Hepatobiliary Surgery - part 3 docx

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Fig. 4.2B. Middle phase image at the same level looks similar. The three lesions are
demonstrated.
Fig. 4.2C. Late phase images. The three lesions are seen on these two images. The
lesion in Segment VIII and the lesion in the lateral aspect of Segment II/III are very
low attenuation and likely to represent cysts. The small mass medially in the left
liver (arrows) is most likely a metastasis.
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Fig. 4.2D. Early phase image at the level of the porta. There is an area of low
attenuation anteriorly in Segment IV, abutting the umbilical fissure.
Therapeutic and Palliative Procedures
Percutaneous Cholecystostomy
General Considerations
Percutaneous cholecystostomy (PC) is generally performed in patients with acute
cholecystitis who are too ill to undergo cholecystectomy. The procedure is most often
performed in acute acalculous cholecystitis. Acalculous cholecystitis typically occurs in
elderly and/or extremely ill patients, frequently in the intensive care unit. Definitive
diagnosis may be difficult, but should be suspected in this patients in whom there is no
other explanation for fever and leukocytosis, or when the gallbladder is distended and
tender. PC may represent definitive treatment in these patients. Given the relative ease
and safety, of performing PTC, most interventional radiologists have a low threshold
for performing this procedure in the appropriate clinic situation.
PC may also be performed in cases of calculous cholecystitis in patients consid-
ered poor operative candidates. When gallstones are present, the ultimate treatment
depends on the clinical situation. The procedure may be temporizing in patients
whose condition improves enough to allow for definitive cholecystectomy. In pa-
tients who remain poor surgical candidates, stones may be removed percutaneously

from the gallbladder or common bile duct, and balloon sphincterotomy may be
performed. Rarely, PC may be performed to provide biliary drainage in cases of
distal obstruction.
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Fig. 4.2E. Late phase image at the same level. No mass is demonstrated. This is a
characteristic location for a perfusion artifact, which is what this “lesion” represented.
Fig. 4.2G. Early phase image in the lower liver demonstrating a metastasis in
Segment VI.
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Fig. 4.2H. Middle phase image in the lower liver demonstrating a metastasis in
Segment VI.
Fig. 4.2I. Late phase image in the lower liver demonstrating a metastasis in Segment VI.
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Technique
PC may be performed under ultrasound or CT guidance or even at the bedside
in patients too ill to be transported to the interventional suite. In most cases of
acalculous cholecystitis, thick dark bile is aspirated at the time of drainage. As in-
flammation subsides and cystic duct patency is restored, bile will begin to drain.
Cystic duct patency can be confirmed with a contrast study and the tube can be
capped until the tract has matured (we generally wait at least 3 weeks), at which
point the tube can be removed.
Percutaneous Biliary Drainage
Indications
Percutaneous biliary drainage is indicated in cases of obstructive jaundice caus-

ing cholangitis or intractable pruritus, or where an elevated bilirubin precludes other
treatment. This latter situation occurs most commonly in patients requiring chemo-
therapy, but may also apply in patients being considered for hepatic embolization.
Asymptomatic jaundice does not require treatment. In particular, intervention solely
to reduce a high bile duct obstruction (at or above the confluence) may cause many
more problems than it solves. We usually try to avoid treating patients when cross
sectional imaging suggests subsegmental isolation, as the goals of drainage can rarely
be accomplished. Preoperative biliary drainage remains controversial except for the
treatment of biliary sepsis.
The hepatobiliary disease management team should evaluate each patient to
determine the need for drainage. Once the need for drainage is determined, con-
sideration should be given as to whether an endoscopic or percutaneous drainage
approach is more appropriate. In general, patients with low bile duct obstruction
are managed endoscopically by the gastroenterologists. Percutaneous drainage is
reserved for cases of high bile duct obstruction or for patients whose biliary tree
cannot be accessed endoscopically (e.g., previous bypass procedure or gastric or
duodenal tumors).
Technique
As with PTC, the optimal approach to the biliary tree is determined by many
factors. Good quality diagnostic imaging is essential for proper planning of a percu-
taneous biliary drainage. It is important to identify the level of obstruction, the
status of the portal vein, the presence of hepatic atrophy or ascites, and the extent of
parenchymal disease. Operator preference, while important, is secondary to the need
to maximize the safety and efficacy of the procedure.
Punctures are generally performed using 21 or 22 gauge needles. Right-sided
drainage is performed from a lower intercostal or, when possible, subcostal approach.
Left-sided drainage is generally performed from an epigastric approach (Figs. 4.3A-F).
We use a 21-gauge diamond tipped, two-part needle for the initial punctures. After
the needle is inserted into the liver, contrast is injected until the biliary tree is opaci-
fied. Multiple passes may be necessary until a duct is visualized. If the initial duct

