Single Institution Outcomes of TIPS (Transjugular Intrahepatic Portosystemic Shunt) Diameter Reduction Using Single Balloon Expandable Covered Stent Deployment in Hourglass Conformation.

Tuesday, March 7, 2023

3:45 PM – 3:54 PM

Location: Phoenix Convention Center, 226ABC

Presenting Author(s)

TB

Timothy J. Breider, BS

Medical Student
Rush University Medical Center

Disclosure information not submitted.

Author/Co-author(s)

BH

Bradley D. Hunt, BS

Medical Student
Rush University Medical Center
David Tabriz, MD, MBA

Assistant Professor of Radiology
Cleveland Clinic Florida
RR

Rehan Riaz, MD

Assistant Professor of Radiology
Rush University Medical Center
Kumar Madassery, MD

Associate Professor, Vascular and Interventional Radiology
Rush University Medical Center, Rush Oak Park
Jordan Tasse, MD

Physician
Rush University Medical Center
UT

Ulku Turba, MD, FSIR

Professor
Rush University Medical Center
Bulent Arslan, MD, FSIR

Professor and Interim Chair
Rush University Medical Center

Disclosure(s):

Kumar Madassery, MD: Abbott Vascular: Consultant (Ongoing); Cook Mediical: Consultant (Ongoing); Koninklijke Philips: Consultant (Ongoing); PENUMBRA INC: Consultant (Ongoing)

Jordan Tasse, MD: No financial relationships to disclose

Ulku Turba, MD, FSIR: No financial relationships to disclose

Bulent Arslan, MD, FSIR: Angiodynamics Inc: Advisory Committee or Review Panel Member (Ongoing), Consultant (Ongoing); BD Bard: Consultant (Ongoing), Speaking and Teaching (Ongoing); Blackswan Vascular Inc: Consultant (Ongoing), Ownership Interest (Ongoing), Speaking and Teaching (Ongoing); Cook Inc: Consultant (Ongoing), Speaking and Teaching (Ongoing); Medtronic Inc: Consultant (Ongoing), Speaking and Teaching (Ongoing); Penumbra: Speaking and Teaching (Ongoing)

Purpose: Hepatic encephalopathy and/or liver failure are potential complications of TIPS creation. Depending on severity of these complications TIPS diameter reduction or TIPS occlusion may become necessary. One method of shunt reduction is expansion of a covered balloon expandable stent in an hourglass formation within the original TIPS stent. This easy to perform technique effectively reduces shunt diameter in a controlled fashion and increases the portosystemic gradient. The purpose of this study was to assess technical and clinical outcomes of TIPS reduction using only this technique.

Materials and Methods: Electronic medical records were reviewed to identify all TIPS reductions performed using an intra-stent balloon expandable stent (Viabahn VBX, Gore; Newark, Delaware). Clinical notes immediately prior to and 30 days following the reduction were used to identify rates of resolution and improvement of symptoms, changes in shunt diameter and portosystemic gradient, systemic ammonia levels, and MELD score.

Results: In total, 19 intra-stent TIPS reductions were identified (8M, 11F). Indications for reduction included overt hepatic encephalopathy (14) and acute liver failure due to ischemia (5). Original shunts ranged in diameter from 5-10mm with an average of 7.5mm. Reduction procedure reduced shunt diameters between 1 to 7mm with an average reduction of 2.9mm. This coincided with an average gradient increase of 5.8 mmHg. Following reduction, 63% of patients had resolution of shunt related symptoms within 30 days. An additional 10% had partially reduced symptoms and 26% had no improvement of symptoms. The average change in MELD pre and post reduction was 0.7. Blood ammonia levels were reduced on average by 78 µ/dL. Technical success rate of reduction procedures was 100% with an average fluoroscopy time of 15.3 minutes. Of note, in one patient who was overcorrected, subsequent shunt expansion was easily performed due to prior use of this technique.

Conclusion: TIPS reduction continues to be a procedure that is poorly standardized across institutions. One institution’s use of an hourglass shaped balloon expandable stent was shown to be technically feasible and effective in reducing portosystemic gradients, symptoms, and plasma ammonia levels. Compared to other methods available, this procedure is quick, easily performed, and has the option of controlling shunt diameter.