Technical considerations in covering and deploying a wallstent endoprosthesis for the salvage of a failing transjugular intrahepatic portosystemic shunt

THE transjugular intrahepatic portosystemic shunt (TIPS) has become an accepted treatment for many patients with recurrent variceal hemorrhage or intractable ascites. Numerous studies have demonstrated its high rate of technical and clinical success, low morbidity, and competitive efficacy in the treatment of a group of sick patients for whom few good options exist (1- 10). If there is one drawback regarding TIPS, it is its lack of durability. Delayed shunt malfunction occurs in 40%-60% (11) of cases, and although easily treatable, the need for revision elevates the cost of the procedure and subjects patients to the risks inherent in a second invasive procedure.' Histologic evaluation of malfunctioning shunts has suggested that bile extravasation may be an important stimulus to the formation of proliferative neointima (12,13). This position is strengthened by animal experimentation in which TIPS created with stent-grafts demonstrated less intimal hyperplasia and longer patency than control shunts (14). Recent case reports have suggested that stent-grafts may have a role in the treatment of patients with recurrent intimal hyperplasia (15,16). This note reports the successful salvage of a TIPS, which had restenosed several times during the course of 2 years, with a covered Wallstent. This note will focus on the technical aspects of Wallstent covering and delivery.