Transjugular Intrahepatic Portosystemic Shunt Occlusion Complicated with Biliary Fistula Successfully Treated with a Stent Graft: A Case Report

Biliary Complications Post Transjugular Intrahepatic Portosystemic Shunt in a Child With Portal Vein Cavernous Transformation

The transjugular intrahepatic portosystemic shunt is a rising interventional procedure with multiple indications and high technical success but with risks of biliary injuries, an underreported scenario. We present an 11-year-old patient with biliary injury with a leak, biloma formation, and biliary obstruction caused by the percutaneous procedure. Interventional radiology drainages addressed these complications by resolving the leak and biloma. These biliary complications in percutaneous procedures and their management are rarely reported in the medical literature, making their management not standard. We highlight drainage management and the importance of sharing it to add experience to this clinical scenario and encourage sharing cases with similar diagnoses.

Bad Connection: Stent-to-Stent Fistulization After Common Bile Duct and Transjugular Intrahepatic Portosystemic Shunt Stenting

A 29-year-old man with chronic portal venous thrombosis resulting in portal biliopathy required stenting of his common bile duct (CBD) and underwent a transjugular intrahepatic portosystemic shunt (TIPS) procedure to decrease portal pressures. He later presented with abdominal pain in the setting of prolonged CBD stent placement and was found to have air within his TIPS stent with a fistula on endoscopic retrograde cholangiopancreatography between his fully covered CBD stent and bare metal TIPS stent. There was concern that further intervention would lead to an air embolus. We suggest that when multiple stents are indicated, stent selection with close monitoring is critical.

Transient hemodynamic instability caused by TIPS

Variceal bleeding belongs to the one of the complications of portal hypertension and is a life-threatening condition. A transjugular intrahepatic portosystemic shunt (TIPS) is indicated in case of failure of the pharmacological and endoscopic therapy, even if it is associated with complications. Stent migration to the heart, is a rare event which may cause perforation of the right cardiac chambers or damage to the tricuspid valve. However, it may not be a problem in some cases. There are two approaches to extraction - percutaneous or surgical. Leaving the stent in situ is possible, especially in polymorbid patients. Choosing an optimal approach often requires interdisciplinary cooperation.

Late polymicrobial transjugular intrahepatic portosystemic shunt infection in a liver transplant patient: A case report

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.