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Gadour E, Gardezi SA. Transjugular intrahepatic portosystemic shunt and non-selective beta-blockers act as friends or foe in decompensated cirrhosis: A comparative review. World J Gastrointest Surg 2025; 17:103395. [DOI: 10.4240/wjgs.v17.i4.103395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2024] [Revised: 02/11/2025] [Accepted: 03/10/2025] [Indexed: 03/29/2025] Open
Abstract
The management of portal hypertension and its complications, such as variceal bleeding, in patients with cirrhosis often involves the use of nonselective beta-blockers (NSBBs) and a transjugular intrahepatic portosystemic shunt (TIPS). Both treatment modalities have demonstrated efficacy; however, each presents distinct challenges and benefits. NSBBs, including propranolol, nadolol, and carvedilol, effectively reduce portal pressure, but are associated with side effects such as bradycardia, hypotension, fatigue, and respiratory issues. Additionally, NSBBs can exacerbate conditions such as refractory ascites, hepatorenal syndrome, and hepatic encephalopathy. In contrast, TIPS effectively reduces the incidence of variceal rebleeding, controlling refractory ascites. However, it is associated with a significant risk of hepatic encephalopathy, shunt dysfunction, and procedure-related complications including bleeding and infection. The high cost of TIPS, along with the need for regular follow-up and potential re-intervention, poses additional challenges. Furthermore, patient selection for TIPS is critical, as inappropriate candidates may experience suboptimal outcomes. Future studies comparing NSBBs and TIPS should focus on refining the patient selection criteria, enhancing procedural techniques, optimising combination therapies, and conducting long-term outcome studies. Personalised treatment approaches, cost-effectiveness analyses, and improved patient education and support are essential for maximising the use of these therapies.
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Affiliation(s)
- Eyad Gadour
- Multi-organ Transplant Centre of Excellence, Liver Transplantation Unit, King Fahad Specialist Hospital, Dammam 32253, Saudi Arabia
- Internal Medicine, Zamzam University College, School of Medicine, Khartoum 11113, Sudan
| | - Syed A Gardezi
- Department of Gastroenterology, John Hopkins Aramco Healthcare, Dhahran 34465, Saudi Arabia
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de Mattos AA, de Mattos AZ, Manica M, Tovo CV. Which patients benefit the most? An update on transjugular intrahepatic portosystemic shunt. World J Hepatol 2025; 17:99809. [PMID: 40027554 PMCID: PMC11866145 DOI: 10.4254/wjh.v17.i2.99809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 12/23/2024] [Accepted: 01/09/2025] [Indexed: 02/20/2025] Open
Abstract
This is a narrative review in which the advances in technical aspects, the main indications, limitations and clinical results of the transjugular intrahepatic portosystemic shunt (TIPS) in portal hypertension (PH) are addressed. With the emergence of the coated prosthesis, a better shunt patency, a lower incidence of hepatic encephalopathy (HE) and better survival when compared to TIPS with the conventional prosthesis are demonstrated. The main indications for TIPS are refractory ascites, acute variceal bleeding unresponsive to pharmacological/endoscopic therapy and, lastly, patients considered at high risk for rebleeding preemptive TIPS (pTIPS). Absolute contraindications to the use of TIPS are severe uncontrolled HE, systemic infection or sepsis, congestive heart failure, severe pulmonary arterial hypertension, and biliary obstruction. The control of hemorrhage due to variceal rupture can reach up to 90%-100% of cases, and 55% in refractory ascites. Despite evidences regarding pTIPS in patients at high risk for rebleeding, less than 20% of eligible patients are treated. TIPS may also decrease the incidence of future decompensation in cirrhosis and increase survival in selected patients. In conclusion, TIPS is an essential treatment for patients with PH, but is often neglected. It is important for the hepatologist to form a multidisciplinary team, in which the role of the radiologist with experience in interventional procedures is prominent.
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Affiliation(s)
- Angelo Alves de Mattos
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil
| | - Angelo Zambam de Mattos
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil
| | - Muriel Manica
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil
| | - Cristiane Valle Tovo
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil.
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Zhao N, Shi A, Huang W, He J, Wang D, Zhang Y, Guo H, Zhou B, Gan H, Pang P. Three-dimensional volumetric CT image fusion and trans-abdominal US: Adjunct guidance to portal vein cannulation for TIPS. Eur J Radiol 2025; 183:111875. [PMID: 39671727 DOI: 10.1016/j.ejrad.2024.111875] [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: 09/29/2024] [Revised: 11/11/2024] [Accepted: 12/03/2024] [Indexed: 12/15/2024]
Abstract
PURPOSE To describe portal vein cannulation under adjunct guidance for transjugular intrahepatic portosystemic shunts (TIPS). METHODS Medical records of 86 patients who underwent TIPS, including conventional TIPS, 3D volumetric CT image fusion (CT-fluoroscopy image fusion)-guided TIPS, and trans-abdominal ultrasound (US)-guided TIPS at our institute from March 2016 to June 2024 were reviewed. Baseline characteristics, clinical outcomes, and procedural data were analyzed. RESULTS Technical success was achieved in 35 conventional TIPS patients (92.11 %), 20 CT-fluoroscopy image fusion-guided TIPS patients (95.24 %), and 26 transabdominal US-guided TIPS patients (96.30 %). Among patients who underwent a successful procedure, the procedural time and contrast usage were lower in the CT-fluoroscopy image fusion-guided and trans-abdominal US-guided TIPS groups than in the conventional group. There was a statistical significance in the cumulative fluoroscopic time between CT-fluoroscopy image fusion-guided TIPS and conventional TIPS groups (43.19 ± 14.92 vs 63.05 ± 30.33 min, p = 0.012). No immediate experienced complications were observed. Furthermore, the incidence of post-procedural complications among the three groups was not statistically different during follow-up. CONCLUSIONS CT-fluoroscopy image fusion and trans-abdominal US-guided portal vein cannulation are feasible, safe, and effective adjunct methods for patients undergoing TIPS. These methods provide shorter procedural time and lower contrast usage for TIPS placement.
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Affiliation(s)
- Ni Zhao
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Anya Shi
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Weile Huang
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Jianan He
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Dashuai Wang
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Yongyu Zhang
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Hui Guo
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Bin Zhou
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China; Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China.
| | - Hairun Gan
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China; Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China.
| | - Pengfei Pang
- Center for Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China; Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
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4
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Gómez Gómez A, Espuche Jiménez C, Romero Martínez M, Morales López G, Tudela Quiñonero L. Migration of a transjugular intrahepatic portosystemic shunt stent towards the pulmonary artery. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 39508124 DOI: 10.17235/reed.2024.10819/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2024]
Abstract
We present the case of a 73-year-old male, recipient of a liver transplant a year ago, with migration of a "Be-Graft" stent used in a pre-transplant transjugular intrahepatic portosystemic shunt towards the pulmonary artery. The stent was incidentally discovered via imaging tests during hospitalization due to acute cholangitis.
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Li XY, Li Y, Li WQ, Ju S, Dong ZH, Luo JJ. Enhancing transjugular intrahepatic portosystemic shunt procedure efficiency with digital subtraction angiography image overlay technology in esophagogastric variceal bleeding. World J Gastrointest Surg 2024; 16:2870-2877. [PMID: 39351548 PMCID: PMC11438804 DOI: 10.4240/wjgs.v16.i9.2870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 06/29/2024] [Accepted: 07/31/2024] [Indexed: 09/18/2024] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a pivotal intervention for managing esophagogastric variceal bleeding in patients with chronic hepatic schistosomiasis. AIM To evaluate the efficacy of digital subtraction angiography image overlay technology (DIT) in guiding the TIPS procedure. METHODS 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. RESULTS 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). CONCLUSION 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.
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Affiliation(s)
- Xiao-Yan Li
- Vascular and Wound Center, Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Yao Li
- Vascular and Wound Center, Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Wen-Qiang Li
- Vascular and Wound Center, Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Shuai Ju
- Vascular and Wound Center, Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Zhi-Hui Dong
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Jian-Jun Luo
- Department of Interventional Radiology, Zhongshan Hospital Fudan University, Shanghai 20032, China
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Hunt C, Patel M, Bayona Molano MDP, Patel MS, VanWagner LB. Radiological and Surgical Treatments of Portal Hypertension. Clin Liver Dis 2024; 28:437-453. [PMID: 38945636 DOI: 10.1016/j.cld.2024.03.003] [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: 07/02/2024]
Abstract
Interventions for portal hypertension are continuously evolving and expanding beyond the realm of medical management. When complications such as varices and ascites persist despite conservative interventions, procedures including transjugular intrahepatic portosystemic shunt creation, transvenous obliteration, portal vein recanalization, splenic artery embolization, surgical shunt creation, and devascularization are all potential interventions detailed in this article. Selection of the optimal procedure to address the underlying cause, treat symptoms, and, in some cases, bridge to liver transplantation depends on the specific etiology of portal hypertension and the patient's comorbidities.
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Affiliation(s)
- Charlotte Hunt
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Mausam Patel
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Maria Del Pilar Bayona Molano
- Department of Radiology, Keck School of Medicine, University of Southern California, 1500 San Pablo Street, Health Sciences Campus, Los Angeles, CA 90033, USA
| | - Madhukar S Patel
- Division of Organ Transplantation, Department of Surgery, UT Southwestern Medical Center, 5939 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Boulevard, Suite HP4.420M, Dallas, TX 75390-8887, USA.
