TY - JOUR
T1 - Intravascular US-guided direct intrahepatic portacaval shunt with a PTFE-covered stent-graft
T2 - Feasibility study in swine and initial clinical results
AU - Petersen, B.
AU - Uchida, B. T.
AU - Timmermans, H.
AU - Keller, F. S.
AU - Rosch, J.
N1 - Copyright:
Copyright 2017 Elsevier B.V., All rights reserved.
PY - 2001
Y1 - 2001
N2 - PURPOSE: To determine the feasibility of the creation of a direct intrahepatic inferior vena cava (IVC)-to-portal-vein shunt with puncture guided by a transfemorally placed intravascular ultrasound (IVUS) probe and use of a polytetrafluoroethylene (PTFE)-covered stent-graft. MATERIALS AND METHODS: In five swine, transjugular access was used to perform a direct puncture from the IVC to the portal vein with use of a modified Rosch-Uchida Portal Access set directed with real-time IVUS (9 MHz) introduced from a transfemoral venous approach. The direct intrahepatic portocaval shunt (DIPS) was then created with single or overlapping PTFE-covered Palmaz stents placed through a 10-F sheath and dilated to a diameter of 8 mm. Follow-up was performed with transhepatic portography at 2, 4, and 8 weeks. Animals were killed when shunts occluded or at the termination of the study at 8 weeks. Gross and microscopic histologic study was performed on sacrificed animals. A similar technique was used to create DIPS in five patients with intractable ascites, with follow-up by US and venography. RESULTS: All experimental DIPS created in swine were created without complications. Portal vein punctures were achieved in four of five swine on the first or second pass of the needle. Follow-up transhepatic portography at 2 weeks demonstrated occlusion of two shunts, both explained by technical reasons at sacrifice. At 4 and 8 weeks, the remaining three shunts were patent on portography. Histology showed a thin neointimal lining with no significant tissue ingrowth or hyperplasia. Clinically, in five patients, successful puncture of the portal vein from the IVC was achieved in one to three passes. Creation of DIPS led to a reduction of mean portosystemic gradient from 18-29 mm Hg (mean, 24 mm Hg) to 9-10 mm Hg (mean, 9 mm Hg). One patient died of liver failure 2 days after creation of DIPS. The other four patients were doing well 2-15 months (mean, 8 months) after the procedure, with patency confirmed by US and venography. CONCLUSION: Creation of DIPS is technically feasible, and the direct IVC-to-portal-vein puncture can be done accurately with real-time IVUS guidance. Further studies and longer follow-up are necessary to determine if the short length of the PTFE-covered stent-graft and avoidance of the hepatic vein will increase the long-term patency compared to standard transjugular intrahepatic portosystemic shunt creation.
AB - PURPOSE: To determine the feasibility of the creation of a direct intrahepatic inferior vena cava (IVC)-to-portal-vein shunt with puncture guided by a transfemorally placed intravascular ultrasound (IVUS) probe and use of a polytetrafluoroethylene (PTFE)-covered stent-graft. MATERIALS AND METHODS: In five swine, transjugular access was used to perform a direct puncture from the IVC to the portal vein with use of a modified Rosch-Uchida Portal Access set directed with real-time IVUS (9 MHz) introduced from a transfemoral venous approach. The direct intrahepatic portocaval shunt (DIPS) was then created with single or overlapping PTFE-covered Palmaz stents placed through a 10-F sheath and dilated to a diameter of 8 mm. Follow-up was performed with transhepatic portography at 2, 4, and 8 weeks. Animals were killed when shunts occluded or at the termination of the study at 8 weeks. Gross and microscopic histologic study was performed on sacrificed animals. A similar technique was used to create DIPS in five patients with intractable ascites, with follow-up by US and venography. RESULTS: All experimental DIPS created in swine were created without complications. Portal vein punctures were achieved in four of five swine on the first or second pass of the needle. Follow-up transhepatic portography at 2 weeks demonstrated occlusion of two shunts, both explained by technical reasons at sacrifice. At 4 and 8 weeks, the remaining three shunts were patent on portography. Histology showed a thin neointimal lining with no significant tissue ingrowth or hyperplasia. Clinically, in five patients, successful puncture of the portal vein from the IVC was achieved in one to three passes. Creation of DIPS led to a reduction of mean portosystemic gradient from 18-29 mm Hg (mean, 24 mm Hg) to 9-10 mm Hg (mean, 9 mm Hg). One patient died of liver failure 2 days after creation of DIPS. The other four patients were doing well 2-15 months (mean, 8 months) after the procedure, with patency confirmed by US and venography. CONCLUSION: Creation of DIPS is technically feasible, and the direct IVC-to-portal-vein puncture can be done accurately with real-time IVUS guidance. Further studies and longer follow-up are necessary to determine if the short length of the PTFE-covered stent-graft and avoidance of the hepatic vein will increase the long-term patency compared to standard transjugular intrahepatic portosystemic shunt creation.
KW - Endovascular stent-graft
KW - Portacaval
KW - Shunts
KW - Stents and prostheses
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U2 - 10.1016/S1051-0443(07)61887-9
DO - 10.1016/S1051-0443(07)61887-9
M3 - Article
C2 - 11287535
AN - SCOPUS:0035072770
SN - 1051-0443
VL - 12
SP - 475
EP - 486
JO - Journal of Vascular and Interventional Radiology
JF - Journal of Vascular and Interventional Radiology
IS - 4
ER -