A Rare Case With Multiple Variations Of Liver And Associated Arteries.

Variations of liver, its arterial supply and branching pattern of coeliac trunk are not uncommon as separate entity but this case presents several variations. During routine dissection, a multi-lobular liver, with irregular inferior margin, was observed occupying only right upper quadrant of the abdomen. An extra (accessory) lobe was hanging from its inferior surface. Common hepatic artery was giving eight branches, six on left side and two on right side. Five of the left branches were entering liver but none was passing through porta hepatis. Coeliac trunk showed tetrafurcation; the additional branch was supplying pancreas and transverse colon. Knowledge of these variations or combinations is important in open access surgeries, endoscopic surgeries and diagnostic and interventional radiology of the region.

The Safety and Efficacy of Hemostasis with Clo-Sur P.A.D. after Transcatheter Arterial Chemoembolization

PURPOSE: We wanted to evaluate the safety and efficacy of a new hemostatic device, Clo-Sur P.A.D., at an arterial access site after performing femoral arterial catheterization to achieve transcatheter arterial chemoembolization (TACE). MATERIALS AND METHODS: From August 2002 to March 2005, 113 patients who underwent TACE and agreed on using the Clo-Sur P.A.D. were enrolled in this study. We evaluated the mean time interval from compression to the first movement and also to the first walk. We also evaluated such complications as rebleeding, pseudoaneurysm, vascular occlusion, hematoma, infection and pain. For 92 patients who had previous experiences with manual compression, we evaluated their preference of hemostatic method by asking them. RESULTS: Successful hemostasis was achieved with the Clo-Sur P.A.D. in 105 subjects (92%). The mean time interval from compression to the first movement was 201 minutes, and that to the first walk was 267 minutes. There was no statistical difference between the complicated and the uncomplicated groups for the mean time, prothrombin time, Child-Pugh class and platelet count (p > 0.05). Rebleeding occurred in 3 patients (2.7%) and mild hematoma around puncture site was noted in 5 patients (5.4%). Eighty-seven patients (95%) preferred Clo-Sur P.A.D. to the manual compression method. CONCLUSION: The Clo-Sur P.A.D. is a safe and effective hemostatic device and it provides early ambulation after TACE.

Polyvinyl Alcohol Embolization Adjuvant to Oily Chemoembolization in Advanced Hepatocellular Carcinoma with Arterioportal Shunts

OBJECTIVE: To assess the feasibility and safety of polyvinyl alcohol (PVA) embolization adjuvant to transarterial oily chemoembolization (P-TACE) in advanced hepatocellular carcinoma (HCC) with arterioportal shunts (APS). MATERIALS AND METHODS: Nineteen patients who underwent PVA embolization for APS before a routine chemoembolization (TACE) procedure were retrospectively reviewed. 10 of these 19 patients underwent follow-up TACE or P-TACE after P-TACE (Group A), but nine patients underwent only initial P-TACE because of progression of HCC and/or underlying liver cirrhosis (Group B). Hepatic function tests, APS grades, and portal flow directions were evaluated before and after P-TACE sessions. Complications after procedures and survival days were also evaluated. RESULTS: In group A, APS grade was improved in eight patients and five of six patients with hepatofugal flow showed restored hepatopetal flow postoperatively. No immediate complication was developed in either group. Transient hepatic insufficiency developed in eight (42.1%) of 19 patients after P-TACE, and seven (87.5%) of these eight recovered within two weeks under conservative care. The mean and median survival time all study subjects was 280 days and 162 days. CONCLUSION: P-TACE is feasible and safe in advanced HCC patients with APS.

Microvascular Injury of the Peribiliary Plexus Associated with Transarterial Chemoembolization: A Study of Surgical Specimens

PURPOSE: We attempted to evaluate the relationship between transarteiral chemoembolization (TACE) and injury to the peribiliary plexus by evaluating the number of microvessels in the peribiliary plexus of surgical specimen. MATERIALS AND METHODS: Surgical specimens were obtained from 78 hepatocellular carcinoma patients and 22 patients with liver metastases. They were divided into 4 groups (Group 1; hepatocellular carcinoma without TACE [n=30], Group 2; hepatocellular carcinoma receiving preoperative TACE once [n=37], Group 3; hepatocellular carcinoma receiving preoperative TACE more than two times [n=11] and Group 4; metastatic carcinoma of the liver patients without a history of liver disease [n=22]). Immunohistochemical staining for factor VIII-related antigen was performed in all the specimens and the number of microvessels in the inner capillary layer and the outer venous layer of the bile duct (> 200 micrometer in diameter) was counted. RESULTS: The mean numbers of microvessels in the inner capillary layer were 4.50, 4.08, 1.64 and 2.05, and those in the outer venous layer were 25.23, 20.00, 18.36 and 12.32 for the 4 groups, respectively. The number of microvessels in group 4 was statistically fewer than that of group 1 (p<0.01). In the hepatocellular carcinoma patients, the number of microvessels was decreased as the number of TACE sessions was increased. CONCLUSION: The number of microvessels in the peribiliary plexus is increased in chronic liver disease patients. It may be from the increased portal pressure and flow stagnation in the sinusoidal and portal venules. TACE can have an effect on microvascular injury of the peibiliary plexus, and this can be a cause of bile duct necrosis and biloma.

