Search

Background: Cavernous transformation of the portal vein (CTPV) due to portal vein obstruction is a rare vascular anomaly defined as the formation of multiple collateral vessels in the hepatic hilum. This study aimed to investigate the imaging features of intrahepatic portal vein in adult patients with CTPV and establish the relationship between the manifestations of intrahepatic portal vein and the progression of CTPV., Methods: We retrospectively analyzed 14 CTPV patients in Beijing Tsinghua Changgung Hospital. All patients underwent both direct portal venography (DPV) and computed tomography angiography (CTA) to reveal the manifestations of the portal venous system. The vessels measured included the left portal vein (LPV), right portal vein (RPV), main portal vein (MPV) and the portal vein bifurcation (PVB)., Results: Nine males and 5 females, with a median age of 40.5 years, were included in the study. No significant difference was found in the diameters of the LPV or RPV measured by DPV and CTA. The visualization in terms of LPV, RPV and PVB measured by DPV was higher than that by CTA. There was a significant association between LPV/RPV and PVB/MPV in term of visibility revealed with DPV (P = 0.01), while this association was not observed with CTA. According to the imaging features of the portal vein measured by DPV, CTPV was classified into three categories to facilitate the diagnosis and treatment., Conclusions: DPV was more accurate than CTA for revealing the course of the intrahepatic portal vein in patients with CTPV. The classification of CTPV, that originated from the imaging features of the portal vein revealed by DPV, may provide a new perspective for the diagnosis and treatment of CTPV., (Copyright © 2023 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved.)

Background: Meso-Rex bypass is the surgical intervention of choice for children with extrahepatic portal vein obstruction (EHPVO). Patency of Rex vein, umbilical recessus of the portal vein, is a prerequisite for this surgery. Conventional diagnostic modalities poorly detect patency, while transjugular wedged hepatic vein portography (WHVP) accurately detects patency in 90%., Objectives: We aimed to assess Rex vein patency and portal vein branching pattern in children with EHPVO using transjugular WHVP and to identify factors associated with Rex vein patency., Methods: Transjugular WHVP was performed in 31 children with EHPVO by selective cannulation of left and right hepatic veins. Rex vein patency, type of intrahepatic portal venous anatomy (Types A-E), and factors associated with patency of Rex vein were studied., Results: The patency of Rex recess on transjugular WHVP was 29%. Complete obliteration of intrahepatic portal venous radicles was the commonest pattern (Type E, 38.7%) while Type A, the favorable anatomy for meso-Rex bypass, was seen in only 12.9%. Patency of the Rex vein, but not the anatomical pattern, was associated with younger age at evaluation (patent Rex: 6.6 ± 4.9 years vs. nonpatent Rex: 12.7 ± 3.9 years, p = 0.001). Under-5-year children had a 12 times greater chance of having a patent Rex vein (odds ratio: 12.22, 95% confidence interval: 1.65-90.40, p = 0.004). Patency or pattern was unrelated to local factors like umbilical vein catheterization, systemic thrombophilia, or disease severity., Conclusion: Less than one-third of our pediatric EHPVO patients have a patent Rex vein. Younger age at evaluation is significantly associated with Rex vein patency., (© 2024 European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Background: Targeted puncture of an appropriate portal venous branch during transjugular intrahepatic portosystemic shunt (TIPS) procedure may reduce the risk of postprocedural overt hepatic encephalopathy (HE). This study aimed to describe blood distribution under portography and combined it with puncture site to determine portal flow diversion, and to evaluate its prognostic value in predicting post-TIPS overt HE., Methods: In this retrospective analysis of patients with cirrhosis undergoing TIPS, we included 252 patients to describe blood distribution under portography and 243 patients to assess the association between portal flow diversion and post-TIPS overt HE., Results: At the first stage, 51 (20.2%) patients were identified as type A (unilateral type with the right portal branch receives blood from splenic vein [SV]), 16 (6.4%) as type B (unilateral type with the right branch receives blood from superior mesenteric vein [SMV]) and 185 (73.4%) as type C (fully mixed type). At the second stage, 40 patients were divided into the SV group, 25 into the SMV group and 178 into the mixed group. Compared with the mixed group, the risk of post-TIPS overt HE was significantly higher in the SMV group (adjusted HR 3.70 [95% CI 2.01-6.80]; p < 0.001), whereas the SV group showed a non-significantly decreased risk (adjusted HR 0.57 [95% CI 0.22-1.48]; p = 0.25). Additionally, the SMV group showed a substantial increase in ammonia level at 3 days and 1 month after procedure., Conclusions: Our results support the clinical use of portal flow diversion for risk stratification and decision-making in the management of post-TIPS overt HE., (© 2022. The Author(s).)

Intra-abdominal thromboses are a poorly characterised thrombotic complication of COVID-19 and are illustrated in this case. A 42-year-old man with chronic hepatitis B (undetectable viral load, FibroScan 7.4 kPa) developed fever and cough in March 2020. 14 days later, he developed right upper quadrant pain. After being discharged with reassurance, he re-presented with worsening pain on symptom day 25. Subsequent abdominal ultrasound suggested portal vein thrombosis. CT of the abdomen confirmed portal and mid-superior mesenteric vein thromboses. Concurrent CT of the chest suggested COVID-19 infection. While reverse transcription PCR was negative, subsequent antibody serology was positive. Thrombophilia screen excluded inherited and acquired thrombophilia. Having been commenced on apixaban 5 mg two times per day, he is currently asymptomatic. This is the first case of COVID-19-related portomesenteric thrombosis described in the UK. A recent meta-analysis suggests 9.2% of COVID-19 cases develop abdominal pain. Threshold for performing abdominal imaging must be lower to avoid this reversible complication., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Computed tomography arterial portography (CTAP) is widely used with a fixed scan timing and contrast medium quantity; however, these parameters are not necessarily optimal. In this study, CTAP scan timing was analyzed by different bolus tracking methods to monitor the inflow of the contrast medium in real-time. A total of 249 patients who underwent CTAP were assessed. In 30 patients, the CTAP scanning began 33 s after contrast medium injection started (fixed method). In 74 patients, the regions of interest (ROIs) were established at two places in the inferior vena cava above the hepatic vein (inferior vena cava-ROI method). In 145 patients, the ROI was established at two places in the liver parenchyma (liver parenchyma-ROI method). Scan timing was considered appropriate when the difference in the CT value between the hepatic and portal veins approached 0; this was observed significantly more with the liver parenchyma-ROI method than with the other methods. CTAP scan timing with the liver parenchyma-ROI method was better than that with the fixed and inferior vena cava-ROI methods.

