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Lopera JE. A Comprehensive Review of Transjugular Intrahepatic Portosystemic Shunt-Related Complications. Semin Intervent Radiol 2023; 40:55-72. [PMID: 37152793 PMCID: PMC10159729 DOI: 10.1055/s-0043-1767670] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is one of the most technically complex procedures in interventional radiology, the need to connect two veins with variable anatomy, located in two different planes in hard and many times small cirrhotic livers using a needle, can be quite challenging. Despite more than 30 years of performing TIPS, the complex hemodynamics of the portal system are not fully understood, and sometimes unpredictable alterations of the portal flow can lead to serious unexpected complications. The best strategies to prevent TIPS complications are optimal patient selection, meticulous technique, operator experience, and immediate correction of identified adverse events. The purpose of this article is to review the technical complications with TIPS, the unique complications related to the use of stent grafts, and the late complications after the procedure, with emphasis on ways to prevent and treat them.
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Affiliation(s)
- Jorge E. Lopera
- Department of Radiology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
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2
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Perez IC, Haskal ZJ, Hogan JI, Argo CK. Late polymicrobial transjugular intrahepatic portosystemic shunt infection in a liver transplant patient: A case report. World J Hepatol 2022; 14:846-853. [PMID: 35646273 PMCID: PMC9099098 DOI: 10.4254/wjh.v14.i4.846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/08/2021] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Infection of a transjugular intrahepatic portosystemic shunt (TIPS) stent is a rare and serious complication that most commonly occurs during TIPS creation and revision. Patients typically present with recurrent bacteremia due to shunt occlusion or vegetation. To date there are approximately 58 cases reported. We present a patient diagnosed with late polymicrobial TIPS infection five years following TIPS creation.
CASE SUMMARY A 63-year-old female status-post liver transplant with recurrent cirrhosis and portal hypertension presented with sepsis and recurrent extended-spectrum beta-lactamase Escherichia coli bacteremia. Computed tomography of the abdomen revealed an occluded TIPS with thrombus extension into the distal right portal vein, and focal thickening of the cecum and ascending colon. Colonoscopy revealed patchy ulcers in these areas with histopathology demonstrating ulcerated colonic mucosa with fibrinopurulent exudate. Shunt thrombectomy and revision revealed infected-appearing thrombus. Patient initially cleared her infection with antibacterial therapy and TIPS revision; however, soon after, she developed Enterobacter cloacae bacteremia and Candida glabrata and C. albicans fungemia with recurrent TIPS thrombosis. She remained on antifungal therapy indefinitely and later developed vancomycin-resistant Enterococcus faecium with recurrent TIPS thrombosis. The option of liver re-transplant for removal of the infected TIPS was not offered given her critical illness and complex shunt anatomy. The patient became intolerant to linezolid and elected hospice care.
CONCLUSION Clinicians should be aware that TIPS superinfection may occur as long as five years following TIPS creation in an immunocompromised patient.
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Affiliation(s)
- Irene Caridad Perez
- Department of Medicine, University of Virginia Medical Center, Charlottesville, VA 22903, United States
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging, Division of Vascular and Interventional Radiology, University of Virginia Medical Center, Charlottesville, VA 22903, United States
| | - John I Hogan
- Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia Medical Center, Charlottesville, VA 22903, United States
| | - Curtis K Argo
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, Charlottesville, VA 22903, United States
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3
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Mehmood F, Khalid A, Frager S. Perihepatic Biloma in a Non-cirrhotic Patient After Transjugular Intrahepatic Portosystemic Shunt (TIPS). Cureus 2022; 14:e23399. [PMID: 35481310 PMCID: PMC9033531 DOI: 10.7759/cureus.23399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
Biloma is an intrahepatic or extrahepatic collection of bile within the abdominal cavity. It can occur spontaneously, or as a result of trauma to the biliary tree. The clinical presentation can be variable and non-specific. Early diagnosis is crucial given the high mortality rate. Diagnostic modalities include abdominal ultrasound, hepatobiliary scintigraphy, computerized tomography (CT), and magnetic resonance imaging (MRI). Treatment options include interventional radiology (IR)-guided drainage, endoscopic drainage, or surgical drainage with a bile leak repair. We report a case of a middle-aged non-cirrhotic patient who presented with abdominal pain and was noted to have extensive portal vein thrombosis. She underwent transjugular intrahepatic portosystemic shunt (TIPS) with thrombectomy and the hospital course was complicated by elevated liver enzymes and found to have intrahepatic biloma requiring IR-guided drainage.
