Transjugular Intrahepatic Portosystemic Shunt Dysfunction Research Articles

Transjugular intrahepatic portosystemic shunt for portal hypertension with chronic portal vein occlusion

PurposeThis study aims to evaluate the long-term patency of transjugular intrahepatic portosystemic shunt (TIPS) and determine the predictors of shunt dysfunction in patients with chronic portal vein occlusion (CPVO). MethodThis retrospective study was conducted from December 2010 to December 2020 in patients with portal hypertension and CPVO. Patients were followed up from initial TIPS insertion to December 2022 or death. Details of TIPS procedure, adverse events and clinical outcomes were recorded. The cumulative rate of shunt patency was calculated by the Kaplan-Meier method and compared by using the log-rank test. Independent predictors of shunt dysfunction were calculated with the Cox regression model. A nomogram comprising independent variables was developed to enhance the predictive accuracy of shunt patency. ResultsOne hundred six patients (mean age, 45.3 years ± 13.6; 71 males and 35 females) were enrolled in the study. TIPS procedure was technically successful in 100 of 106 patients (94.3 %). The primary shunt patency rates for all 100 patients were 78.9 %, 74.7 %, 67.2 %, and 62.4 % at 6, 12, 24, and 36 months, respectively, and the overall shunt patency rates were 88.9 %, 86.8 %, 83.6 %, and 81.2 % at 6, 12, 24, and 36 months, respectively. Independent predictor of shunt dysfunction were inadequate inflow from superior mesenteric vein or splenic vein (the maximum diameter < 8 mm) and platelet count ≥ 300 × 109/L. The developed nomogram is a simple tool for accurately predicting shunt patency. ConclusionsIn patients with CPVO, inadequate inflow and high platelet count are important factors for TIPS dysfunction.

Abstract No. 47 Efficacy of Post TIPS Ultrasound in Predicting TIPS Dysfunction in the Controlled Expansion Endoprosthesis Era

Evaluate the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) ultrasound (US) in predicting TIPS dysfunction in the controlled expansion endoprosthesis era. A retrospective review of patients who underwent TIPS with a controlled expansion stent (Viatorr CX, WL Gore, Flagstaff, AZ) from January 1, 2018, to March 30, 2021, was performed. Patient demographics, clinical data, US studies and venograms were reviewed. Follow-up US timeline was defined as follows: baseline ≤30 days, early 31-365 days, and late >365 days. US was indicative of ‘TIPS dysfunction’ in the presence of elevated velocity, spatial gradient, temporal gradient, or reversal of flow in PV branches by standard criteria. TIPS occlusion on US was defined as absence of flow on doppler. TIPS venogram with portosystemic gradient (PSG) measurement was performed in all patients with recurrence of portal hypertension symptoms. Patients with TIPS dysfunction on US underwent venogram only if they had recurrence of symptoms or occlusion on US. Mean PSG ≤10 mm Hg was considered abnormal. 121 patients underwent TIPS placement. 83% (n = 100) had follow-up US, approximately 1.3 US per patient. Mean follow-up duration was 425 days. US was done as baseline in 88%, early in 57% and late in 28% of patients. US TIPS occlusion was reported in 5/100 (5%) patients. All those patients were symptomatic and underwent venograms showing occlusion or stenosis with elevated PSG. TIPS dysfunction without occlusion was reported in 56/100 (56%) patients: 28 at baseline, 19 at early and 9 at late US evaluations. Among these, 19/56 underwent venogram due to recurrence of symptoms: 12 had elevated PSG or occlusion and 7 had patent TIPS with normal PSG. 25/99 (25%) patients had venogram due to recurrence of symptoms despite normal US: 9 had elevated PSG or occlusion and 16 had patent TIPS with normal PSG. Mean duration from TIPS placement to stenosis or occlusion on venogram was 84 days. Excluding patients with TIPS occlusion on US, 44/94 (46%) of patients had recurrence of symptoms post TIPS. In this cohort, TIPS dysfunction on US had positive predictive value for stenosis or occlusion of 63%, negative predictive value of 64%, sensitivity of 57% and specificity of 69%. In the era of controlled expansion TIPS stents, current standard sonographic criteria of TIPS dysfunction have limited utility in predicting TIPS stenosis. However, ultrasound remains useful for diagnosing TIPS occlusion.