Background: Mesenteric angiography is a sensitive method for visualizing portal perfusion in the dog., Objectives: To evaluate hepatic portal perfusion in dogs with incompletely resectable hepatic tumors using mesenteric angiography., Animals: Five client-owned dogs with incompletely resectable hepatic tumors evaluated with mesenteric angiography., Methods: Retrospective case series. Electronic medical records at the Animal Medical Center were analyzed to identify dogs that underwent mesenteric portography to determine blood flow to nonresectable hepatic tumors and subsequently determine ideal routes for transarterial embolization, vascular stent placement, or both. The images obtained from mesenteric angiography were analyzed and compared to those obtained from computed tomography angiography., Results: Portography was accomplished using direct mesenteric venography in 3 dogs with hepatocellular carcinoma (HCC), cranial mesenteric arteriography in 1 dog with hepatic adenoma or well-differentiated HCC, and via splenic arteriovenous fistula in 1 dog with diffuse hepatic hemangiosarcoma metastases. Mean pixel densities in areas of hepatic tumor growth identified statistically significant decreases in portal blood flow (P = .02) compared to normal hepatic parenchyma., Conclusions and Clinical Importance: Initial findings indicate that the blood supply to large and metastatic hepatic tumors in dogs may correlate with that in humans, such that the majority of the tumor blood supply arises from the hepatic artery and not the portal vein. Differences in blood supply between normal hepatic parenchyma and hepatic tumors might be exploited by developing selective tumor therapies such as arterial embolization or chemoembolization that largely spare normal liver tissue. Further investigation is warranted., (© 2018 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.)

Purpose: Portal vein (PV) embolization (PVE) is traditionally performed via a PV sheath with selective embolization of PV branches. Here, the efficacy and safety of PVE with the use of only an 18-gauge needle is reported., Materials and Methods: Consecutive patients who underwent PVE from 2009 through 2017 were retrospectively reviewed. Forty-five patients (mean age, 60 y ± 7.6; 38 men) underwent 45 PVE procedures. Hepatocellular carcinoma, cholangiocarcinoma, and metastases accounted for 26 (58%), 13 (29%), and 6 (13%) patients, respectively. PVE was performed by puncturing a branch of right PV with an 18-gauge needle under US guidance. Via the same needle, direct portography was performed, followed by PVE with an N-butyl cyanoacrylate/Lipiodol mixture. Percentage increase of future liver remnant (FLR) volume and increase in ratio of FLR to total liver volume were estimated as measures of efficacy. Complications were reported according to Society of Interventional Radiology classification. Fluoroscopy time, procedure time, and dose-area product (DAP) were recorded., Results: Technical success rate was 100%. The median DAP, fluoroscopy time, and procedure time were 74,387 mGy·cm 2 (IQR, 90,349 mGy·cm 2 ), 3.5 min (IQR, 2.10 min), and 24 min (IQR, 10.5 min). Among the 23 patients with complete CT volumetry data, mean increase in the ratio of FLR to total liver volume and percentage increase of FLR volume were 12.5% ± 7.7 and 50% ± 33, respectively. There were 3 minor complications (asymptomatic nonocclusive emboli in FLR) and 3 major complications (1 hepatic vein emboli, 1 subphrenic collection, and 1 hepatic infarct)., Conclusions: PVE via a sheathless 18-gauge needle approach is feasible, with satisfactory FLR hypertrophy., (Copyright © 2019. Published by Elsevier Inc.)

This study is to investigate the computed tomography (CT) image quality of the low- tube-voltage protocol with low contrast agent dose.CT portography was performed in 118 cirrhosis patients with body mass index (BMI) less than 25 kg/m under 2 protocols: Protocol A, tube voltage of 90 kVp/395 mAs and contrast agent dosage of 1.2 mL/kg, and, Protocol B, tube voltage of 120 kVp/200 mAs and contrast agent dosage of 1.5 mL/kg.The number of patients in each protocol was 59. The CT value noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) in portal veins was comparatively analyzed between the 2 protocols. The subjective image quality was further assessed on 5-point scales. Radiation dose was also recorded and statistical analysis was performed.The CT value, CNR, and SNR of the images were higher at 90 kVp than those at 120 kVp (P < .05). There was no significant difference in image noise between the 2 protocols (P > .05). The CT dose index volume, dose-length product, and effective dose at 90 kVp were 18.2%, 16.0%, and 16.0% less than that at 120 kVp, respectively. There was no difference in image quality score between the 2 protocols (P > .05). The average amount of contrast agent was decreased by 17.8% when the 90 kVp protocol was used.CT portography at 90 kVp combined with low-dosage contrast agent leads to a significant reduction in radiation dose and improved SNR and CNR, without deterioration of image quality.

Background: Data regarding transsplenic portal venous access for diagnostic imaging and endovascular intervention in children are limited, possibly due to concerns regarding high bleeding risks and resultant underutilization., Objective: To investigate the safety and utility of transsplenic splenoportography and portal venous interventions in children., Materials and Methods: A retrospective review was performed of all pediatric patients undergoing percutaneous transsplenic portal venous access and intervention at two large tertiary pediatric institutions between January 2012 and April 2017 was performed. Parameters assessed included procedural indications, procedural and relevant prior imaging, technical details of the procedures, laboratory values and clinical follow-up., Results: Transsplenic portal venous access was achieved in all patients. Diagnostic transsplenic splenoportography was performed in 22 patients and was 100% successful at providing the desired anatomical and functional information. Four transsplenic portal venous interventions were performed with 100% success: meso-Rex shunt angioplasty, snare targeted transjugular intrahepatic portosystemic shunt (TIPS) creation through cavernous transformation, pharmacomechanical thrombectomy for acute thrombosis, and transplant portal vein angioplasty. Intraperitoneal bleeding occurred in 2/26 (7.7%) and one case required transfusion (3.8%). No cases of hemorrhage were observed when transsplenic access size was 4 Fr or smaller., Conclusion: Transsplenic splenoportography in children is safe and effective when noninvasive imaging methods have yielded incomplete information. Additionally, a transsplenic approach has advantages for complex portal interventions. Bleeding risks are proportional to tract access size and may be mitigated by tract embolization.

Objectives: The blind portal vein puncture remains the most challenging step during transjugular intrahepatic portosystemic shunt (TIPS) creation. We performed a prospective randomised clinical trial to compare three-dimensional (3D) roadmap with CO 2 wedged hepatic vein portography for portal vein puncture guidance., Methods: Between March 2017 and May 2017, 30 patients were enrolled and randomly allocated to the study group (3D roadmap) or the control group (CO 2 wedged hepatic vein portography)., Results: Technical success of TIPS procedures was achieved in all 30 patients. The mean number of needle passes was significantly lower in the study group (2.0 ± 1.0) compared to the control group (3.7 ± 2.5; p = 0.021). A total of six (40%) patients in the study group and three (20%) in the control group required only one puncture for the establishment of TIPS. There were no significant differences in total fluoroscopy time (p = 0.905), total procedure time (p = 0.199) and dose-area product (p = 0.870) between the two groups., Conclusions: 3D roadmap is a safe and technically feasible means for portal vein puncture guidance during TIPS creation, equivalent in efficacy to CO 2 wedged hepatic vein portography. This technique could reduce the number of needle passes, thereby simplifying the TIPS procedure., Key Points: • 3D roadmap can be used to guide portal vein puncture. • Compared with CO 2 venography, 3D roadmap reduced the number of needle passes. • 3D roadmap has a potential to simplify the TIPS procedure.

