CardioVascular and Interventional Radiology

, Volume 34, Issue 1, pp 92–99

Management of Transjugular Intrahepatic Portosystemic Shunt (TIPS)-associated Refractory Hepatic Encephalopathy by Shunt Reduction Using the Parallel Technique: Outcomes of a Retrospective Case Series

  • Daniel T. Cookson
  • Zubayr Zaman
  • James Gordon-Smith
  • Hamish M. Ireland
  • Peter C. Hayes
Clinical Investigation

Abstract

Purpose

To investigate the reproducibility and technical and clinical success of the parallel technique of transjugular intrahepatic portosystemic shunt (TIPS) reduction in the management of refractory hepatic encephalopathy (HE).

Materials and Methods

A 10-mm-diameter self-expanding stent graft and a 5–6-mm-diameter balloon-expandable stent were placed in parallel inside the existing TIPS in 8 patients via a dual unilateral transjugular approach. Changes in portosystemic pressure gradient and HE grade were used as primary end points.

Results

TIPS reduction was technically successful in all patients. Mean ± standard deviation portosystemic pressure gradient before and after shunt reduction was 4.9 ± 3.6 mmHg (range, 0–12 mmHg) and 10.5 ± 3.9 mmHg (range, 6–18 mmHg). Duration of follow-up was 137 ± 117.8 days (range, 18–326 days). Clinical improvement of HE occurred in 5 patients (62.5%) with resolution of HE in 4 patients (50%). Single episodes of recurrent gastrointestinal hemorrhage occurred in 3 patients (37.5%). These were self-limiting in 2 cases and successfully managed in 1 case by correction of coagulopathy and blood transfusion. Two of these patients (25%) died, one each of renal failure and hepatorenal failure.

Conclusion

The parallel technique of TIPS reduction is reproducible and has a high technical success rate. A dual unilateral transjugular approach is advantageous when performing this procedure. The parallel technique allows repeat bidirectional TIPS adjustment and may be of significant clinical benefit in the management of refractory HE.

Keywords

Interventional radiology Hepatic encephalopathy Transjugular intrahepatic portosystemic shunt 