Safety and effectiveness of transjugular intrahepatic portosystemic shunt in hepatocellular carcinoma patients with portal hypertension: a systematic review and meta-analysis

<h3>AIM</h3> To evaluate the safety and effectiveness of transjugular intrahepatic portosystemic shunt (TIPS) in hepatocellular carcinoma (HCC) patients with portal hypertension. <h3>MATERIALS AND METHODS</h3> Databases including PubMed, EMBASE, and Cochrane Library (in English, until 1 October 2020) were searched for eligible studies. Data were pooled by the random-effects model using the Stata 13.0 software. Heterogeneity was assessed by I² statistic and subgroup analyses. <h3>RESULTS</h3> Ten studies (all case series) meeting the inclusion criteria were enrolled, including 655 HCC patients in whom TIPS was performed. The portosystemic pressure gradient reduction was statistically significant (standardized mean difference [SMD] –2.99, 95% confidence interval [CI]: –3.51, –2.47). The technical success rate was 99.7%. The response rates of oesophagogastric variceal bleeding (OGVB) and refractory ascites were 99.5% and 88.2%, respectively. The 30-day, 90-day, and 365-day overall survival (OS) rates were 91.9%, 61.1%, and 46.3%, respectively. During follow-up, hepatic encephalopathy occurred in 29% of the patients, while TIPS dysfunction was observed in 23% of the patients. Few technique-related complications were reported, including tumour rupture (<i>n=</i>5), abdominal bleeding (<i>n=</i>8), and acute liver failure (<i>n=</i>2). <h3>CONCLUSION</h3> TIPS is a safe and effective treatment in HCC patients. Portal vein tumour thrombosis (PVTT) and cavernous transformation are the major cause of procedural failure and contribute to poor survival. Searching for the presence of PVTT and cavernous transformation is essential for assessing the safety and effectiveness of TIPS in HCC patients.

In a patient with active variceal bleeding brought on by Systemic Lupus Erythematosusinduced Cirrhosis, a transjugular intrahepatic portosystemic shunt revision and embolization of an arterioportal fistula were performed simultaneously.

Based on the type and severity of the shunt failure, transjugular intrahepatic portosystemic shunt (TIPS) occlusion is a frequent event that can be addressed. Arterioportal fistulas (APFs) are uncommon connections between the systemic artery and portal venous systems that can cause symptomatic portal hypertension. In this instance, we go over how to treat a patient who has variceal bleeding brought on by TIPS dysfunction that has been made more difficult by the existence of an APF. Keywords : Transjugular intrahepatic portosystemic shunt, Arterioportal fistula, Embolization, Endovascular intervention, Portal hypertension

Transjugular intrahepatic portosystemic shunt (TIPS) complications: what diagnostic radiologists should know.

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for portal hypertension complications and can successfully treat variceal bleeding and refractory ascites. Although TIPS is relatively safe, procedural- or shunt-related morbidity can reach 20%, and procedural complications have a fatality rate of 2%. Delayed recognition and treatment of TIPS complications can lead to life-threatening clinical scenarios. Complications can vary from stent migration or malpositioning to nontarget organ injury, TIPS dysfunction, encephalopathy, or liver failure. This review aims to outline the role of diagnostic radiology in assessing post-TIPS complications.

Use of doppler ultrasound to predict need for transjugular intrahepatic portosystemic shunt revision.

BACKGROUNDTransjugular intrahepatic portosystemic shunt (TIPS) is used to treat complications of portal hypertension, such as ascites and variceal bleeding (VB). While liver doppler ultrasound (DUS) is used to assess TIPS patency, trans-shunt venography (TSV) is the gold standard.AIMTo determine the accuracy of DUS to assess TIPS dysfunction and for need for revision.METHODSRetrospective review of patients referred for TIPS revision from 2008-2021. Demographics, DUS parameters at baseline and at the DUS preceding TIPS revision, TSV data were collected. Receiver operating characteristics curves, sensitivity, specificity, performance for doppler to predict need for revision were performed. Univariate and multivariate analyses were used to predict clinical factors associated with need for TIPS revision.RESULTSThe cohort consisted of 89 patients with cirrhosis (64% men, 76% white, 31% alcohol as etiology); median age 59 years. Indication for initial TIPS were VB (41%), refractory ascites (51%), and other (8%). TIPS was revised in 44%. On univariate analysis, factors associated with need for TIPS revision were male (P = 0.03), initial indication for TIPS (P = 0.05) and indication for revision (P = 0.01). Revision of TIPS was associated with lower mortality (26% vs 46%) and significantly lower rates of transplant (13% vs 24%; P = 0.1). In predicting need for TIPS revision, DUS has a 40% sensitivity, 45% specificity, PPV 78%, and NPV 14%. The most accurate location for shunt velocity measure was distal velocity (Area under the curve: 0.79; P = 0.0007). CONCLUSIONDUS has poor overall sensitivity and specificity in predicting need for TIPS revision. Non-invasive methods of predicting TIPS dysfunction are needed since those needing TIPS revision had better survival.

