Cavernous Transformation Of Portal Vein Research Articles

Biliary Complications Post Transjugular Intrahepatic Portosystemic Shunt in a Child With Portal Vein Cavernous Transformation

Biliary Complications Post Transjugular Intrahepatic Portosystemic Shunt in a Child With Portal Vein Cavernous Transformation

Efficacy and safety of precision-guided transjugular extrahepatic portosystemic shunt (TEPS) in the management of cavernous transformation of the portal vein with portal hypertension: a case series.

Performing a Transjugular intrahepatic portal system shunt (TIPS) in patients with portal vein cavernous transformation (CTPV) poses significant challenges. As an alternative, transjugular extrahepatic portal vein shunt (TEPS) may offer a potential solution for these patients. Nonetheless, the effectiveness and safety of TEPS remain uncertain. This case series study aimed to evaluate the efficacy and safety of TEPS in treating patients with CTPV portal hypertension complications. The study encompassed a cohort of 22 patients diagnosed with CTPV who underwent TEPS procedures. Of these, 13 patients manifested recurrent hemorrhagic episodes subsequent to conventional therapies, 8 patients grappled with recurrent or refractory ascites, and 1 patient experienced acute bleeding but refused endoscopic treatment. Comprehensive postoperative monitoring was conducted for all patients to rigorously evaluate both the technical and clinical efficacy of the intervention, as well as long-term outcomes. The overall procedural success rate among the 22 patients was 95.5% (21/22).During the TEPS procedure, nine patients were guided by percutaneous splenic access, three patients were guided by percutaneous hepatic access, five patients were guided by transmesenteric vein access from the abdomen, and two patients were guided by catheter marking from the hepatic artery. Additionally, guidance for three patients was facilitated by pre-existing TIPS stents. The postoperative portal pressure gradient following TEPS demonstrated a statistically significant decrease compared to preoperative values (24.95 ± 3.19mmHg vs. 11.48 ± 1.74mmHg, p < 0.01).Although three patients encountered perioperative complications, their conditions ameliorated following symptomatic treatment, and no procedure-related fatalities occurred. During a median follow-up period of 14months, spanning a range of 5 to 39months, we observed four fatalities. Specifically, one death was attributed to hepatocellular carcinoma, while the remaining three were ascribed to chronic liver failure. During the follow-up period, no instances of shunt dysfunction were observed. Precision-guided TEPS appears to be a safe and efficacious intervention for the management of CTPV.

Experience of adult liver transplantation with the severe portal vein cavernous transformation

Experience of adult liver transplantation with the severe portal vein cavernous transformation

Lieno-Adrenal Shunt a Rescue for Porto-Systemic Decompression in 23-Year-Old Female

Extra hepatic portal vein obstruction is one of the commonest cause of portal hypertension and upper gastrointestinal bleed in the third world. Portal vein cavernous transformation is one of the hallmarks of EHPVO. Despite various lesser invasive interventional approaches for management of EHPVO, surgical shunts still play an important role in long term treatment of patients with EHPVO. Here we present a case of 23 years old female who presented to the OPD with complains of dull aching abdominal pain for a year which was insidious on onset and gradually progressive. The pain was non-radiating, localized to the left upper quadrant of the abdomen which aggravated on lying on the left side. She underwent lieno-adrenal shunt for porto-systemic decompression and management of EHPVO. This case aims to highlight the use of leino-adrenal shunt as a feasible alternative to Linton’s shunt.

