Prominent Eustachian Valve Mimicking a Transjugular Intrahepatic Portosystemic Shunt–Associated Thrombosis

CASE REPORT Transjugular intrahepatic portosystemic shunt (TIPS) is an important intervention for treating the complications of portal hypertension but can result in adverse effects, such as thrombosis.1 In this novel case report, a patient with advanced cirrhosis with a TIPS was found to have what appeared to be a mobile thrombus attached at the end of the stent and free-floating within the inferior vena cava (Video 1). The patient was treated with anticoagulation with follow-up ultrasounds revealing no significant changes in size at 6 months (Video 1). In the interim, the patient developed gastrointestinal bleeding secondary to gastric antral vascular ectasia necessitating anticoagulation discontinuation. On further review of venogram imaging (Video 2), the mobile lesion was identified to be a prominent eustachian valve (EV). An EV is an embryological remnant from fetal life responsible for directing oxygen-rich blood from the inferior vena cava toward the foramen ovale.2 Although typically benign, it has been previously mistaken for intracardiac mass or atrial thrombus.3,4 EVs are typically diagnosed with ultrasound imaging and can be difficult to identify unless an experienced radiologist knows to look for them.4 This case highlights the importance of broadening the differential to include mimickers for suspected TIPS thrombosis that do not respond to anticoagulation. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Video of a prominent eustachian valve that was initially mistaken to be a mobile thrombus attached to the end of a TIPS and free-floating within the IVC. Video on the left is the patient\u0027s initial ultrasound and video on the right is 6 months later.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_bjxbyoez"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2","caption":"Hepatic venogram completed by interventional radiology confirming the presence of a prominent eustachian valve.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_69uws2b0"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} DISCLOSURES Author contributions: G. Malik: patient chart review, writing a manuscript draft with review and editing; E. Herget: performing ultrasound and clot assessment, manuscript review and editing; HH Nguyen: patient's primary physician, manuscript review and editing; MG Swain: overall responsibility for conduct and coordination and is the article guarantor Video 2. Financial disclosure: None to report. Informed consent was obtained for this case report.