Transjugular Intrahepatic Portosystemic Shunt Patency Research Articles

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.

Validation of 4D flow cardiovascular magnetic resonance in TIPS stent grafts using a 3D-printed flow phantom

BackgroundFour-dimensional (4D) flow cardiovascular magnetic resonance (CMR) is feasible for portal blood flow evaluation after placement of transjugular intrahepatic portosystemic shunts (TIPS) in patients with liver cirrhosis. However, clinical acceptance of 4D flow CMR in TIPS patients is limited due to the lack of validation studies. The purpose of this study was to validate 4D flow CMR-derived measurements in TIPS stent grafts using a three-dimensional (3D)-printed flow phantom. MethodsA translucent flow phantom of the portal vasculature was 3D-printed. The phantom consisted of the superior mesenteric vein and the splenic vein draining into the portal vein, the TIPS-tract, and the hepatic vein. A TIPS stent graft (Gore® Viatorr®) was positioned within the TIPS-tract. Superior mesenteric vein and splenic vein served as inlets for blood-mimicking fluid. 4D flow CMR acquisitions were performed at 3T at preset flow rates of 0.8 to 2.8 l/min using velocity encoding of both 1.0 and 2.0 m/s. Flow rates and velocities were measured at predefined levels in the portal vasculature and within the stent graft. Accuracy of 4D flow CMR was assessed through linear regression with reference measurements obtained by flow sensors and two-dimensional (2D) phase contrast (PC) CMR. Intra- and interobserver agreement were assessed through Bland–Altman analyses. ResultsAt a velocity encoding of 2.0 m/s, 4D flow CMR-derived flow rates and velocities showed an excellent correlation with preset flow rates and 2D PC CMR-derived flow velocities at all vascular levels and within the stent graft (all r ≥ 0.958, p ≤ 0.003). At a velocity encoding of 1.0 m/s, aliasing artifacts were present within the stent graft at flow rates ≥ 2.0 l/min. 4D flow CMR-derived measurements revealed high intra- and interobserver agreement. ConclusionsThe in vitro accuracy and precision of 4D flow CMR is unaffected by the presence of TIPS stent grafts, suggesting that 4D flow CMR may be used to monitor TIPS patency in patients with liver cirrhosis.

Transjugular Intrahepatic Portosystemic Shunt in Liver Transplant Recipients: Outcomes in Six Adult Patients.

Transjugular intrahepatic portosystemic shunt (TIPS) is regularly used in treatment of clinically significant portal hypertension. Liver transplant recipients are, however, rarely indicated for the procedure. The study retrospectively examines the results of TIPS placement in 6 patients after OLT. 4 males and 2 females (aged 36 to 62years), treated with TIPS between 2007 a 2018, were included in the study. 5 patients had previously undergone liver transplantation for liver graft cirrhosis, 1 patient for Budd-Chiari syndrome. The piggyback caval reconstruction technique was selected in 4/6 cases. PH developed after OLT due to the recurrence of underlying liver condition and sinusoidal obstruction syndrome in half of the cases, respectively. Indications for TIPS were refractory ascites in 4 cases and variceal bleeding in 2 cases. Standard TIPS technique was used and technical success was achieved in all cases with a procedure-related complication in 1 patient. One patient died shortly after TIPS placement. The remaining patients all reported regression of clinically significant PH. Late complications appeared in 2 patients. Liver retransplantation after TIPS creation was performed in 1 case. Median TIPS patency was 55months. 2/6 patient continue to thrive with a patent shunt. Transjugular intrahepatic portosystemic shunt in OLT recipients is technically feasible. Favorable clinical outcomes were reported particularly in patients treated for sinusoidal obstruction syndrome who were indicated to TIPS for refractory ascites.

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.

