Signature: © Pol J Radiol, 2015; 80: 277-280
DOI: 10.12659/PJR.893642
Received: 2015.01.22
Accepted: 2015.02.28
Published: 2015.05.22
Authors’ Contribution:
A Study Design
B Data Collection
C Statistical Analysis
D Data Interpretation
E Manuscript Preparation
F Literature Search
G Funds Collection
CASE REPORT
Endovascular Removal of the Viatorr Stent-Grafts.
Report of Two Cases
Wojciech CwikielABDEF, Magnus BergenfeldtACDE, Inger KeussenABDE
Department of Radiology, Univerity of Lund Hospital, Lund-S, Sweden
Author’s address: Wojciech Cwikiel, Department of Radiology, Univerity of Lund Hospital, Lund-S, Sweden,
e-mail: wojciech.cwikiel@med.lu.se
Summary
Background:
The dysfunction of misplaced or dislodged endovascular endoprostheses, may be a serious
complication, and endovascular removal may be attempted in some cases.
Case Report:
A Viatorr® stent-graft (Gore, Flagstaff, AR, USA) is an endoprosthesis designed and commonly
used for creation of a transjugular intrahepatic portosystemic shunt (TIPS). Two Viatorrs were
accidentally dislodged during TIPS procedure. In another patient, the Viatorr was malpositioned,
with its distal end being placed in the bile duct. All endoprostheses were successfully removed
without serious complications.
Conclusions:
Removal of a misplaced or dislodged Viatorr endoprosthesis is possible using interventional
methods.
MeSH Keywords:
PDF file:
Device Removal • Endovascular Procedures • Hypertension, Portal •
Portasystemic Shunt, Transjugular Intrahepatic • Stents
http://www.polradiol.com/abstract/index/idArt/893642
Background
TIPS is currently one of the generally accepted treatment
methods for patients with symptomatic portal hypertension (PH). The procedure may be challenging, requires
appropriate skills of the performing physician. A rate of up
to 20% of procedure-related complications has been reported [1]. A inadequate placement of endoprostheses used for
TIPS creation requires additional interventions. In case of
migration of the endoprosthesis, need of advanced surgical
procedures has been reported [2–4]. We reported successful
retrieval of two dislodged Viatorrs in one patient and one
misplaced endoprosthesis in another patient, with the use
of endovascular methods.
Case Reports
Case one
A 55-year-old male with liver cirrhosis was admitted due
to bleeding from gastric varices. Ascites and chronic occlusion of the portal vein (PV) were diagnosed on CT of the
abdomen and the patient was referred for TIPS combined
with PV recanalization.
Following informed consent and initiation of general anesthesia, a 4 F Cobra catheter (Cordis, Johnson&Johnson,
Miami Lake, FL, USA) was placed through the left transjugular access and wedged with a tip in the branch of
the right hepatic vein. CO2 injection showed partly patent but very small intrahepatic PV branches and occlusion
of the main PV to the confluence of the superior mesenteric vein and the splenic vein. Following replacement of
the catheter with a 10-F introducer sheath, several unsuccessful attempts of transjugular transhepatic puncture
of the intrahepatic PV branches were carried out using a
Rösch-Uchida transjugular liver access set (Cook Inc.,
Bloomington, IN, USA).
In order to facilitate transjugular, transhepatic access to
PV, a trans-splenic puncture of the splenic vein branch was
performed using a 22-G needle, and a 5-F introducer sheath
was placed. Subsequently, a 4-F Cobra catheter jointly with
a 0.035-inch glidewire (Terumo, Tokyo, Japan) was manipulated through the splenic vein and into the occluded part of
PV in the liver. That catheter was exchanged over the wire
for a 6×20-mm dilation balloon (Powerflex Pro, Cordis), and
then via the transjugular access, a transhepatic puncture
towards the balloon was performed from the right hepatic
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Case Report
Figure 1. Snare placed over the cranial edge of the Viatorr dislodged
to the right atrium.
© Pol J Radiol, 2015; 80: 277-280
Figure 3. Viatorr connecting the bile duct with IVC.
IVC and the removal procedure was repeated as described
above (Figure 2). Thereafter, two new Viatorr endoprostheses (8×80+20 mm) were placed in an adequate position,
with subsequent good function of the TIPS. The transsplenic tract was embolized with två 3×10-mm coils (Cook
Inc) and gelfoam pledgets.
