Congenital portosystemic venous shunt

Etiology and treatment of recurrent consciousness disorders following hepatobiliary surgery: Insights from a portosystemic shunt case study

Intrahepatic portosystemic venous shunt is a rare vascular anomaly that can occur congenitally or iatrogenically, leading to hyperammonemia and neurological complications such as hepatic encephalopathy. This report presents the case of a woman in her early 70s who developed recurrent episodes of altered consciousness following hepatobiliary surgery. Subsequent magnetic resonance angiography revealed an intrahepatic portosystemic venous shunt, and the patient underwent successful treatment with percutaneous transhepatic portal vein embolization. After treatment, her symptoms resolved completely, and she remained asymptomatic during an 8-month follow-up period. This report underscores the importance of considering intrahepatic portosystemic venous shunt in the differential diagnosis of postoperative neurological symptoms. Our findings suggested that percutaneous transhepatic portal vein embolization was effective in managing this case, leading to symptom resolution and sustained improvement during follow-up. Although this approach appears promising, further investigation is needed to establish its broader applicability. Early detection and appropriate management may help improve patient outcomes in selected cases.

Extrahepatic portosystemic shunt concealed in congenital heart disease and neurodevelopmental disorder: a case report

Background

Neurodevelopmental disorders (NDDs) are often associated with congenital heart diseases (CHDs). Congenital portosystemic shunt (CPSS) is a rare abnormality of the portal system in which toxic substances that are not adequately metabolized by the liver circulate throughout the body and can cause non-specific neuropsychiatric symptoms. We describe a case of CHD and NDD in which neuropsychiatric symptoms due to extrahepatic CPSS became evident in adulthood.

Case summary

A 24-year-old man underwent a thorough examination for liver dysfunction. He had a history of repaired tetralogy of Fallot and autism spectrum disorder. He was also diagnosed with depression at 21 years of age. Abdominal contrast-enhanced computed tomography revealed an abnormal vessel descending from the main trunk of the portal vein and entering the left common iliac vein, which was diagnosed as a CPSS. Hyperammonaemia, focal nodular hyperplasia of the liver, and high signal intensity in the bilateral globus pallidus on T1-weighted brain magnetic resonance imaging were also observed. Transcatheter occlusion of the CPSS with a multilayer device (Vascular Plug II; AGA Medical Corporation, Plymouth, MN, USA) significantly improved neuropsychiatric symptoms, abnormal blood data, and head and liver lesions.

Discussion

Some of the neuropsychiatric symptoms in this patient were thought to have been caused by portosystemic encephalopathy (PSE) associated with CPSS. The symptoms of PSE and NDD are sometimes similar and difficult to differentiate. Although complications of CHD and NDD are common, screening for secondary treatable neuropsychiatric disorders, such as PSE, should be considered.

Imaging features, classification and clinical features of intrahepatic congenital portosystemic shunts

Congenital portosystemic shunts (CPSS) are a rare developmental anomaly diverting blood flow from the portal venous system and the liver to the systemic venous system. This case series examines the sonographic imaging findings, shunt classification, ultrasound shunt ratios, and outcomes in nine children (5 females, 4 males) admitted to our institution between 2015 and 2022 were included in this study. The shunts were initially categorized by the Parks classification and were followed by serial ultrasounds. Clinical presentation, clinical course, laboratory data, shunt ratios, and time to shunt closure were all followed on subsequent ultrasounds. The most common type of CPPS was the Type 3 shunt. In cases where shunt ratios were measured, the shunt ratio gradually decreased in tandem with decreasing ammonia levels until spontaneous closure was achieved. Predictors of lack of shunt closure included high shunt ratios and Type 4 shunts. Patients with CPPS can be followed with the shunt ratio calculation obtained from sonographic imaging, which may correlate to ammonia levels and indicate risk of hepatic encephalopathy as well as predict speed and timing of closure.

Case Report: Type Ib Abernethy malformation

Congenital extrahepatic portosystemic shunt, also known as Abernethy malformation, is a rare anatomic vascular malformation. Patients with Abernethy malformation may present with abdominal pain, abnormal liver function tests, hepatopulmonary syndrome, pulmonary hypertension, and/or portosystemic encephalopathy. Accurate identification of the shunt and portal vein and effective management of complications is vital in these patients. Routine imaging examinations are useful for the diagnosis and classification of Abernethy malformation. However, these examinations may miss some portal vein branches. Digital subtraction angiography is invaluable when routine imaging cannot precisely identify the hepatic portal vein in this situation.

New strategy using laparoscopic hepatectomy for an intrahepatic portal-hepatic venous shunt with hyperammonemia (with video)

Intrahepatic portal and hepatic venous shunts have been reported in children (Takama et al. Surg Case Rep 2020;6(1):73) but are very rare in adults (Papamichail et al. Hepatobiliary Pancreat Dis Int 2016;15(3):329-333). Treatment is indicated in cases of portal hypertension or hyperammonemia. We evaluated and reported the usefulness, safety, and effectiveness of laparoscopic liver resection for this case. After performing intraoperative ultrasonography, the hilar plate was manipulated to identify the target Glissonean branch of segment 5 (G5). Bulldog forceps were then used for test clamping, which was identified by negative staining, Segment 5 was dissected and hepatic parenchymal resection was performed. The hepatic veins running within the ischemic area were dissected, and hepatic parenchymal resection, including intrahepatic portal and hepatic venous shunts, was performed. The operation time was 257 min, and she was discharged on the 8th postoperative day, with no complications. Serum ammonia levels decreased rapidly postoperatively. Laparoscopic liver resection may be effective for intrahepatic portal and hepatic venous shunts.

