Long term impact of transjugular intrahepatic portosystemic shunt (TIPS) creation on hepatic morphology

PURPOSE

The purpose of this study was to evaluate long-term morphologic changes occurring in the liver after TIPS creation with correlation with hepatic function to gain insight on the physiologic impact of TIPS on the liver.

METHODS

This retrospective study included patients who underwent TIPS creation between 2005 and 2022 and had contrasted CT or MRI studies prior to and between 1 and 2 years post procedure. Strict exclusion criteria were applied to avoid confounding. Parenchymal volume and vessel measurements were assessed on the pre- and post-TIPS CT or MRI and MELD scores calculated.

RESULTS

Of 580 patients undergoing TIPS creation, 65 patients (mean age, 55 years; 36 males) had pre-TIPS and post-TIPS imaging meeting inclusion criteria at median 16.5 months. After TIPS, the mean MELD score increased (12.9 to 15.4; p = 0.008) and total liver volume decreased (1730 to 1432 mL; p < 0.001). However, the magnitude of volume change did not correlate with MELD change. Neither portosystemic gradient nor TIPS laterality correlated with total or lobar hepatic volume changes or MELD changes. The main portal vein diameter increased (15.0 to 18.7 mm; p < 0.001). Thrombosis of the hepatic vein used for TIPS creation resulted in a mean increase in MELD of +4.1 compared to -2.1 in patients who had a patent and normal hepatic vein (p = 0.007).

CONCLUSIONS

Given lack of correlation between portosystemic gradient, hepatic atrophy, hepatic function, and TIPS laterality, the alterations in portal flow dynamics after TIPS may not be impactful to hepatic function. However, hepatic vein patency after TIPS correlated with improved hepatic function.

Intravascular Ultrasound Guidance for Transjugular Intrahepatic Portosystemic Shunt Creation Reduces Laboratory Markers of Acute Liver Injury

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.

Utility of CBCT and AVD for intraprocedural diagnosis and treatment of lower GI bleeding

BACKGROUND

Intraprocedural Cone Beam CT (CBCT) is assessed to examine if use improves diagnosis and embolization rates of acute lower GI bleed (LGIB) and if automatic vessel detection (AVD) software can identify feeding vessels (FV) for embolization.

METHODS

Patients with inconclusive DSA findings had CBCT and retrospective analysis with AVD software (Innova 3100, GE Company, USA). Technical success was defined as the ability to detect a lower GIB site while clinical success was defined as successful embolization without evidence of rebleeding or death within 30 days. AVD technical success was defined by the ability to identify the FV on both CTA and CBCT upon independent review by 3 blinded IRs, who also assigned a degree of certainty on a 5-point Likert scale.

RESULTS

74 patients in total were treated for lower GI bleed of which 34 had indeterminate DSA. Of those, 10 patients received DSA only, of which 1 was super selective. 24 patients with GIB on pre-procedural CTA and inconclusive DSA underwent CBCT. Use of CBCT identified 9 bleeds not seen on DSA and an additional source artery in 1 case representing a 42% change in intraprocedural management as all findings were embolized. When a bleed could not be identified on CBCT, but the FV could be identified on CTA, the same suspected FV could be selected on AVD 62% of the time with an average certainty of 4.0.

CONCLUSION

CBCT is useful in the intraprocedural detection of GIB when DSA is indeterminate. Furthermore, AVD software can feasibly be utilized to accurately identify FVs for empiric treatment when intraprocedural imaging is inconclusive.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Intravascular Ultrasound-Guided Transvenous Biopsy of Retroperitoneal Lymph Nodes: Diagnostic Accuracy and Safety Compared with CT-Guided Percutaneous Biopsy

PURPOSE

To compare the diagnostic accuracy and adverse event rates of intravascular ultrasound (US)-guided transvenous biopsy (TVB) versus those of computed tomography (CT)-guided percutaneous needle biopsy (PNB) for retroperitoneal (RP) lymph nodes.

MATERIALS AND METHODS

In this single-institution, retrospective study, 32 intravascular US-guided TVB procedures and a sample of 34 CT-guided PNB procedures for RP lymph nodes where targets were deemed amenable to intravascular US-guided TVB were analyzed. Procedural metrics, including diagnostic accuracy, defined as diagnostic of malignancy or a clinically verifiable benign result, and adverse event rates were compared.

RESULTS

The targets of intravascular US-guided TVB were primarily aortocaval (47%, 15/32) or precaval (34%, 11/32), whereas those of CT-guided PNB were primarily right pericaval (44%, 15/34) or retrocaval (44%, 15/34) (P < .001). The targets of intravascular US-guided TVB averaged 2.4 cm in the long axis (range, 1.3-3.7 cm) compared with 2.9 cm (range, 1.4-5.7 cm) for those of CT-guided PNB (P = .02). There was no difference in the average number of needle passes (3.8 for intravascular US-guided TVB vs 3.9 for CT-guided PNB; P = .68). The diagnostic accuracy was 94% (30/32) and the adverse event rate was 3.1% (1/32) for intravascular US-guided TVB, similar to those of CT-guided PNB (accuracy, 91% [31/34]; adverse event rate, 2.9% [1/34]).

CONCLUSIONS

Intravascular US-guided TVB had a diagnostic accuracy and adverse event rate similar to CT-guided PNB for RP lymph nodes, indicating that intravascular US-guided TVB may be as safe and effective as conventional biopsy approaches for appropriately selected targets.

Coaxial Stent Graft inside a Constraining Stent for Transjugular Intrahepatic Portosystemic Shunt Reduction

A technique to create a coaxial, self-expanding stent graft inside a constraining, bare-metal, balloon-expandable stent for transjugular intrahepatic portosystemic shunt (TIPS) reduction is described. The key steps are performed on a back table rather than inside the patient, and the resulting construct is deployed using standard unsheathing maneuvers. The construct was used in 4 patients to make 6 TIPS diameter reductions (mean postreduction diameter, 6 mm; range, 0-8 mm), all resulting in increases in the portosystemic pressure gradient (mean increase, 6 mm Hg; range, 1-19 mm Hg). On average, hepatic encephalopathy improved 1 point on the West Haven scale (range, 0-2).

Hemodialysis Reliable Outflow (HeRO) graft creation in upper extremities abandoned due to stent obstruction via recanalization and HeRO outflow component insertion across stent interstices

BACKGROUND

The purpose of this study was to assess the feasibility and outcomes of recanalization and subsequent HeRO graft outflow component insertion across stent interstices in patients with an otherwise abandoned upper extremity.

METHODS

Over a 10-year period, 15 patients underwent central venous recanalization by interventional radiology across the interstices of one or more occluded stents for the purpose of subsequent HeRO graft creation. A tunneled central venous catheter was left across the stent and occlusions with tip in right atrium. On a later date, the catheter was used for rapid guidewire access for HeRO graft implantation in the OR by vascular surgery. Procedural and clinical outcomes were determined by retrospective review. Primary and secondary HeRO graft patency rates were estimated with the Kaplan-Meier technique.

RESULTS

The technical success rates of recanalization across stent interstices was 100% (15/15). Between one and four overlapping stent walls were traversed. The technical success of the patients who underwent attempted HeRO graft implantation with outflow component traversing across stent interstices was 91% (11/12). No major complications were encountered with either recanalization or HeRO graft implantation. The primary and secondary HeRO patency rates at 12 months were 64% and 80%, respectively.

CONCLUSION

HeRO graft insertion across stent interstices is feasible and can provide effective permanent AV access; thus, the presence of stents across the subclavian and brachiocephalic veins should not be considered a contraindication.