Semin intervent Radiol 2024; 41(02): 220-225
DOI: 10.1055/s-0044-1786539
Richard Wu
1
Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
,
Nima Kokabi
1
Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
,
Jonah M. Adler
1
Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
,
Anant D. Bhave
2
Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
,
Christopher S. Morris
2
Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
,
Wael E. Saad
3
Division of Vascular and Interventional Radiology, Department of Radiology, University of Utah Hospital, Salt Lake City, Utah
,
David S. Majdalany
4
Division of Cardiology, Mayo Clinic, Scottsdale, Arizona
,
Bill S. Majdalany
2
Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
› Author Affiliations
Funding No funding was received for the development of this manuscript.
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Transjugular intrahepatic portosystemic shunts (TIPS) are widely performed and have replaced more invasive surgical shunt alternatives in the treatment of medically and endoscopically refractory portal hypertensive variceal bleeds and ascites.[1]
[2] In the setting of refractory gastroesophageal variceal hemorrhage, creation of a TIPS to decompress the portal system is often combined with variceal embolization to directly treat the source of hemorrhage and decrease rebleed rates.[3] While coil or plug embolization is performed to interrupt flow into the variceal circuit, the addition of sclerotherapy to permeate through and eliminate the variceal circuit has been suggested as a more efficacious therapy with lower rebleed rates.[4]
[5]
[6] Controlling the distribution of sclerosants in a high-flow system that may have large capacitance and multiple inflow vessels, however, may result in incomplete treatment and the potential for non-target embolization. Herein, a case of TIPS creation and variceal sclerotherapy complicated by paradoxical cerebral embolization is reported followed by a review of the pertinent literature.
Disclosures
No relevant financial disclosures.
N.K.: Research Grant and Proctor, Sirtex Medical.
B.S.M.: Scientific Advisory Board, Balt Medical.
Authors' Contribution
All authors have read and contributed to this manuscript.
Publication History
Article published online:
10 July 2024
© 2024. Thieme. All rights reserved.
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References
1
García-Pagán JC,
Saffo S,
Mandorfer M,
Garcia-Tsao G.
Where does TIPS fit in the management of patients with cirrhosis?. JHEP Rep Innov Hepatol 2020; 2 (04) 100122
2
Rajesh S,
George T,
Philips CA.
et al.
Transjugular intrahepatic portosystemic shunt in cirrhosis: an exhaustive critical update. World J Gastroenterol 2020; 26 (37) 5561-5596
3
Qi X,
Liu L,
Bai M.
et al.
Transjugular intrahepatic portosystemic shunt in combination with or without variceal embolization for the prevention of variceal rebleeding: a meta-analysis. J Gastroenterol Hepatol 2014; 29 (04) 688-696
4
Lakhoo J,
Bui JT,
Lokken RP,
Ray Jr CE,
Gaba RC.
Transjugular intrahepatic portosystemic shunt creation and variceal coil or plug embolization ineffectively attain gastric variceal decompression or occlusion: results of a 26-patient retrospective study. J Vasc Interv Radiol 2016; 27 (07) 1001-1011
5
Saad WEA,
Sabri SS.
Balloon-occluded retrograde transvenous obliteration (BRTO): technical results and outcomes. Semin Intervent Radiol 2011; 28 (03) 333-338
6
Saad WEA,
Wagner CC,
Lippert A.
et al.
Protective value of TIPS against the development of hydrothorax/ascites and upper gastrointestinal bleeding after balloon-occluded retrograde transvenous obliteration (BRTO). Am J Gastroenterol 2013; 108 (10) 1612-1619
7
Garcia-Tsao G,
Groszmann RJ,
Fisher RL,
Conn HO,
Atterbury CE,
Glickman M.
Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology 1985; 5 (03) 419-424
8
Meseeha M,
Attia M.
Esophageal Varices. 2022 . Accessed April 15, 2024 at:
http://www.ncbi.nlm.nih.gov/pubmed/28846255
9
Vianna A,
Hayes PC,
Moscoso G.
et al.
Normal venous circulation of the gastroesophageal junction. A route to understanding varices. Gastroenterology 1987; 93 (04) 876-889
10
Alqahtani SA,
Jang S.
Pathophysiology and management of variceal bleeding. Drugs 2021; 81 (06) 647-667
11
Gaba RC,
Couture PM,
Lakhoo J.
