Direct Intrahepatic Portocaval Shunt Research Articles

A245 A TERTIARY CENTRE REVIEW OF PORTO-SYSTEMIC SHUNTS: AN INCREASINGLY IMPORTANT TOOL IN LIVER DISEASE MANAGEMENT

Abstract Background Portal hypertensive complications arising from chronic liver disease are increasingly prevalent. Radiologically placed porto-systemic shunts are used successfully to address complications such as ascites and recurrent variceal bleeding. Purpose We sought, with approval from ethics to electronically chart review the UHN experience for TIPSS (transjugular intrahepatic porto-systemic shunt) and DIPS (direct intrahepatic porto-caval shunt) over time. Method We employed a search strategy focused on radiologic databases, to identify UHN patients who had received a porto-systemic shunt insertion over three decades between January 1, 1990, to September 14, 2021. A total of 238 UHN patients that had a shunt imaged, re-assessed, or inserted were included in this retrospective electronic chart review. Demographic information was recorded at baseline. Data pertaining to clinical outcomes of portal hypertension such as refractory ascites, recurrent gastrointestinal bleeding and ESLD progression was recorded at baseline, 1 month, 3 months and 6 months post-shunt insertion. HVPG was recorded pre-shunt and post-shunt insertion. Transplant-free survival and post-operative complications was also assessed. Patients were followed until death or liver transplant. Result(s) Out of 238 patients confirmed, 219 had a TIPSS insertion and 19 a DIPS insertion. The average age at time of shunt was 55.1 ± 8.4 years. 53.7% (n=128) of patients were male. Indications for portosystemic shunt placement included refractory ascites (n=141), recurrent gastrointestinal bleeding (n=73), hydrothorax (n=10), hepatorenal syndrome (n=8), and portal vein thrombosis (n=4). Etiology of disease was categorized as alcohol-associated liver disease (n=107), non-alcohol associated fatty liver disease (n=36), viral hepatitis (n=27), autoimmune hepatitis (n=38) and vascular liver disease (n=20). Relevant events noted post procedure included hepatic encephalopathy (n=34), hydrothorax (n=17), vascular (including stent) thrombosis (n=17) and renal failure (n=4). 12 months post-shunt insertion 2.5% (n=6) of patients had died or received liver transplant; of these 1.7% (n=4) were transplanted. HPVG fell consistently post-procedure: 15.6 ± 1.5mmHg pre-shunt to 5.9 ± 1.2mmHg post-shunt. There was no observable increase in MELD-Na score in the first month post-shunt. Temporal trends showed that more patients aged 50 to 69, and more female patients, are now receiving shunt insertion than at the initiation of the chart review. Image Conclusion(s) Portosystemic shunt placement in the form of TIPSS or DIPS insertion is an increasingly common and effective treatment for portal hypertension in patents with advanced liver disease at UHN. Disclosure of Interest None Declared

The change in the liver volume after direct intrahepatic portocaval shunt in patients with Budd-Chiari syndrome with diffuse hepatic vein occlusion.

To evaluate the changes in the liver volume and function after direct intrahepatic portocaval shunt (DIPS) in patients with Budd-Chiari syndrome (BCS) with diffuse hepatic vein (HV) occlusion. The clinical data of 29 patients with BCS who underwent DIPS for intractable ascites caused by diffuse hepatic vein occlusion in the Affiliated Hospital of Xuzhou Medical University were analysed retrospectively; the patients included 8 males and 21 females, with an average age of 33.3 ± 6.3years. The patients underwent abdominal CT scanning and liver function examinations before DIPS, and 1week, 3months, 6months and 12months after DIPS. The changes of the liver volume and liver function before and after DIPS were compared. All 29 patients underwent DIPS successfully. 28 patients survived during the follow-up of 12-33months, with a median follow-up of 16months. The patients' liver function were significantly improved at 3, 6 and 12months after the operation compared to before the operation (P < 0.05). The liver volumes measured before the operation and 1week, 3months, 6months and 12months after the operation were 2124.586 ± 420.889 cm3, 1926.263 ± 372.268 cm3, 1480.592 ± 183.061 cm3, 1461.904 ± 153.027 cm3 and 1469.286 ± 148.549 cm3, respectively. Compared with the preoperative liver volume, the liver volume had decreased significantly at 1week, 3months, 6months and 12months after the operation (P < 0.05). However, there was no significant difference in the liver volumes at 6 and 12months after the operation (P = 0.35). Direct intrahepatic portocaval shunt has achieved satisfactory clinical results in the treatment of BCS with diffuse hepatic vein occlusion. The congestive hepatomegaly was gradually reduced after the operation. The liver volume (which was defined as the clinical efficacy in this study) remained stable after 6months.

