Transcaval TIPS in patients with failed revision of occluded previous TIPS

Pull-through technique for recanalization of occluded portosystemic shunts (TIPS): technical note and review of the literature

Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction is an important problem after creation of shunts. Most commonly, TIPS recanalization is performed via the jugular vein approach. Occasionally it is difficult to cross the occlusion. We describe a hybrid technique for TIPS revision via a direct transhepatic access combined with a transjugular approach. In two cases, bare metal stents or polytetrafluoroethylene (PTFE)-covered stent grafts had been placed in TIPS tract previously, and they were completely obstructed. The tracts were inaccessible via the jugular vein route alone. In each case, after fluoroscopy or computed tomography-guided transhepatic puncture of the stented segment of the TIPS, a wire was threaded through the shunt and snared into the right jugular vein. The TIPS was revised by balloon angioplasty and additional in-stent placement of PTFE-covered stent grafts. The patients were discharged without any complications. Doppler sonography 6 weeks after TIPS revision confirmed patency in the TIPS tract and the disappearance of ascites. We conclude that this technique is feasible and useful, even in patients with previous PTFE-covered stent graft placement.

Direct intrahepatic portacaval shunt: An experimental study

AIM: To determine the feasibility of creating direct intrahepatic portacaval shunt (DIPS) in swine with puncture under sonographic guidance.

METHODS: DIPS was created in 10 domestic swine under sonographic guidance. Liver function, blood ammonia level and portosystemic gradient (PSG) were compared before and after the procedure. Patency of shunt was followed by portography every 7 d after DIPS.

RESULTS: DIPS was successfully established in all 10 swine without any complications. One day after procedure the alanine aminotransferase (ALT), aspartate aminotransferase (AST), and blood ammonia level (BAL) of swine rose from 5.40 ± 0.69, 16.00 ± 0.79 and 35.66 ± 4.10 to 34.20 ± 3.46, 59.70 ± 2.22 and 66.94 ± 3.44 respectively (P < 0.05). The PSG decreased from 0.59 ± 0.20 kPa to 0.24 ± 0.11 kPa after DIPS (P < 0.05). The shunt of 10 swine was kept patent from 7-28 d (median patency time was 14 d).

CONCLUSION: This initial experience demonstrated that creating intrahepatic portacaval shunt from retrohepatic segment of IVC to portal vein with puncture under sonographic guidance in swine is safe and feasible. Further studies are necessary to perform DIPS in cirrhosis patients.

Transcaval transjugular intrahepatic portosystemic shunt: preliminary clinical results

OBJECTIVE

To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins.

MATERIALS AND METHODS

Transcaval TIPS, performed in six patients, was indicated by active variceal bleeding (n=2), recurrent variceal bleeding (n=2), intractable ascites (n=1), and as a bridge to liver transplantation (n=1). The main reasons for transcaval rather than classic TIPS were the presence of an unusually acute angle between the hepatic veins and the level of the portal bifurcation (n=3), hepatic venous occlusion (n=2), and inadequate small hepatic veins (n=1).

RESULTS

Technical and functional success was achieved in all patients. The entry site into liver parenchyma from the inferior vena cava was within 2 cm of the atriocaval junction. Procedure-related complications included the death of one patient due to hemoperitoneum despite the absence of contrast media spillage at tractography, and another suffered reversible hepatic encephalopathy.

CONCLUSION

In patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins, transcaval TIPS creation is feasible.