Radiation exposure during transjugular intrahepatic portosystemic shunt creation in patients with complete portal vein thrombosis or portal cavernoma



This study aims to evaluate radiation exposure in patients with complete portal vein thrombosis (CPVT) or portal cavernoma (PC) undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation using real-time ultrasound guidance for portal vein targeting.

Materials and methods

This is a single institution retrospective analysis. Between August 2009 and September 2018, TIPS was attempted in 49 patients with CPVT or PC. Radiation exposure (dose area product [DAP], air KERMA (AK) and fluoroscopy time [FT]), technical success, clinical success, complications and survival were analyzed.


In total, 29 patients had CPVT and 20 patients had PC. 41/49 patients had cirrhosis. TIPS indications were refractory ascites (n =  25), variceal bleeding (n = 16) and other (n = 8). TIPS was successfully placed in 94% (46/49) of patients via a transjugular approach alone (n = 40), a transjugular/transhepatic approach (n = 5) and a transjugular/transsplenic approach (n = 1). Median DAP was 261 Gy * cm2 (range 29–950), median AK was 0.2 Gy (range 0.05–0.5), and median FT was 28.2 min (range 7.7–93.7). Mean portosystemic pressure gradient decreased from 16.8  ±  5.1 mmHg to 7.5  ±  3.3 mmHg (P <  0.01). There were no major procedural complications. Overall clinical success was achieved in 77% of patients (mean follow-up of 21.1 months). Encephalopathy was observed in 16 patients (34%), grade II–III encephalopathy in 7 patients (15%). TIPS revision was performed in 15 patients (32%). Overall survival rate was 75%.


In our experience, the use of real-time ultrasound guidance allowed the majority of the TIPS to be performed via a transjugular approach alone with a reasonably low radiation exposure considering the high technical difficulties of the selected cohort of patients with CVPT or PC.

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  1. 1.

    Rossle M (2013) TIPS: 25 years later. J Hepatol 59:1081–1093

    PubMed  Google Scholar 

  2. 2.

    Miller DL, Balter S, Cole PE, Lu HT, Schueler BA, Geisinger M et al (2003) Radiation doses in interventional radiology procedures: the RAD-IR study: part I: overall measures of dose. J Vasc Interv Radiol 14(6):711–727

    PubMed  Google Scholar 

  3. 3.

    Mahmoud AE, Helmy AS, Billingham L, Elias E (1997) Poor prognosis and limited therapeutic options in patients with Budd-Chiari syndrome and portal venous system thrombosis. Eur J Gastroenterol Hepatol 9:485–489

    CAS  PubMed  Google Scholar 

  4. 4.

    VanHa TG, Hodge J, Funaki B, Lorenz J, Rosenblum J, Straus C et al (2006) Transjugular intrahepatic portosystemic shunt placement in patients with cirrhosis and concomitant portal vein thrombosis. Cardiovasc Intervent Radiol 29(5):785–790

    Google Scholar 

  5. 5.

    Fanelli F, Angeloni S, Salvatori FM, Marzano C, Boatta E, Merli M et al (2011) Transjugular intrahepatic portosystemic shunt with expanded-polytetrafuoroethylene-covered stents in non-cirrhotic patients with portal cavernoma. Dig Liver Dis 43(1):78–84

    PubMed  Google Scholar 

  6. 6.

    European Association for the Study of the Liver (2016) EASL Clinical Practice Guidelines: vascular diseases of the liver. J Hepatol 64(1):179–202

    Google Scholar 

  7. 7.

    Han G, Qi X, He C, Yin Z, Wang J, Xia J et al (2011) Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis. J Hepatol 54(1):78–88

    PubMed  Google Scholar 

  8. 8.

    Miller DL, Kwon D, Bonavia GH (2009) Reference levels for patient radiation doses in interventional radiology: proposed initial values for US practice. Radiology 253(3):753–764

    PubMed  PubMed Central  Google Scholar 

  9. 9.

    Miraglia R, Maruzzelli L, Cortis K, D’Amico M, Floridia G, Gallo G et al (2016) Radiation exposure in transjugular intrahepatic portosystemic shunt creation. Cardiovasc Intervent Radiol 39(2):210–217

    PubMed  Google Scholar 

  10. 10.

    Bundy JJ, Chick JFB, Hage AN, Gemmete JJ, Srinivasa RN, Johnson EJ et al (2018) Contemporary interventional radiology dosimetry: analysis of 4784 discrete procedures at a single institution. J Am Coll Radiol 15(9):1214–1221

    PubMed  Google Scholar 

  11. 11.