Interventional radiological techniques in the management of hepatic artery stenosis after liver transplantation / 中华器官移植杂志

Objective To evaluate the safety and efficacy of the interventional techniques for the management of hepatic artery stenosis (HAS) after orthotopic liver transplantation (OLT).Methods Seven patients diagnosed with HAS after OLT were treated with interventional procedures. Three (patients) presented with biliary ischemic complications, 1 with hepatic abscess, and 3 with elevation of liver enzymes and bilirubin levels. Interventional techniques included transcatheter hepatic arterial thrombolysis with a low dose of urokinase (UK), and stent placement in the stenotic segment of the hepatic artery. All patients were followed up regularly by duplex ultrasound scan after discharge.(Results) HAS with over 70 % degree at the anastomosis was found in 3 patients. Complete occlusion of the proper hepatic artery was found in 4 patients, and the hepatic artery flow was re-established in these patients at 3 to 7 days after transcatheter hepatic arterial thrombolysis. However, an over 90 % degree of stenosis at the anastomosis was seen in 4 cases. Stent placement in the stenotic segment of the hepatic artery was performed successfully in 7 patients, and significant improvement of liver (function) was seen in these patients at 2 weeks after the procedures. No complications related to the procedure occurred. The 7 patients had a good clinical course with normal graft function during a mean follow-up of 9 months (4 to 18 months), and patent hepatic artery flow was identified by follow-up Doppler ultrasonography.Conclusion Transcatheter endovascular interventional techniques are safe and effective methods for treatment of HAS after OLT.

Radiologic Management of Hepatic Arterial Stenosis or Thrombosis Following Liver Transplantation

PURPOSE: To assess the results and usefulness of interventional procedures for hepatic arterial stenosis or thrombosis following liver transplantation. MATERIALS AND METHODS: During the past five years, eight patients aged 1-59 (mean, 39) years among 187 liver transplant recipients showed elevated of liver enzyme levels (AST/ALT) and decreased arterial flow at Doppler ultrasound. Hepatic arteriography revealed luminal stenosis or occlusion at the proper hepatic artery, and six patients, one of whom required thrombolysis before the procedure, underwent percutaneous transluminal angioplasty (PTA) using a balloon. In two with thronbosis, thrombolysis without PTA was performed. In order to increase hepatic arterial flow, four patients underwent additional coil embolization of the gastroduodenal or splenic artery. RESULTS: Hepatic arterial flow recovered in all six patients after PTA. Three required repeat PTA for restenosis and one of these needed stent placement after repeated PTA. At follow-up, 6-17 months later, the three had good hepatic function. Within four days, the other three expired due to graft failure, hepatorenal syndrome and sepsis. One of the patients who underwent thrombolysis without PTA expired and the other required retransplantation. In this case there were no procedure - related complications. CONCLUSION: Radiologic interventions are useful for treatment of hepatic arterial stensis or thrombosis in patients with liver transplantations.

Safety of Superselective Transcatheter Arterial Chemoembolization through Cystic Artery for Treatment of Hepatocellular Carcinoma

