Portal Vein Access Research Articles

Safety of Percutaneous Transmesenteric and Transsplenic Access for Portosystemic Shunt Creation in Patients with Portal Vein Obstruction: Single-Center Experience and Review of Literature.

To evaluate the safety of ultrasound-guided percutaneous mesenteric vein access compared to transsplenic portal vein access for portosystemic shunt placement in patients with portal vein obstruction. Eight patients underwent portosystemic shunt creation through either a transsplenic (n = 4) or transmesenteric (n = 4) approach. The superior or inferior mesenteric vein was percutaneously accessed under ultrasound guidance using a 21G needle and a 4F sheath. Hemostasis at the mesenteric access site was achieved with manual compression. For transsplenic access, sheath sizes between 6 and 8F were used and tract embolization with gelfoam was performed. Portosystemic shunt placement was successful in all patients. While there were no bleeding complications with transmesenteric access, hemorrhagic shock requiring splenic artery embolization occurred in one patient in which the transsplenic approach was used. Ultrasound-guided mesenteric vein access seems feasible and a valid alternative to the transsplenic access in case of portal vein obstruction. Level of Evidence Level 4, case series.

Clinical Impact and Safety of Non-Target Punctures (NTP) during Portal Vein Access in TIPS Procedure.

Although non-target puncture (NPT)-related complications are well known to clinicians performing TIPS, there is no NTP-focused study to assess the true clinical sequalae of NTP-related complications. In this study, the aim was to evaluate the incidence, safety, clinical outcomes and complications related to NTPs during the portal access of TIPS procedures. A retrospective review of 369 TIPS procedures from October 2007 to September 2019 was performed. We identified inadvertent NTPs, including biliary, hepatic artery, lymphatic and capsular punctures. Next, the medical records and images were reviewed and analyzed to assess the safety and clinical outcomes of these cohorts. A total of 71 NTPs were identified in 56 patients (15.18% of 369 patients). Of 369 TIPS patients, there were (1) 28 biliary punctures (7.6%), (2) 16 extracapsular punctures (4.3%), (3) 15 lymphatic punctures (4.1%) and (4) 12 hepatic artery punctures (3.3%). The overall complication rate was 2.2% (8/369). Based on the Clavien-Dindo classification, three patients (0.8%) had a minor complication. In addition, five patients (1.4%) experienced grade II-V major complications, such as symptomatic hemoperitoneum, arterio-biliary fistula or hemorrhagic shock leading to death. Mortality (0.5%) was only caused by extracapsular puncture combined with other NTP. NTPs during the portal access of TIPS procedures are associated with low complication risk. However, when extracapsular punctures are combined with other NTPs, a more severe complication, including mortality, can occur. Nevertheless, all patients with NTP should be closely monitored at a higher level of care after TIPS placement.

Safety and feasibility of a novel bi-directional portal vein access kit during transjugular intrahepatic portosystemic shunt creation

BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) creation remains as one of the more technically challenging endovascular procedures. Portal vein access from the hepatic vein often requires multiple needle passes, which increases procedure times, risk of complications, and radiation exposure. With its bi-directional maneuverability, the Scorpion X access kit may be a promising tool for easier portal vein access. However, the clinical safety and feasibility of this access kit has yet to be determined.Materials and methodsIn this retrospective study, 17 patients (12 male, average age 56.6 ± 9.01) underwent TIPS procedure using Scorpion X portal vein access kits. The primary endpoint was time taken to access the portal vein from the hepatic vein. The most common indications for TIPS were refractory ascites (47.1%) and esophageal varices (17.6%). Radiation exposure, total number of needle passes, and intraoperative complications were recorded. Average MELD Score was 12.6 ± 3.39 (range: 8–20).ResultsPortal vein cannulation was successfully achieved in 100% of patients during intracardiac echocardiography-assisted TIPS creation. Total fluoroscopy time was 39.31 ± 17.97 min; average radiation dose was 1036.76 ± 644.15 mGy, while average contrast dose was 120.59 ± 56.87 mL. The average number of passes from the hepatic vein to the portal vein was 2 (range: 1–6). Average time to access the portal vein once the TIPS cannula was positioned in the hepatic vein was 30.65 ± 18.64 min. There were no intraoperative complications.ConclusionsClinical utilization of the Scorpion X bi-directional portal vein access kit is both safe and feasible. Utilizing this bi-directional access kit resulted in successful portal vein access with minimal intraoperative complications.Level of evidenceRetrospective cohort.

