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.


Reference

1. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W;. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46:922–938. PMID: 17879356.
Article
2. Stine JG, Shah NL, Argo CK, Pelletier SJ, Caldwell SH, Northup PG. Increased risk of portal vein thrombosis in patients with cirrhosis due to nonalcoholic steatohepatitis. Liver Transpl. 2015; 21:1016–1021. PMID: 25845711.
Article
3. Wils A, van der, van Hoek B, Pattynama PM. Transjugular intrahepatic portosystemic shunt in patients with chronic portal vein occlusion and cavernous transformation. J Clin Gastroenterol. 2009; 43:982–984. PMID: 19417681.
Article
4. Nyman UR, Semba CP, Chang H, Hoffman C, Dake MD. Percutaneous creation of a mesocaval shunt. J Vasc Interv Radiol. 1996; 7:769–773. PMID: 8897349.
Article
5. Hong R, Dhanani RS, Louie JD, Sze DY. Intravascular ultrasoundguided mesocaval shunt creation in patients with portal or mesenteric venous occlusion. J Vasc Interv Radiol. 2012; 23:136–141. PMID: 22221479.
Article
6. Burke C, Taylor AG, Ring EJ, Kerlan RK Jr. Creation of a percutaneous mesocaval shunt to control variceal bleeding in a child. Pediatr Radiol. 2013; 43:1218–1220. PMID: 23447003.
Article
7. Bercu ZL, Sheth SB, Noor A, Lookstein RA, Fischman AM, Nowakowski FS, et al. Percutaneous mesocaval shunt creation in a patient with chronic portal and superior mesenteric vein thrombosis. Cardiovasc Intervent Radiol. 2015; 38:1316–1319. PMID: 25189666.
Article
8. Moriarty JM, Kokabi N, Kee ST. Transvenous creation of a mesocaval shunt: report of use in the management of extrahepatic portal vein occlusion. J Vasc Interv Radiol. 2012; 23:565–567. PMID: 22464719.
Article
9. Davis J, Chun AK, Borum ML. Could there be light at the end of the tunnel? Mesocaval shunting for refractory esophageal varices in patients with contraindications to transjugular intrahepatic portosystemic shunt. World J Hepatol. 2016; 8:790–795. PMID: 27429715.
Article
10. Chu HH, Kim HC, Jae HJ, Yi NJ, Lee KW, Suh KS, et al. Percutaneous transsplenic access to the portal vein for management of vascular complication in patients with chronic liver disease. Cardiovasc Intervent Radiol. 2012; 35:1388–1395. PMID: 22159907.
Article
11. Bertram H, Pfister ED, Becker T, Schoof S. Transsplenic endovascular therapy of portal vein stenosis and subsequent complete portal vein thrombosis in a 2-year-old child. J Vasc Interv Radiol. 2010; 21:1760–1764. PMID: 20884237.
Article
12. Tuite DJ, Rehman J, Davies MH, Patel JV, Nicholson AA, Kessel DO. Percutaneous transsplenic access in the management of bleeding varices from chronic portal vein thrombosis. J Vasc Interv Radiol. 2007; 18:1571–1575. PMID: 18057293.
Article
13. Lee JY, Song SY, Kim J, Koh BH, Kim Y, Jeong WK, et al. Percutaneous transsplenic embolization of jejunal varices in a patient with liver cirrhosis: a case report. Abdom Imaging. 2013; 38:52–55. PMID: 22527157.
Article
Full Text Links
  • YMJ
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr