Transjugular Intrahepatic Portosystemic Shunt Procedure Research Articles

Variceal Tamponade: Teaching New Dogs Old Tricks! A Performance Improvement Project

Introduction: Acute esophageal variceal hemorrhage is a dreaded complication of chronic liver disease that nearly every endoscopist will encounter during their career. In the event of failed endoscopic treatment, it is vital for one to be knowledgeable on the proper use and placement of balloon tamponade as a bridge to repeat endoscopy or transjugular intrahepatic portosystemic shunt procedure. There are many obstacles that can make the use of balloon tamponade more challenging, such as maintaining the knowledge and skill for placement given rarity of use, locating all necessary required components for proper function (these are not provided from the tube manufacturer), and educating the team and ancillary staff on tube care post-placement. Our aim in this project was to standardize the balloon tamponade process by re-educating our gastroenterology providers on tube placement and developing a balloon tamponade “kit” containing all required accessories and instructions to improve the ease and safety when this emergency intervention is required. Methods: We devised a five-question pre and post-intervention survey to test our seven staff gastroenterologists and six fellows on their knowledge of locating all components of the balloon tamponade tube, details of tube placement, and post-placement tube instructions. The intervention included introduction of our new tube kit along with a one-on-one, 20-25 minute demonstration of tube assembly, placement, troubleshooting, and post tube care instructions. We then measured improvement between pre and posttest surveys using a paired t-test. Results: There was a statistically significant improvement in confidence with each tested component of our survey, as well as for the entire group of questions post-education intervention (P<0.001), see Table 1.Table: Table. Pre/Post Test SummaryConclusion: Our balloon tamponade project was a success in standardizing the use of this device. It was also effective in refreshing our providers on proper tube placement, use, and post-placement tube care. Moving forward, our institution will continue to utilize this balloon tamponade kit until newer options become standard of care. Sample size may have been a limitation in our study. In the future, we are planning to reproduce this project to include the internal medicine residents who are typically first line in acute variceal hemorrhage cases prior to gastroenterology consultation and are usually involved in tube placement.

National assessment of early hospitalization after liver transplantation: Risk factors and association with patient survival.

Hospitalization is known to occur frequently in the first 6 months following liver transplantation (LT). Using a novel data linkage between the Scientific Registry of Transplant Recipients and Centers for Medicare and Medicaid Services, our study has 2 objectives: (1) to determine risk factors for "early" hospitalization (ie, within 6 months of LT); and (2) to quantify the importance of hospitalization history in the first 6 months with respect to subsequent patient survival (ie, survival, conditional on surviving 6 months post-LT). The study population consisted of patients aged ≥18 years who underwent deceased donor LT between January 1, 2003 and December 31, 2010, with Medicare as primary or secondary insurance and were discharged alive from the index LT hospitalization (n = 7220). The early hospitalization rate was 2.76 per patient-year and was significantly associated with many recipient factors (eg, recipient age, hepatitis C, diabetes, poor renal function including dialysis, and recipient of transjugular intrahepatic portosystemic shunt procedure before LT), as well as donor race and donation after cardiac death. Conditional on surviving 6 months after LT, the covariate-adjusted death rate increased by 22% for each additional hospitalization occurring in the first 6 months (hazard ratio, 1.22; P < 0.001). In conclusion, several LT recipient factors are significantly associated with early hospitalization. Moreover, a patient's hospitalization profile during follow-up months 0-6 is a very strong predictor of survival thereafter. Efforts and resources should be devoted toward identifying LT recipients at risk for early hospitalization and modifying the actionable risk factors such as hepatitis C, diabetes, and body mass index to improve resource utilization and overall outcomes. Liver Transplantation 23 1143-1152 2017 AASLD.

