Purpose or Case Report: Female conjoined throraco-omphalopagus twins were delivered via cesarean section at 35 weeks 5 days gestational age to a 38-year-old mother who received standard prenatal care. After resuscitation, the twins were transferred to the neonatal ICU, where they remained for monitoring and growth as they were assessed for potential separation.
CT angiography was performed at 3-4 months of life using a staged approach. Selective IV and oral contrast administration was used over two visits to delineate shared and non-shared structures. Most significantly, there was a single shared liver with anomalous hepatic venous drainage. Twin A had three normal caliber hepatic veins draining into a normal IVC, but a large branch of the middle hepatic vein traversed midline into Twin B and received hepatic venous drainage from Twin B via numerous anomalous vessels. Twin B had a normal IVC but three diminutive hepatic veins, thought to be due to reduced venous drainage as a result of the anomalous shared vasculature.
After multidisciplinary discussion, interventional radiology was consulted for hepatic venogram and intervention as needed. The anomalous communicating vessels were identified on hepatic venogram via Twin A femoral approach. Occlusion of the anomalous branches was achieved with serial embolization of the primary draining vessel on the Twin A side using Amplatzer vascular plugs. Successful occlusion was confirmed on venography after the final embolization procedure.
Follow-up Doppler ultrasound exams confirmed improved hepatic venous outflow in Twin B, initially with reversal of flow in the anomalous veins back toward the IVC of Twin B, followed by nonvisualization of the anomalous veins on later exams. CT angiography later showed enlarged caliber of the native Twin B hepatic veins. Following the optimization of hepatic venous outflow, the multispecialty surgical team proceeded with separation. The twins were separated at 13 months of age without complication. In addition to restoring venous outflow to allow for a successful surgical outcome, it was noted that the Amplatzer devices were used as surgical landmarks during separation for identification of shared anatomy. Through careful planning and execution, diagnostic and interventional radiology techniques played a critical role in this successful outcome.
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