Lost in the biliary maze, case of TIP stent misplacement successfully treated with EDGE. The TIPS procedure is a highly effective method employed used to address complications related to portal hypertension, including variceal bleeding. Potential risks include hepatic encephalopathy, infection, hemorrhage, and stent dysfunction or migration. A rare intraprocedural concern is stent malposition. A 67-year-old female with history of rheumoid gastric bypass and alcohol-associated cirrhosis presented at an outside hospital with hematemesis and hemorrhagic shock. She underwent upper endoscopy with attempted endoscopic control of varicea. However, this was unsuccessful, and she then underwent emergent TIPS. During the TIPS procedure, a stent was malpositioned between the right hepatic vein into the biliary tree, creating a venobiliary fistula. This was identified immediately, and a vascular plug was placed to occlude this. A left hepatic vein TIPS was performed, which was successful in achieving hemostasis. This vascular plug and right-sided TIPS stent caused biliary occlusion and cholangitis, and the patient was transferred to our hospital for further management. A multidisciplinary team collectively decided that an EDGE procedure with backup by interventional radiology and hepatobiliary surgery would be the modality of treatment. The endoscopic methods. First, the excluded stomach was identified via endoscopic ultrasound. Next, the bypass was reversed using a luminoposin metal stent, and the stent was dilated and affixed with endoscopic sutures. After this, a side-viewing scope was used to identify the major papilla, which was within a duodenal diverticulum. A cholangioscope was advanced into the biliary tree, and the partially covered metal stent from the attempted TIPS procedure was identified in the proximal common bile duct. This was unable to be removed with a cholangioscope, and balloon dilation was used to destabilize the stent from its position, after which both the stent and the occluding plug were removed with toothed forceps. Balloon dilation was used after this, and an attempt to tamponade the fistula. After this, a fully covered metal stent was placed in the distal common bile duct to allow for decompression. Occlusion cholangiogram after the procedure did demonstrate a small persistent fistula. However, a post-procedural venogram done in the interventional radiology suite demonstrated no residual communication. Here we see the venogram from the initial TIPS attempt, with the gallbladder being visualized with IV contrast. After this, an occluding plug was placed, as seen on the left of the screen, and a left-sided TIPS was performed with confirmed patency on venogram, as seen here. Next we go to our fluoroscopy pictures from the EDGE procedure. Here is the EUS scope being advanced, the excluded stomach being identified, and the lumen-opposing metal stent being deployed, right here. The stent is dilated and affixed with endoscopic sutures, and the side-viewing scope is advanced, with access gained into the biliary tree. First a wire is advanced with cholangiogram to confirm placement. We can see that this initial wire placement was in the pancreatic duct, so the wire was withdrawn and placed into the common bile duct, as seen here. Next, a cholangioscope was advanced into the common bile duct, with attempted removal of the partially covered metal stent from the TIPS attempt, as well as the vascular plug. We can see that this was unsuccessful, and balloon dilation was used to attempt to destabilize this partially covered metal stent. We can see the balloon being advanced here, it is dilated. and toothed forceps are used after this in order to both remove the 8x8 partially covered metal stent as well as the occluding plug as seen here. Balloon dilation is also used after this in order to attempt to tamponade the fistula. Next, a 10x4 fully covered metal stent is used in the distal common bile duct to achieve biliary decompression. We can see placement of the stent shortly in the next series of images. As seen here, an occlusion cholangiogram is then performed with conformation and some persistence of venobiliary fistula. Next, we go to our endoscopic pictures. The first series demonstrates the lumen opposing metal stent and endoscopic sutures. The next series demonstrates the papilla within the duodenum as well as the cholangioscopic images. Finally, this is our venogram done in the interventional radiology suite post-procedurally without a persistent fistula. Some clinical implications from this case. It is important to recognize and manage TIPS complications early. Finally, for high-risk patients such as this, in this case, the patient was in septic shock as well as some anatomical challenges including their Roux-en-Y history and the fact that their major papilla was within a duodenum. This made this case additionally challenging. Finally, in cases like this, it is important to involve a multidisciplinary team. Our team included interventional radiology, gastroenterologists, and surgeons. Some conclusions from this case. Innovative and complex management strategies are crucial for rare complications of TIPS. This case highlights the need for specialized expertise in managing these associated biliary injuries. Finally, this case adds valuable knowledge to the medical field regarding TIPS procedure complications.

TIPS procedure

stent misplacement

venobiliary fistula

EDGE procedure

portal hypertension