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.     

Flouroscopically–guided transhepatic puncture for difficult TIPS re-do procedures utilizing the En Snare retrieval device: A new approach to occluded TIPS in patients with recurrent ascites

Portal hypertension and variceal bleeding are complications due to cirrhosis. Transjugular Intraphepatic Portosystemic shunt (TIPS) procedure is a well-established treatment for recurrent ascites and variceal bleeding related to portal hypertension. After a TIPS has been placed, the potential of TIPS occlusion or stenosis is high. A TIPS re-do procedure has been used in treatment of progressive clinical symptoms. The standard approach is via the jugular route to recannulate the TIPS shunt. Rarely, it cannot be performed from the jugular approach. Therefore, a fluoroscopically -guided transhepatic approach has been devised for these difficult situations. This case describes the use of the transhepatic route through an indwelling Viatorr covered stent utilizing an En-Snare device to help complete the TIPS re-do procedure. With this newer approach to TIPS re-do procedures, endovascular specialists can achieve TIPS patency despite difficult venous anatomical challenges and the various types of available TIPS stents presently on the market.     

门静脉金属内支架置入治疗门静脉海绵样变

目的：探讨经皮肝穿刺和经颈内静脉肝内门体分流术(TIPS)途径门静脉内支架置入治疗门静脉海绵样变(CTPV)的疗效及安全性。方法回顾性分析于本科治疗的8例 CTPV 患者的临床及影像学资料。所有患者均行门静脉金属内支架置入治疗,其中3例经 TIPS 途径放置,5例经经皮肝穿刺途径放置。结果所有患者支架置入均一次性成功,无腹腔内出血等严重并发症发生。术中即刻复查造影显示支架内血流通畅,术后1 d~2周患者腹痛及消化道出血症状均明显减轻或消失。术后所有患者均获得完整随访,随访1个月~3年,1例患者术后1 年复查支架闭塞,再次置入1枚支架后血流通畅,其余患者彩超提示支架内血流通畅,未再发消化道出血或腹痛。结论经皮肝穿刺或经 TIPS 途径门静脉金属内支架置入治疗 CTPV 是一种安全有效方法。     

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   

Ultrasonography-guided percutaneous transhepatic portacaval shunt creation

We successfully created a percutaneous transhepatic portacaval shunt under ultrasonography (US) guidance in a 46-year-old man with refractory ascites. The shunt was created to salvage an attempt to create a transjugular intrahepatic portosystemic shunt (TIPS) that failed because of the elevated level of portal vein bifurcation due to alcoholic liver cirrhosis. Under US guidance, we simultaneously punctured the right branch of the portal vein and the inferior vena cava (IVC) using a two-step biliary drainage set. An Amplatz gooseneck snare was introduced transjugularly to retrieve the percutaneously inserted guidewire. The intrahepatic tract between the portal vein and the IVC was dilated using a balloon catheter, and a stent was placed in the tract. The patient showed complete resolution of ascites at discharge. We assume that our method is an alternative method for TIPS creation in patients with inadequate anatomical relations between the portal vein branches and the hepatic veins. This approach is thought to be feasible for patients with occluded or small hepatic veins.     

Recanalization of an Occluded Intrahepatic Portosystemic Covered Stent via the Percutaneous Transhepatic Approach

A 41-year-old woman with liver cirrhosis had recurrent portal hypertension and bleeding from esophageal varices due to complete occlusion of a previously inserted transjugular intrahepatic portosystemic shunt stent. Because recanalization of the stent by the transjugular approach was unsuccessful, ultrasound-guided entry to the splenic vein and portal vein was used. After catheter-directed intrathrombus thrombolysis, successful opening of the stent was achieved and a stent was placed. We herein report a rare case in which thrombolysis and recanalization of a TIPS stent were performed via a percutaneous transhepatic approach.     

Early TIPS failure in association with left mesenterico-gonadal spontaneous portosystemic venous shunt; a case report

Transjugular intrahepatic portosystemic shunt (TIPS) periprocedural thrombosis rates have fallen significantly since the introduction of polytetrafluoroethylene-covered stent grafts. We present a case of a cirrhotic patient with portal hypertension presenting with early TIPS thrombosis in association with an underlying competing spontaneous left mesenterico-gonadal venous shunt, an uncommon variant of spontaneous portal systemic shunt (SPSS). The patient presented with bleeding distal duodenal varices refractory to endovascular therapy, and although a successful TIPS procedure was performed for this indication, early thrombosis was determined by follow-up abdominopelvic computed tomographic angiography (CTA) scan. Despite undergoing a standard TIPS revision procedure, blood flow through the TIPS remained hepatofugal. During a TIPS revision, portal vein angiography revealed competing large inferior mesenteric vein (IMV) varices shunting into the left renal vein via the left gonadal vein. The initial abdominal CTA was later reviewed by a non-invasive cardiovascular radiologist, and the presence of the competing left mesenterico-gonadal shunt was retrospectively identified. Radiologists interpreting CTA exams should be aware of SPSS generally and mesenterico-gonadal shunts specifically. Pre-procedural knowledge of underlying SPSS can affect post procedural outcomes and should be emphasized in the final CTA report.     