Combined Transhepatic-Transsplenic Direct Intrahepatic Portocaval Shunt in a Child with Budd-Chiari Syndrome

A 6-year–old girl presented emergently with 3 episodes of hematemesis over 3 days and abdominal distension for 10 days. Physical examination revealed distended superficial abdominal veins. Ultrasonography (US) showed thrombosed hepatic veins and infrahepatic inferior vena cava (IVC) with ascites, which is diagnostic of chronic Budd-Chiari syndrome with portal hypertension. Direct intrahepatic portocaval shunt creation was planned under general anesthesia. Bilateral jugular and brachiocephalic veins were chronically occluded (Fig 1a), and femoral venography showed chronic occlusion of the IVC (Fig 1b).

2428 Direct Intrahepatic Portocaval Shunt (DIPS) as a Therapeutic Option in Acute Variceal Hemorrhage

INTRODUCTION: Direct Intrahepatic Portocaval Shunt (DIPS) is a modified transjugular intrahepatic portosystemic shunt (TIPS) procedure, in which a stent is placed across the inferior vena cava directly into the portal vein under intravascular ultrasound guidance. DIPS is a recognized salvage therapy for acute variceal hemorrhage, but not commonly utilized. Indications for DIPS include patients with hepatic venous anomalies not amenable to TIPS, distorted post-surgical vascular anatomy of the liver, intrahepatic portal venous thrombus, or a prior failed TIPS. CASE DESCRIPTION/METHODS: A 73-year-old male with a history of cirrhosis from alcohol and hepatitis C virus and right lobe hepatocellular carcinoma status-post laparoscopic microwave ablation presented with hematemesis. An EGD revealed a gastric varix (Figure 1), which was deemed too large for treatment with cyanoacrylate glue deposition. A TIPS was attempted but failed due to hepatic venous anomalies. Subsequently, the varix was treated with a balloon-occluded antegrade transvenous obliteration (BATO) and a balloon occluded retrograde transvenous obliteration (BRTO). Figure 2 demonstrates the BATO, which coiled the afferent vessels to the varix (red arrow), and the BRTO, which coiled the efferent gastro-renal shunt of the varix (blue arrow). Two days after the BATO/BRTO, the patient had recurrent melena and anemia. An EGD doppler-guided glue deposition into the gastric varix was attempted but failed. A TIPS was not a viable option as an ultrasonography revealed a new portal vein thrombus extending into the anterior and posterior branches of the right portal vein. Thus, a DIPS was performed. Under intravascular ultrasound guidance, a catheter (red arrows) was advanced from the IVC directly to the left portal vein creating a shunt with stent placement as seen in Figure 3. The pre-procedure portosystemic gradient was 18 mm Hg, and post-procedure portosystemic gradient was 5 mm Hg with a reduction in the gastric varix. The patient is well three-months post-procedure without recurrent melena or anemia. DISCUSSION: This case demonstrates the successful utilization of DIPS in a patient where TIPS was not feasible due to hepatic venous anomalies and a portal vein thrombus. Furthermore, DIPS was successful in the treatment of a variceal hemorrhage when other therapies such as cyanoacrylate glue deposition, BATO, and BRTO failed. Therefore, DIPS should be utilized in challenging cases of variceal hemorrhage when performed by an experienced interventional radiologist.

03:18 PM Abstract No. 270 Parallel TIPS versus DIPS for second percutaneous portosystemic shunt placement in cirrhotic patients with an existing TIPS

