Fig. 1. Transhepatic portogram demonstrating cavernous collaterals.

Fig. 2. Transjugular portogram via RHV to RPV puncture.

A 48-year-old white male Pugh-Child Class B EtOH cirrhotic with marked ascites who had quit drinking 5 years earlier presented to us after repeated acute variceal hemorrhages. The bleeding was managed tenuously endoscopically however he had a slow persistent drop in Hgb.

We initially attempted transhepatic PV recanalization (fig 1), but were unsuccessful. A 5f catheter was left in place and transjugular access was achieved into the intrahepatic RPV (fig 2). TIPS shunt was created between RHV, RPV, and a large cavernous collateral with reduction of initial PV/RA gradient of 30 mmHg to a final PV/RA gradient of 8 mmHg (fig 3). Finally, injection of the previously placed transhepatic catheter in a cavernous collateral revealed outflow through the TIPS (fig 4).

The patient was discharged on the second post-procedural day and was re-admitted for 23 hour admit on the following day for new onset encephalopathy which was successfully medically treated. It was also noted at the re-admission that there was significant reduction in the patient’s abdominal girth and relayed by his wife that he had been putting out copious amounts of urine. At two months post-procedure he has not re-bled and his abdomen is flat and encephalopathy is controlled.

Fig. 3. Transjugular portogram after TIPS shunt placement. Final PV/RA gradient 8mmHg.

Fig. 4. Transhepatic portogram after TIPS placement showing flow from large collaterals in liver hilum out through TIPS shunt.