Abdominal Intervention for Liver Transplant Candidates

The interventional radiologist plays a critical role in the multi-disciplinary approach to the liver transplant patient.
Pretransplant, the interventionalist uses diagnostic angiographic procedures to define the anatomy for the surgeon. Increasingly, successful interventional radiologic procedures such as transjugular intrahepatic portosystemic shunt (TIPS) and biliary stricture dilation allow transplantation to be delayed. In the posttransplant patient, interventional radiologic manipulation is more effective than surgery in the management of many postoperative
complications.

Interventional radiology as a subspecialty of radiology arose following the introduction of diagnostic catheter angiography in the 1950s, as initially described by Seldinger.
Technical advances in angiography led to so-called interventional applications. One of the earliest was the use of diagnostic catheters for the treatment of gastrointestinal hemorrhage by infusion of vasoconstrictive drugs. The development of the modern balloon dilatation catheter for transluminal angioplasty by Gruntzig et al in the mid-1970s was an important step in converting this predominantly diagnostic modality into a therapeutic one. More recent innovations include a variety of percutaneous drainage procedures and the use of vascular and biliary stents.

Pretransplantation

Diagnostic Arteriography

The pretransplant evaluation is usually performed without angiography. Noninvasive modalities such as ultrasound, computed tomography, and magnetic resonance imaging have largely replaced angiography for diagnostic evaluation in the liver transplant
population. However, on occasion angiography is necessary. Arteriography can easily define the arterial anatomy of the native liver if a significant abnormality or variation is suspected on noninvasive imaging. If the celiac trunk is narrowed by atherosclerosis or
compression by the median arcuate ligament, then aortography not only confirms this prior to transplantation, but also gives precise anatomic detail.

Occasionally, a patient is referred for transplant with known or suspected thrombosis of the portal vein. The surgeon, before contemplating transplant, must be able to find a superior mesenteric vein or vein branch large enough to support the anastomosis to the donor portal vein. Cut-film superior mesenteric arteriography with tolazoline hydrochloride enhancement and prolonged venous filming can delineate this anatomy.

Percutaneous Transhepatic Cholangiography, Biliary Drainage, and Stricture Dilation

Chronic biliary obstruction with subsequent hepatic failure is a common indication for liver transplantation. Primary sclerosing cholangitis, congenital obstructions, and surgical bile duct injuries account for many such candidates. In the course of evaluating these patients for transplantation, it is not unusual to find central ductal strictures that have not been completely treated. If so, liver function can be stabilized or even improved by repair of the underlying abnormality, and transplantation can be deferred. In some instances, this delay is critical in allowing other medical conditions to stabilize.

Abscess Drainage using Minimally Invasive Surgical Solutions and Procedures and Abscess Drainage

What is a percutaneous abscess drainage?

Everyone knows what an abscess is, and how painful it can be, and how ill it can make you feel. In the past, drainage of an abscess inside your chest or abdomen would have required an open operation. Now it is possible to drain abscesses by inserting a fine plastic tube, called a drainage catheter, into it through the skin, with only a tiny incision.
This procedure is called percutaneous (through the skin) abscess drainage.

Why do I need a percutaneous abscess drainage?

Other tests that you probably have had done, such as an ultrasound scan or a CT scan, will have shown that you have an abscess, and that it is suitable for draining through a small tube, rather that by an open operation. Abscesses can make you very ill, and if they occur after surgery, will delay your recovery. Although antibiotics can help, they cannot really be effective against a large abscess. However, once pus has been drained, this can be sent to the laboratory for tests to show which is the best antibiotic to treat the remaining infection.

Who has made the decision?

The consultant in charge of your case, and the radiologist doing the drainage will have discussed the situation, and feel that this is the best treatment option for you. However, you will also have the opportunity for your opinion to be taken into account, and if, after discussion with your doctors, you do not want the procedure carried out, then you can decide against it.

Who will be doing the percutaneous abscess drainage?

A specially trained doctor called a radiologist. Radiologists have special expertise in using x-ray and scanning equipment, and also in interpreting the images produced. They need to look at these images while carrying out the procedure.

Where will the procedure take place?

Generally in the x-ray department, perhaps in a special “screening” room, which is adapted for specialized procedures. If it is necessary to use the CT scanner to guide the drainage, then it will obviously be done in the CT scanning room. It may be done in an operating theater, using mobile x-ray equipment or a portable ultrasound scanner.

How do I prepare for percutaneous abscess drainage?

You need to be an in-patient in the hospital. You will probably be asked not to eat for four hours beforehand, though you may be told you can drink some water. You may receive a sedative to relieve anxiety, as well as an antibiotic. You will be asked to put on a hospital gown.

If you have any allergies, you must let your doctor know. If you have previously reacted to intravenous contrast medium, the dye used for kidney x-rays and CT scanning, then you must also tell your doctor about this.

What actually happens during a percutaneous abscess drainage?

