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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Contributed by : Dr Amruta Varma
Contributed by : Dr Amruta Varma
Parallel, direct intrahepatic portosystemic shunt (DIPS) creation in a patient with a preexisting unsalvageable occluded DIPS and recurrent ascites.
Parallel, direct intrahepatic portosystemic shunt (DIPS) creation in a patient with a preexisting unsalvageable occluded DIPS and recurrent ascites.
Introduction:
Introduction:
The creation of a Direct Intrahepatic Portocaval Shunts (DIPS) is an effective therapy in patients suffering from Budd-Chiari Syndromes (BCS) presenting with complications of portal hypertension such as refractory ascites and gastrointestinal bleeding. A major limitation is stent dysfunction secondary to acute stent thrombosis, pseudo intimal hyperplasia, or intimal hyperplasia particularly in Budd Chiari syndrome due to underlying pro-thrombotic status. Several methods such as balloon angioplasty , thrombosuction , thrombolysis and in-stent insertion have been used to recanalize the original DIPS stent. In spite of these methods, a few cases with obstructed stents, recanalization is suboptimal , recurrent or fails. In such cases creation of another parallel dips is needed.
The creation of a Direct Intrahepatic Portocaval Shunts (DIPS) is an effective therapy in patients suffering from Budd-Chiari Syndromes (BCS) presenting with complications of portal hypertension such as refractory ascites and gastrointestinal bleeding. A major limitation is stent dysfunction secondary to acute stent thrombosis, pseudo intimal hyperplasia, or intimal hyperplasia particularly in Budd Chiari syndrome due to underlying pro-thrombotic status. Several methods such as balloon angioplasty , thrombosuction , thrombolysis and in-stent insertion have been used to recanalize the original DIPS stent. In spite of these methods, a few cases with obstructed stents, recanalization is suboptimal , recurrent or fails. In such cases creation of another parallel dips is needed.
In this report, we present a case of a patient presenting with refractory ascites after one year of occlusion of DIPS stenting and failure to recanalize the existing stent. The patient was successfully treated with a parallel DIPS.
In this report, we present a case of a patient presenting with refractory ascites after one year of occlusion of DIPS stenting and failure to recanalize the existing stent. The patient was successfully treated with a parallel DIPS.
Case presentation:
Case presentation:
A 27 year old msn, known to have Budd Chiari syndrome had presented in 2020 with complaints of abdominal distension due to ascites. He also complained of and malena. In 2022, a DIPS procedure was performed on him.(Fig 1 , video 1).
A 27 year old msn, known to have Budd Chiari syndrome had presented in 2020 with complaints of abdominal distension due to ascites. He also complained of and malena. In 2022, a DIPS procedure was performed on him.(Fig 1 , video 1).
VIDEO 1.mp4Fig 1: Supra hepatic IVC seen on Triple phase CT (arrow). There is occlusion of the hepatic veins , consistent with the findings of Budd- Chiari syndrome.
Video 1 : Direct Intrahepatic Portosystemic shunt done in march 2022 . Shunt gram shows patent stent.
On follow up, after one year of DIPS , he presented to us with recurrent ascites. On duplex ultrasound there was occlusion of the DIPS stent. Endoscopy at that time showed Grade 3 esophageal varices. His hemoglobin was 7.3 g/dL, white cell count of 9,000/cubic mL, and platelets of 58,000/cubic mL. The total bilirubin was 3.2 mg/dL, creatinine 1.1 mg/dL, and INR 1.4. On examination, the patient had abdominal fullness. Multiple attempts were made via femoral and jugular approach (video 2) to recanalize the stent , however was not successful. A decision was made for creation of parallel DIPS.
On follow up, after one year of DIPS , he presented to us with recurrent ascites. On duplex ultrasound there was occlusion of the DIPS stent. Endoscopy at that time showed Grade 3 esophageal varices. His hemoglobin was 7.3 g/dL, white cell count of 9,000/cubic mL, and platelets of 58,000/cubic mL. The total bilirubin was 3.2 mg/dL, creatinine 1.1 mg/dL, and INR 1.4. On examination, the patient had abdominal fullness. Multiple attempts were made via femoral and jugular approach (video 2) to recanalize the stent , however was not successful. A decision was made for creation of parallel DIPS.
VIDEO 2.mp4VIDEO 2- DIPS gram (September 2023 ) via transjugular approach showing blocked stent.
