Transjugular Intrahepatic Portosystemic Shunt Revision Research Articles

Viatorr Stent Migration and Retrieval during Transjugular Intrahepatic Portosystemic Shunt Revision.

Transjugular intrahepatic portosystemic shunt (TIPS) is an important interventional option for the treatment of complications related to cirrhosis and portal hypertension. Emergent TIPS placement can be a life-saving measure in patients with uncontrolled variceal hemorrhage. After TIPS placement, patients may benefit from additional interventions for clinical optimization including stent dilation, stent extension, and embolization of varices. Here, we describe a case of emergent TIPS placement and revision which resulted in TIPS stent migration requiring stent removal and replacement. We discuss our technique and review previously reported methods for the management of migrated TIPS stents.

Clinical outcomes of transjugular intrahepatic portosystemic shunt with PTFE-covered stents after liver transplantation and technical results in split and whole liver graft recipients.

To assess the outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation using PTFE-covered stents in liver transplant (LT) recipients and to analyze the technical result of TIPS creation in split grafts (SG) compared with whole liver grafts (WG). Single-center, retrospective study, analyzing LT patients who underwent TIPS using PTFE-covered stents. Clinical and technical variables were analyzed. Between 2005 and 2021, TIPS was created using PTFE-covered stents in 48 LT patients at a median of 43 months (range, 0.5-192) after LT. TIPS indications were refractory ascites (RA) in 33 patients (69%), variceal bleeding (VB) in 9 patients (19%), others in 6 (12%). Ten patients (21%) received a SG. Technical success rate was 100% in both groups: in two WG recipients, (5%) a second attempt was required. An unconventional approach (combined transhepatic or transplenic access) was needed in 2 WG (5%) and 2 SG recipients (20%). Two procedure-related death occurred in the WG group. After a median follow-up of 22 months (range, 0,1-144), 16 patients (48%) in the RA group did not require post-TIPS paracentesis, in the VB group rebleeding occurred in 3 patients (33%). Fifteen patients (31%) underwent TIPS revision. Overt hepatic encephalopathy occurred in 14 patients (29%). Patient survival at 6 months, 1 year, and 3 years was 77%, 66%, and 43%, respectively. The feasibility and safety of TIPS creation in SG are comparable to that of WG. TIPS creation using PTFE-covered stents represents a viable option to treat portal hypertensive complications in LT recipients. • TIPS creation using PTFE-covered stents represents a viable option to treat complications of PH in LT recipients. • TIPS creation in LT SG recipients appears to be safe and feasible as in WG. • Results from this study may help to refine the management of LT patients with recurrent portal hypertensive complications encouraging physicians to consider TIPS creation as a treatment option in both SG and WG recipients.

S2694 An Uncommon Cause of Upper Gastrointestinal Bleeding

Introduction: We present a case of GI bleeding due to a direct communication between a pancreatic fistula and the splenic vein. Case Description/Methods: A 55 year-old female with a history of endometrial cancer, superficial lower extremity thrombus, and alcohol use presented with abdominal pain and dark red blood in her stools requiring blood transfusion. She reported recent ibuprofen use. An upper endoscopy showed small esophageal varices without red wales or stigmata of recent hemorrhage. A CT demonstrated extensive subacute thrombosis of the right and left portal veins, main portal vein (PV), proximal superior mesenteric vein (SMV) and splenic vein (SV). The pancreas appeared atrophic and contained small cysts. There was small ascites. Liver biopsy demonstrated mild steatohepatitis without fibrosis. She underwent placement of a transjugular intrahepatic portosystemic shunt (TIPS) with thrombectomy from the PV, SMV, and SV and was started on anticoagulation. Due to bleeding recurrence, she underwent TIPS revision with tPA injection and additional mechanical thrombectomy. Subsequently on an ultrasound, TIPS thrombosis was again noted and during TIPS revision, a communication was noted between the pancreatic duct and splenic vein, finally identifying the likely source of bleeding. A splenic vein stent was placed. Discussion: This case highlights an uncommon cause of upper GI bleeding and reinforces the importance of keeping a broad differential diagnosis for a patient with portal hypertension. Our patient had a complicated course with 2 TIPS revisions and esophageal varices, but the source of her bleeding was neither variceal nor mucosal. (Figure) Splenic vein thrombus can result as a complication of pancreatitis and subsequently lead to “sinestrial” (left-sided) portal hypertension and the formation of gastric varices which can also present with gastrointestinal bleed (GIB). Our patient did not have the classic finding of sinestral portal hypertension associated with SV thrombosis: gastric varices. Furthermore, during her initial TIPS placement and even her initial thrombectomy, no pancreatic fistula was observed. Although not always visualized due to the intermittent nature of bleeding, hemosuccus pancreaticus in the setting of chronic alcoholic pancreatitis most commonly involves the splenic artery (60-65%) and less commonly involves the gastroduodenal artery. Our patient’s case is unusual because angiogram demonstrated direct communication between a pancreatic fistula and the splenic vein, not the splenic artery.Figure 1.: Large clot burden at superior mesenteric vein.