    Longo JM, Bilbao JI, Rousseau HP, Joffre FG, Vinel JP, García-Villarreal L et al (1992) Color Doppler-US guidance in transjugular placement of intrahepatic portosystemic shunts. Radiology 184(1):281–284

    CAS  PubMed  Google Scholar 

  12. 12.

    Miraglia R, Gerasia R, Maruzzelli L, D’Amico M, Luca A (2017) Radiation doses to operators performing transjugular intrahepatic portosystemic shunt using a flat-panel detector-based system and ultrasound guidance for portal vein targeting. Eur Radiol 27(5):1783–1786

    PubMed  Google Scholar 

  13. 13.

    Thornburg B, Desai K, Hickey R, Hohlastos E, Kulik L, Ganger D et al (2017) Pretransplantation portal vein recanalization and transjugular intrahepatic portosystemic shunt creation for chronic portal vein thrombosis: final analysis of a 61-patient cohort. J Vasc Interv Radiol 28(12):1714–1721

    PubMed  Google Scholar 

  14. 14.

    Chen Y, Ye P, Li Y, Ma S, Zhao J, Zeng Q (2015) Percutaneous transhepatic balloon-assisted transjugular intrahepatic portosystemic shunt for chronic, totally occluded, portal vein thrombosis with symptomatic portal hypertension: procedure technique, safety, and clinical applications. Eur Radiol 25(12):3431–3437

    PubMed  Google Scholar 

  15. 15.

    Haskal ZJ, Duszak R, Furth EE (1996) Transjugular intrahepatic transcaval portosystemic shunt: the gun-sight approach. J Vasc Interv Radiol 7(1):139–142

    CAS  PubMed  Google Scholar 

  16. 16.

    Citron SJ, Brantley SD (1998) TIPS in portal vein occlusions: facilitation with percutaneous splenic access. J Vasc Interv Radiol 9:363–364

    CAS  PubMed  Google Scholar 

  17. 17.

    Habib A, Desai K, Hickey R, Thornburg B, Vouche M, Vogelzang RL et al (2015) Portal vein recanalization-transjugular intrahepatic portosystemic shunt using the transsplenic approach to achieve transplant candidacy in patients with chronic portal vein thrombosis. J Vasc Interv Radiol 26:499–506

    PubMed  Google Scholar 

  18. 18.

    La Mura V, Abraldes JG, Berzigotti A, Erice E, Flores-Arroyo A, García-Pagán JC et al (2010) Right atrial pressure is not adequate to calculate portal pressure gradient in cirrhosis: a clinical-hemodynamic correlation study. Hepatology 51:2108–2116

    PubMed  Google Scholar 

  19. 19.

    Kliewer MA, Hertzberg BS, Heneghan JP, Suhocki PV, Sheafor DH, Gannon PA Jr et al (2000) Transjugular Intrahepatic Portosystemic Shunts (TIPS): effects of respiratory state and patient position on the measurement of Doppler velocities. Am J Roentgenol 175:149–152

    CAS  Google Scholar 

  20. 20.

    Wambersie A (2005) International commission on radiological units and measurements. Patient dosimetry for X-rays used in medical imaging. ICRU Report 74. J ICRU 5(2):4–6

    Google Scholar 

  21. 21.

    https://www.iaea.org/resources/rpop/health-professionals/nuclear-medicine/diagnostic-nuclear-medicine/diagnostic-reference-levels-in-medical-imaging. Accessed 03 Dec 2019

  22. 22.

    Stecker MS, Balter S, Towbin RB, Miller DL, Vañó E, Bartal G et al (2009) Guidelines for patient radiation dose management. J Vasc Interv Radiol 20(7 suppl):S263–S273

    PubMed  Google Scholar 

  23. 23.

    Miller DL, Balter S, Wagner LK, Nikolic B, Bartal G, Cardella JF et al (2004) Quality improvement guidelines for recording patient radiation dose in the medical record. J Vasc Interv Radiol 15:423–429

    PubMed  Google Scholar 

  24. 24.

    Miraglia R, Maruzzelli L, Cortis K, Tafaro C, Gerasia R, Parisi C, Luca A (2015) Digital subtraction angiography during transjugular intrahepatic portosystemic shunt creation or revision: data on radiation exposure and image quality obtained using a standard and a low-dose acquisition protocol in a flat-panel detector-based system. Abdom Imaging 40(6):1808–1812

    PubMed  Google Scholar 

  25. 25.

    https://www.iaea.org/resources/rpop/health-professionals/radiology/erythema. Accessed 03 Dec 2019

  26. 26.

    Englesbe MJ, Kubus J, Muhammad W, Sonnenday CJ, Welling T, Punch JD et al (2010) Portal vein thrombosis and survival in patients with cirrhosis. Liver Transpl 16:83–90

    PubMed  Google Scholar 

  27. 27.

    Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J et al (2000) Portal vein in adults undergoing liver transplantation. Transplantation 69:1873–1881

    CAS  PubMed  Google Scholar 

  28. 28.

    Schepis F, Vizzutti F, Garcia-Tsao G, Marzocchi G, Rega L, De Maria N et al (2018) Under-dilated TIPS associate with efficacy and reduced encephalopathy in a prospective, non-randomized study of patients with cirrhosis. Clin Gastroenterol Hepatol 16(7):1153.e7–1162.e7

    Google Scholar 

  29. 29.

    Miraglia R, Maruzzelli L, Tuzzolino F, Petridis I, D’Amico M, Luca A (2017) Transjugular intrahepatic portosystemic shunts in patients with cirrhosis with refractory ascites: comparison of clinical outcomes by using 8- and 10-mm PTFE-covered stents. Radiology 284(1):281–288

    PubMed  Google Scholar 

  30. 30.

    Chivot C, Robert B, Bouzerar R, Popoff R, Yzet T (2018) 3D C-arm cone beam CT for targeting the portal vein during TIPS: initial clinical experience. Eur J Radiol 106:20–25

    PubMed  Google Scholar 

  31. 31.

    Caporossi JM, Vidal V, Jacquier A, Reyre A, Flavian A, Muller C, Gaubert JY, Bartoli JM, Moulin G, Varoquaux A (2015) Balloon occlusion versus wedged hepatic venography using iodinated contrast for targeting the portal vein during TIPS. Diagn Interv Imaging 96(4):357–363

    PubMed  Google Scholar 

  32. 32.

    Rouabah K, Varoquaux A, Caporossi JM, Louis G, Jacquier A, Bartoli JM, Moulin G, Vidal V (2016) Image fusion-guided portal vein puncture during transjugular intrahepatic portosystemic shunt placement. Diagn Interv Imaging 97(11):1095–1102

    CAS  PubMed  Google Scholar 

  33. 33.

    Tacher V, Petit A, Derbel H, Novelli L, Vitellius M, Ridouani F, Luciani A, Rahmouni A, Duvoux C, Salloum C et al (2017) Three-dimensional image fusion guidance for transjugular intrahepatic portosystemic shunt placement. Cardiovasc Interv Radiol 40(11):1732–1739

    Google Scholar 

  34. 34.

    Luo X, Wang X, Yu J, Zhu Y, Xi X, Ma H, Eur YL (2018) Transjugular intrahepatic portosystemic shunt creation: three-dimensional roadmap versus CO2 wedged hepatic venography. Radiol 28(8):3215–3220

    Google Scholar 

  35. 35.

    Luo X, Wang X, Zhao Y, Ma H, Ye L, Yang L, Tsauo J, Jiang M, Li X (2017) Real-time 3D CT image guidance for transjugular intrahepatic portosystemic shunt creation using preoperative CT: a prospective feasibility study of 20 patients. AJR Am J Roentgenol 208(1):W11–W16

    PubMed  Google Scholar 

  36. 36.

    Qin JP, Tang SH, Jiang MD, He QW, Chen HB, Yao X, Zeng WZ, Gu M (2015) Contrast enhanced computed tomography and reconstruction of hepatic vascular system for transjugular intrahepatic portal systemic shunt puncture path planning. World J Gastroenterol 21(32):9623–9629

    PubMed  PubMed Central  Google Scholar 

  37. 37.

    Böning G, Lüdemann WM, Chapiro J, Jonczyk M, Hamm B, Günther RW, Gebauer B, Streitparth F (2018) Clinical experience with real-time 3-D guidance based on C-Arm-acquired cone-beam CT (CBCT) in transjugular intrahepatic portosystemic stent shunt (TIPSS) placement. Cardiovasc Intervent Radiol 41(7):1035–1042

    PubMed  Google Scholar 

  38. 38.

    Haochen W, Yinghua Z, Jian W (2019) Intrahepatic arterial localizer guided transjugular intrahepatic portosystemic shunt placement: feasibility, efficacy, and technical success assessed by a case series-a STROBE-compliant article. Medicine (Baltimore) 98(33):e16868

    Google Scholar 

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Correspondence to Roberto Miraglia.

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Miraglia, R., Maruzzelli, L., Cannataci, C. et al. Radiation exposure during transjugular intrahepatic portosystemic shunt creation in patients with complete portal vein thrombosis or portal cavernoma. Radiol med 125, 609–617 (2020). https://doi.org/10.1007/s11547-020-01155-5

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  • Ascites
  • Bleeding
  • Liver
  • Cirrhosis