Parallel TIPS for treatment of refractory ascites and hepatic hydrothorax

The development of medically refractory ascites portends a grim prognosis for patients with liver cirrhosis, and is associated with median survival of six months and marked impairment of quality of life [13]. Hepatic hydrothorax is a sequela of cirrhotic ascites in which fluid moves into the pleural space via diaphragmatic defects [4]. Transjugular intrahepatic portosystemic shunt (TIPS) creation is a safe and accepted treatment for both refractory ascites and hepatic hydrothorax, and has been shown to prolong survival [5] and achieve low (approximately 2530 %) recurrence [5, 6]. For patients who fail to respond to TIPS, treatment options comprise orthotopic liver transplantation (OLT) for cure and serial large-volume paracentesis (LVP) or thoracentesis for symptomatic relief [79]. The former is limited by the scarcity of donor organs and the latter is an inconvenient approach associated with high recurrence and no survival benefit [2, 5]. Placement of a second parallel TIPS has been used to achieve clinically meaningful portosystemic pressure gradient (PSG) reduction in the setting of variceal hemorrhage [10]. However, formal descriptions of this technique in the treatment of intractable ascites and hepatic hydrothorax are lacking. Herein, we present two cases in which ascites and hydrothorax refractory to both medical treatment and primary TIPS improved markedly after creation of a parallel TIPS.