Percutaneous transhepatic treatment of a posttransplant portal vein thrombosis and a preexisting spontaneous splenorenal shunt

Abstract

Percutaneous transhepatic treatment of portal vein thrombosis after liver transplantation in a patient with a preexisting high volume spontaneous splenorenal shunt is presented. Local thrombolysis with urokinase and balloon angioplasty of the main portal vein stenosis were performed followed by shunt embolization to restore hepatopetal portal blood flow.

Transjugular Intrahepatic Portosystemic Shunt for Portal Cavernoma with Symptomatic Portal Hypertension in Non-cirrhotic Patients

“…It has been increasingly recognized that applications of a percutaneous transhepatic or transsplenic approach could facilitate targeting a landing site [22][23][24][25], thereby decreasing the difficulty of portal venous puncture [11,15,[26][27][28]. In our study, all but one patient underwent TIPS procedures with the help of a transhepatic or transsplenic approach, because poor or no visualization of portal vein and its branches were revealed by indirect portography.…”

Hepatic encephalopathy after liver transplantation in a patient with a normally functioning graft: Treatment with embolization of portosystemic collaterals

“…In liver transplant recipients, large collateral veins may steal flow from the portal vein because they may remain patent even with a very low portosystemic pressure gradient. These collateral veins may reduce portal flow through a competitive flow‐steal phenomenon, thus precipitating portal vein thrombosis 4. Large spontaneous portosystemic shunts may also have a detrimental effect on graft function 5.…”

Perioperative Management of Spontaneous Splenorenal Shunts in Orthotopic Liver Transplant Patients

“…1,2,5,8,10,[14][15][16][17][18][19][20][21][22][23][24][25][26][27] Possible treatment options include preoperative further selective shunting of flow such as transjugular intrahepatic portosystemic shunts, intraoperative assessment of portal flow with a decision to intervene if there is evidence of inadequate flow to the allograft, automatic intraoperative ligation of the shunt, close monitoring of the shunt and the functional status of the transplant liver without intervention, creation of portorenal anastomosis in the case of portal vein thrombosis, or postoperative percutaneous interventions to embolize a symptomatic shunt. …”

“…Therefore, in patients with an SRS less than 10 mm in diameter, intervention may be unnecessary. [6][7][8] However, the posttransplant patient with a persistent splenorenal shunt should be monitored carefully for evidence of compromised allograft function, as there is increased risk for liver dysfunction, portal vein thrombosis, and hepatic encephalopathy in these patients. Regular evaluation of liver function tests as well as surveillance sonographic duplex imaging should be performed.…”

“…5,6 After orthotopic liver transplant, porto-systemic collaterals typically involute as the low-resistance vascular bed of the allograft leads to decreased flow through the aberrant channels. [7][8][9] However, large shunts, those measuring larger than 10 mm, are less likely to collapse and may continue to steal flow from the new organ. Additionally, shunts may reconstitute, and the steal may worsen if the intrinsic allograft vascular resistance becomes elevated, as may occur with rejection, fluid overload, and other posttransplant phenomena.…”