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7
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Yu Q, Rao A, Fergus J, Lorenz J, Zangan S. Endovascular Retrieval of a Damaged Transjugular Intrahepatic Portosystemic Shunt Stent Graft. J Vasc Interv Radiol 2024; 35:926-929.e2. [PMID: 38417783 DOI: 10.1016/j.jvir.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/16/2024] [Accepted: 02/17/2024] [Indexed: 03/01/2024] Open
Affiliation(s)
- Qian Yu
- Vascular and Interventional Radiology, Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Avenue, MC 2026, Chicago, IL 60637.
| | - Amith Rao
- Vascular and Interventional Radiology, Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Avenue, MC 2026, Chicago, IL 60637
| | - Jonathan Fergus
- Vascular and Interventional Radiology, Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Avenue, MC 2026, Chicago, IL 60637
| | - Jonathan Lorenz
- Vascular and Interventional Radiology, Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Avenue, MC 2026, Chicago, IL 60637
| | - Steven Zangan
- Vascular and Interventional Radiology, Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Avenue, MC 2026, Chicago, IL 60637
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Lopera Valle JS, Muñoz-Caicedo B, Muñoz Durán JA, Hidalgo Oviedo JM. Biliary Complications Post Transjugular Intrahepatic Portosystemic Shunt in a Child With Portal Vein Cavernous Transformation. Cureus 2024; 16:e58525. [PMID: 38957814 PMCID: PMC11218419 DOI: 10.7759/cureus.58525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 07/04/2024] Open
Abstract
The transjugular intrahepatic portosystemic shunt is a rising interventional procedure with multiple indications and high technical success but with risks of biliary injuries, an underreported scenario. We present an 11-year-old patient with biliary injury with a leak, biloma formation, and biliary obstruction caused by the percutaneous procedure. Interventional radiology drainages addressed these complications by resolving the leak and biloma. These biliary complications in percutaneous procedures and their management are rarely reported in the medical literature, making their management not standard. We highlight drainage management and the importance of sharing it to add experience to this clinical scenario and encourage sharing cases with similar diagnoses.
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Affiliation(s)
- Johan S Lopera Valle
- Department of Interventional Radiology, Hospital Universitario San Vicente Fundación, Medellín, COL
| | | | | | - José M Hidalgo Oviedo
- Department of Interventional Radiology, Hospital Pablo Tobón Uribe, Medellín, COL
- Department of Radiology, Universidad de Antioquia, Medellín, COL
- Department of Interventional Radiology, Hospital Universitario San Vicente Fundación, Medellín, COL
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9
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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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10
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Kalo E, Read S, George J, Roberts SK, Majumdar A, Ahlenstiel G. Attitudes towards transjugular intrahepatic portosystemic shunt (TIPS) in Australia: a national survey of TIPS centres. BMJ Open Gastroenterol 2024; 11:e001308. [PMID: 38519047 DOI: 10.1136/bmjgast-2023-001308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/20/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive therapeutic option to treat the sequelae of portal hypertension. It is unclear whether current international recommendations are reflected in current clinical practice across Australia and the extent of variations in care. This study aimed to address this gap in knowledge and benchmark the current landscape of TIPS services in Australia against international guidelines. METHODS We designed a 42-item questionnaire according to practice-based recommendations and standards of international guidelines to investigate current landscape of TIPS service across four key domains: (1) service provision, (2) patient selection and indications, (3) best procedure practice, and (4) postoperative care. RESULTS Gastroenterologist/hepatologists from 23 major liver centres (67.6%) across Australia currently performing TIPS completed the questionnaire. Between 2017 and 2020, there were 456 elective TIPS insertions. Units offering TIPS service had a low median number of TIPS insertions (n=7 per annum). More than half of respondents (56.5%) did not have institutional clinical practice protocols. There was marked variation in practices across institutions in terms of TIPS indications and patient selection. Despite variations, the success rate of elective TIPS was high at 91.7% (79-100%), with 86.6% (29-100%) for rescue TIPS. There was significant variation in postoperative follow-up and care. CONCLUSION Current TIPS practice in Australia varies significantly across institutions. There is a need for a national consensus clinical practice guidelines to improve access and minimise unwarranted variation. A national registry for TIPS could measure, monitor, and report on quality of clinical care and patient outcomes.
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Affiliation(s)
- Eric Kalo
- Blacktown Mt Druitt Clinical School and Research Centre, Western Sydney University, Blacktown, New South Wales, Australia
- Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Scott Read
- Blacktown Mt Druitt Clinical School and Research Centre, Western Sydney University, Blacktown, New South Wales, Australia
- Westmead Institute for Medical Research Storr Liver Centre, Westmead, New South Wales, Australia
| | - Jacob George
- Faculty of Medicine, Westmead Institute for Medical Research Storr Liver Centre, Westmead, New South Wales, Australia
- Gastroenterology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Avik Majumdar
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Golo Ahlenstiel
- Blacktown Mt Druitt Clinical School and Research Centre, Western Sydney University, Blacktown, New South Wales, Australia
- Blacktown Hospital, Blacktown, New South Wales, Australia
- Westmead Institute for Medical Research Storr Liver Centre, Westmead, New South Wales, Australia
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11
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Lee EW, Eghtesad B, Garcia-Tsao G, Haskal ZJ, Hernandez-Gea V, Jalaeian H, Kalva SP, Mohanty A, Thabut D, Abraldes JG. AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology 2024; 79:224-250. [PMID: 37390489 DOI: 10.1097/hep.0000000000000530] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Affiliation(s)
- Edward Wolfgang Lee
- Department of Radiology and Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute Cleveland Clinic, Cleveland, Ohio, USA
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging/Interventional Radiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Universitat de Barcelona (UB). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Arpan Mohanty
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Dominique Thabut
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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12
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Khatri S, Villegas GE, Smith M. Management of inadvertent puncture of the hepatic capsule accompanied by post-TIPS hemoperitoneum secondary to bleeding diathesis. Radiol Case Rep 2023; 18:3798-3803. [PMID: 37663566 PMCID: PMC10474355 DOI: 10.1016/j.radcr.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/03/2023] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Since its advent, the transjugular intrahepatic portosystemic shunt (TIPS) procedure has been accepted as an effective option to treat patients with complications of portal hypertension. While generally considered a safe procedure, TIPs can be associated with certain complications, including inadvertent puncture of the liver capsule with the needle/catheter combination during needle passes. In addition, the accompanying post-TIPS intraperitoneal hemorrhage has not been well reported and guidelines behind its management are not well described. We present a case of a 33-year-old male with refractory ascites who underwent TIPS, during which the hepatic capsule was inadvertently punctured, leading to the development of hemoperitoneum in the patient due to a bleeding diathesis.
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Affiliation(s)
| | | | - Matthew Smith
- Department of Radiology, NYC Health + Hospital/Queens, Queens, NY, USA
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13
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Mishra AK, Mandal M, Mohamed IR, Lal S, Bhujade H. Successful surgical management of cardiac tamponade following direct intrahepatic portosystemic shunt in a child with Budd-Chiari syndrome: A potentially life-threatening situation. Ann Pediatr Cardiol 2023; 16:370-373. [PMID: 38766449 PMCID: PMC11098295 DOI: 10.4103/apc.apc_107_23] [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: 07/05/2023] [Revised: 09/12/2023] [Accepted: 01/06/2024] [Indexed: 05/22/2024] Open
Abstract
Direct intrahepatic portosystemic shunt is a technique of portocaval shunting performed through the percutaneous route in patients with Budd-Chiari syndrome. Stent migration into right-sided heart chambers or perforations causing hemopericardium and cardiac tamponade is rare and underreported. In a child with a coexisting decompensated liver disease, surgical intervention and cardiopulmonary bypass can be challenging. However, surgical management in these life-threatening situations is better than redo interventions.
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Affiliation(s)
- Anand Kumar Mishra
- Department of Cardiothoracic and Vascular Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Meenakshi Mandal
- Department of Cardiothoracic and Vascular Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Irshad R. Mohamed
- Department of Cardiothoracic and Vascular Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sadhna Lal
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harish Bhujade
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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14
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Feinggumloon S, Haber Z, Saab S, Kaldas F, Eghbalieh N, Luong TT, McWilliams JP, Lee EW. Clinical Impact and Safety of Non-Target Punctures (NTP) during Portal Vein Access in TIPS Procedure. Biomedicines 2023; 11:1630. [PMID: 37371725 DOI: 10.3390/biomedicines11061630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Although non-target puncture (NPT)-related complications are well known to clinicians performing TIPS, there is no NTP-focused study to assess the true clinical sequalae of NTP-related complications. In this study, the aim was to evaluate the incidence, safety, clinical outcomes and complications related to NTPs during the portal access of TIPS procedures. METHODS A retrospective review of 369 TIPS procedures from October 2007 to September 2019 was performed. We identified inadvertent NTPs, including biliary, hepatic artery, lymphatic and capsular punctures. Next, the medical records and images were reviewed and analyzed to assess the safety and clinical outcomes of these cohorts. RESULTS A total of 71 NTPs were identified in 56 patients (15.18% of 369 patients). Of 369 TIPS patients, there were (1) 28 biliary punctures (7.6%), (2) 16 extracapsular punctures (4.3%), (3) 15 lymphatic punctures (4.1%) and (4) 12 hepatic artery punctures (3.3%). The overall complication rate was 2.2% (8/369). Based on the Clavien-Dindo classification, three patients (0.8%) had a minor complication. In addition, five patients (1.4%) experienced grade II-V major complications, such as symptomatic hemoperitoneum, arterio-biliary fistula or hemorrhagic shock leading to death. Mortality (0.5%) was only caused by extracapsular puncture combined with other NTP. CONCLUSIONS NTPs during the portal access of TIPS procedures are associated with low complication risk. However, when extracapsular punctures are combined with other NTPs, a more severe complication, including mortality, can occur. Nevertheless, all patients with NTP should be closely monitored at a higher level of care after TIPS placement.
