V. Tacher1,4,5, A. Petit1, H. Derbel1,4, M. Chiaradia1, F. Ridouani1,

D. Azoulay2,4, C. Duvoux3,4, H. Kobeiter1,4

1 Department of Radiology, Henri Mondor University Hospital, Créteil, France

2Abdominal Surgery Department, Henri Mondor University Hospital, Créteil, France

3Hepatology Department, Henri Mondor University Hospital, Créteil, France

4Paris Est-Créteil University, Créteil, France

5 Unité INSERM U955 Equipe n°18

TIPS en guidage 3D

SFICV 2017 - Deauville

RAPPELS HISTORIQUES

TIPS: Transjugular Intrahepatic Porto systemic Shunt

ou Shunt Porto Cave par voie trans-jugulaire

DÉFINITION :

Création artificielle d’un shunt intra-hépatique entre une veine hépatique et une branche de la veine porte à partir d’une veine jugulaire interne.

Effective and durable therapy for treating complications of portal hypertension : hémorragies digestives et ascites réfractaires

TECHNIQUES THERAPEUTIQUES

•OBJECTIF:• Baisser la pression dans le système porte.

•Voie d’abord :

• CHIRURGICALE : morbi-mortalité très élevée

• RADIOLOGIE INTERVENTIONNELLE

RAPPELS ANATOMIQUES

ProblProbléématiquematique

• Technical challenge of TIPS placement: portal vein puncture from the hepatic vein usually made “blindly”

Rossle M. TIPS: 25 years later. J Hepatol 2013

25°

ProblProbléématiquematique

• Portal vein puncture:

– Time-consuming

– Increase x-ray exposure

– Complications: intraperitoneal bleeding, capsule injury, hemobilia, hepatic artery injury

– Echec de pose

Haskal ZJ et al. Quality improvement guidelines for transjugular intrahepatic portosystemic shunts. JVIR 2003Boyer TD et al. American Association for the Study of Liver D. The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: update 2009. Hepatology 2010Rossle M. TIPS: 25 years later. J Hepatol 2013Leong S et al. Reducing risk of transjugular intrahepatic portosystemic shunt using ultrasound guided single needle pass. World J Gastroenterol 2013

Cone-Beam Computed Tomography

CBCT – Acquisition des images

Acquisition: mouvement circulaire transversal ou en tête (180° plus le cône d’acquisition)

Vitesse de rotation: approx. entre 3 et 20 sec

Cadence image: 15 à 60 images par sec

Images par acquisition: approx. 100 à 750

Taille du détecteur: 17 x 17 cm à 30 x 40 cm

Mouvement transversal Mouvement en tête

Images de projection

CBCT – Acquisition des images

Acquisition: mouvement circulaire transversal ou en tête (180° plus le cône d’acquisition)

Vitesse de rotation: approx. entre 3 et 20 sec

Cadence image: 15 à 60 images par sec

Images par acquisition: approx. 100 à 750

Taille du détecteur: 17 x 17 cm à 30 x 40 cm

Mouvement transversal Mouvement en tête

Images de projection

CBCT – Acquisition des images

Mouvement transversal Mouvement en tête

Images de projection

Reconstruction(RPF / Itérative)

Guidage par CBCT

Fusion d’images

Guidage par CBCT

Guidage par CBCT

Guidage par CBCT

Guidage par CBCT

• Purpose : To assess feasibility, safety and efficiency of a 3D portal venous

phase computed tomography image fusion with 2D fluoroscopy for TIPS procedure

2017

•• Approved study by the Institutional Review Approved study by the Institutional Review BoardBoard

•• Prospective studyProspective study, , January 2015-January 2016

•• Inclusion of cirrhotic patients with portal Inclusion of cirrhotic patients with portal hypertension symptoms needing TIPS hypertension symptoms needing TIPS placement as :placement as :– Uncontrollable variceal hemorrhage ;

– Recurrent variceal hemorrhage despite endoscopic therapy ;

– Portal hypertensive gastropathy ;

– Refractory ascites ;

– Hepatic hydrothoraxBoyer TD et al. American Association for the Study of Liver D. The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: update 2009. Hepatology 2010

MaterialMaterial and and MethodsMethods

•• Primary criteriaPrimary criteria

– Initial technical success: TIPS patency between the hepatic vein and a branch of the portal vein at the end of the procedure

– Hemodynamic success: reduction of the porto-systemic gradient to 5-12 mmHg

– Clinical success: resolution of the clinical indication

•• Secondary criteriaSecondary criteria

– Volume of injected iodinated contrast agent

– X-ray exposure (dose–area product/Gy.cm²)

– Fluoroscopy time (min)

MaterialMaterial and and MethodsMethods

•• Patients: Patients: n = 16•• Patients characteristics and clinical parametersPatients characteristics and clinical parameters

•• TIPS placementTIPS placement– Right portal vein: n=13– Left portal vein (right hepatectomy or right portal vein

thrombosis): n=3

Patients Characteristics (Mean [min-max]/n [%])Age (years) 56 (48-64)Sex (M/F) 12/4

Cause of cirrhosis (n [%])Alcohol 13 (81%)Viral hepatitis 5 (22%)

NASH 3 (19%)

