Diagnosis of an Accessory Portal Vein and Its Clinical Implications for Portosystemic Shunts

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.

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Clinical Implications of an Expandable Metallic Mesh Stent for Malignant Portal Vein Stenosis in Management of Unresectable or Recurrent Pancreatic Cancer

Pancreatic Cancer - Clinical Management ◽

10.5772/29228 ◽

2012 ◽

Author(s):

Yoshinori Nio

Keyword(s):

Pancreatic Cancer ◽

Portal Vein ◽

Clinical Implications ◽

Portal Vein Stenosis ◽

Metallic Mesh ◽

Recurrent Pancreatic Cancer ◽

Vein Stenosis

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Ultrasonic Evaluation of Spontaneous Portosystemic Shunts in Patients with Budd-Chiari Syndrome

Iranian Journal of Radiology ◽

10.5812/iranjradiol.103658 ◽

2020 ◽

Vol In Press (In Press) ◽

Author(s):

Ji-Chen Wang ◽

Shi-Feng Cai ◽

Chen Su ◽

Hui-Li Fan ◽

Yong-Hao Gai ◽

...

Keyword(s):

Inferior Vena Cava ◽

Portal Vein ◽

Inferior Vena ◽

Vena Cava ◽

Main Portal Vein ◽

Budd Chiari Syndrome ◽

Portosystemic Shunts ◽

Chiari Syndrome ◽

Vein Diameter ◽

Portal Trunk

Background: Spontaneous portosystemic shunts (SPSS) are one of the hallmarks of Budd-Chiari syndrome (BCS). Ultrasound can accurately show the location and type of portosystemic collaterals. Objectives: To study the sonographic feature of SPSS in patients with BCS and to evaluate differences in the main portal vein diameter among multiple types of portosystemic shunts. Patients and Methods: Ultrasonographies of 44 patients with SPSS among 352 BCS patients between June 2000 and November 2015 were reviewed retrospectively. The SPSS in 44 BCS patients were first detected by ultrasound and then confirmed via digital subtraction angiography (DSA), computed tomography angiography (CTA) or magnetic resonance venography (MRV). The location, course, diameter and hemodynamics of the spontaneous portosystemic shunts were observed by ultrasound. In addition, one-way analysis of variance (ANOVA) was performed to evaluate the difference in the main portal vein diameter between the different shunt types. Results: The blood drainage patterns of SPSS in 44 of 352 patients with BCS were classified as the following five types: portal-umbilical shunts (15/44), portal-hepatic shunts (11/44), portal-accessory hepatic shunts (6/44) (the accessory hepatic veins included the inferior right hepatic vein and the caudate lobe vein), splenorenal shunts (8/44) and main portal vein-inferior vena cava shunts (4/44). The corresponding hemodynamics of the five types mentioned above were obtained. Main portal vein-inferior vena cava shunts had a significantly larger mean portal trunk diameter compared with all other types (P < 0.05 for all comparisons). In addition, the mean portal trunk diameters in portal-umbilical shunts and portal-hepatic shunts were obviously larger than that of splenorenal shunts (P < 0.05), while there were no statistically significant differences between the other types. Conclusion: Spontaneous portosystemic shunts are not rare in patients with BCS. Ultrasound is a reliable means for their diagnosis and it offers substantial information for use in clinical treatment.

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Retrospective liver histomorphological analysis in dogs in instances of clinical suspicion of congenital portosystemic shunt

Journal of Veterinary Research ◽

10.2478/jvetres-2019-0026 ◽

2019 ◽

Vol 63 (2) ◽

pp. 243-249 ◽

Cited By ~ 1

Author(s):

Małgorzata Sobczak-Filipiak ◽

Józef Szarek ◽

Iwona Badurek ◽

Jessica Padmanabhan ◽

Piotr Trębacz ◽

...

Keyword(s):

Portal Vein ◽

Developmental Disorders ◽

Clinical Symptoms ◽

Histopathological Examination ◽

Vascular Anomaly ◽

Clinical Suspicion ◽

Diagnostic Process ◽

Histopathological Analysis ◽

Portosystemic Shunts ◽

Vascular Connections

AbstractIntroduction: The clinical symptoms of portosystemic shunts (PSSs) and hepatic microvascular dysplasia (HMD) – portal vein hypoplasia (PVH) in dogs are similar. PSSs are abnormal vascular connections between the portal vein system and systemic veins. HMD is a very rare developmental vascular anomaly, recognisable during histopathological examination. The study aim was to assess the prevalence of HMD–PVH and hepatocellular and vascular pathologies in the liver. Material and Methods: Liver biopsies from 140 dogs (of different breeds and both sexes) arousing clinical suspicion of PSS were examined histopathologically. Results: An initial PSS diagnosis was confirmed in 125 dogs (89.29%). HMD–PVH was found in 12.32% of dogs, as an isolated disease in 9.29%, especially in Yorkshire terriers, and with extrahepatic PSS in 6.67%. Histopathological analysis of muscles around sublobular veins showed that HMD cases presented hypertrophy or hypertrophy with fibrosis. In 2.17% of all dogs with liver vascular developmental disorders calcification was visible around vessels (without correlation by degenerative changes in those vessels), suggesting prior onset of deep metabolic disorders. Clinical suspicion of PSS was also formed upon quite different pathological processes in young dogs. Conclusion: Histopathological findings diagnosed the type of vascular anomalies (PSS or HMD–PVH) or other pathological changes conclusively, therefore detailed hepatic histopathology is an indispensable component of the clinical diagnostic process.

