PMC2703746_01
Tight and irregular stenosis of the common bile duct (white arrow) with upstream dilatation of its narrowed segment, in addition to multiple flat impressions. One solitary stone was also present (black arrow).
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fig1
Endoscopic retrograde cholangiopancreatography (ERCP) established the diagnosis of portal biliopathy by revealing irregular outline of the CBD in addition to several flat impressions, presumably caused by venous collaterals (Figure 1).
Coronal MRI T2 weighted image showing a solid tumor-like mass at the hepatic hilum (portal cavernoma), (white arrow) in addition to hyposignal (thrombus) at the level of mesentiricoportal confluence (black arrow).
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fig2
Preoperative magnetic resonance imaging (MRI) of the abdomen showed persistence of superior mesenteric and portal vein thrombosis, and cavernous transformation of the portal vein (Figure 2).
Operative photograph. The right ovarian vein, 6 mm in diameter draining into the IVC (inferior vena cava) just caudal to the right renal vein.
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fig3
IVC. In a search for potential H-shunt options, and considering the fact that patient's thrombophilia would made the use of a synthetic graft prone to thrombosis, a large 6 mm in diameter right ovarian vein draining into the IVC just caudal to the right renal vein appeared to be of adequate size and quality to be utilized as an autologous conduit, to perform a portosystemic shunt (Figure 3). Indeed, approximately 8 cm of its length was mobilized and the right ovarian vein was divided and ligated distally.
Operative photograph. Completion of the end-to-side right portoovarian anastomosis with a continuous 6-0 PDS suture, before (a) and after (b) clamp removal (PV: portal vein, IVC: inferior vena cava).
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fig4
After systemic anticoagulation with heparin, the proximal end of the ovarian vein was anastomosed end-to-side to the distal portal vein with a continuous 6-0 PDS suture (Figures 4(a)  and 4(b)).
Postoperative coronal abdominal contrast enhanced CT scan shows opacification of the mesogonadal shunt (white arrow) confirming its patency.
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fig5
The patient had an uncomplicated postoperative course and an abdominal CT scan (Figure 5) performed prior to discharge home confirmed patency of the shunt, despite difficulty visualizing the shunt by US examination.