Adjustable diameter TIPS in the pediatric patient: the constrained technique.

Placement of transjugular intrahepatic portosystemic shunt (TIPS) is necessary in children with portal hypertension complicated by variceal bleeding or ascites. However, placement of adult-sized endografts may be problematic due to the smaller anatomy of pediatric patients. On the other hand, placement of fixed diameter smaller stents have the corresponding problem of not accommodating future growth of the child. We describe a novel method to create an adjustable diameter TIPS as a technical solution to these problems. In this technique, a balloon expandable bare metal stent is placed concentrically around the ePTFE TIPS endograft, creating an intentional narrowing in the shunt diameter than can be expanded with balloon dilation at future procedures as needed. This allows for optimal calibration of shunt hemodynamics according to the child's growth and prevents the potential need for placement of additional shunts or technically challenging TIPS reduction procedures.