In Reply to: Case 1001-01 -- TIPS Reduction with a Hand-Made Stent-Graft posted by Editor on October 04, 2001 at 12:06:03:
Interesting case. I completely agree with your decision of not occluding the shunt. That maneuver has proven to be counterproductive. Ricardo Paz-Fumigalli and Marti Crain reported a death after intentional occlusion of a functional TIPS in a patient with refractory encephalopathy. If I remember correctly, they attributed their death to drastic hemodynamic changes shortly after TIPS occlusion.
I am not sure that you needed a stent-graft in this case. We have used reducing stents in similar patients twice. It seems to me that every time I use a different technique. In our first case, we used a technique described by Haskal in which we only applied sutures to a Wallstent. The TIPS sheath was advanced all the way into the shunt. Subsequently, we advanced the "tied stent" through the sheath and pushed it with the introducing dilator of the TIPS sheath. (we had cut the introducing dilator to make it look like a pusher catheter). It was just like deploying a vena-tech filter. Our second case, we used a vista-flex stent and placed it over a Wallstent. The deployment was very similar. In both cases, we were successful in increasing the portosystemic gradient. Other models of reducing stents have been described and usually work in decreasing refractory encephalopathy. In my previous experience, patients who develop refractory encephalopathy have been patients in very poor shape, with terminal liver failure, usually class C with high scores (greater than 10).