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Budd Chiari Syndrome|Budd Chiari Syndrome|80|Male
Budd Chiari Syndrome|Budd Chiari Syndrome|80|Male
2016angioangioplastyascitesballoondecidedenterexpandablefemoralguidewirehepatichypertensivejugularoutflowportalSIRstenttranshepaticveinveins
Portal Vein Thrombosis|TIPS|38|Female
Portal Vein Thrombosis|TIPS|38|Female
2016advanceangioascitesaxialbiliarybiopsybranchdilateembolizationembolizeembolizedendoscopicendoscopicallygastrointestinalgelfoamguidewirehepatichugelivermesentericparenchymapatientportalpunctureraaberecanalizesheathSIRsplenicstandardthrombosedtipstranshepatictransplantationvaricesveinvenouswire
Portal Hypertension | Stenting, TIPS | 78 | Male
Portal Hypertension | Stenting, TIPS | 78 | Male
2016biliaryendoscopyloopmassoccludedopacificationoutlinepatientportalrotateSIRtipsvein
Portal Vein Thrombosis, Cirrhosis, Varices|Recanalization, TIPS|49|Female
Portal Vein Thrombosis, Cirrhosis, Varices|Recanalization, TIPS|49|Female
2016anastomosisembolizeembolizingparenchymaportalsheathSIRsplenicthrombosedthrombustipsvaricesveinvenogramvenouswedge
Portal Vein Thrombosis, Ascites, Cirrhosis|Recanalization, TIPS (Trans-splenic)|65|Male
Portal Vein Thrombosis, Ascites, Cirrhosis|Recanalization, TIPS (Trans-splenic)|65|Male
2016advancedilateembolizelivermaintainsperfusedperfusionperipheralportalpullpuncturerecanalizeSIRsnaresplenicthrombosedthrombustipsvaricesveinvenogramvenography
GI Bleed (Warfarin)|TIPS (Trans-hepatic, Trans-splenic)|33|Female
GI Bleed (Warfarin)|TIPS (Trans-hepatic, Trans-splenic)|33|Female
2016aasldanticoagulateanticoagulationcavacompleteendoscopyhepatologyobservationportalSIRstentstentedsurgeonstips
Mesenteric Venous Thrombosis|Mechanical Thrombectomy, Balloon Maceration|30|Female
Mesenteric Venous Thrombosis|Mechanical Thrombectomy, Balloon Maceration|30|Female
2016anticoagulatedapproachbleedingcirculatingclotconduitdeviceflowhypercoagulableinjectintrinsiclyticmesentericoutflowplasmaportalpulmonarySIRsubsequentlysystemicthrombectomythrombolysistipsveinvenogramvenouswire
Cirrhosis, Acute EV hemorrhage|TIPS, Variceal Embolization|35|Female
Cirrhosis, Acute EV hemorrhage|TIPS, Variceal Embolization|35|Female
2016acuteadditionadjunctiveangiographicbleedingcatheterizedcirrhoticclinicalcomparedcongestivedataembolizationembolizeembolizedendoscopicesophagealgastricgradienthematemesisinstitutionmedicalmeldpharmacologicportalportogramrebleedingrefractorySIRstentsurvivalsystemictherapytipsvaricealvaricesveinversus
Cirrhosis, Acute GV Hemorrhage, Hepatic Encephalopathy|BTO|44|Female
Cirrhosis, Acute GV Hemorrhage, Hepatic Encephalopathy|BTO|44|Female
2016accessacuteanatomicantegradeapproachascitesballoonbrtocirrhoticclinicalcoilcomparedcontraindicationembolizeencephalopathyesophagealformationgastricgastrorenalgelfoamhepatichypertensiveincidencelipiodollivermeldobliterationocclusionpatientpatientspercutaneousphysiologicportalportosystemicposteriorratesrebleedingretrogradeSIRsplenicsubmucosalsuccesssystemictetradecyltipstranshepatictransvenousvaricealvaricesvarixveinvenous
PVT, Cirrhosis, Ascities,Variceal bleeding|TIPS, Transplenic Approach|
PVT, Cirrhosis, Ascities,Variceal bleeding|TIPS, Transplenic Approach|
2016cirrhosisdecompensatedhepatobiliaryportalSIRtransplantedvaricealvein
Cirrhosis, Acute GV hemorrhage|TIPS, Variceal Embolizaiton|78|Female
Cirrhosis, Acute GV hemorrhage|TIPS, Variceal Embolizaiton|78|Female
2016anatomicantegradeballoonbrtocirrhoticclosedcombinedembolicesophagealgastricgastrorenalhighlightmeldmulticenterobliterationocclusionoutflowportalposteriorpursuedrebleedingsclerosingSIRsplenicstatisticallysubmucosalsystemictipstransvenousvaricealvaricesvenousversus
Portal Vein Thrombosis, Cirrhosis|Recanalization, TIPS (Trans-splenic)|57|Male
Portal Vein Thrombosis, Cirrhosis|Recanalization, TIPS (Trans-splenic)|57|Male
2016anastomosisbilirubininterpositioninterventionalpatencySIRthrombustransplantedvenography
Refractory Ascites | TIPS
Refractory Ascites | TIPS
2016hepatologistrefractorySIRtipsultrasound
Refractory Ascites | TIPS
Refractory Ascites | TIPS
2016hepatologistrefractorySIRtipsultrasound
Transcript

The second case, quick case. It's a old man, 80 years old. virus C, he had a TIPS two years ago

and now he starts developing a small ascites for three months. And he had a new episode of bleeding, endoscopy showed that it was a hypertensive gastrophaty. All the ultrasound that he performed showed patent tips, that this tip was patent.

