Successful treatment of recurrent hepatic encephalopathy with revision of transjugular intrahepatic portasystemic shunt and embolisation of splenorenal shunt

We present a case of 64-year-old US veteran who developed recurrent hepatic encephalopathy (HE) following transjugular intrahepatic portasystemic shunt (TIPSS) procedure. The patient had a history of metabolic syndrome and cirrhosis due to non-alcoholic steatohepatitis. He had undergone sleeve gastrectomy 1 year earlier with preoperative TIPSS placement. He developed recurrent symptoms of HE despite optimising his medications, resulting in poor quality of life and multiple hospitalisations. A liver Doppler ultrasound and CT scan of the abdomen was obtained which showed a patent TIPSS and a prominent shunt between the splenic vein and left renal vein via the left gonadal vein. This was treated with reduction of TIPSS, by placement of a covered stent in an hourglass configuration within the existing TIPSS stent and simultaneous embolisation of the splenorenal shunt by interventional radiology. The patient had complete resolution of symptoms following the procedure without any recurrence of HE.

Pelvic congestion syndrome is an interdisciplinary issue

This paper discusses an essential interdisciplinary issue, pelvic congestion syndrome (PGS). PGS is a venous disorder with gonadal vein and/or pelvic venous plexus dilation that results in pelvic venous plethora. The authors address PGS prevalence, causes, underlying pathophysiological mechanisms, major clinical manifestations, diagnostic tools, and treatment approaches. Pharmacotherapy (gonadotropin-releasing hormone agonists, danazol, combined oral contraceptives, progestins, phlebotonics, etc.) is the first-line treatment that provides only a temporary effect. Image-guided vascular surgery (embolization, stenting) is of particular importance among surgical interventions. Surgical technique and critical results of the studies on the efficacy of gonadal vein embolization (from 47% to 100%) are described. The paper details major complications of surgical interventions and highlights issues requiring further researches, i.e., the effects on female fertility, predicted full recovery considering compromised somatic and/or gynecological anamnesis. Finally, the importance of timely diagnosis, greater awareness of primary care physicians on the signs and symptoms of this disorder, and a need to refer these women to vascular surgeons are addressed. KEYWORDS: pelvic congestion syndrome, gonadal vein embolization, pelvic pain, May–Thurner syndrome, nutcracker syndrome. FOR CITATION: Antropova E.Yu., Sharafutdinov B.M., Mazitova M.I. et al. Pelvic congestion syndrome is an interdisciplinary issue. Russian Journal of Woman and Child Health. 2021;4(4):346–350 (in Russ.). DOI: 10.32364/2618-8430-2021-4-4-346-350.

CT findings after left renal vein division during abdominal aortic surgery

Background The rationale behind left renal vein division (LRVD) is the assumption that adequate collateral draining channels will develop. Purpose To describe computed tomography (CT) findings after LRVD during aortic surgery. Material and Methods Among 61 consecutive patients who underwent LRVD during aneurysm repair or revascularization for aortic occlusive disease between January 2003 and December 2017, 51 patients (40 men, mean age 71.4 ± 8.4 years) were enrolled. Contrast-enhanced CT images were analyzed to evaluate collateral drainage, patency, left renal vein diameter, and left renal parenchymal thickness. A total of 115 radiologic reports were reviewed to check whether these findings were accurately mentioned. Results The median time period of the first postoperative follow-up CT was 36 days (range 7–1351 days). The gonadal vein (n = 47) was the most common collateral draining channel, followed by the retroperitoneal veins (n = 42) and adrenal vein (n = 33). Thrombosis occurred in five patients between postoperative days 7 and 17 in the remnant renal vein (n = 3), remnant renal vein plus gonadal and adrenal veins (n = 1), and gonadal vein (n = 1). There was a significant decrease in renal vein diameter (–0.48 ± 2.12 mm, P = 0.006). There was no significant difference in parenchymal thickness (−0.25 ± 1.27 mm, P = 0.193). Neither LRVD nor any associated findings were correctly stated on radiologic reports. Conclusion Postoperative contrast-enhanced CT can delineate collateral draining channels and complications following LRVD. However, these findings tend to be either missed or misinterpreted.