V2 - Lost in the Biliary Maze: A Rare Case of TIPS Stent Misplacement Successfully Treated with EDGE

Alejandra Vargas, MD¹, Michael Saadeh, MD², Steve D'Souza, MD³, Ana Vilela, MD¹, Adam Lustig, MD¹, Parth Parekh, MD^1
1Eastern Virginia Medical School, Norfolk, VA; ²University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH; ³Case Western Reserve University / MetroHealth, Cleveland, OH

Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) is a efficacious procedure employed to address complications related to portal hypertension, such as variceal hemorrhage. Despite its success, TIPS is associated with various potential complications, including hepatic encephalopathy, infection, hemorrhage, and stent dysfunction or migration. While rare, stent malposition represents another possible complication.

Case Description/Methods: A 67-year-old woman with a history of Roux-en-Y gastric bypass and alcohol-associated cirrhosis complicated by esophageal varices, presented with acute hematemesis and hemorrhagic shock. She underwent emergent endoscopy with attempted band ligation; however, hemostasis was unable to be achieved endoscopically, and she underwent emergent TIPS. After TIPS, it was later discovered that the 8-mm partially covered stent was inadvertently placed in the common bile duct (CBD) from the right hepatic vein, creating a venobiliary fistula. The misplaced stent was occluded with a vascular plug, then a successful left-sided TIPS and variceal embolization were performed. The patient was transferred to our hospital with cholangitis and bacteremia, complicated by septic shock. After multidisciplinary discussion, it was determined that an endoscopic ultrasound directed transgastric endoscopic retrograde cholangiopancreatography for stent removal would be necessary. Electrocautery-enhanced delivery of a lumen apposing metal stent was used to establish a gastro-gastrostomy and access the excluded stomach. Endoscopic sutures were placed for fixation. The major papilla was identified within a diverticulum, after which the CBD was cannulated and sphincterotomy was performed. Using a cholangioscope, the CBD was explored, revealing the partially covered metal stent in the upper third of the CBD. A grasping device was used to remove the stent and the vascular plug from the biliary tree, followed by a balloon for tamponade. Subsequently, a 10-mm covered metal stent was inserted into to decompress the CBD. Post-procedure hepatic venograms showed no persistent venobiliary communication. The patient had an uneventful recovery.

Discussion: We present a case report describing the first known occurrence of TIPS stent misplacement in the common bile duct, which required innovative and complex management with endoscopic ultrasound directed transgastric endoscopic retrograde cholangiopancreatography and stent removal. Given the rarity of this complication and the need for specialized expertise, the management of TIPS-associated biliary injuries requires a multidisciplinary approach with close collaboration between interventional radiologists, gastroenterologists, and surgeons.


Disclosures:


Alejandra Vargas, MD¹, Michael Saadeh, MD², Steve D'Souza, MD³, Ana Vilela, MD¹, Adam Lustig, MD¹, Parth Parekh, MD¹, V2, Lost in the Biliary Maze: A Rare Case of TIPS Stent Misplacement Successfully Treated with EDGE, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.