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

Long-Term Improvement in Liver Function Following Transjugular Intrahepatic Portosystemic Shunt in Patients With Budd–Chiari Syndrome

Transjugular intrahepatic portosystemic shunt (TIPS) relieves hepatic venous obstruction in Budd-Chiari syndrome (BCS), but the effect on liver function is unclear, particularly outside the immediate post-treatment period. This study aims to evaluate the long-term impact of TIPS on liver function and outcomes in BCS patients. Twenty patients with BCS who underwent TIPS from 1999 to 2018 were included. Demographic data and clinical data at the time of TIPS procedure, 6 months, 12 months, 2 years, 5 years, and 10 years post-TIPS were collected. There were 13 (13/20, 65%) women and 7 (7/20, 35%) men with a mean age at the time of TIPS of 42.6±12.8 years. The median time from BCS diagnosis to TIPS was 41 (IQR: 4-165) days. The number of patients with severe ascites decreased significantly from 10/17 (58.8%) at the time of TIPS, to 1/16 (7.7%), 1/13 (7.7%), 2/16 (12.5%), 1/14 (7.1%), and 0/8 (0%) at 6 months, 12 months, 2 years, 5 years and 10 years post-TIPS, respectively.4/20 (20%) patients developed new hepatic encephalopathy post-TIPS procedure. Child-Pugh score significantly decreased from a score of 9.4±1.8 pre-TIPS to 7.6±1.8at 6 months, 7.4±1.5at 12 months, 7.3±1.6at 2 years, 6.8±1.5at 5 years, and 6.4±0.7at 10 years post-TIPS. Fifteen (15/20, 75%) patients required TIPS revision including 4 (4/15, 26.7%) within 30 days, 2 (2/15, 13.3% within 1 month to 1 year, and 9 (9/15, 60%) at more than 1 year. Eight (8/20, 40%) patients underwent liver transplantation (LT) at median time of 7.3 (IQR 3.2-12.9) years after TIPS. TIPS placement for BCS results in sustained resolution of symptoms and improved liver function. Despite the frequent need for revisions, the long-term durability of TIPS can forgo the need for LT in the majority of patients.

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.

Outcomes of transjugular intrahepatic portosystemic shunt using 12 mm diameter polytetrafluoroethylene covered stents in cirrhotic patients with portal hypertension.

PURPOSE We aimed to evaluate the safety and efficacy of 12 mm diameter polytetrafluoroethylene (PTFE)- covered stents for the creation of transjugular intrahepatic portosystemic shunt (TIPS) in cir- rhotic patients with portal hypertension complicated by variceal bleeding and volume-overload. METHODS This retrospective study included 360 patients who had TIPS created between January 2004 and December 2017 using 12 mm diameter PTFE-covered stents. Demographic data, model for end- stage liver disease (MELD) score, etiology of cirrhosis, and Charlson comorbidity index were recorded. Symptoms of hepatic encephalopathy (HE), variceal re-bleeding, improvement in vol- ume-overload, TIPS revisions and the need for intervention, and overall survival were assessed. RESULTS The mean age of the patients was 56.8 ± 9.9 years, and the technical success rate was 99.4%. The rates of improvement of volume-overload post-TIPS were 59.5%, 69.8%, and 81.7% at 3, 6, and 12 months, respectively. About 93.3% of patients were free from paracentesis or thoracentesis at 12 months. The rates of re-bleeding post-TIPS were 4%, 12%, and 12.9% at 3, 6, and 12 months, respectively. The rate of TIPS revision at 12 months was 6.5%. Percentage of patients with any symptoms of HE were 34.4%, 42.9%, and 49.5% at 3, 6, and 12 months, respectively. All HE were appropriately medically managed and no patients required a TIPS reduction. CONCLUSION TIPS placement using 12 mm PTFE-covered stents is efficacious in cirrhotic patients with portal hypertension complicated by variceal bleeding or refractory volume-overload, with an accept- able safety profile.

