Seminars in interventional radiology
-
Semin Intervent Radiol · Sep 2014
ReviewThe history and future of transjugular intrahepatic portosystemic shunt: food for thought.
The origins of transjugular intrahepatic portosystemic shunt (TIPS) date back to the 1960s with inadvertent portal access during the early years of transjugular cholangiography. TIPS is now the most frequently performed portal hypertension decompressive procedure performed by interventional radiologists, and has become the primary portosystemic shunt (surgical or percutaneous) performed in the United States. One of the least discussed major advantages of TIPS in the transplant era is that it is intrahepatic and thus is removed in situ during a liver transplant, while extrahepatic shunts (surgical or percutaneous) have to be ligated or revised during the liver transplantation. ⋯ With the advent of commercially available expanded polytetraflouroethylenne (e-PTFE) covered stents a decade ago, 12- to 24-month TIPS patency has improved significantly (by ∼20-30%). However, hepatic encephalopathy (although not proven to have increased due to e-PTFE covered stents grafts) remains a significant morbidity problem. The article discusses the history of TIPS, critiques the retrospective encephalopathy data in the literature, and discusses futuristic TIPS-design ideas about the management of post-TIPS hepatic encephalopathy.
-
Pulmonary embolism (PE) and deep vein thrombosis are two elements of the same pathophysiological process referred to as venous thromboembolism. PE occurs when a thrombus migrates from a deep vein to the pulmonary arteries. Although the true incidence of PE is not known, it is estimated that 530,000 cases of PE occur annually in the United States. ⋯ Several treatment options are available for patients diagnosed with PE. The mainstay of treatment is anticoagulation, but given the high mortality associated with some presentations of symptomatic PE, some advocate more aggressive therapy. In this article we discuss such therapies and their potential and appropriate use.
-
Radiofrequency (RF) ablation has been increasingly utilized as a minimally invasive treatment for primary and metastatic liver tumors, as well as tumors in the kidneys, bones, and adrenal glands. The development of high-current RF ablation has subsequently led to an increased risk of thermal skin injuries at the grounding pad site. The incidence of skin burns in recent studies ranges from 0.1-3.2% for severe skin burns (second-/third-degree), and from 5-33% for first-degree burns.(1-3).
-
Chylous leaks, such as chylothorax and chylopericardium, are uncommon effusions resulting from the leakage of intestinal lymphatic fluid from the thoracic duct (TD) and its tributaries, or intestinal lymphatic ducts. The cause can be either traumatic (thoracic surgery) or nontraumatic (idiopathic, malignancy). Treatment has traditionally consisted of dietary modification (nonfat diet) and/or surgery (TD ligation, pleurodesis). ⋯ In this article, the authors describe the etiologies of chylothorax, patient population, outcomes, and long-term follow-up of TDE patients. Relevant lymphatic anatomy and physiology are reviewed, with special attention paid to the formation of the duct by tributaries at the cisterna chyli (CC). The technique of TDE is outlined, including bilateral pedal lymphangiography, TD cannulation, and embolic agents used for the procedure.
-
Trauma patients are at exceedingly high risk of development of venous thromboembolism (VTE) including deep venous thrombosis and pulmonary embolism (PE). The epidemiology of VTE in trauma patients is reviewed. PE is thought to be the third major cause of death after trauma in those patients who survive longer than 24 hours after onset of injury. ⋯ Unfortunately, two sets of guidelines are available for insertion of filters in trauma patients, with conflicting recommendations. The introduction of retrievable IVC filters seems to offer a unique solution for VTE protection in the trauma patient population, which often consists of younger members of our population. Lastly, current generations of FDA-approved retrieval filters are discussed.