You will lie on the x-ray or scanning table, in the position that the radiologist has decided is most suitable. You need to have a needle put into a vein in your arm, so that the radiologist can give you a sedative to relax you, or painkillers. You may also have a monitoring device attached to your chest and finger, and may receive oxygen through small tubes in your nose.

The radiologist will keep everything as sterile as possible, and may wear a theatre gown and operating gloves. Your skin will be cleaned with antiseptic, and then most of the rest of your body covered with a theatre towel. The radiologist will use the ultrasound machine or the CT scanner to decide on the most suitable point for inserting the fine, plastic drainage catheter. Then your skin will be anesthetized with local anesthetic, and a fine needle inserted into the abscess.

What happens next will vary in different situations. The pus may simply be drained through that needle, or a slightly larger needle or plastic tube, which is then withdrawn altogether. Alternatively, it may be necessary to place a larger drainage tube into the abscess and attach it to the skin so that pus can continue to drain for some days.

Will it hurt?

Unfortunately, it may hurt a little, for a very short period of time, but any pain you have should be controlled with painkillers.

When the local anesthetic is injected, it will sting to start with, but this soon wears off, and the skin and deeper tissues should then feel numb. Later, you may be aware of the needle, or the wire and catheter, passing into the abscess, and sometimes this is painful. There
will be a nurse, or another member of clinical staff, standing next to you and looking after you. If the procedure does become painful for you, then they will be able to arrange for you to have more painkillers through the needle in your arm. Generally, placing the catheter in the abscess only takes a short time, and once in place it should not hurt at
all.

How long will it take?

Every patient’s situation is different, and it is not always easy to predict how complex or how straightforward the procedure will be. It may be over in 20 minutes, or very occasionally it may take longer than 90 minutes. As a guide, expect to be in the x-ray department for about an hour altogether.

What happens afterwards?

You will be taken back to your ward on a trolley. Nurses on the ward will carry out routine observations, such as taking your pulse, blood pressure and temperature, to make sure that there are no problems. You will generally stay in bed for a few hours, until you have recovered.

If the drainage catheter has been left in your body for the time being, then it will be attached to a collection bag. It is important that you try and take care of this. You should try not to make any sudden movements, for example getting up out of a chair, without remembering the bag, and making sure that it can move freely with you. It may need to be emptied occasionally, so that it does not become too heavy, but the nurses will want to measure the amount in it each time.

How long will the catheter stay in, and what happens next?

These are questions which only the doctors looking after you can answer. It may only need to stay in a short time. It is possible that you will need further scans or x-rays to check that the abscess has been drained satisfactorily. You will be able to lead a normal life with the
catheter in place. When the catheter is taken out, this does not hurt at all.

Are there any risks or complications?

Percutaneous abscess drainage is a very safe procedure, and there are very few risks or complications that can arise. Perhaps the biggest problem is being unable to place the drainage tube satisfactorily in the abscess. If this happens, your consultants will arrange another method of draining the abscess, which may involve surgery.

Rarely, you may get a shivering attack (a rigor) during the procedure, but this is generally treated satisfactorily with antibiotics.

Despite these possible complications, the procedure is normally very safe, and will almost certainly result in a great improvement in your medical condition. Very occasionally an operation is required, but if the percutaneous drainage had not been attempted, then this operation would have been necessary anyway.

Biliary Catheters – Bile Drainage and Biliary Tube Care

A biliary catheter, or biliary tube, is a tube that goes through your skin and liver into your bile ducts to drain your bile, a fluid that aids in the digestion of food. Reasons for needing a biliary tube include blockage of the bile ducts, the presence of a hole in the bile ducts, and as preparation for surgery on the bile ducts. In some cases, the bile drains out of your body into a drainage bag. In other cases, the catheter drains the bile into the bowel, and you do not need a bag on the outside.

Possible Problems and Complications
The main problem that can occur with your biliary tube is infection: skin infection around the catheter or bile duct infection. A skin infection can be prevented by taking good care of the skin around the catheter. It is important that you follow these instructions (unless instructed otherwise by your doctor):

    • Keep the skin around your biliary catheter dry.

You can take showers if you cover the area with plastic wrap. If the area does get wet, dry the skin completely after you shower.

    • Keep the skin around your biliary catheter clean.

Clean the area every day or every other day with a cotton swab that has been moistened with peroxide. Always wash your hands before you clean the catheter site.

    • Keep the skin around your biliary catheter covered.

After cleaning the skin around the catheter insertion site, cover the area with a clean bandage or dressing. Change the dressing if it gets wet.

Signs of skin infection include redness, soreness, and swelling of the skin around the catheter. If you notice any of these signs, even if they are very mild, you should follow these instructions unless your doctor specifies otherwise:

  • Clean the site more often than before.
  • Apply antibiotic ointment to the skin around the catheter after each time you clean it.
  • If your symptoms DO improve promptly, keep up the extra care for a total of one week, and then go back to your usual skin care routine.