Retrospective evaluation of early thrombosis in transjugular intrahepatic portosystemic polytetrafluoroethylene-coated shunts under 2-day postinterventional heparinization

The development of acute thrombosis within the TIPS tract may be prevented by prophylactic anticoagulation; however, there is no evidence of the correct anticoagulation regimen after TIPS placement. The purpose of this single-center retrospective study was to evaluate the short-term occlusion rate of transjugular intrahepatic portosystemic shunts (TIPSs) with polytetrafluorethylene (PTFE)-coated stents under consequent periprocedural full heparinization (target partial thromboplastin time [PTT]: 60–80 s). We analyzed TIPS placements that were followed up over a six-month period by Doppler ultrasound in 94 patients and compared the study group of 54 patients who received intravenous periprocedural full heparinization (target PTT: 60–80 s) without any other anticoagulation to patients with prolonged anticoagulation medication. The primary endpoint was TIPS patency after six months. The primary patency rate was 88.3% overall, and in the study group, 90.7%, with an early thrombosis rate of 3.2% (study group: 1.9%) and a primary assisted patency rate of 95.7% (study group: 96.3%). In the study group, one case of TIPS thrombosis occurred on the 23rd day after TIPS placement. Two patients underwent reintervention because of stenosis or buckling. Moreover, the target PTT was not attained in 8 of the 54 patent TIPSs. Four patients had an increased portosystemic pressure gradient, without stenosis, and the flow rate was corrected by increasing the TIPS diameter by dilation. Two-day heparinization seems sufficient to avoid early TIPS thrombosis over a six-month period.

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.

Evaluation of transjugular intrahepatic portosystemic shunt (TIPS) as a previous step to liver transplantation in pediatric patients.

Transjugular intrahepatic portosystemic shunt (TIPS) was designed to treat complications of portal hypertension (PH). The objective of this study was to analyze the results of the TIPS performed in pediatric patients in our institution as a previous step to liver transplantation (LT). A retrospective, descriptive study of pediatric patients with liver cirrhosis undergoing TIPS prior to LT from 2015 to 2020 was carried out. TIPS was performed in 10 patients. The reason for TIPS was hard-to-control ascites in 7 patients (70%), upper gastrointestinal bleeding due to esophageal varices in 1 patient (10%), and portal hypoplasia in 2 cases (20%). No intraoperative complications were recorded. Stent patency was achieved in all cases. TIPS patency until LT was observed in 6 patients (60%). Indirect signs of patency were noted in 1 patient (10%). 2 patients (20%) required re-intervention, with patency being achieved in the second attempt. And finally, no patency was observed after 3 attempts in 1 patient (10%). A decrease in portocaval gradient (p = 0.001) and an increase in portal velocity (p = 0.006) were observed. No platelet count changes were found. A slight, non-significant increase in ammonia was noted. TIPS is a safe and effective procedure to reduce complications of hard-to-control PH in pediatric patients. It allows general condition to be optimized, deterioration to be avoided, and portal vein narrowing to be alleviated in cirrhosis patients as a previous step to LT.

Safety and efficacy of DEM-TACE performed with drug-eluting microspheres smaller than 300 μm in patients with HCC and TIPS

Aim: Safety and efficacy evidence of drug-eluting-microspheres trans-arterial chemoembolization (DEM-TACE) in patients with hepatocellular carcinoma (HCC) and trans-jugular intrahepatic portosystemic shunt (TIPS) is lacking. The aim of this retrospective study was to report the safety and efficacy of DEM-TACE procedures performed with microspheres smaller than 300 μm in patients with HCC and TIPS in a high-volume transplant center. Methods: Embolization was standardized by initiating DEM-TACE with microspheres smaller than 100 μm, and if stasis was not achieved, adjunctive embolization with 100-300 or 200 μm microspheres was administered. With regards to efficacy, the oncological response was evaluated and categorized according to mRECIST criteria at 1, 3-6, 9-12, and 15-18 months. Reporting the safety profile, detailed laboratory analysis was performed before, at 36-48 h, and 30-60 days after the procedure. Adverse events (AEs) were recorded; post-embolic syndrome was defined as the onset of fever/nausea/pain after the procedure. Late onset hepatobiliary complications were evaluated by follow-up imaging with computed tomography or magnetic resonance (CT/MR). Results: From December 2007 to November 2020, 17 HCC patients (25 HCC nodules) with patent TIPS underwent 20 DEM-TACE. Embolization was performed only with microspheres smaller than 100 μm in 3/20 DEM-TACE (15%); adjunctive embolization with 100-300 or 200 μm microspheres was required in 17/20 DEM-TACE (85%). Reported early AEs were post-embolic syndrome (9/20; 45%) all of grade 1-2, late AEs were asymptomatic acute liver bile duct injury (2/20; 10%), and in one case we observed hepatic abscess (1/20; 5%) resulting in death due to sepsis. With regards to efficacy, the oncological response was evaluated and categorized according to mRECIST criteria. Complete response (CR) at 1, 3-6, 9-12, and 15-18 months was 52%, 50%, 50%, and 50%, respectively. Objective response (CR + partial response) at 1, 3-6, 9-12, and 15-18 months was 95%, 71%, 70%, and 50%, respectively. Conclusion: DEM-TACE with drug-eluting-microspheres smaller than 300 μm can be performed in appropriately selected patients with TIPS.

