Portal Venography Research Articles

Dual-energy CT Portal Venography: Clinical Application Values and Future Opportunities.

Standard multidetector computed tomography (MDCT) uses a single X-ray tube to emit a mixed energy X-ray beam, which is received by a single detector. The difference is that dual-energy CT (DECT), a new equipment in recent years, employs a single X-ray tube or two X-ray tubes to emit two single-energy X-ray beams, which are received by a single or two detectors. The application of dual-energy technology to portal venography has become one of the research hotspots. This paper will elaborate on the clinical application values of DECT portal venography in improving portal vein image quality, distinguishing the nature of portal vein thrombus, reducing contrast agent dose and radiation dose, and will discuss the possibility of its movement from research to routine practice and future development opportunities.

Balloon-Assisted Portal Vein Embolization Using n-Butyl-2-Cyanoacrylate–Lipiodol–Iopamidol Mixture in Swine: A Comparison of 2 Formulations

PurposeTo compare 2 ratios of n-butyl-2-cyanoacrylate (nBCA)–ethiodized oil (Lipiodol)–iopamidol (NLI) in balloon-assisted portal vein embolization (PVE) in swine. Materials and MethodsIn an in vitro study, NLI prepared at a ratio of 2:3:1 (NLI231) or 1:4:1 (NLI141) was injected into 2.5- or 10-mL syringes filled with swine blood, and the viscosity of NLI was measured to determine an appropriate balloon occlusion time. Two portal vein branches in 8 female swine (n = 16 vein branches) were embolized with NLI231 (n = 8) or NLI141 (n = 8) under balloon occlusion. Portal venography was performed before, immediately after, and 3 days after PVE to evaluate the migration of NLI and the recanalization of embolized portal vein branches. Then, the livers were removed for histopathologic evaluation. ResultsThe times to peak viscosity of NLI231 in the 2.5- and 10-mL syringes were 55.8 seconds (SD ± 7.0) and 85.2 seconds (SD ± 6.3), and those to peak viscosity of NLI141 were 129.2 seconds (SD ± 11.8) and 254.0 seconds (SD ± 21.8), respectively. No migration of NLI231 was observed in all 8 procedures immediately or 3 days after PVE. Migration of NLI141 was observed in 6 of 8 procedures within 3 days after PVE. The migration frequency of the embolic material was lower in the NI231 group than in the NLI141 group (0/8 vs 6/8; P = .051). Histologically, NLI231 occupied the portal veins without any thrombi, whereas NLI141 was accompanied by thrombi in the portal veins. ConclusionsNLI231 may be more suitable than NLI141 for balloon-assisted PVE in swine.

Diagnostic and monitoring value of ultrasound, computed tomography angiography, and portal venography in surgical ligation of congenital extrahepatic portosystemic shunts

PurposeTo investigate the diagnostic and monitoring value of ultrasound (US), computed tomography angiography (CTA), and portal venography in surgical ligation of congenital extrahepatic portosystemic shunts (CEPS) in children. MethodsWe retrospectively analysed different imaging examinations of 15 children with CEPS. Development of the portal vein before shunt occlusion, shunt location, portal vein pressure, main symptoms, diameter of the main portal vein, and location of secondary thrombosis after shunt occlusion were recorded. Final classification diagnosis was made by portal venography after shunt occlusion, and consistency with other imaging examinations in diagnosing development of the portal vein was calculated using Cohen’s kappa. ResultsCompared with portal venography after shunt occlusion, US, CTA, and portal venography before shunt occlusion had poor consistency in showing the development of hepatic portal veins (Kappa value 0.091–0.194, P > 0.05). Six cases developed portal hypertension (40–48 cmH2O) during the temporary occlusion test, and US showed that portal veins gradually expanded after shunt ligation. Eight patients with haematochezia had inferior mesenteric vein (IMV)-iliac vein (IV) shunts. After surgery, secondary IMV thrombosis was observed in eight cases and secondary splenic vein thrombosis in four cases. ConclusionPortal venography with occlusion testing is very important to accurately evaluate the development of the portal vein in CEPS. The portal vein needs to expand gradually, and partial shunt ligation surgery is necessary in cases diagnosed as portal vein absence or hypoplasia before occlusion testing to avoid severe portal hypertension. After shunt occlusion, US is effective in monitoring portal vein expansion, and both US and CTA can be used to monitor secondary thrombi. IMV-IV shunts can cause haematochezia and are prone to secondary thrombosis after occlusion.

