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Polytetrafluoroethylene-covered Nitinol Stent-Graft for Transjugular Intrahepatic Portosystemic Shunt Creation: 3-year Experience¹

¹ From the Departments of Radiological Sciences (P.R., F.M.S., F.F., M.B., M.R., G.M., D.P., R.P.) and Gastroenterology (O.R.), Policlinico Umberto I, Viale Regina Elena 324, 00161 Rome, Italy. Received March 4, 2003; revision requested May 23; final revision received September 29; accepted October 28. Address correspondence to P.R. (e-mail: plinio.rossi@uniroma1.it).

View larger version (92K): [in a new window]   Figure 1a. Anteroposterior digital portal venograms in 68-year-old man with alcoholic cirrhosis (Child-Pugh class A), treated with TIPS for recurrent variceal bleeding after two sessions of sclerotherapy. (a) Image shows a deployed stent-graft (10 mm x 5 cm) too short to cover the whole intraparenchymal tract; it was released with its bare portion (arrows) inside the liver parenchyma, to allow the covered portion to reach the hepatic vein (arrowhead). (b) Image obtained 9 months later shows marked stenosis (arrow) in the initial portion of the parenchymal tract at the site of the bare stent. Patient had recurrent symptoms and an increased PSG (22 mm Hg). (c) Image obtained after TIPS revision shows a new stent-graft (10 mm x 7 cm; stent-within-a-stent technique), deployed to cover the whole intraparenchymal tract, with a consequent decrease in PSG to 6 mm Hg.

View larger version (96K): [in a new window]   Figure 1b. Anteroposterior digital portal venograms in 68-year-old man with alcoholic cirrhosis (Child-Pugh class A), treated with TIPS for recurrent variceal bleeding after two sessions of sclerotherapy. (a) Image shows a deployed stent-graft (10 mm x 5 cm) too short to cover the whole intraparenchymal tract; it was released with its bare portion (arrows) inside the liver parenchyma, to allow the covered portion to reach the hepatic vein (arrowhead). (b) Image obtained 9 months later shows marked stenosis (arrow) in the initial portion of the parenchymal tract at the site of the bare stent. Patient had recurrent symptoms and an increased PSG (22 mm Hg). (c) Image obtained after TIPS revision shows a new stent-graft (10 mm x 7 cm; stent-within-a-stent technique), deployed to cover the whole intraparenchymal tract, with a consequent decrease in PSG to 6 mm Hg.

View larger version (154K): [in a new window]   Figure 1c. Anteroposterior digital portal venograms in 68-year-old man with alcoholic cirrhosis (Child-Pugh class A), treated with TIPS for recurrent variceal bleeding after two sessions of sclerotherapy. (a) Image shows a deployed stent-graft (10 mm x 5 cm) too short to cover the whole intraparenchymal tract; it was released with its bare portion (arrows) inside the liver parenchyma, to allow the covered portion to reach the hepatic vein (arrowhead). (b) Image obtained 9 months later shows marked stenosis (arrow) in the initial portion of the parenchymal tract at the site of the bare stent. Patient had recurrent symptoms and an increased PSG (22 mm Hg). (c) Image obtained after TIPS revision shows a new stent-graft (10 mm x 7 cm; stent-within-a-stent technique), deployed to cover the whole intraparenchymal tract, with a consequent decrease in PSG to 6 mm Hg.

View larger version (119K): [in a new window]   Figure 2a. Digital portal venograms in 66-year-old woman with posthepatitic cirrhosis (Child-Pugh class A) who had undergone TIPS creation with a Viatorr stent (10 mm x 6 cm) for ascites and repeated bleeding after sclerotherapy. (a) Anteroposterior image obtained after TIPS revision for recurrent ascites, performed 5 months after TIPS creation, shows a hepatic vein stenosis (arrow). The PSG was 15 mm Hg. (b) Left anterior oblique image obtained after treatment with a balloon-expandable PTFE-covered stent (Jostent). The PSG decreased to 4 mm Hg. The patient did very well, and 2 years later color Doppler US (not shown) showed a patent stent with no stenosis.

View larger version (119K): [in a new window]   Figure 2b. Digital portal venograms in 66-year-old woman with posthepatitic cirrhosis (Child-Pugh class A) who had undergone TIPS creation with a Viatorr stent (10 mm x 6 cm) for ascites and repeated bleeding after sclerotherapy. (a) Anteroposterior image obtained after TIPS revision for recurrent ascites, performed 5 months after TIPS creation, shows a hepatic vein stenosis (arrow). The PSG was 15 mm Hg. (b) Left anterior oblique image obtained after treatment with a balloon-expandable PTFE-covered stent (Jostent). The PSG decreased to 4 mm Hg. The patient did very well, and 2 years later color Doppler US (not shown) showed a patent stent with no stenosis.

