North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.

Cryoablation of low-flow vascular malformations

PURPOSE

We aimed to evaluate the safety and effectiveness of cryoablation in the treatment of low-flow malformations, specifically venous malformation (VM) and fibroadipose vascular anomaly (FAVA).

METHODS

We conducted a retrospective review of 11 consecutive patients with low-flow malformations (14 lesions; 9 VM, 5 FAVA), median lesion volume 10.8 cm3, (range, 1.8-55.6 cm3) with a median age of 19 years (range, 10-50 years) who underwent cryoablation to achieve symptomatic control. Average follow-up was at a median of 207 days postprocedure (range, 120-886 days). Indications for treatment included focal pain and swelling. Technical success was achieved if the cryoablation ice ball covered the region of the malformation that corresponded to the patient's symptoms. Clinical success was considered complete if all symptoms resolved and partial if some symptoms persisted but did not necessitate further treatment.

RESULTS

The technical success rate was 100%. At 1-month follow-up, 13 of 14 lesions (93%) had a complete response and one (7%) had a partial response. At 6-month follow-up 12 of 13 (92%) had a complete response and 1 (8%) had a partial response. A total of 6 patients underwent primary cryoablation. Out of 9 VM cases, 7 had prior sclerotherapy and 2 had primary cryoablation. Out of the 5 FAVA cases, 1 had prior sclerotherapy and the remaining 4 cases underwent primary cryoablation. There were 3 minor complications following cryoablation including 2 cases of skin blisters and 1 case of transient numbness. These complications resolved with conservative management.

CONCLUSION

Cryoablation is safe and effective in the treatment of low-flow vascular malformations, either after sclerotherapy or as primary treatment.

Percutaneous Cholecystolithotomy Using Cholecystoscopy

The morbidity and mortality of cholecystectomy can increase to 10% in high surgical risk patients. The technique for percutaneous cholecystolithotomy consists of 3 steps: (1) percutaneous cholecystostomy, (2) tract dilation and cholecystolithotomy, and (3) tract evaluation and catheter removal. Cholecystoscopy is critical in guiding the lithotripsy probe for fragmentation of large stones and is useful for locating small stone fragments not seen in cholangiography. Cholecystoscopy is also useful for assessing ambiguous lesions and in distinguishing between stone vs debris or mass. Technical success rate of percutaneous cholecystolithotomy using cholecystoscopy ranges from 93% to 100%. Procedure related complication rate has been reported as 4%-15%. The most common complication is bile leak during the procedure or after catheter removal. Although recurrence rate of gallstones has been reported up to 40%, the symptom recurrence rate is much lower. Therefore, percutaneous cholecystolithotomy using cholecystoscopy can be an alternative to cholecystectomy in high surgical risk patients with symptomatic gallstones.

Modified Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) Techniques for the Treatment of Gastric Varices: Vascular Plug-Assisted Retrograde Transvenous Obliteration (PARTO)/Coil-Assisted Retrograde Transvenous Obliteration (CARTO)/Balloon-Occluded Antegrade Transvenous Obliteration (BATO)

Gastric varices in the setting of portal hypertension occur less frequently than esophageal varices but occur at lower portal pressures and are associated with more massive bleeding events and higher mortality rate. Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices has been well documented as an effective therapy for portal hypertensive gastric varices. However, BRTO requires lengthy, higher-level post-procedural monitoring and can have complications related to balloon rupture and adverse effects of sclerosing agents. Several modified BRTO techniques have been developed including vascular plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, and balloon-occluded antegrade transvenous obliteration. This article provides an overview of various modified BRTO techniques.

Laparoscopic Nephrectomy: Initial Case Report

A tumor-bearing right kidney was completely excised from an 85-year-old woman using a laparoscopic approach. A newly devised method for intra-abdominal organ entrapment and a recently developed laparoscopic tissue morcellator made it possible to deliver the 190 gm. kidney through an 11 mm. incision.