Imaging in Vascular Liver Diseases

Vascular liver diseases (VLDs) include different pathological conditions that affect the liver vasculature at the level of the portal venous system, hepatic artery, or venous outflow system. Although serological investigations and sometimes histology might be required to clarify the underlying diagnosis, imaging has a crucial role in highlighting liver inflow or outflow obstructions and their potential causes. Cross-sectional imaging provides a panoramic view of liver vascular anatomy and parenchymal patterns of enhancement, making it extremely useful for the diagnosis and follow-up of VLDs. Nevertheless, multiparametric ultrasound analysis provides information useful for differentiating acute from chronic portal vein thrombosis, distinguishing neoplastic invasion of the portal vein from bland thrombus, and clarifying the causes of venous outflow obstruction. Color Doppler analysis measures blood flow velocity and direction, which are very important in the assessment of VLDs. Finally, liver and spleen elastography complete the assessment by providing intrahepatic and intrasplenic stiffness measurements, offering further diagnostic information.

Living Donor Liver Transplantation for Congenital Portosystemic Shunt Presenting With Hyperinsulinemic Hypoglycemia

BACKGROUND

A congenital portosystemic shunt (CPSS) is defined as abnormal vascular communications between the portal vein and the systemic vein. Encephalopathy, hepatopulmonary syndrome, and portopulmonary hypertension are manifestations in patients with CPSS. Hyperinsulinemic hypoglycemia is also one of the manifestations of CPSS. Hyperinsulinemic hypoglycemia secondary to CPSS is caused by a lack of hepatic first-pass elimination of insulin, which is secreted from pancreatic beta cells.

CASE PRESENTATION

A 7-month-old boy had hypergalactosemia detected by newborn mass screening. Enhanced abdominal computed tomography showed the absence of the portal vein trunk and extrahepatic portosystemic communication between the superior mesenteric vein and the inferior vena cava. He had suffered from uncontrollable hyperinsulinemic hypoglycemia under protein and lactose restriction. We performed living donor liver transplantation (LDLT) using a left lateral segment graft from his father. The postoperative course was uneventful and the hypoglycemic attacks disappeared.

CONCLUSION

We believe that uncontrolled hyperinsulinemic hypoglycemia secondary to CPSS is an indication of LDLT.

Congenital portosystemic shunts: experience of a tertiary Tunisian referral center

Congenital portosystemic shunt is a rare condition in which communications between the systemic venous circulation and the portal veins drain blood directly into the systemic circulation. Diagnosis may occur from the prenatal period to adulthood. Nevertheless, diagnosing and treating a congenital portosystemic shunt, particularly in the perinatal stage, remain challenging, as multiple complications can occur. This study aimed to describe the clinical characteristics of 3 cases of congenital portosystemic shunts diagnosed during pregnancy or the neonatal period, the diagnostic procedures, and their outcomes. This study reported 3 cases of full-term newborns with a congenital portosystemic shunt diagnosed at neonatal age. Case 1 was antenatally diagnosed with a congenital portosystemic shunt, which was confirmed postnatally via computed tomography and was associated with malformed ductus venosus and hypoplasia of the right portal vein. Cases 2 and 3 were siblings: a boy who had diffuse hemangiomatosis and a congenital portosystemic shunt complicated with severe persistent pulmonary hypertension and a girl who presented with a congenital portosystemic shunt and Kell alloimmunization. Congenital portosystemic shunts can be detected on prenatal ultrasounds during the etiologic workup of one of its complications or may be incidentally identified later in life. Children with congenital portosystemic shunts may develop various biological abnormalities, such as pulmonary hypertension, hypoxemia, encephalopathy, and liver tumors. A multidisciplinary approach and standardized protocols are required to optimize the management of congenital portosystemic shunts and minimize the short- and long-term consequences of congenital portosystemic shunts.

Abernethy syndrome as a cause of liver transplantation

Congenital portosystemic shunts are rare abnormalities in which blood flow from the liver is diverted to the systemic circulation. We would like to present the case of a 48-year-old male, during his neurological follow-up he was diagnosed with a congenital intrahepatic portosystemic shunt. Embolization of the portosystemic communicating veins was attempted on two occasions, but without success. Due to the poor clinical course, the patient was presented to our transplant committee and a liver transplant was decided upon.

Case Report: Management of a congenital intrahepatic portosystemic shunt with portal vein aneurysm in a child using 3D computer-assisted partial right hepatectomy

Congenital portosystemic shunts (CPSS) are rare pediatric vascular malformations characterized by abnormal development of the portal vein, which is attributed to incomplete embryonic remodeling of the hepatic and surrounding vasculature. CPSS manifests in two main forms: intrahepatic and extrahepatic. This study details the management of a pediatric patient diagnosed with Congenital Intrahepatic Portosystemic Shunt (CIPS) who was referred to our institution. By using a computer-assisted surgical system, the right hepatectomy was successfully performed, guided by precise intraoperative navigation based on three-dimensional reconstructions of enhanced CT imagery. The patient exhibited a favorable postoperative recovery trajectory, with the absence of complications or recurrence throughout the monitoring period.

Elevated systemic total bile acids escalate susceptibility to alcohol-associated liver disease

Excessive alcohol consumption is a major global health problem. Individuals with alcoholic liver disease often exhibit elevated serum total bile acids (TBAs). Nevertheless, the extent to which high TBA contributes to alcohol-associated liver disease (AALD) remains elusive. To investigate this, wild-type mice were categorized into normal (nTBA) and high (hTBA) TBA groups. Both groups underwent chronic-binge ethanol feeding for 4 weeks, followed by additional weekly ethanol doses. Ethanol feeding worsened AALD in both male and female mice with elevated serum TBA, characterized by liver dysfunction and steatosis. Decreased hepatic expression of genes involved in mitochondrial β-oxidation and lipid transport in ethanol-fed hTBA mice suggests that altered fatty acid metabolism contributed to AALD. Our findings, which represent the first to link high serum TBA to increased AALD susceptibility, underscore the importance of proactive serum TBA screening as a valuable tool for identifying individuals at high risk of developing AALD.

Impact of Portal Flow on the Prognosis of Children With Congenital Portosystemic Shunt: A Multicentric Observation Study in Japan

BACKGROUND

Although congenital portosystemic shunts (CPSSs) are increasingly being recognized, the optimal treatment strategies and natural prognosis remain unclear, as individual CPSSs show different phenotypes.

