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TIPS complications
TIPS Complications R a j i v S a w h n e y , M D a n d S u s a n D. W a l l , M D
The transjugular intrahepatic portosystemic shunt (TIPS) is a nonoperative means of decompressing the portal venous system. It is less invasive than a surgical portosystemic shunt procedure and is associated with less morbidity and mortality; thus, TIPS is an attractive treatment option for acutely ill patients suffering from the complications of portal hypertension. However, TIPS is a technically challenging procedure associated with significant inherent morbidity as well as a small but real procedure-related mortality. Procedural complications include bleeding from capsular perforation or extrahepatic puncture of the portal vein, parenchymal injury to the biliary tree or hepatic artery, stentrelated problems including migration and stent infection, contrastinduced renal failure, and cardiac arrhythmia. Shunt-related complications include encephalopathy, liver failure, and pulmonary hypertension. A thorough knowledge of procedural complications and their treatment is necessary for any interventionalist performing TIPS. An understanding of expected shunt-related complications is helpful in guiding optimal patient selection. Copyright © 1998 by W.B. Saunders Company
he transjugular intrahepatic portosystemic shunt (TIPS) procedure has been shown to be an effective method to treat the sequelae of portal hypertension, especially acute variceal bleeding and recurrent variceal bleeding refractory to medical management. Physiologically, TIPS is analogous to a side-by-side portacaval surgical shunt. However, the relatively less invasive TIPS procedure has less morbidity and mortality than an open surgical procedure. A 30-day mortality rate of 40% to 100% has been reported for patients who have undergone an emergent surgical shunt and 4% to 20% for patients who have undergone an elective surgical shunt, a The reported 30-day mortality rate after TIPS ranges between 7% and 45% with a direct procedure-related mortality of less than 2%.1 Although the less invasive TIPS procedure provides portal decompression without subjecting patients to open laparotomy, complications related to the TIPS procedure do occur. This article reviews the spectrum of complications that follow TIPS (Table 1). In addition, techniques to avoid potential complications and subsequent treatment options should complications occur are discussed.
T
Mortality The direct procedure-related mortality has been reported to be less than 2%. Intraperitoneal bleeding and intraprocedural myocardial infarction account for most of these deaths. The From the Department of Radiology, Veterans Affairs Medical Center, SF, University of California, San Francisco. Address reprint requests to Rajiv Sawhney, MD, Assistant Professor of Radiology, Department of Radiology (114), Veterans Affairs Medical Center, SF, 4150 Clement St, San Francisco, CA 94121. Copyright © 1998 by W.B. Saunders Company 1089-2516/98/0102-000558.00/0 80
reported post-TIPS 30-day mortality rate of 7% to 45% (3% to 15% in most series) appears to be related to the severity of the patient's liver disease and comorbid conditions, as most deaths are seen in the most critically ill patients. 1,2
Complications Related to Initial Venous Access Local puncture site hematomas are uncommon. They can be related to an uncorrected coagulopathy or to inadvertent carotid artery puncture. The initial venous access can be made using landmarks noted on physical examination, or direct ultrasound guidance can be used to further minimize the risk of inadvertent carotid artery puncture. Some investigators use a micro puncture system (21-gauge needle and 0.018-in wire) for added safety. Most importantly, correction of any coagulation abnormalities should be undertaken before beginning the TIPS procedure. An inadvertent tracheal puncture without clinical consequence has been described in a pediatric patient.1
Complications Related to Hepatic Venous Access and Hepatic-Wedged Venography The guidewire and catheter must pass through the right atrium as an appropriate hepatic vein is accessed. If there is buckling of the wire or catheter within the right atrium, cardiac arrhythmias can occur (Fig 1). This has been reported to occur in less than 5% of cases in one series. I Complete heart block has been described during TIPS) The risk of buckling into the right atrium is minimized by keeping the stiff outer sheath across the right atrium and by appropriate fluoroscopic visualization of the system during hepatic venous and portal venous access maneuvers. Contrast or CO2 wedged-hepatic venography is often performed to visualize the portal venous system. This method of visualizing the portal venous system is quick and simple. However, there have been a few reported cases of severe laceration of the liver capsule and ultimately death after wedged hepatic venography? The laceration is believed to occur secondary to an injection that is too forceful with the catheter wedged too peripherally within the liver. This is especially devastating in patients with massive ascites that impairs local tamponade of bleeding through the capsule tear. It is recommended that the catheter be wedged in a central position away from the liver capsule and the wedged hepatic venogram be performed with a small volume and low force (CO2 wedged hepatic venogram using 30 to 50 mk uncompressed gas at 15 mL/sec).
