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Yu Q, Ahmed O, Gutti S, Iyer D, Kwak D, Ahmed SS, Said A, Angle JF, Navuluri R, Lorenz JM, Patel M. Meta-analysis of transjugular intrahepatic portosystemic shunt creation with or without intravascular ultrasound guidance. Br J Radiol 2024; 97:1112-1117. [PMID: 38588565 PMCID: PMC11135803 DOI: 10.1093/bjr/tqae074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 05/26/2023] [Accepted: 04/04/2024] [Indexed: 04/10/2024] Open
Abstract
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.
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Affiliation(s)
- Qian Yu
- Vascular and Interventional Radiology, Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, IL 60637, United States
| | - Osman Ahmed
- Vascular and Interventional Radiology, Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, IL 60637, United States
| | - Subhash Gutti
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, 20007, United States
| | - Deepak Iyer
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, 20007, United States
| | - Daniel Kwak
- Vascular and Interventional Radiology, Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, IL 60637, United States
| | - Syed Samaduddin Ahmed
- College of Osteopathic Medicine, Midwestern University Chicago, Chicago, IL, 60515, United States
| | - Adam Said
- University of Illinois at Urbana-Champaign, Champaign, IL, 61820, United States
| | - J Fritz Angle
- Vascular and Interventional Radiology, University of Virginia Health System, Charlottesville, VA, United States
| | - Rakesh Navuluri
- Vascular and Interventional Radiology, Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, IL 60637, United States
| | - Jonathan M Lorenz
- Vascular and Interventional Radiology, Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, IL 60637, United States
| | - Mikin Patel
- Vascular and Interventional Radiology, Department of Radiology, University of Chicago Medical Center, University of Chicago, Chicago, IL 60637, United States
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Meram E, Russell E, Ozkan O, Kleedehn M. Variceal and Nonvariceal Upper Gastrointestinal Bleeding Refractory to Endoscopic Management: Indications and Role of Interventional Radiology. Gastrointest Endosc Clin N Am 2024; 34:275-299. [PMID: 38395484 DOI: 10.1016/j.giec.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
For over 60 years, diagnostic and interventional radiology have been heavily involved in the evaluation and treatment of patients presenting with gastrointestinal bleeding. For patients who present with upper GI bleeding and have a contraindication to endoscopy or have an unsuccessful attempt at endoscopy for identifying or controlling the bleeding, interventional radiology is often consulted for evaluation and consideration of catheter-based intervention.
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Affiliation(s)
- Ece Meram
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA
| | - Elliott Russell
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA
| | - Orhan Ozkan
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA
| | - Mark Kleedehn
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA.
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Shi H, Zhuang Z, Zhang S, Li W, Zhang W, Zhang Z, Yang M, Yu J, Zhou X, Chen S, Wang J, Luo J, Ma J, Yan Z. CBCT-based three-dimensional dual-phase vascular image fusion: a novel technique for interventional real-time TIPS guidance. RADIOLOGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00117-024-01265-5. [PMID: 38381153 DOI: 10.1007/s00117-024-01265-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 01/03/2024] [Indexed: 02/22/2024]
Abstract
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.
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Affiliation(s)
- Huibin Shi
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
| | - Zhiquan Zhuang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
| | - Suming Zhang
- Shanghai Siemens Medical Co., LTD, Shanghai, China
| | - Wenyi Li
- Shanghai Siemens Medical Co., LTD, Shanghai, China
| | - Wen Zhang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
| | - Zihan Zhang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
| | - Minjie Yang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
| | - Jiaze Yu
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
| | - Xin Zhou
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
| | - Shiyao Chen
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian Wang
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianjun Luo
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China.
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China.
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.
| | - Jingqin Ma
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China.
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China.
| | - Zhiping Yan
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
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Gupta VF, Agassi A, Martin JG, Cline BC, Kim CY, Ronald J. Intravascular Ultrasound Guidance for Transjugular Intrahepatic Portosystemic Shunt Creation Reduces Laboratory Markers of Acute Liver Injury. J Vasc Interv Radiol 2023; 34:1680-1689.e2. [PMID: 37400054 DOI: 10.1016/j.jvir.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/13/2023] [Accepted: 06/23/2023] [Indexed: 07/05/2023] Open
Abstract
PURPOSE To compare the laboratory markers of acute liver injury after transjugular intrahepatic portosystemic shunt (TIPS) creation performed using intravascular ultrasound (IVUS) guidance with those using other techniques. MATERIALS AND METHODS This single-center, retrospective study examined 293 TIPS procedures performed between 2014 and 2022 (160 men; mean age, 57.4 years; 71.7% with ascites, 158 with IVUS). Laboratory changes on postprocedural day (PPD) 1 were classified based on Common Terminology Criteria for Adverse Events (CTCAE) grades and were compared between IVUS and non-IVUS cases. RESULTS IVUS cases had a lower baseline Model for End-Stage Liver Disease (MELD) score (12.5 vs 13.7, P = .016), higher pre- (16.8 vs 15.2, P = .009), and post-TIPS (6.6 vs 5.4 mm Hg, P < .001) pressure gradient, smaller stent diameter (9.2 vs 9.9 mm, P < .001), and fewer needle passes (2.4 vs 4.2, P < .001). IVUS predicted a lower PPD 1 CTCAE grade for aspartate transaminase (8.0% vs 22.2% grade ≥ 2, P = .010), alanine transaminase (ALT) (2.2% vs 7.1%, P = .017), and bilirubin (9.4% vs 26.2%, P < .001), findings confirmed using multivariable regression and propensity score analysis. IVUS predicted fewer adverse events (1.3% vs 8.1%, P = .008) and an increased likelihood of PPD 1 discharge (81% vs 59%, P = .004). IVUS was not associated with differences in PPD 30 MELD scores or 30-day survival; however, higher PPD 1 ALT (β = 1.96, P = .008) and bilirubin levels (β = 1.38, P = .004) predicted larger PPD 30 MELD score increase. Higher increases in ALT level predicted worse 30-day survival (hazard ratio, 1.93; P = .021). CONCLUSION IVUS resulted in less laboratory evidence of acute liver injury immediately following TIPS creation.
