Portal Vein Recan

In this episode, our host Dr. Chris Beck interviews interventional radiologist Dr. Riad Salem about indications, technique, and cross-specialty collaboration in portal vein recanalization in the cirrhotic patient population.

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SHOW NOTES

Portal vein cavernoma is a serious consequence of portal vein thrombosis, and it is sometimes viewed as a contraindication for liver transplantation. Dr. Salem explains that recanalizing this occlusion can improve outcomes after transplantation because it makes the native portal vein intraoperatively usable for transplant surgeons.

Patients are usually referred to Dr. Salem through HCC tumor boards. He usually performs a full workup to ensure that patients are fully prepared for transplant, in case there is sudden liver decompensation. He also does high quality imaging with triple-phase CT, since it can show the exact vasculature of the splenic vein and intraparenchymal splenic venous system.

In the early days of portal vein recanalization, Dr. Salem would approach each case by gaining TIPS access. Nowadays, he prefers transsplenic access since it makes more anatomical sense to recanalize in the direction of the liver and it reduces the amount of procedural time. He encourages IRs to shed the mindset that splenic access has a prohibitively high bleeding risk. Dr. Salem describes the rest of the procedure, which includes puncturing the splenic vein, finding a remaining cord of the portal vein, puncturing the portal vein if needed, and recanalizing with a through-and-through technique and a TIPS. Throughout the episode, he shares pearls of wisdom for identifying the splenic vein, his preferred tools, and embolizing varices.

Finally, Dr. Salem describes his one month follow-up with cross-sectional imaging and ultrasound to check for varices, measure the diameter of the portal vein, and plan for future transplant.

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RESOURCES

TIPS University Episodes:
https://www.backtable.com/shows/vi/cm...

Preoperative portal vein recanalization-transjugular intrahepatic portosystemic shunt for chronic obliterative portal vein thrombosis: Outcomes following liver transplantation:
https://pubmed.ncbi.nlm.nih.gov/35220...

Portal Vein Recanalization and Transjugular Intrahepatic Portosystemic Shunt Creation for Chronic Portal Vein Thrombosis: Technical Considerations:
https://pubmed.ncbi.nlm.nih.gov/26997...

Portal vein recanalization-transjugularintrahepatic portosystemic shunt using the transsplenic approach to achieve transplant candidacy in patients with chronic portal vein thrombosis:
https://pubmed.ncbi.nlm.nih.gov/25666...

When and why portal vein thrombosis matters in liver transplantation: a critical audit of 174 cases:
https://pubmed.ncbi.nlm.nih.gov/24299...

Percutaneous Ultrasound-Guided Superior and Inferior Mesenteric Vein Access for Portal Vein Recanalization–Transjugular Intrahepatic Portosystemic Shunt: A Case Series:
https://www.ncbi.nlm.nih.gov/pmc/arti...

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The BackTable Podcast is a resource for interventional radiologists, vascular surgeons, interventional cardiologists, and other interventional and endovascular specialists to learn tips, techniques, and the ins and outs of the devices in their cabinets.

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