Transient segmental liver ischaemia after polytetrafluoroethylene transjugular intrahepatic portosystemic stent-shunt procedure

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A 36-year-old man with alcohol/hepatitis C induced cirrhosis (Childs C) was admitted with oesophageal variceal bleeding. Variceal band ligation failed to control the haemorrhage and he therefore underwent a transjugular intrahepatic portosystemic stent-shunt (TIPSS) procedure utilising a polytetrafluoroethylene (PTFE) covered stent. The portal pressure gradient was reduced from 29 to 9 mmHg. The patient did not experience any post procedure pain or rise in transaminases. Routine Doppler ultrasonography 3 days post TIPSS insertion demonstrated adequate flow and a heterogenous area in the right lobe of the liver. A subsequent CT scan revealed a low attenuation perfusion defect in the right hemi liver in keeping with liver ischaemia (left panel). This was found to be a transient phenomenon as the follow up CT scan, 6 months later, showed resolution of these changes (right panel).

Early studies have suggested that covered stents may improve shunt patency [1], [2]. In this case, a (PTFE) shunt (Viatorr; W.L.Gore Flagstaff, AZ) was used which has a 2 cm uncovered section to preserve portal vein and a variable length PTFE covered section for lining the parenchymal tract. The shunt was fashioned from the right branch of the portal vein to the inferior vena cava (IVC). The PTFE covering extended to the IVC, therefore blocking outflow of the right hepatic vein and inducing hepatic vein thrombosis. In this case, the effect was transient presumably due to the development of collaterals allowing the right hepatic vein to drain into the left and middle hepatic veins. There has been some concern that this liver injury might lead to deterioration in liver function with liver necrosis and atrophy in the affected area. However, no significant functional or clinical result ensued in this case. There is, however, a potential problem, which should be borne in mind when using these devices.

In summary PTFE shunts, which occlude the hepatic vein, may improve patency but the risk of hepatic venous outflow obstruction is yet to be fully described.

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References 

1. Hulek P, Fejfar T, Vanasek T, Karjina A, Lojik M, Zizka J, et al.  Covered stents significantly reduce the incidence of in stent stenosis of TIPS: results of RCT in humans. J Hepatol. 2001;34:A1034
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2. Angermayr B, Cejna M, Koenig F, Karnel F, Hackl F, Gangl A, et al.  Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stentgrafts versus bare stents. Hepatology. 2003;38:1043–1050
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