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.     

Helical CT angiography of transjugular intrahepatic portosystemic shunts

Shunt dysfunction due to draining hepatic vein and/or stent stenosis is a common long-term complication of transjugular intrahepatic portosystemic shunts (TIPS). Currently, Doppler sonography is the preferred modality for routine screening of TIPS for the detection of these complications. However, this method is time-consuming, highly operator-dependent, and difficult to perform because of the anatomic attributes of the cirrhotic liver. The use of helical CT angiography (HCTA) for imaging TIPS has been recently described. HCTA of TIPS is performed after a rapid i.v. injection of a bolus of low osmolality contrast medium, followed by helical data acquisition of the region of the shunt using thin sections. The data are then reprocessed a overlapping intervals and various reformations are obtained. Preliminary reports show the sensitivity and specificity of the helical CT angiography to be comparable with Doppler sonography.     

Color and pulsed Doppler ultrasound findings in normally functioning transjugular intrahepatic portosystemic shunts.

OBJECTIVE: To evaluate blood flow changes inside normally functioning transjugular intrahepatic portosystemic shunts (TIPS), using color Doppler ultrasound (CDUS) and pulsed Doppler ultrasound (PDUS). METHODS: A total of 72 patients (mean age 54, range 36-78 years) underwent TIPS placement, portal angiography, CDUS and PDUS examinations. Measurements inside the stent were taken at the portal side, at the central part and at the venous end of the TIPS. RESULTS: In well functioning TIPS the mean peak velocity (PV) on the portal side was 37 m/s (range 22-65 cm/s), in the area of the incoming intrahepatic portal branch the mean PV was 59 cm/s (range 40-95 cm/s) and at the side of the incoming hepatic vein the mean PV was 135 cm/s (range 88-220 cm/s). In the punctured hepatic and portal veins the mean PV was 25 cm/s (range 15-30 cm/s) and 18 cm/s (10-22 cm/s), respectively. The flow increase from the portal to the mid part (P less than or = 0.001) and to the venous side was statistically significant (P less than or = 0.001). CONCLUSION: A velocity gradient between the portal and the venous side of a TIPS is a normal finding caused by branches of the portal and hepatic vein joining the TIPS from the side and it is characteristic of a normally functioning TIPS.     

经颈静脉肝内门-腔静脉分流术的护理

经颈静脉肝内门-腔静脉之间建立一个人工分流通道(transjugular intrahepatic portosystemic shunt,TIPS),可使部分或全部门静脉血液分流入腔静脉,有效地降低门静脉压力,控制和预防食管、胃底静脉和直肠静脉曲张破裂,并可促进腹水吸收,已成为救治门静脉高压症的有效方法[1,2].     

Feasibility of electromagnetically guided transjugular intrahepatic portosystemic shunt procedure

Objectives: To develop an electromagnetic navigation technology for transjugular intrahepatic portosystemic shunt (TIPS) creation and translate it from phantom to an in-vivo large animal setting.

Material and methods: A custom-designed device for TIPS creation consisting of a stylet within a 5 French catheter as well as a software prototype were developed that allow real-time tip tracking of both stylet and catheter using an electromagnetic tracking system. Feasibility of navigated TIPSS creation was tested in a phantom by two interventional radiologists (A/B) followed by in-vivo testing evaluation in eight domestic pigs. Procedure duration and number of attempts needed for puncture of the portal vein were recorded.

Results: In the phantom setting, intervention time to gain access to the portal vein (PV) was 144?±?67?s (A) and 122?±?51?s (B), respectively. In the in-vivo trials, TIPS could be successfully completed in five out of eight animals. Mean time for the complete TIPS was 245?±?205?minutes with a notable learning curve towards the last animal.

Conclusions: TIPS creation with the use of electromagnetic tracking technology proved to be feasible in-vitro as well as in-vivo. The system may be useful to facilitate challenging TIPSS procedures.     

