Stent-grafts for de novo TIPS: technique and early results

Retrospective evaluation of early thrombosis in transjugular intrahepatic portosystemic polytetrafluoroethylene-coated shunts under 2-day postinterventional heparinization

The development of acute thrombosis within the TIPS tract may be prevented by prophylactic anticoagulation; however, there is no evidence of the correct anticoagulation regimen after TIPS placement. The purpose of this single-center retrospective study was to evaluate the short-term occlusion rate of transjugular intrahepatic portosystemic shunts (TIPSs) with polytetrafluorethylene (PTFE)-coated stents under consequent periprocedural full heparinization (target partial thromboplastin time [PTT]: 60–80 s). We analyzed TIPS placements that were followed up over a six-month period by Doppler ultrasound in 94 patients and compared the study group of 54 patients who received intravenous periprocedural full heparinization (target PTT: 60–80 s) without any other anticoagulation to patients with prolonged anticoagulation medication. The primary endpoint was TIPS patency after six months. The primary patency rate was 88.3% overall, and in the study group, 90.7%, with an early thrombosis rate of 3.2% (study group: 1.9%) and a primary assisted patency rate of 95.7% (study group: 96.3%). In the study group, one case of TIPS thrombosis occurred on the 23rd day after TIPS placement. Two patients underwent reintervention because of stenosis or buckling. Moreover, the target PTT was not attained in 8 of the 54 patent TIPSs. Four patients had an increased portosystemic pressure gradient, without stenosis, and the flow rate was corrected by increasing the TIPS diameter by dilation. Two-day heparinization seems sufficient to avoid early TIPS thrombosis over a six-month period.

Evaluation of Doppler-ultrasonography in the diagnosis of transjugular intrahepatic portosystemic shunt dysfunction: A prospective study

AIM

To prospectively evaluate the performance of Doppler-ultrasonography (US) for the detection of transjugular intrahepatic portosystemic shunt (TIPS) dysfunction within a multicenter cohort of cirrhotic patients.

METHODS

This study was conducted in 10 french teaching hospitals. After TIPS insertion, angiography and liver Doppler-US were carried out every six months to detect dysfunction (defined by a portosystemic gradient ≥ 12 mmHg and/or a stent stenosis ≥ 50%). The association between ultrasonographic signs and dysfunction was studied by logistic random-effects models, and the diagnostic performance of each Doppler criterion was estimated by the bootstrap method. This study was approved by the ethics committee of Tours.

RESULTS

Two hundred and eighteen pairs of examinations performed on 87 cirrhotic patients were analyzed. Variables significantly associated with dysfunction were: The speed of flow in the portal vein (P = 0.008), the reversal of flow in the right (P = 0.038) and left (P = 0.049) portal branch, the loss of modulation of portal flow by the right atrium (P = 0.0005), ascites (P = 0.001) and the overall impression of the operator (P = 0.0001). The diagnostic performances of these variables were low; sensitivity was < 58% and negative predictive value was < 73%. Therefore, dysfunction cannot be ruled out from Doppler-US.

CONCLUSION

The performance of Doppler-US for the detection of TIPS dysfunction is poor compared to angiography. New tools are needed to improve diagnosis of TIPS dysfunction.

Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt: a randomized controlled trial

BACKGROUND & AIMS

The first studies comparing covered stents (CS) and bare stents (BS) to achieve Transjugular Intrahepatic Portosystemic Shunt (TIPS) were in favor of CS, but only one randomized study has been performed. Our aim was to compare the primary patency of TIPS performed with CS and BS.

METHODS

The study was planned as a multicenter, pragmatic (with centers different in size and experience), randomized, single-blinded (with blinding of patients only), parallel group trial. The primary endpoint was TIPS dysfunction defined as either a portocaval gradient ⩾12mmHg, or a stent lumen stenosis ⩾50%. A transjugular angiography with portosystemic pressure gradient measurement was scheduled every 6months after TIPS insertion.

RESULTS

137 patients were randomized: 66 to receive CS, and 71 BS. Patients who were found to have a hepato-cellular carcinoma, or whose procedure was cancelled were excluded, giving a sample of 129 patients (62 vs. 67). Median follow-up for CS and BS were 23.6 and 21.8months, respectively. Compared to BS, the risk of TIPS dysfunction with CS was 0.60 95% CI [0.38-0.96], (p=0.032). The 2-year rate of shunt dysfunction was 44.0% for CS vs. 63.6% for BS. Early post TIPS complications (22.4% vs. 34.9%), risk of hepatic encephalopathy (0.89 [0.53-1.49]) and 2-year survival (70% vs. 67.5%) did not differ in the two groups. The 2-year cost/patient was 20k€ [15.9-27.5] for CS vs. 23.4k€ [18-37] for BS (p=0.52).

CONCLUSIONS

CS provided a significant 39% reduction in dysfunction compared to BS. We did not observe any significant difference with regard to hepatic encephalopathy or death.