A CLINICAL CASE OF PORTAL BILIOPATHY

Background. The term «portal biliopathy» (PB) refers to abnormalities of the entire biliary tract including intrahepatic and extrahepatic bile ducts, the cystic duct as well as the gallbladder in patients with portal hypertension. Objective. To describe a clinical case of portal biliopathy. Material and methods. Clinical observation of a patient aged 42, who was examined and treated at the 2nd City Clinical Hospital, Minsk, Belarus in February 2023. Results. Esophagogastroduodenoscopy and ultrasonography revealed portal hypertension, grade 2-3 esophageal varices and changes in the bile ducts. The subsequent use of computed tomography, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography made it possible to identify cavernous transformation of portal vein due to occlusive thrombosis as well as portal biliopathy with extensive stenosis of the ductus choledochus. Conclusions. The presented clinical case demonstrates the asymptomatic course of a severe pathology known as extrahepatic portal vein obstruction (EHPVO) with the development of portal hypertension and portal biliopathy.

Location and extent of cavernous transformation of the portal vein dictates different visceral side revascularization in Meso-Rex bypass

BackgroundAs an emerging standard of care for portal vein cavernous transformation (PVCT), Meso-Rex bypass (MRB) has been complicated and variated. The study aim was to propose a new classification of PVCT to guide MRB operations.MethodsDemographic data, the extent of extrahepatic PVCT, surgical methods for visceral side revascularization, intraoperative blood loss, operating time, changes in visceral venous pressure before and after MRB, postoperative complications and the condition of bypass vessels after MRB were extracted retrospectively from the medical records of 19 patients.ResultsThe median age of the patients (13 males and 6 females) was 32.5 years, while two patients were underage. Causes of PVCT can be summarized as follows: thrombophilia such as dysfunction of antithrombin III or proteins C; secondary to abdominal surgeries; secondary to abdominal infection or traumatic intestinal obstruction, and unknown causes. Intraoperatively, the median operation time was 9.5 h (7–13 h), and the intraoperative blood loss was 300 mL (100-1,600 mL). Ten cases used autologous blood vessels while 10 used allogeneic blood vessels. The vascular anastomosis was divided into the following types according to the site and approach: Type (T) 1-PV pedicel type, T2-confluence type, T3-major visceral vascular type; and T4-collateral visceral vascular type. Furthermore, the visceral venous pressure before and after MRB dropped significantly from 36 cmH2O (28–44) to 24.5 cmH2O (15–31) (P < 0.01). Postoperatively, one patient had delayed wound healing, two developed biochemical pancreatic fistulae, one experienced lymphatic leakage, the former caused by heat damage of the pancreatic tissues, the latter by cutting lymphatic vessels in the mesentery or removing the local lymph nodes during the process of separating the superior mesenteric vein, and one was re-operated on for an intervening intestinal fistulae. Postoperative enhanced CT scans revealed a significant improvement in abdominal varix in the patients with patent bypass, and at the 1-year postoperative follow-up, enhanced CT scans of six patients showed that the long axis of the spleen was reduced by ≥ 2 cm.ConclusionsMRB can effectively reduce visceral venous pressure in patients with PVCT. It is feasible to determine the PVCT type according to the extent of involvement and to choose individualized visceral side revascularization performances.

Distal splenorenal shunt surgery in the management of portal vein thrombosis (PVT) secondary to cavernous transformation of portal vein (CTPV) in the pediatric population: Experiences from vicente sot

Distal splenorenal shunt surgery in the management of portal vein thrombosis (PVT) secondary to cavernous transformation of portal vein (CTPV) in the pediatric population: Experiences from vicente sot

Computed tomography imaging features to evaluate the severity of portal hypertension and predict the rebleeding risk after endoscopic treatment in cirrhotic patients with variceal hemorrhage

