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Nischal G Kundaragi Department of Interventional radiology and Interventional Oncology, Aster CMI Hospital, New Airport Road, Bengaluru, Karnataka, 560092, IndiaE-mail: drngk@yahoo.com |
Nischal G Kundaragi
Department of Interventional radiology and Interventional Oncology, Aster CMI Hospital, New Airport Road, Bengaluru, Karnataka, 560092, IndiaFigure 1: Method to measure inferior vena cava to shunt distance.
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Figure 2: 66-year-old male, known Hepatitis B virus cirrhosis, presented with recurrent HE (a) Contrast-enhanced computed tomography coronal maximum intensity projection image in a patient with recurrent hepatic encephalopathy, who had undergone unsuccessful coil occlusion of the shunt. The gastrorenal shunt is poorly seen because of the metal artifact from the coils. Large gastric varices are seen in the gastric fundus. (b) Left renal venogram showing the patent left renal vein and previously placed coils. Balloon-occluded retrograde transvenous obliteration (BRTO) failed due to the inability to catheterize the shunt from a femoral approach. (c) Fluoroscopic image (right anterior oblique projection) taken during deflation of the balloon following coil-assisted BRTO from the jugular approach shows coils and shunt occlusion. |
Figure 2: 66-year-old male, known Hepatitis B virus cirrhosis, presented with recurrent HE (a) Contrast-enhanced computed tomography coronal maximum intensity projection image in a patient with recurrent hepatic encephalopathy, who had undergone unsuccessful coil occlusion of the shunt. The gastrorenal shunt is poorly seen because of the metal artifact from the coils. Large gastric varices are seen in the gastric fundus. (b) Left renal venogram showing the patent left renal vein and previously placed coils. Balloon-occluded retrograde transvenous obliteration (BRTO) failed due to the inability to catheterize the shunt from a femoral approach. (c) Fluoroscopic image (right anterior oblique projection) taken during deflation of the balloon following coil-assisted BRTO from the jugular approach shows coils and shunt occlusion.
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Figure 3: 57-year-old male, known NASH cirrhosis, presented with active gastric variceal bleeding. (a) Contrast-enhanced computed tomography coronal maximum intensity projection image shows a small gastrorenal shunt with ISD of 3.69 cm and mid caval narrowing above and below the hepatic segment of inferior vena cava (IVC). Angle between shunt and renal vein is obtuse. Vertical line drawn along the IVC margin measures 4.71 cm. (b) Fluoroscopic image shows sheath in renal vein and catheter in shunt. (c) Fluoroscopic image during successful balloon-occluded retrograde transvenous obliteration demonstrating staining of shunt. Easy negotiation of balloon occlusion catheter into shunt through transjugular access. |
Figure 3: 57-year-old male, known NASH cirrhosis, presented with active gastric variceal bleeding. (a) Contrast-enhanced computed tomography coronal maximum intensity projection image shows a small gastrorenal shunt with ISD of 3.69 cm and mid caval narrowing above and below the hepatic segment of inferior vena cava (IVC). Angle between shunt and renal vein is obtuse. Vertical line drawn along the IVC margin measures 4.71 cm. (b) Fluoroscopic image shows sheath in renal vein and catheter in shunt. (c) Fluoroscopic image during successful balloon-occluded retrograde transvenous obliteration demonstrating staining of shunt. Easy negotiation of balloon occlusion catheter into shunt through transjugular access.
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Figure 4: 46-year-old female, known idiopathic cirrhosis, presented with active gastric variceal bleeding. (a) Contrast-enhanced computed tomography Coronal maximum intensity projection, ISD ~2.7 cm. (b) Fluoroscopic image showing 5F Cobra catheter and Amplatz wire forming large arc from jugular access. Negotiation of 6F balloon catheter was difficult and strain noted on inferior vena cava and renal vein. (c) Venogram performed after inflating balloon. No collaterals were seen. Easy negotiation of shunt vein was done through the transfemoral approach with long straight sheath support and subsequent successful balloon-occluded retrograde transvenous obliteration. |
Figure 4: 46-year-old female, known idiopathic cirrhosis, presented with active gastric variceal bleeding. (a) Contrast-enhanced computed tomography Coronal maximum intensity projection, ISD ~2.7 cm. (b) Fluoroscopic image showing 5F Cobra catheter and Amplatz wire forming large arc from jugular access. Negotiation of 6F balloon catheter was difficult and strain noted on inferior vena cava and renal vein. (c) Venogram performed after inflating balloon. No collaterals were seen. Easy negotiation of shunt vein was done through the transfemoral approach with long straight sheath support and subsequent successful balloon-occluded retrograde transvenous obliteration.