METHODS

The medical records of 122 patients who were diagnosed with CPSSs at 15 participating hospitals in Japan between 2000 and 2019 were collected for a retrospective analysis based on the state of portal vein (PV) visualization on imaging.

RESULTS

Among the 122 patients, 75 (61.5%) showed PV on imaging. The median age at the diagnosis was 5 months. The main complications related to CPSS were hyperammonemia (85.2%), liver masses (25.4%), hepatopulmonary shunts (13.9%), and pulmonary hypertension (11.5%). The prevalence of complications was significantly higher in patients without PV visualization than in those with PV visualization (P < 0.001). Overall, 91 patients (74.6%) received treatment, including shunt closure by surgery or interventional radiology (n = 82) and liver transplantation (LT) or liver resection (n = 9). Over the past 20 years, there has been a decrease in the number of patients undergoing LT. Although most patients showed improvement or reduced progression of symptoms, liver masses and pulmonary hypertension were less likely to improve after shunt closure. Complications related to shunt closure were more likely to occur in patients without PV visualization (P = 0.001). In 25 patients (20.5%) without treatment, those without PV visualization were significantly more likely to develop complications related to CPSS than those with PV visualization (P = 0.011).

CONCLUSION

Patients without PV visualization develop CPSS-related complications and, early treatment using prophylactic approaches should be considered, even if they are asymptomatic.

LEVEL OF EVIDENCE

Level III.

The Significance of Congenital Portosystemic Shunts in Congenital Heart Disease and the Bizarre Phenomenon of Alternating Portosystemic and Systemic-Portal Shunting

Congenital portosystemic shunts (CPSSs) are rare vascular anomalies characterized by abnormal connections between the portal/splanchnic veins and the systemic veins. CPSSs often occur as an isolated congenital anomaly, but they can also coexist with congenital heart disease (CHD). Owing to their myriad consequences on multiple organ systems, familiarity with CPSS is of tremendous importance to the care of patients with CHD. The rationale and timing for interventions to embolize CPSS in this scenario are discussed. Specific shunt embolization techniques are beyond the scope of this article.

Novel Staged Device Occlusion of Portosystemic Shunt With Atrial Flow Regulator in IVC Stent Platform

We present the cases of 2 children diagnosed with extrahepatic portosystemic shunts, a very rare vascular anomaly, on investigation of cardiac symptomatology. Poorly developed portal venous systems necessitated staged shunt occlusion. This was achieved using atrial flow regulator devices positioned in an inferior vena cava stent platform performed in the cardiac catheterization laboratory.

Off-label use of muscular VSD device for closure of a rare congenital portosystemic shunt

BACKGROUND

Congenital portosystemic shunt (CPSS) is a vascular malformation in which portal blood drains toward the systemic circulation, leading to pulmonary hypertension.

CASE PRESENTATION

A 10-year-old patient was brought for evaluation because of dyspnea on exertion. Echocardiography revealed a pulmonary hypertension of 75 mmHg, and multi-slice CT angiography revealed the presence of a CPSS. Closure was finally implemented using a muscular ventricular septal defect device. Follow-up of the patient revealed a gradual decline in pulmonary hypertension.

CONCLUSIONS

CPSS is an overlooked cause of reversible pulmonary hypertension (PH). Closure of such lesions and reversal pulmonary hypertension are possible via catheterization. The preferred device type depends largely on the intervening team. Plugs are the first choice for interventional radiologists, while ventricular and atrial septal occluder devices and duct occluders are preferred by pediatric cardiologists.

Intrahepatic portosystemic shunts, from prenatal diagnosis to postnatal outcome: a retrospective study

OBJECTIVE

Congenital intrahepatic portosystemic shunts (IHPSS) are rare vascular malformations resulting in blood bypassing the liver to the systemic circulation. Previous studies included symptomatic patients diagnosed postnatally, but the outcome of IHPSS diagnosed prenatally is rarely reported. We present a cohort of children prenatally diagnosed with IHPSS and report their natural course and outcome.

METHODS AND DESIGN

This was a retrospective study of all fetal cases diagnosed by ultrasound with IHPSS between 2006 and 2019 at a single tertiary centre which were prospectively followed up at the paediatric gastroenterology unit. The postnatal outcome was compared between patients with a single versus multiple intrahepatic shunts.

RESULTS

Twenty-six patients (70.3% boys) were included in the study, of them, eight (30.8%) patients had multiple intrahepatic shunts. The median gestational age at diagnosis was 29.5 weeks. Growth restriction affected 77% of the cohort. Postnatally, spontaneous shunt closure occurred in 96% of patients at a median age of 7.5 months (IQR 2.2-20 months). Failure to thrive (FTT) and mild developmental delay were observed in eight (30.8%) and seven (26.9%) patients, respectively. FTT was significantly more prevalent in patients with multiple shunts compared with patients with a single shunt (62.5% vs 16.7%, p=0.02); however, the rate of shunt closure and age at time of closure were similar between these groups. All patients survived with limited to no sequelae.

CONCLUSIONS

IHPSS usually close spontaneously by 2 years of age. Children with prenatally detected IHPSS may develop FTT and mild developmental delay. Close surveillance at a paediatric gastroenterology unit may be beneficial.

Congenital extrahepatic Portosystemic shunt with hypoplasia of the intrahepatic inferior vena cava: A rare case report

Congenital portosystemic shunt (CPS) is a rare vascular anomaly resulting in diversion of splanchnic or portal blood into the systemic circulation. Other vascular malformations associated with this entity are uncommon. A 4-year-old female child with a diagnosis of acute viral hepatitis had an incidental finding of extrahepatic CPS on a Doppler abdominal ultrasound. Contrast-enhanced computed tomography showed a dilated portal vein having H-type side-to-side communication with a hypoplastic intrahepatic portion of the inferior vena cava and a prominent dilated azygos vein. There was retroaortic left renal vein drained into the IVC which was visualized in its entirety. Echocardiography findings were normal and the patient was discharged after symptomatic treatment that achieved improvement. With the expansion of abdominal imaging, incidental cases of CPS are increasingly being diagnosed in children. Although vascular malformations associated with CPS are rare, early diagnosis of cases helps avoid complications during shunt closure.

