Percutaneous Mesocaval Shunt

Abstract

Extrahepatic portal vein occlusion (EHPVO) is a primary vascular condition characterized by chronic obstruction of the extrahepatic portal vein and is a significant cause of ectopic varices, variceal bleeding, and morbidity. Transjugular intrahepatic portosystemic shunt is a critical procedure in decompressing the portal system. An unfortunate cohort of patients with refractory variceal bleeding who suffer from coexistent chronic portal vein thrombosis, often have limited treatment options. We present a case of EHPVO, complicated with hepatitis C virus infection and cirrhosis with refractory variceal bleed in which percutaneous mesocaval shunt was performed.

 

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Keywords

EHPVO (extrahepatic portal venous obstruction) - percutaneous mesocaval shunt - ectopic varices

Introduction

Extrahepatic portal vein occlusion (EHPVO) is a primary vascular condition characterized by chronic obstruction of the extrahepatic portal vein[1] and is a significant cause of ectopic varices, variceal bleeding, and morbidity.

Transjugular intrahepatic portosystemic shunt (TIPS) is a key procedure in refractory variceal bleeding and decompresses the portal system. However, patients with EHPVO or chronic portal vein thrombosis with contraindications for TIPS face limited treatment options and dismal outcomes.[2]

We hereby describe a case of EHPVO, who subsequently developed hepatitis C virus (HCV) infection and cirrhosis, with chronic portal and mesenteric vein thrombosis. The patient presented with refractory ectopic variceal bleed and was treated with a percutaneous mesocaval shunt, emphasizing the utility of the procedure, with a goal of encouraging wider adoption.

 

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Case Report

A 35-year-old male with EHPVO (diagnosed 20 years back) presented with recurrent hematemesis and melena. He developed HCV infection in 2010 and chronic liver disease (CLD) in 2011. Over the past 9 years, his bleeding episodes increased, requiring multiple transfusions and variceal ligations.

Considering the high mortality, decompensation risk, and technical difficulty of a surgical mesocaval shunt, a decision to perform a percutaneous mesocaval shunt was taken ([Fig. 1A]).

Fig. 1 (A) Schematic representation of procedure. (B and C) Puncture of superior mesenteric vein (SMV) collateral through transjugular access under fluoroscopy guidance (guided by balloon and wire placed through transsplenic access).

Under general anesthesia, a 10Fr TIPS sheath (Rösch-Uchida Transjugular Liver Access Set, Cook) was placed in the inferior vena cava (IVC). A balloon catheter (10 mm × 4 cm Advance 35LP Balloon Catheter, Cook) was advanced over a Amplatz Extra Stiff Wire (0.038″ × 145 cm) into the superior mesenteric vein (SMV) collateral/splenic vein junction through a transsplenic approach.

IVC venogram was taken from 10Fr TIPS sheath and the puncture needle (0.038″ trocar stylet of TIPS set) was directed toward the SMV collateral under transabdominal ultrasound and fluoroscopy guidance ([Fig. 1B]). A small volume of contrast was injected through the jugular access to confirm its position within the collateral. Suboptimal predilatation of the track was done with 6 mm balloon (6 mm × 6 cm Armada 35 PTA Balloon Catheter, Abbott), following which a partially covered polytetrafluoroethylene stent (10 mm × 12 cm Niti-S ComVi-type partially covered stent, Taewoong) was immediately deployed across the newly formed track and poststent balloon dilatation was done (10 mm) to ensure adequate apposition.

Poststent venography through the splenic access showed significant reduction of flow within the collaterals, good forward flow into the IVC, and no contrast extravasation ([Fig. 2A ]and [Fig. 2B]).

Fig. 2 (A) Prestenting splenic venogram demonstrating extensive collaterals/ectopic varices. (B) Poststenting venogram demonstrating flow into the inferior vena cava (IVC) and significant reduction in collaterals. (C) 3-year follow-up contrast computed tomography (CT) demonstrating patency of the shunt (also demonstrating a partially intrahepatic course through caudate lobe, which is considered protective against delayed stent migration[4]).

