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PURPOSE To evaluate the prevalence and extension of macrovascular invasion (MaVI) in a large cohort of hepatocellular carcinoma (HCC) patients and analyze the association between MaVI and overall survival (OS). METHODS From 2011 to 2018, 2540 patients with newly diagnosed HCC who were managed in our institution were enrolled in this retrospective study. Tumor invasion of the intrahepatic branches of the portal or hepatic veins was defined as peripheral MaVI. Tumor invasion of the main portal vein or inferior vena cava was defined as central MaVI. RESULTS MaVI prevalence was 16.2% (n = 411). Among patients with Barcelona Clinic Liver Cancer (BCLC) stage C and Child-Pugh class A, 165 patients presented with peripheral MaVI and 89 patients with central MaVI. The median OS was 13.2 months (95% confidence interval [CI]: 11.4-15.4) in the peripheral MaVI group and 6.6 months (95% CI: 3.6-9.5) in the central MaVI group (p

With the rise in popularity of structured reports in radiology, we sought to evaluate whether free-text CT reports on pancreatic ductal adenocarcinoma (PDAC) staging at our institute met published guidelines and assess feedback of pancreatic surgeons comparing free-text and structured report styles with the same information content. We retrospectively evaluated 298 free-text preoperative CT reports from 2015 to 2017 for the inclusion of key tumor descriptors. Two surgeons independently evaluated 50 free-text reports followed by evaluation of the same reports in a structured format using a 7-question survey to assess the usefulness and ease of information extraction. Fisher’s exact test and Chi-square test for independence were utilized for categorical responses and an independent samples t test for comparing mean ratings of report quality as rated on a 5-point Likert scale. The most commonly included descriptors in free-text reports were tumor location (99%), liver lesions (97%), and suspicious lymph nodes (97%). The most commonly excluded descriptors were variant arterial anatomy and peritoneal/omental nodularity, which were present in only 23% and 42% of the reports, respectively. For vascular involvement, a mention of the presence or absence of perivascular disease with the main portal vein was most commonly included (87%). Both surgeons’ rating of overall report quality was significantly higher for structured reports (p

To compare the safety and efficacy of integrated iodine-125 (I-125) seed implantation (sequential implantation of helical I-125 seed implant into the main portal vein and of I-125 seeds into the branch tumor thrombus directly forming main portal vein tumor thrombus (MPVTT)) combined with transarterial chemoembolization (TACE) versus TACE alone for hepatocellular carcinoma (HCC) with MPVTT. From December 2016 to January 2020, 46 HCC patients with MPVTT were analyzed. In the combination group, 21 patients received helical I-125 seed implantation in the main portal vein through a patent small portal vein branch and TACE in a single session. After 7–10 days, I-125 seeds were implanted percutaneously into the branch tumor thrombus directly forming MPVTT. In the TACE group, 25 patients received TACE alone. Thereafter, TACE was repeated as needed in both groups. Adverse events, tumor response, and overall survival (OS) of the two groups were compared. No adverse events grade ≥ 3 were observed in either group. The optimal objective response rate and disease control rate for MPVTT in the combination group and TACE group were 52.4% versus 4.0% (P

Introduction: Knowledge of the normal portal vein anatomy and its variations is imperative for various hepatic interventional procedures and liver surgeries like during creation of transjugular intrahepatic portosystemic shunt (TIPS), partial hepatectomy and Liver transplantation. Aims and Objective: The aim of our study was to determine and analyse the spectrum of variations in the main and right portal vein anatomy and their prevalence in Indian population using MDCT. Materials and Methods: Triple phase abdomen CT of 688 patients done on a 64 slice MDCT scanner between February 2012 and March 2014, were retrospectively evaluated by two radiologists independently. Out of these, 500 patients met the inclusion criteria. Axial images of portal and venous phase along with the maximum-intensity-projection and volume rendered images were reviewed and branching patterns of main and right portal vein were recorded. Results: Normal portal vein anatomy was present in 67% of the patients. Main portal vein (MPV) variations were seen in 15.2% of the patients. The most common variant was Z-type pattern (7.6%). Next common was trifurcation pattern (6.6%). Right portal vein (RPV) variations were seen in 17.8% of patients and the most common pattern was early segmental branching (6.8%). Other RPV branching variations were RPV trifurcation (3.6%), RPV quadrification (3.6%), and superior-inferior division (1.4%). Miscellaneous branching variations of RPV were seen in 2.4% of all patients. Conclusion: Variations in the main portal vein and right portal vein anatomy are quite common and can be clearly detected with MDCT. Keywords: Portal vein branching, Portal vein MDCT, MPV variation, RPV variation.