Gastroesophageal variceal filling and drainage pathways: an angiographic description of afferent and efferent venous anatomic patterns. J Clin Imaging Sci 2015; 5 (01) 61
12
Kiyosue H,
Ibukuro K,
Maruno M,
Tanoue S,
Hongo N,
Mori H.
Multidetector CT anatomy of drainage routes of gastric varices: a pictorial review. Radiographics 2013; 33 (01) 87-100
13
Hagen PT,
Scholz DG,
Edwards WD.
Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984; 59 (01) 17-20
14
Hara H,
Virmani R,
Ladich E.
et al.
Patent foramen ovale: current pathology, pathophysiology, and clinical status. J Am Coll Cardiol 2005; 46 (09) 1768-1776
15
Lechat P,
Mas JL,
Lascault G.
et al.
Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988; 318 (18) 1148-1152
16
Webster MWI,
Chancellor AM,
Smith HJ.
et al.
Patent foramen ovale in young stroke patients. Lancet 1988; 2 (8601) 11-12
17
Mojadidi MK,
Zaman MO,
Elgendy IY.
et al.
Cryptogenic stroke and patent foramen ovale. J Am Coll Cardiol 2018; 71 (09) 1035-1043
18
Kent DM,
Dahabreh IJ,
Ruthazer R.
et al.
Device closure of patent foramen ovale after stroke: pooled analysis of completed randomized trials. J Am Coll Cardiol 2016; 67 (08) 907-917
19
Seib GA.
Incidence of the patent foramen ovale cordis in adult American whites and American negroes. Am J Anat 1934; 55 (03) 511-525
20
Tuennemann J,
Mössner J,
Hoffmeister A.
Acute cerebrovascular incident as a complication of TIPS procedure. Z Gastroenterol 2013; 51 (04) 381-383
21
Appenrodt B,
Schepke M,
Kuntz-Hehner S,
Schmiedel A,
Sauerbruch T.
A patient with portal hypertension and blindness after transjugular intrahepatic portosystemic shunt. Eur J Gastroenterol Hepatol 2006; 18 (04) 447-449
22
Lam YY,
Yu CM,
Zhang Q,
Yan BP,
Yip GWK.
Enhanced detection of patent foramen ovale by systematic transthoracic saline contrast echocardiography. Int J Cardiol 2011; 152 (01) 24-27
23
Vizzutti F,
Rega L,
Arena U.
et al.
Paradoxical embolization in TIPS: take a closer look to the heart. Ann Hepatol 2015; 14 (01) 127-131
24
Braun M,
Gliech V,
Boscheri A.
et al.
Transcatheter closure of patent foramen ovale (PFO) in patients with paradoxical embolism. Periprocedural safety and mid-term follow-up results of three different device occluder systems. Eur Heart J 2004; 25 (05) 424-430
25
Hutchison DCS,
Sapru RP,
Sumerling MD,
Donaldson GWK,
Richmond J.
Cirrhosis, cyanosis and polycythaemia: multiple pulmonary arteriovenous anastomoses. Am J Med 1968; 45 (01) 139-151
26
Hoffbauer FW,
Rydell R.
Multiple pulmonary arteriovenous fistulas in juvenile cirrhosis. Am J Med 1956; 21 (03) 450-460
27
Gaba RC,
Zivin SP,
Dikopf MS.
et al.
Characteristics of primary and secondary hepatic malignancies associated with hepatopulmonary shunting. Radiology 2014; 271 (02) 602-612
28
Zamirian M,
Aslani A,
Sharifkazemi M.
Prediction of intrapulmonary right to left shunt with left atrial size in patients with liver cirrhosis. Eur J Echocardiogr 2008; 9 (01) 1-64
29
Sawant P,
Vashishtha C,
Nasa M.
Management of cardiopulmonary complications of cirrhosis. Int J Hepatol 2011; 2011: 280569
30
Hopkins WE,
Waggoner AD,
Barzilai B.
Frequency and significance of intrapulmonary right-to-left shunting in end-stage hepatic disease. Am J Cardiol 1992; 70 (04) 516-519
31
Vedrinne J-M,
Duperret S,
Bizollon T.
et al.
Comparison of transesophageal and transthoracic contrast echocardiography for detection of an intrapulmonary shunt in liver disease. Chest 1997; 111 (05) 1236-1240
32
Alipour Z,
Armin A,
Mohamadi S.
et al.
