Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3663_Библиотеки_им_академика_М_И_Перельмана

A 49-year-old man with a history of hypercoagulability pre­sented with recurrent intractable small bowel variceal hemor­rhage. His portal, superior mesenteric, splenic veins, and inferior vena cava (IVC) were chronically thrombosed. Patient had a failed attempt at transjugular intrahepatic portosystemic shunt (TIPS) creation, and rethrombosis of reanalyzed IVC. His bleeding initially responded to proximal splenic artery and gas­troduodenal artery embolization; however, it recurred 2months later (Fig.43.1). Fluoroscopy guided percutaneous trans- colonic (Fig. 43.2a) transhepatic access of a large varix in the porta hepatis (Fig.43.2b) was performed by targeting a tri- loop snare in the IVC with a 22G Chiba needle (Fig.43.2c). The percuta­neous 0.018″ wire was captured from the jugular access, and the parenchymal tract was predilated with a 7mm balloon to allow for sheath introduction into the varix. A 10 mm×36mm bal­loon expandable stent (Valeo, Bard Inc., USA) was deployed. The percutaneous trans-colonic wire was removed, and nal venography showed a widely patent shunt with effective decom­pression of the portal ow (Fig.43.3). Perioperative antibiotic coverage was administered. The patient presented several times thereafter with GI bleeding that was addressed with shunt revi­sion; the shunt remains patent 3years after creation.