Interventional Ziv Paul
J. Haskal,
MD2 M. Radosevich,
#{149} Ernest
MD
J. Ring, Margaret
#{149}
Role ofParallel Portosystemic with Persistent
to allow
further
portal
de-
compression. In two other patients, a second TIPS was placed because the initial shunt functioned suboptimally. The mean postprocedural portosystemic gradient in the patients who received one TIPS was 10.2 mm Hg ± 3.7. In patients who received two TIPS, the mean postprocedural gradient was 19.1 mm Hg ± 3.8 after placement of the first TIPS and 12.5 mm Hg ± 3.5 after placement of the second. Two patients developed their first episode of encephalopathy after placement of two TIPS. The methods and indications for placing two TIPS in this select population are discussed. Index
terms:
Hypertension,
portal,
95.711 #{149}Liver, cirrhosis, 761.794 ventional procedure, 761.1229
Radiology
I
From
1992;
the
94.711, Liver, inter-
#{149}
185:813-817
Department
of Radiology,
Univer-
sity of California, San Francisco, 501 Parnassus Aye, San Francisco, CA 94143. Received May 6, 1992; revision requested June 23; revision received July 17; accepted July 27. Address reprint
requests
to E.J.R.
Current address: Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia. RSNA, 1992 2
M. LaBerge, MD #{149}Marc Y. Peltzer, RN #{149}Roy L. Gordon, MD
MD
Transjugular Intrahepatic Shunts In Patients Portal Hypertension’
Transjugular intrahepatic portosystemic shunts (TIPS) were placed in 93 patients between June 1990 and January 1992 for treatment of variceal hemorrhage. In each case, a Wallstent (Schneider USA, Minneapolis) was used to support the hepatic parenchymal tract between the hepatic and portal veins. Currently, these stents have a maximal diameter of 10 mm. In eight of 93 patients, major portal hypertension persisted after placement of a 10-mm-diameter shunt, manifested by continued rapid variceal filling and elevated portosystemic gradients. A second TIPS was placed parallel to the first in these patients
MD #{149} Jeanne M. Doherty,
Radiology
T
of a between the venous systems
HE percutaneous
creation
communication portal and hepatic has
long
been
considered
a feasible
method of decompressing pertension (1-8). During years,
techniques
have
portal hythe past 20 been
described
patients
for establishing the hepatic vein-to.portal vein connection, but, until recently, there has not been a good way to maintain the patency of the resulting shunt (7-9). Several studies have now shown that expandable metallic stents
placed
across
the
parenchymal
channel rapidly develop an endotheliumlike lining to form an effective and durable conduit. Several investigators have begun to clinically evaluate the role of transjugular intrahepatic portosystemic shunts (TIPS) with different types of metallic stents (3,4,9-14). We have been using the Wallstent (Schneider USA, Minneapolis) for TIPS placement for the past 2 years and have found that it has several features that can help facilitate the procedure. Wallstents are directly mounted on a 7-F delivery catheter and, unlike other available stents, do not require preliminary passage of a large, thin-walled introducer sheath into the portal vein. The delivery catheter is flexible so that it tends not to buckle or kink as it is advanced through hard cirrhotic liver parenchyma
or around
an
acute
portal
vein
entry angle. Once expanded, the Wallstent maintains a cylindrical lumen through relatively sharp bends and conforms to the course of the yenous structures when it extends from a small peripheral portal branch into a more central vein that has a large enough diameter to form an adequate shunt. Because of these features, TIPS can be established with the Wallstent from virtually any point of entry into the portal venous system. The technical problems that occur by
using
TIPS
Wallstents
are related
for
to the
placement
relatively
radiopacity of the stent and its variable length. During deployment, these devices shorten considerably (from 10 cm to 6.8 or 4.2 cm), and, because they are somewhat difficult to visualize at fluoroscopy (especially in
of
poor
with
ascites),
precise
posi-
tioning may be difficult. A more important criticism of the Wallstent is that, as currently manufactured, it has a maximum diameter of only 10 mm, which, in some patients with severe portal hypertension, may not be large enough to reduce portal pressure sufficiently to prevent recurrent bleeding (15-17). Herein, we describe our experience with placement of two parallel TIPS in a group of patients who required more decompression than could be achieved with one TIPS and discuss the possible clinical advantage of using two small shunts instead of one large shunt. MATERIALS
AND
METHODS
Patients Between June 1990 and January 1992, TIPS were placed in 93 patients. In 10 patients, a second TIPS was placed parallel to the first. The 10 patients included eight
men and two women
with
a mean
age of
51 years (range, 39-62 years). Nine patients had cirrhosis due to alcoholic liver disease and one had primary biliary cirrhosis. According to the Childs-Pugh classification of hepatocellular disease, two patients had class B disease and eight had class C disease. All patients underwent TIPS placement because of recurrent esophageal or gastric variceal hemorrhage despite repeat sclerotherapy. Six patients were actively bleeding
at the
patients ment
variceal derwent
time of TIPS placement. underwent elective TIPS
within
placement
Abbreviations: lopathy, TIPS systemic
4 days
hemorrhage,
=
of an episode
Three place-
of
and one patient within
1 month
PSE = portosystemic transjugular intrahepatic
unof
encephaporto-
shunt.
813
hemorrhage. sodes
The
of prior
average
variceal
four (range, All patients
number
of epi-
hemorrhage
one to six). underwent
was
had
complete
agogastroduodenoscopy
within
esoph12 hours
of TIPS placement. Nine patients had marked (3+ to 4+) esophageal varices and one had marked (4+) gastric varices with lesser (1 +) esophageal varices. In one patient, a distal splenorenal (Warren) shunt had
been
Figure
placed
1.
3 months
Images
before
obtained
TIPS
with class C Laennec cirrhosis current acute variceal hemorrhage.
renal
been
placed
was still patent (Fig a mesocaval shunt
1 month
before
the shunt was occluded In seven of the 10 patients, two were placed as part of the original placement;
dure persisted
because
marked after
placement
portal
TIPS
(Fig 2). TIPS proce-
hypertension of one
10-mm
shunt. This was manifested by continued rapid variceal flow and a high residual portosystemic pressure gradient. In one
patient, a second TIPS was placed after the first because a preexisting thrombus
limited
shunt.