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4
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Biliary Obstruction After Transjugular Intrahepatic Portosystemic Shunt Placement. ACG Case Rep J 2021; 8:e00618. [PMID: 34169113 PMCID: PMC8219257 DOI: 10.14309/crj.0000000000000618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 03/10/2021] [Indexed: 11/24/2022] Open
Abstract
A 19-year-old man with noncirrhotic portal hypertension status post transjugular intrahepatic portosystemic shunt, gastric esophageal varices status post coil embolization, and thrombophilia because of Factor V Leiden heterozygosity presented with jaundice and elevated liver enzymes. His cholangiogram during endoscopic retrograde cholangiopancreatography demonstrated biliary tract obstruction at the bifurcation of the right and left hepatic ducts. With the aid of digital single-operator cholangioscopy, the patient was found to have a perforation of the common hepatic duct from the shunt. This case presents a novel use for digital single-operator cholangioscopy in identifying this rare complication and appropriately differentiating biliary compression vs perforation from transjugular intrahepatic portosystemic shunt.
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Schwartz A, Garg A, Statz G, Smock J. Endotipsitis: a rare case of endovascular infection with ESBL Klebsiella pneumoniae. BMJ Case Rep 2020; 13:13/4/e233972. [PMID: 32345585 DOI: 10.1136/bcr-2019-233972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Endotipsitis is a vegetative endovascular infection of a transjugular intrahepatic portosystemic shunt (TIPS). There is currently no uniformly accepted diagnostic criterion, and most cases are diagnosed by clinical diagnosis of recurrent bacteraemia in patients with TIPS and no identifiable source after appropriate investigation. We present a case of 62-year-old man in whom endotipsitis was suspected clinically after emergent TIPS placement complicated by TIPS thrombosis, need for TIPS revision and recurrent bacteraemia. The diagnosis was confirmed using an Indium-111-labelled leucocyte scan (tagged white blood cell scan). This case highlights the potential risks of endotipsitis with TIPS procedures and provides insight into the utilisation of an old diagnostic tool in a new diagnostic role.
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Affiliation(s)
- Andrei Schwartz
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Aayushi Garg
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Giselle Statz
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Justin Smock
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Moulin B, Chevallier O, Abdulmalak G, Luu M, Latournerie M, Minello A, Gehin S, Cercueil JP, Midulla M, Loffroy R. Persistence of gastric or esophageal varices on final angiography increases transjugular intrahepatic portosystemic shunt revision rate after polytetrafluoroethylene-covered stent shunt creation. Quant Imaging Med Surg 2018; 8:174-181. [PMID: 29675358 DOI: 10.21037/qims.2018.03.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background To assess the association between final polytetrafluoroethylene (PTFE)-covered stent transjugular intrahepatic portosystemic shunt (TIPS) angiographic parameters and free shunt revision survey. Methods Series of two comparison groups were generated with persistence of varices or not, the 25th, 50th, and 75th percentile as cutoff for each angle and a 15-mm distance as cutoff for distance D. Kaplan Meier free shunt revision curves were then created and compared with Log Rank test. Results Mean follow-up was 455 days. Thirteen (19.4%) patients had shunt revision. Significant free shunt revision survey difference was found between post-procedural angiographic persistent varices group and the group without varices (P=0.0001). Shunt revision rate at 3, 12 and 24 months was respectively 13%, 29%, and 39% in the group with varices versus 0%, 2.7% and 2.7% in the group without. No difference was found between groups for angles A, B, C and distance D. Conclusions Persistence of gastric or esophageal varices on final trans-TIPS angiography increases TIPS revision rate after PTFE-covered stent shunt creation whereas geometric parameters have no influence.
