MR Angiographic guidance for transjugular intrahepatic portosystemic shunt procedures

The authors used magnetic resonance (MR) angiography to guide catheter placement in transjugular intrahepatic portosystemic shunt (TIPS) procedures in nine of 18 patients and compared the results with those of the nine patients for whom prior planning based on MR angiography was not done. Two-dimensional time-of-flight MR venography was performed during breath hold, and projection venograms were formatted in sagittal, coronal, and axial planes. MR angiography defined venous anatomy sufficiently to shorten the procedure and help minimize invasiveness. With MR angiographic guidance, intrahepatic needle punctures were significantly fewer (without MR guidance: mean, 12.1; with MR guidance: mean, 3.6; P < 0.001) and associated complications were absent (without MR guidance: failed placement, n = 1; bleeding requiring blood transfusions, n = 1; death due to intraperitoneal hemorrhage with hemobilia, n = 1; and death due to hepatic capsular perforation, n = 1). The average time for the procedure was 2.9 hours without MR angiographic guidance and 1.8 hours with MR angiographic guidance (P < 0.001). The authors conclude that MR angiography is a useful technique for defining portal and hepatic venous anatomy before the TIPS procedure and that planning based on MR angiography may decrease the difficulty and length of the procedure.     

Embolization of nonvariceal portosystemic collaterals in transjugular intrahepatic portosystemic shunts

Percutaneous embolization of large portosystemic collaterals was performed in three patients following placement of a transjugular intrahepatic portosystemic shunt in order to improve hepatopetal portal flow. Improved hepatic portal perfusion was achieved in these cases, thereby theoretically reducing the risk of chronic hepatic encephalopathy.     

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.     

Inadvertent arteriovenous stenting during transjugular intrahepatic portosystemic shunt procedure and the importance of hepatic artery perfusion

Penetrating the hepatic artery during transjugular intrahepatic portosystemic shunt (TIPS) is a relatively frequent but almost always benign complication. We report a patient in whom the right hepatic artery, originating from the superior mesenteric artery, was inadvertently catheterized and stented. The arteriovenous fistula was treated with a detachable balloon positioned within the hepatic artery. A second TIPS was attempted and successfully created during the same session. The patient died of cardiac failure, attributed to rapid resolution of massive ascites after TIPS with circulatory overload. At autopsy, the liver distal to the arterial occlusion balloon was infarcted, illustrating the importance of hepatic artery perfusion in liver cirrhosis.     

Acute Budd-Chiari syndrome: Treatment with transjugular intrahepatic portosystemic shunt

The case of a 28-year-old man with acute Budd-Chiari syndrome due to veno-occlusive disease is reported. Transjugular intrahepatic portosystemic shunt (TIPS) was performed after upper gastrointestinal endoscopy, duplex sonographic and abdominal computed tomographic examination, inferior cavogram with hepatic venous catheterization, and transvenous biopsy. A 10-mm parenchymal tract was created. The patient did well after the procedure; ascites resolved and liver function improved markedly. The shunt has remained patent up to now for 6 months.     

Early sonographic evaluation of the transjugular intrahepatic portosystemic shunt (TIPS)

The purpose of this study was to evaluate duplex and color Doppler findings in patients before and within 24 h after transjugular intrahepatic porto-systemic shunts (TIPS). Conventional duplex and color Doppler were used in the assessment of 19 patients who underwent TIPS as part of a prospective protocol. Patients were examined within 24 h before and after the procedure. Before TIPS, patency, flow direction, and peak flow velocity in the main portal vein and hepatic artery were studied, as well as patency and flow direction in hepatic veins, splenic vein, and inferior vena cava (IVC). Immediately after the procedure, sonographic identification of stent position, shunt patency, and flow dynamics were evaluated and patency and flow direction of hepatic veins, splenic vein, and IVC were determined. The portogram performed at the end of the procedure was compared with the 24-h sonographic studies after TIPS to determined sonographic/angiographic correlation. No intraparenchymal abnormalities or perihepatic fluid collections were detected after the procedure. The metallic stent was clearly seen in all patients. Mean peak shunt flow velocities were 139±50 cm/sec within 24 h after TIPS. Absence of flow through the shunt was correctly identified in one case and confirmed angiographically. Mean peak flow velocity in the portal vein before TIPS was 22±13.6 cm/sec and increased to 43.6±9.1 cm/sec after TIPS (p<0.05). The hepatic artery peak systolic velocity increased from 77±51 cm/sec before TIPS to 119±53 cm/sec after the procedure (p=0.029). Conventional duplex and color Doppler ultrasound proved to be a useful non-invasive diagnostic method to assess patients who have undergone TIPS. We propose its use as the primary diagnostic modality in these patients.     