So we decided to evaluate the stent, through the angio suite. Through the jugular approach we could categorize the hepatic vein here, we inject. But it was really impossible to get into the stent. The angle here is not

good, so we inject here. We can see it on stasis of the contrast. We cannot see the outflow of the hepatic veins and we try to introduce stent without success. We try to frame our approach and again we cannot enter the stent. We can't put through femoral or jugular approach, it was really impossible

to get into the stent. To check if the stent was really open we did an injection, there's a leak/g trunk. Here's the spleen vein, here's the portal, and here's the TIPS.

Again we see the images of the hepatic veins here, the same image but we cannot see very well the outflow from those veins. So here we could not understand what's going on, and we decided to measure the gradient and see that it was working like a Budd-Chiari

syndrome. The stent is against the wall, against the top of the wall of the vein, and it's blocking the outflow of the hepatic veins. So what to do?

We cannot enter the stent as I told you, cannot enter through jugular or femoral approach. So we think about to put a stent here, just a stent through the right vein to the cava, or we decided to make a transhepatic puncture of the

right branch of the portal vein, and put a wire here to the right hepatic vein, and is [UNKNOWN] to the jugular and we withdraw everything and make a through-and-through technique. So now we have the guidewire going through the jugular and the transhepatic approach.

Now we can put a balloon here. We put a 10 millimeters balloon, this image is after the angioplasty but we see that stenosis/g are very important [UNKNOWN] so we decide to put a stent. We used an express 10 millimeter stent, a balloon expandable stent, and here is the final image. We have no more hepatic veins and the shunt is working properly.

So the patient had a good recovery. I also stopped bleeding, it was a successful case. Thank you very much. Unfortunately the system does not work. I'm sorry. Thank you. >> [APPLAUSE]

So the first case is a female patient, 38 years old with known schistosomiasis for three years. It's the third episode of gastrointestinal bleeding, upper gastrointestinal bleeding. They tried management endoscopically and clinical without success.

She also has small ascites and low platelets, and she has a history of biliary bypass 15 years ago. After the failure of the endoscopic management they sent the patient to the CT. And here we can see an axial image with huge varices in the gastro-oesophageal junction. Very huge spleen.

A big splenic vein and we cannot see the main portal branch, it's thrombosed with some recanalization, a cavernomatous transformation. We decided to put the patient in the angio suite to confirm the images. And here is the [UNKNOWN] injection, we can see his molar sides. We can see some signs of chronic liver disease, the huge spleen and

again the venous phase, the thrombosis of the portal, portal thrombosis. And a cavernomatous transformation here showing just the left portal branch here patent. So we are faced with a young lady with portal thrombosis,

cavernomatous transformation. She's bleeding, she's in acute bleeding and we need to do something. What should be your first approach here? Standard TIPS, BRTO, splenic embolization or try to

recanalize the portal transhepatic puncture. So let's see here. Let's see if it's gonna work. As we thought. [LAUGH] I think it's not working.

Well, we decided to try to perform a standard TIPS. So we took the jugular vein. We put the needle in the right hepatic vein, we did a biopsy of the liver and then we tried to puncture the right portal branch but it was really impossible.

The portal branch was thrombosed. We tried to puncture the left branch of the portal. And again, we could puncture but it was really impossible to advance the wire through the thrombosed portal. So we gave up to perform a standard TIPS and we think about another approach. What to do

now. Again, BRTO, splenic embolization, try to recanalize the portal through the splenic axis or transhepatic axis. Well, I think it's not working. You are voting but

[BLANK_AUDIO] Let's try again. >> [INAUDIBLE] >> Yes it is. I checked everything with the guy downstairs. [LAUGH]

Well, let's go. So here we decided to make a trans-splenic approach, splenic embolization. Well, you can have some results but it's not warranted. So in case of splenic vein thrombosis,

I think it's a good approach, but not here. Here if we do a trans-splenic approach we can easily embolize the varice and try to recanalize the portal vein. So we did it with NPAS from Cook, the axis/g set. And then we put a Raabe sheath, 7 French

Raabe sheath, and we could advance it until the splenic mesenteric junction. And with our Roadrunner guidewire we could advance not, it was not difficult to go into the right portal branch, put a balloon, and dilate the main in the right portal branch. So with the Raabe sheath in the right portal branch working as a landmark, we make a puncture to the

right portal branch. We could just narrow/g it here if necessary but it wasn't. We could put a wire here like here. I do not need to use there, it was easy to advance the wire and now I dilate the parenchyma in the portal vein. Put a Wallstent, it's a public insurance patient.

