P0634 - Right and Left-Sided Portal Hypertension: Treatment Options for Non-Tumoral, Non-Pancreatic Segmental Portal Thrombosis With Acute Variceal Bleeding in a Cirrhotic Patient With Hepatic Hydrothorax
New York Medical College-Saint Michael's Medical Center Newark, New Jersey
Yashwitha Sai Pulakurthi, MBBS1, Theresa Aquino, MD2, Muhammad Hussain, MD3, Murad Qirem, MD2, Wajeeha Aiman, MBBS4, Theodore DaCosta Jr., MD3, Yatinder Bains, MD3 1New York Medical College-Saint Michael's Medical Center, Newark, NJ; 2Saint Michael's Medical Center, Newark, NJ; 3Saint Michael's Medical Center, New York Medical College, Newark, NJ; 4Saint Michael's Medical Center, Newark, NJ
Introduction: Partial splenic embolization is a procedure to decrease splenic steal syndrome in patients with left-sided portal hypertension due to splenic vein thrombosis (SVT). We present its use in combination with other techniques for the treatment of variceal bleeding with segmental thrombosis involving the superior mesenteric (SMV), splenic (SV) and portal veins (PV).
Case Description/Methods: A 67 year old female with history significant for hepatitis C, splenomegaly, anemia presented with shortness of breath for 1 week. CTA chest showed large right pleural effusion, hepatic cirrhosis, splenomegaly, and massive gastroesophageal varices (GEV) draining from the splenic vein to the enlarged azygos. Hepatic hydrothorax, thrombocytopenia and coagulopathy were present. Triple phase CT A/P showed segmental thrombosis of the confluence of PV, SMV and SV. Patient was not a candidate for chemical anticoagulation given the high risk of bleeding. Massive GEV were found to be draining from the SV into a hypertrophied azygos vein (AV) with no splenorenal shunt. Interventional radiology (IR) performed TIPS (mean gradient from 22 to 11mmHg, 8mm), PV and SMV mechanical thrombectomy with GEV ETOH ablation. One day later, the patient had an episode of hematemesis. Gastroenterology performed an EGD which showed grade 3 EV and type 2 submucosal GV, the day after TIPS, with continued blood loss. Subsequently, TIPS stent was expanded from 8mm to 10mm with final portal gradient of 5mmHg and subtotal gel foam/gentamicin embolization of spleen was performed. The patient required no further interventional or blood transfusions and was referred to the liver transplant center.
Discussion: TIPS and retrograde transvenous obliteration (RTO) is the mainstay treatment for GEV refractory to medical and endoscopic treatments. RTO was not performed in this case due to Portal vein thrombosis, high risk of pulmonary embolism and technical limitations (short neck). Subtotal splenic embolization was performed, which has its own risk factors fact, including abscess formation, and theoretical immunological implications, but provides effective short to medium-range reduction of splenic steal in sinistral portal hypertension.
Figure: Fig a: White Star – Hydrothorax; Blue Triangle- massive gastroesophageal varices.
Fig b a: Yellow Arrow-Portal Thrombus.
Fig c: Orange Arrow-Portal Thrombus extending into the splenic vein and SMV.
Fig e: Gastroesophageal varices (GOV 2)
Fig f: Gastroesophageal varices at GE junction
Fig g: Gastroesophageal varices extending into cardia of the stomach
Fig h: Orange Star-chronic thrombus producing left sided portal hypertension, isolating the splenic vein and producing massive gastroesophageal varices draining into masses -azygous vein shunt Blue Triangle- GE varices.
Fig i: Pre-Subtotal splenic artery embolization showing persistent filling of gastroesophageal varices, after TIPS revision and splenic-portal-SMV thrombectomy.
Fig j: Post-Subtotal splenic artery embolization showing no filling of gastroesophageal varices.
Disclosures:
Yashwitha Sai Pulakurthi indicated no relevant financial relationships.
Theresa Aquino indicated no relevant financial relationships.
Muhammad Hussain indicated no relevant financial relationships.
Murad Qirem indicated no relevant financial relationships.
Wajeeha Aiman indicated no relevant financial relationships.
Theodore DaCosta Jr. indicated no relevant financial relationships.
Yatinder Bains indicated no relevant financial relationships.
Yashwitha Sai Pulakurthi, MBBS1, Theresa Aquino, MD2, Muhammad Hussain, MD3, Murad Qirem, MD2, Wajeeha Aiman, MBBS4, Theodore DaCosta Jr., MD3, Yatinder Bains, MD3. P0634 - Right and Left-Sided Portal Hypertension: Treatment Options for Non-Tumoral, Non-Pancreatic Segmental Portal Thrombosis With Acute Variceal Bleeding in a Cirrhotic Patient With Hepatic Hydrothorax, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.
