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Li Y, Sun J, Zhou T, Wang W, Wang G, Hou Q, Chen Z, Wang Q, Xu K, Ye Y, Bao J. Untimely surgery for stent-fracture-related death after transjugular intrahepatic portosystemic shunt: a case report. Ther Adv Chronic Dis 2024; 15:20406223241243258. [PMID: 38645893 PMCID: PMC11027586 DOI: 10.1177/20406223241243258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 03/14/2024] [Indexed: 04/23/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is a life-saving procedure for patients with severe portal hypertension and persistent variceal bleeding. Stent fracture is a rare and severe complication; however, its cause and mechanisms remain poorly defined. This case helps understand the factors contributing to its occurrence, complications, and subsequent poor outcomes. A 63-year-old male was presented with ruptured bare stent after a TIPS procedure. The upper edge of the bare stent was ruptured, and its fraction subsequently migrated to the entrance of the right atrium. Meanwhile, a mural thrombus was formed in the inferior vena cava. A surgery for the removal of free fracture was planned for preventing the form of pulmonary embolism. Before the surgery, the fracture was shifted to the right inferior pulmonary artery. Therefore, the surgery was canceled for further evaluation. Then, hematemesis suddenly occurred with a high possibility of variceal bleeding and/or gastric ulcer bleeding. Despite comprehensive treatments, the patient symptoms were still worsened with the development of chest tightness, shortness of breath, severe hypoxia, and heart failure. Finally, the patient succumbed to systemic multiorgan failure and death. Taken together, a ruptured unstable stent should be removed as early as the patient is hemodynamically stable, as it is difficult to balance between hemostasis therapy and anticoagulation treatment in patients with liver-cirrhosis-related severe portal hypertension. Physicians should be on high alert of the potential complications of bare stent rapture after TIPS.
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Affiliation(s)
- Yunjiang Li
- Radiology Department, Affiliated Hangzhou Xixi Hospital, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Junhui Sun
- Hepatobiliary and Pancreatic Surgery Department, The Affiliated First Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Tanyang Zhou
- Hepatobiliary and Pancreatic Surgery Department, The Affiliated First Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Weiwei Wang
- Hepatology Department, Affiliated Hangzhou Xixi Hospital, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Guowei Wang
- Radiology Department, Affiliated Hangzhou Xixi Hospital, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qingming Hou
- Radiology Department, Affiliated Hangzhou Xixi Hospital, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zuhua Chen
- Radiology Department, Affiliated Hangzhou Xixi Hospital, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qiang Wang
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Huddinge, Sweden
| | - Keyang Xu
- Centre for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Yunfeng Ye
- Radiology Department, Affiliated Hangzhou Xixi Hospital, Zhejiang Chinese Medical University, No. 2 Hengfu Street, Liuxia, Xihu, Hangzhou, Zhejiang 310023, China
| | - Jianfeng Bao
- Hepatology Department, Affiliated Hangzhou Xixi Hospital, Zhejiang Chinese Medical University, No. 2 Hengfu Street, Liuxia, Xihu, Hangzhou, Zhejiang 310023, China
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Liu QJ, Cao XF, Pei Y, Li X, Dong GX, Wang CM. Stent fracture after transjugular intrahepatic portosystemic shunt placement using the bare metal stent/stent-graft combination technique. World J Gastrointest Surg 2023; 15:2133-2141. [PMID: 37969720 PMCID: PMC10642472 DOI: 10.4240/wjgs.v15.i10.2133] [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: 05/18/2023] [Revised: 08/22/2023] [Accepted: 09/12/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND A transjugular intrahepatic portosystemic shunt (TIPS) is widely placed to treat portal hypertension. Because the Viatorr® stent (W. L. Gore and Associates, Flagstaff, AZ, United States) is not available in all hospitals in China, the bare metal stent (BMS)/stent-graft combination technique is still popular for TIPS construction. Stent fracture is a complication after TIPS placement using this technique, with limited available literature focusing on it. AIM To