Contrast echocardiography in detection of portopulmonary venous anastomosis

Multi-organ infarction following percutaneous transhepatic esophageal variceal obliteration with glue injection: a case report

Percutaneous transhepatic variceal obliteration (PTVO) is currently one of the best treatment options for controlling acute recurrent bleeding in cirrhotic patients. Nevertheless, this procedure is associated with major and minor complications such as fever, pain, fatal intraperitoneal hemorrhage, and rarely, embolization of embolic agents to the systemic circulation. Only one study has reported systemic emboli following the use of glue-lipiodal mixture for percutaneous transhepatic embolization of esophageal varices and here we report another case of this complication. Here, we report a 44-year-old man presenting with multi-organ infarction following PTVO with glue-Lipiodol mixture. He was a known case of liver cirrhosis who was admitted for recurrent bleeding from esophageal varices. The patient became a candidate for transjugular intrahepatic portosystemic shunt surgery; however, he did not provide consent for this procedure. the patient eventually decided to undergo PTVO as an alternative option. Twelve hours after the procedure, the patient developed neurological symptoms such as left side weakness, dysarthria, and fecal incontinence. Further investigation showed glue particles in brain, liver, spleen and both lungs. Contrast echocardiography and splenoportography did not show any evidence of right-to-left shunt. Thus, conservative management was initiated for the patient, which resulted in the gradual improvement after three weeks. Prior evaluation with splenoportography and contrast echocardiography before performing PTVO may help in the early detection of any connection with systemic circulation. Also, based on the desired procedure, the most appropriate glue/Lipiodol ratio and injection technique should be selected to minimize the risk of adverse events.

Utility of low-dose gelatin sponge particles and 5% ethanolamine oleate iopamidol mixture in retrograde transvenous obliteration (GERTO) for gastric varices

OBJECTIVE

To determine the utility of low-dose gelatin sponge particles and 5% ethanolamine oleate iopamidol (EOI) mixture in retrograde transvenous obliteration (GERTO) for gastric varices (GV).

METHODS

57 consecutive patients who underwent balloon-occluded retrograde transvenous obliteration (B-RTO) for GV were divided into three groups with Hirota's grade by balloon-occluded retrograde transvenous venography. Hirota's Grade 1 patients were assigned to G1 group and underwent treatment with 5% EOI. Grade ≥ 2 patients prior to August 2015 were G ≥ 2 group treated with 5% EOI, and those treated thereafter were GERTO group. The amount of EOI used per unit GV volume (EOI/GV ratio), the times to embolization and recurrence rate of GV were evaluated.

RESULTS

The EOI/GV ratio was 0.66 ± 0.19 in G1, 1.5 ± 0.8 in G ≥ 2, and 0.58 ± 0.23 in GERTO (G ≥ 2 vs GERTO, p < 0.0001). The times to embolization were 26.5 ± 10.5 min for G1, 39.2 ± 26.8 for G ≥ 2, and 21.4 ± 9.4 for GERTO (G ≥ 2 vs GERTO, p = 0.005). The recurrence rate was not significantly different in any of the groups.

CONCLUSION

GERTO was performed in lower amount of sclerosants and in less time compared to conventional B-RTO in Hirota's grade ≥2.

ADVANCES IN KNOWLEDGE

Feasibility of low-dose gelatin sponge particles and 5% EOI mixture as sclerosants for GV.

Portopulmonary venous anastomosis as a rare cause of embolic stroke following endoscopic cyanoacrylate injection for gastric variceal hemorrhage: A case report and review of the literature

We report the case of a non‐cirrhotic 25‐year‐old female patient with cryptogenic portal hypertension who underwent cyanoacrylate injection for acute gastroesophageal variceal bleeding with a subsequent embolic stroke via a previously unrecognised portopulmonary venous anastomosis.

Isolated Gastric Varices Refractory to Balloon-occluded Retrograde Transvenous Obliteration (BRTO) Successfully Treated by Shunt-occluded Endoscopic Injection Sclerotherapy (SO-EIS): A Case Report and Review of the Literature

Balloon-occluded retrograde transvenous obliteration (BRTO) is widely used to treat isolated gastric varices (IGVs) in Japan. However, BRTO is difficult to perform for IGVs with many small collateral veins, and no secondary treatment has been established. We herein report a rare case of IGVs refractory to BRTO successfully treated by shunt-occluded endoscopic injection sclerotherapy (SO-EIS), which is a combination therapy of major shunt occlusion by a balloon catheter and endoscopic injection sclerotherapy. Since SO-EIS can be performed regardless of the IGVs' anatomical configuration, it may be a promising alternative treatment for IGVs refractory to BRTO.

Portopulmonary venous anastomosis in balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices

BACKGROUND AND AIM

Several reports have described portopulmonary venous anastomosis (PPVA). However, in balloon-occluded retrograde transvenous obliteration (BRTO), attention has not been paid to paradoxical embolism. The objective of this study was to investigate the existence of a right-left shunt due to PPVA when the drainage vein is occluded by a balloon during BRTO.

