Summary of Event: A transjugular intrahepatic portosystemic shunt (TIPS) stent (Viatorr) was misplaced into main portal vein and superior mesenteric vein. This misplaced covered stent was then successfully retrieved using the rigid endobronchial forceps. Teaching Point: Before release the covered portion of the TIPS stent (Viatorr), it is necessary to confirm the position of uncovered portion in portal vein and covered portion in parenchymal tract. The endobronchial forceps technique is a safe and efficient method for retrieving a misplaced TIPS stent.
Device Removal ; Mesenteric Veins ; Methods ; Portal Vein ; Portasystemic Shunt, Surgical* ; Portasystemic Shunt, Transjugular Intrahepatic ; Stents* ; Surgical Instruments*

Transjugular intrahepatic portosystemic shunts (TIPS) are widely used in the management of bleeding gastric varices (GV). More recently, several studies have demonstrated balloon-occluded retrograde transvenous obliteration (BRTO) as an effective treatment method for bleeding isolated GV, especially in patients with contraindications for a TIPS placement. Both TIPS and BRTO can effectively treat bleeding GV with low rebleeding rates. Careful patient selection for TIPS and BRTO procedures is required to best treat the patient's individual clinical situation.
Balloon Occlusion ; Embolization, Therapeutic ; Esophageal and Gastric Varices* ; Hemorrhage ; Humans ; Methods ; Patient Selection ; Portasystemic Shunt, Surgical* ; Portasystemic Shunt, Transjugular Intrahepatic

OBJECTIVETo evaluate the effects of portaazygous disconnection (PAD), portacaval shunt (PCS) and distal splenocaval shunt (DSCS) on the portosytemic shunting (PSS), hepatic function (HF), hepatic mitochondrial respiratory function (HMRF), oral glucose tolerance test (OGTT) and arterial ketone body ratio (KBR) in order to provide a sound basis for selecting suitable operations for patients.

METHODSUsing a cirrhotic portal hypertensive model induced by CCl4/ethanol in Wistar rats, the PSS, HF, HMRF, OGTT and KBR were determined three weeks after PCS, DSCS and PAD.

RESULTSIt was revealed that: (1) In the cirrhotic portal hypertension rats, the PSS increased significantly, HMRF and hepatic reserve function (HRF) decreased significantly when compared with the control rats. (2) At the time of first postoperative week, the mean blood glucose value in the 120-minute OGTT in each PAD, PCS and DSCS groups had significant differences compared with the cirrhotic control group. But during the second and third postoperative weeks, the mean blood glucose values in the 120-minute OGTT in both PAD and DSCS groups had no significant differences compared with the cirrhotic control group except for the PCS group. The values of KBR in the three operative groups decreased significantly compared with the cirrhotic control group during the two postoperative weeks. In the third postoperative week, only the values of KBR in the PCS group had a significant difference compared with the cirrhotic control group. (3) After PCS, the PSS was further increased; HF and HMRF were significantly decreased. Little improvement was found in the third postoperative week. (4) After DSCS and PAD, the above mentioned indices were less influenced, and they were restored more quickly than those in the PCS group.

CONCLUSIONWe found that PAD and DSCS are more desirable than PCS.

Animals ; Hypertension, Portal ; etiology ; surgery ; Liver Cirrhosis, Experimental ; complications ; surgery ; Portacaval Shunt, Surgical ; Portasystemic Shunt, Surgical ; methods ; Rats ; Rats, Wistar

