Arterio-biliary fistula after transjugular intrahepatic portosystemic shunt: a life-threatening complication of the new technique for therapy of portal hypertension.

We report on a 70-year old woman with chronic active hepatitis and portal gastropathy who was treated with TIPS. On day 28 after TIPS implantation hemobilia occurred and radiological examination of the abdomen showed migration and kinking of the portal stent. During an emergency intervention the dislocated stent was splinted with a further stent. The suspected portobiliary fistula, however, could not be detected. The subsequent angiography of the hepatic artery showed an arteriobiliary fistula in the area of the dislocated stent. By means of microparticles and coils this fistula could be occluded angiographically; the bleeding stopped completely. Three days after the successful occlusion of the arterio-biliary fistula the patient died of disseminated intravascular coagulation. We therefore recommend in case of hemobilia after TIPS placement an immediate evaluation of the bleeding to exclude an arterio-biliary communication. In order to avoid stent dislocation it is advisable not to use combination of stents with a different design (e.g., Wall-stent and Palmaz-stent).