Korean J Radiol.  2001 Dec;2(4):204-209. 10.3348/kjr.2001.2.4.204.

Transcaval TIPS in Patients with Failed Revision of Occluded Previous TIPS

• Seong CK
• Kim YJ
• Shin TB
• Park HY
• Kim TH
• Kang DS

• KMID: 754089
• DOI: http://doi.org/10.3348/kjr.2001.2.4.204

Abstract

OBJECTIVE
To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) in patients with occluded previous TIPS. MATERIALS AND METHODS: Between February 1996 and December 2000 we performed five transcaval TIPS procedures in four patients with recurrent gastric cardiac variceal bleeding. All four had occluded TIPS, which was between the hepatic and portal vein. The interval between initial TIPS placement and revisional procedures with transcaval TIPS varied between three and 31 months; one patient underwent transcaval TIPS twice, with a 31-month interval. After revision of the occluded shunt failed, direct cavoportal puncture at the retrohepatic segment of the IVC was attempted. RESULTS: Transcaval TIPS placement was technically successful in all cases. In three, tractography revealed slight leakage of contrast materials into hepatic subcapsular or subdiaphragmatic pericaval space. There was no evidence of propagation of extravasated contrast materials through the retroperitoneal space or spillage into the peritoneal space. After the tract was dilated by a bare stent, no patient experienced trans-stent bleeding and no serious procedure-related complications occurred. After successful shunt creation, variceal bleeding ceased in all patients. CONCLUSION: Transcaval TIPS placement is an effective and safe alternative treatment in patients with occluded previous TIPS and no hepatic veins suitable for new TIPS.

Keyword

Hypertension, portal; Interventional procedures, complications; Shunts, portosystemic

MeSH Terms

Esophageal and Gastric Varices/*surgery
Feasibility Studies
Gastrointestinal Hemorrhage/*surgery
Human
Male
Middle Age
Portal Vein/radiography/*surgery
Portasystemic Shunt, Surgical/*methods
*Portasystemic Shunt, Transjugular Intrahepatic
Reoperation
Stents
Treatment Failure
Vascular Patency
Vena Cava, Inferior/radiography/*surgery

Figure

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  Fig. 1 A 52-year-old man with postnecrotic liver cirrhosis and variceal bleeding. Portal venogram obtained through splenic vein injection before transcaval TIPS placement shows occluded previous shunt, which was between the right hepatic and posterior segmental branch of the right portal vein (small arrows). Note filling of prominent gastric cardiac varices with gastrorenal shunt (arrow).

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  Fig. 2 A 51-year-old man with alcoholic liver cirrhosis who underwent one standard TIPS and two parallel transcaval TIPS. After transcaval portal vein puncture, contrast material injection through a side-arm adapter of a sheath, with simultaneous retraction of the sheath over the wire, demonstrates slight spillage of contrast material (arrow).

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  Fig. 3 A 52-year-old man with postnecrotic liver cirrhosis and variceal bleeding. Radiograph demonstrates balloon dilatation of the parenchymal tract (small arrows). Note the extravasation of contrast materials into hepatic subcapsular or subdiaphragmatic pericaval space (arrow). Moderate extravasation of contrast materials is apparent, and an opacified right bile duct is also seen.

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  Fig. 4 A 52-year-old man with postnecrotic liver cirrhosis and variceal bleeding. Portal venogram obtained after transcaval stent placement shows good flow through the stent without opacification of gastric cardiac varices, which were embolized with stainless coils. Trans-stent extravasation of contrast material was not apparent. The postprocedural portosystemic pressure gradient was 5 mmHg.

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