Transjugular intrahepatic collateral-systemic shunt is effective for cavernous transformation of portal vein with variceal bleeding

Abstract

Background: The transjugular intrahepatic portal collateral-systemic shunt (transcollateral TIPS) is used to treat portal hypertension-related complications in patients with cavernous transformation of the portal vein (CTPV) and whose main portal vein cannot be recanalized. It is still not clear whether transcollateral TIPS can be as effective as portal vein recanalization–transjugular intrahepatic portosystemic shunt (PVR–TIPS). This study aimed to evaluate the efficacy and safety of transcollateral TIPS in the treatment of refractory variceal bleeding with CTPV. Methods: Patients with refractory variceal bleeding caused by CTPV were selected from the database of consecutive patients treated with TIPS in Xijing Hospital from January 2015 to May 2021. They were divided into the transcollateral TIPS group and the PVR–TIPS group. The rebleeding rate, overall survival, shunt dysfunction, overt hepatic encephalopathy (OHE) and operation-related complications were analyzed. Results: A total of 192 patients were enrolled, including 21 patients with transcollateral TIPS and 171 patients with PVR-TIPS. Compared with the patients with PVR-TIPS, the patients with transcollateral TIPS had more noncirrhosis (52.4% vs. 19.9%, p = 0.002), fewer splenectomies (14.3% vs. 40.9%, p = 0.018), and more extensive thrombosis (38.1% vs. 15.2%, p = 0.026). There were no differences in rebleeding, survival, shunt dysfunction, or operation-related complications between the transcollateral TIPS and PVR-TIPS groups. However, OHE was significantly lower in the transcollateral TIPS group (9.5% vs. 35.1%, p = 0.018). Conclusion: Transcollateral TIPS is an effective treatment for CTPV with refractory variceal bleeding.

Efficacy and Safety of Precision-Guided Transjugular Extrahepatic Portosystemic Shunt (TEPS) in the Management of Cavernous Transformation of the Portal Vein with Portal Hypertension: A Case Series

“…During the initial development stages of the TIPS procedure, bleeding emerged as a significant contributor to perioperative mortality in patients [13]. Interventional radiologist have long been concerned about the potential risk of bleeding in extrahepatic portosystemic shunts, as the extrahepatic portal venous system lacks the protection of the Glisson's capsule, unlike the intrahepatic PV [14].In our case series, two patients experienced moderate intra-abdominal bleeding, one during transsplenic puncture and the other during stent deployment.To mitigate the risk of bleeding, we primarily employed three strategies: (1) using ultrasound guidance to puncture the spleen parenchyma, thus avoiding insertion of the puncture needle into the main splenic vein (SV) and employing spring coils or tissue glue to seal the puncture site during sheath removal, and combining this with splenic artery embolization if necessary; (2) minimizing the number of intra-abdominal punctures to precisely guide the placement of the catheter or balloon at the intended location, with the goal of establishing the portal-caval shunt with fewer than two punctures, which represents the fundamental technique ensuring safety in our cases; and (3) refraining from pre-dilation before stent implantation.…”

“…recently reported on the safety of lateral branch shunting, covering 21 cases primarily focusing on intrahepatic/perihepatic shunts. Whether cases of retroperitoneal collateral vessel shunting were included remains unclear [14]. Based on the aforementioned studies, exploring retroperitoneal collateral shunting appears promising when other suitable shunting pathways are unavailable.…”

“…Earlier reports on lateral branch TIPS have indicated that when the PV end of the stent is anchored in small collateral vessels, the shunt efficiency is compromised, resulting in inadequate portal decompression and recurrent bleeding in patients [15,20]. In contrast to anchoring the PV end within a thrombus or collateral vessels, Precision TEPS anchors it in the SV, the root of the SMV, or larger collateral vessels, resulting in a notable enhancement of shunt efficiency and a reduction in the risk of stent occlusion [14,15,20,21].However, considering the short follow-up period in this study, additional observations are required to assess its long-term outcomes.…”