We cannot use [UNKNOWN] here, so we put on Wallstent, and embolize the varices with some fiber/g coils. And here's the final aspect, the embolized varices, the TIPS is working. The patient stopped bleeding,

we withdraw the sheath through the spleen. Through the spleen, put in some Gelfoam plugs/s and make an angio in the end to confirm that there is no bleeding, no active bleeding, nothing is going wrong. So everything was fine, the patient stops bleeding and had hepatic

transplantation after 18 months. The biopsy showed severe fibrosis with unknown etiology.

78 year old male patient with [UNKNOWN] liver disease, portal hypertension,

known large gallbladder mass. Came to the emergency room pouring out blood. Did not go to the endoscopy suite, after talking to the endoscopy folks and ER doctor. We decided that he will come directly to the IR.

Now, here you can see that patient also has biliary ductile system dilation. Here is your masked, kind of stressed out portal vein. So having this, my biggest concern here was to get into the portal. but my concern was that I might end up going into the mass first.

And it probably will be a futile exercise, and considering that he was pouring out blood I wanted to get into the portal vein as quickly and as soon as possible. So how do I go back? How do I go back sorry?

>> Just click on this. >> Okay we got it. So [BLANK AUDIO]. again using the software we kind of outlined the mass here got the outline of the hepatic vein. Outline of the right portal vein and again it's one of those cases

where it's better to be lucky than good. Luckily it was all there and once it's lined, I again gave it a shot because patient was bleeding. I had no other choice but to go in. And here is the wire. You can see and we were able to create a successful tips without

actually going into this. Had this technology not been there I would have still attempted it, but I felt a little more comfortable, a little more guided mentally prepared to go in, because I really was avoiding going

through this mass and [INAUDIBLE] you can see the masses here and here, it takes us here, and I take some cases from my colleagues. >> Thanks [INAUDIBLE] just a quick comment Doctor Kapoor/g those I/g guide lines are self drawn in cuz- >> Yeah they are drawn in.

>> You don't segment the bloodvessels so they rotate with you when you rotate the arm. >> Exactly we are somewhat lucky in a way that one of the Siemens engineer is at the clinic seven days a week [INAUDIBLE] so he might be here. Randy are you here?

He wanted to come but maybe not. >> We've used a similar vein soft way for placement of a TIPS in particularly difficult access. We've also tried for opacification of occluded HJ loop by sticking the loop percutanously just injecting, not even necessarily putting

anything large [INAUDIBLE] very skinny needle, and at least showing you both sides of obstruction. > That's a great approach thank you. >> Thanks very much. >> [APPLAUSE]

advances a snare and I'll show you in a second and then sort of get your system all the way down but here's the thrombus main portal vein, and then we would dilate this and there're a few principles that you wanna think about when you are doing a PVR TIPS. One of them is that you wanna put a short TIPS in and by short I don't mean on this end,

I mean on here, cause you wanna leave a sufficient portal venous area here for the surgeon to do an end-to-end anastomosis. But notice here that the vein looks okay, was thrombosed before, there's still some clot in there, but if you just reestablish flow this is what it looks like a month later,

it looks like this after a second TIPS check, no anticoagulation, no further follow up. So the flow was very high here and this will lice and it will open. The other principle here is we have not taken the approach of embolizing

all of the varices in the first setting and that's because years ago we weren't sure these veins would stay open. Turns out they do stay open, but we didn't wanna embolize all the other outflow, then the portal vein thrombosis then you have zero outflow.

So we've now done this on a stage procedure, you do this part first and then you embolize the varices a little bit later on and the person went on to have a transplant end-to-end anastomosis and this is the same patient preimposed with an end-to-end anastomosis.

Another patient here, ascites, cavernomas transformation, no portal vein etc. So how do you TIPS this patient? So the first thing we do again is a wedge venogram, and interestingly the wedge venogram generates a lot of controversy in TIPS sessions, I tend to do mine with a 60 cc syringe,

I use the sheath so I can wedge a lot of liver and I use 20 cc of contrast and 40 cc of saline nice, thin concentration and then you can do a nice wedge venogram like you do here but notice the cavernoma, there is no main portal vein,

so now the issue is you have the TIPS this patient, so we started about 20 somewhat cases ago doing a transplenic approach, and you place a 5F sheath and you puncture the splenic parenchyma or the vein in the parenchyma that leads directly out the splenic

vein and that's what we have here,

need to focus on when you need to do the next step is this is not where the portal vein is, everybody would wanna sort of recanalize starting from here, that's not where the thrombus portal vein is,

it actually migrates cranially, it's here, this is the thrombus portal vein and we know this is small cardiac veins so we pull the catheter back and this is where we advance our catheter, our wire and now we're through.