The Evolution of Transjugular Intrahepatic Portosystemic Shunt: Tips

Since Richter's description in the literature in 1989 of the first procedure on human patients, transjugular intrahepatic portosystemic shunt (TIPS) has been worldwide considered as a noninvasive technique to manage portal hypertension complications. TIPS succeeds in lowering the hepatic sinusoidal pressure and in increasing the circulatory flow, thus reducing sodium retention, ascites recurrence, and variceal bleeding. Required several revisions of the shunt TIPS can be performed in case of different conditions such as hepatorenal syndrome, hepatichydrothorax, portal vein thrombosis, and Budd-Chiari syndrome. Most of the previous studies on TIPS procedure were based on the use of bare stents and most patients chose TIPS 2-3 years after traditional treatment, thus making TIPS appear to be not superior to endoscopy in survival rates. Bare stents were associated with higher incidence of shunt failure and consequently patients required several revisions during the follow-up. With the introduction of a dedicated e-PTFE covered stent-graft, these problems were completely solved, No more reinterventions are required with a tremendous improvement of patient's quality of life. One of the main drawbacks of the use of e-PTFE covered stent-graft is higher incidence of hepatic encephalopathy. In those cases refractory to the conventional medical therapy, a shunt reduction must be performed.

Should stent-grafts replace bare stents for primary transjugular intrahepatic portosystemic shunts?

Transjugular intrahepatic portosystemic shunt (TIPS) creation using bare stents is a second-line treatment for complications of portal hypertension due in part to the relatively high number of reinterventions and the occurrence of new or worsened encephalopathy. Initially, custom-made stent-grafts were used for TIPS revision in cases of biliary fistulae. Subsequently, custom stent-grafts were used for de novo TIPS creation. With the introduction of the VIATORR(®) TIPS endoprosthesis a dedicated stent-graft became available for TIPS creation and revision. The VIATORR(®) demonstrated its efficacy and superiority to uncovered stents in retrospective analyses, case-matched analyses, and randomized studies. The improved patency of stent-grafts has led many to requestion the role of TIPS as a second-line therapy. Currently, randomized trials are warranted to redefine the role of TIPS in the treatment of complications of portal hypertension.

Stent-grafts for transjugular intrahepatic portosystemic shunt creation: specialized TIPS stent-graft versus generic stent-graft/bare stent combination

PURPOSE

To compare functional and anatomic outcomes of transjugular intrahepatic portosystemic shunts (TIPSs) created with the specialized Viatorr stent versus a Wallstent/Fluency stent combination.

MATERIALS AND METHODS

Retrospective review of patients who underwent TIPS creation with stent-grafts was conducted over a 54-month period ending in June 2008. Patients were divided into three groups: Viatorr only, Fluency only, and combined Viatorr/Fluency, the latter of which was included in the overall evaluation but excluded from the comparative analysis between the Viatorr and Fluency groups. Patient demographics, Child-Pugh scores, and portosystemic gradient (PSG) reduction were compared. Patencies were calculated using the Kaplan-Meier method and compared.

RESULTS

A total of 126 TIPSs created with stent-grafts were found: 28 with Fluency stents, 93 with Viatorr devices, and five combined. No significance in demographic factors or PSGs was found among groups (P > .05). Major encephalopathy rates were 3.6% and 4.3% in the Fluency and Viatorr groups, respectively (P = 1.000). Hemodynamic success rates were 93% and 98% in the Fluency and Viatorr groups, respectively (P = .099). The primary unassisted patency rates at 6, 9, and 12 months were 87%, 81%, and 81%, respectively, in the Fluency group and 95%, 93%, and 89%, respectively, in the Viatorr group (P = .03). Portal and hepatic end stenoses were the causes of TIPS narrowing in the Fluency and Viatorr groups, respectively.

CONCLUSIONS

The Wallstent/Fluency stent combination is associated with a 1-year patency rate greater than 80%, with no significant difference versus the Viatorr stent regarding technical and hemodynamic success and encephalopathy rate. However, the Viatorr stent is associated with improved patency (89%) versus this bare stent/stent-graft combination.

Influence of the secondary deployment of expanded polytetrafluoroethylene-covered stent grafts on maintenance of transjugular intrahepatic portosystemic shunt patency

PURPOSE

To evaluate the effects of secondary deployment of expanded polytetrafluoroethylene (ePTFE)-covered stent grafts in the treatment of dysfunctional transjugular intrahepatic portosystemic shunts (TIPSs) in comparison with other common approaches (conventional angioplasty or implantation of bare metal stents).

MATERIALS AND METHODS

A retrospective review of 121 dysfunctional bare metal TIPS presenting between 2000 and 2004 was conducted. The group was divided into four subgroups according to the type of intervention: conventional angioplasty (52 cases; 43%), bare metal stent deployment (35 cases; 28.9%), nondedicated ePTFE-covered stent-graft deployment (15 cases; 12.4%), and dedicated ePTFE-covered stent-graft deployment (19 cases; 15.7%). In all four groups, the primary patency after the specific intervention was calculated and mutually compared.

RESULTS

Primary patency rates after 12 and 24 months were 49.7% and 25.3%, respectively, in conventional angioplasty; 74.9% and 64.9%, respectively, with bare metal stents; 75.2% and 64.5%, respectively, with nondedicated ePTFE-covered stent grafts; and 88.1% and 80.8%, respectively, with dedicated ePTFE-covered stent grafts.

CONCLUSIONS

In the treatment of dysfunctional TIPS, better patency after the intervention was obtained by deploying dedicated ePTFE-covered stent grafts in comparison with conventional angioplasty, bare metal stents, and nondedicated ePTFE-covered stents.

Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study

An 80% dysfunction rate at 2 years limits the use of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of complications of portal hypertension. The use of covered stents could improve shunt patency; however, long-term effect and safety remain unknown. Eighty patients randomized to be treated by TIPS either with a covered stent (Group 1) or an uncovered prosthesis (Group 2) were followed-up for 2 years. Doppler US was performed every 3 months. Angiography and portosystemic pressure gradient measurement were performed every 6 months or whenever dysfunction was suspected. Actuarial rates of primary patency in Groups 1 and 2 were 76% and 36% respectively (P=0.001). Clinical relapse occurred in four patients (10%) in Group 1 and 12 (29%) in Group 2 (P<0.05). Actuarial rates of being free of encephalopathy were 67% in Group 1 and 51% in Group 2 (P<0.05). Probability of survival was 58% and 45% at 2 years, respectively, in Groups 1 and 2 (NS). The mean Child-Pugh score improved only in Group 1 (from 8.1+/-1.6 to 7+/-2.2 at 2 years -P<0.05). We also compared the Doppler-US parameters between patent and dysfunctioning shunts. In patent shunts, the mean velocity within the portal vein was significantly higher but the performance of Doppler-US was not accurate enough to predict shunt dysfunction. In conclusion, the improvement in TIPS patency by using covered prostheses is maintained over time with a decreased risk of encephalopathy, while the risk of death was not increased.

Small intestinal submucosa sandwich Zilver stent-grafts for TIPS: experimental pilot study in swine

The aim of this study was the evaluation of preliminary suitability of the piglet small intestinal submucosa (SIS) sandwich Zilver endograft for experimental transjugular intrahepatic portosystemic shunt (TIPS) creation. TIPS was created in six swine. The five surviving animals underwent the follow-up portogram and were sacrificed at four weeks after TIPS creation. Gross and histologic examination was performed in all animals. TIPS creation was successful in all animals. One animal died four days after TIPS creation. In the five surviving animals, one shunt was occluded and four shunts were stenosed on the follow-up portogram. The mean percentage narrowing of the most advanced stenoses was 72% (range, 60%-100%). The most advanced stenosis was located in the parenchymal tract in three shunts and in the hepatic vein portion in one shunt. Gross and histologic examination showed abundant neointimal formation composed mainly of fibroblasts leading to the significant shunt stenoses. The piglet SIS sandwich Zilver stent-graft was found to offer only limited TIPS patency and should not be used for the definitive long-term TIPS study.

Portal Hypertension and Obstructive Jaundice after Hepatic Interventions: Report of Two Unusual Complications

We report two unusual complications after a transjugular intrahepatic portosystemic shunt and a biliary stent placement, respectively. One patient with cirrhosis and portal hypertension developed obstructive jaundice secondary to compression of the right hepatic duct by a stent graft placed in the transjugular intrahepatic portosystemic shunt. In another patient, biliary stents caused obstruction of the portal vein, resulting in symptomatic portal hypertension. An awareness of these possible complications is important for early diagnosis and appropriate treatment of such complications.

Transjugular intrahepatic portosystemic shunt--role in treating intractable variceal bleeding, ascites, and hepatic hydrothorax

Transjugular intrahepatic portosystemic shunt (TIPS) patency can be improved by the use of covered stents. Although this technical advance may lower the costs associated with TIPS, the overall role of TIPS in the management of portal hypertension may not change. Currently, bare metal TIPS is indicated in the treatment of acute refractory variceal hemorrhage, in the secondary prevention of variceal hemorrhage, for the management of ascites refractory to both medical management and large-volume paracentesis, and in the control of hepatic hydrothorax refractory to medical management.

Expanded PTFE-covered stent-grafts in the treatment of transjugular intrahepatic portosystemic shunt (TIPS) stenoses and occlusions

BACKGROUND

We evaluated the efficacy of the VIATORR endoprosthesis for the management of transjugular intrahepatic portosystemic shunt (TIPS) dysfunction.

METHODS

Twelve consecutive patients (10 men and two women, mean age 52.7 years) with recurrent TIPS dysfunction underwent TIPS revision with use of the VIATORR endoprosthesis. Nine patients were asymptomatic and three patients had developed recurrent variceal bleeding. All patients had previous shunt revisions (mean 2.1 revisions per patient) with angioplasty or bare stents. Follow-up included clinical assessment, Doppler ultrasound, and portal venography.

RESULTS

TIPS revision was successful in all patients, without complications. The mean portosystemic pressure gradient decreased from 16.8 +/- 2.7 mmHg to 6.5 +/- 2.6 mmHg. Hemostasis was achieved in all three patients who had recurrent variceal bleeding at the time of the procedure. Mean follow-up was 21.9 +/- 10.7 months. In two patients TIPS dysfunction occurred at 14 and 30 months after stent-graft placement, respectively. The primary patency rates were 100% after 12 months and 88.8% after 24 months. Two patients (16.6%) developed encephalopathy after stent graft placement.

CONCLUSION

TIPS revision using the VIATORR endoprosthesis appears to be an effective and durable method to control shunt dysfunction.

Improved clinical outcome with transjugular intrahepatic portosystemic stent-shunt utilizing polytetrafluoroethylene-covered stents

BACKGROUND AND AIMS

Transjugular intrahepatic portosystemic stent-shunt (TIPSS) with standard uncovered stents has a 50% one-year primary patency rate, and is complicated by hepatic encephalopathy in 35% of patients. Newer covered stents appear to have improved patency. This large study aimed to assess the shunt function and clinical efficacy of polytetrafluoroethylene-covered stents in a single centre.