A bile duct infection occurs if the biliary tube becomes blocked. The best way to avoid this is to flush your biliary tube with sterile saline solution once a day. Flushing with saline keeps the inside of the tube as clean as possible. If your biliary catheter drains bile into an external drainage bag, rinse the bag out with water every day. Lastly, keep your appointments to have your biliary tube changed. It is much easier to replace the catheter than it is to place the original one, and the change can usually be done as an outpatient procedure. Biliary tube changes are typically done every 2-3 months.

If you notice leakage of bile around the biliary tube, this may be a sign that the catheter is blocked. Blockage is frequently accompanied by biliary duct infection; symptoms of this include fever and chills. If you think that your biliary tube may be blocked, contact your interventional radiologist and/or primary care physician immediately. These doctors will arrange for prompt treatment of your problem. In most cases, you will need to have your biliary tube changed, and you may need antibiotic medicine.

Gastrostomy – Minimally Invasive Surgical Solutions and Procedures and Gastrostomy

Gastrojejunostomy
With gastrojejunostomy, or transgastric jejunostomy, techniques similar to direct gastrostomy tube placement can be used to advance a feeding tube through the stomach and duodenum into the jejunum to allow gastrojejunostomy tube feedings. Because gastrojejunostomy tube placement is more difficult and more expensive than gastrostomy tube placement and because it is associated with a higher incidence of tube occlusion and dislodgement, the technique is probably best reserved for patients at higher risk of aspiration. When necessary, previously placed gastrostomy tubes can be converted to gastrojejunostomy tubes.

What is a percutaneous gastrostomy?
Percutaneous gastrostomy is a technique whereby a narrow plastic tube is placed through the skin, directly into your stomach. Once in place the tube can be used to give you liquid food directly into your stomach, to provide nutrition. Because it is done through the skin, it is called percutaneous, and gastrostomy means making an opening into the stomach.

Why do I need percutaneous gastrostomy?
There are several reasons why you may not be able to eat normally at the present time. There may be a blockage at the back of your throat or in your gullet (esophagus), and this is preventing food going down normally. It may be that you have had a stroke, and that this is causing you problems with swallowing, or your gullet may not be working properly for other reasons. If you have had a small plastic tube inserted through your nose, down into your stomach, it may not be large enough to get adequate amounts of food into your stomach. Obviously, if you do not receive enough nutrition, then you will become very ill.

Who has made the decision?
The doctors in charge of your case and the radiologist doing the percutaneous gastrostomy will have discussed the situation and feel that this is the best option. However, you will also have the opportunity for your opinion to be taken into account and if, after discussion with your doctors you do not want the procedure carried out, then you can decide against it.

Who will be doing the percutaneous gastrostomy?
A specially trained doctor called a radiologist will perform the procedure. Radiologists have special expertise in using x-ray and scanning equipment and also in interpreting the images produced. They need to look at these images whilst carrying out the procedure.

Where will the procedure take place?
The procedure is generally carried out in the x-ray department, in a special “screening” room, adapted for this sort of specialized procedure.

How do I prepare for percutaneous gastrostomy?
You need to be an in-patient in the hospital. You may receive a sedative beforehand to relieve anxiety, and possibly an antibiotic. You will be asked to put on a hospital gown. If you have any allergies you must let your doctor know. If you have ever reacted to intravenous contrast medium, the dye used in x-ray departments for kidney x-rays and CT scanning; you must also tell your doctor about this.

What actually happens during a percutaneous gastrostomy?
You will lie on the x-ray table, generally flat on your back. You need to have a needle put into a vein in your arm so that the radiologist can give you a sedative or pain killers. Once in place this needle will not cause any pain. You will have a monitoring device
attached to your finger and will possibly receive oxygen through a small tube in your nose. You may also have a monitoring device attached to your chest.

The radiologist will keep everything as sterile as possible and may wear a theatre gown and operating gloves. The skin below your ribs will be cleaned with antiseptic and most of the rest of your body covered with a theatre towel. Tanaehe radiologist will use the x-ray equipment or an ultrasound machine to decide on the most suitable point for inserting the feeding tube. This will generally be below your left lower ribs. The skin in this area will be anesthetized with local anesthetic.
This can sting a little to start with, but rapidly wears off.

The radiologist will then pass a thin, hollow needle into your stomach using x-rays or ultrasound as a guide. Once the needle is in your stomach, some air will be put in, which makes room for a guidewire to be placed down through the needle into your stomach. The needle is then removed, leaving the guidewire in place, and then a series of small
tubes are passed over the wire, one after another, to enlarge the pathway from the skin into your stomach. Once this pathway is wide enough, a tube (catheter) can be put in through the skin and into your stomach over the guidewire. The guidewire is then removed. The tube will be used to give you food, and is large enough to ensure that you receive adequate nutrition. Once this tube is in place the radiologist will secure the stomach to the muscles underneath the skin with stitches, to prevent the tube falling out. It is also necessary to secure the tube with stitches to the skin surface, again to make it secure.

