Transjugular Intrahepatic Portosystemic Shunt Patency Research Articles

T1001 Monitoring of Eptfe Coated Transjugular Intrahepatic Portosystemic Shunt Patency By Contrast-Enhanced Ultrasound

T1001 Monitoring of Eptfe Coated Transjugular Intrahepatic Portosystemic Shunt Patency By Contrast-Enhanced Ultrasound

Monitoring of ePTFE coated transjugular intrahepatic portosystemic shunt patency by contrast-enhanced ultrasound

Objectives: Because of their high patency rates ePTFE coated transjugular intrahepatic portosystemic stents (TIPS) have become standard treatment for portal hypertension related complications. TIPS function evaluation is generally performed by colour-doppler ultrasound (CDUS). In this pilot series the feasibility of contrast-enhanced ultrasound (CEUS) for function monitoring of ePTFE-coated stents was evaluated.

Single-Session Treatment of Portal Vein Thrombosis Using Combined Pharmacomechanical Thrombolysis

A patient with portal hypertension developed thrombosis of her transjugular intrahepatic portosystemic shunt (TIPS) and the portal vein. The Trellis device (Bacchus Vascular, Santa Clara, CA) was used to achieve rapid lysis of the portal vein thrombus and help restore portal and TIPS patency in a single session.

Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long‐term results of a randomized multicentre study

An 80% dysfunction rate at 2 years limits the use of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of complications of portal hypertension. The use of covered stents could improve shunt patency; however, long-term effect and safety remain unknown. Eighty patients randomized to be treated by TIPS either with a covered stent (Group 1) or an uncovered prosthesis (Group 2) were followed-up for 2 years. Doppler US was performed every 3 months. Angiography and portosystemic pressure gradient measurement were performed every 6 months or whenever dysfunction was suspected. Actuarial rates of primary patency in Groups 1 and 2 were 76% and 36% respectively (P=0.001). Clinical relapse occurred in four patients (10%) in Group 1 and 12 (29%) in Group 2 (P<0.05). Actuarial rates of being free of encephalopathy were 67% in Group 1 and 51% in Group 2 (P<0.05). Probability of survival was 58% and 45% at 2 years, respectively, in Groups 1 and 2 (NS). The mean Child-Pugh score improved only in Group 1 (from 8.1+/-1.6 to 7+/-2.2 at 2 years -P<0.05). We also compared the Doppler-US parameters between patent and dysfunctioning shunts. In patent shunts, the mean velocity within the portal vein was significantly higher but the performance of Doppler-US was not accurate enough to predict shunt dysfunction. In conclusion, the improvement in TIPS patency by using covered prostheses is maintained over time with a decreased risk of encephalopathy, while the risk of death was not increased.

Is color-Doppler US a reliable method in the follow-up of transjugular intrahepatic portosystemic shunt (TIPS)?

Transjugular intrahepatic portosystemic shunt (TIPS) has become a widely accepted treatment for complications of portal hypertension. Shunt or hepatic vein stenoses or occlusions are common short- and mid-term complications of the procedure, with a one-year primary patency ranging from 25% to 66%. When promptly identified, shunt stenosis or occlusion may be treated before the recurrence of gastrointestinal bleeding or ascites. The revision is usually successful and the primary-assisted patency of TIPS is approximately 85% at one year. Doppler sonography is a widely accepted screening modality for TIPS patients, both as a routine follow-up in asymptomatic patients and in those cases with clinically suspected TIPS malfunction. In a routine US follow-up, a TIPS patient is scheduled for a control 24 h after the procedure, and then after one week, 1 month, 3 months, and at 3-month intervals thereafter. Venography is at present performed solely on the basis of a suspected shunt dysfunction during the sonographic examination. Color-Doppler sonography is the most reliable method for monitoring the shunt function after TIPS implantation. Several studies have shown that Doppler sonography is a sensitive and relatively specific way to detect shunt malfunction, particularly when multiple parameters are examined. Achieving high sensitivity is optimal so that malfunctioning shunts can be identified and shunt revision can be performed before symptomatic deterioration. Venous angiography is at present indicated only on the basis of US suspicion of shunt compromise. Power-Doppler US and US contrast media can be useful in particular conditions, but are not really fundamental.