US-Guided, Direct Puncture Retrograde Thoracic Duct Access, Lymphangiography, and Embolization: Feasibility and Efficacy

PURPOSE

To describe technical details, success rate, and advantages of direct puncture of the thoracic duct (TD) under direct ultrasound (US) guidance at venous insertion in the left neck.

MATERIALS AND METHODS

All patients who underwent attempted thoracic duct embolization (TDE) via US-guided retrograde TD access in the left neck were retrospectively reviewed. Indications for lymphangiography were iatrogenic chyle leak, pulmonary lymphangiectasia, and plastic bronchitis. Ten patients with mean age 41.4 years (range, 21 d to 72 y) underwent US-guided TD access via the left neck. Technical details, procedural times, and clinical outcomes were evaluated. TD access time was defined as time from start of procedure to successful access of TD, and total procedural time was defined from start of procedure until TDE.

RESULTS

All attempts at TD access via the neck were successful. Technical and clinical success of TDE was 60%. There were no complications. Mean TD access time was 17 minutes (range, 2-47 min), and mean total procedure time was 49 minutes (range, 25-69 min). Mean follow-up time was 5.4 months (range, 3-10 months).

CONCLUSIONS

TDE via US-guided access in the left neck is technically feasible and safe with a potential decrease in procedure time and elimination of oil-based contrast material.

Sclerotherapy of Diffuse and Infiltrative Venous Malformations of the Hand and Distal Forearm

PURPOSE

Venous malformations (VM) involving the hand and forearm often lead to chronic pain and dysfunction, and the threshold for treatment is high due to the risk of nerve and skin damage, functional deterioration and compartment syndrome. The purpose of this study is to demonstrate that sclerotherapy of diffuse and infiltrative VM of the hand is a safe and effective therapy.

MATERIALS AND METHODS

A retrospective review of all patients with diffuse and infiltrative VM of the hand and forearm treated with sclerotherapy from 2001 to 2014 was conducted. All VM were diagnosed during the clinical visit by a combination of physical examination and imaging. Sclerotherapy was performed under imaging guidance using ethanol and/or sodium tetradecyl sulfate foam. Clinical notes were reviewed for signs of treatment response and complications, including skin blistering and nerve injury.

RESULTS

Seventeen patients underwent a total of 40 sclerotherapy procedures. Patients were treated for pain (76%), swelling (29%) or paresthesias (6%). Treatments utilized ethanol (70%), sodium tetradecyl sulfate foam (22.5%) or a combination of these (7.5%). Twenty-four percent of patients had complete resolution of symptoms, 24% had partial relief of symptoms without need for further intervention, and 35% had some improvement after initial treatment but required additional treatments. Two skin complications were noted, both of which resolved. No motor or sensory loss was reported.

CONCLUSION

Sclerotherapy is a safe and effective therapy for VM of the hand with over 83% of patients experiencing relief.

Management of iatrogenic bile duct injuries: role of the interventional radiologist

Bile duct injuries are infrequent but potentially devastating complications of biliary tract surgery and have become more common since the introduction of laparoscopic cholecystectomy. The successful management of these injuries depends on the injury type, the timing of its recognition, the presence of complicating factors, the condition of the patient, and the availability of an experienced hepatobiliary surgeon. Bile duct injuries may lead to bile leakage, intraabdominal abscesses, cholangitis, and secondary biliary cirrhosis due to chronic strictures. Imaging is vital for the initial diagnosis of bile duct injury, assessment of its extent, and guidance of its treatment. Imaging options include cholescintigraphy, ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and fluoroscopy with a contrast medium injected via a surgically or percutaneously placed biliary drainage catheter. Depending on the type of injury, management may include endoscopic, percutaneous, and open surgical interventions. Percutaneous intervention is performed for biloma and abscess drainage, transhepatic biliary drainage, U-tube placement, dilation of bile duct strictures and stent placement to maintain ductal patency, and management of complications from previous percutaneous interventions. Endoscopic and percutaneous interventional procedures may be performed for definitive treatment or as adjuncts to definitive surgical repair. In patients who are eligible for surgery, surgical biliary tract reconstruction is the best treatment option for most major bile duct injuries. When reconstruction is performed by an experienced hepatobiliary surgeon, an excellent long-term outcome can be achieved, particularly if percutaneous interventions are performed as needed preoperatively to optimize the patient's condition and postoperatively to manage complications.