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Affiliation(s)
- Sasikorn Feinggumloon
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Zachary Haber
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Sammy Saab
- Division of Hepatology, Department of Medicine, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Fady Kaldas
- Division of Liver and Pancreas Transplantation Surgery, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Navid Eghbalieh
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Thanh T Luong
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Justin P McWilliams
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Division of Liver and Pancreas Transplantation Surgery, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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15
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Kang RD, Nezami N, Park P, DePalma AA, Loya MF, Mhaskar R, Engel C, Zwiebel B, Hoots G, Shaikh J. Safety and feasibility of a novel bi-directional portal vein access kit during transjugular intrahepatic portosystemic shunt creation. CVIR Endovasc 2023; 6:24. [PMID: 37074479 PMCID: PMC10115920 DOI: 10.1186/s42155-023-00366-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/14/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) creation remains as one of the more technically challenging endovascular procedures. Portal vein access from the hepatic vein often requires multiple needle passes, which increases procedure times, risk of complications, and radiation exposure. With its bi-directional maneuverability, the Scorpion X access kit may be a promising tool for easier portal vein access. However, the clinical safety and feasibility of this access kit has yet to be determined. MATERIALS AND METHODS In this retrospective study, 17 patients (12 male, average age 56.6 ± 9.01) underwent TIPS procedure using Scorpion X portal vein access kits. The primary endpoint was time taken to access the portal vein from the hepatic vein. The most common indications for TIPS were refractory ascites (47.1%) and esophageal varices (17.6%). Radiation exposure, total number of needle passes, and intraoperative complications were recorded. Average MELD Score was 12.6 ± 3.39 (range: 8-20). RESULTS Portal vein cannulation was successfully achieved in 100% of patients during intracardiac echocardiography-assisted TIPS creation. Total fluoroscopy time was 39.31 ± 17.97 min; average radiation dose was 1036.76 ± 644.15 mGy, while average contrast dose was 120.59 ± 56.87 mL. The average number of passes from the hepatic vein to the portal vein was 2 (range: 1-6). Average time to access the portal vein once the TIPS cannula was positioned in the hepatic vein was 30.65 ± 18.64 min. There were no intraoperative complications. CONCLUSIONS Clinical utilization of the Scorpion X bi-directional portal vein access kit is both safe and feasible. Utilizing this bi-directional access kit resulted in successful portal vein access with minimal intraoperative complications. LEVEL OF EVIDENCE Retrospective cohort.
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Affiliation(s)
- Richard D Kang
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Experimental Therapeutics Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA
| | - Peter Park
- Emory University, School of Medicine, Department of Radiology and Image Guided Medicine, Atlanta, GA, USA
| | - Anthony A DePalma
- Emory University, School of Medicine, Department of Radiology and Image Guided Medicine, Atlanta, GA, USA
| | - Mohammed F Loya
- Mid-Atlantic Permanente Medical Group, Kaiser Permanente, Rockville, MD, USA
| | - Rahul Mhaskar
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Chad Engel
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
- Department of Radiology, University of South Florida Health, Tampa General Hospital, Tampa, FL, USA
| | - Bruce Zwiebel
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
- Department of Radiology, University of South Florida Health, Tampa General Hospital, Tampa, FL, USA
| | - Glenn Hoots
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
- Department of Radiology, University of South Florida Health, Tampa General Hospital, Tampa, FL, USA
| | - Jamil Shaikh
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA.
- Department of Radiology, University of South Florida Health, Tampa General Hospital, Tampa, FL, USA.
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16
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Chen J, Bai X, Wang C, Li J, Xu W. Preliminary clinical observation of double C-arm digital subtraction angiography guidance during transjugular intrahepatic portosystemic shunt placement. BMC Gastroenterol 2023; 23:112. [PMID: 37024803 PMCID: PMC10077684 DOI: 10.1186/s12876-023-02745-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 03/26/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND This study aimed to investigate the safety, preliminary clinical experience, and technical advantages of double C-arm digital subtraction angiography -assisted portal vein puncture for transjugular intrahepatic portosystemic shunt. METHODS Clinical data of 25 patients with portal hypertension caused by liver cirrhosis were retrospectively analyzed from January 2021 to June 2022. The fluoroscopy time, puncture time, mean portosystemic pressure gradient, dose area product, and intraoperative and postoperative complications were recorded. RESULTS Transjugular intrahepatic portosystemic shunt was performed in all 25 patients, with a success rate of 100%. The fluoroscopy time, puncture time, and dose area product were 33.6 ± 8.5 min, 9.1 ± 5.7 min, and 126 ± 53 Gy·cm2, respectively. The mean portosystemic pressure gradient decreased from 22.5 ± 6.3 mmHg to 10.5 ± 2.3 mmHg (p < 0.01). No serious intraoperative and postoperative complications were found. CONCLUSION Double C-arm digital subtraction angiography-assisted portal vein puncture is safe and feasible in transjugular intrahepatic portosystemic shunt operation. It can reduce the difficulty of the operation and possesses evident technical advantages.
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Affiliation(s)
- Jianqiao Chen
- Zhuhai Hospital Affiliated With Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
| | - Xiao Bai
- Zhuhai Hospital Affiliated With Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
| | - Chunyan Wang
- Zhuhai Hospital Affiliated With Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
| | - Jihua Li
- Zhuhai Hospital Affiliated With Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
| | - Weiguo Xu
- Zhuhai Hospital Affiliated With Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China.
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17
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Posa A, Tenore L, Barbieri P, Mazza G, Sala E, Iezzi R. The Role of the Transjugular Intrahepatic Porto-Systemic Shunt in an Emergency Setting. Life (Basel) 2023; 13:868. [PMID: 37109397 PMCID: PMC10146175 DOI: 10.3390/life13040868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023] Open
Abstract
Transjugular intrahepatic porto-systemic shunt (TIPSS) is an interventional radiology procedure whose aim is to create artificial communication between the portal and the hepatic blood flow in order to reduce the pressure gradient in portal hypertension. The indications to perform a TIPSS procedure can be framed in an elective or emergency setting: refractory ascites to diuretic therapy and secondary prophylaxis of variceal hemorrhage are the most frequent reasons for executing a TIPSS in an election context, while acute uncontrolled variceal bleeding is the principal indication that a TIPSS needs to be performed in an emergency setting. In recent years, the role of the TIPSS has been redefined for several conditions, such as ectopic varices, portal vein thrombosis, Budd-Chiari syndrome, hepatic veno-occlusive disease, and many others. This review aims to perform a deep analysis of when and why a TIPSS procedure should be carried out in an emergency, pointing out the related most common technical difficulties and complications.
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Affiliation(s)
- Alessandro Posa
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Lorenzo Tenore
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Pierluigi Barbieri
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Giulia Mazza
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Evis Sala
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Istituto di Radiodiagnostica, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
| | - Roberto Iezzi
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Istituto di Radiodiagnostica, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
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18
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Li WC, Zhong BY, Zhang S, Shen J, Wang W, Zhu XL. Emergent Transjugular Intrahepatic Portosystemic Shunt as a First-Line Therapy in Patients with Cirrhosis with Acute Gastroesophageal Variceal Hemorrhage. J Vasc Interv Radiol 2023; 34:344-350. [PMID: 36414117 DOI: 10.1016/j.jvir.2022.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 10/20/2022] [Accepted: 11/13/2022] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To investigate the safety and effectiveness of emergent transjugular intrahepatic portosystemic shunt (TIPS) as first-line therapy in patients with advanced cirrhosis with acute variceal hemorrhage. MATERIALS AND METHODS From July 2016 to June 2019, 76 patients with advanced cirrhosis and acute variceal hemorrhage were included in this retrospective study. All patients underwent emergent TIPS as first-line therapy within 24 hours. Gastroesophageal varices in patients with cirrhosis were diagnosed with contrast-enhanced computed tomography because emergent endoscopy has not been routinely performed in this center. The primary outcomes were the control rate of bleeding and the rate of rebleeding. Secondary outcomes were the technical success rate of procedure, transplantation-free survival, the mean hospitalization time, the time of stay in the intensive care unit, and adverse events. RESULTS All patients underwent TIPS creation successfully and were transferred to general wards. The median follow-up time was 21.7 months (interquartile range, 12.6-28.1 months). The control rate of bleeding (≤5 days) was 100%. The rates of early (>5 days to 6 weeks) and late (>6 weeks to 2 years) rebleeding were 6.6% and 1.3%, respectively. The 6-week, 1-year, and 2-year transplantation-free survival rates were 94.7%, 93.4%, and 84.6%, respectively. The incidences of acute liver failure, hepatic encephalopathy, and shunt dysfunction were 5.3%, 25%, and 5.3%, respectively. CONCLUSIONS Emergent TIPS as a first-line therapy in patients with advanced cirrhosis with acute variceal hemorrhage is safe and effective. This study provides an alternative approach for medical centers without emergent endoscopy facility to manage the condition.
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Affiliation(s)
- Wan-Ci Li
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, Suzhou, China
| | - Bin-Yan Zhong
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, Suzhou, China
| | - Shuai Zhang
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, Suzhou, China
| | - Jian Shen
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, Suzhou, China
| | - Wansheng Wang
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, Suzhou, China
| | - Xiao-Li Zhu
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, Suzhou, China.
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19
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Lopera JE. A Comprehensive Review of Transjugular Intrahepatic Portosystemic Shunt-Related Complications. Semin Intervent Radiol 2023; 40:55-72. [PMID: 37152793 PMCID: PMC10159729 DOI: 10.1055/s-0043-1767670] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is one of the most technically complex procedures in interventional radiology, the need to connect two veins with variable anatomy, located in two different planes in hard and many times small cirrhotic livers using a needle, can be quite challenging. Despite more than 30 years of performing TIPS, the complex hemodynamics of the portal system are not fully understood, and sometimes unpredictable alterations of the portal flow can lead to serious unexpected complications. The best strategies to prevent TIPS complications are optimal patient selection, meticulous technique, operator experience, and immediate correction of identified adverse events. The purpose of this article is to review the technical complications with TIPS, the unique complications related to the use of stent grafts, and the late complications after the procedure, with emphasis on ways to prevent and treat them.
