BRIEF REPORT

Intravascular Ultrasound-Guided Mesocaval Shunt

Creation in Patients with Portal or Mesenteric

Venous Occlusion

Richard Hong, MD, Riaz S. Dhanani, MD, John D. Louie, MD, andDaniel Y. Sze, MD, PhD

ABSTRACT

Extrahepatic mesocaval shunts were successfully created in three patients with refractory variceal hemorrhage, complete portal veinor superior mesenteric vein occlusion, and contraindications to shunt surgery. The use of intravascular ultrasound guidance andcovered stents allowed safe and effective transvenous shunt creation without the necessity of percutaneous transabdominal mesentericvenous puncture.

ABBREVIATIONS

DIPS � direct intrahepatic portosystemic shunt, IVC � inferior vena cava, IVUS � intravascular ultrasound, MELD � Modelfor End-stage Liver Disease, MIP � maximum-intensity projection, PV � portal vein, SMV � superior mesenteric vein,

TIPS � transjugular intrahepatic portosystemic shunt

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Developments in the management of portal hypertension andvariceal bleeding have achieved a significant reduction inmortality in the past few decades (1). Pharmacologic andendoscopic therapies are considered first-line treatments forthe prevention or treatment of variceal bleeding (2). Optionswhen first-line therapy fails include transjugular intrahepaticportosystemic shunt (TIPS) creation, liver transplantation, andsurgical shunts (3,4). Use of surgical portosystemic shuntsdecreased drastically after the advent of endoscopic therapies,TIPS creation, and liver transplantation (5).

In the event of occlusion of the portal vein (PV) and itstributaries, TIPS creation becomes technically difficult orunfeasible, depending on the chronicity and extent of ob-struction (6–8). In such cases, surgical shunts are still theleading option for decompression of variceal bleeding.However, shunt surgery carries a high mortality rate ofapproximately 20%–50% in the emergent setting (9). Min-imally invasive creation of a mesocaval shunt was previ-

From the Division of Interventional Radiology, Stanford University MedicalCenter, 300 Pasteur Drive, H-3646, Stanford, CA 94305-5642. Received July25, 2011; final revision received and accepted September 30, 2011. Addresscorrespondence to D.Y.S.; E-mail: dansze@stanford.edu

None of the authors have identified a conflict of interest.

© SIR, 2012

J Vasc Interv Radiol 2012; 23:136–141

lDOI: 10.1016/j.jvir.2011.09.029

usly described in a patient in whom a surgical attempt athunt creation failed as a result of extensive intraabdominaldhesions (10), but this technique required percutaneousransabdominal puncture that traversed viscera. Herein, weescribe three cases in which extrahepatic mesocavalhunts were successfully created with the use of intravas-ular ultrasound (IVUS) guidance for the control of varicealleeding without the need for percutaneous transabdominalesenteric vein access.

The institutional review board granted exemption frombtaining patient consent for this retrospective report. Pa-ient data were handled in accordance with the Healthnsurance Portability and Accountability Act.

ASE REPORTS

ase 116-year-old female subject with chronic PV thrombo-

is was admitted with hematemesis, hematochezia, andyncope, with a hematocrit level of 27%. PV thrombosisad originally occurred after a cord blood transplantationerformed for aplastic anemia at age 1 year. The patientnderwent surgical creation of a proximal splenorenalhunt and splenectomy at age 15 years to treat chronicariceal bleeding refractory to medical and endoscopicherapies. Serial postoperative endoscopies and prophy-

actic sclerotherapy of esophageal varices were per-

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Volume 23 � Number 1 � January � 2012 137

formed every 2–3 months, successfully preventing hem-orrhage until this episode.

Emergent endoscopy demonstrated grade 1 nonbleedingesophageal varices, portal gastropathy, and a duodenal ulcerwith oozing. The splenorenal shunt could not be identified onabdominal US, suggesting shunt occlusion, and because of herprevious surgeries, the risk of surgical shunt revision or newshunt creation was deemed to be unacceptably high. Whileundergoing a magnetic resonance (MR) scan, the patient hadan episode of massive hematemesis requiring resuscitation,and the subsequent scan confirmed occlusion of the splenore-nal shunt, periduodenal cavernous transformation, and activeextravasation into the duodenum (Fig 1a).

Renal venography and IVUS failed to identify thesplenorenal shunt. Arterial portography confirmed shuntocclusion, obliteration of the PV, and cavernous transfor-mation surrounding the duodenum. Gastroduodenal arteriog-raphy did not reveal active extravasation, but because of herhemodynamic instability and duodenal ulcer, the arterywas empirically embolized with gelatin sponge slurry(Surgifoam; Ethicon, Somerville, New Jersey).

