RPS 1709 - TIPS and liver venous intervention

RPS 1709-K
Keynote lecture
RPS 1709-1
Transjugular intrahepatic portosystemic shunt for the treatment of veno-occlusive disease after liver transplantation: a single-centre experience
Purpose: Veno-occlusive disease (VOD) is a rare and life-threatening vascular disease, usually seen after haematopoietic stem cell transplantation, but reported also in liver transplant (LT) recipients. Treatment is based on the use of supportive measurements (diuretics, paracentesis) or the employment of anticoagulants and profibrinolytic-antithrombotic agents. Recently, the role of a transjugular intrahepatic portosystemic shunt (TIPS) has been proposed in patients not responsive to medical treatment. However, little data is available on the efficacy and long term follow-up. We present our experience in using the TIPS as a treatment for VOD in LT recipients not responsive to medical treatment.
Methods: Retrospectively, charts of all adults LT recipients who underwent TIPS creation in a single-centre, using ePTFE covered stent, from 2004-2019 were reviewed. In 3 cases, TIPS was performed as a rescue treatment for VOD not responsive to medical treatment.
Results: All patients had a histological diagnosis of VOD performed 2, 5, and 6 months after LT, respectively. 2 patients had refractory ascites and 1 had refractory hydrothorax. Technical success of TIPS was obtained in all cases with a significant reduction of the portosystemic pressure gradient (PPG) (baseline PPG 17, 15, and 10 mmHg, respectively, final PPG 7, 5, and 5 mmHg, respectively). No immediate or delayed complications were reported. Clinical success was achieved in all 3 patients. No patients had post-TIPS hepatic encephalopathy. Until today, all patients are still alive and in good clinical conditions with a follow-up of 130, 49, and 27 months, respectively.
Conclusion: In our experience, TIPS creation was associated with good clinical outcome in the long term in LT recipients with VOD not responsive to medical treatment.
Limitations: A small number of patients.
Ethics: n/a
Funding: No founding was received for this work.
RPS 1709-2
Transitional care for patients with cirrhosis: a multidisciplinary care model for the prevention of complications post-TIPS
Purpose: To evaluate the efficacy of transitional care interventions of multidisciplinary teams for patients with cirrhosis post-TIPS.
Methods: 68 patients who had undergone TIPS were randomly allocated to a control or intervention group. Patients in the control group received conventional care and patients in the intervention group received conventional care combined with transitional care. The compliance behaviour, the incidence of HE and shunt dysfunction, Child-Pugh scores, and ammonia of the two groups were compared at 1, 3, 6, and 12 months post-TIPS.
Results: Repeated measures analysis of variance showed significant group effects from 1, 3, 6, and 12 months post-TIPS for the compliance behaviour scores of the two groups. The intervention group had significantly higher compliance behaviour scores than the control group 1, 3, and 6 months post-TIPS, respectively. The incidences of HE in the intervention group were significantly lower than the control group 12 months after TIPS. The incidences of shunt dysfunction in the intervention group were significantly lower than the control group 12 months after TIPS. The group effects, time effects, and group*time interaction showed no significant difference in Child-Pugh scores and blood ammonia between the two groups.
Conclusion: Post-TIPS transitional care interventions increase the accessibility of patients to scientifically informed nursing, significantly improve patients? compliance behaviour and health, and decrease the incidence of HE and shunt dysfunction.
Limitations: n/a
Ethics: Review board approved.
Funding: The Foundation of the Shanghai Public Health Bureau, 201740143. The Project of Medical Key Specialty of Shanghai Municipality, ZK2015A22.
RPS 1709-3
Portal vein embolisation is effective in moderately severe liver fibrosis/cirrhosis
Purpose: Preoperative portal vein embolisation (PVE) increases future remnant liver (FRL) volume before hemihepatectomy. It is critically discussed when PVE fails in patients with early-stage fibrotic/cirrhotic liver diseases. The purpose of this study was to analyse the hypertrophy rate following PVE in different stages of liver fibrosis/cirrhosis.
Methods: In a retrospective review, patients with malignant liver diseases and PVE of the right lobe were selected from our clinical database. All PVEs were realised by ipsilateral access and using the embolic agent n-butyl-2-cyanoacrylate. Computed tomographic volumetry was performed before and 3-6 weeks after PVE to assess the hypertrophy rate of the left lobe. Patients were characterised by the presence of liver diseases using Child-Pugh scores: A) no cirrhosis and B) moderately severe liver disease. The hypertrophy rate was compared to the severity of liver fibrosis/cirrhosis using a Mann-Whitney-Test.