Assessment of the Possibility of Radiation Dermatitis in the Legs of Interventional Radiologists

Background: Fluoroscopy guided imaging, which is going to be more routine these days, requires a long time of fluoroscopic observing that could increase the radiation dose of the physician and other staff who have to stay near the patient during the procedure. In our department, one of the senior interventionists observed hair loss in his lower limb. Objectives: The objective of this study was to measure the radiation dose of the physician’s leg during common procedures in order to find out that whether the radiation dose exceeds the threshold of deterministic effects of radiation. Patients and Methods: Thermoluminescent-dosimeters (TLD-100) set on the leg part of the anthropomorphic whole body phantom PBU-50 was used in order to measure the radiation dose in two centers where our interventionist worked. Meanwhile, the duration of exposure in important procedures was observed and recorded in center 1 for 2 months. During this period, data including age, height, and weight of the patients, and radiation exposure time, dose (mGy) and dose area product (dap) (µGy.cm2) were recorded. Results: The result of TLD dosimetry showed that the mean effective dose in center 1 and 2 was 0.20 and 0.86 mSv, and also the mean-dose (mSv)/min) in these centers was 0.02 ± 0.00 and 0.20 ± 0.015 mSv/min, respectively. Conclusion: The effective annual dose of interventionists who work in center 1 and 2 was 143.08 and 1226.78 mSv, respectively. The high radiation dose delivered to the leg of physicians in center 2 could be an important cause of radiation dermatitis occurred on the leg of our interventionist. Patient dose during most of the procedures was less than the threshold dose for occurring erythema. However, unfortunately in transjugular intrahepatic portosystemic shunt (TIPS) procedure, which is a time-consuming procedure, the patient radiation dose exceeds the threshold. It would be useful if a plan was designed to reduce the dose of patients and even physicians.

Transjugular intrahepatic portosystemic shunt does not independently increase risk of death in high model for end stage liver disease patients.

Physicians often exclude patients with a model for end‐stage liver disease (MELD) score ≥ 18 from a transjugular intrahepatic portosystemic shunt (TIPS) procedure due to the concern for higher risk of death. We aimed to determine if TIPS increased the risk of death in these patients. We analyzed the interaction between TIPS and MELD in 106 patients with TIPS and 79 with intractable ascites without TIPS. We performed Cox proportional hazard regression, including both TIPS and MELD as time‐dependent covariates together with their interaction, to calculate the impact of TIPS on the risk of death associated with a high MELD score. We found a negative interaction between a high MELD score and a history of TIPS, with potentially important effect sizes. Patients with MELD scores ≥18 had a 51% lower incremental risk of death (lower risk than would be expected from the combined independent risks of MELD and needing/receiving TIPS) associated with TIPS than patients with MELD scores <18 (hazard ratio for TIPS, 0.49; 95% confidence interval, 0.10‐2.45) in the first 6 months following TIPS. There was an 80% lower incremental risk of death among patients with a MELD score ≥18 (hazard ratio for TIPS, 0.20; 95% confidence interval, 0.03‐1.23) 6 months after the TIPS procedure. Conclusion: Risk of death is associated with underlying disease severity as shown by the MELD score and the need for TIPS, and both history of TIPS and high MELD score independently increased the risk of mortality. However, the risk of death after TIPS was progressively lower than expected as the MELD score increased. (Hepatology Communications 2017;1:460–468)

Hepatic vein pressure predicts GFR in cirrhotic patients with hemodynamic kidney dysfunction.

The role of “nephrocongestion” in hemodynamic renal disease is understudied. Intra‐abdominal hypertension accompanies liver disease and renal disease. Our hypothesis states that in those patients with liver disease, hepatic vein pressure measured during a transjugular intrahepatic portosystemic shunt (TIPS) procedure reflects intra‐abdominal pressure and predicts estimated glomerular filtration rate (eGFR). We gathered data from our clinical database and chart review on a cohort of cirrhotic patients who received TIPS at Montefiore as part of their clinical care between 2004 and 2014. We evaluated association of demographic and measured variables with eGFR in those subjects without end‐stage renal disease (ESRD). Using multivariate regression, we examined the relationship between eGFR and hepatic vein pressure while adjusting for age, proteinuria, and ultrasound evidence for parenchymal kidney disease. The mean age of the subjects was 57 years old. Two thirds of the patients were male, 23% were White, and 20% were Black. A higher percentage of patients with chronic kidney disease (CKD), as determined by lower than 60 mL/min/1.73 m2, had proteinuria and ultrasound evidence for parenchymal kidney disease. A multivariate linear regression showed a significant and negative association between hepatic vein pressure and eGFR when adjusting for age, race, and proteinuria. Hepatic vein pressure is negatively and significantly associated with eGFR in those patients with liver failure. This finding has major implications for the way we evaluate hemodynamic renal disease.

