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Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
M. C. Kryger and Z. J. Haskal
Bibliography
1. Kortes N, Gnutzmann D, Konietzke P, Mayer P, Sumkauskaite M,
Kauczor HU, Radeleff BA.Occlusion of a long-term Transpleural
biliary drainage tract using a gelatin Pledget (Hep-plug™).
Cardiovasc Intervent Radiol. 2017;40(11):1800–3. https://doi.
org/10.1007/s00270- 017- 1695- 0.
2. Saad WE, Wallace MJ, Wojak JC, Kundu S, Cardella JF. Quality
improvement guidelines for percutaneous transhepatic cholangiogra-
phy, biliary drainage, and percutaneous cholecystostomy. J Vasc Interv
Radiol. 2010;21(6):789–95. https://doi.org/10.1016/j.jvir.2010.01.012.
3. Strange C, Allen ML, Freedland PN, Cunningham J, Sahn
SA.Biliopleural stula as a complication of percutaneous biliary drainage: experimental evidence for pleural inammation. Am Rev Respir
Dis. 1988;137(4):959–61. https://doi.org/10.1164/ajrccm/137.4.959.
4. Turkington RC, Leggett JJ, Hurwitz J, Eatock MM. Cholethorax
following percutaneous transhepatic biliary drainage. Ulster Med
J. 2007;76(2):112–3.
Glue Embolization ofaHigh Output
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Biliary Fistula After RFA
JorgeE.Lopera
A 74-year-old male with small bowel carcinoid tumor and
multiple liver metastases underwent radiofrequency ablation
of a segment 6 liver tumor. He developed high fevers thereafter and was admitted with sepsis 1week after the ablation.
Contrast-enhanced CT imaging demonstrated a large abscess
in the right lobe with an air -uid level (Fig.66.1). A percutaneous drain was placed in the collection and the infection
was controlled. The drain had a persistent daily bilious output of 100–200 cc for the preceding 10 days. A contrast
abscessogram showed that the cavity communicated with
biliary radicles (Fig.66.2). Cone beam CT demonstrated a
biliary stula to the segment 6 radicles with no communication with the central bile ducts (Fig.66.3).
The drain was exchanged for a 10Fr sheath, through
which an angled catheter was advanced into the biliary tree
66
Fig. 66.1 Axial contrast-enhanced CT scan shows a large abscess in
the right lobe with an air-uid level
J. E. Lopera (*)
Department of Radiology, UT Health San Antonio,
San Antonio, TX, USA
e-mail: Lopera@uthscsa.edu
Fig. 66.2 Fluoroscopic abscess study shows communication of the
cavity with multiple biliary radicles in the right lobe (arrow)
(Fig.66.4). nBCA cyanoacrylate glue mixed with Lipiodol
(Trull, Codman, Raynham, MA) in a 1:2 ratio was injected
until all the biliary radicles were casted full of glue
(Fig. 66.5). The bilious output ceased and the drain was
removed 3 days later. MRI obtained 2 years later showed
atrophy of the segment 6 (Fig.66.6). The patient’s carcinoid
disease progressed to his death 4years later.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_66
236
66 Glue Embolization ofaHigh Output Biliary Fistula After RFA
237
ab
Fig. 66.3 Cone beam CT images in axial (a) and sagittal (b) projections show the cavity (c) in communication with segment 6 biliary radicles (arrows)
Fig. 66.4 Spot radiograph shows a safety wire placed inside the
abscess cavity, a 10 Fr sheath and a 5 Fr angled catheter within the biliary system
Fig. 66.5 Spot radiograph shows multiple biliary radicles now lled
with glue. A new drainage catheter was placed over the safety wire
Fig. 66.6 Axial MRI obtained 2 years later shows abnormal signal and
atrophy of segment 6 (arrow)
EVOH Embolization ofaSubtle
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Arterio- Biliary Fistula:
FromArtery into theBile Duct
ZivJHaskal
A 71-year-old man underwent left hepatectomy and chemoradiation for cholangiocarcinoma 2years prior. Since then he
had increasing intermittent episodes of fever, chills, and
night sweats attributed to recurrent cholangitis. Imaging
showed air in the biliary tree due to his roux anastomosis and
focal ductal obstruction in the anterior margin of the residual
liver (Fig.67.1). He underwent US and uoroscopic-guided
biliary drainage of the affected segment (Fig. 67.2
Cholangiogram). One week later, he developed hemobilia
requiring transfusion; hepatic angiography (with tube withdrawal) did not reveal a cause (Fig.67.3), and the catheter
was upsized; he was discharged 4days later. He returned
emergently 4days later with recurrent hemobilia, anemic.
Hepatic arteriography was performed in multiple projections whilst lming at 7.5fps revealing a suspected irregular
narrowing and subtle enlargement of an artery traversing the
tube (Fig.67.4a, b). Because of the need to assure of embolization beyond, across, and proximal to this potential pseudoaneurysm (PSA), EVOH (18 concentration) was slowly
67
Fig. 67.2 Cholangiography during initial drain placement demon-
strates several isolated obstructed ducts converging upon a narrowed
bilioenteric anastomosis (arrow)
Fig. 67.1 Contrast-enhanced abdominal CT shows the left hepatectomy and subtle area of ductal dilation near anterior surface of the liver
at the resection margin (arrows)
Z. J Haskal (*)
Department of Radiology and Medical Imaging, Interventional
Division, University of Virginia, Charlottesville, VA, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_67
Fig. 67.3 Single images from rst multi-view hepatic angiography
during transient over-the-wire removal of the biliary catheter showed no
contrast entering the biliary tree (or catheter path); no hepatic artery
injury was diagnosed by the operator
injected over >5min, casting the artery beyond, the evident
PSA across the tube, and proximal artery (Fig.67.5). During
injection, EVOH was seen entering the biliary tree, deni-
238
67 EVOH Embolization ofaSubtle Arterio-Biliary Fistula: FromArtery into theBile Duct
ab
239
Fig. 67.4 Two images from hepatic angiography at the second session.