Results: 56 patients with malignant liver diseases, 17 women/39 men, mean age of 64.5±10.3 years, underwent PVE of the right lobe. Patients had the following Child-Pugh scores: A) 41 patients and B) 15 patients. The overall hypertrophy rate was 25.9±25.4%. Hypertrophy rates did not differ significantly between stages of liver diseases: Child-Pugh A) 26.0±27.2% and Child-Pugh B) 21.3±17.4%; p=0.374.
Conclusion: PVE is an excellent approach to induce FLR hypertrophy before hemihepatectomy, not only in patients with no cirrhosis (Child-Pugh A), but also in patients with a moderate fibrosis/cirrhosis (Child-Pugh B).
Limitations: A limited number of patients with parenchymal liver diseases.
Ethics: The study was IRB approved.
Funding: No funding was received for this work.
RPS 1709-5
A simple CT-based score model/nomogram for predicting technical success and midterm outcomes in TIPS treatment for symptomatic portal cavernoma
Purpose: To investigate the clinical significance of a CT-based score model/nomogram for predicting technical success and midterm outcomes in transjugular intrahepatic portosystemic shunt (TIPS) treatment for the symptomatic cavernous transformation of the portal vein (CTPV).
Methods: Patients with symptomatic CTPV who had undergone TIPS from January 2011-December 2016 were retrospectively analysed. The CTPV was graded with a 1-5 score based on contrast-CT imaging findings of the diseased vessel. Outcome measures were technical success rate, stent patency rate, and midterm survival. The nomogram was constructed and verified by calibration and decision curve analysis.
Results: A total of 84 patients (50 men, 34 women; mean age, 52.9±14.6 years) were enrolled. Inter-reader agreement of CTPV score was ?=0.83. TIPS were successfully placed in 82% of patients (69/84). The independent predictor of technical success was a CTPV score (odds ratio [OR] 1.91, 95% confidence interval [CI] 0.86, 3.62, P=0.024, AUC=0.90). The independent predictors for primary TIPS patency were a CTPV score and splenectomy (OR 4.12, 95% CI 0.86, 7.67, P=0.034, and OR 3.91, 95% CI 0.62, 6.76, P=0.041, respectively). The survival rates differed significantly between the TIPS success and failure groups. The clinical nomogram was constructed by patient age, model for end-stage liver disease (MELD), and a CTPV score. The calibration curves and decision curve analysis verified the usefulness of the CTPV score-based nomogram for clinical practice.
Conclusion: TIPS should be considered a safe and feasible therapy for patients with symptomatic CTPV. Furthermore, the CT-based score model/nomogram might aid interventional radiologists with therapeutic decision-making.
Limitations: A small, retrospective study.
Ethics: n/a
Funding: Health and Family Planning Commission of Chengdu (Sichuan, China) (grant 2015080) and Sichuan Province (grant 17PJ430).
RPS 1709-6
Variation of perfusion of the liver in cirrhotic patients undergoing TIPS placement for refractory ascites: a DCE-MRI study
Purpose: Patients with cirrhosis often develop severe complications of portal hypertension such as refractory ascites that can be treated by a transjugular intrahepatic portosystemic shunt (TIPS).
By shunting the portal blood supply to the systemic circulation, TIPS makes liver perfusion dependent on the efficiency of the hepatic arterial buffer response.
Dual input mono compartment (DIMC) DCE-MRI is an MR perfusion technique useful in quantifying the contribution of the hepatic artery and portal vein to liver perfusion in the basal condition.
In this work, we tested DCE-MRI to monitor liver perfusion before and after TIPS placement.
Methods: TIPS procedure and baseline DCE-MRI were performed the same day; post-TIPS DCE-MRI when the patients? conditions were permissive. All the MRI studies were performed on a 1.5T Achieva Philips, 5ch body coil, with 3DSPGR sequence, TR/TE/FA:5ms/1.66ms/15°, matr:256x256, 11 slices 8 mm thk, para-coronal acquisition, 90dyns, 2s/dyn. A bolus of 0.1 mmol/kg Gd-DTPA was injected after 8dyns. ROIs on input vessels and liver contours were drawn by an expert radiologist. After the images conversion to traces concentration, the DIMC model was applied with in-house "FANTASTIC" software. Portal flow rate (PFR), arterial flow rate (AFR), hepatic flow rate (HFR), the arterial fraction (AF), and the mean transit time (MTT) were calculated.
