Overlapping TIPS stents in Budd-Chiari with distorted anatomy: case two

Dr Homoyoon Mehrzad discusses a challenging case involving a 28-year-old patient with a rare form of BCS. The patient presented with portal hypertension, abdominal pain, fever, and hepatomegaly. Diagnosis was aided by transjugular biopsy and CT imaging, revealing inferior vena cava compression, a patent portal vein, and significant ascites. Dr Mehrzad utilized multiple overlapping TIPS stents to alleviate portal pressure, demonstrating improved flow dynamics and longer-term stent patency. The case highlights the safety and efficacy of mechanical thrombectomy and balloon angioplasty in managing stent blockages, emphasizing tailored interventions and meticulous management strategies for BCS.

Dr. Homoyoon Mehzrad (00:15):
Hello. I’m Dr. Homoyoon Mehzrad, Consultant and Interventional Radiologist at the Queen Elizabeth Hospital of Birmingham, United Kingdom. Today’s topic is Overlapping TIPS stents in Budd-Chiari patients with distorted anatomy, and it’s part of the TIPS Complex Case Educational Series brought to you by Cook Medical. Let’s begin.

(00:33):
This was a young patient; she was a 28-year-old female who presented with abdominal pain and fever, hepatomegaly, and a Budd-Chiari picture clinically. However, when we did the venogram we found out that the hepatic veins were patent but there was portal hypertension on the pressure measurements. We undertook a transjugular liver biopsy which showed that there was venous congestion of the small vessels of the liver, basically the small venous blood vessels, and this is classified as a rare form of small vessel Budd-Chiari syndrome. A decision was made to undertake TIPS to alleviate the pressure and symptoms for this patient.

(01:14):
So I want to show you the CT scan from August 2016. You can see typical cell Budd-Chiari appearance, very mottled appearance of the liver parenchyma, quite significant amount of ascites in the abdomen, and pleural effusions. Further down on the CT scan, you can see that the beginning of the portal vein is patent but very typical picture of hypertrophy of the liver, hepatomegaly, caudate lobe hypertrophy, some compression of the IBC, but patent portal vein so we undertook a TIPS stent to help her symptoms. This is the picture. We can see that the hepatic vein is patent. There wasn’t much of a stenosis, there is patency but, as I said, this was a small vessel Budd-Chiari syndrome.

(02:09):
We undertook a standard TIPS procedure using the Cook equipment. We managed to get access into the right portal vein, as you can see. Confirming position, we placed a long TIPS stent, an 8 cm one. We ballooned that and we had good flow through the TIPS stent from the portal vein up into the hepatic veins and right atrium. The patient was placed in anticoagulation. She re-presented with abdominal pain a short time afterwards and, despite anticoagulation, the TIPS stent had become blocked with thrombus and there was really a question about how compliant the patient was with her anticoagulation and medication at that time.

(03:04):
In November 2017, we went back in to unblock the TIPS stent and you can see here basically we’ve brought in the long sheath. We’ve got a catheter here when we do the venogram. There is thrombus and occlusion of the superior aspect of the TIPS stent. There’s no flow through it. We got a catheter through into the blocked, occluded stent. You can see there’s thrombus there with limited contrast flow. But when we got into the portal vein there was normal flow within the portal vein and it was going to both sides, but not the TIPS stent. There again, you can see the thrombus within the TIPS stents in the mid and superior aspects, so we had to de-clot that. We did a thrombectomy on the TIPS stent and we then had to extend the TIPS stent both at the superior and inferior aspect We placed another stent, three in total now, one in the superior aspect of the original and one in the inferior aspect. We ballooned that and this is the final picture where we see contrast injected into the main portal vein, no filling of the portal vein in the intrahepatic segments, but it goes through the TIPS stent directly all the way into the hepatic vein and into the right atrium.

(04:38):
This lady re-presented, unfortunately, two months later with further blocked TIPS and de-clotting was performed with mechanical thrombectomy and ballooning and good flow was established within the TIPS stents.

(04:53):
Really this was all about compliance with anticoagulation, so she then developed better compliance with anticoagulation and, since then, she comes for her annual venogram and check, she’s not had any more thrombus within the TIPS stents. They are patent and they’re working well and that’s several years down the line now.

(05:12):
We can say it’s safe to use multiple overlapping TIPS stents in these complex Budd-Chiari patients. Better flow can be established if you have more than one stent and there is good long-term patency. But the key bit is compliance with anticoagulation and medication is important. It is safe to use mechanical thrombectomy devices in TIPS patients. We’ve done that on several cases and it’s effective strategy with ballooning to unblock blocked stents.

(05:44):
That wraps up this complex case. We hope you found it useful. If you have any comments of case ideas you’d like to see in future episodes, please send your feedback to TIPScases@cookmedical.com and be sure to keep an eye out for the next complex case. Thank you.

Dr Homoyoon Mehrzad was a paid consultant of Cook Medical at the time of recording.