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TIPS-related Hepatic Encephalopathy: Management Options with Novel Endovascular Techniques¹

¹ From the Division of Diagnostic Imaging, Section of Vascular and Interventional Radiology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 325, Houston, TX 77030-4009 (D.C.M., M.J.W., K.A.); and North County Radiology, Vista, Calif (R.R.S.). Presented as an education exhibit at the 2002 RSNA scientific assembly. Received February 6, 2003; revision requested April 23 and received June 5; accepted June 9. Address correspondence to D.C.M. (e-mail: dmadoff@di.mdacc.tmc.edu).

View larger version (73K): [in a new window]   Figure 1.  Diagram illustrates the proposed complex feedback mechanisms that can lead to hepatic encephalopathy. BCAA/AAA = branched chain-aromatic amino acids, BZD = benzodiazepines, DA = dopamine, GABA = -aminobutyric acid, GLU = glutamic acid, 5HT = serotonin, SCFA = short chain fatty acids.

View larger version (136K): [in a new window]   Figure 2a.  Changes in hemodynamics after TIPS creation. (a) Pre-TIPS venogram demonstrates antegrade blood flow through the portal venous system and retrograde blood flow through esophageal varices (arrow). (b) Post-TIPS venogram shows that the majority of blood flows through the TIPS, bypassing the hepatic parenchyma. Note the decrease in blood flow through the esophageal varices (arrow).

View larger version (129K): [in a new window]   Figure 2b.  Changes in hemodynamics after TIPS creation. (a) Pre-TIPS venogram demonstrates antegrade blood flow through the portal venous system and retrograde blood flow through esophageal varices (arrow). (b) Post-TIPS venogram shows that the majority of blood flows through the TIPS, bypassing the hepatic parenchyma. Note the decrease in blood flow through the esophageal varices (arrow).

View larger version (87K): [in a new window]   Figure 3.  Permanent TIPS occlusion. Drawing illustrates coil embolization, which has been used to occlude a TIPS permanently and completely. Note the enlarged esophageal varix.

View larger version (92K): [in a new window]   Figure 4a.  Temporary TIPS occlusion. (a) Drawing shows an occlusion balloon within the TIPS, with development of thrombus below (portal side). (b) Thrombus remains within the intraparenchymal tract following removal of the occlusion balloon. (c) If necessary, recanalization can be performed to reestablish flow through the TIPS.

View larger version (88K): [in a new window]   Figure 4b.  Temporary TIPS occlusion. (a) Drawing shows an occlusion balloon within the TIPS, with development of thrombus below (portal side). (b) Thrombus remains within the intraparenchymal tract following removal of the occlusion balloon. (c) If necessary, recanalization can be performed to reestablish flow through the TIPS.

View larger version (89K): [in a new window]   Figure 4c.  Temporary TIPS occlusion. (a) Drawing shows an occlusion balloon within the TIPS, with development of thrombus below (portal side). (b) Thrombus remains within the intraparenchymal tract following removal of the occlusion balloon. (c) If necessary, recanalization can be performed to reestablish flow through the TIPS.

View larger version (89K): [in a new window]   Figure 5.  Shunt reduction with a constrained stent. Drawing shows a constrained Wallstent placed within a preexisting TIPS. A suture was threaded through the stent mesh and tied with multiple knots to reduce the stent lumen at its midportion. Small curved arrows (here and in the remaining diagrams) indicate turbulent blood flow within the shunt; long arrow shows that overall blood flow through the shunt remains in the antegrade direction.

View larger version (90K): [in a new window]   Figure 6a.  Shunt reduction with the Forauer-McLean method. (a) Drawing shows a Wallstent placed within a 15-mm Palmaz stent. (b) If necessary, the constrained stent can be expanded in stepwise fashion. Immediately after balloon dilation, the constrained shunt diameter is wider.

View larger version (90K): [in a new window]   Figure 6b.  Shunt reduction with the Forauer-McLean method. (a) Drawing shows a Wallstent placed within a 15-mm Palmaz stent. (b) If necessary, the constrained stent can be expanded in stepwise fashion. Immediately after balloon dilation, the constrained shunt diameter is wider.