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

BackgroundTransjugular 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 presentationWe report one such patient who experienced ongoing portal hypertension induced upper gastro-intestinal haemorrhage despite multiple TIPS revisions and a patent primary TIPS.ConclusionFollowing creation of a parallel TIPS, the patient remains in clinical remission with no further bleeding.

Bleeding ectopic varices: clinical presentation, natural history, and outcomes

Bleeding complications from ectopic varices are often difficult to manage. We aimed to study the natural history and outcomes of bleeding ectopic varices to better understand appropriate clinical management. This...

Cranial stent position is independently associated with the development of TIPS dysfunction

Complications of portal hypertension can be treated with transjugular intrahepatic portosystemic shunt (TIPS) in selected patients. TIPS dysfunction is a relevant clinical problem. This study investigated the prognostic value of two-dimensional (2D) TIPS geometry for the development of TIPS dysfunction. Three hundred and seven patients undergoing TIPS procedure between 2014 and 2019 were analyzed in this monocentric retrospective study. 2D angiograms from the patients with and without TIPS dysfunction were reviewed to determine geometric characteristics including insertion and curve angles and the location of the stent. Primary outcome was the development of TIPS dysfunction. A total of 70 patients developed TIPS dysfunction and were compared to the dysfunction-free (n = 237) patients. The position of the cranial stent end in the hepatic vein and the persistence of spontaneous portosystemic shunts were significantly associated with the development of TIPS dysfunction. Among significant parameters in univariable regression analysis (portal vein-pressure after TIPS, Child–Pugh Score before TIPS, MELD before TIPS and white blood cell count before TIPS), multivariable models showed cranial stent position (p = 0.027, HR 2.300, 95% CI 1.101–4.806) and SPSS embolization (p = 0.006, HR 0.319, 95% CI 0.140–0.725) as the only predictors of TIPS dysfunction. This monocentric study demonstrates that the position of the cranial stent end is independently associated with the development of TIPS dysfunction. The distance of the cranial stent end to the IVC at the time of TIPS placement should be less than 1 cm in 2D angiography.

Effects of transjugular intrahepatic portosystemic shunt treatment of patients with liver cirrhosis and portal hypertension: Case series.

Rationale:Transjugular intrahepatic portosystemic shunt (TIPS) is well established as an effective treatment tool for portal hypertension. However, the effects of TIPS in patients with liver cirrhosis and portal hypertension have not been adequately verified in clinical trials.Patient Concerns:To evaluate the effects of TIPS in patients with liver cirrhosis and portal hypertension with or without portal vein thrombosis (PVT).Interventions:A total of 55 patients with liver cirrhosis and portal hypertension received TIPS treatment from December 2014 to April 2018 were enrolled. Clinical data, including portal pressure, Child-Pugh score, and relevant complications were recorded.Outcomes:TIPS was successfully performed in 54 patients. The overall technical success rate was 98.19% without serious technical complications. After TIPS treatment, portal pressure was significantly reduced from 38.13 ± 4.00 cmH2O to 24.14 ± 3.84 cmH2O (P < 0.05). In addition, symptoms including gastrointestinal bleeding and ascites were improved after TIPS treatment. During the 6 to 21-month follow up, hepatic encephalopathy in 15 patients (27.8%), shunt dysfunction in 5 patients (9.3%), rebleeding in 12 patients (22.2%) and deterioration of liver function in 2 patients (3.7%) were recorded. Moreover, there were no significant differences in the rates of rebleeding and hepatic encephalopathy between patients with PVT and the non-PVT group, whereas the occurrence rate of TIPS dysfunction was higher in the PVT group, but not statistically significant.Lessons:TIPS treatment could alleviate the symptoms of liver cirrhosis and portal hypertension in individuals with or without PVT. However, complications during follow-up should be appropriately noted and addressed with corresponding treatments.

Evaluation of impact of elective invasive examinations in patients with transjugular intrahepatic portosystemic shunt in the long-term follow up.

