Download PDF
Digestive Disease Interventions 2020; 04(02): 148-156
DOI: 10.1055/s-0040-1712117
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Transjugular Intrahepatic Portosystemic Shunts in High-Risk Patients

David S. Shin
1   Division of Interventional Radiology, University of Washington, Seattle, Washington
,
Hong Vo
1   Division of Interventional Radiology, University of Washington, Seattle, Washington
,
Guy Johnson
1   Division of Interventional Radiology, University of Washington, Seattle, Washington
,
Raimund Pichler
2   Division of Nephrology University of Washington, Seattle, Washington
,
Scott W. Biggins
3   Division of Gastroenterology and Hepatology, Liver Care Line, University of Washington, Seattle, Washington
4   Center for Liver Investigation Fostering discovEry (C-LIFE), University of Washington, Seattle, Washington
› Author Affiliations
Further Information

Publication History

16 December 2019

30 March 2020

Publication Date:
09 June 2020 (online)

Also available at
    Permissions and Reprints

Abstract

Cirrhosis with complications of portal hypertension portends a poor prognosis. Transjugular intrahepatic portosystemic shunts (TIPS) can successfully treat some of these complications in select patients. While the safety and efficacy of TIPS have improved significantly over the past decade, certain patients are categorized as high-risk based on various demographic, laboratory, and comorbid factors. Herein, we provide an in-depth review of TIPS in these settings, including high model for end-stage liver disease score, hepatic malignancy, advanced age, cardiac disease, renal dysfunction, and pregnancy, and discuss their impact on patient selection and procedural considerations.

