Inadvertent misplacement or migration of a “Viatorr” stent graft (W.L. Gore & Associates, Inc. Flagstaff, AR) during transjugular intrahepatic portosystemic shunt (TIPS) creation can occur either during stent deployment or subsequent manipulation of balloons or catheters within the stent.[1] [2] [3] Minor degrees of stent migration in the cephalad or caudal direction often have no clinical consequence. However, major cephalad migration of the stent graft can result in outflow obstruction of the inferior vena cava or problems during hepatic venous anastomosis of the transplanted liver.[4] The reported techniques for the removal of a centrally migrated stent graft involve using a loop snare to capture the cephalad portion of the stent and retrieving it into a large caliber sheath,[2] using forceps-like device for holding the proximal end to allow subsequent passage of a snare,[5] or forceful pulling of the stent into the sheath and surgical removal of the stent graft.[3]

Caudal migration of the stent graft can result in occlusion of the major portal vein branch. Major caudal migration can result in diverting the entire portal flow into the TIPS. It can also interfere with portal vein anastomosis during liver transplantation. Removal of caudally migrated TIPS stent is often difficult as the cranial segment of the stent graft is within the parenchymal tract, limiting the ability to snare the hepatic venous end of the stent graft for retrieval. Balloon-assisted repositioning of the stent graft is rarely successful. In this case, we report successful removal of a caudally migrated TIPS stent with the “involute” technique.