A successful endovascular repositioning of migrated transjugular intrahepatic portosystemic shunt (TIPS) stent

Abstract

The transjugular intrahepatic portosystemic shunt (TIPS) procedure is performed to create an intrahepatic tract between the hepatic and portal veins which helps to shunt blood away from the hepatic sinusoids. This shunt decreases the portal venous pressure and secondary morbidities, including variceal bleeding and recurrent ascites. However, stent migration is a known complication of TIPS stent placement which may occur both during the procedure or postprocedural. We present a case of a 58-year-old male with history of liver cirrhosis in the setting of alcohol abuse and chronic hepatitis C infection who presented with melena and hematemesis. Esophagogastroduodenoscopy showed 4 columns of large grade IV esophageal varices with stigmata of recent bleeding. Despite endoscopic variceal banding, the patient had persistent episodes of hematemesis and became hemodynamically unstable requiring pressor support. The decision was made to proceed with emergent transjugular intrahepatic portosystemic shunt placement. After obtaining transhepatic portal access and initial stent deployment, the stent migrated from the TIPS tract into the main portal vein. While maintaining through-and-through wire access, the stent was successfully mechanically retracted using an angioplasty balloon and it was appropriately repositioned within the original TIPS tract. The stent was then further secured in place with a slightly larger stent which was deployed within the hepatic portion of the initially migrated stent. This technique was successful and obviated complete removal of the stent and follow-up imaging demonstrated patent flow and adequate positioning several months after the procedure.

A rare case of severe tricuspid regurgitation caused by TIPS stent migrating into the right atrium

“…[5][6][7] In some cases, stents may migrate backwards into the portal system or shift into the right heart or even reach the pulmonary arteries that can result in various complications, including tricuspid valve insufficiency, damage to the pulmonary arteries, and embolism or occlusion of the pulmonary vasculature. 6,7 Consequently, it is of great importance to exercise caution during the placement of TIPS devices and to ensure complete deflation of balloons before undertaking any manipulations 3,8 In this case, it is noteworthy that secondary stenting, which is mandatory especially in cases of occlusion, significantly increased the risk of migration. The ideal TIPS configuration involves a direct conduit between the right or middle hepatic vein and the right portal vein, a geometry that minimizes the risk of migration.…”

Viatorr Stent Migration and Retrieval during Transjugular Intrahepatic Portosystemic Shunt Revision

“…One study described utilizing a larger Viabahn stent to hold the balloon repositioned Viatorr stent in place. 13 A balloon catheter can also be utilized during snare-mediated retrieval. The stent is immobilized utilizing the balloon, while a snare is advanced over the shaft and onto the stent for the purpose of retrieval.…”

“…There are few case studies describing techniques for Viatorr stent graft repositioning or retrieval, which describes the utilization of a balloon catheter to engage a migrated Viatorr stent. [13][14][15] This technique can be utilized to drag a caudally migrated stent back into position. One study described utilizing a larger Viabahn stent to hold the balloon repositioned Viatorr stent in place.…”