763 - Congenital & Iatrogenic Pediatric Liver Shunts: Evaluation and Management for the Interventional Radiologist

Learning Objectives:

• Review types of congenital and surgical pediatric liver shunts, along with clinical findings, shunt anatomy imaging, and pre-/post-operative planning including angiographic mapping for Rex shunt creation.


• Explore work-up, techniques and complications related to IR endovascular shunt closure

Background: Congenital portosystemic shunts (CPSS): Represent vascular malformations which allow mesenteric blood to bypass the portal system and enter systemic circulation. Types of intrahepatic and extrahepatic CPSSs are delineated here, for which interventional radiologists (IRs) help lead workup/management.

Iatrogenic/Surgical liver shunts (ILS): Portal venous shunts can also be surgically created to manage portal hypertension when restoring physiologic portal flow is not feasible. Various shunt types based on anatomy and flow physiology are described (examples in Table 1).

Clinical Findings/Procedure Details: CPSS: Review initial imaging for CPSS morphology (doppler US, CT, MRI). Preoperative planning in the IR suite is described, particularly hepatic venography for target vessel caliber/length measurements and balloon occlusion testing. Venographic findings and pressure parameters important for endovascular vs surgical closure decision-making are elucidated, as well as for singular vs staged procedures. Post-closure complications are outlined, including acute pulmonary hypertension, portal hypertension, or incomplete closure.

ILS: IRs lead diagnostic imaging and preoperative planning for surgical liver shunts, ie angiography to map portal anatomy and left portal Rex recess patency. We provide imaging examples of postsurgical shunt complications, including stenosis/thrombosis, and therapeutic angioplasty or stenting. Balloon occlusion testing with portal pressure measurements for shunt closure planning is also discussed. Unique pediatric considerations for TIPS are examined for when surgical shunt is not feasible.

Conclusion and/or Teaching Points: CPSS: IRs who direct shunt diagnostics/management should understand indications for endovascular vs surgical planning, single vs staged closure, as well as associated postprocedural complications.

ILS: Despite predominantly surgical creation, IRs are pivotal in both evaluating and treating ILS dysfunction.