Portal Hypertension
Vijay Menon, BS
Medical Student
University of Missouri - Kansas City School of Medicine
Disclosure information not submitted.
Ben Aziz, MD, MS
Resident Physician
University of Missouri - Kansas City
Molly Pasque, BS
Medical Student
University of Missouri - Kansas City
Herschel R. Gupta, BS
Medical Student
UMKC School of Medicine
Zachary Gaughan, MD
Resident Physician
University of Missouri - Kansas City
Travis Brown, DO
Physician
University of Missouri - Kansas City
Brian Do, DO
Physician
University of Missouri - Kansas City
Two patients in their 60s with extensive portal vein thrombosis (PVT) necessitating TIPS were included. In both cases, portosystemic shunt was created via a trans-splenic approach, due to unfavorable anatomy and portal thrombus. Utilizing catheter and guidewire, trans-parenchymal subintimal access was obtained from the portal vein to the hepatic venous system. The wire and catheter were advanced to the inferior vena cava (IVC), and snared from a trans-jugular approach flossing the patient. Thus allowing stent graft deployment via a traditional transjugular approach.
Both patients demonstrated improved PV patency on post-procedure imaging. No immediate complications were observed. In one case, ascites was significantly improved, and patient was subsequently discharged to hospice. In the second case, subsequent imaging demonstrated improved mesenteric edema and resolving bowel ischemia. This patient was successfully discharged, and is undergoing routine surveillance for shunt patency.
Conclusion and/or Teaching Points: TIPS has been proven effective for patients with refractory ascites, variceal bleeding, or portal vein thrombus {1}. Classically, portosystemic shunt is created from the right or middle HV to an intrahepatic PV. In cases with difficult anatomy, or portal vein thrombus, trans-splenic access may be obtained to provide a portal vein target for needle passes from a trans-jugular approach {2,3}. In both cases presented in this review, transplenic access was utilized for direct portosystemic shunt creation via a needle-less trans-parenchymal subintimal approach. This novel technique has not been previously described in the literature, and should be considered in cases where traditional TIPS is not possible.