Segmental Budd Chiari Syndrome

Segmental hepatic ischemia following placement of transjugular intrahepatic portosystemic shunt (TIPS) is extremely rare (only 2 cases previously described in literature) and thought to be due to thrombosis of the hepatic vein above the stent graft. We describe a case of segmental Budd Chiari Syndrome (BCS) developing following TIPS placement for ascites in a patient with veno-occlusive disease (VOD). A 65 year-old Caucasian male with acute myelogenous leukemia relapsed and was treated with salvage Gemtuzumab (Mylotarg) and subsequent allogenic stem-cell transplant 4 years prior to presentation. Post-transplant course was complicated by chronic graft-versus-host disease (GVHD) involving skin, lung, and liver. Five months prior to admission, he noted an increase in abdominal girth and lower extremity edema. Over the next several months, the ascites increased requiring multiple paracenteses (SAAG>1.1) and became refractory to diuretic therapy. A transjugular liver biopsy showed a hepatic venous wedge gradient of 25mmHg and marked sinusoidal fibrosis, hepato-portal sclerosis, and mild GVHD consistent with VOD. In view of the post sinusoidal outflow obstruction, relatively good liver synthetic function, and since the patient was not a transplant candidate, TIPS was placed from middle hepatic vein to the left portal vein for the management of ascites. Ultrasound performed the following day confirmed patency of TIPS. The patient's ascites improved immediately following TIPS. Two days later, he was found to have an acute worsening of his transaminases with AST of 432 and ALT of 1169 u/l with normal bilirubin. CT scan showed a wedge-shaped hypodense region in left hepatic lobe consistent with ischemia. Branches of the hepatic artery and portal vein were patent within the affected liver segment. The middle hepatic vein was not clearly visualized, and given the distribution of the ischemia was likely thrombosed. He was managed conservatively with hydration and monitoring and transaminases improved over the next few days. However, he developed respiratory decompensation and eventually, multi-organ system failure. His family opted to withdraw further care. No autopsy was performed. We present a case of segmental BCS – an extremely rare complication of TIPS which can be diagnosed on imaging when there is a high index of clinical suspicion (high transaminases post procedure in the absence of other causes). It is generally self limited and managed conservatively.

Transjugular Intrahepatic Portosystemic Shunt Patency and Clinical Outcome in Patients with Budd-Chiari Syndrome: Covered versus Uncovered Stents

To retrospectively compare primary patency and reintervention rates, clinical outcome, and improvement in hepatic dysfunction (Child-Pugh score) in patients with Budd-Chiari syndrome treated with transjugular intrahepatic portosystemic shunt (TIPS) using bare stents or expanded polytetrafluoroethylene (PTFE)-covered stents. Approval of study and treatment protocol and waiver of informed consent for the retrospective study were obtained from institutional review board. Informed consent was obtained from each patient before procedure. Four male and nine female consecutive patients (mean age, 35.7 years) with Budd-Chiari syndrome treated with TIPS from January 1994 to November 2003 were included. In six patients, TIPS creation was performed with bare stents (group A). After April 2001, TIPS creation was performed in seven patients with expanded PTFE-covered stent-grafts (group B). Follow-up (group A mean, 22.7 months +/- 10.53 [standard deviation]; group B mean, 23.1 months +/- 7.81) was performed at 7 days, 30 days, and 3 months and subsequently every 3 months. Liver function was evaluated every 3 months. Primary end points were 6- and 12-month TIPS patency rates. Secondary end points were reintervention rate and clinical outcome. Patency rates were estimated (Kaplan-Meier method) and compared (log-rank test). Continuous (Mann-Whitney U test) and categoric (chi(2) test) data were compared. Significant differences before and after treatment were determined (Wilcoxon test). Mean primary patency duration was 4.46 months +/- 3.40 in group A and 22.29 months +/- 8.15 in group B. In group B, a significant increase in primary patency rate (100% and 85.7% vs 16.7% and 0% at 6 and 12 months; P < .001, log-rank test) and a decrease in reintervention rate (0.29 +/- 0.49 vs 6.17 +/- 1.72, P < .001) were observed. Both groups had a significantly decreased Child-Pugh score; group B had a more persistent and significantly higher reduction. Expanded PTFE-covered stent-grafts significantly increased primary patency rate of TIPS in patients with Budd-Chiari syndrome, with reduced reintervention rate and prolonged clinical improvement.

Covered stents for TIPS: are all problems solved?

