Intrahepatic vascular shunts: Strategy for early diagnosis, evaluation and management

[Endovascular technologies in the treatment of patients with blunt abdominal trauma]

Trauma is one of the leading causes of disability and mortality in working-age population. Abdominal injuries comprise 20-30% of traumas. Uncontrolled bleeding is the main cause of death in 30-40% of patients. Among abdominal organs, spleen is most often damaged due to fragile structure and subcostal localization. In the last two decades, therapeutic management has become preferable in patients with abdominal trauma and stable hemodynamic parameters. In addition to clinical examination, standard laboratory tests and ultrasound, as well as contrast-enhanced CT of the abdomen should be included in diagnostic algorithm to identify all traumatic injuries and assess severity of abdominal damage. Development of interventional radiological technologies improved preservation of damaged organs. Endovascular embolization can be performed selectively according to indications (leakage, false aneurysm, arteriovenous anastomosis) and considered for severe damage to the liver and spleen, hemoperitoneum or severe polytrauma. Embolization is essential in complex treatment of traumatic vascular injuries of parenchymal abdominal organs. We reviewed modern principles and methods of intra-arterial embolization for the treatment of patients with traumatic injuries of the liver and spleen.

Attach importance to the individualized treatment of adult portal hypertension based on etiology and pathogenesis: A review

There are many factors that can cause portal hypertension and secondary symptoms such as ascites, splenomegaly, and variceal hemorrhage, can seriously affect patients' quality of life and even threaten their lives. In this paper, we summarize various causes of portal hypertension based on etiology and pathogenesis and give individualized treatment strategies in order to remind clinicians to pay attention to the identification of different causes and select corresponding treatment, so that patients are provided with the optimal treatment strategies and benefit from them.

Hepatic Arterioportal Fistulas: A Retrospective Analysis of 97 Cases

BACKGROUND AND AIMS

Hepatic arterioportal fistulas (HAPFs) are abnormal shunts or aberrant functional connections between the portal venous and the hepatic arterial systems. Detection of HAPFs has increased with the advances in diagnostic techniques. Presence of HAPFs over a prolonged period can aggravate liver cirrhosis and further deteriorate liver function. However, the underlying causes of HAPFs and the treatment outcomes are now well characterized. This study aimed to summarize the clinical characteristics of patients with HAPFs, and to compare the outcomes of different treatment modalities.

METHODS

Data of 97 patients with HAPFs who were admitted to the Second Xiangya Hospital between January 2010 and January 2020 were retrospectively reviewed. Demographic information, clinical manifestations, underlying causes, treatment options, and short-term outcomes were analyzed.

RESULTS

The main cause of HAPF in our cohort was hepatocellular carcinoma (78/97, 80.41%), followed by cirrhosis (10/97, 10.31%). The main clinical manifestations were abdominal distention and abdominal pain. Treatment methods included transcatheter arterial embolization (n=63, 64.9%), surgery (n=13, 13.4%), and liver transplantation (n=2, 2.1%); nineteen (19.6%) patients received conservative treatment. Among patients who underwent transcatheter arterial embolization, polyvinyl alcohol, lipiodol combined with gelatin sponge, and spring steel ring showed comparable efficacy.

CONCLUSIONS

Hepatocellular carcinoma and cirrhosis are common causes of HAPFs. Transcatheter arterial embolization is a safe and effective method for the treatment of HAPFs, and polyvinyl alcohol, lipiodol combined with gelatin sponge, and spring steel ring showed comparable efficacy in our cohort.

Physiologically-Based Pharmacokinetic Modeling in Renal and Hepatic Impairment Populations: A Pharmaceutical Industry Perspective

The predictive performance of physiologically‐based pharmacokinetics (PBPK) models for pharmacokinetics (PK) in renal impairment (RI) and hepatic impairment (HI) populations was evaluated using clinical data from 29 compounds with 106 organ impairment study arms were collected from 19 member companies of the International Consortium for Innovation and Quality in Pharmaceutical Development. Fifty RI and 56 HI study arms with varying degrees of organ insufficiency along with control populations were evaluated. For RI, the area under the curve (AUC) ratios of RI to healthy control were predicted within twofold of the observed ratios for > 90% (N = 47/50 arms). For HI, > 70% (N = 43/56 arms) of the hepatically impaired to healthy control AUC ratios were predicted within twofold. Inaccuracies, typically overestimation of AUC ratios, occurred more in moderate and severe HI. PBPK predictions can help determine the need and timing of organ impairment study. It may be suitable for predicting the impact of RI on PK of drugs predominantly cleared by metabolism with varying contribution of renal clearance. PBPK modeling may be used to support mild impairment study waivers or clinical study design.