In two
TIPS
was
placed
patients
returned
the first pression
shunt. had
these was
at a later with
first second
when
the
placement.
the second after
in
portal decomin both of TIPS
patients,
4 months
time
the the
a malfunction
at primary
of these
placed
into
patients,
Adequate been achieved
patients
In one
inflow other
I day portal
the
TIPS
original
in a 39-year-old
man
splenorenal 3 months bleeding
placement; the shunt 1). In another patient,
and reA distal
(Warren) shunt had been placed before the TIPS; repeat episodes of occurred despite the shunt. Left
venography
compression
demonstrated
on
the
renal
extrinsic
vein
limiting
sple-
norenal shunt flow. (a) Transjugular portogram demonstrates numerous short gastric varices and filling of retropentoneal collateral veins. The inferior vena cava is faintly opacified from collateral flow. The portosystemic gradient was 26 mm Hg. (b) Mesenteric venogram obtained after dilation of the right hepatic-to-right portal vein TIPS with a
10-mm
balloon
catheter
demonstrates
an
abrupt change in the opacity (straight arrow) as it enters the shunt. Numerous vances remain (curved arrow). The portosystemic gradient remained elevated at 17 mm Hg. These findings indicate that the 10-mm TIPS is not large enough to decompress the portal yenous system. The caudal one-third of the shunt could not be fully distended to 10 mm despite repeated balloon inflations because of the rigidity of the surrounding liver parenchyma. (c) Selective left portal venogram demonstrates retrograde portal flow into the shunt. Competing unopacified inflow from the superior mesenteric vein and fugal flow
from
the right
change togram
portal
in opacity obtained
vein
accounts
for the
within the shunt. (d) Porafter placement of an 8-mm
a.
b.
left hepatic-to-left portal vein TIPS parallel to the first TIPS shows excellent flow through both shunts and no evidence of vanceal ent was
filling. The final portosystemic 8.8 mm Hg. Repeat endoscopy
formed
10 days
ageal
or gastric
obtained shows
11 days both
TIPS
after
demonstrated (e) Explant
liver
no esophspecimen
transplantation
to be patent.
d.
e. 814
later varices.
gradiper-
Radiology
#{149}
December
1992
procedure
because
enced
an
bleeding.
the
episode The
shunt
was
a stenosis was found ment. Even though been
embolized
dure
and
was
still
fill rapidly,
catheterized,
of the
occluded,
these and
portal
varices pressure
vein
first the
had
proce-
Human
new
formed consent was obtained from all patients or their next of kin. TIPS placement with the Wallstent is currently under an Investigative Device Exemption; however, the patients in this study were part of a
use
of
to reestablish continued remained
to
Research
elevated. A second TIPS was placed to achieve more complete portal decompression. In the second patient with recurrent
preliminary
variceal placed
with
hemorrhage, I I days after
explicable that did
intrastent not respond
a second TIPS was the first when an innarrowing to balloon
spectrum
The protocol for patient selection and the methods used to perform TIPS placement were approved by the Committee on
and seg-
large
present. Despite and restenting
patency,
Methods
experivariceal
in the stented the coronary
as part
varices were angioplasty shunt
patient
of recurrent
was found angioplasty.
investigation
exemption. Both first and the
at our institution.
modified
second technique
predating
TIPS
were
In-
this
placed
described
elsewhere and briefly summarized herein (5,9,13,14). After intravenous administration of sedation, analgesia, and a broad-
the
intrahepatic
vena
cava.
size
and
portion
A hepatic location
through
sodi-
of the
vein
was
then
inferior
of appropriate selectively
the
liver
toward
a right
or
left
portal vein branch. The needle passes were repeated until a portal branch was entered. A guide wire and a 5-F catheter were then threaded into the main portal Portal and
phy
b.
(1 g ceftizoxime
catheterized by using a curved angiographic catheter, and the sheath was advanced into this vein. A sheathed 16gauge Colapinto needle (Cook, Bloomington, Ind) was placed via the outer 9-F sheath and directed ventrocaudally
vein. sured,
a.
antibiotic
um), the right internal jugular vein was percutaneously punctured. A 40-cm-long, 9-F, side-arm sheath was advanced into
was
vein splenic
pressures were or mesenteric
meavenogra-
performed.
The parenchymal tract was then dilated with an 8-mm angioplasty balloon catheter, and an expandable catheter-delivered metallic stent was placed. A Wallstent was used in all cases. Depending on the length of the tract, either a 42- or 68-mm-long stent was used; additional overlapping stents were placed if added shunt length was required. A minimum overlap of I cm was used to avoid stent separation if continued stent expansion were to occur. After the stent was deployed, it was distended with an 8-mm angioplasty balloon. Splenic venography was performed by hand injecting contrast media, and repeat measurements of the pressures were obtamed. The shunts were then maximally dilated with a 10-mm balloon catheter if prominent varices were still rapidly opacifled and there was a substantial residual portosystemic gradient. Pressure measurements and splenic venography were then performed once again. A second TIPS was placed parallel to the first in patients in whom the varices continued to fill promptly and the pressure gradient remained
high.
The technique for placement of a second TIPS was essentially the same as that for the first except that the portal and hepatic venous anatomy had already been mapped out during the first procedure, and the position of the opaque stent in the first shunt facilitated fluoroscopic targeting
for
different
second
hepatic
portal
vein
vein
was
used
puncture.
A
to form
d.
C-
Figure
the
Images obtained in a 57-year-old man with class C Laennec cirrhosis and recurrent variceal hemorrhage after sclerotherapy. The patient presented with massive bleeding despite mesocaval shunt placement I month earlier. Arteriograms in numerous projections demonstrated the mesocaval shunt to be entirely occluded. (a) Venous phase of a superior mesenteric arteriogram demonstrates filling of large coronary varices (arrow). A major branch of the mesenteric vein is occluded (arrowheads). The inferior vena cava is faintly opacified from collateral flow. The portal vein is not seen. (b) Late hepatic arteriogram demonstrates opacification of the portal vein as a result of hepatofugal flow. (c) Transjugular splenic venogram obtamed after placement of a 10-mm right hepatic-to-right portal vein TIPS demonstrates substantial residual variceal flow. (d) Repeat venogram obtained after placement of an 8-mm left hepatic-to-left portal vein TIPS demonstrates no residual variceal filling.
Volume
2.
