Our next clinical spotlight features a portal vein thrombosis (PVT) case treated by Dr Malkhaz Mizandari and his team at the Tbilisi State Medical University (Georgia).  Dr. Mizandari went on to publish a wider case series using similar techniques as those described in the individual case review below. That paper was published in the Universal Journal of Medical Science and can be found here.

A 60-year-old man was admitted with a history of three weeks of fatigue and abdominal discomfort. He was diagnosed with hepatitis C induced liver cirrhosis (Child-Pugh B). The CT scan reported a vascular mass in the left lobe with total thrombosis of the left portal vein.  The thrombus had advanced into the main PV, so that only the right branch remained patent. Blood tests showed severe hypoalbuminemia (25 g/L) and thrombocytopenia (70), moderate hypocoagulation (INR - 1,48, PT - 16,8, PT% - 61,9) and moderate changes of liver enzymes (AST - 99,8 u/L, ALT - 76,0 u/L, GGT - 158 u/L). He underwent percutaneous ultrasound (US) guided biopsy of the left lobe mass, confirming the presence of HCC. 

Because of the PV thrombosis, the patient was not a candidate for surgical resection or a TACE procedure. The HabibTM VesOpen procedure which aimed to restore normal blood flow to the right PV was approved following a multi-disciplinary team (MDT) discussion.  The right PV was accessed through an 18 G puncture needle using real-time US guidance. Portography with contrast dye showed the position of the upper border of the PV thrombus.  A 0.035” wire was passed through the thrombus into the superior mesenteric vein (SMV) using a 5Fr guide catheter and portography "below" the thrombus was performed to identify the "lower" border of the PV thrombus.

An 8 Fr introducer sheath was positioned and the 5Fr endoluminal device (HabibTM VesOpen – not available for sale in the United States) was introduced into the thrombus for 2 consecutive sessions of radiofrequency ablation using a RITA 1500X generator set at 15W for 120 seconds  (to ensure that the entire length of the stricture was ablated) . A 14 mm diameter self-expanding vascular stent was positioned into the thrombus and post-dilated with a 10mm balloon (Cook Medical, Winston-Salem, North Carolina, USA). Postprocedure portography showed complete restoration of the patency of the main PV, restoring normal blood flow into the right portal vein.  During withdrawal of the VesOpen, catheter, the transhepatic access route was also ablated to prevent restored blood flow from the PV entering the peritoneal cavity.

The patient's condition improved gradually; eight weeks after the procedure his albumin increased to 32 g/dL. Improvement of coagulation (PT, PT%, APTT, INR), liver function tests, appetite and other functional indicators improved as well. The patient refused to undergo TACE but a repeat CT scan 5 months after the Habib VesOpen procedure revealed a significant decrease in the size of the tumour, and both PV branches were patent (including the untreated left branch).

The clinical team concluded that the decrease in tumor mass and the restoration of blood flow in the left PV could likely be explained by an immune response induced by the RF treatment.

As seen in the below image from WCIO 2016, Dr. Mizandari also performs RFA in the bile and pancreatic ducts. More on those treatment methodologies later!

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AuthorFrancois Poulin