25759562 Visualization

A 65 Age - year Age - old Age woman Sex presented Clinical_event with a complaint of right Biological_structure upper Biological_structure quadrant Biological_structure pain Sign_symptom .
Three Date years Date prior Date , the patient was incidentally diagnosed with idiopathic Detailed_description BCS Disease_disorder during health checkup Clinical_event ; Doppler Detailed_description ultrasound Diagnostic_procedure ( US Diagnostic_procedure ) examination showed obstruction Sign_symptom of the middle Biological_structure and Biological_structure left Biological_structure hepatic Biological_structure veins Biological_structure , and investigations for underlying thrombophilia Disease_disorder were unremarkable.
She was treated with warfarin Medication to maintain an international Diagnostic_procedure normalized Diagnostic_procedure ratio Diagnostic_procedure between Lab_value 2 Lab_value and Lab_value 3 Lab_value , but discontinued Other_event after Date at Date least Date 1 Date year Date due to non Detailed_description - compliance Detailed_description ; the patient did not consult Clinical_event with any doctors for 2 Duration years Duration .
She has remained asymptomatic Sign_symptom for the past Duration 3 Duration years Duration until recently she started experiencing steadily worsening Detailed_description , intermittent Frequency pain Sign_symptom in the right Biological_structure upper Biological_structure quadrant Biological_structure of her abdomen, with no associated Sign_symptom or Sign_symptom alleviating Sign_symptom factors Sign_symptom .
Physical Diagnostic_procedure examination Diagnostic_procedure was only notable for mild right Biological_structure upper Biological_structure quadrant Biological_structure tenderness Sign_symptom .
Laboratory Diagnostic_procedure tests Diagnostic_procedure revealed mildly Lab_value elevated Lab_value bilirubin Diagnostic_procedure ( 2.2 Lab_value mg/dL Lab_value ) and albumin Diagnostic_procedure deficit Lab_value ( 2.38 Lab_value g/dL Lab_value ).
Her Child Diagnostic_procedure - Pugh Diagnostic_procedure ( CP Diagnostic_procedure ) score was 8 Lab_value , Model Diagnostic_procedure for Diagnostic_procedure End Diagnostic_procedure - Stage Diagnostic_procedure Liver Diagnostic_procedure Disease Diagnostic_procedure ( MELD Diagnostic_procedure ) score was 11 Lab_value , Rotterdam Diagnostic_procedure score was 0.15 Lab_value , and BCS Diagnostic_procedure - TIPS Diagnostic_procedure prognostic Diagnostic_procedure index Diagnostic_procedure ( BCS Diagnostic_procedure - TIPS Diagnostic_procedure PI Diagnostic_procedure ) score was 6.3 Lab_value .
A contrast Detailed_description - enhanced Detailed_description computed Diagnostic_procedure tomography Diagnostic_procedure ( CT Diagnostic_procedure ) scan showed non Sign_symptom - visualized Sign_symptom middle Biological_structure and Biological_structure left Biological_structure hepatic Biological_structure veins Biological_structure , hepatomegaly Sign_symptom with hypertrophy Sign_symptom of the caudate Biological_structure lobe Biological_structure , splenomegaly Sign_symptom , hepatic Biological_structure venous Sign_symptom collaterals Sign_symptom , and a saccular Detailed_description aneurysm Sign_symptom located at the extrahepatic Biological_structure portal Biological_structure vein Biological_structure main Biological_structure branch Biological_structure measuring 3.2 Distance cm Distance in Distance height Distance and 2.5 Area cm Area × Area 2.4 Area cm Area in Area diameter Area (Figure ​1A).
The aneurysm Sign_symptom was thought to be associated with BCS Disease_disorder as there was no History preceding History history History of History trauma Disease_disorder and it had not been present on Doppler Detailed_description US Diagnostic_procedure examination performed 3 Date years Date previously Date .
