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Stenosis of transjugular intrahepatic portosystemic shunts: presentation and management
1Division of Vascular and Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA.
Objective:
The purpose of this study was to define the incidence, nature, and presentation of stenoses that develop in patients with transjugular intrahepatic portosystemic shunts (TIPS) and to assess the efficacy of treatment that prolongs shunt patency.
Materials And Methods:
TIPS were successfully created in 108 patients over a 43-month period. Of the 93 patients with adequate radiologic or pathologic follow-up, 60 had no shunt problems and 33 developed shunt stenoses or occlusions. Follow-up of these 93 patients included sonography, venography, and/or pathologic confirmation. Presentations of stenoses, types of therapy, and patency after treatment were evaluated in all patients.
Results:
In the cohort group, 35% of the patients had shunt problems (mean time to presentation, 7.4 months after TIPS). Forty stenoses and eight occlusions occurred in the 33 patients. Of the 48 shunt problems, 35 (73%) were detected with routine radiologic screening, 12 (25%) presented with recurrent symptoms, and one (2%) was confirmed by pathologic evaluation. Of the 33 patients with stenoses and occlusions, 21 had one reintervention, six had two reinterventions, three had three reinterventions, one had four reinterventions, and two received no therapy. These reinterventions included 30 restentings, 11 angioplasties, four new shunts, and one thrombolysis alone. Of the 31 primary reinterventions, 23 (74%) were restentings, six (19%) were angioplasties, and two patients received a new TIPS. Of the 10 secondary reinterventions, six were restentings, three were angioplasties, and one was a new TIPS. Of the four tertiary reinterventions, one was a restenting, two were angioplasties, and one was thrombolysis. Kaplan-Meier survival analysis revealed the primary patency of the shunt to be 67% at 6 months, 48% at 1 year, and 26% at 2 years. The primary-assisted patency of the shunt was 96% at 6 months and 87% at 3 years. The secondary patency was 99% at 1 year and 89% at 3 years.
Conclusion:
Stenoses are common after TIPS procedures and frequently can be detected on routine screening studies. Shunt revision can effectively extend the patency of TIPS. Restenting is generally required for hepatic vein stenoses. Angioplasty should be the first line of therapy for intrashunt stenoses, as only 44% of patients will require restenting.