Congenital extrahepatic portosystemic shunt masquerading as chronic portal vein thrombosis: A case report

INTRODUCTION AND IMPORTANCE

Congenital extra hepatic portosystemic shunt (CEPS) is a rare vascular malformation in which splanchnic and portal blood is shunted into the systemic circulation eluding the liver. Type 1 CEPS is sometimes difficult to differentiate from pathologies such as chronic portal veinthrombosis as the portal vein may not be visualized in either entities.

CASE PRESENTATION

A 3-year-old male child with a week of abdominal pain was diagnosed with chronic portal vein thrombosis in an out-of-hospital setting. Repeat abdominal ultrasound was done at our institution and we were able to visualize termination of the portal vein to the suprarenal infra-hepatic inferior vena cava with an end to side pattern and a focal hypoechoic hepatic lesion at segment eight of the liver. There was no evidence of cavernous transformation or sign of portal hypertension. Subsequently, tri-phasic computed tomography revealed similar findings, with the portal vein terminating at the suprarenal inferior vena cava. The focal hepatic lesion showed peripheral contrast enhancement in the arterial phase and appeared as a central non-enhancing area with evidence of homogeneous enhancement on the subsequent sequences.

CLINICAL DISCUSSION

Type 1 CEPS can be easily confused with chronic portal vein thrombosis as the portal vein may not be visible and the hepatic artery shows compensatory enlargement in both entities. However, portal vein thrombosis is usually associated with underlying predisposing factors and can result in the development of secondary signs of portal hypertension and cavernous transformation which are critical to distinguish it from CEPS.

CONCLUSION

Chronic portal vein thrombosis is a great mimicker that should be distinguished from CEPS on ultrasound. A meticulous scan with color flow is helpful to scrutinize vascular anatomy, identify findings associated with CEPS such as hepatic lesions, and exclude signs of chronic portal vein thrombosis.

Congenital hepatic hemangioma: an unusual case report of pulmonary hypertension

BACKGROUND

Pulmonary hypertension (PH) in newborns is a rare but serious condition that often requires immediate intervention and quick diagnosis of the correct etiology to prevent mortality. Congenital hepatic hemangioma (CHH) is an example of an extrathoracic etiology of PH.

CASE PRESENTATION

Herein, we report the case of a newborn with a giant liver hemangioma, who presented with an early onset of PH and was successfully treated with intra-arterial embolization.

CONCLUSIONS

This case illustrates the importance of suspicion and prompt evaluation of CHH and related systemic arteriovenous shunts among infants with unexplained PH.

Congenital intra-hepatic porto-systemic shunts diagnosed during intrauterine life: Systematic review

OBJECTIVE

To describe the ultrasonographic characteristics of congenital porto-systemic venous shunts (CPSS) diagnosed during pregnancy, their outcomes, and their evolution.

METHODS

Two independent researchers selected 493 review articles and case reports through the analysis of titles, abstracts, and full text. The PubMed and LILACS databases were searched. Through the application of filters according to the PRISMA protocol, only six articles were used in the research. The following information was collected, when available: gestational age at diagnosis, gender, birth weight, type of shunt, associated anomalies/complications and treatment/progression.

RESULTS

The data were obtained from 27 cases, with 22 (82%) fetuses diagnosed with intra-hepatic CPSS and 5 (18%) with extra-hepatic CPSS. The median time of intrauterine diagnosis was 33 weeks. In 12 (57.1%) of the 21 pregnancies evaluated, delivery was preterm. The estimated fetal weight ranged from 1150 to 3760 g, with 4 (25%) cases at <3rd, 3 (18.75%) cases at <10th, 8 (50%) cases at <50th, and 1 (6.25%) case at >97th percentile for gestational age. The most frequent obstetric complication was fetal growth restriction, which occurred in nine (60%) cases. As for postnatal treatment, 19 (70.4%) cases were conservatively treated, and 8 (29.6%) cases required surgical intervention.

CONCLUSION

The diagnosis of CPSS still represents a challenge during prenatal care. Its early identification aims to provide guidance to pregnant women and their families, as well as follow-up and anticipation of possible complications, in addition to the evaluation of the mode of delivery and postnatal follow-up, directing the short- and long-term prognosis.

Non-target lung embolization during portal vein embolization due to an unrecognized portosystemic venous fistula: A case report

BACKGROUND

Portal vein embolization (PVE) is an effective and relatively safe procedure performed prior to major hepatic resection to enhance future liver remnant. Non-target embolization during PVE is rare, and if it occurs, it usually affects the future liver remnant. Intrahepatic portosystemic venous fistulas are extremely rare in non-cirrhotic livers. We report a case of non-targeted lung embolization during PVE due to an unrecognized intrahepatic portosystemic fistula.

CASE SUMMARY

A 60-year-old male presented with metastatic colon cancer of the liver. The patient underwent preoperative right PVE. During the embolization procedure, a small amount of glue and lipiodol emulsion was embolized to the heart and lungs through an unrecognized intrahepatic portosystemic fistula. The patient remained clinically stable and underwent the planned hepatic resection after 4 wk, with an uneventful postoperative course.

CONCLUSION

Conventional portograms and careful evaluation prior to PVE are advisable to avoid such complications.

Unique case of pelvic congestion syndrome caused by a new communication branch of the portal-vena cava system

Congenital portosystemic shunt (CPS) is a developmental anomaly of the portal vein system. The disease can cause blood from the portal vein to flow into the vena cava, resulting in various atypical clinical manifestations. Pelvic congestion syndrome (PCS) caused by CPS is particularly rare. A young woman with PCS had an abnormal communicating branch of the left ovarian vein (OV). Her left OV drained normally into the left renal vein, and at the same time communicated with the portal vein, forming an extrahepatic portosystemic shunt. With embolization of her left OV, the patient was cured of PCS.