PurposeTo investigate the association of computed tomography (CT) imaging features and severity of portal hypertension (PH) and develop a nomogram to predict high-risk PH in cirrhotic patients with gastroesophageal variceal hemorrhage (GVH). MethodsThe study retrospectively enrolled 158 cirrhotic patients with a history of endoscopic treatment for GVH. Hepatic vein pressure gradient (HVPG) was measured and the patients were classified into high-risk (HVPG > 16 mmHg) or low-risk (HVPG ≤ 16 mmHg) PH group. Pre-treatment CT features, including cavernous transformation of portal vein (CTPV), hilar periportal space (a distance between right portal vein and posterior edge of segment IV of the liver), and depth of right posterior hepatic notch sign (a sharp indentation in the right medial posterior liver surface), were evaluated. Risk factors associated with high-risk PH were analyzed, and a nomogram based on the imaging features was developed. ResultsHigh-risk PH group showed a higher rebleeding rate after treatment than that of the low-risk (P = 0.029). Multivariate analysis indicated that larger hilar periportal space (P < 0.001), less frequencies of CTPV (P = 0.044) and deeper right posterior hepatic notch (P < 0.001) were independent risk factors associated with high-risk PH. A nomogram based on the three CT imaging features was established to predict high-risk PH with an excellent discrimination (c-statistic 0.854). ConclusionThe nomogram based on CT features of hilar periportal space, depth of right posterior hepatic notch and CTPV can help to distinguish cirrhotic patients with high-risk PH, who are more vulnerable of variceal rebleeding after endoscopic treatment.

Application of transmesenteric vein extrahepatic portosystemic shunt in treatment of symptomatic portal hypertension with cavernous transformation of portal vein

PurposeTo evaluate the feasibility and efficacy of a transmesenteric vein extrahepatic portosystemic shunt (TmEPS) for the treatment of cavernous transformation of the portal vein (CTPV). Materials and methodsThe clinical data of 20 patients with CTPV who underwent TmEPS between December 2020 and January 2022 ​at Henan Provincial People's Hospital were retrospectively collected. The superior mesenteric vein (SMV) trunk was patent or partially occluded in these patients. An extrahepatic portosystemic shunt between the inferior vena cava and the SMV was established using a stent graft through an infraumbilical median longitudinal mini-laparotomy. The technical success, efficacy, and complication rates were evaluated, and the pre- and postoperative SMV pressures were compared. Patients' clinical outcomes and shunt patency were assessed. ResultsTmEPS was successfully performed in 20 patients. The initial puncture success rate of the balloon-assisted puncture technique is 95%. The mean SMV pressure decreased from 29.1 ​± ​2.9 ​mmHg to 15.6 ​± ​3.3 ​mmHg (p ​< ​0.001). All symptoms of portal hypertension resolved. No fatal procedural complications occurred. During the follow-up period, hepatic encephalopathy occurred in two patients. The remaining patients remained asymptomatic. All shunts were patent. ConclusionsTmEPS is a feasible, safe, and effective treatment option for patients with CTPV.

Congenital hypothyroidism: a case report of an Egyptian child with congenital heart disease, pelvic kidney and cavernous transformation of portal vein

BackgroundA case of thyroid hormone deficiency which presented at birth. Thyroid hormones are essential for brain development and normal cognitive function. Common symptoms of congenital hypothyroidism (CH) include constipation, decreased activity, increased sleep and feeding difficulty. Common signs include dry skin, macroglossia and umbilical hernia. If congenital hypothyroidism is left untreated after birth, it can lead to permanent intellectual disability and growth failure.Case presentation.Here, we report a 10.5-year-old female with the typical features of CH. She is the sixth in order of birth of consanguineous Egyptian parents. No family history of similar condition. Our patient had primary CH caused by thyroid agenesis. She had congenital heart disease, pelvic kidney, cavernous transformation of portal vein and parenchymatous liver disease.ConclusionsCongenital hypothyroidism is associated with an elevated risk of congenital anomalies. Clinical suspicion of symptoms and signs of congenital hypothyroidism are important for early diagnosis and prevention of serious problems that are related to congenital hypothyroidism.

