Radiological and Surgical Treatments of Portal Hypertension.

Interventions for portal hypertension are continuously evolving and expanding beyond the realm of medical management. When complications such as varices and ascites persist despite conservative interventions, procedures including transjugular intrahepatic portosystemic shunt creation, transvenous obliteration, portal vein recanalization, splenic artery embolization, surgical shunt creation, and devascularization are all potential interventions detailed in this article. Selection of the optimal procedure to address the underlying cause, treat symptoms, and, in some cases, bridge to liver transplantation depends on the specific etiology of portal hypertension and the patient's comorbidities.

The Use of Intracardiac Echocardiography in Transjugular Intrahepatic Portosystemic Shunt Procedure.

Transjugular intrahepatic portosystemic shunt (TIPS) is a complex intervention with a steep learning curve that requires centers of expertise to improve technical success and reduce complications. Portal venous access is the most challenging step of the procedure and requires planning and image guidance strategies to prevent vascular or bile duct injury and further complications. Intracardiac echocardiography (ICE) has been reported to be a safe and accurate tool that provides images of the portal vein anatomy in real time.

Updates on the Model for End-Stage Liver Disease Score and Impact on the Liver Transplant Waiting List: A Narrative Review.

The model for end-stage liver disease (MELD) score is an established indicator of cirrhosis severity and a predictor of morbidity and mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation and for allocation in liver transplantation. Since the adoption of the score, its use has been expanded to multiple new indications requiring model modifications, including relevant clinical and demographic variables, to increase predictive accuracy. The purpose of this report is to provide an update on the modifications made to the MELD score, comparing their performance with C statistics, advantages and disadvantages, and impact on mortality at 3 months after placing a TIPS or awaiting liver transplantation.

Complex filter removal using forceps from combined transfemoral and transjugular approach unhooking the filter apex using forceps and dual access: Two case reports.

Modern inferior vena cava filters (IVCFs) are intended to be retrieved once a thrombotic process or risk of pulmonary embolism has resolved independent of administration of anticoagulation. IVCF removal can be challenging with the risk of complications including venous perforation, filter migration, and device fracture. IVCF removal has been described using the nomenclature of routine versus advanced retrieval.

Large-Bore Mechanical Thrombectomy for Subacute Portal Vein Thrombosis in Patient With Acute Bleeding.

Portal vein thrombosis remains a clinical challenge with limited treatment options. A patient was admitted with decompensated nonalcoholic steatohepatitis and a history of recurrent esophageal and gastric variceal hemorrhages. Contrast-enhanced computed tomography revealed hepatic cirrhosis with concomitant and extensive thrombosis of the portal, splenic, and superior mesenteric veins.

An expert spotlight on inferior vena cava filters.

: Inferior vena cava (IVC) filters are mechanical filtration devices designed as an alternative to surgical ligation/plication of the IVC. Their use has been controversial, especially with the introduction of retrievable filters and expanded/prophylactic indications.: Authors discuss the types of available IVC filters, indications for placement, evidence on their effectiveness in general and specific patient populations, procedural considerations, off-label use, complications, and filter retrieval.

Emergent mechanical thrombectomy for right atrial clot and massive pulmonary embolism using flowtriever.

This case demonstrated a feasible alternative to treat "clot in transit" associated with pulmonary embolism using FlowTriever Inari device. The pre-existing approved AngioVac device requires extracorporeal circulation support and more invasiveness. FlowTriever permits mechanical thrombectomy with versatile approach without additional extracorporeal perfusion setting.

Impact of liver-directed therapy and non-therapy on the waiting time list of patient candidates for liver transplantation: retrospective survival analysis.

Aim Of The Study: To determine whether liver-directed therapies (LDT) and no therapy affect waiting list times for liver transplant candidates from a single center.

Material And Methods: This retrospective study included patients > 12 years of age diagnosed with hepatocellular carcinoma between January 2014 and June 2019 and followed until the date of transplant, date of delisting, loss to follow-up, or date of death. Waiting list time and associated factors were analyzed using Kaplan-Meier and Cox proportional-hazards methods.

Congenital intrahepatic portosystemic venous shunt embolization: A two-case experience.

Congenital intrahepatic portosystemic venous shunts are rare vascular malformations which are incidentally discovered on imaging or once hepatic encephalopathy becomes clinically apparent. Surgical ligation and endovascular embolization are potential treatments.

Discovery of a spontaneous portosystemic shunt following portal vein embolization.

Introduction: Right portal vein embolization (PVE) has become a crucially important option in the minimally-invasive treatment of hepatocellular carcinoma or secondary liver malignancy before partial hepatectomy or trisegmentectomy to reduce perioperative morbidity. The main goal of PVE is to increase the volume of the future liver remnant (FLR), which can provide complete liver metabolic functionality without risk of developing posthepatectomy liver failure, also known as "small for size syndrome." PVE accomplishes this via the redirection of portal venous flow toward the left portal vein circulation resulting in an increased left hepatic lobe volume.

Predictive Value of Hepatic Venous Pressure Gradient for Graft Hemodynamics in Living Donor Liver Transplantation.

The hepatic venous pressure gradient (HVPG) measurement is known to correlate with the severity of portal hypertension in patients with liver cirrhosis. This retrospective study investigated the clinical value of preoperative measurement of HVPG in patients who underwent adult-to-adult living donor liver transplantation (LDLT) and its predictive value for hepatic hemodynamics after graft reperfusion. For this study, 75 patients who underwent adult-to-adult LDLT were divided into 2 groups (HVPG <16 mm Hg or HVPG ≥16 mm Hg) to investigate the correlation between preoperative HVPG and characteristics and surgical outcomes of the patients, including portal vein flow (PVF) and hepatic artery flow (HAF) after graft reperfusion.

Challenges in interventional radiology: the pregnant patient.

A pregnant patient presenting to interventional radiology (IR) has a different set of needs from any other patient requiring a procedure. Often, the patient's care can be in direct conflict with the growth and development of the fetus, whether it be optimal fluoroscopic imaging, adequate sedation of the mother, or the timing of the needed procedure. Despite the additional risks and complexities associated with pregnancy, IR procedures can be performed safely for the pregnant patient with knowledge of the special and general needs of the pregnant patient, use of acceptable medications and procedures likely to be encountered during pregnancy, in addition to strategies to protect the patient and her fetus from the hazards of radiation.

Iatrogenic migration of VenaTech LP IVC filter to superior vena cava secondary to guidewire entrapment: case report and review of literature.

Modern inferior vena cava (IVC) filters are generally safe devices for preventing pulmonary embolus, with fewer complications compared to earlier techniques of caval interruption. Despite continuing improvement in filter designs and insertion methods, complications still occur. The IVC filter complications resulting from iatrogenic causes are rare and include but are not limited to misplacement, filter tilting, incomplete deployment, and filter migration.