Use of transabdominal ultrasound-guided transjugular portal vein puncture on radiation dose in transjugular intrahepatic portosystemic shunt formation

Preoperative simulation results and intraoperative image fusion guidance for transjugular intrahepatic portosystemic shunt placement: a feasibility study of nineteen patients

PURPOSE

The purpose is to evaluate the feasibility and efficacy of preoperative simulation results and intraoperative image fusion guidance during transjugular intrahepatic portosystemic shunt (TIPS) creation.

METHODS

Nineteen patients were enrolled in the present study. The three-dimensional (3D) structures of the bone, liver, portal vein, inferior vena cava, and hepatic vein in the contrast-enhanced computed tomography (CT) scanning area were reconstructed in the Mimics software. The virtual Rosch-Uchida liver access set and the VIATORR stent model were established in the 3D Max software. The puncture path from the hepatic vein to the portal vein and the release position of the stent were simulated in the Mimics and 3D Max software, respectively. The simulation results were exported to Photoshop software, and the 3D reconstructed top of the liver diaphragm was used as the registration point to fuse with the liver diaphragmatic surface of the intraoperative fluoroscopy image. The selected portal vein system fusion image was overlaid on the reference display screen to provide image guidance during the operation. As a control, the last 19 consecutive cases of portal vein puncture under the guidance of conventional fluoroscopy were analyzed retrospectively, including the number of puncture attempts, puncture time, total procedure time, total fluoroscopy time, and total exposure dose (dose area product).

RESULTS

The average time of preoperative simulation was about 61.26 ± 6.98 minutes. The average time of intraoperative image fusion was 6.05 ± 1.13 minutes. The median number of puncture attempts was not significantly different between the study group (n = 3) and the control group (n = 3; P = 0.175). The mean puncture time in the study group (17.74 ± 12.78 min) was significantly lower than that in the control group (58.32 ± 47.11 min; P = 0.002). The mean total fluoroscopy time was not significantly different between the study group (26.63 ± 12.84 min) and the control group (40.00 ± 23.44 min; P = 0.083). The mean total procedure time was significantly lower in the study group (79.74 ± 37.39 min) compared with the control group (121.70 ± 62.24 min; P = 0.019). The dose area product of the study group (220.60 ± 128.4 Gy. cm2) was not significantly different from that of the control group (228.5 ± 137.3 Gy. cm2; P = 0.773). There were no image guidance-related complications.

CONCLUSION

The use of preoperative simulation results and intraoperative image fusion to guide a portal vein puncture is feasible, safe, and effective when creating a TIPS. The method is cheap and may improve portal vein puncture, which may be valuable for hospitals lacking intravascular ultrasound and digital subtraction angiography (DSA) equipment equipped with a CT-angiography function.

Transjugular intrahepatic portosystemic shunt creation (TIPS) in the angio-CT-a hybrid intervention with image fusion

OBJECTIVE

For transjugular intrahepatic portosystemic shunt (TIPS) creation, ultrasound guidance for portal vein puncture is strongly recommended. However, outside regular hours of service, a skilled sonographer might be lacking. Hybrid intervention suites combine CT imaging with conventional angiography allowing to project 3D information into the conventional 2D imaging and further CT-fluoroscopic puncture of the portal vein. The purpose of this study was to assess whether TIPS using angio-CT facilitates the procedure for a single interventional radiologist.

METHODS

All TIPS procedures from 2021 and 2022 which took place outside regular working hours were included (n = 20). Ten TIPS procedures were performed with just fluoroscopy guidance and ten procedures using angio-CT. For the angio-CT TIPS, a contrast-enhanced CT was performed on the angiography table. From the CT, a 3D volume was created using virtual rendering technique (VRT). The VRT was blended with the conventional angiography image onto the live monitor and used as guidance for the TIPS needle. Fluoroscopy time, area dose product, and interventional time were assessed.

RESULTS

Hybrid intervention with angio-CT did lead to a significantly shorter fluoroscopy time and interventional time (p = 0.034 for both). Mean radiation exposure was significantly reduced, too (p = 0.04). Furthermore, the mortality rate was lower in patients who underwent the hybrid TIPS (0% vs 33%).

CONCLUSION

TIPS procedure in angio-CT performed by only one interventional radiologist is quicker and reduces radiation exposure for the interventionalist compared to mere fluoroscopy guidance. The results further indicate increased safety using angio-CT.