Feasibility of computed tomography portal venography in the preoperative evaluation of emergent TIPS creation for cirrhotic patients with acute variceal bleeding

ObjectivesTo evaluate the feasibility of computed tomography portal venography (CTPV) in the preoperative evaluation of emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for cirrhotic patients with acute variceal bleeding (AVB). MethodsOne hundred and forty-eightcirrhotic patients with AVB undergoing emergent TIPS creation from January 2016 to December 2022 in our institution were enrolled in the retrospective study. The primary outcome was the consistency between CTPV and endoscopy in the classification and grading of gastroesophageal varices (GEVs). The second outcome was extraluminal CTPV findings. The consistency of CTPV and endoscopy in the classification and grading of GEVs was determined by Kappa values. ResultsEmergent TIPS creation was technically successful in all patients. Forty-five patients underwent preoperative endoscopy. The results of CTPV diagnosis of GEVs classification were that 112, 28, and 8 patients were classified as gastroesophageal varices type 1 (GOV1), GOV2, and isolated gastric varices type 1 (IGV1), respectively. In diagnosing the classification and grading of GEVs, CTPV showed substantial agreement with preoperative endoscopy, with Kappa values of 0.823 and 0.625, respectively. CTPV provided the afferent and afferent vessels of GEVs for emergent TIPS creation. ConclusionCTPV is feasible and effective to act as an alternative preoperative evaluation method to endoscopy for cirrhotic patients with AVB undergoing emergent TIPS creation.

EUS-guided coil placement and cyanoacrylate glue injection for gastric variceal bleeding with obvious spontaneous portosystemic shunts.

Ectopic embolism caused by cyanoacrylate glue for the treatment of gastric varices with obvious spontaneous portosystemic shunts is a serious complication of endoscopic therapy. This study was performed to investigate the safety and therapeutic effect of EUS-guided coil placement and cyanoacrylate glue injection for gastric varices with obvious spontaneous portosystemic shunts. Six patients with gastric variceal bleeding and obvious spontaneous portosystemic shunts were included in this study. We evaluated the success rate of variceal occlusion after intraoperative embolization, the postoperative rebleeding rate at 48 h and 2 weeks posttreatment, and the incidence of ectopic embolism and other adverse events. Gastroscopy and computed tomography portal venography (CTPV) were performed 7 months later. All patients underwent successful coil placement and cyanoacrylate glue injection under EUS guidance. The blood flow was confirmed by Doppler examination, the target vessels were successfully blocked, and no rebleeding had occurred at 48 h or 2 weeks after endoscopic treatment. Gastroscopy was repeated 7 months after endoscopic treatment, revealing local ulcer formation. CTPV was also repeated 7 months after endoscopic treatment, showing that the coils were present in the target vessels with no displacement, the portosystemic shunt vessels were occluded, and no ectopic embolization had occurred. The coil placement combined with cyanoacrylate glue embolism is a safe and effective method for patients with gastric variceal bleeding and obvious spontaneous portosystemic shunts.