Safety and Efficacy of Microwave Ablation for Hepatocellular Carcinoma in the Setting of Transjugular Intrahepatic Portosystemic Shunt

This retrospective analysis reviews five patients with transjugular intrahepatic portosystemic shunt (TIPS) who underwent percutaneous microwave ablation of hepatocellular carcinoma between January 2017 and September 2020. Mean tumor diameter was 2.0cm (range 1.3-2.9cm), and mean tumor distance from TIPS was 2.3cm (range 1.5-3.3cm). There were no major adverse events, and the TIPS patency was 100% post-ablation. The technical success rate was 100%, and the complete response rate was 100%. In this small study, percutaneous microwave ablation appears safe and effective for the treatment of hepatocellular carcinoma in patients with TIPS in the short-term follow-up period.

S2610 Perihepatic Biloma: A Rare Complication After Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure and an effective therapeutic option for managing portal hypertension complications. Biliary complications after TIPS are uncommon. Here we present a case of recurrent perihepatic biloma in a woman who underwent TIPS. Case Description/Methods: A 40-year-old woman was admitted for epigastric abdominal pain for five days. She reported taking oral contraceptive pills (OCPs) for one month before presentation. She had epigastric tenderness on examination and normocytic anemia (Hgb 10 g/L) on admission labs. CT scan of the abdomen showed a large thrombus in the main portal vein extending into the right and left portal venous branches. The patient was started on heparin drip and underwent TIPS with thrombectomy. Hypercoagulability workup was unremarkable. The post-procedure course was complicated by elevation of alkaline phosphatase (552 U/L), AST (293 U/L), and ALT (324 U/L). Abdomen MRI showed patent TIPS and persistent complete thrombosis of all intrahepatic portal venous branches. She underwent repeat thrombolysis. However, liver enzymes continued to rise, and a repeat MRI showed intrahepatic biloma at the mid aspect of TIPS (Figure 1A, B). IR-guided drainage of the biloma was performed. The hospital course was complicated by fever and leukocytosis. A follow-up CT scan showed a 13 cm complex fluid collection at the dome of the liver (Figure 2A). She underwent drainage of the new collection and received IV Cefoxotin with an interval decrease in the collection size (Figure 2B). Fever resolved, and liver enzymes normalized. Discussion: Bilomas are either intra- or extrahepatic collections of bile that can occur spontaneously, or as a result of trauma to the biliary tree, including iatrogenic injury. Bilomas are usually asymptomatic but may present with abdominal pain due to symptomatic bile peritonitis or secondary bacterial infection leading to abscess formation and sepsis. A biloma may wall off or may continue to have active bile leakage. CT intravenous cholangiography, MRI with gadolinium, and Tc99 scintigraphy can identify bile leak. Differential diagnoses include hepatic cyst and hematoma, liver abscess, loculated ascites, and postoperative fluid collections, including seroma and lymphocele. Treatment options include endoscopic drainage, IR guided, or surgical drainage with bile leak repair.Figure 1.: 1A, and 1B: MRI coronal T2W, MRI axial T2W and MRI coronal post contrast, respectively, showing intrahepatic biloma (white arrow) abutting a portion of the TIPS (yellow arrow) with upstream intrahepatic biliary ductal dilatation (blue arrow). 2A and 2B: CT coronal image demonstrates a new peri-hepatic collection surrounding the hepatic dome (black arrow) and interval placement of a percutaneous drainage catheter and decrease in size of the peri-hepatic collection (black arrow).