Background: Superior mesenteric vein-portal vein confluence resection combined with pancreatoduodenectomy (SMPVrPD) is occasionally required for resection of pancreatic head tumors. It remains unclear whether such situations require splenic vein (SV) reconstruction for decompression of left-sided portal hypertension (LSPH)., Methods: The data from 93 of 104 patients who underwent pancreatoduodenectomy (PD) for pancreatic head malignancies were reviewed. Surgical outcomes in three groups-standard PD (control group), PD combined with vascular resection and SV preservation (SVp group), and SMPVrPD with SV resection (SVr group)-were compared. The influence of division and preservation of the two natural confluences (left gastric vein-portal vein and/or inferior mesenteric vein-SV confluences) on portal hemodynamics were evaluated using three-dimensional computed tomographic portography., Results: No mortality occurred. The morbidity rates were not significantly different among the three groups (18/43, 8/21, and 7/29, respectively; p = 0.306). In the SVr group, three patients had gastric remnant venous congestion, and three had esophageal varices without hemorrhagic potential. No patients had splenomegaly, or severe or prolonged thrombocytopenia. These LSPH-associated findings were less frequently observed when the two confluences were preserved., Conclusions: SMPVrPD without SV reconstruction can be safely conducted. Additionally, preservation of these two confluences may reduce the risk of LSPH., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Objectives: We present a patient with portal vein thrombosis due to chronic cholangitis after undergoing a living-donor liver transplant., Case Presentation: A 52-year-old woman with a history of hepatitis B virus-related liver cirrhosis underwent a living-donor liver transplant. After the surgery, the patient had recurrent episodes of cholangitis because of common and intrahepatic bile duct stricture. Biliary stricture because of cholangitis eventually resulted in acute portal vein thrombosis. A stent was inserted by percutaneous transluminal portography. Blood flow through the portal vein progressively improved from the third through the 10th day after stent placement. The anticoagulation regimen was change to acetylsalicylic acid and clopidogrel hydrogen sulfate (Plavix). On poststenting day 10, a follow-up computed tomographic scan showed good patency of the main portal vein and no evidence of arterioportal shunting., Conclusions: Cholangitis after living-donor liver transplant is a rare cause of portal vein thrombosis. Regular follow-up examinations with color Doppler ultrasound are required to monitor portal vein flow in patients with biliary complications after living-donor liver transplant.

Background: Portal vein embolization is performed weeks before extended hepatic resections to increase the future liver remnant and prevent posthepatectomy liver failure. Portal vein embolization performed closer to the operation also could be protective, but worsening of portal hyper-perfusion is a major concern. We determined the hepatic hemodynamic effects of a portal vein embolization performed 24 hours prior to hepatic operation., Methods: An extended (90%) hepatectomy was performed in swine undergoing (portal vein embolization) or not undergoing (control) a portal vein embolization 24 hours earlier (n = 10/group). Blood tests, hepatic and systemic hemodynamics, hepatic function (plasma disappearance rate of indocyanine green), liver histology, and volumetry (computed tomographic scanning) were assessed before and after the hepatectomy. Hepatocyte proliferating cell nuclear antigen expression and hepatic gene expression also were evaluated., Results: Swine in the control and portal vein embolization groups maintained stable systemic hemodynamics and developed similar increases of portal blood flow (302 ± 72% vs 486 ± 92%, P = .13). Portal pressure drastically increased in Controls (from 9.4 ± 1.3 mm Hg to 20.9 ± 1.4 mm Hg, P < .001), while being markedly attenuated in the portal vein embolization group (from 11.4 ± 1.5 mm Hg to 16.1 ± 1.3 mm Hg, P = .061). The procedure also improved the preservation of the hepatic artery blood flow, liver function, and periportal edema. These effects occurred in the absence of hepatocyte proliferation or hepatic growth and were associated with the induction of the vasoprotective gene Klf2., Conclusion: Portal vein embolization preconditioning represents a potential hepato-protective strategy for extended hepatic resections. Further preclinical studies should assess its medium-term effects, including survival. Our study also supports the relevance of hepatic hemodynamics as the main pathogenetic factor of post-hepatectomy liver failure., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To investigate the prevalence and site of origin of extrahepatic arteries originating from hepatic arteries on early phase CT during hepatic arteriography (CTHA) was accessed. Visualization of these elements on digital subtraction hepatic angiography (DSHA) was assessed using CTHA images as a gold standard., Materials and Methods: A total of 943 patients (mean age 66.9 ± 10.3 years; male/female, 619/324) underwent CTHA and DSHA. The prevalence and site of origin of extrahepatic arteries were accessed using CTHA and visualized using DSHA., Results: In 924 (98.0%) patients, a total of 1555 extrahepatic branches, representing eight types, were found to originate from hepatic arteries on CTHA. CTHA indicated the following extrahepatic branch prevalence rates: right gastric artery, 890 (94.4%); falciform artery, 386 (40.9%); accessory left gastric artery, 161 (17.1%); left inferior phrenic artery (IPA), 43 (4.6%); posterior superior pancreaticoduodenal artery, 33 (3.5%); dorsal pancreatic artery, 26 (2.8%); duodenal artery, 12 (1.3%); and right IPA, 4 (0.4%). In addition, 383 patients (40.6%) had at least one undetectable branch on DSHA. The sensitivity, specificity, and accuracy of visualization on DSHA were as follows: RGA, 80.0, 86.8, and 80.4%; falciform artery, 53.9, 97.7, and 80.0%; accessory LGA, 64.6, 98.6, and 92.3%; left IPA, 76.7, 99.8, and 98.7%; PSPDA, 100, 99.7, and 99.9%; dorsal pancreatic artery, 57.7, 100, and 98.8%; duodenal artery, 8.3, 99.9, and 98.7%; and right IPA, 0, 100, and 99.6%, respectively., Conclusion: Extrahepatic arteries originating from hepatic arteries were frequently identified on CTHA images. These arteries were frequently overlooked on DSHA.

