Technical Advances in Transjugular Intrahepatic Portosystemic 1 Gerald
Zemel,
MD Becker, MD W. Bancroft, MD F. Benenati MD T Katzen, MD
Gaiyj
Josiah James Barry
A transjugular
intrahepatic
portosystemic
shunt
(TIPS)
can
be
created
with the Palmaz balloon-expandable stent. This article describes a transjugular-only approach with a 16-gauge needle. A functional and efficacious shunt can be achieved in most cases with stent diameters of8-1O mm. Occasionally, a 12-mm-diameter shunt is necessary for effective variceal decompression. The procedure is considered successful when the portosystemic gradient is lowered to 12 percutaneously
mm
Hg
shunt
or
less
after
outflow
tion
has
TIPS
can
been
placement.
develop
treated
after
Hepatic the
successfully
undoubtedly
transjugular-only treatment
stent
can
be
with
stenosis
the
remains
and
full
complicaplacement.
safely
impact
to be
in the
This stent
successfully
however,
hypertension
vein
procedure. additional
performed
approach; of portal
TIPS
with
of TIPS
a
on the
determined.
INTRODUCTION Management ofvariceal hemorrhage remains a substantial challenge. Medical management, sclerotherapy, and transhepatic embolization have proved useful; however, surgical portosystemic shunts are associated with the lowest frequency of rebleeding (1-3). U
TIPS
Abbreviation:
Index
terms:
tional
procedure,
i
From
33176. February
Esophagus,
varices.
761.1229,
1992;
RadloGraphics
transjugular
=
the Department
761.1247
intrahepatic 71.75
pcntosystemic
Hypertension.
portal,
#{149}
Portal
#{149}
vein,
shunt
957.71
1
95.71
Shunts,
#{149}
1
Livcr.
#{149}
portosystcmic.
cirrhosis.
761.79-i
Liver.
#{149}
interven-
95.4532
12:615-622 of Radiology,
Miami
Vascular
Institute,
Recipient ofa Summa Cum Laude award for a scientific 18, 1992; revision requested March 20 and received
Baptist
Hospital
of Miami,
8900
exhibit at thc 1991 RSNA scientific April 6; accepted April 7. Address
N Kcndall assembly. reprint
Dr.
Miami,
FL
Received requests
to
G.Z. ©RSNA,
1992
See the commentary
by Miller
following
this
article.
615
The high morbidity and mortality associated with surgical shunts and the lack of improvement in long-term survival have prompted a search for safer, more effective methods of portal decompression. In 1969, R#{246}schet al (4) created a true portacaval shunt in swine with percutaneous techniques. Thirteen years later, Colapinto et al (5) successfully performed balloon dilation within a parenchymal tract created percutaneously between hepatic and portal venous branches in 15 patients with life-threatening variceal hemorrhage. Shunt patency was limited with an insufficient lowering of the portal pressure. Palmaz et al (6,7) effectively maintained patency of a parenchymal tract created between portal and hepatic veins in portal hypertensive dogs by using balloon-expandable stents. The first human application of the Palmaz stent for the creation of a transjugular intrahepatic portosystemic shunt (TIPS) was achieved by Richter et al (8) in 1988. Subsequent articles (9-1 1) reported promising resuits and established the clinical feasibility of TIPS. We describe technical modifications of methods reported in previous articles and outline our current TIPS technique, which involves the use of a transjuguiar-only approach with Palmaz balloon-expandable stents.
U TECHNIQUE .
Patient
Preparation
Preprocedural patient preparation generally involves sterilization of the puncture site, with TIPS performed after administration of local anesthetics. No substantial bleeding has occurred as a result ofTIPS. Therefore, coagulopathy is not corrected before the procedure to minimize transfusion requirements. Because the jugular access used for the procedure is eliminated immediately afterward, antibiotics are not given routinely.
.
