Volume 4 Number 1 Winter 98

Master List Volume 4 Number 1 Winter 1998

IN THIS ISSUE

UAB Radiology

On The Web

FAQs

Transjugular Intrahepatic Portosystemic Shunts (TIPS)

Research In Radiology At UAB - Presented at RSNA '97
(Radiological Society of NA)

UAB Radiology on the Web

The dramatic growth of the internet has finally begun to provide clinically useful improvements in information and image management to patients and referring physicians utilizing the UAB department of radiology. Many of these advances involve "the world wide web" ("the web"), an internet standard that provides for the presentation of formatted text and graphics via the internet in a platform independent manner with hypertextual links. The UAB radiology department is currently using the web for internal information sharing via the department "intranet," external information provision via the department internet "home page" and educational purposes through the web based "radiology teaching file." Most exciting from the viewpoint of referring physicians will be the upcoming web based "radiology image distribution project," to be implemented during the next calendar year.

Personnel within the radiology department have been taking advantage of the radiology intranet web server for the past year. Recently presented at the Radiological Society of North America (RSNA) annual meeting, this web server provides an up-to-date database with attending daily work schedules, faculty call schedules and resident rotation schedules. There is also a complete database of all radiology personnel (over 300 people), including beeper and phone numbers, a pictorial directory of the radiology residents and fellows, an events calendar, informational postings such as faculty meeting minutes, and a software distribution section with software updates and utilities. Maintained by Dr. Steve Willing, this page is currently available at http://vulcan.rad.uab.edu

In contrast, the radiology department "home page" at http://www.rad.uab.edu is primarily aimed at users outside the department such as referring physicians and resident, fellow or faculty applicants. It provides general information about the radiology department and its training programs, as well as a web version of this newsletter and a pictorial faculty directory. There are links to other UAB sites and other radiology sites, as well as to our web based radiology teaching file.

The UAB Radiology Teaching File is used heavily by our own residents, residents in other radiology training programs, and also by practicing radiologists and physicians. With over 400 cases, it is the largest collection of radiology teaching cases on the web in America and was recognized with a certificate of merit at the recent RSNA annual meeting. Teaching cases contain a brief patient history, pertinent images and a description of the findings as well as the diagnosis and a brief discussion. Cases are used as unknown cases by radiology residents and fellows, but also as a searchable database of imaging findings by radiologists and other physicians. It currently attracts over 2000 "hits" per day and is used regularly by residents and physicians throughout the world.

Digital image distribution on the Web

The implementation by imaging equipment manufacturers of the DICOM Standard for image communication and the emergence of improved image compression have made reliable efficient distribution over the web possible for a substantial percentage of UAB radiology images.

Improvements in UAB health system information services and network infrastructure should make this a clinical reality within the next year. Upgrades of PIN terminal to Pentium Windows 95 and ongoing upgrades of the health systems network to the ATM standard will allow for rapid reliable image distribution and viewing without the expensive dedicated viewing hardware and network bottlenecks we would have seen in the recent past. Recent successful implementation of the Clinical Document Access Project will also provide a framework upon which to attach the web based image distribution.

For the past year the radiology department has been concentrating on the infrastructure needed for this ambitious project, including conversion to digital imaging and upgrades of existing digital equipment to DICOM standards. Initial web based image distribution will focus on areas in which digital images are already being obtained. Currently the department performs all radiology in the emergency department on a new digital system, and almost all portable radiographs in the hospital are digital. Upright chest radiographs in the hospital are made with a direct digital system, while CT, MRI and Ultrasound are inherently digital modalities. Neuroangiography and soon all body angiography will be performed on digital systems, and GI fluoroscopy has recently converted one room to digital, with the other two to be converted in 1998.

