Combined Y-configured stents for revising occluded transjugular intrahepatic portosystemic shunt

PURPOSEWe aimed to determine the technical feasibility, safety and prognosis of the transjugular intrahepatic portosystemic shunt (TIPS) revision by combined Y-configured stents placement.METHODSWe retrospectively evaluated 12 patients who received TIPS revision using Y-stenting technique between June 2015 and January 2019. The rates of technical success, complication, shunt patency, hepatic encephalopathy and mortality were described and analyzed.RESULTSThe combined Y-configured stents were successfully placed in 11 of 12 patients (92%) without major complications. The median portosystemic pressure gradient (PPG) decreased from 23 mmHg (interquartile range, IQR, 18.5–27.5 mmHg) to 10 mmHg (IQR, 9–14 mmHg). The left internal jugular vein approach was used in 5 patients. Four patients required a shunt extension with an extra stent to resolve the stenosis at the portal venous terminus. Two patients developed hepatic encephalopathy, which was medically controlled within 3 months after the procedure. The TIPS patency and survival rates were both 100% during a median follow-up period of 10 months (IQR, 5.5–14 months).CONCLUSIONTIPS revision by combined Y-configured stents placement was technically feasible and safe with favorable clinical outcomes.

Transjugular intrahepatic portosystemic shunt (TIPS) has been widely used for the treatment of portal hypertension complications by decompressing the portal venous system (1). Shunt patency has been greatly improved since the introduction of dedicated polytetrafluoroethylene-covered stents. However, dysfunction still occurs in 8%–20% of patients within the first year after TIPS creation (2).TIPS dysfunction can arise from acute thrombosis and pseudointimal hyperplasia within the stent or at the hepatic vein outflow (3–5). Angioplasty, with or without stent placement, is frequently attempted to restore adequate TIPS function. In some cases where TIPS dysfunction is associated with altered shunt configuration or stent displacement, especially in a “T-bone” configuration, entry to the previous shunt seems to be challenging (6). This troublesome situation is more likely to occur when TIPS is created with a non-Viatorr stent, such as Fluency stent-grafts (Bard & BD). This type of stent is still widely used due to its relatively low cost, though its rigid structure may change the shunt orientation gradually. Moreover, a combined transjugular and transhepatic approach has been described (7, 8). After a percutaneous transhepatic puncture of the stent strut, a wire is passed through the lumen to inferior vena cava (IVC) and snared from the transjugular access to establish the channel. Of note, this approach brings a relatively high risk for bleeding and prolonged operative time when compared with only transjugular access (9). Parallel TIPS is generally used as the last resort (10, 11). Despite its proven efficacy, parallel stent placement through the portal vein may increase the risk of intraabdominal hemorrhage and aggravate liver function.Herein, inspired by the stent-in-stent technique used in the placement of bilateral biliary metallic stents and coronary stents (12–14), we tried to recanalize the occluded TIPS via endovascular puncture of the strut of the existent stent and followed with deployment of a new covered stent with a “Y” configuration (Fig. 1). The purpose of the present study is to evaluate the technical feasibility, safety and clinical outcomes of this new TIPS revision technique.Open in a separate windowFigure 1A schematic of Y-configured stents implantation. The angle between the initial stent (arrowheads) and the right hepatic vein was approximately 90°. A new stent (long arrow) was deployed through the mesh of the initial stent to restore the portosystemic shunt.     

Self-expanding stents in transjugular intrahepatic portosystemic shunt: experience with nitinol Strecker stents

The aim of our study was to evaluate the performance and efficacy of a new self-expanding stent (nitinol Strecker stent) in the transjugular intrahepatic portosystemic shunt (TIPS) procedure. We have successfully placed 64 nitinol Strecker stents in 48 patients. The average portosystemic gradient decreased from 22 to 11 mm Hg. Balloon dilatation was necessary in 12 of 35 angiographically controlled cases at 5 days (34%), because of incomplete stent expansion, small thrombi within the stent or obstruction. At 1–6 months stent malfunctions occurred in 8 of 23 patients who underwent control angiography (34%) and at 6–24 months in 6 of 7 patients (85%). Rebleeding occurred in 2 of 39 patients (follow-up > 1 month) (5%) and temporary crises of de novo encephalopathy were observed in 11 of 48 patients (23%). Refractory ascites completely resolved in 4 of 6 patients (66%) and improved in the remaining 2 cases. Compared with other self-expanding stents, nitinol Strecker stents seem to be equally effective in TIPS; no increase in complication rate was observed, either clinical or stent-related. Correspondence to: P. Rossi     

