First Successful Removal of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in a Case of Endotipsitis

Abstract

Purpose: Introduction: The creation of TIPS involves placement of a stent between the hepatic vein and the intrahepatic portion of the portal vein, decompressing portal hypertension. TIPS is indicated for cirrhotic ascites refractory to diuretics. Endotipsitis is a rare complication of TIPS (1.33%), the management of which is antibiotics. However, removal of shunt may be required in the presence of life-threatening sepsis unresponsive to antibiotics. Case Report: A 66-year-old white female with nonalcoholic steatohepatitis (NASH) cirrhosis and diabetes mellitus underwent placement of polytetrafl uoroethylene(PTFE) coated TIPS for refractory ascites. Post procedure hospital course was complicated by bacteremia (vancomycin resistant Enterococcus and Escherichia coli) and candidemia treated with daptomycin and voriconazole. She returned to the hospital within 10 days with fever, chills, left upper quadrant pain and worsening ascites. Blood culture grew vancomycin resistant Enterococcus in 4/4 bottles. A liver Doppler showed TIPS stenosis and portal vein thrombosis. A transesophageal echocardiogram (TEE) revealed a TIPS containing a 19 × 7 mm mobile lesion consistent with thrombus/vegetation extending into right atrium. The patient continued to remain septic. The decision was made to attempt removal of the TIPS by interventional radiology after discussing the life-threatening nature of the procedure and that no such attempt has been reported in the literature. Right internal jugular vein was accessed using a micropuncture set which was serially dilated to 24 French. A 25 mm loop snare was used to grasp the cephalad aspect of the stent. The 24 French sheath was then advanced over the stent while held in place by the snare. Both sheath and stent were then removed over a wire. The patient went into septic shock requiring vassopressors following the TIPS removal and was managed in intensive care but is alive and medically stable 2 years later. Conclusion: Removal of PTFE-coated TIPS for endotipsitis with persistent sepsis is feasible and a potentially life saving procedure in experienced hands.