PMC3563163_01
62-year-old man with portal vein thrombosis with cavernous transformation. Preprocedural coronal CT image demonstrates complete occlusion of the main portal vein (arrows), with reconstitution of intrahepatic branches (arrowheads) (a). Preprocedural axial CT image better demonstrates the multiple cavernous collaterals at the level of the hepatic hilum (arrows) (b).
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fig1
CT demonstrated portal vein occlusion with cavernous transformation (Figure 1).
62-year-old man with portal vein thrombosis with cavernous transformation. Angiogram following transjugular access to the portal system demonstrates access into a network of cavernous collaterals (arrows), with patent intrahepatic branches. The wire could not be navigated through the occluded main portal vein from this approach.
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fig2
Contrast injection demonstrated multiple portal venous collaterals consistent with cavernous transformation (Figure 2).
62-year-old man with portal vein thrombosis with cavernous transformation. Sequential digital subtraction images following traversal of the main portal vein occlusion from the transhepatic approach. An angioplasty balloon is inflated within the occluded main portal vein (a). The Rosch-Uchida needle from the transjugular approach is used to puncture the balloon (b). An angled Glidewire is passed through the Rosch-Uchida needle into the portal system (c).
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fig3
Next, an 8 mm x 2 cm Optapro balloon (Cordis Corporation, Miami, FL) was positioned at the site of desired portal vein access and inflated with contrast (Figure 3(a)). Under fluoroscopic guidance, with the contrast-filled balloon as a target, the transjugular Rosch-Uchida needle was used to puncture the balloon (Figure 3(b)). Following balloon rupture, the glidewire advanced easily through the needle into the portal system (Figure 3(c)).
62-year-old man with portal vein thrombosis with cavernous transformation. Portography from the splenic vein demonstrates filling of multiple varices and nonfilling of the occluded portal vein. The portosystemic gradient is 23 mm Hg.
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fig4
Portography demonstrated chronic occlusion of the portal vein at the confluence of the superior mesenteric vein and splenic vein, with multiple varices (Figure 4).
62-year-old man with portal vein thrombosis with cavernous transformation. Rapid inline flow through the TIPS following stent-graft placement from the main portal vein to the proximal right hepatic vein and bare metal stent placement in the more proximal main portal vein. The final portosystemic gradient is 11 mm Hg.
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fig5
TIPS without significant variceal filling (Figure 5).