Percutaneous imaging guided techniques of PV patency and...
Transcript of Percutaneous imaging guided techniques of PV patency and...
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Percutaneous imaging guided
techniques of PV patency and
integrity management - catheter
directed local thrombolysis,
stenting, endoluminal
RFA&angioplasty or endoluminal
RFA&stenting
M.Mizandari, K.Kuntelia,
N.Habib
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Material:• 20 patients with PV patency problem in total;
• 15 underwent percutaneous recanalization using a novel endovascular bipolar radiofrequency device; RFA was followed
a) by balloon angioplasty in 7 cases (6 - HCC, 1-retroperitoneal sarcoma)
b) vascular stent placement in 8 cases (7 - HCC, 1 -liver cirrhosis).
• In 3 cases PV percutaneous recanalization was performed by stent placement to pancreatitis induced PV thrombosis/stricture; in one of them the stent placement the same time was used to restore PV integrity also (porto-biliary fistula was documented).
• In 2 cases PV percutaneous recanalization was performed by catheter directed local thrombolysis(clinically manifested fresh PV thrombosis, caused by thrombophylia and HCC).
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Technique:
• The PV tributary was percutaneously accessedunder US guidance and 5Fr guiding catheterwas manipulated through the block usingguidewire technique under DSA guidance.
• In case of thrombolysis thrombolytic agent wasinjected directly below the thrombus
• For RFA processing the endoluminalradiofrequency device was inserted into thethrombus; procedure was completed byimmediate balloon angioplasty or stenting.
• The stenting procedure was completed by self-expanding vascular stent placement
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Portal Vein Tumor
thrombus recanalization
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Pre-procedure CT. PVT- patent
branch of RPV-yellow,
completely obliterated LPV - red
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VesOpen procedure
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VesOpen procedure – 2 RFA sessions has been
performed before stent positioning
RF
RF
stent positioned
Balloon
Balloon Balloon
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VesOpen procedure - stent is released, balloon
postdilation has been performed
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VesOpen procedure – restored blood flow from PV
confluence the the RPV has been documented
Before VesOPenAfter VesOpen
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CT after VesOpen
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Results:
• The technical success rate was 85.0%; in 3cases (15.0%) wire conduction through theorganized thrombus was impossible.
• Posprocedure portography documentedsignificantly improved portal vein blood flow inall patients, to whom the procedure wascompleted.
• Porto-biliary fistula was successfully managedby percutaneous stenting.
• Patients tolerated the procedure easily; nointraprocedural complications were detected.
• In 1 case serious postprocedure bleeding wasdocumented, which led to polyorganic failureand death.
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Conclusions:
• The percutaneous management of PV patency andintegrity problems by percutaneous stenting andendoluminal RFA is an effective technique
• It should be suggested as a treatment option forotherwise incurable patients and might be used asa bridge for further treatment.
• Post-procedure intraperitoneal bleeding is apossible life-threatening complication whichshould be prevented by procedure track ablation orembolization.
• A larger study is needed to assess the usefulnessand long-term impact of PV percutaneousintervention on patient outcome
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PV stenting in case of
pancreatitis induced PV
patency problem
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We suggest pancreas divisum; 1- pseudocyst,
2 – dilated PD, 3 – stones in Wirsung, 4 –
stones in Santorini, 5 – obstructed PV
(pancreatitis induced thrombosis)
12
3
4 55
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Pancreatic psedocyst drainage under CT
guidance
Wire is adequately positioned in PD
Drainage “target” – pancreatic pseudocyst
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Pseudocyst drainage under CT guidance
(Jan.17,2015)
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PV recanalization by stenting
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PV recanalization by stenting – restored patency and track
ablation by 5 FR endoluminal RF device in order to prevent the
bleeding
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PV patency has been restored – CT before and after PV
stent placement
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Stent in situ; SMV connection with intrahepatic
PV is completely restored. Huge collaterals
arising from spleen hilum identify the SV
patency problem, which is not clinically
important, causing just the spleen enlargement
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CT and fluoroscopy guided PD drainage
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BAPDL
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Fistulography after BAPDL
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Percutaneal management of
pancreatitis induced bilio-
portal fistula
66 years old patient with
mechanical jaundice and
cholangitis. The primary
suggestion was CBD neoplasm,
but CT suggested CBD stones;
patient was referred to IR for
PTC
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BAPDL procedure (stone – yellow arrow, bilio-
portal fistula –red arrow, PV – green arrow)
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BAPDL procedure (bilio-portal fistula –red
arrow, PV – green arrow)
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BAPDL has been stopped and finished by
external-internal drainage
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PV confluence patency problem - most likely the
complication of previous pancreatitis; most likely the
bilio-portal fistula is also induced by pancreatitis
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PV stenting
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PV stenting
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PV stenting
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PV stenting
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PV stenting
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PV stenting
Stone
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Thanks!