Aim This study sought to evaluate the incidence, risk factors, and clinical outcomes of portal vein thrombosis after hepatectomy. Furthermore, we proposed a novel classification and treatment strategy for portal vein thrombosis after hepatectomy. Methods We retrospectively analyzed 398 patients who underwent hepatectomy and enhanced computed tomography imaging within 14 days after surgery in our hospital from 2009 to 2019. Portal vein thrombosis was classified into three categories according to the location of the thrombus – main, hilar, and peripheral – with main portal vein thrombosis further subclassified into three grades. Each patient's treatment strategy was determined based on their portal vein thrombosis classification and grading. From 2015, enhanced computed tomography imaging was performed routinely on patients who underwent anatomical hepatectomy on postoperative day 7. Results Portal vein thrombosis was diagnosed in 57 patients (14.3%) during the study period. Multivariate analysis revealed that a Pringle maneuver time of 75 minutes or longer was a significant predictor of portal vein thrombosis (P = .012). In total, 52 patients (91%) with portal vein thrombosis recovered by surgery, anticoagulant therapy, or without specific treatment. There was no instance of mortality recorded. Conclusions Patients who undergo hepatectomy are at high risk for portal vein thrombosis, especially when the Pringle maneuver time is long. The proposed classification and treatment strategy may be useful for clinical management of patients with portal vein thrombosis after hepatectomy., Patients who undergo hepatectomy are at high risk for portal vein thrombosis, especially when the Pringle maneuver time is long. The proposed classification and treatment strategy may be useful for clinical management of patients with portal vein thrombosis after hepatectomy.

Optimal treatments for patients with advanced hepatocellular carcinoma (HCC) are still limited and their prognosis remains dismal. Yet, there have been rare cases that have shed light on longer survival in these patients assisted by various treatments. This paper aims to present an extraordinary case of far advanced HCC that had been properly managed in spite of continuous recurrence. A patient visited the hospital with a ruptured large HCC with main portal vein tumor thrombosis but survived longer than 14 years owing to active and prompt interventions. (J Liver Cancer 2020;20:148-153)

Portal Vein (PV) is a type of blood vessel that takes blood from gestational tract, gallbladder, pancreas and spleen to the liver. The liver receives its blood through PV. Portal vein ascends obliquely to the right in permitted margin of small omentum, originating behind the back of Pancreas.

Portal hypertension is a result of an increase in intrahepatic resistance in the main portal vein. The Meso-Rex shunt is used to bypass the obstructed portal vein and restore the venous flow into the liver. This procedure alleviates the need for a hepatic transplant. The Meso-Rex shunt has proven to be an effective treatment for extrahepatic portal vein obstruction, thus saving children from a complete transplant. There are variants to this bypass surgery, and sonography is commonly used to assess the condition pre- and postoperatively. In this case, the shunt was uniquely different from the typical Meso-Rex bypass surgery. Particular vasculature made it imperative for the sonographer to review the prior sonograms and review the chart information before preforming the examination. It should also be noted that sonographers must adapt the protocols to give the utmost treatment.

In recent years, three-dimensional (3-D) printing technology has become a standard tool that is used in several medical applications such as education, surgical training simulation and planning, and doctor-patient communication. Although liver surgery is ideally complemented by the use of preoperative 3-D-printed models, only a few publications have addressed this topic. We report the case of a 29-year-old Caucasian woman admitted for a Klatskin tumor infiltrating the right portal vein requiring surgery that required complex vascular reconstruction. A life-sized liver model with colorful plastic vessels and realistic looking tumor was created with the aim of planning an optimal surgical approach. According to the 3-D model, we performed a right hepatic trisectionectomy, also removing enbloc the tract of portal vein encased by the tumor and the neoplastic thrombus, followed by a complex vascular reconstruction between the main portal vein and the left portal branch. After 22 months of follow-up, the patient was alive and continuing chemotherapy. The use of the 3-D models in liver surgery helps clarify several useful preoperative issues. The accuracy of the model regarding anatomical findings was high. In the case of complex vascular reconstruction strategies, rational use of 3-D printing technology should be implemented.

In patients with complete portal vein thrombosis, the main portal vein is obstructed, resulting in development of hepatopetal collateral vessels. In cases of complete portal vein thrombosis, interventional procedures are challenging, with the greatest difficulty in the form of passing the guide wire across the level of obstruction. A recognizable main portal vein remnant has been deemed as a mandatory criterion in previous reports. Here, we report a case of cavernous trans-formation of the portal vein in a pediatric patient after liver transplant who had no obvious detectable portal vein remnant on radiologic imaging. Using digital subtraction angiography, we were successful in passing a guide wire through the level of obstruction and placing a stent, thus causing successful recanalization of the occluded segment.

Background:Advanced hepatocellular carcinoma (HCC) with Portal vein invasion has an extremely dismal prognosis. We report a rare case of advanced HCC with portal vein tumor thrombus (PVTT). First, Lenvatinib(Len) combined with Toripalimab(Tor) was treated. The patient was successfully treated with radical surgical resection after the tumor thrombus shrank. Postoperative pathology showed complete response (CR).Case presentation:A 52-year-old male patient had a massive liver cancer in his right liver, and the tumor thrombus grew to the main portal vein. He passed 4 cycles of Len combined with Tor, the tumor shrank rapidly, the level of tumor markers dropped rapidly, The tumor thrombus was successfully confined from the main portal vein to the right branch of the portal vein. Therefore, the patient underwent a right hepatectomy and successfully removed a complete PVTT. Histopathological results showed that the primary tumor and tumor thrombus were only infiltrated by inflammatory cells, and there were no viable tumor cells.Conclusions:Len combined with Tor can be used as a preoperative neoadjuvant regimen for the treatment of advanced HCC with massive macrovascular invasion.