经颈静脉肝内门体静脉分流术术前MRA评价

目的探讨磁共振血管成像（MRA）在经颈静脉肝内门体静脉分流术（TIPS）术前检查中的应用。方法对59例拟行TIPS治疗的患者行术前MRA检查,观察引起门静脉高压的病因、肝静脉及门静脉形态、走行,测量穿刺点处血管管径,并与正常对照组（50例）比较。结果门静脉高压组中单纯肝硬化49例,肝硬化合并肝癌4例,单纯门静脉血栓3例,脾静脉狭窄1例,布-加综合征2例。门静脉高压组与正常对照组肝静脉分型（3支型∶2支型∶1支型）分别为14∶39∶12、12∶34∶14 肝右静脉、肝中静脉、肝左静脉穿刺点管径符合数为52∶40∶28、46∶34∶23。门静脉右支和左支安全穿刺点分别位于（16.2&#177;3.1）mm、（14.2&#177;3.8）mm以远。结论MRA是一种有价值无损伤的检查方法,对TIPS术前疾病诊断及血管定位有着重要的意义。     

Transjugular intrahepatic portosystemic shunt in a patient with cavernomatous portal vein occlusion

A 23-year-old woman with liver cirrhosis secondary to primary sclerosing cholangitis was referred to us for the treatment of recurrent bleeding from esophageal varices that had been refractory to endoscopic sclerotherapy. Her portal vein was occluded, associated with cavernous transformation. A transjugular intrahepatic portosystemic shunt (TIPS) was performed after a preprocedural three-dimensional computed tomographic angiography evaluation to determine feasibility. The portal vein system was recanalized and portal blood flow increased markedly after TIPS. Esophageal varices disappeared 3 weeks after TIPS. Re-bleeding and hepatic encephalopathy were absent for 3 years after the procedure. We conclude that with adequate preprocedural evaluation, TIPS can be performed safely even in patients with portal vein occlusion associated with cavernous transformation.     

Transjugular intrahepatic portosystemic shunt. Experiences at a liver transplantation center

Objective: Transjugular intrahepatic portosystemic shunt (TIPS) placement is an established therapy for portal hypertension that leads to variceal bleeding or refractory ascites. We present experiences of the role of TIPS at a liver transplantation center.Material and Methods: One hundred and ten patients were referred to the Radiological Department for TIPS placement. One of the 110 patients had recurrent cirrhosis after liver transplantation with refractory ascites. Function of the TIPS was controlled with Doppler US at 1 day, 1 week, 4 weeks and 4 months after TIPS placement and subsequently every 3 months. Shunt insufficiency was supposed when the blood flow velocity within the stent tract was under 50 cm/s and was an indication for TIPS revision.Results: TIPS was placed in 101 patients. After TIPS placement, 10 patients underwent liver transplantation. While waiting for the new liver, none of them developed variceal rebleeding, ascites or other complications of portal hypertension. Two of the 101 patients had episodes of rebleeding. The frequency of patients undergoing TIPS revision within the first year after TIPS placement was 67.5%, within the second year 38.0% and within the third year 24.4%. The revisions led to sufficient reduction of the portosystemic pressure gradient.Conclusion: In some liver transplant candidates, TIPS can be useful in minimizing the risk of complications of portal hypertension during the waiting time for a liver transplantation. TIPS can be monitored by Doppler US and revised if occlusion occurs.     

Bile resistance of coated transjugular intrahepatic portosystemic shunt stents in a flow-model

PURPOSE: We sought to test the bile resistance of transjugular intrahepatic portosystemic shunt (TIPS) stents with 3 different coatings. MATERIALS AND METHODS: Three stents with different coating materials (monolayer polyethylene terephthalate [PETP], monolayer polytetrafluoroethylene [PTFE], and double layer [PTFE]) were tested in a flow model. After testing the sealing of the system with isotonic saline solution, fresh human bile was circulated. Constant pressure was 50 cm H2O. Bile resistance of the stent membranes was analyzed. RESULTS: Two of the 3 stents proved completely resistant to water. Only the PETP stent was resistant to bile. The PTFE-coated stents were not bile resistant. CONCLUSION: The bile resistance of coated TIPS stents and, thus, the dependency of TIPS shunt patency is called into question. The stent with the reported superior patency rates does not show experimental bile resistance.     

