Transjugular Intrahepatic Portosystemic Shunt Creation in a Polycystic Liver Facilitated by Hybrid Cross-sectional/Angiographic Imaging

doi:10.1097/01.RVI.0000208984.17697.58

Journal of Vascular and Interventional Radiology

Volume 17, Issue 4, April 2006, Pages 711-715

https://doi.org/10.1097/01.RVI.0000208984.17697.58 Get rights and content

Polycystic liver disease (PCLD) has long been considered to represent a contraindication to transjugular intrahepatic portosystemic shunt (TIPS) creation, primarily because of the risk of hemorrhage. Three-dimensional (3D) navigation within the enlarged and potentially disorienting parenchyma can now be performed during the procedure with the development of C-arm cone-beam computed tomography, which relies on the same equipment already used for angiography. Such a hybrid 3D reconstruction-enabled angiography system was used for safe image guidance of a TIPS procedure in a patient with PCLD. This technology has the potential to expedite any image-guided procedure that requires 3D navigation.

Section snippets

CASE REPORT

Our institutional review board does not require approval for this type of retrospective case report.

A 62-year-old woman with an 18-year history of symptomatic polycystic kidney disease, PCLD, and hypertension presented with progressive abdominal distension, pain, and refractory hypertension. She was functionally anuric and had an operational Brescia-Cimino shunt. The patient underwent elective bilateral radical nephrectomies for relief of bulk symptoms and renovascular contribution to

DISCUSSION

TIPS creation has essentially completely replaced surgical portosystemic shunt creation for treatment of complications of portal hypertension. The original consensus document published by the National Digestive Diseases Advisory Board in 1995 (8) outlined indications and contraindications, but many guidelines were based on skepticism and theoretical risks without scientific evidence. The updated guidelines from the American Association for the Study of Liver Diseases (1) show that some of the

Acknowledgments

The authors thank Mervin Nicolas for outstanding technical support.

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Citation Excerpt :
This has been used to create a TIPS in the setting of polycystic liver disease, previously a contraindication for TIPS creation due to distorted anatomy and the risk of hemorrhage. Cone-beam CT was used in this procedure after an initial pass with a 22-gauge needle to appropriately redirect the needle into the portal vein with a single additional pass30 (Fig. 7). Cone-beam CT has also been used to generate a three-dimensional rotational angiogram from a wedged CO2 portogram, with subsequent overlay of this image during fluoroscopic needle passage to guide the portal vein puncture31 (Fig. 2E).
The most challenging part of transjugular intrahepatic portosystemic shunt creation is arguably the transvenous access from the hepatic vein to the portal vein. As experience and technology have evolved, the image guidance aspect of this critical step in the procedure has become more robust. Improved means to target the portal vein include both direct and indirect methods of portal vein opacification, cross-sectional imaging for both targeting and access, and novel use of transabdominal and intravascular ultrasound guidance. These techniques are described herein.

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: The instrumentation portion of this project was supported by NIH R01 EB003524, Siemens Medical Solutions, and the Lucas Foundation. N.S. and T.M. are employees of Siemens Medical Solutions. None of the other authors have identified a conflict of interest.

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Transjugular Intrahepatic Portosystemic Shunt Creation in a Polycystic Liver Facilitated by Hybrid Cross-sectional/Angiographic Imaging

Section snippets

CASE REPORT

DISCUSSION

Acknowledgments

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

Hepatology

Am J Kidney Dis