AJR 2004; 182:1301-1304
© American Roentgen Ray Society
Stent-Graft for TIPS in a Hepatocellular Carcinoma Patient with Main Portal Vein Invasion
Jin Hur1,
Kwang-Hun Lee,
Jae Hoon Lee,
Jeong-Sik Yu,
Jong Yoon Won and
Do-Yun Lee
1 All authors: Department of Diagnostic Radiology and Research Institute of
Radiological Science, Yonsei University College of Medicine, YongDong
Severance Hospital, 146-92, Dogok-Dong, Kangnam-Ku, Seoul 135-270, South
Korea.
Received June 26, 2003;
accepted after revision September 11, 2003.
Address correspondence to K.-H. Lee.
Introduction
The transjugular intrahepatic portosystemic shunt (TIPS) has evolved as an
important, minimally invasive treatment for managing the complications of
portal hypertension [1,
2]. However, TIPS placement in
patients with portal vein occlusion resulting from hepatic malignancy has been
described in relatively few case reports
[3–5].
When TIPS placement is performed in patients with portal hypertension due to
tumor thrombus, shunt dysfunction caused by stenosis and occlusion is a common
problem. Recently, several studies have reported that polytetrafluoroethylene
stent-grafts can prolong TIPS patency
[6] and thus potentially reduce
the need for shunt follow-up and revision and the risk of recurrent symptoms
associated with shunt stenosis or occlusion. We report a TIPS placement, using
polytetrafluoroethylene stent-grafts, in a hepatocellular carcinoma patient
with invasion of the main portal vein.
Case Report
A 58-year-old man was admitted to our emergency department with acute
gastrointestinal bleeding. Endoscopy revealed bleeding from gastric varices
and grade III esophageal varices. Endoscopic sclerotherapy was performed but
was insufficient to eradicate varices.
The patient had been diagnosed the previous year as having a hepatocellular
carcinoma involving nearly the entire right lobe of the liver with a tumor
thrombus in the right portal vein on three-phase contrast-enhanced CT. At that
time, his serum levels of 
-fetoprotein and total bilirubin were 20,208
IU/mL and 1.3 mg/dL, respectively. Transcatheter arterial chemoembolization
was performed using a mixture of 50 mg of doxorubicin (Adriamycin, Ildong), 10
mL of iodized oil (Lipiodol, Andre Guerbet), and gelatin sponge pledgets
(Gelfoam, Upjohn). After 3 months, Chemo-Port insertion was performed for the
treatment of diffuse hepatocellular carcinoma with tumor thrombus in the main
portal vein.
Two days after sclerotherapy, the patient had a second episode of massive
variceal bleeding. Laboratory testing showed a hemoglobin level of 8.3 g/dL,
total bilirubin of 2.4 mg/dL, albumin of 2.5 g/dL, and prothrombin time of
12.1 sec. His condition was classified as Child-Pugh class C. Repeated massive
variceal hemorrhage led us to consider a TIPS procedure for life-saving
purposes. Accordingly, the right jugular vein was punctured and a 9-French
Ring Transjugular Intrahepatic Access Set (RTPS-100, Cook) was advanced. A
16-gauge Colapinto needle was used to access the portal system, and a shunt
was created between the right hepatic vein and the splenic vein. In general,
the Colapinto needle is advanced into the right hepatic vein in an
anteromedial direction, several centimeters into the liver parenchyma; then
suction is applied to the needle as it is slowly withdrawn. When blood is
aspirated, contrast medium is injected to determine which vascular structure
is punctured. However, in cases such as this, when the portal vein is occluded
by tumor thrombus, blood aspirated is absent or scant.
Therefore, we first advanced the Colapinto needle in an estimated portal
vein direction and injected contrast medium. The outline of the tumor thrombus
in the portal vein was then visualized, and a 0.035-inch hydrophilic guidewire
(Terumo) was manipulated through the obstructed segment of the portal vein
(Fig. 1A). A 5-French catheter
was advanced into the occlusion, and contrast medium was injected to define
the anatomy of the obstruction and to distend the residual portal vein lumen.
The guidewire and catheter were then manipulated through the remaining
obstructed portal vein segment into the superior mesenteric vein. Direct
portography, which was performed at the level of the superior mesenteric vein,
failed to visualize hepatopetal flow because of the main portal vein
obstruction. However, gastric fundal varices and the gastrorenal shunt were
seen (Fig. 1B). After the
thrombosed portal vein was dilated with an 8-mm-diameter angioplasty balloon
catheter (Ultrathin, Boston Scientific), two polytetrafluoroethylene
stent-grafts (S&G Biotech) 10 mm in diameter and 7 cm long were inserted
from the splenic vein through the thrombosed portal vein, and a Wallstent
(Medi-Tech/Boston Scientific) of 10 mm in diameter and 5 cm long was inserted
in the right hepatic vein. The 7-cm-long stent-grafts were constructed with a
distal 2-cm bare portion and a proximal 5-cm graft portion. Balloon dilation
after stenting was performed using an 8-mm angioplasty balloon
(Fig. 1C). The pressure
gradient between the main portal vein and the right atrium was adequately
reduced to 9 mm Hg after the TIPS procedure. The variceal bleeding was
immediately controlled, but rebleeding occurred 3 days later. At direct
portography performed using the TIPS tract, the patency of the shunt tract was
found to be well preserved, but marked gastric fundal varices were visualized
(Fig. 1D). Transcatheter
variceal embolization was performed via the TIPS tract to the splenic vein
using a 3-French coaxial microcatheter (Renegade, Medi-Tech/Boston Scientific)
with a mixture of 0.5 mL of Histoacryl tissue adhesive (Braun) and 1 mL of
iodized oil to exclude the gastric fundal varices
(Fig. 1E).