185
Number
#{149}
3
Radiology
815
#{149}
the proximal end end was constructed tal vein branch on liver from the first the second shunt portal bifurcation
vein alongside lateral first
the first stent
lobar and
of the shunt; the distal by puncturing a porthe opposite side of the TIPS. The distal end of was positioned near the either in the main portal
branch.
second
The
TIPS
or in the ipsi-
locations
are
given
of the in the
Table.
Statistical
Analysis
The Student
t test
was
of data.
groups
data are expressed deviation.
used
for
statisti-
The quantitative
as mean
±
standard
Among 93 patients who have received TIPS at our institution, one 8-mm shunt was placed in 20 patients (21%), one 10-mm shunt in 63 (68%), and two shunts in 10 (11%). The mean portosystemic gradient before TIPS placement was 17.6 mm Hg ± 2.7 for patients in whom one TIPS placed
and
24.0
mm
Hg
± 2.6
for
patients in whom two TIPS were placed. The mean portosystemic gradient after TIPS placement was 10.2 mm Hg ± 3.7 in the 83 patients in whom one TIPS was placed and 19.1 mm Hg ± 3.8 (after placement of the first
TIPS)
and
12.5
mm
Hg
± 3.5
(af-
ter placement of the second TIPS) in the 10 patients in whom two TIPS were placed. In the patients with two TIPS, the residual gradient after placement of the first TIPS was signifhigher than that in the pain whom only one TIPS was placed (P < .001). The additional pressure reduction achieved by plac-
ing the second TIPS was also statistically significant (P < .01). There was no significant difference between the final pressure gradients in the two groups (P > .10). Portal decompression was achieved in eight of the 10 patients in whom two TIPS were placed by distending the second shunt to 8 mm. Two parallel 10-mm shunts were placed in two patients with hemorrhage to decompress their marked varices. Transcatheter embolization of residual varices was performed in six patients as part of the first TIPS procedure and in one patient after the second TIPS was placed. Portal flow was initially hepatopedal in six of the 10 patients who received two TIPS. Intrahepatic portal flow became totally diverted through the shunt after placement of the first Radiology
#{149}
acute
encephalopathy
when the TIPS were placed. In each of these cases, the encephalopathy resolved within 3 days of TIPS placement with medical therapy (eg, dietary protein restriction and administration of lactulose). Three patients were free of encephalopathy before TIPS placement and have remained patients
developed
their
before
decompressive
effective
first
that
only
9%
of patients
with
these
shunt
Johansen
only
elimination
This
of flow
to the
in
the
the
encephalopathy
flow
venting they rates
thy
highly
recurrent
(PSE)
(6,15,18).
variceal
and
accelerated
Endoscopic
12-20-mm in terms
provided
can amount
be unof
by the different
sizes. According
to
shunt
Poiseuille’s
law,
volu-
metric flow through a tubular conduit is proportional to the fourth power of the radius of the conduit. Thus, small in shunt
diameter
the
vides shunt shunt;
40% of the flow and 20% of the a 10-mm shunt
varices.
between
groups of the
on flow:
of the
volumetric
shunt
of equal
through
have
An 8-mm
shunt
of a 10-mm flow of a 12-mm provides 48%
flow
of a 12-mm
length.
Of
parallel
great
pro-
note,
the
conduits
such
two sideby-side 8- and 10-mm shunts provide 68% of the flow of a single 12-mm shunt, whereas two 10-mm shunts are essentially equivalent to a 12-mm shunt. Many theories have been proposed
portacaval
effective
are also associated of portosystemic
rate
effect
in
et
as the shunts in patients with TIPS is additive; theoretically,
conventional
are
ex-
PSE.
the
DISCUSSION Although
portacaval patients
groups of patients with placement of 8-, 10-, and 12-20-mm-diameter shunts, respectively. This progressive increase, particularly the 20% rise
flow
shunts
preva-
quent development of PSE. Sarfeh al (21,26) reported encephalopathy rates of 9%, 19%, and 39% in three
a high-
resulted
(25-
8%
of the shunt apinfluence the subse-
to directly
changes
segment.
an
perienced postoperative Increasing the size
shunts
stenotic
found
side-to-side 6% of their
(10-12-mm),
with
but
(28)
de-
sizes
lence of repeat hemorrhage in patients who received small-stoma
10- and derstood
patent,
as
10-mm-diameH-grafts and
PSE
Five of the remaining six patients are still alive an average of 4 months (range, 3-7 months) after dual-TIPS placement. One of these patients had an episode of variceal bleeding 3 months after the procedure. Venography was performed and demonstrated recurrent varices. One of the fully
just
shunts
found
shunts;
transplantation.
was
are
velop
pears
grade stenosis was identified near hepatic venous end of the other shunt. The shunt was dilated, and another stent was placed through
shunts
as conventional-size
at preventing variceal hemorrhage but result in a much lower prevalence of PSE. Some researchers reported that recurrent bleeding was reliably
27).
medical management. Both of these patients eventually underwent hepatic transplantation. Two other patients who eventually underwent transplantation had no further bleeding and no evidence of encephalopathy
tially
prevented with 8- and ter prosthetic mesocaval
onset of encephalopathy after placement of two TIPS. Except for occasional episodes of confusion associated with lapses in compliance with
icantly tients
816
had
lactulose therapy, encephalopathy was generally well controlled
RESULTS
was
tients
so. Two
cal analyses; P values of less than .05 were used to assess a significant difference between
TIPS in three patients and in all cases after both shunts had been placed. Five of the six actively bleeding pa-
for
pre-
bleeding,
with high encephalopa-
liver sclerotherapy
failure is
generally also very successful in controlling acute variceal bleeding, but it does not relieve underlying portal hypertension, so recurrent bleeding is common. Selective shunts, such as the distal splenorenal shunt, have a lower prevalence of associated PSE than do conventional portosystemic shunts but may not be applicable to patients with advanced liver disease. The prognosis remains poor in these patients, and, without liver transplantation, there is very little difference in long-term survival, regardless of which therapy is used (19-24). Extensive reports in the surgery literature now suggest that small, par-
relating changes in portal perfusion with PSE after shunt placement, including the importance of maintaining
sures
elevated splanchnic (28) and prograde
portal
flow
shown PSE
are
venous presintrahepatic
(21-25,29).
