Percutaneous porto-mesenteric venous endoconduit creation to restore portal venous flow

A 64-year-old male who underwent orthotopic liver transplant for alcoholic cirrhosis complicated by portal vein (PV) thrombosis and allograft rejection requiring re-transplantation with portocaval hemitransposition. The donor PV was anastomosed to the recipient IVC with constriction of the suprahepatic IVC to divert venous flow into the liver. Seven years later, the recipient developed refractory life-limiting hepatic encephalopathy despite adequate liver function. Review of the cross-sectional imaging showed the PV in proximity from the native splenorenal shunt (SRS) with intervening liver parenchyma (Fig. 41.1). Diagnostic arteriography and venography with intravascular ultrasound evaluation of the PV and SRS (Figs. 41.2 and 41.3) was performed to assess for feasibility of creating an endovenous conduit in between these structures. Delayed arteriograms revealed small intrahepatic portal venous branches with hepatofugal flow towards the IVC. The splenomesenteric (SM) venous outflow was directed into systemic circulation via the SRS. A staged procedure consisting of an initial creation of endovenous conduit between the PV and the SRS, followed by embolization of the SRS was agreed upon during a multidisciplinary conference.