Image fusion-guided portal vein puncture during transjugular intrahepatic portosystemic shunt placement

Meta-analysis of transjugular intrahepatic portosystemic shunt creation with or without intravascular ultrasound guidance

OBJECTIVE

To conduct a meta-analysis to assess the efficacy of intravascular ultrasound (IVUS) during transjugular intrahepatic portosystemic shunt (TIPS) creation.

METHODS

MEDLINE and Embase databases were queried until July 2022 for comparative studies reporting procedure metrics for TIPS creation with or without IVUS guidance. Meta-analysis was performed with random-effects modelling for total procedural time, time to portal venous access, fluoroscopy time, iodinated contrast volume use, air kerma, dose area product, and number of needle passes. Intraoperative procedure-related complications were also reviewed.

RESULTS

Of 95 unique records initially identified, 6 were eligible for inclusion. A total of 194 and 240 patients underwent TIPS with and without IVUS guidance. Pooled analyses indicated that IVUS guidance was associated with reduced total procedure time (SMD -0.76 [95% CI -1.02, -0.50] P < .001), time to portal venous access (SMD -0.41 [95% CI -0.67, -0.15] P = .002), fluoroscopy time (SMD, -0.54 [95% CI -1.02, -0.07]; P = .002), contrast volume use (SMD, -0.89 [95% CI -1.16, -0.63]; P < .001), air kerma (SMD, -0.75 [95% CI -1.11, -0.38]; P < .001) and dose area product (SMD, -0.98 [95% CI -1.77, -0.20]; P = .013). A total of 4.2 and 7.8 needle passes were required in the IVUS and non-IVUS group, respectively (SMD, -0.60 [95% CI -1.42, 0.21]; P = .134). Pooled complication rates were 15.2% (12/79) and 21.4% (28/131), respectively.

CONCLUSION

IVUS guidance during TIPS creation improves procedural metrics including procedural time, contrast usage, and radiation exposure.

ADVANCES IN KNOWLEDGE

(1) The use of IVUS during TIPS is associated with shorter procedural time, lower contrast usage, and radiation exposure. (2)The use of IVUS is not associated with higher complication rates.

CBCT-based three-dimensional dual-phase vascular image fusion: a novel technique for interventional real-time TIPS guidance

BACKGROUND

Due to the invisibility of the portal vein (PV), how to puncture the PV accurately and safely in transjugular intrahepatic portosystemic shunt (TIPS) creation remains a challenge of the procedure.

OBJECTIVES

We aimed to provide the first evaluation of the safety, feasibility, and efficiency of cone beam computed tomography (CBCT)-based three-dimensional (3D) dual-phase vascular image fusion for interventional real-time guided PV puncture during TIPS procedures.

MATERIALS AND METHODS

From January 2021 to May 2021, 13 patients undergoing TIPS were prospectively enrolled in this study. Images of the hepatic artery (HA) and PV in 3D were acquired and overlaid on interventional fluoroscopy images in a dual-phase display mode for real-time PV puncture guidance. The number of PV puncture attempts, puncture time, overlaid image accuracy, dose area product, fluoroscopy time, and interventional complications were recorded.

RESULTS

Portal vein puncture guided by CBCT-based 3D dual-phase vascular image fusion was successfully performed on 92.3% (12/13) patients. The mean number of PV puncture attempts was 1.8 ± 0.7 (1-3). The mean puncture time and fluoroscopy time was 3.5 ± 1.2 (2-6) min and 25.1 ± 9.4 (15-45) min, respectively. The mean dose area product was 39.49 ± 7.88 (28.81-52.87) mGym2. The error between the reference position of the fusion image and the interventional PV angiography image was less than 0.5 cm. No interventional complication was observed.

CONCLUSION

Our results show that 3D dual-phase vascular image fusion might be a safe and feasible technique for interventional real-time guided PV puncture during TIPS. This novel technique might help to reduce the number of PV puncture attempts and the puncture time as well as lower the risks of interventional complications.

Augmented Reality Navigation System for Biliary Interventional Procedures With Dynamic Respiratory Motion Correction

OBJECTIVE

Biliary interventional procedures require physicians to track the interventional instrument tip (Tip) precisely with X-ray image. However, Tip positioning relies heavily on the physicians' experience due to the limitations of X-ray imaging and the respiratory interference, which leads to biliary damage, prolonged operation time, and increased X-ray radiation.