TIPS for Adults Without Cirrhosis With Chronic Mesenteric Venous Thrombosis and EHPVO Refractory to Standard-of-Care Therapy.

Extrahepatic portal vein occlusion (EHPVO) from portal vein thrombosis is a rare condition associated with substantial morbidity and mortality. The purpose of this study is to investigate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) for the treatment of chronic EHPVO, cavernomatosis, and mesenteric venous thrombosis in adults without cirrhosis who are refractory to standard-of-care therapy. Thirty-nine patients with chronic EHPVO received TIPS. Laboratory parameters and follow-up were assessed at 1, 3, 6, 12, and 24months, and every 6months thereafter. Two hepatologists adjudicated symptom improvement attributable to mesenteric thrombosis and EHPVO before/after TIPS. Kaplan-Meier was used to assess primary and overall TIPS patency, assessing procedural success. Adverse events, radiation exposure, hospital length-of-stay and patency were recorded. Cavernoma was present in 100%, with TIPS being successful in all cases using splenic, mesenteric, and transhepatic approaches. Symptom improvement was noted in 26 of 30 (87%) at 6-month follow-up. Twelve patients (31%) experienced TIPS thrombosis. There were no significant long-term laboratory adverse events or deaths. At 36months, freedom from primary TIPS thrombosis was 63%; following secondary interventions, overall patency was increased to 81%. TIPS in chronic, noncirrhotic EHPVO with cavernomas and mesenteric venous thrombosis is technically feasible and does not adversely affect liver function. Most patients demonstrate subjective and objective benefit from TIPS. Improvement in patency rates are needed with proper timing of adjuvant anticoagulation.

Tips for removing transjugular intrahepatic portosystemic shunt stent located deep to the union site of SMV & splenic vein during liver transplantation

Transjugular intrahepatic portosystemic shunt (TIPS) is usually used for patients with end-stage liver disease as a bridge to liver transplantation. Additional techniques are required for removing the stent to perform vessel anastomosis in liver transplantation. A 57-year-old female had hepatitis B treated with Entecavir. She underwent TIPS 25 months before living donor transplantation. She had liver cirrhosis with splenomegaly and patent TIPS without bland thrombus in the portal vein on the CT scan. First, after performing full liver mobilization for total hepatectomy, we clamped the proximal hilum using a vessel clamp. And then, all hepatic veins were transected. Intrahepatic hilum transection was performed including intrahepatic portal vein. The TIPS stent's tip in the portal side was removed using the eversion technique. Since then, the TIPS stent's tip in the IVC side was removed after IVC total clamping. Case 2 had the stent's tip down to SMV, so the stent was cut at the middle after eversion as much as possible to anastomosis the portal vein. Safe and accurate stent removal is required when performing liver transplantation in patients who have TIPS.

Drug-eluting beads TACE is safe and non-inferior to conventional TACE in HCC patients with TIPS

