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.     

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.     

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.     

经肝段下腔静脉人路经颈静脉肝内门体分流术的适应证及解剖基础

目的　探讨肝硬化门静脉高压患者肝静脉与门静脉间存在解剖异常时 ,行经肝段下腔静脉直接穿刺门静脉分支 ,完成经颈静脉肝内门体分流术 (TIPS)的适应证及相关解剖基础 ,评估其安全性和可行性。方法　 6 5例肝硬化门静脉高压患者行经肝段下腔静脉直接穿刺门静脉完成TIPS分流术。静脉曲张出血 5 2例 ,难治性腹水 12例 ,等待肝移植 1例。结果　 6 5例经肝段下腔静脉TIPS分流术均获成功 ,技术成功率 10 0 % ,未出现术中技术相关并发症 ,1年内初步开通率明显高于常规TIPS。结论　经肝段下腔静脉入路TIPS技术用于肝静脉与门静脉间解剖异常病例是安全可行的 ,结果提示由于肝内分流道曲度较小 ,1年内支架初步开通率明显提高。     

经肝段下腔静脉建立TIPS分流道的初步临床结果

目的 评估经肝段下腔静脉TIPS分流术在肝静脉与门静脉间解剖异常时操作的可行性，讨论其临床意义。方法 65例肝硬变门静脉高压患者行经肝段下腔静脉直接穿刺门静脉完成TIPS分流术。结果 65经肝段下腔静脉TIPS分流术均获成功，技术成功率100％，未出现术中技术相关并发症，一年内再狭窄率明显低于常规TIPS，3例肝性脑病经限流支架置入得以控制。结论 经肝段下腔静脉TIPS分流术技术用于肝静脉与门静脉间解剖异常病例是安全有效的，同时提示由于肝内分流道曲度较小，一年内支架开通率明显提高。     

Viatorr支架行TIPS术治疗门静脉高压性静脉曲张消化道出血效果评估

目的评价应用Viatorr支架行经颈静脉肝内门体分流术(TIPS)术治疗门静脉高压性静脉曲张消化道出血的可行性、安全性和临床效果。方法回顾性分析2015年10月至2018年11月收治的42例肝硬化门静脉高压性静脉曲张消化道出血患者临床资料,所有患者符合TIPS治疗指征,均接受Viatorr支架行TIPS术治疗。术中检测门静脉压力梯度(PPG)。术后1、3、6、12个月,之后每年随访超声或增强CT检查,评价分流道通畅情况,并通过电子病历、临床或电话随访患者肝功能、凝血4项、再出血、肝性脑病发生和生存时间。配对t检验分析术前、术后PPG、总胆红素、血清白蛋白和凝血酶原时间变化,Kaplan-Meier法分析分流道通畅率和生存率。结果 42例均成功施行TIPS术,技术成功率为100%。共植入直径8 mm Viatorr支架42枚。PPG均值由术前(26.85±6.00) mmHg(1 mmHg=0.133 kPa)降低为(11.62±4.54) mmHg(t=11.359,P<0.05),平均降低(55.63±16.77)%。与术前相比,术后3 d总胆红素浓度升高(P<0.05),血清白蛋白降低(P<0.05),凝血酶原时间延长(P<0.05)。术后1个月总胆红素、血清白蛋白和凝血酶原时间与术前水平差异均无统计学意义(P>0.05)。术后中位随访14.5(2~39)个月,再出血发生率为9.5%(4/42),其中1例接受分流道再通;肝性脑病发生率为19.1%(8/42)。术后1、2、3年分流道通畅率分别为91.9%、83.9%、77.4%,生存率分别为94.7%、89.4%、82.0%。肝硬化相关死亡率为9.5%(4/42),均于术后2~30个月死于终末期肝病伴多脏器功能衰竭。结论 Viatorr支架行TIPS术治疗肝硬化门静脉高压性静脉曲张消化道出血具有较高的技术成功率,术后分流道通畅率高,肝性脑病发生率低。     