Endovascular creation of a mesocaval shunt was per-formed based on a modification of the technique used fordirect intrahepatic portosystemic shunt (DIPS) creation(11). Briefly, a 12-F � 80-cm sheath (Check-Flo; Cook,Bloomington, Indiana) with a 6-cm slit cut into its side 10cm from the tip was inserted into the right femoral vein. A10-F � 30-cm sheath (Flexor; Cook) was then inserted intothe right jugular vein and coupled with the femoral sheathafter passing a through-and-through guide wire with the aidof a snare. An 8-F longitudinal side-firing intravascular USprobe (AcuNav; Acuson/Siemens, Mountain View, Califor-nia) was inserted into the femoral sheath, and a transjugular

Figure 1. Images from a 16-year-old female subject with chroncreation. The patient presented with massive duodenal variceal hecontrast-enhanced MR scan shows occlusion of the proximal spcavernous transformation (arrowheads). High signal intensity wit21-gauge needle was passed through the wall of the suprarenaguidance. Venography depicts prominent circumferential periduoddilated in the tract, successfully decompressing the varices. (d) Obshows continued patency of the shunt and decompression of the

access set (AngioDynamics, Latham, New York) was in- b

erted into the jugular sheath. The metal cannula of theransjugular access set was advanced through the precut slitf the femoral sheath.

Under real-time IVUS guidance, the cannula was aimednd the 21-gauge needle was passed through the wall of theuprarenal inferior vena cava (IVC), inferior to the uncinaterocess of the pancreas, into the superior mesenteric veinSMV). Venography and hemodynamic measurements re-ealed a mesenteric-systemic gradient of 25 mm Hg (Fig 1b).he 10-F jugular sheath was advanced through the slit of the

emoral sheath, and an 8 mm � 5 cm VIATORR stent-graftW. L. Gore and Associates, Flagstaff, Arizona) was deployedo line the entire extravascular tract. The stent-graft extended 1m into the IVC, and the gold band delineating the edge of theraft material was just inside the SMV. Final venographyonfirmed complete diversion of flow away from the cavern-us transformation and a decrease in the gradient to 5 mm HgFig 1c).

The bleeding stopped immediately and has not recurred in1 months of follow-up, with a baseline hematocrit level of2%. The Model for End-stage Liver Disease (MELD) scoreas 4 preoperatively, fell to �2 immediately following shunt

reation, and stabilized at 4 during follow-up. Computed to-ography (CT) performed at 1 month after shunt creation

emonstrated patency of the shunt and resolution of the duo-enal varices (Fig 1d).

ase 260-year-old woman with chronic hepatitis B and C pre-

ented to an outside hospital with dizziness and melena.ndoscopy revealed large ulcerated but nonbleeding gastricarices. An attempt at variceal banding resulted in brisk

thrombosis after splenectomy and proximal splenorenal shuntge. (a) Oblique coronal maximum-intensity projection (MIP) fromnal shunt and drainage of the SMV (arrow) into periduodenalduodenum (asterisk) represents extravasated gadolinium. (b) A

black arrow) into the SMV (white arrow) under real-time IVUSarices (arrowheads). (c) A VIATORR stent-graft was deployed andoronal MIP reconstruction of a follow-up CT scan 2 months later

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transferred to our institution. A triphasic CT scan revealedinfiltrative hepatocellular carcinoma of the right hepaticlobe with extensive tumor thrombus obliterating the right, left,and main PVs (Fig 2a). The SMV and splenic vein were

Figure 2. Images from a 60-year-old woman with chronic hepa(a) Oblique coronal MIP image from contrast-enhanced CT scanwith poorly developed cavernous transformation (arrowheads)tumor thrombus extending to the confluence of the SMV, inferiomain drainage via a large spontaneous splenogastrorenal shuntportion at the venous confluence, allowing inflow from all threeshown in this composite image. An AMPLATZER II plug was depin the inflow short gastric vein (white arrow), and static sclerosubtraction artifact (arrowhead). (d) Curved planar reformat of CTresolution of gastric varices.

oth patent and draining through varices. t

Under general anesthesia, the same technique was useds in case 1. IVUS confirmed large PV tumor thrombusxtending into the portosplenic confluence. A 21-gaugeccess needle was advanced through the wall of the IVC at

and C. The patient presented with gastric variceal hemorrhage.nstrates occlusion of the main PV by tumor thrombus (arrow)cess to the SMV was achieved, and direct venography shows

enteric vein, and splenic vein (arrow). Composite image showssk). (c) A VIATORR stent-graft was deployed with the uncovereds. Inflow from the inferior mesenteric vein and splenic veins arein the outflow (black arrow), embolization coils were deployednd contrast medium were trapped in between, as shown by

obtained 7 months later demonstrates patency of the shunt and

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Volume 23 � Number 1 � January � 2012 139

tissue and the uncinate process of the pancreas, into theSMV at its confluence with the splenic vein. Venographyconfirmed occlusion of the PV with extension of thrombusto the portosplenic confluence (Fig 2b). Large gastric var-ices were seen arising from the splenic vein, with outflow toa large splenorenal shunt. Passage of a 10-F jugular sheathrequired predilation of the tract to 5 mm. A 10-mm � 7-cmVIATORR stent-graft (W. L. Gore and Associates) wasdeployed such that the uncovered portion extended into thesplenic vein but allowed flow through the interstices fromthe SMV.