OBJECTIVE: Although a transjugular intrahepatic portosystemic shunt (TIPS) is commonly placed to manage isolated gastric varices, balloon-occluded retrograde transvenous obliteration (BRTO) has also been used. We compare the long-term outcomes from these procedures based on our institutional experience. MATERIALS AND METHODS: We conducted a retrospective review of patients with isolated gastric varices who underwent either TIPS with a covered stent or BRTO between January 2000 and July 2013. We identified 52 consecutive patients, 27 who had received TIPS with a covered stent and 25 who had received BRTO. We compared procedural complications, re-bleeding rates, and clinical outcomes between the two groups. RESULTS: There were no significant differences in procedural complications between patients who underwent TIPS (7%) and those who underwent BRTO (12%) (p = 0.57). There were also no statistically significant differences in re-bleeding rates from gastric varices between the two groups (TIPS, 7% [2/27]; BRTO, 8% [2/25]; p = 0.94) or in developing new ascites following either procedure (TIPS, 4%; BRTO, 4%; p = 0.96); significantly more patients who underwent TIPS developed hepatic encephalopathy (22%) than did those who underwent BRTO (0%, p = 0.01). There was no statistically significant difference in mean survival between the two groups (TIPS, 30 months; BRTO, 24 months; p = 0.16); median survival for the patients who received TIPS was 16.6 months, and for those who underwent BRTO, it was 26.6 months. CONCLUSION: BRTO is an effective method of treating isolated gastric varices with similar outcomes and complication rates to those of TIPS with a covered stent but with a lower rate of hepatic encephalopathy.
Ascites ; Esophageal and Gastric Varices* ; Hepatic Encephalopathy ; Humans ; Hypertension, Portal ; Methods ; Portasystemic Shunt, Surgical* ; Retrospective Studies ; Stents*

Hemodynamics ; Humans ; Hypertension, Portal ; physiopathology ; surgery ; Portal Vein ; physiopathology ; Portasystemic Shunt, Surgical ; methods

Humans ; Hypertension, Portal ; etiology ; surgery ; Liver Cirrhosis ; complications ; surgery ; Liver Transplantation ; Portasystemic Shunt, Surgical ; methods

OBJECTIVETo retrospectively analyze the safety and efficacy of mechanical thrombectomy combined with pharmacologic thrombolysis to treat non-acute and symptomatic portal vein thrombosis (PVT) using an intrahepatic portosystemic shunt (IPS) assisted by percutaneous transhepatic approach.

METHODSFrom April 2006 to May 2012, 18 patients with non-acute and symptomatic PVT were treated with balloon dilation, sheath-directed thrombus aspiration and continuous infusion of urokinase using the IPS assisted by percutaneous transhepatic approach. The significance of differences in the portosystemic gradient measured before and after therapy was assessed by paired samples t-test, and survival analysis was made by the Kaplan-Meier method.

RESULTSIPS was successfully created in all patients. The mean duration of the thrombolytic therapy was 65.3 +/- 29.5 h, and the mean concentration of urokinase used for the thrombolysis was 2324000 +/- 945000 U. Comparison of the mean portosystemic gradients showed a significant improvement in response to the therapy (before: 33.8 +/- 4.9 mm Hg vs. after: 15.4 +/- 2.1 mm Hg; P less than 0.001). The overall rate of clinical improvement was 94.4%. One patient died on day 2 post-therapy and another two patients experienced mild hepatic encephalopathy or right hemothorax, respectively, on day 5 post-therapy, with conservative medical management achieving complete recovery for both. The mean follow-up time was 18.6 +/- 17.5 months, during which only one patient died and five others experienced shunt dysfunction; all remaining patients showed maintenance of shunt patency without symptoms of recurrence.

CONCLUSIONMechanical thrombectomy combined with pharmacologic thrombolysis via the IPS assisted by percutaneous transhepatic approach is a safe and effective therapeutic option for patients with non-acute and symptomatic PVT.

Adult ; Aged ; Female ; Humans ; Male ; Middle Aged ; Portal Vein ; Portasystemic Shunt, Surgical ; methods ; Retrospective Studies ; Thrombolytic Therapy ; Venous Thrombosis ; therapy