So notice now that we've gotten through we have our sheath, went through the thrombus portal vein and here's the cavernoma and the cavernoma almost always maintains profusion of the peripheral portal vein, that's a nice feature of this whole thing and then we pull back, we advance into the right portal vein,

we advance a snare and just like Mark was describing we then puncture into the snare and then we pull, we puncture through, and then we pull our system, and now we have through and through access, jugular access out the

splenic vein. Notice the short TIPS that we place, we did not dilate it yet, we dilate the thrombus portal vein, it's completely thrombosed but we just dilated it and we dilate the TIPS and the vein,

it looks like this immediately after. No anticoagulation, no urokinase, streptokinase, TPA etc. it looks like this immediately after and the pressure is so high that this will remain patent

and this person was transplanted. Another case here, complete cavernomas transformation, wedge venogram as I describe, trans splenic access, huge varices, very easy to do this maneuver, it's actually so much easier to go this way than our first 40 cases or so where we were going through the liver and drilling

back. So it's much easier to go this way and here we are into the peripheral portal vein that again is perfused by the cavernoma. It maintains peripheral perfusion of the portal vein and we puncture the same thing through and through, we have large varices,

we dilate the same thing as I mentioned before. This is at the end of the TIPS procedure, this is a completely thrombosed portal vein. It looks like this at the end of the procedure, we leave the varices

alone for the first time. We bring them back a month or so later, that's how we have one month venography and we've learnt about what happens to that and after we embolize the varices, this is

the portal vein. So this vein did not exist a couple of months ago but this person underwent a liver transplantation. This is pre, no portal vein and this is post, native portal vein anastomosis.

I'm sorry. No, this is pre and post 18 months because the TIPS are still there, and this person was transplanted eventually. So here are the results

it with my campy/g it just sort of drills down,

and you can be pretty aggressive with that because you know it's gonna stay in the lumen. But we just could not make this last a little bit. So this is where we use the snare in the back and the wire, similar to what Mark was talking about in the cava with something like

this and then we get through and through access. So this is what this person looks like, she's noncirrhotic, she has no main portal vein, she has huge varices, and so we got through and through access, did the usual trick.

Pull through and through and then we stented all the way. Now she had obstruction down here so it's not like we're jailing or anything. There's nothing. We are jailing things but it's not like there was inline flow. So usually what I do with these cases is I wanna recreate a low

pressure system here so that anything that drains can go here and then drain back up. So this is what we didn't in this case. And plus we had extra [INAUDIBLE] here I don't know if you notice this but I'm sure many people notice that

this is a little something that's not anatomic. So we put a stent graft there and extend to that all the way and that's what she looks like at completion and this is what she looks like at follow up CTV we have two year follow up on her. The alternative here is that the GI and hepatology team would say endoscopy over three months observation etc. etc.

But I don't know that you can undergo life long endoscopy and observation like that when you can do this. And now just do imaging once a year now and maybe extend down to once every three years, so a different way to do this and we'll be recommending this for our future guidelines.

So outside a report of 5 patients, I do think there's a patient population with noncirrhotic complete obliterative PVT that needs to be considered. She's done well and again if you look at the AASLD guidelines they don't mention this. They say, anticoagulation observation endoscopy etc.

But I do think it's something to be considered in a 33 year old, you can't think about endoscopy lifelong. So to conclude in terms of the problem to solve here is the

complete obliterative PVT, this is not partial portal vein thrombosis where you can just do a TIPS and just get through the clotted etc, this is complete chronic obliterative PVT. You wanna re-establish flow but you can leave the clot intact, you

don't have to chase that at the end of the procedure. We don't anticoagulate people, place a short TIPS because it leaves a lot of room for the surgeons but that's something I suggest you do and discuss with your surgeons cause some guys say well I need just a couple of centimeters I don't need four or five centimeters.

We transplanted 23 people already,

be able to hear it. So this first case is a young woman who had undergone what is quickly becoming a very popular bariatric procedure in the United States, a sleeve gastrectomy. This was done recently, three weeks earlier.

And she has been unwell for the last 48 hours with sort of a gastroenteritis type of symptoms and presents to the ER with diffused abdominal pain, vomiting, and diarrhea. I won't show you her detailed labs, suffice to say lactate was normal, white blood count was normal,

as was amylase. So being a good ER they did what all ERs do. They immediately put her into the scanners and did a contrast-enhanced CT. I think they did that before they examined her. So she has a completely impacted Mesenteric Venous System with fresh

clot that is distending the veins and it's extending up to and including all of her portal system. So these are the salient causes of the Mesenteric Venous Thrombosis and let's say parenthetically she was subsequently found to have a hypercoagulable state, and she was dehydrated by virtue of her recovery from her recent surgery.

So historically the treatment is systemic anticoagulation, and then if peritoneal signs develop, this mandates typically an exploratory laparotomy. These are very, very challenging cases to do surgically.

