Use of balloon-expandable stents in transjugular intrahepatic portosystemic shunts in cases of Wallstent endoprosthesis technical failure and revision of shunt stenosis

Thirteen patients underwent placement of a balloon-expandable stent either at initial transjugular intrahepatic portosystemic shunt (TIPS) creation (n = 3) because of immediate technical failure of the Wallstent or at shunt revision because of failure of the Wallstent to reduce the portosystemic gradient 相似文献   

A new nitinol monofilament stent: early experience with use for transjugular intrahepatic portosystemic shunts

The purpose of this study was to investigate the suitability of a new nitinol monofilament stent (Niti-S) for transjugular intrahepatic portosystemic shunt (TIPS) creation. TIPS was performed with a Niti-S stent in 22 patients for variceal bleeding (n = 20) or intractable ascites (n = 2). The efficacy, complication, and patency rates during the follow-up period (up to 27 months, mean 13.9 months) were evaluated. TIPS was successfully performed in all patients. The mean portosystemic pressure gradient decreased from 23.8 ± 7.2 mmHg to 10.2 ± 3.1 mmHg. No mortality or significant morbidity was encountered at 1 month. Variceal bleeding and/or ascites were controlled in all patients. Primary patency rates were 77.3% at 6 months and 71.8% at 1 year. Secondary patency rates were 95.4% up to 26 months. TIPS with the Niti-S stent produced short-term technical and clinical results comparable to the other commercially available stents. A prospective randomized comparison study is indicated.     

Treatment of Budd-Chiari syndrome with transjugular intrahepatic portosystemic shunt (TIPS)

PURPOSE: This study was performed to evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of patients affected by Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: From January 1999 to December 2006, 15 patients (seven male and eight female subjects, age range 7-52 years) with BCS uncontrolled by medical therapy were treated with TIPS placement. In seven cases BCS was idiopathic, in four it was caused by myeloproliferative disorders and in four by other disorders. One patient also had portal vein thrombosis. In 5/15 cases TIPS was created through a transcaval approach. Eight patients (53.4%) received a bare stent, and seven (46.6%) received a stent graft. The follow-up lasted a median of 29.4 (range 3.2-68) months. RESULTS: Technical success was achieved in all patients without major complications. TIPS was very effective in decreasing the portosystemic pressure gradient from 26.2+/-5.8 to 10+/-6.2 mmHg. All patients but two were alive at the time of writing. Acute leukaemia was the cause of the single early death and was unrelated to the procedure. The patient with portal vein thrombosis underwent thrombolysis before TIPS, but the vein occluded again after 3 weeks, and the patient died 6 months later. The other patients showed significant improvements in liver function, ascites and symptoms related to portal hypertension. Primary patency was 53.3%, and primary assisted patency was 93.3%. No patient required or was scheduled for liver transplantation. CONCLUSIONS: TIPS is an effective and safe treatment for BCS and may be considered a valuable alternative to traditional surgical portosystemic shunting or liver transplantation.     

Pull-Through Technique for Recanalization of Occluded Portosystemic Shunts (TIPS): Technical Note and Review of the Literature

Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction is an important problem after creation of shunts. Most commonly, TIPS recanalization is performed via the jugular vein approach. Occasionally it is difficult to cross the occlusion. We describe a hybrid technique for TIPS revision via a direct transhepatic access combined with a transjugular approach. In two cases, bare metal stents or polytetrafluoroethylene (PTFE)-covered stent grafts had been placed in TIPS tract previously, and they were completely obstructed. The tracts were inaccessible via the jugular vein route alone. In each case, after fluoroscopy or computed tomography-guided transhepatic puncture of the stented segment of the TIPS, a wire was threaded through the shunt and snared into the right jugular vein. The TIPS was revised by balloon angioplasty and additional in-stent placement of PTFE-covered stent grafts. The patients were discharged without any complications. Doppler sonography 6 weeks after TIPS revision confirmed patency in the TIPS tract and the disappearance of ascites. We conclude that this technique is feasible and useful, even in patients with previous PTFE-covered stent graft placement.     