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Affiliation(s)
- Vikram F Gupta
- Duke University School of Medicine; Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Andre Agassi
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Jonathan G Martin
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Brendan C Cline
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Charles Y Kim
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - James Ronald
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina.
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5
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Herren JL, Shah KY, Patel M, Niemeyer MM. Intravascular Ultrasound for Transjugular Intrahepatic Portosystemic Shunt Creation: "TIPS" and Tricks. Semin Intervent Radiol 2023; 40:212-220. [PMID: 37333747 PMCID: PMC10275661 DOI: 10.1055/s-0043-1768609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Affiliation(s)
- Josi L Herren
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Ketan Y Shah
- Department of Radiology, MD Anderson Cancer Center, Houston, Texas
| | - Meet Patel
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Matthew M Niemeyer
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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6
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Sinha I, Goldman DT, Patel RS, Nowakowski FS. Advanced Techniques for Accessing the Portal Vein during Transjugular Intrahepatic Portosystemic Shunt Creation. Semin Intervent Radiol 2023; 40:79-86. [PMID: 37152804 PMCID: PMC10159696 DOI: 10.1055/s-0043-1767688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Transjugular portosystemic shunt (TIPS) placement is a widely accepted method for reducing portal pressures in conditions including symptomatic varices, refractory ascites, hepatic hydrothorax, portomesenteric thrombosis, and Budd-Chiari syndrome. The traditional method for performing TIPS involves "blind" access into a portal vein branch from a hepatic vein, typically right portal vein to right hepatic vein, using preoperative imaging and intraoperative wedged portography for guidance. However, standard access technique may not always be feasible due to occluded portal or hepatic veins, distorted anatomy, or prior TIPS. In this article we discuss alternative techniques for accessing the portal vein for TIPS placement when standard methods are not sufficient.
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Affiliation(s)
- Ishan Sinha
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Daryl T. Goldman
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rahul S. Patel
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Francis S. Nowakowski
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
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7
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Zhuang Z, Ma J, Ju S, Gu G, Zhang W, Yang M, Zhang Z, Ma L, Yan Z, Luo J. A new alternative technique for the guidance of transjugular intrahepatic portosystemic shunt creation using DSA overlay reference. Acta Radiol 2023; 64:868-873. [PMID: 35313745 DOI: 10.1177/02841851221086963] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Portal vein puncture (PVP) is a critical step during transjugular intrahepatic portosystemic shunt (TIPS) and correlates to several complications. Techniques guiding PVP are needed. PURPOSE To evaluate the safety, feasibility, and efficiency of digital subtraction angiography (DSA) overlay reference during TIPS creation and compare it with transhepatic portal vein (THPV) guiding. MATERIAL AND METHODS The clinical records of 185 patients at three medical centers who underwent TIPS placement were reviewed. Portal vein access was guided by THPV guiding in 120 cases and DSA overlay reference in 60 cases. The number of punctures, portal vein entry time, procedural adverse events, technical and hemodynamic success rate were analyzed to compare the safety, feasibility, and efficiency of the two methods. RESULTS The median numbers of punctures in group 1 and group 2 were 2 (1-4) and 2 (1-5), respectively (P = 0.094). There was no statistical difference between two groups in needle passes. The median portal vein entry time of group 1 was 12 min (8-16 min) and 13 min (8-16 min) in group 2. No significant difference was found in the PVP time (P = 0.802). Arterioportal fistula formation occurred in 15 patients in group 1; two patients in group 2 had hepatic artery injury. The patients in group 2 had lower rates of procedural adverse events (P = 0.047). Median dose area product of G1 was lower than G2 statistically (P<0.001). There was no significant difference in total fluoroscopy time (P = 0.856). CONCLUSION DSA overlay reference has lower procedural adverse events rates compared with THPV guiding TIPS. It seems to be a safe and effective method for guiding PVP.
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Affiliation(s)
- Zhiquan Zhuang
- Shanghai Institute of Medical Imaging, Shanghai, PR China.,Department of Interventional Radiology, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China.,National Clinical Research Centre for Interventional Medicine, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China
| | - Jingqin Ma
- Shanghai Institute of Medical Imaging, Shanghai, PR China.,Department of Interventional Radiology, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China.,National Clinical Research Centre for Interventional Medicine, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China
| | - Shuai Ju
- Department of Interventional Radiology, Jinshan Hospital, 12478Fudan University, Shanghai, PR China
| | - Guoqiang Gu
- Department of Radiology, Minhang Hospital, 12478Fudan University, Shanghai, PR China
| | - Wen Zhang
- Shanghai Institute of Medical Imaging, Shanghai, PR China.,Department of Interventional Radiology, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China.,National Clinical Research Centre for Interventional Medicine, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China
| | - Minjie Yang
- Shanghai Institute of Medical Imaging, Shanghai, PR China.,Department of Interventional Radiology, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China.,National Clinical Research Centre for Interventional Medicine, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China
| | - Zihan Zhang
- Shanghai Institute of Medical Imaging, Shanghai, PR China.,Department of Interventional Radiology, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China.,National Clinical Research Centre for Interventional Medicine, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China
| | - Li Ma
