Delayed Wallstent migration after a transjugular intrahepatic portosystemic shunt procedure: relocation with a loop snare

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.

Endovascular Removal of the Viatorr Stent-Grafts. Report of Two Cases

BACKGROUND

The dysfunction of misplaced or dislodged endovascular endoprostheses, may be a serious complication, and endovascular removal may be attempted in some cases.

CASE REPORT

A Viatorr(®) stent-graft (Gore, Flagstaff, AR, USA) is an endoprosthesis designed and commonly used for creation of a transjugular intrahepatic portosystemic shunt (TIPS). Two Viatorrs were accidentally dislodged during TIPS procedure. In another patient, the Viatorr was malpositioned, with its distal end being placed in the bile duct. All endoprostheses were successfully removed without serious complications.

CONCLUSIONS

Removal of a misplaced or dislodged Viatorr endoprosthesis is possible using interventional methods.

Endovascular caudal retraction of the cranial end of a misplaced Viatorr TIPS prior to liver transplantation

Transjugular intrahepatic portosystemic shunt (TIPS) extension far into the inferior vena cava (IVC) or the right atrium may complicate or preclude orthotopic liver transplantation depending on the space available for placement of a hemostatic clamp in the suprahepatic IVC. Until 2004, most TIPS were performed with bare metal stents, which integrate into the vessel wall, making percutaneous or intraoperative repositioning uncertain. Most TIPS are currently created with stent grafts that have an outer fabric to increase shunt patency and prevent endothelial ingrowth. We describe the first known manipulation of a covered stent graft prior to transplantation. The stent graft, which extended well into the IVC, was snared from a femoral approach and deflected caudally in order to document feasibility and nonadherence to the vein wall prior to definitive surgical planning of liver transplantation. Provisions were made for endovascular retraction during actual transplant surgery 9 weeks later, but this became unnecessary when manual retraction of the exposed liver enabled suprahepatic IVC clamping. Due to the nonadherent nature of the outer graft material, compared with a bare metal stent, extension of a stent graft into the IVC or right atrium may not preclude transplantation, and intraoperative endovascular retraction may be considered.

Atrial laceration caused by removal of a transjugular intrahepatic portosystemic shunt necessitates emergent cardiopulmonary bypass during liver transplant: a case report

In situ transjugular intrahepatic portosystemic shunting (TIPS) can complicate liver transplantation. We present a case where an intraoperative attempt to remove a malpositioned TIPS resulted in atrial laceration. Massive transfusion and emergent institution of cardiopulmonary bypass allowed patient resuscitation and completion of surgery. We describe our surgical and anesthesiologic management, and discuss the absence of criteria to predict when TIPS may become adherent to the inferior vena cava or the right atrium and difficult to remove.

Transjugular intrahepatic portosystemic shunt-related complications and practical solutions

Despite the clinical complexity of patients with severe liver disease and the technical demands associated with the creation of a transjugular intrahepatic portosystemic shunt (TIPS), the major complication rate of this procedure is less than 5%. Delayed recognition and treatment of complications related to TIPS can have life-threatening consequences. This article provides an overview of the spectrum of periprocedural and delayed complications related to the performance of TIPS and offers the reader pearls for both avoiding and managing those complications.

Management of Central Venous Stent Migration in a Patient with a Permanent Inferior Vena Cava Filter

Stent embolization is a rare complication in the treatment of central venous stenoses in patients receiving long-term hemodialysis. The authors report a case of nitinol stent embolization into the right atrium in which the stent could not be repositioned across an indwelling permanent inferior vena cava (IVC) filter. The migrated stent was managed by advancing the stent to the superior margin of the IVC filter and then deploying a second suprarenal IVC filter to prevent repeat embolization.