References

  1. 1.
    Zuckerman DA, Darcy MD, Bocchini TP et al (1997) Encephalopathy after transjugular intrahepatic portosystemic shunting: analysis of incidence and potential risk factors. AJR Am J Roentgenol 169:1727–1731PubMedGoogle Scholar
  2. 2.
    Forauer AR, Mclean GK (1998) Transjugular intrahepatic portosystemic shunt constraining stent for the treatment of refractory postprocedural encephalopathy: a simple design utilizing a Palmaz stent and Wallstent. J Vasc Interv Radiol 9:443–446CrossRefPubMedGoogle Scholar
  3. 3.
    Madoff DC, Wallace MJ, Ahrar K et al (2004) TIPS-related hepatic encephalopathy: management options with novel endovascular techniques. Radiographics 24:21–37CrossRefPubMedGoogle Scholar
  4. 4.
    Maleux G, Heye S, Verslype C, Nevens F (2007) Management of transjugular portosystemic shunt-induced refractory hepatic encephalopathy with the parallel technique: results of a clinical follow-up study. J Vasc Interv Radiol 18:986–9935CrossRefPubMedGoogle Scholar
  5. 5.
    Holden A, Ng R, Gane E et al (2006) A technique for controlled partial closure of a transjugular intrahepatic portosystemic shunt tract in a patient with hepatic encephalopathy. J Vasc Interv Radiol 17:1957–1961CrossRefPubMedGoogle Scholar
  6. 6.
    Saket R, Sze D, Razavi M et al (2004) TIPS reduction with use of stents or stent-grafts. J Vasc Interv Radiol 15:745–751PubMedGoogle Scholar
  7. 7.
    Maleux G, Verslype C, Heye S et al (2007) Endovascular shunt reduction in the management of transjugular portosystemic shunt-induced hepatic encephalopathy: preliminary experience with reduction stents and stent-grafts. AJR Am J Roentgenol 188:659–664CrossRefPubMedGoogle Scholar
  8. 8.
    Quaretti P, Michieletti E, Rossi S (2001) Successful treatment of TIPS-induced hepatic failure with an hourglass stent-graft: a simple new technique for reducing shunt flow. J Vasc Interv Radiol 12:887–890CrossRefPubMedGoogle Scholar
  9. 9.
    Sze DY, Hwang GL, Kao JS et al (2008) Bidirectionally adjustable TIPS reduction by parallel stent and stent-graft deployment. J Vasc Interv Radiol 19:1653–1658CrossRefPubMedGoogle Scholar
  10. 10.
    Kroma G, Lopera J, Cura M et al (2009) Transjugular intrahepatic portosystemic shunt flow reduction with adjustable polytetrafluoroethylene-covered balloon-expandable stents. J Vasc Interv Radiol 20:981–986CrossRefPubMedGoogle Scholar
  11. 11.
    Madoff DC, Perez-Young IV, Wallace MJ et al (2003) Management of TIPS-related refractory hepatic encephalopathy with reduced Wallgraft endoprostheses. J Vasc Interv Radiol 14:369–374CrossRefPubMedGoogle Scholar
  12. 12.
    Ferenci P, Lockwood A, Mullen K et al (2002) Hepatic encephalopathy—definition, nomenclature, diagnosis and quantification: final report of the Working Party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology 35:716–721CrossRefPubMedGoogle Scholar
  13. 13.
    Paz-Fumagalli R, Crain MR, Mewissen MW et al (1994) Fatal hemodynamic consequences of therapeutic closure of a transjugular portosystemic shunt. J Vasc Interv Radiol 5:831–834CrossRefPubMedGoogle Scholar
  14. 14.
    Haskal ZJ, Cope C, Soulen MC et al (1995) Intentional reversible thrombosis of transjugular intrahepatic portosystemic shunts. Radiology 195:485–488PubMedGoogle Scholar
  15. 15.
    Kerlan RK Jr, LaBerge JM, Baker EL (1995) Successful reversal of hepatic encephalopathy with intentional occlusion of transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 6:917–921CrossRefPubMedGoogle Scholar
  16. 16.
    Kochar N, Tripathi D, Ireland H et al (2006) Transjugular intrahepatic portosystemic shunt (TIPSS) modification in the management of post-TIPSS refractory hepatic encephalopathy. Gut 55:1617–1623CrossRefPubMedGoogle Scholar
  17. 17.
    Haskal ZJ, Middlebrook MR (1994) Creation of stenotic stent to reduce flow through a transjugular intrahepatic portosystemic shunt. J Vasc Interv Radiol 5:827–830CrossRefPubMedGoogle Scholar
  18. 18.
    Gerbes AL, Waggershauser T, Holl J et al (1998) Experiences with novel techniques for reduction of stent flow in transjugular intrahepatic portosystemic shunts. Z Gastroenterol 36:373–377PubMedGoogle Scholar
  19. 19.
    Rouillard SS, Bass NM, Roberts JP et al (1998) Severe hyperbilirubinemia after creation of transjugular intrahepatic portosystemic shunts: natural history and predictors of outcome. Ann Intern Med 128:374–377PubMedGoogle Scholar
  20. 20.
    Barton RE, Rosch J, Saxon RR et al (1995) TIPS: short and long-term results: a survey of 1750 patients. Semin Interv Radiol 12:364–369CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2010

Authors and Affiliations

  • Daniel T. Cookson
    • 1
    • 2
  • Zubayr Zaman
    • 1
  • James Gordon-Smith
    • 1
  • Hamish M. Ireland
    • 1
  • Peter C. Hayes
    • 3
  1. 1.Departments of RadiologyRoyal InfirmaryEdinburghUK
  2. 2.Department of RadiologyMiddlemore HospitalAucklandNew Zealand
  3. 3.Departments of HepatologyRoyal InfirmaryEdinburghUK

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