It has
repeatedly
that
strongly
correlated
encephalopathy,
prosthetic of patients shunting
reversed (21).
of patients maintained
receiving prograde
of pres-
flow (21with portacaval with prodeveloped
whereas
those with cephalopathic
rates with
ervation of prograde portal 23). In one report of patients identical 10-mm grafts, only 11% grade flow after
been
lower
50%
flow became In addition,
8-mm flow,
of en80%
shunts compared
December
1992
with 42% of those receiving 10-mm shunts and 10% of those receiving 14-20-mm
shunts. In another study,
Johansen
(28)
found that prograde flow was not maintained in any patients with 1012-mm shunts, and he theorized that elevated residual splanchnic venous pressure was the critical factor in determining
oped
whether
patients
encephalopathy.
devel-
Regardless
of
mechanism, each of these authors emphasized the value of small-diameter shunts in minimizing the risk of the patient subsequently developing encephalopathy. On the basis of these observations, we have been attempting to create TIPS that are just large enough to prevent recurrent variceal hemorrhage but not so large as to cause a high prevalence of postprocedural encephalopathy. Our procedural end points have included elimination of hepatofugal flow into varices and reduction of the portosystemic gradient to less than 15 mm Hg because hemorrhage is rare below this pressure (25). A second TIPS was indicated in those patients in whom these end points could not be achieved with one 10-mm TIPS. The TIPS technique offers a unique advantage over small-diameter surgical shunts in that the optimal shunt size can theoretically be tailored to the individual patient’s hemodynamthe
ics.
This
is possible
because
TIPS
is
performed with angiographic guidance so that, unlike at surgery, where only changes in portal pressure can be measured intraprocedurally, variceal flow dynamics can also be directly observed during TIPS with repeat venography. The metallic stent used to support progressively
the tract can then be enlarged up to its maxi-
mum diameter with increasing diameter balloon catheters until a shunt is formed that is just large enough to eliminate variceal flow. Alternatively, in some patients, the size of the shunt can be even further reduced with selective catheterization of the varices when flow in them begins to slow and then embolization with ethanol and stainless steel coils until the variceal flow becomes completely stagnant. With this approach, hepatopedal portal flow was maintained in half of our patients after TIPS placement. In 11% of the TIPS procedures reported herein (10 of 93 cases), a 10mm shunt was insufficient to ade-
Volume
185
Number
#{149}
3
quately decompress the portal system. Not only was portal pressure still very high (19.1 mm Hg) after placement of the first TIPS in these cases, there was also rapid filling of the coronary vein and numerous other gastric varices. In most of these cases, shunt flow could have been doubled by using a stent capable of distention beyond 10 mm (eg, the Palmaz stent [Johnson & Johnson International Systems, Warren, NJ]). Because inserting a stent of this size is not possible with the currently available Walistent, adding a second shunt was the only alternative for increasing the volume of shunt flow in these cases. This represents a disadvantage of the use of Wallstents for TIPS placement, since inserting a second TIPS is clearly more difficult than enlarging an existing shunt. However, the number of cases in which two shunts were required was relatively small (10 of 93 patients), and we believe that the ease of insertion of the Wallstent compared with that of other available stents more than offsets this disadvantage. In addition, many patients with small cirrhotic livers have hepatic veins that are less than 10 mm in diameter and, in these cases, placement of two TIPS is the only alternative for increasing shunt flow. There is also an important theoretical advantage to placement of two small TIPS instead of one large shunt that could warrant the continued use of this approach even if a larger Wallstent becomes available. Because 12-mm shunts are generally totally diverting and the risk of postprocedural encephalopathy is greatly increased in patients who receive totally diverting shunts, it may be better to use two smaller shunts and retain the option of later occluding one of them with coils or detachable balloons should encephalopathy subsequently become a major clinical problem. #{149} Acknowledgment: The authors thank C. Cox for his assistance in the preparation this
Stephen of
4.
5.
7.
8.
9.
10.
11.
2.
3.
SR. Garcia F, Tio portacaval in the dog. AIR
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IJ, Rypins
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EB, Mason
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decompressive operations. Ann Surg 1982; 48: 261-263. Sarfeh IJ, Rypins EB, Fardi M, Conroy RM, Mason GR, Lyons KP. Clinical implications of portal hemodynamics after small-diameter portacaval H graft. Surgery 1984; 96:223-229. years of selective tal hypertension.
26.
Garcia F, Sibbitt RR, et al. Exintrahepatic portacaval shunt stents with chronic portal hypertension. AJR 1986; 147:1251-1254. Richter GM, Noeldge G, PalmazJC, Roessle M. The transjugular intrahepatic portosystemic stent-shunt (TJPSS): results of a pilot study. Cardiovasc Intervent Radiol 1990; 13:200-207. Rosch J, Uchida BT, Putnam JS, Buschman RW, Law RD. Hershey AL. Experimental intrahepatic portacaval anastomosis: use of expandable Gianturco stents. Radiology 1987; 162:
RR, Reuter
shunt stents: early experience 1985; 145:821-825. Colapinto RF, Stronell RD, Gildiner M, et al. Formation of intrahepatic portosystemic shunts using a balloon dilatation catheter: preliminary clinical experience. AJR 1983;
Gray
manuscript.
PalmazJC,
JC, Sibbitt
Expandable
140:709-714. 6.
References 1.
Palmaz
FO.
Clin
A systematic
diameters. RM,
Sarfeh
of portal portacaval
Ann IJ.
flow H-
in man. Ann Surg 1984; 200:706-710. K. Partial portal decompression for hemorrhage. Am J Surg 1989; 157:479-
482.
29.
Rypins EB, Sarfeh IJ. Does portal pressure influence direction of portal flow and encephalopathy rates after 10-mm portacaval shunts in man7J Surg Res 1984; 37:119-122.
481-485.
