The natural history of parallel transjugular intrahepatic portosystemic stent shunts using uncovered stent: the role of host-related factors

Refractory portal hypertension complications successfully managed by parallel transjugular intrahepatic portosystemic shunt (TIPS): a case report

Background

Transjugular intrahepatic portosystemic shunt (TIPS) is an established intervention to treat complicated portal hypertension refractory to medical or endoscopic management. TIPS dysfunction results in the recurrence of portal hypertension symptoms. In cases of TIPS dysfunction or persistent portal hypertension despite a patent primary TIPS, the creation of parallel TIPS may be the only intervention to effectively reduce portal pressure. Since the introduction of dedicated TIPS stents (Viatorr®) the incidence of TIPS dysfunction has reduced profoundly. Nevertheless, the creation of a parallel TIPS can still be necessary in the current dedicated TIPS stent era.

Case presentation

We report one such patient who experienced ongoing portal hypertension induced upper gastro-intestinal haemorrhage despite multiple TIPS revisions and a patent primary TIPS.

Conclusion

Following creation of a parallel TIPS, the patient remains in clinical remission with no further bleeding.

Parallel transjugular intrahepatic portosystemic shunt (TIPS) for TIPS dysfunction: technical and patency outcome

Background

Several methods have been used in treating TIPS dysfunction, including balloon angioplasty with/without telescoping stent. However, there are some cases refractory to recanalization and parallel shunt (PS) should be tried. The aim is to evaluate the technical and patency outcomes of the PS. We retrospectively reviewed the medical records of patients (n = 37) with refractory TIPS dysfunction who were managed by PS. All clinical, laboratory, and technical data as well as radiological data over 1 year were collected. Technical success was the primary outcome while complications and shunt patency were the secondary outcomes.

Results

Thirty-three out of the 37 patients (89.2%) of the study were Budd-Chiari syndrome cases. Caval puncture was done in 34/37 (91.9%) of cases while the hepatic vein puncture was done in 3/37 cases (8.1%). Portal entry through the left branch was done in 22 patients (59.5%), from neck of PV in 13 patients (35.1%) to right PV in 2 patients (5.4%). Technical success was achieved in 100% of cases. Porto-systemic pressure gradient (PSG) before PS insertion was 32.5 ± 8.1 mmHg and it became 8.9 ± 2.3 mmHg after the PS insertion (P < 0.01). The median primary patency duration was 11 months. The estimated 12 and 18 months primary patency rates were 32/37 (86.5%) and (78.4%) respectively. Intra-procedure complications occurred in 8 patients (21.6%) and were successfully treated medically. Acute PS thromboses occurred in 4 patients (10.8%) and required early successful interventions.

Conclusion

It is proven from this study that patients with refractory TIPS occlusion have another chance for a second PS to treat portal hypertension symptoms. Moreover, the PS is a durable, safe, and effective treatment on mid-term basis.

Parallel transjugular intrahepatic portosystemic shunt with Viatorr® stents for primary TIPS insufficiency: Case series and review of literature

BACKGROUND

Transjugular intrahepatic portosystemic shunts (TIPS) can alleviate complications of portal hypertension such as ascites and variceal bleeding by decreasing the portosystemic gradient. In limited clinical situations, parallel TIPS may be only solution to alleviate either variceal bleeding or ascites secondary to portal hypertension when the primary TIPS fails to do so. Data specifically addressing the use of this partially polytetrafluoroethylene covered nitinol stent (Viatorr®) is largely lacking despite Viatorr® being the current gold standard for modern TIPS placement.

CASE SUMMARY

All three patients had portal hypertension and already had a primary Viatorr® TIPS placed previously. All patients have undergone failed endoscopy to manage acute variceal bleeding before referral for a parallel stent (PS). PS were placed in patients presenting with recurrent variceal bleeding despite existence of a widely patent primary TIPS. Primary stent patency was verified with either Doppler ultrasound or intra-procedural TIPS stent venography. Doppler ultrasound follow-up imaging demonstrated complete patency of both primary and parallel TIPS. All three patients did well on clinical follow-up of up to six months and no major complications were recorded. A review of existing literature on the role of PS in the management of portal hypertension complications is discussed. There are three case reports of use of primary and PS Viatorr® stents placement, only one of which is in a patient with gastrointestinal variceal bleeding despite a patent primary Viatorr® TIPS.