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Affiliation(s)
- Benjamin Moulin
- Department of Vascular and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
| | - Olivier Chevallier
- Department of Vascular and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
| | - Gilles Abdulmalak
- Department of Vascular and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
| | - Maxime Luu
- Department of Clinical Investigation, François-Mitterrand University Hospital, Dijon, France
| | - Marianne Latournerie
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, Dijon, France
| | - Anne Minello
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, Dijon, France
| | - Sophie Gehin
- Department of Vascular and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
| | - Jean-Pierre Cercueil
- Department of Vascular and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, Center of Mini-Invasive Image-Guided Therapies, François-Mitterrand University Hospital, Dijon, France
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7
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Biliary stenosis after transjugular intrahepatic portosystemic shunt. Clin Res Hepatol Gastroenterol 2018; 42:e19-e21. [PMID: 28986125 DOI: 10.1016/j.clinre.2017.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/20/2017] [Indexed: 02/04/2023]
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8
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Salagre García A, Muñoz Codoceo C, Gómez Domínguez E, Fernández Vázquez I, Castellano Tortajada G. Cholestasis after TIPS placement in a patient with primary sclerosing cholangitis: an uncommon complication. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 110:124-126. [PMID: 29278002 DOI: 10.17235/reed.2017.5159/2017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We present the case of a patient with primary sclerosing cholangitis who presented a rapidly evolving cholestatic syndrome, with severe hyperbilirubinemia after placing a TIPS. It was resolved with a biliary prosthesis inserted by ERCP. To date, no similar cases have been described in the literature, as it is a rare complication and, on the other hand, the experience with TIPS in patients with PSC is limited. The causes of hyperbilirubinemia after TIPS placement are very varied and it is crucial to perform a differential diagnosis to establish an early treatment.
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Affiliation(s)
| | - Carolina Muñoz Codoceo
- Servicio de Medicina del Aparato Digestivo, Hospital Universitario 12 de Octubre, España
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9
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McCarty TR, Sack J, Syed B, Kim R, Njei B. Fungal endotipsitis: A case report and literature review. J Dig Dis 2017; 18:237-240. [PMID: 28127943 PMCID: PMC5462863 DOI: 10.1111/1751-2980.12451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/16/2017] [Accepted: 01/19/2017] [Indexed: 12/11/2022]
Abstract
Endotipsitis is a broad term used to describe sustained and clinically significant bacteremia or fungemia from a suspected vegetation or thrombus within the transjugular intrahepatic portosytemic shunt (TIPS) device. Endotipsitis is a rare infection in post-TIPS patients and given the diagnostic challenges, there is a need to establish formal diagnostic criteria. Bacterial causes of endotipsitis have been well documented in the literature, but few fungal-associated etiologies have been published to date. With this paucity of data, treatment strategies are lacking regarding the role of antifungal duration, the aggressiveness of medical therapy, and the role of liver transplantation. We present a case of Candida-associated endotipsitis and suggest a need for preferred management strategies in an effort to decrease the significant morbidity and mortality of the infection.
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Affiliation(s)
- Thomas R. McCarty
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT, USA
| | - Jordan Sack
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT, USA
| | - Bakhtiar Syed
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT, USA
| | - Roger Kim
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT, USA
| | - Basile Njei
- Yale University School of Medicine, Section of Digestive Diseases, New Haven, CT, USA,Investigative Medicine Program, Yale Center of Clinical Investigation, New Haven, CT, USA
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10
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Meijer B, Simsek M, Blokzijl H, de Man RA, Coenraad MJ, Dijkstra G, van Nieuwkerk CM, Mulder CJ, de Boer NK. Nodular regenerative hyperplasia rarely leads to liver transplantation: A 20-year cohort study in all Dutch liver transplant units. United European Gastroenterol J 2016; 5:658-667. [PMID: 28815029 DOI: 10.1177/2050640616680550] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/18/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Nodular regenerative hyperplasia is an uncommon liver condition associated with several autoimmune disorders and drugs. The clinical symptoms of nodular regenerative hyperplasia vary from asymptomatic to severe complications of portal hypertension (nodular regenerative hyperplasia-syndrome). OBJECTIVE The purpose of this study was to identify the prognosis and optimal management, as well as the role of liver transplantation, in nodular regenerative hyperplasia. METHODS The pathology databases of all three Dutch liver transplant units were retrospectively scrutinised for explanted livers diagnosed with nodular regenerative hyperplasia or without clear diagnosis. Pre- and post-transplantation clinical, biochemical, radiological and histological information was obtained from electronic and paper records. RESULTS In total, 1886 patients received a liver transplant. In 255 patients, nodular regenerative hyperplasia could not be excluded. After detailed chart review, the native livers of 11 patients (0.6%) (82% male, median age: 44 years) displayed nodular regenerative hyperplasia. Seven patients (64%) had underlying disorders or drug exposure which possibly caused nodular regenerative hyperplasia. Laboratory and imaging abnormalities were present in all patients but did not contribute to the diagnosis of nodular regenerative hyperplasia. Five-year survival was 73% (median follow-up: four years, range: 2-248 months). CONCLUSION Nodular regenerative hyperplasia is a rare finding in patients, predominantly young males, transplanted for end-stage liver disease with unknown aetiology. Nonetheless, liver transplantation may have an important role in end-stage nodular regenerative hyperplasia-syndrome.
