physiological. Type I PVT can be removed low dissection of the portal vein (PV) or thrombectomy; porto-portal anastomosis is then performed with or without an interposed vascular graft. Physiological reconstruction used for type II PVT includes vascular interposition between mesenteric veins and PV, collateral-PV and splenic vein-PV anastomosis. Non-physiological reconstruction used for type III PVT includes cavoportal hemitransposition, renoportal anastomosis, portal vein arterialization and multivisceral transplantation. All portal reconstruction techniques were reviewed. This tailored classification system stratifies PVT patients by surgical complexity, risk of postoperative complications and long-term survival. We advocate using the tailored classification for PVT grading before LT, which will urge transplant surgeons to make a better preoperative planning and pay more attention to all potential strategies for portal reconstruction. Further verification in a large-sample cohort study is needed.
Topics: Allografts; Anastomosis, Surgical; Dissection; Humans; Liver; Liver Transplantation; Patient Care Planning; Portal Vein; Postoperative Complications; Preoperative Period; Prevalence; Thrombectomy; Venous Thrombosis
PubMed: 32550747
DOI: 10.3748/wjg.v26.i21.2691 -
Journal of Digestive Diseases Apr 2021Portal vein thrombosis (PVT) is a common and severe complication of liver cirrhosis. So far, there have been few consensuses or practice guidelines on the management of... (Review)
Review
Portal vein thrombosis (PVT) is a common and severe complication of liver cirrhosis. So far, there have been few consensuses or practice guidelines on the management of PVT in liver cirrhosis. In this expert consensus, we systematically review the epidemiology, risk factors, imaging examinations, diagnosis, assessment of disease severity, and treatment strategy of PVT in liver cirrhosis, based on the most recent evidence and expert opinions, to further standardize the diagnosis and treatment of the disease in clinical practice.
Topics: China; Consensus; Humans; Liver Cirrhosis; Portal Vein; Portasystemic Shunt, Transjugular Intrahepatic; Treatment Outcome; Venous Thrombosis
PubMed: 33470535
DOI: 10.1111/1751-2980.12970 -
Chirurgia (Bucharest, Romania : 1990) Dec 2022Surgical treatments of advanced tumors have expanded in the last two decades as a result of ad-vances in surgical techniques, advanced interventional radiology methods,... (Review)
Review
Surgical treatments of advanced tumors have expanded in the last two decades as a result of ad-vances in surgical techniques, advanced interventional radiology methods, improved intensive care unit settings and increased overall life expectancy. Advanced liver tumors represent a broad category from various malignancies such as liver metastasis or native liver tumors. Not uncom-monly these tumors are not amenable to curative treatment and require down-staging, or local control at the initial diagnosis. Herein we discuss the portal vein embolization (PVE), transarterial radioembolization (TARE) with Yttrium-90 (Y-90), and surgical options namely, two-staged hepatectomy (TSH), and associating liver partition and portal vein ligation for staged hepatecto-my (ALPPS) as bridging strategies for definitive surgical treatment.
Topics: Humans; Yttrium Radioisotopes; Treatment Outcome; Liver Neoplasms; Liver; Hepatectomy; Portal Vein; Ligation
PubMed: 36584055
DOI: 10.21614/chirurgia.2767 -
International Journal of Surgery... Oct 2020Since first described, Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has garnered boisterous praise and fervent criticism. Its... (Review)
Review
Since first described, Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has garnered boisterous praise and fervent criticism. Its rapid adoption and employment for a variety of indications resulted in high perioperative morbidity and mortality. However recent risk stratification, refinement of technique to reduce the impact of stage I and progression along the learning curve have resulted in improved outcomes. The first randomized trial comparing ALPPS to two stage hepatectomy (TSH) for colorectal liver metastases (CRLM) was recently published demonstrating comparable perioperative morbidity and mortality with improved resectability and survival following ALPPS. In this review, as ALPPS enters the thirteenth year since conception, the current status of this contentious two stage technique is presented and best practices for deployment in the treatment of CRLM is codified.
Topics: Colorectal Neoplasms; Hepatectomy; Humans; Ligation; Liver; Liver Neoplasms; Portal Vein; Treatment Outcome
PubMed: 32305531
DOI: 10.1016/j.ijsu.2020.04.009 -
Inflammatory Bowel Diseases Jan 2021Portal vein thrombosis (PVT) is a poorly described complication of inflammatory bowel disease (IBD). We sought to better characterize presentations, compare treatments,...
