Parallel transjugular intrahepatic portosystemic shunt with Viatorr(®) stents for primary TIPS insufficiency: Case series and review of literature

BACKGROUND: Transjugular intrahepatic portosystemic shunts (TIPS) can alleviate complications of portal hypertension such as ascites and variceal bleeding by decreasing the portosystemic gradient. In limited clinical situations, parallel TIPS may be only solution to alleviate either variceal bleeding or ascites secondary to portal hypertension when the primary TIPS fails to do so. Data specifically addressing the use of this partially polytetrafluoroethylene covered nitinol stent (Viatorr(®)) is largely lacking despite Viatorr(®) being the current gold standard for modern TIPS placement. CASE SUMMARY: All three patients had portal hypertension and already had a primary Viatorr(®) TIPS placed previously. All patients have undergone failed endoscopy to manage acute variceal bleeding before referral for a parallel stent (PS). PS were placed in patients presenting with recurrent variceal bleeding despite existence of a widely patent primary TIPS. Primary stent patency was verified with either Doppler ultrasound or intra-procedural TIPS stent venography. Doppler ultrasound follow-up imaging demonstrated complete patency of both primary and parallel TIPS. All three patients did well on clinical follow-up of up to six months and no major complications were recorded. A review of existing literature on the role of PS in the management of portal hypertension complications is discussed. There are three case reports of use of primary and PS Viatorr(®) stents placement, only one of which is in a patient with gastrointestinal variceal bleeding despite a patent primary Viatorr(®) TIPS. CONCLUSION: Viatorr(®) PS placement in the management of variceal hemorrhage is feasible with promising short term patency and clinical follow-up data.