Mixed 5 (31%)

TIPS indication (n [%])Refractory ascite 10 (63%)Acute bleeding 6 (38%)

Hydrothorax 1 (6%)

Results

•• Primary Criteria Primary Criteria Evaluation parameter ValueInitial technical success n = 15 (94%)Hemodynamical success • Pre-procedural portosystemic gradient (mmHg) 21 (13-27)• Post-procedural portosystemic gradient (mmHg) 6 (5-7)Immediate complication (periprocedural) NoneMedian hospital stay (day) 5 (3-7)

Initial complicationsRebleeding (n=1), encephalopathy (n=3), inexplicable fever (n=1), death (n=2)

Median follow-up 14 months (7-19)

Late complicationsOne late death (severe encephalopathy despite TIPS reduction)

Clinical sucess 9 (56%)

Results

•• Secondary criteriaSecondary criteria

Parameter ValueDAP (Gy.cm²) 91 (65 – 133)Fluoroscopy time (min) 15 (15 – 21)Injected contrast media volume (ml) 65 (50 – 70)

Results

• Niveaux de références pour la pose de TIPS– Temps de fluoroscopie : 60min

– PDS : 3 Gy

Miller DL, Kwon D, Bonavia GH. Reference levels for patient radiation doses in interventional radiology: proposed initial values for U.S. practice. Radiology 2009

•• CBCT imaging:CBCT imaging:– 3D “CT scan-like” images or 3D angiography

images

– 3D multimodality image fusion on live fluoroscopy

• Routinely adopted in interventional radiology

• Image fusion technique : essential and systematically used for TIPS placement in our department

Tacher V et al.. Image guidance for endovascular repair of complex aortic aneurysms: comparison of two-dimensional and three-dimensional angiography and image fusion. JVIR2013Abi-Jaoudeh N et al. Image Fusion During Vascular and Nonvascular Image-Guided Procedures. Techniques in vascular and interventional radiology. 2013Tacher et al. Feasibility of Three-Dimensional MR Angiography Image Fusion Guidance for Endovascular Abdominal Aortic Aneurysm Repair. JVIR 2016

Discussion : Advantages

• Various image guidance techniques to improve safety and efficacy of the procedure:

– Image fusion after portal CT-scan segmentation

– 2D or 3D CO2-wedged hepatic portography

– Portography after direct trans-abdominal puncture

– US guidance Raza SA et al. Transhepatic puncture of portal and hepatic veins for TIPS using a single-needle pass under sonographic guidance. AJR 2006Sze DY et al. Transjugular intrahepatic portosystemic shunt creation in a polycystic liver facilitated by hybrid cross-sectional/angiographic imaging. JVIR 2006Bell BM et al. Transjugular intrahepatic portosystemic shunt creation using a three-dimensional fluoroscopy guidance system in patients with the Budd-Chiari syndrome. Proc (Bayl Univ Med Cent) 2015Luo X al. C-Arm Cone-Beam Volume CT in Transjugular Intrahepatic Portosystemic Shunt: Initial Clinical Experience. Cardiovasc Intervent Radiol 2015Tsauo J et al. Three-dimensional path planning software-assisted transjugular intrahepatic portosystemic shunt: a technical modification. CVIR 2015Ketelsen D et al. Three-dimensional C-arm CT-guided transjugular intrahepatic portosystemic shunt placement: Feasibility, technical success and procedural time. Eur Radiol 2016.

Discussion

Guidage par fusion

Image fusion-guided portal vein puncture during transjugular intrahepatic portosystemic shunt placementK. Rouabah et al. Diagnostic and Interventional Imaging 2016

Guidage par portographie 2D au CO2

Courtoisie du Dr Olivier Sutter et du Pr Olivier Serror

Guidage par portographie 3D au CO2

2D 3D

Courtoisie du Dr Olivier Sutter et du Pr Olivier Serror

Guidage échographique

Courtoisie du Dr Frédéric Douane, CHU Nantes

Guidage échographique - Ponction hépatique percutanée

Transhepatic Puncture of Portal and Hepatic Veins for TIPS Using a Single-Needle Pass Under Sonographic Guidance Syed A. Raza JVIR 2006

Temps de scopie (min)

Marquards S CVIR 2016E. Da Silva JFR 2013Courtoisie du dr F. DouaneV. Tacher CVIR 2017

NA NA

PDS (Gy x cm2)

Marquards S CVIR 2016E. Da Silva JFR 2013Courtoisie du dr F. DouaneV. Tacher CVIR 2017

• TIPS with CBCT does not require :– a second radiologist (TIPS placement under US

guidance) – a percutaneous portal system puncture and

opacification for a 2D angiography acquisition to guide the portal branch puncture

– iodinated contrast media or CO2 wedge injection into a hepatic vein for 2D or 3D portography acquisition technics (risk of capsule rupture during wedge injection)

– iodinated contrast media IV injection

Discussion : Advantages

• 3D portal venous phase computed tomography image fusion with 2D fluoroscopy guidance for TIPS placement: feasible, efficient and safe

• By identifying virtual needle path, CBCT and pre-procedural CT image enable real time multiplanar guidance and facilitate TIPS placement

Conclusion

TIPS en guidage 3D