Transjugular intrahepatic portocaval shunt after thrombus disruption in partially thrombosed portal veins

Abstract

Portal vein (PV) thrombosis increases the risk of variceal bleeding in cirrhotic patients with portal hypertension. Its presence also complicates PV access during transjugular porto-caval shunt (TIPS) placement. We overcame this obstacle by using ultrasound (US) guidance for PV entry. Clot disruption by balloon catheters was then performed before placing the vascular endoprostheses for portal-venous shunting. We treated 3 cirrhotic patients in such fashion with good clinical results. Portal thrombi progressively disappeared after shunting due to both balloon disruption and the rise in portal blood flow velocity.

Feasibility and long-term evolution of TIPS in cirrhotic patients with portal thrombosis

“…Conversely, during the follow-up of cirrhotic patients a PT occurred in 0.6-26% [9][10][11][12][13][14][15]; this variability depends on the criteria of thrombosis and diagnostic method.…”

“…Yet, we attempted a TIPS procedure in 14 patients with portal cavernoma and this was successful in 12 patients, as in three-quarters of the patients in the Van Ha series [31] and six out of nine of the patients in the Senzolo series [8]. Simultaneous sonographic and radioscopic guidance allowed improving the safety and acuteness of the puncture and catheterization of the remaining portal structures [1,8,13,32]. Nevertheless, this procedure remains difficult, and needs well-trained sonographists and radiologists with an experience of at least 40-50 TIPS procedures per year.…”

“…Early thrombosis may be solved by in-situ chemical or mechanical thrombolysis; thereafter, thrombosis has to be managed with a stent, which allows restoring the portal lumen by pressing the clot against the vein wall [13,16,28]. In cases of cavernoma, after the puncture of the intrahepatic portal vein remnant, the portal vein lumen is progressively restored by saline injection and cautious balloon dilation.…”

Successful recanalization of portal vein thrombosis before liver transplantation using transjugular intrahepatic portosystemic shunt

“…19 However, TIPS has been performed successfully in patients with cirrhosis with occluded portal veins. [20][21][22][23][24][25][26][27] Table 1 lists the features of these patients obviously selected in being considered potentially remediable at the time of OLT. Radosevich et al 20 successfully performed TIPS placement in 7 of 10 patients by transjugular catheterization 27 were complications directly attributed to TIPS placement, which developed in 2 of 9 patients (laceration of the liver, intramesenteric hematoma, and eventually death in 1 patient; laceration of the inferior vena cava in 1 patient).…”

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

“…Nowadays, percutaneous recanalization procedures such as transhepatic angioplasty [8], local high-dose infusion of thrombolytic agents [9,10], and TIPS placement [11] have been described. These procedures significantly reduce the morbidity and mortality in these patients.…”