Complications Related to Transparenchymal Needle Puncture and Transparenchymal Tract Formation The most technically challenging aspect of the TIPS procedure is the transparenchymal puncture from the hepatic vein to the
Techniques in Vascular and Interventional Radiology, Vol 1, No 2 (June), 1998: pp 80-85
TABLE 1. Categories of TIPS Complications 1. Related to initial venous access Cervical hematoma, inadvertent carotid puncture 2. Related to hepatic venous access and hepatic wedged venography Cardiac arrhythmia, capsular perforation 3. Related to transparenchymal needle puncture and transparenchymal tract formation Biliary fistula, hepatic artery injury, extrahepatic bleeding 4. Related to stent placement Portal vein thrombosis, malpositioning, hemolysis 5. Related to portosystemic shunting Encephalopathy, liver failure 6. Additional complications Pulmonary hypertension, radiation damage, contrast nephropathy, stent-related infection
portal vein. Frequently, several transparenchymal needle passes are required to achieve successful portal venous access. Any structure in the path of the transparenchymal needle pass is subject to significant injury, These include the biliary system (Fig 2), gallbladder, hepatic artery (Fig 3), right kidney, inferior vena cava, and extrahepatic portal vein. Puncture of the biliary tract may result in cholangitis, cholecystitis (Fig 4), or biliary venous fistula with hemobilia. It has been shown that a fistula between the TIPS and the biliary tree results in excessive pseudointimal hyperplasia within the stent, causing early TIPS stenoses or occlusion. 5 These patients need early TIPS revisions with balloon dilatation and possible deployment of a coaxial stent. A covered stent may be necessary to prevent further bile contamination of the TIPS. If patency cannot be maintained, a dual TIPS will be necessary, Injury of the hepatic artery may be occult without any clinical compromise. However, hemorrhage, hepatic ischemia from hepatic artery occlusion, or focal hepatic infarction may occur. 6,r Transcatheter embolization of the injured hepatic arterial branch is necessary if significant hemorrhage occurs. Life-threatening hemorrhage also may occur if the transparenchymal needle enters the portal venous system in the extrahepatic portion of the portal vein (Fig 5). In this situation, hemoperitoneum results after balloon dilatation of the portal
Fig 1. A portal venogram performed during the initial TIPS procedure shows the TIPS sheath buckled in the right atrium. This configuration can lead to cardiac arrhythmias. TIPS COMPLICATIONS
Fig 2. Transgression of the biliary tree can occur during TIPS. In this case, injection of contrast into the parenchymal segment of an acutely occluded TIPS showed a biliary fistula.
vein puncture site, because the extrahepatic portal vein is bare without surrounding liver parenchyma to tamponade the bleeding. Before tract dilation, oblique views may be necessary to confirm an adequate intrahepatic location of the portal vein entry site to avoid potential serious hemorrhage. Portal vein rupture attributable to extrahepatic portal vein balloon dilatation can be treated by quickly completing the TIPS with stent placement. Immediate deployment of a stent will help divert blood flow to the lower central venous system, and the stent may mechanically seal the tear. 8 Alternatively, emergent placement of a stent-graft to cover the point of rupture may be necessary.9 Hemorrhage also has been described when the needle pass out of the hepatic vein is made too centrally with subsequent laceration of the hepatic vein/inferior vena cava junction.l°
Fig 3. Transgression of the hepatic artery can occur during TIPS puncture. In this case, puncture of the right hepatic artery leads to inadvertent catheterization. Note opacification of the celiac artery. 81
Fig 5. Extravasation of contrast from extrahepatic puncture of the portal vein during placement of a second parallel TIPS,
Fig 4. inadvertent puncture of the gallbladder can lead to hemobilia or bile peritonitis. (A) In this case, hemobilia resulted in acute cholecystitis; ultrasound showed fluid/fluid level in the gallbladder consistent with hemobilia; (B) The patient was treated by placement of percutaneous cholecystostomy tube.
shunt occlusion or shunt dysfunction. Inadequate stent length results in incomplete covering of the hepatic venous end or portal venous end of the track and may result in shunt dysfunction or acute thrombosis of the shunt. Stent shortening, which tends to occur over time, will exacerbate this problem (Fig 7). Acute thrombosis generally can be avoided by initially placing the stent(s) with adequate length within the hepatic vein and portal vein. In addition, the stent should conform to a gentle curve throughout its course without angulation. This, along with selection of an adequately sized hepatic vein, will reduce the likelihood of subsequent hepatic venous stenosis. Portal vein thrombosis can be induced by stent implantation or can result from subsequent TIPS occlusion (Fig 8). This devastating complication is uncommon, but when it occurs, portal vein occlusion may compromise subsequent liver transplantation. Splenoportal venous thrombosis during the initial
Transgression of the liver capsule (Fig 6) can be seen moderately frequently, occurring in up to 30% of cases in one series. 1 Transcapsular punctures usually do not result in hemodynamic compromise. Again, it is critical to correct any coagulation abnormalities before beginning the procedure. Additionally, by obtaining an oblique or lateral view, anatomic distinction can be made between the right hepatic vein and the middle hepatic vein. The correct direction of the needle pass, anterior or posterior, then can be chosen, thus limiting the risk of capsule puncture. If significant bleeding from a transcapsular puncture is suspected, the transcapsular track can be embolized. As operators gain more experience with TIPS, the frequency of transparenchymal puncture complications will decrease.
