Endovascular Management of Portal Vein Obstruction in Hepatobiliary Cancer Patients.

Abstract Background:Obstruction of the splenoportal or mesoportal venous system occurs in approximately 15-25 % of patients with hepatobiliary malignancies. These patients are prone to develop obstruction of the portal and mesenteric veins both because of local factors (tumor compression, stenosis after surgery) and systemic factors (hypercoagulability). Diagnosis requires a high index of clinical suspicion because symptoms may be non-specific and directly attributed to the existing malignancy. Cross-sectional imaging methods (contrast-enhanced CT scan and MRI) are key to diagnosis. The best treatment strategy has not been established. The purpose of this article is to describe a single center experience in the endovascular management of portal and mesenteric venous obstruction with metallic stent placement on patients with hepatobiliary neoplasms.Results:IRB approved, HIPAA compliant study. Retrospective review of medical and imaging records of 21 consecutive patients with hepato-biliary malignancy who underwent endovascular portal vein recanalization and stent placement between January 2012 and March 2020. Clinical diagnoses were pancreatic cancer (n=19), colon cancer metastatic to the liver (n=1) and cholangiocarcinoma (n=1). The presenting symptoms were: ascites (n=5), abdominal pain, portal vein thrombosis, abnormal liver function tests and ascites (n=4), abdominal pain and ascites (n=4), abdominal pain and diarrhea (n=3), gastrointestinal bleed (n=3) and abdominal pain (n=2). Study results are presented in means and percentages. Stent patency and patient survival are presented with Kaplan-Meier method. The technical success rate was 100%. Self-expandable and balloon-expandable stents were placed. A transhepatic approach was used in 20 cases (95.2%); trans-splenic access in one. Primary stent patency was 95.2%, 84%, and 68% at 1, 3 and 6 months respectively. All stent occlusions were caused by tumor progression. A total of 80% of patients reported symptomatic improvement. Patient survival at 10 months was 40%. The early death rate was 4.76%. Portal vein perforation with massive bleeding was seen in one patient and managed with self-expandable stent-graft placement. There were no bleeding complications from the percutaneous tracts.ConclusionEndovascular recanalization with stent placement is safe with high technical and clinical success. Stent patency is acceptable and determined by disease progression.