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Comparison of Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Cirrhosis With or Without Portal Vein Thrombosis: A Retrospective Study

Frontiers in Medicine ◽

10.3389/fmed.2021.737984 ◽

2021 ◽

Vol 8 ◽

Author(s):

Hong-Liang Wang ◽

Wei-Jie Lu ◽

Yue-Lin Zhang ◽

Chun-Hui Nie ◽

Tan-Yang Zhou ◽

...

Keyword(s):

Portal Vein ◽

Portal Vein Thrombosis ◽

Variceal Bleeding ◽

Meld Score ◽

Refractory Ascites ◽

Complication Rates ◽

Vein Thrombosis ◽

Portosystemic Shunts ◽

Shunt Dysfunction ◽

End Stage

Aim: The purpose of our study was to conduct a retrospective analysis to compare the effectiveness of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of patients with cirrhosis with or without portal vein thrombosis (PVT).Methods: We included a total of 203 cirrhosis patients successfully treated with TIPS between January 2015 and January 2018, including 72 cirrhosis patients with PVT (35.5%) and 131 without PVT (64.5%). Our subjects were followed for at least 1 year after treatment with TIPS. Data were collected to estimate the mortality, shunt dysfunction, and complication rates after TIPS creation.Results: During the mean follow-up time of 19.5 ± 12.8 months, 21 (10.3%) patients died, 15 (7.4%) developed shunt dysfunction, and 44 (21.6%) experienced overt hepatic encephalopathy (OHE). No significant differences in mortality (P = 0.134), shunt dysfunction (P = 0.214), or OHE (P = 0.632) were noted between the groups. Age, model for end-stage liver disease (MELD) score, and refractory ascites requiring TIPS were risk factors for mortality. A history of diabetes, percutaneous transhepatic variceal embolization (PTVE), 8-mm diameter stent, and platelet (PLT) increased the risk of shunt dysfunction. The prevalence of variceal bleeding and recurrent ascites was comparable between the two groups (16.7 vs. 16.7% P = 0.998 and 2.7 vs. 3.8% P = 0.678, respectively).Conclusions: Transjugular intrahepatic portosystemic shunts are feasible in the management of cirrhosis with PVT. No significant differences in survival or shunt dysfunction were noted between the PVT and no-PVT groups. The risk of recurrent variceal bleeding, recurrent ascites, and OHE in the PVT group was generally similar to that in the no-PVT group. TIPS represents a potentially feasible treatment option in cirrhosis patients with PVT.

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Multiple acquired portosystemic shunts secondary to primary hypoplasia of the portal vein in a cat

Journal of Veterinary Medical Science ◽

10.1292/jvms.17-0648 ◽

2018 ◽

Vol 80 (6) ◽

pp. 874-877

Author(s):

Satoko SUGIMOTO ◽

Shingo MAEDA ◽

Masaya TSUBOI ◽

Kohei SAEKI ◽

James K. CHAMBERS ◽

...

Keyword(s):

Portal Vein ◽

Portosystemic Shunts

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Spontaneous thrombosis of large splenorenal shunt during balloon-occluded retrograde transvenous obliteration in a patient with chronic persistent hepatic encephalopathy. Is this catheter assisted trans-venous occlusion?

Gastroenterology Insights ◽

10.4081/gi.2017.6906 ◽

2017 ◽

Vol 8 (1) ◽

Author(s):

Lijesh Kumar ◽

Cyriac Abby Philips ◽

Prakash Zacharias ◽

Sudarshan Patil ◽

Philip Augustine

Keyword(s):

Hepatic Encephalopathy ◽

Portal Vein ◽

Portal Vein Thrombosis ◽

Hepatic Dysfunction ◽

Venous Occlusion ◽

Splenorenal Shunt ◽

Chronic Hepatic Encephalopathy ◽

Vein Thrombosis ◽

Portosystemic Shunts ◽

First Time

Large spontaneous portosystemic shunts in cirrhosis are implicated in recurrent and/or chronic persistent hepatic encephalopathy. In long standing cases, these shunts lead to portal vein thrombosis and hepatic dysfunction. Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular technique that is usually employed for shunt closure in the patients manifesting the features of chronic hepatic encephalopathy. There are several reports documenting systemic and portal vein thrombosis as a part of the procedure. We report first time a patient in whom the difficult and partial BRTO procedure led to the extensive thrombosis of the large splenorenal shunt itself without sclerosant instillation.

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