Parallel transjugular intrahepatic portosystemic shunt with Viatorr^® stents for transjugular intrahepatic portosystemic shunt insufficiency: A case report and review of literature

Abstract

BACKGROUND Transjugular intrahepatic portosystemic shunts (TIPS) can alleviate complications of portal hypertension such as ascites and variceal bleeding by decreasing the portosystemic gradient. In limited clinical situations, parallel TIPS may be only solution to alleviate either variceal bleeding or ascites secondary to portal hypertension when the primary TIPS fails to do so. Data specifically addressing the use of this partially polytetrafluoroethylene covered nitinol stent (Viatorr ® ) is largely lacking despite Viatorr ® being the current gold standard for modern TIPS placement. CASE SUMMARY All three patients had portal hypertension and already had a primary Viatorr ® TIPS placed previously. All patients have undergone failed endoscopy to manage acute variceal bleeding before referral for a parallel stent (PS). PS were placed in patients presenting with recurrent variceal bleeding despite existence of a widely patent primary TIPS. Primary stent patency was verified with either Doppler ultrasound or intra-procedural TIPS stent venography. Doppler ultrasound follow-up imaging demonstrated complete patency of both primary and parallel TIPS. All three patients did well on clinical follow-up of up to six months and no major complications were recorded. A review of existing literature on the role of PS in the management of portal hypertension complications is discussed. There are three case reports of use of primary and PS Viatorr ® stents placement, only one of which is in a patient with gastrointestinal variceal bleeding despite a patent primary Viatorr ® TIPS. CONCLUSION Viatorr ® PS placement in the management of variceal hemorrhage is feasible with promising short term patency and clinical follow-up data.

Refractory portal hypertension complications successfully managed by parallel transjugular intrahepatic portosystemic shunt (TIPS): a case report

“…(Dabos et al 1998 ) Parallel TIPS has since been predominantly reserved for when the primary TIPS is inaccessible or unfavourable for recanalization and for persisting portal hypertension despite verified patency on imaging. (Raissi et al 2019 ) It has demonstrated similar patency rates in the mid-term compared to TIPS of patients who do not undergo parallel TIPS. (Raissi et al 2019 ; Helmy et al 2006 )…”

Parallel transjugular intrahepatic portosystemic shunt (TIPS) for TIPS dysfunction: technical and patency outcome

“…It is noteworthy that following the previously mentioned studies, one publication of case series and limited case report studies were published [20][21][22]. Luo et al reported the outcome of 18 patients with portal hypertension with PS insertion.…”

Repeat Stent Placement through Lateral Fenestration of the Existing Dysfunctioning DIPS Stent Graft: An Alternative to Parallel TIPS/DIPS Procedure in a Case of Blocked Primary TIPS/DIPS

“…7 In 1992, Haskal et al first reported creation of a second parallel TIPS tract to reduce the portosystemic pressure gradient. 8 More recently, He et al 9 and Raissi et al 10 have also described the feasibility and effectiveness of parallel TIPS. Parallel TIPS involves the creation of a second new tract, usually from the right hepatic vein to the right branch of the portal vein, parallel to the first stent and using the first stent as a marker.…”

“…If not, then a combination of PTFE covered and uncovered stent can be used. 10 We describe a unique technique where in cases of TIPS/ DIPS revision a new tract can be created through a lateral direct puncture across the fenestrations of the existing dysfunctioning stent graft. This technique can be used when it is not possible to gain access into the proximal hepatic venous end of the blocked stent.…”