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Affiliation(s)
- Jorge E. Lopera
- Department of Radiology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
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20
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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: 2] [Impact Index Per Article: 1.0] [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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21
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Bayona Molano MDP, Rice S. The Use of Intracardiac Echocardiography in Transjugular Intrahepatic Portosystemic Shunt Procedure. Semin Intervent Radiol 2023; 40:15-18. [PMID: 37152794 PMCID: PMC10159727 DOI: 10.1055/s-0043-1764283] [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 intrahepatic portosystemic shunt (TIPS) is a complex intervention with a steep learning curve that requires centers of expertise to improve technical success and reduce complications. Portal venous access is the most challenging step of the procedure and requires planning and image guidance strategies to prevent vascular or bile duct injury and further complications. Intracardiac echocardiography (ICE) has been reported to be a safe and accurate tool that provides images of the portal vein anatomy in real time. The use of ICE has become the standard of care in several centers. It is now frequently used to target the portal vein in complex TIPS procedures. This review article describes some technical aspects and indications of ICE-guided TIPS.
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Affiliation(s)
| | - Samuel Rice
- Interventional Radiology Division, UT Southwestern Medical Center, Dallas, Texas
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22
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Deltenre P, Zanetto A, Saltini D, Moreno C, Schepis F. The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions. Hepatology 2023; 77:640-658. [PMID: 35665949 DOI: 10.1002/hep.32596] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/14/2022] [Accepted: 05/16/2022] [Indexed: 01/28/2023]
Abstract
In selected patients with cirrhosis and ascites, transjugular intrahepatic portosystemic shunt (TIPS) placement improves control of ascites and may reduce mortality. In this review, we summarize the current knowledge concerning the use of TIPS for the treatment of ascites in patients with cirrhosis, from pathophysiology of ascites formation to hemodynamic consequences, patient selection, and technical issues of TIPS insertion. The combination of these factors is important to guide clinical decision-making and identify the best strategy for each individual patient. There is still a need to identify the best timing for TIPS placement in the natural history of ascites (recurrent vs. refractory) as well as which type and level of renal dysfunction is acceptable when TIPS is proposed for the treatment of ascites in cirrhosis. Future studies are needed to define the optimal stent diameter according to patient characteristics and individual risk of shunt-related side effects, particularly hepatic encephalopathy and insufficient cardiac response to hemodynamic consequences of TIPS insertion.
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Affiliation(s)
- Pierre Deltenre
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology , CUB Hôpital Erasme, Université Libre de Bruxelles , Brussels , Belgium.,Department of Gastroenterology and Hepatology , CHU UCL Namur, Université Catholique de Louvain , Yvoir , Belgium.,Department of Gastroenterology and Hepatology , Clinique St Luc , Bouge , Belgium
| | - Alberto Zanetto
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy.,Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology , Padova University Hospital , Padova , Italy
| | - Dario Saltini
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology , CUB Hôpital Erasme, Université Libre de Bruxelles , Brussels , Belgium.,Laboratory of Experimental Gastroenterology , Université Libre de Bruxelles , Brussels , Belgium
| | - Filippo Schepis
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy
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23
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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: 1.5] [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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24
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Zhang YL, Nie CH, Zhou TY, Zhou GH, Zhu TY, Chen SQ, Wang HL, Wang BQ, Yu ZN, Jing L, Xia Q, Chen HT, Sun JH. Coil and n-butyl-2-cyanoacrylate migration into the stomach after TIPS for gastroesophageal variceal bleeding: a case report and literature review. J Cardiothorac Surg 2022; 17:304. [PMID: 36496435 PMCID: PMC9737996 DOI: 10.1186/s13019-022-02062-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established therapeutic option for the management of variceal hemorrhage in patients with cirrhosis. The simultaneous migration of the coil and n-butyl-2-cyanoacrylate (NBCA) is an extremely rare but significant complication after TIPS. Because of its rare presentation, there are currently no definitive recommendations for the management of this condition. CASE PRESENTATION A 46-year-old man with hepatitis B cirrhosis underwent TIPS placement for uncontrolled gastroesophageal varix (GEV) bleeding secondary to portal hypertension in August 2018. During the procedure, large GEVs were embolized using a coil and NBCA. After a year, coil and NBCA migration into the stomach was observed. Attempts to remove the coil using biopsy forceps during esophagogastroduodenoscopy failed. The patient refused further intervention on the coil to prevent further complications and received conservative therapy instead. Close surveillance with endoscopy is recommended for detecting coils and varices. CONCLUSIONS The present case reports an extremely rare but significant complication after TIPS, which highlights the management and follow-up recommendation for such rare complications. Our experience may provide guidance for the management of future similar cases and stimulate discussion about treatment methods of similar patients.
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Affiliation(s)
- Yue-Lin Zhang
- grid.13402.340000 0004 1759 700XHepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China ,Zhejiang Provincial Research Center for Diagnosis and Treatment of Heapatobiliary Diseases, Hangzhou, 310003 Zhejiang Province China
| | - Chun-Hui Nie
- grid.13402.340000 0004 1759 700XHepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China ,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, 310003 Zhejiang Province China
| | - Tan-Yang Zhou
- grid.13402.340000 0004 1759 700XHepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China ,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, 310003 Zhejiang Province China
| | - Guan-Hui Zhou
- grid.13402.340000 0004 1759 700XHepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China ,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, 310003 Zhejiang Province China
| | - Tong-Yin Zhu
- grid.13402.340000 0004 1759 700XHepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China ,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, 310003 Zhejiang Province China
| | - Sheng-Qun Chen
- grid.13402.340000 0004 1759 700XHepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China ,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, 310003 Zhejiang Province China
| | - Hong-Liang Wang
- grid.13402.340000 0004 1759 700XHepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China ,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, 310003 Zhejiang Province China
| | - Bao-Quan Wang
- grid.13402.340000 0004 1759 700XHepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China ,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, 310003 Zhejiang Province China
| | - Zi-Niu Yu
- grid.13402.340000 0004 1759 700XHepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China ,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, 310003 Zhejiang Province China
| | - Li Jing
- grid.13402.340000 0004 1759 700XHepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China ,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, 310003 Zhejiang Province China
| | - Qi Xia
- grid.13402.340000 0004 1759 700XDepartment of Infectious Disease, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003 Zhejiang Province China
| | - Hong-Tan Chen
- grid.13402.340000 0004 1759 700XDepartment of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003 Zhejiang Province China
| | - Jun-Hui Sun
- grid.13402.340000 0004 1759 700XHepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003 Zhejiang Province China ,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, 310003 Zhejiang Province China
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Colaneri M, Lombardi A, Maffezzoni M, Sambo M, Fabbiani M, Quaretti P, Asperges E, Moramarco L, Sacchi P, Bruno R. The infection risk after transjugular intrahepatic portosystemic shunt: A multiple competing risk analysis from a tertiary care center. Dig Liver Dis 2022; 54:1686-1690. [PMID: 35697589 DOI: 10.1016/j.dld.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 05/07/2022] [Accepted: 05/13/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Infections following transjugular intrahepatic portosystemic shunt (TIPS) placement have been poorly described. We aim to investigate the rate and the potential predictors of infections occurring after TIPS placement. METHODS Single center, retrospective, observational study. All patients who had undergone TIPS placement in the last 10 years with a minimum 1-year FU, were considered. Multiple competing risk analyses were performed to identify infection risk factors and a multivariable Cox proportional-hazard regression model to evaluate the predictors of death. RESULTS Forty-nine patients were considered. Among these, 23 (46%) developed at least 1 infection during the FU, at a median time of 237.7 days (IQR 151.5) from the TIPS placement. We did not find any predictor of infection, while MELD score and cancer were associated with death (p = .04; HR 1.14; CI 1.00- 1.30). CONCLUSION We found a high rate of all-type infections during the FU times. However, most of these infections occurred as late-onset infections and were caused by Gram-positive microorganisms. Thus, TIPS procedure itself does not seem to be burdened with high infectious perioperative risk.
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Affiliation(s)
- Marta Colaneri
- Infectious Diseases I Unit, IRCCS San Matteo, Pavia, Italy and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, V.le Golgi, 19, PV, 27100, Padiglione n. 42, Pavia, Italy.
| | - Andrea Lombardi
- Department of Pathophysiology and Transplantation, University of Milano, Milano, Italy; Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Marcello Maffezzoni
- Infectious Diseases I Unit, IRCCS San Matteo, Pavia, Italy and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, V.le Golgi, 19, PV, 27100, Padiglione n. 42, Pavia, Italy
| | - Margherita Sambo
- Infectious Diseases I Unit, IRCCS San Matteo, Pavia, Italy and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, V.le Golgi, 19, PV, 27100, Padiglione n. 42, Pavia, Italy
| | - Massimiliano Fabbiani
- Infectious and Tropical Diseases Unit, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Pietro Quaretti
- Diagnostic Radiology and General Interventional Radiology, IRCCS San Matteo, Pavia, Italy
| | - Erika Asperges
- Infectious Diseases I Unit, IRCCS San Matteo, Pavia, Italy and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, V.le Golgi, 19, PV, 27100, Padiglione n. 42, Pavia, Italy
| | - Lorenzo Moramarco
- Diagnostic Radiology and General Interventional Radiology, IRCCS San Matteo, Pavia, Italy
| | - Paolo Sacchi
- Infectious Diseases I Unit, IRCCS San Matteo, Pavia, Italy and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, V.le Golgi, 19, PV, 27100, Padiglione n. 42, Pavia, Italy
| | - Raffaele Bruno
- Infectious Diseases I Unit, IRCCS San Matteo, Pavia, Italy and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, V.le Golgi, 19, PV, 27100, Padiglione n. 42, Pavia, Italy; Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, Italy
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Transjugular intrahepatic portosystemic shunt (TIPS) complications: what diagnostic radiologists should know. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:4254-4270. [PMID: 36123434 DOI: 10.1007/s00261-022-03685-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 01/18/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for portal hypertension complications and can successfully treat variceal bleeding and refractory ascites. Although TIPS is relatively safe, procedural- or shunt-related morbidity can reach 20%, and procedural complications have a fatality rate of 2%. Delayed recognition and treatment of TIPS complications can lead to life-threatening clinical scenarios. Complications can vary from stent migration or malpositioning to nontarget organ injury, TIPS dysfunction, encephalopathy, or liver failure. This review aims to outline the role of diagnostic radiology in assessing post-TIPS complications.