CLINICAL RELEVANCE STATEMENT

This study aimed to evaluate the feasibility of using angio-CT in TIPS procedures during non-standard working hours. Results indicated that the use of angio-CT significantly reduced fluoroscopy time, interventional time, and radiation exposure, while also leading to improved patient outcomes.

KEY POINTS

• Image guiding such as ultrasound is recommended for transjugular intrahepatic portosystemic shunt creation but might be not available for emergency cases outside of regular working hours. • Transjugular intrahepatic portosystemic shunt creation using an angio-CT with image fusion is feasible for only one physician under emergency settings and results in lower radiation exposure and faster procedures. • Transjugular intrahepatic portosystemic shunt creation using an angio-CT with image fusion seems to be safer than using mere fluoroscopy guidance.

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

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

A Comprehensive Review of Transjugular Intrahepatic Portosystemic Shunt-Related Complications

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.

The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions

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.

Intravascular US: Applications in Interventional Radiology

Interventional radiology applications of intravascular US (IVUS) continue to expand, complementing intraprocedural angiography and providing a unique vantage from which to guide endovascular interventions. Vascular pathologic conditions become sonographically visualized rather than inferred from the planar appearance of the opacified vascular lumen. Perivascular targets become sonographically visualized rather than approximated on the basis of fluoroscopic landmarks. The authors introduce broad categories of IVUS catheters, namely radial and side-firing varieties, as well as prevailing options for each and their technical specifications. Common applications within interventional radiology are covered in a systems approach, including deep venous thrombosis, May-Thurner syndrome, nutcracker syndrome, transjugular intrahepatic portosystemic shunts, aortic interventions, peripheral arterial disease, and endovascular or perivascular biopsy. Discussions are accompanied by technical pearls from the authors, and summarized evidence where IVUS has been shown to reduce procedural time, intravascular contrast agent dose, radiation exposure, and morbidity in each space is presented. Finally, emerging applications and future directions are discussed. ^©RSNA, 2022.

Local diagnostic reference levels in diagnostic and therapeutic pediatric cardiology at a specialist pediatric hospital in South Africa

Introduction: Children may be at a higher risk of experiencing the detrimental effects of ionizing radiation arising from medical radiation imaging. Dose optimisation is therefore recommended to provide assurance that their exposure is as low as reasonably achievable. To this end, periodic assessment of dose levels and establishment of Local Diagnostic Reference Levels (LDRLs) in medical facilities is necessary. There is a general paucity in the literature of data pertaining to dose levels in pediatric interventional radiology. This study establishes LDRLs in diagnostic and therapeutic heart catheterization procedures at a specialist pediatric hospital in a resource constrained country.

Material and methods: Dose indicators from actual patient procedures were collected from the archive and analyzed retrospectively to determine the median, 25th, and 75th percentiles of the total Air Kerma Area Product (KAP), Cumulative Air Kerma (CAK), total Fluoroscopy Time (FT), and a total number of Cine Images (CI) of selected interventional procedures. The dose indicators were also age-stratified into five age groups defined by the International Commission on Radiation Protection publication 135. The results were compared to values available from similar studies in the literature to benchmark our dose levels. Local Dose Reference Levels were set as the 75th percentile values.

Results: For diagnostic procedures (n = 80), the 75th percentiles of KAP, CAK, FT, and CI were 4.0 Gy·cm2, 31.5 mGy, 14.3 min, and 315 frames, respectively and 3.2 Gy·cm2, 30.5 mGy, 17.5 min, and 606 frames, respectively for therapeutic procedures (n = 143).

Conclusions: The LDRLs from this study did not vary significantly from those published in the literature, suggesting that practices at our center were comparable to international norms. Regular reviews of the LDRLs must be conducted to check that the dose levels do not deviate considerably.