ObjectivesThis study aims to compare the safety and effectiveness between transarterial chemoembolization (TACE) with drug-eluting beads (DEB-TACE) and conventional TACE (cTACE) using lipiodol-based regimens in HCC patients with a transjugular intrahepatic portosystemic shunt (TIPS).MethodsThis retrospective study included patients with patent TIPS who underwent TACE from January 2013 to January 2019 that received either DEB-TACE (DEB-TACE group, n = 57) or cTACE (cTACE group, n = 62). The complications, liver toxicity, overall survival (OS), time to progression (TTP), and objective response rate (ORR) were compared between the groups.ResultsAltogether, 119 patients (50 ± 11 years, 107 men) were evaluated. The incidence of adverse events, including abdominal pain within 7 days (45.6% vs 79.0%, p < 0.001) and hepatic failure within 30 days (5.3% vs 19.4%, p = 0.027), were significantly lower in the DEB-TACE group than in the cTACE group. Compared to the cTACE group, the DEB-TACE group also showed mild liver toxicities in terms of increased total bilirubin (8.8% vs 22.6%), alanine aminotransferase (5.3% vs 21.0%), and aspartate aminotransferase (10.5% vs 29.0%) levels. The DEB-TACE group had better ORR than the cTACE group (70.2% vs 50.0%). The median OS and TTP were longer in the DEB-TACE group (11.4 vs 9.1 months, hazard ratio [HR] = 2.46, p < 0.001; 6.9 vs 5.2 months, HR = 1.47, p = 0.045). Multivariable analysis showed that α-fetoprotein levels, Barcelona clinic liver cancer stage, and treatment allocation were independent predictors of OS.ConclusionDEB-TACE is safe and effective in HCC patients with a TIPS and is potentially superior to cTACE in terms of complications, liver toxicities, OS, TTP, and ORR.Key Points• DEB-TACE is safe and effective in HCC patients after a TIPS procedure.• DEB-TACE improves overall survival, objective response rate, and liver toxicities and is non-inferior to cTACE in terms of time to progression.• DEB-TACE might be a potential new therapeutic option for HCC patients with TIPS.

Transjugular intrahepatic portosystemic shunt creation may be associated with hyperplastic hepatic nodular lesions in the long term: an analysis of 18 pediatric and young adult patients.

Retrospective studies have demonstrated the efficacy and safety of pediatric and adolescent transjugular intrahepatic portosystemic shunt (TIPS), but long-term outcomes warrant further investigation. To report on the development of hyperplastic hepatic nodular lesion development in children and young adults (<21 years) with TIPS patency >3years. Eighteen children and young adults, including 10 (55.6%) females and 8 (44.4%) males, underwent TIPS creation with >3years' patency and follow-up evaluation at a tertiary children's hospital. The mean age at the time of TIPS creation was 12.5±5.1 years (range: 1.5-20.0years). The mean model for end-stage liver disease (MELD) at the time of TIPS creation was 8.1±1.6 (range: 6-11). Indications for TIPS creation included acute variceal bleeding (8/18, 44.4%), primary (1/18, 5.6%) or secondary (7/18, 38.9%) prevention of varices, portal vein thrombosis (1/18, 5.6%), and splenic sequestration (1/18, 5.6%). Technical successes, intra-procedural parameters, hemodynamic and clinical successes, TIPS patencies, adverse events, imaging evaluations, and follow-ups were recorded. All (100%) TIPS placements were successful; however, a direct intrahepatic portosystemic shunt was created in one (5.6%) patient. Mean reduction of the portosystemic shunt gradient was 9.1±3.3mmHg (range: 4-16 mmHg). Seventeen (94.4%) patients demonstrated clinical success with resolution of their initial clinical indication for TIPS placement. The 3-year TIPS primary, primary-assisted, and secondary patencies were 83.3% (15/18), 94.4% (17/18), and 100% (18/18), respectively. Two (11.1%) patients developed mild, medically controlled hepatic encephalopathy. One (5.6%) patient developed hepatopulmonary syndrome. Nine (50%) patients developed single or multiple hepatic nodules at a mean imaging surveillance time after TIPS of 4.4±3.0years (range: 1.5-10.2years). Six (33.3%) patients developed nodules >1 cm with imaging features most consistent with focal nodular hyperplasia or focal nodular hyperplasia-like nodules. The mean follow-up duration was 5.7±2.9years (range: 3.0-13.1 years). Long-term (>3years) portosystemic shunting via TIPS is associated with the development of hepatic nodular lesions in children. Consequently, children with TIPS may need gray-scale assessment of hepatic parenchyma as part of routine ultrasound exams and extended imaging surveillance until more is understood regarding the natural history of induced nodularity.