Intrahepatic portal venous systems in adult patients with cavernous transformation of portal vein: Imaging features and a new classification

BackgroundCavernous transformation of the portal vein (CTPV) due to portal vein obstruction is a rare vascular anomaly defined as the formation of multiple collateral vessels in the hepatic hilum. This study aimed to investigate the imaging features of intrahepatic portal vein in adult patients with CTPV and establish the relationship between the manifestations of intrahepatic portal vein and the progression of CTPV. MethodsWe retrospectively analyzed 14 CTPV patients in Beijing Tsinghua Changgung Hospital. All patients underwent both direct portal venography (DPV) and computed tomography angiography (CTA) to reveal the manifestations of the portal venous system. The vessels measured included the left portal vein (LPV), right portal vein (RPV), main portal vein (MPV) and the portal vein bifurcation (PVB). ResultsNine males and 5 females, with a median age of 40.5 years, were included in the study. No significant difference was found in the diameters of the LPV or RPV measured by DPV and CTA. The visualization in terms of LPV, RPV and PVB measured by DPV was higher than that by CTA. There was a significant association between LPV/RPV and PVB/MPV in term of visibility revealed with DPV (P = 0.01), while this association was not observed with CTA. According to the imaging features of the portal vein measured by DPV, CTPV was classified into three categories to facilitate the diagnosis and treatment. ConclusionsDPV was more accurate than CTA for revealing the course of the intrahepatic portal vein in patients with CTPV. The classification of CTPV, that originated from the imaging features of the portal vein revealed by DPV, may provide a new perspective for the diagnosis and treatment of CTPV.

Percutaneous Direct Puncture of Retropancreatic Splenic Vein and Portal Thrombectomy in a Patient With Liver Transplantation and Simultaneous Splenectomy.

Portal vein thrombosis following liver transplantation is generally managed by endovascular treatment. Although several techniques are available for portal venous access, trans-splenic access is of interest because it avoids damage to the liver graft. However, the spleen cannot be punctured to access the portal vein after splenectomy. We herein report a case of portal vein thrombosis following living donor liver transplantation with simultaneous splenectomy successfully treated by percutaneous intervention with direct puncture of the retropancreatic splenic vein. The splenic vein was punctured under computed tomography guidance in the prone position. Portal venography revealed a contrast defect due to a thrombus in the extrahepatic to intrahepatic portal vein. The portal vein was reopened after thrombectomy, and the portal vein thrombosis did not recur for 2 y. The technique and advantages of our approach are described.

S1790 Portal Biliopathy in a Patient Who Underwent a Whipple Procedure With Portal Vein Reconstruction

Introduction: Portal biliopathy is a condition that is defined as abnormalities in the biliary tract due to portal hypertension. Some patients may present with abdominal pain, fever, jaundice, or pruritis. Rarely, portal hypertension secondary to portal vein abnormalities cause peri-biliary varices. We report a case of a patient with a peri-biliary variceal bleed due to portal hypertension from acquired portal vein stenosis. Case Description/Methods: A 59-year-old female with a past medical history of pancreatic ductal adenocarcinoma presented to the hospital with 5 days of Black tarry stools. Two years prior, she was diagnosed with pancreatic head adenocarcinoma and underwent a pancreaticoduodenectomy with portal vein reconstruction. Subsequent CT scans demonstrated post surgical portal vein stenosis. On admission, she denied fevers, abdominal pain, or hematemesis. Labs were notable for a hemoglobin of 5.7 g/dl, INR of 1.6, and bilirubin of 1.0 mg/dl. Physical exam demonstrated an abdominal fluid wave and melena on digital rectal exam. CT abdomen showed post Whipple anatomy, severe portal vein stenosis, large volume ascites, and extensive upper abdominal collaterals including peri-portal and peri-biliary varices. Upper endoscopy revealed blood in the afferent jejunal limb. Bleeding was found to be originating from the choledochojejunostomy. Multiple large visible vessels with stigmata of recent bleeding were visualized within the common bile duct. A single hemostatic clip was placed on one of the vessels, resulting in increased bleeding. Hemostasis was achieved with cyanoacrylate injection. The patient was transferred to the interventional radiology suite, where she underwent portal venography confirming severe stenosis of the porto-mesenteric confluence. Interventional radiology performed portal vein balloon dilation and stent placement. The patient had no further bleeding following the procedure (Figure). Discussion: Bleeding from peri-biliary varices is a rare cause of upper GI bleeding. In this case, non cirrhotic portal hypertension from acquired portal vein stenosis after pancreaticoduodenectomy led to clinically significant gastrointestinal bleeding. Portal biliopathy is an uncommon and late presentation in patients with extrahepatic portal vein obstruction. In many cases, patients present with signs and symptoms of biliary obstruction. Treatment of PB should involve a multidisciplinary discussion among various subspecialties including gastroenterology, interventional radiology, and hepatobiliary surgery.Figure 1.: A. Choledochojejunostomy with visible varices. B. Hemostatic clip placement with subsequent bleeding. C. Injection of cyanoacrylate glue with hemostasis. D. Portal venography demonstrating portal vein stenosis at the porto-mesenteric confluence.

