Hepatoma, arterioportal shunting, and hyperkinetic portal hypertension: therapeutic embolization

Lipiodol Pneumonitis Following Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma

Transcatheter arterial chemoembolization (TACE) is a useful palliative therapeutic modality for hepatocellular carcinoma (HCC). Postembolization syndromes, such as fever, abdominal pain, and elevated liver enzyme levels are commonly known complications of TACE. One post-TACE pulmonary complication, lipiodol pneumonitis, is rarely reported. Lipiodol pneumonitis after TACE appears to be associated with chemical injury due to accidental perfusion of lipiodol to the lung vasculature, promoted by arteriovenous shunts within the hypervascular HCC. Here, we report a 42-year-old man with unresectable HCC and hepatic vein thrombosis. The patient was initially treated with TACE. The following day after TACE, acute respiratory symptoms such as dyspnea and cough developed with decreased oxygen saturation. Chest X-ray and computed tomography showed multiple patches and diffuse ground-glass opacities in both lung fields, suggesting of lipiodol pneumonitis. The patient's condition and radiologic abnormalities subsequently improved after 2 weeks of conservative treatment alone.

Clinical impact of combined transarterial chemoembolization and radiotherapy for advanced hepatocellular carcinoma with portal vein tumor thrombosis: An external validation study

PURPOSE

To evaluate the relationship between portal vein tumor thrombosis (PVTT) response and clinical outcomes in patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization followed by radiotherapy (TACE-RT).

MATERIALS AND METHODS

The study enrolled 329 patients in the training set and 179 patients in the validation set. All patients who were treated with TACE-RT from 2002 to 2008 and satisfied the inclusion criteria were enrolled in the study. The median follow-up period was 11.7 months (range, 1.6-108.6) in the training set and 11.9 months (range, 1.7-105.1) in the validation set.

RESULTS

After TACE-RT, PVTT response was complete or partial in 32 (9.7%) and 134 (40.7%) patients of the training set and in 18 (10.1%) and 96 (53.6%) patients in the validation set, respectively. Failure to obtain PVTT response was significantly related with elevated post-treatment Child-Pugh score (P<0.001). Furthermore, progression-free survival was significantly related with PVTT response (P<0.001, hazard ratio 0.33, 95% confidence interval 0.25-0.42) in multivariate analysis. In receiver-operating characteristics analysis of 1-year progression prediction, the PVTT response showed an area under the curve of 0.74. Most of the findings were successfully reproduced in the independent external validation set.

CONCLUSIONS

Positive PVTT response was closely associated with favorable clinical outcomes. The PVTT response to TACE-RT reduces metastasis and makes it possible to maintain normal liver function and achieve longer survival.

Combined transjugular intrahepatic portosystemic shunt and other interventions for hepatocellular carcinoma with portal hypertension

AIM: To evaluate combination transjugular intrahepatic portosystemic shunt (TIPS) and other interventions for hepatocellular carcinoma (HCC) and portal hypertension.

METHODS: Two hundred and sixty-one patients with HCC and portal hypertension underwent TIPS combined with other interventional treatments (transarterial chemoembolization/transarterial embolization, radiofrequency ablation, hepatic arterio-portal fistulas embolization, and splenic artery embolization) from January 1997 to January 2010 at Beijing Shijitan Hospital. Two hundred and nine patients (121 male and 88 female, aged 25-69 years, mean 48.3 ± 12.5 years) with complete clinical data were recruited. We evaluated the safety of the procedure (procedure-related death and serious complications), change of portal vein pressure before and after TIPS, symptom relief [e.g., ascites, hydrothorax, esophageal gastric-fundus variceal bleeding (EGVB)], cumulative rates of survival, and distributary channel restenosis. The characteristics of the patients surviving ≥ 5 and < 5 years were also analyzed.

RESULTS: The portosystemic pressure was decreased from 29.0 ± 4.1 mmHg before TIPS to 18.1 ± 2.9 mmHg after TIPS (t = 69.32, P < 0.05). Portosystemic pressure was decreased and portal hypertension symptoms were ameliorated. During the 5 year follow-up, the total recurrence rate of resistant ascites or hydrothorax was 7.2% (15/209); 36.8% (77/209) for EGVB; and 39.2% (82/209) for hepatic encephalopathy. The cumulative rates of distributary channel restenosis at 1, 2, 3, 4, and 5 years were 17.2% (36/209), 29.7% (62/209), 36.8% (77/209), 45.5% (95/209) and 58.4% (122/209), respectively. No procedure-related deaths and serious complications (e.g., abdominal bleeding, hepatic failure, and distant metastasis) occurred. Moreover, Child-Pugh score, portal vein tumor thrombosis, lesion diameter, hepatic arterio-portal fistulas, HCC diagnosed before or after TIPS, stent type, hepatic encephalopathy, and type of other interventional treatments were related to 5 year survival after comparing patient characteristics.

