Chronic portal vein thrombosis (PVT) is a challenging condition to diagnose and manage due to the presence of complex, concomitant comorbidities and rapidly evolving clinical evidence. The purpose of this article is to review the clinical presentation, guidelines and evidence supporting invasive and noninvasive management strategies for PVT, including information about the technical evolution and outcomes for portal venous recanalization (PVR) with transjugular intrahepatic portosystemic shunt (TIPS) creation (PVR-TIPS), particularly in the setting of newly available literature and guidelines. Additionally, we describe our technique for PVR-TIPS.

Benign biliary strictures can occur as sequelae after inflammatory processes of the hepato-pancreato-biliary system; they can also occur as a major complication after liver and pancreas surgery. Such strictures are so strongly associated with outcomes after liver and pancreas surgery that they are now included as a required “core outcome” for reporting after a liver transplant. Options for the management of benign biliary strictures include endoscopic, percutaneous, and surgical techniques. Retrograde endoscopy or antegrade percutaneous interventions are first-line therapies, with surgical management reserved for recalcitrant cases. Overall, biliary strictures are best managed by multidisciplinary teams at tertiary-care centers to ensure that the most advanced and least invasive approaches are available. This article reviews all three techniques for the management of benign biliary strictures, with a focus on multidisciplinary approaches for complex stricture disease.

Liver augmentation techniques are critical in managing primary liver cancer and liver metastases, particularly for patients with insufficient future liver remnants (FLR). These methods aim to reduce the risk of post hepatectomy liver failure (PHLF), a major cause of postoperative mortality. Techniques such as portal vein embolization (PVE), liver venous deprivation (LVD), and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induce hypertrophy of the FLR, enabling curative surgery for patients previously deemed inoperable. Functional assessment tools, including hepatobiliary scintigraphy and MRI with hepatocyte-specific contrast, are increasingly utilized to evaluate liver function and predict postoperative outcomes. Pathophysiology and factors influencing liver regeneration including patient-specific conditions are explored. Additionally, tumor-specific considerations, such as hepatocellular carcinoma in cirrhotic livers, and biliary malignancies with cholestasis, highlight the need for tailored approaches. Emerging innovations, including artificial intelligence, show promise in improving volumetric assessments and patient selection. Advancements in liver augmentation techniques have expanded surgical eligibility, improved oncologic outcomes, and reduced complications, marking a transformative shift in the management of liver cancers.

Liver resection can improve survival in patients with primary or secondary liver tumors, but insufficient future liver remnant (FLR) volume can be a contraindication to surgery in these patients. Portal vein embolization (PVE) has been the standard preoperative strategy used to induce FLR hypertrophy in this population; however, PVE provides only modest hypertrophy over a relatively long time frame. The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique offers rapid hypertrophy but is a more invasive and complex procedure. Liver vein deprivation (LVD) has therefore been introduced as an alternative, less invasive technique for inducing preoperative liver hypertrophy. This article outlines the rationale underlying the LVD procedure and the techniques that are commonly used for percutaneous portal and hepatic vein embolization. The literature is then reviewed to assess the outcomes associated with LVD vs with PVE and ALPPS. Contemporary case series have demonstrated that LVD is safe and more effective than PVE in achieving adequate FLR hypertrophy within a shorter interval. Additionally, although ALPPS remains the fastest method for FLR augmentation, LVD offers a less invasive alternative. LVD therefore expands the interventional radiologist’s armamentarium for liver regeneration, addressing PVE’s limitations by achieving greater and quicker hypertrophy without the surgical stress of ALPPS. Early clinical experience and emerging data suggest that LVD can improve the odds of successful resection and may narrow the gap between endovascular and surgical hypertrophy techniques.

Management of portal hypertension commonly involves the creation of a transjugular intrahepatic portosystemic shunt (TIPS). Despite significant advancement in procedural techniques, hepatic encephalopathy (HE) continues to be one of the most consequential complications following TIPS creation. In this manuscript, we describe in detail several factors associated with the clinical condition of patients and TIPS creation that increase the likelihood of post TIPS development of hepatic encephalopathy. We also discuss the management of the post-TIPS encephalopathic patient.