Will it hurt?
Unfortunately, while the procedure is being done, it may hurt for a very short period of time, but any pain that you have will be controlled with painkillers. When the local anaesthetic is injected it will sting to start with, but this soon wears off, and the skin and deeper tissues should then feel numb. Later you will be aware of the tubes being passed into your stomach, but this should just be a feeling of pressure and not pain. There will be a nurse or some other member of staff standing next to you and looking after you. If the procedure does become painful for you then they will be able to arrange for you to have more painkillers through the needle in your arm. Generally, placing the catheter in the stomach takes only a short time and once in place it should not hurt at all.

How long will it take?
Every patient’s situation is different and it is not always easy to predict how complex or how straightforward the procedure will be. It may be over in 30 minutes but occasionally it can take as long as 90 minutes. As a guide, expect to be in the x-ray department for about an hour and a half altogether.

What happens afterwards?
You will be taken back to your ward on a trolley. Nurses on the ward will carry out routine observations, such as taking your pulse and blood pressure, to make sure that there are no problems. If you have been up and about previously, then you will generally need to stay in bed for a few hours afterwards, until you have recovered.

It is important to try and look after the feeding tube. You should try not to make any sudden movements, for example getting up out of a chair or out of bed without remembering the tube. However, you will be able to lead a perfectly normal life with the tube in place.

How long will the tube stay in and what happens next?
This is a question which can only be answered by the doctors looking after you. It all depends on why you needed the tube in the first place. You do need to discuss this fully with your consultant. The tube needs to stay in place until you can eat and drink normally, and in some cases this might not be for a very long time.

The tube will have a little stopper at its end to stop it leaking. When it is time to put liquid food down the tube, the stopper is removed and liquid food is drawn up into a large syringe and sent down the tube to your stomach. You may be able to learn to do this yourself, or someone may need to do it for you. Once enough food has been put down
the tube, it is necessary to clean the tube by passing clear salt water, called saline, through it, again using a syringe. The stopper is then placed back in the tube, which is then covered.

You will have a specially trained dietician looking after you, who will decide how much liquid food you need to put down the tube, and will show you how to look after the tube properly. He/she will also give you more information about the type of liquid food you are injecting. About two weeks after the procedure the nurses on the ward will take out the
stitches on the skin surface, which are holding the tube in place. The tube should then stay in all by itself.

Are there are risks or complications?
Percutaneous gastrostomy is a very safe procedure. However, there are some risks and complications that can arise, as with any medical treatment.

The biggest problem could be not being able to get the tube into your stomach. This can sometimes happen if you have not been able to eat for a long time and your stomach has shrunk quite a lot. It may not be possible to find it with a small needle. If this happens you may need an operation to place the tube.

Sometimes there is a leak around the tube. This is less likely to happen if the stomach has been attached to the muscles beneath the skin, but it can still sometimes occur. This can lead to the skin around the tube becoming very red and sore. An attempt will be made to treat this but it may become necessary to remove the tube for healing to occur. You need to keep the area around the tube very clean and very dry.

Very rarely a blood vessel can be punctured accidentally when passing the needle into the stomach. This can result in bleeding. This may stop by itself, or if not, you may need a blood transfusion. Occasionally it may require another procedure to block the bleeding artery. This would be done by a radiologist using a fine plastic tube put into the artery.
Very rarely, it may need an operation to stop the bleeding. However, this is a very rare complication.

Needle Biopsy Procedure offered by Minimally Invasive Surgical Solutions and Procedures

What is a percutaneous biopsy?
A needle biopsy is a medical test performed by interventional radiologists to identify the cause of a lump, mass, or other abnormal condition in the body. During the procedure, a small piece of tissue is taken out of your body using only a tiny incision so that it can be examined under a microscope by a pathologist, an expert in making
diagnoses from tissue samples. Because this biopsy is done through the skin, it is called a percutaneous biopsy.

Common Needle Biopsy Sites

  • Adrenal glands
  • Bone
  • Kidney
  • Liver
  • Pancreas
  • Lung masses (Thoracic)

What is a percutaneous biopsy?
A needle biopsy is a way of taking a small piece of tissue out of your body, using only a tiny incision, so that it can be examined under a microscope by a pathologist, an expert in making diagnoses from tissue samples. Because this biopsy is done through the skin, it is called a percutaneous biopsy.

Why do I need a percutaneous biopsy?
Other tests that you probably have had performed, such as an ultrasound scan or a CT scan, will have shown that there is an area of abnormal tissue inside your body. From the scan, it is not always possible to say exactly what the abnormality is due to, and the simplest way of finding out is by taking a tiny piece of it away for a
pathologist to examine.

Who has made the decision?
The consultant in charge of your case, and the radiologist doing the biopsy will have discussed the situation, and feel that this is the best thing to do. However, you will also have the opportunity for your opinion to be considered, and if, after discussion with your doctors, you do not want the procedure carried out, then you can decide against
it.


Who will be doing the percutaneous biopsy?

A specially trained doctor called an interventional radiologist. Radiologists have special expertise in using x-ray and scanning equipment, and also in interpreting the images produced. They need to look at these images while carrying out the biopsy.

