Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation
Abstract Background Percutaneous trans-splenic portal vein recanalization (PVR) has been reported for facilitation of transjugular intrahepatic portosystemic shunts (TIPS), however has not been applied to patients undergoing direct intrahepatic portosystemic shunt (DIPS). We report the utilization o...
| Main Authors: | , , , , |
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| Format: | Article |
| Language: | English |
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SpringerOpen
2020-01-01
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| Series: | CVIR Endovascular |
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| Online Access: | https://doi.org/10.1186/s42155-019-0096-7 |
| _version_ | 1818866128516022272 |
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| author | Osman Ahmed Abhijit L. Salaskar Steven Zangan Anjana Pillai Talia Baker |
| author_facet | Osman Ahmed Abhijit L. Salaskar Steven Zangan Anjana Pillai Talia Baker |
| author_sort | Osman Ahmed |
| collection | DOAJ |
| description | Abstract Background Percutaneous trans-splenic portal vein recanalization (PVR) has been reported for facilitation of transjugular intrahepatic portosystemic shunts (TIPS), however has not been applied to patients undergoing direct intrahepatic portosystemic shunt (DIPS). We report the utilization of trans-splenic-PVR with DIPS creation in a patient with chronic portal and hepatic vein occlusions undergoing liver transplantation evaluation. Case presentation A 48-year-old male with decompensated alcoholic cirrhosis complicated by refractory ascites, hepatic encephalopathy, and variceal bleeding underwent CT that demonstrated chronic occlusion of the hepatic veins (HV), extrahepatic portal vein (PV), and superior mesenteric vein (SMV). Due to failed attempts at TIPS at outside institutions, interventional radiology was consulted for portal vein recanalization (PVR) with TIPS to treat the portal hypertension and ascites and also facilitate an end-to-end PV anastomosis at transplantation. After an initial hepatic venogram confirmed chronic HV occlusion, a DIPS with trans-splenic PVR was planned. The splenic vein was accessed under sonographic guidance using a micropuncture set and subsequently upsized to a 6 French sheath over a stiff guidewire. A splenic venogram via this access confirmed occlusion of the PV with drainage of the splenic vein (SV) through gastric varices. The thrombosed PV was then recanalized and angioplastied to restore PV flow via the transsplenic approach. A transjugular liver access kit with a modified 21-gauge needle was advanced into the IVC through the internal jugular vein (IJV) sheath and directed towards the target snare in PV. The needle was used to subsequently puncture the PV through the caudate lobe and facilitate placement of a wire into the SV. The initial portosystemic gradient (PSG) was 20 mmHg. The IJV sheath was advanced through the hepatic parenchymal tract into the main-PV and a stent-graft was placed across the main PV and into the IVC. A portal venogram demonstrated brisk blood flow through the DIPS, resolution of varices and a PSG of 8 mmHg. One month after the procedure, the patient had a significant reduction in ascites and MELD-NA score. Patient is currently listed and awaiting transplantation. Conclusions In the setting of chronically occluded portal and hepatic veins, trans-splenic PVR DIPS may serve as an effective bridge to liver transplantation by facilitating an end to end portal vein anastomosis. |
| first_indexed | 2024-12-19T10:58:31Z |
| format | Article |
| id | doaj.art-0366914fcaca47259b5febdc3df04114 |
| institution | Directory Open Access Journal |
| issn | 2520-8934 |
| language | English |
| last_indexed | 2024-12-19T10:58:31Z |
| publishDate | 2020-01-01 |
| publisher | SpringerOpen |
| record_format | Article |
| series | CVIR Endovascular |
| spelling | doaj.art-0366914fcaca47259b5febdc3df041142022-12-21T20:24:43ZengSpringerOpenCVIR Endovascular2520-89342020-01-01311410.1186/s42155-019-0096-7Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantationOsman Ahmed0Abhijit L. Salaskar1Steven Zangan2Anjana Pillai3Talia Baker4Section of Interventional Radiology, Department of Radiology, University of ChicagoDepartment of Interventional Radiology, Amita Saint Francis HospitalSection of Interventional Radiology, Department of Radiology, University of ChicagoDepartment of Gastroenterology, Section of Hepatology, University of ChicagoDepartment of Surgery, Section of Transplant Surgery, University of ChicagoAbstract Background Percutaneous trans-splenic portal vein recanalization (PVR) has been reported for facilitation of transjugular intrahepatic portosystemic shunts (TIPS), however has not been applied to patients undergoing direct intrahepatic portosystemic shunt (DIPS). We report the utilization of trans-splenic-PVR with DIPS creation in a patient with chronic portal and hepatic vein occlusions undergoing liver transplantation evaluation. Case presentation A 48-year-old male with decompensated alcoholic cirrhosis complicated by refractory ascites, hepatic encephalopathy, and variceal bleeding underwent CT that demonstrated chronic occlusion of the hepatic veins (HV), extrahepatic portal vein (PV), and superior mesenteric vein (SMV). Due to failed attempts at TIPS at outside institutions, interventional radiology was consulted for portal vein recanalization (PVR) with TIPS to treat the portal hypertension and ascites and also facilitate an end-to-end PV anastomosis at transplantation. After an initial hepatic venogram confirmed chronic HV occlusion, a DIPS with trans-splenic PVR was planned. The splenic vein was accessed under sonographic guidance using a micropuncture set and subsequently upsized to a 6 French sheath over a stiff guidewire. A splenic venogram via this access confirmed occlusion of the PV with drainage of the splenic vein (SV) through gastric varices. The thrombosed PV was then recanalized and angioplastied to restore PV flow via the transsplenic approach. A transjugular liver access kit with a modified 21-gauge needle was advanced into the IVC through the internal jugular vein (IJV) sheath and directed towards the target snare in PV. The needle was used to subsequently puncture the PV through the caudate lobe and facilitate placement of a wire into the SV. The initial portosystemic gradient (PSG) was 20 mmHg. The IJV sheath was advanced through the hepatic parenchymal tract into the main-PV and a stent-graft was placed across the main PV and into the IVC. A portal venogram demonstrated brisk blood flow through the DIPS, resolution of varices and a PSG of 8 mmHg. One month after the procedure, the patient had a significant reduction in ascites and MELD-NA score. Patient is currently listed and awaiting transplantation. Conclusions In the setting of chronically occluded portal and hepatic veins, trans-splenic PVR DIPS may serve as an effective bridge to liver transplantation by facilitating an end to end portal vein anastomosis.https://doi.org/10.1186/s42155-019-0096-7Portal vein recanalizationPVRDirect intrahepatic portosystemic shuntDIPSPortal vein occlusionHepatic vein occlusion |
| spellingShingle | Osman Ahmed Abhijit L. Salaskar Steven Zangan Anjana Pillai Talia Baker Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation CVIR Endovascular Portal vein recanalization PVR Direct intrahepatic portosystemic shunt DIPS Portal vein occlusion Hepatic vein occlusion |
| title | Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation |
| title_full | Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation |
| title_fullStr | Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation |
| title_full_unstemmed | Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation |
| title_short | Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation |
| title_sort | transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation |
| topic | Portal vein recanalization PVR Direct intrahepatic portosystemic shunt DIPS Portal vein occlusion Hepatic vein occlusion |
| url | https://doi.org/10.1186/s42155-019-0096-7 |
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