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Figure 5: 70-year-old male, known hepatitis B virus cirrhosis, presented with recurrent hepatic encephalopathy. (a) Contrast-enhanced computed tomography coronal maximum intensity projection image showing gastrorenal and splenorenal shunts with ISD ~3.13 and 5.10 cm, respectively. Previously, TACE was performed for ruptured segment 6 HCC with complete response to treatment (arrow). (b) Fluoroscopic image showing balloon catheters in both shunts. Transfemoral approach for gastrorenal and jugular approach for splenorenal shunt. Coils were placed in collaterals. (c) Fluroscopic image after completion of BRTO procedure showing contrast staining of shunts. |
Figure 5: 70-year-old male, known hepatitis B virus cirrhosis, presented with recurrent hepatic encephalopathy. (a) Contrast-enhanced computed tomography coronal maximum intensity projection image showing gastrorenal and splenorenal shunts with ISD ~3.13 and 5.10 cm, respectively. Previously, TACE was performed for ruptured segment 6 HCC with complete response to treatment (arrow). (b) Fluoroscopic image showing balloon catheters in both shunts. Transfemoral approach for gastrorenal and jugular approach for splenorenal shunt. Coils were placed in collaterals. (c) Fluroscopic image after completion of BRTO procedure showing contrast staining of shunts.
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Figure 6: 69-year-old male, known idiopathic liver cirrhosis, presented with recurrent hepatic encephalopathy. (a) Contrast-enhanced computed tomography oblique Coronal maximum intensity projection (MIP) image showing gastrorenal (open arrow) and splenorenal (arrow) shunts with ISD ~3.32 and 5.09 cm, respectively. (b) CECT oblique coronal MIP image showing proximal (arrow) and distal (arrow heads) splenorenal shunts with distance between them measuring 2.46 cm. (c) Fluoroscopic image showing two microcatheters in the gastrorenal shunt by femoral approach and distal splenorenal shunt by jugular approach. Shunt venogram performed through distal splenorenal shunt (arrow heads). Coils were placed in collateral. (d) Fluoroscopic image showing contrast staining of distal splenorenal shunt after placing coils and balloon. Proximal splenorenal shunt venogram after accessing through femoral route (arrow). Difficult cannulation by transfemoral route. (e) Inability to pass balloon catheter (due to wire instability) into the proximal splenorenal shunt; therefore, it was embolized with coils (arrow). (f) Fluoroscopic image showing two balloons in gastrorenal (open arrow) and distal splenorenal shunts and sclerosant staining of shunts. |
Figure 6: 69-year-old male, known idiopathic liver cirrhosis, presented with recurrent hepatic encephalopathy. (a) Contrast-enhanced computed tomography oblique Coronal maximum intensity projection (MIP) image showing gastrorenal (open arrow) and splenorenal (arrow) shunts with ISD ~3.32 and 5.09 cm, respectively. (b) CECT oblique coronal MIP image showing proximal (arrow) and distal (arrow heads) splenorenal shunts with distance between them measuring 2.46 cm. (c) Fluoroscopic image showing two microcatheters in the gastrorenal shunt by femoral approach and distal splenorenal shunt by jugular approach. Shunt venogram performed through distal splenorenal shunt (arrow heads). Coils were placed in collateral. (d) Fluoroscopic image showing contrast staining of distal splenorenal shunt after placing coils and balloon. Proximal splenorenal shunt venogram after accessing through femoral route (arrow). Difficult cannulation by transfemoral route. (e) Inability to pass balloon catheter (due to wire instability) into the proximal splenorenal shunt; therefore, it was embolized with coils (arrow). (f) Fluoroscopic image showing two balloons in gastrorenal (open arrow) and distal splenorenal shunts and sclerosant staining of shunts.
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Figure 7: 63-year-old male, known alcoholic cirrhosis, presented with active gastric variceal bleeding. (a) The ISD measures 2.67 cm on the contrast-enhanced computed tomography coronal maximum intensity projection image. (b) Fluoroscopic image taken after inflation of the occlusion balloon with contrast medium, and the injection of contrast medium fills the large shunt. A phrenic collateral vein had been embolized with coils. Note that the sheath tip is placed in the left renal vein. |
Figure 7: 63-year-old male, known alcoholic cirrhosis, presented with active gastric variceal bleeding. (a) The ISD measures 2.67 cm on the contrast-enhanced computed tomography coronal maximum intensity projection image. (b) Fluoroscopic image taken after inflation of the occlusion balloon with contrast medium, and the injection of contrast medium fills the large shunt. A phrenic collateral vein had been embolized with coils. Note that the sheath tip is placed in the left renal vein.
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Figure 8: 65-year-old male, known hepatitis B virus cirrhosis, presented with active gastric variceal bleeding. (a) Contrast-enhanced computed tomography coronal maximum intensity projection image with ISD ~3.5 cm. (b) Fluoroscopic image showing abnormal curves of 5F catheter with glide wire in distal aspect of shunt and difficulty negotiating the shunt. (c) Fluoroscopic image after balloon inflation. Sheath tip in the shunt. This case demonstrates the concept that the larger the distance of the shunt from inferior vena cava, the more difficult it is to cannulate the shunt from the femoral route. |
Figure 8: 65-year-old male, known hepatitis B virus cirrhosis, presented with active gastric variceal bleeding. (a) Contrast-enhanced computed tomography coronal maximum intensity projection image with ISD ~3.5 cm. (b) Fluoroscopic image showing abnormal curves of 5F catheter with glide wire in distal aspect of shunt and difficulty negotiating the shunt. (c) Fluoroscopic image after balloon inflation. Sheath tip in the shunt. This case demonstrates the concept that the larger the distance of the shunt from inferior vena cava, the more difficult it is to cannulate the shunt from the femoral route.
