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Endovascular Shunt Reduction in the Management of Transjugular Portosystemic Shunt-Induced Hepatic Encephalopathy: Preliminary Experience with Reduction Stents and Stent-Grafts

¹ Department of Radiology, University Hospitals Gasthuisberg, Herestraat 49, Leuven, Belgium, B/3000.
² Department of Hepatology, University Hospitals Gasthuisberg, Leuven, Belgium, B/3000.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —35-year-old woman (patient 1) who received a transjugular intrahepatic portosystemic shunt for ascites and 3 months later had recurrent episodes of comatose state due to hepatic encephalopathy. Portogram shows portosystemic shunt with Wallstent (Boston Scientific) inserted for refractory ascites.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —35-year-old woman (patient 1) who received a transjugular intrahepatic portosystemic shunt for ascites and 3 months later had recurrent episodes of comatose state due to hepatic encephalopathy. Photograph shows Memotherm reduction stent (Angiomed) used to manage hepatic encephalopathy. Narrowest part (arrow) of reduction stent (arrowheads) was 5 mm in diameter.

View larger version (150K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —35-year-old woman (patient 1) who received a transjugular intrahepatic portosystemic shunt for ascites and 3 months later had recurrent episodes of comatose state due to hepatic encephalopathy. Radiograph shows Memotherm reduction stent (arrowheads) within Wallstent shunt. Narrowest part of reduction stent (arrow) was 5 mm in diameter.

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —35-year-old woman (patient 1) who received a transjugular intrahepatic portosystemic shunt for ascites and 3 months later had recurrent episodes of comatose state due to hepatic encephalopathy. Completion portogram after reduction shows no angiographic reduction of shunt although reduction stent (arrowheads) is in place and narrowest part of stent (arrow) is 5 mm in diameter. There was no difference in portosystemic pressure gradient before and after shunt reduction.

View larger version (183K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —68-year-old man (patient 10) who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement because of refractory ascites and then shunt reduction because of multiple episodes of stupor and unconsciousness. Portogram shows Viatorr stent-graft (W. L. Gore and Associates) used for TIPS.

View larger version (60K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —68-year-old man (patient 10) who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement because of refractory ascites and then shunt reduction because of multiple episodes of stupor and unconsciousness. Photograph shows self-expanding OptiMed reduction stent-graft with narrowest (5-mm) diameter (arrow) within shunt.

View larger version (184K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —68-year-old man (patient 10) who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement because of refractory ascites and then shunt reduction because of multiple episodes of stupor and unconsciousness. Portogram shows shunt placement resulting in reopacification of intrahepatic portal veins and clear reduction of shunt diameter in narrow segment (arrow) of reduction stent-graft.

View larger version (164K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —58-year-old man (patient 11) who underwent emergency transjugular intrahepatic portosystemic shunt (TIPS) procedure because of variceal bleeding unresponsive to pharmacologic and endoscopic treatment. One month after TIPS procedure, patient became stuporous and was treated with reduction stent. Portogram shows TIPS.

View larger version (68K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —58-year-old man (patient 11) who underwent emergency transjugular intrahepatic portosystemic shunt (TIPS) procedure because of variceal bleeding unresponsive to pharmacologic and endoscopic treatment. One month after TIPS procedure, patient became stuporous and was treated with reduction stent. Photograph shows Memotherm reduction stent (Angiomed) relined with Viatorr stent-graft (W. L. Gore and Associates), which was centrally constrained to 5-mm diameter.

View larger version (181K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —58-year-old man (patient 11) who underwent emergency transjugular intrahepatic portosystemic shunt (TIPS) procedure because of variceal bleeding unresponsive to pharmacologic and endoscopic treatment. One month after TIPS procedure, patient became stuporous and was treated with reduction stent. Completion portogram shows antegrade reopacification of intrahepatic portal veins and clearly visible narrow segment (arrow) of portosystemic shunt. Coils (arrowheads) placed to occlude esophageal varices, which reopacified immediately after shunt reduction, are evident.

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