METHODS

A total of 316 patients with uncovered stents before the introduction of covered stents (group 1) and 157 patients with the Viatorr Gore polytetrafluoroethylene-covered stents at the time of TIPSS creation (group 2) were studied.

RESULTS

The mean follow-up was 22.8+/-25.4 and 13.1+/-12.5 months, respectively (P<0.01). Shunt insufficiency was greater in group 1 [54 versus 8% at 12 months; relative hazard (RH) 8.6; 95% confidence interval (CI) 4.8-15.5; P<0.001]. The incidence of variceal rebleeding was greater in group 1 (11 versus 6% at 12 months; RH 2.4; 95% CI 1.1-5.1; P<0.05). The incidence of hepatic encephalopathy was greater in group 1 (32 versus 22% at 12 months; RH 1.5; 95% CI 1.1-2.3; P<0.05). Mortality was similar in the two groups.

CONCLUSION

The Viatorr type of polytetrafluoroethylene-covered stent results in vastly improved patency compared with uncovered stents, with reduced rates of variceal rebleeding and hepatic encephalopathy. This type of covered stent has the potential for superior clinical efficacy compared with uncovered stents.

Acute Effects of Liver Vein Occlusion by Stent-Graft Placed in Transjugular Intrahepatic Portosystemic Shunt Channel: An Experimental Study

The purpose of this study was to evaluate the effects of hepatic vein occlusion by stent-graft used in transjugular intrahepatic portosystemic shunt (TIPS). The experiments were performed in six healthy pigs under general anesthesia. Following percutaneous transhepatic implantation of a port-a-cath in the right hepatic vein, TIPS was created with a stent-graft (Viatorr; W L Gore, Flagstaff, AZ, USA). The outflow from the hepatic vein, blocked by the stent-graft was documented by injection of contrast medium and repeated injections of (99)Tc(m)-labeled human serum albumin through the port-a-cath. After 2 weeks, the outflow was re-evaluated, the pigs were sacrificed, and histopathologic examination of the liver was performed. Occlusion of the hepatic vein by a stent-graft had a short and temporary effect on the outflow. Histopathological examination from the affected liver segment showed no divergent pattern. Stent-grafts used in TIPS block the outflow from the liver vein, but do not have a prolonged circulatory effect and do not affect the liver parenchyma.

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.

A flexible stent with small intestinal submucosa covering for direct intrahepatic portocaval shunt: experimental pilot study in swine

The suitability of the flexible sandwich Zilver stent-graft (SZSG) with a biologically active tissue layer (small intestinal submucosa) for creation of the intravascular ultrasound (IVUS)-guided direct intrahepatic portocaval shunt (DIPS) was explored in six young swine in a search for a flexible system to replace the rigid polytetrafluoroethylene (PTFE) stent originally used by this group with limited success. The portal vein was punctured from the inferior vena cava through the caudate lobe of the liver using IVUS guidance. After balloon dilation of the puncture tract, DIPS was successfully created in all animals with use of an SZSG 9 mm in diameter and 6 cm or 8 cm long. Only one DIPS remained well patent at 14 days when the animal had to be killed because of encephalopathy. DIPS in the other five animals were found to be either severely stenosed (3 animals) or occluded (2 animals) at 4 weeks due to accelerated formation of neointimal hyperplasia (NIH) in the liver parenchymal portion of the shunt and superimposed thrombosis. The lack of high pressure in the portal system contributed to early endograft closure. The flexible stent and the covering fail badly. The reason for this could be due to either component. More work is required to find a reliable flexible system with long-term patency. Exploration of the IVUS-guided direct extrahepatic portocaval shunt is suggested.

Bile leakage during transjugular intrahepatic portosystemic shunt creation: in vitro effect of bile on growth and function of human umbilical vein endothelium

PURPOSE

To evaluate the effect of bile on growth and proliferation of human umbilical vein endothelium cultured in vitro, with a view toward clarifying the effect of bile leakage during transjugular intrahepatic portosystemic shunt creation.

MATERIALS AND METHODS

This study was approved by the ethical review committee, and written informed consent was obtained from all mothers. Endothelial cells (ECs) were collected from human umbilical veins and cultured in vitro. After 24-48 hours in culture, ECs were distributed into groups supplemented with the following concentrations of bile in the culture medium: 0%, 5.0%, 10.0%, 15.0%, 20.0%, and 25.0%. The cells were harvested 5 days after supplementation with bile. The morphologic features, von Willebrand factor (vWF) level, tetrazolium salt (MTT) assay value of light absorption, total protein level, and nitric oxide synthase (NOS) activity of the ECs were evaluated.

RESULTS

All explanted cells were identified as ECs by using the vWF test. Compared with ECs in the control group without bile, ECs in culture medium with a bile concentration of 5.0%, 10.0%, or 15.0% showed no marked morphologic changes, whereas ECs in culture medium with a bile concentration of 20.0% or 25.0% were reduced greatly in number and looked markedly immature. The MTT value of light absorption, total protein level, and vWF secretion were significantly decreased (P < .05 for all) in ECs in culture medium with 25.0% bile compared with these parameters in ECs in culture medium without bile, although these parameters did not significantly differ between the ECs in culture medium of 5.0% or 10.0% bile and the ECs in culture medium without bile. Compared with NOS activity in ECs when no bile was present in the culture medium, NOS activity in ECs was significantly decreased at all bile concentrations (P < .05).

