| PART I To evaluate the clinical significance of CT angiography in diagnosis of arterioportal shunts associated with HCCObjective To evaluate the clinical significance of CT angiography (CTA) in diagnosis of arterioportal shunts (APS) associated with hepatocellular carcinoma (HCC). Methods 127 consecutive HCC patients accepted both dynamic enhancement CT and digital subtraction angiography (DSA) examinations. The interval between CT and DSA exam is from 3 to 15 days. Based on transverse CT images in hepatic artery phase, CTA was performed for all the patients with positive APS signs in dynamic enhancement CT or DSA exams. By contrast with DSA results, we analyzed the features of APS and the capabilities of transverse CT and CTA images in APS diagnosis.Results In all 127 HCC cases, 52 cases with APS were conformed by DSA (40.9%), 33 with central type of APS (26%), 19 with peripheral type (15%). For all 33 cases with central type of APS conformed by DSA, we didn't found any false negative cases both on transverse CT and CTA images; combined with CTA, we excluded all the four false positive cases showed by transverse CT images. For the 19 cases with peripheral type of APS in DSA, 3 cases displayed false negative results both in transverse CT and CTA images; CTA excluded 6 from 8 false positive cases displayed in transverse CT images. Combined CTA to transverse CT images, diagnosis sensitivity of APS reached to 94.2% (49/52); specificity reached to 97.3% (73/75); accuracy reached to 97.6% (124/127); the predictive value of positive cases was 100% (49/49) and the predictive value of negative cases was 96.2% (75/78). In all 49 cases with APS showed in CT exam, 40 cases (81.6%) had the same range of early enhanced portal vein in arterial phase in CTA as in DSA. By contrast with DSA, the coincidence rate of the type of APS diagnosed by CTA was 88.5% (46/52), 90.9% (30/33) of central type of APS and 84.2% (16/19) of peripheraltype. The supplying arteries of central type of APS were intuitively displayed by CTA in 23 cases, 19 from proper hepatic artery, 4 from gastro-duodenal artery.Conclusion Using CTA techniques based on the dynamic enhancement CT exams, the accuracy of APS diagnosis could match to DSA. CTA images not only can correctly show the type of APS, evaluate the shunt flow of APS, but also can intuitively display the supplying artery of central type of APS and help to analysis the mechanisms of APS. CTA techniques could provide much important information in guiding HCC treatment which complicated with APS.PART II Budd-Chiari syndrome: dynamic enhancement findings with multi-slice helical CT and CT angiography analysisObjective Using multi-slice CT to investigate the dynamic enhancement regulations of liver and their mechanism in Budd-Chiari syndrome(BCS), analysis the value of CT angiography in BCS diagnosis.Methods 28 cases with BCS confirmed by digital subtraction angiography(DSA) were retrospectively analyzed. All patients underwent dynamic enhancement examinations with multi-slice CT within 1 week before DSA. The relevant vessels were reconstructed respectively with MIP, VR and MPR. Compared with the results of DSA, we analyzed the dynamic enhancement regulations of liver in BCS, estimated the value of dynamic enhancement CT exams and CTA techniques in judging the obstruction level and showing collateral vessels. Results Of all 28 cases, CT correctly showed the obstruction level in 26 cases, and 2 had incorrect results which proved to be membranous obstruction of the inferior vena cava superior to diaphragm. In 22 cases with hepatic vein obstructions, hepatic parenchyma displayed typical patchy enhancement in 19, atypical patchy enhancement in 3. 8 cases among these showed benign nodules. Simultaneously, CT showed stenosis and rigidity of portal vein branches in 20, enlargement of hepatic artery in 14, hepatic collateral vessels in 20 out of 22 cases. In 6 cases with simple obstruction of inferior vena cava, hepatic changes were not found. Collateral circulations in or out of liver corresponded to the obstruction level.Conclusion Dynamic enhancement examinations with multi-slice CT can correctly reflect the hepatic hemodynamic changes. Transverse images, combined with CTA, can explicitly display the obstruction level of vascular lesions and collateral circulations in BCS.PART HI Comparison of long term effects of intra-arterially delivered ethanol and gelfoam for the treatment of severe arterioportal shunt in patients with hepatocellular carcinomaObjective To evaluate long-term effect of ethanol embolization for the treatment