punctured is not optimal for placement of a drainage catheter, a second needle is
used to puncture a suitable duct once the ducts have been filled with contrast. The
optimal duct for drainage should be peripheral so as to avoid large, central vessels,
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and also to provide enough intraductal space above the level of obstruction for an
adequate number of catheter side holes through which the bile will drain.
Once a suitable duct is punctured, the needle is exchanged over a small (.018)
guide wire for a three part system consisting of a thin metal stiffener, a thin inner
introducer sheath, and a 7F outer introducer sheath. The inner two pieces are re-
moved leaving the outer portion of the introducer, through which catheters and
wires of appropriate size to perform the drainage can be placed. Generally, every
attempt is made to cross through the obstruction in order to allow placement of an
internal-external drainage catheter that has a loop in the duodenum and side
holes above and below the level of obstruction. The interventionalist has a
large armamentarium of catheters and guidewires to facilitate passage through various
types of obstructions. At times, an obstruction cannot be negotiated nor is it preferable
to minimize manipulation in the setting of sepsis; in these cases an external catheter
is placed initially. Attempts are generally made at a later time to convert the initial
catheter to an internal-external catheter. At the time of initial drainage, bile specimens
are obtained for culture and, if necessary, cytology. Brush biopsy can also be performed,
either initially or as a second procedure.
Depending on the level of obstruction, the goals of drainage may not be accom-
plished with one catheter. The higher the obstruction, the less likely it is that one
drainage will suffice. It is unnecessary to drain every hepatic segment in order to
normalize bilirubin and relieve pruritus. Unfortunately, the need to drain multiple
segments seems more common in the setting of cholangitis, where isolated systems
are contaminated and continue to cause symptoms in the absence of drainage. As
mentioned previously, we ardently avoid treating patients where cross sectional im-

aging suggests subsegmental isolation, but will at times place as many as three drain-
age catheters (generally one left-sided catheter, one catheter in the right anterior
sector and one in the right posterior sector). Whereas each catheter is difficult for
the patient to tolerate, every effort is made to use as few catheters as possible.
Complications
With the advent of micropuncture technology, targeted punctures, and improved
antibiotics, biliary drainage is much safer now than when first developed. Major
complications include bleeding and sepsis. Coagulopathy must be addressed prior
to drainage and all patients should receive prophylactic antibiotics. Complications
such as pneumothorax and biliary-pleural fistula are very uncommon.
Internal Stent Placement
General Considerations
Internal stents may provide drainage with improved quality of life compared to
percutaneous drainage catheters. Most interventionalists place self-expanding, flexible
metallic stents. Metal stents cannot be changed, and because of limited duration of
patency (generally 5-7 months) they are rarely employed in benign disease (Figs.
4A-D). Plastic stents can be placed percutaneously and may be appropriate in
certain situations.
While most patients and referring physicians are anxious to have percutaneous
drainage catheters converted to internal stents as quickly as possible, it is important
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to consider each case carefully to determine the appropriate timing for internaliza-
tion. In general, when one is confident that no future drainage procedures will be
necessary or possible, it is appropriate to place an internal stent. In cases of low bile
duct obstruction, stent placement may be primarily performed. In cases where a
stent would extend above the confluence, the stent may interfere with future inter-
ventions and placement should be delayed until all necessary drainage procedures
have been performed. Multiple stents may be placed at the same time. Nearly all

