Portal vein embolization for closure of marked arterioportal shunt of hepatocellular carcinoma to enable radioembolization:A case report

BACKGROUND Marked arterioportal shunt(APS)can be a contraindication for transarterial radioembolization(TARE)because of the risk of radiation-induced liver toxicity or pneumonitis.To date,the best method to close marked APS to reduce intrahepatic shunt(IHS)and hepatopulmonary shunt(HPS)before TARE has not been elucidated.CASE SUMMARY This case report describes a novel strategy of embolization of the portal venous outlet to reduce IHS and HPS caused by marked APS before TARE in a patient with advanced hepatocellular carcinoma(HCC).The patient had a significant intratumoral shunt from the tumor artery to the portal vein and had already been suspected based on pre-interventional magnetic resonance angiography,and digital subtraction angiography(DSA)confirmed the shunt.Selective right portal vein embolization(PVE)was performed to close the APS outlet and DSA confirmed complete closure.Technetium-99m macroaggregated albumin was administered and single photon emission computed tomography revealed a low HPS with 8.4%.Successful TARE was subsequently performed.No major procedurerelated complication occurred.CONCLUSION Closure of APS with PVE during mapping angiography of advanced-stage HCC to enable reduction of HPS and subsequent TARE is feasible.

Comparison of ethanol-soaked gelatin sponge and microspheres for hepatic arterioportal fistulas embolization in hepatic cellular carcinoma

Hepatic arterioportal fistulas(APFs)are common in hepatocellular carcinoma(HCC).Moreover,correlated with poor prognosis,APFs often complicate antitumor treatments,including transarterial chemoembolization(TACE).AIM To compare the efficacy of ethanol-soaked gelatin sponges(ESG)and microspheres in the management of APFs and their impact on the prognosis of HCC.METHODS Data from patients diagnosed with HCC or hepatic APFs between June 2016 and December 2019 were retrospectively analyzed.Furthermore,APFs were embolized with ESG(group E)or microspheres(group M)during TACE.The primary outcomes were disease control rate(DCR)and objective response rate(ORR).The secondary outcomes included immediate and first follow-up APF improvement,overall survival(OS),and progression-free survival(PFS).RESULTS Altogether,91 participants were enrolled in the study,comprising 46 in group E and 45 in group M.The DCR was 93.5%and 91.1%in groups E and M,respectively(P=0.714).The ORRs were 91.3%and 66.7%in groups E and M,respectively(P=0.004).The APFs improved immediately after the procedure in 43(93.5%)patients in group E and 40(88.9%)patients in group M(P=0.485).After 2 mo,APF improvement was achieved in 37(80.4%)and 33(73.3%)participants in groups E and M,respectively(P=0.421).The OS was 26.2±1.4 and 20.6±1.1 mo in groups E and M,respectively(P=0.004),whereas the PFS was 16.6±1.0 and 13.8±0.7 mo in groups E and M,respectively(P=0.012).CONCLUSION Compared with microspheres,ESG embolization demonstrated a higher ORR and longer OS and PFS in patients of HCC with hepatic APFs.

Effect of arterioportal shunting in radical resection of hilar cholangiocarcinoma

Background The resection and reconstruction of the hepatic artery is often required in radical surgery for hilar cholangiocarcinoma. In this study, we report our experience in performing arterioportal shunting as an alternative for the arterial reconstruction. Methods Four patients with hilar cholangiocarcinoma underwent extended left hepatectomy and caudate Iobectomy combined with en bloc resection of the hepatic artery and arterioportal shunting with restriction of the arterial caliber. The efficacy of arterioportal shunting was assessed by computed tomography angiography （CTA）. Results All the four patients recovered uneventfully without any complications. CTA showed a patent shunt and normal liver regeneration. No signs of portal hypertension were found at one year of follow-up. Conclusions Arterioportal shunting with restriction of the arterial caliber appears to be a feasible and safe alternative for the microvascular reconstruction after hepatic artery resection in radical surgery for hilar cholangiocarcinoma.