Keywords

TIPS - MELD - cirrhosis - portal hypertension - ascites
 

  • References

  • 1 Salerno F, Merli M, Riggio O. , et al. Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites. Hepatology 2004; 40 (03) 629-635
    CrossrefPubMedGoogle Scholar
  • 2 García-Pagán JC, Caca K, Bureau C. , et al; Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362 (25) 2370-2379
    CrossrefPubMedGoogle Scholar
  • 3 Bass N. Role of TIPS in portal hypertension: variceal bleeding and ascites. Techniques in Vascular and Interventional Radiology 1998; 1: 44-50
    CrossrefPubMedGoogle Scholar
  • 4 Boyer TD, Haskal ZJ. ; American Association for the Study of Liver Diseases. The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005; 41 (02) 386-400
    CrossrefPubMedGoogle Scholar
  • 5 Dariushnia SR, Haskal ZJ, Midia M. , et al; Society of Interventional Radiology Standards of Practice Committee. Quality improvement guidelines for transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 2016; 27 (01) 1-7
    CrossrefPubMedGoogle Scholar
  • 6 Salerno F, Cammà C, Enea M, Rössle M, Wong F. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology 2007; 133 (03) 825-834
    CrossrefPubMedGoogle Scholar
  • 7 Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000; 31 (04) 864-871
    CrossrefPubMedGoogle Scholar
  • 8 Kamath PS, Wiesner RH, Malinchoc M. , et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001; 33 (02) 464-470
    CrossrefPubMedGoogle Scholar
  • 9 Salerno F, Merli M, Cazzaniga M. , et al. MELD score is better than Child-Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt. J Hepatol 2002; 36 (04) 494-500
    CrossrefPubMedGoogle Scholar
  • 10 Gaba RC, Couture PM, Bui JT. , et al. Prognostic capability of different liver disease scoring systems for prediction of early mortality after transjugular intrahepatic portosystemic shunt creation. J Vasc Interv Radiol 2013; 24 (03) 411-420 , 420.e1–420.e4, quiz 421
    CrossrefPubMedGoogle Scholar
  • 11 Allegretti AS, Frenk NE, Li DK. , et al. Evaluation of model performance to predict survival after transjugular intrahepatic portosystemic shunt placement. PLoS One 2019; 14 (05) e0217442
    CrossrefPubMedGoogle Scholar
  • 12 Biggins SW, Rodriguez HJ, Bacchetti P, Bass NM, Roberts JP, Terrault NA. Serum sodium predicts mortality in patients listed for liver transplantation. Hepatology 2005; 41 (01) 32-39
    CrossrefPubMedGoogle Scholar
  • 13 Biggins SW, Kim WR, Terrault NA. , et al. Evidence-based incorporation of serum sodium concentration into MELD. Gastroenterology 2006; 130 (06) 1652-1660
    CrossrefPubMedGoogle Scholar
  • 14 Bambha KM, Biggins SW. Inequities of the model for end-stage liver disease: an examination of current components and future additions. Curr Opin Organ Transplant 2008; 13 (03) 227-233
    CrossrefPubMedGoogle Scholar
  • 15 Kim WR, Biggins SW, Kremers WK. , et al. Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med 2008; 359 (10) 1018-1026
    CrossrefPubMedGoogle Scholar
  • 16 Guy J, Somsouk M, Shiboski S, Kerlan R, Inadomi JM, Biggins SW. New model for end stage liver disease improves prognostic capability after transjugular intrahepatic portosystemic shunt. Clin Gastroenterol Hepatol 2009; 7 (11) 1236-1240
    CrossrefPubMedGoogle Scholar
  • 17 Ferral H, Gamboa P, Postoak DW. , et al. Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score. Radiology 2004; 231 (01) 231-236
    CrossrefPubMedGoogle Scholar
  • 18 Pan JJ, Chen C, Caridi JG. , et al. Factors predicting survival after transjugular intrahepatic portosystemic shunt creation: 15 years' experience from a single tertiary medical center. J Vasc Interv Radiol 2008; 19 (11) 1576-1581
    CrossrefPubMedGoogle Scholar
  • 19 Montgomery A, Ferral H, Vasan R, Postoak DW. MELD score as a predictor of early death in patients undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) procedures. Cardiovasc Intervent Radiol 2005; 28 (03) 307-312
    CrossrefPubMedGoogle Scholar
  • 20 Ascha M, Hanouneh M. , S Ascha M, et al. Transjugular intrahepatic porto-systemic shunt in patients with liver cirrhosis and model for end-stage liver disease ≥15. Dig Dis Sci 2017; 62 (02) 534-542
