Symptomatic Intrahepatic Portosystemic Venous Shunt: Embolization with an Alternative Approach
Shuichi Tanoue1,
Hiro Kiyosue1,
Eiji Komatsu2,
Yuzo Hori3,
Tohru Maeda2 and
Hiromu Mori1
1 Department of Radiology, Oita Medical University, 1-1, Idaigaoka,
Hasama-machi, Oita-gun, Oita, 879-5593, Japan.
2 Department of Radiology, Oita Prefectural Hospital, 476, Bunyo, Oita-shi,
Oita, 870-8511, Japan.
3 Department of Radiology, Nagatomi Neurosurgical Hospital, Omichi-Machi,
Oita-shi, Oita, 870-0822, Japan.
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Fig. 1A. —Drawings illustrate three approaches to access intrahepatic
portosystemic venous shunts. For transileocolic obliteration, catheter
(open arrow) is advanced into portal venous system via ileocolic vein
(solid arrow) through small abdominal incision.
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Fig. 1B. —Drawings illustrate three approaches to access intrahepatic
portosystemic venous shunts. For percutaneous transhepatic obliteration,
catheter (arrow) is advanced into portal venous system after
percutaneous puncture of intrahepatic portal branch.
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Fig. 1C. —Drawings illustrate three approaches to access intrahepatic
portosystemic venous shunts. For retrograde transcaval obliteration, two
catheters are retrogradely advanced into portal venous system through shunt
vessel (arrowhead) via bilateral transfemoral venous access. One
catheter (open arrow), which is advanced into main portal vein
through shunt, is straight catheter used for portography and to measure portal
venous pressure during procedure. Other catheter (solid arrow) is
used to place embolic materials.
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Fig. 2. —Transcaval retrograde portogram shows intrahepatic
portosystemic venous shunt with aneurysmal dilatation (arrow) in
48-year-old man. Arrowhead indicates a catheter advanced into main portal vein
via shunt.
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Fig. 3. —Transcaval retrograde hepatic venogram shows intrahepatic
portosystemic venous shunt between left hepatic vein and left portal vein in
53-year-old woman. Note portal venous anastomosis of medial branches
(arrowheads).
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Fig. 4. —Transcaval retrograde hepatic venogram shows hepatic venous
anastomosis between right hepatic vein and accessory hepatic vein
(arrow) in 64-year-old woman.
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Fig. 5A. —Multiple intrahepatic portosystemic venous shunts in
62-year-old woman who did not have cirrhosis and who presented with memory
disturbance and trembling. Blood examination revealed hyperammonemia and low
Fischer's ratio. Patient was treated by transileocolic obliteration.
Transileocolic portogram revealed multiple intrahepatic portosystemic venous
shunts in left lobe (arrowheads). Gianturco coils (William Cook
Europe, Bjaeverskov, Denmark) and fibered microcoils were placed into shunt
vessels.
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Fig. 5B. —Multiple intrahepatic portosystemic venous shunts in
62-year-old woman who did not have cirrhosis and who presented with memory
disturbance and trembling. Blood examination revealed hyperammonemia and low
Fischer's ratio. Patient was treated by transileocolic obliteration.
Transileocolic portogram obtained after embolization shows complete
obliteration of intrahepatic portosystemic venous shunts.
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Fig. 6A. —Single intrahepatic portosystemic venous shunt in 72-year-old
woman who did not have cirrhosis and who presented in coma. Blood examination
revealed hyperammonemia and low Fischer's ratio. Patient was treated by
retrograde transcaval obliteration. Retrograde transcaval portography was
performed with catheter advanced into portal vein via shunt vessel
(arrowhead). Portogram shows intrahepatic portosystemic venous shunt
between right portal vein and accessory hepatic vein (open arrow)
with portal vein aneurysm (solid arrow). Gianturco coil (William Cook
Europe, Bjaeverskov, Denmark), detachable microcoils, and fibered platinum
microcoils were positioned in shunt just before aneurysmal dilatation.
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Fig. 6B. —Single intrahepatic portosystemic venous shunt in 72-year-old
woman who did not have cirrhosis and who presented in coma. Blood examination
revealed hyperammonemia and low Fischer's ratio. Patient was treated by
retrograde transcaval obliteration. Portogram obtained after procedure shows
complete obliteration of intrahepatic portosystemic venous shunt.
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Fig. 7A. —Graphs show changes in laboratory data and portal venous
pressures after treatment in study group. Serum ammonium levels decreased
significantly (p < 0.01) after treatment. Data are expressed as
ratios relative to normal values because units and normal values differed
among institutions.
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Fig. 7B. —Graphs show changes in laboratory data and portal venous
pressures after treatment in study group. Fischer's ratios increased
significantly (p = 0.028) after treatment. This value was not
measured in four patients.
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Fig. 7C. —Graphs show changes in laboratory data and portal venous
pressures after treatment in study group. Portal venous pressure increased
significantly (p = 0.018) after treatment. Dotted lines represent
range of normal values. In two patients, portal venous pressure was higher
than normal values both before and after treatment; both patients had
associated liver cirrhosis. Pressure levels were within normal range in other
patients. Portal venous pressure was not measured in three patients.
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Fig. 8A. —Schematic drawings of normal development of intrahepatic
portal and hepatic venous systems. Drawing shows embryo at 5 weeks' gestation.
Vitelline venous plexus is surrounded by liver cords to form hepatic
sinusoids. Bilateral umbilical veins (UV) form sinusoids. CV = cardinal vein,
HS = hepatic sinusoid, D = duodenum, VV = vitelline vein.
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Fig. 8B. —Schematic drawings of normal development of intrahepatic
portal and hepatic venous systems. Drawing shows embryo at 8 weeks' gestation.
Sinusoids start to develop, forming portal and hepatic venous systems. Right
umbilical vein and cranial portion of left umbilical vein are regressed.
Dorsal communication between caudal vitelline veins persists as part of main
portal vein. Note tubular structure between left umbilical vein and inferior
vena cava, which is called ductus venosus. DV = ductus venosus, LVV = left
vitelline vein.
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Fig. 8C. —Schematic drawings of normal development of intrahepatic
portal and hepatic venous systems. Drawing shows fetus at 12 weeks' gestation.
Note advanced differential growth of portal and hepatic venous systems.
Presence of residual communication between hepatic venous system and portal
venous system at this stage corresponds with intrahepatic portosystemic venous
shunt after birth. DV = ductus venosus, SMV = superior mesenteric vein, IVC =
inferior vena cava.
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Fig. 8D. —Schematic drawings of normal development of intrahepatic
portal and hepatic venous systems. Drawing shows fetus with normally developed
portohepatic venous system before birth. HV = hepatic vein, DV = ductus
venosus, PV = portal vein.
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Copyright © 2003 by the American Roentgen Ray Society.
