Revision of a Transjugular Intrahepatic Portosystemic Shunt Using a Percutaneous Transhepatic Approach

Introduction Transjugular intrahepatic portosystemic shunts (TIPS) involve creating a direct connection between the hepatic vein and a branch of the portal vein as a treatment for the sequelae of portal hypertension, such as refractory ascites or bleeding esophageal varices. Stent occlusion is a long-term complication and requires re-stenting. In cases where it is not possible to access the stent intravascularly, a percutaneous transhepatic approach can be used to assist in accessing the stent for subsequent angioplasty. This case demonstrates an uncommon percutaneous approach to access an existing occluded TIPS stent.

Case Report The patient is a 44-year-old female with hepatic cirrhosis, portal hypertension, and recurrent ascites who previously had a TIPS placed. Visceral Doppler of the liver was preformed, which showed no flow in the TIPS concerning for complete occlusion. Using a standard internal jugular vein approach, multiple attempts to cannulate the TIPS stent were unsuccessful due to TIPS occlusion. This prompted a percutaneous transhepatic approach to access the existing TIPS. This method allowed successful access of the TIPS and subsequent angioplasty and maceration of the thrombus. Deployment of a VIATORR TIPS stent inside the existing TIPS was performed. Post angioplasty portal venogram demonstrated brisk flow in the portal vein and TIPS stent.

Learning Points Along with the standard intravascular approach, a percutaneous transhepatic approach can be used to assist in accessing a malfunctioning TIPS stent. This patient was successfully treated with the assistance of a percutaneous transhepatic approach to access the occluded TIPS.