CONCLUSION

Low concentrations of bile do not markedly inhibit cell growth; the inhibiting effect of bile on ECs progresses with an increase in bile concentration.

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.

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.

PTFE-covered stents improve TIPS patency in Budd-Chiari syndrome

Transjugular intrahepatic portosystemic shunt (TIPS) have been shown to be an efficient portal-systemic derivative treatment for Budd-Chiari syndrome (BCS) patients uncontrolled by medical therapy. However, the main drawback of TIPS for this condition is a very high rate of shunt dysfunction. Recently, polytetrafluoroethylene (PTFE)-covered stents have been shown to reduce the incidence of TIPS dysfunction in patients with cirrhosis. The aim of the study was to assess the incidence of TIPS dysfunction in 2 cohorts of BCS patients treated with bare or PTFE-covered stents. The study included 25 TIPS procedures (16 bare stents and 9 covered stents) with a median follow-up period of 20.4 months (range, 3.9-124.8). Fourteen of 16 patients (87%) receiving bare stents had TIPS dysfunction compared to 3 of the 9 patients (33%) receiving PTFE-covered stents (P = .005). The actuarial rates of primary patency in the bare-stent group were 19% at 1 year compared with 67% in the PTFE-covered stent group (P = .02; log-rank test). The number of additional interventional procedures to maintain TIPS patency was significantly greater in the bare-stent than in the PTFE-covered stent group (1.9 +/- 1.2 vs. 0.6 +/- 0.9; P = .007). The number of patients with clinical relapses was greater in the bare-stent group compared to the PTFE-covered stent group (13 vs. 5 episodes in 9 and 3 patients, respectively). In conclusion, PTFE-covered stents have a considerable advantage over bare stents for the TIPS treatment of BCS patients, with a lower dysfunction rate, a lower number of reinterventions, and fewer prosthesis requirements. PTFE-covered stents are preferable in patients with Budd-Chiari Syndrome.

Early and long-term clinical and radiological follow-up results of expanded-polytetrafluoroethylene-covered stent-grafts for transjugular intrahepatic portosystemic shunt procedures

The purpose of this study was to assess the therapeutic efficacy and immediate and long-term safety of expanded-tetrafluoroethylene covered stent-grafts for transjugular intrahepatic portosystemic shunts in patients with portal hypertension-related complications. A cohort of 56 patients suffering from severe portal hypertension-related complications underwent implantation of an expanded-polytetrafluoroethylene-covered stent-graft. All patients suffered from severe liver cirrhosis graded Child-Pugh A (n=8; 16%), B (n=13; 21%) or C (n=35; 63%). In 44 patients, the stent-graft was placed during the initial TIPS procedure (de novo TIPS); in the other 12 patients, the stent-graft was placed to repermeabilize the previously placed bare stent (TIPS revision). Follow-up was performed with clinical assessment, duplex ultrasound and, if abnormal or inconclusive, with invasive venography and pressure measurements. Per- en immediate post-procedural complications occurred in four patients (4/56, 7%). None of them was lethal. During follow-up, stent occlusion appeared in one patient and stenosis in two; no recurrence of bleeding was noted in all patients treated for variceal bleeding (n=28), and 24 of the 28 patients (86%) suffering from refractory ascites and/or hepatic hydrothorax were free of regular paracenteses and/or drainage of pleural effusion after shunt creation. The 30-day and global mortality for the total study population (n=56) was, respectively, 7% (n=4) and 28.5% (n=16). In the patient subgroup with variceal bleeding (n=28), 30-day mortality was 3.5% (n=1) and global mortality 14.2% (n=4). In the ascites and/or hydrothorax subgroup (n=28), 8.1% (n=3) mortality at 30 days was found and global mortality was 32.4% (n=12). In 10 patients of the 56 studied patients (18%), isolated hepatic encephalopathy occurred, which was lethal in 4 (Child C) patients (7%). Three of these four patients died within the 1st month after TIPS placement. A very high primary patency rate of TIPS can be obtained long-term after implantation of an e-PTFE-covered stent-graft, leading to a definitive resolution of portal hypertension-related complications. The incidence of TIPS-induced hepatic encephalopathy is acceptable.

Polytetrafluoroethylene-covered nitinol stent-graft for transjugular intrahepatic portosystemic shunt creation: 3-year experience

PURPOSE

To prospectively evaluate the use of a recently developed expanded polytetrafluoroethylene (PTFE)-covered nitinol stent-graft in preventing the need for repeated intervention after transjugular intrahepatic portosystemic shunt (TIPS) creation.

MATERIALS AND METHODS

Fifty-three consecutive patients underwent TIPS procedures between January 2000 and February 2002. Minimum patient follow-up was 9 months (mean, 16.3 months). Fifty-six stent-grafts were implanted in 53 patients; eight of the devices were 8 mm in diameter and 48 were 10 mm in diameter. The stent length varied from 4 to 7 cm. Indications for the procedure included recurrence of bleeding after sclerotherapy (28 patients with cirrhosis, one patient without), refractory ascites or hydrothorax (21 patients with cirrhosis, one patient without), and Budd-Chiari syndrome (two patients).