BackgroundPatients with hepatocellular carcinoma (HCC) with main portal vein tumor thrombus (mPVTT) have poor prognosis. Promising systemic therapies, such as target therapies, have limited benefits. The purpose of this study is to retrospectively evaluate the benefits of conventional TACE (c-TACE) and to establish a prognostic stratification of HCC patients with mPVTT.MethodsThis is a single center retrospective study conducted over 5 years (duration of performing c-TACE), on consecutive HCC patients with mPVTT receiving c-TACE. Univariable and multivariable analysis were used to explore factors independently associated with overall survival (OS). Based on Cox-regression analysis, prognostic models were developed and internally validated by bootstrap methods. Discrimination and performance were measured by Akaike information criterion, concordance index, and likelihood ratio test.ResultsA total of 173 patients were included. Median OS was 6.0 months (95%CI: 3.92~8.08). The independent variables correlated with survival were largest tumor diameter, tumor number, mPVTT extension, and AFP. In the final model, patients were assigned 2 points if largest tumor diameter ≥8 cm, or tumor number ≥2, 1point if main trunk was complete obstructed, or AFP ≥400 ng/ml. By summing up these points, patients were divided into three risk groups according to the score at the 15rd and 85th percentiles, in which median OS were 18, 7, and 3.5months, respectively (pConclusionsc-TACE could provide survival benefits in HCC patients with mPVTT and the proposed prognostic stratification may help to identify good candidates for the treatment, and those for whom c-TACE may be futile.

A systematic review was conducted to provide an overview of the efficacy and safety of 125I irradiation stent placement for patients with hepatocellular carcinoma (HCC) and main portal vein tumor thrombosis (MPVTT). Six studies with 406 patients were included in the final analysis. The median overall survival for patients treated with 125I irradiation stent placement was 10.3 months. The most common radiation-related adverse event was leukopenia. The stent-related adverse events consisted of fever, abdominal pain, hemorrhage, and anorexia. No stent or seed migration was reported. Overall, the use of an 125I irradiation stent has the potential to act as an alternative therapy for patients with HCC with MPVTT.

BACKGROUND Main portal vein tumor thrombus (MPVTT), which has a high incidence, is the major complication of terminal liver cancer. The occurrence of MPVTT is always a negative prognostic factor for patients with hepatocellular carcinoma (HCC). Therefore, attention should be paid to the treatment of MPVTT and its complications. AIM To evaluate the efficacy of transarterial chemoembolization/transarterial embolization (TACE/TAE)+125I seeds implantation with transjugular intrahepatic portosystemic shunt (TIPS) in treating MPVTT and its complications. METHODS From January 2007 to March 2015, 85 consecutive patients with MPVTT were nonrandomly assigned to undergo treatment with TACE/TAE + TIPS and 125I implantation (TIPS-125I group) or TACE/TAE + TIPS only (TIPS only group) in Beijing Shijitan Hospital, and all clinical data were collected. During 24 mo follow-up, the incidence of overall survival, stent stenosis and symptom recurrence was analyzed to evaluate the efficacy of TIPS-125I. RESULTS During 24 mo follow-up of all patients, we collected data at 6, 12 and 24 mo. The rates of survival were 80%, 45%, and 20%, respectively, in the TIPS-125I group, whereas those in the TIPS only group were 64.4%, 24.4%, and 4.4%, respectively (P < 0.05). The rates of symptom recurrence were 7.5%, 22.5%, and 35%, respectively, in the TIPS-125I group, whereas those in the TIPS only group were 31.1%, 62.2%, and 82.2% (P < 0.05). The rates of stent restenosis were 12.5%, 27.5%, and 42.5%, respectively, in the TIPS-125I group, and 42.2%, 68.9%, and 84.4%, respectively, in the TIPS only group (P < 0.05). TIPS-125I was found to be significantly favorable in treating MPVTT and its complications in patients with HCC. CONCLUSION TACE/TAE+125I combined with TIPS is effective in treating MPVTT and its complications, improving quality of life of patients and reducing mortality.

The craniocaudal (CC) length of the right lobe of the liver ( RLL), liver texture, size of the main portal vein, and hemodynamics of the hepatic artery were sonographically evaluated in female diabetic and nondiabetic patients. A one-way analysis of variance, a Tukey post hoc test, and a Kruskal-Wallis with post hoc Dunn’s test were employed. Nonsymptomatic differences in liver anatomy were detected among patients with noncontrolled type 2 diabetes. They exhibited the longest CC length of the RLL ( P = .04) as well as an enlarged main portal vein ( P = .04). The hepatic artery resistive index was higher among patients with controlled type 2 diabetes ( P = .04). These differences were not attributed to fatty infiltration. Patients with noncontrolled type 2 diabetes exhibited significantly higher alanine aminotransferase, lower high-density lipoprotein cholesterol, and higher triglyceride levels than non–type 2 diabetes patients. Longitudinal sonography may provide valuable diagnostic information in the management of type 2 diabetes.