All of our GI surgeons involved in this case were not at all really wanting to go in and do a thrombectomy. So a newer approach is to create a TIPS. This is a TIPS in a person with a normal liver, non-cirrhotic liver and then using that TIPS as a conduit to create outflow cuz you

need outflow, you need inflow [COUGH] To do catheter directed therapy. So this was our initial portal venous access as you can imagine it was very difficult to know when we were in because if you inject too much contrast you'll kind of obscure things, and if you don't inject enough contrast,

you can't really be sure. It's not like you're doing a DVT case where you've got the beautiful venogram with the contrast perfectly opacified and a long sausage of clot. This is always [INAUDIBLE] Sort of this snagle-tooth appearance of contrast.

So that was signs that we were in and then it was simply a matter of getting down and again with a looped wire confirming that we were coursing down through the main portal vein and into the SMV. From that point, we did a venogram again to confirm that we were in the Mesenteric Venous System. We then went ahead and did a conventional TIPS with a stent graft.

And then at this point, and this is something that other members of the audience here might have a different approach. We tend to use the androgen in this setting. There is a black box warning for use in the pulmonary arteries and certainly if you're doing anything that is going to be close to the SA node, you need to be very,

very careful for [UNKNOWN] Arrhythmias. So our approach is to activate the device for no more than 20 seconds at a time, monitor the heart rate, make sure the heart rate returns to baseline and of course have atropine standing by.

And that's actually been a very successful approach not just in TIPS, but in the pulmonary arteries. I know that's not the experience that some others have had. This was a very hard to manage clot, so we had to supplement that with balloon meseration, and then even the over-the-wire percutaneous

thrombectomy device which is, for those of you who aren't familiar with that, it's sort of a rotating basket that spins at about 3,000 RPMs, and it's inserted and delivered over an 025 wire. This is a Nitrex wire that the device is being used in. You can see we're making some progress

here but it's by no means a great looking appearance. We've got a little bit of flow now trickling through the splenic vein but even our TIPS, our fresh TIPS created within this normal liver is accumulating some clot within it and you do have to be careful with these kind of devices and the chain link fence,

they can become entrapped. So you have to be very careful as you're monitoring your delivery. So once we'd established some slow flow through from the SMV through the portal vein, we then did again something that would be considered controversial.

As we said this woman had a sleeve gastorectomy three weeks earlier. She has morbid obesity. It's going to be very difficult to determine if she is having oozing from her surgical bed. So this obviously involved big conversation with intensive care, with GI surgery, hepatobiliary surgery,

us and so forth. So the consensus of that was we were going to be monitoring her very, very closely but [INAUDIBLE] Overnight. And this is what came out of that. This was the next day. We did do some touch up angioplasty with these images and we did

have this area where we had some refractory thrombus just at the root of the main portal vein and as we worked on that some more again with a variety of thrombectomy devices, this was the best we could get. But the flow through here on a DSA venogram was so robust as you'll

see some examples that Riyadh will show where if you're having good flow, just the patient's own intrinsic lytic system, their own intrinsic plasma can take care of this. So we decided at this point to stop and she did well.

The rest of her recovery was uneventful. She was eating by the next day. She was discharged the following day. This is six months later. Everything is wide open and a year out she had symptom-free. She had been worked up and was found to have a hypercoagulable syndrome,

so she's gonna be on lifelong anticoagulation. She's also on Lactulose, just sort of prophylactically. She doesn't have any discernible systemic encephalopathy issues, but she was to be coming back for occlusion of her TIPS. She's so happy with the outcome she's kinda worried if we occlute

her TIPS something bad will happen. So she's subsequently moved to Texas. So if any of you are from Texas, there's a patient from Philadelphia who needs to TIPS embolization.

She's not coming back to Philly for that. She's said that. So that was just an example of using the TIPS as a conduit both to approach clot and to get outflow and because the clot volume is so massive, a combination of mechanical and pharmacological techniques is typically required.

Any questions before Scott shows the case? >> [INAUDIBLE] Exactly. >> [INAUDIBLE] >> Yes, you could have just gotten trans-hepatic access into the portal vein percutaneously, you could have gone transjugularly and gone in temporarily but,

I think the conventional wisdom of folks who have done this for acute Mesenteric Venous Thrombosis, is that you need to have that outflow of the TIPS. You're trying to create continuity of a vascular system and having that outflow through the TIPS enables the clot to be bathed with your

lytic, and endogenous plasma and so on. That's the rationale. >> [INAUDIBLE] And I agree with Tim, I'd put the TIPS in, and the idea is you wanna raise the flow. [INAUDIBLE]

How long do you [INAUDIBLE] >> Well that's a very good question. The largest series in the literature is from Asia, I think there's six or eight cases. It's really limited to case reports so we don't have a lot of data.