In the management of patients with decompensated liver cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) insertion is well-established but common recommendations in the follow up management are inconsistent. Doppler sonography is commonly used for detection for TIPS dysfunction whilst data on the impact of elective invasive examinations are scarce. The aim of this retrospective analysis is to evaluate potential benefits of elective invasive examinations in the follow up management of patients after TIPS insertion METHODS:  Data of all patients receiving TIPS at the university hospitals of Muenster and Bonn between 2013 and 2018 (n = 534) were collected. The impact of performance of elective invasive examinations at 12 months after TIPS insertion on the occurrence of liver related events (LREs) and frequency of TIPS revisions within 24 months after TIPS insertion was analyzed. No significant differences were found concerning occurrence of liver related events after 24 months depending on whether an elective invasive examination was performed. Occurrence of hepatic encephalopathy, relapse of initial indication for TIPS, as well as death or liver transplantation all did not differ. These findings were verified by a subgroup analysis including only patients who did not experience a LRE or TIPS revision within the first 12 months after TIPS procedure. The analyzed data suggest no evidence for a beneficial impact due to implementation of an elective invasive examination program after TIPS insertion. Invasive examinations should remain reserved to patients with suspected TIPS dysfunction.

Transjugular intrahepatic portosystemic shunt: a meta-analysis of 8 mm versus 10 mm stents.

IntroductionTransjugular intrahepatic portosystemic shunt (TIPS) is an approach that is used to alleviate portal hypertension-related symptoms. The optimal stent diameter for TIPS remains controversial.AimTo assess outcomes in patients who underwent TIPS using 8 mm and 10 mm stents.Material and methodsThe PubMed, Embase, and Cochrane Library databases were queried for all pertinent studies. The meta-analysis was conducted using RevMan v5.3. This meta-analysis was registered at the PROSPERO website (Number: CRD42020212392).ResultsEighty-two potentially relevant articles were initially detected, with seven of these ultimately being included in this meta-analysis. Patients in the 10 mm stent group exhibited a significantly higher Δportosystemic pressure gradient (ΔPPG) relative to the 8 mm group (p = 0.04), whereas no differences between groups were observed with respect to postoperative hepatic encephalopathy (HE, p = 0.25), re-bleeding (p = 0.82), liver transplantation (p = 0.45), or mortality (p = 0.43) rates. The TIPS dysfunction rate was significant lower in the 10 mm group (p = 0.01). In Asian studies, the postoperative HE rate was found to be significantly lower in the 8 mm group relative to the 10 mm group (p = 0.02), whereas all other endpoints were comparable between these groups. In Western studies, ΔPPG values were significantly greater in the 10 mm group (p < 0.0001), whereas all other endpoint data were comparable between these groups.ConclusionsTIPS with 10 mm stents provides a lower TIPS dysfunction rate. However, 8 mm stents may be recommended for Asian patients, as they can decrease the risk of postoperative HE.

Diagnostic value of conventional ultrasound and shear wave elastography in detecting transjugular intrahepatic portosystemic shunt dysfunction.

Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction can cause recurrent portal hypertension (PH)-related complications such as ascites and gastroesophageal variceal bleeding. Portography is invasive and costly limits its use as a screening modality. To assess the clinical value of conventional ultrasound in combination with point shear wave elastography (pSWE) to predict TIPS dysfunction. A total of 184 patients with cirrhosis scheduled for TIPS implantation were enrolled in this study and evaluated retrospectively. The splenoportal venous blood flow parameter, liver stiffness (LS), and spleen stiffness (SPS) were measured. Outcome measures included differences in portal vein velocity (PVV), splenic vein velocity (SPVV), LS, and SPS. The accuracy of change in PVV (ΔPVV), SPVV (ΔSPVV), and SPS (ΔSPS) to diagnose TIPS dysfunction was investigated. TIPS dysfunction occurred in 28 of 184 patients (15.2%). Eighteen (64.3%) patients had shunt stenoses and 10 (35.7%) had shunt occlusion. Portal vein diameter (PVD), PVV, splenic vein diameter (SPVD), SPVV, LS, and SPS were not significantly different between the TIPS normal and TIPS dysfunction groups. Compared with the TIPS normal group, PVV and SPVV of the TIPS dysfunction group decreased significantly, whereas SPS increased significantly (P < 0.001). The values of areas under the receiver operating characteristic curves of ΔPVV, ΔSPVV, and ΔSPS for the diagnosis of TIPS dysfunction were 0.97, 0.96, and 0.87, respectively. pSWE showed a diagnostic efficacy comparable to conventional ultrasound for diagnosing TIPS dysfunction and can be used routinely after TIPS procedures.