Results of a retrospective multicenter trial of the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt creation

PURPOSE: To report the results of a multicenter experience with the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt (TIPS) creation in which patency and clinical outcome were evaluated. MATERIALS AND METHODS: One hundred consecutive patients with portal hypertension, with a mean age of 52 years (range, 22-86 years), underwent implantation of the Viatorr TIPS stent-graft at one of three hospital centers. The indications for TIPS creation were variceal bleeding (n = 81) and refractory ascites (n = 19). Twenty patients had Child-Pugh class A disease, 46 had class B disease, and 34 had class C disease. Eighty-seven patients underwent de novo TIPS placements, with 13 treated for recurrent TIPS stenosis. Sixty-two patients were available for follow-up portal venography and portosystemic pressure gradient (PSG) measurement commencing 6 months after Viatorr stent-graft placement. RESULTS: The technical success rate was 100%. TIPS creation resulted in an immediate decrease in mean PSG (+/-SD) from 21 mm Hg +/- 6 to 7 mm Hg +/- 3. Acute repeat intervention (within 30 days) was required for portal vein thrombosis (n = 1), continued bleeding (n = 3), and encephalopathy (n = 1). The all-cause 30-day mortality rate was 12%. Two patients developed acute severe refractory encephalopathy, which led to death in one case. New or worsening encephalopathy was identified in 14% of patients. The incidence of recurrent bleeding was 8%. The cumulative survival rate at 1 year was 65%. Sixty-two patients available for venographic follow-up had a mean PSG of 9 mm Hg +/- 5 at a mean interval of 343 days (range, 56-967 days). There were four stent-graft occlusions (6%) and seven hemodynamically significant stenoses (11%), four within the stent-graft and three in the non-stent-implanted hepatic vein. The primary patency rate at 1 year by Kaplan-Meier analysis was 84%. CONCLUSIONS: This retrospective multicenter experience with the Viatorr stent-graft confirms the preliminary findings of other investigators of good technical results and improved patency compared with bare stents. Early mortality and symptomatic recurrence rates are low by historical standards. The theoretical increase in TIPS-related encephalopathy was not demonstrated. Longer-term follow-up will be required to determine whether the additional cost of the Viatorr stent-graft will be offset by reduced surveillance and repeat intervention.     

Dacron-covered stent-grafts in transjugular intrahepatic portosystemic shunts: initial experience

PURPOSE: To retrospectively review the authors' experience with use of a Dacron-covered stent-graft in transjugular intrahepatic postosystemic shunts (TIPS). MATERIALS AND METHODS: The need for internal review board approval was waived. Informed consent was obtained from all patients. The study was compliant with the Health Insurance Portability and Accountability Act. A retrospective analysis was performed of 16 patients who received a Dacron-covered stent-graft during revision or de novo creation of TIPS. There were 13 men and three women aged 44-80 years (mean age, 61 years). Primary unassisted and assisted patency rates and secondary patency rates were estimated. The primary unassisted patency of patients who underwent de novo placement of stent-grafts (n = 10) was compared with that of patients with stent-grafts placed during shunt revision (n = 6); in all patients, stent-grafts were placed within stents. Primary unassisted patency was also compared between patients in whom the covered stent was confined to the parenchymal tract (n = 7) and those in whom the stent extended 1 cm or more into the portal vein (n = 9). Patency was estimated with the Kaplan-Meier method, and group comparisons were performed with the log-rank test. RESULTS: Primary unassisted patency rates following stent-graft placement at 4, 12, and 24 months (+/- standard error) were 64% +/- 14, 54% +/- 15, and 40% +/- 16, respectively. The rates for primary assisted patency were 78% +/- 12, 67% +/- 14, and 67% +/- 14 and those for secondary patency were 91% +/- 9, 81% +/- 12, and 54% +/- 23. At 12 months, primary unassisted patency with de novo stent-graft placement was 90% +/- 9, whereas that with stent-grafts placed during TIPS revision was 17% +/- 15 (P = .005). At 12 months, the primary unassisted patency in patients with stent-grafts confined to the parenchymal tract was 75% +/- 22, and that of patients with stent-grafts extending at least 1 cm into the portal vein was 40% +/- 17 (P = .21). CONCLUSION: In this small series, satisfactory long-term patency was observed among patients in whom Dacron-covered stent-grafts were placed during revision or de novo creation of TIPS. More favorable outcomes were observed when the stent-graft was placed during de novo TIPS creation and when the device was confined to the parenchymal tract.     