Complications Related to Stent Placement A variety of complications are attributable to the metal stent used in TIPS. Inappropriate positioning of the stent can lead to 82
Fig 6. Free extravasation of contrast into ascites from extracapsular excursion of the transjugular puncture needle. SAWHNEY AND WALL
Fig 8. Extension of thrombus into the main portal vein after TIPS occlusion.
implantation procedure is thought to be caused by extended cannulation and catheter manipulation within these vessels. It is recommended that catheter manipulations and balloon dilatation within the portal venous system be kept to a minimum, with only a short length of balloon being placed within the portal vein during dilation to avoid unnecessary trauma. 1 An unusual case of TIPS occlusion and acute portal, splenic, and mesenteric venous thrombosis has been described. 11 Inadvertent placement of the stent too deep within the portal vein or too central such that the stent lies within the inferior vena cava or right atrium (Fig 9) will make future surgery for liver transplantation difficult) 2 Central malposition will also make subsequent re-access of the shunt for reintervention difficult. Stent migration into the right atrium has been described. This has been treated with stent retrieval with a snare device.13-16A case of fatal right atrium rupture from stent embolization has been reported.17 Stent-induced intravascular hemolysis has been described in approximately 10% of patients in one series, presumably caused by microtrauma caused by the wire mesh of the stent.18 Hemolysis is rarely severe and usually resolves within 12 to 15 weeks after initial stent placement. Pseudointimal proliferation within the stent causing TIPS stenoses and shunt dysfunction is seen commonly. Routine shunt surveillance with ultrasound and TIPS venography and revision are required to maintain TIPS patency. This is addressed in an accompanying article.
Complications Related to Portosystemic Shunting Fig 7. Inappropriate stent positioning can lead to shunt dysfunction. (A) In this case, the initial stent extended just into the hepatic vein. (B) The patient returned 6 months later with shunt stenosis. (C) In this case, the cause of the shunt stenosis was shortening of the stent into the parenchymal tract.
TIPS COMPLICATIONS
As blood is shunted away from the liver before detoxification, hepatic encephalopathy is fairly common in TIPS patients. Several large series have reported a post-TIPS encephalopathy rate of 5% to 35%, which compares favorably with the rate reported in surgical side-to-side portacaval shunt series. I Postprocedure encephalopathy occurs more commonly in 83
patients with a history of hepatic encephalopathy. Indeed, in patients without a history of hepatic encephalopathy, less than 10% develop postprocedure encephalopathy. 1 Most affected patients are treated successfully with dietary protein restriction and lactulose, with less than 5% of patients developing refractory encephalopathy after TIPS. 2 Additionally, the diameter of the shunt appears to correlate with the incidence of postprocedure encephalopathy. Therefore, if an acceptable portosystemic gradient and lack of briskly filling varices can be achieved with an 8-mm shunt, no further dilation should be undertaken. However, it is often necessary to dilate to 10 mm to achieve this. It has been shown that liver function worsens after shunting. Serious hepatic failure resulting in death has been reported in 3% to 7% of patients. 2 Should liver deterioration become significant or encephalopathy unacceptable despite medication, intentional TIPS occlusion using balloon occlusion techniques can be performed to restore adequate portal blood flow to the liver. In addition, stenosis within the celiac or hepatic artery may impede flow to the liver, and angioplasty may be required. Pulmonary hypertension, pulmonary edema, heart failure, and circulatory hyperdynamic state have all been described after portosystemic shunting.19-23
Additional Complications Intraprocedural myocardial infarction can occur. This probably is not related to anything inherent about the TIPS procedure, but rather is attributable to the overall medical condition of acutely ill patients with life-threatening bleeding. Early in operator experience, the TIPS procedure can take several hours to complete. The patient can be exposed to considerable radiation, and radiation dermatitis has been described. 24With experience, procedure and fluoroscopy times have decreased. Operators can reduce patient exposure with pulsed fluoroscopy and use of other fluoroscopy reduction techniques. Contrast-related nephropathy is possible. Adequate preprocedure and postprocedure hydration can help minimize this risk. Allergic reactions to contrast must be treated routinely, and preprocedure steroid prophylaxis in patients with prior contrast reactions is recommended. A case of fatal fungemia from an infected TIPS stent has been reported. 25 An interesting case of paradoxical cerebral emboli in a patient with a patent foramen ovale and right-to-left shunt has been described. 26
Conclusions
Fig 9. Inadvertent deployment of the TIPS stent into the right atrium. (A) The tip of the stent extends well into the right atrium. (B) The stent was pulled down into the inferior vena cava with a snare before liver transplantation.
