Transjugular intrahepatic portosystemic shunt (TIPS) is a pivotal intervention for managing esophagogastric variceal bleeding in patients with chronic hepatic schistosomiasis.

To evaluate the efficacy of digital subtraction angiography image overlay technology (DIT) in guiding the TIPS procedure.

We conducted a retrospective analysis of patients who underwent TIPS at our hospital, comparing outcomes between an ultrasound-guided group and a DIT-guided group. Our analysis focused on the duration of the portosystemic shunt puncture, the number of punctures needed, the total surgical time, and various clinical indicators related to the surgery.

The study included 52 patients with esophagogastric varices due to chronic hepatic schistosomiasis. Results demonstrated that the DIT-guided group experienced significantly shorter puncture times (P < 0.001) and surgical durations (P = 0.022) compared to the ultrasound-guided group. Additionally, postoperative assessments showed significant reductions in aspartate aminotransferase, B-type natriuretic peptide, and portal vein pressure in both groups. Notably, the DIT-guided group also showed significant reductions in total bilirubin (P = 0.001) and alanine aminotransferase (P = 0.023).

The use of DIT for guiding TIPS procedures highlights its potential to enhance procedural efficiency and reduce surgical times in the treatment of esophagogastric variceal bleeding in patients with chronic hepatic schistosomiasis.

Transmesenteric access for portal vein reconstruction and transjugular intrahepatic portosystemic shunt allows for intervention in patients with unfavorable anatomy and can be performed via multiple methods but may be difficult to obtain in patients with complex anatomy.

We present a case report describing a method of obtaining transmesenteric access in the porta hepatis to facilitate direct intrahepatic portosystemic shunt creation in a young patient with recurrent variceal bleeding. This patient anatomy was unfavorable, and initially he was thought to be a poor candidate for any intervention, but this technique allowed for successful decompression of the varices safely and effectively.

This is a technique to consider in similar complex cases and expands treatment for those who previously would not have been considered for intrahepatic shunt formation.

Portal vein puncture (PVP) is a critical step during transjugular intrahepatic portosystemic shunt (TIPS) and correlates to several complications. Techniques guiding PVP are needed.

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.

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.

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).

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.

Transjugular intrahepatic portosystemic stent-shunt (TIPSS) is a minimally invasive procedure used for the treatment of portal hypertension. Intrahepatic hematoma is the rare complication caused by hepatic arterial injuries from TIPSS procedure.

This case report illustrated a 77-year-old man with hepatitis B virus-induced cirrhosis who underwent TIPSS.

The patient suffered from intrahepatic hematoma and hepatic pseudoaneurysm because of the hepatic artery injury after TIPSS.

The hepatic artery laceration began at the level of the branch of the left hepatic artery was embolized.

The acute intrahepatic hematoma and hepatic pseudoaneurysm of the patient were cured.

In this report, we describe a cirrhosis patient with a large intrahepatic hematoma secondary to TIPSS, and a literature review is also presented. The intrahepatic hematoma and hepatic pseudoaneurysm should be paid more attention after TIPSS while early-stage prevention should be carried out.

Portal hypertension (PH) is associated with complications including refractory ascites and variceal haemorrhage and can be treated endovascularly with a Transjugular Intrahepatic Portosystemic Shunt (TIPS). Portal vein puncture during TIPS using real-time transabdominal ultrasound guidance is one of many portal vein puncture techniques and is seldom used compared with other methods. The purpose of this manuscript is to describe this technique and its associated procedural outcomes at a quaternary liver transplant hospital.

Clinical data of all patients who underwent ultrasound-guided TIPS at our institution between 1 January 2009 and 1 January 2019 were retrospectively obtained from electronic medical records and reviewed. Patient demographics, indications, procedural outcomes and complications were recorded.

Forty-four ultrasound-guided TIPS procedures were performed during the study period. The most common indication for TIPS was refractory ascites (n = 26; 57%) and variceal haemorrhage (n = 12; 26%). Technical success rate was 100%. No intraprocedural complications occurred. Periprocedural complication rate was 35% (n = 16) with encephalopathy (n = 8; 17%) and sepsis (n = 5; 11%) the most common. One patient with sepsis died. No other TIPS-related deaths occurred. Median fluoroscopy time, contrast volume, air kerma and dose area product values for all procedures were 35 minutes (IQR 24-51), 100 ml (IQR 70-160), 0.95 Gy (IQR 0.50-1.53) and 127 Gycm² (IQR 68.75-206), respectively.

Transabdominal ultrasound-guided portal vein puncture during TIPS is safe and technically feasible. When compared to fluoroscopically guided methods, it is associated with lower intraprocedural complication rates, fluoroscopy times, contrast volumes and radiation doses in our experience. Radiation doses, FTs and contrast volumes were also considerably lower than recommended limits.

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

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.

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.