ACR Appropriateness Criteria radiologic management of hepatic malignancy

Management of hepatic malignancy is a challenging clinical problem involving several different medical and surgical disciplines. Because of the wide variety of potential therapies, treatment protocols for various malignancies continue to evolve. Consequently, development of appropriate therapeutic algorithms necessitates consideration of medical options, such as systemic chemotherapy; surgical options, such as resection or transplantation; and locoregional therapies, such as thermal ablation and transarterial embolization. The authors discuss treatment strategies for the 3 most common subtypes of hepatic malignancy treated with locoregional therapies: hepatocellular carcinoma, neuroendocrine metastases, and colorectal metastases. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria radiologic management of benign and malignant biliary obstruction

The optimal treatment for patients with biliary obstruction varies depending on the underlying cause of the obstruction, the clinical condition of the patient, and anticipated long-term effects of the procedure performed. Endoscopic and image-guided procedures are usually the initial procedures performed for biliary obstructions. Various options are available for both the radiologist and endoscopist, and each should be considered for any individual patient with biliary obstruction. This article provides an overview of the current status of radiologic procedures performed in the setting of biliary obstruction and describes multiple clinical scenarios that may be treated by radiologic or other methods. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices

Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal bleeding is less common than esophageal variceal bleeding; however, it is associated with a high morbidity and mortality rate and its management is largely uncharted due to a relatively less-established literature. In the West (United States and Europe), the primary school of management is to decompress the portal circulation utilizing the transjugular intrahepatic portosystemic shunt (TIPS). In the East (Japan and South Korea), the primary school of management is to address the gastric varices (GVs) specifically by sclerosing them utilizing the balloon-occluded retrograde transvenous obliteration (BRTO) procedure. The concept (1970s), evolution, and development (1980s-1990s) of both procedures run parallel to one another; neither is newer than the other is. The difference is that one was adopted mostly by the East (BRTO), while the other has been adopted mostly by the West (TIPS). TIPS is effective in emergently controlling bleeding for GVs even though the commonly referenced studies about managing GVs with TIPS are studies with TIPS created by bare stents. However, the results have improved with the use of stent grafts for creating TIPS. Nevertheless, TIPS cannot be tolerated by patients with poor hepatic reserve. BRTO is equally effective in controlling bleeding GVs as well as significantly reducing the GV rebleed rate. But the resultant diversion of blood flow into the portal circulation, and in turn the liver, increases the risk of developing esophageal varices and ectopic varices with their potential to bleed. Unlike TIPS, the blood diversion that occurs after BRTO improves, if not preserves, hepatic function for 6-9 months post-BRTO. The authors discuss the detailed results and critique the literature, which has evaluated and remarked on both procedures. Future research prospects and speculation as to the ideal patients for each procedure are discussed.

Pancreaticoportal fistula and disseminated fat necrosis after revision of a transjugular intrahepatic portosystemic shunt

A 59-year old man with alcohol related cirrhosis and portal hypertension was referred for transjugular intrahepatic portosystemic shunt (TIPS) to treat his refractory ascites. Ten years later, two sequential TIPS revisions were performed for shunt stenosis and recurrent ascites. After these revisions, he returned with increased serum pancreatic enzyme levels and disseminated superficial fat necrosis; an iatrogenic pancreaticoportal vein fistula caused by disruption of the pancreatic duct was suspected. The bare area of the TIPS was subsequently lined with a covered stent-graft, and serum enzyme levels returned to baseline. In the interval follow-up period, the patient has clinically improved.