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The TIPS procedure is a relatively minimally invasive procedure, but several important complications can occur. Interventionalists who perform TIPS should be aware of these complications, use techniques to help avoid these complications, and be knowledgeable regarding treatment options should complications occur. Delayed stenoses and occlusions are expected. Regular surveillance and reintervention are required to maintain TIPS patency, Likewise, post-TIPS encephalopathy is seen at a rate comparable to that seen after side-to-side portacaval surgical shunts. Excluding these two expected post-TIPS sequelae, the complications related to the TIPS procedure can be estimated overall to be less than 10%. 1 SAWHNEY AND WALL
References 1. Freedman AM, Sanyal AJ, Tisnado J, et al: Complications of transjugular intrahepatic portosystemic shunt: A comprehensive review. Radiographics 13:1185-1210, 1993 2. Kerlan RK, LaBerge JM, Baker EL, et al: Successful reversal of hepatic encephalopathy with intrahepatic occlusion of transjugular intrahepatic portosystemic shunts. JVIR 6:917-921, 1995 3. Lee EN, Mankad S, Shaver J, et al: Transjugular intrahepatic portosystemic shunt (TIPS) complicated by complete heart block. Anaesthesia and Intensive Care 25:312-313, 1997 4. Semba CP, Saperstein L, Nyman U, et al: Hepatic laceration from wedged venography performed before transjugular intrahepatic shunt placement. JVl R 7:143-146, 1996 5. LaBerge JM, Ferrell LD, Ring EJ, et al: Histopathologic study of stenotic and occluded transjugular intrahepatic portosystemic shunts. JVlR 4:779-786, 1993 6. Haskal ZJ, Pentecost MJ, Rubin RA: Hepatic arterial injury after transjugular intrahepatic portosystemic shunt placement: Report of two cases. Radiology 188:85-88, 1993 7. Sawhney R, Wall SD, Yee J, et al: Hepatic Jnfarction: Unusual complication of a transjugular intrahepatic portosystemic shunt. JVlR 8:129-132, 1997 8. Davis AG, Haskal Z J: Extrahepatic portal vein puncture and intraabdominal hemorrhage during transjuguiar intrahepatic portosystemic shunt creation. JVlR 7:863-866, 1996 9. Krajina A, Hulek P, Ferko A, et al: Extrahepatic portal venous laceration in TIPS treated with stent graft placement. HepatoGastroenterology 44:667-670, 1997 10. Yonker-Sell AE, Connolly LA: Mortality during transjugular intrahepatic portosystemic shunt placement. Anesthesiology 84:231-233, 1996 11. Beheshti MV, Jones MP: Shunt occlusion and acute portal, splenic and mesenteric venous thrombosJs complicating placement of a transjugular intrahepatic portosystemic shunt. JVlR 7:277-281, 1996 12. Wilson MW, Gordon RL, LaBerge JM, et al: Liver transplantation complicated by malpositioned transjugular intrahepatic portosystemic shunts. JVlR 6:695-699, 1995 13. Sanchez RB, Roberts AC, Valji K, et al: Wallstent misplaced during transjuguiar placement of an intrahepatic shunt: Retrieval with a loop snare. AJR 159:129-130, 1992
TIPS COMPLICATIONS
14. Lipton M, Cynamon J, Bakal CW, et al: Percutaneous retrieval of two Wallstent endoprostheses from the heart through a single jugular sheath. JVIR 6:469-472, 1995 15. Cekirge S, Foster RG, Weiss JP, et al: Percutaneous removal of an embolized Wallstent during a transjugular intrahepatic shunt procedure. JVIR 4:559-560, 1993 16. Cohen GS, Ball DS: Delayed Wallstent migration after a transjugular intrahepatic portosystemic shunt procedure: Relocation with a loop snare. JVlR 4:561-563, 1993 17. Prahlow JA, O'Bryant JJ: Cardiac perforation due to Wallstent embolization: A fatal complication of the transjugular intrahepatic portosystemic shunt procedure. Radiology 205:170-172, 1997 18. Sanyal A J, Freedman AM, Purdum PP, et al: The hematologic consequences of transjugular intrahepatic portosystemic shunts. Hepatology 23:32-39, 1996 19. van der Heijde RMJL, Lameris JS, van den Berg B, et al: Pulmonary hypertension after transjugular intrahepatic portosystemic shunt (TIPS). Eur Respir J 9:1562-1564, 1996 20. van der Linden P, Le Moine O, Ghysels M, et al: Pulmonary hypertension after transjugular Jntrahepatic porfosystemic shunt: Effects on right ventricular function. Hepatology 23:982-987, 1996 21. Willoughby PH, Beers RA, Murphy KD: Pulmonary edema after transjugular intrahepatic portosystemic shunt. Anesth Analg 82:885896, 1996 22. Braverman AC, Steiner MA, Picus D, et al: High-output congestive heart failure following transjugular intrahepatic portal-systemic shunting. Chest 107:1467-1469, 1995 23. Azoulay D, Castaing D, Dennision A, et al: Transjugular intrahepatic portosystemic shunt worsens the hyperdynamic circulatory state of the cirrhotic patient: Preliminary report of a prospective study. Hepatology 19:129-132, 1994 24. Knautz MA, Abele DC, Reynolds TL: Radiation dermatitis after transjugular intrahepatic portosystemic shunt. South Med J 90:352356, 1997 25. Schiano TD, Atillasoy E, Fiel MI, et al: Fatal fungemia resulting from an infected transjugular intrahepatic portosystemic shunt stenL Am J Gastroentero192:709-710, 1997 26. PonecRJ, KowdleyKV: Paradoxicalcerebralemboliaftertransjugular intrahepatic portosystemic shunt and coil embolization for treatment of duodenal varices. Am J Gastroentero192:1372-1373, 1997