The patient was followed-up at 1, 3, 6, 12, 18, 24, and 36 months. During this 3-year follow-up, the patient has had no episodes of variceal bleed since the procedure and no complaints/features of hepatic encephalopathy ([Fig. 2C]).

 

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Discussion

EHPVO involves chronic obstruction of the extrahepatic portal vein, sometimes extending to the intrahepatic portal vein, splenic vein, or SMV.[1] Ectopic varices are defined as dilated portosystemic collateral veins located in sites other than the gastroesophageal region, constituting approximately 20 to 30% of those with extrahepatic portal hypertension.[3]

Operative mesocaval shunt creation using Vitallium tubes was first described in 1945, with surgical shunts having a high mortality rate (as much as 20–50% if emergent).[2] Furthermore, many of these patients may not be suitable candidates to undergo major surgical procedures.[2]

Percutaneous mesocaval shunt as an alternative to decompress the portal system was first described by Nyman et al in 1996 in an original case report, and, to the best of our knowledge, only 10 cases have been published in English literature so far ([Table 1]).[4] [5]

Table 1 Summary of previous cases of percutaneous mesocaval shunts[5]

Age (years)/sex	Clinical history	Imaging guidance	Technical approach	Outcome/follow-up	References
37/M	Idiopathic cirrhotic PVT	CT and fluoroscopy	Transcolonic	Thrombosis (+) Recurrent variceal bleeding (-) HE: NR (not reported) Follow-up period: 14 months	Nyman et al[4]
57/M	Metastatic CRC with multiple metastasectomies Extrahepatic PVT Failed TIPS attempt	CT and fluoroscopy	Transgastric	Thrombosis (+) Recurrent variceal bleeding (+) HE: NRFollow-up period: 3 months	Moriarty et al[7]
16/F	Chronic PVT Recurrent GI bleeding Failed previous splenorenal shunt	Fluoroscopy and IVUS	Endovascular side-firing IVUS	Thrombosis (-) Recurrent variceal bleeding (-) HE: NR Follow-up period: 11 months	Hong et al[8]
60/F	HCC with PV obliteration due to tumor thrombi Failed variceal banding	Fluoroscopy and IVUS	Endovascular side-firing IVUS	Thrombosis (-) Recurrent variceal bleeding (-) HE: NR Follow-up period: 10 months	Hong et al[8]
55/M	Pancreatic teratoma S/P Whipple OP Segmental occlusion of SMV Failed endoscopic clipping	Fluoroscopy and IVUS	Endovascular side-firing IVUS	Thrombosis (-) Recurrent variceal bleeding (-) HE: NR Follow-up period: 3 months	Hong et al[8]
13/M	EHPVO Failed surgical attempt Retroperitoneal rhabdomyosarcoma S/P surgical resection and RT	CT	Transabdominal	Thrombosis (-) Recurrent variceal bleeding (-) HE: NR Follow-up period: 18 months	Burke et al[9]
58/F	HCV cirrhosis with recurrent ascites Portal and SMV thrombosis Failed previous splenorenal shunt and TIPS	Fluoroscopy	Transabdominal	Thrombosis (-) Recurrent variceal bleeding (-) HE: Yes (mild HE at 6 months, managed medically) Follow-up period: 3 months	Bercu et al[6]
N/A	Cirrhosis with PVT	CT and fluoroscopy	Transabdominal	N/A	Davis et al[2]
16/F	Chronic PVT Choledochal cyst S/P surgical resection	Fluoroscopy	Transsplenic	Thrombosis (-) Recurrent variceal bleeding (+) HE: No episodes of HE Follow-up period: 24 months	Yoon et al[5]
72/F	Acute necrotizing pancreatitis with secondary cholangitis (biliary strictures) S/P Choledochojejunostomy Portal and splenic vein thrombosis	Fluoroscopy and ultrasound (transabdominal)	N/A	Thrombosis (-) Recurrent variceal bleeding (-)HE: Yes (mild HE at 3 months, managed medically) Follow-up period: 3 months	Phatharacharukul et al[10]
35/M	EHPVO and HCV cirrhosis with recurrent variceal bleeding Chronic portal and SMV thrombosis	Fluoroscopy and ultrasound (transabdominal)	Transsplenic	Thrombosis (-) Recurrent variceal bleeding (-) HE: No episodes of HE Follow-up period: 36 months	Present case