Percutaneous management of biliary leaks: biliary embosclerosis and ablation

Biliary leaks after hepatobiliary surgery are not uncommon. In certain situations minimal invasive percutaneous techniques may result in avoidance or reduction of the extent of surgery. Minimal invasive percutaneous techniques include (1) percutaneous bile collection (biloma) drainage, (2) percutaneous transhepatic biliary drainage, (3) biliary leak site embolization/sclerosis, and (4) leaking biliary segment ablation. There are two clinical applications for biliary ablation. The first is actual bile leak site ablation or embosclerosis to reduce an aperture or ablate a fistula (block a hole). The second is ablating an entire biliary segment to cease bile production and induce hepatic segmental atrophy (cease bile production). This article discusses the techniques used for biliary leak site embosclerosis/ablation (including biliary-cutaneous tract ablation) and biliary segmental ablation.

Management of venous outflow complications after liver transplantation

Liver transplantation can be complicated by stenosis of the hepatic venous or inferior vena cava outflow. Venous outflow stenosis occurs at rates of 1 to 6% depending on the type of anastomosis. Stenoses can develop acutely as a result of technical problems or can present much later after the transplant due to intimal hyperplasia or perianastomotic fibrosis. Common clinical presentations include hepatic dysfunction, liver engorgement, ascites, abdominal pain, and occasionally variceal bleeding. Treatment can generally be accomplished via a transjugular approach, but percutaneous transhepatic access may be needed when the anastomosis cannot be catheterized from the jugular access. Angioplasty can achieve technical success in restoring anastomotic patency in close to 100% of cases, but restenosis is frequent. Repeat angioplasties may be needed. In adults and pediatric patients with adult sized hepatic veins, stenting may be a better option. Resolution of clinical signs and symptoms is seen in 73 to 100% of cases. Major complications are uncommon, with stent migration being one of the more difficult complications to manage.

Clinical practice of interventional and cardiovascular radiology: current status, guidelines for resource allocation, future directions

The practices of interventional radiology and interventional neuroradiology are centered on high-quality direct patient care. These subspecialties have long histories of innovative care that has often revolutionized the treatment of disease and illness. More recently, however, this success has brought about competition from former referring physicians as they have gained access to technology and training that will enable them to obtain credentials for procedures that were formerly in the exclusive domain of interventionalists. Unfortunately, many interventional radiologists find themselves ill-equipped to compete for referrals. This is primarily because many interventional radiology practices lack complete clinical practices, which are critically important in facilitating referrals from the nonspecialists. Accordingly, this document details the critical importance of a complete clinical practice and further outlines the steps required to achieve this goal.

Long-term outcome after chemoembolization and embolization of hepatic metastatic lesions from neuroendocrine tumors

OBJECTIVE

Hepatic artery chemoembolization and hepatic artery embolization (HAE) are accepted treatments of patients with hepatic metastasis from neuroendocrine tumors. Long-term outcome data are limited. We present our experience in the use of hepatic artery chemoembolization in the treatment of patients with hepatic metastasis from neuroendocrine tumors.

MATERIALS AND METHODS

Forty-six patients with carcinoid (n = 31) or islet cell (n = 15) tumors were treated. Overall and progression-free survival times starting with the first treatment were calculated. Potential factors affecting survival, including presence of extrahepatic disease and resection of the primary lesion, were analyzed. Relief of symptoms was subjectively determined for tumors with hormonal secretion.

RESULTS

The 46 patients underwent 93 hepatic artery chemoembolization or HAE sessions. The mean overall survival time for the entire group was 1,273 +/- 185 days. The mean overall survival times for the carcinoid (1,255 +/- 163 days) and islet cell tumor (1,311 +/- 403 days) subgroups were similar (p = 0.66). The progression-free survival times for the carcinoid (602 +/- 144 days) and islet cell (501 +/- 107 days) tumor subgroups also were similar (p = 0.72). The survival time of patients without known extrahepatic metastasis (n = 18; 1,571 +/- 291 days) trended toward significance compared with that of patients with known extrahepatic disease (n = 26; 770 +/- 112 days; p = 0.08). Resection of the primary tumor in 19 of 46 patients did not affect survival (resection survival, 1,558 +/- 400 days; nonresection survival, 1,000 +/- 179 days; p = 0.44). Twenty of 25 patients with hormonally active tumors had relief of symptoms after one cycle of treatment. The 30-day mortality was 4.3%.

