Transjugular intrahepatic portosystemic shunting with covered stents in children: A preliminary study of safety and patency

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(A) Diagnostic model to measure BV, BF, and Ktrans. (B) Model for the standard deviation of BV, BF, and Ktrans." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A.J. Revert Ventura, R. Sanz Requena, L. Martí-Bonmatí, Y. Pallardó, J. Jornet, C. Gaspar" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A.J." "apellidos" => "Revert Ventura" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Sanz Requena" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Martí-Bonmatí" ] 3 => array:2 [ "nombre" => "Y." "apellidos" => "Pallardó" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Jornet" ] 5 => array:2 [ "nombre" => "C." 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"apellidos" => "Zurera" "email" => array:1 [ 0 => "lzurera61@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.J." "apellidos" => "Espejo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Canis" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Bueno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Vicente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "J.J." "apellidos" => "Gilbert" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Radiodiagnóstico, Hospital Universitario Reina Sofía, Córdoba, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Pediatría, Hospital Universitario Reina Sofía, Córdoba, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "TIPS recubierto en niños. Estudio preliminar sobre su seguridad y permeabilidad" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1855 "Ancho" => 894 "Tamanyo" => 225303 ] ] "descripcion" => array:1 [ "en" => "(A) Eleven-year-old kid of 59 pounds of weight with direct portography showing patency of the portal system and the opacification of the gastric varices (arrow). (B) After the implantation of the covered TIPS such varices were not opacified and the final transhepatic gradient was 1mmHg." ] ] ] "textoCompleto" => "IntroductionToday creating a transjugular intrahepatic portosystemic shunting (TIPS) is an efficient proceeding for the management of complications of portal high blood pressure in adult cirrhotic patients–especially high digestive hemorrhage–HDH and refractory ascites when both medical therapy and conventional endoscopic therapy have failed.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>However there is no much experience with TIPS among the pediatric population and the greatest series of cases collected in the medical literature are just 12 children.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Even though the technique of implantation and the indications are similar in both groups of population children have a series of special considerations.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>On the other hand the patency of TIPS in adults with covered endoprostheses is substantially greater than with uncovered endoprostheses.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> However the majority of series of cases published in children used the latter with a high rate of restenosis.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>Our goal is to present our initial experience in 6 children with different etiology-portal hypertension treated with covered TIPS in an effort to analyze security and patency retrospectively as well as the technical considerations of its implantation.Material and methodsBetween May 2009 and April 2011 TIPS were implanted in 6 children with secondary HDH and portal hypertension. The sample consisted of 3 boys and 3 girls with an average age of 10.6 years (6–16 years) and an average weight of 73.8 pounds (44–132 pounds). The etiology of portal hypertension was cirrhotic in 5 children (2 cystic fibrosis, 1 congenital hepatic fibrosis, 1 extrahepatic biliary atresia, 1 Caroli-type complex biliary cystic malformation) and non-cirrhotic in one patient with thrombosis and portal cavernomatosis 6 years after liver transplant from a living donor due to biliary atresia. All children presented with hypersplenism–5 of them with associated plateletpenia and endoscopic evidence of gastroesophageal varices that had caused repeated clinical presentations of HDH unresolved through the standard medical therapy or in 2 of the children with endoscopic variceal ligation. In the remaining 4 such ligation could not be done because the varices were located in the gastric fundus and could not be approached endoscopically (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Four of the patients showed HDH during the implantation of TIPS and required blood transfusion. None of the children had signs of hepatic encephalopathy or ascites prior to the implantation of TIPS. In all of them the portal axis was studied through Doppler-ultrasound showing patency in 5 children whereas in one girl chronic thrombosis with the aforementioned cavernomatosis could be identified.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>All proceedings were done under general anesthesia. The technique of implantation and the equipment used were the same used in adults (Ring TIPSS-200 set; Cook Inc., Bjaeverskov, DK).<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> The right internal jugular vein was punctioned with the help of ultrasound control and a 10F introducer kit was inserted. The suprahepatic vein whose approach was more appropriate (right/middle) was used. The needle used for intrahepatic punction and to be able to access the portal system was the Colapinto needle included in the set (16G). As a wire the indirect portography and/or embedded suprahepatic phlebography was used. In all children direct portography was done through a conventional calibrated pigtail 5F catheter to select the adequate length of endoprosthesis, visualize portal anatomy, and do one hepatic hemodynamic study to brief on the transhepatic gradient between the portal vein and the right atrium/inferior caval vein before and after the implantation of TIPS. Dilation of intrahepatic tract between the suprahepatic vein and the portal branch was done through a conventional catheter-balloon of 8mm diameter. Gastric varices were never embolized whatsoever. The maximum dose of iodinated contrast media during the whole proceeding was 3ml/2.2lbs of weight.In all cases nitinol-prosthesis covered with polytetrafluoroetilene (PTFE) (Viatorr®; W.L. Gore and Associates, Flagstaff, AZ) of 10mm diameter were used. The length of the prosthesis was variable leaving the proximal end in the suprahepatic vein so it would not “show up” in the right atrium–to avoid technical complications during the future transplant. The goal of the proceeding was to achieve a 5–12mmHg-gradient.No antibiotic drugs or platelet antiaggregants were used after TIPS. All children were followed both clinic