Download as Power PointTable 1: Patient characteristics, ISD, approach, and end results
Age / sex M – Male, F - Female |
Reason for BRTO | Type of shunt | IVC-shunt distance (ISD) in cm | Transfemoral approach | TransJugular approach | No of times Glide wire slipped back into renal / IVC, transfemoral approach | Result |
---|---|---|---|---|---|---|---|
37 years/M | EHPVO with Gastric variceal bleeding | splenorenal shunt | 3.0 | Successful | Not attempted | One | Patient recovered completely |
63 years/M | Alcoholic liver Cirrhosis with Gastric variceal bleeding | Gastrorenal shunt | 2.67 | Successful | Not attempted | Nil | Patient recovered completely |
65 years/M | Hepatitis B Cirrhosis with Gastric variceal bleeding | Gastrorenal shunt | 3.50 | Successful | Not attempted | Three | Patient recovered completely |
23 years/M | EHPVO with Gastric variceal bleeding | Gastrorenal shunt | 2.92 | Successful | Not attempted | One | Patient recovered completely |
60 years/M | Alcoholic liver cirrhosis with Gastric variceal bleeding | Gastro-Renal shunt | 2.81 | Successful | Not attempted | One | Patient recovered completely |
61 years/M | NASH cirrhosis with Recurrent encephalopathy | Gastrorenal shunt | 3.36 | Successful | Not attempted | Two | Patient recovered completely |
57 years/M | NASH cirrhosis with Gastric variceal bleeding | Gastrorenal shunt | 3.39 | Attempted but failed to pass balloon | Successful | Wire was not stable to pass balloon catheter | Patient recovered completely |
66 years/M | Hepatitis B cirrhosis with Recurrent hepatic encephalopathy | Gastrorenal shunt | 4.45 | Attempted but failed to pass balloon | Successful | Wire was not stable to pass balloon catheter | Patient on follow-up > 6 months. No encephalopathy. Rectal bleed due to internal hemorrhoids at 3 months |
46 years/F | Idiopathic liver cirrhosis with Gastric variceal bleeding | Gastrorenal shunt | 2.77 | Successful | Attempted but failed to pass balloon | Wire was stable but too much strain while passing balloon catheter | Patient died due to liver / multiorgan failure |
63 years/M | Alcoholic liver cirrhosis with Gastric variceal bleeding | Two Shunts (Gatsrorenal & Splenorenal) With Common Renal Vein Drainage | 3.13 | Successful BRTO done with balloon in at junction of shunts | Attempted but failed to pass balloon. Coils were put in to the splenorenal shunt | Wire was stable but too much strain while passing balloon catheter | Patient recovered completely |
80 years/M | Alcoholic cirrhosis with Gastric variceal bleeding | Gastrorenal shunt | 3.37 | Successful | Not attempted | Two | Patient recovered completely |
74 years/M | Hepatitis B cirrhosis with Gastric variceal bleeding | Gastrorenal shunt | 2.70 | Successful | Not attempted | Nil | Patient recovered completely |
63 years/M | Hepatitis C cirrhosis with Gastric variceal bleeding | Gastrorenal shunt | 3.39 | Successful | Not attempted | Two | Patient recovered completely |
70 years/M | Hepatitis B cirrhosis with treated case of ruptured HCC (TACE 2 times). Recurrent encephalopathy | Gastrorenal and splenorenal shunt | 3.13 and 5.10 | Successful for gastrorenal shunt | Successful for splenorenal shunt | Not attempted | Patient recovered completely |
69 years/M | Idiopathic liver cirrhosis with recurrent HE | Gastrorenal and two splenorenal shunts | 3.38, 5.09, and 7.55(5.09 +2.46cm) | Successful for gastrorenal shunt and successful for coiling of proximal splenorenal shunt, but failed for balloon placement | Successful for distal splenorenal shunt | Proximal splenorenal shunt. 3 times | Patient died due to sepsis and liver failure at 3 months |
64 years/M | NASH cirrhosis with Recurrent encephalopathy | Gastrorenal shunt | 3.82 | Not attempted | Successful | Not attempted | On follow up. Recovering well |
BRTO: Balloon-occluded retrograde transvenous obliteration, IVC: Inferior vena cava
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Figure 9: Effect of ISD on sheath/wire placement through transjugular (a and b) and transfemoral (c and d) approach. Longer the ISD (double-headed arrows), easier the cannulation of shunt through jugular approach (a) and difficult through femoral approach (c) and vice versa (b and d). |
Figure 9: Effect of ISD on sheath/wire placement through transjugular (a and b) and transfemoral (c and d) approach. Longer the ISD (double-headed arrows), easier the cannulation of shunt through jugular approach (a) and difficult through femoral approach (c) and vice versa (b and d).
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