Fujian Medical University Union Hospital: Prior TIPS Occlusion with Ectopic Small Bowel Variceal Bleeding Treated in One Procedure
🔎 Recently, the interventional radiology team led by Dr. Hui Zheng at Fujian Medical University Union Hospital, together with the organ transplantation team led by Dr. Dahong Teng, performed TIPS recanalization and ectopic variceal embolization in a patient with decompensated cirrhosis undergoing liver transplant evaluation. During the evaluation, he developed massive melena again, with hemoglobin falling to about 50 g/L and unstable blood pressure. Drugs and transfusion failed to control the bleeding.
📋 Preoperative portal venous CTV revealed two key problems:
• The combined-type TIPS stent placed at another hospital 6 years earlier was completely occluded. The bare stent protruded too far into the portal vein, leading to in-stent pseudointimal hyperplasia, renewed portal hypertension, and reopening of collateral circulation.
• The bleeding source was not the common gastroesophageal varices, but ectopic small bowel varices. In the literature, this type accounts for a small proportion of variceal bleeding. It is deep-seated and easily missed on conventional endoscopy.
⚠️ The main difficulty was the old stent. The portal end of the bare stent was encased in hyperplastic intima, which limited guidewire passage and positioning of the new stent. Improper manipulation risked injuring the main portal vein. The team's approach was:
1. Abandon the portion of the old bare stent that protruded too far into the portal vein;
2. Disrupt the occluded stent and hyperplastic tissue within the portal vein;
3. Re-establish the portal vein entry point and deploy a dedicated covered stent (2nd-generation Viatorr), so that the entire shunt tract is covered;
4. Superselectively catheterize the ectopic small bowel varix through the TIPS tract and embolize it.
🛠️ The procedure took about 2 hours. Post-procedure venography showed a patent shunt, and the ectopic varix no longer opacified.
📊 After the procedure, the patient's hemoglobin gradually recovered, blood pressure stabilized, and gastrointestinal bleeding stopped.
💡 Our takeaway: in patients who rebleed after TIPS, consider both whether the shunt is occluded and whether the bleeding comes from an atypical site. CTV helped identify both. In such patients, TIPS recanalization also buys time for liver transplantation.
📌 Important caveats:
• TIPS revision and covered stents are well established internationally. This case is an application in a complex setting, not a new technique.
• This is a single-case experience. Portal pressure gradient values and long-term follow-up data are not included here.
• Regular ultrasound or CT follow-up is needed after TIPS. Rebleeding or worsening ascites should prompt evaluation of shunt patency.