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Yao W, Liu JC, Wu YJ, Yang CT, Ju SG, Wang YL, Wang CY, Huang SJ, Bai YW, Chen Y, Li TQ, Zhou C, Xiong B. Effect of underdilated transjugular intrahepatic portosystemic shunt on prognosis in patients with prior splenectomy: a propensity score-matched case-control study. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:3615-3627. [PMID: 35821274 DOI: 10.1007/s00261-022-03600-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE This study aimed to investigate whether underdilated transjugular intrahepatic portosystemic shunt (TIPS) could reduce the risk of hepatic encephalopathy (HE) and ameliorate impaired hepatic function in patients with a history of splenectomy. METHODS A retrospective case-control study was conducted with 96 patients who had prior splenectomy and TIPS placement from August 2016 to May 2022. All patients were divided into two groups based on the diameter of expansion balloon catheters, the underdilated group (6-mm balloon catheter, n = 60) and a control group (8-mm balloon catheter, n = 36). Following the 1:1 propensity score matching (PSM), 33 patients in the underdilated group and 33 patients in the control group were included. RESULTS During a median follow-up of 36 months, a quicker recovery in liver function after TIPS placement was showed in the underdilated group. The mean TBIL content (16.562 ± 6.549 μmol/L vs 23.871 ± 11.609 μmol/L, P = 0.019) and the mean CLIF-C AD score (41.108 ± 5.223 vs 45.100 ± 4.429, P = 0.033) in the underdilated group were significantly lower than those in the control group during 6 to 12 months after the procedure. In line with the control group, the ability to reduce portal pressure gradient (PPG) and achieve a significantly clinical remission of PVT and ascites severity was showed in the underdilated group 3 months after TIPS creation (P < 0.001). The Kaplan-Meier analysis demonstrated that no statistically significant differences were found in the cumulative incidence of no overt HE (OHE) (log-rank P = 0.383), cumulative incidence without shunt dysfunction (log-rank P = 0.283), cumulative incidence of no variceal rebleeding (log-rank P = 0.696), and survival (log-rank P = 0.341) (log-rank P = 0.341) between the two groups during the follow-up period. CONCLUSION For patients with prior splenectomy, it is safe to employ underdilated TIPS, as the stents will eventually self-expand to 8 mm. The present study has shown some degree of liver function preservation in the underdilated group, which may be related to slower progressive changes in the portal hemodynamics.
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Affiliation(s)
- Wei Yao
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Jiefang Avenue #1277, Wuhan, 430022, China
| | - Jia-Cheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Jiefang Avenue #1277, Wuhan, 430022, China
| | - Yong-Juan Wu
- Department of Radiology, Xiangyang Central Hospital Affiliated Hospital of Hubei University of Arts and Science Xiangyang, Hubei, 441021, People's Republic of China
| | - Chong-Tu Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Jiefang Avenue #1277, Wuhan, 430022, China
| | - Shu-Guang Ju
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Jiefang Avenue #1277, Wuhan, 430022, China
| | - Ying-Liang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Jiefang Avenue #1277, Wuhan, 430022, China
| | - Chao-Yang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Jiefang Avenue #1277, Wuhan, 430022, China
| | - Song-Jiang Huang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Jiefang Avenue #1277, Wuhan, 430022, China
| | - Yao-Wei Bai
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Jiefang Avenue #1277, Wuhan, 430022, China
| | - Yang Chen
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Jiefang Avenue #1277, Wuhan, 430022, China
| | - Tong-Qiang Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Jiefang Avenue #1277, Wuhan, 430022, China
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Jiefang Avenue #1277, Wuhan, 430022, China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. .,Hubei Province Key Laboratory of Molecular Imaging, Jiefang Avenue #1277, Wuhan, 430022, China.
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Yin X, Gu L, Zhang M, Yin Q, Xiao J, Wang Y, Zou X, Zhang F, Zhuge Y. Covered TIPS Procedure-Related Major Complications: Incidence, Management and Outcome From a Single Center. Front Med (Lausanne) 2022; 9:834106. [PMID: 35602500 PMCID: PMC9116508 DOI: 10.3389/fmed.2022.834106] [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: 12/13/2021] [Accepted: 03/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Objective Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established procedure for treating complications of portal hypertension. Due to the complexity of anatomy and difficulty of the puncture technique, the procedure itself might brought potential complications, such as puncture failure, bleeding, infection, and, rarely, death. The aim of this study is to explore the incidence, management, and outcome of TIPS procedure-related major complications using covered stents. Methods Patients who underwent TIPS implantation from January 2015 to December 2020 were recruited retrospectively. Major complications after TIPS were screened and analyzed. Results Nine hundred and forty-eight patients underwent the TIPS procedure with 95.1% (n = 902) technical success in our department. TIPS procedure-related major complications occurred in 30 (3.2%) patients, including hemobilia (n = 13; 1.37%), hemoperitoneum (n = 7; 0.74%), accelerated liver failure (n = 6; 0.63%), and rapidly progressive organ failure (n = 4; 0.42%). Among them, 8 patients died because of hemobilia (n = 1), accelerated liver failure (n = 4), and rapidly progressive organ failure (n = 3). Conclusion The incidence of major complications related to TIPS procedure is relatively low, and some of them could recover through effective medical intervention. In our cohort, the overall incidence is about 3%, which causes 0.84% death. The most fatal complication is organ failure and hemobilia.
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Affiliation(s)
- Xiaochun Yin
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Lihong Gu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Ming Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Qin Yin
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Jiangqiang Xiao
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yi Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiaoping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Feng Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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29
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Single Puncture TIPS—A 3D Fusion Image-Guided Transjugular Intrahepatic Portosystemic Shunt (TIPS): An Experimental Study. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12105267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Background: The use of a transjugular intrahepatic portosystemic shunt (TIPS) has been established as an effective treatment for portal hypertension. Despite the rapid development of this use, serious peri-procedural complications have been reported in over 10% of cases. This has largely been attributed to the access to the portal vein, also referred to as a “blind puncture”, which often requires multiple attempts. The aim of this study was to demonstrate the safety, reproducibility and accuracy of the use of real-time 3D fusion image-guided (3DFIG) single puncture TIPS to minimize the complications that are related to the “blind puncture” of TIPS procedures. Methods: A 3DFIG TIPS approach was utilized on 22 pigs by combining pre-procedural cross-sectional imaging (CT, MR or CBCT) with intra-procedural cone beam CT or angiogram imaging, which allowed for the improved 3D visual spatial orientation of the portal vein and real-time tracking of the needle in 3D. Results: Thirty-five portosystemic shunts were successfully deployed in all 22 subjects without any peri-procedural complications. Overall, 91% (32/35) of the procedures were carried out using a single puncture. In addition, the mean fluoroscopy time in our study was more than 12 times lower than the proposed reference level that has previously been proposed for TIPS procedures. Conclusion: Multi-modality real-time 3DFIG TIPS can be performed safely using a single puncture, without complications, and can potentially be used in both emergency and non-emergency clinical situations.
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Cannella R, Tselikas L, Douane F, Cauchy F, Rautou PE, Duran R, Ronot M. Imaging-guided interventions modulating portal venous flow: evidence and controversies. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 4:100484. [PMID: 35677591 PMCID: PMC9168703 DOI: 10.1016/j.jhepr.2022.100484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 12/07/2022]
Abstract
Portal hypertension is defined by an increase in the portosystemic venous gradient. In most cases, increased resistance to portal blood flow is the initial cause of elevated portal pressure. More than 90% of cases of portal hypertension are estimated to be due to advanced chronic liver disease or cirrhosis. Transjugular intrahepatic portosystemic shunts, a non-pharmacological treatment for portal hypertension, involve the placement of a stent between the portal vein and the hepatic vein or inferior vena cava which helps bypass hepatic resistance. Portal hypertension may also be a result of extrahepatic portal vein thrombosis or compression. In these cases, percutaneous portal vein recanalisation restores portal trunk patency, thus preventing portal hypertension-related complications. Any portal blood flow impairment leads to progressive parenchymal atrophy and triggers hepatic regeneration in preserved areas. This provides the rationale for using portal vein embolisation to modulate hepatic volume in preparation for extended hepatic resection. The aim of this paper is to provide a comprehensive evidence-based review of the rationale for, and outcomes associated with, the main imaging-guided interventions targeting the portal vein, as well as to discuss the main controversies around such approaches.