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The transjugular intrahepatic portosystemic shunt (TIPS) is a nonoperative means of decompressing the portal venous system. It is less invasive than a surgical portosystemic shunt procedure and is associated with less morbidity and mortality; thus, TIPS is an attractive treatment option for acutely ill patients suffering from the complications of portal hypertension. However, TIPS is a technically challenging procedure associated with significant inherent morbidity as well as a small but real procedure-related mortality. Procedural complications include bleeding from capsular perforation or extrahepatic puncture of the portal vein, parenchymal injury to the biliary tree or hepatic artery, stentrelated problems including migration and stent infection, contrastinduced renal failure, and cardiac arrhythmia. Shunt-related complications include encephalopathy, liver failure, and pulmonary hypertension. A thorough knowledge of procedural complications and their treatment is necessary for any interventionalist performing TIPS. An understanding of expected shunt-related complications is helpful in guiding optimal patient selection. Copyright © 1998 by W.B. Saunders Company
he transjugular intrahepatic portosystemic shunt (TIPS) procedure has been shown to be an effective method to treat the sequelae of portal hypertension, especially acute variceal bleeding and recurrent variceal bleeding refractory to medical management. Physiologically, TIPS is analogous to a side-by-side portacaval surgical shunt. However, the relatively less invasive TIPS procedure has less morbidity and mortality than an open surgical procedure. A 30-day mortality rate of 40% to 100% has been reported for patients who have undergone an emergent surgical shunt and 4% to 20% for patients who have undergone an elective surgical shunt, a The reported 30-day mortality rate after TIPS ranges between 7% and 45% with a direct procedure-related mortality of less than 2%.1 Although the less invasive TIPS procedure provides portal decompression without subjecting patients to open laparotomy, complications related to the TIPS procedure do occur. This article reviews the spectrum of complications that follow TIPS (Table 1). In addition, techniques to avoid potential complications and subsequent treatment options should complications occur are discussed.
T
Mortality The direct procedure-related mortality has been reported to be less than 2%. Intraperitoneal bleeding and intraprocedural myocardial infarction account for most of these deaths. The From the Department of Radiology, Veterans Affairs Medical Center, SF, University of California, San Francisco. Address reprint requests to Rajiv Sawhney, MD, Assistant Professor of Radiology, Department of Radiology (114), Veterans Affairs Medical Center, SF, 4150 Clement St, San Francisco, CA 94121. Copyright © 1998 by W.B. Saunders Company 1089-2516/98/0102-000558.00/0 80
reported post-TIPS 30-day mortality rate of 7% to 45% (3% to 15% in most series) appears to be related to the severity of the patient's liver disease and comorbid conditions, as most deaths are seen in the most critically ill patients. 1,2
Complications Related to Initial Venous Access Local puncture site hematomas are uncommon. They can be related to an uncorrected coagulopathy or to inadvertent carotid artery puncture. The initial venous access can be made using landmarks noted on physical examination, or direct ultrasound guidance can be used to further minimize the risk of inadvertent carotid artery puncture. Some investigators use a micro puncture system (21-gauge needle and 0.018-in wire) for added safety. Most importantly, correction of any coagulation abnormalities should be undertaken before beginning the TIPS procedure. An inadvertent tracheal puncture without clinical consequence has been described in a pediatric patient.1
Complications Related to Hepatic Venous Access and Hepatic-Wedged Venography The guidewire and catheter must pass through the right atrium as an appropriate hepatic vein is accessed. If there is buckling of the wire or catheter within the right atrium, cardiac arrhythmias can occur (Fig 1). This has been reported to occur in less than 5% of cases in one series. I Complete heart block has been described during TIPS) The risk of buckling into the right atrium is minimized by keeping the stiff outer sheath across the right atrium and by appropriate fluoroscopic visualization of the system during hepatic venous and portal venous access maneuvers. Contrast or CO2 wedged-hepatic venography is often performed to visualize the portal venous system. This method of visualizing the portal venous system is quick and simple. However, there have been a few reported cases of severe laceration of the liver capsule and ultimately death after wedged hepatic venography? The laceration is believed to occur secondary to an injection that is too forceful with the catheter wedged too peripherally within the liver. This is especially devastating in patients with massive ascites that impairs local tamponade of bleeding through the capsule tear. It is recommended that the catheter be wedged in a central position away from the liver capsule and the wedged hepatic venogram be performed with a small volume and low force (CO2 wedged hepatic venogram using 30 to 50 mk uncompressed gas at 15 mL/sec).
