Extrahepatic portal vein tear with intraperitoneal hemorrhage during TIPS

Complications of transjugular intrahepatic portosystemic shunt (TIPS) in the era of the stent graft - What the interventionists need to know?

Transjugular intrahepatic portosystemic shunt (TIPS) is created between a hepatic vein (HV) and the portal vein (PV) to alleviate the symptoms of portal hypertension. Despite high procedural success rates, a myriad of complications may occur at every step of TIPS creation. These complications may be attributable to the procedure itself or the shunt. Portal vein puncture is the most challenging and rate-limiting step, with extrahepatic portal vein puncture being the most devastating tabletop complication. Hepatic encephalopathy is the most common shunt-related complication after TIPS. Unlike bare metallic stents, covered stents have a longer patency rate and lower incidence of TIPS dysfunction. Most of the TIPS dysfunction that occurs with stent-grafts is due to technical errors and mechanical factors. TIPS revision often requires a combination of angioplasty, mechanical thrombectomy, and thrombolytics with a need for additional stenting in some cases. This review article focuses on procedure and shunt-related complications, as well as preventive and management strategies.

Transjugular intrahepatic portosystemic shunt-related complications and practical solutions

Despite the clinical complexity of patients with severe liver disease and the technical demands associated with the creation of a transjugular intrahepatic portosystemic shunt (TIPS), the major complication rate of this procedure is less than 5%. Delayed recognition and treatment of complications related to TIPS can have life-threatening consequences. This article provides an overview of the spectrum of periprocedural and delayed complications related to the performance of TIPS and offers the reader pearls for both avoiding and managing those complications.

Transvenous extrahepatic portacaval shunt: feasibility study in a Swine model

PURPOSE

To evaluate the feasibility of intravascular ultrasonography (US)-guided access to the extrahepatic segment of the main portal vein (PV) to create a transvenous extrahepatic portacaval shunt (TEPS) as an easier and more durable alternative to transjugular intrahepatic portosystemic shunt.

MATERIALS AND METHODS

PV access from the inferior vena cava (IVC) to the main PV was performed in eight pigs by using intravascular US guidance. Either a prototype stent-graft (n = 6) or Wallgraft (n = 2) was used to create the shunt. Intravascular US demonstrated the main PV to be in direct contact with the IVC in all animals. A mean of 1.75 needle passes were needed to enter the PV. Immediate postprocedure computed tomography (CT) of the abdomen helped identify and quantify the presence of hemoperitoneum. Shunt venography was performed at 2 weeks, followed by necropsy.

RESULTS

PV access and TEPS creation were successful in all animals. Contrast medium extravasation, due to inadequate coverage of the portacaval tract, was identified in four procedures and addressed by the placement of additional devices in three cases and prolonged balloon inflation in one. Abdominal CT demonstrated small amounts of hemoperitoneum in five animals and moderate to large amounts in three. Two animals did not live to the 2-week follow-up study. One animal was sacrificed on the day of the procedure owing to intraperitoneal hemorrhage; the second died of intussusception-related bowel necrosis 10 days after TEPS creation. Shunts were occluded or severely stenotic at venography and necropsy in the remaining six animals.

CONCLUSION

TEPS is technically feasible after intravascular US-guided PV access.