Case Report: Percutaneous portal-central venous bypass: a novel salvage therapy for refractory variceal bleeding in TIPS-ineligible patients with portal vein tumor thrombus.

Background: Acute esophagogastric variceal bleeding (EGVB) is a lethal complication in patients with hepatocellular carcinoma (HCC) complicated by portal vein tumor thrombus (PVTT). While transjugular intrahepatic portosystemic shunt (TIPS) is a standard treatment for portal hypertension, it is often contraindicated or technically challenging in patients with extensive main portal vein occlusion (Vp4 type) or severe hepatic dysfunction. Case summary: We report the first clinical application of a novel salvage technique, percutaneous portal-central venous bypass (PPCV), in a 56-year-old man with HCC, decompensated cirrhosis, and extensive PVTT. The patient presented with life-threatening EGVB refractory to endoscopic therapy and was deemed ineligible for TIPS due to the extent of the tumor thrombus and critical instability. PPCV was performed by percutaneously puncturing the portal vein under ultrasound guidance and establishing an extracorporeal shunt connected to a pre-existing subclavian central venous catheter. Results: The procedure was technically successful and achieved immediate hemodynamic improvement. Direct portal venous pressure decreased significantly from 40.6 mmHg pre-connection to 18.8 mmHg post-connection. Clinical hemostasis was achieved within 24 h, and the patient remained stable for 2 weeks until discharge. Although the patient succumbed to tumor progression 2 months later, no recurrent bleeding or procedure-related complications were observed. Conclusion: PPCV is a simple, feasible, and effective salvage therapy for rapidly reducing portal pressure and controlling refractory bleeding. It provides a vital therapeutic option for high-risk HCC patients with PVTT who are contraindicated for TIPS.