Balloon-targeted access of right portal vein for transluminal intrahepatic portosystemic shunt creation in the setting of portal vein thrombosis

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 (1,2). 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 (1–3). Sharp recanalization of occluded vessels in other anatomic locations and balloon-targeted puncture technique are also well-described (4,5). 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. DOI: 10.1097/01.RVI.0000064848.87207.06 Figure 1. (a)Abdominal CT with intravenous contrast material administration demonstrates occlusive thrombus within the main PV (arrow), a shrunken cirrhotic liver, and ascites. (b) Transhepatic venography confirms the CT finding of thrombus within the main PV and thrombus extension into the splenic vein and SMV. Patency of the intrahepatic PVs is seen before TIPS creation. Letters to the Editor