METHODS

We construct an augmented reality (AR) navigation system for biliary interventional procedures. It includes system calibration, respiratory motion correction and fusion navigation. Firstly, the magnetic and 3D computed tomography (CT) coordinates are aligned through system calibration. Secondly, a respiratory motion correction method based on manifold regularization is proposed to correct the misalignment of the two coordinates caused by respiratory motion. Thirdly, the virtual biliary, liver and Tip from CT are overlapped to the corresponding position of the patient for dynamic virtual-real fusion.

RESULTS

Our system is respectively evaluated and achieved an average alignment error of 0.75 ± 0.17 mm and 2.79 ± 0.46 mm on phantoms and patients. The navigation experiments conducted on phantoms achieve an average Tip positioning error of 0.98 ± 0.15 mm and an average fusion error of 1.67 ± 0.34 mm after correction.

CONCLUSION

Our system can automatically register the Tip to the corresponding location in CT, and dynamically overlap the 3D virtual model onto patients to provide accurate and intuitive AR navigation.

SIGNIFICANCE

This study demonstrates the clinical potential of our system by assisting physicians during biliary interventional procedures. Our system enables dynamic visualization of virtual model on patients, reducing the reliance on contrast agents and X-ray usage.

Transjugular intrahepatic portosystemic shunt creation (TIPS) in the angio-CT-a hybrid intervention with image fusion

OBJECTIVE

For transjugular intrahepatic portosystemic shunt (TIPS) creation, ultrasound guidance for portal vein puncture is strongly recommended. However, outside regular hours of service, a skilled sonographer might be lacking. Hybrid intervention suites combine CT imaging with conventional angiography allowing to project 3D information into the conventional 2D imaging and further CT-fluoroscopic puncture of the portal vein. The purpose of this study was to assess whether TIPS using angio-CT facilitates the procedure for a single interventional radiologist.

METHODS

All TIPS procedures from 2021 and 2022 which took place outside regular working hours were included (n = 20). Ten TIPS procedures were performed with just fluoroscopy guidance and ten procedures using angio-CT. For the angio-CT TIPS, a contrast-enhanced CT was performed on the angiography table. From the CT, a 3D volume was created using virtual rendering technique (VRT). The VRT was blended with the conventional angiography image onto the live monitor and used as guidance for the TIPS needle. Fluoroscopy time, area dose product, and interventional time were assessed.

RESULTS

Hybrid intervention with angio-CT did lead to a significantly shorter fluoroscopy time and interventional time (p = 0.034 for both). Mean radiation exposure was significantly reduced, too (p = 0.04). Furthermore, the mortality rate was lower in patients who underwent the hybrid TIPS (0% vs 33%).

CONCLUSION

TIPS procedure in angio-CT performed by only one interventional radiologist is quicker and reduces radiation exposure for the interventionalist compared to mere fluoroscopy guidance. The results further indicate increased safety using angio-CT.

CLINICAL RELEVANCE STATEMENT

This study aimed to evaluate the feasibility of using angio-CT in TIPS procedures during non-standard working hours. Results indicated that the use of angio-CT significantly reduced fluoroscopy time, interventional time, and radiation exposure, while also leading to improved patient outcomes.

KEY POINTS

• Image guiding such as ultrasound is recommended for transjugular intrahepatic portosystemic shunt creation but might be not available for emergency cases outside of regular working hours. • Transjugular intrahepatic portosystemic shunt creation using an angio-CT with image fusion is feasible for only one physician under emergency settings and results in lower radiation exposure and faster procedures. • Transjugular intrahepatic portosystemic shunt creation using an angio-CT with image fusion seems to be safer than using mere fluoroscopy guidance.

CT2X-IRA: CT to x-ray image registration agent using domain-cross multi-scale-stride deep reinforcement learning