View larger version (125K): [in a new window]   Figure 3a. Images in a 59-year-old man with posthepatitic cirrhosis (Child-Pugh class C) who had undergone TIPS creation for refractory ascites; a Viatorr stent (10 mm x 6 cm) was used. The PSG decreased from 24 to 7 mm Hg. After 3 months, because of recurrent ascites, the patient underwent a TIPS revision. (a) Anteroposterior portal venogram obtained before TIPS revision shows a stenosis (arrow) of the portal vein at the level of the bare portion of the stent. (b) Transverse intravascular US image obtained during the revision shows a stenosis secondary to a parietal thrombus formation (T). (c) Anteroposterior venogram obtained after treatment of the stenosis with deployment of a new bare self-expanding stent; the PSG decreased from 19 to 8 mm Hg. (d) Photograph obtained after liver transplantation 3 months later shows a patent stent lumen with evidence of the old thrombus (arrowhead) partially surrounding the bare stent.

View larger version (138K): [in a new window]   Figure 3b. Images in a 59-year-old man with posthepatitic cirrhosis (Child-Pugh class C) who had undergone TIPS creation for refractory ascites; a Viatorr stent (10 mm x 6 cm) was used. The PSG decreased from 24 to 7 mm Hg. After 3 months, because of recurrent ascites, the patient underwent a TIPS revision. (a) Anteroposterior portal venogram obtained before TIPS revision shows a stenosis (arrow) of the portal vein at the level of the bare portion of the stent. (b) Transverse intravascular US image obtained during the revision shows a stenosis secondary to a parietal thrombus formation (T). (c) Anteroposterior venogram obtained after treatment of the stenosis with deployment of a new bare self-expanding stent; the PSG decreased from 19 to 8 mm Hg. (d) Photograph obtained after liver transplantation 3 months later shows a patent stent lumen with evidence of the old thrombus (arrowhead) partially surrounding the bare stent.

View larger version (122K): [in a new window]   Figure 3c. Images in a 59-year-old man with posthepatitic cirrhosis (Child-Pugh class C) who had undergone TIPS creation for refractory ascites; a Viatorr stent (10 mm x 6 cm) was used. The PSG decreased from 24 to 7 mm Hg. After 3 months, because of recurrent ascites, the patient underwent a TIPS revision. (a) Anteroposterior portal venogram obtained before TIPS revision shows a stenosis (arrow) of the portal vein at the level of the bare portion of the stent. (b) Transverse intravascular US image obtained during the revision shows a stenosis secondary to a parietal thrombus formation (T). (c) Anteroposterior venogram obtained after treatment of the stenosis with deployment of a new bare self-expanding stent; the PSG decreased from 19 to 8 mm Hg. (d) Photograph obtained after liver transplantation 3 months later shows a patent stent lumen with evidence of the old thrombus (arrowhead) partially surrounding the bare stent.

View larger version (59K): [in a new window]   Figure 3d. Images in a 59-year-old man with posthepatitic cirrhosis (Child-Pugh class C) who had undergone TIPS creation for refractory ascites; a Viatorr stent (10 mm x 6 cm) was used. The PSG decreased from 24 to 7 mm Hg. After 3 months, because of recurrent ascites, the patient underwent a TIPS revision. (a) Anteroposterior portal venogram obtained before TIPS revision shows a stenosis (arrow) of the portal vein at the level of the bare portion of the stent. (b) Transverse intravascular US image obtained during the revision shows a stenosis secondary to a parietal thrombus formation (T). (c) Anteroposterior venogram obtained after treatment of the stenosis with deployment of a new bare self-expanding stent; the PSG decreased from 19 to 8 mm Hg. (d) Photograph obtained after liver transplantation 3 months later shows a patent stent lumen with evidence of the old thrombus (arrowhead) partially surrounding the bare stent.

View larger version (16K): [in a new window]   Figure 4. Graph shows Kaplan-Meier analysis for primary patency. The 1-year primary patency rate is 83.8%.

View larger version (18K): [in a new window]   Figure 5. Graph shows Kaplan-Meier analysis for primary patency in patients in whom the stent reached the IVC (90.8% at 1 year; dotted line) versus those in whom the stent was too short (79.5% at 1 year; solid line; log-rank test, P = .25).

View larger version (126K): [in a new window]   Figure 6. Right anterior oblique digital portal venogram obtained after TIPS procedure shows good position of the stent, although its bare portion (arrowheads) extends almost to the middle of the portal vein.

View larger version (15K): [in a new window]   Figure 7. Graph shows Kaplan-Meier analysis for survival. The survival rate at 489 days is 82.7%.