Creation of transjugular intrahepatic portosystemic shunts with stent-grafts: initial experiences with a polytetrafluoroethylene-covered nitinol endoprosthesis.

PURPOSE: To evaluate the safety and performance of a recently developed expanded polytetrafluoroethylene (ePTFE)-covered nitinol stent-graft to create transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension and related complications. MATERIALS AND METHODS: The ePTFE-covered nitinol stent-graft was used to create TIPS in 16 patients with recurrent variceal bleeding (n = 13) or refractory ascites (n = 3). Follow-up was performed with duplex ultrasonography, clinical assessment, and venography at 6 months. Technical success and portosystemic pressure gradients (PPGs) before and after stent-graft implantation and at follow-up were assessed. Two patients died during follow-up. Histopathologic follow-up data were available for one patient at autopsy and for the other after liver transplantation. RESULTS: The implantation technical success rate was 100%. Mean (+/- SD) PPG was reduced from 24 mm Hg +/- 5 to 9 mm Hg +/- 2. Histopathologic analysis of the explanted endoprostheses revealed no inflammatory response or neointima formation. The venographic follow-up data available for 10 patients demonstrated 100% in-graft patency (mean follow-up, 289 days +/- 26). Revisions with implantation of a new ePTFE-covered nitinol stent-graft or another commercially available stent in 10 patients were necessary because of hepatic vein stenosis above the grafted portion and/or relative diameter mismatch causing TIPS dysfunction. CONCLUSION: The ePTFE-covered nitinol stent-graft was used successfully to create TIPS and has the potential to prolong TIPS patency upon complete coverage to the hepatocaval junction.     

Intravascular ultrasound-guided direct intrahepatic portacaval shunt: midterm follow-up

PURPOSE: To describe the midterm patency and clinical results of the intravascular ultrasound (US)-guided direct intrahepatic portacaval shunt (DIPS) procedure for the treatment of intractable ascites and variceal bleeding. MATERIALS AND METHODS: From February 23, 1999, to December 18, 2002, inferior vena cava (IVC)-to-portal vein (PV) shunts were created in 40 patients for ascites (n = 35) and bleeding (n = 5). Intravascular US was used to guide direct puncture from the IVC to the PV. The shunts were completed with the use of single (n = 15) or overlapping (n = 25) polytetrafluoroethylene (PTFE)-covered Palmaz stents. These stent-grafts were deployed primarily at diameters of 8 mm. The diameter of the shunt was increased in three cases to achieve a target portosystemic gradient (PSG) of 15 mm Hg or lower. All patients were followed clinically and with portography with manometry. RESULTS: All DIPSs were created successfully. Mean PSGs were reduced from 23 mm Hg before DIPS creation to 9 mm afterward. During the follow-up period of a maximum of 38 months, 22 of 40 patients died or underwent liver transplantation (mean follow-up, 9 months; median, 6 months). At the time of this report, 18 of 40 patients remain living after follow-up ranging in duration from 8 to 38 months (mean, 22 months; median, 16.5 months). During the follow-up period, there was one stent-graft occlusion and three stenoses. These four patients were successfully treated by additional stent-graft placement. In addition, two patients developed IVC stenosis cephalad to the DIPS, which required IVC stent placement. The primary patency rates by Kaplan-Meier analysis were 100% at 6 months and 75% (95% CI, 53%-97%) at 12 months. CONCLUSION: Intravascular US-guided direct IVC-to-PV shunts may be created successfully with minimal complications. Primary patency of the shunt is greater than that with conventional TIPS with a bare wire stent and appears equal to that with TIPS with a PTFE-covered stent-graft.     