Endoscopic ultrasound-guided vascular interventions: An expanding paradigm.

Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images "real-time" helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.

S2992 Extensive Portomesenteric Venous Thrombosis Due to JAK2 V617F Mutation as an Indication for Multivisceral Transplantation

Introduction: Cavernous transformation of the portal vein (CTPV) involving periportal or intrahepatic venous collateral network is a sequelae of chronic portal vein thrombosis (PVT). This adaptation increases the risk of complications and poor outcomes from revascularization procedures. In cases with diffuse portomesenteric venous thrombosis, multivisceral transplantation (MT) may be indicated. Case Description/Methods: An otherwise healthy female was diagnosed with Janus kinase 2 V617F (JAK2) mutation at age 43 during work up for PVT of unknown etiology. Her disease progressed with bleeding esophageal varices, portal hypertensive gastropathy, and splenomegaly. Liver biopsy was negative for cirrhosis. Bone marrow biopsy was negative for leukemia or fibrosis. She developed mesenteric vein thrombosis (MVT) at age 45 and was started on rivaroxaban, but then transitioned to high dose enoxaparin due to worsening thrombus progression. At age 47 she underwent thrombolysis for new MVT. Four months later, on current presentation, she endorsed worsening abdominal pain. Physical exam demonstrated ascites and pitting lower extremity edema. Abdominal ultrasound with venous duplex demonstrated absent flow in the portal vein. Computed tomography angiography (CTA) revealed progressive portal, superior mesenteric, and splenic vein thromboses despite anticoagulation (AC) compliance. Transjugular intrahepatic portosystemic shunt (TIPS) procedure was unsuccessful. Post-procedure CTA demonstrated an enlarging hepatic hematoma treated by embolization (figure 1). AC was discontinued resulting in worsening clot burden and hepatic ischemia. Given the extent of clot burden, the patient was transferred to another facility for a MT. Discussion: Presented is a rare case of chronic PVT in a patient with JAK2 mutation leading to CTPV refractory to anticoagulation or endovascular intervention, eventually requiring MT. Though JAK2 is associated with myeloproliferative disorders, it is an independent risk factor for the development of PVT. With worsening thrombus chronicity and burden, cavernous transformation may occur which decreases the chance of successful TIPS. When organ ischemia develops due to extensive portomesenteric venous thrombosis, orthotopic liver transplantation is no longer an option. Multivisceral transplantation replaces the liver, small bowel, and other abdominal organs. Replacement of the thrombosed portomesenteric system may be the only recourse to reverse portal hypertension and address the primary disease.Figure 1.: Computed tomography angiography of hematoma in liver segments VII and VIII, demarcated by green lines. A complication from attempted portal vein access.

Transsplenic Portal System Catheterization: Review of Current Indications and Techniques.

Multiple diseases of the portal system require effective portal vein access for endovascular management. While percutaneous transhepatic and transjugular approaches remain the standard methods of portal vein access, transsplenic access (TSA) has gained recognition as an effective and safe technique to access the portal system in patients with contraindications to traditional approaches. Recently, the utility of percutaneous TSA has grown, with described treatments including recanalization of chronic portal vein occlusion, placement of stents for portal vein stenosis, portal vein embolization of the liver, embolization of gastric varices, placement of complicated transjugular intrahepatic portosystemic shunts, and interventions after liver transplant. The authors provide a review of percutaneous TSA, including indications, a summary of related portal vein diseases, and the different techniques used for access and closure. In addition, an imaging-based review of technical considerations of TSA interventions is presented, with a review of potential procedural complications. With technical success rates that mirror or rival the standard methods and reported low rates of major complications, TSA can be a safe and effective option in clinical scenarios where traditional approaches are not feasible. ©RSNA, 2022.

Intravascular Ultrasound Guidance for TIPS Procedures: A Review.