Added Value of Covered Stents in Transjugular Intrahepatic Portosystemic Shunt: A Large Single-Center Experience.

Transjugular intrahepatic portosystemic shunts (TIPS) were historically placed using uncovered bare-metal stents. Current practice has now shifted toward the use of polytetrafluoroethylene (PTFE)-covered stents, given the improved primary patency seen with these stents. The aim of this study was to determine whether there is any added value, such as overall survival or stent patency, when using covered stents versus uncovered stents in TIPS placement in a large cohort. From April 1995 to June 2012, a total of 744 consecutive adult patients underwent de novo TIPS placement (378 receiving uncovered stents, 366 receiving covered stents). Information was obtained on demographics, baseline clinical variables, and outcomes after TIPS placement. Data were collected, compared, and analyzed to assess outcomes including mortality, primary patency (determined via repeat intervention), and secondary patency (determined via ultrasound parameters). Covered stents were associated with significantly improved primary patency (P<0.001) and secondary patency (P<0.001) when compared with uncovered stents in TIPS procedures. Additionally, covered stents were associated with higher estimated overall survival rates and higher survival rates when TIPS was performed emergently and in patients with higher Model for End-Stage Liver Disease (MELD) scores. For example, in patients with MELD scores between 11 and 18, there was a predicted survival of 59.2% with covered stents versus 42.8% with uncovered stents at 1year. This study demonstrated that covered stents offer the additional value of higher estimated overall survival and higher estimated survival in patients undergoing TIPS emergently and in those with higher MELD scores when compared to uncovered stents.

Use of transabdominal ultrasound-guided transjugular portal vein puncture on radiation dose in transjugular intrahepatic portosystemic shunt formation

Transjugular intrahepatic portosystemic shunt (TIPS) creation is used to treat portal hypertension complications. Often the most challenging and time-consuming step in the procedure is the portal vein (PV) puncture. TIPS procedures are associated with prolonged fluoroscopy time and high patient radiation exposures. We measured the impact of transabdominal ultrasound guidance for PV puncture on duration of fluoroscopy time and dose. We retrospectively analyzed the radiation dose for all TIPS performed over a four-year period with transabdominal ultrasound guidance for PV puncture (n=212, with 210 performed successfully and data available for 206); fluoroscopy time, dose area product (DAP) and skin dose were recorded. Mean fluoroscopy time was 12 min 9 s (SD, ±14 min 38 s), mean DAP was 40.3±73.1 Gy·cm2, and mean skin dose was 404.3±464.8 mGy. Our results demonstrate that ultrasound-guided PV puncture results in low fluoroscopy times and radiation doses, which are markedly lower than the only published dose reference levels.

Derivation of Decision Algorithms for the Diagnosis of Hepatic Encephalopathy in Patients With Cirrhosis

Introduction: The presence of hepatic encephalopathy (HE), whether minimal or overt has a significant detrimental effect on patients’ quality of life, safety and survival. Current diagnostic tests are poorly validated or else are not generally applicable or practical for use in the clinical setting. This aim of this study was to identify simple, accurate algorithms for the diagnosis of HE in patients with cirrhosis that can be used in both clinical and research settings. Methods: Fifty-one patients with cirrhosis (30 men, 21 women; mean [range] age of 57.1 [24–81] years) were classified using clinical, psychometric and electroencephalographic variables, as either neuropsychiatrically unimpaired (n = 24), or as having minimal (n = 18) or overt (n = 9) HE. Patients’ neuropsychiatric status was further assessed using a series of alternative tests including: animal naming, Critical Flicker Fusion Frequency (CFF); Inhibitory Control Test (ICT); the SCAN package, and the Stroop test. Reference data were obtained from 61 healthy individuals (21 men, 40 women; mean age 46.4 [20–70] years). Thresholds for the diagnosis of any degree of HE were identified using receiver operating curve characteristics analysis. Diagnostic algorithms for use in clinical and research settings were then constructed using a Classification and Regression Tree growing method. Results: The Stroop test performed best overall; 80% of its generated variables separated healthy controls from patients with both minimal and overt HE. The single best variable was a combined score of the multiple variables from the SCAN package: sensitivity of 95.8% and specificity of 70.1%. An algorithmic construct, consisting of the ICT, SCAN package, and Stroop test, classified patients with a sensitivity of 92.6% and a specificity of 89.4% (Figure 1A). A modified algorithm, utilizing the Stroop test and the EEG, which would be more applicable in the clinical setting, had a sensitivity of 88.9% and a specificity of 94.7% (Figure 1B). Discussion: The derived algorithms have significantly better diagnostic performance than the individual tests currently used. They can be used in the clinical setting for: (i) the initial assessment of patients with cirrhosis to ensure they receive a diagnosis that may otherwise be overlooked thereby allowing them to receive treatment, if required; (ii) confirming the diagnosis of HE where this is in dispute; and, (iii) evaluating suitability for a transjugular intrahepatic portosystemic shunt procedure. In a research setting the derived algorithms will provide a diagnostic standard that is universally applicable. Further validation in independent cohorts of patients is clearly required. The authors have none to declare.

