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

Abstract

Cirrhotic patients with recurrent variceal bleeds who have failed prior medical and endoscopic therapies and are not transjugular intrahepatic portosystemic shunt candidates face a grim prognosis with limited options. We propose that mesocaval shunting be offered to this group of patients as it has the potential to decrease portal pressures and thus decrease the risk of recurrent variceal bleeding. Mesocaval shunts are stent grafts placed by interventional radiologists between the mesenteric system, most often the superior mesenteric vein, and the inferior vena cava. This allows flow to bypass the congested hepatic system, reducing portal pressures. This technique avoids the general anesthesia and morbidity associated with surgical shunt placement and has been successful in several case reports. In this paper we review the technique, candidate selection, potential pitfalls and benefits of mesocaval shunt placement.

Keywords: Portal hypertension; Surgical portacaval shunt; Gastrointestinal hemorrhage; Esophageal and gastric varices; Transjugular intrahepatic portasystemic shunt

Core tip: Cirrhotic patients who have recurrent variceal hemorrhage despite medical and endoscopic therapy have limited options if they are not transjugular intrahepatic portosystemic shunting candidates. One promising new method to decrease portal pressures while avoiding surgical shunt placement is mesocaval shunt placement with fluoroscopic guidance. In this paper we review the technique, candidate selection, potential pitfalls and benefits of mesocaval shunt placement.