Use of Virtual Target Fluoroscopic Display of Three-Dimensional CO2 Wedged Hepatic Vein Portography for TIPS Placement.

To describe and evaluate an image fusion technique for the portal vein puncture guidance during TIPS procedure: a three-dimensional (3D) virtual target fluoroscopic display obtained with an automated 3D carbon dioxide wedged hepatic vein portography (3D CO2-WHVP). All the 37 TIPS creations performed in our institution between 3/2017 and 12/2018 were retrospectively reviewed. Seventeen procedures were guided using the 3D CO2-WHVP technique (group 1) and were compared with the other 20 procedures performed under conventional 2D fluoroscopic guidance (group 2). Image acquisition for the 3D CO2-WHVP consisted of combining a CBCT acquisition and an automatic CO2 injection. Once located on the multiplanar reformatted images of the CBCT acquisition, the portal bifurcation was manually segmented to create a virtual target that was overlaid onto live fluoroscopy allowing a real-time 3D guidance during portal vein puncture. Primary success was 100% in group1 and 95% in group2. Median intervention length, fluoroscopy time and dose area product (DAP) were, respectively, 124 min [IQR 94–137], 40 min [IQR 26–52] and 12140 cGy.cm2 [IQR 10147–18495] in group 1 and 146 min [IQR 118–199], 40 min [IQR 36–60] and 13290 cGy.cm2 [IQR 10138–19538] in group 2. No technical parameter was significantly different between the two groups. Intraprocedural complication rate was 0% in group 1 and 20% in group 2 (p = 0.05). Three-dimensional virtual target fluoroscopic display using a CBCT-acquired CO2 wedged portography is an effective and safe technique to ease intrahepatic puncture of the portal vein during TIPS procedures.