But empirically you kinda wait for that early thrombogenic period to subside, and you wait until the patients is successfully anticoagulated and has gone a period of weeks symptom free. So we were prepared to embolize her when we saw her back at six months. She was so happy and she was very, very ill at the time and she

sort of felt like she dodged a bullet as it were and so we started those discussions at six months and then a year later, we resumed those discussions and she subsequently left the area. But I think within the first few weeks you wanna make sure the patient's

anticoagulated that residual clot. There had been interval improvement in her TIPS ultrasound as well. So that segment of the main portal vein was completely open and free of clot. Yes. >> [INAUDIBLE] In this scenarios you hear a lot [INAUDIBLE] Make these

decisions and not really [UNKNOWN] >> Yes definitely. The thing about TPA, circulating TPA is half life of four to six minutes. But the problem in venous lyces/g is that the clot volume is so high

you get absorption of TPA to the surface of the clot. So you accumulate a systemic lytic state by having still active TPA that's not necessarily circulating but it's bound to clot. And that's why you'll see a big steep rise in bleeding complications with venous thrombolysis in days two three and so on. So we were prepared to do an overnight thrombolysis in her accepting

that there was gonna be potential for a systemic bleeding state and therefore bleeding from the sleeve gastrectomy. We were following her [UNKNOWN] Not that they would have been expected to do anything which they didn't overnight. But we did it more as kind of a medical legal thing so that we could never something did happen,

well the Fibrinogen must have dropped and you never followed it. So we were following those at four hour intervals. Yes, one last question and then we do wanna get on, got some amazing cases for you to see so.

>> So we have something similar to this where we have [INAUDIBLE] I'm not sure cuz [INAUDIBLE] In this scenario you have [UNKNOWN] >> We do now. We didn't at the time we did this case. I think that would be another very interesting approach.

There's more than one way to get to the finish line. You do have to give up wire access for that device, and we like knowing that we were over the wire the whole time. We knew exactly where we were but definitely that's another great option.

All right so, do you wanna share your, one more.

with that, let's go to case one. This is a 35 year old, cirrhotic woman with a MELD

of 11. She has hematemesis related to acute esophageal variceal haemorrhage, you can see the red wale sign, and the endoscopy indicating recent haemorrhage. She has no other major medical comorbidity,

namely no history of encephalopathy, no congestive heart failure, no pulmonary hypertension, and her bleeding is refractory to medical/endoscopic therapy. I think we would all agree that this falls right into the

wheelhouse of TIPS, and so at our institution we would absolutely see a patient like this for that procedure. TIPS and variceal embolization was prescribed, and performed. This is an angiographic image from the TIPS procedure, you can see a right hepatic vein to right portal trunk access, for this portogram with a portal systemic gradient, measured at 21 millimeters mercury elevated, and then you can see the left gastric vein supplying esophageal varices. We

put in a 10 millimeter shunt, with reduction of the portal systemic gradient to 4 millimeters mercury, under the 12 threshold that we typically aim for. And you can see that the left gastric vein flow has reversed, no longer filling the varices. Nonetheless, we catheterized the left gastric vein, showed venographically that the esophageal varices were fed by this vessel, and then close it off with metallic coils.

The outcome of this case was bleeding cessation, an uneventful hospital discharge, and to the best of my knowledge no rebleeding to date. So this is a case of TIPS for acute esophageal variceal bleeding. What do we know about this condition? TIPS is indicated in two circumstances at present according to clinical guidelines. One is this rescue therapy for acute variceal bleeding that's

refractory to medical/endoscopic therapy, and also for esophageal variceal re-bleeding. Using the technique described with a covered stent graft, and a portal systemic gradient reduction to less than 12 millimeters

mercury, you can expect a high immediate clinical success with bleeding cessation, and low rebleeding incidents in general. In addition to the indications that I mentioned, is there a role for earlier TIPS in the process? The data would suggest that the answer is yes. These are two studies published by Garcia-Pagan, multi-center studies, one was an RCT from 2010. Both compared TIPS plus pharmacologic

therapy, to pharmacologic therapy alone, when TIPS was performed within 72 hours of presentation. And both studies showed that the one year bleeding control rate, and the one year survival rate, was improved when TIPS was added to pharmacologic and endoscopic therapy. What about variceal embolization? In the case that I showed, the variceal flow was reversed after we replaced the TIPS. Should

we embolize a varix? I think the data suggests that the answer is yes, although this is debatable. This is a meta-analysis from 2014, spanning six studies, looking at the role of variceal embolization, compared to TIPS alone for variceal hemorrhage. What the authors found was that, the odds of rebleeding

was reduced when the varices were embolized, as compared to not embolized when a TIPS was placed. So in our institution we embolize varices at the time of TIPS placement. Okay, moving on to what's new from 2015/2016. This past year saw publication, actually relatively recently in 2016, of another RCT looking at early TIPS, versus endoscopic therapy, plus pharmacologic therapy for acute

variceal hemorrhage. This study confirmed the findings of the first study I previously showed, which is that variceal rebleeding incidents was much lower when TIPS was performed, in addition to pharmacologic and medical therapy in the early time frame, compared to medical therapy alone. I apologize for the busyness of this slide, but these are two meta-analyses from this

last year as well. Again looking at early TIPS versus plus pharmacologic therapy and medical therapy versus medical therapy alone, and what I'd like to highlight is that both, show that there is benefit to the addition of early TIPS in terms of survival and rebleeding incidents. So to summarise case one, TIPS plus variceal embolization is an accepted management strategy for bleeding or rebleeding

