Brandon C. Perry MD, Presenter: Nothing to Disclose

Jeffrey Scott Pollak MD, Abstract Co-Author: Nothing to Disclose

Giri Shivaram MD, Abstract Co-Author: Nothing to Disclose

Transjugular intrahepatic portosystemic shunt (TIPS) placement is indicated in pediatric patients to manage bleeding and other complications of portal hypertension, with similar rates of technical success, clinical outcomes, and complications as in adults. However, given pediatric patients’ smaller anatomy and potential growth, a fixed shunt diameter is suboptimal. We describe a novel technique for pediatric TIPS using concentric placement of an outer, bare metal balloon expandable stent and inner, ePTFE endograft. This system creates an intentional stenosis of the shunt at initial placement that can be dilated at a later time to accommodate growth of the patient or hemodynamic changes.

A modified TIPS technique was performed on two patients in February and March 2014. Patient 1 (6 year-old female) presented with massive gastric variceal bleeding secondary to portal hypertension from biliary atresia, which was unable to be controlled endoscopically. Patient 2 (15 year-old female) presented with recurrent portal and mesenteric vein thrombosis following splenectomy for idiopathic thrombocytopenic purpura. In both patients, a 6 mm x 27 mm Express LD balloon expandable stent was placed in the hepatic parenchymal tract of the TIPS to constrain a 10 mm diameter VIATORR stent. In patient 1, the constrained segment of the shunt was increased to 8 mm at the time of the initial procedure because of insufficient decompression and in patient 2 the constrained segment was left at 6 mm.

Technical success was achieved in both cases. In each case, the portosystemic gradient was reduced below 12 mmHg. This resulted in control of life-threatening variceal bleeding in Patient 1. She subsequently underwent liver transplant 3 days following TIPS placement. Patient 2 underwent successful catheter-directed thrombolysis through the TIPS to treat portal and mesenteric venous thrombosis.

TIPS can be created in children with the use of ePTFE endografts constrained by balloon expandable stents. This allows for more precise calibration of shunt diameter and allows for future increase in shunt diameter as necessary to accommodate patient growth or change in hemodynamics.

TIPS placement in children can be challenging due to smaller anatomy and considerations regarding future growth. The constrained TIPS technique is safe and may be particularly useful in the pediatric patient.

Perry, B, Pollak, J, Shivaram, G, Description of a Novel Approach for TIPS Placement in the Pediatric Patient: The Constrained TIPS Technique.  Radiological Society of North America 2014 Scientific Assembly and Annual Meeting, - ,Chicago IL. http://archive.rsna.org/2014/14007591.html