The most challenging and time-consuming step of TIPS procedures is obtaining appropriate portal vein (PV) access. Given the lack of real-time direct target visualization, conventional fluoroscopic guidance requires multiple passes, contributing to complications. In comparison, intravascular ultrasound (IVUS) guidance during TIPS procedures provides direct visualization of hepatic structures and real-time guidance for PV puncture. IVUS guidance during TIPS creation improves procedural metrics such as radiation dose, contrast agent volume, procedure time, and technical success rate and is particularly beneficial in technically challenging cases (e.g., in patients portal vein thrombosis, small or variant portal vein anatomy, Budd-Chiari syndrome, or liver masses). The purpose of this review is to summarize current IVUS technology, describe the technical aspects of IVUS-guided TIPS creation, and discuss the clinical indications for and benefits of using IVUS for TIPS creation, while presenting available evidence supporting the technique's use. Given the improved safety profile and overall success rate in comparison with conventional guidance methods, IVUS guidance has the future potential to become the standard practice for TIPS placement.

Role of endoscopic ultrasound in vascular interventions: Where are we now?

From a mere diagnostic tool to an imperative treatment modality, endoscopic ultrasound (EUS) has evolved and revolutionized safer efficient options for vascular interventions. Currently it is an alternative treatment option in the management of gastrointestinal bleeding, primarily variceal type bleeding. Conventional treatment option prior to EUS incorporation had limited efficiency and high adverse events. The characterization and detail provided by EUS gives a cutting edge towards a holistically successful management choice. Data indicates that EUS-guided combination therapy of coil embolization and glue injection has the higher efficacy for the treatment of varices. Conversely, similar treatment options that exist for esophageal and other ectopic variceal bleeding was also outlined. In conclusion, many studies refer that a combination therapy of coil and glue injection under EUS guidance provides higher technical success with fewer recurrence and adverse events, making its adaptation in the guideline extremely favorable. Endo-hepatology is a novel disciple with a promising future outlook, we reviewed topics regarding portal vein access, pressure gradient measurement, and thrombus biopsy that are crucial interventions as alternative of radiological procedures. The purpose of this review is to provide an update on the latest available evidence in the literature regarding the role of EUS in vascular interventions. We reviewed the role of EUS in variceal bleeding in recent studies, especially gastric varices and novel approaches aimed at the portal vein.

Use of an Intrahepatic Arterial Targeting Wire for Guiding Portal Vein Puncture During TIPS Creation in Patients With Obliterative Portal Vein Thrombosis.

Obtaining portal vein access is a challenging step in TIPS creation, particularly in patients with portal vein thrombosis (PVT). We report the use of an intrahepatic arterial targeting wire to provide a target for portal vein puncture in 20 patients with cirrhosis and complete obliterative PVT who underwent TIPS placement. Technical success rate of TIPS placement was 90% (18/20). The median number of punctures was three. No severe complication occurred.

Abstract No. 598 Comparison of right and left portal vein access in transjugular intrahepatic portosystemic shunt

Abstract No. 598 Comparison of right and left portal vein access in transjugular intrahepatic portosystemic shunt

Abstract No. 191 Intravascular ultrasound in the creation of trans-hepatic portosystemic shunts: a systematic review and meta-analysis

We performed a systematic review and meta-analysis to assess the benefit of intravascular ultrasound (IVUS)–guided portal vein access during transjugular intrahepatic portosystemic shunt (TIPS) creation compared with the conventional TIPS technique.

A new alternative technique for the guidance of transjugular intrahepatic portosystemic shunt creation using DSA overlay reference.

Portal vein puncture (PVP) is a critical step during transjugular intrahepatic portosystemic shunt (TIPS) and correlates to several complications. Techniques guiding PVP are needed. To evaluate the safety, feasibility, and efficiency of digital subtraction angiography (DSA) overlay reference during TIPS creation and compare it with transhepatic portal vein (THPV) guiding. The clinical records of 185 patients at three medical centers who underwent TIPS placement were reviewed. Portal vein access was guided by THPV guiding in 120 cases and DSA overlay reference in 60 cases. The number of punctures, portal vein entry time, procedural adverse events, technical and hemodynamic success rate were analyzed to compare the safety, feasibility, and efficiency of the two methods. The median numbers of punctures in group 1 and group 2 were 2 (1-4) and 2 (1-5), respectively (P = 0.094). There was no statistical difference between two groups in needle passes. The median portal vein entry time of group 1 was 12 min (8-16 min) and 13 min (8-16 min) in group 2. No significant difference was found in the PVP time (P = 0.802). Arterioportal fistula formation occurred in 15 patients in group 1; two patients in group 2 had hepatic artery injury. The patients in group 2 had lower rates of procedural adverse events (P = 0.047). Median dose area product of G1 was lower than G2 statistically (P<0.001). There was no significant difference in total fluoroscopy time (P = 0.856). DSA overlay reference has lower procedural adverse events rates compared with THPV guiding TIPS. It seems to be a safe and effective method for guiding PVP.

