Clinical Experience with Real-Time 3-D Guidance Based on C-Arm-Acquired Cone-Beam CT (CBCT) in Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS) Placement

Abstract

Real-time 3-D needle guidance based on CBCT is feasible for TIPSS placement. In terms of puncture attempts, duration and dose, CBCT guidance was not inferior to the control groups and may be a valuable support for interventionists in TIPSS procedures.

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

“…This is clearly less than the most recent reference DAP of 446.00 Gy cm 2 for TIPS procedures in the U.S. [31]. In detail, the DAP in our study is 30-80% lower than the mean DAPs reported in five studies using registration-guided TIPS procedures that range from 144.2 to 563.00 Gy cm 2 [12,[19][20][21][22][23][24] (s. Table 2). The difference between our median DAP of 61.14 Gy cm 2 to the lowest DAP for CACT-assisted TIPS procedures of 90.75 Gy cm 2 reported by Tacher et al might best be explained with the additional radiation exposure of the CACT reported to range from 18.00 to 63.90 Gy cm 2 [12,21,23].…”

“…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].…”

“…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]. All of these techniques aim to visualize the portal vein during the intervention with a varying complexity in displaying the portalvenous anatomy and most of them need to acquire additional 3D datasets (CACT, CE-CACT or MDCTA) causing additional radiation exposure.…”