Portal Hypertension: Imaging, Diagnosis, and Endovascular Management

338 Pages·2017·19.734 MB·English

by  Wael E.A. Saad

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Portal Hypertension
Imaging, Diagnosis, and Endovascular Management
Third Edition
Wael E.A. Saad, MBBCh, FSIR
Professor of Radiology
Director, Vascular & Interventional Radiology and
Neuro-Interventional Radiology
Department of Radiology
University of Michigan Health System
Ann Arbor, Michigan
Thieme
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tioned therein or the contraindications stated by the manufacturers
Names: Saad, Wael E. A., editor.
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Title: Portal hypertension : imaging, diagnosis, and endovascular
tion is particularly important with drugs that are either rarely used
management / [edited by] Wael E.A. Saad.
or have been newly released on the market. Every dosage schedule
Other titles: Portal hypertension (Saad)
or every form of application used is entirely at the user’s own risk
Description: Third edition. | New York : Thieme, [2018] | Includes
and responsibility. The authors and publishers request ev ery user to
bibliographical references and index.
report to the publishers any discrepancies or inaccuracies noticed. If
Identifiers: LCCN 2016043179 (print) | LCCN 2016044313 (ebook) |
errors in this work are found after publication, errata will be posted at
ISBN 978-1-62623-326-3 (eBook) | ISBN 978-1-62623-327-0
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(hardcover : alk. paper) | ISBN 978-1-62623-326-3 (e-book)
Some of the product names, patents, and registered designs referred
Subjects: | MESH: Hypertension, Portal–diagnosis | Diagnostic
to in this book are in fact registered trademarks or proprietary names
Imaging | Hypertension, Portal–surgery | Endovascular Procedures
even though specific reference to this fact is not always made in the
Classification: LCC RC685.H8 (ebook) | LCC RC685.H8 (print) | NLM
text. Therefore, the appear ance of a name without designation as pro-
WI 720 | DDC 616.1/32075–dc23
prietary is not to be construed as a representation by the publisher
LC record available at https://lccn.loc.gov/2016043179
that it is in the public domain.
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Josef Rösch
1925–2016
It is only fitting that this book on the transjugular intrahepatic portosystemic shunt (TIPS) be dedicated to the noted Josef Rösch. Josef
died in January 2016 following an extraordinary clinical, academic, and research career in interventional radiology. His most significant
interventional discovery, TIPS, was serendipitous. Having already spent a year with Charles Dotter, Josef was primed to constantly be
considering new interventional possibilities. Thus, in 1969, his occasional inadvertent portal vein entry during clinical transjugular
cholangiography aroused his research curiosity. This led to the logical next step: a transjugular intrahepatic portosystemic shunt. It
took until the mid-1990s, however, with the development of metallic stents, to make TIPS a viable clinical procedure. Today, three
decades after its clinical introduction, TIPS has become widely accepted as a minimally invasive treatment for portal hypertension,
benefiting millions of patients and essentially replacing surgical portosystemic shunting.
In addition to TIPS, Josef Rösch was the first person to use embolotherapy to control acute gastrointestinal hemorrhage. He pioneered
both the use of self-expandable metallic stents to treat stenoses and occlusions of the major veins, trachea, and esophagus, and the
technique of fallopian tube recanalization. Josef was the driving force in establishing the Dotter Interventional Institute. It is the first
free-standing interventional radiology department in an academic medical center. During his career, Josef received the gold medal
from five prestigious interventional radiology societies, in addition to lifetime achievement awards from the Cardiovascular and Inter-
ventional Society of Europe (CIRSE) and the American Heart Association. The “Josef Rösch Endowed Chair of Interventional Radiology
Research” was established at Oregon Health & Science University in his honor.
Josef was a pioneer and distinguished leader in the development of interventional radiology. He was a great friend and colleague to
interventional radiologists around the world and an inspirational mentor to scores of young trainees. Those who had the opportunity
to work with him or know him were truly fortunate.
Frederick S. Keller, MD
v
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In addition to the late Josef Rösch (who co-wrote Chapter 13 before his death),
this book is dedicated to my mother and father, who taught me beyond med-
icine; to my wife Aya; to my daughters Luna and Solara; and to my brother
Nael (who has co-written Chapter 12), a talented interventional radiologist
dedicated to his patients.