CONCLUSION

The overall survival time after hepatic artery chemoembolization or HAE among patients with neuroendocrine tumors is approximately 3.5 years. The progression-free survival time approaches 1.5 years. The presence of extrahepatic metastasis or an unresected primary tumor should not limit the use of hepatic artery chemoembolization or HAE.

Hepatic Arterial Chemoembolization for Hepatocellular Carcinoma: Comparison of Survival Rates with Different Embolic Agents

PURPOSE

The optimal embolic agent for transhepatic arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) has not been identified. This study reports outcomes of TACE for HCC with Gelfoam powder and polyvinyl alcohol (PVA).

MATERIALS AND METHODS

Eighty-one patients underwent 152 TACE sessions with Gelfoam powder (n = 41) or polyvinyl alcohol (PVA) and Ethiodol (n = 40) as the embolic agent. Chemotherapeutic drugs were the same for all patients (50 mg cisplatin, 20 mg doxorubicin, 10 mg mitomycin-c). The groups were compared based on number of TACE sessions, maximum tumor size, bilirubin level, aspartate and alanine aminotransferase levels, Child-Pugh score, Model for End-stage Liver Disease score, and hepatitis B or C virus positivity. The number of cases of each Child class in each group was also evaluated. Survival starting from the first TACE session was calculated according to Kaplan-Meier analysis. Forty-eight patients died during the study period, 19 received transplants, and 14 were alive at the end of the study period.

RESULTS

The groups were statistically similar in all categories regarding liver function, Child-Pugh score, tumor size, hepatitis status, and percentage of patients with Child class A, B, and C disease. The number of TACE sessions was significantly greater for the Gelfoam powder group (mean, 2.2) versus the PVA group (mean, 1.6; P = .01). Overall survival was similar between groups whether patients who received transplants were included in the analysis (mean, 659 days +/- 83 with Gelfoam powder vs 565 days +/- 71 with PVA; P = .42) or were excluded (mean, 519 days +/- 80 with Gelfoam powder vs 511 days +/- 75 with PVA; P = .93).

CONCLUSION

In similar patient groups, survival after treatment of HCC with TACE with Gelfoam powder or PVA and Ethiodol was similar.

Effects of Schwann cells and donor antigen on long-nerve allograft regeneration

Nerve allotransplantation has been used successfully in human subjects to restore function after traumatic nerve injury and avoid subsequent limb amputation. However, due to the morbidity associated with nonspecific immunosuppression, this reconstructive approach has been limited to patients with particularly severe nerve injuries. It would be desirable to broaden the indications for such procedures through development of less toxic antirejection therapies. A miniature swine model of nerve transplantation was used to investigate the effects of preoperative ultraviolet-B (UV-B)-irradiated donor alloantigen portal venous infusion and injection of cultured major histocompatibility complex (MHC)-matched Schwann cells into the nerve graft. The transplanted ulnar nerves were harvested at 20 weeks. Histomorphometry showed marked enhancement in nerve regeneration through allografts injected with Schwann cells. Serial mixed lymphocyte assays demonstrated suppression of the recipient immune response to the donor antigen after pretreatment, but no additional neuroregenerative effect of donor alloantigen pretreatment.

Comparison of MELD and Child-Pugh scores to predict survival after chemoembolization for hepatocellular carcinoma

PURPOSE

To compare the value of the Child-Pugh and Model for End-stage Liver Disease (MELD) scores to predict patient survival rates after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Eighty-seven patients underwent 169 TACE sessions. Child-Pugh and MELD values were calculated before initial treatment. Survival length was tracked from the date of the first TACE procedure. Transplant recipients were censored from the study at the time of surgery. Child-Pugh and MELD scores as well as bilirubin and albumin levels and International Normalized Ratio were placed in high and low categories defined by their respective medians. Patient survival was compared at 3 months, 6 months, 12 months, and 24 months, and patterns were tested with chi2 or Fisher exact tests. Survival over the entire period was examined with Kaplan-Meier analysis and differences were tested with log-rank tests.