Aim: To evaluate portal vein (PV) stenosis and stent patency after hepatobiliary and pancreatic surgery, using abdominal computed tomography (CT)., Methods: Percutaneous portal venous stenting was attempted in 22 patients with significant PV stenosis (> 50%) - after hepatobiliary or pancreatic surgery - diagnosed by abdominal CT. Stents were placed in various stenotic lesions after percutaneous transhepatic portography. Pressure gradient across the stenotic segment was measured in 14 patients. Stents were placed when the pressure gradient across the stenotic segment was > 5 mmHg or PV stenosis was > 50%, as observed on transhepatic portography. Patients underwent follow-up abdominal CT and technical and clinical success, complications, and stent patency were evaluated., Results: Stent placement was successful in 21 patients (technical success rate: 95.5%). Stents were positioned through the main PV and superior mesenteric vein ( n = 13), main PV ( n = 2), right and main PV ( n = 1), left and main PV ( n = 4), or main PV and splenic vein ( n = 1). Patients showed no complications after stent placement. The time between procedure and final follow-up CT was 41-761 d (mean: 374.5 d). Twenty stents remained patent during the entire follow-up. Stent obstruction - caused by invasion of the PV stent by a recurrent tumor - was observed in 1 patient in a follow-up CT performed after 155 d after the procedure. The cumulative stent patency rate was 95.7%. Small in-stent low-density areas were found in 11 (55%) patients; however, during successive follow-up CT, the extent of these areas had decreased., Conclusion: Percutaneous transhepatic stent placement can be safe and effective in cases of PV stenosis after hepatobiliary and pancreatic surgery. Stents show excellent patency in follow-up abdominal CT, despite development of small in-stent low-density areas., Competing Interests: Conflict-of-interest statement: The authors declare no conflict of interest related to this study.

Purpose: The purpose of this study was to assess the feasibility and utility of image fusion (Easy-TIPS) obtained from pre-procedure CT angiography and per-procedure real-time fluoroscopy for portal vein puncture during transjugular intrahepatic portosystemic shunt (TIPS) placement., Materials and Methods: Eighteen patients (15 men, 3 women) with a mean age of 63 years (range: 48-81 years; median age, 65 years) were included in the study. All patients underwent TIPS placement by two groups of radiologists (one group with radiologists of an experience<3 years and one with an experience≥3 years) using fusion imaging obtained from three-dimensional computed tomography angiography of the portal vein and real-time fluoroscopic images of the portal vein. Image fusion was used to guide the portal vein puncture during TIPS placement. At the end of the procedure, the interventional radiologists evaluated the utility of fusion imaging for portal vein puncture during TIPS placement. Mismatch between three-dimensional computed tomography angiography and real-time fluoroscopic images of the portal vein on image fusion was quantitatively analyzed. Posttreatment CT time, number of the puncture attempts, total radiation exposure and radiation from the retrograde portography were also recorded., Results: Image fusion was considered useful for portal vein puncture in 13/18 TIPS procedures (72%). The mean posttreatment time to obtain fusion images was 16.4minutes. 3D volume rendered CT angiography images was strictly superimposed on direct portography in 10/18 procedures (56%). The mismatch mean value was 0.69cm in height and 0.28cm laterally. A mean number of 4.6 portal vein puncture attempts was made. Eight patients required less than three attempts. The mean radiation dose from retrograde portography was 421.2dGy.cm 2 , corresponding to a mean additional exposure of 19%., Conclusion: Fusion imaging resulting from image fusion from pre-procedural CT angiography is feasible, safe and makes portal puncture easier during TIPS placement., (Copyright © 2016 Editions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Portal vein (PV) thrombosis (PVT) in the absence of liver disease or thrombophilia is rare. We report a 57-year-old male with a history of stage 3 chronic kidney disease who presented at the emergency department 18 months after abdominal surgery with progressive abdominal pain and distention. Computed tomography revealed PVT with multiple collaterals and moderate ascites. He had undergone partial gastrectomy and gastrojejunal anastomosis at an outside facility for gastrointestinal stromal tumors that caused an iatrogenic stenotic lesion in the PV. The patient underwent balloon angioplasty and endovascular deployment of an 8 mm × 100 mm Viabahn covered stent (W. L. Gore and Associates, Flagstaff, Arizona) in the extrahepatic PV via a transhepatic approach; the device allowed complete restoration of prograde portal flow with clinical improvement. At 6 months from the intervention, he remains symptom-free with normal liver function tests and patent endoprosthesis on antiplatelet therapy.

Objectives: Hepatic veno-occlusive disease after liver transplant is rare but potentially fatal. Here, we describe a case of veno-occlusive disease occurring after a liver transplant patient, which resulted in graft failure., Case Report: A 44-year-old woman developed severe ascites accompanied with jaundice, for 1 month after a liver transplant that could not be explicated by common complications. Veno-occlusive disease was diagnosed basing on clinical, pathologic, and radiologic findings. The definitive pathogenesis was difficult to determine. The patient could not show any response to medical therapy, and her deteriorated clinical condition developed to hepatic failure, which called for retransplant., Conclusions: Veno-occlusive disease after a liver transplant can result in graft failure, and re-transplant may be the only alternative resource in critical case.

Background: Hypovascular nodules often occur together with hypervascular hepatocellular carcinoma (HCC). However, it remains controversial whether hypovascular nodules associated with hypervascular HCC have any prognostic value. This study evaluated the prognostic impact of hypovascular nodules co-existing with hypervascular HCC as diagnosed by computed tomography during arterial portography (CTAP) and computed tomography during hepatic arteriography (CTHA), which can sensitively capture the dynamic changes in blood flow through the portal vein and hepatic artery in patients with early stage HCC., Methods: A total of 152 patients with hypervascular HCC (≤ 30 mm, ≤ 3 nodules), who underwent initial local ablation, were analyzed retrospectively. All patients received CTAP and CTHA prior to treatment. Overall survival (OS) was compared among group A (hypervascular HCC only, 107 patients) and group B (hypovascular nodules and hypervascular HCC, 45 patients)., Results: Among all hypovascular nodules, 81% (46 of 57) developed hypervascularization within the follow-up period. The 1- and 2-year hypervascularization rates were 17% and 51%, respectively. OS was significantly longer for group A than for group B (P < 0.001). A Cox proportional-hazards model identified the presence of hypovascular nodules concurrent with hypervascular HCC as an independent poor prognostic factor., Conclusion: The prognosis of hypervascular HCC patients with hypovascular nodules detected during CTAP and CTHA is poor. Clinical HCC categories seem to be dissimilar between patients with and without hypovascular nodules., Competing Interests: The authors have declared that no competing interests exist.

To compare the diagnostic performance of gadoxetic acid-enhanced magnetic resonance imaging (MRI) with that of computed tomography (CT) during hepatic arteriography and arterial portography (CT HA/AP) for detecting hepatocellular carcinoma (HCC) from small hypervascular nodules.This retrospective study included 38 patients with 131 hypervascular nodules (≤2 cm) who had underwent MRI and CT HA/AP within a 2-week interval. Two observers analyzed MRI while other 2 observers analyzed CT HA/AP. Thereafter, MRI observers reviewed the CT HA/AP and magnetic resonance (MR) images again using both modalities. HCC was diagnosed by pathologic or imaging studies according to American Association for the Study of Liver Diseases (AASLD) criteria. Alternative free-response receiver operating characteristic (ROC) analysis was performed on a lesion-by-lesion basis. Diagnostic accuracy (area under the ROC curve [Az]), sensitivity, specificity, and positive and negative predictive values were calculated.The pooled Az was significantly higher for the combined modalities (0.946) than for MRI alone (0.9, P = 0.004), and for MRI than for CT HA/AP alone (0.827, P = 0.0154). Subgroup analysis for HCC ≤1 cm showed the sensitivity of the combined modalities (79.4%) was significantly higher than for MRI (52.9%) and CT HA/AP alone (50%) (both, P < 0.005). The specificity of the combined modalities was not different from MRI alone (98.8% vs. 97.3%, P = 0.5), but was significantly higher than for CT HA/AP alone (98.8% vs. 92.5%, P = 0.022).Hypervascular HCCs >1 to 2 cm can be diagnosed sufficiently by MRI. The combined modalities increased the diagnostic accuracy of HCCs ≤1 cm, compared with MRI or CT HA/AP alone., Competing Interests: The authors have no conflicts of interest to disclose.