assess the incidence of stent fracture after TIPS placement using the BMS/ stent-graft combination technique and to identify the risk factors for stent fracture. We proposed technique modifications to improve the clinical results of TIPS placement with the BMS/stent-graft combination technique. METHODS We retrospectively analyzed the computed tomography (CT) data of all patients with portal hypertension who underwent the TIPS procedure between June 2011 and December 2021 in a single center. Patients implanted with the BMS/stent graft and had follow-up imaging data available were included. We identified patients with stent fracture and analyzed their characteristics. Multivariable logistic regression was applied to identify the potential predictors of stent fracture. RESULTS Of the 68 included patients, stent fracture occurred in seven (10.3%) patients. Based on CT images, the stent fractures were categorized into three types. Our study consisted of four (57.1%) type I fractures, one (14.3%) type II fracture, one (14.3%) type IIIa fracture, and one (14.3%) type IIIb fracture. After adjusting for covariates, multivariable logistic regression revealed that the risk factors for stent fracture were the implantation of a greater number of stents [adjusted odds ratio (aOR) = 22.2, 95% confidence interval (CI): 1.2-415.4, P = 0.038] and a larger proximal sagittal stent bending angle (aOR = 1.1, 95%CI: 1.0-1.3, P = 0.020). CONCLUSION Stent fracture occurred in approximately 10% of patients with portal hypertension who underwent TIPS with the BMS/stent-graft combination technique. The number of implanted stents and stent bending angle at the inferior vena cava end were predictors of stent fracture, which suggests that the incidence of stent fracture could potentially be reduced by procedural modifications.
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Affiliation(s)
- Qi-Jia Liu
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Xiao-Feng Cao
- Department of Interventional Therapy, Yangquan First People’s Hospital, Yangquan 045000, Shanxi Province, China
| | - Yun Pei
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Xuan Li
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Guo-Xiang Dong
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Chang-Ming Wang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing 100191, China
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Keshava SN, Moses V, Sharma A, Ahmed M, Narayanan S, Padmanabhan A, Goel A, Zachariah U, Eapen C. Technical and Medium-Term Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt with Fluoroscopy and Additional Trans-abdominal Ultrasound Guidance. Indian J Radiol Imaging 2021; 31:858-866. [PMID: 35136497 PMCID: PMC8817814 DOI: 10.1055/s-0041-1735928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
- Shyamkumar N. Keshava
- Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vinu Moses
- Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anand Sharma
- Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Munawwar Ahmed
- Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sathya Narayanan
- Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Aswin Padmanabhan
- Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Uday Zachariah
- Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - C.E. Eapen
- Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
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Ding PX, Han XW, Hua ZH, Liu C. Stent Fracture and Fragment Migration to Chordae Tendineae of the Tricuspid Valve after Transjugular Intrahepatic Portosystemic Shunt Procedure. J Vasc Interv Radiol 2017; 28:1293-1295. [DOI: 10.1016/j.jvir.2017.03.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/17/2017] [Accepted: 03/19/2017] [Indexed: 12/15/2022] Open
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Juszkat R, Klimont M, Śliwa M, Krasiński Z. Fractured Superior Mesenteric Artery Stent With Stent Displacement Leading to Recurrent Symptoms of Superior Mesenteric Ischemia. Vasc Endovascular Surg 2017; 51:400-402. [PMID: 28602156 DOI: 10.1177/1538574417714395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We report a case of a patient with recurrent symptoms of superior mesenteric ischemia 7 months after successful percutaneous angioplasty and implantation of a stent in the superior mesenteric artery (SMA). Stent fracture and stent displacement were observed. To the best of our knowledge, this is the first report of SMA stent fracture with stent displacement.