Liver transplantation with simultaneous removal of an intracardiac transjugular intrahepatic portosystemic shunt and a vena cava filter without the utilization of cardiopulmonary bypass

Transjugular intrahepatic shunts (TIPSs) are widely used in the management of portal hypertension complications including variceal bleeding, refractory ascites, and hepatic hydrothorax. Vena cava filters (VCFs) are an important therapeutic modality in the prevention of pulmonary emboli in patients suffering deep venous thrombosis and clinical contraindications for anticoagulation. Stent and filter misplacement or migration may occur, complicating liver transplantation (LT) surgery. We describe the intraoperative management of a patient with cirrhosis, who had a TIPS extending into the right atrium (RA) and a retrohepatic VCF. Stent and filter removals were deferred until the time of LT. Both procedures were performed successfully by complete cava and portal reconstruction. In conclusion, careful assessment and surgical management of patients with stent and filters permits successful LT.

Acute aortic insufficiency complicating stent treatment of supravalvular aortic stenosis: Successful release of trapped leaflets by wiring the stent

This report shows the findings observed in a 7-year-old boy patient having severe supravalvular aortic stenosis who was treated by stent implantation. Immediately after deployment, a severe acute aortic insufficiency developed due to leaflets trapped by the stent. Release was attempted percutaneously. After wiring the proximal stent, snaring the wire and pulling smoothly, the leaflets came free and valve competence was completely restored. The procedure was then successfully completed, with no residual gradient or aortic insufficiency.

Retrieval of intravascular foreign bodies with goose neck snare

PURPOSE

to evaluate the efficacy and advantages of the snare systems in the retrieval of foreign bodies from vascular system.

MATERIALS AND METHODS

the snare technique has been used for intravascular foreign body retrieval. We performed percutaneous extraction of intravascular foreign bodies using combination multipurpose catheters and a nitinol snare loop. In this report, we evaluated the patients who had performed endovascular device reposition or foreign body retrieval from 1998 to 2001.

RESULTS

foreign body retrieval was performed in 15 patients. The foreign bodies consisted of seven fractured port catheters, one sheath fragment, one embolization coil, four wire fragments, one pace-maker transducer and one dislocated endovascular stent. In no case were surgical procedures required, and no complications were encountered.

CONCLUSION

the snare technique is a useful and a safe method as an alternative procedure to surgery. This technique is highly effective with low rate complications.

Tubular foreign body or stent: safe retrieval or repositioning using the coaxial snare technique

OBJECTIVE

To evaluate the utility and advantages of the coaxial snare technique in the retrieval of tubular foreign bodies.

MATERIALS AND METHODS

Using the coaxial snare technique, we attempted to retrieve tubular foreign bodies present in seven patients. The bodies were either stents which were malpositioned or had migrated from their correct position in the vascular system (n=2), a fragmented venous introducer sheath (n=1), fragmented drainage catheters in the biliary tree (n=2), or fractured external drainage catheters in the urinary tract (n=2). After passing a guidewire and/or a dilator through the lumina of these foreign bodies, we introduced a loop snare over the guidewire or dilator, thus capturing and retrieving them.

RESULTS

In all cases, it was possible to retrieve or reposition the various items, using a minimum-sized introducer sheath or a tract. No folding was involved. In no case were surgical procedures required, and no complications were encountered.

CONCLUSION

The coaxial snare technique, an application of the loop snare technique, is a useful and safe method for the retrieval of tubular foreign bodies, and one which involves minimal injury to the patient.

Open cardiotomy for removal of migrating transjugular intrahepatic portosystemic shunt stent combined with liver transplantation

BACKGROUND

Transjugular intrahepatic shunts are widely used for the management of variceal bleeding. Complications such as stent misplacement or migration may occur.

METHODS

We describe the management of a transjugular intrahepatic shunts stent that migrated across the tricuspid valve in a patient with Child-Pugh category C cirrhosis.

RESULTS

An attempt at percutaneous retrieval of the stent was unsuccessful. Due to the unacceptably high risk for mortality from open heart surgery with cardiopulmonary bypass in the setting of cirrhosis, stent removal was deferred until the time of orthotopic liver transplantation. The procedures were performed successfully, and the patient made a good recovery.

CONCLUSION

Surgical stent extraction and valve repair can be performed safely along with orthotopic liver transplantation in carefully selected patients with end-stage liver disease.