Use of an Intrahepatic Arterial Targeting Wire for Guiding Portal Vein Puncture During TIPS Creation in Patients With Obliterative Portal Vein Thrombosis

Obtaining portal vein access is a challenging step in transjugular intrahepatic portosystemic shunt (TIPS) creation, particularly in patients with portal vein thrombosis (PVT). We report the use of an intrahepatic arterial targeting wire (IATW) to provide a target for portal vein puncture in 20 patients with cirrhosis and complete obliterative PVT who underwent TIPS placement. Technical success rate of TIPS was 90% (18/20). The median number of punctures was 3. No severe complication occurred.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Interventions in Portal Hypertension and Its Complications

Portal hypertension is a complication of chronic liver disease. Various radiological interventions are being done to aid in the diagnosis of portal hypertension; further, an interventional radiologist can offer various treatments for the complications of portal hypertension. Diagnosis of portal hypertension in its early stage may require hepatic venous pressure gradient measurement. Measurement of gradient also guides in diagnosing the type of portal hypertension, measuring response to treatment and prognostication. This article attempts to provide evidence-based guidelines on the management of portal hypertension and treatment of its complications.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Differentiation of malignant from non-malignant portal vein thrombosis in liver cirrhosis: the challenging dilemma

Background

PVT is an ultrasonographic finding in up to 8% of patients with liver cirrhosis. Once hepatocellular carcinoma has occurred as the final station in liver cirrhosis, the risk of PVT rises to 40%. Benign and malignant PVT can occur in patients with liver cirrhosis, and it is important to differentiate the nature of PVT as it has a great impact on patient’s management and outcome.

Diagnosis

Confirming portal vein thrombosis and extension by abdominal ultrasound, contrast-enhanced USG, CT, or MRI. Malignant criteria of PVT are pulsatile pattern in Doppler and heterogeneous contrast enhancement, which are especially seen at the arterial phase, neovascularity within PVT, portal vein thrombus with a diameter of > 23 mm while in benign thrombus, PV diameter does not exceed 20 mm. Visible hypervascular tumor is in close proximity to PVT.

Conclusion

It is not uncommon to find portal vein thrombosis in patients with liver cirrhosis, despite the fact that malignant variant is the most frequent, but efforts should be gathered to exclude benign PVT which may change the management of the patients dramatically.

Patients' Radiation Shielding in Interventional Radiology Settings: A Systematic Review

As a result of the increasing risk of developing radiation-related complications, many approaches aimed at reducing this risk and enhancing the outcomes of the patient, doctor or device operator have been developed. In this systematic review, we aim to discuss previous investigations that studied patient shielding or protection within the context of selected interventional radiology procedures. We included original studies that used K_a,r, and P_KA for the assessment of the outcomes of two procedures: transjugular intrahepatic portosystemic shunt creation (TIPS) and hepatic arterial chemoembolization (HAE). A thorough search strategy was conducted on relevant databases to identify all relevant studies. We included 13 investigations, including 12 cross-sectional studies and one randomized controlled trial. Significant diversity was found among all these studies in terms of the used modalities, which made them hard to compare. However, almost all studies agreed that using novel imaging and interventional modalities is useful when obtaining better outcomes and reducing patient radiation exposure. The use of ultrasound-guided procedures and providing adequate lead curtains has also been recommended by the identified studies in order to minimize the frequency of radiation exposure. The reported K_a,r, and P_KA were also variable between studies and were discussed within this study. Our findings indicate that unified guidelines for patient radiation shielding should be urgently investigated.

Portal vein puncture-related complications during transjugular intrahepatic portosystemic shunt creation: Colapinto needle set vs Rösch-Uchida needle set

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.

Ultrasound-guided portal vein puncture during Transjugular Intrahepatic Portosystemic Shunt: Technique and experience of a quaternary liver transplant hospital

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.

Feasibility of Augmented Reality-Guided Transjugular Intrahepatic Portosystemic Shunt

PURPOSE

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

MATERIALS AND METHODS

An AR navigation system for TIPS was designed. Three-dimensional (3D) liver models including portal and hepatic vein anatomy were extracted from preoperative CT images. The 3D models, intraoperative subjects, and electromagnetic tracking information of the puncture needles were integrated through the system calibration. In the AR head-mounted display, the 3D models were overlaid on the subjects, which was a liver phantom in the first phase and live beagle dogs in the second phase. One life-size liver phantom and 9 beagle dogs were used in the experiments. Imaging after puncture was performed to validate whether the needle tip accessed the target hepatic vein successfully.

