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Imaging Diagnosis and Interventional Treatment for Hepatocellular Carcinoma Combined with Arteriovenous Fistula

Imaging Diagnosis and Interventional Treatment for Hepatocellular Carcinoma Combined with... Hindawi Journal of Healthcare Engineering Volume 2021, Article ID 6651236, 13 pages https://doi.org/10.1155/2021/6651236 Research Article Imaging Diagnosis and Interventional Treatment for Hepatocellular Carcinoma Combined with Arteriovenous Fistula 1 2 1 1 1 Zheng Cai , Maohui Ran, Jiantao Song, Wenrui Zhen, and Mingjian Li e Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China Correspondence should be addressed to Zheng Cai; 101026@zmu.edu.cn Received 29 December 2020; Revised 11 February 2021; Accepted 23 February 2021; Published 4 March 2021 Academic Editor: Zhihan Lv Copyright © 2021 Zheng Cai et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In order to explore the imaging diagnosis methods and interventional treatment effects of hepatocellular carcinoma combined with hepatic arteriovenous fistula (HAVF), a total of 120 patients, who were diagnosed as hepatic carcinoma with arteriovenous shunting and underwent medical imaging diagnosis and interventional surgery therapy at a designated hospital by this study from December 2014 to December 2018, were chosen as study subjects. Digital subtraction angiography was performed to analyze the imaging features of hepatocellular carcinoma combined with HAVF in each patient; then, according to these imaging diagnosis results, gelatin sponge or coil was used to block the fistula; mitomycin, carboplatin powder, and lipiodol mixed emulsion was combined or separately utilized for hepatic tumor embolization, in which iodized oil embolization chemotherapy was used for patients with mild paralysis; gelatin sponge granule embolization chemotherapy was used for moderate paralysis patients at their first intervention, and, after about 1 month, if the sputum disappeared, iodized oil embolization was used again; and hepatic arterial infusion chemotherapy was used only for patients with severe paralysis. (e results show that the central type of HAVF is characterized by early angiography of portal vein and large branches and tumor staining after portal vein’s angiography; the peripheral type of HAVF is characterized by portal vein branching in hepatic tumor and double rail sign accompanied by the arterial branch; 112 cases of patients completed embolization chemotherapy; 8 cases of patients only received chemotherapy perfusion; in 109 cases of patients sputum disappeared or shunt decreased at first treatment; and in 113 cases of patients iodine oil was well deposited or the tumor was stably reduced; most of the symptoms of refractory ascites, diarrhea, and upper gastro- intestinal bleeding were controlled or improved, and there were no complications such as pulmonary embolism and hepatic failure. (erefore, HAVF increases the difficulty of interventional therapy, but, as long as the positive and appropriate treatment measures are taken, it can still achieve better curative effect without serious complications, which can effectively alleviate the clinical symptoms of patients and improve the quality of life of patients. (e results of this study provide a reference for the further researches on imaging diagnosis and interventional treatment for hepatocellular carcinoma combined with arteriovenous fistula. divided into two types: central type and peripheral type; and 1. Introduction primary hepatocellular carcinoma often invades the venous Hepatic arteriovenous fistula (HAVF) is an organic and system of the hepatic and HAVF occurs [2]. (e abnormal functional abnormal pathway between hepatic artery and anastomosis of HAVF directs blood flow between the he- portal vein and between hepatic artery and hepatic vein, patic artery and the portal vein and hepatic vein. (e which is more common with hepatocellular carcinoma, presence of HAVF accelerates the spread of tumors in the trauma, hepatic hemangioma, cirrhosis, hepatic biopsy, hepatic and throughout the body, which not only is a cause hepatic abscess, and other diseases with the incidence rate of of tumor cell metastasis in the hepatic, but can also cause 14–63.2% [1]. HAVF is divided into three types: hepatic portal hypertension. HAPVF can cause or aggravate the artery-portal vein fistula (HAPVF), hepatic artery-hepatic symptoms of portal hypertension, such as gastrointestinal vein fistula (HAHVF), and mixed fistula; and HAPVF is bleeding and ascites; severe life can be critical; HAVF can 2 Journal of Healthcare Engineering only for patients with severe paralysis. (e detailed chapters increase the chance of tumor cells spreading through the portal vein and hepatic vein to distant organs and can in- are arranged as follows: Section 2 introduces research ma- terials and methods; Section 3 performs results analysis; crease the false diagnosis of hepatic imaging positive rate [3]. In interventional therapy, lipiodol can cause pulmonary and Section 4 analyzes the imaging diagnosis and interventional systemic embolism through the shunt pathway, and he- treatment of hepatocellular carcinoma with arteriovenous modynamic changes due to shunt can directly affect the fistula; Section 5 is discussion; Section 6 is conclusion. efficacy of transcatheter arterial chemoembolization (TACE) intervention, so understanding the imaging diagnosis and 2. Materials and Methods intervention of HAVF Treatment has important implica- 2.1. General Materials. A total of 120 patients, who were tions [4]. diagnosed as hepatic carcinoma with arteriovenous shunting Digital subtraction angiography (DSA) examination is the and underwent medical imaging diagnosis and interven- gold standard for diagnosing HAVF, in which central HAPVF tional surgery therapy at a designated hospital by this study is located in the portal vein or the primary branch and pe- from December 2014 to December 2018, were chosen as ripheral HAPVF is located in the lower branch of the portal study subjects including 60 cases of HAPVF and 60 cases of vein. It can also be divided into high, medium, and low flow HAHVF. (ese materials contain 40 males and 28 females; types due to different flow rates; generally, the centre type their ages are 34–86 years with an average of 55.74± 10.23 flow rate is high, and the surrounding type flow rate is low [5]. years old; their hepatocellular carcinoma pathology classi- (e location and type of HAVF before interventional em- fication includes 34 cases of massive type, 41 cases of nodular bolization can help to choose the interventional method and type, and 45 cases of diffuse type (Table 1); the HAHVF avoid the occurrence of ectopic embolization and improve the contains 31 cases of central type and 29 cases of peripheral treatment effect. With the improvement of imaging exami- type (Table 2); their hepatic function includes 24 cases of nation technology, the detection rate of HAVF is gradually Child A, 78 cases of Child B, and 18 cases of Child C improved. Doppler ultrasound can find abnormal thickening according to hepatic function rating criteria (Table 3); their of the blood supply artery and abnormal blood flow of the histological classification contains 113 cases of hepatocyte corresponding vein and it is rare to find a direct display of type and 5 cases of hepatic bile duct type and mixed type; abnormal shunt between arteries and veins and enhanced their clinical classification includes 85 cases of simple type computed tomography scans can be seen early in the arterial- (there were no clinical manifestations and clinical exami- portal vein [6]. DSA can clearly show the location and flow of nation showed no obvious cirrhosis), 8 cases of sclerosing HAVF, which is characterized by the dual-track sign of the type (clinical and laboratory tests have obvious cirrhosis portal vein in the arterial phase. (e arterial phase portal vein manifestations), and 27 cases of inflammatory type (faster contrast agent is filled; the contrast agent entering the hepatic disease development accompanied by persistent cancerous vein branch or the right atrium of the vena cava during the hyperthermia or alanine aminotransferase continued to arterial phase where the liver supplies blood to the blood increase more than double); the tumor sizes are in 1–17 cm vessel is not clear, and the tumor staining is not obvious. with an average size of 7.96± 4.23 cm; the α-fetoprotein level When the HAVF flow is low, the arterial and late portal vein is in 1–58100 μg/L with an average level of branches or hepatic veins develop, and most mouthwashes 28950.56± 28095.64 μg/L; the clinical symptoms were appear to be chaotic [7]. Understanding the performance of mainly in 33 patients with ascites, 29 patients with gas- the above DSA can guide the choice of interventional em- trointestinal bleeding, 39 patients with anorexia and diar- bolization methods to avoid complications [8]. rhea, and 19 patients without obvious discomfort. In order to explore the imaging diagnosis methods and interventional treatment effects of hepatocellular carcinoma combined with hepatic arteriovenous fistula (HAVF), a total 2.2. Inclusion and Exclusion Criteria. (e inclusion criteria of 120 patients, who were diagnosed as hepatic carcinoma were the following: (1) patients who refused surgery treat- with arteriovenous shunting and underwent medical imaging ment; (2) patients who did not meet the surgical resection; diagnosis and interventional surgery therapy at a designated (3) patients who met the diagnostic criteria for primary hospital by this study from December 2014 to December 2018, hepatocellular carcinoma with HAHVF; and (4) patients were chosen as study subjects. Digital subtraction angiog- without heart and kidney dysfunction. raphy was performed to analyze the imaging features of (e exclusion criteria were the following: (1) patients with hepatocellular carcinoma combined with HAVF in each poor general condition and signs of failure; (2) patients with patient; then, according to these imaging diagnosis results, extensive systemic metastasis of hepatocellular carcinoma: (3) gelatin sponge or coil was used to block the fistula; mito- patients with secondary infection or systemic infection; (4) mycin, carboplatin powder, and lipiodol mixed emulsion was patients with severe hepatic function disorders; and (5) patients combined or separately utilized for hepatic tumor emboli- with reverse portal blood flow or blocked portal vein trunk. zation, in which iodized oil embolization chemotherapy was used for patients with mild paralysis; gelatin sponge granule embolization chemotherapy was used for moderate paralysis 2.3. Imaging Diagnosis Methods. (e digital subtraction an- patients at their first intervention, and, after about 1 month, if giography examination was as follows: transfemoral puncture, the sputum disappeared, iodized oil embolization was used conventional superior mesenteric artery and celiac artery again; and hepatic arterial infusion chemotherapy was used angiography, selective contrast and interventional therapy, Journal of Healthcare Engineering 3 Table 1: Statistics of hepatic arteriovenous fistula (HAVF) type in fistula is used. According to the size of the fistula shown by the the included materials [n (%)]. comparison, gelatin sponge particles, gauze or stainless steel ring can be used to embolize the fistula, and then perform Massive Nodular Diffuse HAVF type Total TACE treatment. (is requires slow perfusion of 4-Fu 1.0 μg, type type type cisplatin 55 μg, hydroxycamptothecin 35 mg, doxorubicin HAPVF 19 (15.83) 24 (20.00) 33 (27.50) 76 (63.33) 45 mg or mitomycin 25 mg, and lipiodol plus appropriate HAHVF 10 (8.33) 15 (12.50) 9 (7.50) 34 (28.33) amount of suspension for embolization. In addition, it is also Mixed 5 (4.67) 2 (1.67) 3 (2.50) 10 (8.33) possible to intubate the fistula, which requires TACE local fistula 120 lesion treatment first, and then embolize the fistula according Total 34 (28.33) 41 (34.17) 45 (37.50) (100.00) to the above method, and the rest will be treated with TACE. Peripheral type: the catheter can be inserted into the fistula; the treatment method is the same as before; the catheter Table 2: Statistics of hepatic artery-hepatic vein fistula (HAHVF) cannot be inserted into the fistula, so use appropriate amount type in the included materials [n (%)]. of gelatin sponge particles and embolize the contrast agent to HAPVF type Mild Moderate Severe Total observe the embolization of the fistula until the fistula is Central type 11 (18.33) 12 (20.00) 8 (13.33) 31 (51.67) completely embolized and then use TACE. Small-area or Peripheral type 6 (10.00) 13 (21.67) 10 (16.67) 29 (48.33) hepatic portal vein fistula with small blood flow is directly Total 17 (28.33) 25 (41.67) 18 (30.00) 60 (100.00) treated with TACE and hepatic artery-hepatic vein fistula is to select gelatin sponge granules or gauze embolization according to the size of the mouth and then apply TACE. Table 3: Child classification of hepatic function in the included HAVF patients [n (%)]. Child classification of hepatic 2.5. Clinical Efficacy Criteria. Clinical efficacy is divided into function HAVF type Total three levels: complete remission, partial remission, and A B C ineffective remission. Gastrointestinal hemorrhage: vomit- ing or blood in the stool disappears; fecal occult blood HAPVF 10 (8.33) 21 (17.50) 3 (2.50) 34 (28.33) HAHVF 8 (6.67) 16 (13.33) 8 (6.67) 32 (26.67) negative is complete remission; hematemesis or blood in the Mixed fistula 6 (5.00) 41 (34.17) 7 (5.83) 54 (45.00) stool disappears; fecal occult blood positive is partial re- Total 24 (20.00) 78 (65.00) 18 (15.00) 120 (100.00) mission; hematemesis or blood in the stool remains inef- fective. Ascites: abdominal water was significantly reduced total injection volume of contrast agent 20–35 mL/time, rate of by ultrasound at least to complete remission; equal reduction 3–6 mL/s observe tumor blood supply, hepatic arteriovenous in ascites was partial remission; no significant reduction in fistula, and tumor site. According to the arteriovenous fistula ascites was ineffective. Esophageal varices: there is tempo- and the amount of blood in the shunt, there are two different rary esophageal sputum angiography; varicose veins to the methods: central type and peripheral type. Central type: if upper part of the chest esophagus are severe; the middle part patients can overselect the intubation and pass the sputum into of the esophagus is moderate and only the lower part of the the tumor blood vessel, slowly inject iodine under fluoroscopy; esophagus is mild. (e esophageal varices were completely the oil suspension is embolized, and then the catheter is relieved from severe to mild or there was no obvious var- withdrawn to the mouth to seal the mouth with gelatin sponge icose; partial remission was changed from severe to mod- particles. If the catheter tip cannot pass over the fistula, first seal erate or moderate to mild; no significant change in varicose the fistula with gelatin sponge particles and then embolize. veins was ineffective. Peripheral type is mainly used for catheters that cannot be inserted into the fistula. Appropriate amount of gelatin sponge particles are used for embolization. (e contrast agent is 2.6. Observation Indicators. When the patient’s clinical in- dicators are restored, no adverse reactions are considered to pushed by hand to observe the embolism of the oral cavity. After the TACE port is completely blocked, TACE can directly be significant treatment; when the patient’s clinical indi- cators are improved compared to the treatment activities, it treat small blood flow. (e DSA shows that the portal vein, hepatic artery, or inferior vena cava develops in advance during is considered effective; regarding the patient’s clinical items, if the indicator situation has not been improved or is be- the hepatic artery or hepatic parenchyma, which is a combined HAVF. (e HAVF angiography showed a portal vein with a coming more serious, it is considered to be ineffective. Among them, the total clinical efficiency is the sum of large branch of the first or second stage or a peripheral portal vein with a parallel to the artery and HAVF manifests as early significant efficiency. hepatic vein and reflux of contrast agent to right atrium. 2.7. Statistical Methods. (e data of this study were analyzed 2.4. Interventional Treatment Solutions. (e treatment plan by SPSS 19.0 statistical software. (e measurement data and counting data were expressed by takes a different approach depending on the location of the x± s and %, respectively. arteriovenous fistula and the amount of blood diverted (e t and P tests were used, and the results were statistically through it. For the central type, the method of intubating the significant at P< 0.05. 4 Journal of Healthcare Engineering According to DSA angiography, HAHVF is divided into 3. Result Analysis three categories. (e first category is the direct destruction of 3.1. Performance and Classification of Digital Subtraction normal hepatic arteries and tumor veins. For the second Angiography. HAHVF is generally characterized by early type, early tumor vein development can be seen, but the development of hepatic vein, during which the portal vein or shunt is long and slender. (ere is no clear passage between branch development is seen in the arterial phase and is the artery and the vein. (e tumor blood vessel is large and mainly divided into the central type and periphery type. (e obviously twisted, or the tumor blood vessel is light to fistula is located in the portal vein and the primary branch of obvious with multiple blood type changes. For the third type, the arteriovenous fistula and portal vein trunk and branch there are a large number of dense tumor blood vessels, and visualization; peripheral angiography showed simultaneous there is no obvious early venous development during the portal vein branching along the arterial branch and double angiography, but arteriovenous short circuits are found rail sign accompanied by arterial branches. (e venous when embolism exists. HAVF is performed in computed sputum DSA main manifestations included double rail sign tomography or magnetic resonance imaging, central HAVF accompanying the portal vein in the arterial phase, showing is located in the hilar, portal vein, and grade I branch is the filling of the portal vein contrast agent; the contrast agent enhanced earlier than superior mesenteric vein or splenic enters the branch of the hepatic vein or the right atrium of vein, densely developed; density is close to enhanced ab- the vena cava (Table 4). After iodized oil embolization, the dominal aorta, there is nontumor hepatic parenchyma in the iodized oil venous sign appeared, and the line sign was hepatic arterial phase, and the portal vein returned to displayed in the portal vein tumor thrombus after angiog- normal. Peripheral HAVF is located in the surrounding raphy. All patients with moderate or severe arteriovenous hepatic parenchyma, and the branches of the portal vein fistula have a transient focal, multifocal, or diffuse contrast level and below are enhanced earlier than the portal vein agent staining process before the venous branch is devel- (Figure 1). (e Doppler blood flow spectrum can be con- oped. (en, there was a vein development in the corre- sidered as HAVF: the multicoloured mosaic blood flow is in sponding area, and no tubular communication between the the venous lumen; for the hepatic portal vein in the portal arteries and veins was found that is consistent with the vein, see reverse blood flow or two-way blood flow; the blood mechanism of the occurrence of hepatic arteriovenous fis- flow spectrum is the reverse artery sample, high-speed and tula and is also supported in ultrasound. Ultrasound mainly low-resistance type; hepatic vein sputum can be measured in found abnormal thickening of the blood supply artery and the hepatic vein, arterial-like, high-speed, and low-resistance abnormal blood flow of the vein, and there was little direct blood flow spectrum; hepatic artery inner diameter is display of abnormal shunt between arteries and veins. widened [10]. Hepatocellular carcinoma combined with arteriovenous fistula is one of the main factors affecting the prognosis of hepatocellular carcinoma, and it is the focus and difficulty of 3.2. Treatment Results of Chemotherapy Embolization. endovascular treatment of hepatocellular carcinoma. At Since the mouth of the HAPVF is located at the tumor, the present, the treatment methods for HAVF are commonly blood between the tumor and the portal vein is directly used such as spring steel ring, gelatin sponge particles, transported, and intrahepatic dissemination and extrahepatic anhydrous ethanol, and percutaneous transhepatic puncture metastasis of the hepatocellular carcinoma are formed, fol- and injection of anhydrous ethanol to close the mouth. (e lowed by anterior hepatic sinus portal hypertension (Table 5). spring steel ring can permanently embolize the larger arterial A large amount of high-pressure arterial blood directly enters branch, and the embolization site of the gelatin sponge the lower-pressure portal vein through the fistula, causing the particles is in the small and medium arteries, both of which portal pressure to rise further on the basis of the portal are nonselective embolization [9]. At the same time as hypertension caused by the original cirrhosis or portal vein embolization, the tumor is often blocked by the blood supply tumor thrombus, which may cause upper gastrointestinal artery of the tumor, so that the subsequent lipiodol emulsion bleeding. (e original hepatic damage is aggravated and the embolization is not possible or peripheral vascular embo- life of the patient is seriously threatened [11]. (erefore, the lization is inadequate, which seriously affects the emboli- treatment of such patients is to treat the primary hepato- zation effect of the tumor, and the amount of intravascular cellular carcinoma, block the hepatic artery-venous shunt, embolization of absolute ethanol is not easy to control. If improve the hepatic circulation, relieve and eliminate the reflux can lead to ectopic embolization, clinical application symptoms of gastrointestinal bleeding and ascites caused by should not be promoted; the main adverse reactions after portal hypertension, and at the same time further select the sputum and embolization were numbness, fever, and hepatic blood supply artery embolizing the tumor, protecting normal function changes. Symptomatic treatment generally has no hepatic tissue, and reducing the probability of tumor serious consequences. Pain mainly occurs in the operation; spreading through the fistula. (e hepatocellular carcinoma preembolization prophylactic bolus lidocaine can be helpful; combined with HAVF increases the difficulty and risk of postoperative main manifestations of suffocation discom- interventional embolization. However, as long as the patient’s fort, mainly due to the ischemic reaction of the lesion, can be general condition permits, after a detailed understanding of given a small amount of analgesic symptomatic treatment; the type of sputum, the size of the subflow, the presence or the main cause of fever is tumor necrosis after TACE, which absence of portal collateral circulation, etc., a reasonable can be generally relieved after treatment. treatment plan is formulated and the treatment is still safe and Journal of Healthcare Engineering 5 Table 4: Performances of digital subtraction angiography given different types of dynamic portal fistula, n (%). MF: mixed fistula. With inverse hepatic blood flow With portal vein tumor thrombus Group Mild Moderate Severe Total Mild Moderate Severe Total HAPVF 9 (7.500) 12 (10.00) 23 (19.17) 44 (36.67) 14 (11.67) 9 (7.50) 17 (14.17) 40 (33.33) HAHVF 13 (10.83) 6 (5.00) 11 (9.17) 30 (25.00) 7 (5.83) 10 (8.33) 11 (9.17) 28 (23.33) MF 8 (6.67) 17 (14.17) 21 (17.50) 46 (38.33) 15 (12.50) 16 (13.33) 21 (17.50) 52 (43.33) Total 30 (25.00) 35 (21.17) 55 (35.83) 120 (100.0) 36 (30.00) 35 (21.67) 49 (40.83) 120 (100.0) 1.0 1.0 0.9 0.9 0.8 0.8 0.7 0.7 0.6 0.6 0.5 0.5 0.4 0.4 0.3 0.3 0.2 0.2 Massive Nodular Diffuse Total Mild Moderate Severe Toatal Pathological gross classification Dynamic portal Fistula type HAPVF HAPVF HAHVF HAHVF (a) (b) Figure 1: Comparison of relative proportions of different pathological gross classifications (a) and dynamic portal fistula types (b) in the HAPVF and HAHVF. Table 5: Treatment results of chemotherapy embolization given different fistula type and tumor embolization [n (%)]. MF: mixed fistula. Case of embolizing tumor by overpassing fistula Case of embolizing tumor not by overpassing fistula Group Mild Moderate Severe Total Mild Moderate Severe Total HAPVF 24 (20.00) 16 (13.33) 9 (7.50) 49 (40.83) 11 (9.17) 15 (12.50) 10 (8.33) 36 (30.00) HAHVF 17 (14.17) 11 (9.17) 10 (8.33) 38 (31.67) 19 (15.83) 18 (15.00) 12 (10.00) 49 (40.83) MF 11 (9.17) 13 (10.83) 9 (7.50) 33 (27.50) 16 (13.33) 10 (8.33) 19 (15.83) 35 (29.17) Total 52 (43.33) 40 (33.33) 28 (23.33) 120 (100.0) 46 (38.33) 33 (27.5) 41 (34.17) 120 (100.0) feasible and generally does not cause serious hepatic func- chemoembolization; then the catheter retreat to the vicinity tional impairment and hepatic failure. of the pass (Figure 2). At this time, because a part of the (e hepatocellular carcinoma combined with HAVF blood vessels is blocked, the shunt and tumor blood vessels increases the risk and difficulty of interventional therapy, are often clearer, and then the mouth is blocked and the and the high incidence of portal vein tumor thrombus also tumor is further embolized. For peripheral HAPVF, the makes the patient’s prognosis worse. However, for patients chemotherapy drug is first infused, and then the micro- who have not completely occluded the portal vein or have catheter is first selected to the sputum to block the tumor, and the tumor blood vessel is embolized with the lipiodol collateral circulation to the hepatic, it is generally considered safe and effective to treat embolization. Chemotherapeutic emulsion, or the tumor is inserted into the tube and the tumor donor branch is avoided. For the flow rate or pe- drugs and embolic agents can flow through the fistula to nonlesional blood vessels due to the presence of the shunt, ripheral type HAPVF that is difficult to overselect the in- seriously affecting the