Complication of Transjugular Intrahepatic Portosystemic Shunt Placement

Abstract

Purpose: Transjugular intrahepatic portosystemic shunt (TIPS) is an accepted treatment for complications of cirrhosis. Common complications of TIPS include stenosis of the stent and hepatic encephalopathy. An infrequent complication is stent migration into the portal vein or right atrium, reported in 2–9% of cases in the literature. We report a rare case of stent migration into the pulmonary artery after TIPS. Methods: A 50 year-old man with Child-Pugh class C, MELD score of 19, alcoholic cirrhosis presented to an outside hospital with ascites and esophageal variceal bleeding refractory to band ligation. He underwent a successful TIPS placement with a nitinol (Zilver) stent. Six weeks later, the patient presented with recurrent ascites. Evaluation of the TIPS revealed a portosystemic gradient of 22 mmHg and narrowing in the hepatic venous end of the stent. Angioplasty of the stent was performed followed by placement of a second nitinol (Zilver) stent, resulting in a lowering of the gradient to 12 mmHg. One week later, the patient was transferred to our center for liver transplant evaluation. Results: A routine chest x-ray demonstrated the stent projecting over the pulmonary hilum. Pulmonary angiogram confirmed the stent to be in the pulmonary artery. Based on the orientation of the stent in the pulmonary artery, removal was not attempted due to the high risk of pulmonary artery perforation. Subsequent chest x-rays showed stable stent position. The patient continued to remain asymptomatic. Conclusion: An infrequent complication of TIPS is stent migration. Our case of pulmonary artery involvement has been rarely described. Technical aspects of stent placement, such as inappropriate size or type, or inadequate overlap, may contribute to the likelihood of stent migration.Figure: Stent Migration Into Pulmonary Artery After TIPS.