Case Report
Stent-Graft for TIPS in a Hepatocellular Carcinoma Patient with Main Portal Vein Invasion
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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 |  |
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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 α-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).
 View larger version (60K) | 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. |
 View larger version (68K) | 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. |
 View larger version (59K) | 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. |
 View larger version (70K) | 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. |
 View larger version (63K) | 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. |
During 3 months of follow-up examinations, the shunt patency was confirmed by Doppler sonography, and no clinical sign of rebleeding was seen.
| Discussion | |
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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.
 View larger version (53K) | 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. |
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).
 View larger version (51K) | 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. |
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.
Address correspondence to K.-H. Lee.
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