Identification and Treatment of an Unusual Cause of Gastrointestinal Bleeding

Identification and Treatment of an Unusual Cause of Gastrointestinal Bleeding

Image quality enhancement of CT hepatic portal venography using dual energy blending with computer determined parameters.

Previous studies have shown that using some post-processing methods, such as nonlinear-blending and linear blending techniques, has potential to improve dual-energy computed (DECT) image quality. To improve DECT image quality of hepatic portal venography (CTPV) using a new non-linear blending method with computer-determined parameters, and to compare the results to additional linear and non-linear blending techniques. DECT images of 60 patients who were clinically diagnosed with liver cirrhosis were selected and studied. Dual-energy scanning (80 kVp and Sn140 kVp) of CTPV was utilized in the portal venous phase through a dual-source CT scanner. For image processing, four protocols were utilized including linear blending with a weighing factor of 0.3 (protocol A) and 1.0 (protocol B), non-linear blending with fixed blending width of 200 HU and set blending center of 150HU (protocol C), and computer-based blending (protocol D). Several image quality indicators, including signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and contrast of hepatic portal vein and hepatic parenchyma, were evaluated using the paired-sample t-test. A 5-grade scale scoring system was also utilized for subjective analysis. SNR of protocols A-D were 9.1±2.1, 12.1±3.0, 11.6±2.8 and 14.4±3.2, respectively. CNR of protocols A-D were 4.6±1.3, 8.0±2.3, 7.0±2.0 and 9.8±2.4, respectively. The contrast of protocols A-D were 37.7±11.6, 91.9±21.0, 66.2±19.0 and 107.7±21.3, respectively. The differences between protocol D and other three protocols were significant (P < 0.01). In subjective evaluation, the modes of protocols A, B, C, and D were rated poor, good, generally acceptable, and excellent, respectively. The non-linear blending technique of protocol D with computer-determined blending parameters can help improve imaging quality of CTPV and contribute to a diagnosis of liver disease.

S3595 Acute Upper Gastrointestinal Bleeding Masquerading as a Demand ST-segment Elevation Myocardial Infarction