CONCLUSION

Viatorr® PS placement in the management of variceal hemorrhage is feasible with promising short term patency and clinical follow-up data.

Parallel shunt for management of transjugular intrahepatic portosystemic shunt occlusion

AIM

To evaluate the security and efficacy of parallel shunt in the treatment of transjugular intrahepatic portosystemic shunt (TIPS) occlusion.

METHODS

From March 2012 to October 2015, 18 cirrhotic patients who underwent TIPS revision with the creation of parallel shunt were investigated retrospectively in our institution. Parallel shunt was established due to the original shunt occlusion. The mean follow-up period was 16.7 mo ± 10.8 mo (range, 6-42 mo). Technical success and the duration of the first and second operation were recorded. Branch of hepatic vein receiving TIPS, portal pressure gradient and shunt patency were also assessed.

RESULTS

Technical success rate of parallel shunt creation was 100%. The mean duration of the second operation was 57.1 min ± 12.9 min, which was significantly shorter than that of the first operation (89.2 min ± 29.4 min, t = 4.24, P < 0.01). The mean portosystemic pressure gradient significantly decreased from 25.5 mmHg ± 7.4 mmHg (range, 16-37 mmHg) to 10.9 mmHg ± 2.4 mmHg (range, 7-16 mmHg) after the parallel shunt was created (t = 10.1, P < 0.01). Four patients developed recurrent TIPS dysfunction during the follow-up period, of whom three presented with stenosis in the portal vein and one with stenosis in the liver vein. One patient received angioplasty. Insertion of an additional stent-graft was performed in the other three patients. The shunt patency rates at 12 mo after the creation of parallel shunt was 70.1% with Fluency endoprostheses and 87.6% with Fluency endoprostheses and bare stent.

CONCLUSION

The creation of parallel shunt is a safe and effective approach for managing TIPS occlusion.

Parallel shunt for the treatment of transjugular intrahepatic portosystemic shunt dysfunction

OBJECTIVE

To investigate the safety, efficacy and long-term patency of parallel shunts (PS) in the management of the transjugular intrahepatic portosystemic shunt (TIPS) dysfunction.

MATERIALS AND METHODS

Between March 2007 and October 2010, 18 patients (13 men and 5 women) who underwent TIPS revision with the creation of PS were evaluated retrospectively. In the first 10 patients, a 10-mm-diameter Wallgraft endoprosthesis was deployed; in the latter 8 patients, an 8-mm-diameter Fluency endoprosthesis was deployed.

RESULTS

The creation of PS was technically successful in all patients. The mean ± standard deviation portosystemic pressure gradient before and after the procedure was 25.5 ± 7.3 mm Hg (range, 16-37 mm Hg) and 10.9 ± 2.3 mm Hg (range, 7-16 mm Hg), respectively. The duration of follow-up was 16.7 ± 10.8 months (range, 6-42 months). The primary shunt patency rates at 12 months after the creation of PS was 70% with Wallgraft endoprostheses and 87.5% with Fluency endoprostheses.

CONCLUSION

TIPS revision with the creation of PS is a safe, effective and durable method for treating shunt dysfunction.

Parallel shunt for the treatment of transjugular intrahepatic portosystemic shunt dysfunction

Objective

To investigate the safety, efficacy and long-term patency of parallel shunts (PS) in the management of the transjugular intrahepatic portosystemic shunt (TIPS) dysfunction.

Materials and Methods

Between March 2007 and October 2010, 18 patients (13 men and 5 women) who underwent TIPS revision with the creation of PS were evaluated retrospectively. In the first 10 patients, a 10-mm-diameter Wallgraft endoprosthesis was deployed; in the latter 8 patients, an 8-mm-diameter Fluency endoprosthesis was deployed.

Results

The creation of PS was technically successful in all patients. The mean ± standard deviation portosystemic pressure gradient before and after the procedure was 25.5 ± 7.3 mm Hg (range, 16-37 mm Hg) and 10.9 ± 2.3 mm Hg (range, 7-16 mm Hg), respectively. The duration of follow-up was 16.7 ± 10.8 months (range, 6-42 months). The primary shunt patency rates at 12 months after the creation of PS was 70% with Wallgraft endoprostheses and 87.5% with Fluency endoprostheses.

Conclusion

TIPS revision with the creation of PS is a safe, effective and durable method for treating shunt dysfunction.

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.