Combined transhepatic and transjugular approach for mechanical thrombectomy of massive TIPS thrombosis

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated decompressive therapy option to manage ascites and variceal bleeding secondary to portal hypertension. Complications following TIPS procedures include hepatic encephalopathy, liver failure, and TIPS dysfunction. TIPS dysfunction is due to occlusion or stenosis of the TIPS shunt and can be caused by acute or chronic thrombosis. TIPS thrombosis is often treated with mechanical thrombectomy or catheter-directed thrombolytic therapy. Most cases of in-stent occlusion can be treated via a transjugular approach with recanalization or placement of additional stents. We present a case of a 72-year-old female who presented with worsening ascites 17 months after initial TIPS procedure; she was found to have a large thrombus completely occluding the TIPS stent. In our case, a combined transhepatic and transjugular approach was required for TIPS revision given the extent of well-organized clot located near the hepatic venous end of the stent, resulting from prolonged stent occlusion. This was an extremely challenging scenario with two overlapping covered stents and a bare metal stent at the hepatic venous end in the setting of chronic thrombosis and a well-organized fibrous cap. The case highlights the need for optimal initial placement of the primary TIPS shunt to avoid the need for subsequent complex interventions to maintain TIPS shunt patency.     

Portal venous stent placement in patients with pancreatic and biliary neoplasms invading portal veins and causing portal hypertension: initial experience.

PURPOSE: To evaluate the clinical usefulness of portal venous stent placement in patients with pancreatic or biliary neoplasms invading portal veins and causing portal hypertension. MATERIALS AND METHODS: Thirteen patients underwent portal venous stent placement because of gastrointestinal bleeding (n = 8), risk of gastroesophageal varix rupture (n = 4), ascites (n = 4), thrombocytopenia (n = 3), and/or portal venous thrombosis (n = 3). The main portal vein or both the intrahepatic and main portal veins were invaded in six patients (group A). The main portal vein and splanchnic veins were involved in seven patients (group B). Stents were placed across the stenotic (n = 8) or occluded (n = 5) lesions after percutaneous transhepatic portography. Changes in portal venous pressure, stent patency, and survival were evaluated. RESULTS: Mean portal venous pressure decreased significantly immediately after stent placement, from 24.9 mm Hg +/- 5.9 (SD) to 15.8 mm Hg +/- 4.6 (P <.001). In group A, blood flow through the stent was maintained and the symptoms had subsided at follow-up (mean, 12.5 months). In group B, symptoms were improved in five patients, but the stents were occluded in all but one patient at a mean follow-up of 1.5 months. There was a significant difference in stent patency between the patients with (14%) and those without (100%) splanchnic venous involvement (P <.01). CONCLUSION: Stent placement helped to relieve portal hypertension symptoms. Splanchnic venous involvement was associated with worse stent patency.     

Mechanical thrombectomy of acute thrombosis in transjugular intrahepatic portosystemic shunts

RATIONALE AND OBJECTIVES: To evaluate the feasibility of mechanical thrombectomy with the use of the Amplatz thrombectomy device (ATD) in restoring patency to acutely thrombosed stent-shunts after transjugular intrahepatic portosystemic shunt (TIPS) placement. METHODS: Mechanical thrombectomy with the ATD was performed in 10 consecutive patients with angiographically documented complete thrombosis of the stent-shunt (mean +/- SD, 6.6 +/- 3.4 cm), which occurred an average of 2.8 months (range, 0-11 months) after the TIPS procedure. RESULTS: In all patients, immediate restoration of patency of the stent-shunt was achieved after thrombectomy alone (n = 1), thrombectomy plus percutaneous transluminal angioplasty (PTA; n = 4), and thrombectomy, PTA, and stenting (n = 5). The mean activation time of the ATD was 253 +/- 43 seconds. The pressure gradient for portal decompression decreased from 23 +/- 6 mmHg before to 11 +/- 3 mmHg after the procedure. The primary patency rate was 80% at 3 months and 60% at 11 months. CONCLUSIONS: Mechanical thrombectomy with the ATD in acutely thrombosed TIPS is technically feasible. Mechanical thrombectomy is a potential alternative to thrombolysis.     