CONCLUSION: TIPS combined with other interventional treatments seems to be safe and efficacious in patients with HCC and portal hypertension.

Interventional treatment for unresectable hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer and third leading cause of cancer-related death in the world. The Barcelona clinic liver cancer classification is the current standard classification system for the clinical management of patients with HCC and suggests that patients with intermediate-stage HCC benefit from transcatheter arterial chemoembolization (TACE). Interventional treatments such as TACE, balloon-occluded TACE, drug-eluting bead embolization, radioembolization, and combined therapies including TACE and radiofrequency ablation, continue to evolve, resulting in improved patient prognosis. However, patients with advanced-stage HCC typically receive only chemotherapy with sorafenib, a multi-kinase inhibitor, or palliative and conservative therapy. Most patients receive palliative or conservative therapy only, and approximately 50% of patients with HCC are candidates for systemic therapy. However, these patients require therapy that is more effective than sorafenib or conservative treatment. Several researchers try to perform more effective therapies, such as combined therapies (TACE with radiotherapy and sorafenib with TACE), modified TACE for HCC with arterioportal or arteriohepatic vein shunts, TACE based on hepatic hemodynamics, and isolated hepatic perfusion. This review summarizes the published data and data on important ongoing studies concerning interventional treatments for unresectable HCC and discusses the technical improvements in these interventions, particularly for advanced-stage HCC.

Predictors of in-hospital mortality after acute variceal bleeding in patients with hepatocellular carcinoma and concurrent main portal vein thrombosis

BACKGROUND AND AIM

Risk factors for acute variceal bleeding in patients with hepatocellular carcinoma (HCC) and concurrent main portal vein thrombosis (PVT) remain unclear. We aimed to determine risk factors of in-hospital mortality after acute variceal bleeding for HCC patients with concurrent main PVT.

METHODS

We conducted a retrospective analysis of 102 HCC patients (83% men and 17% women) with concurrent main PVT and acute variceal bleeding. All patients received emergent endoscopy to define the bleeding source. Multivariable Cox proportional hazard regression analysis consisting of clinical, laboratory, and endoscopic parameters was performed to identify predictive factors for intrahospital mortality.

RESULTS

Twenty-eight (27.5%) patients died within admission. The median survival of all patients was 56 days. Multivariable Cox proportional hazard regression analyses revealed Child-Pugh score (adjusted hazard ratio [aHR]: 1.29 for each point; 95% confidence interval [CI]: 1.11-1.50), active bleeding on index endoscopy (aHR: 7.50; 95% CI: 3.05-18.4), esophageal varices as the bleeder (compared with gastric varices, aHR: 14.3; 95% CI: 3.12-66.1), failure to control bleeding (aHR: 38.0; 95% CI: 7.44-194), and serum creatinine (aHR: 1.28 for each increase of 1 mg/dL; 95% CI: 1.09-1.50) independently predicted in-hospital mortality.

CONCLUSIONS

Hepatic reserve, active bleeding on index endoscopy, failure to control bleeding, esophageal varices as the bleeder when compared with gastric varices, and renal function were independent predictive factors for in-hospital mortality in HCC patients with acute variceal bleeding and concurrent main PVT.

Transcatheter arterial chemoembolization based on hepatic hemodynamics for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third leading cause of cancer-related deaths in the world. The Barcelona Clinic Liver Cancer (BCLC) classification has recently emerged as the standard classification system for clinical management of patients with HCC. According to the BCLC staging system, curative therapies (resection, transplantation, and percutaneous ablation) can improve survival in HCC patients diagnosed at an early stage and offer potential long-term curative effects. Patients with intermediate-stage HCC benefit from transcatheter arterial chemoembolization (TACE), and those diagnosed at an advanced stage receive sorafenib, a multikinase inhibitor, or conservative therapy. Most patients receive palliative or conservative therapy only, and approximately 50% of patients with HCC are candidates for systemic therapy. TACE is often recommended for advanced-stage HCC patients all over the world because these patients desire therapy that is more effective than systemic chemotherapy or conservative treatment. This paper aims to summarize both the published data and important ongoing studies for TACE and to discuss technical improvements in TACE for advanced-stage HCC.