OBJECTIVE: To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) in patients with occluded previous TIPS. MATERIALS AND METHODS: Between February 1996 and December 2000 we performed five transcaval TIPS procedures in four patients with recurrent gastric cardiac variceal bleeding. All four had occluded TIPS, which was between the hepatic and portal vein. The interval between initial TIPS placement and revisional procedures with transcaval TIPS varied between three and 31 months; one patient underwent transcaval TIPS twice, with a 31-month interval. After revision of the occluded shunt failed, direct cavoportal puncture at the retrohepatic segment of the IVC was attempted. RESULTS: Transcaval TIPS placement was technically successful in all cases. In three, tractography revealed slight leakage of contrast materials into hepatic subcapsular or subdiaphragmatic pericaval space. There was no evidence of propagation of extravasated contrast materials through the retroperitoneal space or spillage into the peritoneal space. After the tract was dilated by a bare stent, no patient experienced trans-stent bleeding and no serious procedure-related complications occurred. After successful shunt creation, variceal bleeding ceased in all patients. CONCLUSION: Transcaval TIPS placement is an effective and safe alternative treatment in patients with occluded previous TIPS and no hepatic veins suitable for new TIPS.
Esophageal and Gastric Varices/*surgery ; Feasibility Studies ; Gastrointestinal Hemorrhage/*surgery ; Human ; Male ; Middle Age ; Portal Vein/radiography/*surgery ; Portasystemic Shunt, Surgical/*methods ; *Portasystemic Shunt, Transjugular Intrahepatic ; Reoperation ; Stents ; Treatment Failure ; Vascular Patency ; Vena Cava, Inferior/radiography/*surgery

OBJECTIVETo investigate the risk factors for selective devascularization in patients with portal hypertension.

METHODSThe clinical data of 160 patients with portal hypertension underwent selective devascularization were retrospectively analyzed. All the patients were divided into high-risk group and low-risk group according to the postoperative complications. Thirty-two clinical factors were analyzed using logistic regression.

RESULTSSingle-factor analysis showed that history of jaundice, Child-Turcotte-Pugh classification, total bilirubin (before the operation), prolongation of prothrombin time, pre-operative free portal pressure, ascites, leukocyte count (1 week after the operation) and hemoglobin (1 week after the operation) were significantly different between the high-risk group and low-risk group (P < 0.05). Logistic regression analysis showed that decrease of free portal pressure, total bilirubin (before the operation), prolongation of prothrombin time, ascites, leukocyte count (1 week after the operation) and hemoglobin (1 week after the operation) were still significantly different between the two groups (chi2 = 53.337, P < 0.01).

CONCLUSIONSThe risk factors of selective devascularization in patients with portal hypertension are decrease of free portal pressure, pre-operative total bilirubin, prolongation of prothrombin time, ascites, post-operative leukocyte count and hemoglobin.

Adult ; Aged ; Female ; Humans ; Hypertension, Portal ; surgery ; Logistic Models ; Male ; Middle Aged ; Portasystemic Shunt, Surgical ; adverse effects ; methods ; Postoperative Complications ; etiology ; Prognosis ; Retrospective Studies ; Risk Factors ; Young Adult

OBJECTIVESTo evaluate the protective effects of affiliating portasystemic shunt on small-for-size graft in liver transplantation.

METHODSFifteen Chinese Bama miniature pigs were divided into three groups: group A (small-for-size liver transplantation), group B (distal splenorenal shunt + small-for-size liver transplantation), and group C (mesocaval H-shape shunt + small-for-size liver transplantation). Animals were followed up for 7 days with survival, dynamical liver function biochemical parameters, liver biopsies, portal venous pressure (PVP) and portal blood flow (PBF).

RESULTSAnimal survivals were as follows: group A, 1/5, group B, 3/5 and group C, 5/5.Group A resulted in abnormal liver function parameters that were significantly ameliorated in group B and C. The histological examination of graft in group A displayed severe pathologic changes including hepatocyte vacuolar change or necrosis, sinusoidal congestion, parenchymal hemorrhage. Affiliating portasystemic shunt significantly alleviated graft injuries in group B and C. PVP rose and peaked up to 28.6 mm Hg (1 mm Hg = 0.133 kPa), PBF fluctuated after reperfusion in group A, but group B and C with affiliating portasystemic shunt showed significantly lower PVP and maintained rather stable PBF after reperfusion. There were also statistical differences in PVP or PBF between group B and C.

CONCLUSIONSAffiliating portasystemic shunt effectively might protect small-for-size graft from injuries after reperfusion.

Animals ; Female ; Liver ; pathology ; Liver Transplantation ; Male ; Models, Animal ; Portal Pressure ; Portal Vein ; physiology ; Portasystemic Shunt, Surgical ; methods ; Random Allocation ; Regional Blood Flow ; Survival Rate ; Swine ; Swine, Miniature