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.

Transjugular intrahepatic portosystemic shunt for the management of symptomatic malignant pseudocirrhosis

Pseudocirrhosis is defined by radiologic changes of the liver parenchyma secondary to metastatic disease and/or cancer treatments, and portends a high rate of morbidity and mortality from sequelae of portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension; however, TIPS is relatively contraindicated in the setting of hepatic metastases. The study aims to determine the technical efficacy and clinical outcomes of patients undergoing TIPS for symptomatic pseudocirrhosis. Retrospective analysis of patients with hepatic malignancy who underwent TIPS between 2008 and 2020 at a single tertiary care center. Patients with imaging findings of pseudocirrhosis and without history of primary liver malignancy or confounding causes of cirrhosis were included. West Haven scores assessing hepatic encephalopathy were obtained from chart review. Technical success was defined as successful TIPS creation with reduction in the portosystemic gradient (PSG). Clinical success was defined as resolution of variceal bleeding and/or ascites. Nine patients (4 female/5 male), average (± SD) age 61.2±9.5 years with metastatic pseudocirrhosis were included for analysis. Primary malignancy was colorectal adenocarcinoma (n=5), neuroendocrine tumor (n=3), and malignant endothelial hemangioendothelioma (n=1). Average Model for End Stage Liver Disease (MELD-Na) score was 15.7±3.7. Technical success was 8/9 (89%) with average PSG reduced from 23.5±11.0 to 6.5±2.8 mmHg (P=0.001). Clinical success was 6/9 (67%). Two patients required TIPS revision after initial clinical success. Mild-moderate HE occurred in 6/9 patients post TIPS (67%), with a highest West Haven score of 2. Time from TIPS to death for acute variceal bleeding and ascites was 4.9±4.2 and 12±16.5 months, respectively. Cause of death was disease progression (n=5), variceal bleeding (n=1), or unavailable (n=2). TIPS in the setting of malignant pseudocirrhosis can be created safely with similar clinical outcomes to TIPS performed for benign disease. Rates of low-grade hepatic encephalopathy may be higher amongst patients undergoing TIPS for pseudocirrhosis.

Comparison of the Covered Self-Expandable Viatorr CX Stent with the Covered Balloon-Expandable BeGraft Peripheral Stent for Transjugular Intrahepatic Portosystemic Shunt (TIPS) Creation: a Single-Centre Retrospective Study in Patients with Variceal Bleeding.

