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Indications / Contraindications
Indications
- Post-surgical portal vein stenosis: most common indication — after liver transplant (anastomotic narrowing at suture line), after Whipple/hepatic resection, after gastric bypass
- Portal vein thrombosis (PVT): acute (<30 days) or chronic with cavernous transformation; cavernous transformation makes stenting significantly harder (may need recanalization)
- Malignant portal vein stenosis: tumor encasement (cholangiocarcinoma, pancreatic cancer) — palliative, often bridging to resection or for intractable portal hypertension
- Post-transplant portal vein stenosis: most amenable — early diagnosis, fresh anastomotic site, good access
- Extrahepatic portal vein occlusion: selected patients with benign etiology (neonatal omphalitis, post-inflammatory)
Hemodynamic Significance Thresholds
| Stenosis Location | Gradient Threshold for Treatment |
|---|---|
| Portal vein stenosis | ≥ 5 mmHg trans-stenotic gradient |
| Hepatic vein / IVC stenosis | ≥ 3–5 mmHg trans-stenotic gradient |
Contraindications
- Complete cavernous transformation of extensive portal vein (relative — experienced centers attempt recanalization)
- Active intraabdominal hemorrhage
- Uncorrectable coagulopathy
- Hepatic encephalopathy (severe)
- Diffuse intrahepatic portal occlusion without identifiable main portal vein
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Pre-Procedure Checklist
CT or MRI portal venous phase with 3D reconstruction: define PV stenosis/occlusion location and extent, collateral vessels, hepatic artery anatomy, liver parenchyma status
Doppler US within 48h: confirm stenosis/occlusion, measure portal vein velocities (<16 cm/s or flow reversal = concerning for significant stenosis)
Liver function labs: LFTs, INR, platelets, albumin — assess baseline hepatic reserve
Assess for concurrent Budd-Chiari if PV occlusion is part of prothrombotic syndrome
Mark planned access site on US: right transhepatic (segment 6 portal vein branch — most common) vs transsplenic vs trans-TIPS approach
Consent: intraperitoneal hemorrhage (transhepatic access), hemobilia, stent thrombosis (especially first 3 months), liver failure, portal vein perforation, need for anticoagulation post-procedure
Anticoagulation: patients with PVT may require ongoing anticoagulation — coordinate with hepatology before procedure
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Relevant Anatomy
Portal Vein Anatomy
- Formation: confluence of superior mesenteric vein + splenic vein at level of pancreatic neck → main portal vein → bifurcation into right and left branches at hepatic hilum
- Right portal vein: short (1–2 cm), then anterior and posterior divisions
- Left portal vein: longer horizontal segment in Rex recess, then umbilical portion
- Post-transplant anatomy: end-to-end portal vein anastomosis is most common; anastomotic narrowing at suture line is typical stenosis location
Access Anatomy
- Transhepatic access target: segment 5 or 6 right portal vein (peripheral branch, accessed from right intercostal approach under US guidance)
- Transsplenic access: alternative when transhepatic route not feasible; splenic vein → portal vein; increased splenic hemorrhage risk
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Technique
Default RadCall approach · share your own below
Supplies
Ultrasound machine (for transhepatic access)
21G Chiba or micropuncture needle
0.018″ access wire → 0.035″ wire exchange set
7–9 Fr vascular sheath
Angled catheter (Kumpe 5 Fr)
0.035″ Glidewire + Amplatz stiff exchange wire
Pressure transducer
Angioplasty balloons 6–10 mm
Self-expanding stent: SMART 8–10 mm
Balloon-expandable stent (Palmaz Blue) for anastomotic stenosis
Covered stent (Viabahn 8–10 mm) for malignant encasement
Gelfoam for tract embolization
Steps
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Transhepatic Access
Under US guidance, puncture peripheral right portal vein branch (segment 5 or 6) with 21G needle using intercostal approach. Confirm venous blood return. Advance 0.018″ wire. Exchange for 0.035″ wire (transition set). Advance 7–9 Fr sheath.
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Portal Venogram
Inject contrast to delineate stenosis/occlusion, collaterals, thrombus. Measure portal vein pressure (normal: 5–10 mmHg; portal hypertension: >12 mmHg).
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Cross Stenosis
Advance angled Glidewire through stenosis into main portal vein distal to obstruction (toward SMV/SV confluence). For complete occlusion: attempt multiple wire angles with rotation; sharp-needle recanalization if needed.
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Pre-Dilation
Balloon angioplasty of stenosis/occlusion to 6–8 mm. Dilate with 3-minute inflation. Assess residual gradient by pressure measurement.
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Stent Deployment
Deploy self-expanding stent to bridge stenosis with 1–2 cm overlap on either side into normal vessel. For post-transplant anastomotic stenosis: balloon-expandable stent preferred (more precise deployment, resistance to compression). Flare stent ends with post-dilation balloon.
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Completion Venogram + Pressure
Confirm stent patency, restoration of portal flow, reduction in pressure gradient. Target: <3 mmHg residual gradient across stent.