Transjugular intrahepatic portosystemic shunt (TIPS) has been used to treat complications of portal hypertension for more than 15 years. The two main drawbacks of TIPS are shunt dysfunction and encephalopathy. Accumulating data and the recent report published by Tripathi et al. show that the use of covered stents improves TIPS patency, by preventing pseudo-intimal hyperplasia, and clinical outcome of patients. Hence, controlled studies are needed to re-assess the role of TIPS using covered stents in the management of portal hypertension.

Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation

Treatment options for patients with portal vein thrombosis are limited. To evaluate the feasibility and efficacy of transjugular intrahepatic portosystemic shunt for portal vein thrombosis with/without cavernomatous transformation. A survey of such patients, referred for transjugular intrahepatic portosystemic shunt between 1994 and 2005, was performed. Success rates, complications, transjugular intrahepatic portosystemic shunt patency and clinical progression were examined. Transjugular intrahepatic portosystemic shunt was attempted in 28 patients (13 cirrhotics). Indications were: presurgery/transplantation (2), worsening of ascites (2), variceal bleeding (15 - 8 elective), refractory ascites (3), portal biliopathy (3) and portal vein thrombosis complicating Budd-Chiari syndrome (2). Transjugular intrahepatic portosystemic shunt was placed successfully in 19 of 28 (73%); 23 of 28 had complete portal vein thrombosis and 9 of 23 had cavernous transformation and transjugular intrahepatic portosystemic shunt was successfully placed in six of these. In the 19 patients with transjugular intrahepatic portosystemic shunt, the mean follow-up was 18.1 months (range 5-70): six patients had stent revisions; three had liver transplantation, one died of bleeding. Most cirrhotic patients had an improvement in the Child-Pugh score. In the failed transjugular intrahepatic portosystemic shunt group, two of nine died, and three had further bleeding. Transjugular intrahepatic portosystemic shunt should be considered for selected patients with symptomatic complete portal vein thrombosis with/without cavernous transformation, as clinical improvement and less rebleeding occur when transjugular intrahepatic portosystemic shunt placement is successful.

Transjugular Portosystemic Shunt in Chronic Portal Vein Occlusion: Importance of Segmental Portal Hypertension in Cavernous Transformation of the Portal Vein

The authors describe a patient with bleeding varices due to chronic portal vein occlusion. A transjugular intrahepatic portosystemic shunt (TIPS) attempt failed because of cannulation of a low-pressure network of portal veins, which communicated only with the chronically thrombosed native portal vein. A second TIPS attempt was successful after transhepatic catheterization of a high-pressure portal system that was continuous with periportal collateral veins and mesenteric veins. After 8 months and one TIPS revision for hepatic vein stenosis, the patient has improved liver function, collapsed varices, and a patent TIPS on ultrasonogram. This case illustrates that cavernous transformation of the portal vein may result in variable intrahepatic portal perfusion and pressures and that TIPS in such cases requires careful selection of an intrahepatic portal vein to achieve adequate portal decompression.

Budd–Chiari syndrome: Long‐term effect on outcome with transjugular intrahepatic portosystemic shunt

The long-term outcome of Budd-Chiari syndrome (BCS) with transjugular intrahepatic portosystemic shunts (TIPS) is not well studied. To address this, the records of 47 consecutive patients with BCS evaluated in one center from January 1989 to April 2004, were analyzed. Seven patients with liver tumors were excluded from analyses. Eleven patients had Bechet's disease, 14 had thrombophiliac disorders, four had myeloproliferative diseases and 11 patients had other or unknown causes. The site of block was hepatic vein in 16 patients, in the suprhepatic inferior vena cava in 19 and not known in five. The majority of patients (21/40; 52.5%) presented with subacute disease with massive ascites and abdominal pain as the dominant manifestations. Eight patients with membranes or segemental block were treated with transluminal angiopalsty, and six were treated with clinical and biochemical recovery. The TIPS was placed through a transcaval puncture in eight patients with progressive liver disease who were on medical therapy and had thrombosis limited to hepatic veins. One patient bled from portal vein puncture, which was managed by placing stent across the punctured site. The TIPS was very effective in decreasing portal pressure gradient, improving synthetic functions, reducing transaminase levels and controlling ascites. Five patients had TIPS dysfunction needing revision. In two patients it was difficult to maintain TIPS patency due to repeated TIPS dysfunction. However, both these patients were asymptomatic with normal liver function tests. Long-term follow up revealed that patients with TIPS had significantly better survival than those treated with medical therapy alone (log-rank test, P = 0.04). In a multivariate Cox-model analysis four variables, namely, more florid presentation, male sex, no treatment with TIPS and increasing Child-Pugh-Turcotte score, adversely affected the survival. Budd-Chiari syndrome needs an individualized multidisciplinary approach and TIPS is indicated in a subgroup of patients with progressive liver disease. It is safe, feasible and improves survival.

