Portal venous embolisation via an unconventional venous approach

Portal venous embolisation via an unconventional venous approach, in a patient who had a previous splenectomy Mathuri Sakthithasan and Mark Callaway Dept of Radiology, Bristol Royal Infirmary, University Hospitals of Bristol and Weston NHS Foundation Trust Mark. callaway@UHBW. nhs. uk

Multiple colorectal liver metastases developed in segment 6, 7, 8 and 4 a, which required extended right hepatectomy. following discussion at MDT right portal vein embolization was recommended , to induce hypertrophy of the left lobe prior to surgery. Portal venous embolisation was carried out under general anesthetic. Initially the left portal vein was the target for puncture, but the left lobe of the liver extended across the midline into the left upper quadrant. The previous splenectomy was not appreciated at this time. A direct puncture of the left intrahepatic portal vein, under ultrasound guidance, was attempted, this was difficult due to the position of the left lobe. A large vessel was punctured following parenchymal staining of contrast. This was thought to be the splenic vein A catheter was then manipulated through the portal vein into the right hepatic vein, which was embolised using cyanoacryl glue and lipiodol. At this stage it was appreciated that this vessel was a tributary and not the left intrahepatic portal vein. A post procedure venogram showed obliteration of the right portal vein and patency of the left portal vein. A CTPA on day one demonstrated the previous splenectomy and the actual route was identified as a large residual gastric or splenic vein, A CT scan at 6 weeks demonstrated hypertrophy of the left lobe and the patent went on to have extended right hepatectomy. This is an example of successful portal vein embolization, using a unusual unconventional and previously not described potential trans gastric approach for PVE

Fig 1: T 1 weighted MRI Liver Multiple low signal metastasis within the liver Fig 2: A venogram following the puncture of the vascular structure in the left upper quadrant. This a tributary of the portal vein and the left intrahepatic portal vein can clearly be seen Figure 3: Post embolization Patent flow within the left portal vein. No flow within the right portal vein. Figure 4: Post Surgery CT Hypertrophy of the left lobe of the liver.