Complications Related to Transparenchymal Needle Puncture and Transparenchymal Tract Formation The most technically challenging aspect of the TIPS procedure is the transparenchymal puncture from the hepatic vein to the
Techniques in Vascular and Interventional Radiology, Vol 1, No 2 (June), 1998: pp 80-85
TABLE 1. Categories of TIPS Complications 1. Related to initial venous access Cervical hematoma, inadvertent carotid puncture 2. Related to hepatic venous access and hepatic wedged venography Cardiac arrhythmia, capsular perforation 3. Related to transparenchymal needle puncture and transparenchymal tract formation Biliary fistula, hepatic artery injury, extrahepatic bleeding 4. Related to stent placement Portal vein thrombosis, malpositioning, hemolysis 5. Related to portosystemic shunting Encephalopathy, liver failure 6. Additional complications Pulmonary hypertension, radiation damage, contrast nephropathy, stent-related infection
portal vein. Frequently, several transparenchymal needle passes are required to achieve successful portal venous access. Any structure in the path of the transparenchymal needle pass is subject to significant injury, These include the biliary system (Fig 2), gallbladder, hepatic artery (Fig 3), right kidney, inferior vena cava, and extrahepatic portal vein. Puncture of the biliary tract may result in cholangitis, cholecystitis (Fig 4), or biliary venous fistula with hemobilia. It has been shown that a fistula between the TIPS and the biliary tree results in excessive pseudointimal hyperplasia within the stent, causing early TIPS stenoses or occlusion. 5 These patients need early TIPS revisions with balloon dilatation and possible deployment of a coaxial stent. A covered stent may be necessary to prevent further bile contamination of the TIPS. If patency cannot be maintained, a dual TIPS will be necessary, Injury of the hepatic artery may be occult without any clinical compromise. However, hemorrhage, hepatic ischemia from hepatic artery occlusion, or focal hepatic infarction may occur. 6,r Transcatheter embolization of the injured hepatic arterial branch is necessary if significant hemorrhage occurs. Life-threatening hemorrhage also may occur if the transparenchymal needle enters the portal venous system in the extrahepatic portion of the portal vein (Fig 5). In this situation, hemoperitoneum results after balloon dilatation of the portal
Fig 1. A portal venogram performed during the initial TIPS procedure shows the TIPS sheath buckled in the right atrium. This configuration can lead to cardiac arrhythmias. TIPS COMPLICATIONS
Fig 2. Transgression of the biliary tree can occur during TIPS. In this case, injection of contrast into the parenchymal segment of an acutely occluded TIPS showed a biliary fistula.
vein puncture site, because the extrahepatic portal vein is bare without surrounding liver parenchyma to tamponade the bleeding. Before tract dilation, oblique views may be necessary to confirm an adequate intrahepatic location of the portal vein entry site to avoid potential serious hemorrhage. Portal vein rupture attributable to extrahepatic portal vein balloon dilatation can be treated by quickly completing the TIPS with stent placement. Immediate deployment of a stent will help divert blood flow to the lower central venous system, and the stent may mechanically seal the tear. 8 Alternatively, emergent placement of a stent-graft to cover the point of rupture may be necessary.9 Hemorrhage also has been described when the needle pass out of the hepatic vein is made too centrally with subsequent laceration of the hepatic vein/inferior vena cava junction.l°
Fig 3. Transgression of the hepatic artery can occur during TIPS puncture. In this case, puncture of the right hepatic artery leads to inadvertent catheterization. Note opacification of the celiac artery. 81
Fig 5. Extravasation of contrast from extrahepatic puncture of the portal vein during placement of a second parallel TIPS,
Fig 4. inadvertent puncture of the gallbladder can lead to hemobilia or bile peritonitis. (A) In this case, hemobilia resulted in acute cholecystitis; ultrasound showed fluid/fluid level in the gallbladder consistent with hemobilia; (B) The patient was treated by placement of percutaneous cholecystostomy tube.
shunt occlusion or shunt dysfunction. Inadequate stent length results in incomplete covering of the hepatic venous end or portal venous end of the track and may result in shunt dysfunction or acute thrombosis of the shunt. Stent shortening, which tends to occur over time, will exacerbate this problem (Fig 7). Acute thrombosis generally can be avoided by initially placing the stent(s) with adequate length within the hepatic vein and portal vein. In addition, the stent should conform to a gentle curve throughout its course without angulation. This, along with selection of an adequately sized hepatic vein, will reduce the likelihood of subsequent hepatic venous stenosis. Portal vein thrombosis can be induced by stent implantation or can result from subsequent TIPS occlusion (Fig 8). This devastating complication is uncommon, but when it occurs, portal vein occlusion may compromise subsequent liver transplantation. Splenoportal venous thrombosis during the initial
Transgression of the liver capsule (Fig 6) can be seen moderately frequently, occurring in up to 30% of cases in one series. 1 Transcapsular punctures usually do not result in hemodynamic compromise. Again, it is critical to correct any coagulation abnormalities before beginning the procedure. Additionally, by obtaining an oblique or lateral view, anatomic distinction can be made between the right hepatic vein and the middle hepatic vein. The correct direction of the needle pass, anterior or posterior, then can be chosen, thus limiting the risk of capsule puncture. If significant bleeding from a transcapsular puncture is suspected, the transcapsular track can be embolized. As operators gain more experience with TIPS, the frequency of transparenchymal puncture complications will decrease.