Portosystemic shunts are rare vascularization disorders, and an uncommon cause of confusional states. We report an 87-year-old male with a previously normal cognitive status who was repeatedly admitted for sudden symptoms of disorientation and functional limitation. The patient had high ammonium levels which lead to the suspicion of the presence a portosystemic shunt, even in the absence of pre-existing liver disease. A contrast enhanced computed tomography of the abdomen confirmed the presence an abnormal communication of the right portal vein with the suprahepatic veins. The communication was embolized and the confusional states of the patient subsided.

Purpose: Transcatheter arterial chemoembolization (TACE) is one of the most effective therapeutic options for hepatocellular carcinoma (HCC) and it is important to protect residual liver function after treatment as well as the effect. To reduce the liver function deterioration, we evaluated the automatic software to predict the embolization area of TACE in 3 dimensions., Materials and Methods: Automatic prediction software of embolization area was used in chemoembolization of 7 HCCs. Embolization area of chemoembolization was evaluated within 1 week CT findings after TACE and compared simulated area using automatic prediction software., Results: The maximal diameter of these tumors is in the range 12-42 mm (24.6 ± 9.5 mm). The average time for detecting tumor-feeding branches was 242 s. The total time to detect tumor-feeding branches and simulate the embolization area was 384 s. All cases could detect all tumor-feeding branches of HCC, and the expected embolization area of simulation with automatic prediction software was almost the same as the actual areas, as shown by CT after TACE., Conclusion: This new technology has possibilities to reduce the amount of contrast medium used, protect kidney function, decrease radiation exposure, and improve the therapeutic effect of TACE., (© 2016 S. Karger AG, Basel.)

Objectives: To assess and compare the accuracy and inter-observer agreement for the detection of liver lesions using Primovist magnetic resonance imaging (pMRI) and computed tomography during arterial portography (CTAP)., Methods: Patients evaluated at St George Hospital Liver Unit for colorectal liver metastases (CRCLM) underwent CTAP as part of standard staging. pMRI was added to the pre-operative assessment. Two radiologists reported CTAP and two reported pMRI. The sensitivity and specificity of CTAP and pMRI were calculated using histopathology as the gold standard., Results: Complete data were available for 62 patients corresponding to 219 lesions confirmed on histopathology. Agreement on the detection of lesions between the two radiologists that reported pMRI was higher than for CTAP (Kappa = 0.80 versus 0.74). Specificity of lesion detection for pMRI was 0.88 and 0.83 for CTAP (P = 0.112). Sensitivity for pMRI was 0.83 and 0.81 for CTAP. For patients who had chemotherapy before evaluation, pMRI had a significantly higher specificity than CTAP (0.79 versus 0.63, P = 0.011)., Conclusions: pMRI is less invasive, has a good inter-observer agreement, has comparable sensitivity and specificity to CTAP in the pre-chemotherapy population and demonstrates better specificity in patients assessed post-chemotherapy. pMRI is a valid alternative to CTAP in the assessment of CRCLM., (© 2015 International Hepato-Pancreato-Biliary Association.)

Rationale and Objectives: To evaluate image quality and radiation exposure of portal venous-phase thoracoabdominal third-generation 192-slice dual-source computed tomography (DSCT) with automated tube voltage adaptation (TVA) in combination with advanced modeled iterative reconstruction (ADMIRE)., Materials and Methods: Fifty-one patients underwent oncologic portal venous-phase thoracoabdominal follow-up CT twice within 7 months. The initial examination was performed on second-generation 128-slice DSCT with fixed tube voltage of 120 kV in combination with filtered back projection reconstruction. The second examination was performed on a third-generation 192-slice DSCT using automated TVA in combination with ADMIRE. Attenuation and image noise of liver, spleen, renal cortex, aorta, vena cava inferior, portal vein, psoas muscle, and perinephric fat were measured. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Radiation dose was assessed as size-specific dose estimates (SSDE). Subjective image quality was assessed by two observers using five-point Likert scales. Interobserver agreement was calculated using intraclass correlation coefficients (ICC)., Results: Automated TVA set tube voltage to 90 kV (n = 8), 100 kV (n = 31), 110 kV (n = 11), or 120 kV (n = 1). Average SSDE was decreased by 34.9% using 192-slice DSCT compared to 128-slice 120-kV DSCT (7.8 ± 2.4 vs. 12.1 ± 3.2 mGy; P < .001). Image noise was substantially lower; SNR and CNR were significantly increased in 192-slice DSCT compared to 128-slice DSCT (all P < .005). Image quality was voted excellent for both acquisition techniques (5.00 vs. 4.93; P = .083)., Conclusions: Automated TVA in combination with ADMIRE on third-generation 192-slice DSCT in portal venous-phase thoracoabdominal CT provides excellent image quality with reduced image noise and increased SNR and CNR, whereas average radiation dose is reduced by 34.9% compared to 128-slice DSCT., (Copyright © 2015 AUR. Published by Elsevier Inc. All rights reserved.)

Aim: To describe a method for the transjugular intrahepatic portal systemic shunt (TIPS) placement performed with the aid of contrast-enhanced computed tomography (CECT) and three-dimensional reconstructed vascular images (3D RVIs), and to assess its safety and effectiveness., Methods: Four hundred and ninety patients were treated with TIPS between January 2005 and December 2012. All patients underwent liver CECT and reconstruction of 3D RVIs of the right hepatic vein to portal vein (PV) prior to the operation. The 3D RVIs were carefully reviewed to plan the puncture path from the start to target points for needle pass through the PV in the TIPS procedure., Results: The improved TIPS procedure was successful in 483 (98.6%) of the 490 patients. The number of punctures attempted was one in 294 (60%) patients, 2 to 3 in 147 (30%) patients, 4 to 6 in 25 (5.1%) patients and more than 6 in 17 (3.5%) patients. Seven patients failed. Of the 490 patients, 12 had punctures into the artery, 15 into the bile duct, eight into the gallbladder, and 18 through the liver capsule. Analysis of the portograms from the 483 successful cases indicated that the puncture points were all located distally to the PV bifurcation on anteroposterior images, while the points were located proximally to the bifurcation in the three cases with intraabdominal bleeding. The complications included three cases of bleeding, of whom one died and two needed surgery., Conclusion: Use of CECT and 3D RVIs to plan the puncture path for TIPS procedure is safe, simple and effective for clinical use.

