Teaching Case

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Dr. Soumil Singhal, Dr. Bibin Sebastian, Dr. M.C. Uthappa, Dr. Rohit Madhurkar

BGS Gleaneagles Global,Intervention Radiology; Kengeri 560060 Bangalore, India; Email:drsoumilsinghal75@gmail.com

Patient

70 years, male

Categories

Area of Interest Gastrointestinal tract, Interventional vascular ; Imaging Technique CT, Conventional radiography, Catheter venography ;

Procedure Diagnostic procedure, Shunts ; Special Focus Haemodynamics / Flow dynamics ;

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Clinical History

A seventy-year-old male patient with known chronic liver disease presented with complaints of recurrent abdominal distention with discomfort and fullness. The patient reported a previous history of haematemesis. Coagulation and serology profile were normal.

Differential Diagnosis List

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TIPS in portal vein thrombosis

Tumour thrombus

Portal hypertension

Imaging Findings

Contrast-enhanced computed tomography showed features of chronic liver disease with portal vein thrombosis and features of recurrent ascites. In view of the clinical condition the patient was planned for liver transplant. However, because of inavailability of the organ, transjugular intrahepatic shunt procedure was planned.
Right internal jugular vein was accessed under ultrasound guidance. Right hepatic vein was cannulated. Portal vein was punctured, however, because of thrombosis the wire could not be navigated. Microwire was used to navigate through the thrombus and coronary balloon was used to dilate and navigate a 0.035 across the thrombus. TIPSS stent was placed and check venogram was acquired.

Discussion

Transjugular intrahepatic portosystemic shunt procedure is a bypass technique which reduces complications related to portal hypertension. The two main indications for TIPS include refractory variceal bleed and ascites. Other indications include Budd Chiari, portal vein thrombosis and ectopic varices. Rösch et al [1] first described this minimally invasive nonsurgical technique in 1969.
TIPS procedure facilitates the reduction of elevated sinusoidal pressure and renin–angiotensin–aldosterone axis which helps in reduction of fluid accumulation. Tips alone is not effective in the treatment of refractory ascites and sometimes short term diuretics may also be required. Hepatic encephalopathy is a major adverse effect post TIPS and up to 40% can develop it following the procedure [2]. Up to 4.5% - 15% of patients of chronic liver disease develop portal vein thrombosis [3]. TIPS in patients with portal vein embolisation is technically challenging. TIPS has shown a beneficial role in recanalisation of portal vein in such cases. Han G et al. and Angelo Luca et al. reported a success of 75% and 100% respectively in cases of portal vein thrombosis [4, 5].

Written informed patient consent for publication has been obtained.

References

[1] Rösch J, Hanafee W N, Snow H. (1969) Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology 1969;92(5):1112–1114 (PMID: 5771827)

[2] Boyer T D, Haskal Z J. (2005) AASLD Practice Guideline. The role of transjugular intra-hepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005;41:1–15. (PMID: 15660434)

[3] Amitrano L, Guardascione M A, Brancaccio V. et al. (2004) Risk factors and clinical presentation of portal vein thrombosis in patients with liver cirrhosis. J Hepatol 2004;40(5):736–741 (PMID: 15094219)

[4] Han, G. et al. (2011) Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis. J Hepatol 54, 78–88 (PMID: 20932597)

[5] Luca A. et al. (2011) Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis. GUT 60, 846–852 (PMID: 21357252)

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