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Affiliation(s)
- Berrie Meijer
- Department of Gastroenterology and Hepatology, VU University Medical Center Amsterdam, The Netherlands
| | - Melek Simsek
- Department of Gastroenterology and Hepatology, VU University Medical Center Amsterdam, The Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert A de Man
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Carin Mj van Nieuwkerk
- Department of Gastroenterology and Hepatology, VU University Medical Center Amsterdam, The Netherlands
| | - Chris Jj Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Center Amsterdam, The Netherlands
| | - Nanne Kh de Boer
- Department of Gastroenterology and Hepatology, VU University Medical Center Amsterdam, The Netherlands
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11
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Bilhemia: A Rare Complication of Transjugular Intraheptic Portosytemic Shunt. ACG Case Rep J 2016; 3:60-2. [PMID: 26504882 PMCID: PMC4612762 DOI: 10.14309/crj.2015.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 06/08/2015] [Indexed: 12/05/2022] Open
Abstract
A 56-year-old woman with cirrhosis due to chronic hepatitis C underwent emergent transjugular intrahepatic portosystemic shunt (TIPS) due to a ruptured esophageal varix during esophagogastroduodenoscopy. Following TIPS, the patient experienced a rapid rise in serum bilirubin with no evidence of biliary obstruction or hepatic injury. She was determined to have bilhemia, a rare but serious complication of TIPS.
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12
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Suhocki PV, Lungren MP, Kapoor B, Kim CY. Transjugular intrahepatic portosystemic shunt complications: prevention and management. Semin Intervent Radiol 2015; 32:123-32. [PMID: 26038620 DOI: 10.1055/s-0035-1549376] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) insertion has been well established as an effective treatment in the management of sequelae of portal hypertension. There are a wide variety of complications that can be encountered, such as hemorrhage, encephalopathy, TIPS dysfunction, and liver failure. This review article summarizes various approaches to preventing and managing these complications.
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Affiliation(s)
- Paul V Suhocki
- Division of Vascular and Interventional Radiology, Duke University Medical Center, Durham, North Carolina
| | - Matthew P Lungren
- Department of Radiology, Stanford University Medical Center, Palo Alto, California
| | - Baljendra Kapoor
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Charles Y Kim
- Division of Vascular and Interventional Radiology, Duke University Medical Center, Durham, North Carolina
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13
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Navaratnam AMD, Grant M, Banach DB. Endotipsitis: A case report with a literature review on an emerging prosthetic related infection. World J Hepatol 2015; 7:710-716. [PMID: 25866608 PMCID: PMC4388999 DOI: 10.4254/wjh.v7.i4.710] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 12/15/2014] [Accepted: 02/02/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the etiology and management of a poorly understood complication of transjugular intrahepatic portosystemic shunt; “endotipsitis”.
METHODS: A MEDLINE database search was carried out, reviewing all papers with specific words in the title or abstract, and excluding appropriately. Of 283 papers that were reviewed, 22 papers reporting 53 cases in total were included in the analyses.
RESULTS: No predominant etiology for endotipsitis was identified, but gram-positive organisms were more common among early-onset infections (P < 0.01). A higher mortality rate was associated with Staphylococcus aureus and Candida spp infections (P < 0.01). There was no trend in choice of antibiotic based on the microorganisms isolated and treatment varied from the guidelines of other vegetative prosthetic infections. In endotipsitis “high risk” organisms have been identified, emphasizing the importance of ensuring optimal antimicrobial therapy and adjunctive management strategies.
CONCLUSION: Higher mortality rate was associated with Staphylococcus aureus and Candida spp infections. A prospective multicenter trial is needed before specific treatment can be recommended.