PURPOSE: To report on the safety and efficacy of superselective transcatheter arterial chemoembolization( TACE) of tumor feeding branches originating from the cystic artery for the treatment of hepatocellular. MATERIALS AND METHODS: From, May 1995 to, September 1999, eleven HCC patients aged between 38 and 82 (mean, 57.4) years with tumor-feeding branches originating from the cystic artery underwent TACE. In eight, for whom superselection of these branches was possible, TACE was done with the use of Gelfoam and a mixture of Lipiodol and cisplatin, while for three, for whom superselection was impossible, a mixture of Lipiodol and cisplatin only was used. Immediately after TACE, remnant tumor staining was angiographically evaluated,and tumor response was determined by follow-up CT at one month. After procedure, the development of cholecystitis was assessed clinically. RESULTS: Post-TACE angiography showed remnant tumor staining in one patient who underwent embolization with Gelfoam and the mixture of Lipiodol and cisplatin, and in one for whom the mixture of Lipiodol & cisplatin only was used. Among the eight for whom Gelfoam and the mixture of Lipiodol and cisplatin was used,one-month follow-up CT showed compact Lipiodol uptake in five, partial Lipiodol uptake in three, no change in tumor size in six, increased tumor size in one, and decreased tumor size in one. Among the three for whom the mixture of Lipiodol and cisplatin only was used, one-month follow-up CT showed neither Lipiodol uptake nor change in tumor size in one patient, partial Lipiodol uptake and increased tumor size in one, and compact Lipiodol uptake and decreased tumor size in one. Cholecystitis developed in only one patient who underwent embolization with Gelfoam and the mixture of Lipiodol and cisplatin, but was cured by conservative treatment. CONCLUSION: Superselective TACE of tumor feeding branches originating from the cystic artery seems to be a safe and effective method for the treatment of hepatocellular carcinoma.

Intraperitoneal Hemorrhage Due to Spontaneous Rupture of Hepatocellular Carcinoma: Comparisons of Tranarterial Oily Chemoembolization and Simple Embolization with Gelfoam

PURPOSE: To compare the safety and effectiveness of transarterial oily chemoembolization (TOCE) and transar-terial embolization (TAE) with Gelfoam in cases of ruptured hepatocellular carcinoma (HCC), and to describe the most important prognostic factors involved in emergency embolization. MATERIALS AND METHODS: Forty-two consecutive patients with spontaneously ruptured HCC underwent emergency TOCE (n = 22) or TGE (n = 20). In the TOCE group, Lipiodol (3 -10 cc), Adriamycin (20 -50 mg), and Mitomycin (2 -10 mg) were used, and these were followed by blockade of the hepatic arterial flow with gelatin sponge particles. In the TAE group, patients underwent only Gelfoam embolization. Using the Kaplan-Meier method, survival time from the time of embolization was estimated, and to analyze prognostic factors, Cox 's proportional hazard regression model was used. RESULTS: Successful hemostasis was achieved in 41 patients (97.6%). Mean survival time was 201 and 246 days in the TOCE and TAE group, respectively, but the difference was not tatistically significant (p > 0.05). Five of the TOCE group (22.7%) and three of the TAE group (15.0%) died of hepatic failure. Analysis of the prognostic factors showed that portal vein involvement by the tumor was the most important factor influencing survival. CONCLUSION: Although TOCE and TAE effectively controlled hemorrhaging from a ruptured HCC, the procedures involve a high risk of hepatic failure. Their goal should, therefore, be solely to achieve hemostasis, and thus decrease parenchymal injury.

Hepatic Infarction Complicating Acute Pancreatitis: A Case Report

Hepatic infarction is relatively uncommon and is usually related to surgery or interventional procedures. Pancreatitis-associated hepatic infarction has not been reported in the literature, and we now describe a case of hepatic infarction in a 31-year-old man with acute pancreatitis. Initial CT scanning demonstrated an enlarged pancreas with multifocal fluid collection, and a large wedge-shaped low attenuation lesion was seen in the right lobe of the liver along with thrombi in the posteroinferior branch of the right portal vein. Hepatic arteri-ography and SMA portography revealed a pseudoaneurysm in the right hepatic artery, thrombi in the main portal vein and its posteroinferior branch, and perfusion defects confined to S6 of the liver.

Prognostic Factors in Transcatheter Arterial Chemoembolizationc of Hepatocellular Carcinoma: Analysis of Morethan 3 Year Survivors

PURPOSE: To determine which prognostic factors contribute to long-term survival after transcatheter arterialchemoembolization(TACE) of hepatocellular carcinoma. MATERIALS AND METHODS: In 100 patients who expired withinone year and 84 who survived or have survived for more than 3 years after TACE, prognostic factors wereretrospectively evaluated. TACE was accomplished by hepatic arterial infusion of a suspension of Lipiodol andanticancer drugs(Mitomycin-C and Adriamycin), either alone or followed by gelfoam embolization. Fisher 's exacttest of probability was used to determine which prognostic factors were statistically significant. RESULTS:Statistically significant prognostic factors were as follows: Child classification(p0.05). CONCLUSION: The prognosisof patients with hepatocellular carcinoma treated by TACE was affected favorably by good liver function(Childclassification A), low alphafetoprotein value, nodular or massive-type tumor, patent main and first-order portalvein, and hypervascular tumor.