Radiology
817
#{149}
J. Haskal,
MD2 M. Radosevich,
#{149} Ernest
MD
J. Ring, Margaret
#{149}
Role ofParallel Portosystemic with Persistent
to allow
further
portal
de-
compression. In two other patients, a second TIPS was placed because the initial shunt functioned suboptimally. The mean postprocedural portosystemic gradient in the patients who received one TIPS was 10.2 mm Hg ± 3.7. In patients who received two TIPS, the mean postprocedural gradient was 19.1 mm Hg ± 3.8 after placement of the first TIPS and 12.5 mm Hg ± 3.5 after placement of the second. Two patients developed their first episode of encephalopathy after placement of two TIPS. The methods and indications for placing two TIPS in this select population are discussed. Index
terms:
Hypertension,
portal,
95.711 #{149}Liver, cirrhosis, 761.794 ventional procedure, 761.1229
Radiology
I
From
1992;
the
94.711, Liver, inter-
#{149}
185:813-817
Department
of Radiology,
Univer-
sity of California, San Francisco, 501 Parnassus Aye, San Francisco, CA 94143. Received May 6, 1992; revision requested June 23; revision received July 17; accepted July 27. Address reprint
requests
to E.J.R.
Current address: Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia. RSNA, 1992 2
M. LaBerge, MD #{149}Marc Y. Peltzer, RN #{149}Roy L. Gordon, MD
MD
Transjugular Intrahepatic Shunts In Patients Portal Hypertension’
Transjugular intrahepatic portosystemic shunts (TIPS) were placed in 93 patients between June 1990 and January 1992 for treatment of variceal hemorrhage. In each case, a Wallstent (Schneider USA, Minneapolis) was used to support the hepatic parenchymal tract between the hepatic and portal veins. Currently, these stents have a maximal diameter of 10 mm. In eight of 93 patients, major portal hypertension persisted after placement of a 10-mm-diameter shunt, manifested by continued rapid variceal filling and elevated portosystemic gradients. A second TIPS was placed parallel to the first in these patients
MD #{149} Jeanne M. Doherty,
Radiology
T
of a between the venous systems
HE percutaneous
creation
communication portal and hepatic has
long
been
considered
a feasible
method of decompressing pertension (1-8). During years,
techniques
have
portal hythe past 20 been
described
patients
for establishing the hepatic vein-to.portal vein connection, but, until recently, there has not been a good way to maintain the patency of the resulting shunt (7-9). Several studies have now shown that expandable metallic stents
placed
across
the
parenchymal
channel rapidly develop an endotheliumlike lining to form an effective and durable conduit. Several investigators have begun to clinically evaluate the role of transjugular intrahepatic portosystemic shunts (TIPS) with different types of metallic stents (3,4,9-14). We have been using the Wallstent (Schneider USA, Minneapolis) for TIPS placement for the past 2 years and have found that it has several features that can help facilitate the procedure. Wallstents are directly mounted on a 7-F delivery catheter and, unlike other available stents, do not require preliminary passage of a large, thin-walled introducer sheath into the portal vein. The delivery catheter is flexible so that it tends not to buckle or kink as it is advanced through hard cirrhotic liver parenchyma
or around
an
acute
portal
vein
entry angle. Once expanded, the Wallstent maintains a cylindrical lumen through relatively sharp bends and conforms to the course of the yenous structures when it extends from a small peripheral portal branch into a more central vein that has a large enough diameter to form an adequate shunt. Because of these features, TIPS can be established with the Wallstent from virtually any point of entry into the portal venous system. The technical problems that occur by
using
TIPS
Wallstents
are related
for
to the
placement
relatively
radiopacity of the stent and its variable length. During deployment, these devices shorten considerably (from 10 cm to 6.8 or 4.2 cm), and, because they are somewhat difficult to visualize at fluoroscopy (especially in
of
poor
with
ascites),
precise
posi-
tioning may be difficult. A more important criticism of the Wallstent is that, as currently manufactured, it has a maximum diameter of only 10 mm, which, in some patients with severe portal hypertension, may not be large enough to reduce portal pressure sufficiently to prevent recurrent bleeding (15-17). Herein, we describe our experience with placement of two parallel TIPS in a group of patients who required more decompression than could be achieved with one TIPS and discuss the possible clinical advantage of using two small shunts instead of one large shunt. MATERIALS
AND
METHODS
Patients Between June 1990 and January 1992, TIPS were placed in 93 patients. In 10 patients, a second TIPS was placed parallel to the first. The 10 patients included eight
men and two women
with
a mean
age of
51 years (range, 39-62 years). Nine patients had cirrhosis due to alcoholic liver disease and one had primary biliary cirrhosis. According to the Childs-Pugh classification of hepatocellular disease, two patients had class B disease and eight had class C disease. All patients underwent TIPS placement because of recurrent esophageal or gastric variceal hemorrhage despite repeat sclerotherapy. Six patients were actively bleeding
at the
patients ment
variceal derwent
time of TIPS placement. underwent elective TIPS
within
placement
Abbreviations: lopathy, TIPS systemic
4 days
hemorrhage,
=
of an episode
Three place-
of
and one patient within
1 month
PSE = portosystemic transjugular intrahepatic
unof
encephaporto-
shunt.
813
hemorrhage. sodes
The
of prior
average
variceal
four (range, All patients
number
of epi-
hemorrhage
one to six). underwent
was
had
complete
agogastroduodenoscopy
within
esoph12 hours
of TIPS placement. Nine patients had marked (3+ to 4+) esophageal varices and one had marked (4+) gastric varices with lesser (1 +) esophageal varices. In one patient, a distal splenorenal (Warren) shunt had
been
Figure
placed
1.
3 months
Images
before
obtained
TIPS
with class C Laennec cirrhosis current acute variceal hemorrhage.
renal
been
placed
was still patent (Fig a mesocaval shunt
1 month
before
the shunt was occluded In seven of the 10 patients, two were placed as part of the original placement;
dure persisted
because
marked after
placement
portal
TIPS
(Fig 2). TIPS proce-
hypertension of one
10-mm
shunt. This was manifested by continued rapid variceal flow and a high residual portosystemic pressure gradient. In one
patient, a second TIPS was placed after the first because a preexisting thrombus
limited
shunt.
