Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation

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.

Techniques for portal vein targeting during a transjugular intrahepatic portosystemic shunt

“…Once splenic vein access is established, the occluded portal vein can be recanalized to allow for the subsequent TIPS ( Figure 9 ). 7 Transsplenic access is a safe technique. As with transhepatic access, the main complication of concern is bleeding from the access tract leading to a hematoma formation, which can be mitigated by a coil or plug embolizing the transsplenic tract.…”

“…As with transhepatic access, the main complication of concern is bleeding from the access tract leading to a hematoma formation, which can be mitigated by a coil or plug embolizing the transsplenic tract. 7 …”

Diagnosis and Management of Acute and Chronic Portomesenteric Venous Thrombosis

“…This technique was described by Dr. Salem and colleagues at Northwestern University in Chicago and its utility and applicability has recently been confirmed by other groups. 35,45 Trans-splenic Access…”

“…The trans-splenic approach is safe and increasingly applied in cases with extensive portal vein thrombosis, especially in patients in whom the transhepatic approach could be problematic. 45,46 Access into the splenic vein gives the operator excellent access into the portal system, with plenty of purchase to attempt recanalization. 46 Trans-splenic access is usually straightforward; ultrasound guided access is recommended.…”

Surgical Perspectives on the American Association for the Study of Liver Diseases Guideline for Anticoagulation and Implications for Liver Transplantation

“…(8)(9)(10) Transsplenic PVR with transjugular intrahepatic portosystemic shunting has also shown promise in achieving PVR for patients being considered for transplantation. (11)(12)(13) Intriguingly, a small randomized control trial from Italy demonstrated the safety and efficacy of enoxaparin in the prevention of PVT among patients with Child-Pugh-Turcotte classes B and C cirrhosis (9% developed PVT on anticoagulation versus 28% without). (9) Furthermore, liver decompensation, defined as the development of ascites, bacterial peritonitis, encephalopathy, or variceal bleeding, was significantly lower in the anticoagulated group.…”