Emergency transjugular intrahepatic portosystemic shunts

The TIPS procedure can provide for emergent decompression of the portal venous system and cessation of life-threatening hemorrhage from gastroesophageal varices. It is a highly sophisticated procedure that should be done only by very experienced interventional radiologists because of the important complications that can occur and are directly related to the procedure. Knowledge of the technical aspects of the procedure that put the patient at increased risk for procedure-related complications can reduce the likelihood of mishap. Similarly, knowledge of the contraindications for TIPS will improve the screening of patients who clinically are at increased risk of post-procedure complications.     

Therapeutic embolization of intrahepatic portosystemic shunts by retrograde transcaval catheterization

A 57-year-old woman presented with hepatic encephalopathy, cirrhosis, and a dual-channel portosystemic venous shunt (PSVS). The shunt was treated successfully by embolization with steel coils via retrograde systemic venous access. Encephalopathy resolved. This new approach is considered safer than the previously reported percutaneous transhepatic route or the mesenteric venous route, requiring a mini-laparotomy.     

覆膜支架在经颈静脉门腔分流术中的应用

目的 评价经颈静脉肝内门腔分流术(TIPS)专用覆膜支架(Viatorr支架)在TIPS中的应用价值.方法 回顾性分析37例在美国俄勒冈州健康生命科技大学Dotter介入放射学研究所采用Viatorr支架行TIPS治疗的患者资料,随访时间为(15.2±9.3)个月(3-42个月).TIPS指征包括门静脉高压相关性的急慢性消化道出血,经药物及内镜治疗无效者17例;顽固性肝源性胸、腹水18例,Budd-Chiari综合征2例.采用配对t检验比较手术前后门腔静脉压力差(PSG)的变化,以Kaplan-Meier曲线分析支架开通率.结果 37例共置入41枚Viatorr支架,其中3枚直径为8 mm,38枚为10 mm,支架带膜长度为4～8 cm,无相关手术并发症.PSG由术前的(22.4±8.4)mm Hg(1 mm Hg=0.133 kPa)降为(8.1±3.2)mm Hg,差异有统计学意义(t=12.754,P<0.01).17例出血患者术后出血均停止,1例于术后17个月复发.18例严重顽固性腹水及肝性胸水患者中,4例术后腹水不消退,其余14例随访期间有2例腹水复发.2例(5.4%)发生分流道阻塞,Kaplan-Meier曲线分析结果显示1年的开通率为97.0%.术后1个月内无病死患者,2例分别于术后3个月及15个月死于多器官功能衰竭,晚期病死率为5.4%,死亡前1周内复查支架均通畅.肝移植患者5例(13.5%).结论 Viatorr支架能明显提高TIPS术后开通率,选择合适的支架,采用正确的释放技术能进一步提高疗效,但长期效果评价尚需验证.     

Radiation dose reduction during transjugular intrahepatic portosystemic shunt implantation using a new imaging technology

ObjectiveTo compare patient radiation dose in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) implantation before and after an imaging-processing technology upgrade.MethodsIn our retrospective single-center-study, cumulative air kerma (AK), cumulative dose area product (DAP), total fluoroscopy time and contrast agent were collected from an age- and BMI-matched collective of 108 patients undergoing TIPS implantation. 54 procedures were performed before and 54 after the technology upgrade. Mean values were calculated and compared using two-tailed t-tests. Two blinded, independent readers assessed DSA image quality using a four-rank likert scale and the Wilcoxcon test.ResultsThe new technology demonstrated a significant reduction of 57% of mean DAP (402.8 vs. 173.3 Gycm², p < 0.001) and a significant reduction of 58% of mean AK (1.7 vs. 0.7 Gy, p < 0.001) compared to the precursor technology. Time of fluoroscopy (26.4 vs. 27.8 min, p = 0.45) and amount of contrast agent (109.4 vs. 114.9 ml, p = 0.62) did not differ significantly between the two groups. The DSA image quality of the new technology was not inferior (2.66 vs. 2.77, p = 0.56).ConclusionsIn our study the new imaging technology halved radiation dose in patients undergoing TIPS maintaining sufficient image quality without a significant increase in radiation time or contrast consumption.     

