Ultrasound-guided transhepatic puncture of the hepatic veins for TIPS placement.

PURPOSE: This retrospective analysis was carried out to assess the feasibility and results of transjugular intrahepatic portal systemic shunt (TIPS) performed with ultrasound (US)-guided percutaneous puncture of the hepatic veins. MATERIAL AND METHODS: Over a period of 3 years, 153 patients were treated with TIPS at our centre. In eight cases, a percutaneous puncture of the middle (n=7) or right (n=1) hepatic vein was required because the hepatic vein ostium was not accessible. Indications for TIPS were bleeding (n=1), Budd-Chiari syndrome (n=1), ascites (n=2), reduced portal flow (n=1) and incomplete portal thrombosis (n=3). A 0.018-in. guidewire was anterogradely introduced into the hepatic vein to the inferior vena cava (IVC) through a 21-gauge needle. In the meantime, a 25-mm snare-loop catheter was introduced through the jugular access to retrieve the guidewire, achieving through-andthrough access. Then, a Rosch-Uchida set was used to place the TIPS with the traditional technique. RESULTS: Technical success was achieved in all patients. There was one case of stent thrombosis. One patient died of pulmonary oedema. Three patients were eligible for liver transplantation, whereas the others were excluded due to shunt thrombosis (n=1) and previous nonhepatic neoplasms (n=3). CONCLUSIONS: The percutaneous approach to hepatic veins is rapid and safe and may be useful for avoiding traumatic liver injuries.

Emergency transjugular intrahepatic portosystemic shunt (TIPS): results, complications and predictors of mortality in the first month of follow-up.

PURPOSE: We conducted a single-centre retrospective analysis of the results and predictors of early mortality in emergency transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS: Between 1992 and 2009, 82 patients with refractory variceal bleeding underwent emergency TIPS at our Institution. The success and complications of the procedure were assessed for each patient. Child class, platelet count, prothrombin time, serum creatinine levels and venous pressure before and after TIPS were studied statistically as possible prognostic factors of early mortality. RESULTS: The technical, haemodynamic, and clinical success rates were 91.6%, 78% and 86.6%, respectively. Complications occurred in 21 cases (25.6%): eight were major (two stent migrations, one pulmonary embolism, one haemoperitoneum, one haemobilia, three intrahepatic haematomas) and 13 were minor (encephalopathy responsive to medical therapy). Twenty-one patients (25.6%) died due to the following causes: disseminated intravascular coagulation (DIC) (n=2), haemorrhage (n=8), cardiopulmonary failure (n=2) and liver failure (n=9). The predictors of mortality were Child's class C, high serum creatinine and prolonged prothrombin time. CONCLUSIONS: The technical success of TIPS may not lead to haemodynamic and clinical success. Complications are often due to impaired coagulation and inadequacy of the stent-graft. Early mortality is only influenced by pre-existing clinical and laboratory factors.

Femoral haemostosis with Vasoseal ES: experience in 150 patients.

PURPOSE: The aim of this study is to assess the effectiveness and safety of the use of Vasoseal ES collagen plug in heavily anticoagulated patients with high risk of complications at the vascular access site who had undergone vascular radiological intervention. MATERIALS AND METHODS: Between January 2002 and March 2003 180 consecutive transfemoral arterial accesses in 169 patients subjected to vascular radiological procedures were performed (bilateral access was performed in 11 patients): 140 percutaneous transluminal angioplasties and 40 transarterial chemoembolisations. All the patients who underwent angioplasty were given 3,000 IU of sodic heparin intravenously during the procedure and later a prolonged antiaggregant therapy was undertaken (ticlopidine 500 mg/day and aspirin 150 mg/day). The sheaths were removed at the end of the surgical manoeuvre and two cartridges of collagen were positioned on the external surface of the artery. The mean values of platelets and partial thromboplastin time were 42,000/ml and 170 s, respectively, in cirrhotic patients against 250,000/ml and 200 s in patients with peripheral arteriopathy. The next day a colour Doppler examination was performed at the puncture site. RESULTS: The technique proved successful in 89.4% of cases (161/180). In 19/180 vascular accesses placement of the haemostatic cartridges was not possible owing to the inability to compress the common femoral artery proximal to the release site (4/19), owing to a pre-existing haematoma (5/19) and owing to the limited presence of subcutaneous tissue (10/19). The mean time required for the placement of Vasoseal ES was 4 min. The mean time-to-haemostasis was 6 min. The mean time-to-mobilisation was 4 hr. Only in two patients was there an onset of a pseudoaneurysm of the right common femoral artery; the lesions were treated with ultrasonography -guided compression. In addition, 16 small local haematomas were recorded. In 4 cases early re-puncture of the femoral artery was performed (24-48 hr following the use of the device) without consequences. CONCLUSIONS: Vasoseal ES is a safe collagen closure device characterised by a high success rate. In anticoagulated patients the device can reduce the time-to-mobilisation and the incidence of complications.