Bile duct, disease, Stenosis, venous, Endoprostheses, vascular

F/73 A 73 years old woman was referred to interventional radiology for the diagnosis and management of the stenosis at the inferior vena cava (IVC) after hepatic surgery. Initially, she was transferred from a local clinic because of chronic dull pain over the right upper quadrant of the abdomen. Her symptom had started about 5 years ago and aggravated in recent three days before admission. Her vital sign was stable at initial visit and she looked not so ill. An about 80x55x54 mm sized multiloculated cystic mass with slightly enhancing soft tissue lesions of mural nodules inside was seen at the posterior segment of the right lobe on initial CT. Part of the mass protruded lobulating through the hepatic capsule and the other also protruded to abut the IVC inferiorly. After the diagnosis of biliary cystadenocarcinoma invading the IVC, she underwent the operation of right lobectomy, Roux-en-Y hepaticojejunostomy and segmental resection and reconstruction of the retrohepatic IVC with a gortex graft. Ascites and lower extremity swelling were not improved until 6 days after the operation and IVC stenosis was suspected. IVC venographies were obtained with a 5-Fr pig-tail type angiocatheter (Pig, DAV, Cook, Bloomington, IN, USA) through the right femoral vein in an interventional suite. Venographies showed no significant stenosis at the anastomosis site between the gortex and suprarenal IVC but collateral veins draining through paravertebral plexuses. The Hepatic segment of the IVC was poorly visualized because of much of venous drainage was done through paravertebral plexuses, but no stenosis was noted, also. Pressure gradient was measured between the right atrium and infraanastomsis segment of the inserted gortex and it was 14 mmHg. Stent insertion was decided because of significant pressure gradient between the right atrium and suprarenal IVC. A large home made nitinol mesh type stent (from S&G Biotech, Seoul) was already prepared from the body of aortic stent graft with the diameter of 30 mm and the length of 120 mm to cover whole length of the operated IVC, because there was no commercially available stent covering the large diameter of the IVC. After smooth cannulation of the anastomosis site with a 5-Fr narrow angle tip angiocatheter (DAV, Cook, Bloomington,IN, USA) and a guide wire (Anlged, Radifocus, Tokyo, Japan), the large stent in introducing set was inserted with over-the-wire technique. After tipping at the junction of the right atrium and IVC, the stent was deployed. Deployment was successful and the pressure gradient between the right atrium and suprarenal IVC was decreased from 14 to 5 mmHg. Venographies showed still remained insignificant stenosis at the anastomosis site, but disappeared collateral flows through paravertebral plexuses.

Management with stent insertion in the patient with a stenosis at the IVC after major hepatic surgery and IVC resection and reconstruction due to biliary cystadenocarcinoma

