A successful endovascular repositioning of migrated transjugular intrahepatic portosystemic shunt (TIPS) stent

The transjugular intrahepatic portosystemic shunt (TIPS) procedure is performed to create an intrahepatic tract between the hepatic and portal veins which helps to shunt blood away from the hepatic sinusoids. This shunt decreases the portal venous pressure and secondary morbidities, including variceal bleeding and recurrent ascites. However, stent migration is a known complication of TIPS stent placement which may occur both during the procedure or postprocedural. We present a case of a 58-year-old male with history of liver cirrhosis in the setting of alcohol abuse and chronic hepatitis C infection who presented with melena and hematemesis. Esophagogastroduodenoscopy showed 4 columns of large grade IV esophageal varices with stigmata of recent bleeding. Despite endoscopic variceal banding, the patient had persistent episodes of hematemesis and became hemodynamically unstable requiring pressor support. The decision was made to proceed with emergent transjugular intrahepatic portosystemic shunt placement. After obtaining transhepatic portal access and initial stent deployment, the stent migrated from the TIPS tract into the main portal vein. While maintaining through-and-through wire access, the stent was successfully mechanically retracted using an angioplasty balloon and it was appropriately repositioned within the original TIPS tract. The stent was then further secured in place with a slightly larger stent which was deployed within the hepatic portion of the initially migrated stent. This technique was successful and obviated complete removal of the stent and follow-up imaging demonstrated patent flow and adequate positioning several months after the procedure.