Portal flow and arterioportal shunting after transjugular intrahepatic portosystemic shunt creation

PURPOSE: It was postulated that a transjugular intrahepatic portosystemic shunt (TIPS) produces arterioportal shunting and accounts for reversed flow in the intrahepatic portal veins (PVs) after creation of the TIPS. This study sought to quantify this shunting in patients undergoing TIPS creation and/or revision with use of a direct catheter-based technique and by measuring changes in blood oxygenation within the TIPS and the PV. MATERIALS AND METHODS: This prospective study consisted of 26 patients. Median Model for End-stage Liver Disease and Child-Pugh scores were 13 and 9, respectively. Primary TIPS creation was attempted in 21 patients and revision of failing TIPS was undertaken in five. In two patients, TIPS creation was unsuccessful. All TIPS creation procedures but one were performed with use of polytetrafluoroethylene-covered stent-grafts. Flow within the main PV (Q(portal)) was measured with use of a retrograde thermodilutional catheter before and after TIPS creation/revision, and TIPS flow (Q(TIPS)) was measured at procedure completion. The amount of arterioportal shunting was assumed to be the increase between final Q(portal) and Q(TIPS), assuming Q(TIPS) was equivalent to the final Q(portal) plus the reversed flow in the right and left PVs. Oxygen saturation within the TIPS and the PV was determined from samples obtained during TIPS creation and revision. RESULTS: Mean Q(portal) before TIPS creation was 691 mL/min; mean Q(portal) after TIPS creation was 1,136 mL/min, representing a 64% increase (P = .049). Mean Q(TIPS) was 1,631 mL/min, a 44% increase from final Q(portal) (P = .0009). Among cases of revision, baseline Q(portal) was 1,010 mL/min and mean Q(portal) after TIPS revision was 1,415 mL/min, a 40% increase. Mean Q(TIPS) was 1,693 mL/min, a 20% increase from final Q(portal) (P = .42). Arterioportal shunting rates were 494 mL/min after TIPS creation and 277 mL/min after TIPS revision, representing 30% of total Q(TIPS) after TIPS creation and 16% of Q(TIPS) after TIPS revision. No increase in oxygen tension or saturation was seen in the PV or TIPS compared with initial PV levels. Q(TIPS) did not correlate with the portosystemic gradient. CONCLUSION: TIPS creation results in significant arterioportal shunting, with less arterioportal shunting seen among patients who undergo TIPS revision. Further work is necessary to correlate Q(TIPS) with the risk of hepatic encephalopathy and liver failure.     

Transjugular intrahepatic portosystemic shunts in hemodialysis-dependent patients and patients with advanced renal insufficiency: safety, caution, and encephalopathy

PURPOSE: To retrospectively determine the acute safety and chronic outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with hemodialysis-dependent end-stage renal disease for control of bleeding and refractory ascites. MATERIALS AND METHODS: Four dialysis-dependent patients and one renal transplant recipient (glomerular filtration rate, 27 mL/min) underwent TIPS creation for treatment of refractory ascites (n = 3) and recurrent portal hypertensive bleeding (n = 1). A sixth patient developed unrelated renal failure 3 years after initial TIPS formation and presented with encephalopathy at that time. All had nearly normal liver function test results and no previous baseline encephalopathy. Three dialysis recipients underwent dialysis immediately after the TIPS procedure in an intensive care unit; one did not. RESULTS: There were no complications of fluid overload or pulmonary edema after TIPS creation in the patients who immediately underwent dialysis. The one patient in whom dialysis was delayed developed respiratory failure and shock liver (ie, ischemic hepatitis). Ascites resolved in all three patients, and no recurrent variceal bleeding occurred during a mean follow-up of 17 months. Severe, grade 2-4 hepatic encephalopathy developed in all patients; in one patient, its onset was delayed until the onset of renal failure 3 years after the original TIPS procedure. Shunt reduction was required in four cases and competitive variceal embolization was required in one to reduce portosystemic diversion. No less than grade 1 episodic baseline encephalopathy was present in all patients despite continued use of the maximum prescribed medical therapy thereafter. CONCLUSIONS: TIPS creation is effective in controlling ascites and bleeding in functionally anephric patients, but at the cost of marked and disproportionate hepatic encephalopathy. Prompt, acute postprocedural dialysis and fluid management is critical for safe creation of a TIPS in dialysis-dependent patients.     