Venography revealed persistent filling of the large gas-tric varices, so sclerosis was performed with 6 mL of 5%ethanolamine oleate (Ethamolin; QOL Medical, Kirkland,Washington) thickened with gelatin sponge into a slurry,injected via a 14-mm occlusion balloon (Python; AppliedMedical, Rancho Santa Margarita, California). The sclero-sant was trapped by placing an AMPLATZER II plug(AGA Medical, Minneapolis, Minnesota) in the splenorenalshunt outflow via the femoral sheath and embolization coils(Nester; Cook) in the gastric vein inflow. Completionsplenic and mesenteric venography demonstrated patencyof the mesocaval shunt and successful eradication of thegastric varices (Fig 2c). The final pressure gradient mea-sured 2 mm Hg, decreased from the initial 16 mm Hg.Serum amylase values fluctuated within the normal rangeduring the 5 days after shunt creation.

A CT scan obtained 2 months after the procedure re-vealed patency of the mesocaval shunt and resolution of thegastric varices (Fig 2d). The patient underwent radioemboli-zation of her liver with glass microspheres (TheraSphere;Nordion, Ottawa, Ontario, Canada) with staged lobar treat-ments, and two subsequent chemoembolization procedures.Follow-up imaging has demonstrated patency of the mesoca-val shunt and good response to treatments with no evidence ofresidual enhancing tumor tissue. The patient’s MELD scorewas 8 preoperatively, peaked at 11 postprocedurally, and hasranged between 5 and 8 since. At 10-month follow-up, thepatient has been free of gastrointestinal bleeding and hasmaintained a normal performance status (Eastern CooperativeOncology Group grade 0).

Case 3A 55-year-old man with a history of pancreatic teratomapresented to an outside hospital with hematemesis andmelena 5 years after a complicated Whipple procedure. Thepatient reported six episodes of upper gastrointestinal hem-orrhage of undiagnosed etiology since the surgery. Endos-copy revealed an anastomotic ulcer, which was treated byplacement of three clips. Three days after discharge, thepatient experienced recurrent massive gastrointestinal hem-orrhage and was transferred to our institution.

A CT scan revealed extensive gastric and jejunal varices(Fig 3a), but beam-hardening artifact from a multitude ofurgical clips obscured the underlying vascular anatomy. Ar-erial portography demonstrated patency of the splenic vein

nd extra- and intrahepatic PVs. Mesenteric angiography with t

elayed venous imaging confirmed a 3-cm segmental occlu-ion of the SMV near its confluence with the splenic vein.enous outflow of the mesenteric circulation coursed through

n extensive network of large gastric varices that drained viahe short gastric and coronary veins into the splenic vein. Aercutaneous transhepatic attempt to recanalize the SMV wasnsuccessful. Thus, IVUS-guided mesocaval shunt creationas performed.

The same technique was used as for cases 1 and 2 excepthat the IVC was punctured in an infrarenal location (Fig 3b).he tract crossed retroperitoneal adipose tissue into a patentranch point of the SMV peripheral to the occlusion (Fig 3c).he tract was predilated to 5 mm, and a 10-mm � 4-cmIATORR stent-graft (W. L. Gore and Associates) was de-loyed and dilated to 10 mm. Venography performed afterhunt creation demonstrated persistent flow through large gas-ric varices. Variceal sclerosis was performed as described inase 2 with administration of 6 mL of sclerosant trapped by a2-mm AMPLATZER II plug. Completion venography con-rmed patency of the mesocaval shunt and obliteration of theastric varices (Fig 3d).

Follow-up CT scan at 1 month showed a patent shunt andisappearance of the gastric varices. Hematocrit level in-reased from 26 to 36% at 2 months. MELD score was 8reoperatively, peaked at 16, and was 8 at 3 months of follow-p, during which time the patient had no recurrent bleeding.

ISCUSSION

onsurgical treatment options for chronic portomesentericenous obstruction mirror techniques applied in systemiceins, including recanalization, thrombolysis, venoplasty,nd placement of stents or stent-grafts. However, successfulecanalization requires patent vessels on both sides of thebstruction and may require creation of a TIPS for im-roved outflow (12,13). The patients described here hadbliterated intrahepatic portal vessels or ligated extrahe-atic vessels that were not amenable to recanalization, andhus required shunting procedures.