Introduction: Acute upper gastrointestinal bleeding (UGIB) is a medical emergency requiring a timely diagnosis with prompt intervention. Patient’s usually present with signs of hemorrhagic shock such as hematemesis/melena, tachycardia, and hypotension. Here, we report a patient with an unusual presentation of UGIB with ST-segment myocardial infarction (STEMI) before the development of conventional symptoms. Case Description/Methods: A 37-year-old male with alcohol use disorder was hospitalized in the medical intensive care unit (ICU) for acute on chronic liver failure, resolving circulatory shock, and acute kidney injury. He complained of retrosternal chest pain and nausea following extubation. He had no fever or cough; chest examination revealed no abnormal findings. Chest X-ray was unremarkable. EKG revealed acute ST elevation in leads II, III, and avF with reciprocal depressions in V2 and V3 (1A). A bedside echocardiogram revealed no focal wall motion abnormalities. Point-of-care ultrasound revealed a distended stomach filled with heterogeneous contents (1C). He was intubated for airway protection in the context of worsening encephalopathy. Intravenous fluid resuscitation was initiated given decreasing BP, and ST-segment changes resolved (1B). Upper GI endoscopy examination revealed clotted blood in the entire examined stomach with an adherent clot at the cardia. The patient underwent massive transfusion protocol with emergent percutaneous portal venography with gastric and esophageal variceal embolization. The next day, his cardiac enzymes normalized and he eventually received a liver transplant and was transferred out of the ICU. Discussion: UGIB complicating STEMI’s (secondary to CAD) are uncommon and can be associated with excess morbidity and mortality. However, patients with STEMI’s from UGIB are seldom reported. Patients with hemorrhagic shock are prone to developing some degree of subendocardial ischemia causing Type 2 NSTEMI’s. In rare instances, patients may develop STEMI due to severe ischemia of the myocardium in the context of hemorrhagic shock and concurrent vasopressor use for mixed circulatory shock. Though common practice to activate the cardiac catheterization lab reflexively to patients with chest pain, STEMI, and elevated cardiac enzymes, it is worth being mindful of the other rarer etiologies that may cloud the clinical picture. Clinicians need to be cognizant of unusual presentations of hemorrhagic shock secondary to GIB to avoid delay in diagnosis and to provide timely intervention.Figure 1.: (A) ST Elevation in II, III, avF with reciprocal ST depression in V1 and V2. (B) Resolved EKG, normal sinus rhythm, (C) Point-of-care ultrasound of stomach filled with heterogeneous contents, (D) UGI endoscopy showed stomach filled with blood, (E) Esophageal and gastric embolization.

Portal Venous Stenosis in Abdominal Tuberculosis

A 35-year-old woman presented with recurrent hematemesis and melena for 3 years. She was diagnosed with tuberculous peritonitis 16 years prior, which resolved after a full course of anti-tuberculosis therapy. Endoscopy revealed severe gastroesophageal varices. Abdominal contrast-enhanced computed tomography showed multiple calcified lymph nodes in the peritoneal and retroperitoneal spaces, with the largest surrounding and constricting the main portal vein (Fig 1). Portal venography via transjugular access was performed, confirming that the portal vein was nearly occluded at the hepatic hilum, with partial cavernous transformation and large gastroesophageal varices (Fig 2a).

Hemodynamic effect through a novel endoscopic intervention in management of varices and hypersplenism (with video)

We previously reported a new and combined EUS-guided intervention in a patient with portal hypertension, consisting of obliteration of varices and partial splenic embolization (PSE). Performing PSE is known to diminish the increase in portal venous pressure after endoscopic intervention for varices. The aim of this study was to use multidetector CT portal venography to evaluate the anatomy of esophagogastric varices (EGV) and the impact on hemodynamics of portosystemic collaterals shortly after the concomitant procedures. From October 2019 to December 2020, 5 patients with cirrhosis and with clinically significant portal hypertension who had variceal bleeding history and hypersplenism were treated with combined endoscopic obliteration for varices and EUS-guided PSE. Multidetector CT portal venography was applied to assess the anatomic drainage patterns of the EGV, diameters of feeders and drainage vessels, and splenic embolization rate. Within 5 days after concomitant endoscopic interventions, we observed decreased mean diameters of the left gastric vein, short gastric vein, and azygos vein as .3mm, 1.0mm, and 5.2mm compared with 3.11mm, 7.1mm, and 5.4mm before the procedures, respectively. Patients showed increased white blood cells (mean count of 2.7× 109/L before vs 5.8× 109/L after) and platelets (mean count of 52.8× 109/L before vs 95.8× 109/L after). The mean splenic embolization rate was 64.5% (range, 28.8%-84.6%). Our experience may illustrate an alternative technique of combining EUS-guided PSE with endoscopic therapy of varices to treat patients with portal hypertension.

