Ces radiol. 2025, 79(2):98-103 | DOI: 10.55095/CesRadiol2025/014

Navigation of portal vein puncture during TIPS using abdominal ultrasonographyOriginal article

Antonín Krajina^{1, 3}, Štěpán Šembera^{2, 3}, Vendelín Chovanec^{1, 3}, Miroslav Lojík¹, Zdeněk Bělobrádek¹, Ondřej Renc^{1, 3}, Jan Mašek^{1, 3}, David Brustman¹, Michal Rek¹, Tomáš Fejfar^{2, 3}, Petr Hůlek^{2, 3}, David Zítko¹, Marcel Homolka¹, Pavel Ryška^{1, 3}, Jan Raupach^{1, 3}

¹ Radiologická klinika LF UK a FN, Hradec Králové

² II. interní gastroenterologická klinika LF UK a FN, Hradec Králové

³ Univerzita Karlova, Lékařská fakulta v Hradci Králové Korespondenční adresa:

Aim: In our retrospective study, we compared the efficacy of portal vein puncture navigation using abdominal ultrasonography versus CO₂ portography. We assessed navigation efficiency according to the number of punctures required to achieve vena portae branch catheterization, the length of the fluoroscopy, and the dose area product (DAP).

Method: The study included 102 consecutive patients who underwent TIPS over a 3-year period (from the beginning of 2022 to the end of 2024). In this cohort, there were 29 women (28%) and 73 men (72%), ranging in age from 27 to 81 years. The main indications for TIPS were refractory ascites in 52 patients (51%) and bleeding with portal hypertension in 50 patients (49%). TIPS was performed as an emergency procedure in 19 patients (18.6%) for uncontrolled variceal bleeding. Child Pugh A, Child Pugh B and Child Pugh C were 22%, 44% and 26% respectively, with 8% of patients having no detectable classification.

Results: Of the 102 TIPS procedures, TIPS was not inserted in 3 patients due to technical failure (2.9%). The number of punctures required to reach the portal vein with guidewire insertion averaged 5.6 (range 1 to 20) in 50 patients whose puncture was guided by CO₂ portography. In the 28 procedures where ultrasound was used for guidance, the mean number of punctures required was 2.7 (range, 1 to 6). The mean duration of fluoroscopy was 28 min (9-50 min) in the 28 procedures performed with CO₂ guidance and 22.8 min (8-43 min) in the 28 procedures with ultrasound guidance. In the group of 19 procedures before angiomachine exchange and with CO₂ navigation, the mean DAP was 181 497 mGy/cm² (27 649-399 657 mGy/cm²), in the group of 17 procedures after angiomachine exchange and navigated by CO₂ portography, the DAP averaged 159 339 mGy/cm² (52 613-309 440 mGy/cm²) and in the youngest group of 21 procedures navigated by ultrasound, the DAP averaged 120 731 mGy/cm² (38 180-315 121 mGy/cm²). Dose measurements with personal dosimeters were performed for 7 procedures. In the part of the procedure until the insertion of the guidewire into the portal vein, the operator had a dose of 6 µSv (0 to 12 µSv) on average, while the physician performing the ultrasound navigation had a dose of 4.4 µSv (0 to 9 µSv) on average. The total dose to the operator averaged 19.5 µSv (8 to 35 µSv).

Conclusion: From the measured values it can be concluded that the number of punctures during navigation with US decreased from 5.6 to 2.7 on average, this result is close to statistic significance (p = 0.052). The fluoroscopic time during the procedure decreased by 7 minutes. However, the dose of the second physician navigating the puncture using ultrasound is comparable to that of the main operator. The DAP decreased after the device upgrade, and even more decreased for procedures performed with ultrasound-guided puncture navigation.

Keywords: portal hypertension, TIPS, puncture navigation, radiation dose.

Accepted: February 20, 2025; Published: June 6, 2025  Show citation