metallic biliary stents are self expanding. Balloon dilatation is extremely painful,
and is rarely, if ever, indicated. In general, if a stent is not fully expanded immedi-
ately (as is often the case), a small angiographic catheter (usually 5F) may be left
through or above the stent to maintain access to the biliary tree. The patient is
brought back to the interventional suite the following day to assess stent expansion
and function. If for any reason an additional stent is needed, it is placed at that time.
The small “covering” catheter is removed only after stent adequacy is documented.
Other Transhepatic Percutaneous Biliary Interventions
Percutaneous, transhepatic biliary access may also be used to allow balloon dila-
tion of strictures, removal of intrahepatic stones, and delivery of brachytherapy or
other intraductal therapies.
Figs. 4.3A-F. Percutaneous biliary drainage catheter placement and subsequent
conversion to Wallstent® (Boston Scientific, Watertown, MA) in a patient with meta-
static pancreatic carcinoma. The patient had undergone a gastrojejunostomy and
could not be approached endoscopically.
Fig. 4.3A. Contrast enhanced CT image showing hepatic metastases, more pronounced
in the right hemiliver. Both the right and left portal veins are patent.
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Most interventional radiologists and surgeons agree that the best long-term out-
come for treatment of bile duct strictures can be expected from primary repair by an
experienced hepatobiliary surgeon. Surgical success may be more limited in patients
who are poor surgical candidates, have portal hypertension, or who have had previ-
ous attempts at surgical repair. These patients may best be treated with percutane-
ous drainage and balloon dilatation. The best results of percutaneous treatment can
be expected in cases of short segment, late presentation, low bile duct strictures.
Balloon dilatation is generally performed as a staged procedure after placement
of a percutaneous drainage catheter. Strictures well below the confluence can gener-
ally be treated with one balloon. Strictures at or near the hilus may require two or

more catheters that permit sequential or simultaneous dilation (using “kissing bal-
loons”) at more than one site. After initial dilatation, a 10-12 F drainage catheter is
left across the treated stricture(s) for approximately 4 weeks, at which time the pa-
tient returns for cholangiographic evaluation. If narrowing persists, repeat dilation
may be performed with a larger balloon, followed by another 4-week period with
the drainage catheter across the treated segment. Once the stricture is shown to be
well treated, a catheter is left above rather than across the treated area. This catheter
is then capped, allowing a physiologic trial of the adequacy of dilation to be per-
formed. If this is well tolerated by the patient, the catheter can be removed. Patients
who fail repeated dilation may require long-term catheter drainage or an attempt at
surgical repair or bypass. As mentioned earlier, due to limited long-term patency, we
are hesitant to place metallic stents to treat benign disease. Stents may be placed in
patients with limited life expectancy due to comorbid conditions or in other rare
cases. A proposed etiology for restenosis after metal stent placement is that the metal
Fig. 4.3B. Image from a left sided percutaneous biliary drainage shows the 21 gauge
puncture needle in a peripheral lateral segment duct.
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wire in biliary stents may cause chronic irritation and mucosal hypertrophy. For this
reason, we prefer to use a stent with the least amount of metal in contact with the
duct wall to treat benign disease.
Brachytherapy involves the local delivery of radiation and may be used to treat
intraductal tumor. The radiation source is generally delivered via catheters placed
through recently inserted metal stents. In addition to providing local treatment of
tumor, brachytherapy may prolong the patency of metallic stents by decreasing the
rate of tumor ingrowth.
Percutaneous Abscess Drainage
Percutaneous drainage techniques may be useful in treating patients with abdomi-
nal abscesses, including hepatic abscess. Percutaneous drainage may be necessary to