    CrossrefPubMedGoogle Scholar
  • 21 Somsouk M, Kornfield R, Vittinghoff E, Inadomi JM, Biggins SW. Moderate ascites identifies patients with low model for end-stage liver disease scores awaiting liver transplantation who have a high mortality risk. Liver Transpl 2011; 17 (02) 129-136
    CrossrefPubMedGoogle Scholar
  • 22 Spengler EK, Hunsicker LG, Zarei S, Zimmerman MB, Voigt MD. Transjugular intrahepatic portosystemic shunt does not independently increase risk of death in high model for end stage liver disease patients. Hepatol Commun 2017; 1 (05) 460-468
    CrossrefPubMedGoogle Scholar
  • 23 Ronald J, Rao R, Choi SS. , et al. No increased mortality after TIPS compared with serial large volume paracenteses in patients with higher model for end- stage liver disease score and refractory ascites. Cardiovasc Intervent Radiol 2019; 42 (05) 720-728
    CrossrefPubMedGoogle Scholar
  • 24 Rajan DK, Haskal ZJ, Clark TW. Serum bilirubin and early mortality after transjugular intrahepatic portosystemic shunts: results of a multivariate analysis. J Vasc Interv Radiol 2002; 13 (2 Pt 1): 155-161
    CrossrefPubMedGoogle Scholar
  • 25 Dhanasekaran R, Gonzales P, West J. , et al. Predictors of early mortality post transjugular intrahepatic portosystemic shunts and the role of hepatic venous pressure gradient. Gastrointest Intervent 2012; 1: 63-68
    PubMedGoogle Scholar
  • 26 Saad N, Rude MK, Darcy M, Hanin JB, Wentworth A, Korenblat KM. Older age is associated with increased early mortality after transjugular intrahepatic portosystemic shunt. Ann Hepatol 2016; 15 (02) 215-221
    PubMedGoogle Scholar
  • 27 Parvinian A, Shah KD, Couture PM. , et al. Older patient age may predict early mortality after transjugular intrahepatic portosystemic shunt creation in individuals at intermediate risk. J Vasc Interv Radiol 2013; 24 (07) 941-946
    CrossrefPubMedGoogle Scholar
  • 28 Suraweera D, Jimenez M, Viramontes M. , et al. Age-related morbidity and mortality after transjugular intrahepatic portosystemic shunts. J Clin Gastroenterol 2017; 51 (04) 360-363
    CrossrefPubMedGoogle Scholar
  • 29 Syed MI, Karsan H, Ferral H. , et al. Transjugular intrahepatic porto-systemic shunt in the elderly: palliation for complications of portal hypertension. World J Hepatol 2012; 4 (02) 35-42
    CrossrefPubMedGoogle Scholar
  • 30 Li Y, Wang F, Chen X, Li B, Meng W, Qin C. Short outcome comparison of elderly patients versus nonelderly patients treated with transjugular intrahepatic portosystemic stent shunt: a propensity score matched cohort study. Medicine (Baltimore) 2017; 96 (29) e7551
    PubMedGoogle Scholar
  • 31 Carvalho MVH, Kroll PC, Kroll RTM, Carvalho VN. Cirrhotic cardiomyopathy: the liver affects the heart. Braz J Med Biol Res 2019; 52 (02) e7809
    PubMedGoogle Scholar
  • 32 Chayanupatkul M, Liangpunsakul S. Cirrhotic cardiomyopathy: review of pathophysiology and treatment. Hepatol Int 2014; 8 (03) 308-315
    CrossrefPubMedGoogle Scholar
  • 33 Busk TM, Bendtsen F, Henriksen JH. , et al. Effects of transjugular intrahepatic portosystemic shunt (TIPS) on blood volume distribution in patients with cirrhosis. Dig Liver Dis 2017; 49 (12) 1353-1359
    CrossrefPubMedGoogle Scholar
  • 34 Van der Linden P, Le Moine O, Ghysels M, Ortinez M, Devière J. Pulmonary hypertension after transjugular intrahepatic portosystemic shunt: effects on right ventricular function. Hepatology 1996; 23 (05) 982-987
    CrossrefPubMedGoogle Scholar
  • 35 Billey C, Billet S, Robic MA. , et al. A prospective study identifying predictive factors of cardiac decompensation after transjugular intrahepatic portosystemic shunt: the Toulouse algorithm. Hepatology 2019; 70 (06) 1928-1941
    CrossrefPubMedGoogle Scholar
  • 36 Ascha M, Abuqayyas S, Hanouneh I. , et al. Predictors of mortality after transjugular portosystemic shunt. World J Hepatol 2016; 8 (11) 520-529
    CrossrefPubMedGoogle Scholar
  • 37 Cazzaniga M, Salerno F, Pagnozzi G. , et al. Diastolic dysfunction is associated with poor survival in patients with cirrhosis with transjugular intrahepatic portosystemic shunt. Gut 2007; 56 (06) 869-875
