1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

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

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

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

10. Follow-up
LFTs remain normal
No episodes of variceal bleeding

11. 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 

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

13. 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