Novel CABIN score outperforms other prognostic models in predicting in-hospital mortality after salvage transjugular intrahepatic portosystemic shunting

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is now established as the salvage procedure of choice in patients who have uncontrolled or severe recurrent variceal bleeding despite optimal medical and endoscopic treatment.AIM To analysis compared the performance of eight risk scores to predict in-hospital mortality after salvage TIPS(sTIPS)placement in patients with uncontrolled variceal bleeding after failed medical treatment and endoscopic intervention.METHODS Baseline risk scores for the Acute Physiology and Chronic Health Evaluation(APACHE)II,Bonn TIPS early mortality(BOTEM),Child-Pugh,Emory,FIPS,model for end-stage liver disease(MELD),MELD-Na,and a novel 5 category CABIN score incorporating Creatinine,Albumin,Bilirubin,INR and Na,were calculated before sTIPS.Concordance(C)statistics for predictive accuracy of inhospital mortality of the eight scores were compared using area under the receiver operating characteristic curve(AUROC)analysis.RESULTS Thirty-four patients(29 men,5 women),median age 52 years(range 31-80)received sTIPS for uncontrolled(11)or refractory(23)bleeding between August 1991 and November 2020.Salvage TIPS controlled bleeding in 32(94%)patients with recurrence in one.Ten(29%)patients died in hospital.All scoring systems had a significant association with in-hospital mortality(P<0.05)on multivariate analysis.Based on in-hospital survival AUROC,the CABIN(0.967),APACHE II(0.948)and Emory(0.942)scores had the best capability predicting mortality compared to FIPS(0.892),BOTEM(0.877),MELD Na(0.865),Child-Pugh(0.802)and MELD(0.792).CONCLUSION The novel CABIN score had the best prediction capability with statistical superiority over seven other risk scores.Despite sTIPS,hospital mortality remains high and can be predicted by CABIN category B or C or CABIN scores>10.Survival was 100%in CABIN A patients while mortality was 75%for CABIN B,87.5%for CABIN C,and 83%for CABIN scores>10.

Surgical treatment of hepatocellular carcinoma with severe intratumoral arterioportal shunt

We report a case of hepatocellular carcinoma (HCC) that caused a severe arterioportal shunt (APS). A 49-year-old man was admitted to hospital due to esophagogastric variceal hemorrhage and HCC, and underwent endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS). He was then referred to our hospital. Abdominal computed tomography revealed a lowdensity lesion in the posterior segment of the liver and an intratumoral APS, which caused portal hypertension. Although the patient underwent EVL, EIS, Hassab’s operation, and transcatheter arterial embolization for APS, he vomited blood due to rupture of esophagogastric varices. Right hepatectomy was performed for the treatment of HCC and APS, although the indocyanine green retention value at 15 min after intravenous injection was poor (30%). The patient’s postoperative course was uneventful. Eventually, APS disappeared and the esophagogastric varices improved.

Portal hypertension induced by congenital hepatic arterioportal fistula:Report of four clinical cases and review of the literature

Intrahepatic arterioportal fistula(IAPF)can be caused by many secondary factors.We report four cases of portal hypertension that were eventually determined to be caused by congenital hepatic arterioportal fistula.The clinical manifestations included ascites,variceal hemorrhage and hepatic encephalopathy.Computed tomography scans from all of the patients revealed the early enhancement of the portal branches in the hepatic arterial phase.All patients were diagnosed using digital subtraction angiography(DSA).DSA before embolization revealed an arteriovenous fistula with immediate filling of the portal venous radicles.All four patients were treated with interventional embolization.The four patients remained in good condition throughout follow-up and at the time of publication.IAPF is frequently misdiagnosed due to its rarity;therefore,clinicians should consider IAPF as a potential cause of non-cirrhotic portal hypertension.

Isolated arterioportal fistula presenting with variceal hemorrhage

We report a case of life-threatening hematemesis due to portal hypertension caused by an isolated arterioportal fistula (APF). Intrahepatic APFs are extremely rare and are a cause of presinusoidal portal hypertension. Etiologies for APFs are comprised of precipitating trauma, malignancy, and hereditary hemorrhagic telangiectasia, but these were not the case in our patient. Idiopathic APFs are usually due to congenital vascular abnormalities and thus usually present in the pediatric setting. This is one of the first cases of adult-onset isolated APF who presented with portal hypertension and was successfully managed through endoscopic hemostasis and subsequent interventional radiological embolization.