Purpose: Human hepatocellular carcinoma (HCC) has unique vascular features, which require selective imaging of hepatic arterial perfusion and portal venous perfusion with vascular catheterization for sufficient evaluation. Unlike in humans, vessels in mice are too small to catheterize, and the importance of separately imaging the feeding vessels of tumors is frequently overlooked in hepatic tumor models. The purpose of this study was to perform selective latex angiography in several mouse liver tumor models and assess their suitability., Materials and Methods: In several ectopic (Lewis lung carcinoma, B16/F10 melanoma cell lines) and spontaneous liver tumor (Albumin-Cre/MST1fl/fl/MST2fl/fl, Albumin-Cre/WW45fl/fl, and H-ras12V genetically modified mouse) models, the heart left ventricle and/or main portal vein of mice was punctured, and latex dye was infused to achieve selective latex arteriography and/or portography., Results: H-ras12V transgenic mice (a HCC and hepatic adenoma model) developed multiple liver nodules that displayed three different perfusion patterns (portal venous or hepatic artery perfusion predominant, mixed perfusion), indicating intra-tumoral vascular heterogeneity. Selective latex angiography revealed that the Lewis lung carcinoma implant model and the Albumin-Cre/WW45fl/fl model reproduced conventional angiography findings of human HCC. Specifically, these mice developed tumors with abundant feeding arteries but no portal venous perfusion., Conclusion: Different hepatic tumor models showed different tumor vessel characteristics that influence the suitability of the model and that should be considered when designing translational experiments. Selective latex angiography applied to certain mouse tumor models (both ectopic and spontaneous) closely simulated typical characteristics of human HCC vascular imaging.

A left-sided gallbladder without a right-sided round ligament, which is called a true left-sided gallbladder, is extremely rare. A 71-year-old woman was referred to our hospital due to a gallbladder polyp. Computed tomography (CT) revealed not only a gallbladder polyp but also the gallbladder located to the left of the round ligament connected to the left umbilical portion. CT portography revealed that the main portal vein diverged into the right posterior portal vein and the common trunk of the left portal vein and right anterior portal vein. CT cholangiography revealed that the infraportal bile duct of segment 2 joined the common bile duct. Laparoscopic cholecystectomy was performed for a gallbladder polyp, and the intraoperative finding showed that the cholecystic veins joined the round ligament. A true left-sided gallbladder is closely associated with several anomalies; therefore, surgeons encountering a true left-sided gallbladder should be aware of the potential for these anomalies.

Objective: This study aimed to clarify the effect of embolization with lipiodol on portal vein hemodynamics., Methods: Time-density curves of the main portal vein on multilevel dynamic multidetector computed tomography during arterial portography were used to analyze peak computed tomography value (PV), time to PV (TPV), arrival time of contrast medium at the main portal vein (ATMPV), slope [(PV - 150) / (TPV - ATMPV)], and slope ratio (slope after embolization / slope before embolization)., Results: In 20 patients with hepatoma, ATMPV and TPV were significantly prolonged and the time-density curve slope was significantly less after embolization. The difference in TPV increased (P = 0.02) and the slope ratio decreased with increasing embolized volume rate (P < 0.001). Strong correlation (R = -0.86) was found between the slope ratio and the embolized volume rate., Conclusions: Time-density curves revealed significant portal vein flow delay after embolization; the degree of which was correlated with the extent of the embolized volume.

The objective of this study was to determine which transabdominal ultrasound parameters correlate with portal vein stenosis (PVS) on percutaneous transhepatic portal venography in pediatric liver transplant patients. A retrospective review was performed of percutaneous transhepatic portal venograms performed between 2005 and 2013. The findings were compared to those from ultrasounds performed before venography and at the baseline. Patients were stratified on the basis of the presence of significant PVS (group 1, >50% stenosis; group 2, ≤50% stenosis) on portal venography. Findings were compared to those for age-matched controls. Twenty portal venograms were performed for 12 pediatric patients. Thirteen of the 20 patients (65%) demonstrated significant PVS (>50%). The mean peak anastomotic velocity (PAV) was 253.6±96 cm/s in group 1, 169.7±48 cm/s in group 2, and 51.3±20 cm/s in the control group. PAV (r=0.672, P=0.002) was the only ultrasound variable that correlated with the presence of significant PVS. A receiver operating characteristic curve was generated from PAV and PVS data (area under the curve=0.75, P=0.08). A threshold velocity of 180 cm/s led to a sensitivity of 83% and a specificity of 71% in predicting significant PVS on portal venography. At the baseline, the mean PAV was 155.8±90 cm/s for group 1 and 69.5±33 cm/s for group 2 (P=0.08); for control subjects, it was 78.9±53 cm/s (P=0.06). PAV is the only measured ultrasound parameter that correlates with significant PVS on portal venography in pediatric liver transplant patients. An elevated baseline PAV may increase the risk of developing PVS., (© 2015 American Association for the Study of Liver Diseases.)

A 65-year-old woman with Budd-Chiari syndrome (BCS) presented with right upper quadrant pain. A computed tomography (CT) scan showed a saccular aneurysm located at the extrahepatic portal vein main branch measuring 3.2 cm in height and 2.5 cm × 2.4 cm in diameter. The aneurysm was thought to be associated with BCS as there was no preceding history of trauma and it had not been present on Doppler ultrasound examination performed 3 years previously. Because of increasing pain and concern for complications due to aneurysm size, the decision was made to relieve the hepatic venous outflow obstruction. Transjugular intrahepatic portosystemic shunt (TIPS) was created without complications. She had complete resolution of her abdominal pain within 2 d and remained asymptomatic after 1 year of follow-up. CT scans obtained after TIPS showed that the aneurysm had decreased in size to 2.4 cm in height and 2.0 cm × 1.9 cm in diameter at 3 mo, and had further decreased to 1.9 cm in height and 1.6 cm × 1.5 cm in diameter at 1 year.

We present a method of intraoperative contrast-enhanced sonographic portography combined with indigo carmine dye injection for anatomic liver resection in hepatocellular carcinoma. During surgery, before dye infusion into the feeding portal vein, the targeted portal vein branch was directly punctured, and a microbubble contrast agent was administered under sonographic guidance. Simultaneous enhancement of the resected hepatic parenchyma with a microbubble contrast agent and blue dye improved estimation of the segmental border in the cutting plane and the tumor resection margin during liver surgery., (© 2014 by the American Institute of Ultrasound in Medicine.)