Use of transjugular intrahepatic portosystemic shunt in liver disease

Persons with cirrhosis have many complications. Two of these complications are refractory ascites and recurrent gastrointestinal hemorrhage. When medical management has proved ineffective in the management of these two complications, a transjugular intrahepatic portosystemic shunt can be a treatment option. This outpatient procedure can reduce ascites, minimize the need for diuretics, and reduce the potential for gastrointestinal hemorrhage. The procedure is associated with the development of hepatic encephalopathy, which requires vigilant nursing observation. Education of the patient and family regarding the potential development of encephalopathy and the need for follow-up by the physician is important. The collaboration of physicians and nurses in the ongoing monitoring and follow-up of these patients can contribute to an improved quality of life and reduced hospitalizations. Nurses play an important role in alerting physicians to changes in patient condition that might indicate a narrowing of the transjugular intrahepatic portosystemic shunt, which requires intervention. (J Vasc Nurs 2000;18:83-7)     

TIPSS术后多普勒超声评价

目的：应用多普勒超声检测经颈静脉肝内门体静脉支架分流术（Transjugular intrahepatic portosystemic stent shunt,TIPSS）术后内支架及其血流情况,包括正常、狭窄和闭塞,探讨多普勒超声在TIPSS术后随访中的价值。方法：32例肝硬化门脉高压患者行TIPSS,术后多普勒超声检查86例次,包括支架内的血流、门静脉和脾静脉的血流方向和速度。结果：随访时间为8月~3年,二维超声清晰显示TIPSS内支架的网状回声,彩色多普勒和能量多普勒显示支架内的血流方向,频谱多普勒显示支架内以及门静脉和脾静脉的血流速度。其中5例病人多普勒血流显示支架内狭窄,支架门静脉端和肝静脉端血流速度减慢,支架内狭窄处为高速湍流。门静脉及脾静脉速度明显降低,为门静脉造影所证实。与非狭窄支架组比较,狭窄支架的血流速度测值差异有显著性意义（P<0.05）。结论：多普勒超声可以方便有效地检测TIPSS术后内支架的血流情况及早期发现分流道的狭窄,是TIPSS术后定期复查和疗效判断的首选方法。     

经颈静脉肝内门体分流术在门静脉高压中的应用

门静脉高压是肝硬化的主要特征,会导致许多相关并发症,经颈静脉肝内门体分流术(transjugular intrahepatic portosystemic shunt, TIPS)已成为治疗门脉高压相关并发症的主要手段。近年来,随着技术的不断进步,经颈静脉肝内门体分流术应用范围不断扩大,本文就该技术的在门静脉高压中的应用做一综述。     

Modified transjugular intrahepatic portosystemic shunt in the treatment of Budd-Chiari syndrome

Aims: The aim of this study was to determine the outcome of a modified transjugular intrahepatic portosystemic shunt (MTIPS) in the treatment of the Budd‐Chiari syndrome (BCS, occlusion of the hepatic veins). Methods: Eleven patients with severe BCS were selected for MTIPS treatment. Three patients had an acute history (< 2 months) and eight had a subacute or a chronic course of the disease. All patients were associated with variceal bleeding and massive ascites. The diagnosis of BCS was established by duplex sonography, computed tomography scan, magnetic resonance imaging, angiography of hepatic veins and inferior vena cava, and liver biopsy. The shunt was established using conventional self‐expandable stents with diameter of 10 cm in all patients. The mean follow‐up was 60.55 ± 42.76 months. Results: The shunt reduced the portosystemic pressure gradient from 30.32 ± 7.69 to 9.08 ± 3.43 mmHg and improved the portal flow velocity from 11.24 ± 2.75 to 52.16 ± 13.68 cm/s. Clinical symptoms as well as the biochemical test results improved significantly during 3 weeks after shunt treatment except for one death caused by hepatic failure. Ten patients are alive without clinical symptoms. Three revisions in two patients were needed during the follow‐up. The inflation of stenosised shunt was performed in one patient, and the inflation of stenosised shunt and the reimplantation of stent in another patient. The other eight patients had no revisions. Conclusions: Modified transjugular intrahepatic portosystemic shunt provides an excellent outcome in patients with BCS (occlusion of the hepatic veins). It may be regarded as an option for the acute and long‐term managements of these patients.     

