Complications and clinical outcome of hepatic artery embolisation in patients with hereditary haemorrhagic telangiectasia

Abstract

BackgroundHepatic artery embolisation (HAE) in patients with hereditary haemorrhagic telangiectasia (HHT) is controversial because of the associated complications and unproven long-term benefit. We present our results in 20 such patients over a time span of 17 years.MethodsStaged HAE was performed using polyvinyl alcohol (PVA) particles and coils. Complications, clinical symptoms and cardiac output were assessed before and after therapy as well as at the end of follow-up (median 92 months, range 26–208 months).ResultsTwo patients died within 30 days following HAE (10 %). Four further deaths resulted from causes unrelated to HAE. Ischaemic cholangitis, cholecystitis and focal hepatic necrosis with biliary sepsis necessitated re-intervention in four patients. In all but one patient, clinical symptoms resolved with mean cardiac output falling from 11.84 ± 3.22 l/min pre-treatment to 8.13 ± 2.67 l/min at the end of follow-up (P < 0.001). One patient required liver transplantation for de novo symptoms of portal hypertension 4 years after primary symptoms had been cured by HAE.ConclusionThe 30-day mortality of HAE in patients with HHT is 10 %. The rate of complications requiring re-intervention is 20 %. Clinical response at long-term follow-up is satisfactory.Key Points• Hepatic artery embolisation (HAE) in hereditary haemorrhagic telangiectasia (HHT) provides long-term benefit.• Mortalities of HAE and liver transplantation in HHT patients are comparable.• In HHT, complications of HAE are lower than those of liver transplantation.• Complications of HAE can be further reduced by refinement of technique.• Complications include ischaemic cholangitis, hepatic necrosis, biliary sepsis and death.

Clinical Outcomes of Patients with Severe Hepatic Hereditary Hemorrhagic Telangiectasia After Banding of the Hepatic Artery and Banding/Ligation of Branches of the Hepatic Artery

“…Hepatic artery embolization has the objective of reducing arteriovenous shunting by occluding branches of the hepatic artery. 10,12 However, it failed to occlude the significantly enlarged hepatic arteries. 22 Given its transient effect and the elevated risk of postembolization necrosis and death, this procedure should be reserved for patients with gastrointestinal tract bleeding and hepatic aneurysm causing intrahepatic hematoma.…”

Preoperative arterial embolization of large liver hemangiomas

“…During the follow-up period, we did not observe ischemic cholangitis, ischemic cholecystitis, pyogenic liver abscess, or focal biliary or hepatic necrosis with or without biliary sepsis. Those biliary complications are well-described as main complications (1.4%-60%) related to hepatic arterial embolization (40)(41)(42)(43). However, most patients displaying biliary complications after hepatic arterial embolization have extensive parenchymal diseases, like hereditary hemorrhagic telangiectasia.…”

Liver Transplantation for High Output Heart Failure Secondary to HHT: A Case Report and Review of the Literature

“…Ischemic cholecystitis and cholangitis were observed in four patients (20%). Focal areas of hepatic necrosis were noted in three of these four patients with multiple biliary abscesses and biliary sepsis in one of them [12]. An expert panel recommended that hepatic artery embolization be avoided in patients with liver AVMs as it is only a temporizing procedure, and is associated with significant morbidity and even mortality [4].…”