Study on the comparative analysis of the efficacy of transmesenteric vein extrahepatic portosystemic shunt and transjugular intrahepatic portosystemic shunt in the treatment of cavernous transformation of portal vein

Objective: To compare the safety and efficacy of transmesenteric vein extrahepatic portosystemic shunt (TEPS) and transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of cavernous transformation of the portal vein (CTPV). Methods: The clinical data of CTPV patients with patency or partial patency of the superior mesenteric vein treated with TIPS or TEPS treatment in the Department of Vascular Surgery of Henan Provincial People's Hospital from January 2019 to December 2021 were selected. The differences in baseline data, surgical success rate, complication rate, incidence rate of hepatic encephalopathy, and other related indicators between TIPS and TEPS group were statistically analyzed by independent sample t-test, Mann-Whitney U test, and Chi-square test. Kaplan-Meier survival curve was used to calculate the cumulative patency rate of the shunt and the recurrence rate of postoperative portal hypertension symptoms in both groups. Results: The surgical success rate (100% vs. 65.52%), surgical complication rate (6.67% vs. 36.84%), cumulative shunt patency rate (100% vs. 70.70%), and cumulative symptom recurrence rate (0% vs. 25.71%) of the TEPS group and TIPS group were statistically significantly different (P < 0.05). The time of establishing the shunt [28 (2141) min vs. 82 (51206) min], the number of stents used [1 (12) vs. 2 (15)], and the length of the shunt [10 (912) cm vs. 16 (1220) cm] were statistically significant between the two groups (t = -3.764, -4.059, -1.765, P < 0.05). The incidence of postoperative hepatic encephalopathy in the TEPS group and TIPS group was 6.67% and 15.79% respectively, with no statistically significant difference (Fisher's exact probability method, P = 0.613). The pressure of superior mesenteric vein decreased from (29.33 ± 1.99) mmHg to (14.60 ± 2.80) mmHg in the TEPS group and from (29.68 ± 2.31) mmHg to (15.79 ± 3.01) mmHg in TIPS group after surgery, and the difference was statistically significant (t = 16.625, 15.959, P < 0.01). Conclusion: The best indication of TEPS is in CTPV patients with patency or partial patency of the superior mesenteric vein. TEPS improves the accuracy and success rate of surgery and reduces the incidence of complications.

Intrahepatic portal venous systems in adult patients with cavernous transformation of portal vein: Imaging features and a new classification

BackgroundCavernous transformation of the portal vein (CTPV) due to portal vein obstruction is a rare vascular anomaly defined as the formation of multiple collateral vessels in the hepatic hilum. This study aimed to investigate the imaging features of intrahepatic portal vein in adult patients with CTPV and establish the relationship between the manifestations of intrahepatic portal vein and the progression of CTPV. MethodsWe retrospectively analyzed 14 CTPV patients in Beijing Tsinghua Changgung Hospital. All patients underwent both direct portal venography (DPV) and computed tomography angiography (CTA) to reveal the manifestations of the portal venous system. The vessels measured included the left portal vein (LPV), right portal vein (RPV), main portal vein (MPV) and the portal vein bifurcation (PVB). ResultsNine males and 5 females, with a median age of 40.5 years, were included in the study. No significant difference was found in the diameters of the LPV or RPV measured by DPV and CTA. The visualization in terms of LPV, RPV and PVB measured by DPV was higher than that by CTA. There was a significant association between LPV/RPV and PVB/MPV in term of visibility revealed with DPV (P = 0.01), while this association was not observed with CTA. According to the imaging features of the portal vein measured by DPV, CTPV was classified into three categories to facilitate the diagnosis and treatment. ConclusionsDPV was more accurate than CTA for revealing the course of the intrahepatic portal vein in patients with CTPV. The classification of CTPV, that originated from the imaging features of the portal vein revealed by DPV, may provide a new perspective for the diagnosis and treatment of CTPV.

