Efficacy of balloon angioplasty, restenting, and parallel shunt insertion for shunt insufficiency after transjugular intrahepatic portosystemic stent-shunt (TIPSS)

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 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.

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

OBJECTIVES

Parallel shunts (PS) are used in the management of transjugular intrahepatic portosystemic stent-shunt (TIPS) insufficiency, a major limitation of the technique. This study describes the natural history of PS, and uses them as a model to assess the role of host factors in the development of primary shunt insufficiency.

METHODS

Out of 338 patients with TIPS, 40 (11.8%) patients required insertion of a PS. Baseline and follow-up data of these patients were collected. Regular shunt surveillance involved biannual clinic visits and transjugular portography.

RESULTS

The non-PS group (group 1; n = 298) and the PS group (group 2; n = 40) had similar baseline demographic and disease characteristics. Index shunts of both groups and the PS produced a significant portal pressure gradient drop (P < 0.001), which was less in the index shunts of Group 2 (P < 0.02 for both). PS had similar cumulative shunt patency rates to those of the index shunts of Group 1, and both were greater than those of index shunts in Group 2 (P < 0.001 for both). The intervention rate (number of interventions/number of check portograms x 100) was similar for PS and the index shunts of Group 1 (38.7% and 43% respectively), but was significantly higher in the index shunts of Group 2 (85.6%; P < 0.01 for both). In Group 1 and Group 2, 144 patients (48.3%) and 21 patients (52.5%) died during follow-up after a median period of 23.4 and 8.9 months respectively.

CONCLUSIONS

These findings do not support the hypothesis that shunt insufficiency is related to host factors.