PURPOSE:To determine the technical and clinical success rates and outcomes of portal vein recanalization (PVR) and portal and visceral vein recanalization (PVVR) with transjugular intrahepatic portosystemic shunt (TIPS) placement for the management of portal vein thrombosis (PVT), including with thrombus extension into tributary visceral veins (PVVT). MATERIALS AND METHODS:This retrospective study included 43 consecutive patients who underwent PVR or PVVR-TIPS placement at a single medical center. Of the 43 patients, 38 (88.4%) had chronic thrombus, and 21 (48.9%) had Yerdel Grade III or IV PVVT. Indications for PVR/PVVR-TIPS included variceal bleeding, refractory ascites, and liver transplant or surgical candidacy for patients with partial or complete occlusion. Evaluated outcomes included technical and clinical success rates, adverse events, main PV and TIPS patency, and reintervention rates. Cox proportional hazards regression analysis was used to evaluate potential predictors of reocclusion and need for reintervention. RESULTS:The technical and clinical success rates were 97.7% and 92.7%, respectively. Seven patients (16.3%) had adverse events. Over a median follow-up of 10.7 months, Kaplan-Meier analysis demonstrated primary patency rates of 86%, 61%, and 46% at 1, 6, and 12 months, respectively. The primary-assisted patency rates were 94%, 87%, and 74% at 1, 6, and 12 months, respectively. Reinterventions were needed in 18 patients (41.9%). No significant predictors of reocclusion or need for reintervention were identified. Eight patients underwent successful liver transplant; 7 received an end-to-end PV anastomosis. CONCLUSIONS:PVR/PVVR-TIPS placement is safe, technically feasible, and associated with durable clinical improvement with high patency rates in patients with PVT, including with extension into tributary visceral veins.

Functional liver assessment has undergone major evolution over the past 30 years. Assessment techniques have progressed from biochemical markers to advanced imaging techniques, particularly nuclear medicine imaging, to improve accuracy. The focus of assessment has also shifted from global hepatic function to precise segmental evaluation. This paradigm shift has greatly influenced liver-directed therapies such as hepatic resection, augmentation, transplantation, and interventional radiology. The aim of this review was to synthesize key developments in liver function assessment, including nuclear medicine techniques, hepatocyte-specific magnetic resonance imaging (MRI), and emerging multimodal and artificial intelligence (AI)-driven approaches. Select literature from the past three decades was examined, with an emphasis on innovations, validation studies, and clinical applications. Incorporating Tc-99 m mebrofenin hepatobiliary scintigraphy (HBS) into liver function assessment allowed quantitative, regional mapping of hepatocellular function. Gadoxetate-enhanced dynamic magnetic resonance imaging (MRI) has created an opportunity for high-contrast resolution images and noninvasive assessment of hepatocyte uptake and excretion. Novel positron emission tomography tracers such as C-11 acetate enabled the combined evaluation of parenchymal function and tumor biology. Studies exploring multimodal fusion, artificial intelligence (AI)-assisted image processing, and incorporating deep learning into predictive models for individualized risk assessment are underway. Overall, integrating anatomical and functional data has become increasingly widespread, allowing for a more precise evaluation of liver function and improvement of therapeutic outcomes. However, reproducibility, standardization, and accessibility remain potential impediments to broad implementation. Future directions for research include prospective validation studies, multimodal fusion, utilizing deep learning in risk stratification, and the development of individualized treatment strategies tailored to patient-specific risk profiles.

Portal hypertension is a complex and multifaceted condition that arises from increased resistance to portal blood flow, often secondary to prehepatic, intrahepatic, or post hepatic etiologies. The most common cause of portal hypertension in the United States is cirrhosis, which leads to structural and dynamic changes in the liver, exacerbating portal resistance and triggering a cascade of complications. Accurate diagnosis and management are critical to mitigating these risks and improving patient outcomes. Noninvasive imaging techniques, including ultrasound, CT, MRI, and elastography, have revolutionized the diagnosis and monitoring of portal hypertension. These modalities provide qualitative and quantitative measures of liver and spleen stiffness, portal vein flow, and morphological changes, enabling early risk stratification and intervention. Invasive techniques, such as hepatic venography with pressure measurement, remain the gold standard for diagnosing portal hypertension, particularly in for cases where in which noninvasive methods are inconclusive. Direct portal pressure measurement, although more invasive than these other techniques, is occasionally necessary in specific clinical scenarios. Liver biopsy, whether percutaneous, transjugular, or transfemoral, remains a crucial tool for histopathological diagnosis and guiding treatment strategy guidance, particularly in cases of chronic liver disease. Diagnosis of portal hypertension, which involves accurate measurement of portal pressure, is essential for early risk stratification and effective management. The available noninvasive and invasive techniques for the diagnosis of portal hypertension are reviewed here.

