Percutaneous CT-guided superior mesenteric vein access for portal vein recanalization-transjugular intrahepatic portosystemic shunt

Successful direct intrahepatic portosystemic shunt (DIPS) creation following transmesenteric porta hepatis access in a young patient with recurrent variceal bleeding

BACKGROUND

Transmesenteric access for portal vein reconstruction and transjugular intrahepatic portosystemic shunt allows for intervention in patients with unfavorable anatomy and can be performed via multiple methods but may be difficult to obtain in patients with complex anatomy.

CASE PRESENTATION

We present a case report describing a method of obtaining transmesenteric access in the porta hepatis to facilitate direct intrahepatic portosystemic shunt creation in a young patient with recurrent variceal bleeding. This patient anatomy was unfavorable, and initially he was thought to be a poor candidate for any intervention, but this technique allowed for successful decompression of the varices safely and effectively.

CONCLUSIONS

This is a technique to consider in similar complex cases and expands treatment for those who previously would not have been considered for intrahepatic shunt formation.

Safety of Percutaneous Transmesenteric and Transsplenic Access for Portosystemic Shunt Creation in Patients with Portal Vein Obstruction: Single-Center Experience and Review of Literature

PURPOSE

To evaluate the safety of ultrasound-guided percutaneous mesenteric vein access compared to transsplenic portal vein access for portosystemic shunt placement in patients with portal vein obstruction.

MATERIALS AND METHODS

Eight patients underwent portosystemic shunt creation through either a transsplenic (n = 4) or transmesenteric (n = 4) approach. The superior or inferior mesenteric vein was percutaneously accessed under ultrasound guidance using a 21G needle and a 4F sheath. Hemostasis at the mesenteric access site was achieved with manual compression. For transsplenic access, sheath sizes between 6 and 8F were used and tract embolization with gelfoam was performed.

RESULTS

Portosystemic shunt placement was successful in all patients. While there were no bleeding complications with transmesenteric access, hemorrhagic shock requiring splenic artery embolization occurred in one patient in which the transsplenic approach was used.

CONCLUSION

Ultrasound-guided mesenteric vein access seems feasible and a valid alternative to the transsplenic access in case of portal vein obstruction. Level of Evidence Level 4, case series.

Portal Vein Recanalization-Transjugular Intrahepatic Portosystemic Shunt (PVR-TIPS) with superior mesenteric vein access and balloon-assisted shunt placement

BACKGROUND

To report the technique and outcome of ultrasound-guided percutaneous access to the superior mesenteric vein (SMV) for balloon-assisted portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) in a patient with chronic portal venous and splenic vein occlusion.

CASE PRESENTATION

A 51-year-old, non-cirrhotic patient with severe portal hypertension was admitted for PVR-TIPS. Neither splenic nor hepatic access was feasible due to chronic portal and splenic vein occlusion. Percutaneous ultrasound-guided direct puncture of the SMV was performed to obtain access for balloon-assisted PVR-TIPS. The transmesenteric approach in combination with a balloon puncture technique for PVR-TIPS was successful, and no immediate complications were observed post-procedure. The subsequent follow-up exams showed patent TIPS and SMV without signs of intraabdominal hemorrhage.

CONCLUSION

Percutaneous ultrasound-guided superior mesenteric vein access for balloon-assisted PVR-TIPS is a feasible option in cases where hepatic or splenic access is not.