The development of improved cross-sectional imagingncluding IVUS for procedure guidance is broadening thecope of feasible percutaneous shunt procedures. During aIPS procedure (11), IVUS is used to guide the needleuncture from the IVC through the caudate lobe into theain PV, avoiding the blind puncture of the TIPS proce-

ure. In the present report, we adapted the imaging tech-ology used for DIPS creation to an extrahepatic applica-ion and created mesocaval shunts in patients who were notandidates for TIPS or DIPS creation. This longitudinalide-firing intravascular US catheter is capable of coloroppler imaging, improving the delineation of interposed

nd targeted vascular structures.The first case of a percutaneously created mesocaval

hunt was described in 1996 by Nyman et al (10). Theirethod involved passage of a 20-gauge Chiba needle

hrough the anterior abdominal wall, transverse colon,

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140 � Intravascular US-Guided Mesocaval Shunts in PV or SMV Occlusion Hong et al � JVIR

and SMV, and into the IVC under CT guidance, andpassage of a guide wire. The patient was then transferredfrom the CT suite to an angiography suite, where theguide wire was snared and a homemade stent-graft wasdeployed. The shunt creation was technically successful,but occluded 1 day after creation and again at 12-monthfollow-up.

There are several advantages of the IVUS techniquedescribed here versus the percutaneous transabdominalmethod. First, our technique is entirely intravascular anddoes not require puncture of the anterior abdominal walland intervening bowel, which should reduce the risk ofperitonitis and shunt infection. Second, the IVUS-guidedtechnique is performed entirely in the angiography suiteand does not require the initial CT-guided SMV-to-IVC

Figure 3. Images from a 55-year-old man with history of pancith recurrent hematemesis. (a) Coronal MIP image demonst

onfluences of jejunal branches (white arrow) and ileal brancheortosplenic confluence, which was patent and surrounded btomach (black arrowhead). (b) IVUS image obtained from withi

(arrowhead), aimed at the confluence of two mesenteric veins (dorsal (D), superior (S), and inferior (I) directions are labeled fcreation confirms access of the SMV at the jejunal venous conflusupplying large gastric varices (asterisk), with drainage via thestent-graft was placed from the SMV to the IVC, and sclerosisAMPLATZER II plug (black arrow).

puncture and subsequent transfer to the angiography suite. m

hird, only one wall of the SMV needs to be punctured,educing the risk of intraperitoneal hemorrhage.

Disadvantages and risks of IVUS-guided mesocavalhunt creation are yet to be defined. Because neither the SMVor infrahepatic IVC are surrounded by solid organ tissue,ajor hemorrhage is a potential risk, particularly if the tract

equires predilation, as was required in two of our cases (11).otable bleeding was not encountered in either case, perhapsecause tamponade of the tracts was achieved by advancementf the sheath. The safe window between the SMV and IVCay be small as a result of interposed structures, including the

uodenum, renal artery and vein, and pancreas. In one of ouratients, the uncinate process of the pancreas was traversed,ntroducing an unknown risk of pancreatitis. In addition, the lackf rigid hepatic parenchyma along the tract to anchor the stent

eratoma treated by Whipple procedure. The patient presentedcclusion of the main trunk of the SMV with separate patent

ite arrowhead). These drained via a large collateral vein to theical clips (asterisk). Prominent gastric varices enveloped theC shows the TIPS metal cannula (arrow) engaging the IVC wall

k) and avoiding the superior mesenteric artery (A). Ventral (V),ntation. (c) Composite image from venography during shunthite arrowhead). A large collateral vein (white arrow) is shownvein (black arrowheads) and PV (black arrow). (d) A VIATORRvarices was obtained while the inflow was occluded with an

reatic trates os (why surgn the IVasterisor orieence (wsplenicof the

ay increase the risk of acute or delayed shunt migration.

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The long-term patency of endovascular mesocavalshunts is unknown. At up to 11 months of follow-up, all ourpatients have not had recurrent hemorrhage, and all havepatent shunts. Midterm patency of DIPSs was reported to beencouraging (14). However, patency of mesocaval shuntsmay be influenced by the proximity to the pancreas, smallercaliber of the tributary mesenteric veins, and intestinalmotility.

In summary, intravascular US guidance facilitates me-socaval shunt creation for the treatment of portal-hyperten-sive hemorrhage in patients who are not candidates forTIPS or DIPS creation. IVUS-guided mesocaval shunt cre-ation may serve as a salvage therapeutic option for portal-hypertensive hemorrhage in patients with absence or oblit-eration of the PV or mesenteric vein.

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