Embolization of Seve re Arterioportal Shunts in the Patients with Hepatocellular Carcinoma: Safety and Influence on Patient Survival

PURPOSE: To evaluate the safety and the influence of embolization of severe arterioportal shunts, and the effect of the procedure on the survival rate of patients with hepatocellular carcinoma combined with portal vein tumor thrombosis. MATERIALS AND METHODS: This study involved a total of 54 patients with hepatocellular carcinoma in whom hepatic arteriography revealed severe arterioportal shunt. From among this total, 34 patients (embolization group) underwent chemoinfusion after shunt embolization, while 19 (control group) underwent chemoinfusion only. The embolic materials included PVA particles and/or Gelfoam pieces. The frequency of postembolization symptoms (Chi-squared test) and changes in laboratory values (paired t-test) were compared between the two groups, and shunt improvement was also evaluated. Patient survival was tested using the Kaplan-Meier method. RESULTS: Fever and RUQ pain were more frequent in the embolization group (p<0.001). The complications of embolization included severe postembolization syndrome (n=1), acute hepatic failure (n=2), hepatic infarction (n=1), and sepsis (n=1). There were no significant changes in laboratory values. Among the 28 patients (24 of embolization group and four of control group) who underwent follow-up angiography, arterioportal shunt became less severe or disappeared in ten of the embolization group. For the embolization and control groups, the mean survival interval was 29.5 +/-5.4 weeks and 10.3 +/-3.1 weeks (p=0.0002), respectively. The best results were seen in the PVA particle group (p=0.01). CONCLUSION: The embolization of severe arterioportal shunts is relatively safe and increases patient survival rate.

Dual Phase CT Hepatic Arteriography in the Evaluation of Hypervascular Hepatocellular Carcinoma

PURPOSE: To assess the diagnostic accuracy of dual-phase computed tomography during hepaticarteriography(CTHA) in depicting hypervascular hepatocellular carcinoma. MATERIALS AND METHODS: Forty patientswith hepatocellular carcinoma underwent dual-phase CTHA. First-phase data was obtained 6 seconds after contrastmedia was injected into the common hepatic artery, while second-phase data was obtained 35-40 seconds later.Lipiodol CT was performed 10-17 days after 2mL of lipiodol was injected into the proper hepatic artery. As agold-standard of 172 lipiodol-uptaken nodules seen on lipiodol CT, the detectability and positive predictive valueof the first and second phases, and the simultaneous interpretation of both phases, were analysed. RESULTS: Allnodules were detected by first-phase CTHA, 162 (94%) by second-phase CTHA, and 170 (99%) by simultaneousinterpretation of both phases. The detection sensitivities of first-phase CTHA and simultaneous interpretation ofboth phases were statistically superior to that of second-phase CTHA. Positive predictive values were 87% withfirst-phase CTHA, 96% with second-phase CTHA, and 97% with simultaneous interpretation of both phases. CONCLUSION: Dual-phase CTHA was useful for increasing detectability and accuracy in the diagnosis of hypervascularhepatocellular carcinoma.

Transcatheter Arterial Embolization of Ruptured Hepatocellular Carcinoma: Effectiveness and Long-term Follow-up

PURPOSE: To evaluate the effectiveness of emergent transcatheter arterial embolization(TAE) in the treatmentof bleeding from ruptured hepatocellular carcinoma(HCC) and long-term follow-up. MATERIALS AND METHODS: Twentypatients with ruptured HCC underwent emergent TAE; diagnosis was based on clinical and radiologic findings.Mesoportography was used to determine the presence of portal vein thrombosis, and celiac angiography to determinethe presence of hypervascular mass and extravasation of contrast material. All patients underwent TAE; a mixtureof adriamycin, mitomycin, lipiodol, and gelfoam particles was used. In four of the 20 patients, adjuvantembolization was performed, using stainless steel coils. After three week of follow-up CT, follow-up TAE wasperformed between two and ten times. RESULTS: Technical and clinical success was up to 100%. Mesoportographyshowed the presence of portal vein thrombosis in nine patients and its absence in 11. In 15 patients, three weeksof follow-up by CT showed lipiodol uptake by the mass and the disappearance of highly attenuated peritoneal fluid.Within one week of embolization, four of the 20 patients died of sepsis, shock, and hepatic failure, and withinone month of this procedure, one died of renal failure. Three-month, six-month, and one-year survival rates afterTAE were repectively 50%, 45%, and 30%; the mean duration of survival was 260 days. In nine patients with portalvein thrombosis, the one-year survival rate was 11%, while in 11 patients not suffering from this condition, therate was 70%; the difference between the two groups was statistically significant(p < 0.05). CONCLUSION: As thefirst choice of treatment for patients with hemoperitoneum from ruptured HCC, emergent TAE is an effective,life-saving therapeutic procedure; in these patients, portal vein thrombosis may be a factor influencing risk andprognosis.