A second portosystemic shunt (sPSS) may be needed in patients with recurrent variceal bleeding or persistent ascites despite an existing transjugular intrahepatic portosystemic shunt (TIPS) due to insufficient portal decompression or shunt occlusion refractory to recanalization. There is no consensus on the best method for sPSS creation. The goal of this study was to compare the technical and clinical outcomes of placing a parallel TIPS (pTIPS) versus direct intrahepatic portocaval shunt (DIPS) as the sPSS. From 2002-2017, a pTIPS (n = 12; median age 62 y, MELD 13) or DIPS (n = 8; 57 y, 12) was placed in 20 patients with an existing TIPS and recurrent symptoms. sPSS indication, procedure details, technical and clinical success rates, and complications were retrospectively reviewed and compared. A sPSS was indicated for persistent ascites or recurrent variceal bleeding in 6 and 6 patients, respectively, in the pTIPS group and 6 and 2 patients in the DIPS group. The existing TIPS was patent in 5/12 patients in the pTIPS group and 4/8 in the DIPS group; the rest were chronically occluded. DIPS was specifically chosen in 5 cases due to anatomical limitations posed by the existing TIPS. In one pTIPS procedure, the existing occluded TIPS prevented full expansion of the new pTIPS, requiring balloon expandable stent placement. Stent-grafts were used in all cases (pTIPS: diameter 10 mm n=8, 8 mm n=4; DIPS: 10 mm n=5, 8 mm n=3, 7 mm n=1). Technical success was 100% in both groups. Mean procedure time for DIPS trended towards shorter versus pTIPS (73±22 vs 97±63 min, p=0.35) with a wider range in pTIPS procedure times (50-101 vs 72-262 min). Mean portosystemic gradient reductions after pTIPS (14.8±4.3 to 6.6±2.6 mm Hg) and DIPS (12.4±3.8 to 5.6±2.9) were similar. Ascites improved and variceal bleeding resolved in all patients. Hepatic encephalopathy worsened in 2 pTIPS and 1 DIPS patients. No acute liver failure occurred. Two pTIPS patients died within 30 days due to sepsis and lung cancer. Technical and clinical outcomes were similar between pTIPS and DIPS for sPSS creation. DIPS may be technically preferable due to anatomical issues in some patients with an existing TIPS.

Hyperbilirubinemia Due to Extrinsic Biliary Compression From Direct Intrahepatic Portocaval Shunt Performed for Portal Hypertensive Bleeding

Direct intrahepatic portocaval shunt (DIPS) is a procedure involving intravascular stent placement through the caudate lobe of the liver for management of portal hypertension. It is employed less frequently than TIPS, and extrinsic biliary compression due to DIPS has never been described in the literature. A 65 year old female with history of non-cirrhotic fibropolycystic liver disease and PVT with cavernoma and sinistral portal hypertension underwent DIPS and ileal variceal embolization for massive ileal variceal bleeding. TIPS was attempted but unsuccessful, so DIPS was subsequently performed. Pre-procedural alkaline phosphatase (AP) was 56U/L, total bilirubin (TB) 1.1mg/dL, and direct bilirubin (DB) was 0.4mg/dL. Post-procedurally she was noted to have AP 326U/L, TB 9.8mg/dL, and DB 6.9mg/dL. There was report of dark stools, with initial concern of hemobilia versus bilhemia. Imaging revealed stable mild intrahepatic and common bile duct (CBD) dilatation. Given new fevers and possible enhancement of CBD, she was treated with piperacillin-tazobactam for presumed cholangitis with subsequent improvement and was discharged home. She returned ten days later with alkaline phosphatase of 2,925U/L with total bilirubin of 41.9mg/dL and direct bilirubin of 29.8mg/dL. MRI revealed intra- and extra-hepatic biliary dilatation to the mid-CBD felt to be due to extrinsic compression by the crossing DIPS. ERCP revealed CBD stenosis which did not appear to be related to crossing DIPS but was stented. Afterwards, her AP peaked at 3,062U/L with TB 56.9mg/dL and DB 38.1mg/dL. Liver biopsy revealed bland cholestasis. Her liver chemistries started to improve. Due to persistent fevers, ERCP was repeated for stent exchange and revealed sigmoid-shaped stenosis in the upper CBD due to extrinsic compression from the crossing DIPS, thus revealing the ultimate diagnosis. Stent was replaced and AP subsequently improved to 104U/L with TB 1.4mg/dL.The differential of hyperbilirubinemia after DIPS procedure includes hemolysis (typically presents with indirect hyperbilirubinemia), as well as hepatic decompensation (increase in all liver chemistries), bilhemia from biliary-venous fistula (isolated hyperbilirubinemia), infection (often a mixed picture), and biliary compression (cholestatic picture). This complicated case illustrates the difficulty in diagnosis of extrinsic biliary compression in a patient with known mild biliary dilation, requiring a second ERCP to make the final diagnosis.2187_A Figure 1. MRCP image of the 1.9 cm segmental narrowing of the mid common bile duct, thought to be related to the crossing DIPS.2187_B Figure 2. MRCP image of 1.9cm segmental narrowing of CBD secondary to extrinsic compression by the crossing TIPS

Direct Intrahepatic Portocaval Shunt for Sinusoidal Obstruction Syndrome Associated with Hepatotoxicity of Pyrrolizidine Alkaloids.