This study compares the safety and efficacy of the ePTFE-covered self-expansible nitinol stent (VIATORR® Controlled Expansion, Gore, Flagstaff, USA) with the ePTFE-covered, balloon-expandable, metallic stent (BeGraft peripheral, Bentley, Hechingen, Germany) for the creation of the transjugular intrahepatic portosystemic shunt (TIPS). From September 2016 to December 2020, 72 consecutive patients receiving TIPS for acute variceal bleeding (rescue and early TIPS, n = 15) or for prophylaxis of variceal rebleeding (n = 57) were enrolled. The main contraindications were patients with vascular liver disease (portal vein thrombosis and Budd-Chiari syndrome). Forty patients (55.6%) received a Viatorr CX stent and 32 patients (44.4%) a BeGraft peripheral stent. Safety endpoints were technical and clinical adverse events and early deaths within 30days after TIPS implantation. Efficacy endpoints were rebleeding rates, recurrence of large varices requiring endoscopic band ligation, or TIPS revision. Groups receiving the Viatorr CX or BeGraft peripheral stent were comparable in all respects except the TIPS indication for acute variceal bleeding (5% vs. 25%, p = 0.015). All patients had a successful intervention, and the physical variables of stent implantation (intervention and fluoroscopy time, reduction of the portosystemic pressure gradient) as well as adjunctive embolization of varices were similar in both groups. Severe clinical complications (Viatorr CX: 5% vs. BeGraft peripheral: 3.1%, p = 0.692), post-TIPS hepatic encephalopathy (12.5% vs. 18.8%, p = 0.743) and death (5% vs. 0%, p = 0.793) were not different between Viatorr CX and BeGraft peripheral groups. With respect to efficacy, freedom from rebleeding and from variceal band ligation during follow-up (100% vs. 100%, p = 1.0), as well as the need for shunt revision (10.5% vs. 18.8%, p = 0.327), was comparable. Compared to the present gold standard, the Viatorr CX stent, the balloon-expandable BeGraft peripheral stent, showed similar results with respect to safety and efficacy.

Abstract No. 195 National trends in transjugular intrahepatic portosystemic shunt placement, revision, and trainee procedure involvement

To evaluate national trends in transjugular intrahepatic portosystemic shunt (TIPS) creation and revision rates and evaluate trainee exposure to TIPS placement and revision Medicare Physician/Supplier Summary Files were evaluated from 2010 to 2018. TIPS shunt creation and revision procedures were aggregated. Procedures involving a trainee were identified. The rate of TIPS placement, revision, and trainee involvement were evaluated in the context of Medicare enrollment and number of diagnostic and interventional radiology residents as well as interventional radiology fellows using Accreditation of Graduate Medical Education (ACGME) data. From 2010 to 2018, annual claims for de novo TIPS placement increased from 1,725 procedures to 1,947 procedures (+12.8%). When controlled for number of Medicare enrollees, this resulted in an increase of 4.8 to 5.0 (+4.0%) TIPS procedures per 100,000 beneficiaries. TIPS revisions increased from 645 procedures in 2010 to 932 (+45%) procedures in 2018. When controlled for Medicare enrollment, this represented an increase from 1.8 to 2.4 (+33%) TIPS revisions per 100,000 Medicare enrollees. Over time, the ratio of TIPS placements to TIPS revisions decreased from 2.7 to 2.1 (-29%), driven by a relatively higher increase of revisions compared to de novo placements. The number of TIPS placements involving a trainee increased from 17% to 26%. Similarly, the rate of trainee involvement in revisions increased from 18% to 29%. Ratio of TIPS placements and revisions per one thousand trainees increased 55% and 111%, respectively. The rate of TIPS placement and revisions continues to increase in the Medicare population, with a disproportionate increase in TIPS revisions compared to placements. Trainee involvement in these procedures has increased nationally from 2010 to 2018. Further research is needed to evaluate the disproportionate increase in TIPS revisions to placements in this population.

Abstract No. 216 Underutilization of transjugular intrahepatic portosystemic shunt in patients over 65: trends from 2010 to 2018 among Medicare beneficiaries

A limited but growing body of evidence indicates a mortality benefit for transjugular intrahepatic portosystemic shunt (TIPS) in older patients. At the same time, the paradoxical increase in pre-transplant waitlist mortality for patients over 65 raises concern for underutilization of TIPS in this growing demographic. The purpose of this study is to analyze the trend in TIPS volume among Medicare beneficiaries from 2010 to 2018 in relation to liver transplant and associated procedures. Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File for the years 2010 to 2018 were extracted using the Current Procedural Terminology codes for liver transplant, TIPS, TIPS revision, and paracentesis. The volume of TIPS amongst Medicare beneficiaries increased by 14.4% from 1588 to 1817 patients. The volume of liver transplants increased by 51.1% from 2107 procedures to 3184 procedures. Consequently, the ratio of TIPS procedures relative to liver transplants decreased from 0.75 to 0.57.The volume of TIPS revision increased by 41.4% from 611 to 864 procedures, and the volume of paracentesis rose by 64.5% from 161,641 to 266,060 procedures. While the rate of TIPS increased modestly amongst Medicare beneficiaries from 2010 to 2018 related to a higher prevalence of end stage liver disease, its rate of increase was far less than that of liver transplant. Given increased pre-transplant waitlist morality for patients over 65, the findings of this study suggest underutilization of TIPS amongst Medicare beneficiaries. Further study of mortality and complications following TIPS in this growing patient population is necessary.

