Portal Hypertension: Imaging, Diagnosis, and Endovascular Management

Portal Hypertension
Contents
Preface
Section I P a t hogenesis and Diagnosis
	Chapter 1: P a t hophysiology and Classification of Liver Cirrhosis and Po
		L i v er Anatomy and Function
		L i v er Cirrhosis: Definition, Classification, and Epidemiology Definition of
			Classification of Cirrhosis
			Epidemiology of Cirrhosis
				Hepatitis B Virus
				Alcoholic Liver Disease
				Hepatitis C Virus
				Nonalcoholic Fatty Liver Disease
		Definition and Classification of P ortal Hypertension
			Definition of Portal Hypertension
				A utoimmune Hepatitis
			Classification of Portal Hypertension
		Budd-Chiari Syndrome
		C onclusion
		Clinical Pearls
	Chapter 2: Clinical Presentation of Portal Hypertension
		V arices
		C omplications from Cirrhosis and P ortal Hypertension
			Ascites
			Spontaneous Bacterial Peritonitis
			Hepatorenal Syndrome
			Serum-Ascites Albumin Gradient
			P ortopulmonary Hypertension and Hepatopulmonary Syndrome
			Hepatic Hydrothorax
			Hepatic Encephalopathy
		S ymptoms and Physical Examination
		Laboratory Evaluation
		R adiologic Evaluation
		C onclusion
		Clinical Pearls
		Severity of Liver Disease Scoring Systems
		R e f erences
	Chapter 3: Noninvasive Cross-Sectional and Vascular Imaging of Portal Hyp
		V enous Pathways in Portal H ypertension
			1. E sophageal and paraesophageal varices
			2. G astric varices
			3. P araumbilical varices and abdominal wall varices
			4. P erisplenic varices
			5. R e troperitoneal varices
			6 . R ectal varices
			7 . S hunts
		Noninvasive Imaging Diagnosis
			Ultrasonography
			C omputed Tomography
			C ontrast-Enhanced Computed T omography
				V ariceal Hemorrhage
				Intrahepatic Shunts
					Arterioportal Shunts
					P ortosystemic Shunts
				Thrombosis and Calcifications
				Cavernous Transformation
				V olumetrics
				Aneurysms and Varices
				Bidimensional and Three-Dimensional R endering
			Magnetic Resonance Imaging
			Magnetic Resonance Venography
			Novel Magnetic Resonance Imaging T echniques
				P hase Contrast
				T1 Mapping
				Magnetic Resonance Elastography
		Summary
		Clinical Pearls
	Chapter 4: Indirect Portal Pressure Measurement and Carbon Dioxide Wedged
		C omparison of End-Hole and Balloon Catheters for HVPG Measurement
		Indirect Portal Pressure Measurement
			T echnique
			The Use and Prognostic Implications of Indirect Portal Pressure Measurement
		W edged CO 2 Portography
			Characteristics of Carbon Dioxide
			Preparation and Use of CO 2
			C omparison of Iodinated C ontrast with CO 2
			C omplications of Wedged CO 2 P ortography
	Chapter 5: Hemodynamic Evaluation of the Liver and T r ansjugular Liver Bio
		Preprocedure Preparation
		T echnique
		Hemodynamic Evaluation of the Liver
			Material Required for the Procedure
			C omplications
			Interpretation of the Hepatic V enous Pressure Gradient
		T r ansjugular Liver Biopsy
			T r ansjugular Liver Biopsy Technique
			Materials
			C omplications
			Specimens
				6 Medical Management of Portal H ypertension C omplications
Section II Medical, Endoscopic, Percutaneous,and Surgical Management
	Chapter 6: Medical Management of Portal H ypertension C omplications
		Anatomy and Physiology
		G a s t rointestinal Varices
		Clinical Pathophysiology
			Esophageal Varices
				Primary Prophylaxis
				T reatment of Variceal Hemorrhage
			G a s t ric Varices
		Hepatic Encephalopathy
			Secondary Prophylaxis
			P ost-TIPS Hepatic Encephalopathy
		Ascites
			Large-Volume Paracentesis
			T r ansjugular Intrahepatic P ortosystemic Shunt
		Hepatic Hydrothorax
			L i v er Transplantation
		Hepatorenal Syndrome
		Spontaneous Bacterial Peritonitis