Management of Ostomy-Related Varices.

Management of Ostomy-Related Varices.

Splenic vein stenting for recurrent chylous ascites in sinistral portal hypertension: a case report

BackgroundSinistral portal hypertension results from obstruction or stenosis of the splenic vein and is characterized by normal portal vein pressures and liver function tests. Gastrointestinal bleeding is the most common presentation and indication for treatment. Although sinistral portal hypertension-related chylous ascites is rare, several cases have described successful treatment with portal venous, rather than splenic venous, recanalization. Splenectomy is effective in the treatment of sinistral portal hypertension-related bleeding, although recent studies have evaluated splenic vein stenting and splenic arterial embolization as minimally-invasive treatment alternatives. Splenic vein stenting may be a viable option for other presentations of sinistral portal hypertension.Case presentationA 59-year-old gentleman with a history of necrotizing gallstone pancreatitis was referred to interventional radiology for management of recurrent chylous ascites. Analysis of ascites demonstrated a triglyceride level of 1294 mg/dL. Computed tomography revealed splenic and superior mesenteric venous stricture. The patient elected to undergo minimally invasive transhepatic portal venography, which confirmed the presence of splenic vein and superior mesenteric vein stenosis. Venography of the splenic vein showed reversal of portal venous flow, multiple collaterals, and a pressure gradient of 14 mmHg. Two 10 mm × 40 mm Cordis stents were placed, which decreased the pressure gradient to 7 mmHg and resolved the portosystemic collaterals. At 6 months follow-up, the patient had no recurrent episodes of ascites.ConclusionThe current case highlights the successful treatment of sinistral portal hypertension-related intractable chylous ascites treated with transhepatic splenic vein stenting. Splenic venous stent patency rates of 92.9% at 12 months have been reported. Rebleeding rates of 7.1% for splenic vein stenting, 16% for splenectomy, and 47.8% for splenic arterial embolization have been reported in the treatment of sinistral portal hypertension-related gastrointestinal bleeding. The literature regarding splenic vein stenting for sinistral portal hypertension-related ascites is less robust. Technical and clinical success in the current case suggests that splenic vein recanalization may be a safe and viable option in other sinistral portal hypertension-related symptomatology.Level of Evidence: Level 4, Case Report.

Efficacy and safety study of direct-acting oral anticoagulants for the treatment of chronic portal vein thrombosis in patients with liver cirrhosis.

This study is designed to investigate the efficacy and safety of direct-acting oral anticoagulants (DOACs) for the treatment of chronic portal vein thrombosis (PVT) in liver cirrhosis patients. In a prospective cohort study, patients were divided into DOACs group (oral rivaroxaban tablets or dabigatran etexilate capsules) and control group (no anticoagulant treatment). Based on propensity score matching method, 40 patients with cirrhosis and chronic PVT in each of the groups were recruited for this study. CT portal venography was used to monitor the portal vein area. Color Doppler ultrasound was used to monitor the portal vein flow rate. Biochemical testing and thromboelastography (TEG) were also used for monitoring the status of PVT. After 3 months of DOACs treatment, the complete/partial recanalization rate of DOACs was 12.8% (5/39). After 6 months of DOACs treatment, the PVT complete/partial recanalization rate of DOACs was 28.2% (11/39). The recanalization rate and portal vein flow velocity improvement were higher than those in the control group (P < 0.05). Patients' total bilirubin level and Child-Pugh scores were improved in the DOACs group. The TEG coagulation index was lower in the DOACs group than in the control group (P < 0.05). There was no statistically significant difference between the DOACs group and control group in the cases of bleeding (P > 0.05). DOACs are effective and safe for chronic PVT in patients with liver cirrhosis. The TEG can predict the risk of bleeding in patients with chronic PVT in cirrhosis, which is more sensitive than conventional coagulation function test.