View larger version (95K): [in a new window]   Figure 7.  Adjunct embolization. Drawing shows the presence of an embolic emulsion within the dead space between the outer TIPS stent and the reducing stent.

View larger version (90K): [in a new window]   Figure 8a.  Coil embolization of the dead space between inner and outer stents. (a) Drawing illustrates the location of coils used for dead space embolization. (b) Anteroposterior image demonstrates the constrained stent (arrow) within the preexisting TIPS stent (arrowhead). (c) Anteroposterior image shows large coils (arrow) placed between the inner and outer stents. (d) TIPS venogram obtained immediately after coil deployment demonstrates flow throughout the original TIPS lumen. Thrombus has not yet formed within the dead space.

View larger version (115K): [in a new window]   Figure 8b.  Coil embolization of the dead space between inner and outer stents. (a) Drawing illustrates the location of coils used for dead space embolization. (b) Anteroposterior image demonstrates the constrained stent (arrow) within the preexisting TIPS stent (arrowhead). (c) Anteroposterior image shows large coils (arrow) placed between the inner and outer stents. (d) TIPS venogram obtained immediately after coil deployment demonstrates flow throughout the original TIPS lumen. Thrombus has not yet formed within the dead space.

View larger version (115K): [in a new window]   Figure 8c.  Coil embolization of the dead space between inner and outer stents. (a) Drawing illustrates the location of coils used for dead space embolization. (b) Anteroposterior image demonstrates the constrained stent (arrow) within the preexisting TIPS stent (arrowhead). (c) Anteroposterior image shows large coils (arrow) placed between the inner and outer stents. (d) TIPS venogram obtained immediately after coil deployment demonstrates flow throughout the original TIPS lumen. Thrombus has not yet formed within the dead space.

View larger version (129K): [in a new window]   Figure 8d.  Coil embolization of the dead space between inner and outer stents. (a) Drawing illustrates the location of coils used for dead space embolization. (b) Anteroposterior image demonstrates the constrained stent (arrow) within the preexisting TIPS stent (arrowhead). (c) Anteroposterior image shows large coils (arrow) placed between the inner and outer stents. (d) TIPS venogram obtained immediately after coil deployment demonstrates flow throughout the original TIPS lumen. Thrombus has not yet formed within the dead space.

View larger version (94K): [in a new window]   Figure 9.  Shunt reduction with a stent-graft. Drawing shows the presence of a stent-graft within the preexisting TIPS stent.

View larger version (64K): [in a new window]   Figure 10a.  Construction of a homemade reduced stent-graft for placement within a TIPS stent. (a) A 4-mm thin-walled e-polytetrafluoroethylene (PTFE) covering was attached to a Palmaz 394 stent. (b) Graft material was sewn to the cross-struts at both ends with a 5-0 prolene suture after the graft was pre-dilated to 6 mm. (c) Stent was crimped on a 6-mm x 8-cm opta-LP (Cordis, Miami Lakes, Fla) balloon and placed through an 11-F peel-away sheath into a 35-cm-long 10-F sheath. (d) A 30-cm-long 12-F sheath (arrows) was then manipulated through the TIPS. (e) Preloaded stent (advanced to the front of the 10-F sheath) (arrows) was then placed so that the leading end of the graft would be near the portal vein entry site. (f, g) Entire device was dilated to 6 mm in this location, and then a 10-mm x 2-cm balloon was used to flair the leading and trailing ends until a seal was obtained. (h) TIPS venogram obtained through the sheath demonstrates the hourglass configuration of the stent-graft, with the dead space (arrows) becoming entirely excluded. Accurate PSG measurements were subsequently made.

View larger version (74K): [in a new window]   Figure 10b.  Construction of a homemade reduced stent-graft for placement within a TIPS stent. (a) A 4-mm thin-walled e-polytetrafluoroethylene (PTFE) covering was attached to a Palmaz 394 stent. (b) Graft material was sewn to the cross-struts at both ends with a 5-0 prolene suture after the graft was pre-dilated to 6 mm. (c) Stent was crimped on a 6-mm x 8-cm opta-LP (Cordis, Miami Lakes, Fla) balloon and placed through an 11-F peel-away sheath into a 35-cm-long 10-F sheath. (d) A 30-cm-long 12-F sheath (arrows) was then manipulated through the TIPS. (e) Preloaded stent (advanced to the front of the 10-F sheath) (arrows) was then placed so that the leading end of the graft would be near the portal vein entry site. (f, g) Entire device was dilated to 6 mm in this location, and then a 10-mm x 2-cm balloon was used to flair the leading and trailing ends until a seal was obtained. (h) TIPS venogram obtained through the sheath demonstrates the hourglass configuration of the stent-graft, with the dead space (arrows) becoming entirely excluded. Accurate PSG measurements were subsequently made.

