Parallel TIPS technique to manage bleeding

Dr Homoyoon Mehrzad, an interventional radiologist at Queen Elizabeth Hospital Birmingham, recaps findings from a 19-year retrospective study by the University of Birmingham on the use of Parallel TIPS (transjugular intrahepatic portosystemic shunt) to manage TIPS insufficiency. Parallel TIPS, involving the placement of an additional stent alongside the original, aims to lower portal pressure gradient (PPG) in symptomatic patients with persistent elevated PPG. The study demonstrated a significant reduction in mean PPG from 16.6 to 10.8 mmHg and showed an 83% resolution of symptoms post-procedure, highlighting the technique’s effectiveness and safety.

Dr Homoyoon Mehrzad (00:15):
Hello, I’m Dr Homoyoon Mehrzad, consultant interventional radiologist at the Queen Elizabeth Hospital Birmingham, United Kingdom. Today’s topic is Parallel TIPS: the Birmingham Experience, and is part of the TIPS complex case series brought to you by Cook Medical. So let’s begin with our presentation. TIPS insufficiency happens for several reasons, either thrombosis or pseudointimal hyperplasia at either the portal vein, site of the stent or the hepatic vein site, or insufficient length of the stent or kinking. Treatment options if this happens are either traditionally to do balloon angioplasty, stent extension, thrombolysis, or rarely a parallel TIPS formation. So there has been a change in the indication for parallel TIPS. Previously, it was because the index TIPS dysfunctioned and thrombosed, and that’s in the area of uncovered TIPS stents. In the area of covered TIPS stents, that’s not really a problem and it’s mainly due to still continued raised portosystemic pressure gradient following the indexed TIPS stent or continued symptoms from the patient.

(01:37):
What do I mean by parallel TIPS? What I mean is basically placement of another TIPS stent beside the original stent, lowering the portal pressure gradient even further. There is growing evidence that lowering the portal pressure gradient further will be beneficial. The accepted normal pressure is to get it down to 12 millimeters of mercury or below, but there are some recommendations that if you get it down to 8 millimeters of mercury, you get even further improvement in quality of life. There is some paucity of data assessing the efficacy of this technique though. So our method for this study was really to look at the parallel TIPS stents we’ve undertaken in our large tertiary transplant liver center. It was a retrospective study which was performed with patient electronic database and case notes.

(02:32):
The first TIPS index stent was placed and the parallel TIPS stent was then performed alongside that, and the study looked over a 19-year period. During this period, the index TIPS was done as a rescue therapy for either refractory variceal bleeding or for ascites. A total of 550 TIPS stents were done in our center over the 19-year period that we looked into during the study. There were 12 patients, that’s 2%, eight male, four female, who had a parallel TIPS, and eight of these were covered stents. Mean age of the patient was 48 years. And the etiology, as you can see on the screen, the largest cause was due to alcoholic liver disease, but there were also causes for PSC, PBC, graft failure, and non-cirrhotic portal hypertension.

(03:27):
The indications for the index TIPS stents: we had five patients that had it done for esophageal variceal hemorrhage, three for gastric variceal hemorrhage, one patient had a stoma variceal hemorrhage, and three for refractory ascites. So index TIPS was performed and the key thing was the main portal pressure gradient pre-index TIPS was 16 millimeters of mercury and the main portal pressure gradient post-index TIPS was 10 millimeters of mercury at the end, so there is significant drop there. How was the parallel TIPS technique performed? Well, it was a standard right internal jugular vein access. We used a Cook Rösch-Uchida TIPS Access Set. We performed portal venography and pressure measurements in the index stent and the index stent was used as a marker to help with access, basically. Normal technique was to try and get a parallel TIPS from the left hepatic vein into the left portal vein.