Where will the biopsy take place?
Generally in the x-ray department, either in the CT scanning room, or else a “special procedures” room, with an ultrasound machine.
Occasionally, biopsies are performed using an ordinary x-ray machine.

How do I prepare for percutaneous biopsy?
You will lie on the x-ray table, generally flat on your back. You need to You may need to be an in-patient in the hospital, although many biopsies can be performed as an out-patient. You will probably have had some blood tests performed beforehand, to check that you do not have an increased risk of bleeding. You will probably be asked not to eat for four hours beforehand, though you may be allowed to drink some water.
You may receive a sedative to relieve anxiety. You will be asked to put on a hospital gown.

If you have any allergies, you must let your doctor know. If you have previously reacted to intravenous contrast medium, the dye used for kidney x-rays and CT scanning, then you must also tell your doctor about
this.

What actually happens during a percutaneous biopsy?
You will lie on the x-ray, ultrasound or scanning table, in the position that the radiologist has decided is most suitable. You may need to have a needle put into a vein in your arm, so that the radiologist can give you a sedative or painkillers.

The interventional radiologist will keep everything as sterile as possible, and may wear a theatre gown and operating gloves. Your skin will be cleaned with antiseptic, and you may have some of your body covered with a theatre towel. The radiologist will use the ultrasound machine or the CT scanner to decide on the most suitable point for inserting the biopsy needle. Then your skin will be anaesthetised with local anaesthetic, and the biopsy needle inserted into the abnormal tissue.

While the first part of the procedure may seem to take a while, actually doing the biopsy does not take very long at all, and the needle may be in and out so quickly that you barely notice it.

Will it hurt?
Most biopsies do not hurt at all, although unfortunately bone biopsies may be painful. When the local anaesthetic is injected, it will sting to start with, but this soon passes off, and the skin and deeper tissues should then feel numb. Later, you may be aware of the needle passing into your body, but this is generally done so quickly, that it does not cause any discomfort at all.

There will be a nurse, or another member of clinical staff, standing next to you and looking
after you. If the procedure does become painful for you, then they will be able to arrange for you to have more painkillers through the needle in your arm.

How long will it take?
Every patient’s situation is different, and it is not always easy to predict how complex or how straightforward the procedure will be. It may be over in 30 minutes, although you may be in the x-ray department for
about an hour altogether.

What happens afterwards?
You will be taken back to your ward on a trolley. Nurses on the ward will carry out routine observations, such as taking your pulse and blood pressure to make sure that there are no problems. You will generally stay in bed for a few hours, until you have recovered. If you have had a lung biopsy, then you will almost certainly have a chest x-ray performed at some stage.

What happens next?
All being well, you will be allowed home either on the same day, or perhaps the next. Do not expect to get the result of the biopsy before you leave, as it always takes a few days for the pathologist to do all the necessary tests on the biopsy specimen.

Are there any risks or complications?
Percutaneous biopsy is a very safe procedure, but there are a few risks or complications that can arise, as with any medical treatment.

If your liver or kidney is being biopsied, then there is a risk of bleeding from the liver, though this is generally very slight. If the bleeding were to continue, then it is possible that you might need a blood transfusion. Very, very rarely, an operation or another radiological procedure is required to stop the bleeding.

If you are having a lung biopsy performed, then it is possible that air can get into the space around the lung. This generally does not cause any real problem, but if it causes the lung to collapse, then the air will need to be drained, either with a needle, or else with a small tube, put in through the skin.

Unfortunately, not all biopsies are successful. This may be because, despite taking every possible care, the piece of tissue which has actually been obtained is normal tissue rather than abnormal.
Alternatively, although abnormal tissue has been obtained, it may not be enough for the pathologist to make a definite diagnosis. The radiologist doing your biopsy may be able to give you some idea as to the chance of obtaining a satisfactory sample.

Despite these possible complications, percutaneous biopsy is normally very safe, and is designed to save you from having a bigger procedure.

Percutaneous biopsy is a very safe procedure, designed to save you having a larger operation. There are some slight risks and possible complications involved, but these are generally minor and do not happen very often.

Nephrostomy – Minimally Invasive Surgical Solutions and Procedures and Nephrostomy

What is a percutaneous nephrostomy catheter?
A percutaneous nephrostomy catheter is a small flexible, rubber tube that is placed through your skin into the kidney to drain your urine, either into your bladder or directly into an external drainage bag.

Why do I need a percutaneous nephrostomy catheter?

  • You may have a blockage of the ureter (the structure that normally carries urine from the kidney to the bladder).
  • There may be a hole in the ureter or bladder, causing urine to leak.
  • To prepare for surgery or other procedures on the kidney and ureter, such as removal of a large kidney stone.

How do I prepare for the procedure?
If you are already a patient in the hospital, your doctors and nurses will provide you with instructions. You will to be admitted to the hospital after this procedure, so please follow these listed instructions:

Unless otherwise instructed, do not eat any solid foods within 6 hours or drink any clear liquids within 2 hours of your scheduled appointment.