treatment effect and ectopic embolism tubation, first test a small amount of lipiodol emulsion and systemic toxic side effects. (erefore, sealing the fistula through the tumor blood supply artery. is the key to treatment [12]. For central or high-flow (e above-mentioned mechanism and imaging findings HAPVF, due to portal vein stealing, the size of the fistula and of hepatocellular carcinoma provide anatomical support for the tumor vessels is unclear, there is conventional micro- gelatin sponge granules to seal the fistula, but multifocal and catheter superselection over the mouth angiography, and a diffuse fistula occlusion is still quite difficult; they are often in pair of distal tumor vessels is treated with iodized oil the fourth and fifth grades of arteriovenous after branching; Proportion (%) Proportion (%) 6 Journal of Healthcare Engineering 1.50 1.45 1.40 1.35 1.30 1.25 1.20 1.15 1.10 1.05 1.00 Massive Nodular Diffuse Child A Child B Child C type type type function function function Figure 2: Weight coefficients of hepatic arteriovenous fistula type and hepatic function classification on imaging diagnosis. the gelatin sponge granule blockage easily causes emboli- shunting of HAVF can make iodine oil cause ectopic em- zation of the blood supply artery itself, which brings ob- bolization through sputum. Entering the portal vein can stacles to drug perfusion and lipiodol embolism. Heavy giant affect normal hepatic tissue, and entering the hepatic vein HAHVF is a safety consideration or a 5–6 mm steel ring can form pulmonary embolism; therefore, it is not appro- embolization; for patients with central embolization of the priate to use iodized oil embolism for such patients. Re- main tumor thrombus, the closure of the fistula should be cently, scholars have used embolization of iodized oil cautious, because it is easy to cause hepatic artery emboli- directly on patients with hepatocellular carcinoma and zation. Moreover, such patients are not suitable for iodized HAVF, which can improve the curative effect without se- oil tumor embolization even if they are successfully blocked rious complications. (e degree of hepatic HAVF is further because their hepatic function is extremely fragile; it is easy divided into three levels of light, medium, and heavy, and the purpose is to determine a suitable treatment plan to improve to induce hepatic coma if there is no effective rich collateral supply after normal embolization. Sometimes, the contrast the efficacy of such patients. In patients with mild hepa- dose or flow rate is not properly grasped, small hepatic tocellular carcinoma HAVF, the hepatic function is more HAVF cannot be found in time, and injection of lipiodol is than Child A grade, and it is more suitable for embolization prone to suppression, mistakenly entering the hepatic vein chemotherapy directly with iodized oil. However, it is worth and entering the pulmonary circulation; sometimes the noting that the mild hepatic artery-hepatic vein fistula is consequences are still very serious, so it is suggested that the more concealed and the angiography is more difficult to find, injection of lipiodol during the operation begins in very slow and the lipiodol can be returned to the pulmonary artery speed to observe the direction of oil column movement, through the sputum. During the operation, it is often while paying attention to the observation of adverse reac- marked by the injection of 3–5 mL of lipiodol and the tions such as cough and timely correction of possible presence of occult light hepatic arteriovenous vein fistula plugging [13]. should be considered at this time. (e treatment method is to stop the injection of lipiodol in time and embolize the larger branch of the hepatic artery with gelatin sponge 4. Efficacy Analysis of Imaging Diagnosis and particles, so that the lipiodol is not blocked by the hepatic Interventional Treatment artery. (e blood flow is flushed into the hepatic vein and 4.1. Angiographic Features of Hepatocellular Carcinoma with returned to the pulmonary artery. Figure 3 shows the an- Arteriovenous Fistula. (e hepatic artery embolization giographic characteristics of different hepatocellular carci- chemotherapy has become the treatment of choice for ad- noma with arteriovenous fistula. vanced hepatocellular carcinoma, and the key for improving (e hepatocellular carcinoma combined with hepatic the efficacy is the availability of iodized oil embolization artery-portal fistula allows a large number of high-pressure chemotherapy, in which it has been thought that the arterial bloods to enter the portal system directly through the Weight coefficient Journal of Healthcare Engineering 7 (a) (b) (c) (d) Figure 3: Angiographic characteristics of different hepatocellular carcinoma with arteriovenous fistula. (a) Primary hepatocellular car- cinoma with severe portal vein fistula; (b) central type hepatic vein-hepatic vein fistula; (c) hepatic artery-hepatic vein fistula; (d) peripheral type hepatic artery fistula. blocked, and then embolization is performed. (e method of fistula, which further increases the portal pressure on the basis of cirrhotic portal hypertension, which also aggravates embolization is safe and reliable, which can improve the hepatic function damage and increases the incidence of efficacy of hepatocellular carcinoma combined with HAVF. upper gastrointestinal bleeding. Hepatic artery-hepatic vein Some scholars have reported that the use of absolute ethanol sputum increases the incidence of pulmonary embolism and to ablate the fistula multiple times until the angiography is one of the main factors affecting the prognosis of patients shows that the arteriovenous fistula is reduced or dis- with hepatocellular carcinoma. (erefore, the treatment appeared before TACE is performed and good results are principle for such cases is considered to treat hepatic ar- obtained. However, embolic materials such as gelatin teriovenous shunt, while treating primary hepatocellular sponge, silk thread segments, polyvinyl alcohol particles, and spring coils are used to embolize the mouth. Because the carcinoma, improve blood supply to the hepatic, protect normal hepatic tissue, and alleviate gastrointestinal bleeding material itself is bulky and the blood flow cannot be com- pletely concentrated in the shunt channel, it is difficult for and ascites caused by portal hypertension. Such clinical symptoms reduce the chance of tumor metastasis through the embolic agent to reach the mouthwash. For accurate the fistula and hepatic hepatocellular vein fistula treatment position, it is easy to cause the main artery of the hepatic because the hepatic hepatocellular vein fistula is often small tumor to be blocked by the main artery and not to perform and multiple and can be blocked with granules or gelatin TACE again. A microcatheter is applied to cross the fistula, sponge, and then TACE treatment is applied [14]. During insert itself into multiple tumor feeding arteries, and care- embolization with ethyl iodide, if the sealing is not complete, fully inject the mixed chemotherapy drug and the appro- a small amount of slow bolus should be given because the priate amount of lipiodol under fluoroscopy; stop embolic agent enters the lungs more often and it is prone to immediately when reflux occurs and then place the catheter head in the mouthwash with gelatin sponge or embolization pulmonary embolism. It corrects understanding and anal- ysis of hepatic arteriovenous fistula combined with hepa- of the mouthwash with absolute ethanol, slowly injecting the tocellular carcinoma which can effectively block the fistula to mixed emulsion to complete the chemoembolization reduce portal pressure, improve hepatic blood supply, create without venous visualization [15]. opportunities for further treatment of hepatocellular car- cinoma, prolong patient’s survival time, and improve quality of life. 4.2. Efficacy Comparison of Interventional Treatment under Different Embolization Modes. (e small branches of the (e control of primary hepatocellular carcinoma mor- bidities can increase the efficacy of TACE, significantly hepatic portal venules and hepatic artery pass through the hepatocyte boundary plate and enter the hepatic lobules, improve patient survival, and prolong survival. With the open to the hepatic sinus, through the hepatic sinus, and the advancement of interventional techniques for hepatocellular latter merge into the interlobular vein and then merge into carcinoma, some scholars believe that, for patients with the hepatic vein. When the hepatic vein, the interlobular hepatocellular carcinoma and HAVF, firstly, the fistula is 8 Journal of Healthcare Engineering catheter is difficult to cross the fistula, because the tumor has vein, and the central venous return are blocked, the hepatic sinus pressure will increase. (rough the common opening, the effect of stealing blood; it can be slowly administered in front of the fistula under fluoroscopy, and the medicine the portal venule and the small branches of the hepatic artery can communicate to form a transvascular vascular-portal basically enters the tumor artery across the fistula; then, fistula. (e branch of the anterior terminal hepatic arterioles according to the conventional scheme chemoembolization in the portal area mainly passes through the fine capillary has a good effect. If the blood flow rate is large, the con- plexus around the interlobular bile duct and is introduced ventional TACE drug enters the hepatic artery less; not only into the hepatic portal vein branch and finally into the does the tumor not reach the effect of embolism, but it will hepatic sinus [16]. When the hepatic portal vein branch aggravate the hepatic damage and easily induce hepatic coma; when the partial flow is too large, the portal vein blood blood flow is blocked, the capillary plexus around the in- terlobular bile duct can be made. In dilation, through these flow is hepatic. At this time, the embolic agent may enter the portal vein or even the esophageal vein, causing ectopic expanded capillary plexus, the input venules communicate with the anterior terminal hepatic arterioles in the portal embolization. (erefore, coaxial microcatheters should be used as much as possible, and TACE should be passed over area to form an arterial-portal fistula of the vascular plexus (Figure 4). Some of the anterior terminal hepatic arterioles the HAPVF arterial fistula. After TACE, the catheter is bypass these capillary plexus and direct blood into the he- retracted to the vicinity of the fistula, the size of the fistula is patic sinus. When the sinus pressure increases, the blood in accurately measured, the arteriovenous shunt is observed, the hepatic sinus flows directly into the anterior terminal and a suitable embolic material embolization is selected. hepatic arterioles of the portal area, forming an artery through the hepatic sinus portal vein spasm. In the case of 5. Discussions advanced hepatocellular carcinoma, most patients choose to undergo embolization without surgical indications, and the 5.1. Formation Mechanism of Hepatocellular Carcinoma combination of arteriovenous fistula is considered to be a Combined with Arteriovenous Fistula. In the case of ad- contraindication for embolism. vanced hepatocellular carcinoma, most of the patients were For patients with hepatocellular carcinoma who are treated with selective interventional embolization. In alone with HAPVF, a treatment plan should be developed combination with arteriovenous fistula, it was previously based on the type of HAPVF and the size of the blood flow. If considered a contraindication for embolism, in which the the portal vein is peripheral, because of the small blood flow, efficacy of interventional embolization is mainly related to conventional chemoembolization is safe and effective, be- the deposition effect of embolized lipiodol in the tumor. (e cause only a small part of embolic agent enters the portal blood flow of the tumor is reduced when the arteriovenous vein during embolization of the hepatic artery, causing fistula is combined, and the fluid pressure change in the embolization of the small branch of the portal vein around tumor blood vessel caused by the formation of the fistula is the tumor to form a tumor and double embolism; tumor also formed. Directly affecting the deposition of iodized oil necrosis is more complete. When HAPVF is the central type, also reduces the effectiveness of interventional therapy. At if the blood flow rate is not large, the chemotherapy is the same time, due to the presence of sputum, lipiodol can embolized according to the conventional scheme, and the enter the normal hepatic tissue with blood flow, cause he- curative effect is better; if the blood flow is large, the embolic patic damage, enter the gastrointestinal artery, cause ectopic agent mainly enters the portal vein and less enters the he- embolization, and enter the lungs to cause pulmonary patic artery, and the tumor will not reach embolism. (e embolism. (e presence of sputum also aggravates the effect, on the contrary, will aggravate the damage of the pressure of the portal vein, causing portal hypertension. In hepatic, and it is easy to induce hepatic coma. At this time, it severe