Noncirrhotic Portal Vein Cavernous Transformation: To TIPS, or Not to TIPS, That Is the Question

Noncirrhotic Portal Vein Cavernous Transformation: To TIPS, or Not to TIPS, That Is the Question

S1809 Portal Cavernoma Cholangiopathy Presenting With Acute Cholangitis

Introduction: Portal cavernoma cholangiopathy (PCC) is defined as abnormalities in the biliary tree due to a portal cavernoma. Most cases occur in non-cirrhotic patients who remain asymptomatic. 5-30% of patients develop symptomatic disease and only 8% of symptomatic cases present with acute cholangitis. This case describes PCC as an uncommon cause of acute cholangitis. Case Description/Methods: A 26-year-old male with a medical history of acute lymphocytic leukemia in remission, cryptogenic cirrhosis, and portal vein thrombosis (PVT) on warfarin presented with 2-weeks of worsening abdominal pain, darkening of the urine, and weight loss. On examination, he was febrile to 101°F, normotensive, and had both scleral and palatal icterus. Initial labs revealed White blood count: 13.5 x10(3)/mcL, total bilirubin 7.5mg/dL, & ALP 398U/L. MRCP showed biliary dilation related to extensive portal vein cavernous transformation and narrowing in the common bile duct (CBD) due to compression by cavernous vessels in porta hepatis (Figure). Endoscopic ultrasound (EUS) showed PVT and collateral flow. Endoscopic retrograde cholangiopancreatography (ERCP) revealed biliary narrowing and beading. These findings were diagnostic of cavernous transformation with cholangiopathy. The patient improved after biliary stent placement with repeat stenting 6 months later. There was a discussion about TIPS and Portal vein reconstruction. However, the patient did not follow through. Discussion: PCC develops through PVT-related ischemia that underlies the development of collateral flow, biliary stricture, and dysmotility predisposing patients to cholangitis. Management is only indicated with symptomatic disease with endoscopic and surgical intervention. We report a rare presentation of PCC successfully managed with ERCP.Figure 1.: A) MRCP: Cavernous transformation of the portal vein. B) EUS: A portal vein thrombus involving area of portal vein confluence and collateral flow consistent with cavernous transformation. C) ERCP: Abnormal areas of narrowing and beading throughout the biliary system with extrinsic stenosis.

Meso-Rex bypass shunt vs. transposition shunt for cavernous transformation of portal vein in children.

BackgroundCavernous transformation of the portal vein (CTPV) causes portal hypertension in children. Among Meso-Rex treatments, it is unclear whether the Meso-Rex bypass shunt (MRB) or the Meso-Rex transposition shunt (MRT) offers lower postoperative morbidity. Our objective was to evaluate postoperative outcomes, comparing MRB and MRT for children with CTPV.MethodsA retrospective study was conducted on children undergoing Meso-Rex for CTPV from January 2010 to December 2020. The primary outcome was shunt complications, including shunt stenosis and thrombus. The secondary outcome was re-operation.ResultsOf the 43 patients included, 21 underwent MRT and 22 underwent MRB. MRT was associated with a higher rate of shunt complications when compared to MRB (23.8 vs. 9.1%, p = 0.191). The patients exhibited a higher rate of re-operation under the MRT than under the MRB (19 vs. 4.5%, p = 0.138). The operative time in the MRT group was significantly shorter than in the MRB group. Compared to MRT, the reduction in the length and thickness of the spleen was significantly greater in the MRB group. The increases in platelets were significantly higher in the MRB group than in the MRT group. The postoperative shunt velocity of MRB was notably faster than MRT. There was no significant difference in postoperative portal pressure between the two groups (p > 0.05).ConclusionBoth MRB and MRT result in acceptable postoperative outcomes, but MRT is associated with higher post-shunt complications, which often increase the re-operation rate. This study suggests that MRB may offer advantages for children with CTPV.