Flexural wave band-gaps in phononic metamaterial beam with hybrid shunting circuits

Periodic arrays of hybrid-shunted piezoelectric patches are used to control the band-gaps of phononic metamaterial beams. Passive resistive-inductive （RL） shunting circuits can produce a narrow resonant band-gap （RG）, and active negative capacitive （NC） shunting circuits can broaden the Bragg band-gaps （BGs）. In this article, active NC shunting circuits and passive resonant RL shunting circuits are connected to the same piezoelectric patches in parallel, which are usually called hybrid shunting circuits, to control the location and the extent of the band-gaps. A super-wide coupled band-gap is generated when the coupling between RG and the BG occurs. The attenuation constant of the infinite periodic structure is predicted by the transfer matrix method, which is compared with the vibration transmittance of a finite periodic structure calculated by the finite element method. Numerical results show that the hybrid-shunting circuits can make the band-gaps wider by appropriately selecting the inductances, negative capacitances, and resistances.

在 transcatheter 以后的征兆的 arterioportal 管的临床的结果动脉的 embolization

AIM: To evaluate the complications and clinical outcomes of transcatheter arterial embolization (TAE) for symptoms related to severe arterioportal fistulas (APFs). METHODS: Six patients (3 males, 3 females; mean age, 63.8 years; age range, 60-71 years) with chronic liver disease and severe APFs due to percutaneous intrahepatic treatment (n=5) and portal vein (PV) tumor thrombosis of hepatocellular carcinoma (n=1) underwent TAE for symptoms related to severe APFs [refractory ascites (n=4), hemorrhoidal hemorrhage (n=1), and hepatic encephalopathy (n=1)]. Control of symptoms related to APFs and complications were evaluated during the follow-up period (range, 4-57 mo). RESULTS: In all patients, celiac angiography revealed immediate retrograde visualization of the main PV before TAE, indicating severe APF. Selective TAE for the hepatic arteries was performed using metallic coils (MC, n=4) and both MCs and n-butyl cyanoacrylate (n=2). Three patients underwent repeated TAEs for residual APFs and ascites. Four patients developed PV thrombosis after TAE. During the follow-up period after TAE, APF obliteration and symptomatic improvement were obtained in all patients. CONCLUSION: Although TAE for severe APFs may sometimes be complicated by PV thrombosis, TAE can be an effective treatment to improve clinical symptoms related to severe APFs.

Wave propagation in beams with anti-symmetric piezoelectric shunting arrays

Piezoelectric shunting arrays are employed to control the wave propagation in flexible beams. Contrary to conven- tional symmetric configuration, a substrate beam with anti-symmetric shunting arrays is investigated by adapted transfer matrix method. Compared with symmetric scheme, the anti-symmetric one demonstrates some distinctive characteristics. Primarily, the longitudinal and fiexural waves are coupled, so they are correlated and must be considered simultaneously. Moreover, the attenuation of flexural wave is much stronger in anti-symmetric scenario, while the longitudinal wave demon- strates the converse side. As a result, the anti-symmetric scheme can be utilized to improve the vibration isolation capability of shunting arrays. Finally, the theoretical analyses are validated by finite element simulations.

Combined endovascular-surgical treatment for complex congenital intrahepatic arterioportal fistula: A case report and review of the literature

BACKGROUND Congenital intrahepatic arterioportal fistula(IAPF) is a rare vascular malformation in infants that causes severe portal hypertension(PH) with poor prognosis if untreated. Currently, radiological embolisation is considered the first-line therapy for simple IAPF; however, it might be not resolutive for complex hepatic vascular lesions. When endovascular embolization is not sufficient to completely obliterate the IAPF, surgical intervention is needed, but it has been associated with severe morbidity and mortality in small children.Furthermore, indications are not defined.CASE SUMMARY We present the first case of a 6-month-old girl with trisomy 21 affected by a complex congenital IAFP, which caused severe PH, successfully treated with an endovascular-surgical hybrid procedure. The novel technique comprised a multistep endovascular embolisation, including a superselective transarterial embolisation of the afferent vessels and a direct transhepatic embolisation of the dilated portal vein segment, combined with selective surgical ligation of the arterial branches that supply the fistula, which were too small to be embolised.The complex IAPF was also associated with severe cholestasis and intra/extrahepatic biliary tree dilatation, which was successfully treated by a temporary biliary drainage. At 24-mo follow-up, the hybrid endovascularsurgical procedure achieved complete occlusion of the complex IAPF and resolution of the PH. A comprehensive review of the literature on congenital IAPF management, focussed on alternative treatment strategies, is also reported.CONCLUSION The combined radiological-surgical approach is a safe and effective treatment option for complex IAPF and avoids major invasive surgery.

