Portal Vein Stenting for Metastatic Neuroendocrine Tumor Maria Jepperson, MD Nishita Kothary, MD Daniel Sze, MD, PhD Department of Radiology Division of Interventional Radiology Stanford University School of Medicine

Disclosures Nishita Kothary, M.D. Scientific Advisor, Siemens Healthcare Daniel Sze, M.D., Ph.D. Advisory Boards: Boston Scientific, Koli Medical, Northwind Medical, RadiAction Medical, SureFire Medical, Treus Medical Consultancies: Amgen, BTG, Codman, Cook, Covidien/Medtronic, EmbolX, W. L. Gore, Guerbet, Viralytics Equity: NDC, Proteus Digital Health Trial Support: W. L. Gore, Merit Medical

Clinical History 66 yr old female with metastatic neuroendocrine carcinoma which resulted in IVC compression and near complete portal vein occlusion, mostly from retroperitoneal lymphadenopathy Planed portal vein recanalization and stenting to decrease her portal hypertension and decrease her risk for future liver dysfunction or variceal bleeding

Clinical History Physical Exam: Labs: Abdomen: lower abdomen with pitting edema Extremities: 1+ DP and PT pulses; 4+ LLE pitting edema to groin, 2-3+ RLE pitting edema Labs: Total Bilirubin 0.7, AST 21, ALT 27, Alk Phos 85, Albumin 3.4

Pre-procedure Imaging Contrast enhanced CT coronal MIP reconstruction demonstrating confluent metastases in the porta hepatitis with encasement and near occlusion of the main portal vein

Portogram demonstrates severe irregular narrowing/near occlusion of main portal vein with cavernous  transformation. Findings  are  concerning  for  tumor  invasion rather than  extrinsic  compression. Incidental note of Wall stent in the IVC and SMART stents in the iliac veins (placed during previous procedure). Simultaneous pressure measurements from the sheath and pigtail catheter demonstrate a gradient of 12 mmHg

Y  stenting  of  the  portal  vein,  SMV,  and  IMV  with  12  mm  x  6  cm  and  10  mm  x  6  cm  SMART  stents

Reestablishment of rapid antegrade flow. Reduction of portal vein to SMV and IMV pressure gradient from 12 mmHg to 0 mmHg.

Follow-up Follow-up contrast enhanced CT obtained 2 months following the procedure shows patent stents

Follow-up LFTs remain normal No episodes of variceal bleeding

Discussion Malignant obstruction is responsible for 5-10% of portal vein occlusion Hepatocellular carcinoma, pancreatic cancer, and bile duct cancer are responsible for 15%–24% of cases with extrahepatic portal venous occlusion Portal vein occlusion leads to portal hypertension, ascites, and variceal bleeding- which can both effect quality of life and mortality 

Discussion Significant factors affecting patency of the portal vein stents included splenic vein involvement, severe hepatic dysfunction, and obstruction of the portal venous system

References Yamakado K, Nakatsuka A, Tanaka N, Fujii A, Isaji S, Kawarada Y, et al. Portal venous stent placement in patients with pancreatic and biliary neoplasms invading portal veins and causing portal hypertension: initial experience. Radiology. 2001;220(1):150–156. Yamakado K, Nakatsuka A, Tanaka N, Fujii A, Terada N, Takeda K. Malignant portal venous obstructions treated by stent placement: significant factors affecting patency. J Vasc Intev Radiol. 2001;12(12):1407–1415. Sakurai, Katsunobu et al. Portal Vein Stenting to Treat Portal Vein Stenosis in a Patient With Malignant Tumor and Gastrointestinal Bleeding. International Surgery 99.1 (2014): 91–95. PMC. Web. 20 Apr. 2016.