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Abstract No. 202: MesoTIPS Combined Approach for the Treatment of Portal Hypertension Secondary to Portal Vein Thrombosis
PURPOSE: We evaluated the use of real-time X-ray imaging fused with MRI (XFM) to guide interventions targeting the portal vein. This technique uses MRI-derived data to provide roadmaps during conventional X-ray fluoroscopy. MATERIALS AND METHODS: Experiments were performed using a dedicated interventional MRI/X-ray suite equipped with a state-of-the-art Siemens Espree MRI scanner and AXIOM Artis dFC. Prior to imaging, jugular access was obtained in an adult swine. After placement of multimodality external fudicial markers over the abdomen, MRI images were obtained with an axial 3D gradient echo data set –low resolution (2.7⫻2.7⫻5 mm) for marker visualization and a contrast-enhanced, 3D T1-weighted for high resolution isotropic (1⫻1⫻1 mm) imaging of the portal vein. Following MRI, the animal was transferred to a calibrated fluoroscopy system, while the portal vein was manually segmented from the MRI images. MRI data was transformed from 3D to 2D to correlate with gantry and table position and combined with live X-ray images. After segmentation of the portal vein, the portal vein contour was subsequently merged onto live fluoroscopic images for guidance. Using a standard Rosch-Uchida set, transjugular portal vein punctures were performed using this XFM technique. RESULTS: Image overlay of the portal vein with real time fluoroscopy was feasible. After the two modalities were fused using the fiducial markers, unrestricted gantry rotation, table panning, and magnification changes were possible during the procedures. Variations of the portal venous anatomy could be readily identified and projected onto fluoroscopy. MRI roadmaps improved operator accuracy and orientation of needle pass from the hepatic vein. Registration errors were decreased when all the external fiducial markers were readily identified and therefore provided high spatial precision. With the image fusion, a single pass allowed immediate access to the portal vein.
Abstract No. 202
MesoTIPS Combined Approach for the Treatment of Portal Hypertension Secondary to Portal Vein Thrombosis. A.A. Chamsuddin, L.A. Nazzal, T. Kabbani, G. Peters, S. Panah; Emory University, Atlanta, GA PURPOSE: To describe a new technique created to relief portal hypertension secondary to portal vein thrombosis, chronic or acute, with combined surgical and endovascular technique. MATERIALS AND METHODS: Nine patients, two females and seven males, mean age 49 years presenting with portal vein thrombosis (4 acute and 5 chronic) underwent MesoTIPS procedure. Five patients presented with severe abdominal pain, one of them had bowel necrosis. Two other patients presented with upper GI bleed. The procedure was initiated by a minilaparotomy performed by a general surgeon; a loop of small bowel was run to isolate a small mesenteric vein and portal system was accessed. Hepatic vein was then accessed by a transjugular approach. During TIPS procedure, when feasible, additional manipulations were performed to resolve portal vein thrombosis such as mechanical thrombectomy (5 patients), thrombolysis infusion (6 patients) and angioplasty (7 patients). Patients were
CONCLUSION: The MesoTIPS combined approach is effective for the relief of portal hypertension secondary to portal vein thrombosis. This approach requires close monitoring in the first two weeks after the procedure because of increased risk of rethrombosis. In addition, MesoTIPS requires more maintenance and revisions in comparison to regular TIPS. 5:36 PM
Abstract No. 203
TIPS Rebleeding Rates for Different Subtypes of Varices in the Era of Covered Stents. N. Abi-Jaoudeh, A.H. Matsumoto, F.J. Angle, B. Arslan, U.C. Turba, M.D. Dake, W. Swee; University of Virginia, Charlottesville, VA PURPOSE: In the pre-covered stent era, the natural history of EV (esophageal varices), GV (gastric varices), and GAVE (gastric antral vascular ectasia) rebleeding rates were confounded by high rates of TIPS dysfunction. Our purpose was to investigate rebleeding rates for TIPS using covered stents with specific attention to the original source of bleeding and recurrent source of bleeding. MATERIALS AND METHODS: We reviewed all TIPS cases using covered stents between 2003 and 2007 assessing TIPS patency and rebleed rates with hemodynamic correlation. Results between 3 subgroups categorized by the original source of bleeding (EV, GV, and GAVE) were compared. RESULTS: We identified 53 patients, 35 men and 18 women, with mean age of 55 (range 17-79). There were 18 patients in the EV group, 29 in the GV group, and 6 in the GAVE group. Etiology of cirrhosis, MELD score (mean 12, range 2-28), pre and post procedure portosystemic gradient (PSG) (mean pre: 17 mmHg and post: 7 mmHg) were evaluated showing no significant difference between subgroups. All cases received 8 mm or 10 mm diameter covered stents, post-dilated to a mean diameter of 8.9 mm (8-12). 17 patients (32%) had complimentary embolization of varices during their initial TIPS procedure; 12 patients in the GV group, 5 in the EV group and none in the GAVE group. Upon discharge, hemostasis was achieved in all patients except one who died. Follow-up was available on 43 patients with mean period of 13.7 months (range 1-49). Primary patency was 95.4% and primary assisted patency was 100%. There were 3 (5.6%) TIPS dysfunctions; 2 which rebled, 1 from the EV group and 1 from the GV group. The third case was asymptomatic with stenosis identified by screening US. There were a total of 7 rebleeds. There was 1 (5.5%) rebleed in the EV group from a GV source S77
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RESULTS: All nine patients had technically successful procedures as defined by reduction of portosystemic gradient to normal values and TIPS patency. Doppler Ultrasound was performed within the first two weeks after MesoTIPS to document shunt patency. At the end of the procedure, one patient experienced a blood pressure drop that required RBC and FFPs transfusions after which the BP normalized. Then Patients were followed up for a mean time of 13.3 months (range 8 days-3 years). Six patients had follow up for at least 6 months; they had on average two TIPS revisions in this period. Following revision they had normal flow and velocities through the TIPS. All patients are still alive and asymptomatic at the current period. One patient had complete rethrombosis of the shunt but he is still asymptomatic.