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.     

Hepatic perfusion as a predictor of mortality after transjugular intrahepatic portosystemic shunt creation in patients with refractory ascites

PURPOSE: To determine whether hepatic perfusion patterns predict mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with severe ascites. MATERIALS AND METHODS: This retrospective study included 22 patients who had enhanced cine magnetic resonance (MR) imaging performed immediately before TIPS creation in the angled coronal plane including the left kidney, liver, and main portal vein. Regions of interest were centered over the liver and kidney, and perfusion curves were generated and reviewed before the standard TIPS procedure was performed. Four patients did not undergo TIPS creation as a result of very poor hepatic perfusion by MR. All patients were followed clinically and by ultrasound surveillance of their shunt. RESULTS: Eleven patients died within 6 months, including all four patients who did not have a TIPS because of MR evidence of poor hepatic perfusion. Of these 11 patients, eight (73%) had unfavorable liver flow consisting of diminished enhancement compared to the kidney and early peak enhancement of less than 50 seconds. The surviving patients all showed a delayed peak enhancement of greater than 50 seconds. CONCLUSIONS: In patients undergoing TIPS creation for refractory ascites, blunted arterial-type hepatic enhancement is a poor prognostic sign. Cine MR imaging with evaluation of hepatic perfusion can be performed and reviewed before the TIPS procedure. Alternative techniques for ascites reduction may be preferred for patients with unfavorable hepatic perfusion.     

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.     

Changes in the distribution of hepatic arterial blood flow following TIPS with uncovered stent and stent-graft: an experimental study

Purpose: To evaluate changes in distribution of hepatic arterial blood flow in the liver following insertion of an uncovered stent and subsequently a stent-graft in the transjugular intrahepatic portosystemic shunt (TIPS) channel. Methods: The experiments were performed in eight healthy pigs under general anesthesia. In a pilot study in one pig, scintigraphic evaluation of arterial perfusion to the liver was done before and after inflation of a balloon in the right hepatic vein. In the other pigs, outflow from the right liver vein was checked repeatedly by contrast injection through a percutaneously inserted catheter. The arterial perfusion through the liver was examined by scintigraphy, following selective injection of macro-aggregate of 99Tc m-labeled human serum albumin 99Tc m-HSA) into the hepatic artery. This examination was done before and after creation of a TIPS with an uncovered stent and subsequently after insertion of a covered stent-graft into the cranial portion of the shunt channel. Results: In the pilot study changes in the arterial perfusion to the liver were easily detectable by scintigraphy. One pig died during the procedure and another pig was excluded due to dislodgement of the hepatic artery catheter. The inserted covered stent obstructed venous outflow from part of the right liver lobe. The 99Tc m-HSA activity in this part remained unchanged after TIPS creation with an uncovered stent. A reduction in activity was seen after insertion of a stent-graft (p= 0.06). Conclusion: The distribution of the hepatic arterial blood flow is affected by creation of a TIPS with a stent-graft, in the experimental pig model.     

Successful treatment of TIPS-induced hepatic failure with an hourglass stent-graft: a simple new technique for reducing shunt flow.

A simple new technique for creating an hourglass reducing stent-graft by means of targeted balloon expansion of each end of a commercially available device is presented. A 67-year-old man with progressive hepatic failure after TIPS creation was treated. A 48-mm-long Jostent stent-graft was placed inside the TIPS through a 10-F introducer and fully expanded only at the proximal and distal ends, resulting in an hourglass shape. Immediate increase of portal pressure was achieved, followed by complete clinical recovery. Advantages of covered versus bare reducing stents are discussed.     

