North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension.

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.

Transjugular intrahepatic portosystemic shunt creation using a three-dimensional fluoroscopy guidance system in patients with the Budd-Chiari syndrome.

When performed for Budd-Chiari syndrome (BCS), transjugular intrahepatic portosystemic shunt (TIPS) creation can be technically difficult due to hepatic congestion and asymmetric hypertrophy. We present three female patients with decompensated BCS in whom TIPS were created using a three-dimensional fluoroscopy guidance system. On a dedicated workstation using three-dimensional volumes of computed tomography imaging, a virtual needle path was created by the operator extending from the needle entry point (hepatic vein stump or inferior vena cava) to the target portal vein. Subsequently, the virtual needle path was overlaid on the fluoroscopy image for guidance of portal venous cannulation. This technology can be used for TIPS procedures in patients with BCS and other complex TIPS cases, as it may help delimit the trajectory of the needle pass and optimally result in more efficient procedures with decreased radiation dose.

Emergent surgical and endovascular repair of a level III carotid arterial gunshot injury.

Traumatic injury to the level III internal carotid artery (ICA) is infrequently encountered; however, rapid and effective treatment is mandatory for the prevention of a neurological catastrophe. Many case reports have demonstrated decreased morbidity and mortality of endovascular repair of traumatic injury to large vessels using covered stents or endovascular coiling of posttraumatic pseudoaneurysms. We present the case of a transected level III ICA requiring emergent, complex sacrifice.