When a 58-year-old woman presented to Duke with severe abdominal pain, vomiting, massive esophageal varices, acute mesenteric ischemia, rising lactate levels, and impending liver failure, there was an extremely poor prognosis for her survival.
Charles Kim, MD, Duke University Hospital’s division chief of interventional radiology, was consulted on the case and examined the patient. The diagnosis was dire: her portal vein had been chronically occluded and she had developed new clot in the intrahepatic portal veins and mesenteric veins, which was the underlying cause of her acute symptoms.
“For patients with clotting of the portal venous system, blood thinners are often used to help decrease the amount of clot and restore patency of the blood vessel, but because of her recent major bleeding episode from her extensive esophageal varices, that wasn’t really an option,” Kim explains. We had to treat opposing processes—high bleeding risk as well as undesired clotting in the setting of her intestines and liver progressing towards ischemia and necrosis, he adds.
Kim had an extensive conversation with the family. “I told them we weren’t sure if we could help her, but if we didn’t do anything her chance of dying in the next couple of days was very high.”
With no other reasonable option, Kim proposed a complex and unusual combination of procedures to be performed concurrently:
- Transplenic and transhepatic recanalization of the chronically occluded extrahepatic portal venous system
- Pharmacomechanical thrombectomy of the acute superior mesenteric vein
- Coil embolization of the massive esophageal varices
- Creation of a transjugular intrahepatic portosystemic shunt (TIPS) into the occluded intrahepatic portal venous system
Four physicians performed the 7-hour operation. Kim explains that the success of each procedure depended on the success of the others, and the team was under immense time pressure to succeed with all of them to save the woman’s life.
“There were a lot of highs and lows,” says Kim. “We would succeed at opening up one vessel and then have a setback with clotting of another. There were many points where we might have contemplated giving up because it wasn’t clear if this was futile, but thanks to the fortitude of the entire team we did not give up.”
The patient made a dramatic recovery and five days after the surgery she was discharged, with full resolution of her pain, nausea, liver abnormalities, intestinal viability, and bleeding.
Kim credits the teamwork among hepatologists, transplant and general surgeons, the ICU staff, nurses, anesthesiologists, and ICU and interventional radiology staff with the successful outcome. “There’s a lot of improvisation in our jobs as we enter scenarios never before tackled,” he says. “Because this combination of complex procedures has not been previously attempted or reported in the medical literature, it wasn’t clear if our effort had any chance for success, but thanks to the fortitude of the entire team and constant encouragement, we kept pushing forward despite the uncertainty.”