    CrossrefPubMedGoogle Scholar
  • 38 Parvinian A, Bui JT, Knuttinen MG, Minocha J, Gaba RC. Right atrial pressure may impact early survival of patients undergoing transjugular intrahepatic portosystemic shunt creation. Ann Hepatol 2014; 13 (04) 411-419
    CrossrefPubMedGoogle Scholar
  • 39 Armstrong MJ, Gohar F, Dhaliwal A. , et al. Diastolic dysfunction on echocardiography does not predict survival after transjugular intrahepatic portosystemic stent-shunt in patients with cirrhosis. Aliment Pharmacol Ther 2019; 49 (06) 797-806
    CrossrefPubMedGoogle Scholar
  • 40 Filì D, Falletta C, Luca A. , et al. Circulatory response to volume expansion and transjugular intrahepatic portosystemic shunt in refractory ascites: relationship with diastolic dysfunction. Dig Liver Dis 2015; 47 (12) 1052-1058
    CrossrefPubMedGoogle Scholar
  • 41 Modha K, Kapoor B, Lopez R, Sands MJ, Carey W. Symptomatic heart failure after transjugular intrahepatic portosystemic shunt placement: incidence, outcomes, and predictors. Cardiovasc Intervent Radiol 2018; 41 (04) 564-571
    CrossrefPubMedGoogle Scholar
  • 42 Arroyo V. Pathophysiology, diagnosis and treatment of ascites in cirrhosis. Ann Hepatol 2002; 1 (02) 72-79
    CrossrefPubMedGoogle Scholar
  • 43 Wadei HM, Mai ML, Ahsan N, Gonwa TA. Hepatorenal syndrome: pathophysiology and management. Clin J Am Soc Nephrol 2006; 1 (05) 1066-1079
    CrossrefPubMedGoogle Scholar
  • 44 Rössle M. TIPS: 25 years later. J Hepatol 2013; 59 (05) 1081-1093
    CrossrefPubMedGoogle Scholar
  • 45 Somberg KA, Lake JR, Tomlanovich SJ, LaBerge JM, Feldstein V, Bass NM. Transjugular intrahepatic portosystemic shunts for refractory ascites: assessment of clinical and hormonal response and renal function. Hepatology 1995; 21 (03) 709-716
    PubMedGoogle Scholar
  • 46 Allegretti AS, Ortiz G, Cui J. , et al. Changes in kidney function after transjugular intrahepatic portosystemic shunts versus large-volume paracentesis in cirrhosis: a matched cohort analysis. Am J Kidney Dis 2016; 68 (03) 381-391
    CrossrefPubMedGoogle Scholar
  • 47 Ginès P, Solà E, Angeli P, Wong F, Nadim MK, Kamath PS. Hepatorenal syndrome. Nat Rev Dis Primers 2018; 4 (01) 23
    Google Scholar
  • 48 Angeli P, Garcia-Tsao G, Nadim MK, Parikh CR. News in pathophysiology, definition and classification of hepatorenal syndrome: a step beyond the International Club of Ascites (ICA) consensus document. J Hepatol 2019; 71 (04) 811-822
    CrossrefPubMedGoogle Scholar
  • 49 Brensing KA, Textor J, Perz J. , et al. Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study. Gut 2000; 47 (02) 288-295
    CrossrefPubMedGoogle Scholar
  • 50 Guevara M, Ginès P, Bandi JC. , et al. Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems. Hepatology 1998; 28 (02) 416-422
    CrossrefPubMedGoogle Scholar
  • 51 Rössle M, Gerbes AL. TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: a critical update. Gut 2010; 59 (07) 988-1000
    CrossrefPubMedGoogle Scholar
  • 52 Wong F, Pantea L, Sniderman K. Midodrine, octreotide, albumin, and TIPS in selected patients with cirrhosis and type 1 hepatorenal syndrome. Hepatology 2004; 40 (01) 55-64
    CrossrefPubMedGoogle Scholar
  • 53 Testino G, Ferro C, Sumberaz A. , et al. Type-2 hepatorenal syndrome and refractory ascites: role of transjugular intrahepatic portosystemic stent-shunt in eighteen patients with advanced cirrhosis awaiting orthotopic liver transplantation. Hepatogastroenterology 2003; 50 (54) 1753-1755
    PubMedGoogle Scholar
  • 54 Alessandria C, Gaia S, Marzano A, Venon WD, Fadda M, Rizzetto M. Application of the model for end-stage liver disease score for transjugular intrahepatic portosystemic shunt in cirrhotic patients with refractory ascites and renal impairment. Eur J Gastroenterol Hepatol 2004; 16 (06) 607-612
    CrossrefPubMedGoogle Scholar
  • 55 Gomes MA, Priolli DG, Tralhão JG, Botelho MF. Hepatocellular carcinoma: epidemiology, biology, diagnosis, and therapies. Rev Assoc Med Bras (1992) 2013; 59 (05) 514-524
    PubMedGoogle Scholar