BACKGROUND
Portal vein thrombosis (PVT) is a poorly described complication of inflammatory bowel disease (IBD). We sought to better characterize presentations, compare treatments, and assess outcomes in IBD-related PVT.
METHODS
We conducted a retrospective investigation of IBD-related PVT at our institution. Multivariable Cox proportional hazards modeling was used to estimate adjusted hazard ratios across treatments.
RESULTS
Sixty-three patients with IBD-related PVT (26 with Crohn disease, 37 with ulcerative colitis) were followed for a median 21 months (interquartile ratio [IQR] = 9-52). Major risk factors included intra-abdominal surgery (60%), IBD flare (33%), and intra-abdominal infection (13%). Primary hematologic thrombophilias were rare and did not impact management. Presentations were generally nonspecific, and diagnosis was incidental. Ninety-two percent of patients (58/63) received anticoagulation (AC), including 23 who received direct oral anticoagulants (DOACs), 22 who received warfarin, and 13 who received enoxaparin. All anticoagulated patients started AC within 3 days of diagnosis. Complete radiographic resolution (CRR) of PVT occurred in 71% of patients. We found that DOACs were associated with higher CRR rates (22/23; 96%) relative to warfarin (12/22; 55%): the hazard ratio of DOACs to warfarin was 4.04 (1.83-8.93; P = 0.0006)). Patients receiving DOACs required shorter courses of AC (median 3.9 months; IQR = 2.7-6.1) than those receiving warfarin (median 8.5 months; IQR = 3.9-NA; P = 0.0190). Incidence of gut ischemia (n = 3), symptomatic portal hypertension (n = 3), major bleeding (n = 4), and death (n = 2) were rare, and no patients receiving DOACs experienced these adverse outcomes.
CONCLUSIONS
We show that early and aggressive use of AC can lead to excellent outcomes in IBD-associated PVT and that DOACs are associated with particularly favorable outcomes in this setting.
Topics: Anticoagulants; Humans; Inflammatory Bowel Diseases; Portal Vein; Retrospective Studies; Venous Thrombosis; Warfarin
PubMed: 32185400
DOI: 10.1093/ibd/izaa053 -
Scientific Reports Feb 2020Idiopathic portal hypertension (IPH) mimics liver cirrhosis in many aspects, and no efficient imaging method to differentiate the two diseases has been reported to date....
Idiopathic portal hypertension (IPH) mimics liver cirrhosis in many aspects, and no efficient imaging method to differentiate the two diseases has been reported to date. In this study, the imaging and pathological characteristics were analysed for both IPH and cirrhosis. From January 2015 to March 2019, ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) images and pathological results from 16 IPH and 16 liver cirrhosis patients, as well as imaging results of 16 normal patients as a control group, were retrospectively reviewed. The age of the patients was 39 ± 20 years. There was a significant difference in the mean lumen diameter, wall thickness and ratio of thickness to diameter between the IPH and liver cirrhosis patients in the main and sagittal portal veins (P < 0.05), as well as in the lumen diameter and ratio of thickness to diameter between the IPH and liver cirrhosis patients in the Segment 3 (S3) portal vein (P < 0.05). In IPH patients, the main imaging changes were portal vein wall thickening, stenosis or occlusion, a low enhancement area along the portal vein in the delay phase in contrast-enhanced imaging, and a non-homogeneous change in T1WI. The corresponding pathological changes included interlobular vein thickening, stenosis, occlusion, portal area fibrosis, and atrophy or apoptosis of hepatocytes. The main imaging characteristic of liver cirrhosis was a nodular change in T1WI, and the related pathological change was pseudolobule formation. The imaging characteristics of IPH include thickening of the portal vein vascular wall, stenosis of the portal vein lumen and the absence of diffuse cirrhosis-like nodules. These imaging features have a definite pathological basis and could help make differential diagnoses between IPH and cirrhosis.
Topics: Adult; Diagnosis, Differential; Female; Humans; Hypertension, Portal; Liver Cirrhosis; Magnetic Resonance Imaging; Male; Middle Aged; Portal Vein; Tomography, X-Ray Computed; Ultrasonography
PubMed: 32051517
DOI: 10.1038/s41598-020-59286-8 -
World Journal of Gastroenterology Oct 2021Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool... (Review)
Review
Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.
