Yonsei Med J.  2018 Jan;59(1):162-166. 10.3349/ymj.2018.59.1.162.

Mesocaval Shunt Creation for Jejunal Variceal Bleeding with Chronic Portal Vein Thrombosis

Affiliations
  • 1Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea. mdkim@yuhs.ac
  • 2Department of Pediatric Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea.

Abstract

The creation of transjugular intrahepatic portosystemic shunt (TIPS) is a widely performed technique to relieve portal hypertension, and to manage recurrent variceal bleeding and refractory ascites in patients where medical and/or endoscopic treatments have failed. However, portosystemic shunt creation can be challenging in the presence of chronic portal vein occlusion. In this case report, we describe a minimally invasive endovascular mesocaval shunt creation with transsplenic approach for the management of recurrent variceal bleeding in a portal hypertension patient with intra- and extrahepatic portal vein occlusion.

Keyword

Portal hypertension; gastrointestinal hemorrhage; thrombosis; transjugular intrahepatic portosystemic shunt (TIPS); mesocaval; shunt

MeSH Terms

Adolescent
Chronic Disease
Esophageal and Gastric Varices/*complications/diagnostic imaging/*therapy
Female
Gastrointestinal Hemorrhage/*complications/diagnostic imaging/*therapy
Humans
Jejunum/*pathology
*Portacaval Shunt, Surgical
Portal Vein/diagnostic imaging/*pathology/surgery
Tomography, X-Ray Computed
Treatment Outcome
Venous Thrombosis/*complications/diagnostic imaging/*therapy

Figure

  • Fig. 1 Portal phase of preoperative contrast-enhanced CT image (A) shows total occlusion of portal vein due to extensive thrombosis (arrow) and cavernous malformation of intrahepatic portal veins with splenomegaly. Capsule endoscopy (B) revealed active bleeding and a large amount of blood clots at proximal jejunum. SMV angiography (C) shows cavernous transformation of intrahepatic portal vein (asterisk), and collateral vessels are seen. Total obliteration of SMV (open arrow) is noted. SMV, superior mesenteric vein.

  • Fig. 2 Mesocaval shunt creation. (A) A 16-G Colapinto needle and a 9-Fr Teflon sheath were coaxially loaded over a guidewire via US-guided puncture of right IJV. Via US-guided puncture of the splenic vein, an 11-mm balloon catheter was placed at the SMV-splenic vein confluence. The inflated balloon was used as a fluoroscopic target. A 0.035-inch guidewire (black arrow) was placed in the dilated hepatic artery to avoid puncture of the target. (B) Final angiography shows patent mesocaval shunt between IVC and SMV. (C) CT-rendered three-dimensional image reveals patent stent graft (white arrow) with partial intrahepatic portion at the proximal end. Additional stent at distal splenic vein (arrowhead) to prevent shunt wasting resulted in an inverted “Y” configuration of stents. (D) Simplified diagram of transsplenic mesocaval shunt technique. Linear arrow represents the direction of puncture (splenic vein stent is not shown). IJV, internal jugular vein; SMV, superior mesenteric vein; IVC, inferior vena cava.


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