Transjugular Intrahepatic Portosystemic Shunt Insertion for the Management of Portal Hypertension in Children

Successful Transjugular Portosystemic Shunt Treatment of Pediatric Sinusoidal Obstruction: Case Report and Review of Literature

Background

In adults with medically refractory sinusoidal obstruction syndrome (SOS), a transjugular intrahepatic portosystemic shunt (TIPS) has been used successfully to improve portal hypertension and symptoms such as ascites. There is limited data on the use of TIPS for SOS in pediatric patients.

Methods

The index case was reviewed retrospectively. PubMed and Medline databases were searched to identify other cases.

Results

A 4-year-old male with high-risk neuroblastoma, developed SOS after tandem autologous stem cell transplant. He was medically managed with defibrotide, diuretics, and peritoneal drainage, but, due to refractoriness, he underwent TIPS day +54 following bone marrow transplant. Hepatic venous pressure gradient improved from 17 to 8 mm Hg following TIPS placement with significant improvement in the patient's clinical status and ascites. However, 15 months later, his shunt remained patent, and he remains clinically well with stable liver enzymes. A literature review identified 13 pediatric cases of TIPS for SOS due to varied causes. TIPS caused a median hepatic venous pressure gradient of 9 mmHg (range, 2-38 mm Hg). The mortality following the procedure was 15%, with 2 cases who died at 2- and 11-days post-TIPS. At the time of the last follow-up (range 8-25 months), 5 patients were alive, and 8 were lost to follow-up.

Conclusion

We present here a pediatric case of SOS due to stem cell transplant treated successfully with TIPS with a review of the literature. A timely, individualized application of TIPS can be effective in treating children with medication-refractory SOS.

Percutaneous shunt vessel embolisation with Amplatzer vascular plugs II and IV in the treatment of dogs with splenophrenic shunts: four cases (2019-2022)

OBJECTIVES

To describe the treatment of four dogs with splenophrenic shunts using percutaneous shunting vessel embolisation with Amplatzer vascular plugs II and IV and provide information on their clinical outcomes.

MATERIALS AND METHODS

Dogs with splenophrenic shunts treated at a veterinary hospital from January 2019 to December 2022 were identified through a medical record search.

RESULTS

Six dogs with splenophrenic shunts were identified. Two dogs were excluded because they were treated with laparoscopic surgery. Four underwent percutaneous shunting vessel embolization with Amplatzer vascular plugs and were included in the case series. A sheath was placed in the left external jugular vein and a balloon catheter was advanced to the shunting vessel under fluoroscopy. Portal vein pressure was confirmed to be within an acceptable range during temporary balloon occlusion. Based on preoperative CT angiography and intraoperative contrast examination, Amplatzer vascular plugs II were selected for two dogs and IV were selected for two dogs. Under fluoroscopy, the plug was deployed into the shunting vessel, and angiography confirmed occlusion. In all cases, the increase in portal pressure after temporary occlusion was within the acceptable range, and complete occlusion of blood flow was possible with a single plug. There were no major procedure-related complications. No dogs developed post-ligation seizures or signs of portal hypertension. In addition, improvements in ammonia values were observed in all cases.

CLINICAL SIGNIFICANCE

Percutaneous splenophrenic shunt embolisation using Amplatzer vascular plugs II and IV is technically feasible in dogs, and assessed by intra-procedure angiography, a single plug completely obstructed blood flow in all dogs. Based on the literature search, this is the first report describing Amplatzer vascular plugs for the treatment of splenophrenic shunts.

Transjugular intrahepatic portosystemic shunt for pediatric portal hypertension: A meta-analysis

To evaluate the feasibility of transjugular intrahepatic portosystemic shunt (TIPS) in children with portal hypertensive complications, PubMed and Cochrane Library were queried to identify clinical studies evaluating TIPS in patients <18 years old. Baseline clinical characteristics, laboratory values, and clinical outcomes were extracted. Eleven observational studies totaling 198 subjects were included in the study. The pooled technical success rate and hemodynamic success rate were 94% (95% confidence interval [CI]: 86-99%) and 91% (95% CI: 82-97%), respectively; ongoing variceal bleeding resolved in 99.5% (95% CI: 97-100%); refractory ascites was improved in 96% (95% CI: 69-100%); post-TIPS bleeding rate was 14% (95% CI: 1-33%); 88% of patients were alive or successfully received liver transplant (95% CI: 79-96%); and shunt dysfunction rate was 27% (95% CI: 17-38%). Hepatic encephalopathy occurred in 10.6% (21/198), though 85.7% (18/21) resolved with medical management only. In conclusion, based on moderate levels of evidence, TIPS is a safe and effective intervention that should be considered in pediatric patients with portal hypertensive complications. Future comparative studies are warranted.