Over the next year radiology, in coordination with health system information services, will implement the clinical image distribution portion of the project. Rapid retrieval of clinical images integrated with the radiologist reports increases efficiency of clinical decision making and thus patient care in the UAB system. We anticipate substantial time savings to our referring physicians by minimizing the need to travel to the radiology department or the film library, substantially reduce time to locate or retrieve images, and allow for multiple consulting physicians to simultaneously review images when needed. Lost exams should be virtually eliminated, resulting in time and cost savings from avoiding repeat exams or missing diagnostic information that previously would have been lost. With widespread availability of clinical images electronically the hospital will also be able to stop filming (and often double filming) digital images with huge direct cost savings on film, chemicals and personnel and facilities space involved with film handling.

Although "the Web" has been over hyped, it is beginning to become a useful tool for radiology and the UAB health
system. Look for UAB Radiology "on the web" to be a big "hit."

We welcome your questions or comments. Please feel free to contact:

J. Kevin Smith, MD, PhD jksmith@uabmc.edu

Lincoln L. Berland, MD lberland@uabmc.edu

Steve J. Willing, MD (swilling@uab.edu)

Kevin Junck, PhD, Director Radiology Informatics kjunck@uabmc.edu

Top of Page

FAQS - Frequently Asked Questions
Transjugular Intrahepatic Portosystemic Shunts

TIPS procedure performed for intractable ascites.

1. Transhepatic portography demonstrates extensive varices. Porto-systemic gradient is 27mm Hg.

2. Tract is dilated with a 10mm x 4cm balloon.

3. A 10mm x 6cm Wall Stent is placed along tract.

4. Post TIPS images show widely patent shunt and decreased filling of varices. Porto-systemic gradient is 8mm Hg.

Q: What is a "TIPS"?

TIPS is an acronym for Transjugular Intrahepatic Portosystemic Shunt. The procedure entails creation of a porto-systemic shunt in the liver parenchyma by an Interventional Radiologist using percutaneous techniques. Although, originally conceived in the late 1960's, the procedure did not become clinically relevant until the advent of metallic stents in the late 1980's. In recent years, the TIPS procedure has become readily available and it now is widely regarded as an important tool in the management of patients with portal hypertension.

Q: What are the current indications for TIPS?

Accepted indications for TIPS include acute variceal bleeding which cannot be controlled with standard medical therapy, including sclerotherapy; and recurrent variceal bleeding in patients who are refractory or intolerant to conventional therapies. Refractory ascites is also quickly becoming an accepted indication for TIPS. TIPS is showing promise in the treatment of patients with Budd-Chiari syndrome.

Q: What are contraindications to a TIPS procedure?

Absolute contraindications for TIPS include; right-sided heart failure with elevated central venous pressures and polycystic liver disease. Relative contraindications include active infection, severe encephalopathy, and portal vein thrombosis.

Q: What pre-procedure evaluation is needed?

History, physical examination, laboratory, and all other tests are reviewed. If the patient is stable, the procedure is scheduled electively to correct coagulopathies if necessary and drain ascites if present. The latter can mobilize the liver and make the angle between the IVC and the hepatic vein sharp which will add considerably to the difficulty of the procedure. If the patient is acutely bleeding, every effort should be made to stabilize the patient and arrest the bleeding. Blood products are transfused as necessary. Coagulopathy and platelets are corrected with fresh frozen plasma and platelet transfusion, if indicated. The procedure is explained to the patient and their families and informed consent is obtained. Antibiotics are recommended by many authors. However, we have not administered antibiotics routinely to our patients, and we have not had any documented infectious complications. A baseline ultrasound study prior to TIPS is crucial to exclude portal vein thrombosis. Although TIPS is possible in the presence of portal vein thrombosis; TIPS is more difficult in these patients and this information should be known prior to TIPS so that technical modifications are made to allow access into the thrombosed portal vein.

Q: How is a TIPS procedure performed?

The TIPS procedure is performed in the angiography suite by a team of interventional radiology nurses and physicians. Conscious sedation is usually adequate for anxiolysis and pain control. Continuous hemodynamic monitoring is performed. Under fluoroscopic guidance, a catheter is advanced from a right internal jugular approach into the right hepatic vein. A needle is then passed anteriorly into the portal vein. The tract is dilated and a metallic stent placed to maintain patency. The procedure is considered successful when the pressure gradient between the portal vein and the IVC is <12mm Hg. An ultrasound of the liver is obtained the next day to confirm patency of the shunt and to obtain baseline velocity measurements for future follow-up.