Wael E.A. Saad, MBBCh, FSIR
vi
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Contents
Foreword by Jeanne M. LaBerge .....................................................................xi
Preface .................................................................................................xiii
Acknowledgments ....................................................................................xv
Contributors .........................................................................................xvii
Section I Pathogenesis and Diagnosis
Chapter 1 Pathophysiology and Classification of Liver Cirrhosis and Portal Hypertension ............2
Faisal M. Sanai, Mona H. Ismail, and Abdullah M.S. Al-Osaimi
Chapter 2 Clinical Presentation of Portal Hypertension ....................................................10
Mona H. Ismail and Abdullah M.S. Al-Osaimi
Chapter 3 Noninvasive Cross-Sectional and Vascular Imaging of Portal Hypertension ...............19
Celia P. Corona-Villalobos, Luciana G. Matteoni-Athayde, Neda Rastegar, and Ihab R. Kamel
Chapter 4 Indirect Portal Pressure Measurement and Carbon Dioxide Wedged Hepatic
Portography ............................................................................................38
Bill S. Majdalany and Minhaj S. Khaja
Chapter 5 Hemodynamic Evaluation of the Liver and Transjugular Liver Biopsy .......................44
George Behrens and Hector Ferral
Section II Medical, Endoscopic, Percutaneous, and Surgical Management
Chapter 6 Medical Management of Portal Hypertension Complications ................................52
Wissam Bleibel and Abdullah M.S. Al-Osaimi
Chapter 7 Endoscopic Classification and Management of Varices ........................................64
David M. Arner and Abdullah M.S. Al-Osaimi
Chapter 8 Paracentesis and the LeVeen and Denver Shunts ...............................................74
Louis G. Martin
Chapter 9 Surgical Management of Portal Hypertension ...................................................81
Kaj H. Johansen
Chapter 10 Percutaneous Management of Surgically Placed Portosystemic Shunts ....................90
Wael E.A. Saad
Section III Endovascular Management: Shunts and Splenic Embolization
Chapter 11 Patient Selection and the Effect of Transjugular Intrahepatic Portosystemic
Shunt on Liver and Kidney Function ...............................................................94
Hector Ferral and George Behrens
Chapter 12 Hepatic and Portal Venous Anatomy Relative to the Transjugular Intrahepatic
Portosystemic Shunt Procedure ..................................................................100
Nael E. Saad and Kathryn J. Fowler
vii
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Contents
Chapter 13 Technique for the Transjugular Intrahepatic Portosystemic Shunt Procedure ...........112
John A. Kaufman, Frederick S. Keller, and Josef Rösch
Chapter 14 The Difficult Transjugular Portosystemic Shunt Procedure:
Unconventional Techniques .......................................................................124
Michael D. Darcy
Chapter 15 The Intravascular Ultrasound–Guided Direct Intrahepatic Portacaval Shunt ............130
Bryan D. Petersen
Chapter 16 Hemodynamic Changes Following the Transjugular Intrahepatic
Portosystemic Shunt ...............................................................................142
Deddeh Ballah and Timothy W.I. Clark
Chapter 17 Budd-Chiari Syndrome: Transjugular Intrahepatic Portosystemic
Shunt and Hepatic Vein Recanalization .........................................................148
Sundeep Punamiya and Hector Ferral
Chapter 18 Transjugular Intrahepatic Portosystemic Shunt Reduction for Post-TIPS Hepatic
Encephalopathy .....................................................................................156
Adam D. Talenfeld and David C. Madoff
Chapter 19 Patency Outcomes of Transjugular Intrahepatic Portosystemic Shunts in the
Stent-Graft Era .......................................................................................167
Bogdan Iliescu, Ziv J. Haskal, and Bertrand Janne d’Othée
Chapter 20 Doppler Surveillance of Transjugular Intrahepatic Portosystemic Shunts in the
Stent-Graft Era .......................................................................................177
Nirvikar Dahiya, Michael F. Lin, and Christine O. Menias
Chapter 21 Transjugular Intrahepatic Shunts for Variceal Bleeding: Results of Clinical Studies .....186
Kunal V. Shah and Timothy W.I. Clark
Chapter 22 Transjugular Intrahepatic Portosystemic Shunts for Ascites and Hepatic
Hydrothorax: Results of Clinical Studies ........................................................192
Jeanne M. LaBerge, Kanti Pallav Kolli, and Robert K. Kerlan Jr.
Chapter 23 The Transjugular Intrahepatic Portosystemic Shunt as a Prelude to and After Liver
Transplantation ......................................................................................199
Bill S. Majdalany and Wael E.A. Saad
Chapter 24 Management of Mesenteric and Portal Vein Thrombosis in
Nontransplanted Patients .........................................................................205
Ron C. Gaba and Wael E.A. Saad
Chapter 25 Percutaneous Mesocaval Shunts .................................................................216
Robert K. Kerlan Jr., Sue J. Rhee, and Jeanne M. LaBerge
Chapter 26 Splenic Artery Embolization for Management of Hypersplenism and Portal
Hypertension ........................................................................................220
Raj A. Jain and Charles E. Ray Jr.
