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.     

Transjugular intrahepatic portocaval shunt (TIPS) and hepatic vein-to-caval stenting as salvage treatment of portal hypertension secondary to neoplasm

A percutaneous transjugular intrahepatic portocaval shunt (TIPS) was successfully performed using Wallstents in a 53-year-old man with neoplastic disease causing portal hypertension and life-threatening variceal hemorrhage. Shortly after-wards, recurrent hemorrhage was investigated by shunt venography which showed that extrinsic narrowing of the hepatic vein and hepatic vena cava was causing shunt thrombosis. Shunt thrombosis was cleared by balloon occlusion of the shunt and forceful retrograde flushing of thrombus into the portal circulation. The compressed hepatic vein and vena cava were then dilated and stented using Gianturco “Z” stents. Bleeding recurred 3 months later due to focal narrowing within the shunt which possibly was due to intimal proliferation. Repeat dilatation and placement of a coaxial Palmaz stent again relieved portal hypertension. Creation of a TIPS for portal hypertension secondary to neoplasm can produce valuable palliation. Complete assessment of hepatic vein and vena cava patency is required to ensure shunt function.     

Prevention of hepatic infarction as acute-phase complication of TIPS by temporary balloon occlusion in a patient with primary myelofibrosis

Severe acute liver dysfunction occurred following transjugular intrahepatic portosystemic shunt (TIPS) creation in a patient with massive ascites due to portal hypertension associated with primary myelofibrosis. On US and TIPS venography, we considered that the acute liver ischemia was induced by TIPS. To avoid diffuse hepatic infarction and irreversible liver damage, a balloon catheter was inserted transjugularly into the TIPS tract and occluded it to increase portal venous flow toward the peripheral liver parenchyma. The laboratory data indicating hepatic dysfunction were improved after the procedure. We should pay attention to the possible occurrence of acute hepatic ischemia and infarction after TIPS creation even in a case of noncirrhotic portal hypertension. In such cases, temporary balloon occlusion of TIPS is an effective therapeutic method, probably as a result of inducing the development of arterial compensation through the peribiliary plexus.     

Improved patency of transjugular intrahepatic portosystemic shunts in humans: creation and revision with PTFE stent-grafts

PURPOSE: To determine whether polytetrafluoroethylene (PTFE) stent-grafts yield longer patency for creation or revision of transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS: Fourteen PTFE-covered Wallstents were placed in 13 patients with TIPS: seven at shunt creation and seven during revision of TIPS with one to five prior thromboses at 1 day to 1 year after initial TIPS formation. In six cases, prior to stent-graft placement persistent biliary-TIPS fistulas were demonstrated despite repeated shunt revisions with additional metallic stents. RESULTS: All but one graft-lined TIPS were widely patent at a mean duration of venographic follow-up of 19 months (median, 17 months; range, 5-32 months). The limiting percentage of stenosis within the grafted shunts was 0%-10%. One patient developed stent-graft thrombosis; the prior biliary-TIPS fistula was seen despite the graft. A second, parallel PTFE-lined transcaval shunt was created in this patient; it was widely patent at 11-month follow-up. In two asymptomatic patients, stenoses developed in the short, nongrafted portions of the outflow hepatic veins. CONCLUSION: PTFE stent-grafts can markedly prolong TIPS patency, potentially reducing the need for shunt follow-up and revision and the risk of recurrent symptoms associated with shunt stenosis or occlusion.     

经皮治疗门静脉血栓的临床研究

目的：研究和评价经皮治疗门静脉血栓技术的可行性和临床效果。材料与方法：16例有门静脉闭塞症状的患者,门静脉血栓均为非海绵状血管变性所致。通过建立经颈列脉肝内门腔静脉分流通道（TIPS）,带膜支架旁路术和经皮抽吸取栓法清除门静脉血栓提高门静脉的血流输出量。结果：13例采用经皮技术治疗获得成功。门静脉血栓所致的门脉高压均得到纠正,静脉曲张破裂出血立即停止;顽固性腹水和黄疸症状得到缓解。结论：经颈静脉门腔静脉分流术,门静脉内带膜支架旁路术和经皮门静脉抽吸取栓法对于治疗非海绵状血管变性和晨瘤栓所致的门静脉闭塞是安全有效的。     

