Unique Method of Transjugular Intrahepatic Portosystemic Shunt Reduction for Refractory Hepatic Encephalopathy

Abstract

We report the case of a 27-year-old female patient with a history of cryptogenic cirrhosis who was admitted to the hospital due to multiple episodes of hematemesis secondary to bleeding esophageal varices. The varices were persistent and refractory to endoscopic intervention, so an emergent transjugular intrahepatic portosystemic shunt (TIPS) was performed by interventional radiology (IR). Months later, the patient returned to the hospital unresponsive with acute intermittent hepatic encephalopathy which required a TIPS reduction by IR. Once the TIPS reduction was performed, the patient's hepatic encephalopathy declined, and her symptoms improved. Here, we present a unique method of TIPS reduction utilizing a single Viabahn VBX balloon-expandable stent (W. L. Gore & Associates, Inc; Flagstaff, AZ) to constrain the existing TIPS stent.

Transjugular Intrahepatic Portosystemic Shunt Reductions

“…26 Recently, Khan and Bailey described a unique method of reduction using the Viabahn VBX Endoprosthesis (W. L. Gore & Associates) factory mounted balloon-expandable stent. 27 In this method, a 10-Fr sheath is placed through the internal jugular vein (IJV), through which the Viabahn VBX is loaded. The sheath is retracted over the middle and proximal segments of the stent, leaving the distal segment unsheathed.…”

“…We are familiar with and have successfully used the later method utilizing a PTFE covered iCast stent described by Kroma et al 26 A newer hourglass technique has also been described using a Viabahn VBX stent-graft by Khan and Bailey. 27 The latter two methods will be described later, as they are the most simple, modern, and reproducible. i. I-Cast: The balloon-expandable stent is lined up such that the cranial (hepatic) portion of the iCast matches the existing TIPS stent.…”