Imaging and radiological interventions in extra-hepatic portal vein obstruction

Table 1 Radiological interventions available to address various changes/complications in extrahepatic portal vein obstruction

Changes/complications in EHPVO	Interventions
Vascular changes
PHT resulting in portoportal and porto-venous collaterals and gastro-esophageal varices-massive upper GI bleed	TIPS PTE
Biliary changes - PCC
Cholangitis	PTBD
Choledocholithiasis and hepaticolithiasis	PTC
Post-surgical bilio-enteric anastomotic site stricture
Visceral changes
Splenic changes
Hypersplenism	PSE
CNS changes-hepatic encephalopathy
Pre intervention-large spontaneous portosystemic	BRTO of porto-systemic shunt
Shunts like spleno-renal shunt and gastro-renal shunt	Deliberate reduction/closure of spleno-renal shunt
Iatrogenic porto-systemic shunts	Deliberate reduction/closure of TIPS
SPSS namely Linton shunt, Warren shunt, Mesocaval shunt, Rex shunt
Endovascular shunts - TIPS
Reappearance/increase in changes of EHPVO secondary to thrombosed/stenosed SPSS/TIPS	Shunt revision by PTA directed chemical or mechanical thrombectomy

BRTO: Balloon occluded trans-venous obliteration; EHPVO: Extrahepatic portal vein obstruction; PCC: Portal cavernoma cholangiopathy; PHT: Portal hypertension; PSE: Partial splenic embolization; PTA: Percutaneous transluminal angioplasty; PTBD: Percutaneous trans-hepatic biliary drainage; PTE: Percutaneous transhepatic/trans-splenic variceal embolization; TIPS: Transjugular intra-hepatic portosystemic shunt; SPSS: Surgical portosystemic shunts; PTC: Percutaneous trans-hepatic cholangioplasty; GI: Gastrointestinal; CNS: Central nervous system.

Table 2 Various routes for gaining access to portal system during transjugular intra-hepatic portosystemic shunt in patients with extrahepatic portal vein obstruction

Route	Condition/preffered when
Transjugular	Routinely used
Transhepatic-IPVB is accessed using US guidance	Poor or non-visualization of MPV
Transsplenic-US guide puncture of SV	Failure of US guided puncture of IPVB
Trans-ileocolic-mini-laparotomy is required to gain access to ileal vein	Failure of all above routes
Trans-RPUV	In combination with above routes to delineate portal tree if LHV-RPUV junction is patent

IPVB: Intrahepatic portal vein branch; MPV: Main portal vein; US: Ultrasound; SV: Splenic vein; RPUV: Recanalised paraumbilical vein; LHV: Left hepatic vein.