Chapter 27 Pediatric Portal Interventions .....................................................................225
Ravi N. Srinivasa, Narasimham L. Dasika, Alexandria Jo, and Wael E.A. Saad
viii
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Contents
Section IV Percutaneous and Endovascular M anagement: Transvenous Obliteration
Chapter 28 Vascular Anatomy and Classification Schema of Gastric Varices Relevant to
Balloon-Occluded Retrograde Transvenous Obliteration ....................................234
Minhaj S. Khaja, Shozo Hirota, Kaoru Kobayashi, Satoshi Yamamoto, and Wael E.A. Saad
Chapter 29 The Conventional Balloon-Occluded Retrograde Transvenous
Obliteration Procedure .............................................................................255
Minhaj S. Khaja and Wael E.A. Saad
Chapter 30 Balloon-Occluded Antegrade Transvenous Obliteration and Variations of Balloon-
Occluded Retrograde Transvenous Obliteration in the Treatment of Gastric Varices ...282
Minhaj S. Khaja and Wael E.A. Saad
Chapter 31 Clinical Outcomes of Balloon-Occluded Retrograde Transvenous Obliteration and
Balloon-Occluded Antegrade Transvenous Obliteration .....................................292
Paula M. Novelli and Wael E.A. Saad
Chapter 32 Management of Duodenal Varices ...............................................................297
Ravi N. Srinivasa, Jeffrey Forris Beecham Chick, and Wael E.A. Saad
Chapter 33 Management of Stomal Varices ..................................................................304
Ravi N. Srinivasa, Jeffrey Forris Beecham Chick, and Wael E.A. Saad
Index ...................................................................................................................315
ix
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Foreword
Over the past few decades, advances in imaging and image- new and better treatments is infectious. He is not only a leading
guided intervention have transformed the management of researcher in this area but is also the preeminent interventional
patients with portal hypertension. Today, the cause and sever- radiology educator in the field.
ity of portal hypertension can be assessed noninvasively, and In this third edition of Portal Hypertension: Imaging, Diag-
treatments can be based on individual parameters and tailored nosis, and Endovascular Management, Dr. Saad has created an
to the needs of each patient. Progress in the management of up-to-date and authoritative text. He has brought together noted
patients with portal hypertension is due in no small measure experts from around the world to explain state-of-the-art devel-
to the efforts of interventional radiologists. Pioneers in the field opments in the endovascular management of patients with por-
like Dr. Josef Rösch, to whom this book is dedicated, made trans- tal hypertension. Recent advances in transvenous obliteration
formative contributions to both the diagnostic imaging of portal are highlighted. In-depth discussions of difficult TIPS situations
hypertension and to the minimally invasive approaches to man- are presented. Special situations such as portal hypertension in
agement. The transjugular intrahepatic portosystemic shunt the pediatric patient and management of patients with portal
(TIPS) procedure, which Dr. Rösch developed in the 1980s and thrombosis are elucidated.
1990s, is now a standard treatment for patients with refractory Anyone interested in being in on the cutting edge of develop-
ascites and variceal bleeding. ments in minimally invasive portal interventions should read this
Dr. Wael E.A. Saad follows in the footsteps of Dr. Rösch and is book. It showcases the value of innovation and creativity in medi-
today one of the leading clinical researchers in the field of portal cine and provides inspiration and direction for young researchers
hypertension. Dr. Saad has pioneered advances such as balloon- in the field.
occluded retrograde transvenous obliteration (BRTO) and endo-
vascular approaches to the management of encephalopathy, and Jeanne M. LaBerge, MD, FSIR
he has gathered evidence to prove the value of these techniques. Professor of Radiology
As was the case with Dr. Rösch, Dr. Saad’s enthusiasm and zeal University of California San Francisco
for understanding the nature of portal hypertension and devising San Francisco, California
xi
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Preface
In 1969, Josef Rösch serendipitously came across and described shunt creation. This does not take away from the TIPS procedure,
the concept of the transjugular intrahepatic portosystemic shunt which remains the mainstay procedure. TIPS itself has also seen
(TIPS), igniting the era of endovascular management of portal advances in the last decade, with the introduction and broad use
hypertension. TIPS was clinically realized with the advent of stent of ePTFE covered stents improving TIPS patency and resultant
technology in the mid-1980s. Ernest J. Ring, and later Jeanne clinical outcomes.
LaBerge, popularized the clinical use of stent-lined TIPS in the This book is the third edition of the Society of Interventional
1990s. With the advent of the broad utilization of commercially Radiology (SIR) book series of Management of Portal Hyperten-
available purpose-built stent-grafts in the early to mid-2000s, a sion (originally called SIR Syllabus) and is the first publication
new era of stent-graft TIPS started with its superior patency. of this series by Thieme Publishers. The book is a contemporary
In the past decade, however, the endovascular management approach to endovascular management of portal hypertension;
of portal hypertension has expanded in its clinical practice to a its publication occurs in interesting times, where outcomes of
broad number of procedures, performed alone or in combination. various techniques have matured to stimulate a healthy addi-
The field is no longer confined to TIPS decompression but now tion to the field of portal hypertension management. I hope and
includes a multitude of other procedures, including portal vein expect you will find it useful to your practice.
recanalization and/or angioplasty, splenic embolization, trans-
venous obliteration (including BRTO and BATO), and peritoneal Wael E.A. Saad, MBBCh, FSIR
xiii
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