and analytically and through a Doppler-ultrasound 4–6 days after the implantation of TIPS and from that moment onwards every 3 months until the completion of this study or the transplant.The correct implantation of TIPS was considered a technical feat and the control of HDH a clinical success.ResultsThe technical success was 100% with one covered endoprosthesis and happened in only one session without associated mortality (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The average transhepatic gradient was 16mmHg (12–21mmHg) though it grew smaller after the implantation of TIPS to 9mmHg (1–15mmHg). In one kid with a post-TIPS transhepatic gradient of 1–15mmHg the TIPS was previously dilated through a catheter-balloon of 10mm diameter though portal pressure could not be reduced (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The proceeding had an average room occupancy–including fluoroscopy time and anesthesia of 192min (150–240min).As immediate complications one of the patients who had a post-TIPS transhepatic gradient of 1mmHg presented with mild hepatic encephalopathy 24h after the implantation of TIPS (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) that resolved in just one week with medical therapy. The girl who was transplanted with thrombosis and portal cavernomatosis suffered the thrombosis of TIPS just after 24h presenting as a serious liver failure that could be recanalized by implanting one 8mm diameter-coaxial endoprosthesis (Dynamic®, Biotronik, Bülack SW) to later be anticoagulated for a month and then treated with platelet antiaggregants (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The clinical success was 100%. No patients showed HDH episodes ever again during the clinical follow-up or until the completion of transplant for an average 8.1 months (1–15 months). Among the 5 patients with plateletpenia (1.000–100.000/mm3) only 1 showed an increasing number of platelets–from 1.000 to 82.000/mm3 at 15 months.Three children were transplanted with no technical complications 7, 9, and 10 months after the implantation of TIPS. The macroscopic piece confirmed its variability (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In the remaining 3 children (one of them in the transplant waiting list and the other 2 with no indication due to their good hepatic function) the patency of TIPS was confirmed through Doppler-ultrasound at 1, 3, and 15 months.DiscussionIn our study the use of covered TIPS allowed us to control HDH in all children with no further rebleeding episodes during follow-up. Our results relate to those published for this type of covered endoprostheses.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> However with uncovered endoprostheses rebleeding episodes have been found in as much as 67% of children<a class="elsevierStyleCrossRef" href="#bib0025">5</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Plateletpenia does not usually get between with the implantation of TIPS<a class="elsevierStyleCrossRefs" href="#bib0025">5,9</a> yet this is exactly what happened in one of our children.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Our technical success was 100% and even though there were some sporadic cases of impossibility to implant the TIPS and major mortality and morbidity associated by hemoperitoneum,<a class="elsevierStyleCrossRefs" href="#bib0025">5,10</a> we can considered it a safe technique. One of our children presented with transient encephalopathy described in 0–11% of cases<a class="elsevierStyleCrossRefs" href="#bib0025">5,10</a> always associated with final gradients <5mmHg and always mild. Another transplanted girl with portal thrombosis presented with acute thrombosis of TIPS that eventually resolved by implanting one coaxial endoprosthesis.Yes despite the complications of portal hypertension in children are similar to those seen in adults the causes are different. Biliary atresia and cystic fibrosis are more common.<a class="elsevierStyleCrossRefs" href="#bib0025">5,10,11</a> Given these children are usually cirrhotic they reach their final stage before they are 2 years old–when they are transplanted or treated with surgical shunts.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> The experience with TIPS in this pediatric population is scarce.<a class="elsevierStyleCrossRefs" href="#bib0010">2,5</a> One of the issues derived from this underuse is that we do not have specific TIPS kits for children and we have to use adult kits. Nevertheless in children the liver and veins are smaller which increases risks when thick and rigid introducers are used (10F). Also we do not know basic data like the age and minimum weight of children, data that we would need to use these adult systems–even though they have proven successful in children of 24 pounds of weight.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> In our series the lowest weight was 44 pounds (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Another important consideration in children is the huge periportal fibrosis occurring in the biliary atresia, in the congenital hepatic fibrosis and in cystic fibrosis. All of them can reduce the caliber of portal branches, cause the displacement of suprahepatic veins (which is more serious in cases of hepatic grafts) and harden the hepatic parenchyma which in adults makes the catheterization of suprahepatic veins, the implantation of rigid introducers in its interior and the hepatic puncture to reach the portal system way harder. Some authors have developed smaller introducers (7F) and thinner needles (18G) that can usually bend during hepatic puncture.<a class="elsevierStyleCrossRefs" href="#bib0025">5,11</a>It has been confirmed that in adults with TIPS with covered endoprosthesis of PTFE the patency is better and the rates of rebleeding and encephalopathy are lower than with uncovered endoprostheses.<a class="elsevierStyleCrossRefs" href="#bib0020">4,13</a> Most endoprostheses implanted in children have been uncovered endoprostheses showing poor patency in the short term<a class="elsevierStyleCrossRefs" href="#bib0015">3,11</a> and a rate of interventions close to 89%.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> However the experience of creating TIPS in children with covered endoprostheses with PTFE is minimum.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The largest series we know of included 7 children (unpublished data) <a class="elsevierStyleCrossRef" href="#bib0040">8</a> implanted with Viatorr®-type covered endoprostheses showing no dysfunctions during an average follow-up period of 5.3 months (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In our series there was only one early occluded TIPS (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) even though after recanalization it kept its secondary patency in 100% during the average 8 month-follow-up; 8-and-10-mm-Viatorr® endoprostheses are available today and they cannot be overdilated them beyond their nominal diameter. Given that among the pediatric population the creation of TIPS is usually a transient therapy until the completion of liver transplant some authors rather use the 8mm-Viatorr® due to the small caliber of portal and suprahepatic vessels.