Transjugular Intrahepatic Portosystemic Shunt Creation in a Polycystic Liver Facilitated by Hybrid Cross-sectional/Angiographic Imaging

ArticleinJournal of Vascular and Interventional Radiology 17(4):711-5 · May 2006with15 Reads
DOI: 10.1097/01.RVI.0000208984.17697.58 · Source: PubMed
Abstract
Polycystic liver disease (PCLD) has long been considered to represent a contraindication to transjugular intrahepatic portosystemic shunt (TIPS) creation, primarily because of the risk of hemorrhage. Three-dimensional (3D) navigation within the enlarged and potentially disorienting parenchyma can now be performed during the procedure with the development of C-arm cone-beam computed tomography, which relies on the same equipment already used for angiography. Such a hybrid 3D reconstruction-enabled angiography system was used for safe image guidance of a TIPS procedure in a patient with PCLD. This technology has the potential to expedite any image-guided procedure that requires 3D navigation.
    • "Intraoperative 3D ultrasound is one such measure (Rose et al., 2000; Rose et al., 2002), but requires a second clinician to manipulate the ultrasound head at a site remote from the interventionalist and moreover seems to require an average of four needle passes (Rose et al., 2000). A method of hybrid cross-sectional angiography imaging is under development by Frisoli and colleagues (Sze, 2006). The Inria and Harvard groups are jointly exploring use of a percutaneously inserted " anchor needle " into the liver with tracking of the external needle base, but analysis of breathing motion in animal models suggests that this approach does not adequately reflect global liver motion and that errors of less than 5 mm apply to only about half of the liver parenchyma (Bricault et al., 2005). "
    [Show abstract] [Hide abstract] ABSTRACT: Creation of a transjugular intrahepatic portosystemic shunt (TIPS) requires passage of a needle toward a moving target that is only seen transiently by X-ray prior to needle passage. Intraoperative, 3D target localization would facilitate target access and improve the safety of the procedure. The clinical assumption is that patients undergoing the TIPS procedure possess rigid, cirrhotic livers that undergo only intraoperative translation without significant deformation or rotation. Based upon this assumption, we hypothesize that the position of any unseen, 3D target point within the liver can be determined intraoperatively by precalculation of the relative positions of the target point to a different 3D point that can be tracked intraoperatively. This paper examines this hypothesis using intraoperatively acquired, biplane, X-ray images of seven patients. In six, we tracked the effects of cardiac and respiratory motion, and in three the effects of needle pressure. Methods involved reconstruction of 3D vessel bifurcation and other trackable intrahepatic points from biplane angiograms, measurement of liver deformation by examining changing distances between these 3D points over time, and comparison of expected to actual displacements of these points with respect to a fixed reference point in the liver. We conclude that, for the rigid livers associated with patients undergoing TIPS, that there is less intraoperative deformation than previously reported by other groups addressing healthy liver deformation, and that the location of an unseen target can be predicted within 3mm accuracy.
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    • "Therefore, 1,000 axial slices—that is, a complete volume, with almost isotropic submillimeter spatial resolution—can be reconstructed on the basis of a single orbit [13]. The usefulness of this new, combined technique has so far been described in only a few case reports of complication management in challenging neurointerventional pro- cedures [14], embolization of pancreatic and small bowel tumors [15] and TIPS placement [16] . However, several further theoretic benefits of C-arm CT have so far not been evaluated . "
    [Show abstract] [Hide abstract] ABSTRACT: The purpose of our study was to evaluate the diagnostic accuracy and scan coverage of flat-detector C-arm CT compared with that of biphasic MDCT for depicting malignant hepatic lesions in patients with hypervascular liver tumors before they undergo transarterial chemoembolization (TACE). Fifteen patients with either hepatocellular carcinoma (HCC, n = 8) or hypervascular liver metastases from uveal melanoma (n = 7) underwent arterial and portal venous C-arm CT of the liver using intraarterial contrast media administration directly before TACE. The number and location of their hepatic malignancies were compared with those on MDCT. The scan coverage was documented and the liver diameter measured on MDCT. Compared with MDCT, the sensitivity and specificity for segmental tumor involvement were 97% (76/78) and 85% (28/33), respectively, for reader 1, and 99% (77/78) and 79% (24/29), respectively, for reader 2. Complete scan coverage of the liver was obtained in five of the 15 patients with C-arm CT. In patients with incomplete scan coverage on C-arm CT, the craniocaudal liver diameter was significantly larger than in those patients with complete scan coverage (mean [95% CI], 22.7 [19.5-25.9] cm vs 20.2 [15.4-25.0] cm, p = 0.0193). Biphasic arterial and portal venous C-arm CT showed a high sensitivity for the detection of malignant liver lesions. However, the liver could not be visualized completely in two thirds of the patients. Therefore, the current scan range limitations need to be overcome to make C-arm CT a valuable adjunct to MDCT for preprocedure evaluation and postprocedure follow-up imaging.
    Full-text · Article · May 2008
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