RESULTS

A technical success rate of 100% was obtained, with an early clinical success rate of 96.2%. During the follow-up period, the recurrence rate was 3.4% (one of 29 patients) for bleeding and 9.0% (two of 22 patients) for ascites. Shunt malfunction occurred in nine of 53 patients (16.9%); in one of these nine patients, shunt occlusion was evident after revision, and a parallel shunt was created. The 1-year primary and secondary patency rates were 83.8% and 98.1%, respectively. In this series, the incidence of encephalopathy (included even as a single short-lived episode) was 47.1% (25 of 53 patients). The 30-day mortality rate was 3.8% (two of 53), and the late mortality rate was 17.3% (eight of 46), excluding seven patients who underwent transplantation.

CONCLUSION

The new PTFE-covered nitinol stent-graft used appears to be excellent in preventing the need for repeated interventions. A primary patency rate of 83.8% and a secondary patency rate of 98.1% were achieved.

Polytetrafluoroethylene-covered stent grafts for TIPS procedure: 1-year patency and clinical results

OBJECTIVES

Polytetrafluoroethylene (PTFE)-covered stent grafts appear to have the potential to improve TIPS patency, but data available are few and controversial. The aim of this prospective nonrandomized trial was to assess TIPS safety and 1-yr patency with a new commercially available PTFE-covered stent graft in comparison with a group of historical controls treated with conventional stents.

METHODS

Between July 1992 and December 1999, 87 consecutive cirrhotics underwent TIPS with conventional stents, while from January 2000 to November 2001, 32 consecutive cirrhotics were treated with PTFE-covered stent grafts. All patients were followed by the same medical team according to a prospective protocol for a diagnostic work-up and a surveillance strategy.

RESULTS

The two groups were comparable for age, sex, etiology, and severity of cirrhosis. The 1-yr probability of remaining free of shunt dysfunction tended to be higher in the covered stent group: 76.3% (95% CI = 58.7-93.9%) versus 57.5% (95% CI = 46.6-68.4%); log rank test: p = 0.055. However, stenoses inside the stent were significantly higher in patients with bare stents (88% vs 17%), while stenoses at the hepatic or portal vein were more frequent in PTFE-covered stent-graft group (50% vs 9% and 33% vs 3%, respectively), (chi2 = 15.42; df = 2.0; p = 0.0004). Stenoses inside the covered portion of the stent did not occur. One-year cumulative rebleeding, encephalopathy, and survival were similar.

CONCLUSIONS

PTFE-covered stents are able to solve pseudointimal hyperplasia within the stent tract, but have a high incidence of hepatic or portal vein stenosis. Improvements in stent design and insertion techniques are necessary to fully achieve the potential benefit of this new device.

Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study

BACKGROUND & AIMS

A 50% dysfunction rate at 1 year is one of the main drawbacks of the transjugular intrahepatic portosystemic shunt procedure. Preliminary experimental and clinical studies suggest that the use of stents covered with polytetrafluoroethylene could tremendously decrease this risk.

METHODS

Eighty patients with cirrhosis and uncontrolled bleeding (n = 23), recurrent bleeding (n = 25), or refractory ascites (n = 32) were randomized to be treated by transjugular intrahepatic portosystemic shunts with either a polytetrafluoroethylene-covered stent (group 1; 39 patients) or a usual uncovered prosthesis (group 2; 41 patients). Follow-up Doppler ultrasound was scheduled at day 7, at 1 month, and then every 3 months for 2 years. Angiography and portosystemic pressure gradient measurements were performed 6, 12, and 24 months after the transjugular intrahepatic portosystemic shunt procedure and whenever dysfunction was suspected. Dysfunction was defined as a >50% reduction of the lumen of the shunt at angiography or a portosystemic pressure gradient >12 mm Hg.

RESULTS

After a median follow-up of 300 days, 5 patients (13%) in group 1 and 18 (44%) in group 2 experienced shunt dysfunction (P < 0.001). Clinical relapse occurred in 3 patients (8%) in group 1 and 12 (29%) in group 2 (P < 0.05). Actuarial rates of encephalopathy were 21% in group 1 and 41% in group 2 at 1 year (not significant). Estimated probabilities of survival were 71% and 60% at 1 year and 65% and 41% at 2 years in groups 1 and 2, respectively (not significant).

CONCLUSIONS

The use of polytetrafluoroethylene-covered prostheses improves transjugular intrahepatic portosystemic shunt patency and decreases the number of clinical relapses and reinterventions without increasing the risk of encephalopathy.

Recurrent TIPS thrombosis after polyethylene stent-graft use and salvage with polytetrafluoroethylene stent-grafts

Increasing data support the use of polytetrafluoroethylene (PTFE) stent-grafts for de novo and revision transjugular intrahepatic portosystemic shunt (TIPS) applications. Animal experiments have indicated that polyethylene terephthalate (PET) stent-grafts provide no improvement or actually worsen TIPS patency compared with controls, but human TIPS experience with PET grafts is more limited. Herein we describe three patients who underwent de novo creation of TIPS with PET-covered stent-grafts at outside institutions, which resulted in immediate and recurring TIPS thromboses despite repeated thrombectomies. After the failed TIPS were revised with PTFE stent-grafts, the presenting symptoms resolved and uninterrupted patency was achieved.

