|Home | About | Journals | Submit | Contact Us | Français|
I read the recent Case Report by Drs. Chan and Liang, entitled "Recanalization of an Occluded Intrahepatic Portosystemic Covered Stent via the Percutaneous Transhepatic Approach" (1). I would respectfully suggest that they have overlooked certain predicate literature. In 2002 we published a report describing the demonstrated rapid and reliable thrombosis of transjugular intrahepatic portosystemic shunt (TIPS) created with polyethylene terephthalate covered stent grafts in humans (2); earlier swine animal TIPS work had already demonstrated rapid occlusion (3). Other papers support this as well (4, 5). As a result, I would say that the Wallgraft (Boston Scientific, Natick, MA) or any polyester-based stent grafts are inappropriate and clearly contraindicated for the creation of de novo TIPS in that their patency is far worse than a bare stent.
The stent grafts that have proven uninterrupted patency for over ten years now, are covered with expanded polytetrafluoroethylene such as the Viatorr (WL Gore and Associates, Flagstaff, AZ). Further, ePTFE TIPS stent grafts require no anticoagulation, something naturally undesirable in a patient with variceal bleeding -- as is the need for prolonged local thrombolysis in patients with a propensity for recurrent variceal bleeding, as in this patient.
Using a transsplenic approach during a prolonged thrombolytic infusion must be considered with caution due to the vascularity of the organ and risk of bleeding in a patient who may now be in a systemically fibrinolytic state. Finally, there are other approaches to recanalizing occluded shunts that have been described including the use of the Colapinto-type needle to provide a stabilizing tool at the mouth of the occluded TIPS (to aid in advancing the guidewire through the occluded shunt), or in rare cases, direct transstent puncture (6) -- an approach that would have worked in the setting of this porous graft material. These approaches have proven routinely fruitful in the author's experience.