Preoperative simulation results and intraoperative image fusion guidance for transjugular intrahepatic portosystemic shunt placement: a feasibility study of nineteen patients

Diagn Interv Radiol. 2024 Mar 6;30(2):107-116. doi: 10.4274/dir.2022.221652. Epub 2023 Mar 24.


Purpose: The purpose is to evaluate the feasibility and efficacy of preoperative simulation results and intraoperative image fusion guidance during transjugular intrahepatic portosystemic shunt (TIPS) creation.

Methods: Nineteen patients were enrolled in the present study. The three-dimensional (3D) structures of the bone, liver, portal vein, inferior vena cava, and hepatic vein in the contrast-enhanced computed tomography (CT) scanning area were reconstructed in the Mimics software. The virtual Rosch-Uchida liver access set and the VIATORR stent model were established in the 3D Max software. The puncture path from the hepatic vein to the portal vein and the release position of the stent were simulated in the Mimics and 3D Max software, respectively. The simulation results were exported to Photoshop software, and the 3D reconstructed top of the liver diaphragm was used as the registration point to fuse with the liver diaphragmatic surface of the intraoperative fluoroscopy image. The selected portal vein system fusion image was overlaid on the reference display screen to provide image guidance during the operation. As a control, the last 19 consecutive cases of portal vein puncture under the guidance of conventional fluoroscopy were analyzed retrospectively, including the number of puncture attempts, puncture time, total procedure time, total fluoroscopy time, and total exposure dose (dose area product).

Results: The average time of preoperative simulation was about 61.26 ± 6.98 minutes. The average time of intraoperative image fusion was 6.05 ± 1.13 minutes. The median number of puncture attempts was not significantly different between the study group (n = 3) and the control group (n = 3; P = 0.175). The mean puncture time in the study group (17.74 ± 12.78 min) was significantly lower than that in the control group (58.32 ± 47.11 min; P = 0.002). The mean total fluoroscopy time was not significantly different between the study group (26.63 ± 12.84 min) and the control group (40.00 ± 23.44 min; P = 0.083). The mean total procedure time was significantly lower in the study group (79.74 ± 37.39 min) compared with the control group (121.70 ± 62.24 min; P = 0.019). The dose area product of the study group (220.60 ± 128.4 Gy. cm2) was not significantly different from that of the control group (228.5 ± 137.3 Gy. cm2; P = 0.773). There were no image guidance-related complications.

Conclusion: The use of preoperative simulation results and intraoperative image fusion to guide a portal vein puncture is feasible, safe, and effective when creating a TIPS. The method is cheap and may improve portal vein puncture, which may be valuable for hospitals lacking intravascular ultrasound and digital subtraction angiography (DSA) equipment equipped with a CT-angiography function.

Keywords: Cirrhosis; portal hypertension; transjugular intrahepatic portosystemic shunt; three-dimensional reconstruction; simulation; image fusion guidance.

MeSH terms

  • Feasibility Studies
  • Hepatic Veins
  • Humans
  • Portal Vein / surgery
  • Portasystemic Shunt, Transjugular Intrahepatic* / methods
  • Retrospective Studies
  • Treatment Outcome