Hematemesis from Migrated Mesocaval Shunt Eroding Through the Duodenal Wall

Abstract

Purpose: Mesocaval shunting (MCS) has emerged as an outgrowth with the development of polytetrafluoroethylene vascular grafts. It has been used when there is a pre-hepatic portal vein occlusion which is not amendable by transjugular intrahepatic portosystemic shunting (TIPS). MCS achieves portal decompression and prevents recurrent variceal bleeding with lower incidences of shunt thrombosis. We demonstrate a rare complication with MCS eroding through duodenal wall. Methods: A 48-year-old female presented with hematemesis and was found to have bleeding gastric and esophageal varices in the setting of of pre-hepatic portal vein occlusion. Patient underwent MCS placement and was placed on Coumadin for anticoagulation. Patient remains well with evidence of serial surveillance endoscopies for 3 years until she developed bilateral lower extremity edema. Ultrasound revealed occlusion of both MCS and inferior vena cava (IVC). Patient was treated with tissue plasminogen activator (tPA). Three months later, patient presented with severe abdominal pain. Endoscopy showed a foreign body at the second portion of the duodenum (Figure 1). CT abdomen showed the MCS tubing that was clearly visualized in preceding scans was no longer detected, indicating its complete erosion through the duodenum.Figure: No Caption available.Results: MCS have been used for decompression of the mesenteric venous system when there is a pre-hepatic portal vein occlusion which is not amendable by transjugular intrahepatic portosystemic shunting (TIPS). It involves the anastomosis of the superior mesenteric vein to the inferior vena cava. Most common complication of mesocaval shunts is occlusion. Literature reported that aortic stent can migrate into duodenum and required emergent surgery to stop the hemorrhage, which caused by the high pulsating pressure inside the arterial system. However, since the venous pressure inside the mesocaval system is much lower than arterial system, MSC migrating out of vascular system is extremely rare. This is the first case reported that MSC migrating and eroding into duodenum. Conclusion: In summary, in contrary to aortic artery prosthesis eroding into the duodenum, which is a medical emergency, MCS eroding into the duodenum can be managed conservatively with close monitoring.