We retrospectively identified 89 consecutive patients from January 2004 to January 2012 to investigate efficacy of direct intrahepatic portocaval shunt (DIPS) combined with inferior vena cava (IVC) stenting for sinusoidal obstruction syndrome (SOS) associated with hepatotoxicity of pyrrolizidine alkaloids. Indications for treatment were variceal hemorrhage and/or refractory ascites. Patients were treated with DIPS plus IVC stenting (group A, n=68) or DIPS alone (group B, n=21). A technical success rate of 100% was obtained in all 89 patients, and there were no early procedure-related adverse events or 30-day mortality. Mean portosystemic gradient decreased in both groups. Changes in aspartate and alanine aminotransferases and total bilirubin did not differ between the groups. Ascites disappeared in group A but was not obvious in group B until IVC stenting. During follow-up, recurrent bleeding and ascites and incidence of hepatic encephalopathy did not differ between the groups. The 1-, 3-, and 5-year survival rate was 98, 89.59, and 80%, respectively. Satisfactory clinical results were obtained for combined DIPS and IVC stenting for SOS associated with pyrrolizidine-alkaloid-related decompensated cirrhosis.

Transjugular liver biopsy after transjugular intrahepatic portosystemic shunt (TIPS) or direct intrahepatic portocaval shunt (DIPS): Is it feasible, effective, and safe?

To evaluate our experience with transjugular liver biopsies (TJLB) in patients with previously placed transjugular intrahepatic portosystemic shunt (TIPS) or direct intrahepatic portocaval shunt (DIPS). A single-institution retrospective review was performed looking at all TJLBs in patients with previously placed TIPS or DIPS over the past seven years. There were six men and one woman (mean age 57.9±8.8 [SD] years; range: 47-71 years). Patient demographics, indications, procedural details, laboratory data, complications, and pathology were recorded. Patients with occluded TIPS were excluded from this study. Seven TJLBs were performed, five in patients who had a TIPS and two who had a DIPS. Of the patients with TIPS, biopsies were performed from the same hepatic vein as TIPS in three procedures and from a different hepatic vein in two procedures. In DIPS patients, both biopsies were performed from the right hepatic vein. The reasons for the transjugular rather than the percutaneous approach to liver biopsy included ascites, coagulopathy, or need for concurrent TIPS/DIPS evaluation and/or revision. All procedures were technically successful with adequate samples obtained. There were no immediate or delayed complications. Our results suggest that if needed a TJLB can safely and effectively be performed in patients with previously placed TIPS or DIPS.

Emergent Salvage Direct Intrahepatic Portocaval Shunt Procedure for Acute Variceal Hemorrhage

PurposeTo review the safety and effectiveness of direct intrahepatic portocaval shunt (DIPS) creation with variceal embolization for acute variceal hemorrhage after a failed transjugular intrahepatic portosystemic shunt (TIPS) creation attempt or in patients with prohibitive anatomy. Materials and MethodsTransjugular intrahepatic portosystemic shunt and DIPS procedures performed for variceal hemorrhage between January 2008 and July 2014 were reviewed. The default procedure was TIPS creation, with DIPS creation reserved for patients with unfavorable anatomy or who had technically unsuccessful TIPS creation. Thirteen patients underwent DIPS creation (mean age, 60 y ± 12; Child–Pugh class A/B/C, 8%/62%/30%; Model for End-stage Liver Disease score, 15 ± 5; range, 8–26) and 117 underwent TIPS creation. Four patients underwent a TIPS attempt and were converted to DIPS creation upon technical failure; 9 were treated primarily with DIPS creation because of preprocedural imaging revealing unfavorable anatomy (intrahepatic portal thrombosis, n = 2; venous distortion from prior hepatic resections, n = 2; severely angulated hepatic veins, n = 5). ResultsDirect intrahepatic portocaval shunt creation with variceal embolization (six gastric or esophageal; seven stomal, duodenal, or rectal) was successful in all patients; 11 also had concomitant variceal sclerotherapy. Mean DIPS procedure time was less than 2 hours. There was 1 major procedural complication. During a mean follow-up of 13.0 months ± 15.5, 1 patient developed DIPS thrombosis and recurrent hemorrhage; 1 patient underwent successful transplantation. Two deaths were observed within 30 days, neither associated with recurrent hemorrhage. ConclusionsDirect intrahepatic portocaval shunt creation appears to be a safe, expedient, and effective treatment for patients with acute variceal hemorrhage who are poor anatomic candidates for TIPS creation or who have undergone unsuccessful TIPS creation attempts.

