Utilizing a Suture-constrained Covered Stent for Shunt Reduction to Treat Transjugular Intrahepatic Portosystemic Shunt-related Refractory Hepatic Encephalopathy: a Retrospective Study

Overview

Journal Jpn J Radiol

Publisher Springer

Specialty Radiology

Date 2024 Jun 26

PMID 38922569

Authors

Maoyuan Mu

Tengchao Zhou

Huanqing Guo

Xiaobo Fu

Zixiong Chen

Weiwei Jiang

Lixue Li

Han Qi

Fei Gao

Affiliations

Soon will be listed here.

Abstract

Purpose: Refractory hepatic encephalopathy (RHE) can occur as a consequence of excessive shunting following the creation of a transjugular intrahepatic portosystemic shunt (TIPS). We describe a technique that utilizes a suture-constrained covered stent for shunt reduction to treat TIPS-related RHE.

Materials And Methods: Between January 2017 and September 2023, 25 patients with TIPS-related RHE who underwent shunt reduction utilizing a suture-constrained covered stent were reviewed. The procedure involved reducing the diameter of a polytetrafluoroethylene-covered stent from 8 to 5 mm with a non-absorbable suture and inserting it into the existing TIPS stent to reduce shunt flow.

Results: Twelve of the 25 patients were evaluated. Shunt reduction was technically successful in all patients and no immediate complications related to the procedures were observed. Varying degrees of improvement in HE symptoms were observed after shunt reduction, with a mean increase in portosystemic gradient of 5 mmHg compared to pre-procedure, and complete disappearance of symptoms was observed in seven (58.3%) individuals. After a median follow-up of 8.3 months, HE recurred in 4 patients (33.3%) and TIPS indication recurred in 2 patients (16.7%) in the form of ascites and variceal bleeding, respectively. One patient (8.3%) developed shunt dysfunction detected by Doppler ultrasound and was accompanied by the presence of hepatic hydrothorax and ascites. At the end of the study, 5 patients (41.7%) were alive, 5 (41.7%) succumbed to liver failure, and 2 (16.7%) succumbed to pneumonia.

Conclusions: Constraining the stent diameter with a suture is feasible, and using this suture-constrained covered stent for shunt reduction can effectively improve TIPS-related RHE. Further investigations are warranted to precisely delineate the impact of the increased portosystemic gradient and to optimize patient survival.

References

Boike J, Thornburg B, Asrani S, Fallon M, Fortune B, Izzy M . North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension. Clin Gastroenterol Hepatol. 2021; 20(8):1636-1662.e36. PMC: 8760361. DOI: 10.1016/j.cgh.2021.07.018. View

Lee H, Lee S . The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: Advantages and pitfalls. Clin Mol Hepatol. 2021; 28(2):121-134. PMC: 9013617. DOI: 10.3350/cmh.2021.0239. View

Casadaban L, Parvinian A, Minocha J, Lakhoo J, Grant C, Ray Jr C . Clearing the Confusion over Hepatic Encephalopathy After TIPS Creation: Incidence, Prognostic Factors, and Clinical Outcomes. Dig Dis Sci. 2014; 60(4):1059-66. DOI: 10.1007/s10620-014-3391-0. View

Riggio O, Nardelli S, Moscucci F, Pasquale C, Ridola L, Merli M . Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Clin Liver Dis. 2012; 16(1):133-46. DOI: 10.1016/j.cld.2011.12.008. View

Sharma B, Sharma P, Lunia M, Srivastava S, Goyal R, Sarin S . A randomized, double-blind, controlled trial comparing rifaximin plus lactulose with lactulose alone in treatment of overt hepatic encephalopathy. Am J Gastroenterol. 2013; 108(9):1458-63. DOI: 10.1038/ajg.2013.219. View

Madoff D, Wallace M, Ahrar K, Saxon R . TIPS-related hepatic encephalopathy: management options with novel endovascular techniques. Radiographics. 2004; 24(1):21-36. DOI: 10.1148/rg.241035028. View

