Radiofrequency Wire Recanalization of Chronically Thrombosed TIPS.

Radiofrequency (RF) guide wires have been applied to cardiac interventions, recanalization of central venous thromboses, and to cross biliary occlusions. Herein, the use of a RF wire technique to revise chronically occluded transjugular intrahepatic portosystemic shunts (TIPS) is described. In both cases, conventional TIPS revision techniques failed to revise the chronically thrombosed TIPS.

Management of gastric varices in the pediatric population with balloon-occluded retrograde transvenous obliteration (BRTO) utilizing sodium tetradecyl sulfate foam sclerosis with or without partial splenic artery embolization.

It is unknown whether spontaneous gastrorenal shunts actually develop in the pediatric population. The minimum age documented in studies from Asia is 32 (range 32-44) years. This study describes three pediatric patients undergoing balloon-occluded retrograde transvenous obliteration (BRTO) for bleeding gastric varices with two of the three patients undergoing combined partial splenic embolization.

Management of stomal varices with transvenous obliteration utilizing sodium tetradecyl sulfate foam sclerosis.

The management of parastomal varices is not established. Transjugular intrahepatic portosystemic shunt (TIPS) creation is the most commonly described treatment; however, the rebleed rate after TIPS is 21-37%. The purpose of the study is to determine the effectiveness of transvenous obliteration using sodium tetradecyl sulfate (STS) and to describe a new simplified technique in obliterating these varices.

Ectopic varices: anatomical classification, hemodynamic classification, and hemodynamic-based management.

Ectopic varices are dilated splanchnic (mesoportal) veins/varicosities and/or are dilated portosystemic collaterals that can occur along the entire gastrointestinal tract outside the common pathologic variceal sites. Ectopic varices are complex and highly variable entities that are not fully understood. Ectopic varices represent 2%-5% of a gastrointestinal tract variceal bleeding.

The conventional balloon-occluded retrograde transvenous obliteration procedure: indications, contraindications, and technical applications.

Transvenous obliteration of gastric varices can be performed from the systemic venous side (draining veins or shunts) or from the portal venous side (portal afferent feeders). Balloon-occluded transvenous obliteration from the systemic veins is referred to as balloon-occluded retrograde transvenous obliteration (BRTO) and balloon-occluded transvenous obliteration from the portal veins is referred to as balloon-occluded antegrade (anterograde) transvenous obliteration (BATO). BRTO is the conventional balloon-occluded transvenous obliteration procedure and BATO is considered an alternative or adjunctive approach.

Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure.

The pathologic anatomy and hemodynamics of the left-sided portal circulation that is associated with gastric varices (GVs) are complex and highly variable. Understanding the pathologic anatomy and hemodynamics associated with GVs is important for clinical management decisions and for the technical descriptive details of the balloon-occluded retrograde transvenous obliteration (BRTO) and balloon-occluded antegrade transvenous obliteration procedures. A reflection of the considerable variability in anatomy, pathology, and hemodynamics is the numerous descriptive and categorical classifications that have been described in the past 2 decades.

Nonocclusive hepatic artery hypoperfusion syndrome (splenic steal syndrome) in liver transplant recipients.

There are numerous causes of reduced arterial inline flow to the liver transplant despite a patent hepatic artery. These include causes of increased peripheral resistance in the hepatic arterial bed, siphoning of the hepatic arterial flow by a dominant splenic artery (splenic steal syndrome), functional reduction of hepatic arterial flow in response to hyperdynamic portal inline flow, and small hepatic graft relative to normal portal inline flow (relative increase of portal flow). These causes are incompletely understood, and perhaps the most controversial of all is the splenic steal syndrome, which is possibly an underrecognized cause of graft ischemia in the United States.

Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes.

Patients with gastric variceal bleeding require a multidisciplinary team approach including hepatologists, endoscopists, diagnostic radiologists, and interventional radiologists. Upper gastrointestinal endoscopy is the first-line diagnostic and management tool for bleeding gastric varices, as it is in all upper gastrointestinal bleeding scenarios. In the United States when endoscopy fails to control gastric variceal bleeding, a transjugular intrahepatic portosystemic shunt (TIPS) traditionally is performed along the classic teachings of decompressing the portal circulation.

