Tract hemostasis using radiofrequency ablation for hepatic arterial bleeding after percutaneous transhepatic portal embolization

A 62-year-old man with colorectal liver metastases received multiple chemotherapy, hepatic arterial chemotherapy, and radiotherapy for 28 months. We planned a two-stage hepatectomy after percutaneous transhepatic portal embolization (PTPE) (1). The Glissonean capsule was hard, but ipsilateral PTPE was completed with a gelatin sponge and ethanolamine oleate under balloon occlusion (2). However, massive arterial bleeding was detected by Doppler ultrasonography after removal of the sheath (Figure 1A). We inserted a radiofrequency ablation (RFA) electrode (15 mm radiofrequency range) into the bleeding site (Figure 1B). We used the radiofrequency (RF) generator (VIVA RFA System, STARmed, Gyeonggi-do, South Korea) and 60 and 100 W power for 30 seconds each. The immediate hemostasis was confirmed (Figures 1C,2). A two-stage hepatectomy was completed. The Japanese guideline showed PTPE-related serious complication rates were 0.4–12.8%, including intra-abdominal hemorrhage, and recommended emergent arterial embolization for pseudoaneurysm rupture and open surgery for other situations (3). We reported that only 1.8% of patients experienced transient intra-abdominal hemorrhage (2). Stiff Glissonean capsule with histologically marked fibrosis and thickening induced by prior radiotherapy and hepatic arterial chemotherapy caused arterial hemorrhage (4). RFA following Doppler ultrasonography can control portal, arterial, and venous bleeding. An RFA system should be set up in the interventional radiology room.

Figure 1 Doppler ultrasonography. Doppler ultrasonography clearly showed massive arterial bleeding splashed into the abdominal cavity (A). The needle tract was ablated with radiofrequency ablation (B), and the arterial blood flow signal completely vanished (C).

Figure 2 Enhanced computed tomography images immediately after portal vein embolization. Multiple hypovascular liver metastases are observed in both hepatic lobes (arrows). In segment 8, a low-attenuation area corresponding to a radiofrequency ablation scar is noted in the subcapsular region (arrowhead), surrounded by a hyperperfusion zone possibly attributable to an arterioportal shunt (A). High-density fluid collection was observed; however, no evident extravasation into the peritoneal cavity is seen, confirming that hemostasis has been achieved. An arterioportal shunt is visualized in the 3D images during the arterial phase (B).

Acknowledgments

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References

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