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> However we (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) as other authors<a class="elsevierStyleCrossRef" href="#bib0040">8</a> used the 10mm-diameter Viatorr® that we initially dilated with 8mm-diameter balloons to only expand their nominal diameter when the transhepatic gradient is >12mmHg. We abide by this strategy because – as it happened in 2 of our children not all patients are candidates to liver transplants. In this minority of growing children there might come a time that the 8mm-endoprosthesis is undersized by the growth of the portal vein that theoretically speaking can cause the relapse of portal hypertension but if this happens we can always overdilate to 10mm-endoprostheses.The minimum experience with the implantation of TIPS in children with liver grafts<a class="elsevierStyleCrossRef" href="#bib0075">15</a> and portal chronic thrombosis is an added technical difficulty to TIPS. In our series both conditions happened in a girl–even so we managed to complete the implantation very difficult on the technical level but without complications and we could proceed to the recanalization of the occluded portal segment too.In sum yet despite the great limitation of this study posed by the small number of sample patients this is the largest series with Viatorr®-type covered endoprostheses ever published for the treatment of HDH due to gastroesophageal varices in cirrhotic children. Our results indicate that both the security and patency can be good yet this will need to be confirmed in future studies.Ethical responsibilitiesProtection of people and animalsAuthors confirm that the proceedings followed abide by the ethical regulations of the corresponding human experimentation committee in full compliance with the World Health Organization and the Declaration of Helsinki.Data confidentialityAuthors confirm that the protocols of their centers have been followed on matters concerning the publishing of data from patients. They also confirm that all patients included in this study have been given enough information and handed over their written informed consent for their participation in this study.Right to privacy and informed consentAuthors confirm that in this report there are no personal data from patients.Authors<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Manager of the integrity of the study: LJZ.</li><li class="elsevierStyleListItem" id="lsti0010">2.Original Idea of the Study: LJZ.</li><li class="elsevierStyleListItem" id="lsti0015">3.Study Design: LJZ, JJE and MC.</li><li class="elsevierStyleListItem" id="lsti0020">4.Data Mining: LJZ, JJE, AB and JJG.</li><li class="elsevierStyleListItem" id="lsti0025">5.Data Analysis and Interpretation: LJZ, JJE and AB.</li><li class="elsevierStyleListItem" id="lsti0030">6.Statistical Analysis: NA.</li><li class="elsevierStyleListItem" id="lsti0035">7.Reference Search: LJZ and AB.</li><li class="elsevierStyleListItem" id="lsti0040">8.Writing: LJZ and AB.</li><li class="elsevierStyleListItem" id="lsti0045">9.Manuscript critical review with intellectually relevant contributions: LJZ, JJE, MC, AB, JV and JJG.</li><li class="elsevierStyleListItem" id="lsti0050">10.Final Version Approval: LJZ, JJE, MC, AB, JV and JJG.</li></ul>Conflict of interestsAuthors reported no conflicts of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres363371" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Material and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec342959" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres363370" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec342960" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Data confidentiality" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Authors" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-10-18" "fechaAceptado" => "2012-01-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec342959" "palabras" => array:3 [ 0 => "Intrahepatic portosystemic shunt" 1 => "Child" 2 => "Portal vein thrombosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec342960" "palabras" => array:3 [ 0 => "Shunt portosistémico intrahepático" 1 => "Niño" 2 => "Trombosis vena porta" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo retrospectively analyze the safety and efficacy of transjugular intrahepatic portosystemic shunting (TIPS) using covered stents in children. Material and methodsWe present 6 children (mean age, 10.6 years; mean weight, 33.5kg) who underwent TIPS with 8mm diameter Viatorr® covered stents for acute (n=4) or recurrent (n=2) upper digestive bleeding that could not be controlled by endoscopic measures. Five of the children had cirrhosis and the other had portal vein thrombosis with cavernous transformation. We analyzed the relapse of upper digestive bleeding, the complications that appeared, and the patency of the TIPS shunt on sequential Doppler ultrasonography or until transplantation. ResultsA single stent was implanted in a single session in each child; none of the children died. The mean transhepatic gradient decreased from 16mmHg (range: 12–21mmHg) before the procedure to 9mmHg (range: 1–15mmHg) after TIPS.One patient developed mild encephalopathy, and the girl who had portal vein thrombosis with cavernous transformation developed an acute occlusion of the TIPS that resolved after the implantation of a coaxial stent.Three children received transplants (7, 9, and 10 months after the procedure, respectively), and the patency of the TIPS was confirmed at transplantation. In the three remaining children, patency was confirmed with Doppler ultrasonography 1, 3, and 5 months after implantation. None of the children had new episodes of upper digestive bleeding during follow-up after implantation (mean: 8.1 months). ConclusionOur results indicate that TIPS with 8mm diameter Viatorr® covered stents can be safe and efficacious for the treatment of upper digestive bleeding due to gastroesophageal varices in cirrhotic children; our findings need to be corroborated in larger series." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ObjetivoAnalizar retrospectivamente la seguridad y eficacia de derivación portosistémica intrahepática por vía transyugular (TIPS) recubierta en niños. Material y métodosPresentamos 6 niños con una edad media de 10,6 años y un peso medio de 33,5kg, a quienes se implantaron endoprótesis recubiertas tipo Viatorr® de 8mm de diámetro por hemorragia digestiva alta (HDA) aguda (n=4) o recurrente (n=2) no controlable por medidas endoscópicas. Cinco niños eran cirróticos y otro un trasplantado hepático con trombosis y cavernomatosis portal. Se valoraron la recidiva de la HDA, las complicaciones y la permeabilidad con ecografías-Doppler secuenciales o hasta el trasplante. ResultadosEn todos los niños se implantó una sola endoprótesis en una única sesión, sin mortalidad asociada. El gradiente transhepático medio inicial fue de 16mmHg (12-21mmHg) y disminuyó tras la implantación del TIPS a 9mmHg (1-15mmHg).Un paciente presentó encefalopatía leve y la niña con trombosis y cavernomatosis portal presentó una oclusión aguda del TIPS, que se resolvió con la implantación de una endoprótesis coaxial.Tres niños fueron sometidos a trasplante a los 7,9 y 10 meses, constatándose la permeabilidad del TIPS. En los 3 restantes se comprobó la permeabilidad con ecografía-Doppler a los 1,3 y 5 meses. Ninguno presentó una nueva HDA durante un seguimiento medio de 8,1 meses. ConclusiónNuestros resultados indican que la seguridad y permeabilidad de las endoprótesis recubiertas tipo Viatorr® para el tratamiento de la HDA por varices gastroesofágicas en niños cirróticos pueden ser buenas, hecho que deberá ser corroborado con series mayores en un futuro." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Zurera LJ, Espejo JJ, Canis M, Bueno A, Vicente J, Gilbert JJ. TIPS recubierto en niños. Estudio preliminar sobre su seguridad y permeabilidad. Radiología. 2014;56:339–345." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1855 "Ancho" => 894 "Tamanyo" => 225303 ] ] "descripcion" => array:1 [ "en" => "(A) Eleven-year-old kid of 59 pounds of weight with direct portography showing patency of the portal system and the opacification of the gastric varices (arrow). (B) After the implantation of the covered TIPS such varices were not opacified and the final transhepatic gradient was 1mmHg." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2176 "Ancho" => 1401 "Tamanyo" => 374174 ] ] "descripcion" => array:1 [ "en" => "(A) Six-year-old girl transplanted from living donor. Indirect portography with contrast injection in the splenic artery showing splenomegalia and thrombosis of extrahepatic portal vein with thick varices (arrow) due to cavernomatosis. (B) Direct portography after catheterization of portal vein through one varicose vein. Transhepatic gradient was 18mmHg. (C) Implantation of recovered patent TIPS with an 8mmHg-gradient. (D) Direct portography after 72h showing occluded TIPS. (E) Direct portography showing recanalization of occluded TIPS after implanting one coaxial endoprosthesis. The final transhepatic gradient was 12mmHg." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "BA, biliary atresia; CHF, congenital hepatic fibrosis; CF, cystic fibrosis; HDH, high digestive hemorrhage; W, woman; TIPS, transjugular intrahepatic portosystemic shunting; LT, liver transplant; US, Doppler-ultrasound; M, male." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age/sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight (lbs) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Etiology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TIPS indication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Gradient (mmHg)</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Follow up \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Pre-TIPS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Post-TIPS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recidivant HDH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 mesesPermeable US \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acute HDHPlateletpenia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 mesesPermeable TX \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acute HDHPlateletpenia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 mesesPermeable TX \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16/W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">132 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CHF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acute HDHPlateletpenia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 mesesPermeable US \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9/W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">E. Caroli \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recidivant HDHPlateletpenia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 mesesPermeable TX \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6/W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LT due to BAPortal thrombosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acute HDHPlateletpenia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 mesPermeable US \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab544294.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic characteristics of children and results." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "APE, acute pulmonary edema; HDH, high digestive hemorrhage; PP, primary patency; SP, secondary patency." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Number \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Model \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">PP (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SP (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Major complications (number) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Control HDA (%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heyman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wallstent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rebleeding (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pozler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wallstent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hemoperitoneum (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hackworth \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wallstent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Encephalopathy (1)Jugular hematoma (1)APE (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Huppert \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wallstent (4)Palmaz (4)Cragg (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hemoperitoneum (2)Encephalopathy (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mermuys \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Viatorr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shivaram \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Viatorr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab544295.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Reference review of TIPS in children." ] ] ] 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Original Report

TIPS recubierto en niños. Estudio preliminar sobre su seguridad y permeabilidad

L.J. Zureraa,

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lzurera61@gmail.com

Corresponding author.