cases, gastrointestinal bleeding can occur; therefore, is better to use a gelatin sponge strip to effectively block the the treatment of sputum has important clinical significance. fistula before embolization. If the central HAPVF portal In the treatment of hepatocellular carcinoma combined with blood flow is hepatic, the contrast agent is thickened to the arteriovenous fistula, the treatment of hepatocellular car- left esophageal vein to the esophageal vein, which is not cinoma should be the ultimate goal, and portal hypertension suitable for embolization; otherwise, it will lead to pulmo- can also be reduced. For the hepatic artery and the portal nary infarction [17]. If the HAPVF is small in the peripheral vein or the hepatic vein, the main purpose of embolization is or central type, the portal vein is not completely occluded or to determine the method according to the change of blood completely occluded but the side branches are abundant and flow, so as to reduce the complications caused by emboli- it is still safe to reduce the embolization dose or the central zation to achieve the purpose of treating tumor. embolization during treatment. Figure 5 shows the impact factors of hepatic arterio- (e principle of treatment of central HAHAF is firstly venous fistula type and hepatic function classification on using microcatheter to overselect the sputum and directly imaging diagnosis. After hepatic arteriovenous angiography, administer partial TACE treatment under fluoroscopy. At hepatic arteriovenous fistula was selected; under the DSA the end of the administration, as the vascular resistance surveillance, different embolization methods were selected increases, when there is more iodine oil or when the mouth according to the size of the fistula. (e diverticulum flow rate is lost, it needs to retreat to the mouth. (e mouthwash is was high, and the distal hepatic artery and branches of the closed with a gelatin sponge to reduce the flushing of the fistula were basically not developed. (e tip of the micro- lipiodol by the blood. If the blood flow is not large, the catheter passes through the mouth of the fistula to iodized oil Journal of Healthcare Engineering 9 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 HAPVF Mixed fistula Total HAHVF HAVF types Mild Moderate Severe Figure 4: Relative proportions of different fistula type and tumor embolization. embolization, and the distal end of the fistula is subjected to hepatic vein and portal vein to confirm the presence of high-pressure disinfection gelatin sponge coarse particle arteriovenous fistula. If the catheter is superselected to the embolization, and the proximal end of the coil is closed to vicinity of the fistula, the area and size of the fistula can be the fistula; if the microcatheter head end cannot pass over displayed, and the hepatic artery can be seen with the ex- the fistula, the coil is first used close to the fistula; confirm the pansion of the portal vein. Sometimes, collateral circulation occlusion of the fistula and then perform the hepatic arterial of cancerous portal hypertension and tumor thrombus angiography [18]. According to the intrahepatic artery development are seen. Contrast examination confirmed that branch and the hepatic tumor angiography, determine HAHVF should be occluded after the fistula, according to whether to do the tumor iodized oil embolization treatment, the degree of tumor vascular development to determine whether the tumor is treated with iodized oil embolization. which ends the iodine oil embolization over the mouth and then uses the high-pressure disinfection gelatin sponge (e contraindications are the same as those for simple coarse particles plus anhydrous alcohol mixture to close the primary hepatocellular carcinoma. Hepatic function and mouth. If it cannot pass the fistula, perform the first infusion various biochemical indicators were significantly lower than chemotherapy; then make the catheter tip close to the normal and the disease course was not proportional, often mouth, and use high-pressure disinfection gelatin sponge accompanied by mild to moderate cirrhosis, oliguria, and coarse particles plus anhydrous alcohol mixture to close the moderate to large amount of ascites. On one hand, there are mouth; for medium and low partial flow, use directly iodized portal fistulas, which are caused by hepatic artery-portal vein oil plus autoclaved gelatin sponge particles to embolize short circuit, insufficient blood supply to the liver, worsening tumor lesions and close fistula. (e first fractional flow is liver damage, and cirrhosis. On the other hand, because the iodized oil embolism lesion; then select the bypass vessel pressure of the hepatic artery is much higher than the pressure of the portal vein, it further hinders the return of with ultra-autoclaved gelatin sponge anhydrous alcohol mixture fistula closure [19]. the portal vein, aggravates the portal hypertension, and (e HAHVF hepatic angiography can be seen in the causes more ascites and oliguria. Due to the difficulty in the arterial phase or early arterial vein visualization of the surgical treatment of HAHVF, especially in the advanced Relative proportion 10 Journal of Healthcare Engineering 1.00 0.09 0.08 0.07 0.06 0.05 0.04 0.03 Massive Nodular Diffuse Child A Child B Child C type type type function function function Figure 5: Impact factors of hepatic arteriovenous fistula type and hepatic function classification on imaging diagnosis. hepatic tissue, and reduces distant metastasis. (e emboli- stage of primary hepatocellular carcinoma, the opportunity for surgical treatment is lost, and the embolization of the zation materials commonly used are mitomycin powder, tumor is easy to cause portal vein or pulmonary embolism, stainless steel ring, polyvinyl alcohol particles, and gelatin which is a contraindication. (erefore, the fistula is first sponge particles, and the choice of embolic material is performed and the superselective occlusion is especially mainly based on the size of HAPVF. necessary. TACE uses microcatheter technology to achieve ac- curate and dense intratumoral embolization, and the portal vein blood supply of small hepatocellular carcinoma is also 5.2. Clinical Significance of Embolization in the Treatment of large. Superselective subsegment embolization makes the Hepatocellular Carcinoma. (e primary hepatocellular terminal small arteries and venules in the tumor occlude carcinoma is very easy to invade the hepatic vein or portal the best and the embolization effect while maximizing the vein system, and its incidence rate is more than 60%. (e protection of normal hepatic tissue. (e patient used main mechanism is direct invasion of the tumor; the tumor microcatheter superselective subsegment embolization, feeding artery passes through the tumor sinus entry vein or and the density of iodized oil deposition was more ideal the artery branch because portal dilation is tumor. Erosion is than that of microcatheter superselective subsegment to direct drainage of the arterial vein and pathological ex- embolization, showing the advantage of using micro- pansion of the nourishing artery around the portal vein; the catheter subsegment embolization. Small hepatocellular role of tumor vascular endothelial growth factor results in carcinoma generally has a relatively long survival period the formation of a neovascular network between the hepatic and requires multiple interventions, in which it is inevitable artery and the portal vein. (e occurrence of HAPVF is that hepatic function damage will occur during TACE related to the location of the tumor, most of which is located treatment (Figure 6). (erefore, it is considered that near the hilum and close to the trunk of the portal vein. In subsegment embolization should be achieved as much as the presence of HAPVF, a large amount of high-pressure possible in the treatment of small hepatocellular carcinoma arterial blood directly enters the portal vein through the with TACE. However, for patients with a long interval of fistula, causing the portal vein pressure to rise further, ag- TACE treatment for the first time or again, it is important gravating the formation of upper gastrointestinal bleeding to find the comprehensiveness of treatment in order to find and ascites. At the same time, the presence of HAPVF other hidden lesions in the hepatic. (e experience is to prevented chemotherapy embolization of cancer and em- retract the catheter into the hepatic artery or the left and bolization must reach the level of capillaries [20]. On the one right hepatic artery trunks and then inject a proper amount hand, it blocks the hepatic artery-portal vein shunt and of lipiodol into the superselective subsegment to prevent relieves gastrointestinal bleeding and ascites caused by portal the omission of smaller lesions and to achieve both diag- hypertension and on the other hand facilitates superselective nosis and treatment. Common complications of small embolization of tumor blood vessels, protects normal hepatocellular carcinoma TACE treatment mainly include Impact factor Journal of Healthcare Engineering 11 50 50 45 45 40 40 35 35 30 30 25 25 20 20 15 15 HAPVF HAHVF Mixed fistula HAPVF HAHVF Mixed fistula HAVF types HAVF types Central type Central type Peripheral type Peripheral type (a) (b) 50 50 45 45 40 40 30 30 HAPVF HAHVF Mixed fistula HAPVF HAHVF Mixed fistula HAVF types HAVF types Central type Central type Peripheral type Peripheral type (c) (d) Figure 6: Distributions of relative proportion of Child classification of hepatic function in the central and peripheral type. postembolic syndrome, cholecystitis, hepatic dysfunction, [22]. After the control of gastrointestinal bleeding and and gastroduodenal lesions; generally symptomatic support improvement of hepatic function, hepatic artery emboli- can be treated [21]. zation chemotherapy is performed to reduce the compli- Hepatic artery-portal sputum has obvious stealing cations associated with intervention and to obtain time for follow-up treatment and prolong the survival time of pa- function, which causes a large amount of hepatic artery blood to be shunted to the portal vein, hepatic ischemia, and tients. Although the microcatheter can be used to cross the hypoxia. After the fistula is blocked, the blood flow of the shunt mouth to enter the branch of the hepatic artery, the hepatic recovers or is close to normal; the hepatic artery- hepatic artery embolization is performed before the fistula to hepatic arterial blood enters the hepatic and improves the treat the tumor, and then the shunt mouth is blocked. metabolism of hepatocytes. (e hepatic function of the However, when the upper digestive to the hemorrhage hepatic artery-portal vein is improved after the patient is occurs, the body is in a state of stress, and the hepatic artery blocked and the main reason is the hepatic artery; after the is simultaneous embolization of unpredictable risks; the closure of the portal vein, hepatic hemodynamics returned experience is to first block the fistula and then hepatic artery to normal. Hepatocellular carcinoma with hepatic artery- embolization after hemorrhage control. portal shunt, direct TACE treatment, and embolic agents can enter the portal system through the fistula to cause plugging. 6. Conclusions In the case of finding difficulty in controlling upper gas- trointestinal bleeding, spring rims or large particles of A total of 120 patients diagnosed as HAVF were chosen as polyvinyl alcohol granules should be selected according to study subjects in this study to explore imaging diagnosis and the specific conditions of DSA examination to block the interventional treatment for hepatocellular carcinoma mouthwash and minimize the pressure on the portal vein combined with arteriovenous fistula. (e results show that Relative proportion of child C Relative proportion of child A Relative proportion of total Relative proportion of child B 12 Journal of Healthcare Engineering [5] K. Himes, A. Bornais, E. Bittenbinder, and J. Cook, “Posterior the central type of HAVF is characterized by early angi- tibial artery pseudoaneurysm with arteriovenous fistula: ography of portal vein and large branches and tumor impact of duplex ultrasound on diagnosis and treatment,” staining after portal vein’s angiography; the peripheral type Journal for Vascular Ultrasound, vol. 41, no. 1, pp. 31–35, 2017. of HAVF is characterized by portal vein branching in hepatic [6] Z. Qamhawi, G. Makris, V. Vergani, and R. Uberoi, “Abstract tumor and double rail sign accompanied by the arterial No. 635 Drug-eluting balloon angioplasty in the treatment of branch; 112 cases of patients completed embolization che- renal dialysis arteriovenous fistula stenosis,” Journal of Vas- motherapy; 8 cases of patients only received chemotherapy cular and Interventional Radiology, vol. 29, no. 4, pp. 263-264, perfusion; in 109 cases of patients sputum disappeared or shunt decreased at first treatment; and in 113 cases of pa- [7] M. D. Rui, S. 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Miyachi et al., “Treatment of taken, it can still achieve better curative effect without se- perimedullary arteriovenous fistula of the spinal cord by rious complications, which can effectively alleviate the superselective neuroendovascular therapy: a case report and clinical symptoms of patients and improve the quality of life literature review,” Journal of Orthopaedic Science, vol. 21, of patients. According to DSA angiography, normal hepatic no. 1, pp. 86–90, 2016. arteries and tumor veins may be directly destroyed; obvious [10] W. T. Rahman, J. Griauzde, and S. T. Chong, “Neurovascular early tumor vein development will shunt and elongate. (ere emergencies,” Contemporary Diagnostic Radiology, vol. 40, is no clear channel between the artery and the vein in the no. 3, pp. 1–7, 2017. clear channel, and the tumor blood vessels are dense and [11] J. Lee, Y.-M. Lim, D. C. Suh, S. C. Rhim, S. J. Kim, and obviously twisted. No obvious early venous development K.-K. 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Imaging Diagnosis and Interventional Treatment for Hepatocellular Carcinoma Combined with Arteriovenous Fistula

