Endovascular caudal retraction of the cranial end of a misplaced Viatorr TIPS prior to liver transplantation

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) extension far into the inferior vena cava (IVC) or the right atrium may complicate or preclude orthotopic liver transplantation depending on the space available for placement of a hemostatic clamp in the suprahepatic IVC. Until 2004, most TIPS were performed with bare metal stents, which integrate into the vessel wall, making percutaneous or intraoperative repositioning uncertain. Most TIPS are currently created with stent grafts that have an outer fabric to increase shunt patency and prevent endothelial ingrowth. We describe the first known manipulation of a covered stent graft prior to transplantation. The stent graft, which extended well into the IVC, was snared from a femoral approach and deflected caudally in order to document feasibility and nonadherence to the vein wall prior to definitive surgical planning of liver transplantation. Provisions were made for endovascular retraction during actual transplant surgery 9 weeks later, but this became unnecessary when manual retraction of the exposed liver enabled suprahepatic IVC clamping. Due to the nonadherent nature of the outer graft material, compared with a bare metal stent, extension of a stent graft into the IVC or right atrium may not preclude transplantation, and intraoperative endovascular retraction may be considered.

Figure 1

Digital subtraction image demonstrating the cranial transjugular intrahepatic portosystemic shunt end near the junction of the right atrium and suprahepatic inferior vena cava.

Figure 2

(a) Axial and (b) coronal CT images at the level of the cranial TIPS demonstrate the precise location to be in the distal suprahepatic vena cava without breech of the right atrial ostium. This was very helpful since the angiographic appearance suggested a right atrial extension.

Figure 3

(a) A Nitinol goose neck snare grasps the cranial end of the expanded tetrafluoroethylene (Viatorr) transjugular intrahepatic portosystemic shunt. (b) After caudal retraction, the cranial transjugular intrahepatic portosystemic shunt is mobile.