View larger version (98K): [in a new window]   Figure 10c.  Construction of a homemade reduced stent-graft for placement within a TIPS stent. (a) A 4-mm thin-walled e-polytetrafluoroethylene (PTFE) covering was attached to a Palmaz 394 stent. (b) Graft material was sewn to the cross-struts at both ends with a 5-0 prolene suture after the graft was pre-dilated to 6 mm. (c) Stent was crimped on a 6-mm x 8-cm opta-LP (Cordis, Miami Lakes, Fla) balloon and placed through an 11-F peel-away sheath into a 35-cm-long 10-F sheath. (d) A 30-cm-long 12-F sheath (arrows) was then manipulated through the TIPS. (e) Preloaded stent (advanced to the front of the 10-F sheath) (arrows) was then placed so that the leading end of the graft would be near the portal vein entry site. (f, g) Entire device was dilated to 6 mm in this location, and then a 10-mm x 2-cm balloon was used to flair the leading and trailing ends until a seal was obtained. (h) TIPS venogram obtained through the sheath demonstrates the hourglass configuration of the stent-graft, with the dead space (arrows) becoming entirely excluded. Accurate PSG measurements were subsequently made.

View larger version (66K): [in a new window]   Figure 10d.  Construction of a homemade reduced stent-graft for placement within a TIPS stent. (a) A 4-mm thin-walled e-polytetrafluoroethylene (PTFE) covering was attached to a Palmaz 394 stent. (b) Graft material was sewn to the cross-struts at both ends with a 5-0 prolene suture after the graft was pre-dilated to 6 mm. (c) Stent was crimped on a 6-mm x 8-cm opta-LP (Cordis, Miami Lakes, Fla) balloon and placed through an 11-F peel-away sheath into a 35-cm-long 10-F sheath. (d) A 30-cm-long 12-F sheath (arrows) was then manipulated through the TIPS. (e) Preloaded stent (advanced to the front of the 10-F sheath) (arrows) was then placed so that the leading end of the graft would be near the portal vein entry site. (f, g) Entire device was dilated to 6 mm in this location, and then a 10-mm x 2-cm balloon was used to flair the leading and trailing ends until a seal was obtained. (h) TIPS venogram obtained through the sheath demonstrates the hourglass configuration of the stent-graft, with the dead space (arrows) becoming entirely excluded. Accurate PSG measurements were subsequently made.

View larger version (92K): [in a new window]   Figure 10e.  Construction of a homemade reduced stent-graft for placement within a TIPS stent. (a) A 4-mm thin-walled e-polytetrafluoroethylene (PTFE) covering was attached to a Palmaz 394 stent. (b) Graft material was sewn to the cross-struts at both ends with a 5-0 prolene suture after the graft was pre-dilated to 6 mm. (c) Stent was crimped on a 6-mm x 8-cm opta-LP (Cordis, Miami Lakes, Fla) balloon and placed through an 11-F peel-away sheath into a 35-cm-long 10-F sheath. (d) A 30-cm-long 12-F sheath (arrows) was then manipulated through the TIPS. (e) Preloaded stent (advanced to the front of the 10-F sheath) (arrows) was then placed so that the leading end of the graft would be near the portal vein entry site. (f, g) Entire device was dilated to 6 mm in this location, and then a 10-mm x 2-cm balloon was used to flair the leading and trailing ends until a seal was obtained. (h) TIPS venogram obtained through the sheath demonstrates the hourglass configuration of the stent-graft, with the dead space (arrows) becoming entirely excluded. Accurate PSG measurements were subsequently made.