Hepatopulmonary syndrome with right-to-left shunt in cirrhotic patients using macro-aggregated albumin lung perfusion scan: comparison with contrast echocardiography and association with clinical data. Mol Imaging Radionucl Ther 2020; 29 (01) 1-6
33
Narsinh KH,
Van Buskirk M,
Kennedy AS.
et al.
Hepatopulmonary shunting: a prognostic indicator of survival in patients with metastatic colorectal adenocarcinoma treated with 90Y radioembolization. Radiology 2017; 282 (01) 281-288
34
Power SP,
Bishay K,
May GR,
Marcuzzi D,
Prabhudesai V.
Portopulmonary venous anastomosis as a rare cause of embolic stroke following endoscopic cyanoacrylate injection for gastric variceal hemorrhage: a case report and review of the literature. JGH Open 2019; 4 (01) 99-102
35
Al Hanayneh M,
Majchel-Koss D,
Walser E,
Goodgame R.
Porto-pulmonary venous anastomosis (PPVA) and its clinical significance: a case report and literature review. Am J Gastroenterol 2014; 109: S362-S363
36
Kariya S,
Komemushi A,
Nakatani M.
et al.
Portopulmonary venous anastomosis in balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices. J Gastroenterol Hepatol 2014; 29 (07) 1522-1527
37
Simón-Talero M,
Roccarina D,
Martínez J.
et al;
Baveno VI-SPSS group from the Baveno Cooperation.
Association between portosystemic shunts and increased complications and mortality in patients with cirrhosis. Gastroenterology 2018; 154 (06) 1694-1705.e4
38
Al-Osaimi AMS,
Caldwell SH.
Medical and endoscopic management of gastric varices. Semin Intervent Radiol 2011; 28 (03) 273-282
39
Saad WEA.
Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes. Semin Intervent Radiol 2012; 29 (02) 118-128
40
Kim DJ,
Darcy MD,
Mani NB.
et al.
Modified balloon-occluded retrograde transvenous obliteration (BRTO) techniques for the treatment of gastric varices: vascular plug-assisted retrograde transvenous obliteration (PARTO)/coil-assisted retrograde transvenous obliteration (CARTO)/balloon-occluded antegrade transvenous obliteration (BATO). Cardiovasc Intervent Radiol 2018; 41 (06) 835-847
41
Vidal-González J,
Quiroga S,
Simón-Talero M,
Genescà J.
Spontaneous portosystemic shunts in liver cirrhosis: new approaches to an old problem. Therap Adv Gastroenterol 2020; 13: 1756284820961287
42
Nardelli S,
Riggio O,
Gioia S,
Puzzono M,
Pelle G,
Ridola L.
Spontaneous porto-systemic shunts in liver cirrhosis: clinical and therapeutical aspects. World J Gastroenterol 2020; 26 (15) 1726-1732
43
Leng X,
Zhang F,
Zhang M.
et al.
Comparison of transjugular intrahepatic portosystemic shunt for treatment of variceal bleeding in patients with cirrhosis with or without spontaneous portosystemic shunt. Eur J Gastroenterol Hepatol 2019; 31 (07) 853-858
44
Laleman W,
Simon-Talero M,
Maleux G.
et al;
EASL-CLIF-Consortium.
Embolization of large spontaneous portosystemic shunts for refractory hepatic encephalopathy: a multicenter survey on safety and efficacy. Hepatology 2013; 57 (06) 2448-2457
45
Lv Y,
Chen H,
Luo B.
et al.
Concurrent large spontaneous portosystemic shunt embolization for the prevention of overt hepatic encephalopathy after TIPS: a randomized controlled trial. Hepatology 2022; 76 (03) 676-688
46
Lipnik AJ,
Pandhi MB,
Khabbaz RC,
Gaba RC.
Endovascular treatment for variceal hemorrhage: TIPS, BRTO, and combined approaches. Semin Intervent Radiol 2018; 35 (03) 169-184
47
Pinchot JW,
Kalva SP,
Majdalany BS.
et al;
Expert Panels on Interventional Radiology and Vascular Imaging.
ACR appropriateness criteria: radiologic management of portal hypertension. J Am Coll Radiol 2021; 18 (5S): S153-S173
48
Kim CY,
Pinchot JW,
Ahmed O.
et al;
Expert Panel on Interventional Radiology.
ACR appropriateness criteria: radiologic management of gastric varices. J Am Coll Radiol 2020; 17 (5S): S239-S254
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