Complications Related to Stent Placement A variety of complications are attributable to the metal stent used in TIPS. Inappropriate positioning of the stent can lead to 82
Fig 6. Free extravasation of contrast into ascites from extracapsular excursion of the transjugular puncture needle. SAWHNEY AND WALL
Fig 8. Extension of thrombus into the main portal vein after TIPS occlusion.
implantation procedure is thought to be caused by extended cannulation and catheter manipulation within these vessels. It is recommended that catheter manipulations and balloon dilatation within the portal venous system be kept to a minimum, with only a short length of balloon being placed within the portal vein during dilation to avoid unnecessary trauma. 1 An unusual case of TIPS occlusion and acute portal, splenic, and mesenteric venous thrombosis has been described. 11 Inadvertent placement of the stent too deep within the portal vein or too central such that the stent lies within the inferior vena cava or right atrium (Fig 9) will make future surgery for liver transplantation difficult) 2 Central malposition will also make subsequent re-access of the shunt for reintervention difficult. Stent migration into the right atrium has been described. This has been treated with stent retrieval with a snare device.13-16A case of fatal right atrium rupture from stent embolization has been reported.17 Stent-induced intravascular hemolysis has been described in approximately 10% of patients in one series, presumably caused by microtrauma caused by the wire mesh of the stent.18 Hemolysis is rarely severe and usually resolves within 12 to 15 weeks after initial stent placement. Pseudointimal proliferation within the stent causing TIPS stenoses and shunt dysfunction is seen commonly. Routine shunt surveillance with ultrasound and TIPS venography and revision are required to maintain TIPS patency. This is addressed in an accompanying article.
Complications Related to Portosystemic Shunting Fig 7. Inappropriate stent positioning can lead to shunt dysfunction. (A) In this case, the initial stent extended just into the hepatic vein. (B) The patient returned 6 months later with shunt stenosis. (C) In this case, the cause of the shunt stenosis was shortening of the stent into the parenchymal tract.
TIPS COMPLICATIONS
As blood is shunted away from the liver before detoxification, hepatic encephalopathy is fairly common in TIPS patients. Several large series have reported a post-TIPS encephalopathy rate of 5% to 35%, which compares favorably with the rate reported in surgical side-to-side portacaval shunt series. I Postprocedure encephalopathy occurs more commonly in 83
patients with a history of hepatic encephalopathy. Indeed, in patients without a history of hepatic encephalopathy, less than 10% develop postprocedure encephalopathy. 1 Most affected patients are treated successfully with dietary protein restriction and lactulose, with less than 5% of patients developing refractory encephalopathy after TIPS. 2 Additionally, the diameter of the shunt appears to correlate with the incidence of postprocedure encephalopathy. Therefore, if an acceptable portosystemic gradient and lack of briskly filling varices can be achieved with an 8-mm shunt, no further dilation should be undertaken. However, it is often necessary to dilate to 10 mm to achieve this. It has been shown that liver function worsens after shunting. Serious hepatic failure resulting in death has been reported in 3% to 7% of patients. 2 Should liver deterioration become significant or encephalopathy unacceptable despite medication, intentional TIPS occlusion using balloon occlusion techniques can be performed to restore adequate portal blood flow to the liver. In addition, stenosis within the celiac or hepatic artery may impede flow to the liver, and angioplasty may be required. Pulmonary hypertension, pulmonary edema, heart failure, and circulatory hyperdynamic state have all been described after portosystemic shunting.19-23
Additional Complications Intraprocedural myocardial infarction can occur. This probably is not related to anything inherent about the TIPS procedure, but rather is attributable to the overall medical condition of acutely ill patients with life-threatening bleeding. Early in operator experience, the TIPS procedure can take several hours to complete. The patient can be exposed to considerable radiation, and radiation dermatitis has been described. 24With experience, procedure and fluoroscopy times have decreased. Operators can reduce patient exposure with pulsed fluoroscopy and use of other fluoroscopy reduction techniques. Contrast-related nephropathy is possible. Adequate preprocedure and postprocedure hydration can help minimize this risk. Allergic reactions to contrast must be treated routinely, and preprocedure steroid prophylaxis in patients with prior contrast reactions is recommended. A case of fatal fungemia from an infected TIPS stent has been reported. 25 An interesting case of paradoxical cerebral emboli in a patient with a patent foramen ovale and right-to-left shunt has been described. 26
Conclusions
Fig 9. Inadvertent deployment of the TIPS stent into the right atrium. (A) The tip of the stent extends well into the right atrium. (B) The stent was pulled down into the inferior vena cava with a snare before liver transplantation.
