Inferior Vena Cava Filter Retrieval: Simple to Complex.

Retrievable inferior vena cava filters were designed to provide mechanical prophylaxis from pulmonary embolism with the intent for retrieval once no longer indicated, and have been utilized at a high rate since their introduction. Unfortunately, retrieval rates have historically lagged behind, in part due to significant rates of failed standard retrieval techniques for filters with prolonged dwell time. Refinement in advanced retrieval techniques has now allowed (in experienced centers) for safe removal of filters previously considered irretrievable. An individualized approach is necessary for each potential advanced filter retrieval to determine appropriate course of action. This review will emphasize complex filter retrieval techniques amidst a larger discussion of inferior vena cava filters and their management.

Portal Vein Recanalization-Transjugular Intrahepatic Portosystemic Shunt (PVR-TIPS) Facilitates Liver Transplantation in Cirrhotic Patients with Occlusive Portal Vein Thrombosis.

Portal vein thrombosis (PVT) is a heterogeneous condition with multiple possible etiologies and to varying degrees has historically limited candidacy for liver transplant (LT) in the cirrhotic patient population due to resultant difficulties in constructing a robust portal vein anastomosis. While intraoperative approaches to managing PVT are well-described, methods which approximate normal portal physiology are not always feasible depending on the extent of PVT, and other nonphysiologic techniques are linked with substantial morbidity and poor long-term outcomes. Portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) creation is an efficacious method of restoring physiologic portal flow in cirrhotic patients prior to LT allowing for end-to-end PV anastomosis, and is the product of decades-long institutional expertise in TIPS/LT and the support of a multidisciplinary liver tumor board. To follow is a review of the pertinent pathophysiology of PVT in cirrhosis, the rationale leading to the development and subsequent evolution of the PVR-TIPS procedure, technical lessons learned, and a summary of outcomes to date.

Contemporary Algorithm for the Management of Hepatocellular Carcinoma in 2021: The Northwestern Approach.

Hepatocellular carcinoma (HCC) is the most common primary liver cancer and a major cause of cancer-related morbidity and mortality around the world. Frequently, concurrent liver dysfunction and variations in tumor burden make it difficult to design effective and standardized treatment pathways. Contemporary treatment guidelines designed for an era of personalized medicine should consider these features in a more clinically meaningful way to improve outcomes for patients across the HCC spectrum. Given the heterogeneity of HCC, we propose a detailed clinical algorithm for selecting optimal treatment using an evidence-based and practical approach, incorporating liver function, tumor burden, the extent of disease, and ultimate treatment intent, with the goal of individualizing clinical decision making.

Embolization of hemorrhage from a ruptured hepatocellular carcinoma via the false lumen of an aortic dissection using transradial access.

BACKGROUND AND AIMS: Transcatheter arterial embolization (TAE) has been repeatedly shown as an effective method of controlling acute hemorrhage. Arterial access for TAE in the emergent setting is typically trans-femoral, though other routes are routinely used. The presence of abnormal vasculature such as an aortic dissection increases the difficulty of TAE. CASE REPORT: This report details a case of acute hemorrhage likely from a ruptured hepatocellular carcinoma in which the celiac artery originated from the false lumen of a type B aortic dissection. CONCLUSION: The false lumen was catheterized via left radial artery access and the bleeding hepatic arterial branch was successfully embolized.

Congenital intrahepatic portosystemic venous shunt embolization: A two-case experience.

Congenital intrahepatic portosystemic venous shunts are rare vascular malformations which are incidentally discovered on imaging or once hepatic encephalopathy becomes clinically apparent. Surgical ligation and endovascular embolization are potential treatments.

Discovery of a spontaneous portosystemic shunt following portal vein embolization.

INTRODUCTION: Right portal vein embolization (PVE) has become a crucially important option in the minimally-invasive treatment of hepatocellular carcinoma or secondary liver malignancy before partial hepatectomy or trisegmentectomy to reduce perioperative morbidity. The main goal of PVE is to increase the volume of the future liver remnant (FLR), which can provide complete liver metabolic functionality without risk of developing posthepatectomy liver failure, also known as "small for size syndrome." PVE accomplishes this via the redirection of portal venous flow toward the left portal vein circulation resulting in an increased left hepatic lobe volume. CASE REPORT: We present a patient with a noncirrhotic liver and a previously unknown portal venous to systemic venous shunt that became apparent after a right PVE was completed. Left untreated, this shunt would have undoubtedly jeopardized the FLR volume. CONCLUSION: The presence of previously undetected portosystemic shunting is a potential cause for otherwise assumed idiopathic PVE failure, and the goal of this article is to underscore the importance of evaluating for these shunts before PVE.

Utilization of a Modified Roux-en-Y Anastomosis as an Access point for Percutaneous Transjejunal Cholangioplasty of Recurrent Biliary Strictures.

INTRODUCTION: Biliary duct injuries pose a significant management challenge due to the propensity for recurrent biliary strictures. Development of a modified Roux-en-Y hepaticojejunostomy known as a Hutson-Russell Pouch (HRP) provides a point of entry for repetitive access to the biliary tree. We aim to highlight the effectiveness of using the HRP as an access point for the long-term management of anastomotic and distal biliary strictures, thereby showcasing the value in potential widespread adoption of this modification to a standard surgical procedure. MATERIALS AND METHODS: IRB-approved retrospective study of 36 patients (10 M, 26 F; mean age 55.19 ± 13.94; 15-83) underwent a total of 110 transjejunal cholangiograms. Indications for cholangiogram included cholangitis (n = 38), surveillance (n = 36), and elevated liver enzymes (n = 36). Technical success was defined by the ability to access and intervene in the biliary tree via HRP access. In case of stenosis, the ability to successfully dilate (< 30%) residual stenosis was considered a technically successful procedure. Clinical success was defined by normalization of the liver function tests or resolution of cholangitis. RESULTS: Technical success was achieved in 83/110 (75.45%) of the cases, and clinical success was achieved in 102/110 (98.2%). Transhepatic access was needed in 27/110 (24.5%) of the cases. Interventions performed included balloon cholangioplasty in 104/110 (94.5%), biliary stone removal in 2/110 (1.8%), biliary stent placement in 2/110 (1.8%), and biliary drain placement in 4/110 (3.6%). There were a total of 9/110 complications (8.2%). CONCLUSION: The HRP was an effective access point in the management of recurrent benign biliary strictures in this cohort.