Meet A New Boss, Not Quite The Old Boss

Excerpt

In considering this comparative study of the Beograft and Viatorr (ref CVIR paper) [1], perhaps a brief perspective on TIPS devices might be helpful. The original device was Prof. Palmaz’s steel stent, placed in a dog he named ‘Rusty.’ Patency was not a concern until enough human cases accumulated to recognize that TIPS narrowed with alacrity, and early TIPS papers and editorials included phrases like ‘TIPS is clouded by unpredictable patency.’ Methodical reports of such issues led to the promising 1994 report by Nishimine et al. using polytetrafluoroethylene (PTFE) hand-sewn to handmade spiral z-stents to create durable TIPS in swine [2]. Thereafter swine models were used to test various expanded PTFE (ePTFE) and varying porosities of polyurethanes and polycarbonate lined or encapsulated stents, both self- and balloon-expandable [3‐5]. PTFE was the standout, and, in handmade and later commercial versions, has demonstrated patency for decades [6, 7], including 20 years in one of my patients. The TIPS ‘device’ has become less of a stent graft than a sturdy scaffold to deliver ePTFE to pave the liver tract, line its outflow to the vena cava ostium, and lastly, resist liver compression. Predictable patencies now allow us to ask long-delayed questions such as the timing of and indications for the procedure and optimal diameter sizing and post-TIPS gradients per patient-specific needs, be they for high or low risk bleeding, fluid management, or mesenteric venous thrombosis. …