Scientific Sessions
CONCLUSION: These results suggest that fusion of MR images with live fluoroscopy is feasible and can facilitate access into the portal vein from a transjugular approach.
followed up by means of Duplex sonography and TIPS revision was performed when restenosis was suspected.
Abstract No. 202
MesoTIPS Combined Approach for the Treatment of Portal Hypertension Secondary to Portal Vein Thrombosis. A.A. Chamsuddin, L.A. Nazzal, T. Kabbani, G. Peters, S. Panah; Emory University, Atlanta, GA PURPOSE: To describe a new technique created to relief portal hypertension secondary to portal vein thrombosis, chronic or acute, with combined surgical and endovascular technique. MATERIALS AND METHODS: Nine patients, two females and seven males, mean age 49 years presenting with portal vein thrombosis (4 acute and 5 chronic) underwent MesoTIPS procedure. Five patients presented with severe abdominal pain, one of them had bowel necrosis. Two other patients presented with upper GI bleed. The procedure was initiated by a minilaparotomy performed by a general surgeon; a loop of small bowel was run to isolate a small mesenteric vein and portal system was accessed. Hepatic vein was then accessed by a transjugular approach. During TIPS procedure, when feasible, additional manipulations were performed to resolve portal vein thrombosis such as mechanical thrombectomy (5 patients), thrombolysis infusion (6 patients) and angioplasty (7 patients). Patients were
CONCLUSION: The MesoTIPS combined approach is effective for the relief of portal hypertension secondary to portal vein thrombosis. This approach requires close monitoring in the first two weeks after the procedure because of increased risk of rethrombosis. In addition, MesoTIPS requires more maintenance and revisions in comparison to regular TIPS. 5:36 PM
Abstract No. 203
TIPS Rebleeding Rates for Different Subtypes of Varices in the Era of Covered Stents. N. Abi-Jaoudeh, A.H. Matsumoto, F.J. Angle, B. Arslan, U.C. Turba, M.D. Dake, W. Swee; University of Virginia, Charlottesville, VA PURPOSE: In the pre-covered stent era, the natural history of EV (esophageal varices), GV (gastric varices), and GAVE (gastric antral vascular ectasia) rebleeding rates were confounded by high rates of TIPS dysfunction. Our purpose was to investigate rebleeding rates for TIPS using covered stents with specific attention to the original source of bleeding and recurrent source of bleeding. MATERIALS AND METHODS: We reviewed all TIPS cases using covered stents between 2003 and 2007 assessing TIPS patency and rebleed rates with hemodynamic correlation. Results between 3 subgroups categorized by the original source of bleeding (EV, GV, and GAVE) were compared. RESULTS: We identified 53 patients, 35 men and 18 women, with mean age of 55 (range 17-79). There were 18 patients in the EV group, 29 in the GV group, and 6 in the GAVE group. Etiology of cirrhosis, MELD score (mean 12, range 2-28), pre and post procedure portosystemic gradient (PSG) (mean pre: 17 mmHg and post: 7 mmHg) were evaluated showing no significant difference between subgroups. All cases received 8 mm or 10 mm diameter covered stents, post-dilated to a mean diameter of 8.9 mm (8-12). 17 patients (32%) had complimentary embolization of varices during their initial TIPS procedure; 12 patients in the GV group, 5 in the EV group and none in the GAVE group. Upon discharge, hemostasis was achieved in all patients except one who died. Follow-up was available on 43 patients with mean period of 13.7 months (range 1-49). Primary patency was 95.4% and primary assisted patency was 100%. There were 3 (5.6%) TIPS dysfunctions; 2 which rebled, 1 from the EV group and 1 from the GV group. The third case was asymptomatic with stenosis identified by screening US. There were a total of 7 rebleeds. There was 1 (5.5%) rebleed in the EV group from a GV source S77
WEDNESDAY
5:24 PM
RESULTS: All nine patients had technically successful procedures as defined by reduction of portosystemic gradient to normal values and TIPS patency. Doppler Ultrasound was performed within the first two weeks after MesoTIPS to document shunt patency. At the end of the procedure, one patient experienced a blood pressure drop that required RBC and FFPs transfusions after which the BP normalized. Then Patients were followed up for a mean time of 13.3 months (range 8 days-3 years). Six patients had follow up for at least 6 months; they had on average two TIPS revisions in this period. Following revision they had normal flow and velocities through the TIPS. All patients are still alive and asymptomatic at the current period. One patient had complete rethrombosis of the shunt but he is still asymptomatic.
Scientific Sessions
CONCLUSION: These results suggest that fusion of MR images with live fluoroscopy is feasible and can facilitate access into the portal vein from a transjugular approach.
followed up by means of Duplex sonography and TIPS revision was performed when restenosis was suspected.