Abbreviations: CRC, colorectal cancer; CT, computed tomography; EHPVO, extrahepatic portal vein obstruction; GI, gastrointestinal; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; IVUS, intravascular ultrasound; N/A, not available; OP, operation; PV, portal vein; PVT, portal vein thrombosis; RT, radiotherapy; S/P, status post; SMV, superior mesenteric vein; TIPS, transjugular intrahepatic portosystemic shunt.

Note Table has been adapted from Yoon et al.[5]

This is perhaps the first reported case with EHPVO and HCV infection with CLD to have undergone a percutaneous mesocaval shunt procedure. Furthermore, the 3-year follow-up of this case is the longest period in published literature.

The main potential complication is life-threatening intra-abdominal hemorrhage. Other complications include hepatic encephalopathy, stent thrombosis, and migration (which can be potentially reduced by creating a partially intrahepatic shunt)[5] ([Fig. 2C]). Theoretical risks include pancreatitis, sepsis, or abscesses.[6]

 

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Conclusion

To conclude, percutaneous mesocaval shunt creation is a promising treatment strategy for the select cohort of cases (with contraindications for TIPS) and may be offered to such patients after careful consideration of factors such as anatomical feasibility.

Our aim is to emphasize the significance and utility of this procedure, with the goal of encouraging wider adoption. Nonetheless, the limited clinical experience and technically challenging and precarious nature of the procedure are roadblocks to mainstream implementation as a standard of care.

 

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Conflict of Interest

None declared.

• References

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• 2 Davis J, Chun AK, Borum ML. Could there be light at the end of the tunnel? Mesocaval shunting for refractory esophageal varices in patients with contraindications to transjugular intrahepatic portosystemic shunt. World J Hepatol 2016; 8 (19) 790-795
• 3 Sarin SK, Kumar CKN. Ectopic varices. Clin Liver Dis (Hoboken) 2012; 1 (05) 167-172
• 4 Nyman UR, Semba CP, Chang H, Hoffman C, Dake MD. Percutaneous creation of a mesocaval shunt. J Vasc Interv Radiol 1996; 7 (05) 769-773
• 5 Yoon JK, Kim MD, Lee DY, Han SJ. Mesocaval shunt creation for jejunal variceal bleeding with chronic portal vein thrombosis. Yonsei Med J 2018; 59 (01) 162-166
• 6 Bercu ZL, Sheth SB, Noor A. et al. Percutaneous mesocaval shunt creation in a patient with chronic portal and superior mesenteric vein thrombosis. Cardiovasc Intervent Radiol 2015; 38 (05) 1316-1319
• 7 Moriarty JM, Kokabi N, Kee ST. Transvenous creation of a mesocaval shunt: report of use in the management of extrahepatic portal vein occlusion. J Vasc Interv Radiol 2012; 23 (04) 565-567
• 8 Hong R, Dhanani RS, Louie JD, Sze DY. Intravascular ultrasound-guided mesocaval shunt creation in patients with portal or mesenteric venous occlusion. J Vasc Interv Radiol 2012; 23 (01) 136-141
• 9 Burke C, Taylor AG, Ring EJ, Kerlan Jr. RK. Creation of a percutaneous mesocaval shunt to control variceal bleeding in a child. Pediatr Radiol 2013; 43 (09) 1218-1220
• 10 Phatharacharukul P, Pyko M, Fayad N. Treatment of noncirrhotic portal hypertension secondary to portal vein thrombosis with endovascular mesocaval shunt creation. Cureus 2020; 12 (05) e8086

Publication History

Article published online:
09 July 2025