			P ortopulmonary Hypertension
		C onclusion
		Clinical Pearls
		R e f erences
	Chapter 7: Endoscopic Classification and Management of Varices
		Esophageal Varices
			Screening
			Management: Primary Prophylaxis
			Classification
			Endoscopic Variceal Ligation
			Endoscopic Sclerotherapy
				T echnique
			S hunt Surgery Operations and TIPS
			Endoscopic Sclerotherapy
			Management of Esophageal V arices Hemorrhage
			Esophageal Stents
			Endoscopic Variceal Ligation
			T r ansjugular Intrahepatic P ortosystemic Shunt
			Cyanoacrylate Injection
			Surgical Decompression
		G a s t ric Varices
			T echnique
			Balloon-Occluded Retrograde T r ansvenous Obliteration and T r ansjugular In
			Management
		E ctopic Varices
		R e f erences
	Chapter 8: P aracentesis and the LeVeen and Denver Shunts
		Large-Volume Paracentesis
			Procedure
		P eritoneovenous Shunts
			Procedure
			S hunt Evaluation and Repair
		Clinical Pearls: Ascites
		Clinical Pearls: Large-Volume P aracentesis
		Clinical Pearls: Disseminated Intravascular Coagulopathy (Consumptive Coagul
		Clinical Pearls: Paracentesis- Induced Circulatory Dysfunction
		Clinical Pearls: Peritoneovenous S hunt
		Clinical Pearls: Spontaneous Bacterial Peritonitis
	Chapter 9: Surgical Management of Portal Hypertension
		General Considerations
		A c ute Management of Recalcitrant V ariceal Bleeding
			Devascularization Procedures
			Emergent Management of Active V ariceal Bleeding
			P ortal Decompressive Shunt Surgery
				T o tal Portosystemic Shunts
					P ortacaval Shunt
					Mesocaval Shunt
					C entral Splenorenal Shunt
				Selective Shunts
				P artial Portosystemic Shunts
			Special Circumstances Budd-Chiari Syndrome
				Extrahepatic Thrombosis of the Portal Vein
		Surgical Management of Intractable Ascites
		R e f erences
			Isolated Splenic Vein Thrombosis
	Chapter 10: Percutaneous Management of Surgically P laced Portosystemic Shu
		Indirect Portography
		S hunt Catheterization Through t he Inferior Vena Cava
		Diagnosis of Shunt Dysfunction
			Chapter 10: Percutaneous Management of Surgically Placed Portosystemic Shunts
			Thrombolysis of Clotted Shunts
			T reatment of Dysfunctional Shunts Balloon Dilatation of the Malfunctioning
			F ollow-Up and Treatment of Shunt Dysfunction
			S t enting of Strictured Shunts
		R e sults and Discussion
			Emergency Variceal Embolization and Sclerosis
				11. P a t ient Selection and t he Effect of T r ansjugular Int
Section III Endovascular Management: S hunts and Splenic Embolization
	Chapter 11: P a t ient Selection and the Effect of Transjugular Intrahepat
		P a t ients with Portal Hypertension w ith Esophageal Varices Who Have Nev
		The Role of Transjugular Intrahepatic Portosystemic Shunt in P a t ients
			P a t ients with Acute Variceal Hemorrhage
			P a t ients with Portal Hypertension Who H a v e Not Developed Esophageal Var
			P a t ients Who Have Survived a Bleeding Episode and Require Treatment to P
		The Role of Transjugular Intrahepatic Portosystemic S hunt in P a t ien
		C onclusion
			Effect of Transjugular Intrahepatic P ortosystemic Shunt on Liver and Kidney
		Clinical Pearls
	Chapter 12: Hepatic and Portal Venous Anatomy Relative to t he Transjugular
		L i v er Morphology and Anatomy
		Hepatic Venous Anatomy
			Right Hepatic Vein
			Middle Hepatic Vein
			L e ft Hepatic Vein
			V ariant Anatomy
		P ortal Venous Anatomy
			Right Portal Vein
			L e ft Portal Vein
			Anatomic Variants
			P a t hophysiologic Variants
		Spatial Relationship of Hepatic and Portal Veins
			P a t hophysiologic Variants
			Imaging Options
		P ortal Hypertension and P ortosystemic Collaterals
		Clinical Pearls
		R e f erences
	Chapter 13: T echnique for the Transjugular Intrahepatic P ortosystemic Shu