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31
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Sun SH, Eche T, Dorczynski C, Otal P, Revel-Mouroz P, Zadro C, Partouche E, Fares N, Maulat C, Bureau C, Schwartz LH, Rousseau H, Dercle L, Mokrane FZ. Predicting death or recurrence of portal hypertension symptoms after TIPS procedures. Eur Radiol 2022; 32:3346-3357. [PMID: 35015124 DOI: 10.1007/s00330-021-08437-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/25/2021] [Accepted: 10/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Accurate prediction of portal hypertension recurrence after transjugular intrahepatic portosystemic shunt (TIPS) placement will improve clinical decision-making. PURPOSE To evaluate if perioperative variables could predict disease-free survival (DFS) in cirrhotic patients with portal hypertension (PHT) treated with TIPS. MATERIALS AND METHODS We recruited 206 cirrhotic patients with PHT treated with TIPS, randomly assigned to training (n = 138) and validation (n = 68) sets. We recorded 7 epidemiological, 4 clinical, and 9 radiological variables. TIPS-distal end positioning (TIPS-DEP) measured the distance between the distal end of the stent and the hepatocaval junction on contrast-enhanced CT scans. In the training set, the signature was defined as the random forest for survival algorithm achieving the lowest error rate for the prediction of DFS which was landmarked 4 weeks after the TIPS procedure. In the training set, a simple to use scoring system was derived from variables selected by the signature. The primary endpoint was to assess if TIPS-DEP was associated with DFS. The secondary endpoint was to validate the scoring system in the validation set. RESULTS Overall, patients with TIPS-DEP ≥ 6 mm (n = 49) had a median DFS of 24.5 months vs. 72.8 months otherwise (n = 157, p = 0.004). In the training set, the scoring system was calculated by adding age ≥ 60 years old, Child-Pugh B or C, and TIPS-DEP ≥ 6 mm (1 point each) since the signature showed high DFS probability at 6.5 months post-landmark in patients that did not meet these criteria: 86%, 80%, and 78%, respectively. The hazard ratio [95 CI] between patients determined to be low-risk (< 2 points) and high-risk (≥ 2 points) was 2.30 [1.35-3.93] (p = 0.002) in the training set and 2.01 [0.94-4.32] (p = 0.072) in the validation set. CONCLUSION TIPS-DEP is an actionable radiological biomarker which can be combined with age and Child-Pugh score to predict death or PHT symptom recurrence after TIPS procedure. KEY POINTS • TIPS-DEP measurement was the third most important but only actionable variable for predicting DFS. • TIPS-DEP < 6 mm was associated with a DFS probability of 78% at 6.5 months post-landmark. • A simple scoring system calculated using age, Child-Pugh score, and TIPS-DEP predicted DFS after TIPS.
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Affiliation(s)
- Shawn H Sun
- Department of Radiology, Columbia University Vagellos College of Physicians and Surgeons, New York, NY, 10032, USA.,Department of Radiology, New York Presbyterian Hospital, New York, NY, USA
| | - Thomas Eche
- Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France
| | - Chloé Dorczynski
- Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France
| | - Philippe Otal
- Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France
| | - Paul Revel-Mouroz
- Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France
| | - Charline Zadro
- Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France
| | - Ephraim Partouche
- Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France
| | - Nadim Fares
- Hepato-Gastroenterology Department, Purpan University Hospital, Toulouse, France
| | - Charlotte Maulat
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | - Christophe Bureau
- Hepato-Gastroenterology Department, Purpan University Hospital, Toulouse, France
| | - Lawrence H Schwartz
- Department of Radiology, Columbia University Vagellos College of Physicians and Surgeons, New York, NY, 10032, USA.,Department of Radiology, New York Presbyterian Hospital, New York, NY, USA
| | - Hervé Rousseau
- Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France
| | - Laurent Dercle
- Department of Radiology, Columbia University Vagellos College of Physicians and Surgeons, New York, NY, 10032, USA. .,Department of Radiology, New York Presbyterian Hospital, New York, NY, USA.
| | - Fatima-Zohra Mokrane
- Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France.
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Transjugular intrahepatic portosystemic shunt with transhepatic portal vein puncture guided by ultrasound: a technical alternative. Eur J Gastroenterol Hepatol 2022; 34:112-116. [PMID: 34748302 DOI: 10.1097/meg.0000000000002174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Evaluation of an alternative technique to perform transjugular intrahepatic portosystemic shunt (TIPS), using abdominal ultrasound to guide portal puncture. METHODS Retrospective analysis of TIPS performed from January 2014 to December 2018 in an interventional radiology service. TIPS were performed according to the classic technique, except at the moment of portal branch puncture, when abdominal ultrasound was used to guide it, visualized its path within the parenchyma in real-time. Qualitative and quantitative variables were analyzed considering a 95% confidence interval and application of the Student's t-test with a significance level of P < 0.05. RESULTS Forty-one TIPS were performed. The technical success rate of ultrasound guidance in portal puncture was 100.0%. After its performance, a reduction in the portosystemic pressure gradient was observed, with an initial gradient average of 18.8 mmHg (12-25 ± 3.6 mmHg) and a final gradient of 9.2 mmHg (5-14 ± 2.4 mmHg). The mean values for the TIPS execution time, fluoroscopy time and the radiation dose, verified through the dose area product, were 65.2 ± 46.7 min, 25 ± 14.1 min and 85.6 ± 70 Gy cm2, respectively. There were no complications related to the inadvertent puncture of nontarget structures or deaths due to complications resulting from TIPS. CONCLUSION The results demonstrate that the portal transhepatic puncture guided by the abdominal ultrasound is an effective and safe procedure and results in time of execution, time of fluoroscopy and radiation dose below the current reference values of the conventional procedure.
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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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Knight GM, Clark J, Boike JR, Maddur H, Ganger DR, Talwar A, Riaz A, Desai K, Mouli S, Hohlastos E, Garcia Pagan JC, Gabr A, Stein B, Lewandowski R, Thornburg B, Salem R. TIPS for Adults Without Cirrhosis With Chronic Mesenteric Venous Thrombosis and EHPVO Refractory to Standard-of-Care Therapy. Hepatology 2021; 74:2735-2744. [PMID: 34021505 DOI: 10.1002/hep.31915] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/06/2021] [Accepted: 05/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Extrahepatic portal vein occlusion (EHPVO) from portal vein thrombosis is a rare condition associated with substantial morbidity and mortality. The purpose of this study is to investigate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) for the treatment of chronic EHPVO, cavernomatosis, and mesenteric venous thrombosis in adults without cirrhosis who are refractory to standard-of-care therapy. APPROACH AND RESULTS Thirty-nine patients with chronic EHPVO received TIPS. Laboratory parameters and follow-up were assessed at 1, 3, 6, 12, and 24 months, and every 6 months thereafter. Two hepatologists adjudicated symptom improvement attributable to mesenteric thrombosis and EHPVO before/after TIPS. Kaplan-Meier was used to assess primary and overall TIPS patency, assessing procedural success. Adverse events, radiation exposure, hospital length-of-stay and patency were recorded. Cavernoma was present in 100%, with TIPS being successful in all cases using splenic, mesenteric, and transhepatic approaches. Symptom improvement was noted in 26 of 30 (87%) at 6-month follow-up. Twelve patients (31%) experienced TIPS thrombosis. There were no significant long-term laboratory adverse events or deaths. At 36 months, freedom from primary TIPS thrombosis was 63%; following secondary interventions, overall patency was increased to 81%. CONCLUSIONS TIPS in chronic, noncirrhotic EHPVO with cavernomas and mesenteric venous thrombosis is technically feasible and does not adversely affect liver function. Most patients demonstrate subjective and objective benefit from TIPS. Improvement in patency rates are needed with proper timing of adjuvant anticoagulation.
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Affiliation(s)
- Gabriel M Knight
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Jeffrey Clark
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Justin R Boike
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Haripriya Maddur
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Daniel R Ganger
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Abhinav Talwar
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Ahsun Riaz
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Kush Desai
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Samdeep Mouli
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Elias Hohlastos
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Juan-Carlos Garcia Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders, Hamburg, Germany
| | - Ahmed Gabr
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Brady Stein
- Department of Medicine, Division of Hematology, Northwestern University, Chicago, IL, USA
| | - Robert Lewandowski
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Bartley Thornburg
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Riad Salem
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
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Patel RK, Chandel K, Tripathy TP, Mukund A. Complications of transjugular intrahepatic portosystemic shunt (TIPS) in the era of the stent graft - What the interventionists need to know? Eur J Radiol 2021; 144:109986. [PMID: 34619618 DOI: 10.1016/j.ejrad.2021.109986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is created between a hepatic vein (HV) and the portal vein (PV) to alleviate the symptoms of portal hypertension. Despite high procedural success rates, a myriad of complications may occur at every step of TIPS creation. These complications may be attributable to the procedure itself or the shunt. Portal vein puncture is the most challenging and rate-limiting step, with extrahepatic portal vein puncture being the most devastating tabletop complication. Hepatic encephalopathy is the most common shunt-related complication after TIPS. Unlike bare metallic stents, covered stents have a longer patency rate and lower incidence of TIPS dysfunction. Most of the TIPS dysfunction that occurs with stent-grafts is due to technical errors and mechanical factors. TIPS revision often requires a combination of angioplasty, mechanical thrombectomy, and thrombolytics with a need for additional stenting in some cases. This review article focuses on procedure and shunt-related complications, as well as preventive and management strategies.
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Affiliation(s)
- Ranjan Kumar Patel
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi 110070, India.
| | - Karamvir Chandel
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi 110070, India
| | - Tara Prasad Tripathy
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi 110070, India
| | - Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi 110070, India.
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Smith TA, Gage D, Quencer KB. Narrative review of vascular iatrogenic trauma and endovascular treatment. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1199. [PMID: 34430640 PMCID: PMC8350708 DOI: 10.21037/atm-20-4332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/12/2020] [Indexed: 11/29/2022]
Abstract
Iatrogenic injury is unfortunately a leading cause of morbidity and mortality for patients worldwide. The etiology of iatrogenic injury is broad, and can be seen with both diagnostic and therapeutic interventions. While steps can be taken to reduce the occurrence of iatrogenic injury, it is often not completely avoidable. Once iatrogenic injury has occurred, prompt recognition and appropriate management can help reduce further harm. The objective of this narrative review it to help reader better understand the risk factors associated with, and treatment options for a broad range of potential iatrogenic injuries by presenting a series of iatrogenic injury cases. This review also discusses rates, risk factors, as well as imaging and clinical signs of iatrogenic injury with an emphasis on endovascular and minimally invasive treatments. While iatrogenic vascular injury once required surgical intervention, now minimally invasive endovascular treatment is a potential option for certain patients. Further research is needed to help identify patients that are at the highest risk for iatrogenic injury, allowing patients and providers to reconsider or avoid interventions where the risk of iatrogenic injury may outweigh the benefit. Further research is also needed to better define outcomes for patients with iatrogenic vascular injury treated with minimally invasive endovascular techniques verses conservative management or surgical intervention.