In two
TIPS
was
placed
patients
returned
the first pression
shunt. had
these was
at a later with
first second
when
the
placement.
the second after
in
portal decomin both of TIPS
patients,
4 months
time
the the
a malfunction
at primary
of these
placed
into
patients,
Adequate been achieved
patients
In one
inflow other
I day portal
the
TIPS
original
in a 39-year-old
man
splenorenal 3 months bleeding
placement; the shunt 1). In another patient,
and reA distal
(Warren) shunt had been placed before the TIPS; repeat episodes of occurred despite the shunt. Left
venography
compression
demonstrated
on
the
renal
extrinsic
vein
limiting
sple-
norenal shunt flow. (a) Transjugular portogram demonstrates numerous short gastric varices and filling of retropentoneal collateral veins. The inferior vena cava is faintly opacified from collateral flow. The portosystemic gradient was 26 mm Hg. (b) Mesenteric venogram obtained after dilation of the right hepatic-to-right portal vein TIPS with a
10-mm
balloon
catheter
demonstrates
an
abrupt change in the opacity (straight arrow) as it enters the shunt. Numerous vances remain (curved arrow). The portosystemic gradient remained elevated at 17 mm Hg. These findings indicate that the 10-mm TIPS is not large enough to decompress the portal yenous system. The caudal one-third of the shunt could not be fully distended to 10 mm despite repeated balloon inflations because of the rigidity of the surrounding liver parenchyma. (c) Selective left portal venogram demonstrates retrograde portal flow into the shunt. Competing unopacified inflow from the superior mesenteric vein and fugal flow
from
the right
change togram
portal
in opacity obtained
vein
accounts
for the
within the shunt. (d) Porafter placement of an 8-mm
a.
b.
left hepatic-to-left portal vein TIPS parallel to the first TIPS shows excellent flow through both shunts and no evidence of vanceal ent was
filling. The final portosystemic 8.8 mm Hg. Repeat endoscopy
formed
10 days
ageal
or gastric
obtained shows
11 days both
TIPS
after
demonstrated (e) Explant
liver
no esophspecimen
transplantation
to be patent.
d.
e. 814
later varices.
gradiper-
Radiology
#{149}
December
1992
procedure
because
enced
an
bleeding.
the
episode The
shunt
was
a stenosis was found ment. Even though been
embolized
dure
and
was
still
fill rapidly,
catheterized,
of the
occluded,
these and
portal
varices pressure
vein
first the
had
proce-
Human
new
formed consent was obtained from all patients or their next of kin. TIPS placement with the Wallstent is currently under an Investigative Device Exemption; however, the patients in this study were part of a
use
of
to reestablish continued remained
to
Research
elevated. A second TIPS was placed to achieve more complete portal decompression. In the second patient with recurrent
preliminary
variceal placed
with
hemorrhage, I I days after
explicable that did
intrastent not respond
a second TIPS was the first when an innarrowing to balloon
spectrum
The protocol for patient selection and the methods used to perform TIPS placement were approved by the Committee on
and seg-
large
present. Despite and restenting
patency,
Methods
experivariceal
in the stented the coronary
as part
varices were angioplasty shunt
patient
of recurrent
was found angioplasty.
investigation
exemption. Both first and the
at our institution.
modified
second technique
predating
TIPS
were
In-
this
placed
described
elsewhere and briefly summarized herein (5,9,13,14). After intravenous administration of sedation, analgesia, and a broad-
the
intrahepatic
vena
cava.
size
and
portion
A hepatic location
through
sodi-
of the
vein
was
then
inferior
of appropriate selectively
the
liver
toward
a right
or
left
portal vein branch. The needle passes were repeated until a portal branch was entered. A guide wire and a 5-F catheter were then threaded into the main portal Portal and
phy
b.
(1 g ceftizoxime
catheterized by using a curved angiographic catheter, and the sheath was advanced into this vein. A sheathed 16gauge Colapinto needle (Cook, Bloomington, Ind) was placed via the outer 9-F sheath and directed ventrocaudally
vein. sured,
a.
antibiotic
um), the right internal jugular vein was percutaneously punctured. A 40-cm-long, 9-F, side-arm sheath was advanced into
was
vein splenic
pressures were or mesenteric
meavenogra-
performed.
The parenchymal tract was then dilated with an 8-mm angioplasty balloon catheter, and an expandable catheter-delivered metallic stent was placed. A Wallstent was used in all cases. Depending on the length of the tract, either a 42- or 68-mm-long stent was used; additional overlapping stents were placed if added shunt length was required. A minimum overlap of I cm was used to avoid stent separation if continued stent expansion were to occur. After the stent was deployed, it was distended with an 8-mm angioplasty balloon. Splenic venography was performed by hand injecting contrast media, and repeat measurements of the pressures were obtamed. The shunts were then maximally dilated with a 10-mm balloon catheter if prominent varices were still rapidly opacifled and there was a substantial residual portosystemic gradient. Pressure measurements and splenic venography were then performed once again. A second TIPS was placed parallel to the first in patients in whom the varices continued to fill promptly and the pressure gradient remained
high.
The technique for placement of a second TIPS was essentially the same as that for the first except that the portal and hepatic venous anatomy had already been mapped out during the first procedure, and the position of the opaque stent in the first shunt facilitated fluoroscopic targeting
for
different
second
hepatic
portal
vein
vein
was
used
puncture.
A
to form
d.
C-
Figure
the
Images obtained in a 57-year-old man with class C Laennec cirrhosis and recurrent variceal hemorrhage after sclerotherapy. The patient presented with massive bleeding despite mesocaval shunt placement I month earlier. Arteriograms in numerous projections demonstrated the mesocaval shunt to be entirely occluded. (a) Venous phase of a superior mesenteric arteriogram demonstrates filling of large coronary varices (arrow). A major branch of the mesenteric vein is occluded (arrowheads). The inferior vena cava is faintly opacified from collateral flow. The portal vein is not seen. (b) Late hepatic arteriogram demonstrates opacification of the portal vein as a result of hepatofugal flow. (c) Transjugular splenic venogram obtamed after placement of a 10-mm right hepatic-to-right portal vein TIPS demonstrates substantial residual variceal flow. (d) Repeat venogram obtained after placement of an 8-mm left hepatic-to-left portal vein TIPS demonstrates no residual variceal filling.
Volume
2.
185
Number
#{149}
3
Radiology
815
#{149}
the proximal end end was constructed tal vein branch on liver from the first the second shunt portal bifurcation
vein alongside lateral first
the first stent
lobar and
of the shunt; the distal by puncturing a porthe opposite side of the TIPS. The distal end of was positioned near the either in the main portal
branch.
second
The
TIPS
or in the ipsi-
locations
are
given
of the in the
Table.
