Application of percutaneous transluminal sharp recanalization in transjugular intrahepatic portosystemic shunt for patients with chronic portal vein occlusion

PURPOSEWe aimed to evaluate the feasibility and safety of a modified technique for portal vein recanalization, percutaneous transluminal sharp recanalization (PTSR), when performing transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of chronic portal vein occlusion (CPVO) and portal hypertension.METHODSNine consecutive patients with CPVO and portal hypertension had undergone TIPS and PTSR procedure after failing in conventional percutaneous catheterization from March 2017 to July 2019. Technical success rates, effectiveness, and complications were evaluated. Follow-up of patients’ clinical outcomes and shunt patency were performed periodically. Primary and secondary shunt patency were analyzed by Kaplan-Meier method.RESULTSThe occluded portal veins were successfully recanalized after failing in conventional percutaneous catheterization, and TIPS procedures were completed in all 9 patients. Two patients suffered from procedure-related complications. A portosystemic pressure gradient <12 mmHg, or a percent reduction of 25% to 50% of baseline, was achieved in all 9 patients after TIPS. During the median follow-up period of 28 months (range, 9–36 months), 1 patient experienced recurrent ascites and the other 8 patients remained asymptomatic. The cumulative rates of primary and secondary shunt patency were 66.67% and 100%, respectively, at 2 years.CONCLUSIONAs a supplementary method, PTSR is a feasible and safe method for portal vein recanalization when performing TIPS for patients with CPVO and portal hypertension.

Portal vein thrombosis is one of the important causes of extrahepatic portal vein obstruction and prehepatic portal hypertension (1). When the acute portal vein thrombosis becomes chronic, the occluded portal vein gradually atrophies, fibrosis develops and chronic portal vein occlusion (CPVO) ensues, eventually leading to the cavernous transformation of portal vein (2), which is a compensatory response to the portal vein occlusion whereby a collateral vein forms to help reduce portal pressure and maintain liver blood perfusion (3, 4). However, they are usually not completely effective in decompressing the portal system, and many patients have persistent portal hypertension and develop serious portal hypertensive complications, such as variceal bleeding and ascites (5).Accumulating evidence has shown that transjugular intrahepatic portosystemic shunt (TIPS) (5–8) or modified TIPS combined with transhepatic or transsplenic approaches (9, 10) is technically feasible and effective to relieve portal hypertension in cirrhotic or non-cirrhotic patients with portal vein thrombosis or CPVO, with a technical success rate of 70% to 100%. Recanalization of the occluded portal vein is the key to the TIPS procedure for patients with portal hypertension and CPVO, while failed portal vein recanalization is the leading cause of TIPS failure (11). Conventional percutaneous catheterization techniques for portal vein recanalization mainly include percutaneous transhepatic and percutaneous transsplenic approaches. Recanalization can be achieved in most cases through either technique alone or in combination; however, they are not feasible in patients with portal vein atrophy and severe fibrosis.Therefore, for the cases of failed portal vein recanalization by conventional percutaneous catheterization, we have developed a procedure of percutaneous transluminal sharp recanalization (PTSR) of the portal vein to complete TIPS. The purpose of this study is to introduce this technique when performing a TIPS procedure for patients with CPVO and portal hypertension, as well as to evaluate its feasibility and safety.