Transcaval Transjugular Intrahepatic Portosystemic Shunt: Preliminary Clinical Results

Objective

To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins.

Materials and Methods

Transcaval TIPS, performed in six patients, was indicated by active variceal bleeding (n=2), recurrent variceal bleeding (n=2), intractable ascites (n=1), and as a bridge to liver transplantation (n=1). The main reasons for transcaval rather than classic TIPS were the presence of an unusually acute angle between the hepatic veins and the level of the portal bifurcation (n=3), hepatic venous occlusion (n=2), and inadequate small hepatic veins (n=1).

Results

Technical and functional success was achieved in all patients. The entry site into liver parenchyma from the inferior vena cava was within 2 cm of the atriocaval junction. Procedure-related complications included the death of one patient due to hemoperitoneum despite the absence of contrast media spillage at tractography, and another suffered reversible hepatic encephalopathy.

Conclusion

In patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins, transcaval TIPS creation is feasible.     

Direct Percutaneous Embolization of Bleeding Stomal Varices

Stomal variceal bleeding can develop in patients with underlying cirrhosis and portal hypertension. Most patients are best treated with transjugular intrahepatic portosystemic shunt (TIPS) creation because this addresses the underlying problem of portal hypertension. However, some patients are not good candidates for TIPS creation because they have end-stage liver disease or encephalopathy. We describe such a patient who presented with recurrent bleeding stomal varices, which was successfully treated with percutaneous coil embolization. The patient had bleeding-free survival for 1 month before death from unrelated causes.     

Transjugular intrahepatic portosystemic shunt: a case report]

Transjugular intrahepatic portosystemic shunt (TIPS) was performed in one patient with refractory esophageal varices due to portal hypertension by liver cirrhosis. R?sch modified Z-stent was placed to keep the lumen. The shunt lowered average portal pressure from 45 to 24 mmHg, and then decompressed the esophageal varices. The shunt was patent still for three months after the creation. No significant complication was observed. This initial success of TIPS in Japan encouragingly support the safeness and effectiveness of this therapy.     

Effects of Intraluminal Irradiation with Holmium-166 for TIPS Stenosis: Experimental Study in a Swine Model

Objective

We wanted to evaluate the effectiveness of intraluminal irradiation with Holmium-166 (¹⁶⁶Ho) for reducing the pseudointimal hyperplasia (PIH) in the transjugular intrahepatic portosystemic shunt (TIPS) tract in a swine model.

Materials and Methods

TIPS was performed in 12 domestic pigs, after the creation of portal hypertension by intraportal injection of a mixture of N-butyl-2-cyanoacrylate (NBCA) and lipiodol. Five pigs first underwent intraluminal irradiation (30 Gy) in the parenchymal tract with using a ¹⁶⁶Ho solution-filled balloon catheter, and this was followed by the placement of a nitinol stent in the TIPS tract. For the seven control pigs, the balloon was filled with saline and contrast media mixture. Two weeks later, follow-up portography and histological analysis were performed.

Results

TIPS was successfully performed in all twelve pigs with achieving artificially induced portal hypertension. Portography performed two weeks after TIPS showed the patent tracts in the TIPS tracts that were irradiated with ¹⁶⁶Ho (5/5, 100%), whereas either completely (5/6, 83.3%) or partially (1/6, 16.7%) occluded TIPS were seen in the seven pigs of the nonirradiated control group, except in one pig that experienced periprocedural death due to bleeding. Histological analysis showed a statistically significant difference for the maximal PIH (irradiated: 32.8%, nonirradiated: 76.0%, p < 0.001) between the two groups.