View larger version (95K): [in a new window]   Figure 10f.  Construction of a homemade reduced stent-graft for placement within a TIPS stent. (a) A 4-mm thin-walled e-polytetrafluoroethylene (PTFE) covering was attached to a Palmaz 394 stent. (b) Graft material was sewn to the cross-struts at both ends with a 5-0 prolene suture after the graft was pre-dilated to 6 mm. (c) Stent was crimped on a 6-mm x 8-cm opta-LP (Cordis, Miami Lakes, Fla) balloon and placed through an 11-F peel-away sheath into a 35-cm-long 10-F sheath. (d) A 30-cm-long 12-F sheath (arrows) was then manipulated through the TIPS. (e) Preloaded stent (advanced to the front of the 10-F sheath) (arrows) was then placed so that the leading end of the graft would be near the portal vein entry site. (f, g) Entire device was dilated to 6 mm in this location, and then a 10-mm x 2-cm balloon was used to flair the leading and trailing ends until a seal was obtained. (h) TIPS venogram obtained through the sheath demonstrates the hourglass configuration of the stent-graft, with the dead space (arrows) becoming entirely excluded. Accurate PSG measurements were subsequently made.

View larger version (106K): [in a new window]   Figure 10g.  Construction of a homemade reduced stent-graft for placement within a TIPS stent. (a) A 4-mm thin-walled e-polytetrafluoroethylene (PTFE) covering was attached to a Palmaz 394 stent. (b) Graft material was sewn to the cross-struts at both ends with a 5-0 prolene suture after the graft was pre-dilated to 6 mm. (c) Stent was crimped on a 6-mm x 8-cm opta-LP (Cordis, Miami Lakes, Fla) balloon and placed through an 11-F peel-away sheath into a 35-cm-long 10-F sheath. (d) A 30-cm-long 12-F sheath (arrows) was then manipulated through the TIPS. (e) Preloaded stent (advanced to the front of the 10-F sheath) (arrows) was then placed so that the leading end of the graft would be near the portal vein entry site. (f, g) Entire device was dilated to 6 mm in this location, and then a 10-mm x 2-cm balloon was used to flair the leading and trailing ends until a seal was obtained. (h) TIPS venogram obtained through the sheath demonstrates the hourglass configuration of the stent-graft, with the dead space (arrows) becoming entirely excluded. Accurate PSG measurements were subsequently made.

View larger version (120K): [in a new window]   Figure 10h.  Construction of a homemade reduced stent-graft for placement within a TIPS stent. (a) A 4-mm thin-walled e-polytetrafluoroethylene (PTFE) covering was attached to a Palmaz 394 stent. (b) Graft material was sewn to the cross-struts at both ends with a 5-0 prolene suture after the graft was pre-dilated to 6 mm. (c) Stent was crimped on a 6-mm x 8-cm opta-LP (Cordis, Miami Lakes, Fla) balloon and placed through an 11-F peel-away sheath into a 35-cm-long 10-F sheath. (d) A 30-cm-long 12-F sheath (arrows) was then manipulated through the TIPS. (e) Preloaded stent (advanced to the front of the 10-F sheath) (arrows) was then placed so that the leading end of the graft would be near the portal vein entry site. (f, g) Entire device was dilated to 6 mm in this location, and then a 10-mm x 2-cm balloon was used to flair the leading and trailing ends until a seal was obtained. (h) TIPS venogram obtained through the sheath demonstrates the hourglass configuration of the stent-graft, with the dead space (arrows) becoming entirely excluded. Accurate PSG measurements were subsequently made.

View larger version (131K): [in a new window]   Figure 11a.  Placement of a constrained Wallgraft endoprosthesis within a preexisting TIPS stent. (a) Anteroposterior image from normal shunt venography through a 9-F vascular sheath shows a TIPS stent. (b) Wallgraft endoprosthesis was deployed on the back table. A dilator was used as a template to determine the reduced endograft diameter. A purse-string suture was woven through the stent mesh and graft material, approximately one-third the distance from the leading end, to create a constrained diameter. (c, d) The trailing end covering of the endograft was removed to prevent occlusion of the hepatic vein following deployment. (e) The stent-graft was then loaded into a new 9-F curved sheath, with the trailing end resheathed first. (f) Anteroposterior image from shunt venography after deployment of the constrained Wallgraft endograft shows an hourglass waist and contrast material within the endograft (white arrow), indicating instantaneous reduction of the shunt diameter. Black arrow indicates the TIPS stent. PSG measurements were obtained. (g) If necessary, an additional constrained endograft (white arrow) may be deployed within the preexisting constrained endograft (black arrow) to further reduce the shunt lumen.