Interventional technique:
Interventional technique:
The occluded the stent had been created between supra-hepatic part of IVC and right portal vei, We planned to create the parallel DIPS between supra-hepatic part of the IVC and the left portal vein. Under local anesthesia, via femoral artery access an arterio-portogram (Fig 2) was Obtained. This showed the left branch of the portk ven to be patent. There were numerous porto-systemic collaterals . Through a right jugular access, a sheath was advanced upto the suprahepatic IVC, An IVC gram showed the supra hepatic portion of the IVC. to be patent(fig 3)
The occluded the stent had been created between supra-hepatic part of IVC and right portal vei, We planned to create the parallel DIPS between supra-hepatic part of the IVC and the left portal vein. Under local anesthesia, via femoral artery access an arterio-portogram (Fig 2) was Obtained. This showed the left branch of the portk ven to be patent. There were numerous porto-systemic collaterals . Through a right jugular access, a sheath was advanced upto the suprahepatic IVC, An IVC gram showed the supra hepatic portion of the IVC. to be patent(fig 3)
Fig 2 : Arterio-portogram shows presence of accessible portal venous system and porto-systemic collaterals .
Fig 3 : IVC gram shows patent suprahepatic part of IVC.
Through the catheter in the IVC, a Colapinto needle was directed anteriorly to puncture the left portal vein. Nitrex guidewire (0.014”) was negotiated through the portal system (fig 4). After serial pre-dilatation using a 2.5 x 40 mm balloon (fig 5) an H1 cathter was advanced over it(Video3).
Through the catheter in the IVC, a Colapinto needle was directed anteriorly to puncture the left portal vein. Nitrex guidewire (0.014”) was negotiated through the portal system (fig 4). After serial pre-dilatation using a 2.5 x 40 mm balloon (fig 5) an H1 cathter was advanced over it(Video3).
Fig 4: Negotiation of Nitrex wire via left portal vein access to right portal vein.
Fig 5 : Pre-dilatation of the track over nitrex wire using 2.5 x 40 mm balloon.
VIDEO 3.mp4VIDEO 3 – Gram after cannulation of portal vein shows portal venous system and presence of porto systemic collaterals.
The Nitrex wire was exchanged for an Amplatz ultra stiff wire and the tract in the liver parenchymal was dilated using a 8 x 80 mm balloon angioplasty catheter (fig 6) .The track length was calculated with simultaneous injection into portal vein and IVC using marker pigtail (video 4), A 10 x 120 mm partially covered Niti stent was deployed (fig 7). Post deployment venogram revealed disappearance of the collaterals and patent parallel stent between the IVC and portal vein. ( video 5)
The Nitrex wire was exchanged for an Amplatz ultra stiff wire and the tract in the liver parenchymal was dilated using a 8 x 80 mm balloon angioplasty catheter (fig 6) .The track length was calculated with simultaneous injection into portal vein and IVC using marker pigtail (video 4), A 10 x 120 mm partially covered Niti stent was deployed (fig 7). Post deployment venogram revealed disappearance of the collaterals and patent parallel stent between the IVC and portal vein. ( video 5)
Fig 6: :Dilatation of the track using 8 x 80 mm balloon angioplasty catheter.
Fig 7: Gram showing patent Parallel DIPS stent between IVC and left portal vein , seen medial to the blocked native stent.
VIDEO 4.mp4VIDEO 5.mp4VIDEO 4 – Marker pigtail gram to calculate the track length.
VIDEO 5: Post parallel DIPS stenting gram suggestive of patent stent between IVC and left portal vein and disappearance of collaterals.
The patient made an uneventful recovery. The ascites resolved completely at the end of one week (fig 8)
The patient made an uneventful recovery. The ascites resolved completely at the end of one week (fig 8)
FIG. 8 : Follow up color doppler ultrasound shows presence of normal blood flow across the parallel stent (arrow) and no flow seen across the index stent. No free fluid noted.