- Shanghai Institute of Medical Imaging, Shanghai, PR China.,Department of Interventional Radiology, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China.,National Clinical Research Centre for Interventional Medicine, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China
| | - Zhiping Yan
- Shanghai Institute of Medical Imaging, Shanghai, PR China.,Department of Interventional Radiology, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China.,National Clinical Research Centre for Interventional Medicine, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China.,Centre for Tumour Diagnosis and Therapy, Jinshan Hospital, 12478Fudan University, Shanghai, PR China
| | - Jianjun Luo
- Shanghai Institute of Medical Imaging, Shanghai, PR China.,Department of Interventional Radiology, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China.,National Clinical Research Centre for Interventional Medicine, Zhongshan Hospital, 12478Fudan University, Shanghai, PR China.,Centre for Tumour Diagnosis and Therapy, Jinshan Hospital, 12478Fudan University, Shanghai, PR China
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8
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Wong YJ, Ho WLD, Abraldes JG. Pre-emptive TIPSS in Acute Variceal Bleeding: Current Status, Controversies, and Future Directions. J Clin Transl Hepatol 2022; 10:1223-1228. [PMID: 36381087 PMCID: PMC9634770 DOI: 10.14218/jcth.2022.00240] [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: 05/18/2022] [Revised: 06/28/2022] [Accepted: 07/11/2022] [Indexed: 12/04/2022] Open
Abstract
Acute variceal bleeding (AVB) is associated with significant short-term morbidity and mortality. Pre-emptive transjugular intrahepatic portosystemic shunt (p-TIPSS) is recommended to prevent rebleeding in AVB patients with a high risk of rebleeding. Despite the benefit of preventing rebleeding and de-novo ascites, the uptake of p-TIPSS remains low because logistic challenges in the real-world setting. In this review, we summarize the current evidence and controversies on p-TIPSS including patient selection for p-TIPSS, particularly in the setting of NASH cirrhosis and acute-on-chronic liver failure, the role of sarcopenia, renal impairment in the setting of p-TIPSS. Finally, we summarize both pharmacological and nonpharmacological strategies to optimize outcomes in patients undergoing p-TIPSS.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Correspondence to: Wong Yu Jun, Department of Gastroenterology & Hepatology, Changi General Hospital, 2, Simei Street 3; Duke-NUS Medical School, 8 College Road, 169857, Singapore. ORCID: https://orcid.org/0000-0002-0727-1183. Tel/Fax: +65-67888833, E-mail:
| | - Wei Ling Danielle Ho
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Juan G. Abraldes
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
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Abstract
The most challenging and time-consuming step of TIPS procedures is obtaining appropriate portal vein (PV) access. Given the lack of real-time direct target visualization, conventional fluoroscopic guidance requires multiple passes, contributing to complications. In comparison, intravascular ultrasound (IVUS) guidance during TIPS procedures provides direct visualization of hepatic structures and real-time guidance for PV puncture. IVUS guidance during TIPS creation improves procedural metrics such as radiation dose, contrast agent volume, procedure time, and technical success rate and is particularly beneficial in technically challenging cases (e.g., in patients portal vein thrombosis, small or variant portal vein anatomy, Budd-Chiari syndrome, or liver masses). The purpose of this review is to summarize current IVUS technology, describe the technical aspects of IVUS-guided TIPS creation, and discuss the clinical indications for and benefits of using IVUS for TIPS creation, while presenting available evidence supporting the technique's use. Given the improved safety profile and overall success rate in comparison with conventional guidance methods, IVUS guidance has the future potential to become the standard practice for TIPS placement.
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10
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Morosetti D, Lenci I, Argirò R, Milana M, Gasparrini F, Crociati S, Tisone G, Floris R, Baiocchi L. Use of Intravascular Ultrasound to Improve Diagnosis and Treatment of Transjugular Intrahepatic Portosystemic Shunt Dysfunction in Patients in the Long-term Follow-up. Euroasian J Hepatogastroenterol 2022; 12:50-56. [PMID: 35990871 PMCID: PMC9357521 DOI: 10.5005/jp-journals-10018-1374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim To evaluate the efficacy of intravascular ultrasound (IVUS) in transjugular intrahepatic portosystemic shunt (TIPS) revision associated with phlebography and invasive pressure measurement in patients with clinical or radiological signs of TIPS malfunction. Background Four patients underwent TIPS revision between February and August 2021. Right internal jugular vein access was achieved under ultrasonographic guidance, a catheter was advanced to achieve the Inferior Vena Cava (IVC) and afterward the Portal vein through the TIPS. Once the Portal vein was achieved, a phlebography was performed, followed by invasive pressure measurement and IVUS exam over the guidewire. Based on the combination of phlebography, invasive pressure measurement, and IVUS evaluations, TIPS dysfunction was treated either with angioplasty or stent apposition. Case description In all patients, we obtained the reduction of porto-systemic gradient. In three patients, angioplasty with a 10 mm diameter balloon catheter was performed. Anticoagulation therapy was added to one patient. In one patient, the Viatorr's proximal extremity in the suprahepatic vein wall was dislocated, so it was lengthened with a “Viabahn” covered stent. None of the patients developed hepatic encephalopathy after both TIPS placement and TIPS revision. No complications related to the procedure were observed during the follow-up. Clinical improvement in the immediate follow-up period was observed in all patients. In two patients, the abdominal ascites resolved. In another one, the abdominal pain disappeared, and a reduction of the longitudinal spleen diameter was recorded at 3 months follow-up. Conclusion The use of IVUS allowed us to correctly visualize the organic cause of TIPS malfunction and to obtain direct visualization of the results of endovascular treatment. How to cite this article Morosetti D, Lenci I, Argirò R, et al. Use of Intravascular Ultrasound to Improve Diagnosis and Treatment of Transjugular Intrahepatic Portosystemic Shunt Dysfunction in Patients in the Long-term Follow-up. Euroasian J Hepato-Gastroenterol 2022;12(1):50–56.