(a) one of the multiple obliquities which did not directly reveal an
abnormality. (b) Another projection, in the best of multiple obliquities,
Fig. 67.5 EVOH casting of the affected artery traversing the biliary
catheter lls the artery proximal, across the catheter and beyond, the
so-called front and back doors. Filling of the suspected pseudoaneurysm is afrmed
showed a subtle suggestion of narrowing, irregularity, and enlargement
across the catheter
Fig. 67.6 Spot radiograph at end of EVOH injection shows the radioopaque embolic within the leading end of the biliary catheter conrming the arterio-biliary connection
tively afrming the PSA a the source of the arterio- biliary
stula (Fig.67.6). The biliary catheter was exchanged and
EVOH and the endobiliary EVOH was removed, adherent to
the catheter (Fig.67.7). His bile cleared immediately after
the procedure and remained so at several weeks follow-up.
Arterial injuries due to percutaneous hepatic interventions may prove elusive. Extravasation of contrast (and
blood) along the partly removed biliary drain cannot be
expected in every case. High suspicion and high-speed lming, with many DSA masks, may be needed to identify subtle
culprit lesions.
Fig. 67.7 Table top image of the biliary catheter immediately after its
exchange at the end of the procedure demonstrates the black EVOH
agent on the catheter, further afrming the arterio-biliary stula
Use ofaVentricular Septal Defect
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Device toSeal aPost-Ablation
Gallbladder Wall Injury
ZivJHaskal andDylanSuttle
A 57-year-old man with hepatitis C cirrhosis presented with
segment 2 and 5 hepatocellular carcinoma (Fig.68.1). His
MELD score was 11, alpha-fetoprotein level 36. The segment 2 tumor was successfully chemoembolized; however,
the 4cm segment 5 tumor vessels could not be isolated from
cystic arteries (Fig.68.2). He underwent microwave ablation
of that mass 2.5weeks later with two microwave antennae
(Neuwave) activated for 9min at 65W (Fig.68.3); the anten-
nae were positioned back from the GB wall.
On day 3, he developed fever, leukocytosis, and elevation
of liver function tests. CT demonstrated that the ablation
zone had encompassed the gallbladder (GB) wall (Fig.68.4);
an externally draining cholecystostomy catheter was placed,
he improved, and was discharged with antibiotics. Catheter
68
Fig. 68.1 Axial image from an MRI demonstrates the mass (yellow
arrows). This abutted the gallbladder
Z. J Haskal (*)
Department of Radiology and Medical Imaging, Interventional
Division, University of Virginia, Charlottesville, VA, USA
D. Suttle
Greensboro Radiology, Greensboro, NC, USA
e-mail: Dylan.suttle@radpartners.com
Fig. 68.2 Cropped image from a digital subtraction common hepatic
angiogram demonstrates the tumor and near imperceptible small arteries supplying it (yellow arteries). Catheterization of several of these
demonstrated dual supply to both tumor and gallbladder (not shown)
studies at 1, 2, and 3months demonstrated no cystic duct;
however, output persisted at >50cc/day. At 4months, a large
GB wall defect and stula into the ablation cavity was rst
demonstrated (Fig. 68.4). Open cholecystectomy was dismissed as too high a risk.
A 10mm×7mm muscular ventriculoseptal defect closure device (Amplatzer) was deployed across the GB wall
defect. Immediate 1- and 2-month contrast studies showed a
complete seal of the stula. After a capped asymptomatic
period of 2months, the GB catheter was removed (Fig.68.5).
He remained asymptomatic at 1-year follow-up (Fig.68.6).
Whilst juxta-gallbladder thermal ablations have been
reported as safe and accomplishable, there remain uncertainties about predicted vs. achieved ablation zones, especially
with heat, compared with cryoablation wherein the iceball
might potentially be monitored and controlled. This nonvascular use of a cardiologic occluder in this setting is new;
however, other atypical uses have been described, such as
aortic pseudoaneurysms.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_68
240
68 Use ofaVentricular Septal Defect Device toSeal aPost-Ablation Gallbladder Wall Injury
Fig. 68.3 Intraprocedural CT images during ablation show the enhancing mass (arrows, left) and position of one of the two MWA antenna (right)
241
Fig. 68.4 Post-ablation coronal CT image 3days after ablation demonstrates the defect in the GB wall (white arrows) in contact with the ablation
cavity (black arrows)
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Z. J. Haskal and D. Suttle
Fig. 68.5 The GB stula (black arrow) into the ablation cavity (white arrow) is demonstrated (left). The deployed muscular VSD device has been
deployed and no further leak is present (white arrow)
Fig. 68.6 Follow-up
sonogram demonstrates the
VSD device adjacent to the
partly sludge-lled thinwalled gallbladder
Part VII
Interventional Oncology: Transarterial and Ablation
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