Small intestinal submucosa sandwich Zilver stent‐grafts for TIPS: Experimental pilot study in swine

The aim of this study was the evaluation of preliminary suitability of the piglet small intestinal submucosa (SIS) sandwich Zilver endograft for experimental transjugular intrahepatic portosystemic shunt (TIPS) creation. TIPS was created in six swine. The five surviving animals underwent the follow‐up portogram and were sacrificed at four weeks after TIPS creation. Gross and histologic examination was performed in all animals. TIPS creation was successful in all animals. One animal died four days after TIPS creation. In the five surviving animals, one shunt was occluded and four shunts were stenosed on the follow‐up portogram. The mean percentage narrowing of the most advanced stenoses was 72% (range, 60%–100%). The most advanced stenosis was located in the parenchymal tract in three shunts and in the hepatic vein portion in one shunt. Gross and histologic examination showed abundant neointimal formation composed mainly of fibroblasts leading to the significant shunt stenoses. The piglet SIS sandwich Zilver stent‐graft was found to offer only limited TIPS patency and should not be used for the definitive long‐term TIPS study.

BUDD-CHIARI SYNDROME

Purpose: The long-term outcome of Budd-Chiari syndrome (BCS) with transjugular intrahepatic portosystemic shunts (TIPS) is not well studied. Methods: To address this we analyzed the records of 47 consecutive patients with BCS evaluated in one centre from January 1989 to April 2004. TIPS was introduced as a treatment option in November 1999. Results: Seven patients with liver tumors were excluded from analyses. Eleven patients had Bechet's disease, 14 had thrombophiliac disorders, 4 had myeloproliferative diseases and 11 patients had other or unknown causes. The site of block was in hepatic veins in 16 patients, in the suprhepatic inferior vena cava in 19 and not known in 5. Eight patients with membranes were treated with transluminal angiopalsty, with clinical and biochemical recovery in 6 patients. TIPS was placed through a transcaval puncture in 8 patients with progressive liver disease on medical therapy and thrombosis limited to hepatic veins. TIPS was very effective in decreasing protal pressure gradient, improving synthetic functions, reducing transaminase levels and controlloing ascites. Five patients had TIPS dysfunction needing revision. In 2 patients it was difficult to mantain TIPS patency due repeated TIPS dysfunction. However, both these patients were asymptomatic with normal liver function tests. Survival rates were 83 ± 7%, 66 ± 9%, and 58 ± 10% at 3, 12 and 36 months in 24 patients treated before introduction of TIPS. In contrast, corresponding survival rates in 16 patients treated after introduction of TIPS were 93.7 ± 6%, 75 ± 17% and 75 ± 17% (log-rank test, P = 0.04). In a multivariate Cox-model anlayses four variables namely increasing INR, Child-Pugh-Turcotte score and serum bilirubin; and florid clincial presentation were predictors of survival. Conclusions: BCS needs an individualized multidisciplinary approach and TIPS is indicated in a subgroup of patients with progressive liver disease. It is safe, feasible and improves survival.

Long-term patency is expected with covered TIPS stents: this effect may not always be desirable!

Background &amp; Aims A 50% dysfunction rate at 1 year is one of the main drawbacks of the transjugular intrahepatic portosystemic shunt procedure. Preliminary experimental and clinical studies suggest that the use of stents covered with polytetrafluorethylene could tremendously decrease this risk. Methods Eighty patients with cirrhosis and uncontrolled bleeding (n = 23), recurrent bleeding (n = 25), or refractory ascites (n = 32) were randomized to be treated by transjugular intrahepatic portosystemic shunts with either a polytetrafluorethylene-covered stent (group 1; 39 patients) or a usual uncovered prosthesis (group 2; 41 patients). Follow-up Doppler ultrasound was scheduled at day 7, at 1 month, and then every 3 months for 2 years. Angiography and portosystemic pressure gradient measurements were performed 6,12, and 24 months after the transjugular intrahepatic portosystemic shunt procedure and whenever dysfunction was suspected. Dysfunction was defined as a &gt;50% reduction of the shunt at angiography or a portosystemic pressure gradient &gt;12 mm Hg. Results After a median follow-up of 300 days, 5 patients (13%) in group 1 and 18 (44%) in group 2 experienced shunt dysfunction (P &lt; 0.0001). Clinical relapse occurred in 3 patients (8%) in group 1 and 12 (29%) in group 2 (P &lt; 0.05). Actuarial rates of encephalopathy were 21% in group 1 and 41% in group 2 at 1 year (not significant). Estimated probabilities of survival were 71% and 60% at year 1 and 65% and 41% at 2 years in groups 1 and 2, respectively. Conclusions The use of polytetrafluorethylene-covered prostheses improves transjugular intrahepatic portosystemic shunt patency and decreases the number of clinical relapses and reinterventions without increasing the risk of encephalopathy.