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Affiliation(s)
- Daniele Morosetti
- Department of Interventional Radiology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Ilaria Lenci
- Department of Experimental Medicine and Surgery, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Renato Argirò
- Department of Interventional Radiology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Martina Milana
- Department of Experimental Medicine and Surgery, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Fulvio Gasparrini
- Department of Interventional Radiology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Sara Crociati
- Department of Interventional Radiology Unit, University of Rome Tor Vergata, Rome, Latium, Italy
- Sara Crociati, Department of Interventional Radiology Unit, University of Rome Tor Vergata, Rome, Latium, Italy, Phone: +39 3331579930, e-mail:
| | - Giuseppe Tisone
- Department of Experimental Medicine and Surgery, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Roberto Floris
- Department of Interventional Radiology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Leonardo Baiocchi
- Department of Experimental Medicine and Surgery, Policlinico Universitario Tor Vergata, Rome, Italy
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11
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Partovi S, Li X, Shwaiki O, Rashwan B, Ruff C, Grozinger G, Gadani S, Szaflarski D, Thompson D, D'Amico G, Levitin A, Kapoor B. Advanced portal venous access techniques for transjugular intrahepatic portosystemic shunt placement. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000815. [PMID: 34952851 PMCID: PMC8710864 DOI: 10.1136/bmjgast-2021-000815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/16/2021] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Sasan Partovi
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Xin Li
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Omar Shwaiki
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Basem Rashwan
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Christer Ruff
- Section of Interventional Radiology, Department of Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Gerd Grozinger
- Section of Interventional Radiology, Department of Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Sameer Gadani
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Diane Szaflarski
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Dustin Thompson
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Guiseppe D'Amico
- Department of Transplant Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Abraham Levitin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Baljendra Kapoor
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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12
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Du H, Zhong B, Zhang P, Wang W, Shen J, Zhang S, Li W, Tang H, Zhou L, Yang W, Zhu X. Percutaneous transhepatic intrahepatic portosystemic shunt for variceal bleeding: A series of six cases and literature review. J Interv Med 2021; 4:49-52. [PMID: 34805948 PMCID: PMC8562267 DOI: 10.1016/j.jimed.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/01/2020] [Accepted: 10/10/2020] [Indexed: 12/03/2022] Open
Abstract
Objectives To present a case series of modified transjugular intrahepatic portosystemic shunts (TIPS) and percutaneous transhepatic intrahepatic portosystemic shunts (PTIPS) in cirrhotic patients with variceal bleeding (VB). In addition, the scientific literature pertaining to PTIPS was reviewed. Methods This retrospective clinical case series included six cirrhotic patients with VB who were treated with PTIPS after the failure of endoscopic band ligation or endoscopic injection sclerotherapy combined with vasoactive drugs. The treatment was conducted between January 2017 and June 2019 at a single institution. Three patients suffered from severe atrophy of the right or left lobar of the liver as well as the main right or left branch of the portal vein. The remaining three patients showed severe atrophy of the whole liver and portal vein, resulting in widening of the liver fissure. A paired t-test was used to compare the changes in portal pressure gradient between before and after the PTIPS operation. The rebleeding rate, treatment efficacy, complications, and technical success rate were all assessed during follow-up. Results All six PTIPS procedures were performed successfully, with no severe procedural-related complications observed. None of the patients experienced VB during a mean follow-up of 22.8 (range, 18.0–28.0) months. The mean portosystemic pressure gradient decreased from 28.3 ± 4.3 mmHg pre-procedure to 12.3 ± 2.6 mmHg immediately post-procedure (P < 0.001). At follow-up, one patient was found to have developed grade 2 hepatic encephalopathy thrice during the first year, according to the West Haven criteria. However, this was resolved following medical treatment. Conclusions When the patient’s portal venous anatomy is unconducive to the performance of TIPS using the transjugular approach, PTIPS can be considered as a safe, effective complementary surgical approach for patients with VB.
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Affiliation(s)
- Hang Du
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Binyan Zhong
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Peng Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wansheng Wang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jian Shen
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shuai Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wanci Li
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haohuan Tang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Linfeng Zhou
- Department of Interventional Radiology, Hubei Cancer Hospital, Hubei Cancer Research Institute, Affiliated Cancer Hospital of Tongji Medical College, Huazhong University of Science and Technology, HuBei, China
| | - Weihao Yang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoli Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
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13
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Cannataci C, Cimo' B, Mamone G, Tuzzolino F, D'Amico M, Cortis K, Maruzzelli L, Miraglia R. Portal vein puncture-related complications during transjugular intrahepatic portosystemic shunt creation: Colapinto needle set vs Rösch-Uchida needle set. Radiol Med 2021; 126:1487-1495. [PMID: 34405340 DOI: 10.1007/s11547-021-01404-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 07/27/2021] [Indexed: 02/07/2023]
Abstract
Transjugular portal vein puncture is considered the riskiest step in TIPS creation with possible incidence of portal vein puncture-related complications (PVPC). The Colapinto and the Rösch-Uchida needle sets are two different needle sets currently available. To date, there have been no randomized control trials or systematic reviews which compare the incidence of PVPC when using the two different needle sets. The aim of this literature review is to assess the rate of PVPC associated with the different needle sets used in the creation of TIPS. From the described search, 1500 articles were identified and 34 met the inclusion criteria. Outcome measured was the prevalence of PVPC using the different needle sets. Overall 212 (3.6%) PVPC were reported in 5865 patients; 142 (3.5%) reported in 4000 cases using the Rösch-Uchida set and 70 (3.7%) in 1865 patients using the Colapinto set (p = 0.69). PVPC in TIPS creation are not related to the choice of needle set used in the procedure. To our knowledge, this is the first review of its kind, the results of which support the theory that while the rate of PVPC is influenced by many factors, choice of needle set does not seem to be one of them.
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Affiliation(s)
| | - Biagio Cimo'
- Radiology Institute, Department of Medicine - DIMED, University of Padua, Padova, Italy
| | - Giuseppe Mamone
- Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), via Tricomi 5, 90127, Palermo, Italy.
| | - Fabio Tuzzolino
- Research Office, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Mario D'Amico
- Azienda Ospedaliera Ospedali Riuniti Villa Sofia- Cervello, Palermo, Italy
| | - Kelvin Cortis
- Medical Imaging Department, Mater Dei Hospital, Msida, Malta
| | - Luigi Maruzzelli
- Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), via Tricomi 5, 90127, Palermo, Italy
| | - Roberto Miraglia
- Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), via Tricomi 5, 90127, Palermo, Italy
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14
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Wang S, Abraldes JG. Nonalcoholic Fatty Liver Disease: A Special Consideration in Transjugular Intrahepatic Portosystemic Shunts? Liver Transpl 2021; 27:323-324. [PMID: 33345412 DOI: 10.1002/lt.25976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/17/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Sarah Wang
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, AB, Canada
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, AB, Canada
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15
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Urade T, Verde JM, García Vázquez A, Gunzert K, Pessaux P, Marescaux J, Giménez ME. Fluoroless intravascular ultrasound image-guided liver navigation in porcine models. BMC Gastroenterol 2021; 21:24. [PMID: 33422010 PMCID: PMC7797115 DOI: 10.1186/s12876-021-01600-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background An intravascular ultrasound catheter (IVUSc) was developed for intracardiac ultrasound to assess interventions with compelling results. However, intrahepatic vascular exploration was rarely tested and was always associated with X-ray techniques. The aim of this study was to demonstrate the feasibility to navigate through the whole liver using an IVUSc, providing high-quality images and making it unnecessary to use ionizing radiation.