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Copyright © 2021 Zheng Cai et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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2040-2295
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2040-2309
DOI
10.1155/2021/6651236
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Abstract

Hindawi Journal of Healthcare Engineering Volume 2021, Article ID 6651236, 13 pages https://doi.org/10.1155/2021/6651236 Research Article Imaging Diagnosis and Interventional Treatment for Hepatocellular Carcinoma Combined with Arteriovenous Fistula 1 2 1 1 1 Zheng Cai , Maohui Ran, Jiantao Song, Wenrui Zhen, and Mingjian Li e Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China Correspondence should be addressed to Zheng Cai; 101026@zmu.edu.cn Received 29 December 2020; Revised 11 February 2021; Accepted 23 February 2021; Published 4 March 2021 Academic Editor: Zhihan Lv Copyright © 2021 Zheng Cai et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In order to explore the imaging diagnosis methods and interventional treatment effects of hepatocellular carcinoma combined with hepatic arteriovenous fistula (HAVF), a total of 120 patients, who were diagnosed as hepatic carcinoma with arteriovenous shunting and underwent medical imaging diagnosis and interventional surgery therapy at a designated hospital by this study from December 2014 to December 2018, were chosen as study subjects. Digital subtraction angiography was performed to analyze the imaging features of hepatocellular carcinoma combined with HAVF in each patient; then, according to these imaging diagnosis results, gelatin sponge or coil was used to block the fistula; mitomycin, carboplatin powder, and lipiodol mixed emulsion was combined or separately utilized for hepatic tumor embolization, in which iodized oil embolization chemotherapy was used for patients with mild paralysis; gelatin sponge granule embolization chemotherapy was used for moderate paralysis patients at their first intervention, and, after about 1 month, if the sputum disappeared, iodized oil embolization was used again; and hepatic arterial infusion chemotherapy was used only for patients with severe paralysis. (e results show that the central type of HAVF is characterized by early angiography of portal vein and large branches and tumor staining after portal vein’s angiography; the peripheral type of HAVF is characterized by portal vein branching in hepatic tumor and double rail sign accompanied by the arterial branch; 112 cases of patients completed embolization chemotherapy; 8 cases of patients only received chemotherapy perfusion; in 109 cases of patients sputum disappeared or shunt decreased at first treatment; and in 113 cases of patients iodine oil was well deposited or the tumor was stably reduced; most of the symptoms of refractory ascites, diarrhea, and upper gastro- intestinal bleeding were controlled or improved, and there were no complications such as pulmonary embolism and hepatic failure. (erefore, HAVF increases the difficulty of interventional therapy, but, as long as the positive and appropriate treatment measures are taken, it can still achieve better curative effect without serious complications, which can effectively alleviate the clinical symptoms of patients and improve the quality of life of patients. (e results of this study provide a reference for the further researches on imaging diagnosis and interventional treatment for hepatocellular carcinoma combined with arteriovenous fistula. divided into two types: central type and peripheral type; and 1. Introduction primary hepatocellular carcinoma often invades the venous Hepatic arteriovenous fistula (HAVF) is an organic and system of the hepatic and HAVF occurs [2]. (e abnormal functional abnormal pathway between hepatic artery and anastomosis of HAVF directs blood flow between the he- portal vein and between hepatic artery and hepatic vein, patic artery and the portal vein and hepatic vein. (e which is more common with hepatocellular carcinoma, presence of HAVF accelerates the spread of tumors in the trauma, hepatic hemangioma, cirrhosis, hepatic biopsy, hepatic and throughout the body, which not only is a cause hepatic abscess, and other diseases with the incidence rate of of tumor cell metastasis in the hepatic, but can also cause 14–63.2% [1]. HAVF is divided into three types: hepatic portal hypertension. HAPVF can cause or aggravate the artery-portal vein fistula (HAPVF), hepatic artery-hepatic symptoms of portal hypertension, such as gastrointestinal vein fistula (HAHVF), and mixed fistula; and HAPVF is bleeding and ascites; severe life can be critical; HAVF can 2 Journal of Healthcare Engineering only for patients with severe paralysis. (e detailed chapters increase the chance of tumor cells spreading through the portal vein and hepatic vein to distant organs and can in- are arranged as follows: Section 2 introduces research ma- terials and methods; Section 3 performs results analysis; crease the false diagnosis of hepatic imaging positive rate [3]. In interventional therapy, lipiodol can cause pulmonary and Section 4 analyzes the imaging diagnosis and interventional systemic embolism through the shunt pathway, and he- treatment of hepatocellular carcinoma with arteriovenous modynamic changes due to shunt can directly affect the fistula; Section 5 is discussion; Section 6 is conclusion. efficacy of transcatheter arterial chemoembolization (TACE) intervention, so understanding the imaging diagnosis and 2. Materials and Methods intervention of HAVF Treatment has important implica- 2.1. General Materials. A total of 120 patients, who were tions [4]. diagnosed as hepatic carcinoma with arteriovenous shunting Digital subtraction angiography (DSA) examination is the and underwent medical imaging diagnosis and interven- gold standard for diagnosing HAVF, in which central HAPVF tional surgery therapy at a designated hospital by this study is located in the portal vein or the primary branch and pe- from December 2014 to December 2018, were chosen as ripheral HAPVF is located in the lower branch of the portal study subjects including 60 cases of HAPVF and 60 cases of vein. It can also be divided into high, medium, and low flow HAHVF. (ese materials contain 40 males and 28 females; types due to different flow rates; generally, the centre type their ages are 34–86 years with an average of 55.74± 10.23 flow rate is high, and the surrounding type flow rate is low [5]. years old; their hepatocellular carcinoma pathology classi- (e location and type of HAVF before interventional em- fication includes 34 cases of massive type, 41 cases of nodular bolization can help to choose the interventional method and type, and 45 cases of diffuse type (Table 1); the HAHVF avoid the occurrence of ectopic embolization and improve the contains 31 cases of central type and 29 cases of peripheral treatment effect. With the improvement of imaging exami- type (Table 2); their hepatic function includes 24 cases of nation technology, the detection rate of HAVF is gradually Child A, 78 cases of Child B, and 18 cases of Child C improved. Doppler ultrasound can find abnormal thickening according to hepatic function rating criteria (Table 3); their of the blood supply artery and abnormal blood flow of the histological classification contains 113 cases of hepatocyte corresponding vein and it is rare to find a direct display of type and 5 cases of hepatic bile duct type and mixed type; abnormal shunt between arteries and veins and enhanced their clinical classification includes 85 cases of simple type computed tomography scans can be seen early in the arterial- (there were no clinical manifestations and clinical exami- portal vein [6]. DSA can clearly show the location and flow of nation showed no obvious cirrhosis), 8 cases of sclerosing HAVF, which is characterized by the dual-track sign of the type (clinical and laboratory tests have obvious cirrhosis portal vein in the arterial phase. (e arterial phase portal vein manifestations), and 27 cases of inflammatory type (faster contrast agent is filled; the contrast agent entering the hepatic disease development accompanied by persistent cancerous vein branch or the right atrium of the vena cava during the hyperthermia or alanine aminotransferase continued to arterial phase where the liver supplies blood to the blood increase more than double); the tumor sizes are in 1–17 cm vessel is not clear, and the tumor staining is not obvious. with an average size of 7.96± 4.23 cm; the α-fetoprotein level When the HAVF flow is low, the arterial and late portal vein is in 1–58100 μg/L with an average level of branches or hepatic veins develop, and most mouthwashes 28950.56± 28095.64 μg/L; the clinical symptoms were appear to be chaotic [7]. Understanding the performance of mainly in 33 patients with ascites, 29 patients with gas- the above DSA can guide the choice of interventional em- trointestinal bleeding, 39 patients with anorexia and diar- bolization methods to avoid complications [8]. rhea, and 19 patients without obvious discomfort. In order to explore the imaging diagnosis methods and interventional treatment effects of hepatocellular carcinoma combined with hepatic arteriovenous fistula (HAVF), a total 2.2. Inclusion and Exclusion Criteria. (e inclusion criteria of 120 patients, who were diagnosed as hepatic carcinoma were the following: (1) patients who refused surgery treat- with arteriovenous shunting and underwent medical imaging ment; (2) patients who did not meet the surgical resection; diagnosis and interventional surgery therapy at a designated (3) patients who met the diagnostic criteria for primary hospital by this study from December 2014 to December 2018, hepatocellular carcinoma with HAHVF; and (4) patients were chosen as study subjects. Digital subtraction angiog- without heart and kidney dysfunction. raphy was performed to analyze the imaging features of (e exclusion criteria were the following: (1) patients with hepatocellular carcinoma combined with HAVF in each poor general condition and signs of failure; (2) patients with patient; then, according to these imaging diagnosis results, extensive systemic metastasis of hepatocellular carcinoma: (3) gelatin sponge or coil was used to block the fistula; mito- patients with secondary infection or systemic infection; (4) mycin, carboplatin powder, and lipiodol mixed emulsion was patients with severe hepatic function disorders; and (5) patients combined or separately utilized for hepatic tumor emboli- with reverse portal blood flow or blocked portal vein trunk. zation, in which iodized oil embolization chemotherapy was used for patients with mild paralysis; gelatin sponge granule embolization chemotherapy was used for moderate paralysis 2.3. Imaging Diagnosis Methods. (e digital subtraction an- patients at their first intervention, and, after about 1 month, if giography examination was as follows: transfemoral puncture, the sputum disappeared, iodized oil embolization was used conventional superior mesenteric artery and celiac artery again; and hepatic arterial infusion chemotherapy was used angiography, selective contrast and interventional therapy, Journal of Healthcare Engineering 3 Table 1: Statistics of hepatic arteriovenous fistula (HAVF) type in fistula is used. According to the size of the fistula shown by the the included materials [n (%)]. comparison, gelatin sponge particles, gauze or stainless steel ring can be used to embolize the fistula, and then perform Massive Nodular Diffuse HAVF type Total TACE treatment. (is requires slow perfusion of 4-Fu 1.0 μg, type type type cisplatin 55 μg, hydroxycamptothecin 35 mg, doxorubicin HAPVF 19 (15.83) 24 (20.00) 33 (27.50) 76 (63.33) 45 mg or mitomycin 25 mg, and lipiodol plus appropriate HAHVF 10 (8.33) 15 (12.50) 9 (7.50) 34 (28.33) amount of suspension for embolization. In addition, it is also Mixed 5 (4.67) 2 (1.67) 3 (2.50) 10 (8.33) possible to intubate the fistula, which requires TACE local fistula 120 lesion treatment first, and then embolize the fistula according Total 34 (28.33) 41 (34.17) 45 (37.50) (100.00) to the above method, and the rest will be treated with TACE. Peripheral type: the catheter can be inserted into the fistula; the treatment method is the same