Glowing medical device fragment floats inside a heart.

TIPS Gone Wrong: A Cautionary Tale of Retained Medical Devices

Nico Varela in Health & Wellness December 2025 • 4 min read.

"When a life-saving procedure turns into a device retrieval mission: A case study on the rare complication of retained TIPS deployment lines and the innovative solutions to fix it."

Transjugular intrahepatic portosystemic shunt (TIPS) procedures are essential for managing complications of liver disease, but, rarely, mechanical issues occur. While uncommon, device migration can lead to serious complications, highlighting the need for careful monitoring and innovative retrieval methods.

A recent case underscores these risks, detailing the instance of a retained deployment line from a TIPS endoprosthesis that embolized to the right heart. The medical team successfully retrieved the retained piece using intravascular ultrasound (US) guidance, showcasing the importance of advanced imaging techniques in addressing such complications.

This article delves into the specifics of this case, emphasizing the potential for retained medical devices and the critical role of vigilant post-operative care in ensuring patient safety. It also explores the broader implications for procedural protocols and device design to minimize future occurrences.

The Case of the Floating Deployment Line

Glowing medical device fragment floats inside a heart.

A 70-year-old woman, awaiting a liver transplant due to end-stage liver disease, was found to have a foreign object in her right atrium during a routine pre-transplant echocardiogram. This object, a long, thin, and mobile structure, was traced back to a TIPS procedure she had undergone a month prior at another hospital.

Initial CT scans failed to detect the foreign body, prompting the team to use intravascular ultrasound (US) to get a clearer picture. The US imaging confirmed the presence of the object and guided the team toward a successful retrieval.

Advanced Imaging: The use of intravascular ultrasound (US) proved critical in locating and retrieving the non-radiopaque deployment line, demonstrating its value in complex cases.
Careful Retrieval: Utilizing a combination of catheters and snares under US guidance, the team successfully removed the deployment line, averting potential complications.
Device Identification: Post-retrieval, the foreign body was identified as a fragment of the GORE VIATORR TIPS Endoprosthesis deployment line.

The successful retrieval highlighted a crucial, yet often overlooked, aspect of medical procedures: the necessity of meticulous device integrity checks post-procedure. It also spotlighted the potential for intravascular US as a problem-solving tool for locating and retrieving non-radiopaque foreign bodies.

Lessons Learned and Future Implications

This case serves as a potent reminder of the potential complications associated with even routine medical procedures. Retained medical devices, though rare, pose significant risks and require immediate intervention.

The successful use of intravascular US in this case underscores the value of advanced imaging techniques in identifying and retrieving non-radiopaque foreign bodies. This approach may expand the role of intravascular US in similar scenarios.

Moving forward, healthcare providers should emphasize thorough device checks after procedures to ensure the integrity of all components. Additionally, device manufacturers could explore design modifications to minimize the risk of component separation and retention. Ultimately, a multi-faceted approach involving vigilant monitoring, advanced imaging, and device improvements is crucial to enhancing patient safety and minimizing the risk of retained medical devices.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1016/j.jvir.2018.04.006, Alternate LINK

Title: Retrieval Of A Retained Transjugular Intrahepatic Portosystemic Shunt Stent Graft Deployment Line

Subject: Cardiology and Cardiovascular Medicine

Journal: Journal of Vascular and Interventional Radiology

Publisher: Elsevier BV

Authors: Ayush Amin, Yi Shuen Chang, Thomas Sullivan, Jason Salsamendi

Published: 2018-09-01

Everything You Need To Know

What is a Transjugular intrahepatic portosystemic shunt (TIPS) procedure, and why is it relevant in this context?

A Transjugular intrahepatic portosystemic shunt (TIPS) procedure is a medical intervention primarily used to manage complications stemming from liver disease. It involves creating a shunt within the liver to redirect blood flow. However, as demonstrated in this specific case, complications such as device migration or retention of parts like the GORE VIATORR TIPS Endoprosthesis deployment line can occur, leading to significant health risks.

What is the significance of a retained GORE VIATORR TIPS Endoprosthesis deployment line, and why is it problematic?

The significance of the GORE VIATORR TIPS Endoprosthesis deployment line being retained lies in its potential to embolize, or travel through the bloodstream, to critical areas like the heart. This can cause severe complications and necessitates immediate intervention. The fact that the medical team successfully retrieved the deployment line using intravascular ultrasound (US) emphasizes the importance of innovative solutions to address such rare but potentially life-threatening issues. This scenario highlights the necessity of strict post-operative checks.

How did intravascular ultrasound (US) aid in resolving the issue of the floating deployment line?

Intravascular ultrasound (US) plays a crucial role in this situation by offering detailed, real-time images of the inside of blood vessels. In the case of a floating deployment line, the advanced imaging allowed the medical team to precisely locate the non-radiopaque fragment of the GORE VIATORR TIPS Endoprosthesis deployment line. This precise visualization guided the careful retrieval process and underscored the technology's value in complex cases where conventional imaging methods might fall short.

What are the broader implications of a retained deployment line from the GORE VIATORR TIPS Endoprosthesis?

The primary implication of the retained deployment line is the risk of serious complications. These range from the potential for the object to block blood flow to causing damage to the heart and other organs. The team's use of intravascular ultrasound (US) to safely retrieve the GORE VIATORR TIPS Endoprosthesis deployment line illustrates the importance of prompt diagnosis and effective interventions in medical device-related complications. This event underscores the need for thorough device integrity checks after the procedure.

What key lessons can be learned from this experience, and what are the implications for the future?

This case underscores the importance of meticulous device integrity checks following procedures like Transjugular intrahepatic portosystemic shunt (TIPS) procedures. It advocates for the use of advanced imaging methods, specifically intravascular ultrasound (US), when complications arise. Moreover, it suggests the importance of continually improving procedural protocols and device design to minimize the risk of future occurrences of retained medical devices, thereby improving patient safety and outcomes. The successful retrieval of the GORE VIATORR TIPS Endoprosthesis deployment line is a testament to the effectiveness of careful monitoring and advanced problem-solving tools.