Hemorrhage from esophageal varices is an infrequent occurrence after a portacaval anastomosis. A stenotic portacaval anastomosis resulted in persistent portal hypertension and variceal hemorrhage. Treatment by transluminal balloon dilatation of the stenotic shunt resolved the hemodynamic abnormality as demonstrated by angiographic and hemodynamic techniques.
Portacaval anastomosis (PCA) significantly reduces the risk of hemorrhage from esophagogastric varices. Approximately 4% of patients (93 of 2,441) who have been treated with a PCA have subsequent variceal hemorrhages (1-61, most of which occur in patients whose shunts have occluded. Indeed, shunt occlusion occurs in approximately 7% of patients with end-to-side PCA (7). Presumably, bleeding from varices may also occur in patients with partially occluded or stenotic portacaval shunts. Although the exact frequency of shunt stenosis is not known, we have observed it in about 5% of our patients with PCA (4, 8).
The present report describes a patient who had several episodes of variceal hemorrhage following an end-to-side PCA. Although the shunt was not occluded, a stenosis of the anastomosis between the portal vein and the inferior vena cava was demonstrated, and hemodynamic evaluation showed persistent hypertension of the portal venous system. The PCA was dilated using a balloon dilatation catheter, the stenosis was alleviated, and hemodynamic decompression of the shunt was achieved. This report is the first description of balloon dilatation of a stenotic end-to-side PCA.
CASE REPORT
The patient was a 55-year-old man with histologically proven alcoholic cirrhosis. Following admission for an upper gastrointestinal tract hemorrhage, endoscopy revealed large bleeding, esophageal varices. Hepatic vein