METHODS

The subjects were 19 patients who underwent BRTO. Whether PPVA was present was confirmed on balloon-occluded retrograde transvenous venography (BRTV). After BRTV, a retrograde bolus injection of 20 mL of carbon dioxide (CO2 ) via the balloon catheter was performed under balloon occlusion, and the flow of bubbles into both ventricles was observed with four-chamber view echocardiography. During the same balloon occlusion, bolus injection of CO2 into the inferior vena cava was performed, followed by echocardiography.

RESULTS

PPVA was confirmed on BRTV in four patients (21.1%). On echocardiography with retrograde CO2 injection, bubbles were confirmed in the left ventricle in six patients (31.6%). On echocardiography with CO2 injection into the inferior vena cava, bubbles were not confirmed in the left ventricle in any cases.

CONCLUSIONS

When the draining vein was occluded with a balloon and blood flow in a gastrorenal or gastrocaval shunt was stopped during BRTO, PPVA was confirmed in 21.1% of cases on retrograde angiography, and a right-left shunt was confirmed in 31.6% of cases on echocardiography.

Stroke after percutaneous transhepatic variceal obliteration of esophageal varix in Caroli syndrome

Here we present the case of an 11-year-old female patient diagnosed with Caroli syndrome, who had refractory esophageal varices. The patient had a history of recurrent bleeding from esophageal varices, which was treated with endoscopic variceal ligation thrice over a period of 2 years. However, the bleeding was not controlled. When the patient finally visited the Emergency Department, the hemoglobin level was 4.4 g/dL. Transhepatic intrajugular portosystemic shunt was unsuccessful. Subsequently, the patient underwent percutaneous transhepatic variceal obliteration. Twenty hours after this procedure, the patient complained of aphasia, dizziness, headache, and general weakness. Six hours later, the patient became drowsy and unresponsive to painful stimuli. Lipiodol particles used to embolize the coronary and posterior gastric veins might have passed into the systemic arterial circulation, and they were found to be lodged in the brain, kidney, lung, and stomach. There was no abnormality of the portal vein on portal venography, and blood flow to the azygos vein through the paravertebral and hemiazygos systems was found to drain to the systemic circulation on coronary venography. Contrast echocardiography showed no pulmonary arteriovenous fistula. Symptoms improved with conservative management, and the esophageal varices were found to have improved on esophagogastroduodenoscopy.

Dynamic CT and MRA findings of a case of portopulmonary venous anastomosis (PPVA) in a patient with portal hypertension: a case report and review of the literature

Portopulmonary venous anastomosis (PPVA), which has been rarely reported in conventional CT and MR studies, is an unusual collateral pathway in patients with portal hypertension. It has clinical implications related to right-to-left shunt that are different from the clinical implications related to other more usual portosystemic shunts in portal hypertensive patients. Here, we report the dynamic CT and MRA findings of a case of PPVA in a patient with portal hypertension, directly demonstrating the shunt flow from the paraesophageal varix to the left atrium via the right inferior pulmonary vein.

Partial pressure of oxygen is lower in the left upper pulmonary vein than in the right in adults with atrial septal defect: difference in P(O2) between the right and left pulmonary veins

BACKGROUND

The right-to-left shunt at the atrial level is responsible for arterial hypoxemia in patients with atrial septal defect.

OBJECTIVES

This study investigated the mechanism of arterial hypoxemia in patients with atrial septal defect by measuring the P(O2) in both the right and left upper pulmonary veins.

SUBJECTS AND METHOD

We prospectively measured the P(O2) in the femoral artery and the right and left upper pulmonary veins during cardiac catheterization in 13 adults (median age, 53 years) and 7 children (median age, 7 years) with secundum atrial septal defect. The adults and children were studied consecutively. Contrast echocardiography was performed to evaluate right-to-left shunt in all adults.

RESULTS

Among the children, there were no patients showing arterial hypoxemia, and there was no difference in the P(O2) (+/-SD) between the right and left upper pulmonary veins (right, 100+/-3.8 mm Hg vs left, 100+/-7.8 mm Hg; p = 0.92). However, arterial hypoxemia was present in 11 of the 13 adult patients, although contrast echocardiography showed more than a moderate degree of right-to-left shunt in only four adults. The P(O2) was lower in the left upper pulmonary vein than it was in the right upper pulmonary vein in all adult patients (right, 91.6+/-13.8 mm Hg vs left, 73.0+/-11.5 mm Hg; p < 0.0001).

CONCLUSION

The P(O2) was lower in the left upper pulmonary vein than it was in the right upper pulmonary vein in adults with atrial septal defect. Care must be taken in measuring pulmonary blood flow if the P(O2) in the left upper pulmonary vein is low enough to influence oxygen content. The decreased P(O2) in the left upper pulmonary vein may contribute to arterial hypoxemia in addition to right-to-left shunt at the atrial level in adults with atrial septal defect.