Transvenous Extrahepatic Portosystemic Shunts (TEPS): Intravascular Ultrasound-Guided Creation of Portocaval, Mesocaval, and Splenorenal Shunts.

PURPOSE: To evaluate the feasibility and long-term safety and effectiveness of intravascular ultrasound (IVUS)-guided transvenous extrahepatic portosystemic shunt (TEPS) creation for patients unsuitable for transjugular intrahepatic portosystemic shunt (TIPS) creation.

MATERIALS AND METHODS: A single-center, retrospective study was performed in 23 patients (19 adult and 4 pediatric; median, 55.7 years; range, 8-75 years; 13 [57%] male) who underwent 24 TEPS creations for variceal bleeding (n = 20, 83%), refractory ascites (n = 3, 13%), or preoperative portal decompression (n = 1, 4%). Rationale for extrahepatic shunt included chronic portal vein occlusion (n = 17, 71%), chronic superior mesenteric vein occlusion (n = 2, 8%), obstructed intrahepatic path (n = 3, 13%), complex Budd-Chiari syndrome (n = 1, 4%), and intentional portosplenic blood flow separation (n = 1, 4%). Baseline characteristics included active cancer (n = 6, 27%), cirrhosis (n = 9, 41%), and liver transplant (n = 4, 22%). Primary outcomes were technical success and periprocedural adverse events. Secondary outcomes were patency, delayed adverse events, and overall survival (OS).

RESULTS: Technical success was 100% for portocaval (n = 16, 67%), superior mesocaval (n = 5, 21%), inferior mesocaval (n = 1, 4%), and splenorenal (n = 2, 8%) shunts. Periprocedural adverse events included 9 Grade 1-2 events (38%) and 1 Grade 3 acute kidney injury (4%). One-year primary patency was 100%, and 3-year primary assisted patency was 100%. Recurrent variceal bleeding developed in 4 patients (17%); refractory ascites did not recur. Eight patients (36%) developed hepatic encephalopathy, managed medically. Hepatopulmonary and portopulmonary syndromes occurred in 1 patient each (4%; 4%). Median OS was 38.4 months, shorter in patients with active cancer (10.4 vs 104.8 months, P = .026).

CONCLUSIONS: IVUS-guided TEPS creation is feasible, effective, and durable in patients with complications of portal hypertension not suitable for conventional recanalization or TIPS creation.