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Tips for TIPS: A combined percutaneous and transjugular approach for intrahepatic portosystemic shunt placement after liver transplant. Ann Hepatol 2021; 22:100162. [PMID: 31862175 DOI: 10.1016/j.aohep.2019.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 11/21/2019] [Accepted: 11/24/2019] [Indexed: 02/04/2023]
Abstract
A 39-year-old female, liver transplanted for Autosomic Dominant Polycystic Kidney Disease (ADPKD) developed refractory ascites early after surgery, with frequent need of large-volume paracentesis. This was associated with severe sarcopenia and kidney impairment. Liver biopsy showed a sinusoidal congestion with a significant enlargement of hepatic portal veins. This picture suggested the diagnosis of vascular obstructions. Due to an unfavorable passage through the piggy-back surgical anastomosis and the angle between the hepatic veins and the portal branches, a conventional placement of a transjugular portosystemic shunt (TIPS) was not feasible. An alternative approach was pursued with success, using a combined percutaneous-transjugular approach and achieving a complete recovery of ascites, sarcopenia and renal function.
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Schembri V, Cassinotto C, Panaro F, Delicque J, Pierredon MA, Piron L, Herrero A, Escal L, Ursic-Bedoya J, Guiu B. Challenging TIPS in Liver Transplant Recipients: The Pull-Through Technique to Address Piggyback Anastomosis. Cardiovasc Intervent Radiol 2018; 41:804-810. [DOI: 10.1007/s00270-018-1886-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/20/2018] [Indexed: 12/15/2022]
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Fagiuoli S, Bruno R, Debernardi Venon W, Schepis F, Vizzutti F, Toniutto P, Senzolo M, Caraceni P, Salerno F, Angeli P, Cioni R, Vitale A, Grosso M, De Gasperi A, D'Amico G, Marzano A. Consensus conference on TIPS management: Techniques, indications, contraindications. Dig Liver Dis 2017; 49:121-137. [PMID: 27884494 DOI: 10.1016/j.dld.2016.10.011] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/27/2016] [Accepted: 10/17/2016] [Indexed: 12/11/2022]
Abstract
The trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology-Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.
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Affiliation(s)
- Stefano Fagiuoli
- Gastroenterologia Epatologia e Trapiantologia, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Raffaele Bruno
- Dept. of Infectious Diseases, Hepatology Outpatients Unit, University of Pavia-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Wilma Debernardi Venon
- Gastroepatologia, AOU Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
| | - Filippo Schepis
- Department of Gastroenterology University of Modena and Reggio Emilia, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Pierluigi Toniutto
- Medical Liver Transplant Section, Department of Medical Sciences Experimental and Clinical, Internal Medicine, University of Udine, Italy
| | - Marco Senzolo
- Unità di Trapianto Multiviscerale, Gastroenterologia, Dipartimento di Scienze Chirurgiche e Gastroenterologiche, Università-Ospedale di Padova, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Francesco Salerno
- Department of Internal Medicine, Policlinico IRCCS San Donato, University of Milan, Italy
| | - Paolo Angeli
- Internal Medicine and Hepatology Department of Medicine (DIMED), University of Padova, Italy
| | - Roberto Cioni
- Dipartimento di Radiologia Diagnostica e Interventistica, UO di Radiologia Interventistica, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Alessandro Vitale
- U.O.C. di Chirurgia Epatobiliare e del Trapianto Epatico, Azienda Ospedaliera Università di Padova, Italy
| | - Maurizio Grosso
- Department of Radiology S. Croce and Carle Hospital Cuneo, Italy
| | - Andrea De Gasperi
- 2° Servizio Anestesia e Rianimazione-Ospedale Niguarda Ca Granda, Milan, Italy
| | | | - Alfredo Marzano
- Gastroepatologia, AOU Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
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Kao SD, Morshedi MM, Narsinh KH, Kinney TB, Minocha J, Picel AC, Newton I, Rose SC, Roberts AC, Kuo A, Aryafar H. Intravascular Ultrasound in the Creation of Transhepatic Portosystemic Shunts Reduces Needle Passes, Radiation Dose, and Procedure Time: A Retrospective Study of a Single-Institution Experience. J Vasc Interv Radiol 2016; 27:1148-53. [PMID: 27052948 DOI: 10.1016/j.jvir.2016.01.137] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/11/2016] [Accepted: 01/12/2016] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To assess whether intravascular ultrasound (US) guidance impacts number of needle passes, contrast usage, radiation dose, and procedure time during creation of transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS Intravascular US-guided creation of TIPS in 40 patients was retrospectively compared with conventional TIPS in 49 patients between February 2010 and November 2015 at a single tertiary care institution. Patient sex and age, etiology of liver disease (hepatitis C virus, alcohol abuse, nonalcoholic steatohepatitis), severity of liver disease (mean Model for End-Stage Liver Disease score), and indications for TIPS (variceal bleeding, refractory ascites, refractory hydrothorax) in conventional and intravascular US-guided cases were recorded. RESULTS The two groups were well matched by sex, age, etiology of liver disease, Child-Pugh class, Model for End-Stage Liver Disease scores, and indication for TIPS (P range = .19-.94). Fewer intrahepatic needle passes were required in intravascular US-guided TIPS creation compared with conventional TIPS (2 passes vs 6 passes, P < .01). Less iodinated contrast material was used in intravascular US cases (57 mL vs 140 mL, P < .01). Radiation exposure, as measured by cumulative dose, dose area product, and fluoroscopy time, was reduced with intravascular US (174 mGy vs 981 mGy, P < .01; 3,793 μGy * m(2) vs 21,414 μGy * m(2), P < .01; 19 min vs 34 min, P < .01). Procedure time was shortened with intravascular US (86 min vs 125 min, P < .01). CONCLUSIONS Intravascular US guidance resulted in fewer intrahepatic needle passes, decreased contrast medium usage, decreased radiation dosage, and shortened procedure time in TIPS creation.