Intrahepatic veno-venous collateralization and misrepresentative hepatic venous pressure gradients in children.

Accurate and reproducible means of measuring the portosystemic gradient are essential for risk stratification and treatment of portal hypertension. To report the reliability of hepatic venous pressure gradients in children with intrahepatic veno-venous collateralization. Between January 2012 and December 2019 (96months), 39 patients with native livers underwent wedge hepatic venography and hepatic venous pressure gradient measurements at a tertiary pediatric center. All archived images were reviewed for balloon isolation of the hepatic vein and hepatic vein-to-hepatic vein (HV-HV) collaterals. HV-HV collaterals were categorized as present on the basis of non-catheterized segmental venous opacification despite appropriate balloon isolation. Hepatic venous pressure gradient was defined as the difference of wedge and free hepatic venous pressures. Wedge portosystemic gradient was defined as the difference between wedge hepatic venous pressure and right atrial (RA) pressures. For patients subsequently undergoing portal venous catheterization, portosystemic gradient was defined as the difference between main portal vein and RA pressures. Thirteen of 39 (33.3%) patients demonstrated HV-HV collaterals on wedge hepatic venography. The mean hepatic venous pressure gradient was 5.2±3.8mmHg (range: 0-15mmHg). The mean hepatic venous pressure gradient was 3.6±2.6mmHg (range: 0-9mmHg) in the presence of HV-HV collaterals and 5.9±4.2mmHg (range: 1-15mmHg) in the absence of HV-HV collaterals (P=0.043). Twelve (30.8%) patients were found to have varices: 10 gastroesophageal, 1 rectal and 1 stomal. The mean hepatic venous pressure gradient in patients with varices was 5.4±47mmHg (range: 0-15mmHg). For patients with varices, mean hepatic venous pressure gradient was 3.0±2.7mmHg (range: 0-9mmHg) in the presence of HV-HV collaterals and 10.3±4.1mmHg (range: 5-15mmHg) in the absence of HV-HV collaterals (P=0.004). Four (10.3%) patients had extrahepatic portal vein occlusion: 3 with cavernous transformation and 1 with type Ib Abernethy malformation. All patients with extrahepatic portal vein occlusion demonstrated HV-HV collaterals compared with 8 of 35 (22.9%) patients without extrahepatic portal vein occlusion (P=0.002). Four of 39 (10.3%) patients underwent direct portal pressure measurements: 3 via transhepatic and 1 via trans-splenic portal access. All had demonstrated HV-HV collaterals on wedged imaging. One had extrahepatic portal vein occlusion. The mean time between wedge portosystemic gradient and portosystemic gradient measurement was 3.75days (range: 0-8days). The mean wedge portosystemic gradient was 4.5±3.1mmHg (range: 2-9mmHg) and the mean portosystemic gradient was 14.5±3.7mmHg (range: 12-20mmHg) (P=0.006). HV-HV collateralization is frequently observed in children undergoing wedged portal venography and leads to misrepresentative hepatic venous pressure gradients. All patients undergoing hepatic venous pressure gradient measurement should have wedged venography to identify HV-HV collaterals and to qualify measured pressures. Additional techniques to obtain representative pressures in the presence of HV-HV collaterals warrant further investigation.

Efficacy of CTPV for Diagnostic and Therapeutic Assessment: Comparison with Endoscopy in Cirrhotic Patients with Gastroesophageal Varices.

