Purpose: To report the feasibility of transsplenic portal vein recanalization (PVR) with direct intrahepatic portosystemic shunt (DIPS) placement in a patient with both chronic portal and hepatic vein occlusion undergoing liver transplantation (OLT) evaluation
Materials and Methods: A 48-year-old man with decompensated alcoholic cirrhosis (MELD-Na 18) and prior failed attempts at transjugular intrahepatic portosystemic shunt presented with persistent refractory ascites, hepatic encephalopathy, and variceal bleeding. Computed tomography demonstrated a cirrhotic liver, stigmata of portal hypertension, and chronic occlusion of the hepatic veins, extrahepatic portal vein, and distal superior mesenteric vein. Interventional radiology was consulted to manage portal hypertension and facilitate OLT for a direct end-to-end portal vein anastomosis. After a venogram confirmed chronic hepatic venous occlusion, DIPS with transsplenic PVR was planned.
Results: Splenic venography via a percutaneous transsplenic access confirmed chronic occlusion of the portal vein with drainage of the splenic vein through gastric varices. The thrombosed portal vein was recanalized and balloon angioplastied. A snare was then placed into the main portal vein as a target for DIPS creation. A TIPS kit with a modified 65-inch, 21-gauge needle was advanced into the inferior vena cava (IVC) from the jugular vein and directed toward the portal vein. With the help of an intravascular echo probe within the IVC, the needle was then punctured through the caudate lobe and facilitated placement of a wire into the splenic vein. An initial portosystemic gradient (PSG) was 20 mm Hg. An 8- to 10-mm adjustable stent graft was placed across the main portal and into the IVC to create the DIPS. The stent was dilated and angioplastied with an 8-mm balloon. A portal venogram demonstrated brisk blood flow through the DIPS and resolution of varices. A post-DIPS PSG was 8 mm Hg. Residual narrowing within the splenic vein was treated with balloon angioplasty to optimize flow through the DIPS. The patient tolerated the procedure well and remained hemodynamically stable. At 1 month, the patient had a significant reduction in ascites and size of his ventral hernia. The MELD-NA score reduced to 12.
Conclusions: In the setting of chronically occluded portal and hepatic veins, transsplenic PVR and DIPS may serve as an effective bridge to transplantation by facilitating an end-to-end portal vein anastomosis for OLT.