		Historical Note
		Procedure Planning
		Present Status
		The Procedure
			Hepatic Vein Catheterization
			P ortal Vein Access Set
			W edged Hepatic Venogram
			P ortal Vein Access
			Pressure Measurements and Portal V enography
			Endograft Deployment
		V ariceal Embolization
		P ostprocedural Management
		P eriprocedural Complications and Their Prevention
		R e f erences
	Chapter 14: The Difficult Transjugular Portosystemic Shunt Procedure: Unconven
		Indications and Contraindications
			L i v er Parenchymal Problems
			Procedures A c c e s s Problems
			Hepatic Vein Problems
			P ortal Vein Problems
			P oral Vein Occlusion
		Outcomes
		Clinical Pearls
		R e f erences
	Chapter 15: The Intravascular Ultrasound Guided Direct Intrahepatic Portaca
		E quipment F emoral Access
		Jugular Access
			E quipment Modifications R ösch-Uchida Liver Access Set
			Needle and Catheter (Puncture Needle Set)
			Intravascular Ultrasonography
		The Procedure
			S t ep 1: Femoral Venous Access and Intravascular Ultrasound Placement
			S t ep 3: The Transcaval Puncture
			S t ep 2: Placement of the Modified RUPS
			S t ep 4: Upsizing the Guidewire
			S t ep 5: Portography, Manometry, and T r act Measurement
			S t ep 6: Intravascular Ultrasound Guided Placement of the VIATORR S t ent
				C ontrol of the Extrahepatic Puncture
		C onclusion
		Direct Intrahepatic Portacaval S hunt Patency
		A c knowledgments
		Clinical Pearls
	Chapter 16: Hemodynamic Changes Following the T r ansjugular Intrahepatic Por
		Intrahepatic Hemodynamic Changes After TIPS
		Hemodynamics of Cirrhosis and P ortal Hypertension in Brief
		S y s t emic Hemodynamic Changes and Clinical Implications for Hepatorenal S
		R e f erences
		C onclusion
		Clinical Pearls
	Chapter 17: Budd-Chiari Syndrome: Transjugular Intrahepatic P ortosystemic Sh
		Hepatic Venous Recanalization S t r a t egies to Recanalize Hepatic V enous
		T reatment of Budd-Chiari S yndrome
			T echnique of Inferior Vena Cava R ecanalization
			T echnique of Hepatic Vein R ecanalization
				3. C ombined transhepatic transvenous approach ( ▶ F i g. 17.5):
			R e sults and Complications of Hepatic V enous Outflow R ecanalization
			T echnique of Combined Inferior Vena Cava and Hepatic Vein Recanalization
			T echnique of Transjugular Intrahepatic P ortosystemic Shunt in Budd-Chiari
		T r ansjugular Intrahepatic P ortosystemic Shunt
		R e f erences
			R e sults and Complications of Transjugular Intrahepatic P ortosystemic S
		C onclusion
	Chapter 18: Transjugular Intrahepatic Portosystemic Shunt R eduction for Post
		Indications for Transjugular Intrahepatic Portosystemic S hunt R eduction
			R e sults
		R eduction s Predecessor: T r ansjugular Intrahepatic P ortosystemic Shunt O
		Early Transjugular Intrahepatic P ortosystemic Shunt Reduction T echniques:
			Balloon-Expanded Stent Graft Sculpting T echniques
			R e sults
		Modern Techniques: Reducing S t ent Grafts
			R e sults
			Purse-String Suture Mediated R eduction Technique
				C oaxial Constraining Stent-Over-Stent-Graft T echnique
				R e sults
			P arallel Constraining Stent and Stent Graft Technique
				R e sults
			Lasso Technique
				R e sults
			Other Transjugular Intrahepatic P ortosystemic Shunt Reduction Studies, Prod
		C onclusion
		Clinical Pearls
		R e f erences
	Chapter 19: Patency Outcomes of Transjugular Intrahepatic P ortosystemic Shun
		Histopathology of Shunt Stenosis
		The Development of TIPS Endografts
			Animal Studies
		Medical Approaches to Inhibit S hunt Stenosis
			Early Human Experience
			Outcomes of Bare Versus Commercially A v ailable Covered Stents
		P a t ency Outcomes of Endograft Use in Budd-Chiari Patients