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.     

Technical advances in transjugular intrahepatic portosystemic shunts.

A transjugular intrahepatic portosystemic shunt (TIPS) can be created percutaneously with the Palmaz balloon-expandable stent. This article describes a transjugular-only approach with a 16-gauge needle. A functional and efficacious shunt can be achieved in most cases with stent diameters of 8-10 mm. Occasionally, a 12-mm-diameter shunt is necessary for effective variceal decompression. The procedure is considered successful when the portosystemic gradient is lowered to 12 mm Hg or less after stent placement. Hepatic vein stenosis in the shunt outflow can develop after the TIPs procedure. This complication has been treated successfully with additional stent placement. TIPS can undoubtedly be performed successfully and safely with a transjugular-only approach; however, the full impact of TIPS on the treatment of portal hypertension remains to be determined.     

Percutaneous salvage of a failing rex shunt

Creation of a mesenterico-left portal vein (PV) shunt with use of autologous internal jugular vein (ie, Rex shunt) is a surgical option for the treatment of symptomatic extrahepatic PV occlusion. Herein a patient is described who underwent angioplasty and stent placement across a shunt stenosis by ultrasound (US)--guided percutaneous transhepatic portal access. Follow-up US has demonstrated continued shunt patency.     

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.     

Are TIPS Stent-Grafts a Contraindication for Future Liver Transplantation?

Our purpose was to assess the feasibility of orthotopic liver transplantation (OLT) in patients priorly having undergone transjugular intrahepatic portosystemic shunt (TIPS) with an expanded tetrafluoroethylene (e-PTFE)-covered endoprosthesis. In 48 patients an e- PTFE-covered endoprosthesis was inserted to treat severe complications of portal hypertension. In 36 patients the endoprosthesis was inserted during TIPS creation (de novo TIPS); in the other 12 patients the endoprosthesis was placed to repermeabilize the previously created, but occluded bare stent (revision TIPS). Eight of them (5 de novo and 3 revision cases) later underwent an OLT. The hospital records of these patients were reviewed from initial admission, through TIPS, the pre-OLT period, and OLT to current postoperative status. Five de novo and 3 revision cases underwent OLT 4–279 days (mean delay: 80.8 days) after TIPS procedure. All OLTs were performed under veno-venous bypass surgery. De visu surgical inspection confirmed correct positioning of the fully patent stent graft, starting in the portal vein and ending at the junction of the hepatic vein to the inferior caval vein. No surgical difficulty was observed during proximal or distal clamping or during resection of the diseased liver. Correctly positioned e-PTFE-covered nitinol endoprostheses do not interfere with a later OLT and may not be considered as a contraindication in patients who need a TIPS as a bridge to OLT.     

Experimental TIPS with spiral Z-stents in swine with and without induced portal hypertension

Purpose To assess the suitability of spiral Z-stents for transjugular intrahepatic portosystemic shunt (TIPS) and the influence of portal hypertension on shunt patency in young swine. Methods TIPS were established using spiral Z-stents in 14 domestic swine. In 7 animals, the portal venous pressure was normal; in the other 7, acute portal hypertension was induced by embolization of portal vein branches. Follow-up portal venography and histologic evaluations were done from 1 hr to 12 weeks after TIPS. Results Follow-up transhepatic portal venograms showed progressive narrowing of the shunt, most priminent in the midportion of the tract. Ingrowth of liver parenchyma between the stent wires found after 3 weeks led to progressive shunt narrowing and shunt occlusion by 12 weeks. A pseudointima grew rapidly inside the stent, peaked in thickness around 4 weeks, and decreased later. Acutely created portal hypertension rapidly returned to normal and there was no difference in TIPS patency between the two groups of animals. Conclusion Although the spiral Z-stent can be used as a device for creation of TIPS in patients with cirrhotic livers, it is associated with extensive liver ingrowth in swine that leads to rapid shunt occlusion. Portal hypertension was only transient in this model.     

Transjugular intrahepatic portosystemic shunt. Experiences at a liver transplantation center

Objective: Transjugular intrahepatic portosystemic shunt (TIPS) placement is an established therapy for portal hypertension that leads to variceal bleeding or refractory ascites. We present experiences of the role of TIPS at a liver transplantation center.Material and Methods: One hundred and ten patients were referred to the Radiological Department for TIPS placement. One of the 110 patients had recurrent cirrhosis after liver transplantation with refractory ascites. Function of the TIPS was controlled with Doppler US at 1 day, 1 week, 4 weeks and 4 months after TIPS placement and subsequently every 3 months. Shunt insufficiency was supposed when the blood flow velocity within the stent tract was under 50 cm/s and was an indication for TIPS revision.Results: TIPS was placed in 101 patients. After TIPS placement, 10 patients underwent liver transplantation. While waiting for the new liver, none of them developed variceal rebleeding, ascites or other complications of portal hypertension. Two of the 101 patients had episodes of rebleeding. The frequency of patients undergoing TIPS revision within the first year after TIPS placement was 67.5%, within the second year 38.0% and within the third year 24.4%. The revisions led to sufficient reduction of the portosystemic pressure gradient.Conclusion: In some liver transplant candidates, TIPS can be useful in minimizing the risk of complications of portal hypertension during the waiting time for a liver transplantation. TIPS can be monitored by Doppler US and revised if occlusion occurs.     