Percutaneous Portosystemic Shunts: TIPS and Beyond.

Percutaneous interventions for portal hypertension have been available since the 1990s. Over time, improved technology-including covered stent grafts-and clinical understanding has expanded the available procedures for percutaneous portal decompression. While transjugular intrahepatic portosystemic shunt creation is the most commonly cited percutaneous intervention, direct intrahepatic portocaval shunt and percutaneous mesocaval shunt creation are important alternatives with specific advantages and applications. This article reviews contemporary, minimally invasive interventional approaches to percutaneous portosystemic shunt creation in terms of procedure rationale, patient selection, interventional technique, and technical outcomes.

Direct intrahepatic portocaval shunt creation via the inter-strut space of the inferior vena cava stent

Direct intrahepatic portocaval shunt creation via the inter-strut space of the inferior vena cava stent J. Tsauo , Y. Yu , X. Luo , Z. Wang , L. Liu , X. Li a,b,c,* a Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu 610041, China Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, China Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China

Educational Exhibit Abstract No. 368 - Portal vein interventions

Learning Objectives To discuss various portal venous interventions offered by interventional radiology including their indications, contraindications, clinical utility, expected outcome, and common complications. Background Different portal vein interventions include portal vein stent (PVS), portal vein embolizaion (PVE), transjugular intrahepatic portosystemic shunt (TIPS), and direct intrahepatic portocaval shunt (DIPS). Clinical Findings/Procedure Details Portal Vein Stent (PVS ): Performed in the setting of portal venous stenosis or occlusion that commonly occurs in neoplastic conditions or post liver transplantation. Liver abscess has been reported as a post procedural complication. Portal Vein Embolization (PVE) : Performed in preoperative treatment of major hepatic resection in patient when the future liver remnant is too small. PVE complications are rare but include transient hemobilia, infection, need for reembolization, portal vein thrombosis, and portal hypertension. Portal Vein Thrombolysis (PVT) : PVT is the preferred treatment for acute intravascular thrombosis. Percutaneous portal vein clot lysis can be initiated in a few minutes providing almost immediate clot dissolution without the need for surgical intervention. Transjugular Intrahepatic Portosystemic Shunt (TIPS) : Indications for TIPS procedure include recurrent or refractory variceal bleeding, Budd Chiari syndrome, hepatic hydrothorax, hepatorenal syndrome, and intractable ascites. Complications include but are not limited to hepatic encephalopathy, heart failure. There is improved survival of patients with refractory ascites when treated with TIPS. Direct Intrahepatic Portocaval Shunt (DIPS) : Indications are similar to TIPS procedure for decompression of portal venous system. DIPS procedure includes direct puncture from the IVC through the caudate lobe to the main portal vein. The safety and effectiveness is increased by eliminating blind PV puncture and hepatic vein stenosis which is the most common cause of chronic TIPS failure. Conclusion and/or Teaching Points Knowledge of portal vein interventions including their indication, clinical utility and expected outcome is critical for clinicians to improve patient care.

Direct percutaneous portocaval shunt creation for haematemesis: Case Report

Creating a direct intrahepatic portocaval shunt (DIPS) is a procedure similar to a transjugular intrahepatic portosystemic shunt (TIPS) in patients for whom the latter is not appropriate due to unsuitable hepato-venous and porto-venous anatomy. We present a patient for whom TIPS was not possible, and DIPS successful.

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.

Budd-Chiari syndrome(BCS) with mesenteric vein thrombosis(MVT) treated by direct intrahepatic portocaval shunt(DIPS) and mechanical thrombectomy

Budd-Chiari syndrome(BCS) with mesenteric vein thrombosis(MVT) treated by direct intrahepatic portocaval shunt(DIPS) and mechanical thrombectomy

Intravascular US-guided Direct Intrahepatic Portacaval Shunt with a PTFE-covered Stent-Graft: Feasibility Study in Swine and Initial Clinical Results

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. 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. 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. 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.