Intentional occlusion of a transjugular intrahepatic portosystemic shunt

The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a well-described means of treating portal hypertension and its complications. Occasionally, the consequences of this shunt prompt the desire for its subsequent obliteration. We report one unsuccessful and one successful method of TIPS occlusion. Key words: TIPS, complications-Occlusion-Thrombosis-Balloon occlusion catheter-Amplatz spi-der-Embolization coil     

TIPSS术中胆汁漏出对内皮细胞NOS活性影响的研究

目的：探讨经颈静脉肝内门腔分流术（TIPSS）中胆汁漏出对内皮细胞一氧化氮合酶（NOS)及一氧化氮（NO）合成的影响,进一步了解胆汁对支架内皮化的影响。方法：取人脐静脉内皮细胞进行体外培养,加入不同浓度（5％、10％、15％、20％、25％）胆汁干预,观察内皮细胞生长状况,并测条件培养液中NO及细胞NOS活性。结果：含5％、10％、15％胆汁的细胞生长状况与不含胆汁者相似,含20％、25％胆汁的细胞明显减少并显幼稚;各浓度胆汁的细胞NOS活性较不含胆汁者明显降低;条件培养液中NO含量均无明显差异。结论：胆汁抑制内 皮细胞的生长,并抑制内皮细胞NOS活性。     

TIPS术中胆汁漏出：刺激平滑肌细胞增生?

目的经颈内静脉肝内门腔静脉分流术（ＴＩＰＳ）中胆道损伤并胆汁漏出，可能是引起ＴＩＰＳ术后支架内平滑肌细胞（ＳＭＣ）增生和狭窄的重要因素。本研究以离体ＳＭＣ培养和ＴＩＰＳ猪模型实验评价胆汁对ＳＭＣ的作用。材料与方法离体ＳＭＣ培养分为三组：Ⅰ组＝１．０％血清＋１．０％胆汁；Ⅱ组＝１０．０％血清＋１．０％胆汁；Ⅲ组＝１０．０％血清。细胞收获点分别为３、１０、１４天。动物实验组共用４５只猪建立ＴＩＰＳ模型，术后处死时间为１０～１６天。结果此前预试验结果：使用２．５％、５．０％、１０．０％胆汁的培养基，ＳＭＣ在３天内全部死亡。离体细胞培养（１．０％胆汁）实验组（Ⅰ、Ⅱ组）中的脱氧核糖核酸（ＤＮＡ）和总蛋白量明显较对照组（Ⅲ组）少（Ｐ＜０．０５），且随着培养时间的延长其差异增加。动物实验组：２８．８９％的标本证实有胆汁漏出。定量分析示胆汁漏组中的ＳＭＣ增殖量较无胆汁漏组少。组织学检查发现有新生胆管在支架内生长。结论２．５％～１０．０％胆汁杀死ＳＭＣ，１．０％胆汁可抑制ＳＭＣ生长。动物实验示胆汁漏出导致ＳＭＣ增生减少，但血栓形成增加，从而使支架闭塞率增高。     