Combined Y-configured stents for revising occluded transjugular intrahepatic portosystemic shunt

We aimed to determine the technical feasibility, safety and prognosis of the transjugular intrahepatic portosystemic shunt (TIPS) revision by combined Y-configured stents placement. We retrospectively evaluated 12 patients who received TIPS revision using Y-stenting technique between June 2015 and January 2019. The rates of technical success, complication, shunt patency, hepatic encephalopathy and mortality were described and analyzed. The combined Y-configured stents were successfully placed in 11 of 12 patients (92%) without major complications. The median portosystemic pressure gradient (PPG) decreased from 23 mmHg (interquartile range, IQR, 18.5-27.5 mmHg) to 10 mmHg (IQR, 9-14 mmHg). The left internal jugular vein approach was used in 5 patients. Four patients required a shunt extension with an extra stent to resolve the stenosis at the portal venous terminus. Two patients developed hepatic encephalopathy, which was medically controlled within 3 months after the procedure. The TIPS patency and survival rates were both 100% during a median follow-up period of 10 months (IQR, 5.5-14 months). TIPS revision by combined Y-configured stents placement was technically feasible and safe with favorable clinical outcomes.

Emergency tips recanalisation and gastroesophageal varices embolisation with an ethylene vinyl alcohol copolymer agent (Squid) and detachable coils

Transjugular intrahepatic portosystemic shunt (TIPS) is currently indicated as first therapeutic option in the main complications of portal hypertension, including bleeding gastroesophageal varices and refractory ascites. In case of bleeding gastroesophageal varices, an adjuvant embolisation within TIPS can be useful to prevent rebleeding. In the present technical note, the management in emergency of a patient with haemorrhagic shock due to bleeding gastroesophageal varices and occluded TIPS is reported. TIPS recanalisation with an adjunctive stent and high-pressure balloon angioplasty and gastroesophageal varices embolisation using detachable coils and a non-adhesive liquid embolic agent were performed during the same emergent procedure. After the procedure, clinical stabilisation of the patient was achieved, with blood transfusions suspension and Blakemore tube removal. At 6 months, regular TIPS patency at colour Doppler and no rebleeding episodes were recorded. To our knowledge, whilst coils are routinely used for varices embolisation, non-adhesive liquid embolic agents have been never mentioned. Liquid embolic agents seem to provide a stable plug strengthening the embolising action of the coils. Further studies involving a cohort of patients with long-term follow-up will be necessary to confirm whether this association can be more effective than coils alone in gastroesophageal varices embolisation.

S2107 Successful Management of Refractory Esophageal Variceal Bleeding Secondary to Chronic Portal Vein Thrombosis by Transsplenic Portal Vein Recanalization and Transjugular Intrahepatic Portosystemic Shunt