Delineation
of Portal
Venous
Anatomy To overcome the complications associated with transhepatic portal venous puncture in patients with coagulopathy, we perform TIPS from a transjugular-only approach. Preliminary color flow imaging of the portal vein is performed to ensure patency. Because of the
Figure 1. Wedged hepatic venogram demon. strates a small amount of portal vein opacification (arrow), which is often useful in guiding portal puncture.
multiple angles involved in the hepatic to portal vein puncture, real-time ultrasound has not proved useful in guiding portal vein cannulation. If an arterial portogram is available or sufficient portal venous opacification can be achieved during wedged hepatic venography, this information is used to guide the portal vein puncture. Cannulation of a patent umbilical vein can facilitate the puncture without adding substantial risk to the procedure. Otherwise, the portal vein puncture is performed “blindly.”
.
Jugular
catheter.
616
I
RadioGraphics
U
Zemel
et al
Venous
Access
A 35-cm-long, 10-F sheath (Cook, Bloomington, Ind) is passed to the suprahepatic infenor vena cava through a right internal jugular venous puncture site. All subsequent catheter manipulations are performed through the sheath. A 5-F selective catheter (Cobra-2 with two side holes) is advanced into the largest middle or, more commonly, right hepatic vein over an angled 0.035-inch Glidewire (Terumo, Piscataway, NJ [Medi-tech/Boston Scientific, Watertown, Mass]). A hepatic venogram is obtained (Fig 1), and the Glidewire is then removed. A 0.035-inch Amplatz Super Stiff guide wire (Medi-tech/Boston Scientific) is placed in the hepatic vein distally through the The
catheter
is removed,
Volume
and
12
the
Number
4
2.
3.
4.
5.
Figures 2-5. (2) Super Stiffguide wire, 16-gauge transjugular needle, and 10.F sheath inserted in the right hepatic vein via the right jugular venous puncture. (3) After removal of the guide wire, the transjugular needie is rotated counterclockwise so that the tip is directed anteriorly and medially. (4) Hepatic parenchyma is punctured (Reprinted, is exchanged ceal blood
with the transjugular needle from the right hepatic with permission, from reference 9.) (5) Guide wire for a 5-F catheter to permit measurement of portal flow.
10-F dilator is replaced into the sheath, permitting safe advancement of the sheath into the hepatic vein without kinking. A 16-gauge Colapinto needle is then advanced through the 10-F sheath over the guide wire until the leading edge of the needie protrudes from the sheath (Fig 2). The reverse bevel of the needle generally prevents sheath puncture during advancement. The arrow on the operator end of the needle (necdie hub) indicates the direction of the needle curve. The guide wire is then removed, and
the sheath side
the
is withdrawn hepatic
vein.
to a position The
hepatic
just
in-
venous
puncture site is selected approximately 2 cm beyond the junction of the hepatic vein and inferior vena cava. With the needle tip at this location, the hub of the needle is rotated approximately 90#{176} counterclockwise (anteriorly) from the perspective of the operator positioned at the patient’s head (Fig 3).
July
1992
.
vein to the proximal right portal vein. is placed into the portal vein, and the needle vein pressure. Arrows = hepatofugal van-
Portal
Vein
Puncture
and
Catheterization The transjugular needle is forcibly advanced to traverse the cirrhotic parenchyma and enter the right or, less commonly, the left portal vein 1-3 cm peripheral to the portal vein bifurcation (Fig 4). Portal vein access is usually achieved after one to three punctures. After three unsuccessful attempts, oblique or lateral
fluoroscopy
alternative
may
hepatic
modification tion
with
followed helps
the
of the the
needle
needle
portal
portal
vein guide
the
access tip
angie.
Aspira-
material,
cannulation.
Once
a 0.035-inch
is advanced
into
tal vein. A 5-F catheter is then guided the parenchymal tract, over the guide and into the portal vein, often requiring siderable force (Fig 5).
Zemel
for
withdrawn,
ofcontrast vein
is punctured, wire
need
or manual
as it is slowly
by an injection confirm
floppy-tip
indicate
vein
et al
U
the
por-
through wire, con-
RadioGraphics
U
617
Vein
a. Figure mm
6.
(a) Catheter
x 3-cm
balloon
is exchanged
catheter
for a low-profile
expanded
across
the
8 hepatic
parenchymal tract. (Reprinted, with permission, from reference 9.) (b) Portal venous wall is most resistant to dila. tion, as indicated by the persistent constriction of the angioplasty balloon (arrow).
b.