RESULTS

Mean and median survival times for all patients were 24 and 17 months, respectively. Sixteen patients were censored for transplantation at a mean of 12.9 months. MELD and Child-Pugh scores correlated well with each other (r = 0.68). Child-Pugh score (r = -0.35, P = .04) correlated more strongly with 12-month survival than did MELD score (r = -0.26, P = .12). After high/low score category division, a significantly greater survival difference was predicted by Child-Pugh score (27.2 months vs 10.3 months; P = .03) versus MELD score (27.5 months vs 15.8 months; P = .19). An albumin level greater than 3.4 g/dL was also associated with significantly improved survival (29.3 months vs 10.1 months; P = .0032). Survival differences between high-risk and low-risk groups at the 3-, 6-, 12-, and 24-month intervals were significant for low Child-Pugh scores and for albumin levels greater than 3.4 g/dL. Statistical significance was not approached at any of the time lengths with MELD scores.

CONCLUSIONS

Child-Pugh score correlates better than MELD score to overall patient survival and is a better predictor than MELD score of survival at specific time points. Of the components of the Child-Pugh and MELD systems, albumin level is the most useful predictor of survival.

Endovascular recanalization of the thrombosed filter-bearing inferior vena cava

PURPOSE

To evaluate the authors' preliminary experience with use of endovascular methods to treat inferior vena cava (IVC) thrombosis in patients with IVC filters.

MATERIALS AND METHODS

Catheter-directed thrombolysis, balloon maceration, mechanical thrombectomy, and stent placement were used to treat 10 patients with thrombosis of filter-bearing IVCs causing symptoms in 18 limbs. Procedural challenges, technical and clinical success, complications, postprocedural filter status, and postprocedural pulmonary embolism (PE) prophylaxis were monitored.

RESULTS

Technical and clinical success were achieved in 15 of 18 (83%) and 14 of 18 symptomatic limbs (78%), respectively. Major bleeding (muscular hematoma) occurred in one patient (10%). Postprocedural PE prophylaxis included anticoagulation (n = 8) and placement of a new filter into a newly placed Wallstent (n = 1). During clinical follow-up, no clinically detectable PE was observed. Data pertaining to late limb status were available at a median of 19 months (range 1-46 months) follow-up in seven patients: three patients were asymptomatic, two patients had ambulatory edema only, one patient had constant mild edema, and one patient had constant severe edema. Postprocedural filter stability was radiographically documented at a median of 255 days (range, 4-1021 d) of follow-up.

CONCLUSION

Endovascular recanalization of the occluded IVC is feasible even in the presence of an IVC filter.

Doppler evaluation of transjugular intrahepatic portosystemic shunts

Transjugular intrahepatic portosystemic shunts are becoming an increasingly popular technique for the treatment of portal hypertension and its complications. However, to maintain patency, revisions are periodically required to treat stenosis and thrombosis. At many centers, Doppler sonography is used for routine follow-up. A variety of hemodynamic parameters, including main portal vein velocity, maximum stent velocity, minimum stent velocity, velocity gradient in the stent, temporal changes in stent velocity, flow direction in the intrahepatic portal and hepatic veins, and pulsatility of flow in the stent can be used. Many studies have confirmed that Doppler sonography is a valuable, noninvasive means of detecting stent malfunction, although the criteria vary somewhat at different institutions.

Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax

PURPOSE

To evaluate safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation for hepatic hydrothorax (HHyd).

MATERIALS AND METHODS

Twenty-one patients underwent TIPS creation for HHyd. A prospective TIPS database and medical records were reviewed. Clinical and radiographic outcomes were recorded as complete (symptom/effusion resolution), partial (improved symptoms/effusion), or none. Data patterns were examined with chi(2) tests and Kaplan-Meier analysis.