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

BackgroundSeveral 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.ResultsThirty-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.ConclusionIt 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.

Transjugular intrahepatic portosystemic shunt through left branch versus right branch of portal vein: a meta-analysis.

To compare the clinical outcomes between patients that underwent transjugular intrahepatic portosystemic shunt (TIPS) via the left and right portal veins (PVs). All relevant studies in the Pubmed, Embase, and Cochrane Library databases published as of June 2020 were identified by searching, after which RevMan v5.3 was used to conduct the present meta-analysis. Relevant endpoint data were extracted from each study, related to postoperative hepatic encephalopathy (HE) rates, TIPS dysfunction, re-bleeding, and mortality. A total of eight studies were identified as being relevant for inclusion in this meta-analysis. These studies included 2592 total patients suffering from liver cirrhosis that underwent TIPS treatment via the left (n = 1500) or right (n = 1092) PVs. Rates of postoperative HE were significantly lower in the left PV group relative to the right PV group (5.7% vs. 18.1%, OR 0.19; P < 0.00001), as were rates of TIPS dysfunction (8.1% vs. 16.5%, OR 0.41; P < 0.00001). In contrast, the rates of re-bleeding did not differ significantly between these groups (12.0% vs. 14.9%, OR 0.76; P = 0.11), nor did mortality rates (30.9% vs. 31.0%, OR 0.85, P = 0.22). We did not detect any significant heterogeneity among included studies for any analyzed endpoints, nor was any risk of publication bias pertaining to these studies detected through the use of funnel plots. TIPS conducted via the left PV was associated with decreased rates of postoperative HE and TIPS dysfunction relative to TIPS conducted via the right PV.

Role of Doppler Ultrasound Combined With Clinical Features in the Diagnosis of Transjugular Intrahepatic Portosystemic Shunt Dysfunction in the Era of Covered Stents.

Our goal was to discuss the role of Doppler ultrasound (US), combined with clinical features, in the diagnosis of transjugular intrahepatic portosystemic shunt (TIPS) dysfunction in the era of covered stents. In light of the lack of research regarding the accuracy of Doppler US in TIPS dysfunction evaluations when using covered stents and a recent major meta-analysis, which primarily reviewed studies with bare metal stents but few with covered stents, we aimed to provide our single-center case study for further investigation. All patients from 2010 to 2019 who underwent angiography for a covered stent preceded by a Doppler US examination in our institution were retrospectively reviewed. All of the Doppler US and angiographic examination results showed complete agreement, and 11 of 12 were positive for TIPS dysfunction. Combining the presence of positive clinical signs for TIPS dysfunction with Doppler US may increase its accuracy. Considering our results, there may be a need to reinvestigate Doppler US as a noninvasive, inexpensive, and available tool for the diagnosis of TIPS dysfunction in the era of covered stents, despite recent publications depicting Doppler US as inadequate for evaluating a TIPS.

The Role of Spleen and Liver Elastography and Color-Doppler Ultrasound in the Assessment of Transjugular Intrahepatic Portosystemic Shunt Function

The reference standard for assessing transjugular intrahepatic portosystemic shunt (TIPS) function is venography with portosystemic pressure gradient (PPG) measurement. This procedure is invasive and expensive; thus, we assessed the feasibility, reproducibility and diagnostic accuracy of color-Doppler ultrasound (CDUS) and spleen and liver stiffness (LS) measurements for identifying TIPS dysfunction. Twenty-four patients (15 undergoing TIPS placement and nine undergoing TIPS revision) consecutively underwent CDUS examination and LS and spleen stiffness (SS) determination by transient elastography (TE) and point shear-wave elastography (pSWE). All parameters were taken before TIPS placement/revision (1–15 d before) and 24 h after, just before revision by venography. pSWE inter-observer agreement was assessed by intra-class correlation coefficient (ICC). CDUS and elastographic data were correlated (Pearson coefficient) with pressure gradients (hepatic venous pressure gradient [HVPG], PPG). Main determinants of TIPS dysfunction were investigated by linear regression. Forty-nine paired examinations were performed in total: 49 (100%) SS reliable measurements by pSWE and 38 (88%) by TE. The ICC for pSWE values was 0.90 (95% confidence interval [CI] 0.81‒0.94). SS values significantly correlated with HVPG and PPG (R = 0.51, p = 0.01). The area under the Receiver-Operating Characteristic (AUROC) curve of SS for diagnosing TIPS dysfunction was 0.86 (95% CI 0.70‒0.96) using a 25 kPa cutoff. At multivariate analysis, the flow direction of the intrahepatic portal vein branches and SS values were independently associated to TIPS dysfunction. The intrahepatic portal vein branches flow direction and SS value are two simple, highly sensitive parameters accurately excluding TIPS dysfunction. SS measurement by pSWE is feasible, reproducible and both positively and significantly correlates with HVPG and PPG values.

