Virginia Via Research Day Book 2026

Medical Student Research Case Reports

17 PORTAL VEIN RECANALIZATION IN A YOUNG FEMALE WITH CHRONIC MAIN PORTAL VEIN OCCLUSION AND CAVERNOUS TRANSFORMATION: A CASE REPORT

Cassandra Pfeiffer, OMS-III; Cane Hoffman, MD Corresponding author: cpfeiffer@vcom.edu

VCOM-Virginia, Blacksburg, Virginia

Chronic occlusion of the main portal vein can result from inflammation, thrombosis, infection, or surgical injury, leading to portal hypertension and compensatory cavernous transformation. These fragile periportal varices significantly increase the risk of hemorrhage during hepatobiliary surgery, often rendering operative intervention unsafe. Portal vein recanalization (PVR) provides a minimally invasive method to restore hepatopetal flow, decompress collateral vessels, and enable definitive surgical management. We report the case of a 26-year-old woman who presented for evaluation of PVR following recurrent right-upper quadrant pain, fever, and sepsis one year after a subtotal cholecystectomy. Clinical and imaging evaluation suggested retained gallstones within the gallbladder remnant. A planned completion cholecystectomy was aborted when laparoscopic entry revealed large, engorged periportal varices, creating prohibitive bleeding risk. Contrast-enhanced computed tomography demonstrated complete chronic occlusion of the main portal vein extending to its bifurcation, with

extensive cavernous transformation. Distal right and left intrahepatic portal branches remained patent, and overall liver morphology was preserved. Chronic inflammatory injury related to prior severe cholecystitis was suspected as the underlying etiology. Given ongoing sepsis and the need for definitive biliary surgery, PVR was planned to reduce variceal burden and allow safe operative intervention. Under combined ultrasound and fluoroscopic guidance, transsplenic access to a peripheral splenic vein and transhepatic access to the right and left intrahepatic portal branches were obtained, facilitating a rendezvous approach. Venography confirmed hepatofugal flow and extensive pericholedochal and periportal collateralization. Recanalization and stent placement successfully re established continuous hepatopetal flow into both intrahepatic branches. PVR in non-cirrhotic patients with chronic extrahepatic portal vein obstruction is increasingly recognized as an effective strategy to reverse portal hypertension, decompress cavernous transformation, and improve hepatic perfusion.

Literature from tertiary centers reports technical success rates of approximately 85–90% with significant reduction in collateralization. This case utilized a dual-access transsplenic–transhepatic approach, taking advantage of patent intrahepatic branches and avoiding the need for transjugular intrahepatic portosystemic shunt. By restoring hepatopetal flow, PVR markedly reduced periportal variceal risk and facilitated planning for definitive completion cholecystectomy. This case illustrates that portal vein recanalization can convert an unsafe operative field into one suitable for definitive hepatobiliary surgery, even in complex vascular-biliary pathology. Multidisciplinary collaboration between interventional radiology and hepatobiliary surgery is essential to achieve optimal outcomes in such high-risk patients.

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54 Edward Via College of Osteopathic Medicine (VCOM)