Pediatric liver cirrhosis interventional procedures: from biopsy to transjugular intrahepatic portosystemic shunt

Cirrhosis is a complex diffuse process whereby the architecture of the liver is replaced by abnormal nodules because of the presence of fibrosis. Several pediatric diseases such as extrahepatic portal vein obstruction, biliary atresia, alpha-1-antitrypsin deficit and autoimmune hepatitis can lead to cirrhosis and portal hypertension in children. In this article the authors describe interventional radiology procedures that can facilitate the diagnosis and treatment of diseases associated with liver cirrhosis and portal hypertension in the pediatric population. These procedures include image-guided liver biopsy, mesenteric-intrahepatic left portal vein shunts, balloon-occluded retrograde transvenous obliteration, transjugular intrahepatic portosystemic shunts and splenic embolization.

[Hepatic encephalopathy after portosystemic bypass surgery]

The most effective modern treatment for gastrointestinal bleeding following portal hypertension is portosystemic bypass surgery. Hepatic encephalopathy after these procedures is still an urgent problem in modern pediatric surgery, and radical treatment is unknown. To optimize treatment outcomes in children with hepatic encephalopathy, we should choose adequate treatment considering the risk of hepatic encephalopathy in the future. In this review, the authors discuss modern data on hepatic encephalopathy regarding symptoms, advantages and disadvantages of various treatment methods. Risk of hepatic encephalopathy with and without surgical treatment, as well as methods of diagnosis and treatment are particularly analyzed. Total portosystemic bypass surgery, especially portocaval shunt, is followed by higher risk of hepatic encephalopathy compared to selective shunts and physiological mesoportal bypass. The last two approaches are advisable to improve treatment outcomes in children with hepatic encephalopathy.

Feasibility and clinical effectiveness of transjugular intrahepatic portosystemic shunt creation in pediatric and adolescent patients: a meta-analysis

OBJECTIVE

Transjugular intrahepatic portosystemic shunt (TIPS) is a useful approach in managing complications caused by severe portal hypertension (PH) in adults. In children, TIPS is technically challenging, and previous studies of TIPS in children have yielded inconsistent results. This study aimed to elucidate the feasibility and clinical effectiveness of TIPS in pediatric and adolescent patients.

METHODS

This meta-analysis study identified relevant publications through medical databases. The primary outcomes included technical success, hemodynamic success, and clinical success. The secondary outcomes were primary patency rate, shunt revision rate, and secondary patency rate.

RESULTS

A total of 286 patients representing 13 studies were eligible for analysis. The pooled rates of technical success, hemodynamic success, and clinical success were 95% (95% CI 88-99), 89% (95% CI 81-95), and 93% (95% CI 86-98), respectively. The portosystemic gradient decreased from 21.5 mmHg before TIPS to 8.3 mmHg after TIPS. The pooled estimates of primary patency rate, shunt revision rate, and secondary patency rate were 84% (95% CI 72-94), 35% (95% CI 21-51), and 100% (95% CI 92-100), respectively.

CONCLUSION

Study results suggest that TIPS may be feasible and effective in children with PH of various etiologies as for long-term management.

Techniques and Outcomes of Transjugular Intrahepatic Portosystemic Shunting in Infants with Budd-Chiari Syndrome

PURPOSE

To describe the technical aspects, feasibility, and outcomes in children with Budd-Chiari syndrome (BCS) undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation during infancy.

MATERIALS AND METHODS

A retrospective review of infants with BCS undergoing TIPS creation between January 2012 and December 2018 was performed. Eight infants (5 males) underwent TIPS creation (7 for refractory ascites and 1 for refractory variceal bleeding) during the study period. The median age at TIPS creation was 10.5 months (range, 8-16 months). The median elapsed time between presentation and TIPS creation was 6.5 months (range, 0-13 months). The median weight and median pediatric end-stage liver disease score of the infants at the time of TIPS creation were 6.7 kg (range, 5.4-10 kg) and 13 kg (range, 8-18 kg), respectively.

RESULTS

TIPS creation was successful in all patients. There were no immediate postprocedural complications. An 18-gauge hollow needle was manually curved, through which a 21-gauge Chiba needle was inserted to access the portal vein. All patients received 1 or 2 overlapping bare metal stents. One patient was lost to follow-up after the procedure. The median follow-up duration was 32 months (range, 14-51 months). Four of 7 infants needed reintervention. Two children died during the follow-up period. Two children successfully underwent living donor liver transplant, whereas the remaining 3 children were asymptomatic at the follow-up.