, J.J. Espejoa, M. Canisa, A. Buenoa, J. Vicentea, J.J. Gilbertb

a Unidad de Gestión Clínica de Radiodiagnóstico, Hospital Universitario Reina Sofía, Córdoba, Spain

b Unidad de Gestión Clínica de Pediatría, Hospital Universitario Reina Sofía, Córdoba, Spain

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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Eleven-year-old kid of 59 pounds of weight with direct portography showing patency of the portal system and the opacification of the gastric varices &#40;arrow&#41;&#46; &#40;B&#41; After the implantation of the covered TIPS such varices were not opacified and the final transhepatic gradient was 1<span class="elsevierStyleHsp" style=""></span>mmHg&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0020" class="elsevierStylePara elsevierViewall">Today creating a transjugular intrahepatic portosystemic shunting &#40;TIPS&#41; is an efficient proceeding for the management of complications of portal high blood pressure in adult cirrhotic patients&#8211;especially high digestive hemorrhage&#8211;HDH and refractory ascites when both medical therapy and conventional endoscopic therapy have failed&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However there is no much experience with TIPS among the pediatric population and the greatest series of cases collected in the medical literature are just 12 children&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Even though the technique of implantation and the indications are similar in both groups of population children have a series of special considerations&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">On the other hand the patency of TIPS in adults with covered endoprostheses is substantially greater than with uncovered endoprostheses&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However the majority of series of cases published in children used the latter with a high rate of restenosis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Our goal is to present our initial experience in 6 children with different etiology-portal hypertension treated with covered TIPS in an effort to analyze security and patency retrospectively as well as the technical considerations of its implantation&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">Between May 2009 and April 2011 TIPS were implanted in 6 children with secondary HDH and portal hypertension&#46; The sample consisted of 3 boys and 3 girls with an average age of 10&#46;6 years &#40;6&#8211;16 years&#41; and an average weight of 73&#46;8 pounds &#40;44&#8211;132 pounds&#41;&#46; The etiology of portal hypertension was cirrhotic in 5 children &#40;2 cystic fibrosis&#44; 1 congenital hepatic fibrosis&#44; 1 extrahepatic biliary atresia&#44; 1 Caroli-type complex biliary cystic malformation&#41; and non-cirrhotic in one patient with thrombosis and portal cavernomatosis 6 years after liver transplant from a living donor due to biliary atresia&#46; All children presented with hypersplenism&#8211;5 of them with associated plateletpenia and endoscopic evidence of gastroesophageal varices that had caused repeated clinical presentations of HDH unresolved through the standard medical therapy or in 2 of the children with endoscopic variceal ligation&#46; In the remaining 4 such ligation could not be done because the varices were located in the gastric fundus and could not be approached endoscopically &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Four of the patients showed HDH during the implantation of TIPS and required blood transfusion&#46; None of the children had signs of hepatic encephalopathy or ascites prior to the implantation of TIPS&#46; In all of them the portal axis was studied through Doppler-ultrasound showing patency in 5 children whereas in one girl chronic thrombosis with the aforementioned cavernomatosis could be identified&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">All proceedings were done under general anesthesia&#46; The technique of implantation and the equipment used were the same used in adults &#40;Ring TIPSS-200 set&#59; Cook Inc&#46;&#44; Bjaeverskov&#44; DK&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> The right internal jugular vein was punctioned with the help of ultrasound control and a 10F introducer kit was inserted&#46; The suprahepatic vein whose approach was more appropriate &#40;right&#47;middle&#41; was used&#46; The needle used for intrahepatic punction and to be able to access the portal system was the Colapinto needle included in the set &#40;16G&#41;&#46; As a wire the indirect portography and&#47;or embedded suprahepatic phlebography was used&#46; In all children direct portography was done through a conventional calibrated pigtail 5F catheter to select the adequate length of endoprosthesis&#44; visualize portal anatomy&#44; and do one hepatic hemodynamic study to brief on the transhepatic gradient between the portal vein and the right atrium&#47;inferior caval vein before and after the implantation of TIPS&#46; Dilation of intrahepatic tract between the suprahepatic vein and the portal branch was done through a conventional catheter-balloon of 8<span class="elsevierStyleHsp" style=""></span>mm diameter&#46; Gastric varices were never embolized whatsoever&#46; The maximum dose of iodinated contrast media during the whole proceeding was 3<span class="elsevierStyleHsp" style=""></span>ml&#47;2&#46;2<span class="elsevierStyleHsp" style=""></span>lbs of weight&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In all cases nitinol-prosthesis covered with polytetrafluoroetilene &#40;PTFE&#41; &#40;Viatorr<span class="elsevierStyleSup">&#174;</span>&#59; W&#46;L&#46; Gore and Associates&#44; Flagstaff&#44; AZ&#41; of 10<span class="elsevierStyleHsp" style=""></span>mm diameter were used&#46; The length of the prosthesis was variable leaving the proximal end in the suprahepatic vein so it would not &#8220;show up&#8221; in the right atrium&#8211;to avoid technical complications during the future transplant&#46; The goal of the proceeding was to achieve a 5&#8211;12<span class="elsevierStyleHsp" style=""></span>mmHg-gradient&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">No antibiotic drugs or platelet antiaggregants were used after TIPS&#46; All children were followed both clinic and analytically and through a Doppler-ultrasound 4&#8211;6 days after the implantation of TIPS and from that moment onwards every 3 months until the completion of this study or the transplant&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The correct implantation of TIPS was considered a technical feat and the control of HDH a clinical success&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">The technical success was 100&#37; with one covered endoprosthesis and happened in only one session without associated mortality &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The average transhepatic gradient was 16<span class="elsevierStyleHsp" style=""></span>mmHg &#40;12&#8211;21<span class="elsevierStyleHsp" style=""></span>mmHg&#41; though it grew smaller after the implantation of TIPS to 9<span class="elsevierStyleHsp" style=""></span>mmHg &#40;1&#8211;15<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46; In one kid with a post-TIPS transhepatic gradient of 1&#8211;15<span class="elsevierStyleHsp" style=""></span>mmHg the TIPS was previously dilated through a catheter-balloon of 10<span class="elsevierStyleHsp" style=""></span>mm diameter though portal pressure could not be reduced &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The