Fig. 4.3C. The needle was successfully exchanged for an angiographic catheter,
which was advanced over a steerable wire to the duodenum. This catheter assembly
was then exchanged for the internal-external drainage catheter shown here. The
catheter extends from the lateral segment duct across the common hepatic duct
occlusion and terminates with the distal pigtail in the duodenum. The image nicely
depicts the level of obstruction and shows that this catheter drains both the right
and left hemi-livers.
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treat postoperative abscesses or other collections of fluid such as bile or infected
ascites. Abscess can be diagnosed based on clinical and radiographic findings. Drainage
catheters can be placed under CT, ultrasound, or fluoroscopic guidance.
Fig. 4.3D. Immediately after conversion of the drainage catheter to a Wallstent®.
The catheter has been removed over a guidewire, which extends via the lateral
segment to the distal duodenum. The stent has not yet been opened or shortened to
its stated dimensions and is seen extending from the distal 3rd duodenum to the
left hepatic duct.
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A primary pyogenic liver abscess can also be treated by percutaneous catheter
placement under imaging guidance. Liver abscess may be associated with stone dis-
ease or biliary obstruction (an infected biloma), or may develop due to ascending infec-
tion via the portal venous system in such entities as diverticulitis and appendicitis.
Fig. 4.3E. One day after placement of the stent. The stent has opened and short-
ened. Scout image prior to injection of contrast. An angiographic catheter is still
present through the stent to allow injection of contrast to assess for stent patency
and location within the biliary tree.
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Abscesses which develop spread from the portal venous system may be associated
with septic pyelophlebitis. Imaging findings of a hepatic mass with portal vein occlu-
sion may mimic those of primary hepatocellular carcinoma. Absence of clinical or
imaging findings of cirrhosis, clinical signs and symptoms of infection, and appro-
priate antecedent history suggest the correct diagnosis. Percutaneous needle aspira-
tion may be performed for confirmation and be followed by percutaneous drainage.
Hepatic abscesses are frequently multi-septated, and it is often impossible to com-
pletely evacuate them at the time of initial catheter placement. However, with im-
age-guided catheter manipulation and appropriate antibiotics, most abscesses can
be effectively managed with a single catheter. There are those who advocate treat-
ment with aspiration alone or with aspiration combined with intracavitary antibiot-
ics. While this obviates the need for patients to deal with a catheter, more than one
aspiration is generally required for complete treatment.
Fig. 4.3F. The angiographic catheter has been positioned at the top of the stent, and
contrast has been injected. The stent is perfectly positioned from the confluence of
the right and left hepatic ducts to the duodenum. The intrahepatic ducts are de-
compressed, and contrast flows nicely through the stent.
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Percutaneous Hepatic Cyst Drainage
Similar interventional techniques may be applied in the treatment of simple
hepatic cysts as well as echinococcal cysts. Simple hepatic cysts are relatively common.
High quality imaging is mandated to prove that all criteria for a simple cyst are met.
Cystadenomas, cystadenocarcinomas, and cystic metastases must not be overlooked.
Asymptomatic simple cysts do not require treatment. Hepatic cysts may become
symptomatic due to their large size which can cause pain or compression of adjacent
structures. Historically, therapy for large hepatic cysts has been surgical, now often

performed laparoscopically. However, percutaneous drainage is a viable alternative
which may obviate the need for surgery in a variety of situations. Catheter place-
ment may be combined with sclerotherapy using absolute alcohol, betadine solu-
tion, or an antibiotic solution.
Fig. 4.4A. A biliary obstruction above the bifurcation of the right and left hepatic
ducts was noted. Separate punctures were performed and internal/external biliary
catheters were placed through the obstruction and into the duodenum.
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While percutaneous treatment or even aspiration of hydatid cysts has traditionally
been avoided due to the risk of anaphylaxis, the procedure can be performed safely and
may be combined with injection of hypertonic saline or other scolicidal agents.
Percutaneous Methods for Ablation of Hepatic Neoplasms
General Considerations
While surgery remains the best hope for curative treatment in patients with most
primary and secondary malignancies of the liver, many patients are not candidates
for resection at the time of their presentation. This may be due to the extent or
distribution of disease, underlying liver function or general medical condition of the
patient. For these patients, minimally invasive, percutaneous ablative techniques
represent attractive therapeutic alternatives. Ablative therapies performed by
interventional radiologists include arterial embolization or chemoembolization, and
chemical or thermal ablation.
Embolotherapy
General Considerations
Transarterial embolization of hepatic tumors is made possible by the dual blood
supply of the liver. While the preponderant blood flow to normal hepatic paren-
chyma comes from the portal vein, the major blood supply to many liver tumors is
derived from the hepatic arterial system. This treatment has been used primarily to
Fig. 4.4B. Fluroscopy was used to confirm positioning of the biliary catheters.