Purpose: To evaluate the feasibility of combining transcatheter computed tomography (CT) arterial portography or transcatheter CT hepatic arteriography with percutaneous liver ablation for optimized and repeated tumor exposure., Materials and Methods: Study participants were 20 patients (13 men and 7 women; mean age, 59.4 y; range, 40-76 y) with unresectable liver-only malignancies--14 with colorectal liver metastases (29 lesions), 5 with hepatocellular carcinoma (7 lesions), and 1 with intrahepatic cholangiocarcinoma (2 lesions)--that were obscure on nonenhanced CT. A catheter was placed within the superior mesenteric artery (CT arterial portography) or in the hepatic artery (CT hepatic arteriography). CT arterial portography or CT hepatic arteriography was repeatedly performed after injecting 30-60 mL 1:2 diluted contrast material to plan, guide, and evaluate ablation. The operator confidence levels and the liver-to-lesion attenuation differences were assessed as well as needle-to-target mismatch distance, technical success, and technique effectiveness after 3 months., Results: Technical success rate was 100%; there were no major complications. Compared with conventional unenhanced CT, operator confidence increased significantly for CT arterial portography or CT hepatic arteriography cases (P < .001). The liver-to-lesion attenuation differences between unenhanced CT, contrast-enhanced CT, and CT arterial portography or CT hepatic arteriography were statistically significant (mean attenuation difference, 5 HU vs 28 HU vs 70 HU; P < .001). Mean needle-to-target mismatch distance was 2.4 mm ± 1.2 (range, 0-12.0 mm). Primary technique effectiveness at 3 months was 87% (33 of 38 lesions)., Conclusions: In patients with technically unresectable liver-only malignancies, single-session CT arterial portography-guided or CT hepatic arteriography-guided percutaneous tumor ablation enables repeated contrast-enhanced imaging and real-time contrast-enhanced CT fluoroscopy and improves lesion conspicuity., (Copyright © 2014 SIR. Published by Elsevier Inc. All rights reserved.)

We describe an elderly woman who presented with an unusual primary arterioportal fistula and cavernous transformation of the portal vein caused by portal thrombosis, which were subsequently managed with endovascular coil embolization and transjugular intrahepatic portosystemic shunt using 2 stents after balloon remodeling. This case shows a rarely seen condition in the elderly and a novel management strategy that should be considered in the management of this complex disease., (Published by Elsevier Inc.)

Purpose: We investigated intrahepatic vascular changes in patients undergoing right portal vein ligation (PVL) or portal vein embolization (PVE) in conjunction with the ensuing hypertrophic response and function of the left liver lobe., Methods: Between December 2008 and October 2011, 7 patients underwent right PVL and 14 patients PVE. Computed tomographic (CT) volumetry to assess future remnant liver (FRL) and functional hepatobiliary scintigraphy were performed in all patients before and 3 weeks after portal vein occlusion. In 18 patients an intraoperative portography was performed to assess perfusion through the occluded portal branches., Results: In all patients after initially successful PVL, reperfused portal veins were observed on CT scan 3 weeks after portal occlusion. This was confirmed in all cases during intraoperative portography. Intrahepatic portoportal collaterals were identified in all patients in the PVL group and in one patient in the PVE group. In all other PVE patients, complete occlusion of the embolized portal branches was observed on CT scan and on intraoperative portography. The median increase of FRL volume after PVE was 41.6 % (range 10-305 %), and after PVL was only 8.1 % (range 0-102 %) (p = 0.179). There were no differences in FRL function between both groups., Conclusion: Preoperative PVE and PVL are both methods to induce hypertrophy of the FRL in anticipation of major liver resection. Compared to PVE, PVL seems less efficient in inducing hypertrophy of the nonoccluded left lobe. This could be caused by the formation of intrahepatic portoportal neocollateral vessels, through which the ligated portal branches are reperfused within 3 weeks.

Purpose: Congenital portosystemic shunts (CPSS) with portal venous hypoplasia cause hyperammonemia. Acute shunt closure results in portal hypertension. A transcatheter method of staged shunt reduction to afford growth of portal vessels followed by shunt closure is reported., Methods: Pressure measurements and angiography in the CPSS or superior mesenteric artery (SMA) during temporary occlusion of the shunt were performed. If vessels were diminutive and the pressure was above 18 mmHg, a staged approach was performed, which included implantation of a tailored reducing stent to reduce shunt diameter by ~50 %. Recatheterization was performed approximately 3 months later. If the portal pressure was below 18 mmHg and vessels had developed, the shunt was closed with a device., Results: Six patients (5 boys, 1 girl) with a median age of 3.3 (range 0.5-13) years had CPSS portal venous hypoplasia and hyperammonemia. Five patients underwent staged closure. One patient tolerated acute closure. One patient required surgical shunt banding because a reducing stent could not be positioned. At median follow-up of 3.8 (range 2.2-8.4) years, a total of 21 procedures (20 transcatheter, 1 surgical) were performed. In all patients, the shunt was closed with a significant reduction in portal pressure (27.7 ± 11.3 to 10.8 ± 1.8 mmHg; p = 0.016), significant growth of the portal vessels (0.8 ± 0.5 to 4.0 ± 2.4 mm; p = 0.037), and normalization of ammonia levels (202.1 ± 53.6 to 65.7 ± 9.6 μmol/L; p = 0.002) with no complications., Conclusion: Staged CPSS closure is effective in causing portal vessel growth and treating hyperammonemia.

Objective: The objective of this study was to determine whether unenhanced magnetic resonance (MR) angiography using repetitive arterial or vein labeling (RAVEL) is feasible to visualize effectively the intrahepatic portal vein (PV) at 3.0 T., Methods: Forty patients underwent liver MR imaging (MRI) with unenhanced MR portography using RAVEL. Two radiologists performed a consensus review of unenhanced MR portography and portal-phase MRI with regard to anatomic type of PV, vessel conspicuity, and image quality., Results: For determination of the anatomic type of PV, the 2 techniques were equivalent. There were tendencies toward increased conspicuity for right segmental PV and its branches with unenhanced MR portography and for left PV with conventional MRI, although significant differences were not found between MRIs (P > 0.05). Image quality for unenhanced MR portography was poor in 1, moderate in 8, and good in 31 patients., Conclusions: Unenhanced MR portography using RAVEL at 3.0 T is feasible and provides effective visualization of intrahepatic PV.

Objective: The Glissonian approach during hepatectomy is a selective vascular clamping procedure associated with low rates of technical failure and complications. The aim of the present study was to assess the feasibility of a right Glissonian approach in relation to portal vein anatomy., Methods: This was a prospective study conducted over a 12-month period, which included 32 patients for whom preoperative three-dimensional reconstruction using contrast-enhanced computed tomography in the portal venous phase and portography for right portal vein embolization were available, and in whom a right Glissonian approach was applied during right hepatectomy. Preoperative imaging data were correlated with intraoperative Doppler ultrasound findings (considered as the reference dataset). Causes of failures and complications specifically related to the Glissonian approach were identified., Results: Right hepatectomy was performed for colorectal liver metastases (n = 25), hepatocellular carcinoma on cirrhosis (n = 6) and intrahepatic cholangiocarcinoma (n = 1). The Glissonian approach was effective in 24 (75%) patients. In the remaining eight (25%) patients, failure was caused by incomplete clamping (n = 2) or clamping of the left portal pedicle (n = 6). The portal anatomy was aberrant in six patients with failure, showing portal trifurcation (n = 1), right portal trifurcation (n = 1) and a common trunk between the right anterior and left portal branch (n = 4). An angle of less than 50° between the portal vein and left portal branch was reported in association with extended clamping to the left portal branch (selectivity = 72%, specificity = 71%). Intraoperative bleeding and biliary fistula occurred in two patients with non-normal portal anatomy., Conclusions: The right Glissonian approach was effective in 75% of patients. Failure of the procedure (including the extension of clamping to the left pedicle) mostly occurred in patients with portal vein variations, which can be accurately assessed using a combination of preoperative imaging and intraoperative Doppler ultrasound., (© 2013 International Hepato-Pancreato-Biliary Association.)