Methods An ex vivo pig visceral block and an in vivo pig model were used in this study. The IVUS equipment was composed of an US system, and of an 8 French lateral firing IVUSc capable of producing 90-degree sector images in the longitudinal plane. After accessing the intravascular space with the IVUSc into the models, predetermined anatomical landmarks were visualized from the inferior vena cava and hepatic veins and corroborated. Results IVUS navigation was achieved in both models successfully. The entire navigation protocol took 87 and 48 min respectively, and 100% (21/21) and 96.15% (25/26) of the landmarks were correctly identified with the IVUSc alone in the ex vivo and in vivo models respectively. IVUS allowed to clearly visualize the vasculature beyond third-order branches of the hepatic and portal veins. Conclusions A complete IVUS liver navigation is feasible using the IVUSc alone, making it unnecessary to use ionizing radiation. This approach provides high-definition and real-time images of the complex liver structure and offers a great potential for future clinical applications during diagnostic and therapeutic interventions.
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Affiliation(s)
- Takeshi Urade
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France. .,IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France.
| | - Juan Manuel Verde
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.,IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - Alain García Vázquez
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.,IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | | | - Patrick Pessaux
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.,IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France.,Department of General, Digestive and Endocrine Surgery, Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France
| | - Jacques Marescaux
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.,IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - Mariano Eduardo Giménez
- Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.,IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
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16
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Yang J, Zhu J, Sze DY, Cui L, Li X, Bai Y, Ai D, Fan J, Song H, Duan F. Feasibility of Augmented Reality-Guided Transjugular Intrahepatic Portosystemic Shunt. J Vasc Interv Radiol 2020; 31:2098-2103. [PMID: 33261744 DOI: 10.1016/j.jvir.2020.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Jian Yang
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of Technology, Beijing, China
| | - Jianjun Zhu
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of Technology, Beijing, China
| | - Daniel Y Sze
- Division of Interventional Radiology, Stanford University School of Medicine, Palo Alto, California
| | - Li Cui
- Department of Interventional Radiology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing 100853, China
| | - Xiaohui Li
- Department of Interventional Radiology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing 100853, China
| | - Yanhua Bai
- Department of Interventional Radiology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing 100853, China
| | - Danni Ai
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of Technology, Beijing, China
| | - Jingfan Fan
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of Technology, Beijing, China
| | - Hong Song
- School of Computer Science and Technology, Beijing Institute of Technology, Beijing, China
| | - Feng Duan
- Department of Interventional Radiology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing 100853, China.
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17
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Madhusudhan KS, Sharma S. Ultrasonography in pediatric Budd-Chiari syndrome. Pediatr Radiol 2020; 50:1768-1780. [PMID: 32870359 DOI: 10.1007/s00247-020-04753-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/25/2020] [Accepted: 06/03/2020] [Indexed: 02/06/2023]
Abstract
Budd-Chiari syndrome is a vascular pathology of the liver, commonly seen in adults and uncommon in children. Most children with Budd-Chiari syndrome present with ascites, and an etiology is found in only about 50%. Ultrasonography (US) with color Doppler is the main modality used in the diagnosis. US imaging additionally guides radiologic interventions and follow-up after recanalization or shunt procedure. In this pictorial review, we illustrate the findings in pediatric Budd-Chiari syndrome as seen on B-mode and color Doppler US and describe the role of US in guiding percutaneous radiologic interventions, with a brief description of the role of US contrast agent and sonoelastography in this setting.
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Affiliation(s)
| | - Sanjay Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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18
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Grimsbo MC, Brown MA, Lindquist JD, Schramm KM, Kirkpatrick DL, Ryu RK, Trivedi PS. Intracardiac Echocardiography-Guided TIPS: A Primer for New Operators. Semin Intervent Radiol 2020; 37:405-413. [PMID: 33041487 DOI: 10.1055/s-0040-1715875] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Matthew C Grimsbo
- Long School of Medicine, University of Texas Health Science Center, San Antonio, Texas
| | - Matthew A Brown
- Division of Vascular and Interventional Radiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan D Lindquist
- Division of Vascular and Interventional Radiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Kristofer M Schramm
- Division of Vascular and Interventional Radiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel L Kirkpatrick
- Division of Vascular and Interventional Radiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Robert K Ryu
- Division of Vascular and Interventional Radiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Premal S Trivedi
- Division of Vascular and Interventional Radiology, University of Colorado School of Medicine, Aurora, Colorado
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19
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Kwak DH, Ramaswamy RS, Harrod M, Duncan JR. Analyzing Radiation Use during Transjugular Intrahepatic Portosystemic Shunt Creation. J Vasc Interv Radiol 2020; 31:2089-2097.e3. [PMID: 33023803 DOI: 10.1016/j.jvir.2020.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 04/26/2020] [Accepted: 05/04/2020] [Indexed: 10/23/2022] Open
Abstract
Portal vein access during transjugular intrahepatic portosystemic shunt creation was examined in 11 patients. Radiation metrics (kerma area product, reference point air kerma, and fluoroscopy times) during portal vein access were significantly greater for conventional versus intravascular US-guided transjugular intrahepatic portosystemic shunt (54.8 mGy ∙ cm2 ± 27.6 vs 8.4 mGy ∙ cm2 ± 5.0, P = .009; 210.4 mGy ± 109.1 vs 29.5 mGy ± 18.4, P = .009; 19.1 min ± 8.6 vs 8.9 min ± 4.6, P = .04). Wedged hepatic venography is a major contributor to radiation exposure. Intravascular US guidance is associated with significantly reduced radiation use.