Arterioportal shunt incidental to treatment with oxaliplatin that mimics recurrent gastric cancer

Arterioportal shunt(APS) is an organic communication between the hepatic arterial system and the portal venous system. The APS is one of the major causes of transient hepatic attenuation differences on dynamic computed tomography(CT) or magnetic resonance imaging(MRI). This condition is usually associated with trauma,liver cirrhosis,and malignancies of the liver. However,there has been no report about oxaliplatininduced APS. A 41-year-old male was diagnosed with Stage ⅢB gastric cancer. The patient initially underwent neoadjuvant chemotherapy with capecitabine and oxaliplatin After 3 cycles of therapy,the mass had markedly decreased,and a total gastrectomy with splenectomy was performed. Since the malignancy was locally invasive,the patient was continued on the same regimen of the adjuvant chemotherapy. After 3 more cycles,a computed tomography revealed a 1 cm sized arterial-enhancing nodule in the right lobe of the liver. An MRI revealed an arterial enhancing lesion,and a positron emission tomography CT scan showed a hypermetabolic lesion in the same portion of the liver. We tried to perform a liver biopsy; however,an ultrasonography could not detect any mass. A presumptive diagnosis of an APS due to a recurred cancer was made. We found a similar but slightly different case report of an oxaliplatin-induced liver injury,mimicking a metastatic tumor on an MRI. Based on a prior report,the patient was continuedon treatment with adjuvant chemotherapy following discontinuation of oxaliplatin. After 2 cycles,the arterial enhancing liver mass resolved,supporting the final diagnosis of an APS,related to oxaliplatin-induced sinusoidal injury. The patient has not experienced any a relapse after two years of additional follow up recurrent gastric cancer upon interpretation of multiple imaging modalities.

Diagnosis and management of arterioportal fistula occurring after percutaneous transhepatic portal vein cannula-assisted TIPS

To the Editor:Transjugularintrahepaticportosystemicshunt(TIPS)isusuallyconsideredthechoiceformanagingcomplicationsofportal hypertensionsuchasrefractoryascites,esophagogastricvariceal bleedingandrecurrentbleedinguncontrolledwithfirstline treatment.Inrecentyears,TIPShasbeensuccessfullyusedto treat Budd-Chiari syndrome, hepatic hydrothorax, and portal vein thrombosis.One of the key steps during TIPS is the portal vein puncture.

Simultaneous embolization of a spontaneous porto-systemic shunt and intrahepatic arterioportal fistula:A case report

BACKGROUND Hepatic encephalopathy(HE)is a frequent and debilitating complication of chronic liver disease.Recurrent HE is strongly linked with spontaneous portosystemic shunts(SPSSs).Intrahepatic arterioportal fistulas(IAPFs)occur rarely but pose a major clinical challenge and may lead to or worsen portal hypertension.Herein,we present a rare case of recurrent HE secondary to a SPSS combined with an IAPF.CASE SUMMARY A 63-year-old female with primary biliary cirrhosis presented with recurrent disturbance of consciousness for 4 mo.SPSS communicating the superior mesenteric vein with the inferior vena cava and IAPF linking the intrahepatic artery with the portal vein were found on contrast-enhanced abdominal computed tomography.The patient did not respond well to medical treatment.Therefore,simultaneous embolization of SPSS and IAPF was scheduled.After embolization,the symptoms of HE showed obvious resolution.CONCLUSION The presence of liver vascular disorders should not be neglected in patients with chronic liver disease,and interventional therapy is a reasonable choice in such patients.

Coil embolization of arterioportal fistula complicated by gastrointestinal bleeding after Caesarian section: A case report

BACKGROUND Most intrahepatic arterioportal fistulae(IAPF)are acquired.The few cases of congenital fistulae are diagnosed in infants and children.CASE SUMMARY We report a 31-year-old female patient presenting with haematemesis and melena three weeks after delivering her second child.The patient had a 20-year history of abdominal distention and nausea.IAPF,along with splenomegaly and ascites,was found by Doppler sonography and confirmed by computed tomography angiography.The patient was treated with endovascular coil embolization,resulting in occlusion of the fistula.CONCLUSION This was an unusual case of possible congenital IAPF that manifested during a second pregnancy and was complicated by portal hypertension.

