case_images: PMC10864148_01
case_images: Recanalization of portal vein graft occlusion via a percutaneous transmesenteric approach.. A 70-years-old male patient with pylorus resecting pancreaticoduodenectomy due to pancreas cancer.. A. On two-month postoperative follow-up CT images, the SMV graft is occluded with thrombosis; severe stenoses are noted in the proximal and distal anastomoses (arrowheads).. B. Transhepatic, antegrade recanalization was attempted with 0.016", 0.018", and 0.035" guidewires but failed; extravasation of the contrast materials (arrows) is noted due to extraluminal guidewire passage.. C. The patent portion of the SMV (white arrow) caudal to the interpositional graft is accessed using a micropuncture needle (black arrows) under ultrasound guidance.. D. Following the transmesenteric approach under ultrasound guidance, the SMV venogram shows collateral channels forming an ectopic varix at the hepaticojejunostomy (arrows).. E. Antegrade recanalization is successfully performed, and through-and-through access is made.. F. Portogram following self-expandable stent placement shows restoration of hepatopetal blood flow from SMV and disappearance of an ectopic varix at the hepaticojejunostomy.. SMV = superior mesenteric vein
case_images: jksr-85-230-g001.jpg
case_images: PMC10864148_01_jksr-85-230-g001.jpg
case_images: F1
case_images: Careful review of his contrast-enhanced abdominopelvic CT images after surgery revealed that the ePTFE SMV graft had gradually thrombosed and eventually occluded (Fig. 1A), although he was on warfarin. However, only extraluminal passage occurred (Fig. 1B). Under ultrasound guidance, the patent portion of the SMV, caudal to the interpositional graft, was punctured using a micropuncture needle (Fig. 1C). A venogram showed collateral channels (Fig. 1D). A 2.7-F supporting catheter (CXI, Cook Medical, Inc.) was placed, and antegrade recanalization was successfully performed using a 0.014" guidewire (Astato XS-20, Nagoya, Japan) (Fig. 1E). After through-and-through access was made, percutaneous transluminal angioplasty (PTA) was performed for severe stenoses at the proximal anastomosis, and 8-mm/100 mm and 10-mm/80 mm self-expandable stents were placed from the native SMV via the ePTFE graft to the right main portal vein (Fig. 1F).