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Hetts SW, Shieh JT, Ohliger MA, Conrad MB. Hereditary Hemorrhagic Telangiectasia: The Convergence of Genotype, Phenotype, and Imaging in Modern Diagnosis and Management of a Multisystem Disease. Radiology 2021; 300:17-30. [PMID: 33973836 DOI: 10.1148/radiol.2021203487] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease that manifests as vascular malformations in the brain, lung, liver, gastrointestinal tract, nasal mucosa, and skin. Diagnosis and management of HHT is guided in large part by imaging studies, making it a condition with which the radiology community needs familiarity. Proper screening and care lead to improved morbidity and mortality in patients with HHT. International guidelines were recently updated and form the basis for a detailed discussion of the role of imaging and image-guided therapy in HHT. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Steven W Hetts
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
| | - Joseph T Shieh
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
| | - Michael A Ohliger
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
| | - Miles B Conrad
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
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Takenaga S, Narita K, Matsui Y, Fukuda K. Hepatic Encephalopathy due to Congenital Multiple Intrahepatic Portosystemic Venous Shunts Successfully Treated by Percutaneous Transhepatic Obliteration. Case Rep Gastroenterol 2016; 10:701-705. [PMID: 27990104 PMCID: PMC5156888 DOI: 10.1159/000452204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 10/03/2016] [Indexed: 11/19/2022] Open
Abstract
Hepatic encephalopathy due to intrahepatic portosystemic venous shunts (IPSVS) in a non-cirrhotic condition is rare. Here we report a rare case of a patient with congenital multiple IPSVS successfully treated by percutaneous transhepatic obliteration. The patient was a 67-year-old woman who presented to our hospital with progressive episodes of consciousness disorder and vomiting. Laboratory tests revealed hyperammonemia (192.0 μg/dL), and computed tomography revealed multiple IPSVS in both lobes. There was no evidence of underlying liver disease or hepatic trauma. Transcatheter embolization for IPSVS was performed because conservative therapy was not sufficiently effective. After endovascular shunt closure, hepatic encephalopathy improved. The serum ammonia level normalized during the 5-year follow-up period. Thus, transcatheter embolization may be an effective therapy for patients with symptomatic and refractory IPSVS. Careful follow-up is necessary for portal hypertension-related complications after transcatheter embolization for IPSVS.
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Affiliation(s)
- Shinsuke Takenaga
- Department of Radiology, The Jikei University Katsushika Medical Center, Tokyo, Japan
| | - Kenichi Narita
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yo Matsui
- Department of Radiology, Fuji City General Hospital, Fuji, Japan
| | - Kunihiko Fukuda
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
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Arora A, Rajesh S, Meenakshi YS, Sureka B, Bansal K, Sarin SK. Spectrum of hepatofugal collateral pathways in portal hypertension: an illustrated radiological review. Insights Imaging 2015; 6:559-72. [PMID: 26337049 PMCID: PMC4569600 DOI: 10.1007/s13244-015-0419-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/25/2015] [Accepted: 06/29/2015] [Indexed: 12/14/2022] Open
Abstract
The purpose of this article is to describe the various portosystemic collateral pathways pertinent to portal hypertension on multi-detector row computed tomography (MDCT) and their clinical relevance, with special emphasis on the uncommon ones. The knowledge and understanding of the various patterns of portosystemic collateral channels has important implications both for the clinician and the interventionist. MDCT with its advanced post processing capabilities can exquisitely demonstrate these vascular pathways to help in therapeutic decision making. Teaching points • Portosystemic collaterals are an important cause of bleeding and hepatic encephalopathy. • Radiologists should be familiar with the imaging findings to effectively identify them. • Pre-operative knowledge of portosystemic collaterals is essential to avoid inadvertent vascular injury.
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Affiliation(s)
- Ankur Arora
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - S Rajesh
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - Yamini S Meenakshi
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - Binit Sureka
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - Kalpana Bansal
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India.
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Matthews TJ, Trochsler MI, Bridgewater FH, Maddern GJ. Systematic review of congenital and acquired portal-systemic shunts in otherwise normal livers. Br J Surg 2014; 101:1509-17. [PMID: 25200002 DOI: 10.1002/bjs.9619] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 06/11/2014] [Accepted: 06/27/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Portal-systemic shunts (PSSs) are rarely seen in healthy individuals or patients with non-cirrhotic liver disease. They may play an important role in hepatic metabolism as well as in the spread of gastrointestinal metastatic tumours to specific organs. Small spontaneous PSSs may be more common than generally thought. However, epidemiological data are scarce and inconclusive. This systematic review examined the prevalence of reported PSSs and the associated detection methods. METHODS Literature up to 2011 was reviewed for adult patients with proven congenital or acquired PSSs. Only PSSs in normal livers were analysed for the methods of diagnosis. Eligible studies were identified by searching relevant databases, including PubMed, Embase, MEDLINE and the Cochrane Library. The selection of eligible articles was carried out using predefined inclusion criteria (adult, non-surgical PSS) and a set of search terms that were established before the articles were identified. RESULTS Eighty studies were included describing 112 patients with congenital or acquired PSSs. The majority were diagnosed incidentally using Doppler ultrasound imaging and CT. CONCLUSION Congenital and acquired PSSs are rare. They are usually clinically asymptomatic and discovered incidentally by radiological techniques. They may be clinically relevant owing to drug, tumour cell, metabolic and pathogen shunting.
