Percutaneous transhepatic portal vein stenting in a patient with benign non-transplant postoperative portal vein stenosis: A case report
A 45-year-old female patient presented to the gastrointestinal surgery out-patient department with history of pain in right hypochondrium and jaundice of 3 months duration. Ultrasonography (USG) revealed dilated intrahepatic biliary radicles (IHBR) in both lobes of liver with an ill-defined mass lesion in the region of porta hepatis. Multiphase contrast-enhanced computed tomography (CT) scan of the abdomen showed an ill-defined mass lesion involving the left hepatic duct and the primary biliary confluence with resultant dilatation of the IHBR of both lobes []. The mass showed delayed persistent contrast enhancement. Left branch of portal vein was completely encased by the mass with atrophy of the left lobe of liver. The main and right portal vein and the right, left, and proper hepatic arteries were normal. No abdominal lymphadenopathy was seen. The imaging diagnosis was infiltrating cholangiocarcinoma involving left hepatic duct and primary biliary confluence with invasion of left portal vein. The patient was surgically treated with left hepatectomy, hepaticojejunostomy, and portal vein repair. Histopathology confirmed the diagnosis. Subsequently, the patient was treated with chemotherapy and radiotherapy.\nDuring follow-up, the patient presented with short history of abdominal pain and distension after about 8 months of surgery. USG revealed gross ascites and Doppler study showed severely narrowed portal vein. This was followed by contrast-enhanced CT scan of the abdomen which revealed narrowing of extrahepatic portal vein at the site of repair with multiple periportal portosystemic collaterals and gross ascites. No mass lesion was seen in liver or at porta hepatis []. A diagnosis of postoperative benign portal vein stenosis was made and she was treated with percutaneous transhepatic balloon angioplasty of the portal vein, which showed disappearance of most of the collaterals []. Although the symptoms relieved initially, they recurred after 3 weeks and USG showed persistent stenosis of the extrahepatic portal vein. Since the angioplasty showed a positive outcome, percutaneous transhepatic portal vein stenting was planned. After initial balloon dilatation of the stenotic segment, a self-expandable metallic stent (Bloomington Indiana, USA), measuring 4 cm in length and 10 mm in diameter, was placed across the stenosis []. Portal venography after the stenting showed disappearance of the collaterals []. Patient's symptoms improved with minimal ascites on follow-up USG after 1 month. Four months after stenting, the patient again developed moderate ascites with deranged liver functions and vomiting. USG showed ascites with coarsened liver echotexture and patent portal vein stent with normal flow. Two weeks later, the patient died of hepatic failure, which was presumed to be due to postoperative chemo-radiotherapy.