Correlation between portal/hepatic vein gradient and response to transjugular intrahepatic portosystemic shunt creation in refractory ascites

PURPOSE: Transjugular portosystemic shunt (TIPS) creation is widely used in the treatment of patients with refractory ascites caused by portal hypertension. Although it is well-established that an optimal portosystemic gradient (PSG) to prevent recurrent variceal bleeding should be lower than 12 mm Hg, there are no clear data on the correlation between the post-TIPS portal/hepatic vein gradient (PHG) and control of ascites. The purpose of the present study was to determine whether there was any correlation between PHG and control of ascites after TIPS creation. MATERIALS AND METHODS: Portal/hepatic vein gradients before and after TIPS creation were studied in 28 patients who underwent TIPS creation. A multivariate analysis was performed to determine whether the portal/hepatic vein gradient independently predicted response to TIPS. Patients were considered responders if ascites disappeared or there was no further need for paracentesis. Patients were considered nonresponders if they required repeat paracentesis one or more months after TIPS creation. RESULTS: Among patients who experienced a response, the mean pre-TIPS PHG was significantly higher than that in those who did not respond (20.9 mm Hg +/- 5.1 vs 15 mm Hg +/- 3.4; P = .002). A higher pre-TIPS PHG was predictive of better response independent of severity of liver disease and serum creatinine level (odds ratio, 2.45; 95% CI, 1.23-4.9; P = 0.011). CONCLUSION: If the findings established in this study are confirmed in prospective long-term studies, a pre-TIPS PHG measurement can be a useful tool in helping clinicians assess the potential benefit of TIPS in refractory ascites.     

Transjugular intrahepatic portosystemic shunt with an autologous vein-covered stent: results in a swine model.

PURPOSE: To investigate the feasibility, safety, and efficacy of an autologous vein-covered stent (AVCS) to prevent shunt stenosis in a porcine transjugular intrahepatic portosystemic shunt (TIPS) model. MATERIALS AND METHODS: TIPS were created with an AVCS in 12 healthy domestic swine and with a bare stent in 10 additional swine. Tissue response was compared with use of venography, histology, and computerized morphometry analysis 2 weeks after implantation. Differences between AVCS and noncovered stents (established by a t-test), as well as regional differences within a single stent (established by an f test), were considered significant at P <.05. RESULTS: Twenty of 22 TIPS procedures were technically successful. Ten of 12 shunts with an AVCS (83%) and two of 10 with bare stents (20%) remained patent (<50% diameter narrowing) at euthanasia 2 weeks later (P <.01). Histologic evaluation of harvested bare stents showed marked intimal hyperplasia (IH), composed of smooth muscle cells, myofibroblasts, and fibroblasts. In contrast, the AVCS were remarkably free of IH and thromboses. In patent TIPS in both groups, endothelial coverage of the luminal surface was present histologically. IH accounted for 57% (26.27/45.79) of total stent cross-sectional lumen area in the control group and 21% (8.34/39.54) in the AVCS group (P <.01), with no intrashunt differences (P >.05). CONCLUSION: Based on short-term follow-up, AVCS significantly improved TIPS patency by prevention of both IH and in-stent thrombosis. TIPS created with an AVCS was feasible and safe in our porcine model.     

Fifteen years’ experience with transjugular intrahepatic portosystemic shunt (TIPS) using bare stents: retrospective review of clinical and technical aspects

Purpose

The authors present a retrospective analysis of a large series of patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement.

Materials and methods

Between March 1992 and December 2006, 658 patients were referred to our centre for TIPS placement. Indications for the procedure were digestive tract bleeding (52.8%), refractory ascites (35.3%), preservation of portal vein patency prior to liver transplantation (3.0%) and thrombosis of the suprahepatic veins (2.3%). Other indications (6.6%) included pleural ascites, portal thrombosis and hepatorenal and hepatopulmonary syndromes. All patients were evaluated with colour Doppler ultrasonography and in a few cases with computed tomography. The portal system was punctured under sonographic guidance. Wallstent, Palmaz and Nitinol thermosensitive stents were used. Embolisation of persistent varices was performed in 6.8% of cases.

