Angiographic Patterns of Transjugular Intrahepatic Portosystemic Shunt Dysfunction and Interventional Approaches to Shunt Revision
AhmadParvinian, Benedictta O.Omene, James T.Bui, Martha GraceKnuttinen, JeetMinocha, Ron C.Gaba
Department of Radiology, Interventional Radiology Section, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
Address for correspondence: Dr. Ron C. Gaba, Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 West Taylor Street, MC 931, Chicago, IL 60612, USA. E-mail: firstname.lastname@example.org
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Transjugular intrahepatic portosystemic shunt (TIPS) is an established and effective treatment for the complications of portal hypertension. The non-trivial rates of shunt dysfunction inherent to TIPS mandate familiarity with the imaging diagnosis and endovascular management of this phenomenon. Herein, we present a pictorial review of the various angiographic patterns of TIPS dysfunction and illustrate traditional and innovative technical approaches to shunt revision.
Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for the complications of portal hypertension. However, the well-documented safety and efficacy of this procedure may be complicated by shunt dysfunction, which occurs in approximately 15% of covered stents and 44% of bare metal stents. Because TIPS dysfunction may precipitate recurrence of portal hypertensive complications, it is incumbent upon interventional radiologists to be familiar with the diagnosis and management of shunt failure. Herein, we review the various angiographic patterns of TIPS dysfunction and illustrate basic and advanced techniques for shunt revision. Institutional review board approval was obtained for this study.
Patterns of TIPS dysfunction and basic shunt revision techniques
Conventional treatment options for TIPS dysfunction comprise various common techniques - namely, balloon angioplasty, shunt relining, and shunt extension- that may be applied alone or in combination to address an assortment of problems. These approaches are particularly well-suited to the management of intimal hyperplasia [Figures 1 and 2], thrombotic occlusion [Figure 3], hepatic [Figures 4 and 5] and portal [Figure 6] venous end shunt stenosis, abnormal angulation [Figure 7], occult portosystemic pressure gradient elevation [Figure 8], and flow-sumping [Figure 9]. Awareness of benign findings such as pseudostenosis [Figure 10] is important to avoid unnecessary intervention.
Advanced revision techniques
In technically difficult cases, conventional approaches to TIPS revision may not be feasible. For instance, complete shunt occlusion may preclude transjugular wire access and necessitate use of advanced methods such as back-end stiff guide wire [Figure 11] or metal cannula-supported shunt access [Figure 12], or even percutaneous transhepatic recanalization [Figure 13]. Patients with tumor vascular invasion and TIPS occlusion may require shunt extension [Figure 14]. Cases of insufficient portosystemic shunting may call for parallel TIPS [Figure 15] in order to achieve satisfactory clinical response; this technique also permits circumvention of an unsalvageable primary shunt [Figure 16]. Conversely, individuals who develop hepatic encephalopathy or liver failure due to excess portosystemic shunting necessitate TIPS reduction [Figure 17] or occlusion [Figure 18].
TIPS dysfunction is a common phenomenon that requires timely diagnosis and intervention. An understanding of the different causes of shunt failure and the approaches – both standard and innovative – to restoring patency of the shunt will optimize clinical outcomes in patients with portal hypertensive complications.
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