Background and Aims Computed tomography portal venography (CTPV) shows potential in detecting varices that need treatment and their drainage pathways. However, its agreement with endoscopy requires further study. We investigated the feasibility of CTPV as an alternative tool to endoscopy in screening gastroesophageal varices (GEVs) and developed a CTPV-based model to provide a less invasive assessment of endotherapy for cirrhotic patients with GEVs. Methods The study included 33 cirrhotic patients with a recent history of variceal hemorrhage. The presence, grade, and classification of GEVs on endoscopy and CTPV were compared (kappa test). Twenty-four patients were treated endoscopically, including 12 for esophageal varices (EVs), 8 for gastric varices (GVs), and 4 for GEVs. Treatment efficacies were assessed with the newly developed CTPV-based method at 1 week and 1 month after treatment. Efficiency evaluated by CTPV and endoscopy was compared by Fisher's exact test to determine whether CTPV is efficient in the assessment of endotherapy efficacy. Results For the screening and grading/classification of EVs and GVs, substantial agreement (EV kappa: 0.63 and 0.68; GV kappa: 0.62 and 0.75, respectively) was noted between endoscopy and CTPV. The therapeutic efficacy of EVs was higher when assessed by CTPV than when evaluated by endoscopy (37.50% vs. 12.50% at 1 week postoperation, P = 0.22; 62.50% vs. 25.00% at 1 month postoperation, P = 0.07), but without statistical significance. The same trend was also found in the assessment of therapeutic efficacy for GVs (25.00% vs. 16.67% at 1 week postoperation, P = 1; 58.33% vs. 41.67% at 1 month postoperation, P = 0.68). Conclusion CTPV is comparable to endoscopy in the detection of GEVs and in the evaluation of endotherapy efficacy, which suggests that it could be a less invasive alternative for endoscopy in cirrhotic patients with GEVs needing treatment.

Role of Endoscopic Ultrasound to Assess and Manage Portal Hypertension

AbstractPortal hypertension leads to the development of varices along the gastrointestinal tract. Endoscopy plays an important role in the diagnosis and management of varices. Endosonography (EUS) enables visualization and permits access to varices and veins outside the gastrointestinal tract. EUS has emerged as an important tool, with the ability to identify vascular changes, treat gastric and ectopic varices, perform portal pressure measurements, portal venography, and intrahepatic shunt placement. This review discusses the role of endoscopy and the emerging role of EUS in evaluation and management of portal hypertension.

3:00 PM Abstract No. 317 A novel approach to transjugular intrahepatic portosystemic shunt

Creation of a transjugular intrahepatic portosystemic shunt (TIPS) is known to be a technically challenging procedure due to difficulty in maintining right hepatic vein (RHV) access and achieving portal vein (PV) access. Here we describe a modification of the standard technique aimed at improving operator ease and procedure time. The proposed technique begins with the same steps as the standard technique. After a 10 Fr TIPS sheath is navigated into the RHV, a 4 Fr stiff anchor/CO2 injectable catheter (anchor) is advanced through the sheath. Wedge CO2 portal venography is performed. A TIPS needle is advanced through the sheath without its protective catheter, alongside the anchor, into the RHV. The sheath is retracted and the TIPS needle is positioned within the RHV and advanced into PV. Often, multiple passes are required to achieve PV access. The operator is also faced with the challenges of determining PV position and losing RHV access. The anchor allows easily re-advancement of the sheath when needed, saving the time and effort of RHV reselection. The anchor also affords easy repetition of CO2 venography when the TIPS needle is in the liver parenchyma. The stiff anchor minimizes risk of kinking and perforation. The remainder of the procedure, including placement of the endoprosthesis, follows the standard technique. This technique has been performed safely in 35 cases at our institution. An analysis of uncomplicated cases, defined as those without PV thrombus, compared to 46 traditional cases, revealed a near 50% reduction in time from CO2 venography to portal access with the new technique (17.8 ± 1.9 min vs. 34.5 ± 6.3 min, P <0.05). The new technique was also associated with a 21% reduction in FT (25.5 ± 1.6 min vs. 32.2 ± 3.2 min, P <0.05). There were no cases of sheath perforation. The proposed new TIPS technique offers multiple advantages including operator ease and faster PV access, with significant demonstrated reduction in PV access time and FT.