Performance of ultrasound for detection of transjugular intrahepatic portosystemic shunt dysfunction: a meta-analysis

An exploration of radiological signs in post-intervention liver complications

The advent and progression of radiological techniques in the past few decades have revolutionized the diagnostic and therapeutic landscape for liver diseases. These minimally invasive interventions, ranging from biopsies to complex therapeutic procedures like transjugular intrahepatic portosystemic shunt placement and transarterial embolization, offer substantial benefits for the treatment of patients with liver diseases. They provide accurate tissue diagnosis, allow real-time visualization, and render targeted treatment for hepatic lesions with enhanced precision. Despite their advantages, these procedures are not without risks, with the potential for complications that can significantly impact patient outcomes. It is imperative for radiologists to recognize the signs of these complications promptly to mitigate further health deterioration. Ultrasound, CT, and MRI are widely utilized examinations for monitoring the complications. This article presents an overarching review of the most commonly encountered hepatobiliary complications post-radiological interventions, emphasizing their imaging characteristics to improve patient post-procedure management.

Emergent TIPS for acute gastroesophageal variceal bleeding in cirrhotic patients with hepatocellular carcinoma

OBJECTIVES

To estimate the safety and effectiveness of emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for acute variceal bleeding (AVB) in cirrhotic patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Data of thirty-three patients with AVB and HCC undergoing emergent TIPS creation from January 2016 to January 2022 were enrolled and were retrospectively analyzed. The primary outcomes were the safety of emergent TIPS creation, the bleeding control rate, and the rebleeding rate. The secondary outcomes included overall survival (OS), liver function, overt hepatic encephalopathy (HE), and shunt dysfunction.

RESULTS

Emergent TIPS creation was technically successful in 33 patients (100%) and one (3.0%) patient suffered a major procedure-related adverse event. The control rate of bleeding (within 5 days) was 100%. During a median follow-up period of 26.3 months, rebleeding occurred in 6 (18.2%) patients. The median OS was 20.0 months. The 6-week and 1-year survival rates were 87% and 65%, respectively. Laboratory tests showed no significant impairment of liver function following TIPS creation. The incidences of overt HE and shunt dysfunction were 24.2% and 6.1%, respectively.

CONCLUSION

Emergent TIPS creation is feasible and effective for treatment of AVB in cirrhotic patients with HCC.

High resolution flow with glazing flow for optimized flow detection in transjugular intrahepatic portosystemic stent shunt (TIPS): First results

BACKGROUND

Ultrasound follow-up of transjugular intrahepatic portosystemic shunt (TIPS) is challenging due to the bent course of the stent-graft.

OBJECTIVE

Aim of this retrospective study was to assess to which extent the combination of HR flow with Glazing Flow improves hemodynamic assessment in the ultrasound follow-up of TIPS.

METHODS

Comparative studies with CCDS and High Resolution (HR)-Flow with Glazing Flow were evaluated regarding image quality and artifacts on a 5-point scale (0 = cannot be assessed up to 5 = maximum image quality without artifacts). In all cases, an experienced examiner performed the examinations with a 1-6 MHz probe (Resona 7, Mindray).

RESULTS

61 ultrasound examinations in 48 patients were performed; the mean patient age was 54±14.2 years. The use of HR-Flow with Glazing Flow resulted in an improved flow display in 55/61 cases (90.2%). Both methods correlated well (r = 0.71), but HR flow with Glazing flow values were in general higher than CCDS values. The reading resulted in an average value of 2.52±0.54 for CCDS and 3.52±0.57 for HR flow with Glazing flow (p = 0.013).

CONCLUSION

The combination of HR-Flow and Glazing Flow results in improved flow representation and reduction of artifacts in the ultrasound follow-up of TIPS.

Transjugular intrahepatic portosystemic shunt (TIPS) complications: what diagnostic radiologists should know

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for portal hypertension complications and can successfully treat variceal bleeding and refractory ascites. Although TIPS is relatively safe, procedural- or shunt-related morbidity can reach 20%, and procedural complications have a fatality rate of 2%. Delayed recognition and treatment of TIPS complications can lead to life-threatening clinical scenarios. Complications can vary from stent migration or malpositioning to nontarget organ injury, TIPS dysfunction, encephalopathy, or liver failure. This review aims to outline the role of diagnostic radiology in assessing post-TIPS complications.

North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.

Use of doppler ultrasound to predict need for transjugular intrahepatic portosystemic shunt revision

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is used to treat complications of portal hypertension, such as ascites and variceal bleeding (VB). While liver doppler ultrasound (DUS) is used to assess TIPS patency, trans-shunt venography (TSV) is the gold standard.

AIM

To determine the accuracy of DUS to assess TIPS dysfunction and for need for revision.