Color Doppler sonography in the diagnosis of neonatal intrahepatic portosystemic shunts

Intrahepatic portosystemic shunts are infrequent in children. We report 3 cases of neonates who presented with jaundice during the first month of life. Color Doppler sonography in the first 2 cases showed direct communication between the right portal and hepatic veins. Both infants were asymptomatic, and the shunts disappeared spontaneously. The third case involved several shunts and an aberrant medial portal vein. This patient developed heart failure and died after surgery. Color Doppler sonography was useful in the diagnosis and follow-up of the shunts in all 3 cases.     

双源CT在经颈静脉门腔分流术后随访中的应用

目的 观察双源CT在经颈静脉肝内门-体分流术(TIPS)后随访中的应用价值。方法 对28例肝硬化门静脉高压合并上消化道出血或大量腹腔积液接受TIPS的患者,于术后1个月内、3个月内、6个月、12个月、18个月、24个月进行双源CT复查,采用MIP、VR等图像后处理技术,判断肝静脉及门静脉间支架位置通畅情况。结果 28例患者中,3例(10.71%)支架内血栓形成,MIP示支架处低密度灶,对比剂自狭窄处流过,VR示支架位置、角度满意,及时行球囊扩张溶栓治疗;1例(3.57%)支架冗长、成角,再次植入支架;24例(85.71%)TIPS术后未出现分流道狭窄或血栓,MIP成像显示支架通畅,内见对比剂通过,VR显示支架位置、角度满意。结论 双源CT血管成像技术具有安全、无创、准确的优点,且同时能对肝实质进行观察,可作为TIPS术后的首选随访手段。     

The effects of transjugular intrahepatic portosystemic stent shunt on systemic cardiocirculatory parameters

Purpose

We aimed to evaluate the effects of transjugular intrahepatic portosystemic stent shunt (TIPS) on systemic cardiocirculatory parameters in patients treated with TIPS for portal hypertension–associated complications.

Materials and Methods

This prospective study was conducted in an intensive care unit of a German university hospital (October 2010–July 2013). We assessed hemodynamic parameters before and after TIPS placement using single-indicator transpulmonary thermodilution and pulse contour analysis. After exclusion of 5 patients treated with vasoactive agents during study measurements, 15 patients were included in the final statistical analysis.

Results

Transjugular intrahepatic portosystemic stent shunt induced a statistically significant decrease in portal pressure (median, 29 [25%-75% percentile range, 23-37] mm Hg before TIPS vs 21 [18-27] mm Hg after TIPS; P < .01) in parallel with a statistically significant increase in central venous pressure (10 [6-15] mm Hg before TIPS vs 13 [9-16] mm Hg after TIPS; P = .01), cardiac index (3.8 [2.9-4.6] L min^− 1 m^− 2 before TIPS vs 4.5 [3.8-5.4] L min^− 1 m^− 2 14 hours after TIPS; P = .01), and stroke volume index (54 [42-60] mL/m² before TIPS vs 60 [47-63] mL/m² 14 hours after TIPS; P = .03). Arterial blood pressure and systemic vascular resistance index were statistically significantly lower after TIPS.

Conclusions

Transjugular intrahepatic portosystemic stent shunt placement is associated with an increase in central venous pressure and an improvement of global blood flow (cardiac index and stroke volume index) in patients with portal hypertension.     