proceeding had an average room occupancy&#8211;including fluoroscopy time and anesthesia of 192<span class="elsevierStyleHsp" style=""></span>min &#40;150&#8211;240<span class="elsevierStyleHsp" style=""></span>min&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As immediate complications one of the patients who had a post-TIPS transhepatic gradient of 1<span class="elsevierStyleHsp" style=""></span>mmHg presented with mild hepatic encephalopathy 24<span class="elsevierStyleHsp" style=""></span>h after the implantation of TIPS &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; that resolved in just one week with medical therapy&#46; The girl who was transplanted with thrombosis and portal cavernomatosis suffered the thrombosis of TIPS just after 24<span class="elsevierStyleHsp" style=""></span>h presenting as a serious liver failure that could be recanalized by implanting one 8<span class="elsevierStyleHsp" style=""></span>mm diameter-coaxial endoprosthesis &#40;Dynamic<span class="elsevierStyleSup">&#174;</span>&#44; Biotronik&#44; B&#252;lack SW&#41; to later be anticoagulated for a month and then treated with platelet antiaggregants &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The clinical success was 100&#37;&#46; No patients showed HDH episodes ever again during the clinical follow-up or until the completion of transplant for an average 8&#46;1 months &#40;1&#8211;15 months&#41;&#46; Among the 5 patients with plateletpenia &#40;1&#46;000&#8211;100&#46;000&#47;mm<span class="elsevierStyleSup">3</span>&#41; only 1 showed an increasing number of platelets&#8211;from 1&#46;000 to 82&#46;000&#47;mm<span class="elsevierStyleSup">3</span> at 15 months&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Three children were transplanted with no technical complications 7&#44; 9&#44; and 10 months after the implantation of TIPS&#46; The macroscopic piece confirmed its variability &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In the remaining 3 children &#40;one of them in the transplant waiting list and the other 2 with no indication due to their good hepatic function&#41; the patency of TIPS was confirmed through Doppler-ultrasound at 1&#44; 3&#44; and 15 months&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">In our study the use of covered TIPS allowed us to control HDH in all children with no further rebleeding episodes during follow-up&#46; Our results relate to those published for this type of covered endoprostheses&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However with uncovered endoprostheses rebleeding episodes have been found in as much as 67&#37; of children<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Plateletpenia does not usually get between with the implantation of TIPS<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9</span></a> yet this is exactly what happened in one of our children&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Our technical success was 100&#37; and even though there were some sporadic cases of impossibility to implant the TIPS and major mortality and morbidity associated by hemoperitoneum&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;10</span></a> we can considered it a safe technique&#46; One of our children presented with transient encephalopathy described in 0&#8211;11&#37; of cases<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;10</span></a> always associated with final gradients &#60;5<span class="elsevierStyleHsp" style=""></span>mmHg and always mild&#46; Another transplanted girl with portal thrombosis presented with acute thrombosis of TIPS that eventually resolved by implanting one coaxial endoprosthesis&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Yes despite the complications of portal hypertension in children are similar to those seen in adults the causes are different&#46; Biliary atresia and cystic fibrosis are more common&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;10&#44;11</span></a> Given these children are usually cirrhotic they reach their final stage before they are 2 years old&#8211;when they are transplanted or treated with surgical shunts&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The experience with TIPS in this pediatric population is scarce&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a> One of the issues derived from this underuse is that we do not have specific TIPS kits for children and we have to use adult kits&#46; Nevertheless in children the liver and veins are smaller which increases risks when thick and rigid introducers are used &#40;10F&#41;&#46; Also we do not know basic data like the age and minimum weight of children&#44; data that we would need to use these adult systems&#8211;even though they have proven successful in children of 24 pounds of weight&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In our series the lowest weight was 44 pounds &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Another important consideration in children is the huge periportal fibrosis occurring in the biliary atresia&#44; in the congenital hepatic fibrosis and in cystic fibrosis&#46; All of them can reduce the caliber of portal branches&#44; cause the displacement of suprahepatic veins &#40;which is more serious in cases of hepatic grafts&#41; and harden the hepatic parenchyma which in adults makes the catheterization of suprahepatic veins&#44; the implantation of rigid introducers in its interior and the hepatic puncture to reach the portal system way harder&#46; Some authors have developed smaller introducers &#40;7F&#41; and thinner needles &#40;18G&#41; that can usually bend during hepatic puncture&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;11</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">It has been confirmed that in adults with TIPS with covered endoprosthesis of PTFE the patency is better and the rates of rebleeding and encephalopathy are lower than with uncovered endoprostheses&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;13</span></a> Most endoprostheses implanted in children have been uncovered endoprostheses showing poor patency in the short term<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;11</span></a> and a rate of interventions close to 89&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However the experience of creating TIPS in children with covered endoprostheses with PTFE is minimum&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The largest series we know of included 7 children &#40;unpublished data&#41; <a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> implanted with Viatorr<span class="elsevierStyleSup">&#174;</span>-type covered endoprostheses showing no dysfunctions during an average follow-up period of 5&#46;3 months &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In our series there was only one early occluded TIPS &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; even though after recanalization it kept its secondary patency in 100&#37; during the average 8 month-follow-up&#59; 8-and-10-mm-Viatorr<span class="elsevierStyleSup">&#174;</span> endoprostheses are available today and they cannot be overdilated them beyond their nominal diameter&#46; Given that among the pediatric population the creation of TIPS is usually a transient therapy until the completion of liver transplant some authors rather use the 8<span class="elsevierStyleHsp" style=""></span>mm-Viatorr<span class="elsevierStyleSup">&#174;</span> due to the small caliber of portal and suprahepatic vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> However we &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; as other authors<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> used the 10<span class="elsevierStyleHsp" style=""></span>mm-diameter Viatorr<span class="elsevierStyleSup">&#174;</span> that we initially dilated with 8<span class="elsevierStyleHsp" style=""></span>mm-diameter balloons to only expand their nominal diameter when the transhepatic gradient is &#62;12<span class="elsevierStyleHsp" style=""></span>mmHg&#46; We abide by this strategy because &#8211; as it happened in 2 of our children not all patients are candidates to liver transplants&#46; In this minority of growing children there might come a time that the 8<span class="elsevierStyleHsp" style=""></span>mm-endoprosthesis is undersized by the growth of the portal vein that theoretically speaking can cause the relapse of portal hypertension but if this happens we can always overdilate to 10<span class="elsevierStyleHsp" style=""></span>mm-endoprostheses&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The minimum experience with the implantation of TIPS in children with liver grafts<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and portal chronic thrombosis is an added technical difficulty to TIPS&#46; In our series both conditions happened in a girl&#8211;even so we managed to complete the implantation very difficult on the technical level but without complications and we could proceed to the recanalization of the occluded portal segment too&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In sum yet despite the great limitation of this study posed by the small number of sample patients this is the largest series with Viatorr<span class="elsevierStyleSup">&#174;</span>-type covered endoprostheses ever published for the treatment of HDH due to gastroesophageal varices in cirrhotic children&#46; Our results indicate that both the security and patency can be good yet this will need to be confirmed in future studies&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical responsibilities</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of people and animals</span><p id="par0120" class="elsevierStylePara elsevierViewall">Authors confirm that the proceedings followed abide by the ethical regulations of the corresponding human experimentation committee in full compliance with the World Health Organization and the Declaration of Helsinki&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Data confidentiality</span><p id="par0125" class="elsevierStylePara elsevierViewall">Authors confirm that the protocols of their centers have been followed on matters concerning the publishing of data from patients&#46; They also confirm that all patients included in this study have been given enough information and handed over their written informed consent for their participation in this study&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0130" class="elsevierStylePara elsevierViewall">Authors confirm that in this report there are no personal data from patients&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Authors</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study&#58; LJZ&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Original Idea of the Study&#58; LJZ&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Study Design&#58; LJZ&#44; JJE and MC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Data Mining&#58; LJZ&#44; JJE&#44; AB and JJG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Data Analysis and Interpretation&#58; LJZ&#44; JJE and AB&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Statistical Analysis&#58; NA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Reference Search&#58; LJZ and AB&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Writing&#58; LJZ and AB&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Manuscript critical review with intellectually relevant contributions&#58; LJZ&#44; JJE&#44; MC&#44; AB&#44; JV and JJG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Final Version Approval&#58; LJZ&#44; JJE&#44; MC&#44; AB&#44; JV and JJG&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0185" class="elsevierStylePara elsevierViewall">Authors reported no conflicts of interests&#46;</p></span></span>"
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              "identificador" => "sec0035"
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    "fechaRecibido" => "2011-10-18"
    "fechaAceptado" => "2012-01-07"
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          "clase" => "keyword"
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          "palabras" => array:3 [
            0 => "Intrahepatic portosystemic shunt"
            1 => "Child"
            2 => "Portal vein thrombosis"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "Shunt portosist&#233;mico intrahep&#225;tico"
            1 => "Ni&#241;o"
            2 => "Trombosis vena porta"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To retrospectively analyze the safety and efficacy of transjugular intrahepatic portosystemic shunting &#40;TIPS&#41; using covered stents in children&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">We present 6 children &#40;mean age&#44; 10&#46;6 years&#59; mean weight&#44; 33&#46;5<span class="elsevierStyleHsp" style=""></span>kg&#41; who underwent TIPS with 8<span class="elsevierStyleHsp" style=""></span>mm diameter Viatorr<span class="elsevierStyleSup">&#174;</span> covered stents for acute &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41; or recurrent &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41; upper digestive bleeding that could not be controlled by endoscopic measures&#46; Five of the children had cirrhosis and the other had portal vein thrombosis with cavernous transformation&#46; We analyzed the relapse of upper digestive bleeding&#44; the complications that appeared&#44; and the patency of the TIPS shunt on sequential Doppler ultrasonography or until transplantation&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A single stent was implanted in a single session in each child&#59; none of the children died&#46; The mean transhepatic gradient decreased from 16<span class="elsevierStyleHsp" style=""></span>mmHg &#40;range&#58; 12&#8211;21<span class="elsevierStyleHsp" style=""></span>mmHg&#41; before the procedure to 9<span class="elsevierStyleHsp" style=""></span>mmHg &#40;range&#58; 1&#8211;15<span class="elsevierStyleHsp" style=""></span>mmHg&#41; after TIPS&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">One patient developed mild encephalopathy&#44; and the girl who had portal vein thrombosis with cavernous transformation developed an acute occlusion of the TIPS that resolved after the implantation of a coaxial stent&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Three children received transplants &#40;7&#44; 9&#44; and 10 months after the procedure&#44; respectively&#41;&#44; and the patency of the TIPS was confirmed at transplantation&#46; In the three remaining children&#44; patency was confirmed with Doppler ultrasonography 1&#44; 3&#44; and 5 months after implantation&#46; None of the children had new episodes of upper digestive bleeding during follow-up after implantation &#40;mean&#58; 8&#46;1 months&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Our results indicate that TIPS with 8<span class="elsevierStyleHsp" style=""></span>mm diameter Viatorr<span class="elsevierStyleSup">&#174;</span> covered stents can be safe and efficacious for the treatment of upper digestive bleeding due to gastroesophageal varices in cirrhotic children&#59; our findings need to be corroborated in larger series&#46;</p>"