Clinical Images: Transjugular Intrahepatic Portosystemic Shunt Reduction for Management of Recurrent Hepatic Encephalopathy.

Transjugular intrahepatic portosystemic shunt (TIPS) is currently one of the major treatment modalities for complications associated with portal hypertension in patients with cirrhosis.1 The TIPS procedure entails the formation of a low-resistance conduit between the hepatic and portal veins, thereby bypassing the liver parenchyma. One of the major complications associated with TIPS, reported to occur in 15%-30% of TIPS cases,2 is new or worsened hepatic encephalopathy (HE) which can be severely debilitating, with symptoms including confusion, disorientation, lethargy, and frank obtundation. The primary treatment for recurrent HE following TIPS is similar to the treatment provided to any encephalopathic patient and begins with a search for precipitating factors such as infection, electrolyte abnormalities, bleeding, and constipation. Medical treatment with agents such as lactulose and nonabsorbable antibiotics such as rifaximin are usually successful in reversing the problem.3 However, further intervention including shunt reduction or occlusion and organ transplantation is estimated to be required in 3%-7% of patients who continue to suffer from refractory HE.3 We present a case of refractory HE post TIPS revision that was treated with shunt reduction. TIPS revision is a safe and effective procedure for restoring shunt patency if the TIPS becomes occluded. TIPS reduction is a procedure that decreases the diameter of the lumen of the TIPS and subsequently allows less flow through the shunt.

Multicenter Analysis of Clinical Characteristics and Long-Term Outcomes of Transjugular Intrahepatic Portosystemic Shunt Procedure for MPN-Associated Portal Hypertension

The myeloproliferativeneoplasms (MPNs), polycythemia vera(PV), essential thrombocythemia(ET), and primary myelofibrosis(PMF), are clonal stem cell disorders defined by proliferation of one or more myeloid lineages and variable progression to myelofibrosisand leukemia. Portal hypertension (pHTN) occurs in 7-18% of MPN patients and portends a poor prognosis. The most common causes of MPN-associated pHTNinclude splanchnic vein thrombosis (SVT), extramedullaryhematopoiesis (EMH), and nodular regenerative hyperplasia (NRH). pHTNin MPN patients presents similarly to that in patients with cirrhosis, with refractory ascites, gastrointestinal bleeding, and hepatic encephalopathy. Transjugularintrahepatic portosystemicshunt (TIPS) insertion has been used empirically to treat refractory ascites and varicealbleeding in MPN-associated pHTN; however, little data exists on long-term outcomes of MPN patients who have undergone TIPS procedure. To assess the safety and efficacy of TIPS for treatment of pHTNin MPN, we performed a retrospective analysis of outcomes of TIPS procedure in MPN patients at three academic medical centers.Through a defined search of the electronic medical records of the participating institutions, 29 MPN patients were identified who underwent TIPS procedure forpHTNbetween 2000 and 2016. Patients with portal hypertension from causes other than MPN were excluded from the study as were patient with fewer than 6 months of follow-up. Clinical characteristics and long-term outcomes were analyzed.The mean age of the patients was 51.5 years (range 29-86 years) and 65.5% were women. PV and PV-MF were the most common MPN subtypes (58.6%), followed by MPN unclassifiable (20.7%), PMF (10.3%), and ET (10.3%) (Table 1).JAK2V617F mutation was present in all but one patient, while CALR and MPL mutations were detected in one patient each. Budd-Chiari syndrome (BCS) represented the predominant etiology of portal hypertension in 72.4% of patients. Of note, 31% of patients had a multifactorial etiology of portal hypertension. Females with PV comprised 75% of BCS presentations, whereas males with MF comprised 80% of EMH. Indications for TIPS included refractory ascites (86%), esophagealvarices (51.7%), intestinal ischemia (6.9%), and fulminant liver failure (6.9%). All patients demonstrated immediate normalization of portal pressures following TIPS insertion with a covered-uncovered stent-graft. Post-TIPS anticoagulation included warfarin (69%), low-molecular weight heparin (17.2%), andfondaparinux (17.2%). Four patients (13.8%) did not receive anticoagulation following TIPS, two of whom had knownvarices and one who had gastro-intestinal bleeding following TIPS. The majority of patients experienced complete resolution of ascites (96.2%) andvarices (93.3%). Post-TIPS complications included TIPS thrombosis (31.0%; notably these occurred despite anticoagulation), heparin-induced thrombocytopenia (20.7%), low-grade hepatic encephalopathy (20.7%), TIPS stenosis (17.2%), and mild NSTEMI (1 patient). Of the eight patients listed for liver transplant, only one patient required transplant following TIPS. One, two, and three-year overall survival post-TIPS were 96.4%, 92.5% and 85.2%, respectively.Our study represents the largest cohort to date of MPN-associated portal hypertension patients who received TIPS. Our results indicate that TIPS can be performed safely in this high-risk population and can effectively mitigate the clinical consequences of MPN-associatedpHTN. However, the risk of TIPS complications, particularly of thrombosis and hepatic encephalopathy, remains prevalent and must be balanced against the intended clinical benefits. [Display omitted] DisclosuresStein:Incyte: Membership on an entity's Board of Directors or advisory committees.