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Affiliation(s)
- T J Matthews
- Discipline of Surgery, University of Adelaide, Queen Elizabeth Hospital, 28 Woodville Road, Woodville, South Australia 5011, Australia
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Ito K, Fujita T, Shimizu A, Sasaki K, Tanabe M, Matsunaga N. Imaging findings of unusual intra- and extrahepatic portosystemic collaterals. Clin Radiol 2009; 64:200-7. [DOI: 10.1016/j.crad.2008.05.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 05/19/2008] [Accepted: 05/27/2008] [Indexed: 11/18/2022]
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Bussadori R, Bussadori C, Millán L, Costilla S, Rodríguez-Altónaga JA, Orden MA, Gonzalo-Orden JM. Transvenous coil embolisation for the treatment of single congenital portosystemic shunts in six dogs. Vet J 2008; 176:221-6. [PMID: 17466545 DOI: 10.1016/j.tvjl.2007.02.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Revised: 02/14/2007] [Accepted: 02/24/2007] [Indexed: 11/28/2022]
Abstract
This article describes the treatment of single congenital portosystemic shunts (CPSs) (intrahepatic and extrahepatic) using an interventional radiology technique involving embolisation of anomalous vessels with percutaneous coils. Briefly, a multipurpose catheter was introduced into the caudal vena cava and then into the portosystemic shunt. An autoexpandable stent was placed in the caudal vena cava, next to the shunt, in order to avoid coil migrations, and a cobra-like vascular catheter was used to pass through the stent and to place the coils in the shunt. This technique was used for treatment of CPS in six dogs. The results indicate that percutaneous embolisation of a CPS using coils, a less invasive technique than the traditional surgical technique, may result in complete closure of the anomalous vessel without development of portal hypertension.
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Affiliation(s)
- Roberto Bussadori
- Department of Surgery and Radiology, Faculty of Veterinary Medicine, University of León, 24071 León, Spain
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Hiraoka A, Kurose K, Hamada M, Azemoto N, Tokumoto Y, Hirooka M, Hasebe A, Kumagi T, Hirata M, Michitaka K, Minami H, Murakami M, Isobe Y, Horiike N, Onji M. Hepatic encephalopathy due to intrahepatic portosystemic venous shunt successfully treated by interventional radiology. Intern Med 2005; 44:212-6. [PMID: 15805709 DOI: 10.2169/internalmedicine.44.212] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We treated a 66-year-old woman with hepatic encephalopathy secondarily induced by an intrahepatic portosystemic venous shunt (IPSVS). In serial observations, the volume of the liver became smaller and encephalopathy could not be controlled with conservative therapy. We occluded the IPSVS successfully using percutaneous transcatheter embolization with micro coils. Following embolization, encephalopathy disappeared and blood flow of all branches of portal vein improved. In cases with an IPSVS without liver cirrhosis, blood flow in the portal vein and liver volume must be followed carefully, and interventional radiology may be considered effective in those who do not show a satisfactory response to conservative therapy.
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Affiliation(s)
- Atsushi Hiraoka
- Third Department of Internal Medicine, Ehime University of Medicine, Toon, Ehime 791-0295
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Tanoue S, Kiyosue H, Komatsu E, Hori Y, Maeda T, Mori H. Symptomatic intrahepatic portosystemic venous shunt: embolization with an alternative approach. AJR Am J Roentgenol 2003; 181:71-8. [PMID: 12818832 DOI: 10.2214/ajr.181.1.1810071] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Intrahepatic portosystemic venous shunt is relatively rare and not well recognized. Awareness of intrahepatic communications is important because they can cause encephalopathy, and most of these shunts can be completely cured by transcatheter embolization. In this study, we describe the angiographic findings and transcatheter embolization techniques using several approaches for the treatment of intrahepatic portosystemic venous shunt. MATERIALS AND METHODS Between 1989 and 2001, we treated 10 patients with symptomatic intrahepatic portosystemic venous shunt by performing transcatheter embolization with Gianturco coils, fibered platinum coils, detachable balloons, and detachable microcoils using one of three approaches to access the portal venous system: transileocolic obliteration (n = 2), percutaneous transhepatic obliteration (n = 4), or retrograde transcaval obliteration (n = 4). RESULTS In all patients, complete obliteration or nearly complete obliteration was confirmed angiographically, and symptoms related to portal-systemic encephalopathy improved after treatment. Complications were observed in three patients: adhesive ileus in a patient treated by transileocolic obliteration and thrombosis of intrahepatic portal branches in two patients treated by percutaneous transhepatic obliteration. CONCLUSION On angiography, two types of intrahepatic portosystemic venous shunt were seen: intrahepatic portal venous-hepatic venous communication and intrahepatic portal venous-perihepatic venous communication. Transcatheter embolization is effective for treatment of intrahepatic portosystemic venous shunt. Retrograde transcaval obliteration is the least invasive technique and is recommended as the first choice for treatment of portosystemic venous shunt except in patients with multiple shunts.