Arterioportal fistulas in liver transplant recipients.

Arterioportal fistulas (APFs) are classified into intrahepatic (>75% of all reported) and extrahepatic (<25% of all reported ). Anecdotally, investigators are more likely to report more sensational cases (typically extrahepatic APFs), so the actual prevalence of intrahepatic APFs is probably much higher (likely >90% of APFs). All reported APFs in liver transplant recipients have been intrahepatic.

Portal interventions in liver transplant recipients.

Portal vein interventions in liver transplant recipients represent a group of interventions in the management of several disease entities including portal vein stenosis, portal vein thrombosis, and recurrent liver cirrhosis with portal hypertension with and without gastric varices. The procedures performed in these patient populations include portal vein angioplasty with or without stent placement for portal vein stenosis, portal vein thrombolysis with or without stent placement for portal vein thrombosis, transjugular intrahepatic portosystemic shunts or splenic embolization for cirrhosis, and balloon-occluded retrograde transvenous obliteration for gastric varices. This article discusses these disease entities and the minimal invasive procedures used in their management.

Percutaneous portal vein access and transhepatic tract hemostasis.

Percutaneous portal vein interventions require minimally invasive access to the portal venous system. Common approaches to the portal vein include transjugular hepatic vein to portal vein access and direct transhepatic portal vein access. A major concern of the transhepatic route is the risk of postprocedural bleeding, which is increased when patients are anticoagulated or receiving pharmaceutical thrombolytic therapy.

The effect of balloon-occluded transvenous obliteration of gastric varices and gastrorenal shunts on the hepatic synthetic function: a comparison between Child-Pugh and model for end-stage liver disease scores.

Purpose: To evaluate the effect of balloon-occluded transvenous obliteration (BRTO) on the model for end-stage liver disease (MELD) and the Child-Pugh (C-P) score and their individual components.

Methods: A retrospective review of patients undergoing only BRTO without transjugular intrahepatic portosystemic shunt was performed (08, 2007 to 06, 2010). Pre- and post-BRTO MELD and C-P scores were calculated.

Transjugular intrahepatic portosystemic shunts in liver transplant recipients: technical analysis and clinical outcome.

Objective: The purpose of this study is to compare the technical success of transjugular intrahepatic portosystemic shunt (TIPS) in transplanted versus nontransplanted livers and to assess the clinical outcome of TIPS in liver transplant recipients.

Materials And Methods: A retrospective audit of patients receiving a TIPS was performed in two institutions during 1996-2009. The technical success of the TIPS was compared for transplanted versus nontransplanted livers.

ACR Appropriateness Criteria radiologic management of hepatic malignancy.

Management of hepatic malignancy is a challenging clinical problem involving several different medical and surgical disciplines. Because of the wide variety of potential therapies, treatment protocols for various malignancies continue to evolve. Consequently, development of appropriate therapeutic algorithms necessitates consideration of medical options, such as systemic chemotherapy; surgical options, such as resection or transplantation; and locoregional therapies, such as thermal ablation and transarterial embolization.

Ureteric embolization for lower urinary tract fistulae: use of two amplatzer vascular plugs and N-butyl cyanoacrylate employing the "sandwich" technique.

Purpose: This study describes and evaluated the effectiveness of occluding distal ureters in the clinical setting of urinary vaginal (vesicovaginal or enterovesicovaginal) fistulae utilizing a new technique which combines Amplatzer vascular plugs and N-butyl cyanoacrylate.

Materials: This is a retrospective study (January 2007-December 2010) of patients with urinary-vaginal fistulae undergoing distal ureter embolization utilizing an Amplatzer-N-butyl cyanoacrylate-Amplatzer sandwich technique. An 8-12-mm type-I or type-II Amplatzer vascular plug was delivered using the sheath and deployed in the ureter distal to the pelvic brim.

Balloon-occlusion catheter rupture during balloon-occluded retrograde transvenous obliteration of gastric varices utilizing sodium tetradecyl sulfate: incidence and consequences.