Anaesthesia for transjugular intrahepatic portosystemic shunt insertion

### Key points The prevalence of liver disease in the UK has increased substantially over recent decades, principally due to alcohol, non-alcoholic fatty liver disease associated with obesity, and viral hepatitis B and C. Liver cirrhosis may lead to the development of portal hypertension, which has a significant impact on patient outcomes and survival. These patients are clinically challenging and costly to manage, often requiring treatment for consequences of liver failure such as ascites, variceal haemorrhage, sepsis, and renal failure. Transjugular intrahepatic portosystemic shunt (TIPS) insertion offers a minimally invasive option for lowering raised portal pressure, which can provide symptomatic relief and confer a survival benefit in selected patients suffering the complications of portal hypertension. The first TIPS procedures were carried out in the 1980s, and success rates have increased as endovascular and radiological technologies have developed. There are, however, considerable challenges to delivering an effective TIPS service, including the organization of multidisciplinary input with appropriate anaesthetic expertise and support. ### Portal hypertension The liver receives ∼25% of the cardiac output, via a dual blood supply. The hepatic arteries carry oxygenated blood via the aorta and coeliac axis, while the portal vein carries nutrient-rich blood from the gastrointestinal tract to process within the hepatic parenchyma. The …

Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome with diffuse occlusion of hepatic veins.

Either acute or sub-acute Budd–Chiari syndrome (BCS) with diffuse occlusion of hepatic veins has a high mortality rate and remains challenging for clinical treatment. We aimed to evaluate the feasibility and safety of transjugular intrahepatic portosystemic shunt (TIPS) as a treatment for BCS with diffuse occlusion of hepatic veins. From January 2007 to December 2010, 100 patients were randomly recruited onto this study and 91 patients were treated with TIPS. 14 patients were defined as acute BCS group and 86 patients as sub-acute group. Patients with acute BCS had a significantly higher rate of jaundice whereas a lower rate of abdominal and chest varices, gastroesophageal variceal bleeding and refractory ascites than sub-acute group (P < 0.001). TIPS was technically successful in all 91 patients (12 in acute group). The portosystemic pressure gradient (PSG) was decreased to normal level, while total bilirubin (TBIL) and liver function were significantly improved. During follow-up period, the mortality rate of 91 patients who underwent TIPS was 6.59% (6/91), whereas 88.89% of 9 patients who didn’t receive TIPS procedure (2 in acute group). Collectively, TIPS is an effective and safe approach in treating BCS with diffuse occlusion of hepatic veins, which should be performed in time.