Transjugular intrahepatic portosystemic shunts: long-term patency and clinical results in a patient cohort observed for 3-9 years.

To retrospectively assess the outcome of transjugular intrahepatic portosystemic shunt (TIPS) placement in a nonselected group of consecutive patients. TIPS placement was attempted in 82 patients. Patients were followed up for at least 3 years according to a standard protocol that included repeated shunt evaluations. Fifty-four patients underwent TIPS placement for variceal bleeding, 24 for refractory ascites, and four for other indications. Recurrent bleeding, effect on ascites, long-term patency, development of encephalopathy, and survival and complication rates were evaluated with Kaplan-Meier survival analysis and Cox multivariate analysis. TIPS placement was successful in 75 patients (91%). Mean follow-up lasted 29.4 months. Primary patency was 22% and 12%, primary-assisted patency was 67% and 46%, and secondary patency was 91% and 91% at 1- and 5-year follow-up, respectively. Nonalcoholic liver disease (P =.007) and increasing platelet counts (P =.006) independently predicted development of shunt insufficiency. The 1- and 5-year rates of recurrent variceal bleeding were 21% and 27%, respectively. In the majority of patients with refractory ascites, a beneficial effect of TIPS placement was observed. The risk for encephalopathy was 25% at 1-month follow-up and 52% at 3-year follow-up. The risk for chronic or severe intermittent encephalopathy was 15% at 1-year follow-up and 20% at 3-year follow-up. Serum creatinine levels (P =.001) and age (P =.02) were independent risk factors. Overall survival rate was 61%, 49%, and 42% at 1-, 3-, and 5-year follow-up, respectively. Age (P =.03), serum albumin level (P =.02), and serum creatinine level (P <.001) were independently related to mortality. The risk for definitive loss of shunt function was 17% at 5-year follow-up, indicating that surveillance with shunt revision-when indicated-results in excellent long-term TIPS patency. TIPS placement effectively protects against recurrent bleeding.

Improved clinical outcome using polytetrafluoroethylene-coated stents for tips: Results of a randomized study

Background & Aims : A 50% dysfunction rate at 1 year is one of the main drawbacks of the transjugular intrahepatic portosystemic shunt procedure. Preliminary experimental and clinical studies suggest that the use of stents covered with polytetrafluoroethylene could tremendously decrease this risk. Methods : Eighty patients with cirrhosis and uncontrolled bleeding (n = 23), recurrent bleeding (n = 25), or refractory ascites (n = 32) were randomized to be treated by transjugular intrahepatic portosystemic shunts with either a polytetrafluoroethylene-covered stent (group 1; 39 patients) or a usual uncovered prosthesis (group 2; 41 patients). Follow-up Doppler ultrasound was scheduled at day 7, at 1 month, and then every 3 months for 2 years. Angiography and portosystemic pressure gradient measurements were performed 6, 12, and 24 months after the transjugular intrahepatic portosystemic shunt procedure and whenever dysfunction was suspected. Dysfunction was defined as a >50% reduction of the lumen of the shunt at angiography or a portosystemic pressure gradient >12 mm Hg. Results : After a median follow-up of 300 days, 5 patients (13%) in group 1 and 18 (44%) in group 2 experienced shunt dysfunction ( P < 0.001). Clinical relapse occurred in 3 patients (8%) in group 1 and 12 (29%) in group 2 ( P < 0.05). Actuarial rates of encephalopathy were 21% in group 1 and 41% in group 2 at 1 year (not significant). Estimated probabilities of survival were 71% and 60% at 1 year and 65% and 41% at 2 years in groups 1 and 2, respectively (not significant). Conclusions : The use of polytetrafluoroethylene-covered prostheses improves transjugular intrahepatic portosystemic shunt patency and decreases the number of clinical relapses and reinterventions without increasing the risk of encephalopathy.