as before; the catheter Table 2: Statistics of hepatic artery-hepatic vein fistula (HAHVF) cannot be inserted into the fistula, so use appropriate amount type in the included materials [n (%)]. of gelatin sponge particles and embolize the contrast agent to HAPVF type Mild Moderate Severe Total observe the embolization of the fistula until the fistula is Central type 11 (18.33) 12 (20.00) 8 (13.33) 31 (51.67) completely embolized and then use TACE. Small-area or Peripheral type 6 (10.00) 13 (21.67) 10 (16.67) 29 (48.33) hepatic portal vein fistula with small blood flow is directly Total 17 (28.33) 25 (41.67) 18 (30.00) 60 (100.00) treated with TACE and hepatic artery-hepatic vein fistula is to select gelatin sponge granules or gauze embolization according to the size of the mouth and then apply TACE. Table 3: Child classification of hepatic function in the included HAVF patients [n (%)]. Child classification of hepatic 2.5. Clinical Efficacy Criteria. Clinical efficacy is divided into function HAVF type Total three levels: complete remission, partial remission, and A B C ineffective remission. Gastrointestinal hemorrhage: vomit- ing or blood in the stool disappears; fecal occult blood HAPVF 10 (8.33) 21 (17.50) 3 (2.50) 34 (28.33) HAHVF 8 (6.67) 16 (13.33) 8 (6.67) 32 (26.67) negative is complete remission; hematemesis or blood in the Mixed fistula 6 (5.00) 41 (34.17) 7 (5.83) 54 (45.00) stool disappears; fecal occult blood positive is partial re- Total 24 (20.00) 78 (65.00) 18 (15.00) 120 (100.00) mission; hematemesis or blood in the stool remains inef- fective. Ascites: abdominal water was significantly reduced total injection volume of contrast agent 20–35 mL/time, rate of by ultrasound at least to complete remission; equal reduction 3–6 mL/s observe tumor blood supply, hepatic arteriovenous in ascites was partial remission; no significant reduction in fistula, and tumor site. According to the arteriovenous fistula ascites was ineffective. Esophageal varices: there is tempo- and the amount of blood in the shunt, there are two different rary esophageal sputum angiography; varicose veins to the methods: central type and peripheral type. Central type: if upper part of the chest esophagus are severe; the middle part patients can overselect the intubation and pass the sputum into of the esophagus is moderate and only the lower part of the the tumor blood vessel, slowly inject iodine under fluoroscopy; esophagus is mild. (e esophageal varices were completely the oil suspension is embolized, and then the catheter is relieved from severe to mild or there was no obvious var- withdrawn to the mouth to seal the mouth with gelatin sponge icose; partial remission was changed from severe to mod- particles. If the catheter tip cannot pass over the fistula, first seal erate or moderate to mild; no significant change in varicose the fistula with gelatin sponge particles and then embolize. veins was ineffective. Peripheral type is mainly used for catheters that cannot be inserted into the fistula. Appropriate amount of gelatin sponge particles are used for embolization. (e contrast agent is 2.6. Observation Indicators. When the patient’s clinical in- dicators are restored, no adverse reactions are considered to pushed by hand to observe the embolism of the oral cavity. After the TACE port is completely blocked, TACE can directly be significant treatment; when the patient’s clinical indi- cators are improved compared to the treatment activities, it treat small blood flow. (e DSA shows that the portal vein, hepatic artery, or inferior vena cava develops in advance during is considered effective; regarding the patient’s clinical items, if the indicator situation has not been improved or is be- the hepatic artery or hepatic parenchyma, which is a combined HAVF. (e HAVF angiography showed a portal vein with a coming more serious, it is considered to be ineffective. Among them, the total clinical efficiency is the sum of large branch of the first or second stage or a peripheral portal vein with a parallel to the artery and HAVF manifests as early significant efficiency. hepatic vein and reflux of contrast agent to right atrium. 2.7. Statistical Methods. (e data of this study were analyzed 2.4. Interventional Treatment Solutions. (e treatment plan by SPSS 19.0 statistical software. (e measurement data and counting data were expressed by takes a different approach depending on the location of the x± s and %, respectively. arteriovenous fistula and the amount of blood diverted (e t and P tests were used, and the results were statistically through it. For the central type, the method of intubating the significant at P< 0.05. 4 Journal of Healthcare Engineering According to DSA angiography, HAHVF is divided into 3. Result Analysis three categories. (e first category is the direct destruction of 3.1. Performance and Classification of Digital Subtraction normal hepatic arteries and tumor veins. For the second Angiography. HAHVF is generally characterized by early type, early tumor vein development can be seen, but the development of hepatic vein, during which the portal vein or shunt is long and slender. (ere is no clear passage between branch development is seen in the arterial phase and is the artery and the vein. (e tumor blood vessel is large and mainly divided into the central type and periphery type. (e obviously twisted, or the tumor blood vessel is light to fistula is located in the portal vein and the primary branch of obvious with multiple blood type changes. For the third type, the arteriovenous fistula and portal vein trunk and branch there are a large number of dense tumor blood vessels, and visualization; peripheral angiography showed simultaneous there is no obvious early venous development during the portal vein branching along the arterial branch and double angiography, but arteriovenous short circuits are found rail sign accompanied by arterial branches. (e venous when embolism exists. HAVF is performed in computed sputum DSA main manifestations included double rail sign tomography or magnetic resonance imaging, central HAVF accompanying the portal vein in the arterial phase, showing is located in the hilar, portal vein, and grade I branch is the filling of the portal vein contrast agent; the contrast agent enhanced earlier than superior mesenteric vein or splenic enters the branch of the hepatic vein or the right atrium of vein, densely developed; density is close to enhanced ab- the vena cava (Table 4). After iodized oil embolization, the dominal aorta, there is nontumor hepatic parenchyma in the iodized oil venous sign appeared, and the line sign was hepatic arterial phase, and the portal vein returned to displayed in the portal vein tumor thrombus after angiog- normal. Peripheral HAVF is located in the surrounding raphy. All patients with moderate or severe arteriovenous hepatic parenchyma, and the branches of the portal vein fistula have a transient focal, multifocal, or diffuse contrast level and below are enhanced earlier than the portal vein agent staining process before the venous branch is devel- (Figure 1). (e Doppler blood flow spectrum can be con- oped. (en, there was a vein development in the corre- sidered as HAVF: the multicoloured mosaic blood flow is in sponding area, and no tubular communication between the the venous lumen; for the hepatic portal vein in the portal arteries and veins was found that is consistent with the vein, see reverse blood flow or two-way blood flow; the blood mechanism of the occurrence of hepatic arteriovenous fis- flow spectrum is the reverse artery sample, high-speed and tula and is also supported in ultrasound. Ultrasound mainly low-resistance type; hepatic vein sputum can be measured in found abnormal thickening of the blood supply artery and the hepatic vein, arterial-like, high-speed, and low-resistance abnormal blood flow of the vein, and there was little direct blood flow spectrum; hepatic artery inner diameter is display of abnormal shunt between arteries and veins. widened [10]. Hepatocellular carcinoma combined with arteriovenous fistula is one of the main factors affecting the prognosis of hepatocellular carcinoma, and it is the focus and difficulty of 3.2. Treatment Results of Chemotherapy Embolization. endovascular treatment of hepatocellular carcinoma. At Since the mouth of the HAPVF is located at the tumor, the present, the treatment methods for HAVF are commonly blood between the tumor and the portal vein is directly used such as spring steel ring, gelatin sponge particles, transported, and intrahepatic dissemination and extrahepatic anhydrous ethanol, and percutaneous transhepatic puncture metastasis of the hepatocellular carcinoma are formed, fol- and injection of anhydrous ethanol to close the mouth. (e lowed by anterior hepatic sinus portal hypertension (Table 5). spring steel ring can permanently embolize the larger arterial A large amount of high-pressure arterial blood directly enters branch, and the embolization site of the gelatin sponge the lower-pressure portal vein through the fistula, causing the particles is in the small and medium arteries, both of which portal pressure to rise further on the basis of the portal are nonselective embolization [9]. At the same time as hypertension caused by the original cirrhosis or portal vein embolization, the tumor is often blocked by the blood supply tumor thrombus, which may cause upper gastrointestinal artery of the tumor, so that the subsequent lipiodol emulsion bleeding. (e original hepatic damage is aggravated and the embolization is not possible or peripheral vascular embo- life of the patient is seriously threatened [11]. (erefore, the lization is inadequate, which seriously affects the emboli- treatment of such patients is to treat the primary hepato- zation effect of the tumor, and the amount of intravascular cellular carcinoma, block the hepatic artery-venous shunt, embolization of absolute ethanol is not easy to control. If improve the hepatic circulation, relieve and eliminate the reflux can lead to ectopic embolization, clinical application symptoms of gastrointestinal bleeding and ascites caused by should not be promoted; the main adverse reactions after portal hypertension, and at the same time further select the sputum and embolization were numbness, fever, and hepatic blood supply artery embolizing the tumor, protecting normal function changes. Symptomatic treatment generally has no hepatic tissue, and reducing the probability of tumor serious consequences. Pain mainly occurs in the operation; spreading through the fistula. (e hepatocellular carcinoma preembolization prophylactic bolus lidocaine can be helpful; combined with HAVF increases the difficulty and risk of postoperative main manifestations of suffocation discom- interventional embolization. However, as long as the patient’s fort, mainly due to the ischemic reaction of the lesion, can be general condition permits, after a detailed understanding of given a small amount of analgesic symptomatic treatment; the type of sputum, the size of the subflow, the presence or the main cause of fever is tumor necrosis after TACE, which absence of portal collateral circulation, etc., a reasonable can be generally relieved after treatment. treatment plan is formulated and the treatment is still safe and Journal of Healthcare Engineering 5 Table 4: Performances of digital subtraction angiography given different types of dynamic portal fistula, n (%). MF: mixed fistula. With inverse hepatic blood flow With portal vein tumor thrombus Group Mild Moderate Severe Total Mild Moderate Severe Total HAPVF 9 (7.500) 12 (10.00) 23 (19.17) 44 (36.67) 14 (11.67) 9 (7.50) 17 (14.17) 40 (33.33) HAHVF 13 (10.83) 6 (5.00) 11 (9.17) 30 (25.00) 7 (5.83) 10 (8.33) 11 (9.17) 28 (23.33) MF 8 (6.67) 17 (14.17) 21 (17.50) 46 (38.33) 15 (12.50) 16 (13.33) 21 (17.50) 52 (43.33) Total 30 (25.00) 35 (21.17) 55 (35.83) 120 (100.0) 36 (30.00) 35 (21.67) 49 (40.83) 120 (100.0) 1.0 1.0 0.9 0.9 0.8 0.8 0.7 0.7 0.6 0.6 0.5 0.5 0.4 0.4 0.3 0.3 0.2 0.2 Massive Nodular Diffuse Total Mild Moderate Severe Toatal Pathological gross classification Dynamic portal Fistula type HAPVF HAPVF HAHVF HAHVF (a) (b) Figure 1: Comparison of relative proportions of different pathological gross classifications (a) and dynamic portal fistula types (b) in the HAPVF and HAHVF. Table 5: Treatment results of chemotherapy embolization given different fistula type and tumor embolization [n (%)]. MF: mixed fistula. Case of embolizing tumor by overpassing fistula Case of embolizing tumor not by overpassing fistula Group Mild Moderate Severe Total Mild Moderate Severe Total HAPVF 24 (20.00) 16 (13.33) 9 (7.50) 49 (40.83) 11 (9.17) 15 (12.50) 10 (8.33) 36 (30.00) HAHVF 17 (14.17) 11 (9.17) 10 (8.33) 38 (31.67) 19 (15.83) 18 (15.00) 12 (10.00) 49 (40.83) MF 11 (9.17) 13 (10.83) 9 (7.50) 33 (27.50) 16 (13.33) 10 (8.33) 19 (15.83) 35 (29.17) Total 52 (43.33) 40 (33.33) 28 (23.33) 120 (100.0) 46 (38.33) 33 (27.5) 41 (34.17) 120 (100.0) feasible and generally does not cause serious hepatic func- chemoembolization; then the catheter retreat to the vicinity tional impairment and hepatic failure. of the pass (Figure 2). At this time, because a part of the (e hepatocellular carcinoma