Treating Duodenal Varices with Cyanoacrylate Glue Injection

Introduction: Treatment methods for some bleeding complications of portal hypertension such as portal hypertensive gastropathy (PHG), gastric antral vascular ectasias and duodenal varices are diverse and non-uniform. We present the case of a patient with a life threatening upper GI bleed secondary to a duodenal varix, who achieved adequate hemostasis with cyanoacrylate glue injection. Case presentation: A 46 year old female with history of active alcoholic liver disease was admitted with hemorrhagic shock due to a massive GI bleed. Initial resuscitation necessitated intubation, vasopressors and massive transfusion support. Initial EGD demonstrated small esophageal varices without stigmata, mild PHG and a nonbleeding gastric ulcer. Bleeding continued, therefore interventional radiology performed Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) with embolization of gastric and esophageal Hemodynamic instability continued and repeat EGD demonstrated a large, actively bleeding duodenal varix at the third portion of the duodenum. Cyanoacrylate glue was directly injected into the varix and hemostasis was achieved. The patient was discharged home within a few days. Surveillance EGD performed 2 months after discharge, while patient remained sober, revealed mild ulceration in the third portion of the duodenum at the site of glue injection, without presence of varices. After an episode of alcohol binge, she was readmitted with recurrent GI bleed. EGD revealed the previously injected duodenal varix actively bleeding. Endoscopic glue injection was again performed and hemostasis was achieved. Emergent Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure was performed after which the patient was discharged in good condition, without known sequelae, complications or recurrent bleeding. Discussion: Although the successful use of cyanoacrylate glue injection to control bleeding duodenal varices has been reported in numerous cases, its use remains seldom, as gastroenterologists tend to prefer use of alternative methods in such instances. As described in our case and those previously reported, severe portal hypertension remains a risk factor for re-bleeding and complications. Our case demonstrates that adequate control of duodenal variceal bleeds can be achieved initially via cyanoacrylate glue injection but permanent treatment includes TIPS or transplant.

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.

Image fusion-guided portal vein puncture during transjugular intrahepatic portosystemic shunt placement.

The purpose of this study was to assess the feasibility and utility of image fusion (Easy-TIPS) obtained from pre-procedure CT angiography and per-procedure real-time fluoroscopy for portal vein puncture during transjugular intrahepatic portosystemic shunt (TIPS) placement. Eighteen patients (15 men, 3 women) with a mean age of 63 years (range: 48-81 years; median age, 65 years) were included in the study. All patients underwent TIPS placement by two groups of radiologists (one group with radiologists of an experience<3 years and one with an experience≥3 years) using fusion imaging obtained from three-dimensional computed tomography angiography of the portal vein and real-time fluoroscopic images of the portal vein. Image fusion was used to guide the portal vein puncture during TIPS placement. At the end of the procedure, the interventional radiologists evaluated the utility of fusion imaging for portal vein puncture during TIPS placement. Mismatch between three-dimensional computed tomography angiography and real-time fluoroscopic images of the portal vein on image fusion was quantitatively analyzed. Posttreatment CT time, number of the puncture attempts, total radiation exposure and radiation from the retrograde portography were also recorded. Image fusion was considered useful for portal vein puncture in 13/18 TIPS procedures (72%). The mean posttreatment time to obtain fusion images was 16.4minutes. 3D volume rendered CT angiography images was strictly superimposed on direct portography in 10/18 procedures (56%). The mismatch mean value was 0.69cm in height and 0.28cm laterally. A mean number of 4.6 portal vein puncture attempts was made. Eight patients required less than three attempts. The mean radiation dose from retrograde portography was 421.2dGy.cm2, corresponding to a mean additional exposure of 19%. Fusion imaging resulting from image fusion from pre-procedural CT angiography is feasible, safe and makes portal puncture easier during TIPS placement.

Budd-Chiari syndrome: Focus on surgical treatment.

