Transjugular Intrahepatic Portosystemic Shunt: Histologic and Immunohistochemical Study of Autopsy Cases

Terayama, Noboru; Matsui, Osamu; Kadoya, Masumi; Yoshikawa, Jun; Gabata, Toshifumi; Miyayama, Shiro; Takashima, Tsutomu; Kobayashi, Kenichi; Nakanishi, Isao; Nakanuma, Yasuni

doi:10.1007/s002709900193

Cited by 14 publications

(5 citation statements)

References 12 publications

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“…In addition, a single cell layer that mimicked endothelial cells was below various amounts of fibrin thrombus deposits, which was the most superficial layer and this was seen on the luminal surface. These findings showed similarities with the PIH that occurred in human cases (3, 4). The low-powered magnified histologic specimens obtained from the irradiated stents revealed a thinner and more uniform layer of hyperplasia (Fig.…”

Section: Resultssupporting

confidence: 77%

“…Thereafter, it is thickened by the increased myofibroblasts and collagen fibers. PIH in TIPS has known to be pathogenically similar to myointimal hyperplasia after arterial stenting, and the over-proliferation that occurs in both processes leads to luminal stenosis and stent failure (3). The pathophysiology of PIH remains unclear, but biliary leakage into the shunt, exposed liver parenchyma and injured hepatic veins have been suggested as being the initiators of hyperplasia (1, 4).…”

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confidence: 99%

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Effects of Intraluminal Irradiation with Holmium-166 for TIPS Stenosis: Experimental Study in a Swine Model

Park

Kim

et al. 2007

Korean J Radiol

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ObjectiveWe wanted to evaluate the effectiveness of intraluminal irradiation with Holmium-166 (166Ho) for reducing the pseudointimal hyperplasia (PIH) in the transjugular intrahepatic portosystemic shunt (TIPS) tract in a swine model.Materials and MethodsTIPS was performed in 12 domestic pigs, after the creation of portal hypertension by intraportal injection of a mixture of N-butyl-2-cyanoacrylate (NBCA) and lipiodol. Five pigs first underwent intraluminal irradiation (30 Gy) in the parenchymal tract with using a 166Ho solution-filled balloon catheter, and this was followed by the placement of a nitinol stent in the TIPS tract. For the seven control pigs, the balloon was filled with saline and contrast media mixture. Two weeks later, follow-up portography and histological analysis were performed.ResultsTIPS was successfully performed in all twelve pigs with achieving artificially induced portal hypertension. Portography performed two weeks after TIPS showed the patent tracts in the TIPS tracts that were irradiated with 166Ho (5/5, 100%), whereas either completely (5/6, 83.3%) or partially (1/6, 16.7%) occluded TIPS were seen in the seven pigs of the nonirradiated control group, except in one pig that experienced periprocedural death due to bleeding. Histological analysis showed a statistically significant difference for the maximal PIH (irradiated: 32.8%, nonirradiated: 76.0%, p < 0.001) between the two groups.ConclusionIntraluminal irradiation with 30 Gy of 166Ho for TIPS significantly improved the TIPS patency in a swine model of portal hypertension during a 2-week period of follow-up.

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Section: Resultssupporting

confidence: 77%

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confidence: 99%

Effects of Intraluminal Irradiation with Holmium-166 for TIPS Stenosis: Experimental Study in a Swine Model

Park

Kim

et al. 2007

Korean J Radiol

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“…The important mechanisms of restenosis or occlusion of the shunt, as reported in the previous reports, were acute thrombosis, chronic inflammatory reaction, pseudointimal hyperplasia and inhibition of the endothelialization process associated with bile duct injury and bile extravasation within the stented lumen of the hepatic parenchymal tract (9-12). The layers of pseudointimal hyperplasia consist of mesenchymal cells and collagen, and this is covered by a layer endothelial cells.…”

Section: Discussionmentioning

confidence: 80%

Efficacy of a Dexamethasone-Eluting Nitinol Stent on the Inhibition of Pseudointimal Hyperplasia in a Transjugular Intrahepatic Portosystemic Shunt: An Experimental Study in a Swine Model

Seo

Park

et al. 2005

Korean J Radiol

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ObjectiveWe wanted to evaluate the feasibility and efficacy of using a dexamethasone (DM)-eluting nitinol stent to inhibit the pseudointimal hyperplasia following stent placement in the transjugular intrahepatic portosystemic shunt tract (TIPS) of a swine.Materials and MethodsFifteen stents were constructed using 0.15 mm-thick nitinol wire; they were 60 mm in length and 10 mm in diameter. The metallic stents were then classified into three types; type 1 and 2 was coated with the mixture of 12% and 20%, respectively, of DM solution and polyurethane (PU), while type 3 was a bare stent that was used for control study. In fifteen swine, each type of stent was implanted in the TIPS tract of 5 swine, and each animal was sacrificed 2 weeks after TIPS creation. The proliferation of the pseudointima was evaluated both on follow-up portogram and pathologic examination.ResultsOne TIPS case, using the type 1 stent, and two TIPS cases, using the type 2 stent, maintained their luminal patency while the others were all occluded. On the histopathologic analysis, the mean of the maximum pseudointimal hyperplasia was expressed as the percentage of the stent radius that was patent, and these values were 51.2%, 50% and 76% for the type 1, 2, and 3 stents, respectively.ConclusionThe DM-eluting stent showed a tendency to reduce the development of pseudointimal hyperplasia in the TIPS tract of a swine model with induced-portal hypertension.