Comparison of Serum Bile Acid Concentrations Between Maltese and Other Breeds of Dogs With Portosystemic Shunt

BACKGROUND/AIM

Congenital portosystemic shunt (PSS) is a vascular anomaly forming a direct communication between portal and central venous systems, thus bypassing the liver. This condition is related to various clinical symptoms including those manifesting in the central nervous system, gastrointestinal tract, and urinary tract. Treatment of PSS includes medical management and surgery. When evaluating prognosis of dogs with PSS, serum biochemistry profiles including serum bile acid (SBA) and ammonia concentrations are routinely used as screening tests. However, the use of SBA concentration in Maltese is controversial because it can be measured above the reference range even in normal dogs of this breed. In addition, utilizing SBA levels to assess surgical prognosis of PSS is not widely understood in this breed. Thus, the present study evaluated whether SBA could be used as a screening test for PSS in Maltese dogs.

MATERIALS AND METHODS

Medical records of dogs in the Veterinary Teaching Hospital from 2018 to 2020 were retrospectively reviewed.

RESULTS

A total of 23 dogs with PSS and 30 Maltese dogs without PSS were analyzed. Although preoperative SBA levels were significantly higher in Maltese dogs (192 μmol/l) than in other dog breeds (137 μmol/l) with portocaval shunt, its concentrations were significantly decreased after surgery in both Maltese and other breeds of dogs. No significant difference was observed in postoperative SBA levels between Maltese and other dog breeds. The mean SBA levels for Maltese dogs without PSS (8 μmol/l) were within the reference interval (0-25 IU/l).

CONCLUSION

Measuring pre- and post-operative SBA levels to evaluate prognosis of PSS might also be available for Maltese.

Congenital Portosystemic Shunts: Variable Clinical Presentations Requiring a Tailored Endovascular or Surgical Approach

Congenital portosystemic shunts (CPSS) are rare developmental anomalies resulting in diversion of portal flow to the systemic circulation. These shunts allow intestinal blood to reach the systemic circulation directly, and if persistent or large, may lead to long-term complications. CPSS can have a variety of clinical presentations that depend on the substrate that is bypassing hepatic metabolism or the degree of hypoperfusion of the liver. Many intrahepatic shunts spontaneously close by 1 year of age, but extrahepatic and persistent intrahepatic shunts require intervention by a single session or staged closure with a multidisciplinary approach. Early detection and appropriate management are important for a good prognosis. The aim of this case series is to describe the varied clinical presentations, treatment approaches, and outcomes of 5 children with CPSS at our institution. Management of these patients should involve a multidisciplinary team, including interventional radiology, surgery, hepatology, and other medical services as the patient's clinical presentation warrants. Regardless of clinical presentation, if a CPSS persists past 1-2 years of age, closure is recommended.

Congenital Portosystemic Shunt Presenting As Hyperammonemia Following Fontan Operation

The Fontan operation allows survival for children with single ventricle congenital heart disease. In the acute postoperative period, perioperative insults and drastic changes in vascular pressures can potentially cause ischemic liver injury. We present a 3-year-old female with congenital heart disease presenting post-Fontan procedure complicated by altered mental status due to elevated ammonia levels. Etiology of the hyperammonemia was unknown and relatively controlled with medication. Further investigation, however, revealed a congenital portosystemic shunt. Congenital portosystemic shunts, more specifically Abernethy malformations, are rare conditions characterized as intrahepatic or extrahepatic, resulting in diversion of portal flow to systemic.

Radiologic Evaluation of Portosystemic Shunts in Humans and Small Animals: Review of the Literature with Clinical Case Reports

The portal venous system is a network of vessels that carry blood from the capillary beds of the major abdominal organs to the liver. During embryology, the portal venous system can develop aberrantly, leading to vascular connections between the portal and systemic venous circulation known as portosystemic shunts. The purpose of this comparative review with a few short representative case reports was to present the similarities and differences in portosystemic shunts in humans and small animals and their radiologic evaluation. Aberrant vascular connections between the portal and systemic venous circulation enable portal blood to bypass metabolism and detoxification in the liver, leading to significant clinical implications. Portosystemic shunts are very rare in humans, but these connections are much more common in small animals, affecting up to 0.6% of small animals. Portosystemic shunts can be congenital or acquired and are divided into intrahepatic and extrahepatic types. Because of its ability to accurately assess abdominal structures, large vessels, and their flow dynamics without anesthesia, ultrasonography has become the first imaging modality employed for the diagnostic evaluation of portosystemic shunts in both humans and small animals. This is usually followed by contrast-enhanced computed tomographic angiography in order to better define the exact shunt anatomy and to plan treatment. It is important to understand the embryology, anatomy, pathology, and pathophysiology of portosystemic shunts in order to understand the findings of radiologic imaging and to initiate appropriate treatment.

Abernethy Malformation Masquerading as Congenital Heart Disease: A Boy With Cyanosis, Clubbing, and Hypoxia

Abernethy malformation is an extrahepatic congenital portosystemic shunt characterized by the diversion of the portal blood away from the liver through a shunt that drains directly into the inferior vena cava. We present a case of a male child with Abernethy malformation, which was initially diagnosed as cyanotic heart disease due to pulmonary arteriovenous malformation. However, after proper clinical evaluation and investigations, the diagnosis of Abernethy malformation was established. Thereafter, the patient was successfully treated with endovascular embolization. At one year follow-up, marked relief in exertional dyspnea and improvement in physical growth was achieved with no observable complications.

Down Syndrome Patients with Congenital Portosystemic Shunts: A Case Report and Review

Introduction

Down syndrome is due to trisomy 21 and is characterized by intellectual disability, dysmorphic facial features, congenital malformations, and gastrointestinal abnormalities. There is an increased appreciation of congenital portosystemic shunts in Down syndrome patients. Congenital portosystemic shunts have been associated with many defects in body systems, including cardiac, metabolic, and neurological.