Abstract No. 28 Sustained improvement in hepatic function following transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome

While transjugular intrahepatic portosystemic shunt (TIPS) has been shown to relieve hepatic venous obstruction and is a viable alternative to liver transplantation (LT) in Budd-Chiari syndrome (BCS), the effect of TIPS on liver function in patients with BCS is unclear, particularly outside the immediate post-treatment period. 20 patients with BCS who underwent TIPS from 1999-2018 were included. Demographic data and clinical data at the time of TIPS procedure, 6-month, and 12-month post TIPS were collected. There were 13 (65%) women and 7 (35%) men with a mean age of 42.6 ± 12.8 years. 8 (40%) patients had a JAK-2 mutation. Time from BCS diagnosis to TIPS procedure was 10.3 ± 23.3 months. Median follow-up time was 8.4 years. The ascitic burden significantly decreased from pre-TIPS (moderate ascites 10/17 (58.8%)) at 6 (moderate ascites 1/16 (6.3%), P = 0.0001) and 12 (1/13 (7.7%, P = 0.0007)) months follow-up, respectively. Hepatic encephalopathy was present in 5/17 (29.4%) pre-TIPS, 3/16 (18.8%) 6-month post TIPS, and 4/13 (30.8%) 12-months post-TIPS. Serum albumin significantly improved from pre-TIPS (3.0 ± 0.6) through 6 (3.5 ± 0.7 (P = 0.03)) and 12 (3.7 ± 0.6 (P< 0.01)) month follow up. Similarly, total protein significantly improved at 6-months after TIPS (pre-TIPS 6.4 ± 1.4, 6-month 7.3 ± 1 (P = 0.03)). Child-Pugh Score significantly decreased with a score of 9.4 ± 1.8 pre-TIPS, as compared to 7.6 ± 1.8 at 6-months (P = 0.007), and 7.4 ± 1.5 (P = 0.05) at 12-months post TIPS. 15 (75%) patients required TIPS revision with 4/15 (26.7%) within 30 days; 2/15 (13.3%) between 1 month and 1 year, and 9/15 (69.2%) after 1 year. 8 (40%) patients underwent LT at mean 7.68 ± 6 years after TIPS. 3 (15%) patients died at 1.9, 9.8, and 16.9 years following TIPS. In patients with BCS, TIPS significantly resolves symptoms and improves liver synthetic function at 1-year. Despite the frequent need for revision, TIPS for BCS also has good long-term durability and is able to prolong time to LT in a large proportion of patients.

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.

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.

Safety And Efficacy of Transjugular Intrahepatic Portosystemic Shunt Creation For Hepatic Hydrothorax: A Retrospective Review

Background and Objective: Hepatic hydrothorax is a type of pleural effusion that occurs in 5-10% of patients with poor liver function. This causes patients to experience shortness of breath and chest discomfort with the potential for respiratory or cardiovascular collapse. When medical management fails, thoracentesis to directly drain fluid is a second-line therapy but frequent treatment is not recommended. For patients requiring serial thoracentesis, a transjugular intrahepatic portosystemic shunt (TIPS) may relieve hepatic hydrothorax by creating a connection between the portal vein and hepatic vein, thus reducing portal hypertension and decreasing fluid accumulation. Our objective was to assess the safety and efficacy of TIPS for hepatic hydrothorax. &#x0D; &#x0D; Methods: An IRB approved, HIPAA compliant institutional database of 320 patients who underwent TIPS creation between 2011-2016 was retrospectively reviewed for patients whose primary indication for TIPS creation was hepatic hydrothorax. This yielded a total of 24 individual patients. Records were reviewed and evaluated for overall survival (OS), response (as measured by persistent need for thoracentesis), and frequency of new and/or worsening hepatic encephalopathy (HE). &#x0D; &#x0D; Results: Survival was 92%, 62% and 38% for 30 days, 1 year, and 3 year survival, respectively. Response to TIPS was graded as complete (52%), partial (19%), or unresponsive (29%) for an overall response rate of 71%. 29% of patients required TIPS revision. 24% of patients experienced new or worsened hepatic encephalopathy that was successfully managed with medication in all but 1 case. Analysis of relationships between response grades, 1 year survival, and age older vs younger than 60 years did not have statistically significant relationships between MELD scores, Child-Pugh scores, post-TIPS pressure gradients, and serological data. &#x0D; &#x0D; Conclusion: This study reaffirms the safety and efficacy of TIPS for hepatic hydrothorax but further work must be done to identify ideal candidates and prognostic factors for this procedure.

