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Percutaneous Transvenous Coil Embolization (PTCE)

Portosystemic shunts are relatively uncommon congenital vascular anomalies that shunt blood from the abdominal organs around the liver and to the heart, thereby preventing detoxification of the shunted blood. Percutaneous transvenous coil embolization (PTCE) is a minimally invasive procedure using fluoroscopy to place intravenous coils to occlude the shunt vessel. PTCE results in a faster recovery, better outcome, reduced complications, and less mortality.

Portosystemic shunts are relatively uncommon congenital vascular anomalies that shunt blood from the abdominal organs around the liver and to the heart, thereby preventing detoxification of the shunted blood.  This can result in clinical signs related to many organ systems including the neurologic (hepatic encephalopathy), urinary, and gastrointestinal systems.  Shunt vessels outside of the liver (extrahepatic portosystemic shunts) can be repaired surgically with minimal complications whereas shunt vessels located within the liver tissue (intrahepatic portosystemic shunts) are more difficult to access surgically.  Percutaneous transvenous coil embolization (PTCE) is a minimally invasive procedure using fluoroscopy to place intravenous coils to occlude the shunt vessel.  PTCE results in a faster recovery, better outcome, reduced complications, and less mortality.

Vascular coils are placed into the abnormal shunt vessel to occlude flow in the vessel.  This allows the flow from the shunt to be redirected back into the liver to detoxify the blood and restore liver function.  These vascular coils are pushed through a catheter that is placed through the jugular vein in the neck, into the vena cava, and then into the shunt.  Multiple coils are placed until blood flow in the shunt is reduced as dictated by the rise in portal pressure and safety for the patient.  Prior to placing the coils, a stent is placed in the vena cava for the sole purpose of holding the coils in place.

  1. The entire procedure is performed through a 3-4 mm catheter placed in the jugular vein.
  2. PTCE provides safe access the shunt without hemorrhage or organ damage.
  1. Bleeding can occur from the jugular access site.
  2. Residual shunting occurs in close to a quarter of individuals and some of those patients will need a second procedure to place additional coils.
  3. Some  intrahepatic porstosystemic shunts (IHPSS) are not amenable to PTCE.

Cal-CT

PTCE was developed for dogs with intrahepatic porstosystemic shunts (IHPSS) since this type of shunt is typically difficult to approach surgically.  PTCE can be used for extrahepatic shunts as well, however these vessels have other options for surgical repair. 

The following workup is generally performed prior to referral for PTCE:

  • CBC, chemistry panel and urinalysis – IHPSS can result in stereotypical abnormalities in liver enzymes, kidney values and protein levels.
  • Bile acids – reuptake of bile acids in the blood stream can be indicative of the presence of a shunt vessel
  • Abdominal ultrasound – indicators of a shunt may be present including a small liver, plump kidneys and alterations in vascular flow. Sometimes the shunt vessel itself can be identified on the ultrasound.  An ultrasound also evaluates for bladder stones that result from an IHPSS which typically do not show up on an x-ray.
  • CT – a CT will identify the location and size of the shunt. It is also absolutely necessary to allow accurate measurement of the vena cava to choose an appropriate size of stent. 

PTCE is appropriate for dogs and cats with a confirmed IHPSS on CT.

IHPSS CT Your pet must be referred by your primary veterinarian.  You and your pet will have a consultation with our specialists, and they will discuss your pet’s condition and the treatment options. Medical management will be initiated consisting of an antibiotic, lactulose and a low protein diet.  These medications reduce the signs of hepatic encephalopathy and can help with postoperative management.  The goal is to taper off of the medications after the shunt is repaired. All dogs with intrahepatic porstosystemic shunts (IHPSS) are placed on omeprazole for life.  This is an acid reducer that has improved the outcome of dogs treated for IHPSS by reducing their propensity for gastrointestinal bleeding.

PTCE is performed by both of our doctors and our entire team.  Dogs are typically discharged the day after the surgery.  A banadge may be present around the neck and can be removed with a couple of days.  A recheck will be scheduled at MISCA within 2 weeks after the procedure.  A complete clinical summary will be provided to you and your veterinarian summarizing the procedure and providing recommendations. 

Pre Stent

Pre stent

Post Balloon

Pre Balloon

Preballoon