S4746 Life-Threatening Variceal Hemorrhage in MASLD Cirrhosis: A Case for Variant Mesocaval Shunt Placement

Introduction: Variceal hemorrhage is a life-threatening complication of portal hypertension in patients with liver cirrhosis. While transjugular intrahepatic portosystemic shunt (TIPS) is a standard intervention for refractory portal hypertension, chronic portal vein thrombosis can render TIPS technically infeasible. In such complex scenarios, alternative approaches like a variant mesocaval shunt, though rarely performed, may offer a life-saving option by providing portal decompression via an extrahepatic route. Case Description/Methods: A 36-year-old woman with metabolic dysfunction-associated steatotic liver disease/metabolic dysfunction-associated steatohepatitis cirrhosis and known esophageal varices presented to the emergency department with multiple episodes of hematemesis, followed by rapid clinical deterioration and hemorrhagic shock. Her hemoglobin was 6 g/dL, prompting activation of a massive transfusion protocol. While in the emergency department, she had ongoing hematemesis and hematochezia. An emergent esophagogastroduodenoscopy revealed large Grade IV esophageal varices, which were partially banded. Additional findings included portal hypertensive gastropathy and gastric varices. Despite aggressive resuscitation, her bleeding persisted. computed tomography imaging revealed chronic portal vein thrombosis with cavernous transformation, extensive gastric and esophageal varices, along with marked splenomegaly. These findings underscored the severity of portal hypertension and excluded her from TIPS candidacy due to chronic thrombosis and anatomy distorsion of portal vein. Discussion: Given her anatomy and clinical instability, she underwent an emergent variant mesocaval shunt procedure, in which a direct extrahepatic connection was created between a short residual segment of the thrombosed main portal vein and the inferior vena cava (IVC), using an 8 cm VIATORR stent. This procedure differs from standard TIPS in that it bypasses the liver entirely, functioning as a mesocaval shunt rather than a portosystemic intrahepatic shunt. Additionally, she underwent splenic pedicle embolization and coil embolization of portogastric and esophageal varices. Post-procedure, the patient stabilized with no further bleeding and a hemoglobin of 11.2 g/dL. This case highlights the utility of variant mesocaval shunt placement as a viable rescue therapy in select patients with portal hypertension and chronic portal vein thrombosis, when standard interventions like TIPS are not an option. Early recognition and multidisciplinary coordination are critical in the successful management of such high-risk cases.