Objectives: The combination of computed tomography with hepatic arteriography and arterial portography (CTHA/CTAP) can detect additional hepatocellular carcinoma (HCC) nodules undetected by conventional dynamic CT., Methods: In this single-center, randomized, open-label, controlled trial, we randomly assigned 280 patients who were diagnosed as having HCC by conventional dynamic CT, and eligible for radiofrequency ablation (RFA), to undergo CTHA/CTAP before treatment, or to the control group. Newly detected HCC nodules by CTHA/CTAP were intended to be ablated completely. The primary end point was recurrence-free survival and the key secondary end point was overall survival. The analysis was conducted on an intention-to-treat basis. Those with nonablated nodules were treated as for recurrence., Results: A total of 75 nodules were newly diagnosed as HCC by CTHA/CTAP in 45 patients. Three patients (one in the CTHA/CTAP group and two in the control group) who refused treatment were excluded from all analyses. The cumulative recurrence-free survival rates at 1, 2, and 3 years were 60.1, 29.0, and 18.9% in the CTHA/CTAP group and 52.2, 29.7, and 23.1% in the control group, respectively (P=0.66 by log-rank test; hazard ratio, 0.94 for CTHA/CTAP vs. control; 95% confidence interval (CI), 0.73-1.22). The cumulative overall survival rates at 3 and 5 years were 79.7 and 56.4% in the CTHA/CTAP group and 86.8 and 60.1% in the control group, respectively (P=0.50; hazard ratio, 1.15, 95% CI, 0.77-1.71)., Conclusions: CTHA/CTAP may detect recurrent lesions earlier. However, CTHA/CTAP before RFA did not improve cumulative recurrence-free survival or overall survival.

Background: Suboptimal stent-graft placement at the lower anastomosis during transjugular intrahepatic portosystemic shunt (TIPS) may result in early shunt stenosis and occlusion owing to incomplete covering of the parenchymal tract by the covered part of the stent-graft., Purpose: To determine the optimal portal venous projection view for stent-graft placement during TIPS and the potential influence of the portal vein anatomy., Material and Methods: On 76 cirrhotic patients (48 men and 28 women) selected for TIPS, rotational, three-dimensional (3D), catheter-directed angiography of the portal vein was performed. The 3D portograms were reviewed by two independent interventional radiologists to determine the optimal angiographic projection views for stent-graft placement. Intra-observer and inter-observer reliabilities were tested and subgroups of patient portal vein anatomy were categorized., Results: Among all patients, the optimal portal venous projection views for stent-graft placement during TIPS centered around 27° (±14°) right oblique and 3° (±7°) craniocaudal. Of these, 56% were within the standard deviations. Intra-observer reliabilities were 0.60 and 0.62 for the two radiologists, respectively. Inter-observer reliability was 0.48. Anatomical variations in the patient population were: normal portal vein (67%), trifurcation at main portal vein (16%), right posterior portal vein as the first branch of main portal vein (3%), no right posterior portal vein (1%), and other variations (13%). Anatomical subgroups did not influence the best angiographic projection view significantly (F4,295 = 0.91, P = 0.457)., Conclusion: The mean optimal angiographic projection view for TIPS stent-graft placement was 27° right oblique and 3° craniocaudal. Patient anatomic variations do not play a significant role in determining the optimal angiographic view for TIPS stent-graft placement., (© 2013 The Foundation Acta Radiologica.)

Objective: The objective of our study was to clarify the hepatic artery anatomy of the left hemiliver using the fusion image of CT angiography (CTA) and CT arterial portography., Materials and Methods: CTA and CT arterial portography were performed on a 64-MDCT scanner in 144 patients. All images were transferred to a workstation for 3D analysis using the multiimage fusion mode. We classified the left hepatic artery (LHA) and middle hepatic artery (MHA) as type L when only the LHA was present, type MB when a medial branch from the LHA was present, type LM when both the LHA and MHA were present, and type M when only the MHA was present. The hepatic artery was classified into infraportal and supraportal groups on the basis of its relationship with the laterosuperior branch of the left portal vein. We also classified the branching pattern of the arteries to each segment. Pattern 1 was defined as when the LHA divided into the laterosuperior segment artery (A2), which then divided into the lateroinferior segment artery (A3) and medial segment artery (A4). Pattern 2 was defined as when the LHA divided into A3, which then divided into A2 and A4. Pattern 3 was defined as when the LHA divided into A4, which then divided into A2 and A3. Pattern 4 was defined as when the LHA divided into A2, A3, and A4 simultaneously., Results: The prevalence of each type was as follows: type L (n = 37, 25.7%), type MB (n = 44, 30.6%), type LM (n = 53, 36.8%), and type M (n = 6, 4.2%). The number of cases classified as infraportal was 54 (37.5%) and supraportal, 73 (50.7%). The cases classified by branching pattern were as follows: pattern 1, 26 cases (18.0%); pattern 2, eight (5.6%); pattern 3, 93 (64.5%); and pattern 4, 13 (9.0 %)., Conclusion: Three-dimensional fusion images based on CTA and CT arterial portography can show the various anatomic patterns of the left hemiliver hepatic artery in relation to the left portal vein.

Purpose: The purpose of this study was to evaluate the feasibility and potential usefulness of unenhanced magnetic resonance (MR) hepatic portal perfusion using arterial spin labeling (ASL) among healthy volunteers and hepatocellular carcinoma patients., Materials and Methods: The five healthy volunteers underwent unenhanced MR perfusion with inversion time 2 (TI2) values at 500-ms intervals between 2,000 and 4,000 ms, and the 12 patients underwent unenhanced MR perfusion using ASL and computed tomography (CT) perfusion during superior mesenteric artery (SMA) portography. The regions of interest were placed in both the right and left lobes of the liver or both the right anterior and posterior segments of the liver and were placed over the tumor if a lesion was located within a particular perfusion study slice., Results: In the healthy volunteer study, perfusion rate in hepatic parenchyma showed a peak at the TI2 value of 3,000 ms (254.3 ml/min/100 g ± 58.3). In patients, a fair correlation was observed between CT and MR perfusion (r = 0.795, P < 0.01)., Conclusion: Our results demonstrate a significant fair correlation between unenhanced MR hepatic portal perfusion imaging using ASL and CT perfusion during SMA portography.