RESULTS

Endovascular punctures of the portal vein of the liver phantom were repeated 30 times under the guidance of the AR system, and the puncture needle successfully accessed the target vein during each attempt. In the experiments of live canine subjects, the punctures were successful in 2 attempts in 7 beagle dogs and in 1 attempt in the remaining 2 dogs. The puncture time of needle from hepatic vein to portal vein was 5-10 s in the phantom experiments and 10-30 s in the canine experiments.

CONCLUSIONS

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

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Transjugular intrahepatic portosystemic shunt creation via isolated persistent left superior vena cava: a case series

BACKGROUND

Isolated persistent left superior vena cava (PLSVC) is a rare vascular anatomic variant, which can be an incidental finding at the time of an endovascular procedure.

CASE PRESENTATION

This report describes the technical success, adverse events, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation via isolated PLSVC. Three adult patients with cirrhosis and isolated PLSVC underwent TIPS placement successfully with one major adverse event. Two patients required TIPS revision within 90 days. There were no deaths within 90 days.

CONCLUSIONS

TIPS creation via isolated PLSVC is feasible using standard techniques with a left jugular vein approach. Caution is warranted during the procedure to assess for any aberrant drainage pattern to the left atrium and to prepare for potentially challenging instrument navigation through the coronary sinus.

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

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

Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension

These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS.

A stepwise thrombolysis regimen in the management of acute portal vein thrombosis in patients with evidence of intestinal ischaemia

BACKGROUND

Anticoagulation alone in acute, extensive portomesenteric vein thrombosis (PVT) does not always result in spontaneous clot lysis, and leaves the patient at risk of complications including intestinal infarction and portal hypertension.

AIM

To develop a new standard of care for patients with acute PVT and evidence of intestinal ischaemia.

METHODS

We present a case series of patients with acute PVT and evidence of intestinal ischaemia plus ongoing symptoms despite initial systemic anticoagulation, who were treated with a thrombolysis protocol between 2014 and 2019. This stepwise protocol initially uses low-dose systemic alteplase, and in patients with ongoing abdominal pain, and no evidence of radiological improvement, is followed by local clot dissolution therapy (CDT) through a TIPSS. Outcomes and safety were assessed.

RESULTS

Twenty-two patients were included. The mean age was 44.6 (standard deviation [SD] 16.0) years, and 64% had an identifiable prothrombotic risk factor. All patients had intestinal wall oedema and 77% had complete occlusion of all portomesenteric veins. Systemic thrombolysis was started 18.7 (SD 11.2) days after the onset of symptoms. 55% of patients underwent TIPSS insertion for CDT. At the end of treatment, symptoms resolved in 91% of patients and recanalisation in 86%. Only one patient required resection for intestinal ischaemia, and there were no deaths. Major complications occurred in two patients (9%).

CONCLUSIONS

Our stepwise protocol is effective, resulting in good recanalisation rates. It can be commenced early while organising transfer to a centre capable of performing local CDT.

Transjugular intrahepatic portosystemic shunt creation: three-dimensional roadmap versus CO2 wedged hepatic venography

OBJECTIVES

The blind portal vein puncture remains the most challenging step during transjugular intrahepatic portosystemic shunt (TIPS) creation. We performed a prospective randomised clinical trial to compare three-dimensional (3D) roadmap with CO₂ wedged hepatic vein portography for portal vein puncture guidance.

METHODS

Between March 2017 and May 2017, 30 patients were enrolled and randomly allocated to the study group (3D roadmap) or the control group (CO₂ wedged hepatic vein portography).

RESULTS

Technical success of TIPS procedures was achieved in all 30 patients. The mean number of needle passes was significantly lower in the study group (2.0 ± 1.0) compared to the control group (3.7 ± 2.5; p = 0.021). A total of six (40%) patients in the study group and three (20%) in the control group required only one puncture for the establishment of TIPS. There were no significant differences in total fluoroscopy time (p = 0.905), total procedure time (p = 0.199) and dose-area product (p = 0.870) between the two groups.

CONCLUSIONS

3D roadmap is a safe and technically feasible means for portal vein puncture guidance during TIPS creation, equivalent in efficacy to CO₂ wedged hepatic vein portography. This technique could reduce the number of needle passes, thereby simplifying the TIPS procedure.

KEY POINTS

• 3D roadmap can be used to guide portal vein puncture. • Compared with CO ₂ venography, 3D roadmap reduced the number of needle passes. • 3D roadmap has a potential to simplify the TIPS procedure.