Transjugular intrahepatic portosystemic shunt creation via isolated persistent left superior vena cava: a case series

BackgroundIsolated persistent left superior vena cava (PLSVC) is a rare vascular anatomic variant, which can be an incidental finding at the time of an endovascular procedure.Case presentationThis report describes the technical success, adverse events, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation via isolated PLSVC. Three adult patients with cirrhosis and isolated PLSVC underwent TIPS placement successfully with one major adverse event. Two patients required TIPS revision within 90 days. There were no deaths within 90 days.ConclusionsTIPS creation via isolated PLSVC is feasible using standard techniques with a left jugular vein approach. Caution is warranted during the procedure to assess for any aberrant drainage pattern to the left atrium and to prepare for potentially challenging instrument navigation through the coronary sinus.

TRANSUDATIVE CHYLOTHORAX IN LIVER CIRRHOSIS: A RARE MANIFESTATION OF PORTAL HYPERTENSION

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hepatic hydrothorax is a well-recognized pulmonary complication of decompensated liver cirrhosis that can be found in 5-11% of cases. It typically presents as exertional dyspnea in patients with Child-Pugh Class (CPC) B or C cirrhosis and abdominal ascites. The pleural effusion involves the right lung approximately 80% of the time, and pleural fluid analysis is consistent with a transudative effusion. Underlying infection or malignancy should be ruled out. Transudative chylothorax is an exceedingly rare manifestation of portal hypertension in this patient population. CASE PRESENTATION: A 46-year-old man with CPC B, MELD 19 alcoholic liver cirrhosis who recently underwent a transjugular intrahepatic portosystemic shunt (TIPS) procedure with revisions for refractory ascites, presented with progressive cough and dyspnea on exertion for 2 weeks. He reported needing a therapeutic paracentesis approximately every 10 days prior to TIPS; however, since his most recent TIPS revision 4 weeks prior to presentation, he did not have recurrence of his ascites. Exam was notable for diminished breath sounds throughout the right lung fields and trace ascites. Chest radiograph revealed a moderate pleural effusion at the right lower lobe. A thoracentesis yielded 1.5 liters of milky yellow fluid with initial labs suggesting a transudative effusion. A chest tube was placed. Given the milky appearance, further studies were sent, revealing triglycerides at 335 mg/dL and cholesterol at 11 mg/dL, consistent with chylothorax. To evaluate for other etiologies of chylothorax, lymphoscintigraphy was performed, which did not reveal any lymphatic leak or thoracic duct injury. A CT scan of the chest did not demonstrate any lesions concerning for infection or malignancy, and pleural fluid cultures and cytology confirmed the absence of either. The patient underwent TIPS revision with angioplasty, with improvement of the transhepatic pressure gradient. The patient was discharged after increasing his home dose of diuretics and remained asymptomatic at his follow-up appointment 1 week later. DISCUSSION: Liver cirrhosis is an underappreciated cause of chylothorax, with only about 20 cases described in the literature. The pathophysiologic mechanism is thought to be mediated by elevated venous pressures caused by portal hypertension. Diagnostic thoracentesis is required in these patients to rule out malignancy or infection, which are also known etiologies of chylothorax. When the effusion is transudative, interventions aimed at decreasing portal hypertension, such as TIPS, should be considered to prevent recurrence of the chylothorax. CONCLUSIONS: Chylothorax is a rare complication of liver cirrhosis that can be successfully treated by medically managing ascites and/or by TIPS. Reference #1: Chaaban T, Kanj N, Aki IB. Hepatic hydrothorax: an updated review on a challenging disease. Lung. 2019; 197:399-405. Reference #2: Mukherjee A, Sehgal IS, Mittal BR, Dhooria S. Transudative chylothorax: an uncommon illness due to a common cause. BMJ Case Rep. 2018; Feb 7. pii: bcr-2017-223158. Reference #3: Tsauo J, Hoon Shin J, Han K, Yoon HK, Ko GY, Ko HK, Gwon DI. Transjugular intrahepatic portosystemic shunt for the treatment of chylothorax and chylous ascites in cirrhosis: a case report and systematic review of the literature. J Vasc Interv Radiol. 2016; 27: 112-116. DISCLOSURES: No relevant relationships by Argin Baghramian, source=Web Response No relevant relationships by Stefano Iantorno, source=Web Response No relevant relationships by Sonia Lin, source=Web Response No relevant relationships by Alex Rosenberg, source=Web Response