The role of endoscopic ultrasound for portal hypertension in liver cirrhosis.

Chronic liver disease is still a major problem because disease progression will ultimately lead to liver cirrhosis. Portal hypertension is the hallmark in advanced liver disease management. By establishing portal vein access, endoscopic ultrasound (EUS) has been utilized in various clinical applications. In comparison to standard upper gastrointestinal endoscopy, EUS-Doppler has been shown to be a better modality for detecting esophageal and gastric varices along with peri-esophageal collateral veins, para-esophageal collateral veins, and perforating veins, and may be used to objectively predict the recurrence of bleeding. EUS-guided portal vein catheterization has also been proposed to overcome the limitations of trans-jugular approaches. The combination of EUS-elastography and azygos vein evaluation can also enhance the diagnostic accuracy of each modality. Another well-known implementation of EUS-guided procedures is in the management of ascites; particularly in paracentesis and ascitic fluid analysis. In addition, the most common clinical application of EUS in the treatment of portal hypertension is through vascular therapy or creation of intrahepatic portosystemic shunts. Major drawbacks of EUS mainly revolve around technical difficulties, the high cost of the procedure, as well as the requirement of more studies in humans to evaluate EUS-guided advanced therapeutic modalities in portal hypertension.

Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques.

Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.

Use of Cone-Beam Computed Tomography (CBCT) for Targeting the Portal Vein in Transjugular Intrahepatic Portosystemic Shunt (TIPS) Procedures: Comparison of Low-Dose with Standard-Dose CBCT

Background: A transjugular intrahepatic portosystemic shunt (TIPS) is a common treatment for patients with portal hypertension. In these patients, the portal vein can be punctured under the guidance of cone-beam computed tomography (CBCT). Objectives: To compare standard-dose (SD) CBCT with low-dose (LD) CBCT, as three-dimensional (3D) intraprocedural guidance for transhepatic puncture in TIPS placement, in terms of image quality, radiation dose, technical success, and complications. Patients and Methods: A total of 44 patients were retrospectively enrolled in this study. Eighteen patients underwent LD-CBCT, while 26 patients underwent SD-CBCT for guiding the portal vein puncture. A quantitative assessment of image quality was performed by calculating the contrast-to-noise ratio (CNR) of the hepatic portal vein. This analysis was based on a five-point vascular visualization scale (VVS), ranging from optimal (score = 1) to non-diagnostic (score = 5), while a three-point Likert scale was used for motion artifacts (1 = no motion artifacts, 3 = blurred). Image streak artifacts were also rated from one to three, based on the image quality results. Technical success was also investigated, including the number of puncture attempts, time to successful portal vein access, and radiation dose of the TIPS procedure. Results: Based on the results, TIPS could be placed successfully in all cases. Neither VVS (LD-CBCT VVS: 2.78, SD-CBCT VVS: 2.54; P = 0.467), nor the procedure time showed any significant differences between the groups (LD-CBCT: 48.3 min, SD-CBCT: 40.2 min; P = 0.45). Moreover, the objective evaluation of image quality indicated the lower quality of LD-CBCT images; however, the difference was not statistically significant (LD-CBCT CNR: 1.1 ± 0.76, SD-CBCT CNR: 1.3 ± 1.1; P = 0.5). The median number of puncture attempts was the same for SD-CBCT and LD-CBCT (n = 3; range: 1 - 6). Also, the mean dose area product (DAP) was significantly lower in LD-CBCT as compared to SD-CBCT (LD-CBCT: 2733 ± 848 µGm2, SD-CBCT: 6119 ± 1677 µGm2; P &lt; 0.0001). The total DAP was significantly lower using LD-CBCT (LD-CBCT: 14831 ± 9299 µGm2, SD-CBCT: 20985 ± 10127 µGm2; P = 0.047). Conclusion: Both SD-CBCT and LD-CBCT provided successful 3D guidance for portal vein puncture during TIPS creation. Although these methods did not differ significantly in terms of image quality, complications, or number of puncture attempts, LD-CBCT significantly reduced the radiation dose.

