Palliative Portal Vein Stent Placement in Malignant and Symptomatic Extrinsic Portal Vein Stenosis or Occlusion

Abstract

This article evaluates the results of portal vein (PV) stent placement in patients with malignant extrinsic lesions stenosing or obstructing the PV and causing symptomatic PV hypertension (PVHT). Fourteen patients with bile duct cancer (n = 7), pancreatic adenocarcinoma (n = 4), or another cancer (n = 3) underwent percutaneous transhepatic portal venous stent placement because of gastroesophageal or jejunal varices (n = 9), ascites (n = 7), and/or thrombocytopenia (n = 2). Concurrent tumoral obstruction of the main bile duct was treated via the transhepatic route in the same session in four patients. Changes in portal venous pressure, complications, stent patency, and survival were evaluated. Mean ± standard deviation (SD) gradient of portal venous pressure decreased significantly immediately after stent placement from 11.2 mmHg ± 4.6 to 1.1 mmHg ± 1.0 (P \ 0.00001). Three patients had minor complications, and one developed a liver abscess. During a mean ± SD follow-up of 134.4 ± 123.3 days, portal stents remained patent in 11 patients (78.6%); stent occlusion occurred in 3 patients, 2 of whom had undergone previous major hepatectomy. After stent placement, PVHT symptoms were relieved in four (57.1%) of seven patients who died (mean survival, 97 ± 71.2 days), and relieved in six (85.7%) of seven patients still alive at the end of follow-up (mean follow-up, 171.7 ± 153.5 days). Stent placement in the PV is feasible and relatively safe. It helped to relieve PVHT symptoms in a single session.

Refractory Ascites after Pancreato-Duodenectomy - Time to Rethink an Old Dogma

“…On the other side, anticoagulation can be responsible for bleeding along the percutaneous transhepatic route, hypersensitivity, and heparininduced thrombocytopenia. Our patient received antiplatelet therapy but no anticoagulation treatment, in agreement with Novellas et al [7]. These authors prescribed anticoagulation only in case of decreased portal flow, but they do not prescribe it in cases of normalized flow in the portal vein after stenting.…”

“…The incidence rate for portal vein stenosis is reported to be 11% to 23% [5,6], but the incidence of refractory ascites is unknown. Portal hypertension without hepatic dysfunction secondary to PV stenosis causes gastrointestinal bleeding from gastroesophageal or jejunal varices and refractory ascites [7]. Gastrointestinal bleeding is the most serious life-threatening complication.…”

Embolization of percutaneous transhepatic portal venous access tract withN-butyl cyanoacrylate

“…Embolization of percutaneous transhepatic portal venous access tracts to prevent acute bleeding is not a new concept, and there are several reports that have been published in the past emphasizing the importance of such a procedure to prevent a potentially dangerous complication of intraperitoneal haemorrhage. 10,27 In addition, several reports have presented examples of bleeding complications that lead to life-threatening morbidity and mortality. 28,29 Various materials are used for embolization of tracts in the liver parenchyma after portal vein manipulation, including gelatin sponge particles, biological tissue adhesives, coils and vascular plugs.…”

“…28,29 Various materials are used for embolization of tracts in the liver parenchyma after portal vein manipulation, including gelatin sponge particles, biological tissue adhesives, coils and vascular plugs. [10][11][12][13][23][24][25] The most commonly used embolic materials for the closure of percutaneous portal vein access tracts are coils and gelatin sponge particles; however, they have their own drawbacks. With the use of gelatin sponge particles, incomplete tract embolization or delayed bleeding may occur owing to its soluble and impermanent nature.…”

“…According to the literature, various embolic materials, including gelatin sponge particles, biological tissue adhesives, coils and plugs, have been utilized to prevent bleeding from the tracts. [7][8][9][10][11][12][13] Among these materials, gelatin sponge particles and coils are the two most commonly used embolic materials. However, most of these embolic materials have one or more drawbacks, such as incomplete tract embolization when using gelatin sponge particles, which may be the cause of delayed bleeding, and longer procedure time when using coils or plugs.…”