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• W2000733086 abstract "Editor: The technical challenge of transluminal intrahepatic portosystemic shunt (TIPS) creation in the setting of portal vein (PV) thrombosis is well known to interventional radiologists (1Radosevich PM Ring EJ LaBerge JM et al.Transjugular intrahepatic portosystemic shunts in patients with portal vein occlusion.Radiology. 1993; 186: 523-527PubMed Google Scholar, 2Saxon RR Keller FS Technical aspects of accessing the portal vein during the TIPS procedure.J Vasc Interv Radiol. 1997; 8: 733-744Abstract Full Text PDF PubMed Scopus (57) Google Scholar). Multiple approaches to PV localization and access, including contrast material injection into liver parenchyma, transhepatic contrast material injection into thrombosed PV, and targeting with transhepatic placement of PV stents, wire baskets, or snares have been described (1Radosevich PM Ring EJ LaBerge JM et al.Transjugular intrahepatic portosystemic shunts in patients with portal vein occlusion.Radiology. 1993; 186: 523-527PubMed Google Scholar, 2Saxon RR Keller FS Technical aspects of accessing the portal vein during the TIPS procedure.J Vasc Interv Radiol. 1997; 8: 733-744Abstract Full Text PDF PubMed Scopus (57) Google Scholar, 3Haskal ZJ Duszak R Furth EE Transjugular intrahepatic transcaval porto-systemic shunt: the gun-sight approach.J Vasc Interv Radiol. 1996; 7: 139-142Abstract Full Text PDF PubMed Scopus (99) Google Scholar). Sharp recanalization of occluded vessels in other anatomic locations and balloon-targeted puncture technique are also well-described (4Farrell T Lang EV Barnhart WR Sharp recanalization of central venous occlusions.J Vasc Interv Radiol. 1999; 169: 149-154Abstract Full Text PDF Scopus (69) Google Scholar, 5Murphy TP Marks MJ Webb MS Use of a curved needle for true lumen re-entry during subintimal iliac artery revascularization.J Vasc Interv Radiol. 1997; 8: 633-636Abstract Full Text PDF PubMed Scopus (15) Google Scholar). We recently used a combination of these approaches in the setting of bowel ischemia with portal and mesenteric vein thrombosis. A 43-year-old woman with Hepatitis B and cirrhosis initially presented with 1 week of increasing abdominal pain and girth. She was admitted for pain control and therapeutic diuresis for her ascites. On the third hospital day, CT of the abdomen was performed and revealed nonocclusive thrombus in the superior mesenteric vein (SMV), ascites, and a shrunken liver. Three days later, the patient reported acutely increasing abdominal pain, nausea, vomiting, and bloody stools. Nasogastric lavage returned bright red blood. The patient's white blood cell count had increased to 21,000. Repeat CT revealed occlusive thrombus in the PV and SMV along with pneumatosis intestinalis (Fig 1a). The patient was not a candidate for surgery, so a TIPS procedure for splanchnic outflow with subsequent thrombolysis of the PV and SMV was performed the same day in an attempt to salvage her ischemic bowel. A standard approach to the patient's PV failed and targeting was believed indicated. Initial venogram confirmed CT findings and demonstrated patency of intrahepatic PVs before TIPS (Fig 1b). After placing a sheath in the right PV transhepatically with ultrasound guidance, an initial attempt with a 25-mm Amplatz goose neck snare (Microvena, White Bear Lake, MN) as a target was unsuccessful because of the large thrombus burden. The loop could not be expanded. This, in combination with the shrunken cirrhotic liver, frustrated our attempts and required a novel approach. We exchanged the snare wire for a 5.5-F Fogarty Thru-Lumen balloon embolectomy catheter (Edwards Lifesciences, Irvine, CA) and inflated it in the proximal right PV. The position was chosen based on previous small contrast material injections. This target was easily visualized and approached with a Colapinto needle (Fig 2a). Trajectory and intraluminal access were verified by balloon indentation followed by rupture. The remainder of the TIPS procedure was accomplished in the standard fashion. Mechanical thrombolysis of the PV and SMV was performed with use of the 6-F Xpeedior 100 Catheter (Possis, Minneapolis, MN) and the 3000A AngioJet system (Possis). Tissue plasminogen activator was contraindicated because of the patient's ongoing bloody diarrhea and coagulopathy. The transhepatic tract was embolized with several coils during sheath removal. Venography after TIPS creation demonstrated restoration of splanchnic outflow (Fig 2b). The patient's ascites and pneumatosis improved and lactic acid level returned to normal. She was transferred to the local transplant center on hospital day 17 for planned liver transplantation. We believe that the utility of balloon targeting and puncture in this setting resulted from the stability of the target provided in the PV. The three-dimensional space-occupying nature of the balloon in the PV makes approaching the target easy in the setting of distorted liver anatomy. The compliant indentation of the balloon and its subsequent rupture provided excellent confirmation of PV access. We believe this approach may add another tool for accessing the thrombosed PV during the TIPS procedure." @default.
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• W2000733086 date "2003-04-01" @default.
• W2000733086 modified "2023-09-25" @default.
• W2000733086 title "Balloon-targeted Access of Right Portal Vein for Transluminal Intrahepatic Portosystemic Shunt Creation in the Setting of Portal Vein Thrombosis" @default.
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• W2000733086 doi "https://doi.org/10.1097/01.rvi.0000064848.87207.06" @default.
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