CONCLUSIONS

TIPS creation was found to be safe and efficacious in improving portal hypertension and growth in these children, although, with a higher rate of reinterventions, possibly due to the use of small, bare metal stents.

Transjugular intrahepatic portosystemic shunt creation may be associated with hyperplastic hepatic nodular lesions in the long term: an analysis of 18 pediatric and young adult patients

BACKGROUND

Retrospective studies have demonstrated the efficacy and safety of pediatric and adolescent transjugular intrahepatic portosystemic shunt (TIPS), but long-term outcomes warrant further investigation.

OBJECTIVE

To report on the development of hyperplastic hepatic nodular lesion development in children and young adults (<21 years) with TIPS patency >3 years.

MATERIALS AND METHODS

Eighteen children and young adults, including 10 (55.6%) females and 8 (44.4%) males, underwent TIPS creation with >3 years' patency and follow-up evaluation at a tertiary children's hospital. The mean age at the time of TIPS creation was 12.5±5.1 years (range: 1.5-20.0 years). The mean model for end-stage liver disease (MELD) at the time of TIPS creation was 8.1±1.6 (range: 6-11). Indications for TIPS creation included acute variceal bleeding (8/18, 44.4%), primary (1/18, 5.6%) or secondary (7/18, 38.9%) prevention of varices, portal vein thrombosis (1/18, 5.6%), and splenic sequestration (1/18, 5.6%). Technical successes, intra-procedural parameters, hemodynamic and clinical successes, TIPS patencies, adverse events, imaging evaluations, and follow-ups were recorded.

RESULTS

All (100%) TIPS placements were successful; however, a direct intrahepatic portosystemic shunt was created in one (5.6%) patient. Mean reduction of the portosystemic shunt gradient was 9.1±3.3 mmHg (range: 4-16 mmHg). Seventeen (94.4%) patients demonstrated clinical success with resolution of their initial clinical indication for TIPS placement. The 3-year TIPS primary, primary-assisted, and secondary patencies were 83.3% (15/18), 94.4% (17/18), and 100% (18/18), respectively. Two (11.1%) patients developed mild, medically controlled hepatic encephalopathy. One (5.6%) patient developed hepatopulmonary syndrome. Nine (50%) patients developed single or multiple hepatic nodules at a mean imaging surveillance time after TIPS of 4.4±3.0 years (range: 1.5-10.2 years). Six (33.3%) patients developed nodules >1 cm with imaging features most consistent with focal nodular hyperplasia or focal nodular hyperplasia-like nodules. The mean follow-up duration was 5.7±2.9 years (range: 3.0-13.1 years).

CONCLUSION

Long-term (>3 years) portosystemic shunting via TIPS is associated with the development of hepatic nodular lesions in children. Consequently, children with TIPS may need gray-scale assessment of hepatic parenchyma as part of routine ultrasound exams and extended imaging surveillance until more is understood regarding the natural history of induced nodularity.

Long-term Outcome of Transjugular Intrahepatic Portosystemic Shunt in Children With Portal Hypertension

OBJECTIVES

A proportion of children with chronic liver disease have severe portal hypertension (PH) and a preserved synthetic and biliary function. In our institution these children have been managed with transjugular intrahepatic portosystemic shunts (TIPS). We aimed to evaluate the long-term patency of TIPS placed in pediatric patients with PH.

METHODS

Retrospective study of children who underwent TIPS in the last 15 years. We compared patients with cirrhotic PH to those with noncirrhotic PH, and all with an historical cohort of children who underwent a surgical portosystemic shunt. Kaplan-Meier analysis measured long-term shunt patency.

RESULTS

Twenty-nine patients were recorded (cirrhotic PH = 11, noncirrhotic PH  = 18, mean age 10.3 years[±4.3], mean weight 36.7 kg [±20.1], mean pediatric end-stage liver disease score 4.1 [±7.1]); in 5 TIPS was placed after split liver transplantation. Indication for TIPS was variceal bleeding in 18, refractory ascites in 11. Primary patency rates at 6 months and at 1, 2, and 4 years were 91%, 83%, 60%, and 46%, respectively. At last follow-up (mean of 2.8 years [±2.4, range 0.1-8.1 years]) secondary patency (after radiological revision) was 100%. The patency rate of the historical cohort of patients who underwent a surgical portosystemic shunt was 26 of 31 (82%) at a median follow-up of 12.5 years (1.6-25.8).

CONCLUSION

TIPS appears to have a high mid-term patency rate, especially if monitored and revised. Its high clinical success rate, along with a minimally invasive approach, suggests that in this setting TIPS should not be regarded only as a bridge to liver transplantation.

