Date of Award

January 2025

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Joshua Cornman-Homonoff

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) placement remains a primary treatment option for managing the sequelae of portal hypertension. However, the degree of decompression must be balanced to avoid complications of overshunting, such as hepatic encephalopathy (HE), liver failure, and heart failure. Currently, the most utilized device for TIPS creation, the Viatorr endoprosthesis shunt can be dilated to between 8 and 10 mm. However, dilating to the minimal size can decrease the hepatic-venous pressure gradient (HVPG) below goal. However, shunts that were underdilated at placement can self-expand to their minimal diameter. Placing a constraining stent around the endograft theoretically precludes such self-expansion. Consequently, the purpose of this study was to evaluate the effectiveness of placing constraining stents around underdilated TIPS with respect to both technical and clinical outcomes.

All patients who underwent TIPS procedures within the Yale New Haven Hospital system between April 2017 and April 2023 were eligible for inclusion. Patients were excluded if the initial TIPS placement was performed elsewhere or if the relevant portions of the medical record were incomplete. Patients were segregated into two groups based on whether an outer constraining stent was placed at the time of the TIPS procedure: the “Constrained” and “Conventional” groups. A total of 246 patients were included, of whom 113 underwent conventional TIPS placement and 133 constrained TIPS placement. Relevant data were obtained from each TIPS case and were then analyzed.

First, demographic characteristics were similar between groups. Next, intraprocedural data showed that while pre- and post-TIPS portosystemic gradients did not differ significantly between groups, a greater decrease in gradient occurred in the conventional group. Finally, postprocedural outcomes showed no difference in all-cause mortality at 30 days or 1 year. However, rates of revision were higher in the constrained group. As expected, constrained TIPS were more likely to require revisions for inadequate portal decompression.

In conclusion, this study provides evidence that constrained TIPS behave differently than conventional TIPS when under-dilated but not when dilated to the minimum size of currently available endoprostheses. Clinically, patients with constrained TIPS require revision at higher rates due to complications of under-shunting, although no difference in mortality was observed. The technique does not appear to decrease the rate of HE, although the limitations of this study limit the authors’ confidence in this finding.

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This is an Open Access Thesis.

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