RESULTS

Patients included 12 women and nine men, with a mean age of 56 years, all with Child class B (n = 7) or C (n = 14) disease. The technical success rate was 100%. Mean follow-up was 223 days. Twenty-nine percent (six of 21) died within 30 days of TIPS creation, 10% (two of 21) underwent transplantation within 30 days, and 62% (13 of 21) survived beyond 30 days. Data were incomplete in two patients. Clinical response was classified as complete in 63% (12 of 19), partial in 11% (two of 19), and none in 26% (five of 19). Radiographic response was classified as complete in 30% (six of 20), partial in 50% (10 of 20), and none in 20% (four of 20). Nonresponders had multisystem organ failure, and all but one died within 30 days. However, of the 13 patients surviving longer than 30 days, 10 (77%) had a complete clinical response.

CONCLUSION

TIPS is a relatively safe and effective method of controlling HHyd. The majority of patients experienced improvement or resolution of clinical symptoms with a variable reduction in the quantity of pleural fluid. There was a tendency among nonresponders to die within 30 days.

Transjugular intrahepatic portosystemic shunt placement in the setting of polycystic liver disease: questioning the contraindication

Although polycystic liver disease has long been listed as a contraindication to transjugular intrahepatic portosystemic shunt (TIPS) creation, two cases of TIPS placement in that particular clinical setting have been reported. Another case is reported in this article and the clinical course over 21 months of follow-up is examined. The discussion reviews the mechanics of TIPS creation in a polycystic liver and the vague premise of the polycystic liver as a contraindication to TIPS.

Angioscopic observations after percutaneous thrombectomy of thrombosed hemodialysis grafts

PURPOSE

To use angioscopy to evaluate and compare the amount of residual thrombus and endoluminal wall damage in hemodialysis grafts after percutaneous thrombectomy procedures.

MATERIALS AND METHODS

Thirty-nine thrombectomy and angioscopy procedures were performed in 35 patients. Percutaneous thrombectomy methods included eight different mechanical thrombectomy devices and the "lyse and wait" technique. Videotaped images of 33 angioscopic examinations were independently reviewed by three radiologists. Two parameters-the amount of residual thrombus and degree of endoluminal wall damage-were scored on a scale of 1 to 5. Data were initially analyzed to validate the grading system and then further studied to compare the different thrombectomy techniques.

RESULTS

The Spearman rank order analysis validated the data pertaining to the amount of residual thrombus (r = 0.71, P < .0001), but there was poor correlation between reviewers regarding the degree of endoluminal wall damage. Combined scores from three reviewers revealed that the Cragg brush and Percutaneous Thrombectomy Device (PTD) left the smallest amounts of residual thrombus. The other methods tested, listed by increasing amount of residual thrombus, were the Endovac, Hydrolyser, Amplatz Thrombectomy Device, AngioJet, Oasis, and the lyse and wait technique. There were two complications related to angioscopy procedures.

CONCLUSION

Subjective observations reveal that wall-contact thrombectomy devices leave less residual thrombus than hydrodynamic devices, aspiration devices, or the lyse and wait technique.

Hemodynamics revealed by Doppler sonography in patients who have undergone creation of transjugular intrahepatic portosystemic shunts: comparison of 10- and 12-mm metallic stents

OBJECTIVE

The purpose of this study was to determine whether differences exist in baseline flow velocities in the main portal vein and the stent after the creation of transjugular intrahepatic portosystemic shunts with 10- and 12-mm Wallstents.

SUBJECTS AND METHODS

We used Doppler sonography to determine baseline flow velocities in the stent and the main portal vein in 80 patients (38 patients with 10-mm Wallstents dilated to 10 mm and 42 patients with 12-mm Wallstents dilated to 12 mm) who had undergone creation of trans jugular intrahepatic portosystemic shunts without complications.