Arterio-Hepatic Venous Fistula Following Liver Biopsy: A Rare Case Report and Literature Review

Arterio-hepatic venous fistula (AHVF) is an exceedingly rare phenomenon compared to arterio-portal venous fistula with only 8 cases reported in world literature. Many listed causes can be attributed to the development of there are no reported cases of AHVF following a core-needle biopsy. We report a case of 38 year-old-female with EHPVO, who underwent splenectomy with a proximal splenorenal shunt. She had an injury to left hepatic artery, consequent to a blind intra-operative core needle biopsy from the liver, which led to the development of a fistulous connection between left hepatic artery and middle hepatic vein causing high output cardiac failure. She was successfully managed with trans-arterial embolization. The present review emphasizes the possibility of AHVF following a liver biopsy and the role of digital subtraction angiography in the diagnosis, therapeutic intravascular interventions, and follow-up.

Angioembolization of Post-traumatic Intrahepatic Arterioportal Fistula Presenting With Portal Hypertension

Traumatic hepatic arterioportal fistula is an abnormal communication between the hepatic artery and portal vein and is a rare cause of non-cirrhotic portal hypertension with delayed presentation, usually after a remote history of abdominal trauma or an interventional procedure. This case report is of one such rare presentation, wherein a 59-year-old gentleman presented with unexplained ascites and complications of portal hypertension, eventually diagnosed with an arterioportal fistula on a computed tomography scan and managed by angioembolization. There was a remarkable improvement in the complications of portal hypertension after the coil embolization.

Intrahepatic portal-venous shunts during PVE

Portal venous embolization (PVE) is a well-validated technique to promote contralateral liver lobe hypertrophy prior to hepatic resection. We present a case of a patient with Type IV cholangiocarcinoma undergoing PVE prior to hepatic surgical resection. However, intrahepatic portal-venous shunts were incidentally found during the procedure and were subsequently embolized using embolic coils and N-butyl cyanoacrylate. While most patients with congenital portal-venous shunts remain asymptomatic, an unrecognized shunt during PVE could have resulted in a devastating complication secondary to nontarget embolization through the fistula. To our knowledge, this is the first reported case of a portal-venous shunt being discovered during a PVE.

Congenital Intrahepatic Portosystemic Venous Shunt With an Associated Aneurysm: Sonographic Diagnosis

Intrahepatic portosystemic venous shunts with associated aneurysms are extremely rare anomalous communications between intrahepatic portal veins and systemic veins through intrahepatic venous channels. Intrahepatic portosystemic venous shunts are usually asymptomatic but can be the cause of hepatic encephalopathy and hypoglycemia, especially when a high degree of shunting exists. The sonographic incidental finding of an aneurysmal vascular connection between the left portal vein and left hepatic vein as diagnosed by sonography is presented and discussed. When evaluating patients with suspected symptoms of hepatobiliary disease, sonographers and radiologists should carefully scan and meticulously assess the liver for signs of abnormal venous communications.

Traumatic hepatic arteriohepatic venous fistula managed with selective coil embolization: a case report

Hepatic arterioportal fistulae are frequent vascular complications due to neoplasm, trauma and iatrogenic injury. On the other hand, fistulae between the hepatic arteries and hepatic veins (arteriohepatic venous fistula) are rare. We report the case of a 45-year-old male who suffered from a blunt abdominal trauma with abdominal distension. Initial cross-sectional imaging revealed laceration of the right lobe of liver with an arteriovenous fistula and hemoperitoneum. The diagnosis of arteriohepatic venous fistulae was confirmed on digital subtraction angiography (DSA) and treated angiographically with superselective coil embolization. Post-embolization angiogram showed complete occlusion of arteriovenous fistulae. We emphasis on the management part of the fistulae and endovascular treatment.