Conclusion

Intraluminal irradiation with 30 Gy of ¹⁶⁶Ho for TIPS significantly improved the TIPS patency in a swine model of portal hypertension during a 2-week period of follow-up.     

Refractory hepatic encephalopathy due to concomitant transjugular intrahepatic portosystemic shunt and spontaneous mesocaval shunt controlled by embolization of the competitive portosystemic shunt

Spontaneous mesocaval shunt (SMCS) is an uncommon cause of refractory encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) creation. We report a patient who presented with refractory hepatic encephalopathy (HE) post-TIPS creation for variceal bleeding in whom a SMCS was found. Percutaneous transhepatic occlusion of the SMCS reduced the portal vein flow diverted from the liver and provided sufficient liver perfusion to reverse the HE while maintaining satisfactory decompression of esophageal varices.     

Scintigraphic evaluation of hepatic blood flow after intrahepatic portosystemic shunt (TIPS)

In patients with liver cirrhosis a transjugularly placed intrahepatic portocaval shunt (TIPS) is a non-surgical portosystemic device which aims to reduce portal venons pressure. In comparison with Doppler sonography, we evaluated in 28 patients the diagnostic impact of liver perfusion scintigraphy (with technetium-99m diethylene triamine penta-acetic acid) in the assessment of changes in the hepatic blood flow after TIPS shunting. The arterial and portal contributions to hepatic flow were calculated from the areas under the biphasic timeactivity curve. In the course of TIPS shunting, patency is threatened by reocclusion. Angiography is the gold standard for TIPS shunt reassessment. However, there is a need for a less invasive diagnostic procedure, such as scintigraphy or Doppler sonography, for the early detection of shunt insufficiency. Scintigraphy demonstrated that prior to TIPS shunting the portal venons contribution to hepatic perfusion was reduced to 29.2%, this reduction being due to portal hypertension. After TIPS placement a significant increase in portal venous perfusion was observed (38.2%;P<0.02). TIPS shunt occlusion was identified in patients by a significant reduction in the scintigraphically measured portal venons contribution to hepatic blood flow. Hepatic perfusion scintigraphy appears to be a valuable method to determine the immediate effect of TIPS on hepatic blood flow. Post-TIPS follow-up studies of hepatic haemodynamics by liver perfusion scintigraphy appear able to contribute to the detection of TIPS shunt occlusion before the clinical consequences of this complication have become apparent.     

Techniques and Outcomes of Transjugular Intrahepatic Portosystemic Shunting in Infants with Budd-Chiari Syndrome

PurposeTo describe the technical aspects, feasibility, and outcomes in children with Budd-Chiari syndrome (BCS) undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation during infancy.Materials and MethodsA retrospective review of infants with BCS undergoing TIPS creation between January 2012 and December 2018 was performed. Eight infants (5 males) underwent TIPS creation (7 for refractory ascites and 1 for refractory variceal bleeding) during the study period. The median age at TIPS creation was 10.5 months (range, 8–16 months). The median elapsed time between presentation and TIPS creation was 6.5 months (range, 0–13 months). The median weight and median pediatric end-stage liver disease score of the infants at the time of TIPS creation were 6.7 kg (range, 5.4–10 kg) and 13 kg (range, 8–18 kg), respectively.ResultsTIPS creation was successful in all patients. There were no immediate postprocedural complications. An 18-gauge hollow needle was manually curved, through which a 21-gauge Chiba needle was inserted to access the portal vein. All patients received 1 or 2 overlapping bare metal stents. One patient was lost to follow-up after the procedure. The median follow-up duration was 32 months (range, 14–51 months). Four of 7 infants needed reintervention. Two children died during the follow-up period. Two children successfully underwent living donor liver transplant, whereas the remaining 3 children were asymptomatic at the follow-up.ConclusionsTIPS creation was found to be safe and efficacious in improving portal hypertension and growth in these children, although, with a higher rate of reinterventions, possibly due to the use of small, bare metal stents.