Ultrasonographic guidance for portal vein access during transjugular intrahepatic portosystemic shunt (TIPS) placement

Safety and Feasibility of Gun-Sight Technique for Transjugular Intra-hepatic Portosystemic Shunt (TIPS) Creation

PURPOSE

To review technical details, indications for use, success rates and complications of gun-sight technique for transjugular intra-hepatic portosystemic shunt (TIPS) creation.

MATERIALS AND METHODS

A multicenter retrospective review was performed. Forty-two TIPS procedures with gun-sight technique were identified between 2016 and 2021. Eighty-six percent of patients had portal vein thrombosis (PVT), and 21% had undergone prior failed TIPS creation. Demographics, procedure details and outcomes were reviewed. Differences between the groups, event rates and patency rates were evaluated using nonparametric two-sample Wilcoxon rank-sum (Mann-Whitney) test, Fisher's exact test, Kaplan-Meier curves, and log-rank test.

RESULTS

Technical success was 98%. Sixty-seven percent of subjects had transsplenic and 26% had transhepatic access for TIPS creation. Twenty-one adverse events were noted (48%), four of which were definitely related and four were probably related to the use of gun-sight technique. Early (within 90 days) thrombosis occurred in 7/41 patients (17%), all of whom had existing PVT.

CONCLUSION

Gun-sight technique for TIPS creation has a high success rate in this challenging cohort of patients. While complications can occur, most of the adverse events noted were likely associated with TIPS creation itself rather than gun-sight. Early thrombosis only occurred in patients with PVT. Level of Evidence Level 4, Case Series.

Austrian consensus on the diagnosis and management of portal hypertension in advanced chronic liver disease (Billroth IV)

The Billroth IV consensus was developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on the 26th of November 2022 in Vienna.Based on international recommendations and considering recent landmark studies, the Billroth IV consensus provides guidance regarding the diagnosis and management of portal hypertension in advanced chronic liver disease.

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.

Transjugular intrahepatic portosystemic shunt with transhepatic portal vein puncture guided by ultrasound: a technical alternative

OBJECTIVE

Evaluation of an alternative technique to perform transjugular intrahepatic portosystemic shunt (TIPS), using abdominal ultrasound to guide portal puncture.

METHODS

Retrospective analysis of TIPS performed from January 2014 to December 2018 in an interventional radiology service. TIPS were performed according to the classic technique, except at the moment of portal branch puncture, when abdominal ultrasound was used to guide it, visualized its path within the parenchyma in real-time. Qualitative and quantitative variables were analyzed considering a 95% confidence interval and application of the Student's t-test with a significance level of P < 0.05.

RESULTS

Forty-one TIPS were performed. The technical success rate of ultrasound guidance in portal puncture was 100.0%. After its performance, a reduction in the portosystemic pressure gradient was observed, with an initial gradient average of 18.8 mmHg (12-25 ± 3.6 mmHg) and a final gradient of 9.2 mmHg (5-14 ± 2.4 mmHg). The mean values for the TIPS execution time, fluoroscopy time and the radiation dose, verified through the dose area product, were 65.2 ± 46.7 min, 25 ± 14.1 min and 85.6 ± 70 Gy cm2, respectively. There were no complications related to the inadvertent puncture of nontarget structures or deaths due to complications resulting from TIPS.

CONCLUSION

The results demonstrate that the portal transhepatic puncture guided by the abdominal ultrasound is an effective and safe procedure and results in time of execution, time of fluoroscopy and radiation dose below the current reference values of the conventional procedure.

Ultrasound-Guided Portal Vein Access and Percutaneous Wire Placement in the Portal Vein Are Associated With Shorter Procedure Times and Lower Radiation Doses During TIPS Placement

BACKGROUND. TIPS placement is an effective method for treating a number of complications of portal hypertension. Although this complex procedure has been firmly established in treatment algorithms, more data are needed to determine the most efficient and safest ways to perform the procedure. OBJECTIVE. The purpose of this study was to determine the effect of three different techniques of portal vein (PV) cannulation during TIPS placement on procedure efficiency. METHODS. The medical records of patients who underwent TIPS creation between 2005 and 2019 were reviewed. On the basis of the PV access technique used, patients were grouped as follows: group 1 (G1) included patients who underwent a transabdominal ultrasound (US)-guided technique to obtain PV access, group 2 (G2) consisted of those who underwent fluoroscopically guided wedged hepatic portography, and group 3 (G3) included those who underwent percutaneous US-guided PV guidewire placement for fluoroscopic targeting. RESULTS. Of the 264 patients who underwent TIPS creation, 54 (20.5%) were in G1, 172 (65.1%) were in G2, and 38 (14.4%) were in G3. The mean (± SD) fluoroscopic time in G1 (34.8 ± 16.6 minutes) did not differ from that in either G2 (38.9 ± 20.8 minutes; p = .09) or G3 (29.5 ± 14.6 minutes; p = .06). However, G2 patients had significantly longer fluoroscopic times than G3 patients (p = .005). The mean total anesthesia time in G1 (190.2 ± 45.6 minutes) did not differ from that in G2 (199.7 ± 59.5 minutes; p = .15). However, G3 had a mean anesthesia time (162.6 ± 39.7 minutes) that was significantly shorter than that in both G1 (p = .003) and G2 (p < .001). The mean contrast volume was significantly lower in G1 than in G2 (67.9 ± 36.8 mL vs 87.1 ± 42.9 mL; p = .005). More intrahepatic needle passes were required in G2 (median, 4 passes; interquartile range [IQR], 1-7 passes) than in G1 (median, 2 passes; IQR, 1-4 passes; p = .004) and G3 (median, 2 passes; IQR, 1-7.25 passes; p = .04). When complications in G1 and G3 were pooled, this cohort had significantly fewer complications than G2 (p = .01). CONCLUSION. Ultrasound-guided PV access and percutaneous PV guidewire placement for fluoroscopic targeting during TIPS creation are associated with shorter procedure and fluoroscopic times and potentially decreased complications. CLINICAL IMPACT. The present study helps interventional radiologists understand the safest and most efficient way to access the PV, which is a key step during TIPS placement.

Efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) created using covered stents of different diameters: A systematic review and meta-analysis

PURPOSE

The purpose of this study was to make a systematic review and meta-analysis to determine the stent diameter (8mm vs. 10mm) that conveys better safety and clinical efficacy for transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

Four databases were used to identify clinical trials published from inception until March 2020. Data were extracted to estimate and compare one-year and three-year overall survivals, hepatic encephalopathy, variceal rebleeding, and shunt dysfunction rates between patients with 8mm covered stents and those with 10mm covered stents.

RESULTS

Five eligible studies were selected, which included 489 patients (316 men, 173 women). The 8mm covered stent group had higher efficacy regarding one-year or three-year overall survival (odds ratio [OR], 2.88; P=0.003) and (OR, 1.81; P=0.04) and lower hepatic encephalopathy (OR, 0.69; P=0.04) compared with 10mm covered stent group. There were no significant differences in variceal rebleeding rate (OR 0.80; P=0.67). However, shunt dysfunction was lower in 10mm covered stent group (OR, 2.26; P=0.003).

CONCLUSIONS

Our results suggest that the use of 8mm covered stents should be preferred to that of 10mm covered stents for TIPS placement when portal pressure is frequently monitored.