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

Transjugular intra-hepatic portosystemic shunts (TIPS) had been considered a standard procedure in patients suffering from portal hypertension. The most challenging step in TIPS placement is blind puncture of the portal vein. We had established a localization method by introducing an Intra-Hepatic Arterial based puncture directing Localizer (IHAL) with the assistance of the enhanced computed tomography (CT) reconstruction. This study aimed to evaluate the feasibility, efficacy, and technical success of this method.From June 2018 to August 2018, 10 consecutive patients suffering from refractory ascites or esophageal gastric bleeding by liver cirrhosis were included in this retrospective study to evaluate feasibility, efficacy, and technical success of enhanced CT assisted IHAL-guided puncture of the portal vein. As a control, 10 patients receiving TIPS placement before Jun 2018 with cone beam CT (CBCT)-guided puncture were included to compare the reduction of portal-systemic pressure gradient (PSPG), portal entry time (PET), the number of puncture, dose area product (DAP) and contrast medium consumption.Technical success was 100% in the study group (IHAL-guided group) and in 90.0% of the control group (CBCT-guided group). Appropriate IHAL point could be achieved in all patients under the enhanced CT reconstruction assistance. The median number of punctures and DAP in IHAL group were significantly less than those in CBCT group. The reduction of PSPG, PET, and contrast medium consumption in IHAL group showed no significant differences than those in CBCT group.Enhanced CT reconstruction assisted IHAL-guided portal vein puncture is technically feasible and a reliable tool for TIPS placement resulting in a significant reduction of the number of punctures and DAP.

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.

To assess whether intravascular ultrasound (US) guidance impacts number of needle passes, contrast usage, radiation dose, and procedure time during creation of transjugular intrahepatic portosystemic shunts (TIPS).

Intravascular US-guided creation of TIPS in 40 patients was retrospectively compared with conventional TIPS in 49 patients between February 2010 and November 2015 at a single tertiary care institution. Patient sex and age, etiology of liver disease (hepatitis C virus, alcohol abuse, nonalcoholic steatohepatitis), severity of liver disease (mean Model for End-Stage Liver Disease score), and indications for TIPS (variceal bleeding, refractory ascites, refractory hydrothorax) in conventional and intravascular US-guided cases were recorded.

The two groups were well matched by sex, age, etiology of liver disease, Child-Pugh class, Model for End-Stage Liver Disease scores, and indication for TIPS (P range = .19-.94). Fewer intrahepatic needle passes were required in intravascular US-guided TIPS creation compared with conventional TIPS (2 passes vs 6 passes, P < .01). Less iodinated contrast material was used in intravascular US cases (57 mL vs 140 mL, P < .01). Radiation exposure, as measured by cumulative dose, dose area product, and fluoroscopy time, was reduced with intravascular US (174 mGy vs 981 mGy, P < .01; 3,793 μGy * m(2) vs 21,414 μGy * m(2), P < .01; 19 min vs 34 min, P < .01). Procedure time was shortened with intravascular US (86 min vs 125 min, P < .01).

Intravascular US guidance resulted in fewer intrahepatic needle passes, decreased contrast medium usage, decreased radiation dosage, and shortened procedure time in TIPS creation.

The most challenging part of transjugular intrahepatic portosystemic shunt creation is arguably the transvenous access from the hepatic vein to the portal vein. As experience and technology have evolved, the image guidance aspect of this critical step in the procedure has become more robust. Improved means to target the portal vein include both direct and indirect methods of portal vein opacification, cross-sectional imaging for both targeting and access, and novel use of transabdominal and intravascular ultrasound guidance. These techniques are described herein.

Transjugular intrahepatic portosystemic shunt (TIPS) creation is considered as being one of the most complex procedures in abdominal interventional radiology. Our aim was twofold: quantification of TIPS-related patient radiation exposure in our center and identification of factors leading to reduced radiation exposure.

Three hundred and forty seven consecutive patients underwent TIPS in our center between 2007 and 2014. Three main procedure categories were identified: Group I (n = 88)-fluoroscopic-guided portal vein targeting, procedure done in an image intensifier-based angiographic system (IIDS); Group II (n = 48)--ultrasound-guided portal vein puncture, procedure done in an IIDS; and Group III (n = 211)--ultrasound-guided portal vein puncture, procedure done in a flat panel detector-based system (FPDS). Radiation exposure (dose-area product [DAP], in Gy cm(2) and fluoroscopy time [FT] in minutes) was retrospectively analyzed.

DAP was significantly higher in Group I (mean ± SD 360 ± 298; median 287; 75th percentile 389 Gy cm(2)) as compared to Group II (217 ± 130; 178; 276 Gy cm(2); p = 0.002) and Group III (129 ± 117; 70; 150 Gy cm(2) p < 0.001). The difference in DAP between Groups II and III was also significant (p < 0.001). Group I had significantly longer FT (25.78 ± 13.52 min) as compared to Group II (20.45 ± 10.87 min; p = 0.02) and Group III (19.76 ± 13.34; p < 0.001). FT was not significantly different between Groups II and III (p = 0.73).

Real-time ultrasound-guided targeting of the portal venous system during TIPS creation results in a significantly lower radiation exposure and reduced FT. Further reduction in radiation exposure can be achieved through the use of modern angiographic units with FPDS.