S2621 A Case of Hepatic Infarction Following Transjugular Intrahepatic Portosystemic Shunt Placement

INTRODUCTION: Transjugular intrahepatic portosystemic shunt (TIPS) is a therapeutic modality used to manage complications of portal hypertension including refractory ascites and esophageal varices. Post-TIPS complications include hemorrhage, acute hepatic encephalopathy (HE), stent migration, and acute liver failure (ALF). Herein we present a patient with decompensated cirrhosis complicated by hepatic infarction following TIPS placement.1,2 CASE DESCRIPTION/METHODS: A 56-year-old man with decompensated cirrhosis secondary to primary biliary cholangitis (PBC) and autoimmune hepatitis (AIH) overlap underwent TIPS for refractory ascites. Post-TIPS, he developed severe epigastric pain. Imaging revealed known hepatomegaly with cirrhotic morphology and new hypodense areas in the right lobe of the liver suggestive of infarction (Figures 1 and 2). He improved with medical management and was discharged home. Over two years, he required TIPS revisions due to stent malfunction and stent thrombosis with eventual need for orthotropic liver transplant. Native liver histopathology showed focal necrosis (Figure 3) as noted on imaging following the initial TIPS. DISCUSSION: With TIPS, a metal stent creates a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein and decreases portal pressure allowing for blood return to systemic circulation. Hepatic infarction is rare, with a post-TIPS complication rate of 0.5%.3 Proposed pathogenesis of hepatic infarction include direct arterial injury, hepatic artery occlusion, hypotension and shock with decreased hepatic arterial flow, and extrinsic compression of a branch of the hepatic artery after stent deployment.2,4 Portal flow diversion and inadequate compensation of hepatic arterial blood flow may lead to hepatic ischemia resulting in ALF and infarction.2 The Child-Pugh score negatively correlates with the arterial buffer reserve that is integral in facilitating hepatic perfusion following TIPS.5 Manifestations of hepatic infarction include right upper quadrant pain, HE, and elevated liver chemistries, with worsening hyperbilirubinemia suggestive of ALF.5 CT and MRI demonstrate the ischemic insult if present. In our case, we believe the patient did not immediately progress to ALF as his extensive hepatomegaly compensated for the ischemic injury by maintaining steady state as evidenced by clinical improvement without intervention. While rare, this case demonstrates the importance of recognizing hepatic infarction as a post-TIPS complication.Figure 1.: Coronal slice of CT-abdomen and pelvis with IV contrast demonstrating hepatomegaly with cirrhotic morphology and hypodense areas in the right hepatic lobe suggestive of infarction.Figure 2.: Axial slice of CT-abdomen and pelvis with IV contrast demonstrating hepatomegaly with cirrhotic morphology and hypodense area in the right hepatic lobe suggestive of infarction.Figure 3.: Histopathology contrasting necrotic liver parenchyma (top) with non-necrotic liver parenchyma (bottom). (Magnification 40x).

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.