Percutaneous inferior vena cava-to-portal vein shunt (PIPS) using a stent-graft: preliminary results

PURPOSE

To present preliminary results of an inferior vena cava (IVC)-to-portal vein shunt (PIPS) that is created through the caudate lobe of the liver.

METHODS

Sixteen patients (13 men; mean age 50 years, range 32-63) were referred for PIPS procedures because of bleeding varices (n = 11), intractable ascites (n = 4), and hepatorenal syndrome (n = 1). The severity of liver disease was Child's B in 2 and Child's C in 14. The PIPS was created by a transhepatic puncture through the IVC and the portal vein; an endograft made of polytetrafluoroethylene sutured to a Palmaz stent was placed through a jugular approach.

RESULTS

In 13 (81%) patients, the portal vein-to-IVC tracts were successfully created. The postprocedural portal vein-IVC gradients varied from 1 to 9 mm Hg (mean 5). There were 2 deaths in the 30-day periprocedural period from adult respiratory distress syndrome and hepatorenal syndrome. A third patient died at 31 days from liver failure owing to continuing alcohol abuse. In addition, there was 1 case of peritoneal bleeding treated with blood product replacement. The follow-up period ranged from 14 to 671 days (mean 343). None of the patients treated for variceal bleeding had another bleeding episode, but 2 patients who had a PIPS procedure for refractory ascites did not benefit from the procedure. Postprocedure, 46% (6/13) of the patients had hepatic encephalopathy, which was unchanged from baseline. The primary and secondary patency rates at 365 days were 60% and 65%, respectively.

CONCLUSIONS

The preliminary results using a stent-graft to create an IVC-portal vein shunt are encouraging and support further work to better determine the role of this procedure.

Serum bilirubin and early mortality after transjugular intrahepatic portosystemic shunts: results of a multivariate analysis

PURPOSE

To examine the prognostic utility of the serum bilirubin level before transjugular intrahepatic portosystemic shunt (TIPS) creation as an independent predictor of 30-day mortality in patients who underwent TIPS creation for treatment of variceal hemorrhage.

MATERIALS AND METHODS

Multiple covariates from a cohort of 220 consecutive patients undergoing TIPS creation were analyzed with use of univariate and multivariate logistic regression. These included pre-TIPS total bilirubin levels, modified Child-Pugh class, APACHE II score, intubation status, etiology of liver disease, and acute versus elective shunting.

RESULTS

The mean pre-TIPS serum total bilirubin level was 3.2 mg/dL (range, 0.4-40.3 mg/dL). The bilirubin level was <3 mg/dL in 102 patients, > or = 3.0 mg/dL in 58, > or = 4.0 mg/dL in 34, and > or = 5.0 mg/dL in 27. Each 1.0-mg/dL increase in total bilirubin was associated with 40% greater odds of 30-day mortality (odds ratio = 1.4; 95% CI = 1.2-1.7). Using each threshold as its own referent, bilirubin levels at or greater than 3.0, 4.0, and 5.0 mg/dL stratified patients into increased odds of early death by 5.7, 9.7, and 19.2 times, respectively (all P <.001). A pre-TIPS APACHE II score of >18 increased the odds of early death by a factor of 5.6 (95% CI = 2.4-8.7); modified Child-Pugh class C (vs classes A and B combined) alone increased the odds by a factor of 8.1 (95% CI = 3.6-18.1). Only one of 20 patients (5%) with a pre-TIPS bilirubin level >6.0 mg/dL survived more than 30 days after TIPS creation. In acutely bleeding patients (n = 122) undergoing TIPS creation, bilirubin levels > or = 3.0, > or = 4.0, and > or = 5.0 mg/dL stratified patients into odds ratios of 4.4, 7.1, and 9.8, respectively, compared with 7.1, 13.2, and 9.2 for patients undergoing elective TIPS creation. Combining endotracheal intubation (n = 72) and bilirubin strata yielded mortality odds of 8.3, 12.5, and 20.8 compared with odds of 2.3, 4.6, and 11.2 in nonintubated patients. Combining alcoholic cirrhosis (n = 129) with bilirubin levels yielded mortality odds of 8.0, 10.6, and 18.0 compared with other etiologies of liver disease (odds ratios = 2.9, 7.3, and 22.7).

CONCLUSION

An elevated pre-TIPS bilirubin level is a powerful independent predictor of 30-day mortality after TIPS creation with a 40% increased risk of death for each 1-mg/dL increase above 3.0 mg/dL. The predictive value of this criterion is increased in patients who undergo TIPS procedures electively. The magnitude of the effect on mortality is similar to that of APACHE II scores and modified Child-Pugh class but is simpler to ascertain.

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.

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.

Creation of a transrenal arteriovenous dialysis shunt: feasibility study in a swine model

PURPOSE

To investigate the feasibility of percutaneous renal artery and vein access for the creation of a transrenal arteriovenous hemodialysis graft.