A Sri Lankan child with hypersplenism secondary to pre-hepatic portal hypertension, successfully managed with partial splenic artery embolization: a case report and review of the literature

BackgroundHypersplenism, one of the major complications of portal hypertension, is traditionally treated by splenectomy. However, partial splenic artery embolization is an evolving minimally invasive intervention to treat these patients effectively.Case presentationA 13-year-old girl was referred for further evaluation of isolated splenomegaly with pancytopenia. She did not have bleeding manifestations or features of anemia. She never had hematemesis or melena. On examination, she was pale. Abdominal examination revealed massive splenomegaly of 10 cm below the costal margin without hepatomegaly. Rest of the examination was unremarkable. Her investigations revealed a white cell count of 1700/mm3 (neutrophils 9.8% and lymphocytes 88.7%), hemoglobin 9.5 g/dL and platelet count 42,000/mm3. Blood picture showed pancytopenia without abnormal cells. Her reticulocyte count was 1.9%. Complete liver profile was normal. Abdominal ultrasonography revealed massive splenomegaly with the oblique length of 17 cm and normal echogenic liver with normal size. Cavernous transformation of portal vein with portal hypertension was evident. Mesenteric angiogram showed portal vein thrombosis and markedly tortuous splenic artery. Anti-nuclear antibodies and double-stranded DNA were negative. Ham test and urine for hemosiderin were negative. Clauss fibrinogen assay was normal. Hemoglobin high performance liquid chromatography for hemoglobin subtypes was normal. Anti-phospholipid antibodies were negative. JAK2 V617F mutation was not identified. Diagnosis of pre hepatic portal hypertension was made. Her upper gastrointestinal endoscopy was normal. Partial splenic artery coil embolization was done by interventional radiology team. Vaccines against capsulated organisms were given. Post-procedure contrast abdominal computed tomography revealed infarction of approximately 70% of the spleen and blood counts were improved. Index case is in the follow up for 3 years. She is on penicillin prophylaxis with regular blood count and annual upper gastrointestinal endoscopy monitoring.ConclusionsMinimally invasive interventions such as partial splenic artery embolization should be considered in managing the patients with hypersplenism secondary to portal hypertension.

Transjugular Intrahepatic Portosystemic Shunt for Portal Vein Cavernous Transformation: A Systematic Review and Single-Arm Meta-Analysis

Background: Transjugular intrahepatic portosystemic shunt (TIPS) is technically challenging in the treatment of portal vein cavernous transformation (PVCT), and there is no high-quality evidence regarding whether it is an option for patients with PVCT. We carried out a systematic review and meta-analysis to assess the feasibility and safety of TIPS for PVCT. Methods: Systematic search of PubMed, Chinese National Knowledge Infrastructure (CNKI) database, Cochrane Library, Embase, and Wanfang database through December 2021 for appropriate studies reporting efficacy and safety in patients with PVCT undergoing TIPS. The main outcome included the technical success rate, postoperative rebleeding rate, postoperative hepatic encephalopathy rate, stent patency rate, preoperative, and postoperative portal pressure. Results: Ten studies, including 292 patients were included. Our results showed that TIPS was technically successful in 82.97% (95% confidence interval [CI]: 77.14%–88.41%, p = 0.297) with low heterogeneity (I² = 18.39%, p = 0.279). Postoperative rebleeding occurred in 9.56% (95% CI: 4.55%–16.77%, p = 0.073) with moderate heterogeneity (I² = 46.45%, p = 0.06). Postoperative hepatic encephalopathy occurred in 18.55% (95% CI: 9.23%–27.05%, p = 0.343) with moderate heterogeneity (I² = 48.62%, p = 0.049). Stent patency during follow-up was in 78.43% (95% CI: 70.74%–85.20%, p = 0.805) with low heterogeneity (I² = 0%, p = 0.654). Postoperative portal pressure significantly reduced (WMD = 12.79 mm Hg, 95% CI: 12.09–13.48 mm Hg, p < 0.00001) with high heterogeneity (I² = 61.4%, p = 0.02). Both Begg test and funnel plot showed that there was no significant publication bias. Conclusions: TIPS is feasible and safe in patients with PVCT and PVCT should not be considered an absolute contraindication to TIPS.

Efficacy and safety of transcatheter arterial chemoembolization plus hepatic arterial infusion chemotherapy in the treatment of advanced hepatocellular carcinoma with portal vein tumor thrombosis in the main trunk.

