British Journal of Radiology (2006) 79, e162-e165
© 2006 British Institute of Radiology
doi: 10.1259/bjr/10360703
Successful embolisation of intrahepatic portosystemic venous shunt using coils and n-butyl cyanoacrylate through two approach routes
R Yoshimatsu, MD
1,2
Y Takeuchi, MD, PhD
1
H Morishita, MD, PhD
1
N Iida, MD
1
H Okabe, MD
1
T Yamagami, MD, PhD
2 and
T Nishimura, MD, PhD
2
1 Department of Radiology, Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama, Kyoto, 605-0981, 2 Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-chyo, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan
Correspondence: Rika Yoshimatsu; E-mail: rika442{at}koto.kpu-m.ac.jp.
 |
Abstract
|
|---|
Interventional radiological treatment by transcatheter embolisation has been used to treat patients with symptomatic intrahepatic portosystemic venous shunt (IPSVS). We present a case of symptomatic IPSVS treated by both retrograde and antegrade transcatheter embolisation using coils and n-butyl cyanoacrylate.
|
Introduction
|
|---|
Although believed to be rare for many years since it was first described by Raskin et al in 1964 [1], intrahepatic portosystemic venous shunt (IPSVS) has been encountered more frequently in recent years, in parallel with the development of various imaging modalities such as ultrasound and CT [2, 3]. However, even now, IPSVS is not always recognized. When IPSVS causes hepatic encephalopathy, some treatment is required. According to many previous reports, transcatheter embolisation is useful for the treatment of symptomatic IPSVS [4–8]. We present a patient with symptomatic IPSVS who was treated by both retrograde and antegrade transcatheter embolisation with coils and n-butyl cyanoacrylate (NBCA) (Histoacryl-Blue; Braun, Melsungen, Germany).
|
Case report
|
|---|
An 82-year-old woman was admitted to the emergency room of our hospital due to a sudden loss of consciousness. CT and MRI of the head showed no obvious causes for the loss of consciousness. Although she spontaneously regained consciousness after several days, she lost consciousness again 20 days later. At the time of the second loss of consciousness, her serum ammonia level was elevated to 450 mg dl–1 and an electroencephalography examination demonstrated symmetrical high-voltage slow wave patterns. Laboratory studies showed no other abnormal data. Consequently, the patient was diagnosed as having hepatic encephalopathy. She had no medical history of trauma, liver disease, or blackouts.
A contrast-enhanced abdominal CT examination showed an abnormal vessel passing through the right lobe of the liver (Figure 1a
). A Doppler ultrasound study confirmed an abnormal vessel originating from the anterior branch of the portal vein and entering the right hepatic vein. An aneurysm-like structure existed in this shunt vessel. These examinations strongly suggested that the patient's hepatic encephalopathy was caused by hyperammonaemia, which was in turn caused by the existence of an IPSVS. The patient was thus treated using interventional radiological procedures.
View larger version (106K):
[in this window]
[in a new window]
|
Figure 1. An 82-year-old woman with an intrahepatic portosystemic venous shunt (IPSVS) in the right hepatic lobe. (a) Contrast-enhanced abdominal CT shows an abnormal vessel running through the right hepatic lobe (arrow). (b) Direct portography shows only one shunt between the right hepatic vein and the right portal vein (arrow). (c) Direct portogram taken after the embolisation procedure shows the complete obliteration of the IPSVS. Note that the steel coils (arrow) and the NBCA-Lipiodol mixture (arrowhead), both of which were inserted into the IPSVS as embolic agents, are visible.
|
|
First, a 6-French balloon catheter (Clinical Supply, Gifu, Japan) was inserted via the right jugular vein and advanced to the right hepatic vein. Then, 10 ml of 300 mgI ml–1 iopamidol (Iopamiron; Nihon Schering, Osaka, Japan) was administered by manual injection while the balloon was inflated, revealing a tortuous IPSVS running between the right portal vein and the right hepatic vein. The balloon was deflated and the balloon catheter was advanced to the shunt vessel. The shunt vessel was too narrow and too tortuous to be traversed with the catheter. We tried to traverse a 5-French cobra-shaped catheter (Clinical Supply) through the shunt vessel once using a 0.035 inch glide-coated guidewire (Radifocus; Terumo, Tokyo, Japan). However, it was difficult to traverse the shunt with the catheter.
