Direct intrahepatic portocaval shunt for refractory hepatic hydrothorax: a case report

Abstract

Case: A 64-year-old man with complaints of dyspnea and orthopnea secondary to a hepatic hydrothorax refractory to diuretic medication underwent the transjugular intrahepatic portosystemic shunt (TIPS) procedure to decrease the portal vein pressure. The TIPS procedure failed due to severe liver stiffness. Direct intrahepatic portocaval shunt (DIPS), a modified TIPS procedure that directly inserts a stent from the inferior vena cava to the portal vein, was successfully carried out.

Outcome: The DIPS procedure significantly decreased the patient's pleural effusion and respiratory symptoms.

Conclusion: No other medical treatment is available to control refractory pleural effusion caused by portal hypertension; however, the TIPS (or DIPS) procedure can be successfully carried out in patients <60 years old with a Model of End-Stage Liver Disease score <15.

Keywords: Ascites; hypertension, portal; liver cirrhosis; pleural effusion; portosystemic shunt, transjugular intrahepatic.

Figure 1

Schemes of a transjugular intrahepatic portosystemic shunt (TIPS) (A) and a direct intrahepatic portosystemic shunt (DIPS) (B). A, TIPS (original procedure) is created by stenting between the right (Rt.) branch of the portal vein (PV) and the Rt. hepatic vein (HV). B, DIPS is a modified TIPS procedure in which direct stent insertion is carried out from the inferior vena cava (IVC) into the PV through the caudate lobe under intravascular ultrasound (IVUS) guidance.

Figure 2

A, Chest radiographs of a 64‐year‐old man showing severe pleural effusion in the right thoracic cavity on arrival at hospital. B, On day 2, a massive pleural effusion (1520 mL) was drained again, and we continued to i.v. administer two types of diuretics (furosemide, 40 mg; spironolactone, 25 mg/day). C, No pleural effusion was observed on chest radiographs after the direct intrahepatic portosystemic shunt (DIPS) procedure was carried out. D, The patient's clinical course is shown graphically. TIPS, transjugular intrahepatic portosystemic shunt.

Figure 3

Fluoroscopy and angiography in a 64‐year‐old man with refractory pleural effusion caused by portal hypertension. Imaging was carried out during the direct intrahepatic portosystemic shunt procedure. Fluoroscopy image during angiogram showing a guide wire (GW) and 4‐Fr catheter penetrating from the inferior vena cava (IVC) to the portal vein (PV) through the caudal lobe of the liver. This was a direct portosystemic shunt to the IVC that corresponded to the segment between the two arrowheads. A, Digital subtraction angiogram showing portosystemic shunt flow circulating from the PV (white arrow) to the IVC (black arrow), which corresponds to a segment between the two arrowheads. B, A high‐magnification view of the fluoroscopic image showing the replacement of a nitinol stent (E‐Luminexx_R, Bard Peripheral Vascular, Tempe, AZ, USA; diameter, 10 mm; length, 60 mm) between the PV and IVC. An intravascular ultrasound (IVUS) probe was inserted from the right femoral vein to the IVC for real‐time needle guidance. The white and black arrows indicate the PV and IVC, respectively. C, Vertical sector image created by the IVUS probe showing detailed, real‐time visualization, which facilitates needle puncture from the IVC to the PV. CBD, common biliary duct; GB, gall bladder; HA, hepatic artery; SV, splenic vein.