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“…Endothelialization of a TIPS has previously been reported. 8 Only 1 report exists of using this phenomenon to allow a safe and intact anastomosis to be fashioned using vein with the stent still in situ. This was to the larger suprahepatic caval anastomosis and detailed partial inclusion of vein and stent in the circumference of the recipient vein.…”

Section: Discussionmentioning

confidence: 99%

Liver transplantation complicated by embedded transjugular intrahepatic portosystemic shunt: A new method for portal anastomosis?a surgical salvage procedure

et al. 2000

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A transjugular intrahepatic portosystemic shunt (TIPS) is an increasingly used method of treating variceal bleeding from portal hypertension. Many patients are subsequently listed for transplantation, which may be complicated by malposition of the inferior end of the TIPS stent. This report details such a case and offers a surgical technique to salvage this situation. Copyright 2000 by the American Association for the Study of Liver DiseasesA transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for variceal bleeding from portal hypertension. 1 Although most series have reported that TIPSs are a safe bridge to transplantation in selected patients, 2-4 there have been recent warnings to transplant surgeons regarding the specific complications of stent migration and malposition. 5,6 A TIPS may necessitate modification of the surgical procedure, but this is generally a surmountable problem. 7 We report a case of a malpositioned, impacted TIPS extending in the caudal direction that rendered a patient unsuitable for transplantation except by direct anastomosis onto the TIPS-portal vein complex. Case ReportA 43-year-old woman with hepatitis C and alcoholic cirrhosis underwent TIPS placement after 3 variceal bleeds, reducing her portal pressure from 34 to 30 mm Hg. She self-referred 7 months later, after having been lost to follow-up, with recurrent bleeding, lethargy, and worsening ascites, at which time a TIPSogram showed an occluded stent with an associated proximal thrombus that proved resistant to balloon dilatation. A second stent was introduced by the same approach through the initial TIPS and extended inferiorly down the portal vein in an attempt to displace the thrombus. This was successful, with a reduction in portal pressure from 28 to 17 mm Hg, but it was noted that the inferior end of the stent was lying at the portal vein origin. She was then listed for transplantation. A computed tomographic scan of her abdomen confirmed the second TIPS lying at the junction of her splenic and superior mesenteric veins, and angiography suggested extension of the TIPS into the superior mesenteric vein (Fig. 1). Her TIPS was dilated electively 6 months later, with portal pressure reduced from 28 to 21 mm Hg. She was admitted for transplantation, having had her original TIPS in situ for 16 months.At surgery, the initial TIPS stent was seen protruding through the portal vein wall, with the lower stent palpable throughout the length of the portal vein. The lower stent continued to be palpable through the base of the transverse mesocolon into the superior mesenteric vein in the infracolic compartment. The stent was associated with intense thickening of surrounding tissues.The patient was placed on venovenous bypass for the period of caval clamping. Once the recipient portal vein had been opened through the TIPS, it was found that removal of the stent was impossible because of embedding. However, no bare metal was exposed in the lumen, which had reendothelialized over the mesh metal. An anastomosis was ...

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Transjugular Intrahepatic Portosystemic Shunt: Histologic and Immunohistochemical Study of Autopsy Cases

Abstract: Short- and midterm TIPS occlusions were caused by thrombus forming after necrosis of hepatocytes and bile leakage, respectively. Long-term TIPS stenosis was associated with a combination of pseudointimal hyperplasia and ingrowth of hepatocytes.

Cited by 14 publications

References 12 publications

Effects of Intraluminal Irradiation with Holmium-166 for TIPS Stenosis: Experimental Study in a Swine Model

Effects of Intraluminal Irradiation with Holmium-166 for TIPS Stenosis: Experimental Study in a Swine Model

Efficacy of a Dexamethasone-Eluting Nitinol Stent on the Inhibition of Pseudointimal Hyperplasia in a Transjugular Intrahepatic Portosystemic Shunt: An Experimental Study in a Swine Model

Liver transplantation complicated by embedded transjugular intrahepatic portosystemic shunt: A new method for portal anastomosis?a surgical salvage procedure

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