Strategies for appropriate positioning and repositioning the Avalon ECMO cannula in a 17-year-old with left hepatic vein malposition

Introduction Extracorporeal membrane oxygenation (ECMO) is a well-recognized therapy in children with refractory hypoxia. Different cannulas have been used with reported complications with placement, such as cardiac perforation, and multiple reports focusing on avoiding this. However, strategies to avoid hepatic vein cannulation and reposition when it occurs are not well described. Case report Here, we report a case where a 27-Fr Avalon bicaval double lumen cannula in the left hepatic vein was successfully repositioning using serial chest X-rays (CXR) and transthoracic echocardiography (TTE) in a 17-year-old female. Discussion While venovenous (VV) ECMO is preferred by many, placement of the Avalon catheter, a cannula available for VV ECMO, may be challenging due to migration or positioning issues. Specific techniques of wire and catheter advancement as well as confirming wire position in the infra-hepatic inferior vena cava can help ensure appropriate positioning while avoiding hepatic vein cannulation and enabling successful repositioning when it occurs. Conclusion Wire position in the infra-hepatic inferior vena cava helps ensure safe and appropriate Avalon cannula position and placement. The Avalon cannula can be successfully repositioned from the left hepatic vein by retracting the cannula, reinserting the wire and introducer together, and then manipulation techniques using serial CXR and TTE.

Correlation between Hepatic Vein Wave form Changes on Doppler Ultrasound and the Severity of Diseases in Cirrhotic Patients

Background: Cirrhosis is a common problem and is a leading cause of chronic liver disease. Early diagnosis with assessment of severity of diseases may help prevent the associated complications and patients’ sufferings. Now a days Hepatic venous Doppler can be a tool for diagnosis of cirrhosis and to assess correlation between waveform changes and severity of diseases. Objective: The purposes of this study was to determine the significance of hepatic vein waveform changes on doppler ultrasound in cirrhotic patients and to correlate with liver dysfunction. Materials and methods: This study was carried out in the department of Radiology and Imaging of Enam Medical College and Hospital during January 2017 to May 2018. Doppler waveforms were obtained from right hepatic vein in all the cases and classified as triphasic, biphasic and monophasic. Waveform comparisons were made among patients with differing grades of cirrhosis. Child- Pugh class was used to assess severity of cirrhosis. Doppler sonography was done in 80 patients suspecting of having liver cirrhosis. Data on clinical findings, B mode sonographic findings and hepatic vein doppler ultrasound findings were collected and documented in structured forms. Analysis was done using SPSS - 20. Results: Total of 80 patients who met the inclusion criteria are included in the study with mean age of 45.37±7.64 (range 25-75) years. Among these 57 (71%) were males while 23(29%) were females. On the basis of hepatic function 25 (31%) patients presented in Child-Pugh Class A, 31(39%) with Class B and 24(30%) patients had Class C. Hepatic venous waveform was triphasic in 22 (27.5%), biphasic in 28(35%), and monophasic in 30 (37.5%) cases. Our study revealed 88% (21) of Child- Pugh Class C, 23% (7) of Class B and 8% (2) of class A patients had monophasic HV waveform. The hepatic venous waveform progressively changed from triphasic to biphasic to monophasic with advancing grade of cirrhosis. The relationship of these waveforms change had significant relation with hepatic dysfunction (p < 0.022). Conclusion: Hepatic vein wave form changes reflects the change in hepatic circulation associated with progression of liver cirrhosis. It can be used as a new parameter in the assessment of severity of liver cirrhosis. Thus, alteration in hepatic venous blood flow pattern on doppler ultrasound can be a useful noninvasive tool for evaluating diseases severity in patients with cirrhosis. J MEDICINE 2021; 22: 100-106

Induction of Robust Future Liver Remnant Hypertrophy Before Hepatectomy With a Modified Liver Venous Deprivation Technique Using a Trans-venous Access for Hepatic Vein Embolization

Purpose: Hepatic and/or portal vein embolization are performed before hepatectomy for patients with insufficient future liver remnant and usually achieved with a trans-hepatic approach. The aim of the present study is to describe a modified trans-venous liver venous deprivation technique (mLVD), avoiding the potential risks and limitations of a percutaneous approach to hepatic vein embolization, and to assess the safety, efficacy, and surgical outcome after mLVD.Materials and Methods: Retrospective single-center institutional review board-approved study. From March 2016 to June 2019, consecutive oncologic patients with combined portal and hepatic vein embolization were included. CT volumetric analysis was performed before and after mLVD to assess liver hypertrophy. Complications related to mLVD and surgical outcome were obtained from medical records.Results: Thirty patients (62.7 ± 14.5 years old, 20 men) with liver metastasis (60%) or primary liver cancer (40%) underwent mLVD. Twenty-one patients (70%) had hepatic vein anatomic variants. Technical success of mLVD was 100%. Four patients had complications (three minor and one major). FLR hypertrophy was 64.2% ± 51.3% (mean ± SD). Twenty-four patients (80%) underwent the planned hepatectomy and no surgery was canceled as a consequence of mLVD complications or insufficient hypertrophy. Fifty percent of patients (12/24) had no or mild complications after surgery (Clavien-Dindo 0–II), and 45.8% (11/24) had more serious complications (Clavien-Dindo III–IV). Thirty-day mortality was 4.2% (1/24).Conclusion: mLVD is an effective method to induce FLR hypertrophy. This technique is applicable in a wide range of oncologic situations and in patients with complex right liver vein anatomy.