Transhepatic endovascular repair for portal vein haemorrhage.

BACKGROUND: Post-surgical bleeding of the main portal vein (PV) is a rare event but difficult to manage surgically. Among the different options of treatment, endovascular stenting of the PV can be considered. We reported two cases of stent-graft placement in PV with subsequent closure of the portal vein access with two percutaneous closure devices deployed simultaneously. CASES PRESENTATION: The first patient was a 43 years-old woman affected with a pseudoaneurysm of the extrahepatic PV, occurred after a duodenocephalopancreasectomy performed for a neuroendocrine tumour of the pancreatic isthmus. The second patient was a 54 years-old man suffering from multiple episodes of bleeding after liver transplantation, due to a PV fissure. In both cases, a stent graft was placed into the portal system, between the PV and the superior mesenteric vein through a right trans-hepatic access to the portal system. In both cases, a final control showed patency of the mesenteric vein and PV and no endoleak detection. At the end of the procedure, two percutaneous closure devices were loaded, to close the transhepatic portal access. In one case, one of the devices did not work and the entry point was managed with a single device, without further complications. No bleeding was seen though the entry point nor at the US examination performed right after the procedure. After procedure, patients were prescribed with low-molecular weight heparin (LMWH) and kept under surveillance. For both patients, CT scan performed within 24h after the procedure, showed a patent stent-graft and no evidence of any venous portal ischemia. The first patient was then transferred to another hospital, to continue observation and medical management. The second one underwent 2 months of hospitalization, during which he developed a pancreatic fistula and mild renal insufficiency. Then, he left the hospital to its native Country to continue his medical. CONCLUSION: PV stent-graft placement seems a feasible option to manage portal bleeding. Trans-hepatic access is an easy and fast approach. The trans-hepatic portal accesses may be successfully managed with the deployment of percutaneous closure devices.

Parallel Guidewire for Catheter Stabilization in Interventional Radiology: The Anchoring Wire Technique.

This technical note describes the parallel guidewire method: the anchoring technique as a strategy to ease difficult catheterization in various endovascular interventions. Sixteen patients were included in 2017 in whom this technique was used. The type of intervention, the nature of the target and anchored vessels and possible complications on the anchored vessel were reported. This study included thirteen various embolization cases and four visceral vessels angioplasties cases. The success of catheterization by using this technique was achieved in all cases, without complication on the anchored vessels.

CBCT-Based Image Guidance for Percutaneous Access: Electromagnetic Navigation Versus 3D Image Fusion with Fluoroscopy Versus Combination of Both Technologies-A Phantom Study.

PURPOSE: We set out to compare three types of three-dimensional CBCT-based imaging guidance modalities in a phantom study: image fusion with fluoroscopy (IF), electromagnetic navigation (EMN) and the association of both technologies (CEMNIF). MATERIALS AND METHODS: Four targets with a median diameter of 11 mm [first quartile (Q1): 10; third quartile (Q3): 12] with acute angle access (z-axis < 45°) and four targets of 10 mm [8-15] with large angle access (z-axis > 45°) were defined on an abdominal phantom (CIRS, Meditest, Tabuteau, France). Acute angle access targets were punctured using IF, EMN or CEMNIF and large angle access targets with EMN by four operators with various experiences. Efficacy (target reached), accuracy (distance between needle tip and target center), procedure time, radiation exposure and reproducibility were explored and compared. RESULTS: All targets were reached (100% efficacy) by all operators. For targets with acute angle access, procedure times (EMN: 265 s [236-360], IF: 292 s [260-345], CEMNIF: 320 s [240-333]) and accuracy (EMN: 3 mm [2-5], IF: 2 mm [1-3], CEMNIF: 3 mm [2-4]) were similar. Radiation exposure (EMN: 0; IF: 708 mGy.cm2 [599-1128]; CEMNIF: 51 mGy.cm2 [15-150]; p < 0.001) was significantly higher with IF than with CEMNIF and EMN. For targets with large angle access, procedure times (EMN: 345 s [259-457], CEMNIF: 425 s [340-473]; p = 0.01) and radiation exposure (EMN: 0, CEMIF: 159 mGy.cm2 [39-316]; p < 0.001) were significantly lower with EMN but with lower accuracy (EMN: 4 mm [4-6] and CEMNIF: 4 mm [3, 4]; p = 0.01). The operator's experience did not impact the tested parameters regardless of the technique. CONCLUSION: In this phantom study, EMN was not limited to acute angle targets. Efficacy and accuracy of puncture for acute angle access targets with EMN, IF or CEMNIF were similar. CEMNIF is more accurate for large angle access targets at the cost of a slightly higher procedure time and radiation exposure.

Three-dimensional Image Fusion Guidance for Transjugular Intrahepatic Portosystemic Shunt Placement.

INTRODUCTION: To assess the safety, feasibility and effectiveness of image fusion guidance with pre-procedural portal phase computed tomography with intraprocedural fluoroscopy for transjugular intrahepatic portosystemic shunt (TIPS) placement. MATERIALS AND METHODS: All consecutive cirrhotic patients presenting at our interventional unit for TIPS creation from January 2015 to January 2016 were prospectively enrolled. Procedures were performed under general anesthesia in an interventional suite equipped with flat panel detector, cone-beam computed tomography (CBCT) and image fusion technique. All TIPSs were placed under image fusion guidance. After hepatic vein catheterization, an unenhanced CBCT acquisition was performed and co-registered with the pre-procedural portal phase CT images. A virtual path between hepatic vein and portal branch was made using the virtual needle path trajectory software. Subsequently, the 3D virtual path was overlaid on 2D fluoroscopy for guidance during portal branch cannulation. Safety, feasibility, effectiveness and per-procedural data were evaluated. RESULTS: Sixteen patients (12 males; median age 56 years) were included. Procedures were technically feasible in 15 of the 16 patients (94%). One procedure was aborted due to hepatic vein catheterization failure related to severe liver distortion. No periprocedural complications occurred within 48 h of the procedure. The median dose-area product was 91 Gy cm2, fluoroscopy time 15 min, procedure time 40 min and contrast media consumption 65 mL. Clinical benefit of the TIPS placement was observed in nine patients (56%). CONCLUSION: This study suggests that 3D image fusion guidance for TIPS is feasible, safe and effective. By identifying virtual needle path, CBCT enables real-time multiplanar guidance and may facilitate TIPS placement.