Surgical approach to multifocal hepatocellular carcinoma with portal vein thrombosis and arterioportal shunt leading to portal hypertension and bleeding: a case report

It is reported the case of a 69 years man who presented to the Emergency Room because of pain and abdominal distension from ascites. After admission and paracentesis placement, he developed a digestive hemorrhage due to oesophageal varices from portal ipertension secondary to the formation of a portal shunt concomitant with a multifocal HepatoCellular Carcinoma (HCC) with portal vein thrombosis (PVT). The patient underwent endoscopic varices ligation, twice transarterial embolization (TAE) of arterial branches feeding the shunt and subsequent left hepatectomy. During the postoperative course he developed mild and transient signs of liver failure and was discharged in postoperative day 16. He is alive and disease free 8 months after surgery.

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 low-density 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.

Initial experience of transcatheter arterial chemoembolization during portal vein occlusion for unresectable hepatocellular carcinoma with marked arterioportal shunts

The purpose of this study was to assess the clinical effects of transcatheter arterial chemoembolization (TACE) during the corresponding portal vein occlusion (TACE-PVO) in patients with hepatocellular carcinoma (HCC) and marked arterioportal (AP) shunts. This was a prospective, nonrandomized study of TACE-PVO in patients with HCC who had marked AP shunts. The subjects were 21 patients with unresectable HCC and marked AP shunts who underwent shunt embolization with the use of coils and/or gelatin-sponge particles (group A: n = 7) or by TACE-PVO (group B: n = 14). Clinical parameters and data on embolization of AP shunts and on tumor response were assessed prospectively. No major procedure-related complication occurred in either group. Effectiveness of AP-shunt treatment was significantly better in group B than in group A in terms of both immediate results (P = 0.009) and subsequent results (P = 0.028). Tumor response in the therapeutic target area was significantly (P = 0.002) better in group B than in group A. Survival was significantly better in group B than in group A (P = 0.008). TACE-PVO may be a safe and useful therapy for selected patients with unresectable HCC and marked AP shunts.

Three-dimensional conformal radiotherapy for the treatment of arteriovenous shunting in patients with hepatocellular carcinoma

The objective of this study is to evaluate the efficacy of radiotherapy for the treatment of arteriovenous shunting (AVS) in patients with hepatocellular carcinoma (HCC). Between November 1997 and April 2005, 20 HCC patients with AVS were referred to our department for radiotherapy. The radiation was delivered with 10-15 MV X-ray given 5 days per week at 2 approximately 2.5 Gy per fraction. Total doses ranged from 45 to 64 Gy (median dose 60 Gy). The patients were followed up with color Doppler sonography. When non-invasive imaging suggested obliteration, X-ray angiography was performed to verify the results. Four of the 20 AVS proved to be completely obliterated at X-ray angiography in 1.9, 2.8, 1.8 and 2.9 months after radiotherapy. One of the remaining 16 showed obvious regression on Doppler sonography 0.5 months after radiotherapy, but X-ray angiography was not performed to verify the result. Radiation-related hepatic failure did not occur during the follow-up period. In conclusion, radiotherapy is a treatment alternative for AVS in HCC patients and gives patients with poor prognosis the chance to receive further transcatheter arterial embolization.

Comparison of long-term effects between intra-arterially delivered ethanol and Gelfoam for the treatment of severe arterioportal shunt in patients with hepatocellular carcinoma

AIM: To evaluate long-term effect of ethanol embolization for the treatment of hepatocellular carcinoma (HCC) with severe hepatic arterioportal shunt (APS), compared with Gelfoam embolization.

METHODS: Sixty-four patients (ethanol group) and 33 patients (Gelfoam group) with HCC and APS were respectively treated with ethanol and Gelfoam for APS before the routine interventional treatment for the tumor. Frequency of recanalization of shunt, complete occlusion of the shunt, side effects, complications, and survival rates were analyzed between the two groups.

