Portal vein embolization with sotradecol technique and dictation

PROCEDURE: 

1. Main portal venography
2. Right anterior portal vein embolization
3. Right posterior portal vein embolization
4. Postembolization main portal venography

DATE OF PROCEDURE:    

INDICATION:     old    ,    .    

OPERATORS: (Attending),  (Fellow)

COMPARISON: None

MEDICATIONS: None. Sedation medications were administered by the anesthesiology team as the patient was under general anesthesia.

CONTRAST: 0 ml of nonionic contrast 

FLUOROSCOPY TIME: 18.6 minutes

ACCESS SITE: Right abdominal percutaneous access x2

COMPLICATIONS: None

TECHNIQUE: The risks, benefits, and alternatives to the procedure and sedation were explained to the patient, and written informed consent obtained. A timeout was performed.  The patient was placed in a slight right anterior oblique position on the angiography table and the right groin was was prepped and draped in sterile fashion. A timeout was performed.

The abdomen was evaluated by ultrasound. An appropriate entry site to access the right posterior portal vein was chosen and anesthetized with 1% bupivacaine. Using ultrasound guidance, a right posterior portal vein branch was accessed with a 22-gauge Chiba needle. Needle entry was documented. There stylet was removed and intravascular position confirmed by contrast injection under fluoroscopy. A 0.018″ guidewire was inserted through the needle into the main portal vein. A small dermatotomy was made around the needle. The needle was replaced with a transitional 6 F Aprima dilator set. The inner dilator and 0.018″ guidewire were removed. The outer transitional dilator was replaced over an Amplatz guidewire for a 7 F, 25 cm vascular sheath. 

The abdomen was evaluated by ultrasound. An appropriate entry site to access the right anterior portal vein was chosen and anesthetized with 1% bupivacaine. Using ultrasound guidance, a right anterior portal vein branch was accessed with a 22-gauge Chiba needle. Needle entry was documented. The stylet was removed and intravascular position confirmed by contrast injection under fluoroscopy. A 0.018″ guidewire was inserted through the needle into the main portal vein. A small dermatotomy was made around the needle. The needle was replaced with a transitional 6 F Aprima dilator set. The inner dilator and 0.018″ guidewire were removed. The outer transitional dilator was replaced over an Amplatz guidewire for a 7 F, 25 cm vascular sheath. 

A straight flush catheter was placed over the right anterior portal vein guidewire into the main portal vein. Digital subtraction venography was performed using the power injector. The straight flush catheter was removed.

6 F, 13 mm Python balloons were placed over the guidewires. Position of the sheaths and balloons was adjusted and the balloons was inflated in appropriate position to occlude the origin of the anterior and posterior right portal vein. Digital subtraction venography was performed through both sheaths. Digital subtraction venography was then performed through one of the balloons.

Approximately 15 mL of a 3:2:1 air:Sotradecol:Lipiodol foam mixture was injected into each sheath under close fluoroscopic evaluation of the main and left portal veins to ensure no leakage beyond the balloons.

After approximately 15 minutes, an additional 7 to 8 mL of the foam was injected into each sheath.

After an additional 25 minutes, the balloons were deflated and removed. A straight flush catheter was again placed over one of the wires and used to obtain digital subtraction main portal venography.

The wires were removed. The sheaths were cut and the parenchymal tract was embolized with Gelfoam pledgets. The sheaths were completely removed. Sterile dressings were applied.

The patient tolerated the procedure well and left the angiography suite in stable condition without any immediate postprocedural complications. 

FINDINGS: 

1. Preembolization portal venography demonstrates a trifurcation of the portal system into right anterior, right posterior, and left portal vein branches. Percutaneous access is established in the right anterior and right posterior branches.
2. Sotradecol foam infusion shows appropriate filling of the right anterior and right posterior portal systems. No leakage is observed into the main or left portal veins.
3. Post embolization portal venogram demonstrates complete embolization of the right anterior and posterior portal venous vasculature without contrast filling.

IMPRESSION: Successful right anterior and posterior portal vein embolization with Sotradecol foam.