Case two
Figure 2. Removed Viatorrs.
vein using the transjugular access set. With the use of that
access, the tip of the glidewire was advanced into the balloon, and then by pulling back the balloon, the glidewire was
advanced to the splenic vein. Following dilation of the tract
with a 4×40-mm balloon (Powerflex Pro), a 10-F transjugular sheath was advanced through the transhepatic tract and
the recanalized segment of PV. Two Viatorrs (8×80+20 mm
and 8×60+20 mm) were deployed coaxially, connecting the
SMV/splenic vein confluence with the right hepatic vein.
Contrast-enhanced examination showed a short stenosis at
the cranial end of the created shunt and repeated balloon
dilation was attempted. The 8 x40-mm balloon (Powerflex
Pro) inflated partly into the Viatorr was accidentally moved
in the cranial direction, causing dislodgement of the cranial
part of the endoprosthesis to the right atrium.
After replacing the previous sheath with an 18-F sheath
(Cook Inc.), a GooseNeck Snare (EV3, Plymouth, MN, USA)
with a 15-mm loop was introduced over the guide wire.
The loop of the snare was placed over the cranial edge of
the Viatorr (Figure 1). The Viatorr was squeezed and the
sheath was advanced over the endoprosthesis. The Viatorr
was withdrawn into the sheath and was removed together
with the sheath. However, during that withdrawal, the second (coaxially placed in the first one) Viatorr followed into
278
A 43-year-old male with alcohol-related cirrhosis, ascites
and bleeding from the varices was referred for TIPS to the
Department of Endovascular Surgery of a nearby hospital.
CO2 portography was performed in there through a balloon
catheter placed in the branch of the middle hepatic vein,
showing patent PV.
During transjugular, transhepatic attempt to puncture PV,
a bile duct was accidentally entered (Figure 3). That was
misinterpreted by the physician performing the procedure,
who placed a Viatorr connecting the bile duct to the right
hepatic vein. The physician reported later that “the flow
from the SMV was good, the gradient was=0 mmHg, and
the TIPS was created successfully”.
On the following three days the patient’s condition deteriorated and on the fourth day he showed signs of general
sepsis and abdominal distension requiring urgent ICU care.
The inflammatory parameters were high and the laboratory tests were critically elevated (P-bilirubin=466 μmol/L;
CRP=43mg/L; P-creatinine=435 μmol/L). At that time the
error was identified and a percutaneous biliary drainage
catheter was placed percutaneously through the right liver
lobe bile ducts to the duodenum.
Afterwards, the patient was transferred to the Department
of Hepatic Surgery at our hospital, for urgent treatment.
Following an interdisciplinary decision and discussion with
the patient and his family, it was undertaken to attempt
removal of the Viatorr. With the patient under general anesthesia, a paraumbilical vein was punctured using ultrasonographic guidance, and a 4-F Cobra catheter was advanced to
© Pol J Radiol, 2015; 80: 277-280
Figure 4. CO2 portography through the catheter placed through a
paraumbilical vein.
Cwikiel W. et al. – Endovascular removal of the Viatorr stent-grafts…
Figure 6. Removed Viatorr.
Viatorr could be retrieved into the sheath, but then the
Viatorr become partly disintegrated and could not be further retracted in the sheath. However, the entire Viatorr
could be pulled back from the transhepatic tract to the
right atrium (Figure 5).
The Amplatz wire tip was withdrawn from the bile duct
and advanced to the inferior caval vein (IVC). The right
common femoral vein was accessed and another 45-cmlong 16-F sheath was placed with the tip in the IVC. The
Amplatz wire was grasped with a 15-mm snare and withdrawn through that sheath. The snare was then advanced
over the caudal edge of the Viatorr, which was squeezed
and the entire endoprosthesis was pulled back into the
sheath in the IVC.
Figure 5. Viatorr pulled back to the right atrium, partly in the sheath.
the right portal vein branch. CO2 portography through that
catheter showed a hepatofugal flow in the portal vein but
no connection with the bile duct (Figure 4). The percutaneous biliary drainage catheter was removed over the guidewire and replaced with a 8-F sheath. Through the left jugular vein, a 4-F Cobra catheter was introduced jointly with
a 0.035-inch glide-wire through the Viatorr to the common
bile duct. After confirmation of their position, the sheath
was exchanged over the 0.035-inch Amplatz wire for a
45-cm-long 16-F sheath. The loop of the 15-mm GooseNeck
Snare was placed over the wire. Subsequently, a 10×40-mm
dilation balloon was advanced into the Viatorr in order to
facilitate placement of the snare over the cranial edge of the
Viatorr. However, only a part of the cranial portion of the
Viatorr could be grasped with the snare.