Notify our department as soon as possible:

If you take glucophage, insulin, aspirin, or a blood thinner, let us know so that we can adjust your dosage. You may take your other medications as usual.

Let us know if you have an allergy to x-ray (contrast) dye so that we can take the necessary precautions.

Bring all your medications with you on the day of the procedure.

An Angio nurse will attempt to call you 1-2 days before your scheduled appointment to review these instructions, obtain important medical information, and answer any questions or concerns that you may have.

What happens before the procedure?

  • A nurse and an interventional radiologist (a doctor specially trained to perform this procedure) will talk with you about the procedure in detail, answer your questions, and ask you to sign a consent form.
  • You will be asked to put on a hospital gown, and remove anything metal such as jewelry or false teeth/dentures. If possible, you should leave your valuables and jewelry at home.
  • Your family or significant other(s) will be asked to go to our designated waiting area.
  • An IV will be started for fluids, antibiotics, and pain and sedation medication.
  • You may also need labwork drawn prior to the procedure.

What happens during the procedure?
You will be taken into our procedure room where you will be placed on the x-ray table, lying on your stomach. Your blood pressure, heart rate, and oxygen level will be watched closely. Betadine (a brown-colored iodine soap) will be used to wash the area where the tube will be inserted. Lidocaine or Xylocaine (the same medication a dentist
uses to numb your mouth) will be injected to numb the skin and deeper tissues. It will sting and burn for a few seconds before the area becomes numb. A nurse will also be present to give you medications to help you relax and to reduce your pain.

The interventional radiologist will use x-rays and/or ultrasound to locate your kidney and a needle will be inserted through your skin into the kidneys. Contrast (x-ray) dye will be injected through the needle and the nephrostomy catheter will be inserted into the kidney. You may feel some pressure and discomfort when the tube is inserted.

The nephrostomy catheter site will be covered with a dressing. The catheter itself will be connected to a drainage bag. You may attach the bag to your leg with 2 rubber straps. The urine will flow from your kidney through the catheter into the bag. The fluid may contain some blood at first. However, the blood usually clears over time.


What happens after the procedure?

After the procedure you will be taken to the recovery room or up to your hospital room on a stretcher. Your vital signs will be monitored frequently for a few hours. You may eat your usual diet, unless you are nauseated or your physician has other tests scheduled.

Because everyone is different, the length of stay in the hospital will vary. Before you are discharged from the hospital, an angio nurse will provide care instructions and supplies with a family member or significant other present.

Where will the biopsy take place?
Generally in the x-ray department, either in the CT scanning room, or else a “special procedures” room, with an ultrasound machine.
Occasionally, biopsies are performed using an ordinary x-ray machine.

How long will I need the nephrostomy catheter?
This depends on the reason you needed the catheter:

    • A blockage of the ureter either by stones, infection, scar tissue, or tumor- as long as the blockage is present.
    • A hole in the ureter- until the hole has healed.
    • In preparation for surgery or another procedure on your kidney or ureter- until after surgery.

You doctors will discuss with you how long you are likely to need the drainage catheter.

How do I care for the tube?

    • Empty the bag before it is completely full.
    • Sponge baths are recommended to keep the dressing dry.
    • You cannot go swimming.
    • You can take a shower if you put a plastic covering, such as Saran Wrap, over the area.
    • The dressing should be changed every 3 days or when it gets soiled, wet, or loose. This includes the split sponges, 4×4 gauze, and tape. It is very important to wash your hands before removing the old dressing and then again before applying the new dressing. Tegaderm (a clear plastic tape) holding the blue plastic ring in place and telfa should only be changed once a week or when it becomes soiled, wet, or loose.

How do I change the dressing?

  • Assemble supplies: telfa, tegaderm, scissors, split gauze sponges, 4×4 gauze sponges, tape, connecting tube and drainage bag (if needed).
  • Carefully remove the old dressing, being careful not to pull the drainage catheter and keeping the blue plastic ring against the skin.
  • Inspect the skin around the catheter. Note any unusual redness, tenderness, or drainage. (SEE PROBLEMS YOU MAY EXPERIENCE).
  • Wash your hands thoroughly with soap and warm water.
  • Cut a round piece of telfa, the same size as the blue disc, or slightly larger. Cut a slit in the telfa, so that it will fit around the catheter. Place the telfa under the blue disc.
  • Fold a new Tegaderm in half and cut a hole in the center about the same size of the nipple on the blue disc. Put the catheter through this hole and apply the Tegaderm to the skin. If the catheter is attached to a drainage bag, you must first disconnect the bag, then slip the catheter through the Tegaderm.
  • Place two split gauze sponges around the catheter.
  • Fold 4×4 gauze on each side of the catheter, so you are able to curl the catheter once without kinking it. The catheter should rest on the gauze and not to the skin.
  • Cover the catheter with 4×4 gauze and secure the dressing with tape.
  • Put a piece of tape below the dressing to hold the catheter and act as a safety device.
  • The external drainage bag should be rinsed out and cleaned once a week with soap and warm water. Please allow to dry thoroughly.
    You will be given a second bag to use for these changes.