METHODS

Retrospective review of patients referred for TIPS revision from 2008-2021. Demographics, DUS parameters at baseline and at the DUS preceding TIPS revision, TSV data were collected. Receiver operating characteristics curves, sensitivity, specificity, performance for doppler to predict need for revision were performed. Univariate and multivariate analyses were used to predict clinical factors associated with need for TIPS revision.

RESULTS

The cohort consisted of 89 patients with cirrhosis (64% men, 76% white, 31% alcohol as etiology); median age 59 years. Indication for initial TIPS were VB (41%), refractory ascites (51%), and other (8%). TIPS was revised in 44%. On univariate analysis, factors associated with need for TIPS revision were male (P = 0.03), initial indication for TIPS (P = 0.05) and indication for revision (P = 0.01). Revision of TIPS was associated with lower mortality (26% vs 46%) and significantly lower rates of transplant (13% vs 24%; P = 0.1). In predicting need for TIPS revision, DUS has a 40% sensitivity, 45% specificity, PPV 78%, and NPV 14%. The most accurate location for shunt velocity measure was distal velocity (Area under the curve: 0.79; P = 0.0007).

CONCLUSION

DUS has poor overall sensitivity and specificity in predicting need for TIPS revision. Non-invasive methods of predicting TIPS dysfunction are needed since those needing TIPS revision had better survival.

Diagnostic value of conventional ultrasound and shear wave elastography in detecting transjugular intrahepatic portosystemic shunt dysfunction

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction can cause recurrent portal hypertension (PH)-related complications such as ascites and gastroesophageal variceal bleeding. Portography is invasive and costly limits its use as a screening modality.

PURPOSE

To assess the clinical value of conventional ultrasound in combination with point shear wave elastography (pSWE) to predict TIPS dysfunction.

MATERIAL AND METHODS

A total of 184 patients with cirrhosis scheduled for TIPS implantation were enrolled in this study and evaluated retrospectively. The splenoportal venous blood flow parameter, liver stiffness (LS), and spleen stiffness (SPS) were measured. Outcome measures included differences in portal vein velocity (PVV), splenic vein velocity (SPVV), LS, and SPS. The accuracy of change in PVV (ΔPVV), SPVV (ΔSPVV), and SPS (ΔSPS) to diagnose TIPS dysfunction was investigated.

RESULTS

TIPS dysfunction occurred in 28 of 184 patients (15.2%). Eighteen (64.3%) patients had shunt stenoses and 10 (35.7%) had shunt occlusion. Portal vein diameter (PVD), PVV, splenic vein diameter (SPVD), SPVV, LS, and SPS were not significantly different between the TIPS normal and TIPS dysfunction groups. Compared with the TIPS normal group, PVV and SPVV of the TIPS dysfunction group decreased significantly, whereas SPS increased significantly (P < 0.001). The values of areas under the receiver operating characteristic curves of ΔPVV, ΔSPVV, and ΔSPS for the diagnosis of TIPS dysfunction were 0.97, 0.96, and 0.87, respectively.

CONCLUSION

pSWE showed a diagnostic efficacy comparable to conventional ultrasound for diagnosing TIPS dysfunction and can be used routinely after TIPS procedures.

Diagnostic Value of Contrast-Enhanced Ultrasound for Evaluation of Transjugular Intrahepatic Portosystemic Shunt Perfusion

BACKGROUND

In patients with liver cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) displays an effective method for treating portal hypertension. Main indications include refractory ascites and secondary prevention of esophageal bleeding. Color Doppler ultrasound (CDUS) plays a leading role in the follow-up management, whereas contrast-enhanced ultrasound (CEUS) is not routinely considered. We compared the efficacy of CEUS to CDUS and highlighted differences compared to findings of corresponding computed tomography (CT) and magnetic resonance imaging (MRI). (2) Methods: On a retrospective basis, 106 patients with CEUS examination after TIPS were included. The enrollment period was 12 years (between 2008 and 2020) and the age group ranged from 23.3 to 82.1 years. In addition, 92 CDUS, 43 CT and 58 MRI scans were evaluated for intermodal comparison. (3) Results: Intermodal analysis and comparison revealed a high level of concordance between CDUS, CT and MRI in the vast majority of cases. In comparison to CDUS, the correlation of the relevant findings was 92.5%, 95.3% for CT and 87.9% for MRI. In some cases, however, additional information was provided by CEUS (4) Conclusions: CEUS depicts a safe and effective imaging modality for follow-up after TIPS. In addition to CDUS, CEUS enables specific assessment of stent pathologies and stent dysfunction due to its capacity to dynamically visualize single microbubbles at high spatial and temporal resolution. Due to the low number of adverse events regarding the application of contrast agents, CEUS can be administered to a very broad patient population, thus avoiding additional radiation exposure compared to CT angiography in cases with divergent findings during follow-up.