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treat hypervascular tumors such as hepatocellular carcinoma, neuroendocrine me-
tastases, certain sarcomas, and metastases from ocular melanoma.
Some authors believe that embolic therapy should include the local administra-
tion of chemotherapy, referred to as chemoembolization. They theorize that pro-
longed retention of chemotherapeutic agents can be accomplished by concomitant
intra-arterial administration of chemotherapy and embolic material, including io-
dized oil and particulate matter such as Gelfoam or polyvinyl alcohol particles. At
our institution, bland embolization (without chemotherapy) is performed. We be-
lieve that tumor necrosis results from ischemic cell death, and our technique at-
tempts to maximize tumor ischemia while limiting side effects and complications
associated with chemotherapeutic agents.
Indications
Embolization is performed in an attempt to prolong survival in patients with
hepatocellular carcinoma and non-neuroendocrine, hypervascular liver metastases
Fig. 4.4C. Self-expanding metallic stents were placed. Access to the left system has
been removed, while a guidewire remains within the right ductal system.
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who are not surgical candidates. Since neuroendocrine tumors tend to be quite in-
dolent, embolization of neuroendocrine metastases is generally indicated for relief
of symptoms due to hormonal production or tumor bulk. Embolization is occasion-
ally performed to control rapidly enlarging masses.
Contraindications
Embolization should not be performed in the presence of jaundice or hepatic
failure. Better results can be expected for Childs A or Okuda I classified patients.
Any coagulopathy must be corrected and premedication must be given, if necessary,

for contrast allergy. Portal vein thrombosis is a relative contraindication depending
on the distribution of disease, presence of reconstitution, and direction of flow. The
risk of hepatic failure must be considered carefully in this situation. Embolizing very
large tumors carries an increased risk of abscess formation, and size greater than 12
cm is a relative contraindication to embolization.
Technique
Patients are premedicated with prophylactic antibiotics and antiemetics. Patients
with neuroendocrine tumors are given prophylactic octreotide as well. Even nonfunc-
tional neuroendocrine tumors may produce a low level of hormone(s). During or im-
Fig. 4.4D. Completion fluoroscopy demonstrates two well-expanded metallic stents
within the right and left ductal system.
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mediately after embolization, massive cell death may result in the release of vasoactive
substances that can cause hemodynamic instability in the absence of premedication.
A right femoral arterial approach is preferred. Arterial anatomy and portal vein
patency is assessed (Fig. 4.5A). The arterial vascular supply to the tumor(s) is then
determined. The embolization technique varies slightly based on the distribution
and type of tumor. Focal cancers are treated as sub-selectively as possible, with the
smallest particles available (currently 50 micron PVA). Sub-selective treatment in-
volves injecting the embolic material suspended in radiographic contrast directly
into the arterial branches supplying the mass via catheters, or microcatheters posi-
tioned under fluoroscopic/angiographic guidance. Patients with multifocal disease
are also treated as selectively as possible, but this frequently necessitates emboliza-
tion of an entire hemiliver. Even if disease is widespread and bilateral, only one
hemiliver is treated at a time to minimize the risk of hepatic failure. Embolization is
complete when antegrade flow in the vessel(s) supplying the tumor(s) is no longer
present (Fig. 4.5B). At times it is necessary to use larger particles (100 or 200
micron) as the embolization progresses in order to limit the length of the pro-