Supplies may be provided at each appointment. It will be helpful to bring a list of what you need.

How long will it take?
Every patient’s situation is different, and it is not always easy to predict how complex or how straightforward the procedure will be. It may be over in 30 minutes, although you may be in the x-ray department for
about an hour altogether.


You will be scheduled for your tube to be checked every 4 weeks and to be changed every 8 weeks. If you have a morning appointment, please do not eat breakfast, you may have clear liquids. If you have an afternoon appointment, you may eat a light breakfast, but please do not eat lunch. You may take your medications as usual. However, if you are a diabetic on oral hypoglycemics, do not take your pill if you skip breakfast. For those who are diabetic and take insulin regularly: take half of your NPH dose, and take your normal dose of regular insulin if you are eating breakfast. We have chemstrips to take your sugar level and lollipops if you feel your sugar is getting low.

If you are unable to keep your appointment or will be late, please call and let us know.

 

    • The blue plastic ring comes away from the skin.

a. If this is only slightly away from the skin, push it back so that it touches the skin. It should move easily without much force.

b. If it is more than 1 inch away from the skin, you need to call the Angio/Interventional Radiology department, explain the problem and make an appointment for the tube to be checked.

    • The catheter becomes kinked.

a. If it is only slightly kinked, straighten it out and redress it.

b. If the kink is severe and/or there is a knot in the catheter, you need to make an appointment for a tube check.

    • The catheter stops draining into the bag. This may occur for 4 reasons.

a. The catheter may be kinked, so check it when you change the dressing.

b. The stopcock may be turned off, so check to make sure that it is open. When the knob is in line (parallel) with the catheter it is open.

c. If you have done the above and it still does not drain, the catheter may be blocked or the catheter may have moved. Please call the Angio/Interventional Radiology department and make an appointment ASAP to get your tube checked.

    • Skin rash.

If the skin under the tape becomes irritated, you may need to change the type of tape you are using. We can provide you with different tape at your next visit.

    • Leakage around the catheter site and/or the blue plastic ring.

Some clear to light yellow drainage around the catheter insertion site is to be expected for the first 1 to 3 days. If this drainage soaks through the dressing or becomes bloody or contains pus, please call the Angio/Interventional Radiology department for an appointment to check your tube ASAP.

    • Pain.

a. Some discomfort is to be expected for the first week after the insertion of a new catheter. Tylenol, Aspirin, or Ibuprofen may help decrease the pain.

b. If you suddenly develop pain, please call your primary physician and make an appointment to see him/her.

  • Fever.

If you get a fever for more than 12 hours, without another cause for the fever, such as a cold or flu, or if your urine becomes cloudy or bloodier, call the Angio/Interventional Radiology department. If your tube is draining internally, you may be instructed to connect the tube to a drainage bag.

TIPS: Transjugular Intrahepatic Portosystemic Shunts by MISS

What is portal hypertension?
Seen most frequently in patients with liver disease such as cirrhosis or hepatitis, portal hypertension is a condition in which the normal flow of blood through the liver is slowed or blocked by scarring or other damage. Patients with the condition are at risk of internal bleeding or other life-threatening complications. In people with liver failure and cirrhosis, the liver is incapable of processing blood from the bowels. As a result, abnormally high pressure develops within the veins that drain blood from the bowels as the body tries to form other channels for the blood to empty into the main (systemic) circulation. These alternate pathways of blood drainage are known as portosystemic collaterals and consist of fragile veins that surround the esophagus, stomach or other areas in the digestive tract. Because of the fragility of these veins, they are prone to rupturing, which can result in massive amounts of bleeding. The abnormally high pressure within the veins draining into the liver (portal hypertension) can also result in the formation of fluid seeping from the surface of the liver and collecting in large quantities in the abdominal cavity. This is known as ascites. Therapies that lower the blood pressure within the veins draining into the liver can lessen the formation of ascites and lower the risk of bleeding from the fragile veins (varices).

What treatments can lower the blood pressure in the portal venous system?
A number of therapies can lower the pressure of the veins that drain from the bowel into the liver.

The first choice of therapy usually consists of drug therapy with medications known as non-selective beta-blockers. These medications need to be taken every day to produce an effect. Some people may not be able to remain on beta-blocker therapy if they develop side effects from taking them. Other people on beta-blocker therapy will remain at risk for bleeding from varices and from the development of fluid formation (ascites).

Another approach is to seal off the veins to prevent rupturing. In sclerotherapy, a camera (endoscope) is passed down through the esophagus to inject the abnormal veins with substances that close them off. With variceal band ligation, the abnormal veins are tied off with small rubber bands. Although sclerotherapy and variceal band ligation are very effective in targeting the abnormal and fragile veins around the esophagus, they do not lower the pressure of the blood inside the portal venous system. This portal hypertension may continue to allow fluid to develop inside the abdominal cavity, or may allow bleeding to occur from other areas of the bowel such as the stomach (portal gastropathy).

