An Approach to Endovascular and Percutaneous Management of Transjugular Intrahepatic Portosystemic Shunt (TIPS) Dysfunction: A Pictorial Essay and Clinical Practice Algorithm.

Transjugular intrahepatic portosystemic shunts (TIPS) have evolved as an effective and durable nonsurgical option in the treatment of portal hypertension (PH). It has been shown to improve survival in decompensated cirrhosis and may also serve as a bridge to liver transplantation. In spite of the technical improvements in the procedure, problems occur with the shunt which jeopardizes effective treatment of the PH. Appropriate management is vital to ensure the longevity of the conduit. Shunt revision techniques include endovascular revision techniques and new shunt creation or, in the appropriate patients, alternative/rescue therapies. The ability of interventional radiologists to restore adequate TIPS function has enormous implications for quality of life with palliation, morbidity/mortality related to variceal bleeding and survival if transplant candidates can live long enough to receive a new liver. As such, it is imperative that these treatment strategies are understood and employed when these patients are encountered. In this review, the restoration of appropriate shunt function using various techniques will be discussed as they apply to a variety of clinical scenarios, based on literature. In addition, illustrative case examples highlighting our experience at an academic tertiary medical center will be included. It is the intent to have this document serve as a concise and informative reference to be used by those who may encounter patients with suboptimal functioning TIPS.

Endovascular Management of Refractory Hepatic Encephalopathy Complication of Transjugular Intrahepatic Portosystemic Shunt (TIPS): Comprehensive Review and Clinical Practice Algorithm.

Transjugular intrahepatic portosystemic shunt (TIPS) has evolved as an effective intervention for treatment of complications of portal hypertension. The use of polytetrafluoroethylene-covered stents have improved the patency of the shunts and diminished the incidence of TIPS dysfunction. However, TIPS-related refractory hepatic encephalopathy (rHE) poses a significant challenge. Approximately 3-7 % of patients with TIPS develop rHE. Refractory hepatic encephalopathy is defined as a recurrent or persistent encephalopathy despite appropriate medical treatment. Hepatic encephalopathy can be an extremely debilitating complication that profoundly affects quality of life. The approach to management of patients with rHE is complex and typically requires collaboration between different specialties. Liver transplantation is the ultimate treatment for rHE; however, the ongoing shortage of organ donation markedly limits this treatment option. Alternative therapies such as shunt occlusion or reduction can control symptoms and serve as a 'bridge' therapy to liver transplantation. Therefore, interventional radiologists play a key role in the management of these patients by offering a variety of endovascular techniques. The purpose of this review is to highlight some of these endovascular techniques and to develop a therapeutic algorithm that can be applied in clinical practice for the management of rHE.

Successful technical and clinical outcome using a second generation balloon expandable coronary stent for transplant renal artery stenosis: Our experience.

Transplant renal artery stenosis (TRAS) is a vascular complication frequently seen because of increase in the number of renal transplantations. Early diagnosis and management is essential to optimize a proper graft function. Currently, the endovascular treatment of TRAS using angioplasty and/or stenting is considered the treatment of choice with the advantage that it does not preclude subsequent surgical correction. Treatment of TRAS with the use of stents, particularly in tortuous transplant renal anatomy presents a unique challenge to an interventional radiologist. In this study, we present three cases from our practice highlighting the use of a balloon-expandable Multi-Link RX Ultra coronary stent system (Abbott Laboratories, Abbott Park, Illinois, USA) for treating high grade focal stenosis along very tortuous renal arterial segments. Cobalt-Chromium alloy stent scaffold provides excellent radial force, whereas the flexible stent design conforms to the vessel course allowing for optimal stent alignment.

Ultrasound-accelerated vs standard catheter-directed thrombolysis--a comparative study in patients with iliofemoral deep vein thrombosis.

PURPOSE: To compare the thrombolytic efficacy and safety of standard catheter-directed thrombolysis (CDT) and ultrasound (US)-accelerated thrombolysis (UAT) for the treatment of iliofemoral deep vein thrombosis (DVT). MATERIALS AND METHODS: All medical records of patients who underwent CDT or UAT for DVT between June 2004 and October 2011 at a single tertiary care center were reviewed. Target vein patency was graded according to a reporting standard by an independent interventional radiologist. RESULTS: CDT was performed in 19 patients and UAT in 64 patients. The baseline parameters and DVT characteristics, including the duration of symptoms, the location, and the extension did not differ significantly between groups. Both treatment modalities were associated with a similar substantial resolution of thrombus load (CDT = 89%; interquartile range [IQR], 70%-100%; UAT = 82%; IQR, 55%-92% (P = .560). No significant differences in the lytic drug infusion rates, the total lytic doses, the total infusion time, and the use of adjunctive procedures were observed between groups. Major and minor bleeding complications were observed in 8.4% and 4.8% of the patients, with no difference between the treatment groups (P = .709 and P = .918, respectively). During a median follow-up of 35 months (20-55 months), three deaths and 16 cases of repeated thrombosis were observed. The estimated mean event-free survival time was longer after CDT (69 mo) compared with UAT (33 mo) (log-rank test P = .310). CONCLUSIONS: The present study failed to prove any substantial clinical benefit provided by UAT with regard to effectiveness or safety compared with standard CDT. Given the added costs of the US delivery device, prospective randomized data are needed to justify its widespread use for DVT treatment.