Case report: Management of liver cancer complicated by gastric varices rupture and bleeding: transjugular intrahepatic portosystemic shunt utilizing the mesenteric venous pathway

Abstract

To avoid recurrent variceal bleeding, transjugular intrahepatic portosystemic shunt (TIPS) in conjunction with variceal embolization is considered to be an effective strategy. However, due to changes in conditions and variations in the patient's state, individuals undergoing TIPS may face challenges and limitations during procedures. The transjugular technique and combined transsplenic portal venous recanalization (PVR) with TIPS were not effective in this case due to a blocked portal vein and a previous splenectomy. With an abdominal incision, we successfully punctured the mesenteric venous system and navigated the occluded segment of the portal vein through the mesenteric approach. TIPS was then performed under balloon guidance. This study aims to explore the management of risks and complications during surgical operations and propose multiple preoperative surgical techniques to improve the success rate of the procedure.

Keywords: TIPS; hepatocellular carcinoma; interventional; portal hypertension; portal vein thrombosis.

Figure 1

Intraoperative imaging data. (A) Successful puncture through the conventional approach. (B) Local rupture of the portal vein after multiple punctures. (C) Guidewire-assisted catheterization through the mesenteric route into the right branch of the portal vein. (D) Balloon-guided puncture technique. (E) Balloon dilation of the puncture tract and placement of the stent, followed by local balloon dilation within the stent. (F) Post-stent placement angiography reveals mesenteric thrombus. (G) Mesenteric venous stenosis balloon angioplasty. (H) Extended placement area of the mesenteric stent.

Figure 2

Imaging data. (A) Preoperative CT-enhanced arterial phase transverse image. (B) Preoperative CT-enhanced portal venous phase coronal image. (C) Postoperative CT-enhanced arterial phase transverse image. (D) Sagittal effective atomic number map on postoperative CT. (E) Coronal effective atomic number map on postoperative CT.