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Embolize Transhepatic Access Tract (Critical)
As sheath is withdrawn, inject Gelfoam or coils to seal hepatic parenchymal tract and prevent hemorrhage. This step is mandatory — failure to embolize leads to intraperitoneal hemorrhage.
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Hemostasis
Apply pressure to access site. Observe for signs of hemobilia or intraperitoneal bleeding before transport to recovery.
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Troubleshooting
Problem
Cannot cross portal vein occlusion with wire
Likely cause: Dense organized thrombus, cavernous transformation, intimal pannus
Next step: Hydrophilic angled Glidewire + stiff wire. Sharp-needle technique (21G needle advanced over wire as a rigid crossing device). If cavernous transformation: may require collateral recanalization through multiple attempts from different angles. Consider transsplenic approach from opposite direction (from SV/SMV) for bi-directional crossing.
Problem
Hemobilia after procedure (blood in bile, rising bilirubin)
Likely cause: Hepatic artery–biliary fistula from transhepatic needle pass through portal vein and adjacent artery/bile duct
Next step: Urgent hepatic arteriography via femoral access. Identify and coil embolize arterial-biliary communication. If bilirubin rising rapidly: ERCP to clear biliary clots.
Problem
Stent thrombosis within 24h
Likely cause: Inadequate anticoagulation, residual stenosis at stent ends, hypercoagulable state, very low portal flow
Next step: Urgent portal venography via transhepatic access. CDT with rtPA (2–4 mg injected directly into thrombus) + balloon thrombectomy. Transition to therapeutic anticoagulation immediately. Repeat angioplasty of residual stenosis at stent ends.
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Complications
Immediate
- Intraperitoneal hemorrhage from hepatic tract — rare with tract embolization; always embolize on sheath withdrawal
- Hemobilia — hepatic artery injury during transhepatic access; requires arteriography and embolization
- Contrast nephropathy — pre-procedure hydration; minimize contrast volume
- Pneumothorax — intercostal approach; post-procedure chest X-ray if respiratory symptoms
- Biliary injury — rare; hepatic bile duct can be traversed during transhepatic access
Delayed
- Stent thrombosis (10–20% at 1 year without anticoagulation) — most common delayed complication; requires repeat intervention
- Stent migration — uncommon; covered stents carry higher migration risk in high-flow settings
- Re-stenosis from neointimal hyperplasia — repeat balloon dilation usually effective
- Hepatic failure in patients with marginal hepatic reserve
- Portal vein perforation — rare; may require covered stent bridging
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Post-Procedure Care
Immediate Monitoring
- Hospital admission 24h: watch for hemobilia (dark stools, bilious aspirate), peritoneal bleeding signs (pain, tachycardia), fever
- Duplex US at 24h — confirm stent patency and flow direction (hepatopetal = normal)
- Labs: LFTs, CBC, INR at 24h
- Bed rest for 4h after procedure
Anticoagulation Protocol
- Post-transplant PV stent: aspirin 81 mg daily × minimum 3–6 months; some centers add low-dose warfarin (INR 2–3) × 3 months
- PVT with stent: therapeutic anticoagulation (LMWH → warfarin or DOAC) minimum 3–6 months, often indefinitely if underlying prothrombotic condition
- DOAC use in cirrhotic PVT: emerging evidence for rivaroxaban/apixaban; discuss with hepatology
- Follow-up Duplex US at 1 week and 1 month to confirm ongoing patency
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Critical Pearls
✶
Post-transplant = most amenable: Portal vein stenosis after liver transplantation responds best to intervention — fresh anastomotic tissue, high motivation to restore graft function. If caught early (<3 months), balloon angioplasty alone may suffice. If late: stent required.
✶
Tract embolization is mandatory: Every transhepatic access must be embolized on withdrawal with Gelfoam or coils. Failure to embolize the hepatic tract is a major error — leads to intraperitoneal hemorrhage.
✶
Anticoagulate after stenting: Stent thrombosis without anticoagulation approaches 20% at 1 year. Coordinate with hepatology/hematology for anticoagulation plan before the procedure, not after.
✶
Duplex at 24h is mandatory: Stent thrombosis within 24h requires urgent repeat intervention. Early detection = salvageable. Day 1 Doppler shows restoration of hepatopetal flow (portal vein flow toward liver).
✶
Malignant PV stenosis: For tumor encasement, use covered stents (prevent tumor ingrowth). Patency is shorter (~3–6 months) than benign stenting but can provide significant portal hypertension relief for the remaining disease course.
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References & Resources
Key Guidelines
- SIR Standards of Practice
- AASLD Portal Vein Thrombosis Consensus (2014)
- Liver Transplantation Society Guidelines
Primary References
- Garcia-Pagan JC, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370–2379. PMID 20538528.
- Stieber AC, et al. Orthotopic liver transplantation in the presence of portomesenteric venous thrombosis. Transplantation. 1991;52(3):428–433. PMID 1871790.