© Turkish Society of Radiology 2009 P ortal hypertension can be effectively reduced by the surgical cre- ation of a portosystemic shunt. However, in patients after liver transplantation, a preexisting portosystemic shunt may steal the portal blood flow, predisposing the patient to liver dysfunction and even to portal vein thrombosis (1). Moreover, alternate outflow due to a large, active portosystemic shunt has been linked to hepatic encephalopathy (2). Thus, surgical portosystemic shunts must be occluded during the transplantation procedure or soon thereafter. We describe the use of a stent graft to occlude a symptomatic surgical portosystemic shunt in a patient after orthotopic liver transplantation. Case report A 27-year-old woman was referred to our angiography unit 10 days af- ter orthotopic liver transplantation for treatment of a high flow spleno- renal shunt that caused mild disturbances in liver function. The shunt had been identified by findings of a markedly enlarged left renal vein and suprarenal inferior vena cava (IVC) on computed tomography (CT) with contrast medium (Fig. 1), performed as part of the routine pre- transplantation evaluation. The patient reported that the shunt had been surgically created during her childhood in another country. It had been unaccessable for closure during the transplant surgery because of the presence of extensive adhesions. Informed consent was obtained from the patient before the procedure. Owing to the absence of anatomical surgical details, in order to gain access to the shunt, we opted for a retrograde approach from the right femoral vein through the left renal vein into the splenic vein. A 4 F C1 catheter (Terumo, Japan) and a 0.035 inch glidewire (Terumo, Japan) were used. A dilated left renal vein with rapid flow to the IVC was noted, but flow into the portal vein was not demonstrated with several injec- tions of contrast medium (Fig. 2). Vigorous attempts to reach the portal vein from the splenic vein using different catheters were unsuccessful. To reduce the risk of contrast-medium-induced nephropathy, we decid- ed to cannulate the portal vein transhepatically in another session. Un- der fluoroscopic guidance, and after administration of IV sedation, we accessed the right portal vein via the right liver lobe using a 21 G needle (Cook, Bloomington, Indiana, USA) and a Neff set (Cook, Bloomington, Indiana, USA), as in percutaneous transhepatic cholangiography. A 4 F Bernstein catheter (AngioDynamics, New York, USA) over a 0.035 inch glidewire (Terumo, Japan) was used to negotiate into the main portal vein. Direct portography revealed hepatofugal flow toward a splenore- nal shunt and into the left renal vein (Fig. 3). Considering the wide and short communication between the splenic and renal veins, and in order to prevent migration of the emboliz- ing material (Amplatzer vascular plug), we decided to use an IVC fil- INTERVENTIONAL RADIOLOGY CASE REPORT Diagn Interv Radiol DOI 10.4261/1305-3825.DIR.2398-08.1 Stent graft closure of a high flow splenorenal shunt after liver transplantation Sergey Litvin, Eli Atar, Michael Knizhnik, Elchanan Bruckheimer, Alexander Belenky From the Vascular and Interventional Radiology Unit (S.L.  litvin_s@yahoo.com, E.A., M.K., A.B.), Rabin Medical Center, Petah Tikva, Israel; the Department of Pediatric Cardiology (E.B.), Schneider Children Medical Center, Petah Tikva, Israel. Received 21 November 2008; revision requested 24 December 2008; revision received 10 January 2009; accepted 26 January 2009. Published online 25 September 2009 DOI 10.4261/1305-3825.DIR.2398-08.1 ABSTRACT We describe a patient after liver transplantation with a pre- existing surgical splenorenal shunt close to the confluence of the splenic and superior mesenteric veins and a wide, short communication between the splenic and renal veins. To close the shunt, an inferior vena cava filter was inserted in the shunt and a vascular plug was placed in the splenic vein inside the filter. When this failed to stop the flow through the shunt, a covered stent was deployed at the superior mesenteric vein- portal vein junction. Key words:  interventional radiology  liver transplantation  splenorenal shunt