INTRODUCTION: Trans-jugular intrahepatic portosystemic shunt (TIPS) becomes challenging in the presence of portal vein thrombus (PVT). We describe a case of successful management of refractory esophageal variceal bleeding secondary to chronic PVT and splenic vein thrombosis (SVT) by portal vein recanalization – TIPS through transsplenic and transhepatic approach. CASE DESCRIPTION/METHODS: A 29-year-old male with a history of homozygous methylenetetrahydrofolate reductase mutation with normal homocysteine levels on warfarin presented with acute hematemesis. He underwent emergent endoscopic band ligation of esophageal and GOV1 gastric varices. He had a history of chronic PVT with prior mechanical thrombectomy and thrombolysis two years ago, and received band ligation for bleeding esophageal varices in the last year, but did not follow up for surveillance. MRI of abdomen and pelvis revealed chronic PVT with cavernous transformation (Fig A) and chronic SVT. No further bleeding was reported after endoscopy. Liver biopsy one year ago showed benign liver tissue with focal mild congestion and sinusoidal dilation. There was a normal hepatic venous pressure gradient. Given concerns about his compliance and risk of re-bleeding, multidisciplinary team discussion led to consideration of a high-risk TIPS with splenic vein recanalization and stenting. Under ultrasound and fluoroscopic guidance, TIPS was placed using two snare targets. One snare was placed in the occluded portal vein via splenic vein access, and another was placed in the middle hepatic vein via internal jugular vein access. Using the gun-sight technique, a 21-gauge Chiba needle was advanced transhepatically through both the loop snares and then a guidewire was advanced until it could be captured by both the above snares (Fig B). With this newly obtained access, TIPS and splenic stents were successfully deployed (Fig C). Pressure gradient across TIPS was lowered to 6 mm Hg from 16 mm Hg. As varices did not fill on post TIPS portogram, embolization was not performed. He was started on aspirin in addition to his warfarin. Repeat CTA at 3 months demonstrated patent TIPS and splenic stent, and no further episodes of hematemesis were reported. DISCUSSION: In our patient, the gunsight TIPS approach helped decompress portal hypertension and prevent recurrent variceal bleeding when other alternatives including Sugiura surgery carried high morbidity and were not amenable. Post TIPS re-stenosis is a known complication, and may be prevented by aspirin and warfarin use.Figure 1.: Magnetic resonance imaging (MRI) of the abdomen and pelvis showing chronic portal vein thrombosis with cavernous transformation.Figure 2.: Fluoroscopic image showing gun-sight technique: Guide-wire is captured by the first snare in the presumed right portal vein and second snare in the middle hepatic vein.Figure 3.: Fluoroscopic image showing successful deployment of TIPS.

Stent patency and outcome of TIPS through the left versus the right portal branches

BackgroundOur purpose is to compare the stent patency and clinical outcome of trans-jugular intra-hepatic porto-systemic shunt (TIPS) through the left branch portal vein (TIPS-LPV) to the standard TIPS through the right branch (TIPS-RPV). We retrospectively reviewed all patients (n = 54) with refractory portal hypertension who were subjected to TIPS-LPV at our institute (TIPS-LPV) between 2016 and 2018. These patients were matched with 56 control patients treated with the standard TIPS-RPV (TIPS-RPV). The 2 groups were compared regarding the stent patency rate, encephalopathy, and re-interventions for 1 year after the procedure.ResultsTIPS-LPV group showed 12 months higher patency rate (90.7% compared to 73.2%) (P < 0.005). The number of the encephalopathy attacks in the TIPS-LPV group was significantly lower than that of the TIPS-RPV group at 6 and 12 months of follow-up [P = 0.012 and 0.036, respectively]. Re-bleeding and improvement of ascites were the same in the two groups [P > 0.05]. Patients underwent TIPS-LPV needed less re-interventions and required less hospitalizations than those with TIPS-RPV [P = 0.039 and P = 0.03, respectively].ConclusionThe new TIPS approach is to extend the stent to LPV. This new TIPS-LPV approach showed the same clinical efficiency as the standard TIPS-RPV in treating variceal bleeding and ascites. However, it proved a better stent patency with lower rates of re-interventions, encephalopathy, and hospital admissions than TIPS through the right branch.

Comparison of the curative effect of transjugular intrahepatic portosystemic shunt with expanded polytetrafluoroethylene-covered stent and drug combined with gastroscopy as the secondary prevention of esophageal -gastric variceal bleeding in portal hypertension