经颈静脉肝内门体分流术与内镜治疗预防食管胃底静脉曲张出血的效果

目的  分析经颈静脉肝内门体分流术（TIPS）与内镜治疗对食管胃底静脉曲张出血（EGVB）的预防效果,为肝硬化患者早期合理选择治疗方案提供参考依据。 方法  回顾性分析2018年1月~2020年2月于遂宁市中心医院接受一级预防的肝硬化合并食管胃底静脉曲张的89例患者,根据手术方式不同将患者分为两组,其中进行内镜下套扎治疗（EVL）者纳入EVL组（n=43）,进行TIPS治疗者纳入TIPS组（n=46）,比较两组静脉曲张改善效果,治疗前后门静脉内径、肝功能变化以及治疗后患者EGVB、并发症和死亡发生情况。结果TIPS组和EVL组静脉曲张改善有效率分别为90.70%和86.96%,差异无统计学意义（P > 0.05）;两组治疗后肝功能Child-Pugh分级及评分差异无统计学意义（P > 0.05）,TIPS组术后门体循环压力差降低（P < 0.05）,且治疗后3、6、12、24月时门静脉内径门静脉内径低于EVL组,差异有统计学意义（P < 0.05）;两组治疗后EGVB发生率分别为32.56%和17.39%（P > 0.05）,其中TIPS组远期出血（治疗3月后）发生率低于EVL组,差异有统计学意义（P < 0.05）;两组术后并发症发生率、死亡率差异无统计学意义（P > 0.05）。 结论  早期TIPS和EVL用于肝硬化患者一级预防均可有效改食管胃底善静脉曲张,有利于降低EGVB发生风险,且TIPS在降低门静脉压力和远期出血发生率方面较EVL具有一定优势。     

Doppler ultrasound evaluation of transjugular intrahepatic portosystemic shunt function: pitfalls and artifacts

The current literature reflects controversy regarding the accuracy of Doppler ultrasound for the detection of transjugular intrahepatic portosystemic shunt (TIPS) malfunction. Experience has revealed many pitfalls and artifacts that can potentially interfere with the proper performance and interpretation of Doppler studies in patients with TIPS. In this article the author discusses and illustrates the spectrum of pitfalls that may be encountered during Doppler evaluation of TIPS function.     

彩色多普勒超声对经颈静脉肝内门体分流术后支架功能障碍的诊断价值

目的探讨彩色多普勒超声诊断经颈静脉肝内门体静脉分流术(TIPS)后支架功能障碍的临床价值。方法 33例门静脉高压患者,接受TIPS治疗,术后临床怀疑支架功能障碍35例次。超声检测其门静脉主干内径、血流速度以及支架内血流速度,计算充血指数,并与DSA诊断结果对比。结果与DSA比较,超声诊断支架功能障碍符合率为100%,诊断支架狭窄和闭塞符合率为89.5%、93.8%。门静脉左支矢状部内血流方向,支架通畅时,60.0%出现离肝血流,而支架功能障碍时出现离肝血流为5.7%。支架功能障碍时,门静脉流速(26.02±8.49)cm/s,内径(1.49±0.10)cm,血流量(1563.38±529.82)ml/min,充血指数0.14±0.08;与支架通畅时比较,其上述指标均上升(P0.05)。结论彩色多普勒超声诊断TIPS支架功能障碍具有较高的准确性,可作为TIPS术后随访的首选方法。     

右美托咪定监护下麻醉在经颈静脉肝内门体静脉分流术中的应用

目的观察右美托咪定监护下麻醉(MAC)用于经颈静脉肝内门体静脉分流术(TIPS)的麻醉效果。方法4 0例拟行TIPS的患者随机分为右美托咪定组(D组,n=20)和丙泊酚组(P组,n=20),D组和P组首先分别给予负荷剂量的右美托咪定和丙泊酚,然后调整两组的给药剂量使Ramsay镇静评分维持于2~4分,两组患者术前均给予0.1μg/kg的舒芬太尼,且术中酌情追加0.05μg/kg每次。记录麻醉前(T0)、手术开始前(T1)、球囊扩张时(T2)、支架植入时(T3)、术毕(T4)时的平均动脉压(MAP)、心率(HR)、脉搏血氧饱和度(SPO2),舒芬太尼用量、呼吸抑制发生例数、手术时间、清醒时间等。结果 MAP:T1时,P组较D组明显下降(P0.05);T2、T3时,P组的MAP较D组明显升高(P0.05);HR:T3时,P组较D组明显升高(P0.05);SPO2:T1、T2、T4时,P组较D组明显降低(P0.05);P组的苏醒时间长于D组(P0.05);P组的舒芬太尼用量、呼吸抑制的发生例数较D组高(P0.05)。结论右美托咪定行MAC用于TIPS术安全可行。