The balloon was deflated and attempt to withdraw the
Viatorr into the sheath was performed. About 50% of the
The sheath with the endoprosthesis was removed (Figure 6)
and hemostasis was obtained with manual compression. A
puncture of the portal vein was performed from the transjugular approach towards the tip of the catheter inserted through the paraumbilical vein (PV). The 10×2+8-mm
Viatorr was placed in the tract and dilated with a
10×40-mm balloon. CO2 portography confirmed good flow
through the TIPS channel and no flow to the bile duct.
The sheath in the right lobe bile duct was replaced with
an 8-F biliary drainage catheter. Following percutaneous
puncture, a left liver lobe internal-external biliary drainage
catheter was placed to optimize bile outflow. There were
no immediate complications.
In the following three weeks, the patient recovered substantially and his laboratory test results normalized. The
follow-up evaluation at six weeks showed normal bile
ducts and biliary catheters were removed.
Discussion
The first successful TIPS supported with stents in
patients was reported on in 1990 [5]. In the following years TIPS procedure became more common and was
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Case Report
mainly performed by experienced interventional radiologists. Shunt dysfunction requiring invasive revision was
commonly caused by ingrowth of the hyperplastic tissue
through the stent mesh or stenoses at the edge of the stents.
The Viatorr® endoprosthesis developed specifically for TIPS
was introduced in 2001 [6].
Dysfunction of that endoprosthesis was also reported on.
However, long-term results on TIPS with Viatorr are better
than for shunts created with bare stents [7,8].
Before TIPS, assessment of the venous liver circulation is
mandatory, in addition to the routine clinical evaluation of
the patient. Occlusion of the main portal vein is a relative
contraindication for TIPS but the procedure may be done
using a modified technique [9].
During TIPS, blood flow in the portal vein should be evaluated and pressure before and after shunt placement should
be measured. Once placed in the transhepatic tract, the
Viatorr is stable, due to relatively strong, self-expanding
radial forces of the nitinol skeleton, which support a graft
material. Coaxial placement of more than one endoprosthesis may be required e.g. in cases where the occluded segment of the portal vein must be covered as well.
Complications during TIPS procedure include inadvertent puncture of the bile duct, hepatic artery, transhepatic
puncture of the peritoneal cavity, bleeding etc. [1]. Most of
these complications can be corrected immediately without
serious consequences for the patient.
Displacement of the Viatorr from the TIPS channel to facilitate liver transplant was reported on [10]. Endovascular
removal or repositioning of misplaced/dislodged
stents/stent grafts was described [10,11], but to our knowledge, no attempt to remove misplaced or dislodged Viatorr
endoprostheses was reported on.
In the first of our patients, coaxial placement of two
Viatorrs was necessary and the inserted endoprostheses
were balloon-dilated. This first dilation reduced the stability of the Viators in the transhepatic channel. Due to an
© Pol J Radiol, 2015; 80: 277-280
unsatisfactory position of the edge of the cranial Viatorr, a
second balloon dilation was attempted, resulting in inadvertent dislodgement of endoprostheses in the cranial
direction. Due to a possibility of arrhythmia caused by the
cranial edge of Viatorr and suspicion of further migration,
a decision was made to remove and replace the endoprosthesis. Due to its migration, the second Viatorr was also
removed, which was conducted without complications.
In the second patient, the Viatorr was placed in the bile
duct, obviously due to misinterpretation of the anatomy.
That caused serious deterioration of the patient’s condition, which could have had fatal consequences. Treatment
options such as embolization or surgical removal of the
misplaced Viatorr were discussed. However, surgical repair,
which would require partial hepatectomy, was considered
unsafe in the patient with liver cirrhosis, portal hypertension, and ongoing infection. Embolization of the misplaced
Viatorr was able to close communication between bile ducts
and the hepatic vein. However, a foreign body would keep
up the infection and the caudal part of the Viatorr would
further damage the bile ducts. The removal procedure was
more complicated than in the first patient. However, it
could be completed, TIPS was created and bile ducts were
decompressed. Fortunately that patient recovered by the
time of this report, but it is uncertain whether the damage
to the bile ducts will have future consequences or not.
Conclusions
We concluded that the creation of TIPS may be a complicated procedure; it requires careful pre-procedural preparation. TIPS should be performed by a properly trained
interventional radiologist only, to avoid serious complications, as those described in our second patient. Removal of
a Viatorr, if required, is technically possible with endovascular approach.
Statement
All procedures were in accordance with the ethical standards of the institutional and/or national research committee
and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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