The relation between complete or partial ligation of extrahepatic portosystemic shunting and intraoperative mesenteric portovenography (IMP) was evaluated in 72 canines. Of the 72 dogs, 55 had complete ligation and 17 underwent partial ligation of abnormal vessels. IMP allowed evaluation of the number of intrahepatic portal branches and ratio of the diameter of cranial (CrPV) and caudal main portal vein (CaPV) at the shunt location. Nearly all cases in the complete ligation group and nearly half of the cases in the partial ligation group had three or more portal vein branches. CrPV/CaPV was 0.75 ± 0.24 in the complete ligation group and 0.29 ± 0.15 in the partial ligation group. CrPV/CaPV can be an effective new method for assessing IMP.

Objectives The portal vein variation type significantly affects the outcome of transplant surgery, hepatectomies, and interventional radiological procedures. To reveal variation types, especially rare types, we used high-technology multidetector computed tomography. Materials and methods We evaluated multiphase abdominal multidetector computed tomography scans of 278 consecutive patients. Multidetector computed tomography scans were processed for axial, coronal, and axial-oblique multiplane reformation and for maximum intensity projection. Variations of the main portal vein and right portal vein were simulta-neously analyzed by 2 radiologists. Prevalence of each variation and differences in sexes were investigated. Results Variant anatomy was detected in 29.5% of main portal veins and 20.9% of right portal veins. There was no statistical difference between sexes. Type 3 was reported as the most frequent variant of main portal vein, whereas type 4 was the most frequent variant of right portal vein. Some miscellaneous types were also ascertained. Conclusions Different types of anatomic variations may adversely affect the course of surgery and interventional radiological procedures. Fortunately, radiologists can now discover the critical types by using the new generation multidetector computed tomography with 3-dimensional reconstruction techniques. This information should be included in the radiology reports of patients who are scheduled for major surgery.

Recent success of systemic therapeutic agents, including combination immunotherapy, could promote a change in the treatment strategy in patients with advanced hepatocellular carcinoma (HCC). Although hepatic arterial infusion chemotherapy (HAIC) is a treatment option for advanced HCC in Japan, it is not recommended by other guidelines. We discuss the clinical benefits of HAIC compared to sorafenib. The clinical benefits of HAIC are as follows: (1) even a patient with Child–Pugh B HCC (7 or 8 points) is a candidate for HAIC (2) Child–Pugh scores barely decline with the use of HAIC compared with sorafenib (3) HAIC is highly effective in patients with vascular invasion compared with sorafenib; and (4) survival in patients receiving HAIC may not be associated with skeletal muscle volume. In contrast, the disadvantages are problems related with the reservoir system. HAIC has clinical benefits in a subpopulation of patients without extrahepatic metastasis with Child–Pugh A HCC and vascular invasion (especially primary branch invasion or main portal vein invasion) or with Child–Pugh B HCC.

The gall bladder is intimately related to the liver, hepatoduodenal ligament containing the common bile duct, proper hepatic artery and main portal vein, duodenum—pancreas and colon resulting in early and frequent involvement of these structures in gall bladder cancer. Gall bladder straddles segments IV and V of the liver, parts of which are always removed during radical resection for gall bladder cancer. Lymphatic spread occurs to cystic, pericholedochal, and pancreato-duodenal lymph nodes; celiac, superior mesenteric, and aorto-caval are distant lymph nodes.

Purpose: To perform an intra-patient comparison between a single-pass protocol (SP) and a portal venous phase (PVP) by means of both quantitative and qualitative analysis of image quality. Methods: Forty patients (31 M; 9F; aged 20–77 years; BMI 23 ± 4 Kg/m2) underwent both a SP and a PVP using a 64-rows multi-detector CT with a median interval time of 56 days (range 5–903). All patients underwent i.v. bolus injection (2.0 cc/sec) of 1.7 cc/Kg of a non ionic iodinated contrast-media (370 mgI/ml) with scan delays of 67 ± 8 and 90 s for the SP and the PVP, respectively. Signal- (SNR) and contrast-to-noise ratios (CNR) were calculated for most visceral organs and for both abdominal aorta (AA) and main portal vein (MPV). For qualitative analysis, reproduction of abdominal viscera and vascular structures was blindly evaluated and inter-observer agreement calculated by the weighted Cohen k-analysis. Results: Attenuation values (H.U.) of AA (232 ± 53 vs 180 ± 36) and MPV (215 ± 39 vs 187 ± 42) were significantly (p < 0.001) higher in the SP than in PVP, respectively. At qualitative analysis, reproduction of most abdominal viscera was also significantly sharper (p < 0.001) with the SP than the PVP with inter-observer agreement scores (k) ranging from 0.60 to 0.88 for all but one imaging criteria. Conclusions: As the SP resulted in a significantly higher vascular enhancement and in a sharper reproduction of most abdominal viscera, it may be better suited than a PVP for the CT evaluation of non traumatic acute abdomen.