Topics: Endosonography; Humans; Portal Pressure; Portal Vein; Portasystemic Shunt, Surgical; Ultrasonography, Interventional
PubMed: 34790012
DOI: 10.3748/wjg.v27.i40.6874 -
Magnetic Resonance in Medical Sciences... Mar 2022Evaluation of the hemodynamics in the portal venous system plays an essential role in many hepatic pathologies. Changes in portal flow and vessel morphology are often... (Review)
Review
Evaluation of the hemodynamics in the portal venous system plays an essential role in many hepatic pathologies. Changes in portal flow and vessel morphology are often indicative of disease.Routinely used imaging modalities, such as CT, ultrasound, invasive angiography, and MRI, often focus on either hemodynamics or anatomical imaging. In contrast, 4D flow MRI facilitiates a more comprehensive understanding of pathophysiological mechanisms by simultaneously and noninvasively acquiring time-resolved flow and anatomical information in a 3D imaging volume.Though promising, 4D flow MRI in the portal venous system is especially challenging due to small vessel calibers, slow flow velocities, and breathing motion. In this review article, we will discuss how to account for these challenges when planning and conducting 4D flow MRI acquisitions in the upper abdomen. We will address patient preparation, sequence acquisition, postprocessing, quality control, and analysis of 4D flow data.In the second part of this article, we will review potential clinical applications of 4D flow MRI in the portal venous system. The most promising area for clinical utilization is the diagnosis and grading of liver cirrhosis and its complications. Relevant parameters acquired by 4D flow MRI include the detection of reduced or reversed flow in the portal venous system, characterization of portosystemic collaterals, and impaired response to a meal challenge. In patients with cirrhosis, 4D flow MRI has the potential to address the major unmet need of noninvasive detection of gastroesophageal varices at high risk for bleeding. This could replace many unnecessary, purely diagnostic, and invasive esophagogastroduodenoscopy procedures, thereby improving patient compliance with follow-up. Moreover, 4D flow MRI offers unique insights and added value for surgical planning and follow-up of multiple hepatic interventions, including transjugular intrahepatic portosystemic shunts, liver transplantation, and hepatic disease in children. Lastly, we will discuss the path to clinical implementation and remaining challenges.
Topics: Abdomen; Blood Flow Velocity; Child; Humans; Imaging, Three-Dimensional; Magnetic Resonance Imaging; Portal Vein
PubMed: 35082218
DOI: 10.2463/mrms.rev.2021-0105 -
Experimental and Clinical... Apr 2022The hepatic vasculature is a unique system due to a dual supply that includes the hepatic artery and portal vein, which interact when the liver vascular supply is...
OBJECTIVES
The hepatic vasculature is a unique system due to a dual supply that includes the hepatic artery and portal vein, which interact when the liver vascular supply is decreased. Hepatic artery buffer response, an intrinsic regulatory mechanism that compensates for blood supply, maintains increased hepatic artery flow and caliber in response to portal vein failure. Previous studies revealed that portal vein flow showed no alterations to establish adequate blood supply in response to hepatic artery occlusion. Here, we analyzed portal vein flow changes in patients with hepatic artery thrombosis after liver transplant.
MATERIALS AND METHODS
From December 1988 to October 2017, our center performed 580 liver transplant procedures. Those diagnosed with hepatic artery thrombosis (19 females, 24 males) by Doppler ultrasonography during postoperative week 1 were analyzed. Patients received either surgery or endovascular treatment for hepatic artery thrombosis, with patency confirmed by Doppler ultrasonography. We compared portal vein flow velocity and caliber before and after treatment using Wilcoxon signed rank and Mann Whitney U tests.
RESULTS
Mean patient age was 18.9 ± 21.4 years. Portal vein flow velocity pretreatment (median of 70 cm/ s) was significantly higher than posttreatment (median of 52 cm/ s) in all patients (P < .001). Median flow velocity decreased significantly after treatment when subgroups were compared, including age (adult vs child), transplant type (orthotopic transplant vs living donor), and treatment (surgery vs endovascular). However, portal vein flow velocity showed a significantly higher decrease in the surgery subgroup than in the endovascular treatment subgroup (P = .018). There was no significant relationship between portal vein calibers before and after treatment (P = .36).
CONCLUSIONS
The significant decrease in portal vein flow velocity after successful treatment of hepatic artery thrombosis may represent a compensatory flow change of the portal vein in response to diminished hepatic artery flow.
Topics: Adolescent; Adult; Blood Flow Velocity; Child; Female; Hepatic Artery; Humans; Liver Transplantation; Living Donors; Male; Portal Vein; Thrombosis; Treatment Outcome; Young Adult
PubMed: 30702049
DOI: 10.6002/ect.2018.0128