内皮祖细胞种植支架在经颈静脉肝内门体分流术中应用的实验研究

目的 评价内皮祖细胞(EPC)种植支架在经颈静脉肝内门腔分流(TIPS)家猪动物模型中减少分流道再狭窄的疗效.方法 体外分离、培养、鉴定家猪外周血内皮祖细胞,并构建内皮祖细胞种植支架.15头家猪行TIPS介入手术,采用随机区组设计分为EPC种植支架组9头(实验组),裸支架组6头(对照组).术后14 d行直接门静脉造影,然后处死动物,作病理分析及免疫组织化学检查,记录分流道狭窄及阻塞率,并用图像处理软件计算TIPS分流道假性内膜厚度及面积.计数资料用Fisher精确概率法,计量资料行t检验,作统计学分析.结果 15头猪TIPS手术均成功.实验组分流道通畅5头,狭窄2头(狭窄率50%、70%),阻塞2头(共9头).对照组狭窄1头(狭窄率80%),阻塞5头(共6头).2组通畅率差异有统计学意义(P=0.03).实验组假性内膜增生的厚度(肝静脉、肝实质、门静脉段)显著小于对照组[分别为(1.0 ±0.6)、(0.9±0.5)、(1.0±0.4)mm和(1.2±0.4)、(1.3±0.5)、(1.5±0.4)mm,P值均＜0.05].免疫组织化学显示实验组中通畅的分流道有完整的内皮形成;再狭窄分流道的假性内膜主要由胶原纤维组成,而通畅分流道的假性内膜主要由细胞成分组成.结论 体外构建EPC种植支架是可行的,置入后促进了家猪模型TIPS分流道内皮化形成,可以提高分流道的通畅性.     

Rheolytic thrombectomy of an acutely thrombosed transjugular intrahepatic portosystemic stent shunt

As an alternative to chemical thrombolysis, an acutely occluded transjugular intrahepatic portosystemic stent shunt in a 72-year-old women was successfully recanalized using a 5 Fr rheolytic catheter system. No adjunctive thrombectomy treatment was necessary. The underlying stenotic leason was treated with percutaneous transluminal angioplasty and a Palmaz stent. Immediately after the intervention optimal shunt flow was achieved. Ascites vanished within a few days and no further bleeding complications appeared.     

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.     

Efficacy of Doppler ultrasonography for assessment of transjugular intrahepatic portosystemic shunt patency

Purpose To assess the efficacy of Doppler ultrasonography (US) as a noninvasive method for monitoring patency of the transjugular intrahepatic portosystemic shunt (TIPS). Methods Twenty-nine patients who had received TIPS for bleeding esophagogastric varices and/or refractory ascites with portal hypertension underwent Doppler US studies within 2 weeks after TIPS. Further studies were performed in 15 of them at 6 months, in 9 at 1 year, and in 4 at 2 years for a total of 57 US studies. The US findings were compared with the angiographic findings obtained at the same time. Results In 45 of the 57 studies, shunt patency was found by Doppler US, correlating to 44 patencies and one occlusion on angiography. Doppler signal in the shunt could not be detected in 12 studies resulting in the diagnosis of shunt occlusion. This correlated with angiographic occlusion in 8 studies and patency in the remaining 4. All angiographically patent shunts that were occluded by Doppler US had various degrees of stenosis. A number of technical factors were found to be responsible for Doppler US false-positive or false-negative diagnoses, some related to the type of stent used. The Doppler US sensitivity was therefore 92%, the specificity 89%. Conclusion Doppler US is a reliable noninvasive method to evaluate patency of TIPS.     

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.     

腔内超声辅助下经颈静脉肝内门体分流术1例

肝硬化合并反复上消化道出血、顽固性腹水已经成为经颈静脉肝内门体分流术(TIPS)的适应证.国外近年来逐渐开展了腔内超声(IVUS)辅助下TIPS,取得了良好效果.我们尝试使用IVUS辅助进行TIPS,现报道如下.临床资料患者女,58岁.因反复黑便1年余就诊.2015年5月及2016年1月患者分别解柏油样便,量共500～600ml,无呕血、腹痛、黄疸等症状,予内科对症治疗后症状均缓解.     

Application of percutaneous transluminal sharp recanalization in transjugular intrahepatic portosystemic shunt for patients with chronic portal vein occlusion

PURPOSEWe aimed to evaluate the feasibility and safety of a modified technique for portal vein recanalization, percutaneous transluminal sharp recanalization (PTSR), when performing transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of chronic portal vein occlusion (CPVO) and portal hypertension.METHODSNine consecutive patients with CPVO and portal hypertension had undergone TIPS and PTSR procedure after failing in conventional percutaneous catheterization from March 2017 to July 2019. Technical success rates, effectiveness, and complications were evaluated. Follow-up of patients’ clinical outcomes and shunt patency were performed periodically. Primary and secondary shunt patency were analyzed by Kaplan-Meier method.RESULTSThe occluded portal veins were successfully recanalized after failing in conventional percutaneous catheterization, and TIPS procedures were completed in all 9 patients. Two patients suffered from procedure-related complications. A portosystemic pressure gradient <12 mmHg, or a percent reduction of 25% to 50% of baseline, was achieved in all 9 patients after TIPS. During the median follow-up period of 28 months (range, 9–36 months), 1 patient experienced recurrent ascites and the other 8 patients remained asymptomatic. The cumulative rates of primary and secondary shunt patency were 66.67% and 100%, respectively, at 2 years.CONCLUSIONAs a supplementary method, PTSR is a feasible and safe method for portal vein recanalization when performing TIPS for patients with CPVO and portal hypertension.