门静脉血栓形成的TIPS治疗和临床结果

目的 研究和评价经皮治疗门静脉及其属支血栓的技术可行性和临床效果。方法 16例有门静脉及其属支闭塞症状的患，门静脉及其属支血栓均为非海绵状血管变性所致。通过建立经颈静脉肝内门腔静脉分流通道(TIPS)、带膜支架旁路术和经皮抽吸取栓法清除门静脉及其属支血栓提高门静脉的血流输出量。结果 13例采用经皮技术治疗获得成功。门静脉及其属支血栓所致的门脉高压均得到纠正，静脉曲张破裂出血立即停止；顽固性腹水和黄疸症状得到缓解。结论 经颈静脉门腔静脉分流术、门静脉内带膜支架旁路术和经皮门静脉及其属支抽吸取栓法对于治疗非海绵状血管变性和非瘤栓所致的门静脉闭塞是安全有效的。     

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   

Preliminary results of a new expanded-polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt procedures.

OBJECTIVE: The purpose of our study was to evaluate the feasibility and the safety of transjugular intrahepatic portosystemic shunts (TIPS) with a new expanded-polytetrafluoroethylene-covered stent and the influence of the covering on occlusion rate. SUBJECTS AND METHODS: Twenty cirrhotic patients (57 +/- 11 years old) admitted with a history of esophageal variceal bleeding (n = 11), refractory ascites (n = 5), or both (n = 4) were included. Five of the patients were treated for TIPS revision, and 15 as de novo TIPS placements. The endoprostheses used were composed of a 2-cm noncovered nitinol stent and a 4- to 8-cm expanded-polytetrafluoroethylene graft covering, and were placed from the portal vein to the ostium of the hepatic vein. Patients underwent Doppler sonography at discharge and again at 1, 3, 6, 9, 12, and 15 months and underwent venography with portosystemic pressure gradient measurement at 6 months and whenever necessary. RESULTS: At the time of this writing, complications included three TIPS restenoses and one recurrent ascites successfully treated by balloon dilation, two cases of segmentary liver ischemia, and one patient with encephalopathy that required shunt reduction. After TIPS placement, the portosystemic pressure gradient dropped from 18 +/- 5 to 5 +/- 4 mm Hg. Primary and secondary patency rates were 80% and 100%, respectively, at 387 days. CONCLUSION: These results clearly show the feasibility of TIPS placement with the Gore TIPS endoprosthesis stent-graft and its improved patency compared with results in the literature for bare stents. These preliminary results must be certified further with randomized comparative trials between covered and noncovered TIPS stents.     

Concomitant hepatic encephalopathy and refractory ascites: successful treatment with staged embolization of two large portosystemic shunts and transjugular intrahepatic portosystemic shunt placement

A patient with cirrhosis, refractory ascites, and two large competitive portosystemic shunts presented with uncontrollable acute exacerbation of chronic hepatic encephalopathy (HE). A staged procedure was performed by first performing embolization of a large mesogonadal shunt to treat the HE. Three months later, a transjugular intrahepatic portosystemic shunt (TIPS) was created to address the ascites. A large paraumbilical vein shunt was embolized at TIPS placement to minimize the risk of recurrent HE. At 9-month follow-up, the ascites was well controlled with medical management with little or no HE.     

Percutaneous retrieval of a strecker stent misplaced during TIPS

During a transjugular intrahepatic portosystemic shunt (TIPS) procedure, a Strecker stent was accidently pushed into the superior mesenteric vein. After successful shunt placement, the stent was withdrawn into the hepatic vein. A multipurpose basket catheter was attached to the distal end of the stent and a loop snare to the proximal end. In this way it was possible to stretch the stent and retrieve it percutaneously through the jugular sheath.     

门静脉癌栓合并门脉高压症的TIPS姑息治疗

目的 评价门静脉癌栓（portal vein tumor thrombosis,PVTT) 合并门脉高压症患者行经颈静脉肝内门体静脉分流术（transjugular intrahepatic portosystemic shunt,TIPS)姑息治疗的疗效，并讨论其技术特点。方法 本组报告14例终末期肝癌合并门静脉癌栓及门静脉高压症患者，平均年龄53．6％。8例门静脉主干完全堵塞，6例门静脉主干及分支有不同程度栓塞，5例合并门静脉海绵样变。1例单纯上消化道大出血，3例单纯顽固性腹水，10例上消化道大出血合并顽固性腹水。结果 14例中10例患者成功行TIPS治疗，门静脉压力平均从术前37.2mmHg(1mmHg=0.133kPa)降至术后18.2mmHg，平均降低19.0mmHg；腹水减少或消失，消化道出血，腹胀，腹泻等症状缓解，平均生存32.3d。4例失败。结论 TIPS是姑息治疗肝癌合并门静脉癌栓引起的上消化道大出血和顽固性腹水的有效方法。     

Transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension using memotherm stents: a prospective multicenter study

Purpose: In a prospective multicenter study, efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) were evaluated in the treatment of the complications of portal hypertension using a new self-expanding mesh-wire stent (Memotherm). Methods: One hundred and eighty-one patients suffering from variceal bleeding (either acute or recurrent) or refractory ascites were enrolled. Postinterventional follow-up lasted for 8.4 months on average. Differences were analyzed by the log-rank test (chi-square) or Wilcoxon test. Results: Shunt insertion was completed successfully in all patients (n = 181 patients, 100%). During follow-up, shunt occlusion was evident in 23 patients, and shunt stenosis was found in 33 patients (12.7% and 18.2%, respectively). Variceal rebleeding occurred in 20 of 139 patients (14.4%), with at least one episode of bleeding before TIPS treatment. The overall mortality rate of the patients treated by TIPS was 39.8%. In 51.4% of these cases (37 of 72 patients), however, the patients died within 30 days after TIPS placement. Analysis of subgroups showed that patients who underwent emergency TIPS for acute variceal bleeding had a significantly higher early mortality compared with other patient groups (p = 0.0014). Conclusion: In the present prospective multicenter study, we were able to show that insertion of Memotherm stents is an effective tool for TIPS. The occlusion rates seem to be comparable to those reported for the Palmaz stent. It could be shown that in particular, those patients who were treated for acute bleeding were at high risk of early mortality. Consequently, in such a critical condition, the indication for TIPS has to be set carefully.     

Transjugular intrahepatic portosystemic shunting (TIPS) with balloon-expandable and self-expanding stents: Technical and clinical aspects after 3 1/2 years’ experience

Purpose To evaluate prospectively our experience with transjugular intrahepatic portosystemic shunt (TIPS) using four different metallic stents. Methods Between November 1991 and April 1995, 57 patients (41 men and 16 women; age 35–72 years, mean 54 years) underwent the TIPS procedure. Techniques for portal vein localization before and during TIPS were fluoroscopy, computed tomography (CT) studies, wedged hepatic venography, arterial portography, and ultrasound. After predilation we deployed balloon-expandable (n=48) and self-expanding (n=45) metallic stents. Fifteen patients underwent variceal embolization. Initial follow-up angiograms (mean 6.9 months, range 3–24 months) were obtained in 39 of these patients. Results Fifty-three patients (93%) had successful TIPS placement. The mean decrease in portal pressure was 42.7%. Besides fluoroscopy, the most helpful techniques for portal vein localization were venography and CT. Residual stenosis (n=1) and late shortening (n=4) of Wallstents resulted in shunt dysfunction. The technical problems encountered with the Palmaz stent resulted from its lack of flexibility. We combined balloon-expandable and self-expanding stents in 12 patients. The 30-day and late follow-up (mean 11.9 months) percutaneous reintervention rates were 11.3% and 64.2%, respectively. There were no clinically significant complications related to the TIPS insertions. Conclusion An ideal stent does not exist for TIPS, and the authors recommend combining a Palmaz stent with a flexible self-expanding stent.     

Transjugular intrahepatic cavoportal shunt for Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) is characterized by obstruction of the hepatic venous outflow tract. Therapeutic options for BCS are limited. We report a case of a 21-year-old woman with protein S and C deficiency with gross ascites. Treatment with transjugular intrahepatic portosystemic shunt (TIPS) was attempted, which revealed occluded hepatic veins, so transcaval TIPS was performed. No serious procedure-related complication occurred. After successful shunt creation, the patient's symptoms subsided and she was discharged and followed up for 6 months.     

Balloon occlusion portography to diagnose new-onset left hepatic vein thrombosis and widening of an existing wallstent TIPS by palmaz stents for recurrent portal hypertension and variceal bleeding

A 31-year-old man with Child's class A micronodular cirrhosis, left lobe hypertrophy, and a transjugular intrahepatic portosystemic shunt (TIPS) which had been placed 6 months earlier, was admitted for recurrent esophageal bleeding and a portosystemic gradient of 42 mmHg. Balloon occlusion portography documented unsuspected ostial thrombosis of the previously patent left hepatic vein. This was considered the cause of the pressure rise. As it was not possible to insert a second TIPS in parallel, the shunt, stented originally with 10-mm Wallstents, was overdilated to 12 mm, and two 12-mm Palmaz stents were placed coaxially, reducing the portosystemic pressure gradient to 13 mmHg.     