. Portal Vein Tract Dilation, of Varices After measurement
Pressure Measurement, and Visualization of the
mean
pressure
gra-
dient from the portal vein to the suprahepatic inferior vena cava is obtained, the 5-F catheter is exchanged for an 8 mm x 3-cm low-profile balloon catheter (Medi-tech/Boston Scientific)
placed
support. across
the
most
resistant
tion on
the
lated,
line
U
RadioGraphics
fully
parenchymal
tract.
The
to balloon
6).
Cobra
the
Once catheter
is the the
venous
U
anatomy
Zemel
structure
(ie, wall
entire
tract
is advanced
A splenoportal
to demonstrate
for
the
constricting
balloon)
(Fig
wire
expanded
dilation
a persistent
vein.
obtained
Stiffguide
is then
inflated the
splenic
a Super
balloon
producing
tal vein
618
over
The
of the
varices
(Fig
7).
et al
por-
is diinto
the
is then
venogram the
porband
and
out-
L __
Figure 7. Splenoportal venogram outlines the anatomy. Retrograde flow is demonstrated in the enlarged gastric vein (large straight arrow) and inferior mesenteric vein (curved arrow), with stag. nant flow in the portal vein (small straight arrow).
Volume
12
Number
4
8.
9.
10.
11.
Figures 8-11. (8) Selective catheter is exchanged for the 10-F sheath and dilator, the portal vein. (9) Palmaz stent mounted on an 8 mm X 3-cm 7-F balloon catheter parenchymal tract within the 10-F vascular sheath. (10) The 10-F sheath is withdrawn cava, and the Palmaz sured after TIPS, and out the portal system.
.
Stent
stent is deployed by fully expanding a final splenoportogram demonstrates
Placement
in the
Parenchymal
Tract After
splenoportal
venography, the catheter is 10-F dilator, which allows advancement of the 10-F sheath into the portal vein (Fig 8). A 30-mm-long Palmaz balloon expandable stent (Johnson & Johnson, Warren, NJ) mounted on an 8 mm X 3-cm balloon catheter is then advanced through the 10-F sheath, over the guide wire, and across the hepatic parenchymal tract (Fig 9). The leading edge of the stent is positioned to project no more than 5 mm into the portal vein. While
exchanged
maintaining
for the
the
position
of the
stent-balloon
assembly, the sheath is withdrawn into the hepatic vein and the balloon is fully expanded (Fig 10). If one stent is not sufficient to completely cover the tract, a second, and, rarely, third
stent
proximately
July
1992
is deployed 5 mm
as necessary,
with
the
balloon. a patent
(11) shunt
which are advanced into is advanced across the into the inferior vena Portosystemic gradient is meawith hepatopetal flow through-
Once the hepatic parenchymal tract is completely covered and a functional 8-mm shunt has been created, the angiographic side-hole catheter is reintroduced into the portal vein for measurement of the portosystemic gradient. With conventional transluminal angloplasty
techniques,
the
shunt
diameter
creased if necessary (maximum, lower the mean portosystemic 12 mm Hg. A final splenopoi-tal obtained
(Fig
1 1). The
vascular
is in-
12 mm) to gradient below venogram is sheath
is then
removed, and hemostasis is achieved with manual compression. A small sterile dressing is applied over the neck. The clinical status the patient dictates the type of postprocedural monitoring.
of
a
ap-
of overlap.
Zemel
et al
U
RadioGraphics
U
619
DISCUSSION TIPS can be performed U
with
portal
rhage.
However,
relative
able ated
in almost
hypertension
portal
contraindication
that a percutaneous successfully with
vessel of sufficient size is thrombosed. TIPS has been performed varying size. Our experience
16-gauge
Colapinto this
most
when
portal
needles
of
suggests that the can be used safely.
over
distance
be crecollat-
the
with
needle
needle
the
16-gauge needle because Colapinto needle permits nor-to-anterior puncture alocaudal
patients
shunt could an intrahepatic
eral vein
We favor
all
and variceal hemorvein thrombosis is a to TIPS. It is conceiv-
modified
Ross
the bevel on the a more direct posteover the short ceph-
that
must
be
traversed
in
patients.