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Fig. 1A. —58-year-old man with acute upper gastrointestinal bleeding
from gastric fundal varices. Puncture was performed into "reversed
thread and streak" sign of tumor thrombus in portal vein (long black
arrows). Hydrophilic guidewire (0.035-inch) was manipulated through
obstructed segment of portal vein and successfully passed into superior
mesenteric vein (arrowheads). Dense opacification of biliary system
(short black arrows) indicated biliary puncture during creation of
transjugular intrahepatic portosystemic shunt (TIPS). Previously inserted
Chemo-Port catheter (white arrows) for intraarterial chemotherapy is
seen.
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Fig. 1B. —58-year-old man with acute upper gastrointestinal bleeding
from gastric fundal varices. Image from direct portography, which was
performed at level of superior mesenteric vein, does not show hepatopetal flow
because of obstructed main portal vein. However, gastric fundal varices and
gastrorenal shunt are visualized.
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Fig. 1C. —58-year-old man with acute upper gastrointestinal bleeding
from gastric fundal varices. TIPS was created from splenic vein to right
hepatic vein. Two stent-grafts were placed into distal main portal vein that
was involved by tumor thrombus, and one bare stent (Wallstent,
Medi-Tech/Boston Scientific) was placed into proximal portion of right hepatic
vein. Flow and velocity of gastric fundal varix were reduced after
procedure.
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Fig. 1D. —58-year-old man with acute upper gastrointestinal bleeding
from gastric fundal varices. Rebleeding occurred 3 days after TIPS placement.
Image from direct portography, which was performed via TIPS tract, shows that
patency of shunt tract is well preserved. Marked gastric fundal varices
(arrows) are also visualized.
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Fig. 1E. —58-year-old man with acute upper gastrointestinal bleeding
from gastric fundal varices. Transcatheter variceal embolization was performed
using 3-French coaxial microcatheter with Histoacryl tissue adhesive (mixture
of 0.5 mL of Histoacryl [Braun] and 1 mL of iodized oil) via TIPS tract to
splenic vein. Note that gastric fundal varices were completely excluded by
Histoacryl injection.
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During 3 months of follow-up examinations, the shunt patency was confirmed
by Doppler sonography, and no clinical sign of rebleeding was seen.
Discussion
TIPS creation has become a successful nonsurgical technique for creating
portosystemic shunts in the treatment of portal venous hypertension
complicated by variceal bleeding. When nonsurgical techniques are insufficient
to control variceal bleeding, TIPS can be considered for life-saving purposes.
Despite the considerable body of literature on TIPS, shunts in portal vein
occlusion resulting from hepatic malignancy have not been sufficiently
examined. In fact, several authors have used the presence of hepatic
malignancy as a partial exclusion criterion because results have been found to
be poorest among the subgroup of patients with hepatocellular carcinoma
[7].
Reports of portal hypertension due to malignancy treated with TIPS are
scarce
[3–5].
However, to our knowledge no case report is available concerning successful
TIPS creation using a stent-graft in a patient with a tumor thrombus involving
the entire main portal vein.
When TIPS creation is performed in patients with hepatocellular carcinoma,
several problems may occur: namely, intratumoral bleeding, dissemination of
malignant cells into the circulation by repeated hepatocellular carcinoma
puncture, or shunt occlusion by tumor ingrowth into the mesh of the stent.
Thus, we surmise that a stent-graft may have advantages over a bare stent. We
also believe that stent-grafts, which traverse malignancy in TIPS procedures
(Fig. 1F), are appropriate to
reduce shunt occlusions, improve long-term patency, and reduce the potential
for vascular spread of the tumor. The stent-graft we used had an outer
covering of polytetrafluoroethylene, and we believe that this type of
stent-graft is more effective in reducing shunt occlusion by tumor
invasion.
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Fig. 1F. —58-year-old man with acute upper gastrointestinal bleeding
from gastric fundal varices. Abdominal dynamic CT scan obtained 2 months after
TIPS placement at level of distal main portal vein just above portal
confluence shows patent distal portion of TIPS stent. Note junction (thin
arrow) of grafted stent and bare stent. Expansile tumor thrombus
(thick arrows) is seen in distal main portal vein posterior aspect of
stent.
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As in our patient, variceal rebleeding can occur even though the pressure
gradient is sufficiently reduced after TIPS creation. If rebleeding occurs,
transcatheter variceal embolization can be attempted to control it. For this
reason, when the main portal vein is occluded by tumor thrombus, TIPS creation
from the splenic vein is more effective than from the superior mesenteric vein
because the gastric fundal varices can be easily approached through the
stent-graft from the splenic vein for transcatheter variceal embolization. It
is also important that the stent-graft procedure be performed without
obstruction of the superior mesenteric vein orifice by the stent-graft
(Fig. 1G).
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Fig. 1G. —58-year-old man with acute upper gastrointestinal bleeding
from gastric fundal varices. CT scan obtained at level of orifice of superior
mesenteric vein shows that vein is patent (thin arrow). Orifice is
partially covered by bare stent. Thick arrows indicate tumor thrombus in
distal main portal vein.
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In conclusion, this case shows the feasibility and efficacy of the TIPS
technique in a patient with hepatocellular carcinoma involving the main portal
vein and complicated by variceal bleeding. When the TIPS technique is
considered in hepatic malignancy to control variceal bleeding that cannot be
controlled by other nonsurgical techniques, a stent-graft is probably more
advantageous than a bare stent.
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Introduction
Case Report
