Synopsis
Dr Virginia Hernández-Gea from Hospital Clínic, Barcelona, explains her treatment of a 70-year-old patient with alcohol-induced cirrhosis and refractory hepatic encephalopathy (HE). Following recurrent HE episodes post-rescue TIPS procedure, recalibration was necessary. The inventive approach involved placing a parallel TIPS stent alongside a shorter balloon-expandable stent within the existing TIPS tract. This technique aimed to increase the gradient of portosystemic pressure from 8 to 13 mmHg. Utilising specialised materials, the intervention alleviated HE symptoms and prevented further hospital admissions. This case underscores the efficacy of tailored interventions in managing complex hepatic complications, significantly improving patient outcomes in refractory HE cases.
Transcript
Presenter (00:15):
Hello, I’m Dr Virginia Hernández-Gea and today’s topic is TIPS recalibration and it’s part of the TIPS Complex Case Educational Series brought to you by Cook Medical. Let’s begin.
(00:26):
We have the case of a 70-year-old male patient with cirrhosis due to alcohol abuse. The patient had several and severe variceal bleedings and we placed a rescue TIPS in September 2022. We placed a covered stent that was dilated to eight millimeters, and the final GPP was nine millimeters of mercury.
(00:50):
The patient started with recurring hepatic encephalopathy despite all the measurements, medical measurements, so we decided to do an intervention to the TIPS.
(01:05):
We decided not to go for TIPS closure, the irreversible occlusion, because it was a patient who was not a candidate for liver transplant, who previously had very severe variceal bleeding, so we decided to recalibrate the TIPS.
(01:18):
So what we did, and this is the technique that we used, was to–we had two separate punctures in the right internal jugular vein, placing two sheaths in parallel, one at ten French and one at six French.
(01:38):
Then with a catheter balloon, we occluded the TIPS to make sure that the intrahepatic flow was completely adequate before starting the real procedure.
(01:51):
And then what we did in the six-F sheath was placing a balloon-expandable stent right in the middle of the TIPS. Once we had the stent there in the right position we deployed a second covered stent graft in the ten French sheath.
(02:17):
And right after, and while measuring the portal pressure, you can see the catheter inside the stent, measuring and recording the portal pressure. So while measuring we can deploy the balloon-expandable stent and safely control the degree of the narrowing that we want in the TIPS based on the portosystemic gradient that we want to achieve.
(02:42):
However, if we’re not completely confident with the GPP achieved, all the narrowing, we can always do another angioplasty right in the place of the balloon-expandable stent to achieve the target GPP.
(03:04):
After the procedure, the angiography showed that the stent-graft was focally narrowed as a result of this extrinsic compression that we did with the balloon-expandable stent. And the final GPP that was achieved in this patient was 13 millimeters of mercury.
(03:26):
So this is just a schematic reproduction of what we did. And the material that you will need if you want to do that in your center is, you need a second covered stent, ideally the same length of the previous one, and a balloon-expandable stent.
(03:44):
And what you will do is place the balloon-expandable stent right in the middle of the graft stent and deploy a new covered stent, so at the end what you will have is two stents, but outside the new one you will have the expandable–the balloon-expandable–stent narrowing the TIPS, decreasing the diameter of the stent, and therefore increasing portal pressure in the patient.
(04:19):
So what I can tell you about this particular patient is that during the follow up, he was okay. The final GPP was 13, and we could further reduce that with medication, with non-selective beta-blockers, and also with the measurements anti-hepatic encephalopathy, and the patient did perfectly fine during follow up.
(04:43):
So with this I want to wrap up this complex case, and we hope you find it useful. And if you have any comments or case ideas you would like to see in the future episodes, send your feedback to TIPScases@cookmedical.com and be sure to keep an eye out for the next complex case.
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Dr Virginia Hernández-Gea was a paid consultant of Cook Medical at the time of recording.