Mesocaval shunt in patient with portocaval transposition

An 18-year-old woman referred for management of medically refractory ascites after liver transplant with portocaval transposition. She had neuroblastoma at the age of 3 with a complicated treatment course leading to complete obstruction of mesenteric veins and biliary disease. Ultimately, she underwent orthotopic liver transplant with a failed surgical thrombectomy of the portal vein; a portocaval transposition was established to create portal inflow. The patient did well for many years until presenting with hypersplenism and refractory ascites. Diagnostic angiography (Fig. 42.1), venography (Fig. 42.2), and liver biopsy with pressure measurements were performed. After multidisciplinary discussion, we crafted a plan to create a percutaneous mesocaval shunt into the portocaval transposition.