Capability of multidetector CT to diagnose hepatocellular carcinoma-associated arterioportal shunt

AIM: To investigate the capability of multidetector CT (MDCT) to diagnose HCC-associated arterioportal shunt (APS).METHODS: Two hundred and eighty-two patients with HCC received both thin-slice and enhancement MDCT scanning at early hepatic arterial phase, late hepatic arterial phase and portal venous phase, and digital subtract angiography (DSA) examination. Images were analyzed jointly by two experienced radiologists blinded to the opposite examination results, including the existence or not of APS, shunt locations, types and degrees of APS, with or without thrombosis. RESULTS: There were 56 APS associated with HCC, including 48 central, seven peripheral and one mixed, or 42 severe, seven moderate, seven mild APS. Fortyone severe, seven moderate and central APS were all revealed with MDCT and DSA. Seven mild and peripheral APS were all displayed with MDCT; only five of them displayed DSA, two faint shunt APS associated with massive HCC were missed. One mixed APS was demonstrated as severe combined with mild shunt with both MDCT and DSA.CONCLUSION: MDCT could diagnose not only DSA revealed APS, but also missed mild and peripheral APS with DSA due to faint shunt associated with massive HCC, is a simple, effective and noninvasive new technique for diagnosis of HCC-associated APS.

Ruptured high flow gastric varices with an intratumoral arterioportal shunt treated with balloon-occluded retrograde transvenous obliteration during temporary balloon occlusion of a hepatic artery

A patient presented with hematemesis due to gastric variceal bleeding with an intratumoral arterioportal shunt. Contrast-enhanced CT revealed gastric varices and hepatocellular carcinoma with tumor thrombi in the right portal vein. Angiography and angio-CT revealed a marked intratumoral arterioportal shunt accompanied with re? ux into the main portal vein and gastric varices. Balloon-occluded retrograde venography from the gastro-renal shunt showed no visualization of gastric varices due to rapid blood flow through the intratumoral arterioportal shunt. The hepatic artery was temporarily occluded with a balloon catheter to reduce the blood ? ow through the arterioportal shunt, and then concurrent balloon-occluded retrograde transvenous obliteration (BRTO) was achieved. Vital signs stabilized immediately thereafter, and contrast-enhanced CT revealed thrombosed gastric varices. Worsening of hepatic function was not recognized. BRTO combined with temporary occlusion of the hepatic artery is a feasible interventional procedure for ruptured high ? ow gastric varices with an intratumoral arterioportal shunt.

Gastrointestinal bleeding caused by extrahepatic arterioportal fistula associated with portal vein thrombosis

An extrahepatic arterioportal fistula(APF) involving the gastroduodenal artery and superior mesenteric vein is rare and mostly results from iatrogenic injuries.The clinical symptoms associated with APFs may include abdominal pain,gastrointestinal bleeding,ascites,nausea,vomiting,diarrhea,or even congestive heart failure.We present the case of a 70-year-old man who presented with chronic abdominal pain and gastrointestinal bleeding secondary to APF and portal vein thrombosis.The endovascular embolization of APF was accomplished successfully,and symptoms of portal hypertension resolved immediately after intervention.Unfortunately,the patient did not respond well to anticoagulation therapy with warfarin.Therefore,the patient underwent implantation of a transjugular intrahepatic portosystemic shunt,and the complications of portal hypertension resolved.In conclusion,the embolization of APF is technically feasible and effective and can be considered the first-choice therapy in selected patients.

The therapeutic strategies for the slit ventricle syndrome after cyst-peritoneal shunting for the temporal arachnoid cyst in children:six cases report and literatures review

Objective To investigate early diagnosis evidences,optimal therapeutic strategies and the prophylactic methods of the slit ventricle syndrome (SVS) in the temporal lobe arachnoid cysts patients who received the cyst-peritoneal(CP) shunting. Methods Six cases of SVS in the temporal lobe arachnoid cysts patients

A large congenital and solitary intrahepatic arterioportal fistula in an old woman

Arterioportal fistula(APF)is a rare cause of portal hypertension and may lead to death.APF can be congenital,post-traumatic,iatrogenic(transhepatic intervention or biopsy)or related to ruptured hepatic artery aneurysms.Congenital APF is a rare condition even in children.In this case report,we describe a 73-year-old woman diagnosed as APF by ultrasonography,computed tomography,and hepatic artery selective arteriography.The fistula was embolized twice but failed,and she still suffered from alimentary tract hemorrhage.Then,selective arteriography of the hepatic artery was performed again and venae coronaria ventriculi and short gastric vein were embolized.During the 2-year follow-up,the patient remained asymptomatic.We therefore argue that embolization of venae coronaria ventriculi and short gastric vein may be an effective treatment modality for intrahepatic APF with severe upper gastrointestinal bleeding.