Thus, we made a decision to add an approach from the transhepatic site. To visualize the overall shape of the portal venous system and to evaluate the IPSVS correctly, direct portography was performed as follows. A 4-French sheath introducer (Medikit, Tokyo, Japan) was inserted into the right portal branch through the right intercostal space under ultrasound guidance; a 4-French angled catheter (Clinical Supply) was then advanced through the sheath to the superior mesenteric vein. The direct portography obtained from this catheter enabled us to confirm that only one shunt vessel was present (Figure 1b
). During this portography, 18 ml of 300 mgI ml–1 iopamidol was injected at a rate of 6 ml s–1. Next, embolisation using the balloon catheter in the right hepatic vein was performed. The balloon catheter was advanced into the segment of the hepatic venous site of the IPSVS and the balloon was inflated. Then, four 0.035 inch Gianturco coils (Cook, Bloomington, IN) were inserted. To evaluate the embolisation, the balloon was deflated and a direct portography was performed using the 4-French catheter with its tip positioned at the superior mesenteric vein. This examination revealed the persistence of a slow blood flow in the shunt vessel. Thus, the 4-French catheter was re-positioned at the portal venous site of the shunt vessel. Finally, a second embolisation of the portal venous site of the IPSVS was performed using 1 ml of NBCA mixed with Lipiodol (Laboratoire Guerbet, Roissy, France). The ratio of NBCA and Lipiodol was 1:2. A direct portography, in which 18 ml of 300 mgI ml–1 iopamidol was injected at a rate of 6 ml s–1, performed after embolisation via the transhepatic approach showed the complete disappearance of blood flow running through the shunt vessel (Figure 1c). At the time of the withdrawal of the sheath inserted from the intercostals space into the right portal vein, dry gelatin particles (Spongel; Yamanouchi, Tokyo, Japan) were placed in the tract of the withdrawn sheath in the liver parenchyma outside the portal vein to avoid intra-abdominal bleeding through the tract. No complications occurred during the interventional radiological procedures. 3 days after embolisation, the patient's serum ammonia level had decreased to 79 mg dl–1. No further symptoms of encephalopathy have been seen for 8 months.
|
Discussion
|
|---|
Chevallier et al [9] categorised IPSVS into 4 types: (1) patent paraumbilical veins in the liver, commonly encountered in patients with portal hypertension; (2) single or multiple shunts between an intrahepatic portal branch and a hepatic vein located in one of two adjacent liver segments; (3) single or multiple shunts between an intrahepatic portal branch and a hepatic vein located in non-adjacent liver segments; and (4) any tubular communication between the right portal branch and the inferior vena cava. The cause of IPSVS is controversial. Two theories, the congenital origin theory and the acquired theory, have been reported [1, 4, 9, 10]. The former theory suggests a persistent embryonic venous anastomosis, such as the ductus venous or a vitelline vein. The latter theory suggests the formation of a shunt because of portal hypertension, trauma, or a rupture in a portal vein aneurysm. The present case can be classified as Chevallier type II and might be congenital, considering the patient's past medical history.
IPSVS must be treated in patients who develop symptoms of hepatic encephalopathy [10]. Traditionally, surgical treatments were performed [1, 11]. In recent years, however, less invasive interventional radiological treatments, such as transcatheter embolisation, have been widely adopted [4–8]. Three routes to access IPSVSs are feasible: a transiliocolic route [4, 5], a percutaneous transhepatic route [4] and a retrograde transcaval route [4, 6, 7]. For multiple IPSVSs, especially shunts located in bilateral lobes, the transiliocolic route has often been selected because the catheters can be easily controlled [4, 5]. On the other hand, for single or multiple IPSVSs located in one lobe, the less invasive transhepatic route or retrograde transcaval venous route is commonly selected [4, 6, 7]. Especially for large shunts entering the hepatic vein at a point near the inferior vena cava, the retrograde transcaval venous route has often been chosen because of the ease of catheterization [4].
In cases where sufficient embolisation of the IPSVS from a single approach is difficult, Tanoue et al [4] reported the usefulness of performing the procedure via two routes. He reported that among 10 patients with IPSVS who underwent embolisation procedures, 3 IPSVSs were successfully embolised by changing the approach to a transhepatic or transiliocolic approach after embolisation of the IPSVS via a retrograde transcaval approach performed during a different session proved to be insufficient. Additionally, other researchers have recommended that a direct portography should be performed to evaluate the precise number, size and course of the shunt vessels, since other imaging modalities like ultrasound and CT may provide incomplete pictures [5, 6, 8]. In the present case, a retrograde transcaval approach was initially attempted. However, the catheter could not be sufficiently advanced into the shunt vessel because the shunt vessel between the peripheral portal vein and the hepatic vein was too narrow and too tortuous. A transhepatic approach was then performed to enable a direct portography to assist in the morphological evaluation of the IPSVS; the catheter was advanced to the shunt vessel at the portal venous site, resulting in the successful embolisation of the IPSVS without any complications. To our knowledge, no other reports have described an IPSVS treated using two approach routes, retrograde and antegrade, during a single session.
