Minimally invasive percutaneous endovascular therapies in the management of complications of non-alcoholic fatty liver disease (NAFLD): A case report

Abstract

Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of disorders from simple steatosis to inflammation leading to fibrosis, cirrhosis, and even hepatocellular carcinoma. With the progressive epidemics of obesity and diabetes, major risk factors in the development and pathogenesis of NAFLD, the prevalence of NAFLD and its associated complications including liver failure and hepatocellular carcinoma is expected to increase by 2030 with an enormous health and economic impact. We present a patient who developed Hepatocellular carcinoma (HCC) from nonalcoholic steatohepatitis (NASH) cirrhosis. Due to morbid obesity, she was not an optimal transplant candidate and was not initially listed. After attempts for lifestyle modifications failed to lead to weight reduction, a transarterial embolization of the left gastric artery was performed. This is the sixth such procedure in humans in literature. Subsequently she had a meaningful drop in BMI from 42 to 36 over the following 6 months ultimately leading to her being listed for transplant. During this time, the left hepatic HCC was treated with chemoembolization without evidence of recurrence. In this article, we wish to highlight the use of minimally invasive percutaneous endovascular therapies such as transarterial chemoembolization (TACE) in the comprehensive management of the NAFLD spectrum and percutaneous transarterial embolization of the left gastric artery (LGA), a novel method, for the management of obesity.

Keywords: HCC; Hepatocellular carcinoma; Left Gastric artery embolization; NAFLD; NASH; Nonalcoholic fatty liver disease; Nonalcoholic steatohepatitis; TACE; Transarterial chemoembolization.

Figures

Figure 1

68-year-old woman with a past medical history of morbid obesity, type 2 diabetes, and hypertension diagnosed with NAFL and later NASH Cirrhosis. Findings: a) Gray scale US, oblique view in right hypochondrium, showing a coarse echo pattern of the liver with a nodular surface suggestive of cirrhosis. b) Gray scale US, longitudinal view in midline epigastrium shows similar echo pattern in the left lobe of the liver. c ) Six months later, gray scale US, oblique view in midline epigastrium shows a well encapsulated echogenic nodule in left lobe of the liver(between yellow marks). d )Triple phase contrast enhanced MRI axial views, upper abdomen showed a definite well-encapsulated enhancing lesion found on the lateral margin of the lateral segment of the left lobe of the liver measuring 1.8 cm in size (arrow)with arterial phase enhancement e) Definite washout was seen on delayed images ( arrow). Imaging features were consistent with a diagnosis of HCC. Technique: Duplex ultrasonography with GE Logiq E9, 2.5–4 MHz. MAGNETOM Symphony 1.5T, T1 weighted VIBE fat saturated axial sequence, TR 4, TE 2, post 12cc Omniscan contrast injection

Figure 2

68-year-old woman with a past medical history of morbid obesity, type 2 diabetes, and hypertension diagnosed with NAFL and later NASH cirrhosis. Findings: Digital subtraction Angiogram (DSA), serial images in the upper abdomen frontal view. a) Celiac angiogram using a 5-Fr catheter showed a normal-appearing left gastric artery (arrow) in addition to tortuous hepatic arteries and a hypertrophic splenic artery. b) Left gastric arteriogram using a 2.4 French Progreat micro catheter (Progreat ®; Terumo, Tokyo, Japan) showed normal course and caliber of the left gastric artery (arrow). c) Embolization of the fundal branches (arrow) was performed using 500–700 um Embosphere® Microspheres (Embosphere, Biosphere Medical, Rockland, MA, USA). Circle indicates anatomical location of fundus of stomach. d) Stasis of contrast was achieved with no forward flow in the left gastric artery. e) Post-embolization celiac angiogram showed absence of flow into the left gastric artery with normal flow in to common hepatic and splenic arteries. Technique: DSA protocol: trans catheter injection of 12 ml contrast media at a flow of 3 ml/sec, Visipaque (Iodixanol) 320 (GE Healthcare, Waukesha, WI) performed on a clinical angiography system (Axiom Artis FA/BA; Siemens AG, Erlangen, Germany)

Figure 3

68-year-old woman with a past medical history of morbid obesity, type 2 diabetes, and hypertension diagnosed with NAFL and later NASH Cirrhosis. Findings: a) Arterial Phase CT scan, axial image in the upper abdomen after injection of intravenous contrast, reveals a hypodense lesion in segment II of the liver measuring 1.8 x 1.8 cm and containing a well-defined enhancing capsule (arrow) b) Digital subtraction Angiogram (DSA), serial images in the upper abdomen frontal view reveal, of the left hepatic artery reveals a small hypervascular blush (arrow). c) TACE was performed via segment 2/3 hepatic branches with 75mg of Doxorubicin 100–300um drug eluting beads. d) Post chemo-embolization left hepatic angiogram revealed no flow in the segment 2/3 hepatic branch with no hypervascular blush. e) Arterial Phase CT scan, after injection of intravenous contrast axial image in the upper abdomen reveals no enhancement in the previously seen left lobe of liver lesion. Technique: CT scanner: Siemens Somatom emotion, 95 mAs, 130 Kv, slice thickness 2.5mm, intravenous contrast: 100 ml Omnipaque 300. DSA protocol: transcatheter injection of 10 ml contrast media at a flow of 2 ml/sec, Visipaque (Iodixanol) 320 (GE Healthcare, Waukesha, WI) performed on a clinical angiography system (Axiom Artis FA/BA; Siemens AG, Erlangen, Germany)

Figure 4

Graphical illustration of patient’s timeline