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14
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Biliary Obstruction After Transjugular Intrahepatic Portosystemic Shunt Placement in a Patient With Budd-Chiari Syndrome. ACG Case Rep J 2015; 2:101-3. [PMID: 26157927 PMCID: PMC4435373 DOI: 10.14309/crj.2015.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 10/09/2014] [Indexed: 12/18/2022] Open
Abstract
A 20-year-old male presented with 2 months of progressive abdominal distension due to ascites and Budd-Chiari syndrome. He underwent transjugular intrahepatic portosystemic shunt (TIPS) placement, but soon after had elevated liver enzymes. MRCP revealed mild left intrahepatic biliary dilatation without stones or obvious stricture. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a focal stricture due to compression by the TIPS. The stricture was dilated and a 10 Fr x 15-cm plastic stent was placed with excellent biliary drainage. The patient's symptoms and liver tests normalized within 1 week. This is the first case of biliary obstruction due to TIPS placement effectively managed by ERCP.
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15
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Kruel CRP, Guimarães M, Chedid AD, Grezzana-Filho TMDJ, Leipnitz I, Araújo AD, Alvares-da-Silva MR, Kruel CDP. Bilhemia following transjugular intrahepatic portosystemic shunt placement (Tips): liver transplantation as a rescue procedure - case report. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2014; 26:238-40. [PMID: 24190385 DOI: 10.1590/s0102-67202013000300016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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16
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Manzia TM, Gravante G, Di Paolo D, Orlando G, Toti L, Bellini MI, Ciano P, Angelico M, Tisone G. Liver transplantation for the treatment of nodular regenerative hyperplasia. Dig Liver Dis 2011; 43:929-34. [PMID: 21601542 DOI: 10.1016/j.dld.2011.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 03/28/2011] [Accepted: 04/04/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Nodular regenerative hyperplasia (NRH) is the leading cause of non-cirrhotic portal hypertension in Western countries. Although some patients are successfully managed medically or with shunting procedures, others require liver transplantation. The aim of this review was to assess the overall results obtained with liver transplantation and to better define its role in this setting. METHODS Systematic review of all published studies on liver transplantation for NRH without language restrictions, in Medline, Embase and Cochrane Library databases through March 2010. RESULTS 17 studies including a total of 73 patients were identified; 47 (64.3%) were excluded due to lacking inclusion criteria or clinical data and 26 (35.7%) were analysed. Before liver transplantation, the most frequent clinical presentation was gastroesophageal bleeding (65.3%) followed by ascites (61.5%), hepatic encephalopathy (30.7%) and liver failure (11.5%). The mean follow-up reported after liver transplantation was 30.6±27.6 months and patient and graft survival rate was 78.3%. Only one case reported a NRH recurrence 7 years after liver transplantation (LT). CONCLUSIONS Although there are no hard data supporting the role of liver transplantation in symptomatic NRH, onset of severe portal hypertension in this setting may represent a valid indication.
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17
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Ripamonti R, Ferral H, Alonzo M, Patel NH. Transjugular intrahepatic portosystemic shunt-related complications and practical solutions. Semin Intervent Radiol 2011; 23:165-76. [PMID: 21326760 DOI: 10.1055/s-2006-941447] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Renato Ripamonti
- Department of Diagnostic Radiology, Section of Interventional Radiology, Rush University Medical Center, Chicago Illinois
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18
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Hartleb M, Gutkowski K, Milkiewicz P. Nodular regenerative hyperplasia: Evolving concepts on underdiagnosed cause of portal hypertension. World J Gastroenterol 2011; 17:1400-9. [PMID: 21472097 PMCID: PMC3070012 DOI: 10.3748/wjg.v17.i11.1400] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 12/22/2010] [Accepted: 12/29/2010] [Indexed: 02/06/2023] Open
Abstract
Nodular regenerative hyperplasia (NRH) is a rare liver condition characterized by a widespread benign transformation of the hepatic parenchyma into small regenerative nodules. NRH may lead to the development of non-cirrhotic portal hypertension. There are no published systematic population studies on NRH and our current knowledge is limited to case reports and case series. NRH may develop via autoimmune, hematological, infectious, neoplastic, or drug-related causes. The disease is usually asymptomatic, slowly or non-progressive unless complications of portal hypertension develop. Accurate diagnosis is made by histopathology, which demonstrates diffuse micronodular transformation without fibrous septa. Lack of perinuclear collagen tissue distinguishes NRH from typical regenerative nodules in the cirrhotic liver. While the initial treatment is to address the underlying disease, ultimately the therapy is directed to the management of portal hypertension. The prognosis of NRH depends on both the severity of the underlying illness and the prevention of secondary complications of portal hypertension. In this review we detail the epidemiology, pathogenesis, diagnosis, management, and prognosis of NRH.