MATERIALS AND METHODS

Renal-artery-to-ipsilateral-renal-vein conduits were constructed with use of entirely percutaneous techniques in seven swine. Renal artery and vein access was performed in six animals with use of a retrograde (inside-out) technique and in one animal with use of an antegrade (outside-in) technique. Modified 8-F sheaths were used in the first three animals and Wallgrafts were used in the final four animals to form the arterial and venous limbs of each shunt. The arterial and venous limbs were joined together by a subcutaneous segment of 6-mm reinforced polytetrafluoroethylene (PTFE) in five animals and by external conduits in two animals. Wallgrafts were deployed from the renal artery and vein into the segments of PTFE. The free ends of each conduit were tunneled and joined together to close the arteriovenous circuit. Post-shunt angiography was used in all animals to document successful shunt creation and demonstrate rapid arteriovenous shunting as a determinant of technical feasibility. Two of the seven animals received additional anticoagulation therapy and/or antiplatelet therapy to prevent shunt thrombosis during the follow-up period. The three initial animals were killed within 2 hours of shunt creation, and two of the remaining four animals returned for angiographic follow-up, one on day 2 and one on day 9. All animals underwent a complete necropsy to assess for potential complications including hemorrhage and vascular or bowel injury.

RESULTS

Retrograde renal arterial and venous access was successful in all six animals in which it was attempted. Five of six arterial accesses and four of six venous accesses traversed the peritoneum with two arterial accesses and one venous access penetrating a loop of large bowel. Antegrade access was performed and successfully accomplished in the final animal. Brisk arteriovenous shunting was demonstrated on completion angiography in all animals. Graft occlusion was present in the two animals that returned for follow-up and two animals died before follow-up as a result of graft leakage and subsequent hemorrhage. Minimal perinephric and intrarenal hemorrhage was demonstrated at necropsy after shunt insertion in the remaining five animals. Renal infarction was present in all kidneys used for transrenal access.

CONCLUSION

The transrenal approach for the creation of a percutaneous arteriovenous shunt is feasible after renal artery and vein access by either the retrograde or antegrade technique. Additional technical refinements of the procedure and the devices used will be necessary before follow-up studies are conducted.

A new stent-graft for transjugular intrahepatic portosystemic shunts

The transjugular intrahepatic portosystemic shunt (TIPSS) has become an effective method of treatment for the complications of portal hypertension, however shunt dysfunction is common. Covered stent-grafts have been tested in animal models, and customized or "home-made" devices have been deployed in several institutions. We report the use of a new commercially available TIPSS stent-graft in six patients undergoing primary shunting as well as two cases of revision or secondary TIPSS. The device has proved relatively easy to handle and appears to have the technical features likely to improve primary patency. Further follow-up is required to properly assess shunt patency and re-intervention rates.

Intravascular US-guided direct intrahepatic portacaval shunt with a PTFE-covered stent-graft: feasibility study in swine and initial clinical results

PURPOSE

To determine the feasibility of the creation of a direct intrahepatic inferior vena cava (IVC)-to-portal-vein shunt with puncture guided by a transfemorally placed intravascular ultrasound (IVUS) probe and use of a polytetrafluoroethylene (PTFE)-covered stent-graft.

MATERIALS AND METHODS

In five swine, transjugular access was used to perform a direct puncture from the IVC to the portal vein with use of a modified Rosch-Uchida Portal Access set directed with real-time IVUS (9 MHz) introduced from a transfemoral venous approach. The direct intrahepatic portocaval shunt (DIPS) was then created with single or overlapping PTFE-covered Palmaz stents placed through a 10-F sheath and dilated to a diameter of 8 mm. Follow-up was performed with transhepatic portography at 2, 4, and 8 weeks. Animals were killed when shunts occluded or at the termination of the study at 8 weeks. Gross and microscopic histologic study was performed on sacrificed animals. A similar technique was used to create DIPS in five patients with intractable ascites, with follow-up by US and venography.

RESULTS

All experimental DIPS created in swine were created without complications. Portal vein punctures were achieved in four of five swine on the first or second pass of the needle. Follow-up transhepatic portography at 2 weeks demonstrated occlusion of two shunts, both explained by technical reasons at sacrifice. At 4 and 8 weeks, the remaining three shunts were patent on portography. Histology showed a thin neointimal lining with no significant tissue ingrowth or hyperplasia. Clinically, in five patients, successful puncture of the portal vein from the IVC was achieved in one to three passes. Creation of DIPS led to a reduction of mean portosystemic gradient from 18-29 mm Hg (mean, 24 mm Hg) to 9-10 mm Hg (mean, 9 mm Hg). One patient died of liver failure 2 days after creation of DIPS. The other four patients were doing well 2-15 months (mean, 8 months) after the procedure, with patency confirmed by US and venography.

CONCLUSION

Creation of DIPS is technically feasible, and the direct IVC-to-portal-vein puncture can be done accurately with real-time IVUS guidance. Further studies and longer follow-up are necessary to determine if the short length of the PTFE-covered stent-graft and avoidance of the hepatic vein will increase the long-term patency compared to standard transjugular intrahepatic portosystemic shunt creation.

CT-guided transfemoral portocaval shunt creation

A patient with superior vena cava (SVC) occlusion presented with severe ascites and urgent transjugular intrahepatic portosystemic shunt (TIPS) was requested. The patient had a chronically occluded SVC. An alternative to classic TIPS was employed using CT guidance to traverse the left portal vein to the inferior vena cava with a small gauge needle. Fluoroscopic guidance was then used to snare a wire placed through the needle and then work from the femoral vein to create a portocaval shunt that passed through the caudate lobe. This procedure was a technical success and improved the patient's ascites.