Chronic Portal Vein Thrombosis with Percutaneous Main Portal Vein Reconstruction and Coil Embolization of a Massive Coronary Vein: A Case Report.

BACKGROUND Portal vein thrombosis (PVT) is a well-recognized complication in patients with cirrhosis and frequently requires a nuanced approach to treatment. There is a paucity of existing literature and evidence-based recommendations regarding the optimal treatment approach to chronically occluded portal veins. Management options range from observation to anticoagulation and interventional therapies such as transjugular intrahepatic portosystemic shunts (TIPS), thrombolysis, or surgical thrombectomy. For select patients with little success from traditional medical therapies and previously failed TIPS procedures, a direct transhepatic approach to restoring blood flow and resolving variceal bleeding may be appropriate. CASE REPORT A 31-year-old man with a past medical history of portal hypertension, refractory ascites, gastroesophageal varices, and decompensated cirrhosis secondary to alcohol abuse had previously undergone an unsuccessful TIPS placement. Preprocedural imaging demonstrated a cirrhotic liver, splenomegaly, and gastroesophageal varices compatible with portal hypertension. Also noted were focal calcifications in the region of the diminutive main portal vein, medial splenic vein, and superior mesenteric vein, compatible with sequalae of chronic thrombosis. Restoration of flow through the occluded segment of the main portal vein and cessation of variceal bleeding was successfully resolved through the combination of portal vein reconstruction and massive volume embolization of the large coronary vein using a direct, percutaneous approach. CONCLUSIONS A direct, percutaneous approach to main portal vein reconstruction and massive volume embolization after a previously failed TIPS may be a potential alternative approach for select patients.