Results: 21 patients (16 males), 63±11 years with cirrhosis and refractory ascites were included. After TIPS placement, a significant reduction of HFR, PFR, and MTT was observed (p<0.0005, p<0.0001, p< 0.0008, respectively), as well as an increase of the AF (p<0.0001). AFR was found increased although not significative (p=0.094).
Conclusion: MR perfusion can be a valid tool to monitor residual liver perfusion in cirrhotic patients undergoing TIPS implant.
Limitations: The need to analyse the relationship with clinical events such as hepatic encephalopathy.
Ethics: The study was approved by the local ethics committee.
Funding: No funding was received for this work.
RPS 1709-7
Successful right portal vein embolisation with ONYX in oncologic patients with massive hepatic right lobe involvement
Purpose: To evaluate the feasibility and efficacy of ONYX as embolisation agent in preoperative right portal vein embolisation to induce adequate left liver lobe hypertrophy before extended right hepatectomy.
Methods: 23 patients (mean age 58.3 years; 12 males, 11 females) with a radiological diagnosis (TC/RM) of extensive involvement of the only right liver lobe by cholangiocarcinoma (7), metastases (9), and HCC (16), with an undamaged left hepatic lobe and future remnant liver <30%, in patients with normal liver, and <40% in cirrhotic patients were included. All patients underwent sonographically-guided percutaneous puncture of the portal vein, performed with a 21G Chiba-needle and selective catheterisation of the main right branch and its ramifications with 5 Fr catheter and 2.7 Fr microcatheter. In all cases, we used ONYX-18. All patients underwent a CT scan before the right portal vein embolisation and another CT scan 1 month after it was performed to calculate the total liver volume, tumour volume, future remnant liver, and degree of induced compensatory left lobe hypertrophy.
Results: Technical success was achieved in all patients (23) with complete embolisation of the right portal vein branch. In no cases did we observe reflux of ONYX in the left portal vein branch and no major complications.
Conclusion: ONYX proved to be a safe and effective embolic agent for preoperative right portal vein embolisation, as it allows complete embolisation of right portal branches, even the smaller distal branches, with a very low risk of reflux and higher probability to determine a satisfactory left lobe hypertrophy. It is still very expensive, but we hope that its cost will lower in the future to allow its wider employment.
Limitations: A retrospective and single-institution study.
Ethics: n/a
Funding: No funding was received for this work.
RPS 1709-8
Percutaneous closure of portosystemic shunts other than lienorenal shunts in patients with portal hypertension for recurrent hepatic encephalopathy and bleeding
Purpose: To determine the feasibility of a percutaneous approach in embolising non-lienorenal variceal shunts secondary to portal hypertension for recurrent encephalopathy and recurrent bleeding.
Methods: We retrospectively evaluated patients from January 2014-August 2019 who underwent percutaneous closure of variceal shunts other than lienorenal shunts secondary to portal hypertension. A total of 15 patients were found to have undergone shunt closure by percutaneous approach as management for recurrent hepatic encephalopathy (14 patients) and recurrent bleeding (1 patient). We assessed the safety, feasibility, procedural complications, and clinical outcomes of each patient.
Results: Shunt closure and variceal embolisation were performed successfully in all patients. Percutaneous access was achieved through a transhepatic, transplenic, and direct paraumbilical approach by ultrasound and fluoroscopic guidance. Periplenic varix embolisation was performed in 5 patients, perigastric varix embolisation was performed in 4 patients, and umbilical varix embolisation was performed in 5 patients. Both mesocaval and perisplenic varix was embolised in one patient. Embolic materials used were N-butyl cyanoacrylate, coil, and vascular plug devices. There were no procedure-related complications.
Conclusion: Percutaneous access for shunt closure and varix embolisation is a simple alternative image-guided procedure in patients with portal hypertension for recurrent hepatic encephalopathy and bleeding.
Limitations: n/a
Ethics: n/a
Funding: No funding was received for this work.
RPS 1709-9
The safety and efficacy of portal vein embolisation in patients with prior left lateral liver resection
Purpose: To investigate the safety and efficacy of right portal vein embolisation (PVE) following a left lateral liver resection.