经皮经肝门腔静脉分流术血流动力学与支架构型关系的临床研究

目的介绍一种全新肝内分流预应力支架的结构和在经皮经肝肝内门腔静脉分流术（PTPS）中应用的临床结果。分析应用该支架建立的门腔静脉分流道与经典TIPS所用支架血流动力学之间的区别,探讨其潜在的临床意义。方法38例门静脉高压患者采用预应力支架行经皮经肝途径门腔静脉分流术（PTPS）。静脉曲张出血36例,难治性腹水1例及肝肺综合征1例;Child＇s B级27例、C级11例。经皮经肝穿刺进入门静脉右支,再经门静脉左支矢状部穿刺肝段下腔静脉,经皮经肝植入预应力支架于门静脉左支与肝段下腔静脉之间。结果38例采用预应力支架行PTPS均获成功,技术成功率100％,未出现术中与技术相关并发症,术后门腔压力梯度平均下降14cmH2O,平均随访493d,所有患者未发生再出血,难治性腹水得到有效地控制。初步开通率98．9%,明显高于经典直管形裸支架TIPS。结论采用预应力支架经皮经肝途径建立门腔静脉分流是安全可行的,其血流动力学结果提示：预应力支架形状及与相关血管壁间“吻合”严密,符合正常肝内门静脉血流动力学分布,既起到门静脉部分性降压作用,亦保障了门静脉右支血流的肝内灌注,对预防术后分流道再狭窄及降低肝性脑病发生率具有明显的临床意义。     

The use of a polytetrafluoroethylene-covered stent graft for transjugular intrahepatic portosystemic shunt (TIPS): Long-term follow-up of 100 patients

PURPOSE: To retrospectively evaluate results and clinical outcome of transjugular intrahepatic portosystemic shunt (TIPS) after implantation of a polytetrafluoroethylene (PTFE)-covered stent graft. MATERIAL AND METHODS: The stent graft was used in 112 patients with higher risk of primary (i.e. patients with Budd-Chiari syndrome) or secondary shunt failure (patients with occlusion of a previous uncovered stent), or a complicated TIPS procedure with an imminent technical complication requiring covered stent. Patients were scheduled at 3- to 6-month intervals for duplex-sonographic control of shunt function. Radiological revision was performed in patients with a decrease in shunt function by >25%, primary non-response, or relapse of the index symptom. RESULTS: Twelve patients were lost to follow-up, and 100 patients were followed for 22+/-15 months. The actuarial rates of shunt patency were 90, 84, and 74% at 1, 2, and 3 years of follow-up, respectively. Two patients developed early (within 1 month) and 14 patients late shunt failure. Except for one transient rise in liver enzymes due to outflow obstruction by the stent graft, no technical complications were seen. Primary response to treatment was seen in 97% of patients treated for variceal bleeding and 84% of patients treated for refractory ascites. A relapse of the index symptom was seen in 13% of bleeders and 9% of patients treated for refractory ascites. CONCLUSION: TIPS created with a PTFE-covered stent graft showed favorable long-term results.     

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 .     

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.     

Transcaval TIPS in Patients with Failed Revision of Occluded Previous TIPS

Objective

To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) in patients with occluded previous TIPS.

Materials and Methods

Between February 1996 and December 2000 we performed five transcaval TIPS procedures in four patients with recurrent gastric cardiac variceal bleeding. All four had occluded TIPS, which was between the hepatic and portal vein. The interval between initial TIPS placement and revisional procedures with transcaval TIPS varied between three and 31 months; one patient underwent transcaval TIPS twice, with a 31-month interval. After revision of the occluded shunt failed, direct cavoportal puncture at the retrohepatic segment of the IVC was attempted.

Results

Transcaval TIPS placement was technically successful in all cases. In three, tractography revealed slight leakage of contrast materials into hepatic subcapsular or subdiaphragmatic pericaval space. There was no evidence of propagation of extravasated contrast materials through the retroperitoneal space or spillage into the peritoneal space. After the tract was dilated by a bare stent, no patient experienced trans-stent bleeding and no serious procedure-related complications occurred. After successful shunt creation, variceal bleeding ceased in all patients.

Conclusion

Transcaval TIPS placement is an effective and safe alternative treatment in patients with occluded previous TIPS and no hepatic veins suitable for new TIPS.     

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.