Results

Technical success was 98.9%. During a 1,500-day follow-up, the cumulative incidence of stent revision was 25.7% (Nitinol), 32.9% (Wallstent) and 1.8% (Palmaz). Mortality rates were 31.1%, 38.5% and 56.4%, respectively. The technical complications included six cases of heart failure, six of haematobilia, three of stent migration, two of intrahepatic haematoma and one of haemoperitoneum. Eight patients with severe portosystemic encephalopathy (PSE) were treated with a reduction stent.

Conclusions

TIPS placement is safe and effective and may act as a bridge to liver transplantation. Ultrasonography plays a fundamental role in the preliminary assessment, in portal vein puncture and during the follow-up. Stent patency is satisfactory.     

内皮祖细胞种植支架在经颈静脉肝内门体分流术中应用的实验研究

目的 评价内皮祖细胞(EPC)种植支架在经颈静脉肝内门腔分流(TIPS)家猪动物模型中减少分流道再狭窄的疗效.方法 体外分离、培养、鉴定家猪外周血内皮祖细胞,并构建内皮祖细胞种植支架.15头家猪行TIPS介入手术,采用随机区组设计分为EPC种植支架组9头(实验组),裸支架组6头(对照组).术后14 d行直接门静脉造影,然后处死动物,作病理分析及免疫组织化学检查,记录分流道狭窄及阻塞率,并用图像处理软件计算TIPS分流道假性内膜厚度及面积.计数资料用Fisher精确概率法,计量资料行t检验,作统计学分析.结果 15头猪TIPS手术均成功.实验组分流道通畅5头,狭窄2头(狭窄率50%、70%),阻塞2头(共9头).对照组狭窄1头(狭窄率80%),阻塞5头(共6头).2组通畅率差异有统计学意义(P=0.03).实验组假性内膜增生的厚度(肝静脉、肝实质、门静脉段)显著小于对照组[分别为(1.0 ±0.6)、(0.9±0.5)、(1.0±0.4)mm和(1.2±0.4)、(1.3±0.5)、(1.5±0.4)mm,P值均＜0.05].免疫组织化学显示实验组中通畅的分流道有完整的内皮形成;再狭窄分流道的假性内膜主要由胶原纤维组成,而通畅分流道的假性内膜主要由细胞成分组成.结论 体外构建EPC种植支架是可行的,置入后促进了家猪模型TIPS分流道内皮化形成,可以提高分流道的通畅性.     

Symptomatic spleno-mesenteric-portal venous thrombosis: recanalization and reconstruction with endovascular stents

PURPOSE: To evaluate the safety and efficacy of portal reconstruction in patients with symptomatic spleno-mesenteric-portal venous thrombosis. MATERIALS AND METHODS: Portal reconstruction was attempted in 21 patients (seven women, 14 men; mean age, 53.6 years +/- 15.2) with chronic thrombosis of the portal vein alone (n = 8), splenic vein alone (n = 3), or portal, mesenteric, and splenic veins (n = 10). Indications for the procedure were bleeding varices (n = 15), ascites (n = 2), hypersplenism (n = 2), and enteropathy (n = 2). Sixteen procedures were started transhepatically and of these seven were converted to a transjugular intrahepatic portosystemic shunt (TIPS) after successful recanalization of the thrombosed vein. In six patients reconstructions were performed using an intrahepatic portal vein as outflow. Five procedures were performed primarily as TIPS. Wallstents dilated to 7-10 mm were used for reconstruction. The mean follow-up period was 15.2 months +/- 15.9. RESULTS: Technical success of portal reconstruction was 85.7% (18 of 21). Thirty-day mortality was 14.3% (three of 21) but was not procedural related. The cumulative rates of survival, primary patency, and palliation at 43 months of follow-up were 61.2% +/- 13.5%, 63.5% +/- 15.3%, and 31.7% +/- 15.7%, respectively. Secondary patency was 79.1% +/- 13.8%. The only predictor of mortality was the presence of liver disease (P = .001, Cox regression). CONCLUSION: Portal reconstruction is a safe and effective treatment option for patients with symptomatic chronic portal thrombosis. Liver disease predisposes to a higher mortality.     