Migration of a transjugular intrahepatic portosystemic shunt (TIPS) stent: evaluation by transesophageal echocardiography

Transjugular intrahepatic portosystemic shunting (TIPS) is a procedure for end-stage liver disease that involves angiographically guided placement of an intrahepatic expandable metal stent. Mechanical complications of intrahepatic stent placement have been reported, including stent migration to the central venous circulation. This report describes a patient who had embolization of a stent after a TIPS procedure, with subsequent failed percutaneous attempts at stent removal. Transesophageal echocardiography documented the stent caught in the tricuspid valve and apparatus, with its distal end projecting into the right ventricular cavity.

Management of misplaced or migrated endovascular stents

PURPOSE

To report experience with techniques for management of misplaced or migrated endovascular stents.

MATERIALS AND METHODS

During a 5-year period, percutaneous management of 27 misplaced or migrated endovascular stents (16 Palmaz, 11 Wallstents) in 25 patients was attempted. The 17 venous and 10 arterial stents were rescued from the aorta (n = 9), inferior vena cava (IVC) (n = 4), transjugular intrahepatic portosystemic shunt/IVC (n = 2), right atrium (n = 3), right ventricle (n = 2), pulmonary artery (n = 2), iliac vein (n = 2), iliac artery (n = 1), superior vena cava (n = 1), and superior mesenteric vein (n = 1).

RESULTS

Stent management was successful in 26 of 27 cases (96%). Eleven stents were removed percutaneously, two were repositioned and removed with a minor surgical procedure, and 13 were repositioned and deployed in a stable alternate location. The only complication was the development of tricuspid insufficiency in the single case in which the procedure failed (4% complication rate). This patient's stent was eventually surgically removed from the right ventricle.

CONCLUSION

Misplaced or migrated endovascular Palmaz and Wallstents can be effectively managed with few complications by using a variety of percutaneous techniques.

Donor iliac vein interposition during liver transplantation in a patient with a migrated transjugular intrahepatic portosystemic shunt

BACKGROUND

Transjugular intrahepatic portosystemic shunts (TIPS) are sometimes used to reduce the risk of variceal bleeding or treat intractable ascites before orthotopic liver transplantation (OLT). TIPS usually do not make OLT more difficult, but rarely, malposition of TIPS can significantly complicate OLT.

METHOD AND RESULTS

The following report describes a patient in whom an initially well-placed Wallstent migrated to the confluence of the splenic and superior mesenteric veins. During liver transplantation, the portal vein containing the Wallstent was completely resected, and the portal vein was reconstructed with donor iliac vein. After sewing the iliac vein onto the portal remnant, the liver transplant was completed under portosystemic bypass. The patient had an uneventful recovery.

CONCLUSIONS

Wallstents can migrate within the portal vein. An interposition graft of donor vein allows full resection of the portal vein containing a migrated stent and facilitates portosystemic bypass and portal anastomosis.

Transjugular intrahepatic portosystemic shunting (TIPS) with balloon-expandable and self-expanding stents: technical and clinical aspects after 3 1/2 years' experience

PURPOSE

To evaluate prospectively our experience with transjugular intrahepatic portosystemic shunt (TIPS) using four different metallic stents.

METHODS

Between November 1991 and April 1995, 57 patients (41 men and 16 women; age 35-72 years, mean 54 years) underwent the TIPS procedure. Techniques for portal vein localization before and during TIPS were fluoroscopy, computed tomography (CT) studies, wedged hepatic venography, arterial portography, and ultrasound. After predilation we deployed balloon-expandable (n = 48) and self-expanding (n = 45) metallic stents. Fifteen patients underwent variceal embolization. Initial follow-up angiograms (mean 6.9 months, range 3-24 months) were obtained in 39 of these patients.

RESULTS

Fifty-three patients (93%) had successful TIPS placement. The mean decrease in portal pressure was 42.7%. Besides fluoroscopy, the most helpful techniques for portal vein localization were venography and CT. Residual stenosis (n = 1) and late shortening (n = 4) of Wallstents resulted in shunt dysfunction. The technical problems encountered with the Palmaz stent resulted from its lack of flexibility. We combined balloon-expandable and self-expanding stents in 12 patients. The 30-day and late follow-up (mean 11.9 months) percutaneous reintervention rates were 11.3% and 64.2%, respectively. There were no clinically significant complications related to the TIPS insertions.