We have
also
found
the procedure
easier
to
complete than with tial force
with the larger 16-gauge needle the 18-gauge needle. The substannecessary in many patients to puncture the liver from the hepatic to portal vein causes the 18-gauge needle to bend into the right atrium, but the rigidity of the 16-gauge
needle
facilitates
perior gauge
torque needle
when
initiating
hepatic
puncture.
Also,
months
case
the hepatic
of the
puncture.
18-gauge
becomes
very
vein culty
has
entered
been
needle.
important because
often encountered the smaller guide
renchymal
patic
su-
Last,
This
once
of the
in passing wire through
differ-
the portal
and small punctured,
passed
through
was reduced
3 weeks centesis during peritonitis and
within
U
RadioGrapbics
the liver
capsule
paracentesis
has
into
the
punc-
in patients
ascites because a functioning shunt rein resorption of the fluid over time. Aswhich was present in over 70% of our
patients,
620
arterial branches and the needle
cavity. To date, these errant not resulted in sequelae.
We do not perform with sults cites,
vein
(arrow),
Balloon
dilation
of portal
pressure
to
The
hepatic
which
was
not
present
earlier.
U
to a trace
amount
after the TIPS procedure. Parathe procedure could result in is probably unnecessary.
Zemel
et al
vein
site
selected
for
puncture
should be within 2-3 cm of the inferior vena cava. In many cirrhotic patients, the hepatic veins are small and peripheral hepatic venous puncture may result in outflow stenosis caused by an hepatic vein that is smaller than
the diameter era! hepatic
diffi-
a catheter the pa-
tract.
phatic vessels, have all been peritoneal tures have
Elevation
of the stenosis lowered the portosystemic gradient to 10 mm Hg and resulted in a return to hepatopetal coronary vein flow.
Errant punctures with a 16-gauge needle have occurred in many cases. Bile ducts, lym-
been
TIPS.
control offered by the larger has proved to be advantageous
ence
over
after
is obtained through venous approach 6
the pre-TIPS level with retrograde coronary vein flow is caused by a high-grade stenosis of the he-
and probably most important, the larger bore 16-gauge needle accepts a 0.035-inch guide wire, as opposed to the 0.014-inch guide wire in the
Figure 12. Portal venogram the shunt via the right femoral
of the shunt. In addition, venous puncture results
periphin distal
portal vein cannulation and yields a guide wire path with acute angles. These angles are difficult to overcome with the rigid Palmaz stent and delivery system. An alternative, flexible, seLf-expanding stent (Wallstent; Schneider, Minneapolis), has been used for TIPS and can be deployed regardless of the angles and the guide wire path. How-
ever,
we have
found
the balloon-expandable
mechanism of the Palmaz geous because the greater achieved with the Palmaz
control Stenosis
of the final of the
portal hepatic
stent to be advantarange of diameters stent permits more
vein
pressure.
vein
between
the
proximal aspect of the stent(s) and the infenor vena cava has occurred in several patients as early as 4 months after the procedure (Fig 12). This stenosis has resulted in return of the portal pressure to the preshunt level without shunt thrombosis. The stenosis is likely due to
Volume
12
Number
4
a. Figure
b.
13. with persistent of the shunt,
(a)
Splenoportogram filling ofgastric performed 1 week
obtained on completion ofTIPS demonstrates patent shunt (large arrow), veins (small arrows) supplying large varices. (b) Transfemoral catheterization after TIPS, demonstrates flow through the stent (long arrow) with no change gradient. A short gastric vein stump is present (short arrow) without opacification of the seen. Complete variceal decompression was confirmed endoscopically.
in the portosystemic varices
previously
intimal hyperplasia ena or previous lesions
have
plasty
and
been
have
placement. stent
related to flow phenomneedle trauma. Most of these refractory
necessitated
Initially,
was
placed
angio-
was
enlarged
stern
diem
below
Palmaz but we
Despite
resulted
in stent
migration;
Walistent sis after and the
to treat acquired hepatic vein TIPS. The flexible nature ofthis inherent flaring of its ends have
hibited
migration.