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The TIPS procedure is a relatively minimally invasive procedure, but several important complications can occur. Interventionalists who perform TIPS should be aware of these complications, use techniques to help avoid these complications, and be knowledgeable regarding treatment options should complications occur. Delayed stenoses and occlusions are expected. Regular surveillance and reintervention are required to maintain TIPS patency, Likewise, post-TIPS encephalopathy is seen at a rate comparable to that seen after side-to-side portacaval surgical shunts. Excluding these two expected post-TIPS sequelae, the complications related to the TIPS procedure can be estimated overall to be less than 10%. 1 SAWHNEY AND WALL
References 1. Freedman AM, Sanyal AJ, Tisnado J, et al: Complications of transjugular intrahepatic portosystemic shunt: A comprehensive review. Radiographics 13:1185-1210, 1993 2. Kerlan RK, LaBerge JM, Baker EL, et al: Successful reversal of hepatic encephalopathy with intrahepatic occlusion of transjugular intrahepatic portosystemic shunts. JVIR 6:917-921, 1995 3. Lee EN, Mankad S, Shaver J, et al: Transjugular intrahepatic portosystemic shunt (TIPS) complicated by complete heart block. Anaesthesia and Intensive Care 25:312-313, 1997 4. Semba CP, Saperstein L, Nyman U, et al: Hepatic laceration from wedged venography performed before transjugular intrahepatic shunt placement. JVl R 7:143-146, 1996 5. LaBerge JM, Ferrell LD, Ring EJ, et al: Histopathologic study of stenotic and occluded transjugular intrahepatic portosystemic shunts. JVlR 4:779-786, 1993 6. Haskal ZJ, Pentecost MJ, Rubin RA: Hepatic arterial injury after transjugular intrahepatic portosystemic shunt placement: Report of two cases. Radiology 188:85-88, 1993 7. Sawhney R, Wall SD, Yee J, et al: Hepatic Jnfarction: Unusual complication of a transjugular intrahepatic portosystemic shunt. JVlR 8:129-132, 1997 8. Davis AG, Haskal Z J: Extrahepatic portal vein puncture and intraabdominal hemorrhage during transjuguiar intrahepatic portosystemic shunt creation. JVlR 7:863-866, 1996 9. Krajina A, Hulek P, Ferko A, et al: Extrahepatic portal venous laceration in TIPS treated with stent graft placement. HepatoGastroenterology 44:667-670, 1997 10. Yonker-Sell AE, Connolly LA: Mortality during transjugular intrahepatic portosystemic shunt placement. Anesthesiology 84:231-233, 1996 11. Beheshti MV, Jones MP: Shunt occlusion and acute portal, splenic and mesenteric venous thrombosJs complicating placement of a transjugular intrahepatic portosystemic shunt. JVlR 7:277-281, 1996 12. Wilson MW, Gordon RL, LaBerge JM, et al: Liver transplantation complicated by malpositioned transjugular intrahepatic portosystemic shunts. JVlR 6:695-699, 1995 13. Sanchez RB, Roberts AC, Valji K, et al: Wallstent misplaced during transjuguiar placement of an intrahepatic shunt: Retrieval with a loop snare. AJR 159:129-130, 1992
TIPS COMPLICATIONS
14. Lipton M, Cynamon J, Bakal CW, et al: Percutaneous retrieval of two Wallstent endoprostheses from the heart through a single jugular sheath. JVIR 6:469-472, 1995 15. Cekirge S, Foster RG, Weiss JP, et al: Percutaneous removal of an embolized Wallstent during a transjugular intrahepatic shunt procedure. JVIR 4:559-560, 1993 16. Cohen GS, Ball DS: Delayed Wallstent migration after a transjugular intrahepatic portosystemic shunt procedure: Relocation with a loop snare. JVlR 4:561-563, 1993 17. Prahlow JA, O'Bryant JJ: Cardiac perforation due to Wallstent embolization: A fatal complication of the transjugular intrahepatic portosystemic shunt procedure. Radiology 205:170-172, 1997 18. Sanyal A J, Freedman AM, Purdum PP, et al: The hematologic consequences of transjugular intrahepatic portosystemic shunts. Hepatology 23:32-39, 1996 19. van der Heijde RMJL, Lameris JS, van den Berg B, et al: Pulmonary hypertension after transjugular intrahepatic portosystemic shunt (TIPS). Eur Respir J 9:1562-1564, 1996 20. van der Linden P, Le Moine O, Ghysels M, et al: Pulmonary hypertension after transjugular Jntrahepatic porfosystemic shunt: Effects on right ventricular function. Hepatology 23:982-987, 1996 21. Willoughby PH, Beers RA, Murphy KD: Pulmonary edema after transjugular intrahepatic portosystemic shunt. Anesth Analg 82:885896, 1996 22. Braverman AC, Steiner MA, Picus D, et al: High-output congestive heart failure following transjugular intrahepatic portal-systemic shunting. Chest 107:1467-1469, 1995 23. Azoulay D, Castaing D, Dennision A, et al: Transjugular intrahepatic portosystemic shunt worsens the hyperdynamic circulatory state of the cirrhotic patient: Preliminary report of a prospective study. Hepatology 19:129-132, 1994 24. Knautz MA, Abele DC, Reynolds TL: Radiation dermatitis after transjugular intrahepatic portosystemic shunt. South Med J 90:352356, 1997 25. Schiano TD, Atillasoy E, Fiel MI, et al: Fatal fungemia resulting from an infected transjugular intrahepatic portosystemic shunt stenL Am J Gastroentero192:709-710, 1997 26. PonecRJ, KowdleyKV: Paradoxicalcerebralemboliaftertransjugular intrahepatic portosystemic shunt and coil embolization for treatment of duodenal varices. Am J Gastroentero192:1372-1373, 1997
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