Solved on SIR Connect


By Paul R. Sobkin, MD, FRCPC, Jackson Bennett, MD, Mithil B. Pandhi, DO, and Sudhen B. Desai, MD, FSIR


Feedback on inferior mesenteric vein to gonadal vein shunt embolization


Original post, lightly edited for flow: bit.ly/3qCsgcb


The patient is a 66-year-old female with well-preserved hepatic synthetic function and no hepatic varices, and I have been asked by the gastroenterology service to embolize her portosystemic shunt to improve overall hepatic encephalopathy control. She has a history of well-controlled encephalopathy on lactulose with some breakthrough symptoms requiring hospitalization. We are unsure if her previous breakthrough symptoms are due to noncompliance or concurrent infection, such as a UTI. Our potential embolization approach would be transvenous to close the “back door” of the system with a vascular plug in the patient’s gonadal vein just below the left renal vein. Alternatively, we could perform transhepatic approach and embolize the IMV at its anastomosis with the gonadal vein. Does anyone favor one approach over the other, and if so, why?


What is your current practice preference for inferior mesenteric vein to gonadal vein shunt? My preference for approaching portosystemic shunt treatment is transhepatic or transsplenic access.


What challenges have you faced in evaluating patients who require portosystemic shunt embolization? Problems include underlying poor general medical condition, subjectivity, variability of symptoms of encephalopathy, and difficulty in determining compliance with medical therapy. The access can be challenging with poor visualization in cirrhotic, fatty liver and obese patients. The shunts can be difficult to access with tortuous, stenotic veins. If technically difficult, the cases can be long and therefore challenging for conscious sedation.


What is your preferred approach in embolizing portosystemic shunts? I prefer a transhepatic approach guided by ultrasound with a 6F destination sheath and AMPLATZER Vascular Plugs.


32 IRQ | SUMMER 2021


Is there a role for collaboration between gastroenterology and IR for embolization? Definitely. It is important for GI and hepatology to be aware that we can do these procedures and to refer patients for consultation who might benefit from IR. Also, they need to follow the patients for new or worsening varices after the procedure, so we all need to be on the same page.


What specifically prompted you to reach out regarding this case? Because of the large size of the shunt, I was tempted to think I could treat this from a femoral approach, although I suspected that the tortuous multistenotic vein would be difficult to catheterize and that going against the flow would make visualization difficult.


What SIR Connect posts were most valuable to you and why? Most of the respondents believed that transhepatic was the way to go, which gave me confidence in my plan. Also, the post urging caution from Peter Bream, MD, FSIR, was prescient, as the veins can be fragile. Even with


Author name and contact information Paul Robert Sobkin, MD, FRCPC Royal Jubilee Hospital, Victoria, British Columbia, Canada


that warning, I did cause a self-limited retroperitoneal hematoma that was very stressful to observe.


Did the patient’s retroperitoneal hematoma occur during the case or immediately afterwards? How was this managed or monitored? The retroperitoneal hematoma occurred right at the end of the case. The patient began to complain of abdominal and back pain. They were taken to CT from the IR suite where a moderate hematoma without extravasation was evident. The patient was treated conservatively, monitoring vital signs and complete blood counts. There was a drop in the patient’s hemoglobin, but this did not clinically require transfusion and the patient’s symptoms resolved overnight.


Will you, or have you, changed your practice patterns on the basis of responses on SIR Connect? Please describe any changes you are considering. I think there are subtle changes in practice based on other people’s experiences, especially for uncommon scenarios where my partners and I do not have a lot of shared experience. Tips and tricks that others have learned, including cautions based on past complications, all help to avoid tunnel vision when planning a case. This helps to enhance preparedness, instill confidence and decrease stress, all of which benefit me and my patient.


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