Kochar N, Tripathi D, Ireland H, Redhead D, Hayes P . Transjugular intrahepatic portosystemic stent shunt (TIPSS) modification in the management of post-TIPSS refractory hepatic encephalopathy. Gut. 2006; 55(11):1617-23. PMC: 1860128. DOI: 10.1136/gut.2005.089482. View

Fanelli F, Salvatori F, Rabuffi P, Boatta E, Riggio O, Lucatelli P . Management of refractory hepatic encephalopathy after insertion of TIPS: long-term results of shunt reduction with hourglass-shaped balloon-expandable stent-graft. AJR Am J Roentgenol. 2009; 193(6):1696-702. DOI: 10.2214/AJR.09.2968. View

Chung H, Razavi M, Sze D, Frisoli J, Kee S, Dake M . Portosystemic pressure gradient during transjugular intrahepatic portosystemic shunt with Viatorr stent graft: what is the critical low threshold to avoid medically uncontrolled low pressure gradient related complications?. J Gastroenterol Hepatol. 2008; 23(1):95-101. DOI: 10.1111/j.1440-1746.2006.04697.x. View

10.

Otal P, Smayra T, Bureau C, Peron J, Chabbert V, Chemla P . Preliminary results of a new expanded-polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt procedures. AJR Am J Roentgenol. 2002; 178(1):141-7. DOI: 10.2214/ajr.178.1.1780141. View

11.

Pereira K, Carrion A, Salsamendi J, Doshi M, Baker R, Kably I . Endovascular Management of Refractory Hepatic Encephalopathy Complication of Transjugular Intrahepatic Portosystemic Shunt (TIPS): Comprehensive Review and Clinical Practice Algorithm. Cardiovasc Intervent Radiol. 2015; 39(2):170-82. DOI: 10.1007/s00270-015-1197-x. View

12.

Blei A, Cordoba J . Hepatic Encephalopathy. Am J Gastroenterol. 2001; 96(7):1968-76. DOI: 10.1111/j.1572-0241.2001.03964.x. View

13.

Forauer A, McLean G . Transjugular intrahepatic portosystemic shunt constraining stent for the treatment of refractory postprocedural encephalopathy: a simple design utilizing a Palmaz stent and Wallstent. J Vasc Interv Radiol. 1998; 9(3):443-6. DOI: 10.1016/s1051-0443(98)70296-9. View

14.

Schindler P, Seifert L, Masthoff M, Riegel A, Kohler M, Wilms C . TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification. J Clin Med. 2020; 9(2). PMC: 7073830. DOI: 10.3390/jcm9020567. View

15.

Maleux G, Heye S, Verslype C, Nevens F . Management of transjugular intrahepatic portosystemic shunt induced refractory hepatic encephalopathy with the parallel technique: results of a clinical follow-up study. J Vasc Interv Radiol. 2007; 18(8):986-92. DOI: 10.1016/j.jvir.2007.05.009. View

16.

Rowley M, Choi M, Chen S, Hirsch K, Seetharam A . Refractory Hepatic Encephalopathy After Elective Transjugular Intrahepatic Portosystemic Shunt: Risk Factors and Outcomes with Revision. Cardiovasc Intervent Radiol. 2018; 41(11):1765-1772. DOI: 10.1007/s00270-018-1992-2. View

17.

Geeratikun Y, Timmermans H, Uchida B, Jahangiri Y, Horikawa M, Kaufman J . VIDEO: Technique to Restrict the Gore Viatorr Stent-Graft for TIPS Reduction. AJR Am J Roentgenol. 2018; 210(4):W172. DOI: 10.2214/AJR.17.19027. View

18.

Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei A . Hepatic encephalopathy--definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology. 2002; 35(3):716-21. DOI: 10.1053/jhep.2002.31250. View

19.

Cordoba J, Ventura-Cots M, Simon-Talero M, Amoros A, Pavesi M, Vilstrup H . Characteristics, risk factors, and mortality of cirrhotic patients hospitalized for hepatic encephalopathy with and without acute-on-chronic liver failure (ACLF). J Hepatol. 2013; 60(2):275-81. DOI: 10.1016/j.jhep.2013.10.004. View

20.

Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen K . Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014; 60(2):715-35. DOI: 10.1002/hep.27210. View