Case Presentation

Herein, we describe a portosystemic shunt in a Down syndrome patient that resulted in hyperammonemia with altered mental status and choreiform movements. Computed tomography angiography of the abdomen and pelvis identified a connection between the right portal vein and inferior vena cava. An 18 mm Amplatzer PFO closure device was placed within the congenital shunt, significantly improving symptoms. The patient has no sequelae from the related shunt or the device at the 2-year follow-up. We extensively reviewed the literature and identified cases of portosystemic shunts in Down syndrome patients. Shunts can either be extrahepatic or intrahepatic and are classified by vasculature connections.

Conclusion

From our literature review and case presentation, we identify other conditions in patients, including cardiac and gastrointestinal defects. We then review the available treatment options, whether observation or surgical, depending on the patient's clinical picture.

Treating Sudden Onset Hepatic Encephalopathy with Coil Embolization in a Patient with a Congenital Intrahepatic Portosystemic Venous Shunt: A Case Report

Intrahepatic portosystemic venous shunt (IPSVS) is a rare vascular abnormality that involves abnormal communication between the intrahepatic portal vein and systemic veins, such as the hepatic vein or inferior vena cava. Patients with IPSVS are typically asymptomatic, and IPSVS is incidentally discovered via imaging while evaluating other diseases. However, endovascular closure of the shunt should be considered in symptomatic patients with a high-flow shunt. This report presents a patient with congenital IPSVS with sudden onset hepatic encephalopathy treated using percutaneous transhepatic embolization.

Portal vein aneurysm combined with intrahepatic portosystemic venous shunt diagnosed by multimodal imaging techniques: A case report

INTRODUCTION

Portal vein aneurysms (PVA) and intrahepatic portosystemic venous shunts are rarely diagnosed clinically.

PATIENT CONCERNS

A 75-year-old female was admitted to our hospital for evaluation of significant weight loss, diabetes, and an irregularly shaped cystic lesion in the left lateral lobe of the liver.

DIAGNOSIS

The patient was diagnosed with a portal vein aneurysm combined with an intrahepatic portosystemic venous shunt using multiple imaging techniques.

INTERVENTIONS

The patient had no relevant clinical symptoms of PVA with concurrent intrahepatic portosystemic venous shunt; hence, no interventions were performed. Ultrasonography was suggested to be performed every 3 months.

OUTCOMES

The patient did not visit the hospital after discharge; however, 4 telephonic follow-up evaluations showed that the patient was well.

LESSONS

Multimodal imaging techniques should be used to evaluate the source of blood flow, presence or absence of shunts, and the course, number, and location of the shunts to prevent misdiagnosis of this disease.

Fetal Intrahepatic Umbilical-Porto-Systemic Venous Shunts (IHUPSVS): in-utero anatomic classification

OBJECTIVE

Congenital intrahepatic shunts divert highly oxygen and nutrients rich placental blood flow from the liver into the systemic flow having a negative influence on normal fetal growth and postnatal development. The ability to recognize this anomaly helps assess the possible clinical impact, counseling, and management of pregnancy. The present study aimed to propose in utero classification for the Intrahepatic Umbilical-Porto-Systemic Venous Shunt (IHUPSVS) based on our experience.

STUDY DESIGN

A prospective study. Grayscale ultrasound with two and three-dimensional high-definition Doppler modalities was used. IHUPSVS was defined as a diversion of blood from the liver tissue by abnormal communication between a branch of the intrahepatic Umbilical vein or the Portal veins with the systemic circulation (the Hepatic veins or the Sub-Diaphragmatic Vestibulum).

RESULTS

Twenty-five fetuses were diagnosed with IHUPSVS. We identified three main anatomic types: I) Porto-hepatic shunt which was divided into Ia) regular single shunt (15/25, 60%) and Ib) regular multiple shunts, (6/25, 24%) II) Umbilical-Porto-Hepatic shunt divided into a) Umbilical or b) Umbilical combined with Portal hepatic shunt (2/25, 8%) and III) Cavernous- aneurysmatic shunt (2/25, 8%). All the shunts were verified by postnatal targeted sonography.

CONCLUSIONS

This study creates the anatomic basis for common nomenclature and future probable updating for this anomaly.

Congenital portosystemic venous shunt associated with 22q11.2 deletion syndrome: a case report

Background

22q11.2 deletion syndrome (22qDS) is the most common chromosomal microdeletion syndrome and is associated with a high rate of congenital heart disease (CHD) and neurodevelopmental abnormalities. Congenital portosystemic venous shunts (CPSS) are rare developmental abnormalities of the portal venous system. The clinical manifestations of CPSS are varied, and some patients have CHD or genetic chromosomal abnormalities, but their relationship remains unknown. We report the first case of CPSS associated with 22qDS.

Case presentation

A newborn boy referred to our institution was diagnosed with 22qDS due to characteristic facial features and complications of tetralogy of Fallot. A subsequent newborn screening test indicated hypergalactosemia and high blood levels of ammonia and bile acids. Upon closer examination, these abnormalities were found to be caused by the CPSS. Abdominal contrast-enhanced computed tomography and angiography confirmed that abnormal blood vessels ascended from the splenic vein and short-circuited to the left renal vein. Intracardiac repair for CHD was performed at 1 year of age, followed by transcatheter occlusion of the CPSS using a multilayer device (vascular plug) and detachable coil at 2 years of age. After treatment, the abnormal blood parameters promptly normalized.

Conclusions

As the blood flow of CPSS bypasses the liver, the levels of galactose, bile acids, and ammonia in the systemic veins can increase. Some patients with CPSS have CHD, and these toxic substances may cause liver and lung lesions as well as portosystemic encephalopathy (PSE). Several genetic chromosomal abnormalities, including 22qDS, and CPSS have similar symptoms, and neurodevelopmental abnormalities, particularly those caused by PSE, may be difficult to diagnose. Blood tests, such as newborn screening, and abdominal imaging are useful in the early diagnosis of CPSS.