Role of parallel transjugular intrahepatic portosystemic shunts in patients with persistent portal hypertension.

Transjugular intrahepatic portosystemic shunts (TIPS) were placed in 93 patients between June 1990 and January 1992 for treatment of variceal hemorrhage. In each case, a Wallstent (Schneider USA, Minneapolis) was used to support the hepatic parenchymal tract between the hepatic and portal veins. Currently, these stents have a maximal diameter of 10 mm. In eight of 93 patients, major portal hypertension persisted after placement of a 10-mm-diameter shunt, manifested by continued rapid variceal filling and elevated portosystemic gradients. A second TIPS was placed parallel to the first in these patients to allow further portal decompression. In two other patients, a second TIPS was placed because the initial shunt functioned suboptimally. The mean postprocedural portosystemic gradient in the patients who received one TIPS was 10.2 mm Hg +/- 3.7. In patients who received two TIPS, the mean postprocedural gradient was 19.1 mm Hg +/- 3.8 after placement of the first TIPS and 12.5 mm Hg +/- 3.5 after placement of the second. Two patients developed their first episode of encephalopathy after placement of two TIPS. The methods and indications for placing two TIPS in this select population are discussed.     

TIPS recubierto en niños. Estudio preliminar sobre su seguridad y permeabilidad

Objective

To retrospectively analyze the safety and efficacy of transjugular intrahepatic portosystemic shunting (TIPS) using covered stents in children.

Material and methods

We present 6 children (mean age, 10.6 years; mean weight, 33.5 kg) who underwent TIPS with 8 mm diameter Viatorr^® covered stents for acute (n=4) or recurrent (n=2) upper digestive bleeding that could not be controlled by endoscopic measures. Five of the children had cirrhosis and the other had portal vein thrombosis with cavernous transformation. We analyzed the relapse of upper digestive bleeding, the complications that appeared, and the patency of the TIPS shunt on sequential Doppler ultrasonography or until transplantation.

Results

A single stent was implanted in a single session in each child; none of the children died. The mean transhepatic gradient decreased from 16 mmHg (range: 12-21 mmHg) before the procedure to 9 mmHg (range: 1-15 mmHg) after TIPS.One patient developed mild encephalopathy, and the girl who had portal vein thrombosis with cavernous transformation developed an acute occlusion of the TIPS that resolved after the implantation of a coaxial stent.Three children received transplants (7, 9, and 10 months after the procedure, respectively), and the patency of the TIPS was confirmed at transplantation. In the three remaining children, patency was confirmed with Doppler ultrasonography 1, 3, and 5 months after implantation. None of the children had new episodes of upper digestive bleeding during follow-up after implantation (mean: 8.1 months).

Conclusion

Our results indicate that TIPS with 8 mm diameter Viatorr^® covered stents can be safe and efficacious for the treatment of upper digestive bleeding due to gastroesophageal varices in cirrhotic children; our findings need to be corroborated in larger series.     

Autologous vein stent-graft: feasibility study

PURPOSE: To evaluate expandable stents healed into vein wall as autologous vein stent-grafts for endoluminal grafting. MATERIALS AND METHODS: Balloon expandable stents were placed into external jugular veins of eight dogs. Stent and vein patency was followed by ultrasonography. Five weeks after stent placement, jugular veins with endothelialized stent were harvested. The autologous vein stent-grafts were divided into two groups. In group A, autologous vein stent-grafts (n = 3) were placed immediately into Baker solution for microscopic examination. In group B, autologous vein stent-grafts (n = 3) underwent mechanical manipulation; they were compressed, mounted on angioplasty balloon, pushed through a 9-F sheath and dilated. The autologous vein stent-graft endothelialization and changes after mechanical manipulation were evaluated by light and electron microscopy. RESULTS: Stent placement was successful in seven dogs. One stent migrated into the pulmonary artery. One well placed stent was damaged by compression dressing and thrombosed. At 5 weeks, gross and microscopic examinations revealed the autologous vein stent-grafts were fully covered by a 0.115- +/- 0.036-mm-thick neointimal layer. Small wall thrombus was observed in one autologous vein stent-graft. Repeated manipulations did not result in any intimal damage or stent loosening in the autologous vein stent-grafts. CONCLUSION: Expandable stents healed into a vein have potential to be used as autologous vein stent-grafts for endoluminal grafting without risk of disruption during percutaneous transcatheter introduction.     