combined with HAVF blood vessels is blocked, the shunt and tumor blood vessels increases the risk and difficulty of interventional therapy, are often clearer, and then the mouth is blocked and the and the high incidence of portal vein tumor thrombus also tumor is further embolized. For peripheral HAPVF, the makes the patient’s prognosis worse. However, for patients chemotherapy drug is first infused, and then the micro- who have not completely occluded the portal vein or have catheter is first selected to the sputum to block the tumor, and the tumor blood vessel is embolized with the lipiodol collateral circulation to the hepatic, it is generally considered safe and effective to treat embolization. Chemotherapeutic emulsion, or the tumor is inserted into the tube and the tumor donor branch is avoided. For the flow rate or pe- drugs and embolic agents can flow through the fistula to nonlesional blood vessels due to the presence of the shunt, ripheral type HAPVF that is difficult to overselect the in- seriously affecting the treatment effect and ectopic embolism tubation, first test a small amount of lipiodol emulsion and systemic toxic side effects. (erefore, sealing the fistula through the tumor blood supply artery. is the key to treatment [12]. For central or high-flow (e above-mentioned mechanism and imaging findings HAPVF, due to portal vein stealing, the size of the fistula and of hepatocellular carcinoma provide anatomical support for the tumor vessels is unclear, there is conventional micro- gelatin sponge granules to seal the fistula, but multifocal and catheter superselection over the mouth angiography, and a diffuse fistula occlusion is still quite difficult; they are often in pair of distal tumor vessels is treated with iodized oil the fourth and fifth grades of arteriovenous after branching; Proportion (%) Proportion (%) 6 Journal of Healthcare Engineering 1.50 1.45 1.40 1.35 1.30 1.25 1.20 1.15 1.10 1.05 1.00 Massive Nodular Diffuse Child A Child B Child C type type type function function function Figure 2: Weight coefficients of hepatic arteriovenous fistula type and hepatic function classification on imaging diagnosis. the gelatin sponge granule blockage easily causes emboli- shunting of HAVF can make iodine oil cause ectopic em- zation of the blood supply artery itself, which brings ob- bolization through sputum. Entering the portal vein can stacles to drug perfusion and lipiodol embolism. Heavy giant affect normal hepatic tissue, and entering the hepatic vein HAHVF is a safety consideration or a 5–6 mm steel ring can form pulmonary embolism; therefore, it is not appro- embolization; for patients with central embolization of the priate to use iodized oil embolism for such patients. Re- main tumor thrombus, the closure of the fistula should be cently, scholars have used embolization of iodized oil cautious, because it is easy to cause hepatic artery emboli- directly on patients with hepatocellular carcinoma and zation. Moreover, such patients are not suitable for iodized HAVF, which can improve the curative effect without se- oil tumor embolization even if they are successfully blocked rious complications. (e degree of hepatic HAVF is further because their hepatic function is extremely fragile; it is easy divided into three levels of light, medium, and heavy, and the purpose is to determine a suitable treatment plan to improve to induce hepatic coma if there is no effective rich collateral supply after normal embolization. Sometimes, the contrast the efficacy of such patients. In patients with mild hepa- dose or flow rate is not properly grasped, small hepatic tocellular carcinoma HAVF, the hepatic function is more HAVF cannot be found in time, and injection of lipiodol is than Child A grade, and it is more suitable for embolization prone to suppression, mistakenly entering the hepatic vein chemotherapy directly with iodized oil. However, it is worth and entering the pulmonary circulation; sometimes the noting that the mild hepatic artery-hepatic vein fistula is consequences are still very serious, so it is suggested that the more concealed and the angiography is more difficult to find, injection of lipiodol during the operation begins in very slow and the lipiodol can be returned to the pulmonary artery speed to observe the direction of oil column movement, through the sputum. During the operation, it is often while paying attention to the observation of adverse reac- marked by the injection of 3–5 mL of lipiodol and the tions such as cough and timely correction of possible presence of occult light hepatic arteriovenous vein fistula plugging [13]. should be considered at this time. (e treatment method is to stop the injection of lipiodol in time and embolize the larger branch of the hepatic artery with gelatin sponge 4. Efficacy Analysis of Imaging Diagnosis and particles, so that the lipiodol is not blocked by the hepatic Interventional Treatment artery. (e blood flow is flushed into the hepatic vein and 4.1. Angiographic Features of Hepatocellular Carcinoma with returned to the pulmonary artery. Figure 3 shows the an- Arteriovenous Fistula. (e hepatic artery embolization giographic characteristics of different hepatocellular carci- chemotherapy has become the treatment of choice for ad- noma with arteriovenous fistula. vanced hepatocellular carcinoma, and the key for improving (e hepatocellular carcinoma combined with hepatic the efficacy is the availability of iodized oil embolization artery-portal fistula allows a large number of high-pressure chemotherapy, in which it has been thought that the arterial bloods to enter the portal system directly through the Weight coefficient Journal of Healthcare Engineering 7 (a) (b) (c) (d) Figure 3: Angiographic characteristics of different hepatocellular carcinoma with arteriovenous fistula. (a) Primary hepatocellular car- cinoma with severe portal vein fistula; (b) central type hepatic vein-hepatic vein fistula; (c) hepatic artery-hepatic vein fistula; (d) peripheral type hepatic artery fistula. blocked, and then embolization is performed. (e method of fistula, which further increases the portal pressure on the basis of cirrhotic portal hypertension, which also aggravates embolization is safe and reliable, which can improve the hepatic function damage and increases the incidence of efficacy of hepatocellular carcinoma combined with HAVF. upper gastrointestinal bleeding. Hepatic artery-hepatic vein Some scholars have reported that the use of absolute ethanol sputum increases the incidence of pulmonary embolism and to ablate the fistula multiple times until the angiography is one of the main factors affecting the prognosis of patients shows that the arteriovenous fistula is reduced or dis- with hepatocellular carcinoma. (erefore, the treatment appeared before TACE is performed and good results are principle for such cases is considered to treat hepatic ar- obtained. However, embolic materials such as gelatin teriovenous shunt, while treating primary hepatocellular sponge, silk thread segments, polyvinyl alcohol particles, and spring coils are used to embolize the mouth. Because the carcinoma, improve blood supply to the hepatic, protect normal hepatic tissue, and alleviate gastrointestinal bleeding material itself is bulky and the blood flow cannot be com- pletely concentrated in the shunt channel, it is difficult for and ascites caused by portal hypertension. Such clinical symptoms reduce the chance of tumor metastasis through the embolic agent to reach the mouthwash. For accurate the fistula and hepatic hepatocellular vein fistula treatment position, it is easy to cause the main artery of the hepatic because the hepatic hepatocellular vein fistula is often small tumor to be blocked by the main artery and not to perform and multiple and can be blocked with granules or gelatin TACE again. A microcatheter is applied to cross the fistula, sponge, and then TACE treatment is applied [14]. During insert itself into multiple tumor feeding arteries, and care- embolization with ethyl iodide, if the sealing is not complete, fully inject the mixed chemotherapy drug and the appro- a small amount of slow bolus should be given because the priate amount of lipiodol under fluoroscopy; stop embolic agent enters the lungs more often and it is prone to immediately when reflux occurs and then place the catheter head in the mouthwash with gelatin sponge or embolization pulmonary embolism. It corrects understanding and anal- ysis of hepatic arteriovenous fistula combined with hepa- of the mouthwash with absolute ethanol, slowly injecting the tocellular carcinoma which can effectively block the fistula to mixed emulsion to complete the chemoembolization reduce portal pressure, improve hepatic blood supply, create without venous visualization [15]. opportunities for further treatment of hepatocellular car- cinoma, prolong patient’s survival time, and improve quality of life. 4.2. Efficacy Comparison of Interventional Treatment under Different Embolization Modes. (e small branches of the (e control of primary hepatocellular carcinoma mor- bidities can increase the efficacy of TACE, significantly hepatic portal venules and hepatic artery pass through the hepatocyte boundary plate and enter the hepatic lobules, improve patient survival, and prolong survival. With the open to the hepatic sinus, through the hepatic sinus, and the advancement of interventional techniques for hepatocellular latter merge into the interlobular vein and then merge into carcinoma, some scholars believe that, for patients with the hepatic vein. When the hepatic vein, the interlobular hepatocellular carcinoma and HAVF, firstly, the fistula is 8 Journal of Healthcare Engineering catheter is difficult to cross the fistula, because the tumor has vein, and the central venous return are blocked, the hepatic sinus pressure will increase. (rough the common opening, the effect of stealing blood; it can be slowly administered in front of the fistula under fluoroscopy, and the medicine the portal venule and the small branches of the hepatic artery can communicate to form a transvascular vascular-portal basically enters the tumor artery across the fistula; then, fistula. (e branch of the anterior terminal hepatic arterioles according to the conventional scheme chemoembolization in the portal area mainly passes through the fine capillary has a good effect. If the blood flow rate is large, the con- plexus around the interlobular bile duct and is introduced ventional TACE drug enters the hepatic artery less; not only into the hepatic portal vein branch and finally into the does the tumor not reach the effect of embolism, but it will hepatic sinus [16]. When the hepatic portal vein branch aggravate the hepatic damage and easily induce hepatic coma; when the partial flow is too large, the portal vein blood blood flow is blocked, the capillary plexus around the in- terlobular bile duct can be made. In dilation, through these flow is hepatic. At this time, the embolic agent may enter the portal vein or even the esophageal vein, causing ectopic expanded capillary plexus, the input venules communicate with the anterior terminal hepatic arterioles in the portal embolization. (erefore, coaxial microcatheters should be used as much as possible, and TACE should be passed over area to form an arterial-portal fistula of the vascular plexus (Figure 4). Some of the anterior terminal hepatic arterioles the HAPVF arterial fistula. After TACE, the catheter is bypass these capillary plexus and direct blood into the he- retracted to the vicinity of the fistula, the size of the fistula is patic sinus. When the sinus pressure increases, the blood in accurately measured, the arteriovenous shunt is observed, the hepatic sinus flows directly into the anterior terminal and a suitable embolic material embolization is selected. hepatic arterioles of the portal area, forming an artery through the hepatic sinus portal vein spasm. In the case of 5. Discussions advanced hepatocellular carcinoma, most patients choose to undergo embolization without surgical indications, and the 5.1. Formation Mechanism of Hepatocellular Carcinoma combination of arteriovenous fistula is considered to be a Combined with Arteriovenous Fistula. In the case of ad- contraindication for embolism. vanced hepatocellular carcinoma, most of the patients were For patients with hepatocellular carcinoma who are treated with selective interventional embolization. In alone with HAPVF, a treatment plan should be developed combination with arteriovenous fistula, it was previously based on the type of HAPVF and the size of the blood flow. If considered a contraindication for embolism, in which the the portal vein is peripheral, because of the small blood flow, efficacy of interventional embolization is mainly related to conventional chemoembolization is safe and effective, be- the deposition effect of embolized lipiodol in the tumor. (e cause only a small part of embolic agent enters the portal blood flow of the tumor is reduced when the arteriovenous vein during embolization of the hepatic artery, causing fistula is combined, and the fluid pressure change in the embolization of the small branch of the portal vein around tumor blood vessel caused by the