Methods: In this retrospective study, we included 13 patients without liver cirrhosis, aged 58.7±27.6 years, who were scheduled to undergo staged hepatectomy consisting of resection of liver segments ?II? and III, followed by right-sided PVE and eventually right-sided hepatectomy (segments V-VIII), thus leaving segments IV (±I) as the future liver remnant (FLR). Using standardised multi-phase CT, we determined the total functional liver volume (TFLV)?and volume of the FLR ?before and at 3-4 weeks after PVE.? Patient data was retrospectively analysed for peri- and postinterventional complications, especially with regard to liver function, which was assessed by serum levels of albumin, total?bilirubin, ALT, and AST pre-PVE,?1-day post-PVE, and 3-4 weeks post-PVE?.???
Results: The mean TFLV was 1,550cc before PVE and 1,668?cc after PVE. The mean pre-PVE FLR volume was 328cc and the mean post-PVE FLR volume was 505cc, indicating a mean volume increase of the FLR of 69.4±35.0%.? The mean FLR/TFLV ratio post-PVE was 30.0% (range: 22.9-43.0%).?
PVE was successfully performed in all patients without any peri- or post-interventional complications. Although 11/13 patients developed mild transient elevation of AST and ALT after the PVE, values returned to baseline within 4 weeks. Based on FLR hypertrophy and liver function tests, all 13 would have been candidates for the completion of right-sided hepatectomy after PVE, however, since 3 patients were found to have new metastases within the FLR, a total of 10/13 eventually proceeded to surgery. ?

Conclusion: PVE of the right portal vein is safe and efficacious in patients who previously underwent left lateral liver resection.??
Limitations: n/a
Ethics: n/a
Funding: No funding was received for this work.
RPS 1709-10
Non-invasive assessment of portal hypertension with spectral CT iodine density: a correlation study with HVPG
Purpose: To investigate the feasibility of spectral CT iodine density in the evaluation of portal hypertension by correlation with the hepatic venous pressure gradient (HVPG) in patients with liver cirrhosis.
Methods: 31 patients with liver cirrhosis were recruited in this study and all performed 3 phases of contrast-enhanced spectral CT before TIPS, with the HVPG recorded. Multiple regions of interest (ROIs) in liver parenchyma, aorta, and portal vein were selected, and the mean liver parenchymal iodine density (ID) from the arterial phase, venous phase, and delayed phase were recorded. ID of the liver (IDLAP) and spleen (IDSAP) parenchyma for the arterial phase, venous phase (IDLVP), and ID of the portal vein in venous phase (IDPVP) were measured and correlated with HVPG.
Results: No correlation was found between the liver and spleen volume, IDLAP, IDSAP, IDSVP, and IDLVP with HVPG. IDPVP was found to be independently correlated with the HVPG (P<0.01). With the threshold set as 54.3, IDPVP demonstrated 69.5% sensitivity, 62.1% specificity, 72.6% positive predictive value, and 64.7% negative predictive value in the diagnosis of clinically significant portal hypertension (HVPG ?12mmHg), respectively.
Conclusion: Spectral CT iodine density demonstrates feasibility in the evaluation of clinically significant portal hypertension in liver cirrhosis as a non-invasive imaging modality.
Limitations: The small number of patients in a single clinical centre.
Ethics: This prospective study had hospital institutional review board and ethics committee approval.
Funding: No funding was received for this work.
RPS 1709-11
3D/2D-fusion of preprocedural multi-detector-computed-tomography and intraprocedural fluoroscopy for the guidance of portal vein puncture during transjugular intrahepatic portosystemic shunt placement
Purpose: Current guidance techniques for portal vein puncture rely on the acquisition of an intraprocedural C-arm computed tomography (CACT). This could increase the radiation exposure to the patient. The purpose of this study was to assess the technical success, puncture complications, and procedural characteristics of TIPS placement using image fusion of preprocedural multidetector-computed-tomography (MDCT) and intraprocedural fluoroscopy for portal vein puncture guidance.
Methods: From 11/2018-06/2019, 27 consecutive patients (18 men, 59 years) with elective TIPS placement were included. A 3D vascular map (3D-VM) was generated by drawing polylines in the hepatic and portal veins on MDCT, which was acquired for the evaluation of the TIPS procedure. Afterwards, the 3D-VM was semi-automatically registered to fluoroscopic images in two perpendicular views and served as a real-time overlay during the intervention to guide the portal vein puncture. Technical success, puncture complications, and procedural characteristics such as overall procedural time (OPT), puncture time (PT), and the dose area product (DAP) were recorded and compared to the literature.
