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A review of recent experience with transjugular intrahepatic portosystemic shunt creation using intravascular ultrasound

Portal vein access has historically been the most technically challenging step in the creation of transjugular intrahepatic portosystemic shunts (TIPSs). The use of intravascular ultrasound (IVUS) for guidance of portal vein access during TIPS creation has garnered much interest in recent years. Recent literature has suggested potential improvements in procedural metrics that may result from use of IVUS for TIPS. This review aims to provide historical context, detail technical advances and describe recent clinical experience with the use of IVUS for TIPS creation.

A new and improved transjugular intrahepatic portosystemic shunt (TIPS) stent graft: Controlled expansion

Initial underdilation of transjugular intrahepatic portosystemic shunt (TIPS) stents has been a widely proposed and commonly practiced technique to balance portal hypertension relief and the adverse effects associated with excess shunting, especially hepatic encephalopathy. However, this technique has been scrutinized by a number of studies which have shown that underdilated TIPS stents tend to passively expand with time. The recently launched GORE® VIATORR® TIPS Endoprosthesis with Controlled Expansion (VIATORR CX®) may address this problem with its novel diameter control capabilities. This article reviews literature concerning passive expansion of initially underdilated TIPS stents and explores preliminary data investigating the use and efficacy of the VIATORR CX® endoprosthesis.

Recent advances in transarterial embolotherapies in the treatment of hepatocellular carcinoma

Management of hepatocellular carcinoma (HCC) can be maximized with the utilization of multiple treatment modalities including transplant, surgical resection and locoregional therapies including ablative therapies and transarterial embolotherapies. Although transplant and surgical resection offer the best clinical outcomes, a limited number of patients are amenable to these surgical treatment options due to the advanced disease at presentation. Transarterial embolotherapies including conventional transarterial chemoembolization (cTACE), bland transarterial embolization (TAE), drug-eluting beads transarterial chemoembolization (DEB-TACE) and selective internal radiation therapy (SIRT) with Yttrium 90 (⁹⁰Y) have played an increasingly important role for these patients with unresectable HCC. With a better understanding of different transarterial embolotherapies, more personalized and precise treatment should be implemented for these patients with unresectable HCC. In this review, the updated evidence on the current role of each embolotherapy in the treatment of HCC is summarized.

Yttrium-90 Selective Internal Radiation Therapy with Glass Microspheres for Hepatocellular Carcinoma: Current and Updated Literature Review

Hepatocellular carcinoma is the most common primary liver cancer and it represents the majority of cancer-related deaths in the world. More than 70% of patients present at an advanced stage, beyond potentially curative options. Ytrrium-90 selective internal radiation therapy (Y90-SIRT) with glass microspheres is rapidly gaining acceptance as a potential therapy for intermediate and advanced stage primary hepatocellular carcinoma and liver metastases. The technique involves delivery of Y90 infused glass microspheres via the hepatic arterial blood flow to the appropriate tumor. The liver tumor receives a highly concentrated radiation dose while sparing the healthy liver parenchyma due to its preferential blood supply from portal venous blood. There are two commercially available devices: TheraSphere® and SIR-Spheres®. Although, Y90-SIRT with glass microspheres improves median survival in patients with intermediate and advanced hepatocellular carcinoma and has the potential to downstage hepatocellular carcinoma so that the selected candidates meet the transplantable criteria, it has not gained widespread acceptance due to the lack of large randomized controlled trials. Currently, there are various clinical trials investigating the use of Y90-SIRT with glass microspheres for treatment of hepatocellular carcinoma and the outcomes of these trials may result in the incorporation of Y90-SIRT with glass microspheres into the treatment guidelines as a standard therapy option for patients with intermediate and advanced stage hepatocellular carcinoma.

Lymphangiography to Treat Postoperative Lymphatic Leakage: A Technical Review

In addition to imaging the lymphatics and detecting various types of lymphatic leakage, lymphangiography is a therapeutic option for patients with chylothorax, chylous ascites, and lymphatic fistula. Percutaneous thoracic duct embolization, transabdominal catheterization of the cisterna chyli or thoracic duct, and subsequent embolization of the thoracic duct is an alternative to surgical ligation of the thoracic duct. In this pictorial review, we present the detailed technique, clinical applications, and complications of lymphangiography and thoracic duct embolization.