RESULTS

We found no significant difference in the maximum flow velocity in the stent between the patients with 10-mm stents (160.3+/-34.3 cm/sec) and those with 12-mm stents (164.4+/-33.8 cm/sec). We also found no significant difference in the minimum flow velocity in the stent between the 10-mm group (132.4+/-28.9 cm/sec) and the 12-mm group (126.7+/-28.3 cm/sec). However, flow velocity through the main portal vein was significantly higher in the patients with 12-mm stents (53.6+/-18.4 cm/sec) than in those with 10-mm stents (45.1+/-13.8 cm/sec) (p < .03).

CONCLUSION

After creation of transjugular intrahepatic portosystemic shunts, baseline flow velocities in the main portal vein in patients with 12-mm stents exceeded those in patients with 10-mm stents, although neither maximum nor minimum flow velocities in the stent differed between these two groups of patients. These findings suggest that criteria for shunt malfunction that use flow velocity in the main portal vein may need modification when 12-mm stents are being evaluated.

Encephalopathy after transjugular intrahepatic portosystemic shunting: analysis of incidence and potential risk factors

OBJECTIVE

Our purpose was to estimate the incidence of encephalopathy after transjugular intrahepatic portosystemic shunting (TIPS) related primarily to the diversion of portal vein blood flow and to identify periprocedural factors to predict patients at risk.

MATERIALS AND METHODS

All patients who underwent TIPS with at least 1 month of clinical observation after the procedure were monitored for clinically evident encephalopathy. Other variables that could individually induce encephalopathy were retrospectively analyzed for interrelationships with spontaneous or worsened encephalopathy.

RESULTS

Of the 150 patients, 68 (45%) suffered from encephalopathy after TIPS, but in only 33 (22%) was it new or worse than baseline measurements obtained before TIPS; in 18 of these 33 patients, an underlying medical cause was implicated. Fifteen (10%) of the 150 patients developed mental dysfunction, usually mild and well controlled, thought to be related only to TIPS and not to any underlying morbidity. Low portal vein pressures after TIPS were found to be interrelated with new or worsened spontaneous encephalopathy (p = .04). Like-wise, advanced age (> 59 years old) weakly corresponded to the development of encephalopathy after TIPS.

CONCLUSION

TIPS causes an acceptably low rate of encephalopathy that is usually mild. No specific variables exist for predicting the development or progression of encephalopathy after TIPS.

Doppler sonography findings associated with transjugular intrahepatic portosystemic shunt malfunction

OBJECTIVE

Our purpose was to determine the overall accuracy of Doppler sonography and the accuracy of specific Doppler parameters associated with a compromised transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

For 43 patients who had undergone TIPS, 64 correlated sonogram-venogram paired examinations were analyzed. Sonographic parameters assessed included absolute velocities plus absolute and percentage changes in velocities measured in the main portal vein (MPV) and in several intrashunt locations (including peak and minimum velocity). Direction of flow and change in direction of flow in the left and right portal veins were also examined. TIPS malfunction was defined as any shunt with greater than or equal to 50% stenosis or any stenosis with a portosystemic gradient greater than 15 mm Hg.

RESULTS

The prospective interpretation of the sonograms using all available parameters resulted in a sensitivity of 92% and a specificity of 72% for detecting TIPS malfunction. Peak shunt velocity (absolute velocity and velocity change), distal shunt velocity, MPV velocity (absolute velocity and percentage change in velocity), change in minimum shunt velocity, and direction of flow in branch portal veins were found to have statistically significant differences between normal and abnormal shunts. Sensitivities for these individual parameters ranged from 64% to 84%, and specificities ranged from 70% to 100%. When either the MPV velocity or the distal shunt velocity was abnormal, the sensitivity was 94%. When both parameters were abnormal, the specificity for detecting TIPS malfunction was 100%.

CONCLUSION

Doppler sonography is a sensitive and relatively specific means of revealing TIPS malfunction. Accuracy depends on analysis of multiple sonographic parameters.