title: Transjugular Intrahepatic Portosystemic Shunt Flow Reduction with Adjustable Polytetrafluoroethylene-Covered Balloon-Expandable Stents Using the "Sheath Control" Technique.
abstract: OBJECTIVE
  A complication of transjugular intrahepatic portosystemic shunts (TIPS) placement is refractory portosystemic encephalopathy (PSE) often requiring TIPS reduction. We report the results of a "sheath control technique" utilizing constraining sheaths during deployment of polytetrafluoroethylene (PTFE)-covered balloon-expandable stents, minimizing stent migration, and providing additional procedural control.
  
  
  METHODS
  TIPS reduction was performed in 10 consecutive patients for PSE using Atrium iCast covered stents (Atrium Maquet Getinge Group, Germany). Within the indwelling TIPS stent, a 9 mm × 59 mm iCast stent was deployed with 2 cm exposed from the sheath's distal end and the majority of the stent within the sheath to create the distal hourglass shape. During balloon retraction, the stent was buttressed by the sheath. The proximal portion of the stent was angioplastied to complete the hourglass configuration, and the central portion of the stent was dilated to 5 mm. Demographics, pre- and post-procedure laboratory values, and outcomes were recorded.
  
  
  RESULTS
  Ten patients underwent TIPS reduction with 100 % technical success. There was no stent migration during stent deployment. All patients experienced initial improvement of encephalopathy. One patient ultimately required complete TIPS occlusion for refractory PSE, and another developed TIPS occlusion 36 days post-procedure. There was no significant trend toward change in patients' MELD scores immediately post-procedure or at 30 days (p = 0.46, p = 0.47, respectively).
  
  
  CONCLUSIONS
  TIPS reduction using Atrium iCast PTFE balloon-expandable stents using the "sheath control technique" is safe and effective, and minimizes the risk of stent migration.
authors.affiliation: Interventional Radiology Section, Department of Radiology, Icahn School of Medicine at Mount Sinai, Box 1234, One Gustave Levy Place, New York, NY, 10029, USA. Robert.c.blue@gmail.com.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Blue
authors.affiliation: Interventional Radiology Section, Department of Radiology, Icahn School of Medicine at Mount Sinai, Box 1234, One Gustave Levy Place, New York, NY, 10029, USA.
authors.forename: Grace C
authors.initials: GC
authors.lastname: Lo
authors.affiliation: Interventional Radiology Section, Department of Radiology, Icahn School of Medicine at Mount Sinai, Box 1234, One Gustave Levy Place, New York, NY, 10029, USA.
authors.forename: Edward
authors.initials: E
authors.lastname: Kim
authors.affiliation: Interventional Radiology Section, Department of Radiology, Icahn School of Medicine at Mount Sinai, Box 1234, One Gustave Levy Place, New York, NY, 10029, USA.
authors.forename: Rahul S
authors.initials: RS
authors.lastname: Patel
authors.affiliation: Interventional Radiology Section, Department of Radiology, Icahn School of Medicine at Mount Sinai, Box 1234, One Gustave Levy Place, New York, NY, 10029, USA.
authors.forename: F
authors.initials: F
authors.lastname: Scott Nowakowski
authors.affiliation: Interventional Radiology Section, Department of Radiology, Icahn School of Medicine at Mount Sinai, Box 1234, One Gustave Levy Place, New York, NY, 10029, USA.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Lookstein
authors.affiliation: Interventional Radiology Section, Department of Radiology, Icahn School of Medicine at Mount Sinai, Box 1234, One Gustave Levy Place, New York, NY, 10029, USA.
authors.forename: Aaron M
authors.initials: AM
authors.lastname: Fischman
mesh_terms: D000368:Aged; D021721:Balloon Occlusion / Q000295:instrumentation* / Q000379:methods*; D004867:Equipment Design; D005260:Female; D005858:Germany; D006501:Hepatic Encephalopathy / Q000209:etiology* / Q000628:therapy*; D006801:Humans; D008103:Liver Cirrhosis / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011138:Polytetrafluoroethylene; D019168:Portasystemic Shunt, Transjugular Intrahepatic
chemical_list: D011138:Polytetrafluoroethylene