Budd-Chiari syndrome (BCS) is caused by an obstruction in the hepatic venous outflow tract at various levels from small hepatic veins to the inferior vena cava (IVC) due to thrombosis or fibrous sequelae. This rare disease mainly affects young adults. Risk factors have been identified and patients often have multiple risk factors. Myeloproliferative diseases of atypical presentation account for nearly 50% of patients in Europe and North America countries. Multistep management is required for such patients. Interventional revascularization and transjugular intrahepatic portosystemic shunt procedure are indicated after initial anticoagulation therapy, whereas IVC plasty using a patch graft is indicated for obstruction of the IVC. Liver transplantation (LT) is usually indicated as a treatment for liver failure despite various treatments. The outcomes of LT are good, with a 5-year survival after LT of nearly 70%.

Utility of Intravascular US–Guided Portal Vein Access during Transjugular Intrahepatic Portosystemic Shunt Creation: Retrospective Comparison with Conventional Technique in 109 Patients

PurposeTo compare safety and effectiveness of intravascular ultrasound (US)–guided portal vein access during transjugular intrahepatic portosystemic shunt (TIPS) creation with conventional TIPS technique. Materials and MethodsIn this retrospective study, TIPS creation using intravascular US guidance in 55 patients was compared with conventional TIPS creation in 54 patients by 10 operators over a 3-year period. Operators were classified as experienced if they had performed ≥ 20 TIPS procedures at the beginning of the study period. Time to portal vein access, total radiation dose, and needle pass–related capsular perforation were recorded. ResultsBaseline demographic characteristics of patients were similar (P > .05). Mean time to portal venous access was 46 minutes ± 37 for conventional TIPS and 31 minutes ± 19 for intravascular US–guided TIPS (P = .007). Intravascular US guidance allowed significantly shorter times (48 min ± 30 vs 28 min ± 16; P = .01) to portal vein access among operators (n = 5) with limited experience but failed to achieve any significant time savings (44 min ± 43 vs 34 min ± 22; P = .89) among experienced operators (n = 5). Needle pass–related capsular perforation occurred in 17/54 (34%) patients with conventional TIPS and 5/55 (9%) patients with intravascular US–guided TIPS (P = .004). Radiation dose was 2,376 mGy ± 1,816 for conventional TIPS and 1,592 mGy ± 1,263 for intravascular US–guided TIPS (P = .004). ConclusionsIntravascular US–guided portal vein access during TIPS creation is associated with shorter portal vein access times, decreased needle pass–related capsular perforations, and reduced radiation dose.

Inpatient Cost Assessment of Transjugular Intrahepatic Portosystemic Shunt in the USA from 2001 to 2012.

Despite widespread use of transjugular intrahepatic portosystemic shunt (TIPS) for treatment of portal hypertension, a paucity of nationwide data exists on predictors of the economic impact related to TIPS. Using the National Inpatient Sample (NIS) database from 2001 to 2012, we aimed to evaluate factors contributing to hospital cost of patients admitted to US hospitals for TIPS. Using the NIS, we identified a discharge-weighted national estimate of 61,004 TIPS procedures from 2001 to 2012. Through independent sample analysis, we determined profile factors related to increases in hospital costs. Of all TIPS cases, the mean charge adjusted for inflation to the year 2012 is $125,044±$160,115. The mean hospital cost adjusted for inflation is $44,901±$54,565. Comparing pre- and post-2005, mean charges and cost have increased considerably ($98,154 vs. $142,652, p<0.001 and $41,656 vs. $46,453, p<0.001, respectively). Patients transferred from a different hospital, weekend admissions, Asian/Pacific Islander patients, and hospitals in the Northeastern and Western region had higher cost. Number of diagnoses and number of procedures show positive correlations with hospital cost, with number of procedures exhibiting stronger relationships (Pearson 0.613). Comorbidity measures with highest increases in cost were pulmonary circulation disorders ($32,157 increase, p<0.001). The cost of the TIPS procedure is gradually rising for hospitals. Alongside recent healthcare reform through the Affordable Care Act, measures to reduce the economic burden of TIPS are of increasing importance. Data from this study are intended to aid physicians and hospitals in identifying improvements that could reduce hospital costs.

