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      Endovascular Removal of the Viatorr Stent-Grafts. Report of Two Cases

      case-report

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          Summary

          Background

          The dysfunction of misplaced or dislodged endovascular endoprostheses, may be a serious complication, and endovascular removal may be attempted in some cases.

          Case Report

          A Viatorr ® stent-graft (Gore, Flagstaff, AR, USA) is an endoprosthesis designed and commonly used for creation of a transjugular intrahepatic portosystemic shunt (TIPS). Two Viatorrs were accidentally dislodged during TIPS procedure. In another patient, the Viatorr was malpositioned, with its distal end being placed in the bile duct. All endoprostheses were successfully removed without serious complications.

          Conclusions

          Removal of a misplaced or dislodged Viatorr endoprosthesis is possible using interventional methods.

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          Most cited references10

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          Comprehensive review of TIPS technical complications and how to avoid them.

          The goal of this article is to describe potential technical complications related to transjugular intrahepatic portosystemic shunts (TIPS) placement and to discuss strategies to avoid and manage complications if they arise. TIPS is an established interventional therapy for complications of portal hypertension. Although TIPS remains a relatively safe procedure, direct procedure-related morbidity rates are as high as 20%. The technical complexity of this intervention increases the risk for methodologic mishaps during all phases of TIPS placement, including venous access and imaging, transhepatic needle puncture, shunt insertion, and variceal embolization. Thus, interventional radiologists require a thorough stepwise understanding of TIPS insertion, possible adverse sequela, and technical tips and tricks to maximize the safety of this procedure.
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            TIPS with expanded polytetrafluoroethylene-covered stent: results of an Italian multicenter study.

            Our objective is to describe the results of a multicenter prospective trial on the safety and efficacy of transjugular intrahepatic portosystemic shunts (TIPS) using the Viatorr stent-graft. From 2001 to 2003, 114 patients (75 men and 39 women; mean age, 59.3 years) with portal hypertension underwent TIPS with the Viatorr stent-graft. Indications for treatment were variceal bleeding (n = 49, 43.0%), refractory ascites (n = 52, 45.6%), hypertensive gastropathy (n = 10, 8.8%), Budd-Chiari syndrome (n = 1, 0.9%), and hepatorenal syndrome (n = 2, 1.7%). Eight patients (7.0%) had Child-Pugh class A cirrhosis; 60 (52.6%), Child-Pugh class B; and 46 (40.4%), Child-Pugh class C. Patients were monitored by color Doppler sonography and phlebography. The procedure was successful in 113 (99.1%) of 114 patients; in one patient, creation of the track was not feasible. The mean portosystemic pressure gradient decreased from 21.8 to 8.7 mm Hg. Three minor immediate complications (2.6%) occurred (two cases of self-limiting hemoperitoneum and one extrahepatic portal puncture requiring covered stenting). At a mean follow-up of 11.9 months, the overall mortality rate was 31.0% (35/113), with a 30-day mortality rate of 8.8% (10/113). Mortality was significantly higher in patients in Child-Pugh class C with refractory ascites and with post-procedural encephalopathy. Cumulative primary patency rates were 91.9%, 79.9%, and 75.9% at 6, 12, and 24 months' follow-up, respectively. Restenosis occurred in 15 patients (13.3%) within the stent (n = 8, 53.3%) or at the ends of the portal (n = 1, 6.7%) or hepatic (n = 6, 40%) veins and was solved by percutaneous transluminal angioplasty (n = 11), stenting (n = 3), or parallel TIPS (n = 1). The secondary patency rate was 98.2%. Post-procedural encephalopathy occurred in 27 patients (23.9%). The Viatorr stent-graft is safe and effective in TIPS creation, with high primary patency rates. Covering the entire track up to the inferior vena cava can increase patency.
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              Creation of transjugular intrahepatic portosystemic shunts with stent-grafts: initial experiences with a polytetrafluoroethylene-covered nitinol endoprosthesis.

              To evaluate the safety and performance of a recently developed expanded polytetrafluoroethylene (ePTFE)-covered nitinol stent-graft to create transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension and related complications. The ePTFE-covered nitinol stent-graft was used to create TIPS in 16 patients with recurrent variceal bleeding (n = 13) or refractory ascites (n = 3). Follow-up was performed with duplex ultrasonography, clinical assessment, and venography at 6 months. Technical success and portosystemic pressure gradients (PPGs) before and after stent-graft implantation and at follow-up were assessed. Two patients died during follow-up. Histopathologic follow-up data were available for one patient at autopsy and for the other after liver transplantation. The implantation technical success rate was 100%. Mean (+/- SD) PPG was reduced from 24 mm Hg +/- 5 to 9 mm Hg +/- 2. Histopathologic analysis of the explanted endoprostheses revealed no inflammatory response or neointima formation. The venographic follow-up data available for 10 patients demonstrated 100% in-graft patency (mean follow-up, 289 days +/- 26). Revisions with implantation of a new ePTFE-covered nitinol stent-graft or another commercially available stent in 10 patients were necessary because of hepatic vein stenosis above the grafted portion and/or relative diameter mismatch causing TIPS dysfunction. The ePTFE-covered nitinol stent-graft was used successfully to create TIPS and has the potential to prolong TIPS patency upon complete coverage to the hepatocaval junction.
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                Author and article information

                Journal
                Pol J Radiol
                Pol J Radiol
                Pol J Radiol
                Polish Journal of Radiology
                International Scientific Literature, Inc.
                1733-134X
                1899-0967
                2015
                22 May 2015
                : 80
                : 277-280
                Affiliations
                Department of Radiology, Univerity of Lund Hospital, Lund-S, Sweden
                Author notes
                Author’s address: Wojciech Cwikiel, Department of Radiology, Univerity of Lund Hospital, Lund-S, Sweden, e-mail: wojciech.cwikiel@ 123456med.lu.se
                [A]

                Study Design

                [B]

                Data Collection

                [C]

                Statistical Analysis

                [D]

                Data Interpretation

                [E]

                Manuscript Preparation

                [F]

                Literature Search

                [G]

                Funds Collection

                Article
                893642
                10.12659/PJR.893642
                4444167
                c3a06719-aaf5-4ec1-9605-b12834a7d80a
                © Pol J Radiol, 2015

                This is an open access article. Unrestricted non-commercial use is permitted provided the original work is properly cited.

                History
                : 22 January 2015
                : 28 February 2015
                Categories
                Case Report

                Radiology & Imaging
                device removal,endovascular procedures,hypertension, portal,portasystemic shunt, transjugular intrahepatic,stents

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