RESULTS: The occlusion rate of APS after initial treatment in ethanol group was 70.3%(45/64), and recanalization rate of 1 month after embolization was 17.8%(8/45), and complete occlusion rate was 82.8%(53/64). Those in Gelfoam group were 63.6%(21/33), 85.7%(18/21), and 18.2%(6/33). There were significant differences in recanalization rate and complete occlusion rate between the two groups (P < 0.05). The survival rates in ethanol group were 78% at 6 months, 49% at 12 months, 25% at 24 months, whereas those in Gelfoam group were 58% at 6 months, 23% at 12 months, 15% at 24 months. The ethanol group showed significantly better survival than Gelfoam group (P < 0.05). In the ethanol group, there was a significant prolongation of survival in patients with monofocal HCC (P < 0.05) and Child class A (P < 0.05). There were no significant differences in survival rate in the Gelfoam group with regard to the number of tumor and Child class (P > 0.05). The incidence rate of abdominal pain during procedure in ethanol group was 82.8%. There was no significant difference in postembolization syndromes between two groups. Procedure-related hepatic failure did not occur in ethanol group.

CONCLUSION: Ethanol embolization for patients with HCC and severe APS is efficacious and safe, and may contribute to prolongation of the life span versus Gelfoam embolization.

Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial

Bacterial infection may adversely affect the hemostasis of patients with gastroesophageal variceal bleeding (GEVB). Antibiotic prophylaxis can prevent bacterial infection in such patients, but its role in preventing rebleeding is unclear. Over a 25-month period, patients with acute GEVB but without evidence of bacterial infection were randomized to receive prophylactic antibiotics (ofloxacin 200 mg i.v. q12h for 2 days followed by oral ofloxacin 200 mg q12h for 5 days) or receive antibiotics only when infection became evident (on-demand group). Endoscopic therapy for the GEVB was performed immediately after infection work-up and randomization. Fifty-nine patients in the prophylactic group and 61 patients in the on-demand group were analyzed. Clinical and endoscopic characteristics of the gastroesophageal varices, time to endoscopic treatment, and period of follow-up were not different between the two groups. Antibiotic prophylaxis decreased infections (2/59 vs. 16/61; P <.002). The actuarial probability of rebleeding was higher in patients without prophylactic antibiotics (P =.0029). The difference of rebleeding was mostly due to early rebleeding within 7 days (4/12 vs. 21/27, P =.0221). The relative hazard of rebleeding within 7 days was 5.078 (95% CI: 1.854-13.908, P <.0001). The multivariate Cox regression indicated bacterial infection (relative hazard: 3.85, 95% CI: 1.85-13.90) and association with hepatocellular carcinoma (relative hazard: 2.46, 95% CI: 1.30-4.63) as independent factors predictive of rebleeding. Blood transfusion for rebleeding was also reduced in the prophylactic group (1.40 +/- 0.89 vs. 2.81 +/- 2.29 units, P <.05). There was no difference in survival between the two groups. In conclusion, antibiotic prophylaxis can prevent infection and rebleeding as well as decrease the amount of blood transfused for patients with acute GEVB following endoscopic treatment.

Hepatic arterioportal shunts: dynamic CT and MR features

With the increased temporal resolution available in dynamic computed tomography (CT) and magnetic resonance imaging (MRI), hepatic arterioportal shunts are now more frequently encountered than in the past. The condition occurs in various hepatic diseases in which portal or hepatic venous flow is compromised. The underlying mechanism and the degree of shunt affect its appearance at dynamic imaging. The dynamic CT and MRI findings have been summarized as early enhancement of peripheral portal veins, and wedge-shaped transient parenchymal enhancement during the hepatic arterial phase. Recognition of arterioportal shunt can suggest the presence of a previously unsuspected disorder and avoids false-positive diagnosis or overestimation of a hepatic disease. Familiarity with the pathophysiology of arterioportal shunt also allows investigation of the hepatic hemodynamic changes occurring in various hepatic diseases.

Feasibility and potential benefit of maintenance endoscopic variceal ligation in patients with unresectable hepatocellular carcinoma and acute esophageal variceal hemorrhage: a controlled trial

BACKGROUND

Patients with unresectable hepatoma and acute esophageal variceal bleeding have extremely high rates of recurrent bleeding and mortality. This controlled study evaluates the feasibility and potential benefit of maintenance endoscopic variceal ligation in these patients.

METHODS

Patients with unresectable hepatoma and acute esophageal variceal bleeding underwent emergent endoscopic variceal ligation. After hemostasis, patients were randomized to undergo maintenance or esophageal variceal ligation (EVL) as necessary (demand ligation).

