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(A) Axial CT image shows the relation of the left hepatic vein (LHV) (long arrow) and the left portal vein (LPV) (short arrow) in one plane, which was used for percutaneous puncture (the percutaneous puncture tract is marked with white arrows). (B) X-ray image demonstrates transhepatic-portal guidewire snaring. A guidewire is advanced in the portal circulation (arrows) after simultaneous CT-guided puncture of the LPV through an open snare loop located in the LHV (arrow head).
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TIPS was unfeasible because of an excessively cephalad position of the liver and its subsequent alteration in its vessel anatomy. Therefore, creation of a tract between the left hepatic vein and the left portal branch resulting in a portosystemic shunt was proposed (Figure 1A). As a result, guidewire formed a direct access from the right femoral vein through the left hepatic vein into the left portal tract and the splenic vein (Figure 1B).
CT scan of a portosystemic shunt tract that was created by introducing a self-expanding stent graft (Fluency, Bard, Karlsruhe, Germany) and a self-expanding stent (ELuminexx, Bard, Karlsruhe, Germany) (arrow).
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An additional post-interventional CT scan revealed no technical failures (Figure 2).
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Stent fragments in follow-up ultrasound examination. The numbers clearly point to fragments in the vena cava inferior (1), the right atrium (2) and the right ventricle (3).
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Fragments were located in the proximal inferior vena cava, as well as in the right atrium and the right ventricle (Figure 3).