Percutaneous transhepatic variceal embolization (PTVE) has a long history of clinical application and is a simple, inexpensive, and reliable technique for immediate hemostasis, first reported by Swedish scholars Lunderquist and Vang in 1974. It was first reported by Swedish scholars Lunderquist and Vang in 1974 and was the main method of interventional treatment of ruptured esophagogastric variceal bleeding in the 1980s. With the development of endoscopic treatment techniques and TIPSS, the use of PTVE has tended to decrease gradually, but it is still a proven and practical technique. In recent years, the popular use of micro puncture needle (21-23G) in clinical practice has improved the safety of PTVE. Ding Pengxu, Department of Radiological Intervention, First Affiliated Hospital of Zhengzhou University
I. Indications and contraindications
(A) Indications
1.Impossible to treat by internal medicine and the bleeding does not stop.
2.Control of acute bleeding, improvement of the patient’s condition and preparation for elective bypass surgery.
3.The bleeding has been temporarily controlled but refuses to operate or cannot tolerate the operation.
4, those who bleed again after bypass surgery or after endoscopic sclerotherapy injection.
5.Other people who need to know the alteration of portal hemodynamics for ordering bypass surgery plan.
(B) Contraindications
1, the existence of contraindications to angiography, such as coagulation disorders, bleeding tendency can not be corrected after active treatment (including the administration of hemostatic agents, coagulation factors, blood transfusions, etc.)
2, portal vein obstruction or spongiform degeneration.
3, severe cachexia with an expected survival index of <2 weeks
4, those who cannot cooperate with the examination, especially those with confused awakening and severe psychiatric symptoms.
5, relative contraindication with large amount of ascites, difficulty in avoiding tumor by puncture tract, severe hepatic atrophy, etc. When PTVE is really necessary in these cases, ascites should be released, hemostatic agents given, and backup emergency measures (such as blood transfusion, selective hepatic artery embolization, etc.) as appropriate.
6, those with fever and systemic infections.
7, liver and kidney dysfunction.
8, coronary heart disease, hypertension, heart rate arrhythmia, heart failure and other serious heart disease patients.
Second, the operation steps
1.Disinfection of the liver area with towel and local anesthesia at the puncture site; 2.Percutaneous hepatic puncture of the portal vein branches.
3.Exchange into the catheter for portal vein imaging and pressure measurement; 4.Exchange into the catheter for super-selection into the gastric ductus venosus and imaging.
5, embolization of the gastric ductus venosus; 6, portal vein review angiography and pressure measurement.
7.Close the puncture path.
III. Illustration of surgical operation steps
Figure 1: Percutaneous hepatic puncture of portal vein using puncture needle Figure 2: Portal venography after successful puncture
Figure 3: After hyper-selecting the catheter to the gastric coronary vein Figure 4: After using the spring ring, the angiogram shows
The contrast shows esophagogastric fundic varices and complete embolization of the gastric coronary vein
Figure 5: Closure of the puncture tract with a spring ring and gelatin sponge
IV. Complications and their prevention and treatment
1. Intra-abdominal bleeding is mostly caused by the failure of closure of the puncture path. In patients with cirrhosis, the liver itself is compliant, the patient has poor coagulation function, and the number of platelets is reduced, which makes bleeding easy and not easy to stop by itself. In addition, during the puncture operation, the patient’s violent coughing and large breathing movements can tear the liver peritoneum. Conservative treatment is generally feasible for small amount of bleeding. For large amount of bleeding, surgical treatment should be performed along with blood and fluid transfusion.
2. subperitoneal hematomas of the liver are usually self-absorbing and do not require special treatment.
3. fistula formation includes fistulas between hepatic artery-portal vein, arterial bile duct, and hepatic artery-vein; small fistulas do not require special treatment, and large fistulas caused by the hepatic artery can be treated with hepatic artery embolization
4. cholestatic peritonitis caused by bile spillage in the intrahepatic bile ducts through the puncture path, the key to prevention is to close the puncture path.
5, portal vein thrombosis can be formed spontaneously due to slow portal blood flow, or can be caused by embolic agent injection or backflow into the portal vein and catheter damage to the portal vein wall. Soft-tipped catheter and guidewire should be used during operation, and the operation should be completed under fluoroscopic surveillance, and postoperative anticoagulation or platelet removal prophylaxis can be performed if necessary.
6. The location of the pneumothorax puncture site is chosen too high. The way to avoid this is to position the puncture under fluoroscopy. A small amount of pneumothorax need not be treated, and a large amount of pneumothorax should be subjected to negative pressure drainage.
7, intrathoracic hemorrhage is usually caused by injury to the intercostal artery and pulmonary artery during puncture. Puncture should be far from the lower edge of the ribs.
8, mispuncture of other organs in the abdominal cavity are common gallbladder and colon, mainly due to improper puncture location and direction. Image-guided puncture can reduce the occurrence of such complications.
V. Postoperative follow-up
1.Laboratory examination of routine blood, liver function, kidney function and methemoglobin regularly to monitor changes in condition.
2, fiberoptic gastroscopy in 6 to 12 months after the upper gastrointestinal endoscopy or barium meal, focusing on the improvement of esophageal and gastric fundic varices.
3, CT/MRI: CT/MRI should be performed if necessary to further clarify liver lesions, especially for the presence of occupying lesions.
VI. Efficacy evaluation
The advantages of PTVE include low technical difficulty, short operation time, low cost, minimal impact on liver function, and high success rate of emergency hemostasis (75%-95%), which is an emergency means for patients with emergency bleeding who do not have endoscopic treatment conditions or poor endoscopic treatment results, and do not have indications for bypass (including TIPS) and dissection. There is no evidence-based medical evidence on whether PTVE can be used as a measure to prevent ruptured variceal bleeding. For severe fundic varices with high risk of rupture and limited emergency conditions, PTVE can be considered for those who do not consider other therapeutic measures (bypass, dissection, TIPSS, BORTO, etc.).
The disadvantage of PTVE is that it does not reduce portal vein pressure, and most patients have varying degrees of elevated portal vein pressure (5-10 cmH2O) after embolization of varices, the latter of which can lead to postoperative ascites, re-establishment of side branches, and formation of new varices. In addition, the rate of recurrent bleeding after PTVE is high, with the literature reporting rebleeding rates of 55%, 66%, 80%, and 90% at 6 months, 1, 2, and 3 years postoperatively. Combining PTVE with partial splenic artery embolization can reduce portal vein pressure, decrease the incidence of postoperative recurrent bleeding, and improve the symptoms of hypersplenism; combining PTVE with transendoscopic approach to varicose veins can also improve the hemostatic effect.