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Affiliation(s)
- Shuichi Tanoue
- Department of Radiology, Oita Medical University, 1-1, Idaigaoka, Hasama-machi, Oita-gun, Oita, 879-5593, Japan
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Takayama Y, Moriura S, Nagata J, Akutagawa A, Hirano A, Ishiguro S, Matsumoto T, Sato T. Embolization of the left portal vein to inferior vena cava shunts for chronic recurrent hepatic encephalopathy via the mesenteric vein. J Gastroenterol Hepatol 2001; 16:1425-8. [PMID: 11851846 DOI: 10.1046/j.1440-1746.2001.02508.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Diagnostic imaging and embolization therapy for very rare intrahepatic portal-systemic shunts with liver cirrhosis are reported. An 82-year-old woman was admitted to the hospital (Yachiyo Hospital) because of hepatic encephalopathy. Computed tomography with contrast enhancement demonstrated anomalous vessels between the portal vein and the inferior vena cava. Those shunts were suspected as the cause of her encephalopathy with hyperammonemia. Portography through McBurney's laparotomy demonstrated two portal-caval shunts; one was from the bifurcation of the portal vein and the other was from the left portal vein. They seemed to originate from the vascular system of the caudate lobe, and were obstructed with stainless coils. The patient is well with a normal serum ammonia level 40 months following the intervention.
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Affiliation(s)
- Y Takayama
- Department of Surgery, Yachiyo Hospital, Aichi, Japan.
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Affiliation(s)
- K Ibukuro
- Department of Radiology, Mitsui Memorial Hospital, Tokyo, Japan
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Nishie A, Yoshimitsu K, Honda H, Kaneko K, Kuroiwa T, Fukuya T, Irie H, Ninomiya T, Yoshimitsu T, Hirakata H, Okuda S, Masuda K. Treatment of hepatic encephalopathy by retrograde transcaval coil embolization of an ileal vein-to-right gonadal vein portosystemic shunt. Cardiovasc Intervent Radiol 1997; 20:222-4. [PMID: 9134849 DOI: 10.1007/s002709900142] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A 43-year-old non-cirrhotic woman suffered from encephalopathy caused by an extrahepatic portosystemic shunt between the ileal vein and inferior vena cava via the right gonadal vein. Percutaneous transcatheter embolization with stainless steel coils was performed by the retrograde systemic venous approach. Encephalopathy improved dramatically.
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Affiliation(s)
- A Nishie
- Department of Radiology, Faculty of Medicine, Kyushu University, Fukuoka, Japan
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Sakurabayashi S, Sezai S, Yamamoto Y, Hirano M, Oka H. Embolization of portal-systemic shunts in cirrhotic patients with chronic recurrent hepatic encephalopathy. Cardiovasc Intervent Radiol 1997; 20:120-4. [PMID: 9030502 DOI: 10.1007/s002709900118] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE To evaluate the efficacy of embolization of portal-systemic shunts in cirrhotic patients with chronic recurrent hepatic encephalopathy (CRHE). METHODS Seven cirrhotic patients with CRHE refractory to medical treatment (3 men and 4 women, mean age 66 years) were studied. Five patients had splenorenal shunts, 1 had a gastrorenal shunt, and 1 had an intrahepatic portal vein-hepatic vein shunt. Shunt embolization was performed using stainless steel coils, with a percutaneous transhepatic portal vein approach in 4 patients and a transrenal vein approach in 3 patients. RESULTS After embolization, the shunt disappeared in 4 patients on either ultrasound pulsed Doppler monitoring or portography. Complications observed in the 7 patients were fever, transient pleural effusion, ascites, and mild esophageal varices. For 3-6 months after embolization, the 4 patients whose shunts disappeared showed minimal or no reappearance of a shunt, and had no recurrence of encephalopathy. The serum ammonia levels decreased and electroencephalograms also improved. One of the 4 patients, who developed mild esophageal varices, required no treatment. Treatment was effective in 3 of the 4 patients (75%) who underwent embolization via a transhepatic portal vein. CONCLUSION Transvascular embolization of shunts improved the outcome in 4 of 7 patients. The most effective embolization was achieved via the percutaneous transhepatic portal vein approach.
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Affiliation(s)
- S Sakurabayashi
- Division of Gastroenterology, Tokyo Metropolitan Police Hospital, 2-10-41 Fujimi, Chiyoda-ku, Tokyo 102, Japan
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