Balloon angioplasty and stent insertion for the significant stenosis at peripheral arteries and central veins is a daily performing procedure in interventional suites now days. Primary stent insertion for the stenosis of the vascular anastomosis is also widely adopted because of its higher success rate, minimally invasiveness, relatively easy to access and low patient’s morbidity. There are many reports for the interventional management using balloon angioplasty and stent insertion in postoperative vascular stenoses including hepatic and portal veins. Balloon angioplasty could also be adopted, but limited in selected cases because of the potential risk to rupture or injury at anastomosis sites. Repeated balloon angioplasty is also needed in case of re－stenosis. The IVC has a tendency to collapse due to enlarging volume of the liver after major hepatic resection, so balloon angioplasty alone could not make do as expected. Stent insertion in the IVC is easy to perform but potentially complicating because of its large diameter and possible migration of stent. The first possible problem during stent insertion in the IVC starts with the diameter of the stent. Usual commercially available size of vascular stent is 16mm or lesser in the diameter. The diameter of inserted stent in this patient was extremely larger enough to cover the large IVC. It was a home made stent from the body of the aortic stent graft. For the second, enough length of the stent is also important to fix the stent in the exact position and to prevent migration. Guimaraes et al. reported smaller and short hepatic IVC stent migrated to the right atrium. In their report the stenosis and migration was overcame with oversizing the diameter and making longer by suturing-together with two short available stents. They recommended oversizing by at least 2 mm in maximal diameter, especially Wall stent type of closed cell stent. Because the larger the diameter, the higher tendency to shortening of the stent during and after deployment. In our experience, free cell type stent with nitinol mesh does not show significant size discrepancy of the length during and after deployment, so enough large size of a stent could be useful in the management of the stenosis in the IVC. For the third, the size of mesh or strut could also be a point of interest because small size of a mesh or strut could occlude branching or draining vessels by neointima formation. Vascular invasion including the hepatocaval confluence and IVC had been considered as a contraindication of hepatic resection. But after adoption of vascular resection of the involved segment with venovenous bypass and hypothermic perfusion it became contraindication no more. In this patient, IVC invasion was expected preoperatively with the diagnosis based on CT. Resection and reconstruction of the IVC was done during the operation to remove the mass invading the IVC and a gortex graft was interposed between remained retrohepatic and suprarenal IVCs. Clinical manifestations of hepatic vein or intrahepatic IVC stenosis are ascites, lower extremity swelling, abdominal pain, pleural effusion and abnormal hepatic function. These symptoms occur due to increased venous pressure of the hepatic vein and IVC inferior to hepatic segment. Correction of the stenosis is mandatory to improve these symptoms and to recover patients from an operation. In this case, the patient was successfully managed with surgical operation of major hepatic resection due to large biliary cystadenocarcinoma and resection and reconstruction of the tumor invading the IVC. The post-operative vascular complication of the IVC stenosis was also successfully managed by large stent insertion.

1. Azoulay D, Andreani P, Maggi U, et al. Combined liver resection and reconstruction of the supra-renal vena cava: the Paul Brousse experience. Ann Surg 2006;244:80-88 2. Shin JH, Sung KB, Yoon HK, et al. Endovascular stent placement for interposed middle hepatic vein graft occlusion after living-donor liver transplantation using right-lobe graft. Liver Transpl 2006;12:269-276 3. Raju S, Hollis K, Neglen P. Obstructive lesions of the inferior vena cava: clinical features and endovenous treatment. J Vasc Surg 2006;44:820-827 4. Kubo T, Shibata T, Itoh K, et al. Outcome of percutaneous transhepatic venoplasty for hepatic venous outflow obstruction after living donor liver transplantation. Radiology 2006;239:285-290 5. Park KB, Choo SW, Do YS, et al. Percutaneous angioplasty of portal vein stenosis that complicates liver transplantation: the midterm therapeutic results. Korean J Radiol 2005;6:161-166 6. Ing FF, Fagan TE, Grifka RG, et al. Reconstruction of stenotic or occluded iliofemoral veins and inferior vena cava using intravascular stents: re-establishing access for future cardiac catheterization and cardiac surgery. J Am Coll Cardiol 2001;37:251-257 7. Guimaraes M, Uflacker R, Schonholz C, Hannegan C, Selby JB. Stent migration complicating treatment of inferior vena cava stenosis after orthotopic liver transplantation. J Vasc Interv Radiol 2005;16:1247-1252

Fig. 1 A preoperative CT scan shows a multilocular cystic mass with mural nodules inside at the posterior segment of the right lobe of the liver. Parts of the mass are seen to invade and compromise the IVC inferiorly.

Fig. 2A. A venography obtained prior to stent insertion shows no significant focal stenosis at the anastomosis site between the gortex and suprarenal IVC but collateral veins draining through paravertebral plexuses. Pressure gradient between the right atrium and infraanastomsis segment of the inserted gortex was 14mmHg.

Fig. 2B A Venography after stent insertion shows a large inserted IVC stent and still remained insignificant stenosis at the anastomosis site, but disappeared collateral flows through paravertebral plexuses. Pressure gradient decreased to 5 mmHg.