Hepatocellular carcinoma (HCC) is the most common primary liver cancer and the sixth most prevalent malignancy worldwide. The incidence of portal vein tumor thrombosis (PVTT) is recorded as high as 10%-60% in HCC patients. The purpose of this study was to assess the efficacy and safety of transcatheter arterial chemoembolization (TACE) plus hepatic arterial infusion chemotherapy (HAIC) in advanced HCC patients complicated with PVTT in the main trunk. A total of 33 HCC patients were treated with TACE + HAIC or TACE, respectively. The primary endpoint was overall survival (OS), while the secondary endpoints included progression-free survival, objective response rate (ORR), and disease control rate (DCR) of HCC lesions and PVTT in the trunk. Adverse events and main complications were also investigated. A COX model was used to identify the risk factors associated with OS. There were 16 patients receiving TACE + HAIC and 17 receiving TACE. The median OS was longer in the TACE + HAIC group than the TACE group (P < 0.05). There were no significant differences in the ORR and DCR of HCC lesions and PVTT response between the two groups (P > 0.05). Alpha-fetoprotein was <400 ng/ml. Multivariate analysis showed that cavernous transformation of portal vein was associated with longer OS. In terms of complications, the addition of HAIC showed more myelosuppression than the TACE alone group (P < 0.05). Compared with TACE alone, HAIC + TACE may be more safe and provide more benefits for HCC patients complicated with PVTT in the trunk.

A Rare Combination of Vascular Complications from Recurrent Pancreatitis Challenging the Treatment

A 43-year-old male alcoholic with recurrent acute pancreatitis presented with periodic melena. Computed tomography showed a 4.2 cm pseudoaneurysm encroaching on the head of pancreas and cavernous transformation of portal vein (portal cavernoma) caused by chronically thrombosed splenomesenteric portal axis (Figure A and B). The catheter angiogram revealed the pseudoaneurysm arising from a branch of replaced right hepatic artery from superior mesenteric artery (Figure C). Superselective embolization to occlude the feeding branch was performed using embolization coils, but misplacement of a coil resulted in complete occlusion of the right hepatic artery (Figure D.) However, the post- procedural liver function test remained within normal limits.

Modified Meso-Rex bypass with umbilical vein recanalization and intra-operative stenting.

The aim of the study was to evaluate the usefulness of a novel modified Meso-Rex bypass surgical technique with umbilical vein recanalization and intra-operative stenting to treat portal vein cavernous transformation. In total, 13 portal vein cavernous transformation patients underwent Meso-Rex bypass surgery, consisting of bypassgrafts between the superior mesenteric vein (SMV) and the recess of Rex as well as through the ligamentum teres hepatis without stent implantation (Group A, n = 9) and umbilical vein recanalization with intra-operative stent implantation (Group B, n = 4). In Group A, the bypass diameter was 0-6mm (median 3mm) and blood flow velocity 25-115cm/s (median 72cm/s) 1month after Meso-Rex bypass surgery, with open bypass times of 0-67months (median 6months); 6 patients in this group developed postoperative Meso-Rex bypass occlusions. A patient in Group A treated with ligamentum teres hepatis recanalization needed a thrombectomy and stent implantation during a second surgery 2days after the Meso-Rex bypass, because of bypass thrombosis and umbilical vein stenosis. In Group B, the average modified Meso-Rex bypass diameter was 5.5-6.5mm (median 6mm), and the bypass vessels remained open in all patients, with blood flow rates of 45-100cm/s (median 76.5cm/s) 1month after the modified Meso-Rex bypass, up to the endpoint (15-33months, median 24months). The rate of bypass occlusions in Group A and Group B were 22.2% and 0%, 30.0% and 0%, and 55.6% and 0% at 1month, 3months, and 1year, respectively, after bypass surgery. Our novel modified Meso-Rex bypass approach for portal vein cavernous transformation treatment was effective with excellent long-term bypass patency.