Although the patient had no ascites Sign_symptom or variceal Biological_structure bleeding Sign_symptom , the decision was made to create a TIPS Therapeutic_procedure to relieve hepatic Biological_structure venous Biological_structure outflow Detailed_description obstruction Sign_symptom because of increasing pain Sign_symptom and concern for complications Disease_disorder due to aneurysm Sign_symptom size; direct Therapeutic_procedure approach Therapeutic_procedure to the aneurysm Sign_symptom was not considered due to risk of associated complications in the setting of portal Biological_structure hypertension Sign_symptom , and stent Therapeutic_procedure - grafting Therapeutic_procedure was not considered due to concerns about patency in the settings of hepatic Biological_structure venous Biological_structure outflow Detailed_description obstruction Sign_symptom and underlying thrombophilia Sign_symptom .
After informed consent was obtained, the patient was brought Clinical_event to the interventional Nonbiological_location radiology Nonbiological_location suite Nonbiological_location .
The procedure was performed with the patient under conscious Medication sedation Medication .
Portal Therapeutic_procedure vein Therapeutic_procedure access Therapeutic_procedure was obtained via the right Biological_structure hepatic Biological_structure vein Biological_structure under fluoroscopy Diagnostic_procedure , and portography Diagnostic_procedure showed a saccular Detailed_description aneurysm Sign_symptom located at the main Biological_structure portal Biological_structure vein Biological_structure , extensive Severity intrahepatic Biological_structure portal Biological_structure vein Biological_structure thrombosis Sign_symptom , and small Severity splenorenal Biological_structure varices Sign_symptom (Figure ​2A).
A 10 Detailed_description - mm Detailed_description diameter Detailed_description expanded Detailed_description polytetrafluoroethylene Detailed_description ( ePTFE Detailed_description ) covered Detailed_description stent Therapeutic_procedure - graft Therapeutic_procedure ( Fluency Detailed_description Plus Detailed_description ; Bard Detailed_description Peripheral Detailed_description Vascular, Detailed_description Tempe, Detailed_description Arizona, Detailed_description United Detailed_description States Detailed_description ) was deployed across the liver Biological_structure parenchymal Biological_structure tract Biological_structure ; deploying the stent Therapeutic_procedure - graft Therapeutic_procedure into the main Biological_structure portal Biological_structure vein Biological_structure trunk Biological_structure to cover the aneurysm Sign_symptom neck was not considered because it would obstruct Sign_symptom blood flow to the portal Biological_structure vein Biological_structure branches Biological_structure .
Completion portography Diagnostic_procedure showed a widely patent Sign_symptom shunt Sign_symptom and markedly decreased aneurysm Sign_symptom filling (Figure 2B).
The portosystemic Diagnostic_procedure pressure Diagnostic_procedure gradient Diagnostic_procedure ( PPG Diagnostic_procedure ) was decreased Lab_value from 19 Lab_value mmHg Lab_value to 8 Lab_value mmHg Lab_value .
The patient recovered Diagnostic_procedure uneventfully Lab_value and had complete resolution of her abdominal Biological_structure pain Sign_symptom in 2 Date d.
She was discharged Clinical_event on long-term warfarin Medication and remained asymptomatic Sign_symptom after 1 Duration year Duration of follow Clinical_event - up Clinical_event .
Most recent laboratory Diagnostic_procedure tests Diagnostic_procedure revealed normal Lab_value liver Diagnostic_procedure function Diagnostic_procedure , and Doppler Detailed_description US Diagnostic_procedure examination performed at 1, Date 3, Date 6, Date and Date 12 Date mo Date postprocedure Date confirmed a patent Sign_symptom shunt Sign_symptom .
Her CP Diagnostic_procedure score was 5 Lab_value , MELD Diagnostic_procedure score was 8 Lab_value , Rotterdam Diagnostic_procedure score was 0.12 Lab_value , and TIPS Diagnostic_procedure - BCS Diagnostic_procedure PI Diagnostic_procedure score was 6.1 Lab_value .
CT Diagnostic_procedure scans showed that the aneurysm Sign_symptom had decreased in size to 2.4 Distance cm Distance in Distance height Distance and 2.0 Area cm Area × Area 1.9 Area cm Area in Area diameter Area at 3 Date mo Date after Date TIPS Therapeutic_procedure (Figure 1B), and had further decreased to 1.9 Distance cm Distance in Distance height Distance and 1.6 Area cm Area × Area 1.5 Area cm Area in Area diameter Area at 1 Date year Date (Figure ​1C).