The transjugular intrahepatic portosystemic Stent-Shunt (TIPSS): Results of a pilot study

The new concept of TIPSS (Transjugular Intrahepatic Portosystemic Stent-Shunt) using the Palmaz iliac stent was successfully accomplished in 9 patients with severe portal hypertension (7 alcoholic, 2 postinfectious liver cirrhosis) and histories of multiple life-threatening upper GI bleeding. All patients were considered noncandidates for surgical portal decompression. An intrahepatic central connection was made transjugularly between the right hepatic vein and the right portal vein in 8 patients and the left portal vein in 1. The portosystemic gradient dropped from an average of 29±7.2 mmHg to 17.8±2.9 mmHg immediately after, and to 15.7±2.8 mmHg at the latest follow-up control after the procedure. Seven patients survived the procedure and progressed to Child's A stage during the observation period of 1–10 months (mean 5 months). One patient died as a direct complication from the procedure, and another patient 11 days after the procedure from a severe nosocomial infection. In none of the surviving patients has bleeding from varices recurred or encephalopathic coma developed. In one patient the shunt diameter was moderately increased by a routine PTA catheter to further decrease the portosystemic gradient (23 to 14 mmHg) 3 months after the primary procedure. Autopsy in the two patients who died demonstrated open stent-shunts with early neoendothelial incorporation.     

Emergency transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding.

This study was designed to retrospectively evaluate transjugular intrahepatic portosystemic shunt (TIPS) performed on an emergency basis in patients with hemorrhagic shock from recurrent uncontrolled variceal bleeding. Over a 3.5-year period we reviewed the medical records as well as the imaging studies of 16 patients who had uncontrolled variceal bleeding and presented to our department for an emergent placement of TIPS. In our study the technical success was 88% (14/16 patients), the overall mortality was 36% (5/14 patients), and the shunt immediately reduced the portal venous pressure gradient by a mean of 64%. Given the poor outcome of other alternatives, aggressive treatment and placement of TIPS is justified regardless of the severity of the bleeding episode.     

Placement of transjugular intrahepatic portosystemic shunt via the left hepatic vein under sonographic guidance in a patient with right hemihepatectomy

In a patient with refractory ascites after right hemihepatectomy TIPS was created between the left hepatic vein and the left portal vein via a transjugular approach. The puncture was guided only by sonography from the epigastrium. Portosystemic pressure gradient was reduced from 28 to 7 mm Hg and ascites disappeared. This case shows that TIPS can be created with technical and clinical success after right hemihepatectomy as left hepatic vein to left portal vein shunt under sonographic guidance.     

改良式TIPS的解剖学基础研究

目的 探讨肝硬化门脉高压患者下腔静脉、肝静脉与门静脉三者之间的影像解剖学关系,评估改良式TIPS,即经肝段下腔静脉入路经颈静脉肝内门体分流术的安全性与可行性.方法 64例临床证实的肝硬化患者,肝功能Child-Pugh B级40例,C级24例,行肝脏双期增强扫描后行CT多层面重组(MPR)及曲面重建(CPR)后处理,将测量所得数据进行配对t检验.结果 Child-Pugh B级者肝段下腔静脉的长度与C级者相比前者较长(P＜0.05).以肝段下腔静脉穿刺点为A1,肝右静脉开口2 cm处的穿刺点为A2,门静脉分叉部穿刺点为B1,门静脉右支开口2 cm处的穿刺点为B2,A1 B1线的长度与A2 B1线的长度相比前者较短(P＜0.05),A1 B2线和A2 B2线与B2点所在门静脉右支径线的夹角大小相比前者较小(P＜0.05).A1 B1线和A1 B2线分别与所在门静脉径线的夹角相比前者较大(P＜0.05),A2 B1线和A2 B2线分别与所在门静脉径线的夹角相比前者较大(P＜0.05).结论 从解剖学角度分析,改良式TIPS具备安全性及可行性,较传统TIPS术式还具有分流道走行顺畅,对血流动力学影响小的优点.     