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Affiliation(s)
- Daniel H Kwak
- Department of Clinical Sciences, University of Central Florida College of Medicine, Orlando, Florida
| | - Raja S Ramaswamy
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Boulevard, St. Louis, MO 63110
| | - Michael Harrod
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Boulevard, St. Louis, MO 63110
| | - James R Duncan
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Boulevard, St. Louis, MO 63110.
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20
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Farsad K, Narasimhan E, Russell L, Kaufman JA. Transjugular Intrahepatic Portosystemic Shunt Creation Using a Radiofrequency Wire: Prospective Clinical Safety and Feasibility Trial in Cirrhosis. J Vasc Interv Radiol 2020; 31:1401-1407. [PMID: 32792278 DOI: 10.1016/j.jvir.2020.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/22/2020] [Accepted: 05/28/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To assess the safety and feasibility of using a radiofrequency (RF) wire for portosystemic shunt creation. MATERIALS AND METHODS Ten patients undergoing elective creation of a transjugular intrahepatic portosystemic shunt (TIPS) or a direct intrahepatic portosystemic shunt (DIPS) were prospectively enrolled. Primary outcomes were the safety and feasibility of RF wire used for the creation of TIPS and DIPS. Median age was 66.5 ± 6.1 years. Causes of liver disease included alcohol (n = 5), nonalcoholic steatohepatitis (n = 2), hepatitis C virus (n = 1), primary biliary cirrhosis (n = 1), autoimmune hepatitis (n = 1). The median score for model for end-stage liver disease was 11 ± 4.3. The Rosch-Uchida TIPS set was used with intravascular ultrasonography guidance in all cases. A 0.035-inch RF wire was used in lieu of the trocar needle through the 5-F TIPS set catheter to create a track between the hepatic vein and the portal vein. All shunts were created using stent grafts. RESULTS Technical success rate was 100%. In 7 of 10 patients, portal vein access was achieved with a single pass. A DIPS was created in 2 patients based on anatomic favorability. Median fluoroscopy time was 13.3 ± 3.8 min, and median total procedure time was 102 ± 19 min. The wire passed through parenchyma without subjective deflection. There was 1 case of extracapsular puncture with no clinical consequence. The RF wire was too stiff to curve into the main portal vein, requiring wire exchange in all but 1 case. Mean portosystemic gradient decreased from 13.9 ± 3.3 to 5.9 ± 2.1 mm Hg. No immediate complications were encountered. Shunt patency was 100% at 30 days. CONCLUSIONS Creation of TIPS and DIPS using an RF wire was safe and feasible, enabling creation of an intrahepatic track without subjective deflection in cirrhotic patients.
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Affiliation(s)
- Khashayar Farsad
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239.
| | - Evan Narasimhan
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239
| | - Lori Russell
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239
| | - John A Kaufman
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239
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21
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Boike JR, Flamm SL. Transjugular Intrahepatic Portosystemic Shunts: Advances and New Uses in Patients with Chronic Liver Disease. Clin Liver Dis 2020; 24:373-388. [PMID: 32620278 DOI: 10.1016/j.cld.2020.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunts is an established treatment for portal hypertensive complications. Advancements in technology and technique have led to novel indications, including treatment of chronic portal vein thrombosis and use before abdominal surgery to alleviate portal hypertensive complications. Use of TIPS can facilitate the embolization of large portal-systemic shunts to alleviate refractory hepatic encephalopathy owing to excessive portal shunting. Despite these advances, transjugular intrahepatic portosystemic shunts is an invasive procedure with risk for complications and should be performed at a center with expertise to ensure a successful patient outcome.
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Affiliation(s)
- Justin R Boike
- Department of Medicine, Northwestern Feinberg School of Medicine, 676 North St. Clair Street, Suite 1400, Chicago, IL 60611, USA.
| | - Steven L Flamm
- Hepatology Program, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA
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22
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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. AJR Am J Roentgenol 2020; 216:1291-1299. [PMID: 32755214 DOI: 10.2214/ajr.20.23846] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Marteslo JP, Makary MS, Khabiri H, Flanders V, Dowell JD. Intravascular Ultrasound for the Peripheral Vasculature-Current Applications and New Horizons. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:216-224. [PMID: 31780239 DOI: 10.1016/j.ultrasmedbio.2019.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 06/10/2023]
Abstract
Intravascular ultrasound (IVUS) is a proven and rapidly developing imaging modality that can be used for a multitude of both diagnostic and interventional purposes. By allowing for superior intraluminal characterization, compared with angiography, IVUS has emerged as a technically valuable tool in interventional procedures such as transjugular intrahepatic portosystemic shunt/direct intrahepatic portosystemic shunt, venous interventions (May Thurner stenting, inferior vena cava filter placement, recanalization in the setting of chronic venous thrombosis/insufficiency), percutaneous fenestration in the setting of aortic dissection and angioplasty. Additional applications evaluating coronary arteries and plaque morphology have been described, but are outside the scope of this review. In addition to IVUS's merit as a pre- and intra-procedural guidance modality, there are also several advantages compared to the gold standard of angiography which include decreased need for iodinated contrast, decreased radiation exposure and decreased procedural times in certain cases. With current research, such as that aimed at supraharmonic imaging, further improvements in imaging depth, resolution and contrast to noise ratio are on the horizon.
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Affiliation(s)
- Jeffrey P Marteslo
- Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mina S Makary
- Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hooman Khabiri
- Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Vince Flanders
- Northwest Radiology, St. Vincent Health, Indianapolis, Indiana, USA
| | - Joshua D Dowell
- Northwest Radiology, St. Vincent Health, Indianapolis, Indiana, USA.