Objective: To compare the clinical efficacy of transjugular intrahepatic portosystemic shunt (TIPS) with expanded polytetrafluoroethylene (ePTFE)-covered stent and drug combined with gastroscopy as the secondary prevention of esophageal-gastric variceal bleeding in portal hypertension. Methods: Patients with esophageal-gastric variceal bleeding who received TIPS treatment (ePTFE covered stent) or gastroscopy for the first time as the secondary prevention for portal hypertension at Nanfang Hospital of Southern Medical University through March to July 2017 were selected. One year after the operation, liver function changes, ascites remission rates, incidence of hepatic encephalopathy, re-bleeding rate, average hospitalization frequency and expenses, survival time, as well as the TIPS patency conditions were analyzed in the two groups of patients. 2 test, Kaplan-Meier method and Mann-Whitney U test were used to analyze the data. Results: There were 74 and 66 cases in the TIPS and the drug combined gastroscopy group and the follow-up duration (14.57 ± 0.79) was 12-16 months. One year after surgery, the remission rate of ascites in the TIPS group was higher 57.1% (32/56) than that of the drug combined gastroscopy group (0), and the difference was statistically significant (χ(2) = 2 = 36.73, P < 0.01). The cumulative incidence of hepatic encephalopathy at 1, 3, 6, and 12 months after surgery in the TIPS group was 32.4% (24/74), 37.8% (28/74), 40.5% (30/74), and 40.5% (30/74), respectively. The cumulative incidence of hepatic encephalopathy in the drug combined gastroscopy group was 3.0% (2/66), 3.0% (2/66), 3.0% (2/66), and 6.1% (4/66), respectively. Kaplan-Meier analysis showed that the cumulative incidence of hepatic encephalopathy in the TIPS group was higher than that of the drug combined gastroscopy group (χ(2) = 11.29, P < 0.01). The incidence of severe hepatic encephalopathy ( grade III to IV) at 1, 3, 6, and 12 months after surgery in the TIPS group was 2.7% (2/74), 0, 0, and 0, respectively. The incidence of severe hepatic encephalopathy in drug combined gastroscopy group was 0, and there was no statistically significant difference in development of hepatic encephalopathy between the two groups (P > 0.05). The re-bleeding rates of TIPS group and drug combined gastroscopy group were 0 and 27.3% (18/66), respectively, and the difference was statistically significant (χ(2) = 22.42, P < 0.01). There was no death reported during the follow-up period between both groups. The hospitalization frequency times (1.45 ± 0.80) in TIPS group was lower than that of the drug combined gastroscopy group times (3.24 ± 1.80), and the difference was statistically significant (U = -4.52, P < 0.01). Conclusion: In the prevention of esophageal-gastric variceal bleeding, TIPS (ePTFE-covered stent) treatment has the advantages of reducing re-bleeding rate, high ascites remission rate and hospitalizations frequency. In addition, patients treated with TIPS have a higher incidence of hepatic encephalopathy than that of drugs combined with gastroscopy. However, TIPS did not exacerbate the incidence of hepatic encephalopathy, and there was no significant difference in the 1-year survival rate after TIPS and drugs combined with gastroscopy treatment.

Long-term Outcome of Transjugular Intrahepatic Portosystemic Shunt in Children With Portal Hypertension.

A proportion of children with chronic liver disease have severe portal hypertension (PH) and a preserved synthetic and biliary function. In our institution these children have been managed with transjugular intrahepatic portosystemic shunts (TIPS). We aimed to evaluate the long-term patency of TIPS placed in pediatric patients with PH. Retrospective study of children who underwent TIPS in the last 15 years. We compared patients with cirrhotic PH to those with noncirrhotic PH, and all with an historical cohort of children who underwent a surgical portosystemic shunt. Kaplan-Meier analysis measured long-term shunt patency. Twenty-nine patients were recorded (cirrhotic PH = 11, noncirrhotic PH = 18, mean age 10.3 years[±4.3], mean weight 36.7 kg [±20.1], mean pediatric end-stage liver disease score 4.1 [±7.1]); in 5 TIPS was placed after split liver transplantation. Indication for TIPS was variceal bleeding in 18, refractory ascites in 11. Primary patency rates at 6 months and at 1, 2, and 4 years were 91%, 83%, 60%, and 46%, respectively. At last follow-up (mean of 2.8 years [±2.4, range 0.1-8.1 years]) secondary patency (after radiological revision) was 100%. The patency rate of the historical cohort of patients who underwent a surgical portosystemic shunt was 26 of 31 (82%) at a median follow-up of 12.5 years (1.6-25.8). TIPS appears to have a high mid-term patency rate, especially if monitored and revised. Its high clinical success rate, along with a minimally invasive approach, suggests that in this setting TIPS should not be regarded only as a bridge to liver transplantation.