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Affiliation(s)
- Robert Juszkat
- 1 Department of Radiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Michał Klimont
- 1 Department of Radiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Magdalena Śliwa
- 1 Department of Radiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Zbigniew Krasiński
- 2 Department of Vascular Surgery, Poznan University of Medical Sciences, Poznań, Poland
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Kao SD, Morshedi MM, Narsinh KH, Kinney TB, Minocha J, Picel AC, Newton I, Rose SC, Roberts AC, Kuo A, Aryafar H. Intravascular Ultrasound in the Creation of Transhepatic Portosystemic Shunts Reduces Needle Passes, Radiation Dose, and Procedure Time: A Retrospective Study of a Single-Institution Experience. J Vasc Interv Radiol 2016; 27:1148-53. [PMID: 27052948 DOI: 10.1016/j.jvir.2016.01.137] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/11/2016] [Accepted: 01/12/2016] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To assess whether intravascular ultrasound (US) guidance impacts number of needle passes, contrast usage, radiation dose, and procedure time during creation of transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS Intravascular US-guided creation of TIPS in 40 patients was retrospectively compared with conventional TIPS in 49 patients between February 2010 and November 2015 at a single tertiary care institution. Patient sex and age, etiology of liver disease (hepatitis C virus, alcohol abuse, nonalcoholic steatohepatitis), severity of liver disease (mean Model for End-Stage Liver Disease score), and indications for TIPS (variceal bleeding, refractory ascites, refractory hydrothorax) in conventional and intravascular US-guided cases were recorded. RESULTS The two groups were well matched by sex, age, etiology of liver disease, Child-Pugh class, Model for End-Stage Liver Disease scores, and indication for TIPS (P range = .19-.94). Fewer intrahepatic needle passes were required in intravascular US-guided TIPS creation compared with conventional TIPS (2 passes vs 6 passes, P < .01). Less iodinated contrast material was used in intravascular US cases (57 mL vs 140 mL, P < .01). Radiation exposure, as measured by cumulative dose, dose area product, and fluoroscopy time, was reduced with intravascular US (174 mGy vs 981 mGy, P < .01; 3,793 μGy * m(2) vs 21,414 μGy * m(2), P < .01; 19 min vs 34 min, P < .01). Procedure time was shortened with intravascular US (86 min vs 125 min, P < .01). CONCLUSIONS Intravascular US guidance resulted in fewer intrahepatic needle passes, decreased contrast medium usage, decreased radiation dosage, and shortened procedure time in TIPS creation.
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Affiliation(s)
- Steven D Kao
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103; Department of Radiology, University of California Los Angeles Medical Center, Los Angeles, California
| | - Maud M Morshedi
- Department of Radiology, University of California Los Angeles Medical Center, Los Angeles, California
| | - Kazim H Narsinh
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Thomas B Kinney
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Jeet Minocha
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Andrew C Picel
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Isabel Newton
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Steven C Rose
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Anne C Roberts
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Alexander Kuo
- Gastroenterology/Hepatology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Hamed Aryafar
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103.
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Farsad K, Kaufman JA. Novel Image Guidance Techniques for Portal Vein Targeting During Transjugular Intrahepatic Portosystemic Shunt Creation. Tech Vasc Interv Radiol 2016; 19:10-20. [PMID: 26997085 DOI: 10.1053/j.tvir.2016.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The most challenging part of transjugular intrahepatic portosystemic shunt creation is arguably the transvenous access from the hepatic vein to the portal vein. As experience and technology have evolved, the image guidance aspect of this critical step in the procedure has become more robust. Improved means to target the portal vein include both direct and indirect methods of portal vein opacification, cross-sectional imaging for both targeting and access, and novel use of transabdominal and intravascular ultrasound guidance. These techniques are described herein.
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Affiliation(s)
- Khashayar Farsad
- Dotter Interventional Institute, Oregon Health and Science University, Portland, OR.
| | - John A Kaufman
- Dotter Interventional Institute, Oregon Health and Science University, Portland, OR
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