Feasibility of Augmented Reality–Guided Transjugular Intrahepatic Portosystemic Shunt

PurposeTo investigate an augmented reality (AR)–guided endovascular puncture to facilitate successful transjugular intrahepatic portosystemic shunt (TIPS). Materials and MethodsAn AR navigation system for TIPS was designed. Three-dimensional (3D) liver models including portal and hepatic vein anatomy were extracted from preoperative CT images. The 3D models, intraoperative subjects, and electromagnetic tracking information of the puncture needles were integrated through the system calibration. In the AR head-mounted display, the 3D models were overlaid on the subjects, which was a liver phantom in the first phase and live beagle dogs in the second phase. One life-size liver phantom and 9 beagle dogs were used in the experiments. Imaging after puncture was performed to validate whether the needle tip accessed the target hepatic vein successfully. ResultsEndovascular punctures of the portal vein of the liver phantom were repeated 30 times under the guidance of the AR system, and the puncture needle successfully accessed the target vein during each attempt. In the experiments of live canine subjects, the punctures were successful in 2 attempts in 7 beagle dogs and in 1 attempt in the remaining 2 dogs. The puncture time of needle from hepatic vein to portal vein was 5–10 s in the phantom experiments and 10–30 s in the canine experiments. ConclusionsThe feasibility of AR-based navigation facilitating accurate and successful portal vein access in preclinical models of TIPS was validated.

Transhepatic endovascular repair for portal vein haemorrhage

BackgroundPost-surgical bleeding of the main portal vein (PV) is a rare event but difficult to manage surgically. Among the different options of treatment, endovascular stenting of the PV can be considered.We reported two cases of stent-graft placement in PV with subsequent closure of the portal vein access with two percutaneous closure devices deployed simultaneously.Cases presentationThe first patient was a 43 years-old woman affected with a pseudoaneurysm of the extrahepatic PV, occurred after a duodenocephalopancreasectomy performed for a neuroendocrine tumour of the pancreatic isthmus. The second patient was a 54 years-old man suffering from multiple episodes of bleeding after liver transplantation, due to a PV fissure.In both cases, a stent graft was placed into the portal system, between the PV and the superior mesenteric vein through a right trans-hepatic access to the portal system.In both cases, a final control showed patency of the mesenteric vein and PV and no endoleak detection.At the end of the procedure, two percutaneous closure devices were loaded, to close the transhepatic portal access. In one case, one of the devices did not work and the entry point was managed with a single device, without further complications.No bleeding was seen though the entry point nor at the US examination performed right after the procedure.After procedure, patients were prescribed with low-molecular weight heparin (LMWH) and kept under surveillance. For both patients, CT scan performed within 24h after the procedure, showed a patent stent-graft and no evidence of any venous portal ischemia.The first patient was then transferred to another hospital, to continue observation and medical management. The second one underwent 2 months of hospitalization, during which he developed a pancreatic fistula and mild renal insufficiency. Then, he left the hospital to its native Country to continue his medical.ConclusionPV stent-graft placement seems a feasible option to manage portal bleeding.Trans-hepatic access is an easy and fast approach. The trans-hepatic portal accesses may be successfully managed with the deployment of percutaneous closure devices.

Analyzing Radiation Use during Transjugular Intrahepatic Portosystemic Shunt Creation

Portal vein access during transjugular intrahepatic portosystemic shunt creation was examined in 11 patients. Radiation metrics (kerma area product, reference point air kerma, and fluoroscopy times) during portal vein access were significantly greater for conventional versus intravascular US–guided transjugular intrahepatic portosystemic shunt (54.8 mGy ∙ cm2 ± 27.6 vs 8.4 mGy ∙ cm2 ± 5.0, P = .009; 210.4 mGy ± 109.1 vs 29.5 mGy ± 18.4, P = .009; 19.1 min ± 8.6 vs 8.9 min ± 4.6, P = .04). Wedged hepatic venography is a major contributor to radiation exposure. Intravascular US guidance is associated with significantly reduced radiation use.