Q: What are potential complications?

Tips has a 10-15% overall complication rate with a 1-2% acute mortality. Tips related complications can be divided into those related to the technical aspects of the procedure and those related to portal-systemic shunting and it's hemodynamic sequelae.

Under the first category, the most common is perhaps bleeding related to extra hepatic needle puncture. Although we have observed this to occur not infrequently in patients with shrunken fibrous livers surrounded by ascites, this has only rarely resulted in any significant bleeding. However, fatal bleed can occur. Problems with stent placement can occur, but are usually easily handled during the procedure itself.

The most common complication related to portal-systemic shunting is new or worsened hepatic encephalopathy. This can occur in up to 35% of cases; it usually responds well to standard medical therapy. Acute liver failure is an uncommon, but potentially fatal complication of any porto-systemic shunt procedure that is occasionally seen post-TIPS.
The most common delayed complication is restenosis and thrombosis of the shunt. This can occur in up to 75% of the cases, however it is usually easily treated with angioplasty of the area in question and re-stenting as needed.

Q: What kind of results can I and my patients expect?

Initial technical success rates in several large series range from 93-100%. Control of bleeding is usually very effective with no further bleeds at one year in 80-90% of patients with a successful TIPS. Patients treated for refractory ascites can also expect good results with 79-92% experiencing either resolution or significant improvement post-TIPS.

Q: What type of long term care is necessary?

Ultrasound is recommended every three months to evaluate shunt patency and detect occurrence of stenoses. Stenosis and thrombosis of the shunt is a common delayed complication. If a problem is suspected on ultrasound, the patient is referred for angiography. If a problem is present it can be treated at that time. Shunt stenoses are easier to treat when detected prior to shunt thrombosis. Prompt treatment of shunt related problems also helps prevent new variceal bleeds.

Q: Is TIPS available at UAB?

TIPS is performed by the physicians in the Interventional Radiology Section. To date we have performed over 150 TIPS procedures for a variety of indications. Our technical success rate is 97%. Our complication rates have been low and patients have done well with low incidence of rebleeding.

Q: How do I schedule a patient for a TIPS?

Because of the inherently invasive nature of the procedure and its potential risks, patients should generally be discussed with one of the Interventional Radiology physicians prior to scheduling. Patients can be admitted through same-day admitting if desired and can plan to spend one or two nights in the hospital post-procedure. Most of our patients are referred through the UAB Liver Center.

Top of Page

Research Radiology at UAB:
Recent Abstracts Presented at RSNA '97

Scientific Sessions:
P.J. Kenney, MD. Presiding: Genitourinary

L.L. Berland, MD, J.K. Smith, M.D., PhD, T.M. Weber, MD, K. Hodgson, G. Lewey, BS, RT. Long-term gains in report turnaround time maintained after suspending performance improvement program.

T.M. Weber, MD, M.L. Robbin, MD, P.J. Kenney, MD, D.E. Morgan, MD, J.K. Smith, MD, PhD. Ultrasound contrast agent imaging of renal masses.

J.A. Temo, MD, B.J. Wagner, MD, P. Rao, MD, P.J. Kenney, MD. Imaging of adrenal hemangiomas.

T.L. Krebs, MD, B.J. Wagner, MD, P.J. Kenney,. MD. MR appearances of pheochromocytoma of the adrenal gland with pathologic correlation.

L. Needleman, MD, M.L. Robbin, MD, D.L. Brown, MD, G.W. Boland, MD, B.B. Goldberg, MD. Phase II radiology clinical trial of DMP 115, a new ultrasound contrast agent.

B.C. Jones, MD, L.K. Nallamala, MD, MD, J.K. Smith, MD, Ph.D., S. Saddekni, MD, M.L. Robbin, MD, R.L. Ballard, MD, et al. Doppler sonography of transjugular intrahepatic portosystemic shunts: value of intrashunt flow velocity measurements in detecting stenosis of shunt or draining vein.