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Affiliation(s)
- Steven D Kao
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103; Department of Radiology, University of California Los Angeles Medical Center, Los Angeles, California
| | - Maud M Morshedi
- Department of Radiology, University of California Los Angeles Medical Center, Los Angeles, California
| | - Kazim H Narsinh
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Thomas B Kinney
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Jeet Minocha
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Andrew C Picel
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Isabel Newton
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Steven C Rose
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Anne C Roberts
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Alexander Kuo
- Gastroenterology/Hepatology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103
| | - Hamed Aryafar
- Departments of Radiology, University of California San Diego Medical Center, 200 West Arbor Drive #8756, San Diego, CA 92103.
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Qin JP, Tang SH, Jiang MD, He QW, Chen HB, Yao X, Zeng WZ, Gu M. Contrast enhanced computed tomography and reconstruction of hepatic vascular system for transjugular intrahepatic portal systemic shunt puncture path planning. World J Gastroenterol 2015; 21:9623-9629. [PMID: 26327770 PMCID: PMC4548123 DOI: 10.3748/wjg.v21.i32.9623] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/20/2015] [Accepted: 06/10/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To describe a method for the transjugular intrahepatic portal systemic shunt (TIPS) placement performed with the aid of contrast-enhanced computed tomography (CECT) and three-dimensional reconstructed vascular images (3D RVIs), and to assess its safety and effectiveness.
METHODS: Four hundred and ninety patients were treated with TIPS between January 2005 and December 2012. All patients underwent liver CECT and reconstruction of 3D RVIs of the right hepatic vein to portal vein (PV) prior to the operation. The 3D RVIs were carefully reviewed to plan the puncture path from the start to target points for needle pass through the PV in the TIPS procedure.
RESULTS: The improved TIPS procedure was successful in 483 (98.6%) of the 490 patients. The number of punctures attempted was one in 294 (60%) patients, 2 to 3 in 147 (30%) patients, 4 to 6 in 25 (5.1%) patients and more than 6 in 17 (3.5%) patients. Seven patients failed. Of the 490 patients, 12 had punctures into the artery, 15 into the bile duct, eight into the gallbladder, and 18 through the liver capsule. Analysis of the portograms from the 483 successful cases indicated that the puncture points were all located distally to the PV bifurcation on anteroposterior images, while the points were located proximally to the bifurcation in the three cases with intraabdominal bleeding. The complications included three cases of bleeding, of whom one died and two needed surgery.
CONCLUSION: Use of CECT and 3D RVIs to plan the puncture path for TIPS procedure is safe, simple and effective for clinical use.
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MESH Headings
- Adult
- Contrast Media/administration & dosage
- Female
- Hepatic Veins/diagnostic imaging
- Hepatic Veins/surgery
- Humans
- Hypertension, Portal/diagnostic imaging
- Hypertension, Portal/physiopathology
- Hypertension, Portal/surgery
- Imaging, Three-Dimensional
- Male
- Middle Aged
- Portal Vein/diagnostic imaging
- Portal Vein/surgery
- Portasystemic Shunt, Transjugular Intrahepatic/adverse effects
- Portasystemic Shunt, Transjugular Intrahepatic/methods
- Portography/methods
- Postoperative Complications/etiology
- Predictive Value of Tests
- Punctures
- Radiographic Image Interpretation, Computer-Assisted
- Radiography, Interventional/methods
- Retrospective Studies
- Surgery, Computer-Assisted/methods
- Tomography, X-Ray Computed
- Treatment Outcome
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