Mesocaval Shunt to the Rescue: A Lifeline When TIPS Hits a Dead End

Learning Objectives: To describe the patient selection considerations, technical steps, and clinical applications of percutaneous mesocaval shunt creation as an alternative to transjugular intrahepatic shunt (TIPS) placement in patients with presinusoidal portal hypertension.

Background: In patients with portal hypertension, TIPS placement is a well established treatment option. However, patients may not be ideal candidates for TIPS when the etiology of their portal hypertension is presinusoidal. In these patients, percutaneous image-guided mesocaval shunt creation with an anastomosis between the superior mesenteric vein (SMV) and inferior vena cava (IVC) can be utilized as an alternative treatment approach. Our educational exhibit aims to highlight this less common therapeutic option when TIPS is not appropriate.

Clinical Findings/Procedure Details: Four case examples are presented to illustrate case-specifical technical approaches and anatomic variations. A hybrid CT/angiography suite is preferred to allow for multimodal image acquisition. The procedure is performed under general anesthesia with the patient in a supine position. Initial transjugular central access is secured. CT-guided transabdominal access is obtained using an 18-gauge Hawkins needle across the SMV into the IVC. Two 0.018” wires are passed through the needle into the IVC and are snared from the neck for flossed access. A catheter is advanced over one wire from the neck into the SMV and upsized to an 0.035” system (working wire) while the other functions to preserve access (safety wire). Balloon venoplasty establishes a tract to facilitate advancement of a 10fr sheath into the SMV (using a balloon swallow technique). A covered self-expanding stent graft is deployed through the sheath to bridge the SMV-IVC interval and is postdilated to create the mesocaval shunt. Shunt patency is confirmed by demonstrating improved flow dynamics on venography, with brisk SMV to IVC flow and reduction of collateral filling.

Conclusion and/or Teaching Points: Mesocaval shunts are a viable, though less commonly utilized, option for patients with portal hypertension. Our exhibit emphasizes elements of patient selection, technical approaches, preprocedural planning and outcomes in order to equip practitioners with practical knowledge for managing complex patients with portal venous flow anomalies when TIPS is inappropriate.