SIR 2024
Portal Hypertension
Timothy J. Breider, BS
Medical Student
Rush University Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Identify indications for reduction in TIPS diameter
Review and discuss technical options for reduction in TIPS diameter
Background: Patients with portal hypertension presenting with ascites or esophageal varices that are refractory to medical management may be candidates for transjugular intrahepatic portosystemic shunt placement (TIPS). However, shunt placement increases risk of hepatic encephalopathy and ischemic liver failure. If TIPS placement causes adverse effects that cannot be managed medically, complete occlusion of the shunt is not the only option. Various procedures have been described to reduce the size of the shunt allowing for precise control of the portosystemic gradient to manage both original presenting symptoms and adverse effects.
Clinical Findings/Procedure Details:
Methods of TIPS diameter reduction that have been discussed in literature include direct central constriction of a covered stent, parallel stent placement, tapered grafts, or selective intra-shunt stent expansion. Direct constriction uses a silk suture, catheter “lasso”, or balloon expandable stent to mechanically restrain the expansion of a newly placed self-expanding covered stent{1,2}. Parallel stent placement allows for adjustable sizing by inserting a balloon-expandable stent into the original shunt before placement of the self-expanding covered stent{3}. Selective expansion uses a balloon expandable covered stent that can be selectively shaped like an hourglass by using larger balloons at the edges and a smaller diameter balloon at the center.{4}
Conclusion and/or Teaching Points:
In cases of persistent HE and LF, TIPS reduction rather than occlusion is a valid option.
There are various techniques available for the effective reduction of stent diameter.
Selective stent expansion as described above is the easiest to perform and allows the operator to achieve a precise gradient target.