内皮祖细胞种植支架在经颈静脉肝内门体分流术中应用的实验研究

目的 评价内皮祖细胞(EPC)种植支架在经颈静脉肝内门腔分流(TIPS)家猪动物模型中减少分流道再狭窄的疗效.方法 体外分离、培养、鉴定家猪外周血内皮祖细胞,并构建内皮祖细胞种植支架.15头家猪行TIPS介入手术,采用随机区组设计分为EPC种植支架组9头(实验组),裸支架组6头(对照组).术后14 d行直接门静脉造影,然后处死动物,作病理分析及免疫组织化学检查,记录分流道狭窄及阻塞率,并用图像处理软件计算TIPS分流道假性内膜厚度及面积.计数资料用Fisher精确概率法,计量资料行t检验,作统计学分析.结果 15头猪TIPS手术均成功.实验组分流道通畅5头,狭窄2头(狭窄率50%、70%),阻塞2头(共9头).对照组狭窄1头(狭窄率80%),阻塞5头(共6头).2组通畅率差异有统计学意义(P=0.03).实验组假性内膜增生的厚度(肝静脉、肝实质、门静脉段)显著小于对照组[分别为(1.0 ±0.6)、(0.9±0.5)、(1.0±0.4)mm和(1.2±0.4)、(1.3±0.5)、(1.5±0.4)mm,P值均＜0.05].免疫组织化学显示实验组中通畅的分流道有完整的内皮形成;再狭窄分流道的假性内膜主要由胶原纤维组成,而通畅分流道的假性内膜主要由细胞成分组成.结论 体外构建EPC种植支架是可行的,置入后促进了家猪模型TIPS分流道内皮化形成,可以提高分流道的通畅性.     

经颈静脉肝内门腔静脉分流术中胆汁漏出对内皮细胞生长及功能的影响

目的 探讨胆汁对离体培养的内皮细胞生长及功能的影响，进一步了解胆汁对支架内皮化的影响。方法 取人脐静脉内皮细胞进行体外培养，分别加入5％、10％、15％、20％、25％胆汁干预，观察内皮细胞生长状况，收获的细胞测总蛋白，四唑盐（MTT）吸光度值，条件培养液测血管性假性血友病因子（von Willebrand factor，简称vWF)行内皮细胞鉴定及功能测定。结果 含5％、10％、15％胆汁的细胞生长状况与不含胆汁者相似，含20％、25％胆汁的细胞明显减少并显幼稚；含25％胆汁的细胞MTT吸光度值及总蛋白较无胆汁者降低，差异有非常显著性意义（Kruskal-Wallis秩和检验，χ^2=29.913,P=0.0009及χ^2=18.857,P=0.002)；含20％以上浓度胆汁的细胞条件培养液中vWF含量也明显降低，差异有非常显著性意义（Kruskal-Wallis秩和检验，χ^2=27.213,P=0.0001)。所收获的细胞vWF测定均阳性。结论 一定浓度的胆汁具有抑制内皮细胞的生长及分泌vWF的功能。所收获的细胞vWF测定均阳性。结论 一定浓度的胆汁具有抑制内皮细胞的生长及分泌vWF的功能。     

经颈静脉肝内门体静脉分流术术前MRA评价

目的探讨磁共振血管成像（MRA）在经颈静脉肝内门体静脉分流术（TIPS）术前检查中的应用。方法对59例拟行TIPS治疗的患者行术前MRA检查,观察引起门静脉高压的病因、肝静脉及门静脉形态、走行,测量穿刺点处血管管径,并与正常对照组（50例）比较。结果门静脉高压组中单纯肝硬化49例,肝硬化合并肝癌4例,单纯门静脉血栓3例,脾静脉狭窄1例,布-加综合征2例。门静脉高压组与正常对照组肝静脉分型（3支型∶2支型∶1支型）分别为14∶39∶12、12∶34∶14 肝右静脉、肝中静脉、肝左静脉穿刺点管径符合数为52∶40∶28、46∶34∶23。门静脉右支和左支安全穿刺点分别位于（16.2±3.1）mm、（14.2±3.8）mm以远。结论MRA是一种有价值无损伤的检查方法,对TIPS术前疾病诊断及血管定位有着重要的意义。     

Alternative technique for transjugular intrahepatic portosystemic shunt in a young child

Liver transplantation is safer, more readily available and is increasingly being carried out in younger patients. Therapeutic bridging procedures such as transjugular intrahepatic portosystemic shunt have therefore become more relevant to paediatrics, especially in the group of patients who are too unstable for surgery or in whom a liver graft is not available. We describe a transjugular intrahepatic portosystemic shunt procedure in a 4-year-old child with life-threatening variceal bleeding in whom the conventional procedure had failed. This technique may provide an alternative to conventional transjugular intrahepatic portosystemic shunt in this group.     