PTH-105 Introduction of Transjugular Intrahepatic Portosystemic Shunt (TIPSS) Service for Refractory Ascites in A Non-Transplant Liver Unit

<h3>Introduction</h3> TIPSS has been shown to be an effective treatment for patients with refractory ascites (RA).The majority of TIPSS procedures in the UK are performed in a transplant centre. In 2009, Derby Teaching Hospitals introduced TIPSS service. The aim of our study was to evaluate our experience and assess its impact on the care of this patient group. <h3>Methods</h3> 56 successful TIPSS procedures were performed between May 2009 and August 2015, 32 for RA were included in this analysis.Data on patient demographics, aetiology of liver disease, inpatient bed days (6 months before and after the procedure), Model for End-Stage Liver Disease (MELD) scores, Child-Pugh score, procedure details, clinical outcomes, mortality and complications were collected retrospectively from our centres clinical results database.Complete response was defined as no further need for paracentesis and partial if frequency reduced to &gt;50%. <h3>Results</h3> 25/32 (78%) patients were male with a median age of 58 years (range, 39–77 years). 30 patients were Child-Pugh class B, 2 Child-Pugh C, with a median MELD and MELD Na of 11 (range, 6-16) and 14 (range, 6–22) respectively. Alcoholic Liver Disease was most common aetiology of cirrhosis (86.5%) followed by non-alcoholic fatty liver disease (6.45%). Pre-TIPSS and post-TIPSS hepatic venous pressure gradients (HVPG) were 20 mmHg (range, 10–30) and 8 mmHg (range, 1–21) respectively. Cumulative mortality at 1, 3, and 12 months was 3%, 9%,and 18% (n = 28) respectively. One early death (within 30 days) was secondary to pneumonia. Ascites resolved completely after the first procedure in 66% and partially in 6% of patients.Cummulative response rate was 24, 62 and 90 percent at 30,60 and 90 days respectively. Five patients (16%) showed no improvement in RA, of whom 2 underwent liver transplantation. 9 patients (28%) developed hepatic encephalopathy (HE), 5 of whom (16%) developed refractory HE, with 3 patients requiring TIPSS reduction. The number of inpatient days reduced from 23 (range, 4-52) days in the 6 months pre-TIPSS to 8 (range 0–48) in the 6 months post TIPSS. The main reason for hospital admission was elective admission for ascites drainage. <h3>Conclusion</h3> A safe and effective TIPSS service for patients with refractory ascites can be successfully introduced into a comprehensive secondary care liver service by careful patient selection and technical proficiency. Excellent outcomes with acceptable complication rates can be achieved for patients with a significant reduction in resource utilisation (inpatient bed days and paracentesis). An established elective service is an important precursor for the provision of early and rescue TIPSS for variceal bleeding. <h3>Disclosure of Interest</h3> None Declared

Shear Wave Elastography of the Spleen for Monitoring Transjugular Intrahepatic Portosystemic Shunt Function: A Pilot Study.

To assess the feasibility of splenic shear wave elastography in monitoring transjugular intrahepatic portosystemic shunt (TIPS) function. We measured splenic shear wave velocity (SWV), main portal vein velocity (PVV), and splenic vein velocity (SVV) in 33 patients 1 day before and 3 days to 12 months after TIPS placement. We also measured PVV, SVV, and SWV in 10 of 33 patients with TIPS dysfunction 1 day before and 3 to 6 days after TIPS revision. Analyses included differences in portosystemic pressure gradient (PPG), PVV, SVV, and mean SWV before and after TIPS procedures; comparison of median SWV before and after TIPS procedures; differences in PVV, SVV, and SWV before and at different times up to 12 months after TIPS placement; accuracy of PVV, SVV, and SWV in determining TIPS dysfunction; and correlation between PPG and SWV. During 12 months of follow-up, 23 of 33 patients had functioning TIPS, and 10 had TIPS dysfunction. The median SWV was significantly different before and after primary TIPS placement (3.60 versus 3.05 m/s; P = .005), as well as before and after revision (3.73 versus 3.06 m/s; P = .003). The PPG, PVV, and SVV were also significantly different before and after TIPS placement and revision (P < .001). The PPG and SWV decreased, whereas PVV and SVV increased, after successful TIPS procedures. A positive correlation was observed between PPG and SWV (r = 0.70; P < .001), and a negative correlation was observed between PPG and PVV and SVV (r = -0.65; P < .001). The areas under the receiver operating characteristic curve for PVV, SVV, and SWV in determining TIPS dysfunction were 0.82, 0.84, and 0.81, respectively. Splenic SWV is compatible with splenoportal venous velocity in quantitatively monitoring TIPS function and determining TIPS dysfunction.