Transjugular Intrahepatic Portosystemic Shunt Through the Strut of a Previously Placed Stent: Technical Feasibility and Long-Term Follow-Up Results

Technical and Medium-Term Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt with Fluoroscopy and Additional Trans-abdominal Ultrasound Guidance

Background and Objective The aim of the study is to evaluate the technical and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) performed with additional transabdominal ultrasound guidance.

Material and Methods Patients who underwent TIPS between January 2004 to January 2020 in our center were studied. Technical, hemodynamic, angiographic, and clinical outcome were recorded up to 1 year of follow-up.

Results TIPS was attempted in 162 patients (median [range] age 37[3–69] years; 105 were males and 57 were females; Etiology: Budd-Chiari syndrome [BCS] 91, cirrhosis 65, symptomatic acute portal venous thrombosis [PVT] 3, veno-occlusive disease [VOD] 2, congenital portosystemic shunt [CPSS] 1) during the study period. Indication for TIPS was refractory ascites in 135 patients (BCS 86, cirrhosis 49) and variceal bleed in 21 patients (BCS 5, cirrhosis 16). Technical success was seen in 161 of the 162 (99.4%) patients. The tract was created from hepatic vein in 55 patients and inferior vena cava (IVC) in 106 patients. Complications within 1 week post TIPS were seen in 29 of the 162 (18%) patients, of whom one developed unexplained arrhythmia and hypotension and died. Of the patients with available follow-up, clinical success was noted in 120 (81%), while 14 (9%) patients had partial nonresponse and six (4%) had complete nonresponse. Eight (5%) patients died during the follow-up period.

Conclusion The technical success of TIPS creation with additional transabdominal ultrasound guidance is very high with low peri-procedural complication rate. It has enabled the inclusion of a wider spectrum of cases like acute PVT and obliterated hepatic veins which were otherwise considered contraindications.

An Update on the Management of Budd-Chiari Syndrome

Budd-Chiari syndrome (BCS) is an uncommon condition, caused by obstruction to hepatic venous outflow. It is largely underdiagnosed, and a high index of suspicion is required for any patient with unexplained portal hypertension. The understanding of its etiology and pathology is improving with advances in diagnostic techniques. Recent studies reported an identifiable etiology in > 80% of cases. Myeloproliferative neoplasm (MPN) is the most common etiology, and genetic studies help in diagnosing latent MPN. Better cross-sectional imaging helps delineate the site of obstruction accurately. The majority of BCS patients are now treated by endovascular intervention and anticoagulation which have improved survival in this disease. Angioplasty of hepatic veins/inferior vena cava remains under-utilized at present. While surgical porto-systemic shunts are no longer done for BCS, liver transplantation is reserved for select indications. Some of the unresolved issues in the current management of BCS are also discussed in this review.

Recanalization and Reconstruction of a Chronically Occluded Inferior Vena Cava Through an Existing Transjugular Intrahepatic Portosystemic Shunt in the Setting of Budd-Chiari Syndrome

Budd-Chiari syndrome (BCS) results from the occlusion or flow reduction in the hepatic veins or inferior vena cava and can be treated with transjugular intrahepatic portosystemic shunt when hepatic vein recanalization fails.^1-3 Hypercoagulable patients with primary BCS are predisposed to development of new areas of thrombosis within the TIPS shunt or IVC. This case details a patient with BCS, pre-existing TIPS extending to the right atrium, and chronic retrohepatic IVC thrombosis who underwent sharp recanalization of the IVC with stenting into the TIPS stent bridging the patient until his subsequent hepatic transplantation.

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

PURPOSE

We aimed to determine the technical feasibility, safety and prognosis of the transjugular intrahepatic portosystemic shunt (TIPS) revision by combined Y-configured stents placement.

METHODS

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.

RESULTS

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).

CONCLUSION

TIPS revision by combined Y-configured stents placement was technically feasible and safe with favorable clinical outcomes.