J.K. Smith, MD, PhD, M.E. Lockhart, MD, M.L. Robbin, MD, L.L. Berland, MD, T.M. Weber, MD, G.S. Roubin, MD, PhD. Assessment of new criteria for the duplex Doppler ultrasound detection of clinically significant carotid artery stenosis.

Refresher Course:
M.L. Robbin, MD. Update course in diagnostic ultrasound: clinical questions- practical answers. The importance of sonography in the evaluation of abnormal liver function test.

E. Dubovsky, MD, PhD, D.W. Young, MD. Genitourinary nuclear medicine.

W.T. Sobol, PhD. Update course on technical aspects of breast imaging: mammography imaging physics. X-ray equipment considerations.

E. Rubin, MD. Effect of tumor biology on breast cancer detection. Breast cancer growth rates.

infoRAD Exhibits:
J.K. Smith, MD, PhD, D.D. Thornton, MD, L.L. Berland, MD. Optimizing a web based radiology learning file for speed. Received a Certificate of Merit Award.

S.J. Willing, MD. Implementing a radiology departmental intranet: technical requirements and practical application.

Scientific Exhibits:
S. Khoury, MBBCh, C.A. Boles, MD, M.S. Cohen, MD, S. Nagy, MD, W.K. Bernreuter, MD, G. Derman, MD, et al. Soft tissue masses of the hand and wrist: MR imaging with pathologic correlation.

M.D. Bridges, MD, R.V. Finkbeiner, MS. The chest, plain - lobar and segmental anatomy.

Top of Page

Visions is published quarterly by the University of Alabama Hospital, Department of Radiology. Professor and Chairman: Robert J. Stanley, MD, Vice-Chairman for Operations and Academic Affairs: Robert E. Koehler, MD, Vice Chairman for Planning and Administration: Lincoln L. Berland, MD, Director of Outpatient Services: Peter Dempsey, MD. Visions Staff - Managing Editor: Pat Moore. Editors/Writers: Lincoln L. Berland, MD, Rachel Oser, MD, Robert Lopez, MD. Web Master: J. Kevin Smith, MD, PhD. Creative Services Staff - Editor: Jo Lynn Orr. Art Director: Jason Bickell. Please direct questions, comments, and suggestions as follows: Attention Angie French or Lincoln L. Berland, MD. Fax: 975-7213 Address: NHB 623B E-Mail lberland@uabmc.edu UAB Radiology Home Page: www.rad.uab.edu


1. Transhepatic portography demonstrates extensive varices. Porto-systemic gradient is 27mm Hg.	2. Tract is dilated with a 10mm x 4cm balloon.	3. A 10mm x 6cm Wall Stent is placed along tract.	4. Post TIPS images show widely patent shunt and decreased filling of varices. Porto-systemic gradient is 8mm Hg.