Results: TIPS placement by use of 3D/2D-fusion was technical successful with a significant reduction of the PSG (PSGpre-TIPS15±3mmHg, PSGpost-TIPS4±3mmHg; p<0.00001). No major complications occurred. The OPT was 64±29 min and the PT was 14±6 min, which is comparable to the literature. The DAP of 10748±9384uGy*m2 was lower than the reported DAP for CACT-assisted TIPS procedures.
Conclusion: TIPS placement using 3D/2D-fusion is effective, fast, and safe. It has the potential to reduce radiation exposure to the patient by at least 30% compared to published CACT-assisted TIPS procedures.
Limitations: A small, retrospective study without a control cohort. Large cohort studies are required to confirm the benefits for the patients.
Ethics: The Human Subjects Research Review Board of the Hanover Medical School approved our retrospective study and written informed consent was obtained.
Funding: No funding was received for this work.
RPS 1709-12
Application of a liver biopsy as a treatment strategy determinant in Budd-Chiari syndrome
Purpose: Budd-Chiari syndrome (BCS) is hepatic venous outflow obstruction. The primary goal of treatment is the resolution of hepatic congestion in order to improve liver perfusion and preserve hepatocytes function. Medical management, recanalisation of stenotic or occluded hepatic veins, portosystemic shunting, and eventually liver transplantation are the treatment options. The aim of this study is to determine if angioplasty intervention can substitute the portosystemic shunting by means of a new histopathological grading system for zone 3 congestion in BCS.
Methods: In a retrograde study, we reviewed 34 cases of BCS, diagnosed on radiology/pathology basis, who underwent a biopsy of the explanted liver prior to transplantation. Alongside the extent and amount of irreversible fibrosis, we emphasised other pathologic changes including sinusoidal and central venular dilatation. The pathologic slides were rechecked and, according to a new congestion scoring system, patients were categorised considering the extent of central venular and sinusoidal dilatation. Total scores of 3-8 were applied for each patient.
Results: According to radiologic findings, 11 patients were in the proximal type subgroup, all representing a histopathologic score of 4 or less (score 3 in 6 patients, score 4 in the others). The remaining 23 patients were in the distal type category, including 7 patients with score 5 and the rest demonstrating score 6 or more. After pathological/radiological correlation, the study revealed that the more proximal the location of the venous obstruction was, the less sinusoidal and central venular dilatation.
Conclusion: The use of histopathology is beyond determining the presence of fibrosis. Liver biopsy results are useful in predicting the site of venous obstruction in BCS, thus considered as valuable pretreatment findings.
Limitations: The small sample volume.
Ethics: n/a
Funding: No funding was received for this work.
RPS 1709-13
Transjugular intrahepatic portosystemic shunt using the new GORE VIATORR controlled expansion endoprosthesis: a single-centre experience
Purpose: To evaluate the mid-term clinical efficacy and complications of transjugular intrahepatic portosystemic shunt (TIPS) creation using the new controlled expansion ePTFE covered stent (VCX) for portal hypertension complications.
Methods: From 7/2016-6/2019, 139 consecutive patients received TIPS using VCX in a single centre.
Results: TIPS indications were refractory ascites (n=89), variceal bleeding (n=41), and other (n=9). The mean MELD score was 12.0 ± 4.6 (6-33). The mean age was 59.1 ± 10.4 (10-78) and the mean follow-up was 12.2 months (±?8.0, range 1-33). In 9 patients (cavernoma n=4, massive thrombosis n=4, and Budd-Chiari n=1), TIPS was directly dilated to 10 mm in diameter. In 122 patients, TIPS was dilated to 8 mm with a final PSG<12 mmHg or a PSG reduction?40%, compared to the baseline PSG. In 8 patients, not reaching the haemodynamic target, the stent was further dilated to 10 mm in diameter during the same session, reaching the haemodynamic target. Overall clinical success was achieved in 118/139 (85%) patients (80% in refractory ascites, 95% variceal bleeding, and 80% other). Overt hepatic encephalopathy was observed in 21 patients (15%). TIPS revision was performed in 18 patients (13%). 3 patients (2%) underwent stent reduction. 28 patients (20%) died during follow-up of causes not related to TIPS. 17 patients (12%) underwent a liver transplant.
Conclusion: VCX can help to optimise the haemodynamic target during TIPS creation with a good clinical outcome and a reasonably low complication rate.
Limitations: A longer follow-up is necessary to confirm this data.
Ethics: n/a
Funding: No funding was received for this work.


Guillermo Elizondo-Riojas (Netherlands)

Pierleone Lucatelli (Italy)

European Society of Radiology

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