View larger version (178K): [in a new window]   Figure 11b.  Placement of a constrained Wallgraft endoprosthesis within a preexisting TIPS stent. (a) Anteroposterior image from normal shunt venography through a 9-F vascular sheath shows a TIPS stent. (b) Wallgraft endoprosthesis was deployed on the back table. A dilator was used as a template to determine the reduced endograft diameter. A purse-string suture was woven through the stent mesh and graft material, approximately one-third the distance from the leading end, to create a constrained diameter. (c, d) The trailing end covering of the endograft was removed to prevent occlusion of the hepatic vein following deployment. (e) The stent-graft was then loaded into a new 9-F curved sheath, with the trailing end resheathed first. (f) Anteroposterior image from shunt venography after deployment of the constrained Wallgraft endograft shows an hourglass waist and contrast material within the endograft (white arrow), indicating instantaneous reduction of the shunt diameter. Black arrow indicates the TIPS stent. PSG measurements were obtained. (g) If necessary, an additional constrained endograft (white arrow) may be deployed within the preexisting constrained endograft (black arrow) to further reduce the shunt lumen.

View larger version (206K): [in a new window]   Figure 11c.  Placement of a constrained Wallgraft endoprosthesis within a preexisting TIPS stent. (a) Anteroposterior image from normal shunt venography through a 9-F vascular sheath shows a TIPS stent. (b) Wallgraft endoprosthesis was deployed on the back table. A dilator was used as a template to determine the reduced endograft diameter. A purse-string suture was woven through the stent mesh and graft material, approximately one-third the distance from the leading end, to create a constrained diameter. (c, d) The trailing end covering of the endograft was removed to prevent occlusion of the hepatic vein following deployment. (e) The stent-graft was then loaded into a new 9-F curved sheath, with the trailing end resheathed first. (f) Anteroposterior image from shunt venography after deployment of the constrained Wallgraft endograft shows an hourglass waist and contrast material within the endograft (white arrow), indicating instantaneous reduction of the shunt diameter. Black arrow indicates the TIPS stent. PSG measurements were obtained. (g) If necessary, an additional constrained endograft (white arrow) may be deployed within the preexisting constrained endograft (black arrow) to further reduce the shunt lumen.

View larger version (222K): [in a new window]   Figure 11d.  Placement of a constrained Wallgraft endoprosthesis within a preexisting TIPS stent. (a) Anteroposterior image from normal shunt venography through a 9-F vascular sheath shows a TIPS stent. (b) Wallgraft endoprosthesis was deployed on the back table. A dilator was used as a template to determine the reduced endograft diameter. A purse-string suture was woven through the stent mesh and graft material, approximately one-third the distance from the leading end, to create a constrained diameter. (c, d) The trailing end covering of the endograft was removed to prevent occlusion of the hepatic vein following deployment. (e) The stent-graft was then loaded into a new 9-F curved sheath, with the trailing end resheathed first. (f) Anteroposterior image from shunt venography after deployment of the constrained Wallgraft endograft shows an hourglass waist and contrast material within the endograft (white arrow), indicating instantaneous reduction of the shunt diameter. Black arrow indicates the TIPS stent. PSG measurements were obtained. (g) If necessary, an additional constrained endograft (white arrow) may be deployed within the preexisting constrained endograft (black arrow) to further reduce the shunt lumen.

View larger version (207K): [in a new window]   Figure 11e.  Placement of a constrained Wallgraft endoprosthesis within a preexisting TIPS stent. (a) Anteroposterior image from normal shunt venography through a 9-F vascular sheath shows a TIPS stent. (b) Wallgraft endoprosthesis was deployed on the back table. A dilator was used as a template to determine the reduced endograft diameter. A purse-string suture was woven through the stent mesh and graft material, approximately one-third the distance from the leading end, to create a constrained diameter. (c, d) The trailing end covering of the endograft was removed to prevent occlusion of the hepatic vein following deployment. (e) The stent-graft was then loaded into a new 9-F curved sheath, with the trailing end resheathed first. (f) Anteroposterior image from shunt venography after deployment of the constrained Wallgraft endograft shows an hourglass waist and contrast material within the endograft (white arrow), indicating instantaneous reduction of the shunt diameter. Black arrow indicates the TIPS stent. PSG measurements were obtained. (g) If necessary, an additional constrained endograft (white arrow) may be deployed within the preexisting constrained endograft (black arrow) to further reduce the shunt lumen.