A double-wire technique for transjugular intrahepatic portosystemic shunt through a transabdominal-transjugular portosystemic approach

OBJECTIVE: The purpose of this article is to describe a double-wire technique for transjugular intrahepatic portosystemic shunt (TIPS) procedures in which a transabdominal-transjugular portosystemic route is created that allows placement of a safety wire and a working wire. The safety wire provides a backup for the loss of the portosystemic tract and straightens the transjugular portosystemic route through a two-hand technique to facilitate shunt creation. CONCLUSION: Potential advantages of this technique include a precise and expeditious procedure for pediatric patients and those with small and hard liver or with focal lesions.     

MR Angiographic guidance for transjugular intrahepatic portosystemic shunt procedures

The authors used magnetic resonance (MR) angiography to guide catheter placement in transjugular intrahepatic portosystemic shunt (TIPS) procedures in nine of 18 patients and compared the results with those of the nine patients for whom prior planning based on MR angiography was not done. Two-dimensional time-of-flight MR venography was performed during breath hold, and projection venograms were formatted in sagittal, coronal, and axial planes. MR angiography defined venous anatomy sufficiently to shorten the procedure and help minimize invasiveness. With MR angiographic guidance, intrahepatic needle punctures were significantly fewer (without MR guidance: mean, 12.1; with MR guidance: mean, 3.6; P < 0.001) and associated complications were absent (without MR guidance: failed placement, n = 1; bleeding requiring blood transfusions, n = 1; death due to intraperitoneal hemorrhage with hemobilia, n = 1; and death due to hepatic capsular perforation, n = 1). The average time for the procedure was 2.9 hours without MR angiographic guidance and 1.8 hours with MR angiographic guidance (P < 0.001). The authors conclude that MR angiography is a useful technique for defining portal and hepatic venous anatomy before the TIPS procedure and that planning based on MR angiography may decrease the difficulty and length of the procedure.     

个体化经颈静脉肝内门体分流术血流动力学模拟研究

目的 建立个体化肝硬化门静脉高压模型,比较经颈静脉肝内门体分流术（TIPS）不同分流方案的差异。方法 选取1例肝硬化门静脉高压患者并测量数据。采用MIMIC软件建立9种分流方案模型,通过Fluent软件计算后导入计算流体力学（CFD）-Post软件行后处理。比较不同分流方案中门静脉压下降比、门静脉入肝血流比、分流道内来自肠系膜上静脉血流比,采用综合评价系数G进行优劣性评价。结果 分流道位置相同时,分流道直径越大,门静脉压下降越多、门静脉入肝血流越少,其中分流道直径为6 mm时不能充分降压。分流道直径相同时,分流道内来自肠系膜上静脉血流比为门静脉右支分流>主干分流>左支分流。G值在门静脉左支8 mm直径分流方案中最高。结论 TIPS术经门静脉左支构建直径为8 mm分流道方案的预期效果最佳。     

经肝段下腔静脉建立TIPS分流道的初步临床结果

目的 评估经肝段下腔静脉TIPS分流术在肝静脉与门静脉间解剖异常时操作的可行性，讨论其临床意义。方法 65例肝硬变门静脉高压患者行经肝段下腔静脉直接穿刺门静脉完成TIPS分流术。结果 65经肝段下腔静脉TIPS分流术均获成功，技术成功率100％，未出现术中技术相关并发症，一年内再狭窄率明显低于常规TIPS，3例肝性脑病经限流支架置入得以控制。结论 经肝段下腔静脉TIPS分流术技术用于肝静脉与门静脉间解剖异常病例是安全有效的，同时提示由于肝内分流道曲度较小，一年内支架开通率明显提高。     

Hepatic artery-targeting guidewire technique during transjugular intrahepatic portosystemic shunt

Objective

This study evaluated the feasibility and safety of the transjugular intrahepatic portosystemic shunt (TIPS) procedure using the hepatic artery-targeting guidewire technique for the puncture step.

