Keywords parallel TIPS - TIPS dysfunction - variceal bleeding
Introduction
Cirrhosis of the liver is associated with complications of portal hypertension, such
as gastrointestinal bleeding and refractory ascites. The creation of a transjugular
intrahepatic portosystemic shunt (TIPS) is now considered an effective therapy in
managing such complications.[1 ] TIPS dysfunction is secondary to acute stent thrombosis, pseudointimal hyperplasia,
or intimal hyperplasia in the outflow hepatic vein.[2 ]
[3 ]
[4 ] A nonfunctioning TIPS is treated either by balloon angioplasty, stent insertion,
or creating a parallel shunt (PS). PS is the last therapeutic option when the initial
shunt cannot be accessed by a guidewire or percutaneous needle. We report a case of
a patient who presented with refractory variceal bleeding 5 years after chronic TIPS
occlusion. The patient was successfully treated by creating a parallel TIPS after
a failure to recanalize the preexisting TIPS.
Case Report
A 72-year-old man presented to our hospital with massive hematemesis. He was known
to have hepatic cirrhosis for over 11 years. He had undergone TIPS creation 9 years
prior to the presentation due to recurrent variceal bleeding despite endoscopic therapy.
Five years prior to the presentation, he had a history of massive hematemesis. Endoscopy
and duplex ultrasound at that time revealed grade 3 esophageal varices and an occluded
TIPS, respectively. The measured hepatic venous pressure gradient was 23 mm Hg and
TIPS revision was unsuccessful. He was managed conservatively with endoscopic and
medical therapy. On examination, the patient had splenomegaly and ascites. Laboratory
values included hemoglobin of 6.7 g/dL, white cell count of 8,000/cubic mL, and platelets
of 20,000/cubic mL. The total bilirubin was 3.2 mg/dL, creatinine 1.6 mg/dL, and international
normalized ratio 1.4. The measured Model of End-Stage Liver Disease score at the time
of presentation was 19.
Due to continued variceal bleeding, the patient underwent TIPS recanalization procedure
through a transjugular access. This procedure was unsuccessful due to the chronicity
of occluded TIPS. Percutaneous recanalization of the shunt was considered risky due
to the presence of severe thrombocytopenia and ascites. A decision was made to create
a parallel TIPS. The occluded TIPS was created between the right hepatic vein and
the right portal vein. We planned a parallel TIPS between the middle hepatic vein
and the left portal vein. The middle hepatic vein was cannulated and the Colapinto
needle (Cook Medical, Bloomington, Illinois, United States) was directed anteriorly
to puncture the left portal vein ([Fig. 1A ]) using the Haskal Liver Access Set (Cook Medical). A portal venography demonstrated
enlarged esophageal varices ([Fig. 2 ]). The parenchymal tract was dilated ([Fig. 1B ]) and a 10-mm shunt was created by placing a TIPS Niti device (Taewoong Medical,
Gyeonggi-do, South Korea) ([Fig. 3A, B ]). The portal pressure decreased from 36 mm Hg prior to TIPS creation to 8 mm Hg
post-TIPS. There was no antegrade flow in the esophageal varices post-TIPS and no
embolization of the varices was performed. The patient had an uneventful recovery
with no new episodes of gastrointestinal bleeding and resolution of ascites. The patient
developed grade 1 encephalopathy, which was managed with medical therapy.
Fig. 1 (A ) Parallel shunt created between the middle hepatic vein and the left portal vein.
(B ) Liver parenchymal tract dilated with a balloon. Note the waist at the left portal
entry site. Note the previous occluded transjugular intrahepatic portosystemic shunt
between the right hepatic vein and the right portal vein.
Fig. 2 Portal venography shows an enlarged left gastric vein and esophageal varices.
Fig. 3 (A ) Posttransjugular intrahepatic portosystemic shunt (TIPS) venography shows a widely
patent shunt with complete reversal of flow in the esophageal varices. (B ) Parallel TIPS seen on fluoroscopy image.
Discussion
TIPS is now considered an effective therapy in managing complications of portal hypertension.[5 ]
[6 ]
[7 ]
[8 ]
[9 ] It is recommended that patients with TIPS are followed regularly by periodic duplex
examination of the shunt. Secondary interventions may be required to maintain patency
of the shunt. TIPS dysfunction can be secondary to acute stent thrombosis, hepatic
venous outflow neointimal hyperplasia, and pseudointimal hyperplasia within the stentgraft.[4 ] TIPS stent extending up to the hepatic vein ostium is associated with better long-term
patency of TIPS than that terminating within the hepatic vein.[9 ]
An occluded or dysfunctional TIPS is treated based on the etiology of the occlusion.
It is usually accessed through a transjugular venous access. Acute thrombosis is treated
with pharmacological or mechanical thrombolysis followed by balloon angioplasty or
stent extension, depending on the underlying pathology that resulted in acute thrombosis.
Chronic stenosis or occlusion is treated with balloon angioplasty; however, many require
repeat stenting. A percutaneous transhepatic or transplenic access to treat an occluded
TIPS is reported and is applied when the transjugular route is unsuccessful. These
alternative accesses are associated with high risk of bleeding especially in the presence
of thrombocytopenia. If the existent shunt could not be recanalized, then a PS may
be created to reduce portal pressure. In a series of 29 patients with PS placement,
Dabos et al[10 ] described that the PS patency was slightly superior to the patency of the preexisting
TIPS. In another series of 40 patients, Helmy et al[11 ] described that the natural history of PSs as opposed to the non-PSs after a follow-up
of 11.6 months was similar.
In conclusion, PS creation with covered stent grafts, though technically challenging,
is a safe and efficacious method in the management of refractory variceal bleeding
and unsalvageable, preexisting TIPS dysfunction.
