lntetventional Radiology Rounds

Percutaneous Revision of an Acutely Thrombosed ~ransjugularIntrahe atic Portosystemic ShuntP Michael D. Darcy, MD Thomas M. Vesely, MD Daniel Picus, MD William D. Middleton, MD Manhall E. Hicks, MD

Index terms: Liver, interventional procedure, 959.453 * Shunt, portosystemic, 959.453 Stents

JVIR 1992; 3:77-82 Abbreviation: TIPS = transjugular intrahepatic portosystemic shunt

From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, St Louis, MO 63110. Address reprint requests to M.D.D. ~CVIR,1992

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CASE REPORT The patient is a 47-year-old woman with primary biliary cirrhosis who was awaiting liver transplantation. She experienced multiple episodes of variceal bleeding and has undergone endoscopic sclerotherapy four times. Creation of a transjugular intrahepatic portosystemic shunt (TIPS) was considered because of persistent bleeding despite sclerotherapy. Initially, celiac and superior mesenteric arteriography were performed to define the location, morphology, and patency of the portal vein. This demonstrated large gastric and esophageal varices filling from the coronary vein. After initial hepatic venography, a right hepatic vein was chosen for the starting point of the shunt. With use of a 16-gauge Colapinto needle (Cook, Bloomington, Ind), a single pass was made toward the right portal vein. During needle

withdrawal and aspiration, a left portal vein branch was entered (Fig 1). We believed that if a wire could be directed into the main portal vein, then this small branch could act as the initial portal access, analogous to insertion of a biliary drainage catheter through a small peripheral bile duct. A guide wire was directed without significant difficulty into the main portal vein, and the slight tortuosity of the tract appeared to straighten out (Fig 2). Pressure measurements obtained at this time revealed a 20-mm Hg systolic and a 26-mm Hg mean gradient between the portal and hepatic veins. With use of a previously described technique (11, two Palmaz stents (Johnson & Johnson Interventional Systems, Warren, NJ) were deployed and expanded with an 8-mm PE Plus I1 angioplasty balloon (Bard, Billerica, Mass).

I' 2. Figures 1,2. (1) Injection through the transjugular needle shows its entry into a smaller left portal vein branch. The clamp was used to mark the location of the main right portal vein based on the prior superior mesenteric arteriogram. (2) Image acquired during road-mapping shows the apparent straight course of the tract from the hepatic vein to the main portal vein.

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Measurement of the portosystemic gradient after deployment of the stents showed no significant change from values obtained prior to tract dilation. This madient did not improve despite further expansion of the stents with a 10-mm Blue Max angioplasty balloon (Medi-techIBoston Scientific, Watertown, Mass). Because we believed that the caudal end of the lower Palmaz stent might be partially kinking the left portal vein into which it extended. a third stent was deployed to span into the upper main portal vein. Pressure measurements at this point suggested a persistent gradient at the cephalic end of the stents, and, therefore, a fourth Palmaz stent was deployed to bridge further into the hepatic veins. Final pressure measurements showed that the portosystemic gradient had been reduced to 9 mm Hg systolic (14 mm Hg mean gradient). A final injection of contrast material into the portal vein showed rapid flow through the shunt and markedly reduced flow into the varices (Fig 3). The stents exhibited only a gentle curve from the portal to the hepatic vein (Fig 4). Follow-up Doppler ultrasound (US) examination performed 2 days later showed no flow within the shunt and 4. severe angulation of the stents in the 3. Figures 3,4. (3)Digital subtraction portogram shows good flow through the shunt. midportion of the shunt. The patient returned to the angiography suite for (4) Shallow left anterior oblique view shows the final position of the four Palmaz stents repeat evaluation. Initial fluoroscopy after TIPS. At this point, the shunt forms a gentle curve from the portal vein to the hepatic vein. The middle two stents have almost 1cm of overlap. revealed that the middle two stents, which had previously overlapped, were now separated. Steep left and shunt, and the portosystemic gradinificant residual clot; therefore, a right anterior oblique projections ent at the end of this procedure was 9-cm multilumen/multiple-side-hole showed that the stents extended anonly 10 mm Hg systolic. EDM catheter (Peripheral Systems teriorly from the hepatic vein and Following the second procedure, then formed an almost 90" angle back Group, Mountain View, Calif) was the patient did well clinically, with no inserted, and urokinase was infused to the portal vein (Fig 5). After the at a rate of 250,000 IU/h for 3 hours. further variceal bleeding. Color and stents were traversed with a catheAt that point, the majority of the clot duplex Doppler US studies performed ter, contrast material injection into at 1week and 1month demonstrated had lysed. A 6.8-cm-long Wallstent the portal vein confirmed shunt rapid venous flow and complete pathrombosis with extension of the clot (Schneider, Minneapolis, Minn) was tency of the shunt. Flow velocities in then deployed inside of the Palmaz into the right portal vein. A 5-F multhe shunt were 70-80 cmlsec (Fig 8). stents, spanning from the caudal to tiple-side-hole catheter with an endTwo months following the intrastent the cephalic end of the shunt. This occluding wire (Cook) was placed stent placement procedure, the pabraced the Palmaz stents and prethrough the stents, and 600,000 IU tient received a liver transplant. At of urokinase was administered over 1 vented them from forming an acute operation, the coronary vein and angle and kinking the middle portion hour with use of the pulse-spray other collateral veins, which are usuof the shunt (Fig 7). Angiography thrombolysis technique (2) (Fig 6). ally distended in a patient with portal demonstrated good flow through the Follow-up angiography showed sigu

Darcy et a1

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Figure 5. (a) Steep left anterior oblique projection shows the severe angle and separation of the stents in the midportion of the shunt. (b)Steep right anterior oblique projection confirms stent separation and shows overriding of the stents leading to kinking of the tract.

hypertension, were decompressed. The shunt was patent, and the luminal surface of the Wallstent was well endothelialized.