Objective.In computer-assisted minimally invasive surgery, the intraoperative x-ray image is enhanced by overlapping it with a preoperative CT volume to improve visualization of vital anatomical structures. Therefore, accurate and robust 3D/2D registration of CT volume and x-ray image is highly desired in clinical practices. However, previous registration methods were prone to initial misalignments and struggled with local minima, leading to issues of low accuracy and vulnerability.Approach.To improve registration performance, we propose a novel CT/x-ray image registration agent (CT2X-IRA) within a task-driven deep reinforcement learning framework, which contains three key strategies: (1) a multi-scale-stride learning mechanism provides multi-scale feature representation and flexible action step size, establishing fast and globally optimal convergence of the registration task. (2) A domain adaptation module reduces the domain gap between the x-ray image and digitally reconstructed radiograph projected from the CT volume, decreasing the sensitivity and uncertainty of the similarity measurement. (3) A weighted reward function facilitates CT2X-IRA in searching for the optimal transformation parameters, improving the estimation accuracy of out-of-plane transformation parameters under large initial misalignments.Main results.We evaluate the proposed CT2X-IRA on both the public and private clinical datasets, achieving target registration errors of 2.13 mm and 2.33 mm with the computation time of 1.5 s and 1.1 s, respectively, showing an accurate and fast workflow for CT/x-ray image rigid registration.Significance.The proposed CT2X-IRA obtains the accurate and robust 3D/2D registration of CT and x-ray images, suggesting its potential significance in clinical applications.

Clinical Impact and Safety of Non-Target Punctures (NTP) during Portal Vein Access in TIPS Procedure

BACKGROUND

Although non-target puncture (NPT)-related complications are well known to clinicians performing TIPS, there is no NTP-focused study to assess the true clinical sequalae of NTP-related complications. In this study, the aim was to evaluate the incidence, safety, clinical outcomes and complications related to NTPs during the portal access of TIPS procedures.

METHODS

A retrospective review of 369 TIPS procedures from October 2007 to September 2019 was performed. We identified inadvertent NTPs, including biliary, hepatic artery, lymphatic and capsular punctures. Next, the medical records and images were reviewed and analyzed to assess the safety and clinical outcomes of these cohorts.

RESULTS

A total of 71 NTPs were identified in 56 patients (15.18% of 369 patients). Of 369 TIPS patients, there were (1) 28 biliary punctures (7.6%), (2) 16 extracapsular punctures (4.3%), (3) 15 lymphatic punctures (4.1%) and (4) 12 hepatic artery punctures (3.3%). The overall complication rate was 2.2% (8/369). Based on the Clavien-Dindo classification, three patients (0.8%) had a minor complication. In addition, five patients (1.4%) experienced grade II-V major complications, such as symptomatic hemoperitoneum, arterio-biliary fistula or hemorrhagic shock leading to death. Mortality (0.5%) was only caused by extracapsular puncture combined with other NTP.

CONCLUSIONS

NTPs during the portal access of TIPS procedures are associated with low complication risk. However, when extracapsular punctures are combined with other NTPs, a more severe complication, including mortality, can occur. Nevertheless, all patients with NTP should be closely monitored at a higher level of care after TIPS placement.

Preliminary clinical observation of double C-arm digital subtraction angiography guidance during transjugular intrahepatic portosystemic shunt placement

BACKGROUND

This study aimed to investigate the safety, preliminary clinical experience, and technical advantages of double C-arm digital subtraction angiography -assisted portal vein puncture for transjugular intrahepatic portosystemic shunt.

METHODS

Clinical data of 25 patients with portal hypertension caused by liver cirrhosis were retrospectively analyzed from January 2021 to June 2022. The fluoroscopy time, puncture time, mean portosystemic pressure gradient, dose area product, and intraoperative and postoperative complications were recorded.

RESULTS

Transjugular intrahepatic portosystemic shunt was performed in all 25 patients, with a success rate of 100%. The fluoroscopy time, puncture time, and dose area product were 33.6 ± 8.5 min, 9.1 ± 5.7 min, and 126 ± 53 Gy·cm², respectively. The mean portosystemic pressure gradient decreased from 22.5 ± 6.3 mmHg to 10.5 ± 2.3 mmHg (p < 0.01). No serious intraoperative and postoperative complications were found.

CONCLUSION

Double C-arm digital subtraction angiography-assisted portal vein puncture is safe and feasible in transjugular intrahepatic portosystemic shunt operation. It can reduce the difficulty of the operation and possesses evident technical advantages.

