Department of Radiology, McMaster University Medical Center, Hamilton Health Sciences, Hamilton, Ontario, Canada.
Management of clinically important sequelae of portal hypertension, such as variceal bleeding and ascites, may involve a combination of medical, endoscopic, surgical, and interventional approaches and procedures. Although clinically significant esophageal and rectal varices are typically visible endoscopically, ectopic varices may require multiplanar portal venous phase computed tomography or magnetic resonance imaging for diagnosis. A detailed understanding of individual vascular anatomy, flow dynamics, and patient-related factors such as cardiac and hepatic status is necessary for appropriate treatment selection in patients with complicated portal hypertension. The hepatic venous pressure gradient is the key indirect measurement of portal venous pressure. Transjugular intrahepatic portosystemic shunt (TIPS) placement is regarded as the archetypal intervention for treating complicated portal hypertension by reducing portal pressure. Various modifications, such as direct portocaval shunt, may be used in patients with challenging vascular anatomy. A subset of patients with obstructed hepatic venous outflow or portal venous inflow should be considered for recanalization. Splenic artery embolization may be considered for reduction of portal pressure in selected patients, particularly when hypersplenism or splenic vein occlusion is a prominent feature. Gastric and ectopic varices may bleed even when the portal pressure is low, and balloon-occluded retrograde transvenous obliteration (BRTO) in such patients may lead to equal or improved outcome compared with TIPS placement. BRTO is not limited by poor hepatic reserve or encephalopathy; however, it does not reduce portal pressure and may aggravate esophageal varices. Interventional radiology plays an important role in maintaining the patency of surgically created portosystemic shunts, and it remains at the forefront of new approaches in shunt design and placement.