Dear editor

We read with interest the article by Satoshi Tsuchiya et al. published in CVIR Volume 46, Issue 8 [1]. It is a technique well known by many IRs involved in the management of TIPS (Transjugular Intrahepatic Portosystemic Shunt). Various techniques and devices exist to perform intra-TIPS flow reduction [2].

The treatment presented is a simple, safe and quick procedure but it is not new. This particular treatment for partial TIPS reduction using an AVP4 vascular plug (Abbott, Plymouth, MN) placed within a Viator® stent-graft (W. L. Gore, AZ) and fixed within the lumen of the Viator® using a parallel bare self-expandable nitinol stent, was already presented several years ago during the 2016 CIRSE meeting in Barcelona  (P-566, Paul-Ferrer et al.).

The key point in nonresponders patients who develop hepatic encephalopathy (HE) after TIPS placement is to find the balance between TIPS closure and the risk of variceal re-bleeding. For this reason, it is often rational to perform a partial occlusion of the TIPS as a primary treatment. In case there is no clinical improvement of HE, a complete occlusion of the TIPS is always possible [3].

Unfortunately, at this time there is no technique or device to obtain a preset portosystemic gradient (P-S). The presented treatment is unpredictable in obtaining the correct and balanced P-S gradient. On the other hand, there is no clear clinical data to determine whether to choose a 4, 6, or 8 mm AVP4 amplatzer vascular plug.