PMC5725356_01
Portal phase of preoperative contrast-enhanced CT image (A) shows total occlusion of portal vein due to extensive thrombosis (arrow) and cavernous malformation of intrahepatic portal veins with splenomegaly. Capsule endoscopy (B) revealed active bleeding and a large amount of blood clots at proximal jejunum. SMV angiography (C) shows cavernous transformation of intrahepatic portal vein (asterisk), and collateral vessels are seen. Total obliteration of SMV (open arrow) is noted. SMV, superior mesenteric vein.
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F1
Capsule endoscopy confirmed active bleeding with a large amount of blood clot at proximal jejunum (Fig. 1B). However, contrast-enhanced CT demonstrated total intra- and extrahepatic portal vein obliteration with intrahepatic collaterals and splenomegaly, rendering TIPS unfeasible (Fig. 1A). Angiography showed total obliteration of superior mesenteric vein (SMV) with cavernous transformation and collateral vessels (Fig. 1C).
Mesocaval shunt creation. (A) A 16-G Colapinto needle and a 9-Fr Teflon sheath were coaxially loaded over a guidewire via US-guided puncture of right IJV. Via US-guided puncture of the splenic vein, an 11-mm balloon catheter was placed at the SMV-splenic vein confluence. The inflated balloon was used as a fluoroscopic target. A 0.035-inch guidewire (black arrow) was placed in the dilated hepatic artery to avoid puncture of the target. (B) Final angiography shows patent mesocaval shunt between IVC and SMV. (C) CT-rendered three-dimensional image reveals patent stent graft (white arrow) with partial intrahepatic portion at the proximal end. Additional stent at distal splenic vein (arrowhead) to prevent shunt wasting resulted in an inverted "Y" configuration of stents. (D) Simplified diagram of transsplenic mesocaval shunt technique. Linear arrow represents the direction of puncture (splenic vein stent is not shown). IJV, internal jugular vein; SMV, superior mesenteric vein; IVC, inferior vena cava.
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F2
US-guided puncture of right internal jugular vein. Sheath tip was placed at the inferior vena cava (IVC), with a 0.035-inch guidewire placed at nearby common hepatic artery, due to concerns for vascular injury. Under fluoroscopic guidance, the Colapinto needle was advanced towards the target balloon, traversing the caudate lobe (Fig. 2A and D). FL, USA) was placed at splenic vein to prevent shunt wasting. Final angiography revealed patent flow between the SMV to IVC with an inverted "Y"-stent configuration (Fig. 2B, C, and D) with decreased gastric varices.