RESULTS

Fifty-four patients underwent maintenance EVL and 55 demanded EVL. One or more subsequent EVL session could be performed in only 30 patients (55.6%) in the maintenance group (actual maintenance ligation). Logistic regression analysis found that hepatic function determines the feasibility of maintenance ligation (Child-Pugh's A+B vs. C, OR 23.00: 95% CI [5.26, 100.66]). The survival and recurrent bleeding rates were similar in both groups. A subgroup analysis of patients with Child-Pugh's A and B hepatic reserve in both the maintenance EVL group (n = 24) and demand EVL group (n = 25) was performed to assess the potential benefit of maintenance ligation. Maintenance ligation reduced the rate of recurrent bleeding compared with demand ligation (p = 0.043). Cox regression showed that portal vein thrombosis and tumors in both hepatic lobes were also factors together with EVL that determined recurrence of bleeding. Survival was similar in both groups.

CONCLUSIONS

Maintenance ligation is feasible in patients with unresectable hepatoma and variceal hemorrhage if they have a good hepatic reserve. Maintenance ligation might lower the rate of recurrent bleeding in this subgroup of patients.

Successful treatment of bleeding due to ileal varices in a patient with hepatocellular carcinoma

This case report concerns a 62-year-old female who was known to have cirrhosis. An endoscopic examination showed no evidence of haemorrhaging due to either oesophageal or gastric varices. Angiographic studies demonstrated extravasation from the ileal varices. There was a prominent arterio-portal shunt in the liver, and the shunt was considered to be a contributing factor to induce portal hypertension and variceal bleeding in the ileum. Therefore, transcatheter arterial embolization was performed, but was unsuccessful. As a result, the patient underwent a laparotomy, and a dilatating ileocaecal vein and a communicating ovarian vein were selectively ligated. Following the procedure, the haemorrhaging stopped and she then recovered. The patient is doing well 21 months after surgery at the time of writing.

Conformal radiation therapy for hepatoma with portal vein thrombosis

A 43-year-old male patient was diagnosed as having hepatocellular carcinoma with portal vein thrombosis and arterioportal shunts. Three-dimensional conformal radiation therapy (3DCRT) with high focal dose was given to the left portal venous area. Shrinkage of the tumour and thrombus, disappearance of the arterioportal shunts and restoration of the hepatopedal flow of the portal vein was noted 3 months after treatment. The patient received further transarterial embolisation and achieved successful tumour control. No serious complications were encountered. 3DCRT is technically feasible and effective to treat a small volume of liver tissue with a high dose of radiation in this advanced disease.

[Intrahepatic transtumoral arteriovenous fistulae (diagnosis, importance, therapeutic proposals)]

The authors present the angiographic aspects of four patients having an arteriovenous transhepatic transtumoral fistula (two arterioportal and two arteriovenous). The angiographic results of the occlusion with cyanoacrylate (Hystoacryl) of the right hepatic artery in one and by the infusion of Lipiodol in two are also shown. The physiopathological characteristics of each kind of fistula are discussed and the consequences of the passage of the quimioembolizing mixture through the tumor, regarding intrahepatic abscess formation, irregular clinical results and pulmonary complications are commented. These complications make the diagnosis of a transtumoral transhepatic arteriovenous fistula, previously to the chemoembolic treatment important, even though being frequently difficult, because of the reduced caliber of the feeding artery and eventual low transfistular bloodflow. The efficient occlusion of the arterioportal fistula with Histoacryl was favourably compared to the infusion of Lipiodol, which was unable to occlude the arteriovenous fistula. The contraindication to perform chemoembolic treatment of hepatic tumors, when an intrahepatic transtumoral arteriovenous fistula is present and the embolization of the fistular feeding artery is stressed. Ultrasonography using color Doppler and sono-enhancing contrast is appointed as the ideal non-invasive means of making the diagnosis of an hepatic transtumoral fistula and makes it eligible to be the first test in the algorithm for the appraisal of hepatic tumors.