		P ediatric TIPS and Endografts
		R a t ionale for Use of Uncovered S t ents in Some TIPS
		R e f erences
		C onclusion
	Chapter 20: Doppler Surveillance of Transjugular Intrahepatic P ortosystemic
		Sonographic Terminology
			Normal Gray-Scale and Doppler Findings
		Normal Transjugular Intrahepatic P ortosystemic Shunt Examination Ultrasonog
		A bnormal Transjugular Intrahepatic P ortosystemic Shunt Examination S t ent
			S hunt Stenosis
				Main Portal Vein Velocity
				Intrastent Flow Velocity
				Intrahepatic Portal Vein Flow Direction
				Hepatic Artery Velocity
				Hepatic Venous Flow
			Other Complications
		P itfalls and Artifacts
			T r ansjugular Intrahepatic Portosystemic S hunt Stent
			P ortal Vein
		Clinical Pearls
		R e f erences
	Chapter 21: Transjugular Intrahepatic Shunts for Variceal Bleeding: Results o
		Prevention of Variceal Rebleeding: Early Clinical Studies
		The Era of Stent Grafts
		Current Practice Guidelines
			Primary Prevention of Variceal Bleeding
			A c ute Bleeding
			G a s t ric Varices
			Early TIPS
			E ctopic Varices
			V ariceal Embolization
		R e f erences
		C onclusion
		Clinical Pearls
	Chapter 22: Transjugular Intrahepatic Portosystemic Shunts f or Ascites and H
		T reatment Options First-Line Therapy
		P a t hophysiology and Pressures
			Second-Line Therapy
			Indications and Contraindications
			Prospective Cohort Trials: TIPS for Ascites
		R e sults of Clinical Studies: TIPS for R e fractory Ascites
			Outcome Variables
				• Q uality of life and cost
			R andomized Trials: TIPS versus Large-Volume Paracentesis
				Outcomes R eduction in Ascites
		C omplications
			Encephalopathy
			Survival
		Overall Efficacy for Management of Ascites
		Current Ongoing Studies
			Meta-Analyses of Randomized C ontrolled T r i als
		T IPS for Hepatohydrothorax
		C onclusion
		Clinical Pearls
		R e f erences
	Chapter 23: The Transjugular Intrahepatic Portosystemic S hunt as a Prelude t
		T IPS as a Preoperative Prelude to L i v er Transplantation
		T IPS in Liver Transplant Recipients
		T echnical Aspects
			P i ggyback Anastomosis
		Clinical Outcome
			MELD Score and Survival for TIPS After T r ansplant
			Split Grafts, Especially Left Lobe Grafts
			C omparative Analysis of Technical Outcomes Between TIPS in Hepatic Grafts a
			P osttransplant TIPS for Ascites
			Indications Unique to Posttransplant P a t ients
		Clinical Pearls
			C onsiderations in Posttransplant P a t ients
		R e f erences
		C onclusion
	Chapter 24: Management of Mesenteric and Portal Vein Thrombosis in Nontranspl
		Mesenteric and Portal Vein Thrombosis
			Epidemiology and Classification
			Clinical Presentation, Diagnosis, and Sequelae
			T r ansjugular Intrahepatic P ortosystemic S hunt Creation
			C onventional Medical and Surgical Therapies
		Interventional Radiologic Management Approaches and R a t ionale
			Direct Portal and Mesenteric Vein Thrombolysis and Thrombectomy
			P ortal Vein Recanalization for Chronic Occlusion
			P a t ient Selection Procedure Indications
			Procedure Contraindications
			Indirect Mesenteric and Portal V ein Thrombolysis via the Superior Mesenteri
		Procedure Technique and P eriprocedure Patient Care General Considerations
			Direct Mesenteric and Portal Vein Thrombolysis and Thrombectomy
			T r ansjugular Intrahepatic P ortosystemic S hunt Creation
			Indirect Mesenteric and Portal V ein Thrombolysis via the Superior Mesenteri
		Procedure Outcomes
			T r ansjugular Intrahepatic Portosystemic S hunt Flow-Enhanced Clot Dissoluti
			P ortal Vein Recanalization for Chronic Occlusion
			Direct Mesenteric and Portal Vein Thrombolysis and Thrombectomy
			T r ansjugular Intrahepatic P ortosystemic S hunt Thrombolysis and Throm