  • 56 Venook AP, Papandreou C, Furuse J, de Guevara LL. The incidence and epidemiology of hepatocellular carcinoma: a global and regional perspective. Oncologist 2010; 15 (Suppl. 04) 5-13
    PubMedGoogle Scholar
  • 57 Ankoma-Sey V, Wang Y, Dai Z. Hypoxic stimulation of vascular endothelial growth factor expression in activated rat hepatic stellate cells. Hepatology 2000; 31 (01) 141-148
    CrossrefPubMedGoogle Scholar
  • 58 Bjørneboe M, Andersen JR, Christensen U, Skinhøj P, Jensen OM. Does a portal-systemic shunt increase the risk of primary hepatic carcinoma in cirrhosis of the liver?. Scand J Gastroenterol 1985; 20 (01) 59-64
    PubMedGoogle Scholar
  • 59 Bañares R, Núñez O, Escudero M. , et al. Patients with cirrhosis and bare-stent TIPS may have increased risk of hepatocellular carcinoma. Hepatology 2005; 41 (03) 566-571
    CrossrefPubMedGoogle Scholar
  • 60 De Santis A, Iegri C, Kondili L. , et al. Hepatocellular carcinoma in cirrhotic patients with transjugular intrahepatic portosystemic shunt: a retrospective case-control study. Dig Liver Dis 2014; 46 (08) 726-730
    CrossrefPubMedGoogle Scholar
  • 61 Chen B, Pang L, Chen HB, Wu DB, Wang YH, Chen EQ. TIPS is not associated with a higher risk of developing HCC in cirrhotic patients: a systematic review and meta-analysis. J Clin Transl Hepatol 2019; 7 (03) 232-237
    PubMedGoogle Scholar
  • 62 Borentain P, Garcia S, Gregoire E. , et al. Transjugular intrahepatic porto-systemic shunt is a risk factor for liver dysplasia but not hepatocellular carcinoma: a retrospective study of explanted livers. Dig Liver Dis 2015; 47 (01) 57-61
    CrossrefPubMedGoogle Scholar
  • 63 Hüsing-Kabar A, Meister T, Köhler M. , et al. Is de novo hepatocellular carcinoma after transjugular intrahepatic portosystemic shunt increased?. United European Gastroenterol J 2018; 6 (03) 413-421
    CrossrefPubMedGoogle Scholar
  • 64 Miura JT, Rilling WS, White SB. , et al. Safety and efficacy of transarterial chemoembolization in patients with transjugular intrahepatic portosystemic shunts. HPB (Oxford) 2015; 17 (08) 707-712
    CrossrefPubMedGoogle Scholar
  • 65 Tesdal IK, Wikström M, Flechtenmacher C, Filser T, Dueber C. Percutaneous treatment of hepatocellular carcinoma in patients with transjugular intrahepatic portosystemic shunts. Cardiovasc Intervent Radiol 2006; 29 (05) 778-784
    CrossrefPubMedGoogle Scholar
  • 66 Wang Z, Zhang H, Zhao H. , et al. Repeated transcatheter arterial chemoembolization is safe for hepatocellular carcinoma in cirrhotic patients with transjugular intrahepatic portosystemic shunt. Diagn Interv Radiol 2014; 20 (06) 487-491
    CrossrefPubMedGoogle Scholar
  • 67 Kohi MP, Fidelman N, Naeger DM, LaBerge JM, Gordon RL, Kerlan Jr RK. Hepatotoxicity after transarterial chemoembolization and transjugular intrahepatic portosystemic shunt: do two rights make a wrong?. J Vasc Interv Radiol 2013; 24 (01) 68-73
    CrossrefPubMedGoogle Scholar
  • 68 Padia SA, Chewning RH, Kogut MJ. , et al. Outcomes of locoregional tumor therapy for patients with hepatocellular carcinoma and transjugular intrahepatic portosystemic shunts. Cardiovasc Intervent Radiol 2015; 38 (04) 913-921
    CrossrefPubMedGoogle Scholar
  • 69 Kuo YC, Kohi MP, Naeger DM. , et al. Efficacy of TACE in TIPS patients: comparison of treatment response to chemoembolization for hepatocellular carcinoma in patients with and without a transjugular intrahepatic portosystemic shunt. Cardiovasc Intervent Radiol 2013; 36 (05) 1336-1343
    CrossrefPubMedGoogle Scholar
  • 70 Kang JW, Kim JH, Ko GY, Gwon DI, Yoon HK, Sung KB. Transarterial chemoembolization for hepatocellular carcinoma after transjugular intrahepatic portosystemic shunt. Acta Radiol 2012; 53 (05) 545-550
    CrossrefPubMedGoogle Scholar
  • 71 Hu HT, Kim JH, Lee LS. , et al. Chemoembolization for hepatocellular carcinoma: multivariate analysis of predicting factors for tumor response and survival in a 362-patient cohort. J Vasc Interv Radiol 2011; 22 (07) 917-923
    CrossrefPubMedGoogle Scholar
  • 72 Bonekamp S, Jolepalem P, Lazo M, Gulsun MA, Kiraly AP, Kamel IR. Hepatocellular carcinoma: response to TACE assessed with semiautomated volumetric and functional analysis of diffusion-weighted and contrast-enhanced MR imaging data. Radiology 2011; 260 (03) 752-761