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Ramaswamy RS, Charalel R, Guevara CJ, Tiwari T, Akinwande O, Kim SK, Salter A, Darcy M, Malone CD. Propensity-matched comparison of transjugular intrahepatic portosystemic shunt placement techniques: Intracardiac echocardiography (ICE) versus fluoroscopic guidance. Clin Imaging 2019; 57:40-44. [PMID: 31103908 DOI: 10.1016/j.clinimag.2019.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 04/12/2019] [Accepted: 04/26/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare procedure characteristics and outcomes when TIPS is performed under intracardiac echocardiography guidance (iTIPS) compared to conventional fluoroscopic guidance (cTIPS). MATERIALS AND METHODS A retrospective propensity-matched study of 30 iTIPS and 30 cTIPS procedures from January 2014 to March 2017 at a single US high volume academic medical center was performed. iTIPS and cTIPS cases were propensity score matched using predictive variables: age, race, gender, etiology of liver disease, indication for TIPS, MELD score, and portal vein patency. Procedure characteristics and post- procedure outcomes were compared between propensity-matched groups including: total procedure time, technical success, radiation dose, contrast volume, complication rate, 30- day mortality, and revision rate within 3 months. RESULTS Radiation dose (875.3 vs 457.4 mGY, p = 0.039) and contrast volume (141 vs 103 mL, p = 0.005) were significantly decreased in the iTIPS versus the cTIPS group. There was no significant difference in procedure time (81.5 cTIPS vs 84 min iTIPS) or rate of TIPS revisions within 3 months. Average operator experience in the iTIPs group was 4.2 years and cTIPS group 11.0 years (p = 0.0004). All procedures were technically successful with no mortalities within 30 days. CONCLUSION iTIPS resulted in significantly reduced radiation dose and contrast volume. However, there was no difference in total procedure time or overall outcomes despite greater operator experience in the cTIPS group.
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Affiliation(s)
- Raja Siva Ramaswamy
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S Kingshighway Blvd, CB 8131, Saint Louis, MO 63139, United States of America.
| | - Resmi Charalel
- Weill Cornell Medicine, Department of Radiology, 525 East 68th Street, New York, NY 10065, United States of America
| | - Carlos J Guevara
- University of Texas - Houston, Department of Diagnostic and Interventional Imaging, 6431 Fannin St, Houston, TX 77030, United States of America
| | - Tatulya Tiwari
- Veterans Affairs Medical Center - Lexington, Division of Endovascular Surgery, 1101 Veterans Drive, Lexington, KY 40502, United States of America
| | - Olaguoke Akinwande
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S Kingshighway Blvd, CB 8131, Saint Louis, MO 63139, United States of America
| | - Seung K Kim
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S Kingshighway Blvd, CB 8131, Saint Louis, MO 63139, United States of America
| | - Amber Salter
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S Kingshighway Blvd, CB 8131, Saint Louis, MO 63139, United States of America
| | - Michael Darcy
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S Kingshighway Blvd, CB 8131, Saint Louis, MO 63139, United States of America
| | - Christopher D Malone
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S Kingshighway Blvd, CB 8131, Saint Louis, MO 63139, United States of America
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Intravascular Ultrasound in the Creation of Transjugular Intrahepatic Portosystemic Shunts: Review of the Literature and Future Directions. CURRENT RADIOLOGY REPORTS 2019. [DOI: 10.1007/s40134-019-0314-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Downing TM, Khan SN, Zvavanjanja RC, Bhatti Z, Pillai AK, Kee ST. Portal Venous Interventions: How to Recognize, Avoid, or Get Out of Trouble in Transjugular Intrahepatic Portosystemic Shunt (TIPS), Balloon Occlusion Sclerosis (ie, BRTO), and Portal Vein Embolization (PVE). Tech Vasc Interv Radiol 2018; 21:267-287. [DOI: 10.1053/j.tvir.2018.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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3D C-Arm cone beam CT for targeting the portal vein during TIPS: Initial clinical experience. Eur J Radiol 2018; 106:20-25. [DOI: 10.1016/j.ejrad.2018.06.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 05/05/2018] [Accepted: 06/29/2018] [Indexed: 02/07/2023]
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RiChard J, Thornburg B. New Techniques and Devices in Transjugular Intrahepatic Portosystemic Shunt Placement. Semin Intervent Radiol 2018; 35:206-214. [PMID: 30087525 DOI: 10.1055/s-0038-1660800] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Recently, new techniques and devices in transjugular intrahepatic portosystemic shunt (TIPS) placement have emerged that can improve upon the standard procedure. Ultrasound guidance during TIPS with intracardiac echocardiography (ICE), placement of controlled expansion (CX) stents, and portal vein recanalization (PVR) via transsplenic access are three techniques with new data supporting their implementation. ICE guidance can improve the technical success of difficult cases, decrease procedure time, and decrease complications such as capsular puncture, hemobilia, and hepatic artery injury. CX stents offer the operator better control over the final portosystemic gradient, which is particularly useful in patients with a high risk of post-TIPS hepatic encephalopathy. Finally, transsplenic access provides a stable, antegrade route for PVR, which can be used to optimize transplant candidacy as well as treat the sequelae of portal hypertension in patients with portal vein thrombosis. This article will describe the benefits, technical parameters, and patient selection criteria for each of these new techniques.
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Affiliation(s)
- Jamie RiChard
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Bartley Thornburg
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
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Kao SD, Lee EW. A review of recent experience with transjugular intrahepatic portosystemic shunt creation using intravascular ultrasound. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Steven D. Kao
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Three-dimensional Image Fusion Guidance for Transjugular Intrahepatic Portosystemic Shunt Placement. Cardiovasc Intervent Radiol 2017; 40:1732-1739. [DOI: 10.1007/s00270-017-1699-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 05/09/2017] [Indexed: 12/14/2022]
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Gunasekaran SS, Gaba RC. Anatomic Variations of the Right Portal Vein: Prevalence, Imaging Features, and Implications for Successful Transjugular Intrahepatic Portosystemic Shunt Creation. J Clin Imaging Sci 2017; 7:14. [PMID: 28515965 PMCID: PMC5385700 DOI: 10.4103/jcis.jcis_10_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/08/2017] [Indexed: 12/20/2022] Open
Abstract
Given the widespread use of transjugular intrahepatic portosystemic shunt (TIPS) creation for the treatment of portal hypertensive complications, a working knowledge of portal venous anatomy is critical for interventional radiologists. The right portal vein - which is most commonly accessed during TIPS - is subject to various anatomic variants that may potentially impact procedure success. This pictorial essay characterizes the anatomic patterns of the right portal vein branching in terms of type and frequency based on case series review. The work also explains the potential procedural implications of the right portal vein anatomic variations as they pertain to TIPS technical success.
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Affiliation(s)
- Senthil S Gunasekaran
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, Chicago, IL 60612, USA
| | - Ron C Gaba
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, Chicago, IL 60612, USA
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Win AZ. Image guided portal vein access techniques in TIPS creation and considerations regarding their use. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:226. [PMID: 27385392 DOI: 10.21037/atm.2016.05.43] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is a difficult procedure to perform and accessing the portal vein is a very challenging step. There are three broad categories of image guided TIPS creation techniques. Each technique has its advantages and disadvantages. TIPS procedure carries some risk of complications regardless of the guidance technique employed. The technology for TIPS has evolved in parallel with the expanding indications for TIPS. Ultrasound guidance technique offers a safe option, particularly for patients with challenging anatomy. Patient safety should always come first and the US guided technique should be more routinely used. Experience is the main factor in the success of TIPS. Other factors to consider in reducing the all-cause morbidity and mortality are patient selection, patient management and the clinical setting.
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Affiliation(s)
- Aung Zaw Win
- Notre Dame de Namur University, Belmont, CA, USA
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Pillai AK, Andring B, Faulconer N, Reis SP, Xi Y, Iyamu I, Suthpin PD, Kalva SP. Utility of Intravascular US-Guided Portal Vein Access during Transjugular Intrahepatic Portosystemic Shunt Creation: Retrospective Comparison with Conventional Technique in 109 Patients. J Vasc Interv Radiol 2016; 27:1154-9. [PMID: 27363298 DOI: 10.1016/j.jvir.2016.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 05/10/2016] [Accepted: 05/10/2016] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To compare safety and effectiveness of intravascular ultrasound (US)-guided portal vein access during transjugular intrahepatic portosystemic shunt (TIPS) creation with conventional TIPS technique. MATERIALS AND METHODS In this retrospective study, TIPS creation using intravascular US guidance in 55 patients was compared with conventional TIPS creation in 54 patients by 10 operators over a 3-year period. Operators were classified as experienced if they had performed ≥ 20 TIPS procedures at the beginning of the study period. Time to portal vein access, total radiation dose, and needle pass-related capsular perforation were recorded. RESULTS Baseline demographic characteristics of patients were similar (P > .05). Mean time to portal venous access was 46 minutes ± 37 for conventional TIPS and 31 minutes ± 19 for intravascular US-guided TIPS (P = .007). Intravascular US guidance allowed significantly shorter times (48 min ± 30 vs 28 min ± 16; P = .01) to portal vein access among operators (n = 5) with limited experience but failed to achieve any significant time savings (44 min ± 43 vs 34 min ± 22; P = .89) among experienced operators (n = 5). Needle pass-related capsular perforation occurred in 17/54 (34%) patients with conventional TIPS and 5/55 (9%) patients with intravascular US-guided TIPS (P = .004). Radiation dose was 2,376 mGy ± 1,816 for conventional TIPS and 1,592 mGy ± 1,263 for intravascular US-guided TIPS (P = .004). CONCLUSIONS Intravascular US-guided portal vein access during TIPS creation is associated with shorter portal vein access times, decreased needle pass-related capsular perforations, and reduced radiation dose.
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Affiliation(s)
- Anil K Pillai
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390.
| | - Brice Andring
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
| | - Nicholas Faulconer
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
| | - Stephen P Reis
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
| | - Yin Xi
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
| | - Ikponmwosa Iyamu
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Patrick D Suthpin
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
| | - Sanjeeva P Kalva
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
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Jalaeian H, Talaie R, D'Souza D, Taleb S, Noorbaloochi S, Flanagan S, Hunter D, Golzarian J. Minilaparotomy-Assisted Transmesenteric-Transjugular Intrahepatic Portosystemic Shunt: Comparison with Conventional Transjugular Approach. Cardiovasc Intervent Radiol 2016; 39:1413-9. [PMID: 27272888 DOI: 10.1007/s00270-016-1385-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 05/23/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE This study was performed to compare the intrahepatic shunt function outcome and procedural complications of minilaparotomy-assisted transmesenteric (MAT)-transjugular intrahepatic portosystemic shunt (TIPS) placement with the conventional transjugular method. METHODS This is a retrospective review of all patients who had a MAT or conventional TIPS procedure over a 6-year period at our institute. The primary patency rate, fluoroscopy time, technical success, major procedure-related complications, and mortality data were compared between two treatment groups. RESULTS We included 49 patients with MAT-TIPS, and 63 with conventional TIPS, with an average follow-up of 21.43 months. The primary patency rates at 6 and 12 months were 82.9 and 66.7 % in the conventional TIPS group, and 81.0 and 76.5 % in the MAT-TIPS group (p = 1.000, and 0.529), respectively. There was no significant difference in technical success rate, post-procedure portosystemic pressure gradient, fluoroscopy time, and peri-procedural mortality rate between treatment groups. Major procedural-related complications were seen more frequently among MAT-TIPS patients (p = 0.012). In the MAT-TIPS group, 5 (10.2 %) patients developed post-procedure minilaparotomy, wound-related complications, and 5 (10.2 %) developed bacterial peritonitis; whereas, none of patients with conventional TIPS had either of these complications (p = 0.014). CONCLUSION While both MAT-TIPS and conventional TIPS had similar shunt primary patency rate and technical success rate, the MAT approach was associated with a significantly higher rate of minilaparotomy-related wound complications or infectious complications. These complications maybe prevented by a change in post-procedure monitoring and therapy.
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Affiliation(s)
- Hamed Jalaeian
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
| | - Reza Talaie
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Donna D'Souza
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Shayandokht Taleb
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | | | - Siobhan Flanagan
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - David Hunter
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Jafar Golzarian
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
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