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Paterno F, Khan A, Cavaness K, Asolati M, Campsen J, McKenna GJ, Onaca N, Ruiz R, Trotter J, Klintmalm GB. Malpositioned transjugular intrahepatic portosystemic shunt in the common hepatic duct leading to biliary obstruction and liver transplantation. Liver Transpl 2011; 17:344-6. [PMID: 21384518 DOI: 10.1002/lt.22255] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Flavio Paterno
- Baylor Regional Transplant Institute, Baylor University Medical Center, Dallas, TX 75246, USA
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Abstract
INTRODUCTION Infection of transjugular intrahepatic portosystemic stent shunt (TIPSS) called 'Tipsitis' has been reported but appears unusual. We report here our experience of patients who were diagnosed to have Tipsitis at our centre. METHODS Retrospective single centre study. Patients identified from a dedicated data base. Patients with TIPSS with otherwise unexplained sustained bacteraemia were included. RESULTS Over 14 years of age, of 785 patients with TIPSS, eight (1%) had Tipsitis. Indication for TIPSS: variceal bleed, seven; refractory ascites, one. Child-Pugh score: 8.3 (1.4). Seven patients had overlapping stents in situ. Duration to Tipsitis: 21.6 (7.1) months. At diagnosis, TIPSS was occluded in four and patent in three. Tipsitis developed within 2 weeks of shunt interventions in two patients and was owing to development of bilio-venous fistula in one. The organisms identified were: Lactobacillus rhamnosus, Escherichia coli, Enterobacter cloacae, Enterococcusfaecium and Staphylococcus aureus. Median duration of antibiotic therapy: 3 (0.3-3) months. Symptoms initially resolved in all but one. Symptoms recurred in three and this was related to premature cessation of antibiotics in two. Five patients died at a median 1.3 (0.3 to 33) months after Tipsitis with Tipsitis contributing to death in three. CONCLUSION Tipsitis is a rare but serious problem. It should be suspected in patients with TIPSS and unexplained sustained bacteraemia. Shunt interventions, where TIPSS is inserted for variceal bleed, and use of overlapping shunts at TIPSS insertion may be risk factors for its development. Prolonged antibiotics are usually required but Tipsitis may recur despite apparently successful treatment.
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Mizrahi M, Adar T, Shouval D, Bloom AI, Shibolet O. Endotipsitis-persistent infection of transjugular intrahepatic portosystemic shunt: pathogenesis, clinical features and management. Liver Int 2010; 30:175-83. [PMID: 19929905 DOI: 10.1111/j.1478-3231.2009.02158.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is in widespread use for the decompression of portal pressure. The entity of persistent TIPS infection, also known as 'endotipsitis' is a rare but serious complication of TIPS insertion. The exact definition of 'endotipsitis' is still debated, but involves persistent bacteremia and fever together with either shunt occlusion, or vegetation, or bacteremia in the presence of a patent shunt, when other sources of bacteremia have been ruled out. To date, approximately 40 cases of 'endotipsitis' have been described, with predominance for male and alcoholic hepatitis patients. The clinical course is variable, but fever and chills are a constant feature. Bacteremia, can either occur early (<120 days) or late (>120 days) after stent insertion, with some cases occurring many years after the procedure. Although no predominant bacterial species have been described in 'endotipsitis', staphylococci and other Gram-positive bacteria are more commonly seen in early infection. The diagnosis of 'endotipsitis' is difficult and requires a high index of suspicion. A rigorous imaging work-up to rule out other sources of endovascular infection is usually required including ultrasonography, computed tomography and echocardiography. Because removal of the infected stent is impractical, treatment is empirical and based on a prolonged course of antibiotics. If eligible, some patients may be referred for liver transplantation. The use of prophylactic antibiotics during the initial TIPS procedure is controversial, and despite the lack of evidence, prophylaxis is the common practice. The aim of this review was to describe the definition, clinical course, diagnosis, pathogenesis, microbiology, treatment and outcome of endotipsitis.