CONCLUSION

An ideal stent does not exist for TIPS, and the authors recommend combining a Palmaz stent with a flexible self-expanding stent.

The role of transjugular intrahepatic portosystemic shunt for treatment of portal hypertension and its complications: a conference sponsored by the National Digestive Diseases Advisory Board

TIPS is a new and exciting modality for treatment of portal hypertension and its complications. Indications for TIPS remain to be better defined in terms of efficacy and cost-benefit in relationship to other established modes of therapy of portal hypertension. Prospective, randomized controlled trials are needed for these comparisons. Until the role of TIPS in the routine management of the complications of portal hypertension is better defined, TIPS should be used only in situations in which conventional medical and endoscopic therapies have failed.

Percutaneous retrieval of a Strecker stent misplaced during TIPS

During a transjugular intrahepatic portosystemic shunt (TIPS) procedure, a Strecker stent was accidently pushed into the superior mesenteric vein. After successful shunt placement, the stent was withdrawn into the hepatic vein. A multipurpose basket catheter was attached to the distal end of the stent and a loop snare to the proximal end. In this way it was possible to stretch the stent and retrieve it percutaneously through the jugular sheath.

Liver transplantation complicated by malpositioned transjugular intrahepatic portosystemic shunts

PURPOSE

To report the surgical problems encountered during orthotopic liver transplantation as a result of a malpositioned transjugular intrahepatic portosystemic shunt (TIPS).

PATIENTS AND METHODS

Three patients are described in whom TIPS stents were malpositioned in the following locations: extending into the main portal vein, extending into the suprahepatic inferior vena cava, and extending into the right atrium.

RESULTS

Malpositioning of TIPS stents altered and prolonged the operation in all of these patients by interfering with cross-clamping at the usual vascular sites during liver transplantation. Incorporation of the stents into the vascular wall prevented transcatheter retrieval and increased the difficulty of intraoperative removal.

CONCLUSION

Awareness of hepatic vascular anatomy is necessary in avoiding stent malpositioning. If malpositioning is identified, transcatheter approaches may be helpful in repositioning the stent. Otherwise, the transplant surgery team must be made aware of the problem for proper surgical planning prior to liver transplantation.

Hepatopulmonary syndrome: what are we learning from interventional radiology, liver transplantation, and other disorders?

Interventional radiology (pulmonary angiography, coil embolotherapy, and TIPS) in patients with HPS seems to provide both diagnostic data and therapeutic results of clinical importance. The case report by Riegler et al. is instructive and emphasizes the need for further prospective study to analyze the successes and failures in terms of measurable clinical variable in a procedure such as TIPS. The resolution of hypoxemia following liver transplantation and careful patient selection offers hope to patients with severe, debilitating oxygenation abnormalities caused by HPS.

Palmaz stent dislodgement into the left pulmonary artery complicating TIPS: percutaneous retrieval and extraction after venotomy

A Palmaz stent had dislodged into the left pulmonary artery after TIPS. After transfemoral catheterization of the left pulmonary artery, the stent was retrieved into the right femoral vein employing an angioplastic balloon catheter and finally extracted after surgical venotomy.

Current status and future possibilities of transjugular intrahepatic portosystemic shunts in the management of portal hypertension

Transjugular intrahepatic portosystemic shunt (TIPS) is an exciting new method for treating complications of cirrhosis. Technical advances have allowed TIPS to be widely applied in the treatment of variceal bleeding. This article presents and discusses the results of recent experiences in TIPS placement. TIPS can be successfully placed in almost all patients. The complication rate of the procedure is low. TIPS is an effective means of controlling variceal bleeding and is especially useful for controlling bleeding in patients awaiting liver transplantation. It may also have a role in the treatment of ascites and other conditions related to portal hypertension. The most important issue facing TIPS is the long-term patency of the shunt. Potential solutions to the problem of long-term shunt patency are discussed.