Early TIPS failure in association with left mesenterico-gonadal spontaneous portosystemic venous shunt; a case report

Transjugular intrahepatic portosystemic shunt (TIPS) periprocedural thrombosis rates have fallen significantly since the introduction of polytetrafluoroethylene-covered stent grafts. We present a case of a cirrhotic patient with portal hypertension presenting with early TIPS thrombosis in association with an underlying competing spontaneous left mesenterico-gonadal venous shunt, an uncommon variant of spontaneous portal systemic shunt (SPSS). The patient presented with bleeding distal duodenal varices refractory to endovascular therapy, and although a successful TIPS procedure was performed for this indication, early thrombosis was determined by follow-up abdominopelvic computed tomographic angiography (CTA) scan. Despite undergoing a standard TIPS revision procedure, blood flow through the TIPS remained hepatofugal. During a TIPS revision, portal vein angiography revealed competing large inferior mesenteric vein (IMV) varices shunting into the left renal vein via the left gonadal vein. The initial abdominal CTA was later reviewed by a non-invasive cardiovascular radiologist, and the presence of the competing left mesenterico-gonadal shunt was retrospectively identified. Radiologists interpreting CTA exams should be aware of SPSS generally and mesenterico-gonadal shunts specifically. Pre-procedural knowledge of underlying SPSS can affect post procedural outcomes and should be emphasized in the final CTA report.