PROCEDURE: 

  1. Percutaneous portal venogram 
  2. 3D CT venography from the portal vein 
  3. Percutaneous embolization of the segment IV branch portal vein branches
  4. Percutaneous embolization of the right portal vein branches

 

DATE OF PROCEDURE:

CLINICAL HISTORY: __-year-old __ with history of metastatic colon cancer with multiple hepatic metastases, predominantly on the right and within segment IV. Request for preoperative portal vein embolization prior to extended right hepatectomy.

OPERATING PHYSICIAN:  , MD (Attending)/ , MD (Fellow)

MEDICATIONS: Versed 7 mg IV, Fentanyl 350 mcg IV, Zosyn 4.5 mg IV

COMPLICATIONS: None

 

PROCEDURE:

After written and verbal informed consent was obtained the patient was placed supine on the procedure table.  The upper abdomen was prepped and draped in standard sterile manner. The skin and subcutaneous tissue was infiltrated with lidocaine without epinephrine. Using ultrasound guidance, a 22 gauge x 15 cm Chiba needle was used to access a right anterior branch portal vein. An 0.018″ wire was advanced through the needle into the main portal vein. The needle was exchanged for a 6 French coaxial Aprima access set. The introducer and wire were removed a portogram was performed to confirm positioning. The Aprima set was exchanged for a 7 French vascular sheath. 

A pigtail catheter was placed within the main portal vein and digital subtraction venography was performed. Subsequently, 3D CT venography of the portal system was performed via the pigtail catheter. The images were reviewed. 

The pigtail catheter was exchanged for a Sim-1 glidecath which was placed within the left portal vein. Digital subtraction venography was performed. The Sim-1 was then used in conjunction with a renegade hi flow microcatheter and transcend wire to access the segment IVa and IVb branches of the portal vein. These vessels were embolized utilizing 300-500 um embospheres followed by coils. Postembolization venography was performed showing good stasis of contrast. 

Subsequently, the SIM 1 glide catheter was used to access the branches of the right portal vein. Each branch was embolized through the renegade high flow microcatheter with 300-500 um embospheres followed by NBCA glue mixed with Ethiodol in a 1:3 ratio. The microcatheter and glide catheter were removed and disposed of following each embolization.

Finally, the access branch of the right portal vein and access tract were embolized utilizing glue. Hemostasis was achieved with manual compression. A sterile dressing was applied. 

The patient tolerated this procedure well and left the interventional suite in stable condition. Conscious sedation was provided for the patients comfort. 

 

FINDINGS: 

  1. The initial percutaneous portal venogram revealed normal patency of the portal vein with flow into the right and left hepatic lobes.
  2. There is a portal vein to hepatic vein fistula arising off of a branch of the segment IVa. Following embolization, no residual flow through this fistula is demonstrated.
  3. Near-complete stasis of contrast following each embolization within the segment IV branches and the right sided branches of the portal vein as above.

 

IMPRESSION: 

  1. Successful embolization of the right portal vein branches as described above utilizing embospheres particles and glue.
  2. Successful embolization of the segment IV branches arrising from the left portal vein as above utilizing embospheres and coils.