经肝段下腔静脉建立TIPS分流道的初步临床结果

目的 评估经肝段下腔静脉TIPS分流术在肝静脉与门静脉间解剖异常时操作的可行性，讨论其临床意义。方法 65例肝硬变门静脉高压患者行经肝段下腔静脉直接穿刺门静脉完成TIPS分流术。结果 65经肝段下腔静脉TIPS分流术均获成功，技术成功率100％，未出现术中技术相关并发症，一年内再狭窄率明显低于常规TIPS，3例肝性脑病经限流支架置入得以控制。结论 经肝段下腔静脉TIPS分流术技术用于肝静脉与门静脉间解剖异常病例是安全有效的，同时提示由于肝内分流道曲度较小，一年内支架开通率明显提高。     

Self-expanding stents in transjugular intrahepatic portosystemic shunt: experience with nitinol Strecker stents

The aim of our study was to evaluate the performance and efficacy of a new self-expanding stent (nitinol Strecker stent) in the transjugular intrahepatic portosystemic shunt (TIPS) procedure. We have successfully placed 64 nitinol Strecker stents in 48 patients. The average portosystemic gradient decreased from 22 to 11 mm Hg. Balloon dilatation was necessary in 12 of 35 angiographically controlled cases at 5 days (34%), because of incomplete stent expansion, small thrombi within the stent or obstruction. At 1–6 months stent malfunctions occurred in 8 of 23 patients who underwent control angiography (34%) and at 6–24 months in 6 of 7 patients (85%). Rebleeding occurred in 2 of 39 patients (follow-up > 1 month) (5%) and temporary crises of de novo encephalopathy were observed in 11 of 48 patients (23%). Refractory ascites completely resolved in 4 of 6 patients (66%) and improved in the remaining 2 cases. Compared with other self-expanding stents, nitinol Strecker stents seem to be equally effective in TIPS; no increase in complication rate was observed, either clinical or stent-related. Correspondence to: P. Rossi     

经颈静脉肝内门脉左支-体静脉分流术的临床意义

目的 评价选择性门静脉左支作为TIPS分流道的临床意义，分析门静脉左、右支的血液动力学变化及重要液道物质浓度差异对术后预防肝性脑病及远期疗效的影响。方法 341例有目的的选择肝内门静脉左支作为穿刺靶点，行经颈静脉矸内静脉左支门腔分流术建立门腔分流道，避开富含营养、毒素的门静脉右支血液。肝实质通道用8mm直径球囊扩张，限制分流口径。结果 所有患者术后3个月内无一例发生肝性脑病。随访期间TIPS术后341例患者仅5例（1.47%）出现肝性脑病和19例（5.57%)一年随访造影出现支架内狭窄。结论 选择性门静脉左支作为门腔静脉分流道，可心显著降低肝性脑病发生率，对保护肝功能，提高分流道远期开通率具有重要的临床意义。     

Technical advances in transjugular intrahepatic portosystemic shunts.

A transjugular intrahepatic portosystemic shunt (TIPS) can be created percutaneously with the Palmaz balloon-expandable stent. This article describes a transjugular-only approach with a 16-gauge needle. A functional and efficacious shunt can be achieved in most cases with stent diameters of 8-10 mm. Occasionally, a 12-mm-diameter shunt is necessary for effective variceal decompression. The procedure is considered successful when the portosystemic gradient is lowered to 12 mm Hg or less after stent placement. Hepatic vein stenosis in the shunt outflow can develop after the TIPs procedure. This complication has been treated successfully with additional stent placement. TIPS can undoubtedly be performed successfully and safely with a transjugular-only approach; however, the full impact of TIPS on the treatment of portal hypertension remains to be determined.     

Histopathologic study of transjugular intrahepatic portosystemic shunts.

A detailed histopathologic analysis of intrahepatic portosystemic shunts was performed following liver transplantation in five patients. Gross examination revealed that all stents were patent and unchanged in size, shape, and position from initial placement. Histologic examination at 4 days revealed an irregular luminal surface with liver parenchyma protruding between the stent wires and a single, patchy layer of endothelial cells lining the shunt surface. By 3 weeks, the stent wires were covered by a pseudointima of granulation tissue, and the luminal surface was lined with a contiguous layer of endothelial cells. Excessive pseudointimal proliferation resulted in shunt occlusion at 3 months in one patient whose shunt was subsequently reopened percutaneously.     