Aim: To investigate the types, associated anomalies and postnatal outcomes of fetal hepatic venous system (HVS) variants by ultrasound in China.Material and methods: A large-scale and prospective investigation of HVS variants for low-risk singleton pregnant women was performed in three academic tertiary referral care centers in China. Ultrasound imaging wasused for the identification and follow-up of anatomical variants. Follow-up was conducted once every four weeks prenatally and every two months postnatally, mainly concerned on the adverse events that may appear.Results: There were 20848 cases with anatomical variants of fetal HVS identified from 46179 candidates during the study period. Following the anatomical position of variants occurring, four main divisions were present: main portal vein variants (17.9%), intrahepatic portal vein variants (21.30%), intrahepatic persistent right umbilical vein (0.27%) and hepatic vein variants (5.67%). In the fetal period, the pregnancy of all cases was normally continued, except that the pregnancy of two cases, which were associated with multiple anomalies and were terminated by their parents. After birth, approximately 99.47% of the cases with isolated variants orbeing associated no clinic significant anomalies were normally alive. Approximately 0.50% cases were associated with simple ventricular septum defect or tetralogy of Fallot and further treatment was needed.Conclusion: The anatomical variants of fetal HVS may appear as numerical, morphological or positional variants of MPV, intrahepatic PV branches, intrahepatic PRUV and HVs. The majority of cases are isolated or their associated anomalies are not clinically significant and have normal lifeafter birth.

Liver transplantation remains the main curative treatment method for hepatocellular carcinoma. There are several criteria for hepatocellular carcinoma to be eligible for liver transplantation, and it depends on main transplantation centers worldwide. Locoregional treatments and downstaging protocols are used for either to achieve these criteria or to prevent drop outs on the transplant waiting lists. But who can benefit from these bridging therapies effectively for the main purpose of curative treatment? Main contraindications are known for locoregional treatments like cirrhosis or low hepatic function, total main portal vein occlusion, and extrahepatic metastasis. HCCs, which are confined to liver but have high tumor burden, remains the main controversial issue. On this aspect, we reviewed the literature for downstaging protocols for hepatocellular carcinoma with their effect on survival and recurrence rates after liver transplantation. Although candidates for downstaging is still controversial, with the absence of main contraindications, LRT can be applied to selected HCCs, which have a certain degree of tumor burden.

Performed surgically or percutaneously, intraportal islet transplantation involves infusion of islet cells within the main portal vein or its tributaries. Percutaneous injection of islet cells is the most common method of intraportal islet transplantation and can be achieved transhepatically or transjugularly. In this chapter, we provide an overview of complications associated with intraportal delivery of islet cells and describe the different approaches to this method. In the first section, we delineate procedure-related complications of intraportal transplantation corresponding to each technique and provide up-to-date information regarding the incidence, risk factors, diagnostics, and management of each problem. Specifically, we discuss the most common complications that include bleeding, thrombosis, and iatrogenic injury to anatomical structures. In the second section, we highlight the medical complications related to intraportal islet transplantation that occur independently of technique. These include adverse events related to immunosuppressive therapy and liver pathologies such as hepatic steatosis and chronic portal hypertension.

Two cats presented with large volume ascites and the cause was suspected to be portal hypertension. On contrast CT they both showed enhancement of the main portal vein during the arterial phase and an anomalous connection between the celiac artery and extrahepatic portal vasculature, prompting a diagnosis of extrahepatic arterioportal fistula. An extrahepatic arterioportal fistula is a connection between any artery and the portal vein outside the liver and, to our knowledge, this is the first report in cats.

Hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) is a disease that is not uncommon, but the treatments vary drastically between Eastern and Western countries. In Europe and America, the first line of treatment is systemic therapy such as sorafenib and the surgical treatment is not a recommend option. While an increasing number of studies from China and Japan have suggested that surgical treatment results in better outcomes when compared to transcatheter arterial chemoembolization (TACE), sorafenib, or other nonsurgical treatments, and two classification systems, Japanese Vp classification and Chinese Cheng's classification, were very useful to guide the surgical treatment. We have also found that surgical treatment may be more effective, as we have performed surgical treatment for HCC-PVTT patients over a period of approximately 15 years and achieved good results with the longest surviving time being 13 years and onward. In this study, we review the efficacy and principles of current surgical treatments and introduce our new, more effective surgical technique named "thrombectomy first", which means the tumor thrombus in the main portal vein, the bifurcation or the contralateral portal vein should be removed prior to liver resection. Thus, compression and crushing of PVTT during the operation could be avoided and new intrahepatic metastases caused by tumor thrombus to the remnant liver minimized. The new technique is even beneficial to the prognosis of Cheng's classification Types III and IV PVTT. The vital tips and tricks for the surgical approach are described.

Introduction To evaluate the hepatic arterial, bile duct and portal venous anatomy as applicable to major liver resections. Methods The study was conducted on 100 formalin fixed adult cadaveric livers. The hepatic arterial, bile ductal and portal venous anatomy of the liver was dissected from their origin up to their segmental branching. Left and right hemilivers were compared with regard to the single and multiple vascular or biliary pedicles entering their respective hemilivers. Results The anatomy of all the three structures, ie., hepatic artery, bile duct and portal vein were conventional in 39% and variant, i.e., “triple” anomaly in 4% of liver specimens. In 57% liver specimens, the anatomy of one or two structures was variant and individual variation of hepatic artery, bile duct and portal vein anatomy was observed in 34%, 42% and 14% of livers respectively. The anatomy of hepatic artery was classified according to the Michels classification. In 9% of livers, rare variations not included in Michels classification was found. The drainage pattern of bile ducts was grouped according to Blumgart’s classification. In 11% of livers, rare variations not included in Blumgart’s classification were found. The branching pattern of main portal vein was classified according to the Akgul’s classification. In 1% of livers, rare variations in the right portal vein were found. Discussion In the present study, the vasculobiliary anatomies of liver were highly complex with the existence of many anatomic variations. The increasing complexity of hepatic surgical procedures necessitates appropriate knowledge of these anatomic variations.

