Objective:To analyze the technical difficulties of transjugular intrahepatic portosystemic shunt (TIPS).
Methods:The retrospective descriptive study was adopted. The clinical data of 3 367 patients who underwent TIPS at Beijing Shijitan Hospital of Capital Medical University from August 1994 to February 2015 were collected. Observed indices included: (1) situations of TIPS without techincal difficulties, (2) situations of TIPS with technical difficulties, (3) intraoperative situations of reintervention, (4) pre and postoperative portal venous pressure changes. Measurement data with normal distribution were presented as
±s. Comparison was done using t test.
Results:(1) Situations of TIPS without techincal difficulties: of 3 367 patients undergoing TIPS, 1 963 had no technical difficulties, including 1 031 combined with indirect portography, 19 combined with indirect portography and percutaneous transhepatic puncture simultaneously, and 913 receiving TIPS directly. (2) Situations of TIPS with technical difficulties: of 3 367 patients undergoing TIPS, 1 404 had technical difficulties, including 404 of main branch diameter of intrahepatic portal vein≤5 mm, 77 of complete occlusion of hepatic veins, 193 of portal vein cavernous transformation, 19 of portal vein occlusion combined with thick collateral vessels, 142 of completely occlusive thrombosis or tumor thrombus of portal vein and its branches, 176 of unreasonable spatial relationship between hepatic vein or inferior vena cava and main branchs of intrahepatic portal vein, 251 of main branches of intrahepatic portal vein located extrahepaticly (crack widened liver, after partial hepatectomy, etc.), 78 of intrahepatic bile duct dilatation, and 64 of other circumstances (microhepatia, hepatic cyst, polycystic liver, severe liver cirrhosis, huge liver neoplasms, complete occlusion of hepatic vein segmental of inferior vena cava). Of the 1 404 patients, 896 underwent TIPS combined with indirect portography, 480 combined with indirect portography and percutaneous transhepatic puncture, 7 combined with indirect portography and percutaneous transsplenic puncture, 9 combined with indirect portography and femoral vein puncture, 12 combined with indirect portography, percutaneous transhepatic puncture and percutaneous transsplenic puncture. (3) Intraoperative situations of reintervention: of 3 367 patients, 1 035 underwent repeated intervention therapy. Among 126 patients with technical difficulties, 32 with head of stent covered were punctured head of stent using RUPS100 puncture needle. Fiftysix patients had large angel between stent and inferior vena cava, 27 of which were assisted by guiding catheter, 18 were assisted by RUPS100 metallic guide tube and 11 were punctured head of stent by RUPS100 puncture needle. Seventeen patients had complete occlusion at opening position of stent head and close distance from right atrium, 2 of which were assisted by RUPS100 metallic guide tube and 15 were punctured head of stent by RUPS100 puncture needle. Two patients with distal end of stent embeded into the wall of portal vein were assisted by RUPS100 metallic guide tube. Nineteen patients with intrastent occlusion were punctured proliferating tissue using RUPS100 puncture needle. (4) Pre and postoperative portal venous pressure changes: the portal venous pressure of patients without technical difficulties was changed from (3.9±0.7)kPa before TIPS to (2.5±0.4)kPa after TIPS, with a statistically significant difference (t=1.54, P<0.05). The portal venous pressure of patients with technical difficulties was changed from (4.0±0.9)kPa before TIP to (2.5±0.4)kPa after TIPS, with a significant difference (t=1.59, P<0.05).
Conclusions:TIPS could effectively reduce portal vein pressure. Thinner intrahepatic portal vein, portal vein cavernous transformation, portal vein occlusion combined with thick collateral vessels, complete occlusive thrombosis or tumor thrombus of portal vein and its branches, spatial relationships disorder between hepatic vein or inferior vena cava and portal vein main branchs, extrahepatic location of main branches of intrahepatic portal vein, complete occlusion of hepatic veins, intrahepatic bile duct dilatation are technical difficulties of TIPS. Combined use of various interventional techniques could increase technical success rate. In addition, reoperation of occluded TIPS shunt may be solved by applying the guiding catheter and/or puncture.
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