限流支架植入治疗TIPS引起的难治性肝性脑病

目的　评价限流支架装置在缩小 TIPS分流道直径对治疗由门腔分流引起的肝性脑病的有效性。　方法　 9例TIPS术后并发严重肝性脑病患者经颈静脉沿原肝内支架同轴植入可限制血流量的支架装置。　结果　限流支架植入未出现术中并发症 ,平均门静脉压力由术前 12± 4 .2 cm H2 O升至 2 0± 2 .6 cm H2 O,彩色多普勒超声显示分流道内血流减少 4 7.3%±15 .1% ,肝性脑病得到实质性改善和控制。血氨浓度及胆红素明显降低。　结论　用限流支架治疗门腔分流因起的肝性脑病是安全有效的     

Embolization of portal-systemic shunts in cirrhotic patients with chronic recurrent hepatic encephalopathy

Purpose To evaluate the efficacy of embolization of portal-systemic shunts in cirrhotic patients with chronic recurrent hepatic encephalopathy (CRHE). Methods Seven cirrhotic patients with CRHE refractory to medical treatment (3 men and 4 women, mean age 66 years) were studied. Five patients had splenorenal shunts, 1 had a gastrorenal shunt, and 1 had an intrahepatic portal vein-hepatic vein shunt. Shunt embolization was performed using stainless steel coils, with a percutaneous transhepatic portal vein approach in 4 patients and a transrenal vein approach in 3 patients. Results After embolization, the shunt disappeared in 4 patients on either ultrasound pulsed Doppler monitoring or portography. Complications observed in the 7 patients were fever, transient pleural effusion, ascites, and mild esophageal varices. For 3–6 months after embolization, the 4 patients whose shunts disappeared showed minimal or no reappearance of a shunt, and had no recurrence of encephalopathy. The serum ammonia levels decreased and electroencephalograms also improved. One of the 4 patients, who developed mild esophageal varices, required no treatment. Treatment was effective in 3 of the 4 patients (75%) who underwent embolization via a transhepatic portal vein. Conclusion Transvascular embolization of shunts improved the outcome in 4 of 7 patients. The most effective embolization was achieved via the percutaneous transhepatic portal vein approach.     

经颈静脉门腔分流术中Fluency覆膜支架应用的临床观察

目的 评价Fluency覆膜支架在经颈静脉门腔分流术(TIPS)中的临床效果.方法 搜集21例采用Fluency覆膜支架行TIPS治疗患者的临床病例资料进行回顾性分析.本组患者随访时间2.0～24.0个月,平均(10.1±4.6)个月;均为门静脉高压上消化道大出血,其中原发性肝癌门静脉主干癌栓伴大出血1例,布加综合征1例.分析患者术后支架开通情况,门静脉压力及肝功能变化情况.对手术前后门静脉压力及肝功能变化情况的比较采用配对t检验.结果21例患者共放支架25枚,均成功放置,支架直径10 mm 2枚、8 mm为23枚;覆膜支架长度6～8 cm.所有患者术后上消化道出血停止;门静脉压力由术前平均(25.4±3.5)mm Hg(1mm Hg=0.133 kPa)降为(15.4±2.8)mm Hg,手术前后差异有统计学意义(t=12.495,P<0.01).随访期间,1例原发性肝癌伴门静脉主干癌栓患者于术后4个月死亡,1例随访期间发现原发性肝癌的患者术后24个月死亡,1例门静脉高压上消化道大出血患者于术后2个月死于多器官功能衰竭,1例于术后15个月出现肝静脉端狭窄,行第2枚支架治疗效果良好,余17例随访7～17个月支架无狭窄.患者死亡前1周复查超声示支架均通畅.3例术后出现一过性肝性脑病前驱症状,经对症处理后好转.存活6个月以上的19例患者,术前Child肝功能评分(6.3±1.4)分,术后6个月评分(6.4±1.9)分,两者差异无统计学意义(t=0.645,P>0.05).结论采用Fluency覆膜支架行TIPS术,能明显提高TIPS术后开通率,但长期效果及肝性脑病的评价尚需验'证.     

Portal venous branch targeting with a platinum-tipped wire to facilitate transjugular intrahepatic portosystemic shunt (TIPS) procedures

We describe a technique to aid in technically difficult transjugular intrahepatic portosystemic shunt (TIPS) procedures by sonographically guided transabdominal fine-needle portal vein puncture for placement of a 0.018-inch platinum-tipped target guidewire within an appropriate portal venous branch.