The term acute aortic syndrome (AAS) refers to a range of different entities, including dissection, intramural haematoma and penetrating atherosclerotic ulcer. Patients with chronic renal disease and particularly those with dominant polycystic kidney disease are susceptible to this pathology, given the underlying renal arteriopathy and hypertension. Imaging plays a crucial role in diagnosing, grading and guiding management of these patients, with computed tomography angiography (CTA) being on the frontline. Albeit of overlapping of imaging findings between these conditions, specific imaging characteristics help discriminate and guide treatment. Given the nephrotoxic contrast agent involved, tailored CTA protocols or alternative imaging modalities such as MRI or US are necessary in this patient population. This review article discusses the main imaging findings of entities found in the spectrum of AAS, as well as the appropriate use and protocol of imaging modalities, focusing on the appropriate use of nephrotoxic contrast agents, the preservation of renal function and maintenance of optimal diagnostic accuracy.

Superior vena cava (SVC) syndrome results from stenosis and/or occlusion of the central venous system leading to symptomatology associated with head and neck as well as upper-extremity venous congestion. With the rise in central venous catheter use and increasing cases of malignancy, the incidence of SVC syndrome has steadily increased in recent years. This narrative review explores the clinical presentation of SVC syndrome, alongside its evolving etiologies within modern clinical practice and its pathophysiology. In light of this, advanced imaging modalities and management approaches are discussed based on the extensive institutional experience, detailing the preprocedural imaging techniques, conservative and interventional treatment options, and follow-up imaging protocols.

We are thrilled to present to you this special issue of Digestive Disease Interventions focusing on pediatric liver interventions. This edition encompasses the complete spectrum of pediatric liver interventions and associated topics, spanning from minimally invasive interventional radiology to surgical procedures. The articles featured in this issue have been contributed by a diverse group of experienced physicians and clinical researchers who are esteemed leaders in their respective fields. These review articles are meticulously crafted based on the latest evidence and the authors' wealth of clinical expertise.

Purpose: To investigate effects of baseline and early longitudinal body composition changes on mortality and hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS). Materials and Methods: This is a case-control study with analysis of a TIPS registry (1995-2020) including data from patients with cirrhosis with computed tomography (CT) scans obtained within 1 month before and 3 months after TIPS. Core and muscle adiposity index (MAI) on CT were obtained. Multipredictor Cox proportional hazards models were used to assess the effect of body composition variables on mortality or HE. Results: In total, 280 patients (158 men; median age, 57.0 years; median Model for End-stage Liver Disease-sodium [MELD-Na] score, 14.0) were included. Thirty-four patients had post-TIPS imaging. Median baseline CMA was 68.3 cm2 (interquartile range, 57.7-83.5 cm2). Patients with higher baseline CMA had decreased risks of mortality (hazard ratio [HR]: 0.82; P = .04) and HE (HR: 0.82; P = .009). It improved prediction of mortality over MELD-Na and post-TIPS right atrial pressure alone (confidence interval = 0.729). An increase in CMA (HR: 0.60; P = .043) and mSAT (HR: 0.86; P = .022) or decrease in MAI (HR: 1.50; P = .049) from before to after TIPS was associated with a decreased risk of mortality. An increase in mSAT was associated with an increased risk of HE (HR: 1.11; P = .04). Conclusions: CMA on CT scan 1 month before TIPS placement predicts mortality and HE in patients with cirrhosis. Changes in body composition on CT measured 3 months after TIPS placement independently predict mortality and HE.

For end-stage renal disease (ESRD) patients requiring hemodialysis, reliable vascular access is crucial, especially when conventional supradiaphragmatic options are exhausted. This study reviews the technical aspects, clinical outcomes, and complications of translumbar and transhepatic tunneled dialysis catheter (TDC) placements. These alternative infradiaphragmatic approaches provide essential hemodialysis access for patients with central venous occlusions. Translumbar catheter placement is associated with high technical success rates and prolonged patency, while the transhepatic approach serves as a last resort for patients with both superior and inferior vena cava occlusions. Careful patient selection and operator expertise are critical for placement of these advanced infradiaphragmatic dialysis catheter approaches.