LAUSR

To the Editor, Transjugular intrahepatic portosystemic shunt (TIPS) involves the creation of a shunt between the portal and hepatic veins to treat portal hypertension and its complications, including refractory ascites, hepatic hydrothorax, and variceal bleeding [1]. Complications, however, may result from excessive shunting of portal venous blood to the systemic circulation. 17–46% of patients present with hepatic encephalopathy (HE) following a TIPS [2–4]. Although the majority of patients with TIPS-associated HE may be medically managed, 3–7% of patients develop refractory encephalopathy as a result of this high volume shunting [2, 5–7]. TIPS reduction or occlusion may be effective in decreasing the incidence and severity of hepatic encephalopathy. Complete occlusion of the TIPS returns patients to the baseline risk of variceal bleeding and other portal hypertension complications present prior to TIPS [2, 5]. TIPS reduction has become the preferred method of treatment for excessive portal to systemic shunting of blood that is refractory to first-line medical management. The goal of TIPS reduction is to reduce the volume of shunted blood and divert it back to the intrahepatic portal veins by decreasing the diameter of the existing stent. Ideally, achieving a balance between portal and systemic blood flow to maintain the benefit of TIPS in reducing portal hypertension while concurrently treating the encephalopathy is desired. Numerous TIPS reduction methods using various stents and stent grafts have been previously detailed in the literature [5, 6]. TIPS are commonly reduced to a 6–7 mm residual diameter and usually, but not always, require complicated in vivo or backtable techniques [5, 6]. With the advent of the newly introduced Viatorr Controlled Expansion Endoprosthesis (Gore & Associates, Flagstaff, AZ, USA), there is the potential of a simple single-stent deployment for TIPS reduction leaving a residual TIPS diameter of 8 mm. Two patients with hepatic encephalopathy underwent TIPS reduction using the Viatorr Controlled Expansion Endoprosthesis (Gore) (Fig. 1). Pre and post-reduction pressures and hemodynamics were measured using a pressure transducer and a 6-French ReoCath Retrograde Flow Catheter (Transonic Systems), respectively. Mean increase in portosystemic gradient was 4 mmHg (range 2–6 mmHg) with mean percentage increase of 30.5% (range 18.1–42.8%). Mean reduction in portal vein blood flow was 222.5 mL/min (range 45–400 mL/min) with mean percentage reduction of 16.3% (range 4.6–27.9%). Mean reduction in TIPS blood flow was 187 mL/min (range 87–287 mL/min) with mean percentage reduction of 15.9% (range 12.0–19.7%). No minor or major procedural complications occurred. Mean follow-up was 81 days (range 38–124 days). Both patients showed a 1 grade improvement in HE symptoms using West Haven HE criteria. A 69-year-old male with history of alcoholic cirrhosis and portal hypertension complicated by esophageal varices and ascites had a TIPS placed 1278 days prior to presentation (Fig. 2 and Table 1). Since that time he developed & Ravi N. Srinivasa [email protected]