Liver neoplasms, chemotherapeutic infusion. Shunts, portohepatic

59세/ 남자

liver cirrhosis, Child A HBs Ag(+) elevated AFP, esophageal varix

초음파상 간우엽에 multiple hyperechoic mass가 보이고 spiral CT상 arterial phase에서 조영 증강이 뚜렷한 nodule이 보인다. 혈관조영술상 mass는 hypervascular했고 arterioportal shunt가 동반되어 있었다.

Multiple hyperechoic masses are seen in the right lobe of liver (a). Theses masses show prominent enhancement on the arterial phase of spiral CT (b). Multiple hypervascular masses are associated with arterioportal shunts on the angiogram (c,d).

After injection of 5cc of Lipiodol emulsion with SP catheter, it was well accumulated within tumor as well as adjacent portal vein branch even though fistula was already occluded with Gelfoam (a). On post-TAE angiogram, shunt is still existing but markedly reduced (b). Three-week follow-up CT shows compact accumulation of Lipiodol in the liver and atrophic change of the surrounding liver due to occlusion of portal vein branch by Lipiodol(c)

Terumo SP 카테터를 right hepatic artery에 깊숙히 넣어서 Gelfoam 덩어리 (1.5mm x 1.5mm)로 arterioportal vein shunt를 어느정도 막은 뒤 lipiodol 5cc와 Adriamycin 30mg의 혼합액을 천천히 주입하였다. Lipiodol은 tumor내 뿐만 아니라 일부는 shunt로 빠져 나가서 주위 portal vein 분지까지 축적되어 있는 것을 관찰할 수 있었다.

Arterioportal shunt는 간암에 자주 동반되는 데 이때 Lipiodol을 그대로 injection하게 되면 shunt를 통해 portal vein으로 빠져나가 버려 간암내에 축적이 불충분하게 되고 또 portal vein으로 빠져나간 lipiodol로 인해 주위 정상산의 infarction이 초래될 염려가 있다. 따라서 Gelfoam으로 fistula를 우선 막고 난 뒤에 lipiodol을 injection해야 한다.

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