Pediatric Hepatobiliary Interventions in the Setting of Intrahepatic Vascular Malformations, Portal Hypertension, and Liver Transplant

Within the broad spectrum of pediatric hepatobiliary disorders, hepatic vascular malformations, portal hypertension, and hepatic transplant interventions pose numerous challenges. The role of interventional radiology within each of these conditions is discussed herein, beginning with endovascular management of high flow hepatic vascular malformations. Next, while becoming less common in adult populations, surgical portoportal and portosystemic shunts remain prevalent in many pediatric centers. Shunt anatomy is reviewed along with endovascular management techniques for shunt dysfunction. Next, the growing experience with pediatric transjugular intrahepatic portosystemic shunt placement is reviewed along with tips for success in pediatric patients. Finally, pediatric hepatic transplant interventions are discussed with technical notes pertinent to split liver anatomy.

Pressure gradients, laboratory changes, and outcomes with transjugular intrahepatic portosystemic shunts in pediatric portal hypertension

INTRODUCTION

Indications for TIPS are well described in adults and involve complications of PHTN. Complications from PHTN are associated with PSG of > 12 mm Hg in adults. It is unclear if these parameters apply to children with PHTN.

OBJECTIVE

To assess whether adult criteria for TIPS placement can be utilized in children, describe laboratory changes over time, and report outcomes.

METHODS

We performed a retrospective review of 34 pediatric patients who underwent TIPS, examining indications, radiology, PSG reductions, laboratory changes, and outcomes.

RESULTS

Most patients had PHTN due to parenchymal liver disease including congenital hepatic fibrosis (n = 5), biliary atresia (n = 5), cystic fibrosis-related liver disease (n = 3) and cavernous transformation of the portal vein (n = 6). Indications for TIPS included variceal bleeding, recurrent ascites, and maintenance of portal vein flow following thrombolysis. Variceal bleeding was observed in six children with PSG < 12 mm Hg. Minor complications occurred in eight subjects. Continued bleeding occurred in one patient. Six patients were successfully bridged to transplantation, and three patients died secondary to end-stage disease. Standard laboratory tests stabilized after TIPS placement and hematocrit increased.

CONCLUSION

TIPS placement in pediatric patients was performed for complications of PHTN. Unlike adult series, a substantial proportion of our cases treated extrahepatic PHTN from cavernous transformation of the portal vein. Children presented with sequelae of PHTN with PSG below 12 mm Hg, below the adult standard. We found TIPS in pediatrics to be safe and effective with laboratory stabilization and improvement in hematocrit.

Technical Feasibility and Clinical Effectiveness of Transjugular Intrahepatic Portosystemic Shunt Creation in Pediatric and Adolescent Patients

PURPOSE

To examine the technical feasibility and clinical efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation in children and adolescents.

MATERIALS AND METHODS

Retrospective review was performed of 59 patients (mean age 12.6 y [range, 1.5-20 y], mean weight 47.5 kg [range, 11.4-112.2 kg], mean Model for End-stage Liver Disease/Pediatric End-stage Liver Disease score 12.5 [range, 6-33]) who underwent 61 TIPS attempts at 3 tertiary children's hospitals from 2001 to 2017 for acute esophageal or gastroesophageal variceal bleeding, primary and secondary prevention of variceal bleeding, and refractory ascites. Pediatric liver disease etiologies included biliary atresia, cystic fibrosis, and ductal plate anomalies. Technical, hemodynamic, and clinical success and patency rates were reported at 1, 6, 12, and 24 months. Statistical analysis evaluated reasons for clinical failure. Kaplan-Meier analysis measured clinical success, patency, and transplant-free survival.

RESULTS

Technical success was 93.4% (57/61) in 59 consecutive patients. Most common TIPS indications were treating and preventing esophageal and gastroesophageal variceal bleeding (57/59; 96.6%). Hemodynamic success was 94% (47/50). Clinical success was 80.7% (45/56). Two-year clinical success for acute variceal bleeding and ascites was 94.1% and 100%, respectively. Overall patency at 1, 6, 12, and 24 months was 98.0%, 97.8%, 94.3%, and 91.3%. Two-year transplant-free survival was 88.8%. Overall and major complication rates were 21.2% (13/61) and 8.2% (5/61), with 3 mortalities. Gradient reduction < 12 mm Hg correlated with clinical success (P < .01).

CONCLUSIONS

TIPS creation in pediatric patients is technically feasible and clinically efficacious for treatment and prevention of esophageal and gastroesophageal variceal hemorrhage. High 2-year clinical success, patency, and survival rates should encourage providers to consider portosystemic shunts as a bridge to liver transplantation.