Arteriovenous shunting in hepatocellular carcinoma: its prevalence and clinical significance

Arteriovenous shunting has been reported in hepatocellular carcinoma (HCC) and is a recognized contraindication to treatment by transcatheter arterial chemoembolization. This study aims to determine the prevalence of arteriovenous shunting in patients presenting with HCC and the development of shunts in those with inoperable HCC being treated with repeated chemoembolization. In a group of 292 Chinese patients (251 men, 41 women; mean age 54.7 years) presenting with HCC, hepatic angiograms demonstrated arteriovenous shunting in 91 cases (31.2%); shunting into the portal vein was observed in 84 (28.8%) and shunting into the hepatic vein in seven (2.4%). The hepatic angiograms of a separate group of 171 Chinese patients (144 men, 27 women: mean age 55.4 years) undergoing chemoembolization for inoperable HCC were analysed. Arteriovenous shunting developed during treatment in 20 patients (11.7%). Of these 20 patients, one had shunting into the hepatic vein while 19 (11.1%) had arterioportal shunting. Arteriovenous shunting occurred through the tumour or portal vein tumour thrombus in 13 patients, and occurred at sites remote from the tumour in the other seven patients. Shunting disappeared on repeat angiograms in three patients. Various postulated mechanisms responsible for arteriovenous shunting in HCC are reviewed. The recognition of development of arteriovenous shunting during chemoembolization of HCC is important as it has a direct bearing on patient management and prognosis.

Endoscopic variceal ligation versus conservative treatment for patients with hepatocellular carcinoma and bleeding esophageal varices

BACKGROUND

Endoscopic variceal ligation (EVL) is currently a favored treatment for control of bleeding from esophageal varices. However, little is known about the treatment of bleeding varices in hepatocellular carcinoma.

METHODS

EVL was performed in 16 patients with bleeding esophageal varices due to concomitant hepatocellular carcinoma. Treatment results were compared with those of another 23 patients who were conservatively treated.

RESULTS

Comparing the two groups, ligation significantly reduced the risk of fatal bleeding (44% vs 70%; P < 0.05). Significantly fewer patients in the ligation group died at the time of the index hemorrhage (11% vs 52%; P < 0.05). Rebleeding occurred in 44% of the ligation group and 73% in the control group (P > 0.05). The mean days of survival were 40 +/- 20 (range, 7 to 103) in the ligation group and 20 +/- 30 (range, 1 to 136) in the control group (P = 0.08). In the absence of portal vein thrombosis, ligation significantly reduced the rebleeding rate (17% vs 50%, P < 0.05) and the mortality rate (0% vs 100%, P < 0.05).

CONCLUSION

EVL is a good choice for palliation in patients with esophageal variceal bleeding and hepatocellular carcinoma. Aggressive use of EVL may be tried in those patients without portal venous thrombosis.

Intrahepatic arterioportal fistulae: role of transcatheter embolization

Management of 26 arterioportal fistulae (APFs) is reported. Among 13 hepatoma-induced fistulae (group A), conservative treatment was ineffective in 8 patients, and arterial embolization alleviated portal hypertension in the other 5. Of 10 iatrogenic APFs (group B), the 3 largest were successfully embolized, the remaining lesions resolved spontaneously. Three spontaneous nonmalignant APFs (group C) were embolized. Excellent results were obtained in 2 patients, and the other died of severe postembolization hepatic failure. Because long-standing APFs may cause severe portal hypertension with consequent variceal bleeding they should be treated. Arterial embolization is indicated in most patients.

Endoscopic injection sclerotherapy versus conservative treatment for patients with unresectable hepatocellular carcinoma and bleeding esophageal varices

We performed endoscopic injection sclerotherapy (EIS) in the treatment of 37 patients with bleeding esophageal varices due to unresectable hepatocellular carcinoma (HCC). The results were compared with those in another 33 HCC patients treated only conservatively, without EIS, during the same period. A majority of both groups died within 3 weeks after treatment. Comparing the two groups, there was no significant difference in fatal bleeding (66% vs 75%), but significantly fewer of the EIS patients died of the index hemorrhage (43% vs. 83%; p less than 0.01). Also, in the absence of portal vein thrombosis, EIS significantly reduced the risk of fatal bleeding (31% vs. 73%; p less than 0.25). The mean days of survival were 32 +/- 15 (range, 2 to 320) in the EIS group and 10 +/- 14 (range, 2 to 270) in the compared group (p less than 0.001). We conclude that EIS provides temporary control of acute esophageal variceal bleeding in patients with unresectable HCC. The major factors contributing to EIS failure are the lethal propensity of the underlying disease and portal vein thrombosis.