(04:30):
So let’s have a look at some pictures. Here’s a TIPS in a patient who had ongoing gastric variceal hemorrhage despite patent indexed TIPS, as you can see on the screen. There is no significant stenosis and the portal pressure gradient was quite good at 11 millimeters of mercury, but he continued to bleed despite indexed stent and also embolization, so decision was made to put a parallel TIPS stent. What you can see here is that we’ve inserted a second TIPS stent from the left hepatic vein into the left portal vein, and the final picture shows contrast flowing up the portal vein via two stents in the right hepatic vein, one into the left hepatic vein up into the right atrium. The final portal pressure gradient was noted to be four millimeters of mercury, so further reduction in that following the parallel TIPS. The patient improved and there was no further bleeding from gastroesophageal varices.

(05:37):
In the study, the median time between the index TIPS and the parallel TIPS was 72 days. Seven patients had dilatation of the index TIPS in the interim if there was ongoing symptoms or raised portal pressure gradient despite the index TIPS. Clinical indications for placing parallel TIPS, 10 were due to variceal re-bleeds and two were for ascites re-accumulation. Five index TIPS were blocked and narrowed on imaging. The main initial portal gradient before we started the parallel TIPS was 16 millimeters of mercury and following placement of the parallel TIPS, portal pressure gradient came down to six millimeters of mercury, so significant reduction in that gradient. Sixty-seven percent of these patients had covered stents as the parallel TIPS. So you can see that some of that is historical.

(06:35):
These patients were followed up for a median period of 30 months post the parallel TIPS. One patient had transient encephalopathy but no other complications. And I think we’ve found that in our series the encephalopathy is quite low. Ten patients, that’s 83%, had a resolution in their symptoms. Very important, particularly as these were variceal bleeds, largely. One patient had ongoing gastrovariceal bleeding and required thrombin injection. One patient had ascites with no flow in the parallel TIPS, which had occluded four days post procedure. Secondary patency of these stents was 82% with a median number of interventions being at 1.5. Ninety-two percent of patients were alive at one month with 86% one-year survival. Two of these patients were then transplanted during this follow-up period.

(07:34):
Parallel TIPS, we can conclude, is a safe and effective method to treat TIPS insufficiency, and particularly those patients that have ongoing symptoms, particularly variceal bleeding or continued raised portal pressure gradient. We found that we had good outcomes with resolution of the patient’s symptoms. It has an important role in reducing portal pressure and should be considered if any clinical or hemodynamic evidence of primary TIPS shunt failure or unresponsive to further dilatation. The key thing to remember is that we’re talking about a small select group of patients and good discussion between the clinicians and the interventional radiologist is key.

(08:20):
We’ll briefly look at how our series compares with the literature. There are no randomized controlled trials because they’re such a unique set of cases. There are few small case series and retrospective study done between 2006 and 2014. This was published in September 2014 and it was to look at the role of parallel TIPS to reduce portal venous hypertension. They looked at a period from January 2011 to December 2012, 10 patients that were cirrhotic who underwent both primary and parallel TIPS. The parallel TIPS was done to insufficient relief of symptoms, similar to our cases, or unsuccessful reduction in portal pressure gradient. Unlike ours, the majority of their patients were due for ascites and they only had one patient that was having parallel TIPS for variceal hemorrhage. Parallel TIPS was done between three and six months after the index TIPS. You can see the procedure time was reduced between the index TIPS and the parallel TIPS, so that’s an interesting outcome.

(09:31):
They found clinical improvement in their patients and in terms of complications they reported four patients had transient grade 1 or 2 hepatic encephalopathy, which were relieved with medical treatment. So, again, similar low levels of hepatic encephalopathy reported. Three patients went on to have hepatic failure in their series. One was cured after one week of treatment. They had a mean follow-up period of 14 months. Two patients with Child-P class C with several hospital admissions, but they found that overall the ascites and hemorrhage in those patients that underwent parallel TIPS was well controlled. Incidence of hepatic encephalopathy was 30% at three months, 40% at six months, and raising up to 50% at 12 months, so it gradually increased over that one-year period.

(10:26):
These are the references, and that wraps up this complex case. We hope you found it useful. If you have any comments or case ideas you would like to see in the future, send your feedback to TIPScases@cookmedical.com and be sure to keep an eye out for the next complex cases. Thank you very much and hope to see you soon.

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