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Review
. 2022 Feb 18;39(1):107-112.
doi: 10.1055/s-0041-1740938. eCollection 2022 Feb.

Iatrogenic Portal Venous Circulatory Injuries in the IR Suite

Timothy L Arleo  1 , Nima Kokabi  1 , Mircea M Cristescu  1 , Mohammed F Loya  1 , Wael E Saad  2 , Bill S Majdalany  1
Affiliations
Review

Iatrogenic Portal Venous Circulatory Injuries in the IR Suite

Timothy L Arleo et al. Semin Intervent Radiol. .
No abstract available

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Conflict of interest statement

Conflict of Interest The authors have no relevant disclosures.

Figures

Fig. 1
Fig. 1
A 47-year-old man with cryptogenic cirrhosis who presented with esophageal varices underwent preprocedural computed tomography (CT) with intravenous contrast. ( a, b ) Portal vein thrombosis (circled *) is surrounded by cavernous transformation (black arrows). Peripancreatic varices (circled black arrowheads) are also present. The splenic vein (circled white arrowhead) courses medially along its path. ( c ) The portal thrombus (circled *) extends into the right portal vein with surrounding cavernous transformation (black arrows). Gastric varices (circled black arrowhead) and a tortuous splenic vein is in and out of plane (circled white arrowheads). ( d ) Gastroesophageal varices are seen (circled black arrowhead) and the splenic vein at the hilum (circled white arrowhead).
Fig. 2
Fig. 2
Same patient as Fig. 1 during portal vein recanalization and TIPS placement. ( a ) Access into the splenic vein was established using a 22-gauge needle (white arrowhead). ( b ) Next, a microwire (white arrow) was passed centrally through the needle (white arrowhead). ( c ) After attaining splenic vein access, angiography was performed demonstrating extravasation of contrast (black arrows) from the splenic vein. ( d ) Femoral artery access was obtained, and Gelfoam was injected into the splenic artery. Stasis of flow was noted following the injection (white arrow—static contrast column). ( e ) A final celiac artery angiogram demonstrates diffuse vasoconstriction in the left gastric artery (black arrow), common hepatic artery (black arrowhead), and branches of the common hepatic artery due to hypovolemia. There was no distal splenic artery flow (white arrow).
Fig. 3
Fig. 3
The same patient as Figs. 1 and 2 . A postprocedural CT scan with intravenous contrast was performed. The portal thrombus (circled black asterisk) with cavernous transformation (black arrow) remains. Postsplenectomy changes are present with multiple surgical clips and fewer varices around the stomach (circled white asterisk).
Fig. 4
Fig. 4
A 69-year-old woman with neuroendocrine tumor of the lung status-post left pneumonectomy with multiple metastases to the liver with resulting large gastric varices and recurrent GI bleeding. She underwent a preprocedural CT scan with IV contrast. ( a–c ) Numerous gastric varices (black arrowhead) can be observed. A segment 4A hypo-enhancing liver lesion (black arrow) is also visualized. The spleen is enlarged.
Fig. 5
Fig. 5
Same patient as Fig. 4 during transhepatic variceal sclerotherapy. ( a, b ) Portal vein access was achieved with percutaneous transhepatic access of a peripheral right portal vein branch (small white arrowhead) into the main portal vein (large white arrowhead). Contrast injection shows a patent superior mesenteric vein ( a , white arrow) and splenic vein ( b , black arrow). ( c ) A Fogarty balloon (black arrow) was positioned proximal to the gastric varix and inflated. Contrast injection revealed a tortuous gastroesophageal varix (white arrowhead) with a narrow neck proximally (white arrow). ( d ) After attempting to pass the catheter (black arrowhead) through the varix neck, angiography demonstrated rapid extravasation of contrast (black arrows). ( e ) Femoral artery access was obtained, and a catheter (black arrowhead) was used to embolize the proximal splenic artery (white arrows). Stasis of contrast is seen in the splenic artery and intraparenchymal splenic artery branches (white arrowheads). ( f ) Next, a microcatheter (black arrowhead) was used to inject STS into the extravasating gastroesophageal varix (black arrows). ( g ) The first set of coils (white arrow) was delivered and began to collect in the extravasation cavity. ( h ) Stasis of extravasating blood flow was achieved in the gastroesophageal varix (white arrowhead) with the extensive use of coils (white arrows).
Fig. 6
Fig. 6
Same patient as Figs. 4 and 5 . Abdominal radiograph postprocedure reveals residual sclerosant (open arrow) and coils (solid arrow) in the area of extravasation.
Fig. 7
Fig. 7
Same patient as Figs. 4 5 to 6 . Postprocedural CT scan with intravenous contrast reveals ascites and post-embolization changes of the infarcted spleen (white asterisk). ( a ) Sclerosant is visualized in the gastroesophageal varix (black arrow). ( b ) Embolization coils in the gastroesophageal varix are present. The segment 4A hypo-enhancing liver lesion (white arrow) is still visualized.
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