TIPS AND DIPS: HVOTO

Management of hepatic venous outflow tract obstruction (HVOTO) can be categorized into four steps: (1) Symptomatic treatment – Treatment of varices. (2) Relieving the obstruction – Surgery/Tx/Angiographic interventions. (3) Treatment of etiology – Hypercoagulable state, anticoagulation. (4) Regular follow-up for HCC.

In cirrhosis, classic transjugular TIPS are used to create a shunt. In HVOTO, a shunt can be made via extended TIPS or portocaval shunt. However, it has been seen that TIPS has some challenging steps, such as accessing the portal vein, which can be resolved using some methods like: Blind fluoroscopic method; use of CO2 wedged hepatic venography; marker-wire method; indirect portography method after injecting dense contrast into splenic artery/superior mesenteric artery; ultrasound technique; intravascular ultrasound; combined fluoroscopy and ultrasound.

For example, it has been seen that getting access to PV under ultrasound guidance is a safer method as hepatic parenchyma gives a window while creating a shunt between inferior mesenteric vein and inferior vena cava. Similarly, it has been seen that percutaneous sonographic guidance is helpful in TIPS in Budd-Chiari syndrome.

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