Background and aims Endovascular implantation of iodine-125 (125I) seeds strand combined with stent is an effective method of treatment for portal vein tumor thrombosis. The aim of this study was to develop a novel endovascular brachytherapy stent (EVB-Stent) and to evaluate its feasibility of use. Methods An EVB-Stent was implanted into the main portal vein (MPV) in a live porcine model via the percutaneous transhepatic route. Blood samples were collected and tested before and after operation, as well as before euthanasia. Single-photon emission computed tomography (SPECT) combined with CT (SPECT/CT) scan were performed directly after operation and CT scan was performed 2 months after implantation. After the CT scan was performed, all animals were euthanized and histologically examined. Results The novel stent was successfully positioned in all six pigs. No deterioration of liver function was observed during the 2-month follow-up period. SPECT/CT revealed the uniform distribution of radiation around the seeds strand, and the hottest spot was near the center of the MPV. The patency of the stented MPV was confirmed using CT scans. The tissue-accumulated absorbed dose was 31,822.11 mGy at 10 mm transversely away from the midpoint of the 125I seeds strand, with a half-life of 59.4 days. Pathological examination results showed no significant atrophy or inflammation of adjunct liver tissue, and no obvious intima thickening or thrombosis were detected in the stented MPV. Conclusions A liver porcine model was used to demonstrate that the transhepatic placement of a novel endovascular brachytherapy stent, EVB-Stent, is both technically feasible and safe.

Background: An intimate knowledge and awareness of branching patterns of main portal vein is necessary before hepatic surgeries. The presence of portal vein variants increases the risk of bile duct hilar anatomical variations also. This information may be of help for accurate radiological interpretation, to prevent complications like hemorrhage, difficult anastomosis in the recipient, ischemia in the graft and allograft failure at the time of liver transplantation. Hence the present study was conducted with the objective of observing the branching pattern of the main portal vein, to measure length of right portal vein and angle between right and left portal vein. Material and Methods: The present study was conducted on 84 liver specimens of human cadavers fixed with 5% formalin, collected from the Department of Anatomy and Forensic Medicine, MMC&RI, Mysore. The parameters were measured using image J software. Results: Bifurcation of main portal vein was seen in 75 liver specimens [89.3%]. Trifurcation of main portal vein was seen in 9 specimens [ 10.7%]. Mean angle between Right and left portal vein was 146.7°. Mean length of right portal vein was 2.27 cm. Conclusion: Knowledge of portal vein variations is critically significant in surgical resection and transplantation procedures. Resection of any portion of liver should be well planned and clear identification of sub segments of liver is necessary before surgery. Surgeons and radiologists must have a thorough understanding of variants in portal vein anatomy in order to prevent injury to portal vein and for successful radiological interventions.

// Tian-Zhu Yu 1, 2, * , Wen Zhang 1, 2, * , Qing-Xin Liu 1, 2, * , Wen-Hui Li 4, * , Jing-Qin Ma 1, 2 , Zi-Han Zhang 1, 2 , Min-Jie Yang 1, 2 , Jian-Hua Wang 1, 2 , Bing Chen 3 , Shao-Chong Zeng 3 , Jian-Jun Luo 1, 2 , Ling-Xiao Liu 1, 2 , Zhi-Ping Yan 1, 2 1 Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China 2 Shanghai Institute of Medical Imaging, Shanghai, China 3 Department of Radiotherapy, Zhongshan Hospital, Fudan University, Shanghai, China 4 Department of Interventional Radiology, Yancheng Third People’s Hospital, Southeast University, Yancheng, China * These authors have contributed equally to this work Correspondence to: Jian-Jun Luo, email: Luo.jianjun@zs-hospital.sh.cn Ling-Xiao Liu, email: Liu.lingxiao@zs-hospital.sh.cn Zhi-Ping Yan, email: Yan.zhiping@zs-hospital.sh.cn Keywords: hepatocellular carcinoma, main portal vein, tumor thrombus, endovascular brachytherapy, three-dimensional conformal radiotherapy Received: October 20, 2016 Accepted: December 27, 2016 Published: January 05, 2017 ABSTRACT Hepatocellular carcinoma (HCC) patients with main portal vein tumor thrombus have a median survival time of only about 4 months. We therefore compared the safety and efficacy of endovascular brachytherapy (EVBT) and sequential three-dimensional conformal radiotherapy (3-DCRT). From a cohort of 176 patients, we treated 123 with EVBT using iodine-125 seed strands (group A) and the remaining 53 with sequential 3-DCRT (group B). Overall survival, progression free survival and stent patency characteristics were compared between the two groups. Our analysis demonstrated a median survival of 11.7 ± 1.2 months in group A versus 9.5 ± 1.8 months in group B ( p = 0.002). The median progression free survival was 5.3 ± 0.7 months in groupA versus 4.4 ± 0.4 months in group B ( p = 0.010). The median stent patency period was 10.3 ± 1.1 months in group A versus 8.7 ± 0.7 months in group B ( p = 0.003). Therefore, as compared to sequential 3-DCRT, EVBT combined with portal vein stenting and TACE improved overall survival of HCC patients with main portal vein tumor thrombus.