To gradient rhage point quire
now
use
the
stenostent pro-
that
likely
source
variceal
portosystemic
gradient
(12,13). achieve 12 mm oi-rhage
hemorrhage
of bleeding
For this
reason,
portosystemic Hg with TIPS. has occurred
the
gradient
July
1992
was
lowered
is not
in patients of less we
than attempt
the
with
a
1 2 mm
Hg
to
These
patients once
to lower 12 mm
were the
the
shunt
free
from
var-
diameter
portosystemic
gra-
Hg.
a substantial
reduction
in the
por-
tal pressure and portosystemic gradient achieved with TIPS, we have found that, in some cases, the varices continue to fill with contrast material after completion of the shunt (Fig 13a). However, ifthe portosystemic
define the role that the portosystemic plays in recurrent variceal hemorand to determine the appropriate end for a successful percutaneous shunt remore investigation. However, studies
indicate
hemorrhage
additional stenosis
therefore,
TIPS.
iceal
to balloon
an additional in the
with
gradient
splenoportography
is lowered
below
performed
12 mm through
Hg, cathe-
terization of the shunt 5-7 days after TIPS has demonstrated no vanceal opacification (Fig 13b). Unless patients are actively bleeding in the angiographic suite, we have elected not to embolize coronary or short gastric veins during TIPS because an effective shunt will result in a return to hepatopetal flow in these structures.
gradients of less than Recurrent variceal hemin two patients in whom only
to
15 mm
Hg
Zemel
et al
U
RadioGraphics
U
621
4.
CONCLUSION
U With
the
technique
we
describe,
an
portosystemic neously with
shunt can be created very little morbidity.
tions
remain
unanswered,
stent
will
provide
the
however. most
effective
percutaMany quesWhich and
answered
with
future
8.
5.
long-
shunt? Should a stent be placed the entire hepatic venous outflow TIPS to limit hepatic vein stenosis? What is the role of TIPS in the clinical management of patients with vanceal hemorrhage? Should a percutaneous shunt be performed after a patient has bled once or has not responded to sclerotherapy, or is there a role for prophylactic TIPS? Ideally, these questions be
pandable intrahepatic in dogs with chronic 1986; 147:1251-1254. Richter GM, Noeldge
effective
lasting through during
will
7.
R#{246}sch J, Hanafee WN, Snow H. Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology 1969; 92:1112-1114. Colapinto RF, Stronell RD, Birch SJ, et al. Creation of an intrahepatic portosystemic shunt with a GrUntzig balloon catheter. Can MedAssocJ 1982; 126:267-268. PalmazJC, Sibbitt RR, Reuter SR, Garcia F, Tio FO. Expandable intrahepatic portacaval shunt stents: early experience in the dog. AiR 1985; 145:821-825. PalmazJC, Garcia F, Sibbitt RR, et al. Ex-
investigation.
6.
Transjugular
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U 1.
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3.
CelloJP,
GrendellJH, Crass RA, Weber TE, Trunkey DD. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage. N EnglJ Med 1987; 316:11-15. Rikkers LF, Burnet DA, Volentine GD, Buchi KN, Cormier RA. Shunt surgery versus endoscopic sclerotherapy for long-term treatment of variceal bleeding. Ann Surg 1987; 206: 26 1-27 1. Warren WD, HendersonJM, Millikan \VJ. Distal splenorenal shunt versus endoscopic sclerotherapy for long-term management of variceal bleeding. Ann Surg 1986; 203:454462.
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DS.
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GJ, BenenatiJF,
Percutaneous transjugular shunt. JAMA 1991; 266:390-393.
GM,
Noeldge
The transjugular (TIPSS): Intervent
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Roersle
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LaBergeJM, Ring EJ, Gordon RC. Percutaneous intrahepatic portosystemic shunt created via femoral vein approach. Radiology 1991; 181:679-681. Viallet A, Marleau D, Huet M, et al. Hemodynamic evaluation of patients with portal hypertension: relationship between bleeding varices and portohepatic gradient. Gastroenterology 1975; 69:1297-1300. Groszmann Ri, BoschJ, Grace ND, et al. Hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage. Gastroenterology 1990; 99:1401-1407.
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