P178 Good clinical outcomes following direct intrahepatic portocaval shunt (DIPS) for Budd Chiari Syndrome

Introduction Budd Chiari syndrome (BCS) is a rare but potentially life-threatening condition. Recanalization using TIPSS or hepatic venous stenting is key to relieving hepatic congestion. These procedures are impossible in complete HV occlusion. Direct intrahepatic portocaval shunt (DIPS) is a new procedure where a stent is placed directly from the inferior vena cava, often through the caudate lobe, to the portal vein and therefore bypassing the thrombosed HVs. We report our experience in using DIPS for recanalization in BCS. Methods Single centre retrospective analysis from May 2015 to January 2019 comparing outcomes following a DIPS insertion compared to our centre’s previously published data. Results 14 patients were referred for a DIPS procedure. M:F ratio 8:6; age 40.5±13.2; follow up 23.1±15.0 months. HV-BCS type in all. Aetiology: myeloproliferative neoplasm (MPN) in 7, all JAK2+ve with mutation load 17.3±10.2%; PNH, 1; idiopathic, 6 (all –ve following next generation sequencing). Pre-DIPS: MELD 13.1±3.2, UKELD 49.1±13.35, BCS-TIPS PI score 4.45±1.1. Post DIPS portal pressure gradient was 6.9±2.2 mmHg. Clinical indication: variceal bleeding and ascites (n=1) or ascites (n=13). Multidisciplinary consensus to undertake a DIPS insertion as a first line procedure was reached in 13 patients, in 1 patient a TIPSS insertion was initially attempted, when this failed a rescue DIPS was performed. One DIPS insertion (7%) was not successful, this patient is now on the waiting list for transplantation. In all remaining patients, successful stent placement was achieved, and none required escalation to transplantation. Ascites resolution was seen in 7 out of 11 patients at follow up (64%). 2 patients developed hepatic encephalopathy post DIPS (14%). Primary patency rates at 6 months, 1 year, and 2 years were 83%, 83%, 58% respectively. Secondary patency was 100%. Transplant free survival 100% to date. The outcomes are comparable to a previously reported series from the same institution, with similar BCS-TIPS PI but slightly lower MELD. Conclusion Our data demonstrates that with technical excellence, multidisciplinary management, and careful patient selection, DIPS results in very good clinical outcomes in patients unsuitable for standard TIPSS. The outcomes are comparable to standard TIPSS from our historic data. We strongly recommend early referral of all patients with BCS to multidisciplinary teams in centres that offer advanced interventional radiology and liver transplantation.