Transabdominal Ultrasound-guided Transjugular Endovascular Mesocaval Shunt Creation in Extrahepatic Portal Vein Obstruction: A Single-center Experience.

Purpose: Extrahepatic portal vein obstruction is a leading cause of upper gastrointestinal bleeding in India, with limited options once first- and second-line treatments fail. We describe a novel, fully endovascular technique for transjugular mesocaval shunt creation using transabdominal ultrasound guidance and report our single-center outcomes in patients with refractory variceal hemorrhage secondary to extrahepatic portal vein obstruction. Materials and Methods: Five consecutive male patients (age range 17-54 years; mean 31.4 years) with confirmed extrahepatic portal vein obstruction in whom surgical shunting or who were unsuitable for portal vein recanalization with transjugular intrahepatic portosystemic shunt underwent transjugular mesocaval shunt creation between 2024 and 2025. Anticoagulation was initiated with intravenous heparin and transitioned to direct oral anticoagulants. Results: Technical success was achieved in all five patients (100%). Mean procedure time was 71 minutes (range 55-100 minutes), mean fluoroscopy time was 48 minutes (range 38.8-62.3 minutes), and mean postprocedural portosystemic pressure gradient was 5.6 mmHg (range 5-6 mmHg), confirming effective shunt decompression in all cases. Single-pass inferior vena cava-to-superior mesenteric vein puncture was achieved in four of five patients (80%). Four patients had previously undergone splenectomy with distal splenorenal shunt, and one had a prior failed surgical mesocaval shunt. One patient underwent combined portal vein recanalization with transjugular intrahepatic portosystemic shunt and mesocaval shunt creation as a bridge to transplantation, underwent liver transplantation after one month, and died of unrelated sepsis. In the remaining four patients, all shunts remained patent on Doppler follow-up (range 7-14 months), with no recurrent variceal bleeding and no procedure-related complications. Conclusions: Transjugular endovascular mesocaval shunt creation using transabdominal ultrasound guidance is feasible, safe, and reproducible in patients with extrahepatic portal vein obstruction who have undergone failed surgical shunting or are unsuitable for portal vein recanalization with transjugular intrahepatic portosystemic shunt. This approach eliminates the need for percutaneous abdominal wall access, computed tomography guidance, or intravascular ultrasound, making it accessible in resource-constrained settings.