formation of the fistula is the tumor to form a tumor and double embolism; tumor also formed. Directly affecting the deposition of iodized oil necrosis is more complete. When HAPVF is the central type, also reduces the effectiveness of interventional therapy. At if the blood flow rate is not large, the chemotherapy is the same time, due to the presence of sputum, lipiodol can embolized according to the conventional scheme, and the enter the normal hepatic tissue with blood flow, cause he- curative effect is better; if the blood flow is large, the embolic patic damage, enter the gastrointestinal artery, cause ectopic agent mainly enters the portal vein and less enters the he- embolization, and enter the lungs to cause pulmonary patic artery, and the tumor will not reach embolism. (e embolism. (e presence of sputum also aggravates the effect, on the contrary, will aggravate the damage of the pressure of the portal vein, causing portal hypertension. In hepatic, and it is easy to induce hepatic coma. At this time, it severe cases, gastrointestinal bleeding can occur; therefore, is better to use a gelatin sponge strip to effectively block the the treatment of sputum has important clinical significance. fistula before embolization. If the central HAPVF portal In the treatment of hepatocellular carcinoma combined with blood flow is hepatic, the contrast agent is thickened to the arteriovenous fistula, the treatment of hepatocellular car- left esophageal vein to the esophageal vein, which is not cinoma should be the ultimate goal, and portal hypertension suitable for embolization; otherwise, it will lead to pulmo- can also be reduced. For the hepatic artery and the portal nary infarction [17]. If the HAPVF is small in the peripheral vein or the hepatic vein, the main purpose of embolization is or central type, the portal vein is not completely occluded or to determine the method according to the change of blood completely occluded but the side branches are abundant and flow, so as to reduce the complications caused by emboli- it is still safe to reduce the embolization dose or the central zation to achieve the purpose of treating tumor. embolization during treatment. Figure 5 shows the impact factors of hepatic arterio- (e principle of treatment of central HAHAF is firstly venous fistula type and hepatic function classification on using microcatheter to overselect the sputum and directly imaging diagnosis. After hepatic arteriovenous angiography, administer partial TACE treatment under fluoroscopy. At hepatic arteriovenous fistula was selected; under the DSA the end of the administration, as the vascular resistance surveillance, different embolization methods were selected increases, when there is more iodine oil or when the mouth according to the size of the fistula. (e diverticulum flow rate is lost, it needs to retreat to the mouth. (e mouthwash is was high, and the distal hepatic artery and branches of the closed with a gelatin sponge to reduce the flushing of the fistula were basically not developed. (e tip of the micro- lipiodol by the blood. If the blood flow is not large, the catheter passes through the mouth of the fistula to iodized oil Journal of Healthcare Engineering 9 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 HAPVF Mixed fistula Total HAHVF HAVF types Mild Moderate Severe Figure 4: Relative proportions of different fistula type and tumor embolization. embolization, and the distal end of the fistula is subjected to hepatic vein and portal vein to confirm the presence of high-pressure disinfection gelatin sponge coarse particle arteriovenous fistula. If the catheter is superselected to the embolization, and the proximal end of the coil is closed to vicinity of the fistula, the area and size of the fistula can be the fistula; if the microcatheter head end cannot pass over displayed, and the hepatic artery can be seen with the ex- the fistula, the coil is first used close to the fistula; confirm the pansion of the portal vein. Sometimes, collateral circulation occlusion of the fistula and then perform the hepatic arterial of cancerous portal hypertension and tumor thrombus angiography [18]. According to the intrahepatic artery development are seen. Contrast examination confirmed that branch and the hepatic tumor angiography, determine HAHVF should be occluded after the fistula, according to whether to do the tumor iodized oil embolization treatment, the degree of tumor vascular development to determine whether the tumor is treated with iodized oil embolization. which ends the iodine oil embolization over the mouth and then uses the high-pressure disinfection gelatin sponge (e contraindications are the same as those for simple coarse particles plus anhydrous alcohol mixture to close the primary hepatocellular carcinoma. Hepatic function and mouth. If it cannot pass the fistula, perform the first infusion various biochemical indicators were significantly lower than chemotherapy; then make the catheter tip close to the normal and the disease course was not proportional, often mouth, and use high-pressure disinfection gelatin sponge accompanied by mild to moderate cirrhosis, oliguria, and coarse particles plus anhydrous alcohol mixture to close the moderate to large amount of ascites. On one hand, there are mouth; for medium and low partial flow, use directly iodized portal fistulas, which are caused by hepatic artery-portal vein oil plus autoclaved gelatin sponge particles to embolize short circuit, insufficient blood supply to the liver, worsening tumor lesions and close fistula. (e first fractional flow is liver damage, and cirrhosis. On the other hand, because the iodized oil embolism lesion; then select the bypass vessel pressure of the hepatic artery is much higher than the pressure of the portal vein, it further hinders the return of with ultra-autoclaved gelatin sponge anhydrous alcohol mixture fistula closure [19]. the portal vein, aggravates the portal hypertension, and (e HAHVF hepatic angiography can be seen in the causes more ascites and oliguria. Due to the difficulty in the arterial phase or early arterial vein visualization of the surgical treatment of HAHVF, especially in the advanced Relative proportion 10 Journal of Healthcare Engineering 1.00 0.09 0.08 0.07 0.06 0.05 0.04 0.03 Massive Nodular Diffuse Child A Child B Child C type type type function function function Figure 5: Impact factors of hepatic arteriovenous fistula type and hepatic function classification on imaging diagnosis. hepatic tissue, and reduces distant metastasis. (e emboli- stage of primary hepatocellular carcinoma, the opportunity for surgical treatment is lost, and the embolization of the zation materials commonly used are mitomycin powder, tumor is easy to cause portal vein or pulmonary embolism, stainless steel ring, polyvinyl alcohol particles, and gelatin which is a contraindication. (erefore, the fistula is first sponge particles, and the choice of embolic material is performed and the superselective occlusion is especially mainly based on the size of HAPVF. necessary. TACE uses microcatheter technology to achieve ac- curate and dense intratumoral embolization, and the portal vein blood supply of small hepatocellular carcinoma is also 5.2. Clinical Significance of Embolization in the Treatment of large. Superselective subsegment embolization makes the Hepatocellular Carcinoma. (e primary hepatocellular terminal small arteries and venules in the tumor occlude carcinoma is very easy to invade the hepatic vein or portal the best and the embolization effect while maximizing the vein system, and its incidence rate is more than 60%. (e protection of normal hepatic tissue. (e patient used main mechanism is direct invasion of the tumor; the tumor microcatheter superselective subsegment embolization, feeding artery passes through the tumor sinus entry vein or and the density of iodized oil deposition was more ideal the artery branch because portal dilation is tumor. Erosion is than that of microcatheter superselective subsegment to direct drainage of the arterial vein and pathological ex- embolization, showing the advantage of using micro- pansion of the nourishing artery around the portal vein; the catheter subsegment embolization. Small hepatocellular role of tumor vascular endothelial growth factor results in carcinoma generally has a relatively long survival period the formation of a neovascular network between the hepatic and requires multiple interventions, in which it is inevitable artery and the portal vein. (e occurrence of HAPVF is that hepatic function damage will occur during TACE related to the location of the tumor, most of which is located treatment (Figure 6). (erefore, it is considered that near the hilum and close to the trunk of the portal vein. In subsegment embolization should be achieved as much as the presence of HAPVF, a large amount of high-pressure possible in the treatment of small hepatocellular carcinoma arterial blood directly enters the portal vein through the with TACE. However, for patients with a long interval of fistula, causing the portal vein pressure to rise further, ag- TACE treatment for the first time or again, it is important gravating the formation of upper gastrointestinal bleeding to find the comprehensiveness of treatment in order to find and ascites. At the same time, the presence of HAPVF other hidden lesions in the hepatic. (e experience is to prevented chemotherapy embolization of cancer and em- retract the catheter into the hepatic artery or the left and bolization must reach the level of capillaries [20]. On the one right hepatic artery trunks and then inject a proper amount hand, it blocks the hepatic artery-portal vein shunt and of lipiodol into the superselective subsegment to prevent relieves gastrointestinal bleeding and ascites caused by portal the omission of smaller lesions and to achieve both diag- hypertension and on the other hand facilitates superselective nosis and treatment. Common complications of small embolization of tumor blood vessels, protects normal hepatocellular carcinoma TACE treatment mainly include Impact factor Journal of Healthcare Engineering 11 50 50 45 45 40 40 35 35 30 30 25 25 20 20 15 15 HAPVF HAHVF Mixed fistula HAPVF HAHVF Mixed fistula HAVF types HAVF types Central type Central type Peripheral type Peripheral type (a) (b) 50 50 45 45 40 40 30 30 HAPVF HAHVF Mixed fistula HAPVF HAHVF Mixed fistula HAVF types HAVF types Central type Central type Peripheral type Peripheral type (c) (d) Figure 6: Distributions of relative proportion of Child classification of hepatic function in the central and peripheral type. postembolic syndrome, cholecystitis, hepatic dysfunction, [22]. After the control of gastrointestinal bleeding and and gastroduodenal lesions; generally symptomatic support improvement of hepatic function, hepatic artery emboli- can be treated [21]. zation chemotherapy is performed to reduce the compli- Hepatic artery-portal sputum has obvious stealing cations associated with intervention and to obtain time for follow-up treatment and prolong the survival time of pa- function, which causes a large amount of hepatic artery blood to be shunted to the portal vein, hepatic ischemia, and tients. Although the microcatheter can be used to cross the hypoxia. After the fistula is blocked, the blood flow of the shunt mouth to enter the branch of the hepatic artery, the hepatic recovers or is close to normal; the hepatic artery- hepatic artery embolization is performed before the fistula to hepatic arterial blood enters the hepatic and improves the treat the tumor, and then the shunt mouth is blocked. metabolism of hepatocytes. (e hepatic function of the However, when the upper digestive to the hemorrhage hepatic artery-portal vein is improved after the patient is occurs, the body is in a state of stress, and the hepatic artery blocked and the main reason is the hepatic artery; after the is simultaneous embolization of unpredictable risks; the closure of the portal vein, hepatic hemodynamics returned experience is to first block the fistula and then hepatic artery to normal. Hepatocellular carcinoma with hepatic artery- embolization after hemorrhage control. portal shunt, direct TACE treatment, and embolic agents can enter the portal system through the fistula to cause plugging. 6. Conclusions In the case of finding difficulty in controlling upper gas- trointestinal bleeding, spring rims or large particles of A total of 120 patients diagnosed as HAVF were chosen as polyvinyl alcohol granules should be selected according to study subjects in this study to explore imaging diagnosis and the specific conditions of DSA examination to block the interventional treatment for hepatocellular carcinoma mouthwash and minimize the pressure on the portal vein combined with arteriovenous fistula. (e results show that Relative proportion of child C Relative proportion of child A Relative proportion of total Relative proportion of child B 12 Journal of Healthcare Engineering [5] K. Himes, A. Bornais, E. Bittenbinder, and J. 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Journal of Healthcare EngineeringHindawi Publishing Corporation

Published: Mar 4, 2021

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