Presentation
Patient presenting with abdominal pain and markedly elevated liver function tests. History of recent cholecystectomy.
Patient Data
Multiphase CT of the abdomen shows heterogenous enhancement of the liver, with predominantly the central portion enhancing. There is relative caudate lobe hypertrophy around the patent IVC.
The hepatic veins are not well-visualized.
There is large volume ascites and a moderate layering left pleural effusion.
Cholecystectomy clips are present.
Using a selective catheter, after numerous attempts from a transjugular approach, a hepatic vein was accessed, and contrast and wedged CO2 venograms were performed. Diminutive hepatic veins with collateral drainage were seen, consistent with history of Budd-Chiari syndrome. Given the hepatic venous anatomy, decision was made to perform a direct intra-hepatic portosystemic shunt (DIPS).
DIPS was performed with two overlapping Viatorr stents placed to connect the portal vein to the IVC.
Case Discussion
As an alternative to the more commonly used TIPS procedure where a shunt is created between the portal vein and a hepatic vein, the DIPS procedure can be used in patients where there is an inability to catheterize the hepatic vein. This may be due to significant hepatic vein thrombosis or abnormal anatomy 1. Similar to TIPS, such a portosystemic shunt may be necessary in patients that suffer from sequelae of portal hypertension including active or recurrent variceal bleeding or refractory ascites. However, the hepatic vein occlusion and caudate lobe overgrowth characteristic of Budd-Chiari syndrome present difficulties for conventional TIPS, and DIPS has therefore been implemented to circumvent these anatomic obstacles 2.
Like TIPS, DIPS is contraindicated in patients with recurrent hepatic encephalopathy, severe liver insufficiency, pulmonary arterial hypertension, and/or cardiac failure. One reason preventing widespread use of DIPS is relative lack of experience in performing this procedure compared to TIPS 1.
Case co-author: Paul Bellissimo (Midwestern University)
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