Combined Y-configured stents for revising occluded transjugular intrahepatic portosystemic shunt

PURPOSEWe aimed to determine the technical feasibility, safety and prognosis of the transjugular intrahepatic portosystemic shunt (TIPS) revision by combined Y-configured stents placement.METHODSWe retrospectively evaluated 12 patients who received TIPS revision using Y-stenting technique between June 2015 and January 2019. The rates of technical success, complication, shunt patency, hepatic encephalopathy and mortality were described and analyzed.RESULTSThe combined Y-configured stents were successfully placed in 11 of 12 patients (92%) without major complications. The median portosystemic pressure gradient (PPG) decreased from 23 mmHg (interquartile range, IQR, 18.5–27.5 mmHg) to 10 mmHg (IQR, 9–14 mmHg). The left internal jugular vein approach was used in 5 patients. Four patients required a shunt extension with an extra stent to resolve the stenosis at the portal venous terminus. Two patients developed hepatic encephalopathy, which was medically controlled within 3 months after the procedure. The TIPS patency and survival rates were both 100% during a median follow-up period of 10 months (IQR, 5.5–14 months).CONCLUSIONTIPS revision by combined Y-configured stents placement was technically feasible and safe with favorable clinical outcomes.

Transjugular intrahepatic portosystemic shunt (TIPS) has been widely used for the treatment of portal hypertension complications by decompressing the portal venous system (1). Shunt patency has been greatly improved since the introduction of dedicated polytetrafluoroethylene-covered stents. However, dysfunction still occurs in 8%–20% of patients within the first year after TIPS creation (2).TIPS dysfunction can arise from acute thrombosis and pseudointimal hyperplasia within the stent or at the hepatic vein outflow (3–5). Angioplasty, with or without stent placement, is frequently attempted to restore adequate TIPS function. In some cases where TIPS dysfunction is associated with altered shunt configuration or stent displacement, especially in a “T-bone” configuration, entry to the previous shunt seems to be challenging (6). This troublesome situation is more likely to occur when TIPS is created with a non-Viatorr stent, such as Fluency stent-grafts (Bard & BD). This type of stent is still widely used due to its relatively low cost, though its rigid structure may change the shunt orientation gradually. Moreover, a combined transjugular and transhepatic approach has been described (7, 8). After a percutaneous transhepatic puncture of the stent strut, a wire is passed through the lumen to inferior vena cava (IVC) and snared from the transjugular access to establish the channel. Of note, this approach brings a relatively high risk for bleeding and prolonged operative time when compared with only transjugular access (9). Parallel TIPS is generally used as the last resort (10, 11). Despite its proven efficacy, parallel stent placement through the portal vein may increase the risk of intraabdominal hemorrhage and aggravate liver function.Herein, inspired by the stent-in-stent technique used in the placement of bilateral biliary metallic stents and coronary stents (12–14), we tried to recanalize the occluded TIPS via endovascular puncture of the strut of the existent stent and followed with deployment of a new covered stent with a “Y” configuration (Fig. 1). The purpose of the present study is to evaluate the technical feasibility, safety and clinical outcomes of this new TIPS revision technique.Open in a separate windowFigure 1A schematic of Y-configured stents implantation. The angle between the initial stent (arrowheads) and the right hepatic vein was approximately 90°. A new stent (long arrow) was deployed through the mesh of the initial stent to restore the portosystemic shunt.