of hepatocellular carcinoma (HCC) with severe hepatic arterioportal shunt (APS), compared with Gelfoam embolization.Methods 64 patients (ethanol group) and 33 patients (Gelfoam group) with HCC and APS were respectively treated with ethanol and Gelfoam for APS before the routine interventional treatment for the tumor. Frequency of recanalization of shunt, complete occlusion of the shunt, side effects, complications, and survival rates were analyzed in two groups. Results The occlusion rate of APS after initial treatment in ethanol group was 70.3%(45/64), and recanalization rate 1 month after embolization was 17.8%(8/45), and complete occlusion rate was 82.8%(53/64). Those in Gelfoam group were 63.6%(21/33), 85.7%(18/21), 18.2%(6/33). There were significant difference in recanalization rate and complete occlusion rate between two groups (P<0.05). The survival rate in ethanol group were 78% at 6 months, 49% at 12 months, 25% at 24 months, whereas those in Gelfoam group were 58% at 6 months, 23% at 12 months, 15% at 24 months. The ethanol group showed significantly better survival than Gelfoam group (P<0.05). In the ethanol group, there was a significant prolongation of survival in patients with monofocal HCC (P<0.05) and Child class A (P<0.05). There were no significant differences in survival rate in the Gelfoam group according to number of tumor and Child class (P>0.05). The incidence rate of abdominal pain during procedure in ethanol group was 82.8%. There was no significant difference in postembolization syndromes between two groups. Procedure-related hepatic failure was not occurred in ethanol group.Conclusion Ethanol embolization for patients with HCC and severe APS was efficacious and safe, and may contribute to prolongation of the life span versus Gelfoam embolization.PART IV Interventional treatment for Buddi-Chiari syndrome with occlusive hepaticveinsObjective To investigate the interventional methods for Buddi-Chiari syndrome with occlusivehepatic veins and evaluate its therapeutic effects.Methods Thirty-six patients are included in thi study (male 19 cases and female 17cases) aged from 24-63 years old (mean 42.3years). The live functions were Child A in 9 cases, Child B in 21 cases, and Child C in 6 cases. The interventional methods included recanalization of occlusive hepatic veins (by transjugular, transfemoral, and percutaneous transhepatic route), transjugular intrahepatic portosystemic shunt (TIPS).Results Successful recanalization of occlusive hepatic veins were carried out in 19 cases, the pressure of hepatic veins decreased from 37.4 ± 5.24 cmtbO (mean ± SD) to 21.4 ± 4.62 cml^O after recanalization of occlusive hepatic veins (T=12.34, P <0.01). The intrahepatic shunt between port vein and inferior vena cava were successfully built and good clinical responses were obtained in all of 12 patients. The main portal pressure decreased from 45.2 + 3.52 ant^O to 20.4 ±4.12 cmH20 posterior to the shunt.Conclusion There were various interventional methods for Buddi-Chiari syndrome with occlusive hepatic veins, Correct selection of interventional methods can significantly decrease the pressure of hepatic vein and portal vein, and meliorate or eliminate the symptoms and pathological signsPART V Portal venous stent placement for treatment of portal hypertension caused bybenign main portal vein stenosisObjective To evaluate the value of endovascular stent in the treatment of portal hypertensioncaused by benign main portal vein stenosis.Methods Portal vein stents were implanted in 6 patients with benign main portal vein stenosis(inflammatory stenosis in 3 cases, postprocedure of liver transplantation in another 3 cases).Changes in portal vein pressure, portal vein patency, relative clinical symptoms, complicationsand survival were evaluated.Results Six metallic stents were successfully placed across the portal vein stenotic orobstructive lesions in 6 patients. Mean portal venous pressure decreased significantly after stentimplantation from (37.3±4.7) cm H2O to (18.0±1.9) cm H2O. The portal blood flow restored andthe symptoms caused by portal hypertension were eliminated. There was not any severerelated-procedure complication. The patients were followed up for 1 -48 months. The portal veinremained patent during follow-up. All patients survived except for one patient who died of other complications of liver transplantation.Conclusion Percutaneous portal vein stent placement for the treatment of portal hypertension caused by benign main portal vein stenosis is safe and effective.
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