Selective Embolization Combined with Propranolol in Five Infants with Acute Symptomatic Hepatic Hemangioma

Objectives: Hepatic hemangioma (HH) is the most common benign tumor of the liver in infancy. Hepatic lesions are divided into focal, multifocal, and diffuse according to which treatment depends on. Focal HH is the hepatic equivalent of the cutaneous rapidly involuting congenital hemangioma (RICH), ultrasonography reveals a well-circumscribed vascular mass with large feeding and draining vessels. Asymptomatic focal HH should be observed. In comparison, multifocal and diffuse HH are true infantile hemangiomas and associated with cutaneous infantile hemangiomas. Multifocal and diffuse HH, biologically distinct from focal HH as they express GLUT-1, are associated with acquired hypothyroidism and marked by rapid postnatal growth (0–12 months) followed by slow involution (1–5 years). If large lesions are symptomatic, an aggressive management must be initiated. Heart failure through to high-volume shunting and abdominal compartment syndrome may occur.

Methods: We report five infants (mean weight, 4 kg) with hepatic hemangioma (three focal, one multifocal, and one focal/diffuse) who were treated from 2010 to 2018 in our referral center. The diagnosis hepatic hemangioma was made in one infant prenatally, in four infants during the first 2 days of life. Invasive treatment was initiated because of heart failure associated with vascular shunting in five of five infants in combination with beginning disseminated intravascular coagulation. Interventional treatment was performed in the cath laboratory. Access was gained percutaneously from the femoral artery using 4–French (F) sheaths. Occlusion of the shunting vessel was performed in four infants with microcoils, in one infant with a vascular plug and in two infants (one reintervention) with high-volume detachable microcoils. The latter seal particularly well because they can be deposited in a very compact and superselective manner. Interventional treatment was followed by propranolol 2 to 4 mg/kg p.o. for 7 to 37 months.

Result: After the intervention, all children stabilized and the anemia, thrombocytopenia, transaminases, and coagulation parameters normalized. In the long-term follow-up (8 months–5.5 years later), sonographic controls showed normal liver parenchyma. Except in one newborn, calcified residuals showed up in the follow-up after 8 months.

Conclusion: Interventional treatment can be performed through 4-F catheters in infants. It is a gentle and effective method for early and urgent treatment of hemodynamic relevant hemangiomas in combination with propranolol treatment. In the long-term, there was a healing without complications.

Publication History

Article published online:
21 February 2021