    CrossrefPubMedGoogle Scholar
  • 73 Bettinger D, Knüppel E, Euringer W. , et al. Efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPSS) in 40 patients with hepatocellular carcinoma. Aliment Pharmacol Ther 2015; 41 (01) 126-136
    CrossrefPubMedGoogle Scholar
  • 74 Luo SH, Chu JG, Huang H, Yao KC. Safety and efficacy of transjugular intrahepatic portosystemic shunt combined with palliative treatment in patients with hepatocellular carcinoma. World J Clin Cases 2019; 7 (13) 1599-1610
    PubMedGoogle Scholar
  • 75 Qiu B, Li K, Dong X, Liu FQ. Transjugular intrahepatic portosystemic shunt for portal hypertension in hepatocellular carcinoma with portal vein tumor thrombus. Cardiovasc Intervent Radiol 2017; 40 (09) 1372-1382
    CrossrefPubMedGoogle Scholar
  • 76 Liu L, Zhao Y, Qi X. , et al. Transjugular intrahepatic portosystemic shunt for symptomatic portal hypertension in hepatocellular carcinoma with portal vein tumor thrombosis. Hepatol Res 2014; 44 (06) 621-630
    CrossrefPubMedGoogle Scholar
  • 77 Yao J, Zuo L, An G. , et al. Risk factors for hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with hepatocellular carcinoma and portal hypertension. J Gastrointestin Liver Dis 2015; 24 (03) 301-307
    CrossrefPubMedGoogle Scholar
  • 78 Zhao JB, Feng C, Zhu QH, He XF, Li YH, Chen Y. Transjugular intrahepatic portosystemic shunt with covered stents for hepatocellular carcinoma with portal vein tumor thrombosis. World J Gastroenterol 2014; 20 (06) 1602-1607
    CrossrefPubMedGoogle Scholar
  • 79 Benjaminov FS, Heathcote J. Liver disease in pregnancy. Am J Gastroenterol 2004; 99 (12) 2479-2488
    CrossrefPubMedGoogle Scholar
  • 80 Russell MA, Craigo SD. Cirrhosis and portal hypertension in pregnancy. Semin Perinatol 1998; 22 (02) 156-165
    CrossrefPubMedGoogle Scholar
  • 81 Ingraham CR, Padia SA, Johnson GE. , et al. Transjugular intrahepatic portosystemic shunt placement during pregnancy: a case series of five patients. Cardiovasc Intervent Radiol 2015; 38 (05) 1205-1210
    CrossrefPubMedGoogle Scholar
  • 82 Wagner L, Lester R, Saldana L. Exposure of the Pregnant Patients to Diagnostic Radiations: A Guide to Medical Management. Second edition. Madison, WI: Medical Physics Publishing; 1997: 108-158
    Google Scholar
  • 83 Savage C, Patel J, Lepe MR, Lazarre CH, Rees CR. Transjugular intrahepatic portosystemic shunt creation for recurrent gastrointestinal bleeding during pregnancy. J Vasc Interv Radiol 2007; 18 (07) 902-904
    CrossrefPubMedGoogle Scholar
  • 84 Wakeford R, Little MP. Childhood cancer after low-level intrauterine exposure to radiation. J Radiol Prot 2002; 22 (3A): A123-A127
    CrossrefPubMedGoogle Scholar
  • 85 Wakeford R, Little MP. Risk coefficients for childhood cancer after intrauterine irradiation: a review. Int J Radiat Biol 2003; 79 (05) 293-309
    CrossrefPubMedGoogle Scholar
  • 86 National Council on Radiation Protection and Measurements. Medical Radiation Exposure of Pregnant and Potentially Pregnant Women. NCRP report no. 54. Bethesda, MD: National Council on Radiation Protection and Measurements; 1977
    Google Scholar
  • 87 Lodato F, Cappelli A, Montagnani M. , et al. Transjugular intrahepatic portosystemic shunt: a case report of rescue management of unrestrainable variceal bleeding in a pregnant woman. Dig Liver Dis 2008; 40 (05) 387-390
    CrossrefPubMedGoogle Scholar
  • 88 Pillai AK, Joseph AM, Reddick M, Toomay S, Kalva S. Intravascular US-guided transjugular intrahepatic portosystemic shunt creation in a second-trimester pregnancy to prophylactically decompress abdominal wall varices before cesarean section. J Vasc Interv Radiol 2014; 25 (03) 481-483
    CrossrefPubMedGoogle Scholar
  • 89 Kao SD, Morshedi MM, Narsinh KH. , et al. Intravascular ultrasound in the creation of transhepatic portosystemic shunts reduces needle passes, radiation dose, and procedure time: a retrospective study of a single-institution experience. J Vasc Interv Radiol 2016; 27 (08) 1148-1153
    CrossrefPubMedGoogle Scholar