Physiological fetal vascular shunts and failure to regress: what the radiologist needs to know

The fetal circulation is characterized by the presence of three physiological vascular shunts - the ductus arteriosus, the foramen ovale and the ductus venosus. Acting in concert, these shunts preferentially stream blood flow in a pattern that maximizes efficiency of blood oxygenation by the maternofetal unit. Shortly following the transition to extrauterine life, a quick and predetermined succession of events results in closure of these embryological structures with consequent establishment of postnatal vascular flow patterns. While this transition is often seamless, the physiological shunts of the fetus occasionally fail to regress. Such failure to regress can occur in isolation or in association with other congenital malformations. This failed regression challenges the circulatory physiology of the neonate and might have implications for the optimum functioning of several organ systems. When symptomatic, these shunts are treated. Interventions, when undertaken, might be medical, endovascular or surgical. The radiologist's role continues to expand in the assessment of these shunts, in providing a roadmap for treatment and in prompt identification of treatment-related complications. This review is to familiarize radiologists with the embryology, pre- and post-treatment imaging appearances, and associated complications of persistent fetal vascular shunts.

Congenital portosystemic shunt with multiple splenic artery aneurysms: Reversing pulmonary hypertension and preventing aneurysm rupture

We report an unusual occurrence of multiple splenic artery aneurysms and splenomegaly in a young woman with severe pulmonary hypertension, secondary to a congenital portosystemic shunt (CPS). The splenic artery was occluded using an Amplatzer Duct Occluder-II device, and closure of the large intrahepatic CPS was achieved using a muscular ventricular septal defect occluder. There was resolution of splenomegaly with normal pulmonary artery pressures, a few months after the procedure.

Stepwise Treatment for Heterotaxy Syndrome and Functional Single Ventricle Complicated by Infra-Cardiac Total Anomalous Pulmonary Venous Connection with Ductus Venosus Stent Placement and Subsequent Occlusion

Even today, when the surgical outcome of congenital heart disease in the neonatal period has improved, the prognosis for heterotaxy syndrome and functional single ventricle complicated with total anomalous pulmonary venous connection (TAPVC), especially the infra-cardiac type, is catastrophic. We describe a strategy that combines percutaneous ductus venosus (DV) stent placement and occlusion after TAPVC repair to ensure survival from initial surgery to bidirectional cavopulmonary shunt (BCPS) procedure and facilitate subsequent treatment. Three consecutive patients with heterotaxy syndrome and functional single ventricle complicated by infra-cardiac TAPVC treated with our own strategy were retrospectively studied. In two infants, DV stent placement was performed on the day of birth. In one case at 11 days of age. The risk of pulmonary vein obstruction was reduced, and on-pump surgery, including TAPVC repair, was performed on a standby basis. Since the rapid increase in hepatic enzymes occurred on postoperative day 0 to 1 in all cases, percutaneous stent occlusion was performed until postoperative day 3. The procedure improved liver function. One patient died due to severe atrioventricular valve regurgitation, one case underwent BCPS, and one patient was waiting to undergo. DV stent placement can avoid TAPVC repair in the early neonatal period. After TAPVC repair, the portosystemic shunt remained, resulting in hepatic dysfunction, but this could be improved by stent and vertical vein occlusion. A series of stepwise treatments can be useful to help such critically ill infants survive the high-risk neonatal period and achieve good BCPS circulation.

Surgical shunt ligation for a congenital extrahepatic portosystemic shunt with pulmonary hypertension: A case report

Introduction and importance

Case presentation

Clinical discussion

Conclusion

•

Congenital extrahepatic portosystemic shunt (CEPS) is a rare vascular malformation.

•

Our patient had pulmonary hypertension due to CEPS.

•

Pre- and intraoperative shunt occlusion tests were within acceptable limits.

•

He underwent primary surgical portosystemic shunt ligation.

•

No postoperative complications including acute portal hypertension occurred.

Pediatric solid tumors and associated cancer predisposition syndromes: Workup, management, and surveillance. A summary from the APSA Cancer Committee

BACKGROUND/PURPOSE

Cancer predisposition syndromes (CPS) are a heterogeneous group of inherited disorders that greatly increase the risk of developing malignancies. CPS are particularly relevant to pediatric surgeons since nearly 10% of cancer diagnoses are due to inherited genetic traits, and CPS often contribute to cancer development during childhood.

MATERIALS/METHODS

The English language literature was searched for manuscripts, practice guidelines, and society statements on "cancer predisposition syndromes in children". Following review of these manuscripts and cross-referencing of their bibliographies, tables were created to summarize findings of the most common CPS associated with surgically treated pediatric solid malignancies.

RESULTS

Pediatric surgeons should be aware of CPS as the identification of one of these syndromes can completely change the management of certain tumors, such as WT. The most common CPS associated with pediatric solid malignancies are outlined, with an emphasis on those most often encountered by pediatric surgeons: neuroblastoma, Wilms' tumor, hepatoblastoma, and medullary thyroid cancer. Frequently associated non-tumor manifestations of these CPS are also included as a guide to increase surgeon awareness. Screening and management guidelines are outlined, and published genetic testing and counseling guidelines are included where available.

CONCLUSION

Pediatric surgeons play an important role as surgical oncologists and are often the first point of contact for children with solid tumors. In their role of delivering a diagnosis and developing a follow-up and treatment plan as part of a multidisciplinary team, familiarity with common CPS will ensure evidence-based practices are followed, including important principles such as organ preservation and intensified surveillance plans. This review defines and summarizes the CPS associated with common childhood solid tumors encountered by the pediatric surgeon, as well as common non-cancerous disease stigmata that may help guide diagnosis.

TYPE OF STUDY

Summary paper.

LEVEL OF EVIDENCE

5.

