case_images: PMC5933478_01
case_images: Coronal contrast-enhanced CT showing portal vein-SMV confluence narrowing because of extrinsic tumor compression (long solid arrow). Also seen is proximal common hepatic artery (short solid arrow) and proximal splenic artery (short dashed arrow) encasement, without SMA involvement. SMV, superior mesenteric vein.
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case_images: IRE was being considered; however, given this patient's significantly narrowed portal vein-SMV confluence (Fig. 1), the procedure was deemed too high risk for fear of postoperative portal vein thrombosis.
case_images: Digital subtraction venograms after right hepatic lobe portal venous system access. (a) Early phase venogram shows marked narrowing at the main portal vein-SMV confluence, several small collaterals, and overall slow flow. (b) Late phase venogram from a pigtail catheter within the downstream IMV shows continued slow flow with extensive venous collaterals. Faintly visible are previously placed SBRT fiducial markers adjacent (inferior) to the narrowed segment, corresponding to the patient's extrinsic mass. IMV, inferior mesenteric vein; SBRT, stereotactic body radiation therapy.
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case_images: Venography confirmed narrowing of the portal vein-SMV confluence at the level of previously placed radiopaque SBRT fiducial markers (Fig. 2a) and repeat venography from the inferior mesenteric vein demonstrated further significant collateralization (Fig. 2b).
case_images: Digital subtraction venograms after portal vein-SMV confluence stent placement across area of narrowing. (a) Early phase venogram already shows much improved portal venous flow with stent in place. (b) Previously seen extensive collaterals never opacify after stent placement, indicative of improved hemodynamics.
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case_images: Tempe, AZ) was inserted across the area of narrowing, with completion venography demonstrating markedly improved flow with diminished collateralization (Fig. 3a, b).
case_images: Patent stent at 61 days post-IRE (arrow), with patient treated with aspirin in the interim. Metallic artifact within the liver is because of coils from portal tract access. Postoperative edema of the pancreatic head necessitated endoscopic placement of a CBD stent, also seen. CBD, common bile duct; IRE, irreversible electroporation.
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case_images: Follow-up CT at 61 days status post-IRE showed a patent portal vein (Fig. 4).