Korean J Radiol.  2003 Mar;4(1):35-41. 10.3348/kjr.2003.4.1.35.

Transcaval Transjugular Intrahepatic Portosystemic Shunt: Preliminary Clinical Results

• Lee KH
• Lee DY
• Won JY
• Park SJ
• Kim JK
• Yoon W

• KMID: 754040
• DOI: http://doi.org/10.3348/kjr.2003.4.1.35

Abstract

OBJECTIVE
To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins. MATERIALS AND METHODS: Transcaval TIPS, performed in six patients, was indicated by active variceal bleeding (n=2), recurrent variceal bleeding (n=2), intractable ascites (n=1), and as a bridge to liver transplantation (n=1). The main reasons for transcaval rather than classic TIPS were the presence of an unusually acute angle between the hepatic veins and the level of the portal bifurcation (n=3), hepatic venous occlusion (n=2), and inadequate small hepatic veins (n=1). RESULTS: Technical and functional success was achieved in all patients. The entry site into liver parenchyma from the inferior vena cava was within 2 cm of the atriocaval junction. Procedure-related complications included the death of one patient due to hemoperitoneum despite the absence of contrast media spillage at tractography, and another suffered reversible hepatic encephalopathy. CONCLUSION: In patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins, transcaval TIPS creation is feasible.

Keyword

Hypertension, portal; Interventional procedures; Shunts, portosystemic

Figure

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  Fig. 1 Case 2. A 41-year-old man with active variceal bleeding. A, B. Sequential MR images (1 cm slice thickness) depict approximation of the right proximal hepatic vein (arrow in A) and right portal vein (arrow in B). C. After classic puncture at the proximal hepatic vein, only the peripheral portal branch was punctured. Approximation of the estimated proximal right hepatic vein and right portal vein is noted (arrows). D. Following transcaval TIPS creation using a Wallstent 10 mm in dianeter and 7 cm in length, the portosystemic gradient decreased from 34 mmHg to 13 mmHg. Subsequent direct portography demonstrated good flow through the stent and decreased flow into the coronary varix.

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  Fig. 2 Case 4. A 38-year-old woman who was a candidate for liver transplantation. A. Contrast-enhanced CT scan shows a thrombosed hepatic vein (arrow), inhomogeneous parenchymal enhancement, and a substantial amount of ascites, compatible with Budd-Chiari syndrome. B, C. IVC venogram (B) and angiogram (C) obtained after direct intrahepatic puncture show the collateralization typical of Budd-Chiari syndrome. D. Transcaval TIPS was performed due to occlusion of hepatic veins.

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  Fig. 3 Case 6. A 73-year-old man with active variceal bleeding. A. CT scan shows occlusion of the right portal vein due to repeated transcatheter arterial chemoembolization and gastric fundal varices. B, C. Because the middle (B) and left (C) hepatic veins were too small, classic TIPS was not possible. D. Transcaval TIPS was performed via the left portal vein.

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