Q: What is a "TIPS"?	TIPS is an acronym for Transjugular Intrahepatic Portosystemic Shunt. The procedure entails creation of a porto-systemic shunt in the liver parenchyma by an Interventional Radiologist using percutaneous techniques. Although, originally conceived in the late 1960's, the procedure did not become clinically relevant until the advent of metallic stents in the late 1980's. In recent years, the TIPS procedure has become readily available and it now is widely regarded as an important tool in the management of patients with portal hypertension.
Q: What are the current indications for TIPS?	Accepted indications for TIPS include acute variceal bleeding which cannot be controlled with standard medical therapy, including sclerotherapy; and recurrent variceal bleeding in patients who are refractory or intolerant to conventional therapies. Refractory ascites is also quickly becoming an accepted indication for TIPS. TIPS is showing promise in the treatment of patients with Budd-Chiari syndrome.
Q: What are contraindications to a TIPS procedure?	Absolute contraindications for TIPS include; right-sided heart failure with elevated central venous pressures and polycystic liver disease. Relative contraindications include active infection, severe encephalopathy, and portal vein thrombosis.
Q: What pre-procedure evaluation is needed?	History, physical examination, laboratory, and all other tests are reviewed. If the patient is stable, the procedure is scheduled electively to correct coagulopathies if necessary and drain ascites if present. The latter can mobilize the liver and make the angle between the IVC and the hepatic vein sharp which will add considerably to the difficulty of the procedure. If the patient is acutely bleeding, every effort should be made to stabilize the patient and arrest the bleeding. Blood products are transfused as necessary. Coagulopathy and platelets are corrected with fresh frozen plasma and platelet transfusion, if indicated. The procedure is explained to the patient and their families and informed consent is obtained. Antibiotics are recommended by many authors. However, we have not administered antibiotics routinely to our patients, and we have not had any documented infectious complications. A baseline ultrasound study prior to TIPS is crucial to exclude portal vein thrombosis. Although TIPS is possible in the presence of portal vein thrombosis; TIPS is more difficult in these patients and this information should be known prior to TIPS so that technical modifications are made to allow access into the thrombosed portal vein.
Q: How is a TIPS procedure performed?	The TIPS procedure is performed in the angiography suite by a team of interventional radiology nurses and physicians. Conscious sedation is usually adequate for anxiolysis and pain control. Continuous hemodynamic monitoring is performed. Under fluoroscopic guidance, a catheter is advanced from a right internal jugular approach into the right hepatic vein. A needle is then passed anteriorly into the portal vein. The tract is dilated and a metallic stent placed to maintain patency. The procedure is considered successful when the pressure gradient between the portal vein and the IVC is <12mm Hg. An ultrasound of the liver is obtained the next day to confirm patency of the shunt and to obtain baseline velocity measurements for future follow-up.
Q: What are potential complications?	Tips has a 10-15% overall complication rate with a 1-2% acute mortality. Tips related complications can be divided into those related to the technical aspects of the procedure and those related to portal-systemic shunting and it's hemodynamic sequelae. Under the first category, the most common is perhaps bleeding related to extra hepatic needle puncture. Although we have observed this to occur not infrequently in patients with shrunken fibrous livers surrounded by ascites, this has only rarely resulted in any significant bleeding. However, fatal bleed can occur. Problems with stent placement can occur, but are usually easily handled during the procedure itself. The most common complication related to portal-systemic shunting is new or worsened hepatic encephalopathy. This can occur in up to 35% of cases; it usually responds well to standard medical therapy. Acute liver failure is an uncommon, but potentially fatal complication of any porto-systemic shunt procedure that is occasionally seen post-TIPS. The most common delayed complication is restenosis and thrombosis of the shunt. This can occur in up to 75% of the cases, however it is usually easily treated with angioplasty of the area in question and re-stenting as needed.
Q: What kind of results can I and my patients expect?	Initial technical success rates in several large series range from 93-100%. Control of bleeding is usually very effective with no further bleeds at one year in 80-90% of patients with a successful TIPS. Patients treated for refractory ascites can also expect good results with 79-92% experiencing either resolution or significant improvement post-TIPS.
Q: What type of long term care is necessary?	Ultrasound is recommended every three months to evaluate shunt patency and detect occurrence of stenoses. Stenosis and thrombosis of the shunt is a common delayed complication. If a problem is suspected on ultrasound, the patient is referred for angiography. If a problem is present it can be treated at that time. Shunt stenoses are easier to treat when detected prior to shunt thrombosis. Prompt treatment of shunt related problems also helps prevent new variceal bleeds.
Q: Is TIPS available at UAB?	TIPS is performed by the physicians in the Interventional Radiology Section. To date we have performed over 150 TIPS procedures for a variety of indications. Our technical success rate is 97%. Our complication rates have been low and patients have done well with low incidence of rebleeding.
Q: How do I schedule a patient for a TIPS?	Because of the inherently invasive nature of the procedure and its potential risks, patients should generally be discussed with one of the Interventional Radiology physicians prior to scheduling. Patients can be admitted through same-day admitting if desired and can plan to spend one or two nights in the hospital post-procedure. Most of our patients are referred through the UAB Liver Center.