Regarding the embolic agents, stainless steel coils or microcoils have been widely used [4–6]. In general, however, embolisation with coils alone necessitates the use of many coils, making the procedure expensive and time-consuming. In the present case, the catheter inserted from the portal venous site could not be advanced toward the hepatic venous site of the shunt vessel far enough to obtain sufficient space to insert the number of coils required to stop blood from flowing through the shunt. Therefore, NBCA was also used. As a result, the IPSVS was completely embolised. Only one previous report has described the use of NBCA to embolise an IPSVS [7]. NBCA is a liquid acrylic surgical adhesive material that is also widely used as a permanent embolic agent [7, 12]. By adding Lipiodol to the NBCA, the embolised vessel can also be visualized. Furthermore, the adhesion time can be regulated according to the ratio of the mixture of Lipiodol and NBCA. Thus, migration of the embolising agents or hepatic infarction, which are potential complications, can be avoided, as was the case in the present patient.
Received for publication June 16, 2005.
Revision received September 22, 2005.
Accepted for publication October 26, 2005.
|
References
|
|---|
- Raskin NH, Price JB, Fishman RA. Portal-systemic encephalopathy due to congenital intrahepatic shunts. N Engl J Med 1964;270:225–9.[Medline]
- Itai Y, Kuroski Y, Saida Y, Niitsu M, Kuramoto K. CT and MRI in detection of intrahepatic portosystemic shunts in patients with liver cirrhosis. J Computed Assist Tomogr 1994;18:768–73.
- Hirota T, Yamagami T, Matsumoto T, Seo H, Tanaka O, Iida S, et al. Intrahepatic portosystemic venous shunt passing through the left inferior phrenic vein and draining into the left renal vein. Br J Radiol 2004;77:966–8.[Abstract/Free Full Text]
- Tanoue S, Kiyosue H, Komatsu E, Hori Y, Maeda T, Mori H. Symptomatic intrahepatic portosystemic venous shunt: angiographic findings and transcatheter embolization with an alternative approach. AJR Am J Roentgenol 2003;181:71–8.[Abstract/Free Full Text]
- Ohtomo K, Furui S, Saito M, Kokubo T, Itai Y, Iio M. Enormous intrahepatic communication between the portal vein and hepatic vein. Clin Radiol 1986;37:513–4.[CrossRef][Medline]
- Maeda T, Mori H, Aikawa H, Komatsu E, Kagawa K. Therapeutic embolization of intrahepatic portosystemic shunts by retrograde transcaval catheterization. Cardiovasc Intervent Radiol 1993;16:245–7.[Medline]
- Yamagami T, Nakamura T, Iida S, Kato T, Tanaka O, Matsushima S, et al. Hepatic encephalopathy secondary to intrahepatic portosystemic venous shunt: balloon-occluded retrograde transvenous embolization with n-butyl cyanoacrylate and microcoils. Cardiovasc Intervent Radiol 2002;25:219–21.[CrossRef][Medline]
- Fanelli F, Marcelli G, Bezzi M, Salvatori FM, Rossi M, Passariello R. Intrahepatic aneurysmal portohepatic venous shunt: embolization with a tissue adhesive solution. J Endovasc Ther 2003;10:147–53.[CrossRef][Medline]
- Chevallier P, Oddo F, Souci J, Diaine B, Padovani B. Macroscopic intrahepatic portosystemic venous shunt: review of the literature and reclassification. J Radiol 2001;81:597–604.
- Park JH, Cha SH, Han JK, Han MC. Intrahepatic portosystemic venous shunt. AJR Am J Roentgenol 1990;155:527–8.[Free Full Text]
- Chagnon SF, Vallee CA, Barge J, Chevalier LJ, Gal JL, Blery MV. Aneurysmal porto-hepatic venous fistula: report of two cases. Radiology 1986;159:693–5.[Abstract/Free Full Text]
- Han MH, Seong SO, Kim HD, Chang KH, Yeon KM, Han MC. Craniofacial arteriovenous malformation: preoperative embolization with direct puncture and injection of n-butyl cyanoacrylate. Radiology 1999;211:661–6.[Abstract/Free Full Text]
Top
Abstract
Introduction