Statistical
Analysis
The Student
t test
was
of data.
groups
data are expressed deviation.
used
for
statisti-
The quantitative
as mean
±
standard
Among 93 patients who have received TIPS at our institution, one 8-mm shunt was placed in 20 patients (21%), one 10-mm shunt in 63 (68%), and two shunts in 10 (11%). The mean portosystemic gradient before TIPS placement was 17.6 mm Hg ± 2.7 for patients in whom one TIPS placed
and
24.0
mm
Hg
± 2.6
for
patients in whom two TIPS were placed. The mean portosystemic gradient after TIPS placement was 10.2 mm Hg ± 3.7 in the 83 patients in whom one TIPS was placed and 19.1 mm Hg ± 3.8 (after placement of the first
TIPS)
and
12.5
mm
Hg
± 3.5
(af-
ter placement of the second TIPS) in the 10 patients in whom two TIPS were placed. In the patients with two TIPS, the residual gradient after placement of the first TIPS was signifhigher than that in the pain whom only one TIPS was placed (P < .001). The additional pressure reduction achieved by plac-
ing the second TIPS was also statistically significant (P < .01). There was no significant difference between the final pressure gradients in the two groups (P > .10). Portal decompression was achieved in eight of the 10 patients in whom two TIPS were placed by distending the second shunt to 8 mm. Two parallel 10-mm shunts were placed in two patients with hemorrhage to decompress their marked varices. Transcatheter embolization of residual varices was performed in six patients as part of the first TIPS procedure and in one patient after the second TIPS was placed. Portal flow was initially hepatopedal in six of the 10 patients who received two TIPS. Intrahepatic portal flow became totally diverted through the shunt after placement of the first Radiology
#{149}
acute
encephalopathy
when the TIPS were placed. In each of these cases, the encephalopathy resolved within 3 days of TIPS placement with medical therapy (eg, dietary protein restriction and administration of lactulose). Three patients were free of encephalopathy before TIPS placement and have remained patients
developed
their
before
decompressive
effective
first
that
only
9%
of patients
with
these
shunt
Johansen
only
elimination
This
of flow
to the
in
the
the
encephalopathy
flow
venting they rates
thy
highly
recurrent
(PSE)
(6,15,18).
variceal
and
accelerated
Endoscopic
12-20-mm in terms
provided
can amount
be unof
by the different
sizes. According
to
shunt
Poiseuille’s
law,
volu-
metric flow through a tubular conduit is proportional to the fourth power of the radius of the conduit. Thus, small in shunt
diameter
the
vides shunt shunt;
40% of the flow and 20% of the a 10-mm shunt
varices.
between
groups of the
on flow:
of the
volumetric
shunt
of equal
through
have
An 8-mm
shunt
of a 10-mm flow of a 12-mm provides 48%
flow
of a 12-mm
length.
Of
parallel
great
pro-
note,
the
conduits
such
two sideby-side 8- and 10-mm shunts provide 68% of the flow of a single 12-mm shunt, whereas two 10-mm shunts are essentially equivalent to a 12-mm shunt. Many theories have been proposed
portacaval
effective
are also associated of portosystemic
rate
effect
in
et
as the shunts in patients with TIPS is additive; theoretically,
conventional
are
ex-
PSE.
the
DISCUSSION Although
portacaval patients
groups of patients with placement of 8-, 10-, and 12-20-mm-diameter shunts, respectively. This progressive increase, particularly the 20% rise
flow
shunts
preva-
quent development of PSE. Sarfeh al (21,26) reported encephalopathy rates of 9%, 19%, and 39% in three
a high-
resulted
(25-
8%
of the shunt apinfluence the subse-
to directly
changes
segment.
an
perienced postoperative Increasing the size
shunts
stenotic
found
side-to-side 6% of their
(10-12-mm),
with
but
(28)
de-
sizes
lence of repeat hemorrhage in patients who received small-stoma
10- and derstood
patent,
as
10-mm-diameH-grafts and
PSE
Five of the remaining six patients are still alive an average of 4 months (range, 3-7 months) after dual-TIPS placement. One of these patients had an episode of variceal bleeding 3 months after the procedure. Venography was performed and demonstrated recurrent varices. One of the fully
just
shunts
found
shunts;
transplantation.
was
are
velop
pears
grade stenosis was identified near hepatic venous end of the other shunt. The shunt was dilated, and another stent was placed through
shunts
as conventional-size
at preventing variceal hemorrhage but result in a much lower prevalence of PSE. Some researchers reported that recurrent bleeding was reliably
27).
medical management. Both of these patients eventually underwent hepatic transplantation. Two other patients who eventually underwent transplantation had no further bleeding and no evidence of encephalopathy
tially
prevented with 8- and ter prosthetic mesocaval
onset of encephalopathy after placement of two TIPS. Except for occasional episodes of confusion associated with lapses in compliance with
icantly tients
816
had
lactulose therapy, encephalopathy was generally well controlled
RESULTS
was
tients
so. Two
cal analyses; P values of less than .05 were used to assess a significant difference between
TIPS in three patients and in all cases after both shunts had been placed. Five of the six actively bleeding pa-
for
pre-
bleeding,
with high encephalopa-
liver sclerotherapy
failure is
generally also very successful in controlling acute variceal bleeding, but it does not relieve underlying portal hypertension, so recurrent bleeding is common. Selective shunts, such as the distal splenorenal shunt, have a lower prevalence of associated PSE than do conventional portosystemic shunts but may not be applicable to patients with advanced liver disease. The prognosis remains poor in these patients, and, without liver transplantation, there is very little difference in long-term survival, regardless of which therapy is used (19-24). Extensive reports in the surgery literature now suggest that small, par-
relating changes in portal perfusion with PSE after shunt placement, including the importance of maintaining
sures
elevated splanchnic (28) and prograde
portal
flow
shown PSE
are
venous presintrahepatic
(21-25,29).
