Value of echo-enhanced Doppler sonography in evaluation of transjugular intrahepatic portosystemic shunts.

Abstract

The value of echo-enhanced color and power Doppler sonography in the evaluation of transjugular intrahepatic portosystemic shunts (TIPS) was assessed and compared with that of unenhanced Doppler sonography and portal angiography. In a prospective randomized trial, 31 shunts in 30 patients underwent unenhanced conventional color and power Doppler sonography and portal venography including pressure measurements. The patients were allocated to either echo-enhanced conventional color Doppler sonography or echo-enhanced power Doppler sonography. For echo enhancement, a galactose-based suspension was administered IV. Shunt stenoses, if present, were quantified by percentage of stenosis and correlated with angiography, which was the gold standard. The diagnostic confidence of unenhanced and echo-enhanced Doppler sonography was assessed using a visual analog scale. In the diagnosis of shunt occlusion, echo-enhanced Doppler sonography yielded a sensitivity and a specificity of 100% and 100%, respectively, compared with 100% and 89%, respectively, for unenhanced Doppler sonography. Our evaluation of hemodynamically significant stenoses (portosystemic gradient > or = 15 mm Hg) found echo-enhanced Doppler sonography to be superior to unenhanced Doppler sonography (sensitivity and specificity of 82% and 83%, respectively, compared with 64% and 80%, respectively). In the detection of a shunt stenosis based on morphologic criteria only, echo-enhanced Doppler sonography yielded a sensitivity and a specificity of 78% and 100%, respectively, compared with 47% and 50%, respectively, for unenhanced Doppler sonography. Power Doppler imaging did not improve diagnostic accuracy but did increase diagnostic confidence for unenhanced Doppler sonography compared with conventional color Doppler sonography. The diagnostic confidence for sonographic evaluation of TIPS was significantly (p < .001) increased and the variability of hemodynamic measurements was markedly decreased with echo-enhanced sonography. Echo-enhanced Doppler sonography provides images of TIPS like those of angiography and allows morphologic assessment of the shunts, complementary to the essential pulsed Doppler waveform analysis that would be performed in a more guided manner. Also, echo-enhanced Doppler sonography significantly increases the sensitivity and specificity in the diagnosis of shunt dysfunction. The high diagnostic confidence and the diminished variability of spectral Doppler measurements may improve acceptance of sonographic evaluation of TIPS. Echo-enhanced Doppler sonography is safe and effective and may reduce the instances in which TIPS sonographic surveillance is nondiagnostic, in which case angiographic assessment is required.