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Fig. 1. Initial post TIPS venogram showing Wallstent normally positioned in the hepatic vein. |
Fig. 2. Venogram 4 months post TIPS showing a stenosis (arrow) near the portal vein end of the shunt. |
Case Reference No. CC397-06 This 49 year old female underwent TIPS due to bleeding from large gastric varices. Fig. 1 shows the initial result. The portosystemic gradient was successfully lowered to 10 mmHg and the variceal bleeding stopped. At 4 months post TIPS, a routine ultrasound detected a shunt stenosis. Venography (Fig.2) confirmed the stenosis which responded nicely to angioplasty. Note that the hepatic vein and the upper end of the shunt are widely patent. At 1 year post TIPS , ultrasound detected a stenosis in the hepatic vein. At venography, the upper end of the shunt could not be cannulated despite trying multiple catheters. Venography of the draining hepatic vein (Fig. 3) showed that the top end of the stent was now incorporated into a hepatic vein stenosis with the pseudo-intimal hyperplasia enveloping the upper stent. There was still flow through the shunt via the side interstices of the stent. A guidewire would pass though the stent interstices into the portal system (Fig.4) but no catheter (even 3 french) or needle would follow. Transhepatic puncture into the stent was not done since she was an out-patient but will be pursued if planned repeat endoscopy demonstrates recurrent varices. |
Fig. 3. Venogram of draining hepatic vein. The top of the shunt (arrowhead) is incorporated into a hepatic vein stenosis. Portal blood flows through the side interstices (arrow) of the shunt.
Fig. 4. Guidewire passed through the interstices of the shunt into the portal vein. The wire is being passed through a Colapinto needle used to brace the wire. Neither the needle nor any catheter would pass through the side of the shunt. |
Questions 1) Since nothing (from a 3 french catheter up to the Colapinto needle) would pass through the shunt, can you think of any way to cannulate the portal vein without doing a transhepatic puncture ? 2) If endoscopy shows no significant varices, would you pursue trying to open up the top end of the stent ? |
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