Diagnostic Efficacy of Gastric Air Filling in Hepatic Arteriography of the Left Lobe

PURPOSE: To evaluate the diagnostic efficacy of gastric air filling during DSA-hepatic arteriography of the left lobe in overcoming the pitfalls caused by accessory left gastric artery and left hepatic artery from left gastric artery. MATERIALS AND METHODS: In a prospective study, standard hepatic arteriogram and hepatic arteriogram after ingestion of an effervescent agent were performed in 22 patients with anatomic variation of the celiac axis. The anatomic variations were accessory left gastric artery in 15 patients and left hepatic arteryfrom left gastric artery in seven. RESULTS: Hepatic arteriogram after ingestion of an effervescent agent was excellent in differentiating nodular stomach staining from hepatic tumor staining in the left hepatic lobe in patients with accessory left gastric artery, and for evaluation of the left hepatic lobe when this was obscured by stomach staining. CONCLUSION: Hepatic arteriogram after ingestion of an effervescent agent is a simple and safe method for overcoming angiographic pitfalls due to anatomic variation.

Experimental Study of Bleeding Control on Liver Biopsy in Rabbit: N-butyl 2-cyanoacrylate(NBCA) injection and RF electrocauterization

PURPOSE: To evaluate the hemostatic effect of N-butyl 2-cyanoacrylate(NBCA) injection and RF electrocauterization of the tract after fine needle biopsy of the liver, and the histopathologic changes of the liver. MATERIALS AND METHODS: Three lobes of rabbit liver were selected and separately punctured four times with 21 gauge biopsy needles. According to the hemostatic procedure on fine needle biopsy, three groups (1, 2, 3) were formed : group 1, in which there was no maneuver for bleeding control, was the control group ; group 2, in which NBCA was injected into the puncture tract while slowly removing the needle ; group 3, in which RF electrocauterization of the tract was carried out. After completely removing the needle, each group was evaluated for amount of bleeding and histologic change. RESULTS: The amount of bleeding was 0.407gm+/-0.245 in group 1,0.028gm+/-0.036 in group 2 and 0.035gm+/-0.028 in group 3. As compared with the control group(group 1), injecting NBCA into the biopsy tract(P=0.0002) and RF electrocauterization of the tract(P=0.0003) significantly reduced the amount of bleeding after liver biopsy. The amount of bleeding was not statistically different between group 2 and 3, however (P=0.58). In Group 1, the tract was fully filled with blood. Group 2 showed NBCA embolized in the biopsy tract, adhering to hepatocytes and mixed with blood; small vessels adjacent to the puncture tract were filled with NBCA. Group 3 showed tissue degeneration, including necrosis of hepatocytes, vacuolation and neutrophil infiltration. CONCLUSION: Injection of NBCA and RF electrocauterization of the tract after puncture of the liver for biopsy efficiently controlled bleeding. In particular, the efficiency of NBCA injection was due to its effect of plugging the tract and causing the embolization of adjacent small vessels. With regard to procedural handling, RF electrocauterization of the tract is superior to injection of NBCA.

Chemoembolization of Hepatocellular Carcinoma: Long-term Survival and Prognostic Factors

PURPOSE: To analyse the long-term survival rate after transcatheter arterial chemoembolization (TACE) of hepatocellular carcinoma and to determine prognostic factors. MATERIALS AND METHODS: In 1067 hepatocellularcarcinoma patients who had undergone TACE, of long-term survival rate and prognostic factors were retrospecfively analysed. Chemoembolization was accomplished by hepatic arterial infusion of a mixture of Lipiodol and Adriamycin(51%) or by Gelfoam embolization after infusion of the Lipiodol mixture(49%). The survival rate was calculated by the Kaplan-Meier method and multivariate analysis using the weibull model was applied to determine which prognostic factors were statistically significant. RESULTS: Among the 1067 patients, survival rates were asfollows : one-year, 60.6% ; two-year 42.3% ; three-year, 29.1% ; four-year, 23.7% ; and five-year, 14.7 %. The oneyear survival rate and median survival period of 432 patients with tumors 5cm in diameter or smaller were 77.7%and 33 months respectively, significantly higher than those of patients with larger tumors for whom the corresponding figures were 44.8% and 11 months. Other significant prognostic factors(p<0.0001) shown bymultivariate analysis included type of tumor, portal vein invasion and child-pugh classification. CONCLUSION: Theone-year survival rate agter chemoembolization in 1067 patients with hepatocellular carcinoma was 60.6%. The significant prognostic factors were size and type of the tumor, portal vein invasion, and Child-Pugh classification.