Biliary-Venous Fistula Complicating Transjugular Intrahepatic Portosystemic Shunt Presenting With Recurrent Bacteremia, Jaundice, Anemia and Fever

A 50-year-old White man with noncirrhotic portal hypertension presented with bleeding from gastric varices. Bleeding was initially managed with band ligation and subsequent transjugular intrahepatic portosystemic shunt (TIPS). Over the next few months, the patient had recurrent episodes of anemia, jaundice, fever and polymicrobial bacteremia. Computed tomography (CT) of the abdomen and chest, upper and lower endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), and echocardiography failed to explain the bacteremia and anemia. Follow-up CT scan and Doppler sonography 9 months after placement showed TIPS was occluded. Repeat ERCP showed a bile leak with free run-off of contrast from the left hepatic duct into a vascular structure. The patient's status was upgraded for liver transplantation with Regional Review Board agreement and subsequently received a liver transplant. Gross examination of the native liver demonstrated a fistula between the left bile duct and the middle hepatic vein. Pathologic evaluation confirmed focal necrosis of the left hepatic duct communicating with an occluded TIPS and nodular regenerative hyperplasia consistent with noncirrhotic portal hypertension. Infection is rarely reported in a totally occluded TIPS. Biliary fistulas in patent TIPS have been treated by endoluminal stent graft and endoscopic sphincterotomy with biliary stent placement. Liver transplantation may be the preferred treatment if TIPS becomes infected following its complete occlusion.

Transjugular intrahepatic portosystemic shunt (TIPS): indications and long-term patency.

Since the introduction of TIPS (the transjugular intrahepatic portosystemic shunt) into clinical practice in 1989, substantial knowledge, partially derived from controlled trials, has become available regarding technical and clinical aspects of the procedure. A number of prospective studies have assessed the long-term patency of radiological shunts, the recognized main technical weakness of the procedure. Review of published data regarding the optimal indications and long-term patency of TIPS. Information on the long-term patency of TIPS is surprisingly scarce. Within 2 years of TIPS creation, re-interventions to re-establish or maintain the patency of the shunt are required in 70%-90% of patients, and in 20%-40% total occlusion develops. Limited available data suggest, however, that in about 80% of patients the shunt is patent after 3-5 years. There is consensus that TIPS is a main, second-line treatment option for variceal haemorrhage not responding to other therapies. Although widely used for treating refractory ascites, gastric variceal bleeding and Budd-Chiari syndrome, these indications require more study. A number of other potential indications remain poorly defined. TIPS is a major treatment modality to manage the complications of portal hypertension and Budd-Chiari syndrome. The available data indicate that TIPS is not only a short-term treatment option but may provide long-term portosystemic decompression. Technical improvements, e.g. the use of covered or drug-eluting stents, are essential to reduce the high rate of shunt dysfunction.

Doppler ultrasound for TIPS: does it work?

The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of complications of portal hypertension such as variceal hemorrhage and ascites is well established. However, TIPS has a limited patency due to dysfunction consisting in occlusion or stenosis of the intrahepatic tract or stenosis of the outflow hepatic vein. Timing of dysfunction cannot be predicted, so routine surveillance and percutaneous intervention are continuously required to maintain TIPS patency. Trans-shunt venography is the gold standard technique in TIPS evaluation, but it is expensive and invasive. Doppler ultrasound (DU) has been the most commonly used noninvasive tool in TIPS patency. Despite many reported series, its role remains controversial. After more than 10 years of experience with TIPS, we followed our patients with DU and trans-shunt venography to establish Doppler criteria of dysfunction and its accuracy in assessing shunt dysfunction.

Recurrent TIPS Thrombosis after Polyethylene Stent-Graft Use and Salvage with Polytetrafluoroethylene Stent-Grafts

Increasing data support the use of polytetrafluoroethylene (PTFE) stent-grafts for de novo and revision transjugular intrahepatic portosystemic shunt (TIPS) applications. Animal experiments have indicated that polyethylene terephthalate (PET) stent-grafts provide no improvement or actually worsen TIPS patency compared with controls, but human TIPS experience with PET grafts is more limited. Herein we describe three patients who underwent de novo creation of TIPS with PET-covered stent-grafts at outside institutions, which resulted in immediate and recurring TIPS thromboses despite repeated thrombectomies. After the failed TIPS were revised with PTFE stent-grafts, the presenting symptoms resolved and uninterrupted patency was achieved.