Fig. 1. Transjugular portal venography demonstrates large periportal collaterals (arrow) and reconstitution of peripheral portal branches (arrowhead).

A 64-year-old man with known alcoholic cirrhosis presented with recurrent upper gastrointestinal bleeding which was refractory to sclerotherapy and banding. By ultrasound he had moderate ascites and the portal vein was reported normal with hepatopetal flow. He stopped alcoholic consumption eight years prior to current presentation and was considered a liver transplant candidate. TIPS was suggested as a bridge to transplantation.

Using the transjugular route, an attempt was made to access the right portal vein, however, the central branches of the portal system were found occluded and portal venography demonstrated the presence of large periportal collaterals (figure 1). An attempt was made at recanalizing the portal vein from the transjugular approach and a horizontal branch/collateral of the portal system was found (see figure 2). After careful consideration, this branch was thought not to represent the splenic vein. Further attempts to recanalize the portal vein from above were unsuccessful. Because of the extensive intrahepatic portal thrombosis it was decided to use the transsplenic approach to try and recanalize the thrombosed portal system. Using ultrasound guidance, a 22G Chiba needle was used to access a peripheral splenic vein branch and conversion to a 6.5F catheter was accomplished using the Accustick set (Boston Scientific). Splenic venogram (see figure 3) demonstrated occlusion of the splenic vein just beyond the portal confluence. Varices were seen coming off the splenic vein and the portal-systemic pressure gradient was 19 mm Hg. Using a coaxial catheter system an attempt was made at recanalizing the occluded portal system from below. The splenic and portal veins were recanalized to approximately the location of the portal bifurcation. A 10 mm (Microvena) snare was placed at this location to serve as a target. The back end of a Terumo wire (Boston Scientific) was used to puncture through the snare from above (see figure 4). A 5F catheter was placed over the hydrophilic wire and pulled with the snare into the patent portion of the splenic vein (see figure 5). The tract was dilated to 8 mm and 3 overlapping stents were placed to create a TIPS from the mid splenic vein to the right hepatic vein. Portal venography showed brisk flow through the TIPS with minimal filling of varices (see figure 6). The final portal-systemic gradient was 3 mm Hg. The transsplenic tract was embolized with two .035’ coils to reduce the chance of bleeding.

Following this procedure the patient stopped bleeding from his GI tract and ultrasound demonstrated good flow throughout the TIPS (1.3-1.6 m/s) and no evidence of perisplenic or intraabdominal blood.

Questions:

1) How often does ultrasound misinterpret large periportal collaterals as patent main portal vein?

2) What are the risks of the transsplenic approach to the portal system?

3) In the presence of ascites, is the transsplenic approach safer compared to the transhepatic approach?

4) Should the transsplenic approach used in cases of difficult portal localization with the use of a snare?

1. Liang HL, Yang CF, Pan HB, Chen CK, Chang JM. Percutaneous transsplenic catheterization of the portal venous system. Acta Radiol 1997 Mar;38(2):292-5

2. Rasinska G, Wermenski K, Rajszys P. Percutaneous transsplenic embolization of esophageal varices in a 5-year-old child. Acta Radiol 1987 May-Jun;28(3):299-301

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Case 397_05 -- Portal vein thrombosis

Case 797_02 -- Pancreatitis with portal vein thrombosis after biopsy

Case 1097_02 -- Portal vein thrombosis in the setting of acute pancreatitis: treatment with portal reconstruction