Portal vein thrombosis is one of the important causes of extrahepatic portal vein obstruction and prehepatic portal hypertension (1). When the acute portal vein thrombosis becomes chronic, the occluded portal vein gradually atrophies, fibrosis develops and chronic portal vein occlusion (CPVO) ensues, eventually leading to the cavernous transformation of portal vein (2), which is a compensatory response to the portal vein occlusion whereby a collateral vein forms to help reduce portal pressure and maintain liver blood perfusion (3, 4). However, they are usually not completely effective in decompressing the portal system, and many patients have persistent portal hypertension and develop serious portal hypertensive complications, such as variceal bleeding and ascites (5).Accumulating evidence has shown that transjugular intrahepatic portosystemic shunt (TIPS) (5–8) or modified TIPS combined with transhepatic or transsplenic approaches (9, 10) is technically feasible and effective to relieve portal hypertension in cirrhotic or non-cirrhotic patients with portal vein thrombosis or CPVO, with a technical success rate of 70% to 100%. Recanalization of the occluded portal vein is the key to the TIPS procedure for patients with portal hypertension and CPVO, while failed portal vein recanalization is the leading cause of TIPS failure (11). Conventional percutaneous catheterization techniques for portal vein recanalization mainly include percutaneous transhepatic and percutaneous transsplenic approaches. Recanalization can be achieved in most cases through either technique alone or in combination; however, they are not feasible in patients with portal vein atrophy and severe fibrosis.Therefore, for the cases of failed portal vein recanalization by conventional percutaneous catheterization, we have developed a procedure of percutaneous transluminal sharp recanalization (PTSR) of the portal vein to complete TIPS. The purpose of this study is to introduce this technique when performing a TIPS procedure for patients with CPVO and portal hypertension, as well as to evaluate its feasibility and safety.     

Preliminary results of a new expanded-polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt procedures.

OBJECTIVE: The purpose of our study was to evaluate the feasibility and the safety of transjugular intrahepatic portosystemic shunts (TIPS) with a new expanded-polytetrafluoroethylene-covered stent and the influence of the covering on occlusion rate. SUBJECTS AND METHODS: Twenty cirrhotic patients (57 +/- 11 years old) admitted with a history of esophageal variceal bleeding (n = 11), refractory ascites (n = 5), or both (n = 4) were included. Five of the patients were treated for TIPS revision, and 15 as de novo TIPS placements. The endoprostheses used were composed of a 2-cm noncovered nitinol stent and a 4- to 8-cm expanded-polytetrafluoroethylene graft covering, and were placed from the portal vein to the ostium of the hepatic vein. Patients underwent Doppler sonography at discharge and again at 1, 3, 6, 9, 12, and 15 months and underwent venography with portosystemic pressure gradient measurement at 6 months and whenever necessary. RESULTS: At the time of this writing, complications included three TIPS restenoses and one recurrent ascites successfully treated by balloon dilation, two cases of segmentary liver ischemia, and one patient with encephalopathy that required shunt reduction. After TIPS placement, the portosystemic pressure gradient dropped from 18 +/- 5 to 5 +/- 4 mm Hg. Primary and secondary patency rates were 80% and 100%, respectively, at 387 days. CONCLUSION: These results clearly show the feasibility of TIPS placement with the Gore TIPS endoprosthesis stent-graft and its improved patency compared with results in the literature for bare stents. These preliminary results must be certified further with randomized comparative trials between covered and noncovered TIPS stents.     

新型Cordis支架与Wallstent在猪经颈静脉虢人门腔静脉分流？…

目的 用猪的经颈静脉肝内门腔静脉分流术（ＴＩＰＳ）模型全种新型球囊扩张型Ｃｏｒｄｉｓ不锈钢支架,并与Ｗａｌｌｓｔｅｎｔ相比较。方法 分别用Ｃｏｒｄｉｓ支架或Ｗａｌｌｓｔｅｎｔ为２６只正常家猪（每种支架各１３只猪）行ＴＩＰＳ。所有猪在术后１４天被处死。术后对２５种支架的释放系统性能和置入后支架的开通率及回缩程度作对照评价。并对２种以呆的中间段、肝端和门静脉端的增生反应取样作定量对比分析。结果 Ｃｏｒ