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Affiliation(s)
- Tyler Andrew Smith
- Department of Interventional Radiology, University of Utah, Salt Lake City, UT, USA
| | - David Gage
- Department of Medicine, Intermountain Healthcare, Murray, UT, USA
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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: 0.5] [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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Use of Virtual Target Fluoroscopic Display of Three-Dimensional CO 2 Wedged Hepatic Vein Portography for TIPS Placement. Cardiovasc Intervent Radiol 2021; 44:1817-1822. [PMID: 34341874 DOI: 10.1007/s00270-021-02922-1] [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: 02/02/2021] [Accepted: 07/07/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To describe and evaluate an image fusion technique for the portal vein puncture guidance during TIPS procedure: a three-dimensional (3D) virtual target fluoroscopic display obtained with an automated 3D carbon dioxide wedged hepatic vein portography (3D CO2-WHVP). MATERIALS AND METHODS All the 37 TIPS creations performed in our institution between 3/2017 and 12/2018 were retrospectively reviewed. Seventeen procedures were guided using the 3D CO2-WHVP technique (group 1) and were compared with the other 20 procedures performed under conventional 2D fluoroscopic guidance (group 2). Image acquisition for the 3D CO2-WHVP consisted of combining a CBCT acquisition and an automatic CO2 injection. Once located on the multiplanar reformatted images of the CBCT acquisition, the portal bifurcation was manually segmented to create a virtual target that was overlaid onto live fluoroscopy allowing a real-time 3D guidance during portal vein puncture. RESULTS Primary success was 100% in group1 and 95% in group2. Median intervention length, fluoroscopy time and dose area product (DAP) were, respectively, 124 min [IQR 94-137], 40 min [IQR 26-52] and 12140 cGy.cm2 [IQR 10147-18495] in group 1 and 146 min [IQR 118-199], 40 min [IQR 36-60] and 13290 cGy.cm2 [IQR 10138-19538] in group 2. No technical parameter was significantly different between the two groups. Intraprocedural complication rate was 0% in group 1 and 20% in group 2 (p = 0.05). CONCLUSION Three-dimensional virtual target fluoroscopic display using a CBCT-acquired CO2 wedged portography is an effective and safe technique to ease intrahepatic puncture of the portal vein during TIPS procedures.
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Lamanna A, Mitreski G, Maingard J, Owen A, Schelleman T, Goodwin M, Ranatunga D. Ultrasound-guided portal vein puncture during Transjugular Intrahepatic Portosystemic Shunt: Technique and experience of a quaternary liver transplant hospital. J Med Imaging Radiat Oncol 2021; 66:60-67. [PMID: 34278730 DOI: 10.1111/1754-9485.13288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/24/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Anthony Lamanna
- Interventional Radiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Goran Mitreski
- Interventional Radiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Julian Maingard
- Department of Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Andrew Owen
- Interventional Radiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia.,Interventional Radiology Service - Department of Radiology, Barwon Health, Geelong, Victoria, Australia
| | - Tony Schelleman
- Interventional Radiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Mark Goodwin
- Interventional Radiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Dinesh Ranatunga
- Interventional Radiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
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Long S, Sutphin PD, Kalva SP. Revascularization of Chronic Iliac Vein Occlusion Using Balloon-Assisted Transseptal Needle Puncture Technique. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1728996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Objectives To evaluate the utility of a transseptal needle for balloon-assisted sharp recanalization of chronically occluded central venous structures.
Background Chronically occluded central veins are not an uncommon problem, which may arise due to a plethora of reasons. Traditionally, wire and catheter techniques are often used first in an attempt to reestablish flow. When these methods fail, more aggressive techniques are employed, such as sharp recanalization using the back end of wires, Teflon-coated wires, or Rosch–Uchida or Colapinto needles. However, utilization of transseptal needles, traditionally reserved for cardiac procedures, has rarely been described.
Methods Transseptal needle was utilized for balloon-assisted sharp recanalization after traditional wire and catheter techniques failed in revascularization of chronically occluded iliac veins.
Results Transseptal needle was utilized successfully in two cases in revascularization of chronically occluded central veins.
Conclusion Transseptal needle is a viable tool to add to the interventional radiologists’ armamentarium in reestablishing flow in chronically occluded central veins.
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Affiliation(s)
- Simon Long
- Department of Vascular and Interventional Radiology, University of California Irvine, Orange, California, United States
| | - Patrick D. Sutphin
- Department of Vascular and Interventional Radiology, GRB-290 Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Sanjeeva P. Kalva
- Department of Vascular and Interventional Radiology, GRB-290 Massachusetts General Hospital, Boston, Massachusetts, United States
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Cam I, Gencturk M, Shrestha P, Golzarian J, Flanagan S, Lim N, Young S. 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 2021; 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] [MESH Headings] [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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Affiliation(s)
- Isa Cam
- Department of Radiology, Division of Interventional Radiology, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455
| | - Mehmet Gencturk
- Department of Radiology, University of Minnesota, Minneapolis, MN
| | - Prashant Shrestha
- Department of Radiology, Division of Interventional Radiology, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455
| | - Jafar Golzarian
- Department of Radiology, Division of Interventional Radiology, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455
| | - Siobhan Flanagan
- Department of Radiology, Division of Interventional Radiology, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN
| | - Shamar Young
- Department of Radiology, Division of Interventional Radiology, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455
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Parvinian A, Fletcher JG, Storm AC, Venkatesh SK, Fidler JL, Khandelwal AR. Challenges in Diagnosis and Management of Hemobilia. Radiographics 2021; 41:802-813. [PMID: 33939540 DOI: 10.1148/rg.2021200192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hemobilia, or hemorrhage within the biliary system, is an uncommon form of upper gastrointestinal (GI) bleeding that presents unique diagnostic and therapeutic challenges. Most cases are the result of iatrogenic trauma, although accidental trauma and a variety of inflammatory, infectious, and neoplastic processes have also been implicated. Timely diagnosis can often be difficult, as the classic triad of upper GI hemorrhage, biliary colic, and jaundice is present in a minority of cases, and there may be considerable delay in the onset of bleeding after the initial injury. Therefore, the radiologist must maintain a high index of suspicion for this condition and be attuned to its imaging characteristics across a variety of modalities. CT is the first-line diagnostic modality in evaluation of hemobilia, while catheter angiography and endoscopy play vital and complementary roles in both diagnosis and treatment. The authors review the clinical manifestations and multimodality imaging features of hemobilia, describe the wide variety of underlying causes, and highlight key management considerations.©RSNA, 2021.
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Affiliation(s)
- Ahmad Parvinian
- From the Departments of Radiology (A.P., J.G.F., S.K.V., J.L.F., A.R.K.) and Gastroenterology (A.C.S.), Mayo Clinic, 200 First St SW, Rochester MN 55905
| | - Joel G Fletcher
- From the Departments of Radiology (A.P., J.G.F., S.K.V., J.L.F., A.R.K.) and Gastroenterology (A.C.S.), Mayo Clinic, 200 First St SW, Rochester MN 55905
| | - Andrew C Storm
- From the Departments of Radiology (A.P., J.G.F., S.K.V., J.L.F., A.R.K.) and Gastroenterology (A.C.S.), Mayo Clinic, 200 First St SW, Rochester MN 55905
| | - Sudhakar K Venkatesh
- From the Departments of Radiology (A.P., J.G.F., S.K.V., J.L.F., A.R.K.) and Gastroenterology (A.C.S.), Mayo Clinic, 200 First St SW, Rochester MN 55905
| | - Jeff L Fidler
- From the Departments of Radiology (A.P., J.G.F., S.K.V., J.L.F., A.R.K.) and Gastroenterology (A.C.S.), Mayo Clinic, 200 First St SW, Rochester MN 55905
| | - Ashish R Khandelwal
- From the Departments of Radiology (A.P., J.G.F., S.K.V., J.L.F., A.R.K.) and Gastroenterology (A.C.S.), Mayo Clinic, 200 First St SW, Rochester MN 55905
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Tandon B, Ramachandran J, Narayana S, Muller K, Pathi R, Wigg AJ. Outcomes of transjugular intrahepatic portosystemic shunt procedures: a 10-year experience. J Med Imaging Radiat Oncol 2021; 65:655-662. [PMID: 33687155 DOI: 10.1111/1754-9485.13168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 01/24/2021] [Accepted: 02/15/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Transjugular intrahepatic portosystemic shunt (TIPSS) is an effective modality in reducing portal pressure, and its current main indications are for the management of recurrent ascites and variceal bleeding. The demand and indications for TIPSS are growing. However, it is a complicated and technically demanding procedure with poorer outcomes associated with low volume centres. The aim of this study was, therefore, to review the outcomes of TIPSS at a 'low volume' single centre. Outcomes assessed included indications, safety, efficacy and survival. METHODS A retrospective study was undertaken of all patients who underwent a TIPSS procedure over 10 years at tertiary referral centre for complex liver disease and transplantation. Kaplan-Meier method was used to calculate actuarial survival and log-rank analysis was used to determine significant differences in survival. RESULTS Thirty-eight patients underwent the TIPSS procedure between January 2008 and December 2018. Technical, haemodynamic and clinical success were 95%, 92% and 92% respectively. Cumulative survival at one month, one year and five years were 86.8%, 72% and 44.7% respectively. Results achieved standards published in practice parameters to evaluate TIPSS safety and efficacy. CONCLUSION At a low volume centre, TIPSS usage was associated with high rates of technical, haemodynamic (HPVG reduction) and clinical success. Low volume should not be a contraindication to providing a TIPSS service; however, auditing outcomes and understanding specific institutional factors that influence quality are important requirements for low volume centres.