Sharp Central Venous Recanalization by Means of a TIPS Needle

The purpose of this study was to perform an alternative technique for recanalization of a chronic occlusion of the left brachiocephalic vein that could not be traversed with a guidewire. Restoration of a completely thrombosed left brachiocephalic vein was attempted in a 76-year-old male hemodialysis patient with massive upper inflow obstruction, massive edema of the face, neck, shoulder, and arm, and occlusion of the stented right brachiocephalic vein/superior vena cava. Vessel negotiation with several guidewires and multipurpose catheters proved unsuccessful. The procedure was also non-viable using a long, 21G puncture needle. Puncture of the superior vena cava (SVC) at the distal circumference of the stent in the right brachiocephalic vein/superior vena cava, however, was feasible with a transjugular intrahepatic portosystemic shunt (TIPS) set under biplanar fluoroscopy using the distal end of the right brachiocephalic vein as a target, followed by balloon dilatation and partial extraction of thrombotic material of the left brachiocephalic vein with a wire basket. Finally, two overlapping stents were deployed to avoid early re-occlusion. Venography demonstrated complete vessel patency with free contrast media flow via the stents into the SVC, which was reconfirmed in follow-up examinations. Immediate clinical improvement was observed. Venous vascular recanalization of chronic venous occlusion by means of a TIPS needle is feasible as a last resort under certain precautions.     

Traesjugular intrahepatic portosystemic shunt in portai vein thrombosis: Role of the right gastric vein with anomalous insertion

Transjugular intrahepatic portosystemic shunt (TIPS) was performed in two patients with portal vein thrombosis. In both patients, hepatopetal flow had been maintained by an anomalous insertion of the right gastric vein (RGV) into the portal vein bifurcation and into the left portal branch respectively. In one patient, the main portal trunk could not be recanalized and the RGV was used as an accessory portal vein to place one stent for TIPS. In the other case, access through the partial portal-vein occlusion was gained and three stents were placed from the hepatic vein to the main portal vein distal to the thrombus. In portal vein thrombosis, the aberrant insertion of the RGV into the left or right portal branches may maintain patency of the intrahepatic portal system and, in case of unsuccessful recanalization of the porta, may represent the sole pathway for placing a TIPS     

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.     

Reversal of Transjugular Intrahepatic Portosystemic Shunt (TIPS)-Induced Hepatic Encephalopathy Using a Strictured Self-Expanding Covered Stent

Hepatic encephalopathy is a known complication following percutaneous transjugular intrahepatic portosystemic shunt (TIPS) placement. We describe herein a simple and effective strategy of TIPS revision by creating an intraluminal stricture within a self-expanding covered stent, which is deployed in the portosystemic shunt to reduce the TIPS blood flow. This technique was successful in reversing a TIPS-induced hepatic encephalopathy in our patient. An erratum to this article can be found at .     

Role of TIPS as a bridge to hepatic transplantation in Budd-Chiari syndrome.

PURPOSE: To investigate the role of transjugular intrahepatic portosystemic shunt (TIPS) as a bridge to transplantation for patients with Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: Eight patients (five women, three men) with a mean age of 49.8 years (range, 20-61 years) were diagnosed with BCS by means of computed tomography, hepatic venography, and liver biopsy. One patient had acute liver failure, with subacute or chronic failure in seven. TIPS placement was attempted in all eight patients. Clinical follow-up and portograms were obtained in all patients until death or transplantation. RESULTS: TIPS placement was completed in seven of eight patients (87.5%). During the follow-up period, TIPS occlusion occurred in four patients. TIPS revision in this patient, although successful, was complicated by hemorrhage and multiorgan failure, and the patient died. Assisted patency rate, excluding the technical failure, was 100%. Mean follow-up in the six survivors with TIPS was 342 days (range, 19-660 days). All six survivors had complete resolution of their ascites. Albumin levels improved an average of 0.43 g/dL (range, 0.3-1.4 g/dL). Bilirubin levels improved in five of six patients (83%), decreasing by an average of 5.6 mg/dL (range, 3.0-15.2 mg/dL). Of the six survivors, three underwent elective liver transplantation, one is awaiting transplantation, and one has been removed from the transplantation list because of clinical improvement. One patient was a candidate for transplantation but declined to be put on the list. CONCLUSION: Hepatic synthetic dysfunction improves markedly after TIPS placement in patients with BCS. Significant improvement in ascites can also occur. TIPS can be an effective bridge to transplantation for patients with BCS.