Parallel transjugular intrahepatic portosystemic shunt with Viatorr® stents for primary TIPS insufficiency: Case series and review of literature

The Tale of a Bleeding Tree: A Rare Case of Peripancreatic Variceal Hemorrhage Causing Hemosuccus Pancreaticus

Hemosuccus pancreaticus (HP) is a rare cause of upper gastrointestinal bleeding. It was described by Lawal and Farrel in 1931. This disorder has also been referred to as pseudohemobilia or wirsungorrhagia, caused by bleeding into the pancreatic duct. The rarity of this condition can pose a diagnostic challenge. HP is life-threatening and requires immediate attention. The commonly used treatment modality is coil embolization. Surgery is considered in the case of failed embolization or uncontrolled bleeding. Described below, is a case of a 72-year-old female with a history of chronic pancreatitis who presented with anemia secondary to bleeding peripancreatic varices.

Combined transhepatic and transjugular approach for mechanical thrombectomy of massive TIPS thrombosis

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated decompressive therapy option to manage ascites and variceal bleeding secondary to portal hypertension. Complications following TIPS procedures include hepatic encephalopathy, liver failure, and TIPS dysfunction. TIPS dysfunction is due to occlusion or stenosis of the TIPS shunt and can be caused by acute or chronic thrombosis. TIPS thrombosis is often treated with mechanical thrombectomy or catheter-directed thrombolytic therapy. Most cases of in-stent occlusion can be treated via a transjugular approach with recanalization or placement of additional stents. We present a case of a 72-year-old female who presented with worsening ascites 17 months after initial TIPS procedure; she was found to have a large thrombus completely occluding the TIPS stent. In our case, a combined transhepatic and transjugular approach was required for TIPS revision given the extent of well-organized clot located near the hepatic venous end of the stent, resulting from prolonged stent occlusion. This was an extremely challenging scenario with two overlapping covered stents and a bare metal stent at the hepatic venous end in the setting of chronic thrombosis and a well-organized fibrous cap. The case highlights the need for optimal initial placement of the primary TIPS shunt to avoid the need for subsequent complex interventions to maintain TIPS shunt patency.

Refractory portal hypertension complications successfully managed by parallel transjugular intrahepatic portosystemic shunt (TIPS): a case report

Background

Transjugular intrahepatic portosystemic shunt (TIPS) is an established intervention to treat complicated portal hypertension refractory to medical or endoscopic management. TIPS dysfunction results in the recurrence of portal hypertension symptoms. In cases of TIPS dysfunction or persistent portal hypertension despite a patent primary TIPS, the creation of parallel TIPS may be the only intervention to effectively reduce portal pressure. Since the introduction of dedicated TIPS stents (Viatorr®) the incidence of TIPS dysfunction has reduced profoundly. Nevertheless, the creation of a parallel TIPS can still be necessary in the current dedicated TIPS stent era.

Case presentation

We report one such patient who experienced ongoing portal hypertension induced upper gastro-intestinal haemorrhage despite multiple TIPS revisions and a patent primary TIPS.

Conclusion

Following creation of a parallel TIPS, the patient remains in clinical remission with no further bleeding.

A method for revision of a foreshortened transjugular intrahepatic portosystemic shunt (TIPS) stent using transhepatic trans-stent access

The high technical success rate of transjugular intrahepatic portosystemic shunt (TIPS) placement makes the procedure a popular treatment option for symptomatic portal hypertension. Among the major drawbacks of the procedure - hepatic encephalopathy, acute hepatic failure, hemorrhage, biliary injury - TIPS dysfunction is one of the most prevalent, often requiring endovascular reintervention. Conventional techniques for shunt revision rely on transjugular access to the stent; but in technically difficult cases of abnormal angulation or severe stenosis, transhepatic access may also be required. The pull-through method utilizes both transjugular and transhepatic access to achieve stable through-and-through access in order to advance a sheath into the stent and recannulate the shunt. In the case of TIPS foreshortening, however, the distal end of the stent may abut the wall of the hepatic vein, jailing it off and obviating the advancement of a wire out of that end. We present here a case of a modified pull-through method for TIPS revision whereby a transhepatic wire is passed through the interstices of the stent at the distal end to enter into the hepatic vein and IVC. Subsequent snaring of the wire at the transjugular end establishes through-and-through access, and balloon dilation through the interstices allows for insertion of a transjugular sheath into the TIPS stent for recanalization. Our case highlights how the modified pull-through method, using trans-stent access, can be safely performed in patients with a foreshortened TIPS that abuts against the hepatic and portal vessel walls.