It has
repeatedly
that
strongly
correlated
encephalopathy,
prosthetic of patients shunting
reversed (21).
of patients maintained
receiving prograde
of pres-
flow (21with portacaval with prodeveloped
whereas
those with cephalopathic
rates with
ervation of prograde portal 23). In one report of patients identical 10-mm grafts, only 11% grade flow after
been
lower
50%
flow became In addition,
8-mm flow,
of en80%
shunts compared
December
1992
with 42% of those receiving 10-mm shunts and 10% of those receiving 14-20-mm
shunts. In another study,
Johansen
(28)
found that prograde flow was not maintained in any patients with 1012-mm shunts, and he theorized that elevated residual splanchnic venous pressure was the critical factor in determining
oped
whether
patients
encephalopathy.
devel-
Regardless
of
mechanism, each of these authors emphasized the value of small-diameter shunts in minimizing the risk of the patient subsequently developing encephalopathy. On the basis of these observations, we have been attempting to create TIPS that are just large enough to prevent recurrent variceal hemorrhage but not so large as to cause a high prevalence of postprocedural encephalopathy. Our procedural end points have included elimination of hepatofugal flow into varices and reduction of the portosystemic gradient to less than 15 mm Hg because hemorrhage is rare below this pressure (25). A second TIPS was indicated in those patients in whom these end points could not be achieved with one 10-mm TIPS. The TIPS technique offers a unique advantage over small-diameter surgical shunts in that the optimal shunt size can theoretically be tailored to the individual patient’s hemodynamthe
ics.
This
is possible
because
TIPS
is
performed with angiographic guidance so that, unlike at surgery, where only changes in portal pressure can be measured intraprocedurally, variceal flow dynamics can also be directly observed during TIPS with repeat venography. The metallic stent used to support progressively
the tract can then be enlarged up to its maxi-
mum diameter with increasing diameter balloon catheters until a shunt is formed that is just large enough to eliminate variceal flow. Alternatively, in some patients, the size of the shunt can be even further reduced with selective catheterization of the varices when flow in them begins to slow and then embolization with ethanol and stainless steel coils until the variceal flow becomes completely stagnant. With this approach, hepatopedal portal flow was maintained in half of our patients after TIPS placement. In 11% of the TIPS procedures reported herein (10 of 93 cases), a 10mm shunt was insufficient to ade-
Volume
185
Number
#{149}
3
quately decompress the portal system. Not only was portal pressure still very high (19.1 mm Hg) after placement of the first TIPS in these cases, there was also rapid filling of the coronary vein and numerous other gastric varices. In most of these cases, shunt flow could have been doubled by using a stent capable of distention beyond 10 mm (eg, the Palmaz stent [Johnson & Johnson International Systems, Warren, NJ]). Because inserting a stent of this size is not possible with the currently available Walistent, adding a second shunt was the only alternative for increasing the volume of shunt flow in these cases. This represents a disadvantage of the use of Wallstents for TIPS placement, since inserting a second TIPS is clearly more difficult than enlarging an existing shunt. However, the number of cases in which two shunts were required was relatively small (10 of 93 patients), and we believe that the ease of insertion of the Wallstent compared with that of other available stents more than offsets this disadvantage. In addition, many patients with small cirrhotic livers have hepatic veins that are less than 10 mm in diameter and, in these cases, placement of two TIPS is the only alternative for increasing shunt flow. There is also an important theoretical advantage to placement of two small TIPS instead of one large shunt that could warrant the continued use of this approach even if a larger Wallstent becomes available. Because 12-mm shunts are generally totally diverting and the risk of postprocedural encephalopathy is greatly increased in patients who receive totally diverting shunts, it may be better to use two smaller shunts and retain the option of later occluding one of them with coils or detachable balloons should encephalopathy subsequently become a major clinical problem. #{149} Acknowledgment: The authors thank C. Cox for his assistance in the preparation this
Stephen of
4.
5.
7.
8.
9.
10.
11.
2.
3.
SR. Garcia F, Tio portacaval in the dog. AIR
intrahepatic
Villeneuve JP, Pomier-Layrargues C, Duguay L, et al. Emergency portacaval shunt for variceal hemorrhage. Ann Surg 1987; 206:4851. Rosch J, Hanafee W, Snow H, Barenfus M, R.
Transjugular
intrahepatic
NL.
Intrahepatic
portocaval
variceal hemorrhage tion. Transplantation
12.
13.
14.
15.
16. 17. 18.
20.
shunt
for
prior to liver transplanta-
1991; 52:160-162. LaBerge JM, Ferrell LD, Ring EJ, et al. Histopathologic study of transjugular intrahepatic portosystemic shunts. JVIR 1991; 2:549-556. Ring EJ, LakeJR, RobertsJP, Gordon RL, LaBerge JM, Read A. Using percutaneous intrahepatic portosystemic shunts to control variceal bleeding prior to liver transplantation. Ann Intern Med 1992; 116:304-309. LaBerge JM, Ring EJ, Lake JR, et al. Transjugular intrahepatic portosystemic shunt (TIPS): preliminary results in 25 patients. J va Surg 1992; 16:258-267. Sarfeh IJ, Rypins EB. The emergency portacaval H graft in alcoholic cirrhotic patients: influence of shunt diameter on clinical outcome. Am J Surg 1986; 152:290-293. Zemel G. Invited commentary. JVIR 1992; 3:81. Ring EJ. Invited commentary. JVIR 1992; 3:81-82. Sarfeh IJ, Carter JA, Welch HF. Analysis of operative
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portacaval
shunt: an experimental work. Am J Surg 1971; 121:588-592. Rosch I, Hanafee WN, Snow H. Transjugular portal venography and radioloblc portacaval shunt: an experimental study-work in progress. Radiology 1969; 92:1112-1114. Richter GM, Noeldge G, Palmaz JC, et al. Transjugular intrahepatic portacaval stent shunt: preliminary clinical results. Radiology 1990; 14:1027-100. Zemel G, Katzen BT, Becker GJ, Benenati JF, Sallee DS. Percutaneous transjugular portosystemic shunt. JAMA 1991; 266:390-393. RobertsJP, Ring EJ, LakeJR, Sterneck M, Ascher
mortality
after
portal
decompressive
procedures in cirrhotic patients. 1980; 140:306-311. Orloff MJ, Bell RH. Long-term emergency portacaval shunting varices in patients with alcoholic I Surg 1986; 151:176-183. Orloff
MJ, Bell
RH,
Hyde
PV,
Am J Surg survival after for bleeding cirrhosis. Am
Skivolocki
WP.
Long-term results of emergency portacaval shunt for bleeding esophageal varices in unselected patients with alcoholic cirrhosis. Ann Surg 1980; 192:325-340. 21.
Sarfeh
IJ, Rypins
EB, Conroy
RM,
Portacaval H-graft: relationships ameter, portafflow patterns and thy. Ann Surg 1983; 197:422-426. 22.
23.
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