Balloon-occluded retrograde transvenous obliteration (BRTO) is an established procedure for the management of bleeding gastric varices in Asia. Invariably, the sclerosant utilized in Asia is ethanolamine oleate and the inventory used (vascular sheaths, balloon-occlusion catheters, and microcatheters) is not available outside Asia. A total of 41 BRTO procedures were performed with a technical and obliterative (gastric varix obliteration) success rate of 95% (n = 39 of 41) and 85% (n = 35 of 41), respectively.

Balloon-occluded retrograde transvenous obliteration of gastric varices from unconventional systemic veins in the absence of gastrorenal shunts.

Balloon-occluded retrograde transvenous obliteration of gastric varices in the absence of a gastrorenal shunts can still be performed through unconventional venous routes, such as the left inferior phrenic (ascending portion or transverse portion), pericardial, and azygous-hemiazygous veins. This requires detailed knowledge of venous anatomy, impeccable preprocedural imaging for planning, and high-skill set techniques with smaller balloon-occlusion catheters. The technical results appear to be high (67%-83% depending on the access venous system available), but are lower than conventional balloon-occluded retrograde transvenous obliteration via the gastrorenal shunt.

Inventory used for balloon-occluded retrograde (BRTO) and antegrade (BATO) transvenous obliteration: sclerosants and balloon occlusion devices.

The inventory used for the balloon-occluded retrograde transvenous obliteration (BRTO) and balloon-occluded antegrade transvenous obliteration procedures includes coaxial introducer sheath, catheters, balloon occlusion catheters, possibly microcatheters, possibly coils and preeminent vascular occlusion devices, and sclerosant mixtures. The inventory can be collectively categorized into "hardware" (sheaths, catheters, balloon occlusion devices, and alloy embolic agents) and sclerosant mixtures (contrast and sclerosing agents). The hardware inventory used in Japan is different from that used in the United States.

Balloon-occluded antegrade transvenous obliteration with or without balloon-occluded retrograde transvenous obliteration for the management of gastric varices: concept and technical applications.

Alternative routes for transvenous obliteration are sometimes resorted in the management of gastric varices. These alternative routes can be classified into A, portal venous access routes and B, systemic venous access routes. The portal venous approach to transvenous obliteration is called balloon-occluded antegrade transvenous obliteration (BATO) and is a collective definition, including 1-percutaneous transhepatic obliteration (PTO), 2-through an existing transjugular intrahepatic portosystemic shunt [(Trans-TIPS), and 3-trans-iliocolic vein obliteration (TIO)].

Pre- and post-balloon-occluded retrograde transvenous obliteration clinical evaluation, management, and imaging: indications, management protocols, and follow-up.

Patients with gastric variceal bleeding require a multidisciplinary team approach, which includes hepatologists, endoscopists, diagnostic radiologists, and interventional radiologists. Upper gastrointestinal endoscopy is the first-line diagnosis and management tool for bleeding gastric varices (GVs) as it is with all upper gastrointestinal bleeding scenarios. Traditionally, in the United States, when endoscopy fails to control gastric variceal bleeding, a transjugular intrahepatic portosystemic shunt (TIPS) is performed along the classic teachings of decompressing the portal circulation.

Balloon-occluded retrograde transvenous obliteration of gastric varices: conception, evolution, and history.

The idea of transvenous obliteration of varices that complicate portal hypertension dates back to the 1970s. The clinical use of this minimally invasive procedure was probably lost with the advent of transjugular intrahepatic portosystemic shunt shortly afterward. The concept of retrograde obliteration of a gastrorenal shunt through the left renal vein originated from Olson et al at Indiana University.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices.

Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal bleeding is less common than esophageal variceal bleeding; however, it is associated with a high morbidity and mortality rate and its management is largely uncharted due to a relatively less-established literature. In the West (United States and Europe), the primary school of management is to decompress the portal circulation utilizing the transjugular intrahepatic portosystemic shunt (TIPS).

Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Technical Results and Outcomes.

Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal (GV) bleeding is less common than esophageal variceal (EV) bleeding, however, is associated with a high morbidity and mortality. Balloon-occluded retrograde transvenous obliteration (BRTO) is an established procedure for the management of gastric varices in Japan and has shown promising results in the past decade.