Transjugular Intrahepatic Portosystemic Shunts (TIPS) and Surgical Shunts
Pressure inside the portal venous system draining blood into the liver can be relieved by shunting blood away from these veins. Surgical portacaval shunts require an abdominal incision followed by sewing together a portion of the portal venous system to the main venous system. Often these two structures are connected using a short piece of tubing made of Teflon /trademark/. The surgical shunts are highly effective at reducing the risk of bleeding from varices. Most surgical shunts will also relieve ascites. The main drawback of surgical shunts is that they are major vascular surgery, and may be associated with a high risk of complications in some patients.

The transjugular intrahepatic portosystemic shunt (TIPS) acts like a surgical shunt in diverting blood away from the congested portal vein into the main venous system, but it is minimally invasive (not major) surgery. Unlike surgical shunts, TIPS is performed through a small nick in the skin, working through specialized instruments, which are passed through the body using an x-ray camera for guidance. The TIPS procedure creates a shunt within the liver itself, by linking the portal vein with a vein draining away from the liver (a hepatic vein) together with a device called a stent. The stent acts a scaffold to support the connection between these two veins inside the liver. With the TIPS stent in place, the pressure inside the portal veins is relieved by the blood draining through the stent into the vein draining blood away from the liver.

Liver Transplant
The best way to relieve the excessive pressure within a person’s portal venous system is by replacing their liver with a new one capable of filtering the blood. However, many people are not candidates for a liver transplant. The selection process for determining who is a good candidate for a liver transplant may be complicated and require a long period of time. Even in people who are candidates for a liver transplant, less than a third will ever receive a liver; in these people, TIPS may serve as a potentially lifesaving bridge to transplantation while they await the availability of a donor liver.

How well does a TIPS work?
Over 90% of people that undergo TIPS to prevent bleeding from varices will have a relief in their symptoms and experience little to no bleeding thereafter. When TIPS is performed for ascites, 60-80% of people will have relief in their ascites. Some of these patients will no longer require paracentesis, a procedure where a needle is placed into the abdominal cavity to drain away excessive fluid. Other patients will still need paracentesis, but much less often than before the TIPS procedure. When TIPS is performed for other liver conditions, such as Budd-Chiari syndrome, many patients will have a return to nearly normal liver function once the congested blood drains through the TIPS.


How long will a TIPS work?

Unfortunately, the TIPS can develop areas of narrowing or blockage within the liver. Usually, these areas can be detected early through regular ultrasound scans performed every three months. Once an area of narrowing has been identified, it can be treated with a balloon to widen the area of blockage (angioplasty). The angioplasty restores normal blood flow through the TIPS. This procedure, known as a TIPS revision, can be performed as a day procedure on an outpatient basis.

Ongoing research to improve TIPS technology includes a TIPS created with special metal sleeves (stents) lined with a thin synthetic covering to act as an inert barrier between the stent and the liver.

How will I know if I am a candidate for TIPS?
Most patients with portal hypertension do not need to have a TIPS. Patients that have esophageal varices and problems with bleeding can often be managed with the drug therapy described above. However, for those patients that continue to be at risk for bleeding or who cannot tolerate the usual first-line treatments, TIPS may be an effective form of therapy. In patients with ascites who continue to form large amounts of fluids within their abdomen, even while taking water pills (diuretics), and who require frequent sessions of paracentesis to drain away the fluid, TIPS may also be a very effective therapy.

TIPS is performed by an Interventional Radiologist. The Interventional Radiologist will determine from your medical history, physical, blood work and liver imaging (CT scans, ultrasounds and/or MRI scans), in consultation with your gastroenterologist, hepatologist, or surgeon, whether or not you are a candidate for TIPS.

You should discuss all your treatment options with your physician. Some questions to ask include:

  • Can my portal hypertension be controlled with drug therapy?
  • What medications might be appropriate for me?
  • If a procedure is required, am I a candidate for a less
    invasive, Interventional Radiology treatment like a transjugular
    intrahepatic portosystemic shunt?
  • What are the risks and benefits of the treatment plan prescribed for me?

What are the risks of TIPS?
Because blood that normally flows through the liver gets bypassed through a TIPS, some of the substances absorbed into the body from the intestines can build-up within the blood stream and produce a condition known as hepatic encephalopathy. This is a condition that can affect your brain, causing difficulty in concentration, excessive sleepiness and, in rare cases, a coma. Most cases of hepatic encephalopathy are manageable by taking a medication known as lactulose. This is a laxative in a syrup form that reduces the amount of certain types of toxins absorbed by the intestines into the blood stream. In rare situations, a person can develop severe hepatic encephalopathy after TIPS. If this occurs, the TIPS may need to be closed off or a smaller stent placed within the original stent to slow down the amount of blood passing through the TIPS. Other risks of TIPS include hepatic failure, bleeding and infection.