Single Puncture TIPS—A 3D Fusion Image-Guided Transjugular Intrahepatic Portosystemic Shunt (TIPS): An Experimental Study

Background: The use of a transjugular intrahepatic portosystemic shunt (TIPS) has been established as an effective treatment for portal hypertension. Despite the rapid development of this use, serious peri-procedural complications have been reported in over 10% of cases. This has largely been attributed to the access to the portal vein, also referred to as a “blind puncture”, which often requires multiple attempts. The aim of this study was to demonstrate the safety, reproducibility and accuracy of the use of real-time 3D fusion image-guided (3DFIG) single puncture TIPS to minimize the complications that are related to the “blind puncture” of TIPS procedures. Methods: A 3DFIG TIPS approach was utilized on 22 pigs by combining pre-procedural cross-sectional imaging (CT, MR or CBCT) with intra-procedural cone beam CT or angiogram imaging, which allowed for the improved 3D visual spatial orientation of the portal vein and real-time tracking of the needle in 3D. Results: Thirty-five portosystemic shunts were successfully deployed in all 22 subjects without any peri-procedural complications. Overall, 91% (32/35) of the procedures were carried out using a single puncture. In addition, the mean fluoroscopy time in our study was more than 12 times lower than the proposed reference level that has previously been proposed for TIPS procedures. Conclusion: Multi-modality real-time 3DFIG TIPS can be performed safely using a single puncture, without complications, and can potentially be used in both emergency and non-emergency clinical situations.

Advanced portal venous access techniques for transjugular intrahepatic portosystemic shunt placement

Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a well-established but technically challenging procedure for the management of sequelae of end-stage liver disease. Performed essentially blindly, traditional fluoroscopically guided TIPS placement requires multiple needle passes and prolonged radiation exposure to achieve successful portal venous access, thus increasing procedure time and the risk of periprocedural complications. Several advanced image-guided portal access techniques, including intracardiac echocardiography (ICE)-guided access, cone-beam CT (CBCT)-guided access and wire-targeting access techniques, can serve as alternatives to traditional CO₂ portography-based TIPS creation.

Methods

A literature search was performed on the electronic databases including MEDLINE and Embase, from 2000 to the present to identify all relevant studies. The reference list also included studies identified manually, and studies referenced for other purposes.

Findings

The main benefit of these advanced access techniques is that they allow the operator to avoid essentially blind portal punctures, and the ability to visualise the target, thus reducing the number of required needle passes. Research has shown that ICE-guided access can decrease the radiation exposure, procedure time and complication rate in patients undergoing TIPS placement. This technique is particularly useful in patients with challenging portal venous anatomy. However, ICE-guided access requires additional equipment and possibly a second operator. Other studies have shown that CBCT-guided access, when compared with traditional fluoroscopy-guided access, provides superior visualisation of the anatomy with similar amount of radiation exposure and procedure time. The wire-targeting technique, on the other hand, appears to offer reductions in procedure time and radiation exposure by enabling real-time guidance. However, this technique necessitates percutaneous injury to the liver parenchyma in order to place the target wire.

Conclusion

Advanced portal access techniques have certain advantages over the traditional fluoroscopically guided TIPS access. To date, few studies have compared these advanced guided access options, and further research is required.

Use of Virtual Target Fluoroscopic Display of Three-Dimensional CO2 Wedged Hepatic Vein Portography for TIPS Placement

PURPOSE

To describe and evaluate an image fusion technique for the portal vein puncture guidance during TIPS procedure: a three-dimensional (3D) virtual target fluoroscopic display obtained with an automated 3D carbon dioxide wedged hepatic vein portography (3D CO₂-WHVP).

MATERIALS AND METHODS

All the 37 TIPS creations performed in our institution between 3/2017 and 12/2018 were retrospectively reviewed. Seventeen procedures were guided using the 3D CO₂-WHVP technique (group 1) and were compared with the other 20 procedures performed under conventional 2D fluoroscopic guidance (group 2). Image acquisition for the 3D CO₂-WHVP consisted of combining a CBCT acquisition and an automatic CO₂ injection. Once located on the multiplanar reformatted images of the CBCT acquisition, the portal bifurcation was manually segmented to create a virtual target that was overlaid onto live fluoroscopy allowing a real-time 3D guidance during portal vein puncture.

RESULTS

Primary success was 100% in group1 and 95% in group2. Median intervention length, fluoroscopy time and dose area product (DAP) were, respectively, 124 min [IQR 94-137], 40 min [IQR 26-52] and 12140 cGy.cm² [IQR 10147-18495] in group 1 and 146 min [IQR 118-199], 40 min [IQR 36-60] and 13290 cGy.cm² [IQR 10138-19538] in group 2. No technical parameter was significantly different between the two groups. Intraprocedural complication rate was 0% in group 1 and 20% in group 2 (p = 0.05).

