Could there be light at the end of the tunnel? Mesocaval shunting for refractory esophageal varices in patients with contraindications to transjugular intrahepatic portosystemic shunt

Table 1 Summary of published mesocaval shunt placements

Ref.	Case history	Details and outcomes
Nyman et al[6] 1996	37-year-old male with history of recurrent massive variceal bleeds attributed to congenital PVT and failed prior surgical shunt attempt	Visualization	CT angiography
		Approach	Transcolonic
		Duration of follow-up	5, 12 and 14 mo
		Thrombosis	Yes1
		Recurrent bleeding	No
		Hepatic encephalopathy	NR
Moriarty et al[9] 2012	57-year-old male with history of metastatic CRC and extrahepatic PVT who failed prior TIPs and was thought not to be surgical candidate	Visualization	CT and fluoroscopy
		Approach	Transgastric
		Duration of follow-up	3 mo
		Thrombosis	Yes2
		Recurrent bleeding	Yes2
		Hepatic encephalopathy	NR
Bercu et al[8] 2015	58-year-old female with history of HCV cirrhosis, PVT with recurrent ascites who failed prior TIPs attempt and was a poor surgical candidate	Visualization	Fluoroscopy
		Approach	Transabdominal
		Duration of follow-up	3 and 6 mo
		Thrombosis	No
		Recurrent bleeding	No
		Hepatic encephalopathy	Yes3
Hong et al[7] 2012	16-year-old female with history of chronic PVT and hematemesis who was felt to have high surgical risk	Visualization	Fluoroscopy and IVUS
		Approach	Endovascular
		Duration of follow-up	1 mo
		Thrombosis	No
		Recurrent bleeding	No
		Hepatic encephalopathy	NR
Hong et al[7] 2012	60-year-old female with history of HBV, HCV, HCC with thrombus obliterating PV	Visualization	Fluoroscopy and IVUS
		Approach	Endovascular
		Duration of follow-up	2 and 10 mo
		Thrombosis	No
		Recurrent bleeding	No
		Hepatic encephalopathy	NR
Hong et al[7] 2012	53-year-old male with history of pancreatic teratoma treated with Whipple with clot at SMV and splenic veins	Visualization	Fluoroscopy and IVUS
		Approach	Endovascular
		Duration of follow-up	1 and 3 mo
		Thrombosis	No
		Recurrent bleeding	No
		Hepatic encephalopathy	NR

¹The shunt was found to be thrombosed on POD #1 so the patient underwent ballooning of his stent and directed thrombolysis and was started on a therapeutic heparin. His hematocrit began to fall on the heparin but stabilized when the anticoagulation was held;

²The shunt was found to be thrombosed on POD #2 and on POD #3 the patient had a recurrent upper gastrointestinal hemorrhage. A new shunt was placed and the patient had no further bleeding;

³The patient had no encephalopathy at a 3-mo follow-up visit but was noted by an outside hospital to have encephalopathy 6 mo after shunt placement when the patient was hospitalized for concern for partial small bowel obstruction. The patient’s home lactulose and rifaximin had been held; when these medicines were resumed her encephalopathy resolved. NR: Not reported; PVT: Portal vein thrombus; CRC: Colorectal cancer; TIPs: Transjugular intrahepatic portosystemic shunting; HCV: Hepatitis C virus; HBV: Hepatitis B virus; HCC: Hepatocellular carcinoma; SMV: Superior mesenteric vein; PV: Portal vein; CT: Computed tomography.