Preliminary study of the permeability and safety of covered stents-grafts in pediatric TIPS

Transcription

1 Preliminary study of the permeability and safety of covered stents-grafts in pediatric TIPS Poster No.: C-0354 Congress: ECR 2013 Type: Scientific Exhibit Authors: A. Bueno Palomino, L. Zurera Tendero, J. J. Espejo Herrero, M. Canis López, J. García Revillo, J. Vicente Rueda; Cordoba/ES Keywords: DOI: Prostheses, Stents, Catheter arteriography, Interventional vascular /ecr2013/C-0354 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 7

2 Purpose To present our institutional experience on the use of expanded polytetrafluoroethylene (e-ptfe) covered stent-graft for TIPS creation in children. Methods and Materials Five children (three boys and two girls) with gastrointestinal bleeding secondary to portal hypertension underwent TIPS creation between May 2009 and April 2011 at our hospital. The mean age was 9.6 years (range 7-11 years) and mean weight was 36.2 kg (range kg). The etiology of portal hypertension was diverse: cystic fibrosis (2 cases), congenital hepatic fibrosis, extrahepatic biliary atresia and biliary cystic malformation. In all patients a Viatorr e-ptfe covered stent-graft was used Results A single e-ptfe-covered stent-graft was successfully implanted in all patients. No immediate complications or portal vein thrombosis were observed. Portal vein patency were assessed by ultrasound. The procedure took an average of 192 minutes. The portosystemic pressure gradient decreased from 17.5 mmhg (range mmhg) to 6 mm Hg (range 2-11 mmhg). One patient presented encephalopathy symptoms within 24 hours of TIP creation and other showed acute cholangitis manifestations in the first 48 hours. We did not observe re-bleeding, portal vein thrombosis or laboratory alterations during the follow-up (range 2 to 24 months). Children with cystic fibrosis and extrahepatic biliary atresia were transplanted at 3, 7 and 9 months respectively after the TIP creation. Images for this section: Page 2 of 7

3 Fig. 1: Demographics characteristics and results Fig. 2: Pediatric TIPS references review Page 3 of 7

4 Fig. 3: Eleven-year-old boy with extrahepatic biliary atresia and secundary signs of portal hypertension (esophageal varices, splenomegaly and thrombocytopenia) admitted to our hospital for acute gastrointestinal bleeding. The bleeding was initially controlled by medical treatment (somatostatin and blood transfusions), but because of the significant secundary signs of portal hypertension a TIP placement was decided. A) Right hepatic venography shows a patent hepatic vein and access to the main portal vein was achieved B) Portal vein venography shows prominent gastroesophageal varices C) Portal venogram after PTFE covered stent placement shows flow through TIP shunt from portal to hepatic vein. D) The gradient was reduced from 11 to 5 mmhg Page 4 of 7

5 Fig. 4: Tweleve-year-old boy with liver transplant for cystic fibrosis that had developed portal hypertension treated with TIPS. Admitted to our hospital with fever. A) Ultrasounds showed ascites and portal anastomosis stenosis which was subsequently confirmed by CT and portography (B, C). Because of these findings, it was decided to implement a self-expanding stent, obteining good morphological and functional result. Page 5 of 7

6 Conclusion 1. TIPS is a useful treatment in the management of gastrointestinal bleeding secondary to portal hypertension in children. 2. Procedural success depends more on the vascular anatomy and the cause of portal hypertension than the technique itself. 3. The main limiting factor is the TIP stenosis, which can be diagnosed by doppler ultrasound and treated by balloon angioplasty. 4. The use of PTFE-covered stents reduced the rate of stenosis and therefore reoperation, being election on uncovered. 5. Our experience and results indicate the use of e-ptfe-covered stent-graft in children is safe and feasible and show similar outcomes as reported in adult population. However, a greater expertise and long-term follow-up is required. References 1. Mileti E. and Rosenthal P. Management of Portal Hypertension in Children. Current Gastroenterology Reports 2011; 13: Goykhman Y, Ben-Haim M, Rosen G, Carmiel-Haggai M, Oren R, Nakache R et al. Transjugular intrahepatic portosystemic shunt: Current Indications, patient selection and results. Israel Medical Association Journal (IMAJ) 2010; 12 : Hupper P, Goffette P, Astfal W, Sokal E, Brambs H, Schott U, et al. Transjugular intrahepatic portosystemsic shunt in children with biliary atresia. Cardiovascular Interventional Radiology 2002; 25: Heyman M. LaBerge J, Sombely K, Rosenthal P, Mudge C, Ring E. et al. Transjugular intrahepatic portosystemic shunt in children. Pediatric Journal 1997;131: Mermuys K, Maleux G, Heye S, Lombaerts R, Nevens F. Use of the viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt creation in children: Initial clinical experience. Cardiovascular Interventional Radiology 2008; 31: Lorenz J. Placement of transjugular intrahepatic portosystemic shunts in children. Technical Vascular Interventional Radiology 2008; 11: Page 6 of 7

7 7. Tripathi D, Ferguson J, Barkell H, et al. Improved clinical outcome with transjugular intrahepatic portosystemic stent-shunt utilizing polytetrafluoroethylene-covered stents. European Journal Gastroenterology Hepatology 2006; 18: Pozler O, Krajina A, Vanicek H, Hulek P, Zizka J, Michl A, Elias P. Transjugular intrahepatic portosystemic shunt in five children with cystic fibrosis: long term results. Hepato-gastroenterology 2003; 50: Personal Information Page 7 of 7