No clear guidelines exist for the management of symptomatic cases of portal biliopathy, although in prior cases, a stepwise approach is often used depending on the presumed etiology. Initial management, if CBD calculi or cholangitis is suspected, is with endoscopic retrograde cholangiopancreatography, balloon sweep, and stenting. Although difficult to treat, calculi may result in more advanced endoscopic techniques such as large balloon sphincterotomy and intraductal lithotripsy.² Initial biliary tree stent management is centered around plastic stenting or even self-expanding metal stents. It is important to note that metal stents can be difficult to retrieve and can complicate subsequent procedures. For biliary strictures without complicating cholangitis or shunt contraindications, most centers may use surgical portosystemic shunt procedures such as TIPS as first-line management. Other indications include persistent symptoms refractory to other therapies. TIPS is associated with significant clinical improvement, with only one-third of patients continuing to have symptoms afterward.³

The first TIPS procedure with a metal stent was performed on humans in 1988 for end-stage portal hypertension.⁴ The procedure has since gained notoriety, with the most common indications including refractory esophageal varices and ascites. TIPS is designed to decrease portal pressure by placing a stent between the portal and hepatic veins; thus, it can be considered in other causes of portal hypertension such as portal biliopathy.⁵ Initial stent selection during the early years of TIPS was limited to bare metal stents. During the early 2000s, the introduction of covered metal stents was trialed under direct comparison with bare metal stents showing higher rates of 4 and 5-year post-TIPS survival and lower rates of gastrointestinal bleeding and refractory ascites.⁶ The cumulative restenosis rate is significantly lower, and importantly, the overall rate of secondary interventional therapy is lower (20.6% for covered stents vs 49.6% for bare metal stents).⁷ With an improved safety profile, covered stents remain the first-line choice for TIPS procedures.⁸

The only note of biliary TIPS fistulous complications with TIPS stents are those associated with occlusion or stenosis of the TIPS stent leading to TIPS-associated biliary fistula formation.⁹ CBD stents are not associated with fistulous connections as a complication, with only an isolated report of choledochoduodenal fistula after significant migration of a bare metal stent.¹⁰ A TIPS stent-to-CBD stent fistulous connection has not been described in the literature. Bare metal stents have an increased likelihood of creating a fistulous connection with other stents because of their design, compared with covered metal stents. Covered metal stents have been increasingly used for TIPS shunts because of the decreased number of complications associated with them and should especially be considered in patients with portal biliopathy because they often require multiple interventions and CBD stents. As demonstrated in this case, when concomitant procedures such as common bile duct stenting are required, selection of the stent type is critical to reduce complication including stent-to-stent fistulization.