Discussion:
Discussion:
DIPS is now considered an effective therapy in managing complications of portal hypertension. It is recommended that patients with DIPS are followed regularly by periodic duplex Doppler examination of the shunt. Secondary interventions may be required to maintain patency of the shunt. (1) DIPS dysfunction can be secondary to acute stent thrombosis, due to inherit ant prothrombotic status in BCS.(2) . An occluded or dysfunctional DIPS is treated based on the etiology of the occlusion. It is usually accessed through a transjugular venous access. Acute thrombosis is treated with pharmacological or mechanical thrombolysis followed by balloon angioplasty or stent extension, depending on the underlying pathology that resulted in acute thrombosis.(3) Chronic stenosis or occlusion is treated with balloon angioplasty; however, many require repeat stenting. A percutaneous transhepatic or transplenic access to treat an occluded TIPS is reported and is applied when the transjugular route is unsuccessful. These alternative accesses are associated with high risk of bleeding especially in the presence of thrombocytopenia. If the existent shunt could not be recanalized, then a parallel shunt may be created to reduce portal pressure. In a series of 29 patients with PS placement, Dabos et al (4) described that PS patency was slightly superior to the patency of the preexisting TIPS. In another series of 40 patients, Helmy et al (5) described that the natural history of PS as opposed to the non-PS after a follow-up of 11.6 months was similar. In conclusion, PS creation with covered stent grafts, though technically challenging, is a safe and efficacious method in the management of refractory variceal bleeding and unsalvageable, preexisting TIPS dysfunction
DIPS is now considered an effective therapy in managing complications of portal hypertension. It is recommended that patients with DIPS are followed regularly by periodic duplex Doppler examination of the shunt. Secondary interventions may be required to maintain patency of the shunt. (1) DIPS dysfunction can be secondary to acute stent thrombosis, due to inherit ant prothrombotic status in BCS.(2) . An occluded or dysfunctional DIPS is treated based on the etiology of the occlusion. It is usually accessed through a transjugular venous access. Acute thrombosis is treated with pharmacological or mechanical thrombolysis followed by balloon angioplasty or stent extension, depending on the underlying pathology that resulted in acute thrombosis.(3) Chronic stenosis or occlusion is treated with balloon angioplasty; however, many require repeat stenting. A percutaneous transhepatic or transplenic access to treat an occluded TIPS is reported and is applied when the transjugular route is unsuccessful. These alternative accesses are associated with high risk of bleeding especially in the presence of thrombocytopenia. If the existent shunt could not be recanalized, then a parallel shunt may be created to reduce portal pressure. In a series of 29 patients with PS placement, Dabos et al (4) described that PS patency was slightly superior to the patency of the preexisting TIPS. In another series of 40 patients, Helmy et al (5) described that the natural history of PS as opposed to the non-PS after a follow-up of 11.6 months was similar. In conclusion, PS creation with covered stent grafts, though technically challenging, is a safe and efficacious method in the management of refractory variceal bleeding and unsalvageable, preexisting TIPS dysfunction
References:
References:
1. Rathod K, Popat B, Barai P, Amrapurkar D. Parallel transjugular intrahepatic portosystemic shunt (TIPS) creation in a patient with a preexisting unsalvageable occluded tips and refractory variceal bleeding. Journal of Clinical Interventional Radiology ISVIR. 2017 Apr;1(01):040-2
1. Rathod K, Popat B, Barai P, Amrapurkar D. Parallel transjugular intrahepatic portosystemic shunt (TIPS) creation in a patient with a preexisting unsalvageable occluded tips and refractory variceal bleeding. Journal of Clinical Interventional Radiology ISVIR. 2017 Apr;1(01):040-2
2. Cura A, Suri R, El-Merhi F, Lopera J, Kroma G. Causes of TIPS dysfunction. AJR Am J Roentgenol 2008;191(6):1751–1757
2. Cura A, Suri R, El-Merhi F, Lopera J, Kroma G. Causes of TIPS dysfunction. AJR Am J Roentgenol 2008;191(6):1751–1757
3. Alwarraky, M.S., Elzohary, H.A., Melegy, M.A. et al. Parallel transjugular intrahepatic portosystemic shunt (TIPS) for TIPS dysfunction: technical and patency outcome. Egypt J Radiol Nucl Med 51, 229 (2020).
3. Alwarraky, M.S., Elzohary, H.A., Melegy, M.A. et al. Parallel transjugular intrahepatic portosystemic shunt (TIPS) for TIPS dysfunction: technical and patency outcome. Egypt J Radiol Nucl Med 51, 229 (2020).
4. Dabos KJ, Stanley AJ, Redhead DN, Jalan R, Hayes PC. Efficacy of balloon angioplasty, restenting, and parallel shunt insertion for shunt insufficiency after transjugular intrahepatic portosystemic stentshunt (TIPSS). Minim Invasive Ther Allied Technol 1998;7:287–293
4. Dabos KJ, Stanley AJ, Redhead DN, Jalan R, Hayes PC. Efficacy of balloon angioplasty, restenting, and parallel shunt insertion for shunt insufficiency after transjugular intrahepatic portosystemic stentshunt (TIPSS). Minim Invasive Ther Allied Technol 1998;7:287–293
5. Helmy A, Redhead DN, Stanley AJ, Hayes PC. The natural history of parallel transjugular intrahepatic portosystemic stent shunts using uncovered stent: the role of host-related factors. Liver Int 2006;26(5):572–578
5. Helmy A, Redhead DN, Stanley AJ, Hayes PC. The natural history of parallel transjugular intrahepatic portosystemic stent shunts using uncovered stent: the role of host-related factors. Liver Int 2006;26(5):572–578
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