OBJECTIVE. The purpose of this article is to evaluate the radiologic findings predicting the future liver remnant hypertrophy ratio after portal vein embolization of the right branch. MATERIALS AND METHODS. The associations between the radiologic findings and the future liver remnant hypertrophy ratio for 79 patients who underwent portal vein embolization of the right branch between July 2007 and April 2017 were retrospectively analyzed. Multiple linear regression was performed to adjust for potential confounders, and the volume ratio of the right lobe anterior segment, number of proximal small branches from the right anterior and posterior portal veins, transient hepatic parenchymal enhancement, portal vein invasion, and variants of main portal vein anatomy were evaluated. The potential confounders were age, ratio of future liver remnant hypertrophy to total liver volume, indocyanine green clearance rate, maximum serum total bilirubin before portal vein embolization, and history of chemotherapy. RESULTS. Statistically significant associations were found between the future liver remnant hypertrophy ratio and the number of proximal small branches from the right anterior and posterior portal veins (p < 0.001), transient hepatic parenchymal enhancement (p < 0.001), portal vein invasion (p = 0.017), and variants of main portal vein anatomy (p = 0.048). The mean future liver remnant hypertrophy rate was 51.0% (n = 16) in patients without the radiologic findings showing statistically significant differences, and 25.8% (n = 63) in patients with at least one significant finding. CONCLUSION. When added to previously reported factors, the radiologic findings identified can help determine the indications for portal vein embolization and novel strategies for major hepatectomy.

SUMMARY: In the prenatal period, the three types of connections between the portal sinus and main portal vein have been published in the literature: T, X and H-shaped. The T type is the most frequent in the literature, and the aim of our study is to define the percentage of the connection types during the prenatal period in our population. In this prospective study, 237 women between 20 and 38 weeks of pregnancy without a foetal anomaly or pregnancy-related complications were included, and the precordial veins of the foetuses were examined using a wide-band color Doppler technique. The types of connections were determined by two specialists according to the shape of the colour coded vessels in Doppler examinations. The criteria of Czubalski & Aleksandrowicz (2000) were used. All of the connection types in patients were confirmed using video clips and were stored in the picture archiving and communication system. In 237 patients, the types of connection were determined by the first specialist as 189 foetuses (79.7 %) with the X-shaped or side-to-side connection, 16 foetuses (6.8 %) with the T-shaped or end-to-side type and 32 foetuses (13.5 %) with the H-shaped or parallel-coursed vessels connected with a short segment. The most common types of connections between the portal sinus and main portal vein in foetuses are X shaped or side-to-side, which is contrary to previous studies.

To investigate the imaging findings and hepatic artery variations encountered in patients with aberrant left gastric vein (ALGV). A retrospective database search between January 2014 and November 2018 was carried for ALGV. The course and types (1–3) of ALGV, the presence of associated liver lesions, and coexistence of hepatic artery variations were reviewed on CT images. A total of 32 patients (22 men, 68.7%) with a mean age of 52.5 years (range 22–76 years) were found to have ALGV. The prevalence of ALGV was 0.073%. The most frequent type of ALGV was type 1 (n = 22, 68.7%), followed by type 3 (n = 7, 21.8%) and type 2 (n = 3, 9.3%). We noticed mild-to-severe parenchymal hyperdensity at the posterior aspect of segments II and III in patients with type 1 (n = 20/22) and type 2 (n = 2/3) ALGV consistent with fat sparing due to third inflow effect. Two out of seven patients with type 3 ALGV had main portal vein thrombosis; however, the presence of ALGV maintained left portal vein flow in these patients. Twelve (37.5%) patients had accompanying hepatic artery variation. Left hepatic and right hepatic artery variations were detected in 8 (25%) and 2 (6.25%) of the patients, respectively. In 2 patients, Michels type IV variation was detected. Aberrant left gastric vein is associated with hepatic artery variations, which can be important for preoperative and pretransplant planning.

To investigate the feasibility and safety of a helical iodine-125 (I-125) seed implant combined with transcatheter arterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC) with main portal vein tumor thrombus (MPVTT). From December 2016 to February 2018, 26 cases of HCC with MPVTT patients were enrolled in this prospective study. Helical I-125 seed implants were placed into the portal vein through the percutaneous transhepatic route. Subsequently, TACE was performed. Follow-up with enhanced CT was performed every 6–8 weeks and TACE was repeated if the residual or recurrent tumor was found. Treatment response was measured with the modified response evaluation criteria in solid tumors. Complication rates and overall survival were also evaluated. Implantation and TACE were successful in all patients. There were no grade ≥ 3 complications observed in the patients. The objective response rates (ORR) and disease control rates (DCR) of MPVTT at 3 months after implantation were 42.3% and 84.6%, respectively, whereas ORR and DCR of the liver lesions were 34.6% and 46.2%, respectively. The median overall survival was 10.7 months (95% CI 6.2–15.2 months). Helical I-125 seed implants can be safely placed into the human main portal vein. Helical I-125 seed implants combined with TACE for HCC with MPVTT are safe and feasible.