cedure and amount of contrast used. It is also occasionally necessary to search
for other nonhepatic arterial branches supplying the tumors, most commonly
those arising from the right phrenic artery.
Most patients will experience some degree of postembolization syndrome (PES)
after the procedure. This consists of pain, nausea and vomiting, and/or fever. All
patients are maintained on antibiotics and antiemetics for 24 hours. Many patients
will require patient-controlled analgesia (PCA) pumps. PES is generally self-limited,
and typically lasts from 24-72 hours.
Percutaneous Ethanol Injection Therapy (PEIT)
General Considerations
Absolute ethanol causes cell dehydration and denaturation as well as small ves-
sel occlusion, presumably due to endothelial cell damage. PEIT has been used to
treat focal HCC. In general, up to three tumors smaller than 5 cm in diameter can
be treated. It is thought that HCC masses are relatively “soft” in the background of
a “hard” cirrhotic liver, promoting distribution of alcohol in the tumors. The converse
situation occurs with most secondary liver tumors, and PEIT is not indicated for
metastases.
Technique
PEIT is most commonly performed using ultrasound guidance but CT guidance
may also be used. Procedures are performed using local anesthesia with conscious seda-
tion. We use a 22 G Westcott type needle to deliver the ethanol, but almost any needle
can be used. The approximate ethanol volume is calculated from the formula V=4/
3p(r+0.5)
3
. Often it is not possible to inject the entire amount in one session. Even
when the lesion can be well covered in a single treatment, most patients are brought
back the following day for at least a “touch-up”. The platelet count should be checked
daily until treatment is complete as thrombocytopenia may occur after each treatment.
Ideally, we perform PEIT the day after arterial embolization in an attempt to
maximize cytotoxic insult to the tumor, although PEIT certainly may be performed

as a “stand-alone” procedure. We have found that patients are more likely to tolerate
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injection of the entire “calculated” ethanol volume when PEIT is performed the day
after embolization then when it is performed alone.
Radiofrequency Ablation (RFA)
RFA involves inserting a probe with an insulated shaft and un-insulated tip into
a tumor. Probes may be straight or may contain multiple wire tines that are de-
ployed from within the shaft of the probe and opened to various diameters. Grounding
pads are placed on the patient to form an electrical circuit. Current is then applied
to the tip(s) of the probe. Ionic agitation causes frictional heating and results in
coagulation necrosis. Current flow decreases as impedance from tissue desiccation
increases. Currently, the largest diameter necrotic lesion that can be created with a
single probe is approximately 5 cm. Larger areas of necrosis can be created by heat-
ing overlapping spheres of tissue.
Probes are currently 15-19 G, and are most commonly positioned using ultra-
sound guidance. The effectiveness of RFA may be limited by surrounding struc-
tures. Large vessels, such as the inferior vena cava or major hepatic or portal vein
branches, may act as “heat sinks.” Flowing blood through these vessels allows ap-
plied energy to be dissipated and cools the edge of the adjacent tumor making it
impossible to achieve a “treatment margin.” One must also consider potential risk
to adjacent structures such as bowel, gallbladder and diaphragm.
As with PEIT, this ablative treatment is usually performed using local anesthesia
and conscious sedation and may be performed on an outpatient basis.
Figs. 4.5A,B. Arterial emoblization of hepatocellular carcinoma in the right hemiliver.
Fig. 4.5A. Arterial phase image shows a hypervascular mass supplied by branches
of both the anterior and posterior divisions of the right hepatic artery.
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Other Percutaneous Ablative Therapies
Cryoablation probes are not yet small enough to be placed percutaneously, and
percutaneous thermal ablative treatments are currently limited to those that cause
necrosis through heating. In addition to RFA, other less popular modalities that
cause coagulative thermal necrosis include interstitial laser photocoagulation, per-
cutaneous microwave coagulation therapy and high-intensity focused ultrasound.
These techniques are investigational and not widely used at this time; and discus-
sion of each technique is beyond the scope of this chapter.
Portal Vein Embolization
Since most of the trophic blood flow to the liver is via the portal vein, emboliza-
tion of a portion of the portal vein will cause atrophy of the embolized segments or
hemiliver with hypertrophy of the untreated portion. This procedure may be useful
for patients who will undergo resection of a large amount of functional hepatic
parenchyma in order to resect a small volume of disease and/or those who will be left
with a very small amount of residual liver after resection. At our institution, we have
begun to perform embolization of the right portal vein prior to right trisegmentectomy
in patients with small left lateral segments and a large volume of uninvolved right-sided
parenchyma.
Fig. 4.5B. Post-embolization arterial phase image. The branches supplying the tumor
have been sub-selectively embolized. The mass is no longer demonstrated.
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Technique
A peripheral branch of the portal vein is accessed using a percutaneous transhepatic
approach (Figs. 4.6A-H). We prefer to work ipsilateral to the side of embolization to
avoid inadvertent injury to the liver that will remain postoperatively. Various embo-
lic materials have been employed. We use medium size polyvinyl alcohol (PVA)
particles (200µ-300µ) but have also used absolute ethanol. Ethanol requires the use