View larger version (132K): [in a new window]   Figure 11f.  Placement of a constrained Wallgraft endoprosthesis within a preexisting TIPS stent. (a) Anteroposterior image from normal shunt venography through a 9-F vascular sheath shows a TIPS stent. (b) Wallgraft endoprosthesis was deployed on the back table. A dilator was used as a template to determine the reduced endograft diameter. A purse-string suture was woven through the stent mesh and graft material, approximately one-third the distance from the leading end, to create a constrained diameter. (c, d) The trailing end covering of the endograft was removed to prevent occlusion of the hepatic vein following deployment. (e) The stent-graft was then loaded into a new 9-F curved sheath, with the trailing end resheathed first. (f) Anteroposterior image from shunt venography after deployment of the constrained Wallgraft endograft shows an hourglass waist and contrast material within the endograft (white arrow), indicating instantaneous reduction of the shunt diameter. Black arrow indicates the TIPS stent. PSG measurements were obtained. (g) If necessary, an additional constrained endograft (white arrow) may be deployed within the preexisting constrained endograft (black arrow) to further reduce the shunt lumen.

View larger version (112K): [in a new window]   Figure 11g.  Placement of a constrained Wallgraft endoprosthesis within a preexisting TIPS stent. (a) Anteroposterior image from normal shunt venography through a 9-F vascular sheath shows a TIPS stent. (b) Wallgraft endoprosthesis was deployed on the back table. A dilator was used as a template to determine the reduced endograft diameter. A purse-string suture was woven through the stent mesh and graft material, approximately one-third the distance from the leading end, to create a constrained diameter. (c, d) The trailing end covering of the endograft was removed to prevent occlusion of the hepatic vein following deployment. (e) The stent-graft was then loaded into a new 9-F curved sheath, with the trailing end resheathed first. (f) Anteroposterior image from shunt venography after deployment of the constrained Wallgraft endograft shows an hourglass waist and contrast material within the endograft (white arrow), indicating instantaneous reduction of the shunt diameter. Black arrow indicates the TIPS stent. PSG measurements were obtained. (g) If necessary, an additional constrained endograft (white arrow) may be deployed within the preexisting constrained endograft (black arrow) to further reduce the shunt lumen.

View larger version (67K): [in a new window]   Figure 12a.  Occlusion of a spontaneous splenorenal shunt with the transjugular approach. (a) Drawing illustrates development of a splenorenal shunt with excess portosystemic shunting. Blood flow is diverted toward the left renal vein and into the systemic circulation. (b) Balloon catheter is shown occluding the splenorenal shunt. A microcatheter has been placed for infusion of embolic agent. (c) Following embolization, the splenorenal shunt is completely occluded so that blood now flows through the TIPS and hepatic parenchyma.

View larger version (69K): [in a new window]   Figure 12b.  Occlusion of a spontaneous splenorenal shunt with the transjugular approach. (a) Drawing illustrates development of a splenorenal shunt with excess portosystemic shunting. Blood flow is diverted toward the left renal vein and into the systemic circulation. (b) Balloon catheter is shown occluding the splenorenal shunt. A microcatheter has been placed for infusion of embolic agent. (c) Following embolization, the splenorenal shunt is completely occluded so that blood now flows through the TIPS and hepatic parenchyma.

View larger version (66K): [in a new window]   Figure 12c.  Occlusion of a spontaneous splenorenal shunt with the transjugular approach. (a) Drawing illustrates development of a splenorenal shunt with excess portosystemic shunting. Blood flow is diverted toward the left renal vein and into the systemic circulation. (b) Balloon catheter is shown occluding the splenorenal shunt. A microcatheter has been placed for infusion of embolic agent. (c) Following embolization, the splenorenal shunt is completely occluded so that blood now flows through the TIPS and hepatic parenchyma.