RPS 1709 - TIPS and liver venous intervention

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 and materials:

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 committee approval

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.

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 and materials:

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 committee approval

n/a

Funding:

No funding was received for this work.

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 and materials:

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 committee approval

n/a

Funding:

No funding was received for this work.

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 and materials:

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 κ=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 committee approval

n/a

Funding:

Health and Family Planning Commission of Chengdu (Sichuan, China) (grant 2015080) and Sichuan Province (grant 17PJ430).

Purpose:

To investigate the safety and efficacy of right portal vein embolisation (PVE) following a left lateral liver resection.

Methods and materials:

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%).

Conclusion:

PVE of the right portal vein is safe and efficacious in patients who previously underwent left lateral liver resection.

Limitations:

n/a

Ethics committee approval

n/a

Funding:

No funding was received for this work.

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 and materials:

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 committee approval

n/a

Funding:

No funding was received for this work.

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 and materials:

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 committee approval

n/a

Funding:

No funding was received for this work.

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 and materials:

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 committee approval

The study was approved by the local ethics committee.

Funding:

No funding was received for this work.