Combined Y-configured stents for revising occluded transjugular intrahepatic portosystemic shunt

PURPOSE

We aimed to determine the technical feasibility, safety and prognosis of the transjugular intrahepatic portosystemic shunt (TIPS) revision by combined Y-configured stents placement.

METHODS

We retrospectively evaluated 12 patients who received TIPS revision using Y-stenting technique between June 2015 and January 2019. The rates of technical success, complication, shunt patency, hepatic encephalopathy and mortality were described and analyzed.

RESULTS

The combined Y-configured stents were successfully placed in 11 of 12 patients (92%) without major complications. The median portosystemic pressure gradient (PPG) decreased from 23 mmHg (interquartile range, IQR, 18.5-27.5 mmHg) to 10 mmHg (IQR, 9-14 mmHg). The left internal jugular vein approach was used in 5 patients. Four patients required a shunt extension with an extra stent to resolve the stenosis at the portal venous terminus. Two patients developed hepatic encephalopathy, which was medically controlled within 3 months after the procedure. The TIPS patency and survival rates were both 100% during a median follow-up period of 10 months (IQR, 5.5-14 months).

CONCLUSION

TIPS revision by combined Y-configured stents placement was technically feasible and safe with favorable clinical outcomes.

Parallel transjugular intrahepatic portosystemic shunt (TIPS) for TIPS dysfunction: technical and patency outcome

Background

Several methods have been used in treating TIPS dysfunction, including balloon angioplasty with/without telescoping stent. However, there are some cases refractory to recanalization and parallel shunt (PS) should be tried. The aim is to evaluate the technical and patency outcomes of the PS. We retrospectively reviewed the medical records of patients (n = 37) with refractory TIPS dysfunction who were managed by PS. All clinical, laboratory, and technical data as well as radiological data over 1 year were collected. Technical success was the primary outcome while complications and shunt patency were the secondary outcomes.

Results

Thirty-three out of the 37 patients (89.2%) of the study were Budd-Chiari syndrome cases. Caval puncture was done in 34/37 (91.9%) of cases while the hepatic vein puncture was done in 3/37 cases (8.1%). Portal entry through the left branch was done in 22 patients (59.5%), from neck of PV in 13 patients (35.1%) to right PV in 2 patients (5.4%). Technical success was achieved in 100% of cases. Porto-systemic pressure gradient (PSG) before PS insertion was 32.5 ± 8.1 mmHg and it became 8.9 ± 2.3 mmHg after the PS insertion (P < 0.01). The median primary patency duration was 11 months. The estimated 12 and 18 months primary patency rates were 32/37 (86.5%) and (78.4%) respectively. Intra-procedure complications occurred in 8 patients (21.6%) and were successfully treated medically. Acute PS thromboses occurred in 4 patients (10.8%) and required early successful interventions.

Conclusion

It is proven from this study that patients with refractory TIPS occlusion have another chance for a second PS to treat portal hypertension symptoms. Moreover, the PS is a durable, safe, and effective treatment on mid-term basis.

Repeat Stent Placement through Lateral Fenestration of the Existing Dysfunctioning DIPS Stent Graft: An Alternative to Parallel TIPS/DIPS Procedure in a Case of Blocked Primary TIPS/DIPS

A complication of transjugular and direct intrahepatic portosystemic stent (TIPS and DIPS) graft is stent blockage. Routinely described procedures for shunt revision include angioplasty, deployment of endoprosthesis, catheter-directed thrombolysis, or rarely performing a second parallel TIPS/DIPS. We describe a case of hepatic vein outflow tract obstruction who presented with DIPS blockage. We performed a revision where a new stent was placed by a lateral puncture through the fenestration of the existing dysfunctioning DIPS stent graft. In our opinion, this alternate technique has theoretical advantages over the conventionally described parallel TIPS/DIPS as it prevents the creation of a completely new long hepatic parenchymal tract.