Transjugular Intrahepatic Portosystemic Shunt Creation Using a Radiofrequency Wire: Prospective Clinical Safety and Feasibility Trial in Cirrhosis

PurposeTo assess the safety and feasibility of using a radiofrequency (RF) wire for portosystemic shunt creation. Materials and MethodsTen patients undergoing elective creation of a transjugular intrahepatic portosystemic shunt (TIPS) or a direct intrahepatic portosystemic shunt (DIPS) were prospectively enrolled. Primary outcomes were the safety and feasibility of RF wire used for the creation of TIPS and DIPS. Median age was 66.5 ± 6.1 years. Causes of liver disease included alcohol (n = 5), nonalcoholic steatohepatitis (n = 2), hepatitis C virus (n = 1), primary biliary cirrhosis (n = 1), autoimmune hepatitis (n = 1). The median score for model for end-stage liver disease was 11 ± 4.3. The Rosch-Uchida TIPS set was used with intravascular ultrasonography guidance in all cases. A 0.035-inch RF wire was used in lieu of the trocar needle through the 5-F TIPS set catheter to create a track between the hepatic vein and the portal vein. All shunts were created using stent grafts. ResultsTechnical success rate was 100%. In 7 of 10 patients, portal vein access was achieved with a single pass. A DIPS was created in 2 patients based on anatomic favorability. Median fluoroscopy time was 13.3 ± 3.8 min, and median total procedure time was 102 ± 19 min. The wire passed through parenchyma without subjective deflection. There was 1 case of extracapsular puncture with no clinical consequence. The RF wire was too stiff to curve into the main portal vein, requiring wire exchange in all but 1 case. Mean portosystemic gradient decreased from 13.9 ± 3.3 to 5.9 ± 2.1 mm Hg. No immediate complications were encountered. Shunt patency was 100% at 30 days. ConclusionsCreation of TIPS and DIPS using an RF wire was safe and feasible, enabling creation of an intrahepatic track without subjective deflection in cirrhotic patients.

Ultrasound-Guided Portal Vein Access and Percutaneous Wire Placement in the Portal Vein Are Associated With Shorter Procedure Times and Lower Radiation Doses During TIPS Placement.

BACKGROUND. TIPS placement is an effective method for treating a number of complications of portal hypertension. Although this complex procedure has been firmly established in treatment algorithms, more data are needed to determine the most efficient and safest ways to perform the procedure. OBJECTIVE. The purpose of this study was to determine the effect of three different techniques of portal vein (PV) cannulation during TIPS placement on procedure efficiency. METHODS. The medical records of patients who underwent TIPS creation between 2005 and 2019 were reviewed. On the basis of the PV access technique used, patients were grouped as follows: group 1 (G1) included patients who underwent a transabdominal ultrasound (US)-guided technique to obtain PV access, group 2 (G2) consisted of those who underwent fluoroscopically guided wedged hepatic portography, and group 3 (G3) included those who underwent percutaneous US-guided PV guidewire placement for fluoroscopic targeting. RESULTS. Of the 264 patients who underwent TIPS creation, 54 (20.5%) were in G1, 172 (65.1%) were in G2, and 38 (14.4%) were in G3. The mean (± SD) fluoroscopic time in G1 (34.8 ± 16.6 minutes) did not differ from that in either G2 (38.9 ± 20.8 minutes; p = .09) or G3 (29.5 ± 14.6 minutes; p = .06). However, G2 patients had significantly longer fluoroscopic times than G3 patients (p = .005). The mean total anesthesia time in G1 (190.2 ± 45.6 minutes) did not differ from that in G2 (199.7 ± 59.5 minutes; p = .15). However, G3 had a mean anesthesia time (162.6 ± 39.7 minutes) that was significantly shorter than that in both G1 (p = .003) and G2 (p < .001). The mean contrast volume was significantly lower in G1 than in G2 (67.9 ± 36.8 mL vs 87.1 ± 42.9 mL; p = .005). More intrahepatic needle passes were required in G2 (median, 4 passes; interquartile range [IQR], 1-7 passes) than in G1 (median, 2 passes; IQR, 1-4 passes; p = .004) and G3 (median, 2 passes; IQR, 1-7.25 passes; p = .04). When complications in G1 and G3 were pooled, this cohort had significantly fewer complications than G2 (p = .01). CONCLUSION. Ultrasound-guided PV access and percutaneous PV guidewire placement for fluoroscopic targeting during TIPS creation are associated with shorter procedure and fluoroscopic times and potentially decreased complications. CLINICAL IMPACT. The present study helps interventional radiologists understand the safest and most efficient way to access the PV, which is a key step during TIPS placement.