esophageal varices. I believe that the data supports earlier TIPS within the management algorithm for variceal hemorrhage, but its been my experience that wide spread clinical practice adoption is kind of wagged and maybe that's in part to non inclusion, and guidelines at present. And the need for adjunctive

embolization, at the time of TIPS is debatable, but I think it's generally supported in literature. So with that we are going to move on to case

two, this is a 44 year old cirrhotic woman, her MELD is 19, she has an acute gastric variceal hemorrhage, And a history of clinically significant hepatic encephalopathy. You can see the CT scan showing the

submucosal gastric variceal complex, also seen on endoscopy, in this case the patient has a high MELD, which is a potential contraindication to TIPS, she has a history of encephalopathy, a TIPS would potentially worsen that. So this is a perfect case for balloon transvenous obliteration. We prescribed

variceal obliteration, and actually in this case we performed it combined, antegrade and retrograde transvenous obliteration. In my practice I appreciate this approach because, the antegrade access to varices, I think allows for best anatomic delineation, and I think the antegrade

control that you get, really ensures that you embolize or close off all of the antegrade feeders into a gastric variceal complex. So this is a percutaneous transhepatic access for splenic venogram, you can see a large left gastric vein, but more importantly, a posterior gastric vein which supplies the gastric variceal complex, which is drained by

a gastrorenal shunt. What we do is, we get both antegrade and retro-grade access into the complex, we trap it on both sides with balloons, so you can see a posterior gastric vein occlusion balloon with a microcatheter, a gastrorenal shunt occlusion balloon, from an IJ approach with a microcatheter, and then we use sodium tetradecyl sulfate, lipiodol mixture, as it's been described in the literature,

injected from the antegrade approach. You can see clot formation within the gastric variceal complex, and then under balloon occlusion, I trapped the varix on either side with a coil pack, in the antegrade side, a coil pack in the retrograde side, the systemic side, closed off the left gastric vein, and one can perform CRM CT if you have it available, this shows sclerosis in the gastric variceal

complex. And then finally, what you can see on the final splenoportogram is, there's no further gastric variceal filling, we have nice inline flow into the liver through the splenoportal venous system. The portal pressure has slightly increased from 9 to 14, although because we've closed off the patient's physiologic portosystemic shunt. The outcome in this

case was bleeding cessation, an uneventful hospital discharge, and because this patient was illegal to this country, she was actually lost to follow-up unfortunately. So this is balloon transvenous obliteration, for acute gastric variceal bleeding, in a patient with contraindication to TIPS. So what do we know? BTO has an accepted role here for patients

with actively, previously, or high risk gastric varices, it's particularly useful in patients with poor hepatic reserve. I'm highlighting a few clinical scenarios as they've been described in literature where BTO might be useful. Gastric varices alone, or gastric varices in the setting of encephalopathy, as was the case I presented. If complications of portal hypertension are present,

such as ascites, or uncontrolled oesophageal varices, one might consider adding TIPS to the obliteration in order to reduce those portal hypertensive complications. And then in more complicated scenarios, if splenic vein thrombosis, or portal vein thrombosis is present, one might consider adding splenic artery embolization,

or portal vein reconstruction with TIPS, in order to ensure portal venous outflow, and splenic venous outflow. What do we know about the outcomes for these procedures? Well, using techniques including balloon retrograde transvenous obliteration, antegrade transvenous obliteration, like I described, or the modified versions using coil-assisted obliteration, or plug-assisted obliteration, with agents

such as STS foam or gelfoam slurry, have really shown excellent outcomes. The technical success rates are high across different clinical studies, above 90%, and the rebleeding incidence is actually quite low, less than 10%, you see 0% across four of these recently published clinical studies. What's new in this space? The last year saw again, publication of a nice meta-analysis, spanning

a thousand patients, looking at BRTO for gastric varices, over 24 studies. What I'm going to highlight here is that the study showed high technical success rate for BRTO, for treating gastric varices, high clinical success rates and very low complication rates. What you'll notice though is that there is non-trivial incidence of esophageal variceal aggravation, and ascites formation again because

we have eliminated the portosystemic shunt. There was a meta-analysis last year also, they compared TIPS to BRTO. This was looking at 350 patients across, I believe five studies, that compared BRTO to TIPS, and looking at BRTO compared TIPS, the rebleeding incidence was actually lower in the obliteration group compared to TIPS, and obviously the hepatic encephalopathy frequency was higher

in the TIPS group. So to summarize this case I think we can say that, BTO, balloon transvenous obliteration is effective and safe for managing bleeding gastric varices, possibly better than TIPS, based on some of these meta-analysis. The obliterative approach is particularly useful when TIPS is contraindicated, as in the setting of hepatic encephalopathy, or poor liver reserve, and obliteration

alone may be associated with non-trivial rates of oesophageal variceal aggravation, and, or ascites development. So obviously, endoscopy in surveillance is important, and clinical management of ascites is important going forward for these particular

vein thrombus, decompensated cirrhosis with ascites, and had variceal bleeding. There was a discussion, Hepatobiliary Conference, about she can't be placed on anticoagulation, she can't be transplanted