Methods

We retrospectively reviewed 11 consecutive patients (5 men and 6 women, aged 46–76 years (mean 64 years)) with portal hypertension in whom the TIPS procedure was performed. As the first step in the TIPS procedure in all cases, a micro-guidewire was inserted into the hepatic arterial branch accompanying the portal venous branch through a microcatheter coaxially advanced from a 5-French catheter positioned in the coeliac or common hepatic artery. At the puncture step, the tip of the metallic cannula was aimed 1 cm posterior to the distal part of this micro-guidewire, after which the TIPS procedure was performed. Success rate, number of punctures and complications were evaluated.

Results

The TIPS procedure was successfully performed in all 11 patients. The mean number of punctures until success in entering the targeted portal venous branch was 5 (range 1–14). In 3 patients (27%), the right portal venous branch was entered at the first puncture attempt. The hepatic artery was punctured once in one patient and the bile duct was punctured once in another patient. No serious procedure-induced complications occurred.

Conclusion

The TIPS procedure can be accomplished safely, precisely and relatively easily using the hepatic artery-targeting guidewire technique.Transjugular intrahepatic portosystemic shunt (TIPS) placements have continued to increase since the first such procedure was performed in 1988 [1]. Currently, this procedure is accepted as an effective treatment for the complications of portal hypertension, such as variceal bleeding [2] and intractable ascites [2^,3]. In many institutions, including ours, however, this procedure is rarely performed and it might be difficult to maintain the necessary skills.During the TIPS procedure, the puncture from the proximal portion of the hepatic vein (usually a right hepatic vein) to the proximal portion of a branch of the intrahepatic portal vein (usually the right portal vein) is the most important and difficult step [1^,2]. In 1994, Matsui et al [4] introduced a simple technique to assist in this puncture step. This technique was aided by a targeting guidewire in the hepatic arterial branch accompanying the portal venous branch to be punctured. To our knowledge, there has been no subsequent literature on the use of this simple technique, which we have adopted in our institution. This study evaluated the application of the hepatic artery-targeting guidewire technique for the puncture step of the TIPS procedure. We also assessed the occurrence of procedure-induced complications in order to clarify the value of this technique to inexperienced or infrequent operators such as those in our institution.     

经左颈内静脉入路肝内门腔静脉支架分流术（附12例报告）

常规的经颈静脉肝内门腔支架分流术均经右颈内静脉入路。这种入路操作容易，已成为经典途径。本文报告了114例肝硬化门脉高压患者中12例经左颈静脉入路完成Tipss操作。12例患者在造影时发现右颈静脉血栓形成、狭窄甚至闭塞。在右颈内静脉闭塞的情况下，经左侧入路是可行的。     

A modified procedure for transjugular intrahepatic portosystemic shunt flow reduction

The authors present a modified transjugular intrahepatic portosystemic shunt (TIPS) flow reduction procedure to treat TIPS-related refractory hepatic encephalopathy, giving the results and follow-up on six patients. A 6-mm-diameter Uni Wallstent was introduced over a guide wire and deployed beyond the angulated portion of the TIPS. A Wallgraft was then introduced over the same guide wire, pushed through the Uni Wallstent coaxially, and deployed in the TIPS. All cases were technically and clinically successful. There were no deaths in the first month after the procedure. In this study, three patients had more than 1 year's patency.     

Torulopsis glabrata fungemia from infected transjugular intrahepatic portosystemic shunt stent

Transjugular intrahepatic portosystemic shunts (TIPS) are used to manage multiple complications of portal hypertension. Accounts of infection of TIPS stents are uncommon. The literature reports two cases of TIPS-associated Torulopsis glabrata (Candida glabrata) fungemia; both patients died within a year of TIPS placement despite therapy with intravenous antifungal agents. This report describes the successful long-term survival of a patient with Torulopsis TIPS stent infection.