Trans-splenic portal venous access and interventions: Pictorial review and institutional experience

Congress:

ECR 2019

Poster Number:

C-3726

Type:

Educational Exhibit

Keywords:

Education and training, Venous access, Catheters, Ultrasound, Fluoroscopy, Vascular, Spleen, Interventional vascular

Authors:

G. Kumar¹, M. kolber², H. shah², M. Still³, D. Lamus², S. Kalva⁴, M. reddick²; ¹Plano/US, ²Dallas/US, ³Dallas, TX/US, ⁴BOSTON, MA/US

DOI:

10.26044/ecr2019/C-3726

DOI-Link:

https://dx.doi.org/10.26044/ecr2019/C-3726

Fig. 1: Trans-splenic embolization of a large gastric varix

Fig. 2: Trans-splenic recanalization of portal vein and TIPS shunt placement.

Fig. 3: Trans-splenic embolization of IMV-systemic collaterals surrounding colostomy...

Learning objectives

The primary objective is to educate thereader about the option and technique of trans-splenic portal venous access (TSPV) in situations when the conventional transvenous or percutaneous route is unsafe or not feasible.

Background

Conventional methods of portal venous access including transjugular-intrahepatic and percutaneous transhepatic approaches have been well studied and verified for portal access in the creation of TIPS and other mesenteric venous interventions. However,certain clinical scenarios such as portal vein thrombosis (PVT) and interposing tumor pose significant anatomic challenges resulting in high technical failure rate. Trans-splenic portal venous access has been used as an alternative/ rescue method for mesenteric venous access, portal venous (PV) catheterization as well as PV recanalization. Historical risks of trans-splenic access have largely...

Findings and procedure details

In this educational exhibit, we will present several cases oftrans splenic venous access used in the creation of TIPS, variceal embolization, and portal venous recanalization with stenting, etc. Splenic tracts closures were performed with plugs, coils or gel foam. Case 1: (Figure 1) A 54 years oldpt with h/o Alcoholic cirrhosis presented with acute onset hematemesis. EGD was unsuccessful. Emergent abdominal CT scan demonstrated thrombosed main portal vein (MPV) with large gastric varices. Transjugular or percutaneous transhepaticportal venous access was deemed difficult. Ultrasound-guidedaccessto the splenic...

Conclusion

A thorough review of the imaging studiescoupled with knowledge and skills of trans-splenic venous approach can help circumvent limitations of a thrombosed portal vein, or hostile anatomy, and simplify the procedure, cannulation, and embolization of offending vessels.

Personal information

References

1.Selectivetrans-splenicdecompression of gastroesophageal varices by distal splenorenal shunt.WD Warren, R Zeppa, JJ Fomon- Annals of Surgery, 1967 - ncbi.nlm.nih.gov2. 2.Portal vein recanalization-transjugular intrahepatic portosystemic shunt using the trans-splenic approach to achieve transplant candidacy in patients with chronic portal vein thrombosis: proof of concept.B. Thornburg, K.R. Desai, R.M. Hickey, K.T. Sato, R.J. Lewandowski, R. Salem. Journal of Vascular and Interventional Radiology,Vol. 26,Issue 2,S100 3.Percutaneous trans-splenic embolization of roux limb varices in children with chronic portal vein occlusion (PVO) post orthotopic liver transplant (OLT).S. Pimpalwar, A. Annam,...