of occlusion balloons and is not visible radiographically making it somewhat more
cumbersome.
Patients generally wait approximately 2-4 weeks after portal vein embolization
before they undergo resection.
Transjugular Intrahepatic Portosystemic Shunts (TIPS)
Indications
TIPS is indicated for the treatment of recurrent variceal bleeding which
has not responded to medical and/or endoscopic therapy, or for the control of
refractory ascites.
Contraindications
Absolute contraindications include severe hepatic failure and severe right heart
failure, both of which would be exacerbated by shunt creation. Relative
contraindications include portal vein thrombosis, HCC, hepatic metastases, and
polycystic disease involving the liver.
Technique
The procedure can usually be performed using conscious sedation. Ideally, the
right internal jugular is used, although TIPS can be done using the left internal
jugular vein or the external jugular veins. A catheter is placed through a long sheath
into an hepatic vein (usually the right) where a wedge hepatic venogram is performed.
A long steerable needle is then advanced from the hepatic vein to the portal vein.
Most commonly, the right hepatic and right portal veins are used if possible. A wire
is then advanced to the superior mesenteric or splenic vein and pressures are re-
corded. The shunt tract is then predilated with a balloon, after which a flexible
metal stent, usually 10 or 12 mm, is deployed and dilated. Increasingly, covered
stents are being utilized to prevent thrombosis thought to result from communica-
tion with the biliary tree. Pressure gradients between the portal and systemic sys-
tems are obtained. Ideally, a successful TIPS will produce a gradient between the
portal vein and the IVC of between 6 and 12 mm Hg is achieved.
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Figs. 4.6A,B. Portal vein embolization in a patient with colorectal carcinoma meta-
static to liver. The patient had one mass in the lateral segment and another in the
central aspect of Segment VIII, adjacent to the right hepatic vein and the inferior
vena cava, and approaching the middle hepatic vein. The patient underwent em-
bolization of the right portal vein in anticipation of right trisegmentectomy and
wedge resection of the lateral segment mass.
Fig. 4.6A. Contrast enhanced CT image demonstrating the mass in Segment VIII
before embolization.
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Fig. 4.6C. Percutaneous portal venogram prior to embolization. The catheter has
been placed via a right portal venous branch, and the tip of the catheter is within
the main portal vein.
Fig. 4.6B. Contrast enhanced CT image demonstrating the mass in Segment III before
embolization.
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Fig. 4.6D. Percutaneous portal venogram after embolization of the right portal vein.
The catheter is within the main portal vein. Only the left portal venous branches
remain patent. Opacified vessels overlying the right hemiliver are patent Segment
IV branches.
Fig. 4.6E. Contrast enhanced CT image at the level of the Segment VIII lesion, approxi-
mately 2 weeks after embolization of the right portal vein. Note the left liver hypertro-
phy with resultant rotation of the middle hepatic vein toward the right.
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Fig. 4.6F. Post embolization image from a CT Portogram at the same level. Note the
striking perfusion defect in the right hemi-liver.
Fig. 4.6G. Contrast enhanced CT image at the level of the Segment III lesion, approxi-
mately 2 weeks after embolization of the right portal vein. Note the enlargement of the
lateral segment and the unopacified portal vein branches in the right hemi-liver.
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Fig. 4.6H. CT portogram image at the same level as “G.” Note the perfusion defect
in the right hemi-liver.