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Affiliation(s)
- Bhuwan Tandon
- Hepatology and Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Jeyamani Ramachandran
- Hepatology and Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sumudu Narayana
- Hepatology and Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Kate Muller
- Hepatology and Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Ramon Pathi
- Department of Radiology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Alan J Wigg
- Hepatology and Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
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Yao X, Zhou H, Huang S, Tang SH, Qin JP. Effects of transjugular intrahepatic portosystemic shunt using the Viatorr stent on hepatic reserve function in patients with cirrhosis. World J Clin Cases 2021; 9:1532-1542. [PMID: 33728297 PMCID: PMC7942045 DOI: 10.12998/wjcc.v9.i7.1532] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 12/07/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND As transjugular intrahepatic portosystemic shunt (TIPS) creation alters the hemodynamic status of the portal system, whether reduced portal blood supply affects the synthetic reserve function of the liver has been the focus of clinical attention. Since the Viatorr stent entered the Chinese market in 2015, it has not yet been widely used in clinical practice. Further, unlike other countries, the main cause of liver cirrhosis in China is viral hepatitis. Therefore, use of the Viatorr stent to establish a TIPS channel in patients with liver cirrhosis with differing etiologies is of great clinical interest.
AIM To investigate factors affecting changes in liver reserve function after TIPS Viatorr stent implantation.
METHODS Clinical data from 200 patients with cirrhotic portal hypertension who received TIPS treatment from March 2016 to March 2020 were analyzed retrospectively. The patients were divided into three groups (A-C), according to their disease etiology, with post-hepatitis, autoimmune, and alcoholic cirrhosis, respectively. Preoperative and postoperative liver and renal function and coagulation data, Child-Pugh grade, and model for end-stage liver disease (MELD) scores were collected. Statistical analyses were performed using the t-test or chi-square test. The incidence and of hepatic encephalopathy and patient survival were calculated using Kaplan-Meier method.
RESULTS The surgical success rate was 100%, with mean portal pressure gradient (mmHg) decreasing from 25.5 ± 5.22 to 10.04 ± 2.76 (t = 45.80; P < 0.001). After 24 mo, the cumulative incidence of hepatic encephalopathy in group A was significantly lower than that in group B/C, while the cumulative survival rate was significantly higher in group A than in group B/C (P < 0.05 for both). The Child-Pugh score for group A was 6.96 ± 1.21, which was significantly better than those of groups B (7.42 ± 0.99; t = -2.44; P = 0.016) and C (7.52 ± 1.12; t = -2.67; P = 0.009). Further, the MELD score for group A (9.62 ± 2.19) was significantly better than those for groups B (10.64 ± 1.90; t = -2.92; P = 0.004) and C (10.82 ± 2.01; t = -3.29; P = 0.001).
CONCLUSION Insertion of 8 mm internal diameter Viatorr stent has no significant effects on liver reserve function. Changes of liver reserve function in the medium and long term may be related to the etiology and treatment of portal hypertension.
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Affiliation(s)
- Xin Yao
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Hao Zhou
- Department of Gastroenterology, Fengjie County People's Hospital, Chongqing 404600, China
| | - Shan Huang
- Department of Digestive Medicine, General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Shan-Hong Tang
- Department of Digestion, General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Jian-Ping Qin
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
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Transjugular intrahepatic portosystemic shunt placement: portal vein puncture guided by 3D/2D image registration of contrast-enhanced multi-detector computed tomography and fluoroscopy. Abdom Radiol (NY) 2020; 45:3934-3943. [PMID: 32451673 PMCID: PMC7593285 DOI: 10.1007/s00261-020-02589-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background To assess the technical feasibility, success rate, puncture complications and procedural characteristics of transjugular intrahepatic portosystemic shunt (TIPS) placement using a three-dimensional vascular map (3D-VM) overlay based on image registration of pre-procedural contrast-enhanced (CE) multi-detector computed tomography (MDCT) for portal vein puncture guidance. Materials and methods Overall, 27 consecutive patients (59 ± 9 years, 18male) with portal hypertension undergoing elective TIPS procedure were included. TIPS was guided by CE-MDCT overlay after image registration based on fluoroscopic images. A 3D-VM of the hepatic veins and the portal vein was created based on the pre-procedural CE-MDCT and superimposed on fluoroscopy in real-time. Procedural characteristics as well as hepatic vein catheterization time (HVCT), puncture time (PT), overall procedural time (OPT), fluoroscopy time (FT) and the dose area product (DAP) were evaluated. Thereafter, HVCT, PT, OPT and FT using 3D-VM (61 ± 9 years, 14male) were compared to a previous using classical fluoroscopic guidance (53 ± 9 years, 21male) for two interventional radiologist with less than 3 years of experience in TIPS placement. Results All TIPS procedure using of 3D/2D image registered 3D-VM were successful with a significant reduction of the PSG (p < 0.0001). No clinical significant complication occurred. HVCT was 14 ± 11 min, PT was 14 ± 6 min, OPT was 64 ± 29 min, FT was 21 ± 12 min and DAP was 107.48 ± 93.84 Gy cm2. HVCT, OPT and FT of the interventionalist with less TIPS experience using 3D/2D image registered 3D-VM were statistically different to an interventionalist with similar experience using fluoroscopic guidance (pHVCT = 0.0022; pOPT = 0.0097; pFT = 0.0009). PT between these interventionalists was not significantly different (pPT = 0.2905). Conclusion TIPS placement applying registration-based CE-MDCT vessel information for puncture guidance is feasible and safe. It has the potential to improve hepatic vein catherization, portal vein puncture and radiation exposure.
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Pandhi MB, Kuei AJ, Lipnik AJ, Gaba RC. Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding. Semin Intervent Radiol 2020; 37:3-13. [PMID: 32139965 DOI: 10.1055/s-0039-3402015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.
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Affiliation(s)
- Mithil B Pandhi
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Kuei
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Illinois
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Whang G, Chopra S, Tchelepi H. "Bright Band Sign" A Grayscale Ultrasound Finding in Hepatic Infarction. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2515-2520. [PMID: 30666665 DOI: 10.1002/jum.14939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 12/26/2018] [Accepted: 12/27/2018] [Indexed: 06/09/2023]
Abstract
Hepatic infarction is infrequent due to the dual blood supply of the liver and the compensatory relationship between the hepatic artery and portal vein. Most cases occur in liver transplants due to vascular complications. Grayscale sonography combined with color and spectral wave Doppler can assess for vessel patency and parenchymal abnormalities. Liver infarctions appear as hypoechoic nonvascular regions on conventional and Doppler sonography. Here, we describe a grayscale ultrasound feature within liver infarctions in 2 liver transplants and in 1 native liver due to iatrogenic complication. This feature is similar to those described recently in the literature within splenic infarcts.
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Affiliation(s)
- Gilbert Whang
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Shefali Chopra
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Hisham Tchelepi
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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David A, Liberge R, Meyer J, Morla O, Leaute F, Archambeaud I, Gournay J, Trewick D, Frampas E, Perret C, Douane F. Ultrasonographic guidance for portal vein access during transjugular intrahepatic portosystemic shunt (TIPS) placement. Diagn Interv Imaging 2019; 100:445-453. [PMID: 30711496 DOI: 10.1016/j.diii.2019.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/08/2019] [Accepted: 01/16/2019] [Indexed: 02/07/2023]
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Stratmann K, Fitting D, Zeuzem S, Bojunga J, Trebicka J, Friedrich-Rust M, Dultz G. Establishing an indwelling peritoneal catheter as a standard procedure for hospitalized patients with ascites: Retrospective data on feasibility, effectiveness and safety. United European Gastroenterol J 2019; 7:673-681. [PMID: 31210945 DOI: 10.1177/2050640619842442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 03/13/2019] [Indexed: 12/16/2022] Open
Abstract
Background The use of an indwelling peritoneal catheter system in hospitalized patients with ascites could facilitate patient management by the prevention of repetitive abdominal paracentesis. Despite these possible benefits, the use of indwelling catheters is not widely established. Objective This retrospective study aimed to evaluate the feasibility, effectiveness and safety of the use of an indwelling catheter for ascites drainage in the clinical routine. Methods This retrospective study included all indwelling peritoneal catheter placements in our department in hospitalized patients with cirrhosis between 2014 and 2017. Results A total of 324 indwelling catheter placements for ascites in 192 hospitalized patients with cirrhosis were included. The catheter (7F, 8 cm) was placed ultrasound-assisted bed-side on the hospital ward. The technical success rate of the catheter placement was 99.7% (323/324). In 17.5% (64/324) the catheter was placed to optimize ascitic drainage prior to an abdominal intervention (e.g. transjugular intrahepatic portosystemic shunt). The median time of catheter retention was 48 hours (8-168 hours) and the median cumulative amount of drained ascites 8000 ml (550-28,000). The most common adverse event was acute kidney injury (49/324, 15.1%); the risk was particularly higher in patients with a Model for End-Stage Liver Disease (MELD) score ≥ 16 (p = 0.028; odds ratio 2.039). Ascitic fistula after catheter removal was observed in 9.6% (31/324). Catheter-related infections occurred in 4.3% (14/324), and bleeding was documented in three cases (0.8%) with one major bleeding (0.3%). Conclusion The placement of an indwelling catheter for repetitive ascitic drainage in hospitalized patients with cirrhosis can be established in the clinical routine, facilitating patient management. High-MELD patients especially have to be monitored for acute kidney injury.
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Affiliation(s)
- Katharina Stratmann
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Daniel Fitting
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Stefan Zeuzem
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Jörg Bojunga
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Jonel Trebicka
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Mireen Friedrich-Rust
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Georg Dultz
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Frankfurt, Germany
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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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