CONCLUSION

Three-dimensional virtual target fluoroscopic display using a CBCT-acquired CO₂ wedged portography is an effective and safe technique to ease intrahepatic puncture of the portal vein during TIPS procedures.

Feasibility of Augmented Reality-Guided Transjugular Intrahepatic Portosystemic Shunt

PURPOSE

To investigate an augmented reality (AR)-guided endovascular puncture to facilitate successful transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

An AR navigation system for TIPS was designed. Three-dimensional (3D) liver models including portal and hepatic vein anatomy were extracted from preoperative CT images. The 3D models, intraoperative subjects, and electromagnetic tracking information of the puncture needles were integrated through the system calibration. In the AR head-mounted display, the 3D models were overlaid on the subjects, which was a liver phantom in the first phase and live beagle dogs in the second phase. One life-size liver phantom and 9 beagle dogs were used in the experiments. Imaging after puncture was performed to validate whether the needle tip accessed the target hepatic vein successfully.

RESULTS

Endovascular punctures of the portal vein of the liver phantom were repeated 30 times under the guidance of the AR system, and the puncture needle successfully accessed the target vein during each attempt. In the experiments of live canine subjects, the punctures were successful in 2 attempts in 7 beagle dogs and in 1 attempt in the remaining 2 dogs. The puncture time of needle from hepatic vein to portal vein was 5-10 s in the phantom experiments and 10-30 s in the canine experiments.

CONCLUSIONS

The feasibility of AR-based navigation facilitating accurate and successful portal vein access in preclinical models of TIPS was validated.

Transjugular intrahepatic portosystemic shunt placement: portal vein puncture guided by 3D/2D image registration of contrast-enhanced multi-detector computed tomography and fluoroscopy

Background

To assess the technical feasibility, success rate, puncture complications and procedural characteristics of transjugular intrahepatic portosystemic shunt (TIPS) placement using a three-dimensional vascular map (3D-VM) overlay based on image registration of pre-procedural contrast-enhanced (CE) multi-detector computed tomography (MDCT) for portal vein puncture guidance.

Materials and methods

Overall, 27 consecutive patients (59 ± 9 years, 18male) with portal hypertension undergoing elective TIPS procedure were included. TIPS was guided by CE-MDCT overlay after image registration based on fluoroscopic images. A 3D-VM of the hepatic veins and the portal vein was created based on the pre-procedural CE-MDCT and superimposed on fluoroscopy in real-time. Procedural characteristics as well as hepatic vein catheterization time (HVCT), puncture time (PT), overall procedural time (OPT), fluoroscopy time (FT) and the dose area product (DAP) were evaluated. Thereafter, HVCT, PT, OPT and FT using 3D-VM (61 ± 9 years, 14male) were compared to a previous using classical fluoroscopic guidance (53 ± 9 years, 21male) for two interventional radiologist with less than 3 years of experience in TIPS placement.

Results

All TIPS procedure using of 3D/2D image registered 3D-VM were successful with a significant reduction of the PSG (p < 0.0001). No clinical significant complication occurred. HVCT was 14 ± 11 min, PT was 14 ± 6 min, OPT was 64 ± 29 min, FT was 21 ± 12 min and DAP was 107.48 ± 93.84 Gy cm². HVCT, OPT and FT of the interventionalist with less TIPS experience using 3D/2D image registered 3D-VM were statistically different to an interventionalist with similar experience using fluoroscopic guidance (p_HVCT = 0.0022; p_OPT = 0.0097; p_FT = 0.0009). PT between these interventionalists was not significantly different (p_PT = 0.2905).

Conclusion

TIPS placement applying registration-based CE-MDCT vessel information for puncture guidance is feasible and safe. It has the potential to improve hepatic vein catherization, portal vein puncture and radiation exposure.

Clinical Experience with Real-Time 3-D Guidance Based on C-Arm-Acquired Cone-Beam CT (CBCT) in Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS) Placement

PURPOSE

The aim of this study was to evaluate the feasibility of cone-beam computed tomography (CBCT)-based real-time 3-D guidance of TIPSS placement and its positioning compared to standard guiding methods.