DISCUSSION TIPS is being enthusiastically adopted at some centers as a nonoperative alternative to surgical decompression in patients with severe portal hypertension. Initial clinical reports have related high success rates with few complications (3-5). In our early experience with this procedure, we have encountered acute shunt thrombosis, which has not been reported previously to our knowledge. This complication resulted from our failure to recognize the degree of acute angulation of the shunt tract. Published experiences with the TIPS ~rocedureshave stressed the importance of puncturing the portal vein close to the portal bifurcation (33). Shunts to both the right and left portal veins have been created. The choice of entry into the portal vein has been determined mainly by the patient's anatomy. According to Richter et al(3), the best tract is not always the shortest possible, "but rather the most accessible, transparenchymal communication." The dense portal fibrosis encountered in cirrhotic livers requires that considerable force be exerted to puncture the portal vein; several passes are

6.

7.

Figures 6,7. (6)Contrast material injection into the shunt after partial thrombolysis shows kinking of the tract caused by separated and angled stents seen in the midportion of the shunt (arrow).(7) The Wallstent has been deployed within the Palmaz stents and is best seen in the midportion of the shunt (arrow).Note that the midshunt angle has decreased.

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usually required to effect portal entry. Having previously experienced this, we utilized the first-pass portal access rather than puncture again more centrally. It has been our experience, as well as that of others (Becker GJ, personal communication, 1991), that it is sometimes necessary to increase the curve at the end of the Colapinto needle in order to be able to puncture the portal vein near its bifurcation. Apparently in this case, our modification of the needle curve was excessive, causing the needle to deviate cephalad and anterior to the portal bifurcation. In retrospect, we recognize that the left portal branch which was entered was so far anterior to the portal bifurcation that the tract had to angle acutely in a posterior direction to return to the main portal vein. The severe angle of the tract was considered responsible for the stent separation and shifting, Figure 8. Doppler US study obtained at 1month follow-up confirms patency of the which led to occlusion of the shunt. TIPS reinforced by the Wallstent. Complications associated with TIPS ~rocedureshave included minor hematomas at the jugular puncensure that the intrahepatic tract is create a new shunt. ture site (3), chronic shunt occlusion straight. In addition we have demonIn this case, the flexibility of the (4), stent migration (51, and one strated that it is feasible to salvage a death secondary to hemorrhage from Wallstent proved to be a significant shunt by using this intrastent stent advantage compared with the more a transhepatic portal venous tract placement technique. rigid Palmaz stents. Another advan(3). LaBerge et al(4) successfully tage of the Wallstent is that it has the References used balloon angioplasty and placement of an additional stent to salvage smallest-caliber introducing system. 1. Richter GM, Noeldge G, Palmaz JC, The Palmaz stent, however, is more a chronically occluded shunt. In our et al. Transjugular intrahepatic portacaval stent shunt: preliminary cliniradiopaque and also exhibits less case, thrombolysis successfully lysed cal results. Radiology 1990; 174: shortening during expansion. Both of the clot in the shunt; however, fur1027-1030. ther intervention was necessitated by these factors make accurate position2. Bookstein J J , Fellmeth B, Roberts A, ing of the Palmaz stent somewhat the acute angle of the stents, which Valji K, Davis G, Machado T. easier compared with the Wallstent. limited flow and would have caused Pulsed-spray pharmacomechanical The Palmaz stent has the added cathe shunt to reocclude. Of the comthrombolysis: preliminary clinical repability of being expandable to a mercially available stents, the Wallsults. AJR 1989; 152:1097-1100. stent has the greatest flexibility along 12-mm diameter or larger. This may 3. Richter GM, Noeldge G, Palmaz JC, be useful in TIPS cases when a larger its longitudinal axis. This flexibility Roessle M. The transjugular intrashunt is needed to reduce the portohepatic portosystemic stent-shunt allowed the Wallstent to provide (TIPSS): results of a pilot study. Carsystemic gradient and eliminate structural support without kinking diovasc Intervent Radio1 1991; 13: bleeding. Although each stent has its in the middle of the shunt curve. We 200-207. advantages, to our knowledge, there also considered creating a new, 4. LaBerge JM, Ring EJ, Gordon RL. have been no comparative clinical straighter hepatic to portal tract. Intrahepatic portosystemic shunts trials to assess whether structural This option was thought to be prewith the Wallstent expandable metalcharacteristics of one stent are more cluded by thrombus, which had been lic endoprosthesis: preliminary refavorable for TIPS applications. seen in the right portal vein after sults (abstr). JVIR 1991; 2:13. In summary, this case illustrates thrombolysis of the shunt. In addi5. Zemel G, Katzen BT, Becker GJ, Bethe importance of a more central nenati JF, Sallee DS. Percutaneous tion, we believed that it would be transjugular portosystemic shunt. puncture of the portal system plus technically difficult to maneuver JAMA 1991; 266:390-393. the need for rotational fluoroscopy to around the existing stents to

Percutaneous revision of an acutely thrombosed transjugular intrahepatic portosystemic shunt.

lntetventional Radiology Rounds Percutaneous Revision of an Acutely Thrombosed ~ransjugularIntrahe atic Portosystemic ShuntP Michael D. Darcy, MD Tho...
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