Transjugular intrahepatic portosystemic shunt complications: prevention and management

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) insertion has been well established as an effective treatment in the management of sequelae of portal hypertension. There are a wide variety of complications that can be encountered, such as hemorrhage, encephalopathy, TIPS dysfunction, and liver failure. This review article summarizes various approaches to preventing and managing these complications.

Keywords: complications; encephalopathy; interventional radiology; portal hypertension; transjugular intrahepatic portosystemic shunt.

Fig. 1

Intentional TIPS occlusion. A 65-year-old man developed severe, refractory encephalopathy and chronic pulmonary hypertension 4 months after TIPS insertion. (a) Digitally subtracted image demonstrates a widely patent TIPS. (b) After deployment of a 14-mm-diameter Amplatzer Vascular Plug (St. Jude Medical Inc., St. Paul, MN) (arrow), there is occlusion of flow through the TIPS. Clinically, there was significant improvement in the encephalopathy and pulmonary hypertension following TIPS occlusion.

Fig. 2

TIPS flow reduction procedure using the parallel stent technique. A 50-year-old man developed acute hepatic failure and severe encephalopathy 1 month after TIPS insertion. (a) Digitally subtracted image demonstrates a widely patent TIPS extending from middle hepatic vein to right portal vein. (b) After insertion of a separate 10 French and 7 French vascular sheath via the right internal jugular vein with access through the TIPS, a 10 mm × 6 cm covered, 2 cm uncovered Viatorr endoprosthesis was positioned within the TIPS through the 10 French sheath. Prior to deployment, a 7 mm × 15 mm balloon-expandable bare metal stent was placed through the 7-French sheath at the midportion of the TIPS, which was expanded with balloon inflation (arrow). While the balloon was inflated, the Viatorr was deployed. (c) Fluoroscopic spot image demonstrates two overlapping Viatorr endoprostheses with a fully deployed balloon-expandable stent between the two Viatorr endoprostheses (arrow) that narrows the inner stent graft. (d) Patent TIPS after parallel TIPS flow reduction.

Fig. 3

Various malpositioned TIPS configurations that have obstruction of flow with risk for spontaneous thrombosis. (a) The superior margin of the TIPS terminates within the hepatic parenchymal tract. (b) The superior margin of the TIPS abuts the hepatic vein wall. (c) The superior margin of the TIPS abuts the IVC wall. For scenarios B and C, there will be obstruction of flow if a Viatorr endoprosthesis is used. (d) Appropriate TIPS positioning.

Fig. 4

Successful revision of a thrombosed TIPS. A 48-year-old man presented with recurrent ascites six months after successful TIPS insertion using a Viatorr endoprosthesis. Sonographic evaluation of the TIPS was suggestive of TIPS thrombosis. (a) Portal venogram demonstrates complete lack of flow through the TIPS. The portosystemic gradient was 28 mm Hg. (b) Mechanical thrombectomy was performed with a rotational thrombectomy device throughout the TIPS followed by angioplasty throughout the TIPS with a 10-mm-diameter noncompliant balloon. A severe waist was demonstrated at the hepatic vein origin (arrow). Of note, the originally deployed TIPS did not extend to the hepatic vein origin. (c) Follow-up portal venogram demonstrates minimal flow through the TIPS with a persistent subtotal occlusion of the outflow hepatic vein. (d) Completion image demonstrating excellent flow through the TIPS after a 2-cm-longer Viatorr endoprosthesis was deployed within the existing Viatorr, resulting in coverage of the stenosis at the hepatic vein origin. The portosystemic gradient was 7 mm Hg at completion of the case, and the patient's ascites resolved several weeks later.