and we offered a TIPS with a transplenic approach and had complete resolution of her portal vein thrombus. And instead of having banding or some other GI intervention, she was able to undergo this procedure and did well. Another thing that's very simple but participating

year old cirrhotic woman, with a low MELD score of 11, she has an

acute gastric variceal hemorrhage, and she has no TIPS contraindications. No hepatic encephalopathy, normal right heart function, no pulmonary hypertension, no other anatomic contraindications. You can see here on the CT scan, a large, submucosal gastric variceal complex, and it has a systemic outflow via

gastrorenal shunt, to the left renal vein. And for somebody like this who's a TIPS candidate, with a gastric varix, our current clinical practice at University of Illinois, is to do combined TIPS plus variceal embolization. That's what we pursued in this case, we put a 10 millimeter shunt in this patient, her PSG was 11 millimeters mercury, and actually

I'm going to highlight the fact that it's under 12, as was the last case. So that suggested this gastric varices obviously can bleed at lower thresholds, which is something that's well accepted at this point I think. Her PSG reduced to 4 millimeters mercury, you can see that there's a complex supply to the gastric varices, by a short posterior, and left gastric veins and we pursued obliteration.

In preparation we skeletonize the gastric varix, we closed off the left gastric vein, posterior gastric vein. And we isolated a single feeder into the varix, and out of the varix. And similar to the case I just showed you, we got antegrade access, and retrograde access from the systemic side, closed off the systemic side with a large plug, and then under balloon occlusion, injected sclerosing

material from the antegrade side into the varix, and then under balloon occlusion closed off the antegrade side with coils to trap the lesion, on either side with metallic, embolic materials. You can see the stagnant STS mixture in the gastric variceal complex at the end of the procedure, and then post obliteration, here is our final

splenoportogram showing nice inline flow, through the splenic system, out through the TIPS. No further gastric variceal

filling, and a final PSG under 12 millimetres mercury measuring 7. On three month follow up scan, you can see an eradicated gastric variceal complex, and this patient had no rebleeding. So this is a case of TIPS plus balloon transvenous obliteration, for gastric varices. I've been impressed, there's actually very little literature on

this I believe, but I've been impressed with the kind of strikingly low, rebleeding rates, when these two procedures are combined. This was an abstract that was presented here at SIR in 2013, looking at TIPS, BRTO versus BRTO alone. It was a multicenter retrospective study. The sample size was somewhat discrepant the between the two groups

however, what I'm going to highlight here is the rebleeding rate between BRTO and TIPS, was 0% at 24 months. Although not statistically significant compared to BRTO only. This is UVA data, 27 BRTO only patients versus 9 BRTO, TIPS patients, and again this is data from 2013. I'm going to highlight these 0% rebleeding rate for TIPS BRTO at 24 months, compared to 21% at BRTO only. This was statistically

significant. There's really hardly any other data on this. So what's new? Unfortunately, not much, although authors have suggested that this might be a nice middle ground between TIPS and BRTO, for gastric varices. It hasn't really translated into much literature. I think that this approach is somewhat appealing, because you get definitive gastric variceal eradication, and then you get the controlled synthetic

portal venous outflow conduit to kind of control other portal hypertension complications, like esophageal varices and ascites. So to summarise this case, I think combined TIPS and obliteration is an appealing management approach to gastric varices, current studies are somewhat small with

discrepant sample sizes, and this highlights that there may be a need for further, large scale, comparative studies. So I'm going to conclude with that,

so we're now trans splenic, is what we do on everybody and the thing that we learnt is that it turns out that there is almost,

always some thrombus at the end of the procedure and it's our tendency as interventional radiologists to try to chase that clot to thrombectomize it, to remove it, to do something but I will tell you in these cases you leave it alone because the flow will permit it to resolve because at our follow up venography 72% of the time the thrombus is completely

resolved with no intervention, so this is something you wanna think about cause you could get stuck there for hours doing these sorts of things, we have very high KM patency and we have 23 patients that have been transplanted, there is a slight increase in the

bilirubin at 1 month but it did maintain at about 2.4 and it sustained at month 6, and this here. So it goes up a little bit as a result of the TIPS but it is sort of maintained. KM patency, very high so this works,

the vein is maintained you can transplant the patient or you cannot but the KM patency is extremely high in patients after this technique. So we've done 61 cases, we had 1 failure, we have 23 that we transplanted, 22 had an end-to-end anastomosis and 1 had an interposition graft,

37 have not been transplanted but of the 3 transplanted ones all the follow up imaging is clean and there's still excellent

in ultrasound guided procedures, so we've taken these over on two days a week, and so we see these patients with refractory ascites,

and sometimes are sent from a hepatologist in the community who hasn't recognized that possibly a TIPS may be beneficial to them, so this patient, a TIPS was discussed with them and underwent.

in ultrasound guided procedures, so we've taken these over on two days a week, and so we see these patients with refractory ascites,

and sometimes are sent from a hepatologist in the community who hasn't recognized that possibly a TIPS may be beneficial to them, so this patient, a TIPS was discussed with them and underwent.

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