TIPS in portal vein thrombosis and refractory ascites

Dr Virginia Hernández-Gea managed a 53-year-old male with non-alcoholic steatohepatitis and alcohol-induced cirrhosis, complicated by refractory ascites and extensive portal vein thrombosis. Liver transplant was contraindicated, necessitating a cutting-edge approach. Comprehensive imaging revealed partial and complete portal vein thrombosis. Due to thrombosed hepatic veins, traditional TIPS access was unfeasible. The procedure involved ultrasound-guided splenic puncture, angioplasty, and strategic stent placement to establish portal vein connectivity via a transjugular approach. The intervention significantly improved liver function and portal hypertension, eliminating the need for a liver transplant and highlighting the efficacy of advanced recanalization strategies in complex liver pathologies.

Speaker 1 (00:15):
Hello, I’m Doctor Virginia Hernández-Gea. Today’s topic is TIPS and extended PVT, and it’s part of the TIPS Complex Case Educational Series brought to you by Cook Medical. Let’s begin.

(00:27):
We had this case that was a 53-year-old male patient with cirrhosis due to NASH and also alcohol. And the patient had a very large thrombosis affecting the superior mesenteric veins, splenic vein, and portal vein. And he had refractory complications for the hypertension, he had refractory ascites, and was undergoing total volume paracentesis every week.

(00:57):
However, the patient was not a good candidate for liver transplant due to the thrombosis that was a contraindication for the needed anastomosis in the liver transplant. The patient had liver dysfunction and it was like no other option for the patient than getting a liver transplant.

(01:17):
So, we decided to study the case to see if we could recanalize something of the port systemic territory. As you can see here in this CT scan, the main problem was the complete occlusion, the complete thrombosis, between the portal vein and the splenic vein, in this segment here that was completely thrombosed. And also, the portal vein was partially occluded.

(01:48):
So, what we did is to study the case and to look inside the approach, we did an ultrasound, where we could see that the portal vein was small and very tiny, with thrombosis at the hilum. The right hepatic vein was partially thrombosed as well, and we couldn’t see the left hepatic vein. So, with this condition, a transjugular portosystemic shunt, a traditional TIPS, was not fit at all to do in this patient.

(02:23):
We decided to go for selective arteriography to have a vascular map of all the territory and we could verify that the superior mesenteric vein was occluded. The splenic vein was tightened, but it was an occlusion 5 cm from the hilum, and the splenic vein was draining into a splenorenal shunt.

(02:48):
What we did with this arteriography was to identify the structures and where was the genuine portal vein tract. So, we could identify the artery, the bile duct, and the vein. And this is what we want to connect, from the splenic vein to the portal vein, this is what we need to work on connecting, and then be able to place a TIPS via transjugular approach.

(03:30):
So, this is what we had happen (did), splenic vein, a little bit of the portal vein, and this is what we had to connect to give continuity to the flow.

(03:42):
What we did was a guided splenic puncture, and once we were in the splenic vein, progressing and identifying the genuine portal vein. As you can see, it is here.

(04:00):
So, doing several angioplasties in the splenic territory, we could open it up, everything that was previously thrombosed, and arriving into the portal vein.

(04:15):
Once the portal vein was restored, what we did is place a snare in the portal vein to guide the transjugular puncture, placing a TIPS from the right hepatic vein to the right portal vein, and placing a bare stent in the splenic vein. And as you can see here, there is the confluent between the TIPS and the splenic stent. It’s free of stents just in case the patient needs a liver transplant, to allow the anastomosis in this particular place.

(05:00):
However, the patient did great after the procedure. Decompressing the whole territory with a stent made the patient improve not only the liver function, but also the portal hypertension. And the patient dropped off from the liver transplant waiting list, and now he is free of the portal hypertension complications that he had previous to the procedures. So, it was a real success in this case.

(05:36):
So with this, I wrap up this complex case. We hope you find it useful. And if you have any comments or case ideas you would like to see in future episodes, send your feedback to TIPScases@cookmedical.com, and be sure to keep an eye out for the next complex case. Thank you.

Dr Virginia Hernández-Gea was a paid consultant of Cook Medical at the time of recording.