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Affiliation(s)
- Meir Mizrahi
- Liver Unit, Division of Medicine, Jerusalem, Israel
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Singal AK, Kathuria MK, Malhotra A, Goodgame RW, Soloway RD. Bilhemia after trans-jugular intra-hepatic porto-systemic shunt and its management with biliary decompression. World J Gastroenterol 2009; 15:3681-3. [PMID: 19653349 PMCID: PMC2721245 DOI: 10.3748/wjg.15.3681] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Bilhemia or bile mixing with blood is a rare clinical problem. The clinical presentation is usually transient self-resolving hyperbilirubinemia, progressive and rapidly rising conjugated hyperbilirubinemia, or recurrent cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) plays an important role in diagnosis and management. Biliary decompression with endoscopic sphincterotomy is useful in treating these patients. If not recognized and treated in time, the condition can be fatal in a significant proportion of patients. This usually occurs after blunt or penetrating hepatic trauma due to a fistulous connection between the biliary radicle and portal or hepatic venous radical. Cases have been described due to iatrogenic trauma such as liver biopsy and percutaneous biliary drainage. However, the occurrence after trans-jugular intra-hepatic porto-systemic shunt (TIPS) is very rare. We report a case of bilhemia presenting as rapidly rising bilirubin after TIPS. The patient was managed successfully with ERCP and removal of a blood clot from the common bile duct.
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Suhocki PV, Smith AD, Tendler DA, Sexton DJ. Treatment of TIPS/biliary fistula-related endotipsitis with a covered stent. J Vasc Interv Radiol 2008; 19:937-9. [PMID: 18503911 DOI: 10.1016/j.jvir.2008.01.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2007] [Revised: 01/24/2008] [Accepted: 01/24/2008] [Indexed: 12/15/2022] Open
Abstract
"Infective endotipsitis" describes a recurrent bacteremia or fungemia in patients with a transjugular intrahepatic portosystemic shunt (TIPS) in place and no other identifiable source of infection. The present report describes a patient who developed polymicrobial endotipsitis 6 years after TIPS creation. Blood cultures remained positive for polymicrobial growth despite long courses of antibiotic therapy. Communication between the TIPS and an infected biliary tree, precipitated by cholecystitis, was ultimately recognized. The biliary/TIPS fistula was closed with a polytetrafluoroethylene-covered stent. The patient remains asymptomatic and follow-up blood cultures remain negative with a low dose of oral antibiotics 2 years after the procedure.
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Affiliation(s)
- Paul V Suhocki
- Department of Radiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Arepally A, Karmarkar PV, Qian D, Barnett B, Atalar E. Evaluation of MR/Fluoroscopy–guided Portosystemic Shunt Creation in a Swine Model. J Vasc Interv Radiol 2006; 17:1165-73. [PMID: 16868170 DOI: 10.1097/01.rvi.0000228493.07075.fc] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To evaluate three different percutaneous portosystemic shunts created with magnetic resonance (MR) imaging and fluoroscopy guidance in a swine model. MATERIALS AND METHODS In stage 1 of the experiment, an active MR intravascular needle system was created for needle tracking and extracaval punctures. Twenty inferior vena cava (IVC)/superior mesenteric vein (SMV)/portal vein (PV) punctures were performed in 10 swine (weight, 40-45 kg) in a 1.5-T short-bore interventional MR imager. With use of a real-time MR imaging sequence, the needle was guided through the IVC and into the SMV or PV (N = 20 punctures). After confirmation, a wire was advanced into the portal venous system under MR imaging guidance (N = 20). In stage 2, animals were transferred to the radiographic fluoroscopy suite for deployment of shunts. Three different shunts were evaluated in this study: (i) a commercial stent-graft, (ii) a prototype bridging stent, and (iii) a prototype nitinol vascular anastomotic device. Postprocedural necropsy was performed in all animals. RESULTS Successful MR-guided IVC/SMV punctures were performed in all 20 procedures (100%). All three shunts were deployed. Stent-grafts had the poorest mechanism for securing a shunt. The vascular anastomotic device and the bridging stent had more secure anchoring mechanisms but also had higher technical failure rates (50% and 40%, respectively). When deployed successfully, the vascular anastomotic device resulted in no bleeding at the sites of punctures at necropsy. CONCLUSION Percutaneous shunts and vascular anastomoses between the portal mesenteric venous system and IVC were successfully created with use of a combination of MR imaging and conventional fluoroscopy for guidance.
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Affiliation(s)
- Aravind Arepally
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Blalock 545, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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