3D C-Arm cone beam CT for targeting the portal vein during TIPS: Initial clinical experience

Transjugular intrahepatic portosystemic shunt placement: portal vein puncture guided by 3D/2D image registration of contrast-enhanced multi-detector computed tomography and fluoroscopy

“…Therefore, 3D/2D image registered 3D-VM facilitates catheterization of the appropriate hepatic vein followed by successful 3D-guided puncture the portal vein, the most challenging step of TIPS procedures. The demographics of our study population and the indications for TIPS placement are comparable to the recent literature on 3D-guided TIPS procedures [12,[19][20][21][22] except for the studies by Luo et al, who included younger patients with refractory bleeding [23,24]. In our study, the TIPS placement under guidance of the 3D/2D image registered 3D-VM was successfully performed in all cases with a significant reduction of the PSG.…”

“…Reviewing the procedural characteristics, the overall mean PT of 14 ± 6 min and OPT of 64 ± 29 min in our study are short compared to the described studies on imageguided TIPS placement with PTs ranging from 14 min to 32 min [12,19,21,22] and OPTs ranging from 40 min to 115 min (s. Table 2) [20][21][22]. Most of the other studies on guidance techniques did not include additional procedures like variceal embolization or second stent graft placements potentially prolonging the OPT of our study (s. Table 1) [19][20][21][22]. A major reason for the longer OPTs in the previous studies without performing additional procedures might be the time needed for the acquisition of the additional CACT and the quite complex post-processing/reconstruction of the image fusion algorithms used in these studies.…”

“…However, an experienced sonographeur has to be involved in addition to the operator placing the TIPS. More recently, several 3D guidance techniques for TIPS placement have been reported [12,[17][18][19][20][21][22][23][24]. Rouabah et al described a guidance technique based on a 3D volume rendering of the portal vein generated from a contrast-enhanced MDCT Angiography (MDCTA) of the portal trunk acquired shortly before the TIPS, which was superimposed on the fluoroscopic images [19].…”

“…In another study, Luo et al introduced a guidance technique relying on intra-procedural acquisition of a CE-CACT with contrast injection in the superior mesenteric artery to obtain an indirect portomesentericography serving as an overlay [24]. Comparable to this technique are the CE-CACT-assisted guidance techniques published by Chivot et al and Ketelsen et al [12,22]. Chivot et al used an indirect wedge portography during CACT acquisition [22] and Ketelsen et al administered the contrast media via an intravenous access and acquired the CACT in portal venous phase [12].…”

“…Comparable to this technique are the CE-CACT-assisted guidance techniques published by Chivot et al and Ketelsen et al [12,22]. Chivot et al used an indirect wedge portography during CACT acquisition [22] and Ketelsen et al administered the contrast media via an intravenous access and acquired the CACT in portal venous phase [12]. Another group reported on the co-registration of CE-MDCT with an unenhanced CACT and the CE-CACT with intravenous contrast injection for portal vein puncture guidance [21].…”