Spleen Stiffness Performance in the Noninvasive Assessment of Gastroesophageal Varices after Transjugular Intrahepatic Portosystemic Shunts

Objectives

To investigate the performance of spleen stiffness (SS) by using two-dimensional shear-wave elastography (2D-SWE) for assessing the severity of gastroesophageal varices (GEVs) after transjugular intrahepatic portosystemic shunt (TIPS).

Methods

102 eligible patients were categorized as in the post-TIPS short-term (n = 69) and long-term (n = 38) follow-up groups. The performance of SS by using 2D-SWE for evaluating the severity of GEVs was compared with liver stiffness (LS), spleen stiffness-to-liver stiffness ratio (SS/LS), liver stiffness spleen-diameter-to-platelet-ratio score (LSPS), portal hypertension (PH) risk score, platelet count-to-spleen diameter ratio (PSR), and varices risk score by using receiver operating characteristic (ROC) curve and DeLong test.

Results

In the post-TIPS short-term follow-up group, area under the receiver operating characteristic curves (AUCs) of SS were 0.585 for mild (cutoff value = 30.3 kPa), 0.655 for moderate (cutoff value = 30.6 kPa), and 0.739 for severe (cutoff value = 31.9 kPa) GEVs, which were higher than other parameters for severe GEVs. AUCs of SS were lower than other parameters for mild and moderate GEVs, but no difference was found (p > 0.05). In the post-TIPS long-term follow-up group, AUCs of SS were 0.778 for mild (cutoff value = 28.9 kPa), 0.82 for moderate (cutoff value = 29.9 kPa), and 0.824 for severe (cutoff value = 37.7 kPa) GEVs, which were higher than other parameters except for severe GEVs. AUC of SS was lower than other parameters for severe GEVs, but no significant difference was found (p > 0.05).

Conclusion

SS is an effective noninvasive tool to predict GEV severity during the post-TIPS follow-up.

Contrast-enhanced US for the Interventional Radiologist: Current and Emerging Applications

US is a powerful and nearly ubiquitous tool in the practice of interventional radiology. Use of contrast-enhanced US (CEUS) has gained traction in diagnostic imaging given the recent approval by the U.S. Food and Drug Administration (FDA) of microbubble contrast agents for use in the liver, such as sulfur hexafluoride lipid-type A microspheres. Adoption of CEUS by interventional radiologists can enhance not only procedure guidance but also preprocedure patient evaluation and assessment of treatment response across a wide spectrum of oncologic, vascular, and nonvascular procedures. In addition, the unique physical properties of microbubble contrast agents make them amenable as therapeutic vehicles in themselves, which can lay a foundation for future therapeutic innovations in the field in drug delivery, thrombolysis, and vascular flow augmentation. The purpose of this article is to provide an introduction to and overview of CEUS aimed at the interventional radiologist, highlighting its role before, during, and after frequently practiced oncologic and vascular interventions such as biopsy, ablation, transarterial chemoembolization, detection and control of hemorrhage, evaluation of transjugular intrahepatic portosystemic shunts (TIPS), detection of aortic endograft endoleak, thrombus detection and evaluation, evaluation of vascular malformations, lymphangiography, and percutaneous drain placement. Basic physical principles of CEUS, injection and scanning protocols, and logistics for practice implementation are also discussed. Early adoption of CEUS by the interventional radiology community will ensure rapid innovation of the field and development of future novel procedures. Online supplemental material is available for this article. ^©RSNA, 2020.

Role of Doppler Ultrasound Combined With Clinical Features in the Diagnosis of Transjugular Intrahepatic Portosystemic Shunt Dysfunction in the Era of Covered Stents

OBJECTIVES

Our goal was to discuss the role of Doppler ultrasound (US), combined with clinical features, in the diagnosis of transjugular intrahepatic portosystemic shunt (TIPS) dysfunction in the era of covered stents. In light of the lack of research regarding the accuracy of Doppler US in TIPS dysfunction evaluations when using covered stents and a recent major meta-analysis, which primarily reviewed studies with bare metal stents but few with covered stents, we aimed to provide our single-center case study for further investigation.

METHODS

All patients from 2010 to 2019 who underwent angiography for a covered stent preceded by a Doppler US examination in our institution were retrospectively reviewed.

RESULTS

All of the Doppler US and angiographic examination results showed complete agreement, and 11 of 12 were positive for TIPS dysfunction.

CONCLUSIONS

Combining the presence of positive clinical signs for TIPS dysfunction with Doppler US may increase its accuracy. Considering our results, there may be a need to reinvestigate Doppler US as a noninvasive, inexpensive, and available tool for the diagnosis of TIPS dysfunction in the era of covered stents, despite recent publications depicting Doppler US as inadequate for evaluating a TIPS.