MATERIALS AND METHODS

In a prospective, randomized, consecutive study design from 2015 to 2017, we included 21 patients in the CBCT guided group and 15 patients in the ultrasound (US) guided group. The prospective groups were compared in terms of success rate of intervention, portal vein puncture/procedure time, number of puncture attempts and applied dose. We furthermore retrospectively analyzed the last 23 consecutive cases with fluoroscopic guided portal vein puncture in terms of success rate, procedure time and applied dose, as it has been the standard method before US guidance.

RESULTS

The median number of puncture attempts (CBCT: n = 2, US: n = 4, p = 0.249) and the mean puncture time (CBCT: 32 ± 45 min, US: 36 ± 45 min, p = 0.515) were not significantly different. There were furthermore no significant differences in the mean time needed for the total TIPSS procedure (CBCT: 115 ± 52 min, US: 112 ± 41 min, fluoroscopy: 110 ± 33 min, p = 0.996). The mean applied dose of the complete procedure also showed no statistically significant differences (CBCT: 563 ± 289 Gy·cm², US: 322 ± 186 Gy·cm², fluoroscopy: 469 ± 352 Gy·cm², p = 0.069). There were no image guidance related complications.

CONCLUSION

Real-time 3-D needle guidance based on CBCT is feasible for TIPSS placement. In terms of puncture attempts, duration and dose, CBCT guidance was not inferior to the control groups and may be a valuable support for interventionists in TIPSS procedures.

Persistence of gastric or esophageal varices on final angiography increases transjugular intrahepatic portosystemic shunt revision rate after polytetrafluoroethylene-covered stent shunt creation

Background

To assess the association between final polytetrafluoroethylene (PTFE)-covered stent transjugular intrahepatic portosystemic shunt (TIPS) angiographic parameters and free shunt revision survey.

Methods

Series of two comparison groups were generated with persistence of varices or not, the 25^th, 50^th, and 75^th percentile as cutoff for each angle and a 15-mm distance as cutoff for distance D. Kaplan Meier free shunt revision curves were then created and compared with Log Rank test.

Results

Mean follow-up was 455 days. Thirteen (19.4%) patients had shunt revision. Significant free shunt revision survey difference was found between post-procedural angiographic persistent varices group and the group without varices (P=0.0001). Shunt revision rate at 3, 12 and 24 months was respectively 13%, 29%, and 39% in the group with varices versus 0%, 2.7% and 2.7% in the group without. No difference was found between groups for angles A, B, C and distance D.

Conclusions

Persistence of gastric or esophageal varices on final trans-TIPS angiography increases TIPS revision rate after PTFE-covered stent shunt creation whereas geometric parameters have no influence.

Hemorrhage risk with transjugular intrahepatic portosystemic shunt (TIPS) insertion at the main portal vein bifurcation with stent grafts

PURPOSE

The purpose of this study was to assess the incidence of major hemorrhage after transjugular intrahepatic portosystemic shunt (TIPS) insertion using a stent graft at the main portal vein bifurcation.

PATIENTS AND METHODS

TIPS insertion using stent grafts was performed in 215 patients due to non-variceal hemorrhage indications. There were 137 men and 78 women, with a mean age of 57 years±10.6 (SD) (range: 19-90 years). Based on retrospective review of portal venograms, TIPS inserted within 5mm from the portal vein bifurcation were considered "bifurcation TIPS", while those inserted 2cm or greater from the bifurcation were considered intrahepatic. Suspicion for acute major periprocedural hemorrhage were categorized as low, moderate, and high, based on the number of signs of hemorrhage.

RESULTS

Of 215 TIPS inserted for purposes other than hemorrhage, the TIPS was inserted at the portal bifurcation in 41 patients (29 men, 12 women; mean age, 55.9±11.7 (SD); range: 26-79 years) and intrahepatic in 62 patients (37 men, 25 women; mean age, 57.6±10.6 (SD), range: 34-82 years), whereas 112 were indeterminate in location. No active extravasations were identified on post-TIPS portal venograms. Suspicion for acute major hemorrhage was moderate or high in 3/41 (7%) of patients in the TIPS bifurcation group compared to 5/62 (8%) in the intrahepatic TIPS group (P>0.99). There were no significant differences in 30-day mortality rates (1/41 [2%] and 3/62 [5%] respectively; P> 0.99). No deaths or interventions were attributed to acute hemorrhage.

CONCLUSION

TIPS insertion at the portal bifurcation with stent grafts did not incur an elevated risk of hemorrhagic complications.