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Ochsner J. 2016 Summer; 16(2): 113–115.
PMCID: PMC4896651

Clinical Images: Parallel Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Setting of TIPS Occlusion

INTRODUCTION

Placement of a transjugular intrahepatic portosystemic shunt (TIPS) is a well-established procedure for the treatment of portal hypertension and its complications.1 Routine surveillance Doppler ultrasonography is a key test for detecting early complications of TIPS, including shunt stenosis and occlusion.2 When complications occur, shunt revision with angioplasty and possible stenting is frequently attempted first to maintain shunt patency.3 However, if shunt revision fails or in the setting of chronic TIPS occlusion, the placement of a new and parallel TIPS is a viable option for continuing treatment of portal hypertension.4

HISTORY

A 52-year-old man with alcoholic cirrhosis and portal hypertension presented with bleeding gastroesophageal varices. A TIPS had been placed by using a VIATORR (W. L. Gore & Associates, Inc.) stent 3 years prior via the middle hepatic vein at an outside hospital. The patient had not obtained consistent surveillance with ultrasound imaging, and ultrasonography during admission demonstrated occlusion of the TIPS of unknown chronicity. Evidence of decreased flow was present on Doppler ultrasonography as early as 1 year postoperatively, suggesting TIPS dysfunction; however, this problem was not treated. Two separate attempts by interventional radiology staff to revise the shunt by passing a guidewire and needle through the occluded TIPS were unsuccessful (Figure 1). The decision was made to proceed with a parallel TIPS because of the patient's recent massive upper gastrointestinal bleed. Therefore, a new and separate TIPS was created from the right hepatic vein to the portal vein. The shunt was patent on follow-up ultrasonography, and the patient is doing well.

Figure 1.
Angiogram image from an unsuccessful TIPS revision. The interventional radiologist was unable to pass a GLIDEWIRE (Terumo Interventional Systems) or catheter through the lumen of the TIPS secondary to occlusion.

RADIOGRAPHIC APPEARANCE AND TREATMENT

Parallel TIPS placement was performed via a standard right internal jugular vein approach. A 5-French multipurpose catheter was used to select the right hepatic vein. The free hepatic vein pressure measured 21 mmHg, and wedged indirect portal pressure measured 29 mmHg for an initial gradient of 8 mmHg. A sheath was advanced into the right hepatic vein, and a 16-gauge Ross Modified Colapinto needle (Cook Medical) was passed through the liver to access the right portal vein (Figure 2). Over a guidewire, a 5-French pigtail catheter was placed into the portal vein. Care was taken to ensure that the wire and catheter did not pass through the interstices of the prior TIPS stent. Direct portal pressure measured 31 mmHg for a portosystemic gradient of 10 mmHg.

Figure 2.
A guidewire followed by a sheath was advanced into the right hepatic vein, and a 16-gauge Ross Modified Colapinto needle (Cook Medical) was passed through the liver to access the right portal vein. Angiogram image demonstrates opacification of right portal ...

Next, the tract was dilated with an 8-mm balloon. A new 10-mm-diameter, 5-cm covered/2-cm uncovered VIATORR stent was deployed and dilated with an 8-mm noncompliant balloon catheter (Figure 3). Final images demonstrated patency of the TIPS (Figure 4). Final pressures were 27 mmHg in the direct portal vein, 24 mmHg within the shunt, and 23 mmHg in the hepatic vein. Right atrial pressure was 22 mmHg. The portosystemic gradient was reduced from 10 mmHg to 5 mmHg with appropriate decompression of the gastroesophageal varices. Follow-up Doppler ultrasound images demonstrated satisfactory flow through the new TIPS as well as lack of flow through the occluded TIPS (Figure 5).

Figure 3.
A VIATORR (W. L. Gore & Associates, Inc.) stent was deployed and dilated with an 8-mm noncompliant balloon catheter. The new stent is parallel to the previous occluded stent (also pictured).
Figure 4.
Final angiogram after new TIPS placement demonstrates flow of contrast material across the stent, bridging the portal system with the inferior vena cava.
Figure 5.
Ultrasonic color Doppler images performed shortly after parallel TIPS placement show normal flow through the new stent as well as a lack of flow through the occluded stent.

DISCUSSION

With the advent of covered stents for the creation of TIPS, the incidence of shunt dysfunction and occlusion after initial placement has significantly decreased, with a 6-month primary patency rate of 76% for the polytetrafluoroethylene (PTFE)-covered VIATORR stent compared to a 6-month primary patency rate of 48.5% for the bare WALLSTENT (Boston Scientific Corporation).5

The etiology of stenosis and eventual occlusion is thought to be intimal hyperplasia within a bare metal stent or stenosis at the hepatic vein end of a PTFE-covered stent.6-8 TIPS stenosis and occlusion are important causes of morbidity and mortality in patients with portal hypertension status post TIPS.2 For this reason, regular surveillance of the TIPS stent is mandatory and should be achieved through Doppler ultrasonography every 6 months or whenever any change occurs in the patient's clinical status such as rebleed or increasing ascites.2 Prompt intervention is warranted if stenosis or occlusion is detected by ultrasonography, particularly because TIPS revision becomes more difficult with increasing chronicity of occlusion.3 For patients with failed TIPS revision or for patients such as ours who have a chronic TIPS occlusion, a parallel TIPS provides an excellent alternative procedure for continuing treatment of portal hypertension.

Acknowledgments

The authors have no financial or proprietary interest in the subject matter of this article.

REFERENCES

1. Hausegger KA, Karnel F, Georgieva B, et al. Transjugular intrahepatic portosystemic shunt creation with the Viatorr expanded polytetrafluoroethylene-covered stent-graft. J Vasc Interv Radiol. 2004. March; 15 3: 239- 248. [PubMed]
2. LaBerge JM, Somberg KA, Lake JR, et al. Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients. Gastroenterology. 1995. April; 108 4: 1143- 1151. [PubMed]
3. Sterling KM, Darcy MD. Stenosis of transjugular intrahepatic portosystemic shunts: presentation and management. AJR Am J Roentgenol. 1997. January; 168 1: 239- 244. [PubMed]
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5. Cejna M. Should stent-grafts replace bare stents for primary transjugular intrahepatic portosystemic shunts? Semin Intervent Radiol. 2005. December; 22 4: 287- 299. doi:10.1055/s-2005-925555. [PMC free article] [PubMed]
6. Nazarian GK, Ferral H, Castañeda-Zúñiga WR, et al. Development of stenoses in transjugular intrahepatic portosystemic shunts. Radiology. 1994. July; 192 1: 231- 234. [PubMed]
7. Helmy A, Redhead DN, Stanley AJ, Hayes PC. The natural history of parallel transjugular intrahepatic portosystemic stent shunts using uncovered stent: the role of host-related factors. Liver Int. 2006. June; 26 5: 572- 578. [PubMed]
8. Cura M, Cura A, Suri R, El-Merhi F, Lopera J, Kroma G. Causes of TIPS dysfunction. AJR Am J Roentgenol. 2008. December; 191 6: 1751- 1757. doi:10.2214/AJR.07.3534. [PubMed]

Articles from The Ochsner Journal are provided here courtesy of Ochsner Clinic Foundation