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Procedural images for patient 2 [Table 2]. (a) Digitally subtracted angiogram of the mesenteric to intrahepatic portal collateral with the 5-French catheter in the mesenteric side of the collateral. Essentially, this is a partly cavernose portal vein with partial portal vein thrombosis (not shown). The bracket points to where the meso-portal collaterals (duodenal varices) run through the duodenal wall. Above the bracket is the hepatic hilum and below it is extraduodenal. This segment of the collaterals (delineated by the bracket) should not have the "hardware" (in the form of coils or metallic vascular plugs) deployed within it as it is a high risk for mucosal erosion into the lumen of the duodenum. The 0.018-inch guide wire is in a portosystemic collateral that exhibits negligible, if any, portosystemic shunting. The asterisk denotes where the contrast (with powerful injections) empties into the inferior vena cava (systemic circulation). The hollow black arrow points to a portal communicator and the hollow white arrow points to the intrahepatic portal outflow of the duodenal varices. b) Fluoroscopic image of the coil augmented trans-TIPS balloon-occluded antegrade transvenous obliteration (BATO). There are coils (b: Solid white arrow), the portal communicator (a: Hollow black arrow), and coils (b: Hollow white arrow) in part of the intrahepatic portal outflow (a: Hollow white arrow). An air-filled 10 mm balloon (b: Between dashed arrows) is seen occluding the main portal contributor to the duodenal varices. Sclerosant (double density) is seen filing and spanning the duodenal varices between the balloon and the two coil nest. The deployed coils are clear of the submucosal/intramural portion of the porto-portal collaterals. Duodenal varices (bracket).
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F1
TIPS (established 324 days prior) in a portal/BATO approach manner utilizing a balloon occlusion catheter (Cook Flow Catheter, Cook Corp.) and coils. The metallic coils and vascular plugs were used to establish stasis and maximize the sclerosant dwell time, and they were intentionally placed in collaterals far away from the submucosal varices [Figure 1 and Table 3] to avoid the iatrogenic erosion encountered in patient 1. However, there was no significant portosystemic shunting through that portosystemic collateral [Figure 1].
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