Revision of a failed TIPS by use of a stentgraft

Clinical History

TIPS dysfunction

Imaging Findings

Patient had received a transjugular portosystemic shunt (TIPS) because of a subacute Budd-Chiari syndrome with deprived liver function and ascites. After 9 months, she was readmitted because of recurrent ascites. Duplex sonography revealed antegrade flow in the extrahepatic portal vein of 12 cm/s, an antegrade intrahepatic portal flow and a markedly reduced intrashunt flow of 40 cm/s indicating TIPS dysfunction. She was scheduled for invasive angiographic control and reintervention.

Discussion

After antegrade puncture of the right internal jugular vein, the TIPS tract was cannulated by use of a curved catheter which was inserted into the portal vein . The guidewire was exchanged for a 0.035 extrastiff Amplatz guidewire, over which a 10 F sheath was introduced into the TIPS tract. Contrast injection via the sheath revealed a stenosis at the portal entrance of the Wallstents into the liver parenchyma but an additional more severe stenosis at the proximal end of the stent at the entrance into the vena cava (Fig. 1). Since the TIPS tract was created primarily (Budd-Chiari-Syndrome) through liver parenchyma with no remaining bridge within the hepatic vein, the stenoses were considered as in-tract stenoses. Note complete filling of both portal side branches. A 12 mm wide 7 cm long ePTFE stent graft (VIATORR, Gore Inc.) (Fig. 2) was preloaded into the sheath. It consists of nitinol stent body with a graft-free segment at the portal side which is placed into the portal vein. This part is followed by a full PTFE graft which is embedded into the nitinol framework. While the noncovered part is compressed by a loading tube and is pushed forward through the sheath, it will open immediately after leaving the sheath. Thus, the stent graft has to be advanced to the end of the sheath. Holding the graft in place the sheath is withdrawn allowing the noncovered part to expand. Then the sheath is withdrawn to the end of the graft while the rest of the graft is released by pulling back a string which fixes the stent graft on the delivery catheter. This step is illustrated by Fig. 3. While the noncovered part is already open, the horizontal line indicates the transition point from the noncoated to the coated part. After complete delivery of the stent, the graft is dilated by an 10 mm balloon (Fig. 3b). After dilation, full flow through the stent graft was found; no antegrade filling of the portal branches is anymore seen indicating good shunt function (Fig. 4). Duplex revealed improved portal flow of 40 cm/s, hepatofugal flow within the intrahepatic portal veins and an improved intrashunt flow of 120 cm/s. Restenosis within TIPS tracts are frequent. Intrashunt stenoses are discussed to be caused by biliary leaks that trigger neointimal overgrowth. Experimenatl and clinical studies have shown and improved patency if those lesions are treated by stent grafts instead of naked stents by potentially sealing the leaks

Differential Diagnosis List

Final Diagnosis

TIPS recanalization by placement of a stent graft

URL:	https://eurorad.org/case/694
DOI:	10.1594/EURORAD/CASE.694
ISSN:	1563-4086