Transjugular intrahepatic portosystemic shunt with covered stents for hepatocellular carcinoma with portal vein tumor thrombosis

Abstract

Aim: To evaluate transjugular intrahepatic portosystemic shunt (TIPS) with covered stents for hepatocellular carcinoma (HCC) with main portal vein tumor thrombus (PVTT).

Methods: Eleven advanced HCC patients (all male, aged 37-78 years, mean: 54.3 ± 12.7 years) presented with acute massive upper gastrointestinal bleeding (n = 9) or refractory ascites (n = 2) due to tumor thrombus in the main portal vein. The diagnosis of PVTT was based on contrast-enhanced computed tomography and color Doppler sonography. The patients underwent TIPS with covered stents. Clinical characteristics and average survival time of 11 patients were analyzed. Portal vein pressure was assessed before and after TIPS. The follow-up period was 2-18 mo.

Results: TIPS with covered stents was successfully completed in all 11 patients. The mean portal vein pressure was reduced from 32.0 to 11.8 mmHg (t = 10.756, P = 0.000). Gastrointestinal bleeding was stopped in nine patients. Refractory ascites completely disappeared in one patient and was alleviated in another. Hepatic encephalopathy was observed in six patients and was resolved with drug therapy. During the follow-up, ultrasound indicated the patency of the shunt and there was no recurrence of symptoms. Death occurred 2-14 mo (mean: 5.67 mo) after TIPS in nine cases, which were all due to multiple organ failure. In the remaining two cases, the patients were still alive at the 16- and 18-mo follow-up, respectively.

Conclusion: TIPS with covered stents for HCC patients with tumor thrombus in the main portal vein is technically feasible, and short-term efficacy is favorable.

Keywords: Covered stent; Hepatocellular carcinoma; Main portal vein tumor thrombus; Portal hypertension; Transjugular intrahepatic portosystemic shunt.

Figure 1

Portal venogram in a 59-year-old man with hepatocellular carcinoma and lung metastasis, who was treated with transjugular intrahepatic portosystemic shunt for severe varicosis and vomiting blood for 3 d. Puncture was successfully performed in the right branch with tumor thrombus in the trunk and left branch of the portal vein.

Figure 2

Portal venograms in a 41-year-old man with hepatocellular carcinoma and lymphatic metastasis, who was treated with transjugular intrahepatic portosystemic shunt for severe varicosis and vomiting blood for 5 d. A: Injection of a small amount of contrast agent demonstrated tubular and slow blood flow with no dissipation and the portal vein was clearly defined; B: After a catheter was introduced, the portal vein image was confirmed by 30° right anterior oblique angiography; C: After two Fluency stent grafts with a length of 80 mm and diameter of 8 mm were implanted, the shunt was shown to have smooth blood flow by postoperative angiography.

Figure 3

Portal venogram in a 37-year-old man with hepatocellular carcinoma and lung metastasis, who was treated with transjugular intrahepatic portosystemic shunt for severe varicosis and vomiting blood for 5 d. The tumor thrombus was located in the trunk and both left and right branches of the portal vein, and needle puncture was performed in the portal bifurcation. After injection of contrast agent, tumor thrombus was seen as an expansive growth with loose texture, with clear imaging of the portal vein branches.