The Pull-Through Technique for Recanalization of Transjugular Intrahepatic Portosystemic Shunt Dysfunction.

Purpose To evaluate the technical efficacy and safety of the pull-through technique in recanalization of transjugular intrahepatic portosystemic shunt (TIPS) when standard transjugular approach is inaccessible. Materials and Methods A retrospective review of patients underwent TIPS revision via the pull-through technique was performed. Transhepatic directly punctured stent was conducted if the portal vein could not be accessed via standard transjugular approach. Technical success was defined by recanalization of shunt. Clinical success was defined as bleeding interruption and ascites regression without pharmacological support. All patients were followed up by clinical evaluation and Doppler ultrasound. Results Between January 2010 and December 2016, a total of 63 patients underwent TIPS revision, and 14 of them could not be accessed via standard transjugular approaches owing to stenosis or occlusion of the hepatic vein. The pull-through technique was successful in 13 patients, and one patient underwent parallel TIPS. No procedure-related complication was observed. One patient died of liver failure one week after the procedure. During the follow-up, three patients developed hepatic encephalopathy, and one patient developed TIPS dysfunction again and experienced variceal bleeding. The primary patency rate after TIPS revision was 92% (11/12) at 12 months. Conclusion The pull-through technique was effective and safe for recanalization of TIPS inaccessible via standard transjugular approach.

Simultaneous Transjugular Intrahepatic Portosystemic Shunt Revision and Embolization of an Arterioportal Fistula in a Patient with Active Variceal Bleeding from Systemic Lupus Erythematosus-induced Cirrhosis

Transjugular intrahepatic portosystemic shunt (TIPS) occlusion is a common occurrence that can be managed based on the nature and acuity of shunt failure. Arterioportal fistulas (APFs) are rare communications between portal venous and systemic arterial vasculature that can present with symptomatic portal hypertension. In this case, we describe the management of a patient with variceal bleeding due to TIPS dysfunction complicated by the presence of an APF.

Predictive Value of Abnormal Findings on Covered Transjugular Intrahepatic Portosystemic Shunt Baseline Doppler Sonography.

Doppler ultrasound (DUS) is frequently performed as a screening and diagnostic modality to evaluate the transjugular intrahepatic portosystemic shunt (TIPS) for short- and intermediate-term complications of the procedure. However, the clinical significance of initial frequently observed abnormalities in flow velocities, gradient, and direction in patients with covered TIPS is less studied. A retrospective study was performed between January 2005 and December 2014, and all patients undergoing covered TIPS procedure for the management of portal hypertension were included. Abnormal DUS findings were defined as intrashunt peak systolic velocities (PSVs) less than 90 or greater than 190 cm/s, intrashunt gradient greater than 50 cm/s, and abnormal flow direction in the main, right, and/or left portal veins. A total of 283 patients with adequate clinical follow-up and baseline TIPS DUS were included in the study. Median follow-up was 18.2 months. During the follow-up period, portal hypertension symptoms recurred in 83 patients who underwent TIPS angiography and/or revision. Of the 83, 57 had an elevated portosystemic gradient (>12 mm Hg) requiring angioplasty/stenting. With regard to baseline ultrasound, low PSVs were present in 88 patients (31.1%), high PSVs in 44 patients (15.5%), and elevated gradient in 98 patients (34.6%). The rate of developing TIPS stenosis in the future was not higher in patients with abnormal DUS parameters. For example, 26 (19.7%) of 132 patients with abnormal TIPS velocities developed stenosis compared with 31 (20.5%) of 151 patients with normal velocities (P = 0.9). Based on these results, abnormal DUS findings observed on baseline TIPS ultrasound examination have low predictive value for future covered TIPS dysfunction and failure.