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

REFERENCES

U 1.

2.

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.

9.

10.

U

RadioGraphics

U

Zemel

et al

shunt:

preliminary

1990;

174:1027-1030. G, Katzen BT,

Zemel Sallee

DS.

systemic Richter stent-shunt Cardiovasc

shunt

clinical

Becker

stents

hypertension.

G, PalmazJC,

intraphepatic

AJR

et al.

portacaval results.

stern Radiology

GJ, BenenatiJF,

Percutaneous transjugular shunt. JAMA 1991; 266:390-393.

GM,

Noeldge

The transjugular (TIPSS): Intervent

G, PalmazJC,

intrahepatic results Radiol

porto-

Roersle

M.

portosystemic ofa pilot study. 1990; 13:200-

207. 1 1.

12.

13.

622

portacaval portal

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.

Volume

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Technical advances in transjugular intrahepatic portosystemic shunts.

A transjugular intrahepatic portosystemic shunt (TIPS) can be created percutaneously with the Palmaz balloon-expandable stent. This article describes ...
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