Endovascular treatment of a portosystemic shunt presenting with hypoglycemia; case presentation and review of literature

Here we present a rare case of hyperinsulinemic-hypoglycemia due to congenital intrahepatic and extrahepatic portosystemic shunts. Performing percutaneous closure of such shunts has been reported to improve symptomatic hypoglycemia in this setting. This case is unique given the type of shunt (both with intrahepatic and extrahepatic components) and the clinical improvement following placement of a single vascular plug to occlude both intrahepatic and extrahepatic connections.

Presentation of Congenital Portosystemic Shunts in Children

Background: Congenital portosystemic shunts (CPSS) are rare vascular anomalies resulting in communications between the portal venous system and the systemic venous circulation, affecting an estimated 30,000 to 50,000 live births. CPSS can present at any age as a multi-system disease of variable severity mimicking both common and rare pediatric conditions. Case presentations: Case A: A vascular malformation was identified in the liver of a 10-year-old girl with tall stature, advanced somatic maturation, insulin resistance with hyperinsulinemia, hyperandrogenemia and transient hematuria. Work-up also suggested elevated pulmonary pressures. Case B: A young girl with trisomy 8 mosaicism with a history of neonatal hypoglycemia, transient neonatal cholestasis and tall stature presented newly increased aminotransferase levels at 6 years of age. Case C: A 3-year-old boy with speech delay, tall stature and abdominal pain underwent abdominal ultrasound (US) showing multiple liver nodules, diagnosed as liver hemangiomas by hepatic magnetic resonance imaging (MRI). Management and outcome: After identification of a venous malformation on liver Doppler US, all three patients were referred to a specialized liver center for further work-up within 12 to 18 months from diagnosis. Angio-computed tomography (CT) scan confirmed the presence of either an intrahepatic or extrahepatic CPSS with multiples liver nodules. All three had a hyperintense signal in the globus pallidus on T1 weighted cerebral MRI. Right heart catheterization confirmed pulmonary hypertension in cases A and C. Shunts were closed either using an endovascular or surgical approach. Liver nodules were either surgically removed if there was a risk of malignant degeneration or closely monitored by serial imaging when benign. Conclusion: These cases illustrate most of the common chief complaints and manifestations of CPSS. Liver Doppler US is the key to diagnosis. Considering portosystemic shunts in the diagnostic work-up of a patient with unexplained endocrine, liver, gastro-intestinal, cardiovascular, hematological, renal or neurocognitive disorder is important as prompt referral to a specialized center may significantly impact patient outcome.

A case of two shunts in the endovascular treatment of type II Abernethy syndrome

Background

Abernethy malformation is a rare condition defined by a congenital extrahepatic portosystemic shunt, often leading to absence or hypoplasia of the intrahepatic portal venous system. Although there are no consensus treatment guidelines, interventional techniques now offer minimally invasive treatment options for Abernethy malformations. This case report describes a case of Abernethy Syndrome Type II where the patient had two separate extrahepatic portosystemic shunts treated with endovascular occlusion with two Amplatzer plugs and demonstrates the feasibility of this treatment for this rare condition. This case was in a young adult, adding to the scarce literature of treatment for Abernethy syndrome in the adult population.

Case presentation

We report a case of a 20-year-old female patient with neurocognitive behavioral difficulty, voracious appetite, and chronic encephalopathy secondary to type II Abernethy malformation with not one, but two extrahepatic portosystemic shunts. The patient had failed medical management and was not a liver transplant candidate. Therefore, she presented to us for an endovascular treatment option. The two shunts were treated with endovascular occlusion using Amplatzer vascular plugs. Following embolization, flow into the hypoplastic portal vein improved with near complete occlusion of flow into the portosystemic shunts, thus restoring blood flow into the native portal system. At 3 month follow up, a CT demonstrated complete occlusion of the two portosystemic shunts, and a portal vein diminutive in caliber. The portal vein measured 7 mm in diameter on both pre and post-procedure CT scans. The total volume of the liver was found to be 843 cm3 on pre-procedure CT & 1191 cm3 on post-procedure CT.

Conclusions

This report demonstrates the feasibility of using endovascular embolization to treat Abernethy II malformations. The management strategy of Type II Abernethy Syndrome should be to redirect blood flow into the hypoplastic native portal system, allowing for physiologic hepatic metabolism of splanchnic blood, hypertrophy of the portal system, and growth of the liver from the increased trophic flow.

Transcatheter closure of congenital portosystemic shunts – A multicenter experience

Background:

Congenital portosystemic shunts (CPSS) are rare and present variably with hepatic encephalopathy, pulmonary arteriovenous malformations (PAVMs), and pulmonary hypertension (PH).

Objective:

The objective of the study was to see the feasibility of transcatheter closure of CPSS and their outcome.

Materials and Methods:

We analyzed the data of 24 patients of CPSS who underwent transcatheter closure from five institutions (March 2013 to April 2019). Baseline evaluation included echocardiography with bubble contrast study, ultrasound examination of the abdomen, computed tomography angiogram, and cardiac catheterization with test balloon occlusion of the CPSS. The evaluation showed cyanosis due to PAVM in 12, PH in 8, and respiratory distress in 2. Two had both cyanosis and PH. Criteria for eligibility for complete catheter closure of CPSS included demonstration of intrahepatic portal vein (PV) radicals together with a PV pressure of ≤18 mmHg on occlusion.

Results:

The median age and weight were 8 years (0.5–21) and 19.5 kg (4.2–73), respectively. Transcatheter closure was performed in 21 patients (22 procedures) using a variety of occlusive devices and stent-graft exclusion was done in one patient. Closure was not done in 3 in view of high portal venous pressures and hypoplastic PVs. During the follow-up (median: 42 months and range: 61 days–4.8 years), saturation normalized in 14 patients with PAVM. PH declined in all eight patients who underwent the procedure. Respiratory distress improved in two patients.

Conclusions:

Early and short-term follow-up results of catheter closure of CPSS appear promising. However, further, follow-up is needed to demonstrate long-term effectiveness.