To explore the feasibility of reducing radiation dose and improving image quality in CT portal venography (CTPV) using 80 kV and adaptive statistical iterative reconstruction-V(ASIR-V) in slender patients in comparison with conventional protocol using 120 kV and ASIR.Sixty slender patients for enhanced abdominal CT scanning were randomly divided into group A and group B. Group A used the conventional 120 kV tube voltage, 600 mgI/kg contrast dose and reconstructed with the recommended 40% ASIR. Group B used 80 kV tube voltage, 350 mgI/kg contrast dose and reconstructed with ASIR-V from 40% to 100% with 10% interval. The CT values and standard deviation (SD) values of the main portal vein, left branch, and right branch of portal vein, liver, and erector spinae at the same level were measured to calculate the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR). The image quality was subjectively scored by two experienced radiologists blindly using a 5-point criterion. The contrast dose, volumetric CT dose index, and dose length product were recorded in both groups and the effective dose was calculated.There was no significant difference in general data between the two groups (p0.05), the effective dose and contrast dose in group B were reduced by 63.3% (p0.001) and 39.7% (p0.001), respectively compared with group A. With the percentage of ASIR-V increased in group B, the CT values showed no significant difference, while the SD values gradually decreased and SNR values and CNR values increased accordingly. Compared with group A, group B demonstrated similar CT values (p0.05), while the SD values with 80% ASIR-V to 100% ASIR-V were significantly lower than those of 40% ASIR (p0.001), and the SNR values and CNR values with 70% ASIR-V to 100% ASIR-V were significantly higher than those of 40% ASIR (p0.001). The subjective image quality scores by the two radiologists had excellent consistency (kappa value0.75, p0.001), and the final subjective image quality scores and the subjective scores in each of the 5 scoring categories with 60% ASIR-V to 100% ASIR-V were all significantly higher than those of 40% ASIR, and 80% ASIR-V obtained the highest subjective score among different reconstructions.In CTPV, the application of 80 kV and ASIR-V reconstruction in slender patients can significantly reduce radiation dose (by 63.3%) and contrast agent dose (by 39.7%). Compared with the recommended 40% ASIR using 120 kV, ASIR-V with 80% to 100% percentages can further improve image quality and with 80% ASIR-V being the best reconstruction algorithm.CTPV with 80 kV and ASIR-V algorithm in slender patients can significantly reduce radiation dose and contrast agent dose as well as improve image quality, compared with the conventional 120 kV protocol using 40% ASIR.

OBJECTIVE To determine the mean diameter of the main portal vein (PV) in healthy dogs by use of CT angiography, identify any associations between PV diameter and certain dog characteristics, and validate a clinically valuable ratio for quantifying the size of the PV. ANIMALS 100 dogs with no hepatic, cardiac, or vascular anomalies that underwent abdominal CT angiography. PROCEDURES Diameters of the main PV, abdominal aorta (Ao), and caudal vena cava (CVC) were measured by 2 observers at a defined location on postcontrast CT angiographic images in axial, sagittal, and transverse planes. Dog characteristics were evaluated for associations with PV diameter, and a PV:Ao diameter ratio was calculated. Intraclass correlations were calculated to assess intra- and interobserver agreement in vessel diameter measurements. RESULTS Mean diameter values were 7.9 mm (range, 4.1 to 14.8 mm) for the PV, 8.9 mm (range, 3.7 to 13.7 mm) for the Ao, and 11.4 mm (range, 4.4 to 22.5 mm) for the CVC. The PV:Ao diameter ratio was 0.91 mm. The PV diameter was significantly associated with dog body weight but not with dog age, sex, or neuter status. Intra- and interobserver reliabilities for measurements of all 3 vessels were considered excellent (intraclass correlation coefficients > 0.85). CONCLUSIONS AND CLINICAL RELEVANCE Findings indicated that the PV:Ao diameter ratio was a repeatable measurement that may be useful for evaluating the size of the portal vasculature in dogs and possibly for distinguishing healthy PVs from abnormal PVs in dogs with hepatic vascular anomalies.

We determined mean main portal vein diameter in healthy patients evaluated with CT, compared this value to the “upper limit of normal” reported previously, and evaluated effects of age, sex, height, and BMI on portal vein diameter. Our cohort of healthy patients underwent abdominal CT as potential renal donors. We excluded patients with evidence of liver or severe cardiac disease. We recorded patients’ age, sex, height, weight, and BMI. Patients’ main portal vein diameters were measured by fellowship-trained abdominal imagers on non-contrast and post-contrast images in axial and coronal projections at a defined location. A general linear mixed model was used for analysis. 191 patients with 679 main portal vein measurements were included in the analysis. Mean main portal vein diameter was 15.5 ± 1.9 mm; this value was significantly different from the upper limit of normal of 13 mm commonly referenced in the literature (95% CI: 2.22–2.69 mm higher, p