			Indirect Portal and Mesenteric V ein Thrombolysis via the Superior Mesenteri
			P ortal Vein Recanalization for Chronic Occlusion with Combined Therapeuti
		C onclusion
		R e f erences
			Procedure-Related Complications
	Chapter 25: Percutaneous Mesocaval Shunts
		T echnique
			C ombined Transabdominal and T r ansvenous Approach
		Indications and Contraindications
			Exclusively Transvenous Approach
		Outcomes
			T echnical and Hemodynamic Results
		C onclusion
			Clinical Outcomes
		R e f erences
	Chapter 26: Splenic Artery Embolization for Management of H ypersplenism an
		R e sults and Outcomes Hemodynamic Results
			Clinical Outcome
			T r ansplant Population
			C ombination Therapy
		Procedural Aspects
		C omplications
		C onclusion
			Clinical Pearls T echnical Pearls
			Outcomes Pearls
		R e f erences
	Chapter 27: Pediatric Portal Interventions
		T echnique
		T r ansjugular Intrahepatic P ortosystemic Shunts (TIPS)
		V ariceal Sclerotherapy
		P ortal Vein Recanalization
		Splenic Embolization
		C ongenital Portosystemic Shunts
		R e f erences
		P e arls/Take-Home Points
Section IV P ercutaneous and Endovascular Management: Transvenous Obliteration
	Chapter 28: V a scular Anatomy and Classification Schema of Gastric Varice
		Afferent (Portal Venous Inflow) F eeder(s)
		Descriptive Anatomy
			Efferent Systemic Venous Drainage
			The Gastrorenal Shunt
			C entral Variceal Part of the Gastric V ariceal System
			P ericardiophrenic Vein
			R e t roperitoneal Veins
			V ariations in Systemic Venous Drainage
		Classifications
			S aad Gastroduodenal and Mesenteric V ariceal Classification and Classificati
			Hirota Balloon-Occluded Retrograde V enography Classifications and Kiyosue C
			S aad Classification for Afferent Inflow and Efferent Outflow of G a s t roesop
			Kiyosue Classification for Afferent Inflow and Classification-Based Management
			F ukuda-Hirota Hemodynamic Classification for Gastric Varices
			Matsumoto Hemodynamic Classification of Gastric Varices f or Predicting the
		C onclusion
	Chapter 29: The Conventional Balloon-Occluded Retrograde T r ansvenous Oblite
		Indications and Contraindications
		T echnique of the Balloon- Occluded Retrograde Transvenous Obliteration Proc
			A c c e s s and Approach
			Catheter Selection of the G a s t rorenal S hunt
			G a s t r ic Variceal System Occlusion T r apping
				Balloon Positioning, Manipulation, and Occlusion
				V enous Collateral Embolization or Obliteration
				Balloon-Occluded Retrograde Venography
			C one-Beam Computed Tomography Imaging (if Used)
			Indwelling Balloon Inflation (Sclerosant Dwell Time)
			Balloon Deflation and Removal
	Chapter 30: Balloon-Occluded Antegrade Transvenous Obliteration and Variati
		T echnique
		Balloon-Occluded Antegrade T r ansvenous Obliteration
			P ortal Venous Routes
				S y s t emic Venous Routes R outes for Gastric Varices
				R outes for Duodenal Varices
		C onclusion
		Clinical Pearls
		R e f erences
	Chapter 31: Clinical Outcomes of Balloon-Occluded R e t rograde Transvenous O
		Candidates for the BRTO Procedure
		T echnical Success
		P ostprocedure Imaging Evaluation
		Clinical Outcomes
		R e f erences
		Clinical Pearls
	Chapter 32: Management of Duodenal Varices
		Anatomy and Pathophysiology and Hemodynamic Classification
		Management of Duodenal Varices
		Endoscopy and Imaging
			T IPS Decompression with or without R ecanalization
		C onclusion
			T r ansvenous Obliteration
		R e f erences
	Chapter 33: Management of Stomal Varices
		Classification
		Anatomy
		Endoscopy and Imaging
		Management
			T r ansvenous Obliteration
			T IPS Decompression
		R e f erences
		C onclusion
		Clinical Pearls
Index