Contrast enhanced computed tomography and reconstruction of hepatic vascular system for transjugular intrahepatic portal systemic shunt puncture path planning

Abstract

Aim: To describe a method for the transjugular intrahepatic portal systemic shunt (TIPS) placement performed with the aid of contrast-enhanced computed tomography (CECT) and three-dimensional reconstructed vascular images (3D RVIs), and to assess its safety and effectiveness.

Methods: Four hundred and ninety patients were treated with TIPS between January 2005 and December 2012. All patients underwent liver CECT and reconstruction of 3D RVIs of the right hepatic vein to portal vein (PV) prior to the operation. The 3D RVIs were carefully reviewed to plan the puncture path from the start to target points for needle pass through the PV in the TIPS procedure.

Results: The improved TIPS procedure was successful in 483 (98.6%) of the 490 patients. The number of punctures attempted was one in 294 (60%) patients, 2 to 3 in 147 (30%) patients, 4 to 6 in 25 (5.1%) patients and more than 6 in 17 (3.5%) patients. Seven patients failed. Of the 490 patients, 12 had punctures into the artery, 15 into the bile duct, eight into the gallbladder, and 18 through the liver capsule. Analysis of the portograms from the 483 successful cases indicated that the puncture points were all located distally to the PV bifurcation on anteroposterior images, while the points were located proximally to the bifurcation in the three cases with intraabdominal bleeding. The complications included three cases of bleeding, of whom one died and two needed surgery.

Conclusion: Use of CECT and 3D RVIs to plan the puncture path for TIPS procedure is safe, simple and effective for clinical use.

Keywords: 3D vascular reconstruction; Contrast-enhanced computed tomography; Interventional radiology; Transjugular intrahepatic portal systemic shunt.

Figure 1

Axial distance between puncture point of origin (o) and target point (t) of the portal vein. Point of origin (o) is located about 1.5 cm (white line) from the confluence of the right hepatic vein to inferior vena cava, and the red arrow between the two points is the anterior-posterior distance of the puncture.

Figure 2

Determination of rotation angle for puncture set. Contrast-enhanced computed tomography image in Figure 1 is rotated 180 degrees, and the angle between the direction given by the extension line that links the two puncture points and direction of the right vein (red arrow) is the rotation angle (α) for the puncture set.

Figure 3

Comparison of preoperative three-dimensional reconstructed image of the portal vein system and direct portogram obtained with non-iodinated contrast medium (Iopamiro 370) after a successful portal vein puncture. A: Preoperative three-dimensional reconstructed vascular image; B: Direct portogram of the portal vein (PV) during a successful puncture. O: Puncture point of the right hepatic vein; T: Target point of the right PV branch.

Figure 4

Portogram showing target point in transjugular intrahepatic portal systemic shunt puncture. The points were distal to the image bifurcation (T: Target point of the portal vein; B: The bifurcation).