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        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar retrospectivamente la seguridad y eficacia de derivaci&#243;n portosist&#233;mica intrahep&#225;tica por v&#237;a transyugular &#40;TIPS&#41; recubierta en ni&#241;os&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Presentamos 6 ni&#241;os con una edad media de 10&#44;6 a&#241;os y un peso medio de 33&#44;5<span class="elsevierStyleHsp" style=""></span>kg&#44; a quienes se implantaron endopr&#243;tesis recubiertas tipo Viatorr<span class="elsevierStyleSup">&#174;</span> de 8<span class="elsevierStyleHsp" style=""></span>mm de di&#225;metro por hemorragia digestiva alta &#40;HDA&#41; aguda &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41; o recurrente &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41; no controlable por medidas endosc&#243;picas&#46; Cinco ni&#241;os eran cirr&#243;ticos y otro un trasplantado hep&#225;tico con trombosis y cavernomatosis portal&#46; Se valoraron la recidiva de la HDA&#44; las complicaciones y la permeabilidad con ecograf&#237;as-Doppler secuenciales o hasta el trasplante&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">En todos los ni&#241;os se implant&#243; una sola endopr&#243;tesis en una &#250;nica sesi&#243;n&#44; sin mortalidad asociada&#46; El gradiente transhep&#225;tico medio inicial fue de 16<span class="elsevierStyleHsp" style=""></span>mmHg &#40;12-21<span class="elsevierStyleHsp" style=""></span>mmHg&#41; y disminuy&#243; tras la implantaci&#243;n del TIPS a 9<span class="elsevierStyleHsp" style=""></span>mmHg &#40;1-15<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Un paciente present&#243; encefalopat&#237;a leve y la ni&#241;a con trombosis y cavernomatosis portal present&#243; una oclusi&#243;n aguda del TIPS&#44; que se resolvi&#243; con la implantaci&#243;n de una endopr&#243;tesis coaxial&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Tres ni&#241;os fueron sometidos a trasplante a los 7&#44;9 y 10 meses&#44; constat&#225;ndose la permeabilidad del TIPS&#46; En los 3 restantes se comprob&#243; la permeabilidad con ecograf&#237;a-Doppler a los 1&#44;3 y 5 meses&#46; Ninguno present&#243; una nueva HDA durante un seguimiento medio de 8&#44;1 meses&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Nuestros resultados indican que la seguridad y permeabilidad de las endopr&#243;tesis recubiertas tipo Viatorr<span class="elsevierStyleSup">&#174;</span> para el tratamiento de la HDA por varices gastroesof&#225;gicas en ni&#241;os cirr&#243;ticos pueden ser buenas&#44; hecho que deber&#225; ser corroborado con series mayores en un futuro&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Zurera LJ&#44; Espejo JJ&#44; Canis M&#44; Bueno A&#44; Vicente J&#44; Gilbert JJ&#46; TIPS recubierto en ni&#241;os&#46; Estudio preliminar sobre su seguridad y permeabilidad&#46; Radiolog&#237;a&#46; 2014&#59;56&#58;339&#8211;345&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Eleven-year-old kid of 59 pounds of weight with direct portography showing patency of the portal system and the opacification of the gastric varices &#40;arrow&#41;&#46; &#40;B&#41; After the implantation of the covered TIPS such varices were not opacified and the final transhepatic gradient was 1<span class="elsevierStyleHsp" style=""></span>mmHg&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Six-year-old girl transplanted from living donor&#46; Indirect portography with contrast injection in the splenic artery showing splenomegalia and thrombosis of extrahepatic portal vein with thick varices &#40;arrow&#41; due to cavernomatosis&#46; &#40;B&#41; Direct portography after catheterization of portal vein through one varicose vein&#46; Transhepatic gradient was 18<span class="elsevierStyleHsp" style=""></span>mmHg&#46; &#40;C&#41; Implantation of recovered patent TIPS with an 8<span class="elsevierStyleHsp" style=""></span>mmHg-gradient&#46; &#40;D&#41; Direct portography after 72<span class="elsevierStyleHsp" style=""></span>h showing occluded TIPS&#46; &#40;E&#41; Direct portography showing recanalization of occluded TIPS after implanting one coaxial endoprosthesis&#46; The final transhepatic gradient was 12<span class="elsevierStyleHsp" style=""></span>mmHg&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">BA&#44; biliary atresia&#59; CHF&#44; congenital hepatic fibrosis&#59; CF&#44; cystic fibrosis&#59; HDH&#44; high digestive hemorrhage&#59; W&#44; woman&#59; TIPS&#44; transjugular intrahepatic portosystemic shunting&#59; LT&#44; liver transplant&#59; US&#44; Doppler-ultrasound&#59; M&#44; male&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&#47;sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight &#40;lbs&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TIPS indication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Gradient &#40;mmHg&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Follow up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Pre-TIPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Post-TIPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Recidivant HDH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 mesesPermeable US&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acute HDHPlateletpenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 mesesPermeable TX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acute HDHPlateletpenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 mesesPermeable TX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#47;W&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">132&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acute HDHPlateletpenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 mesesPermeable US&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#47;W&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">E&#46; Caroli&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Recidivant HDHPlateletpenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 mesesPermeable TX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#47;W&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LT due to BAPortal thrombosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acute HDHPlateletpenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 mesPermeable US&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab544294.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Demographic characteristics of children and results&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">APE&#44; acute pulmonary edema&#59; HDH&#44; high digestive hemorrhage&#59; PP&#44; primary patency&#59; SP&#44; secondary patency&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Number&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Model&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">PP &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">SP &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Major complications &#40;number&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Control HDA &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heyman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wallstent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rebleeding &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">Encephalopathy &#40;1&#41;Jugular hematoma &#40;1&#41;APE &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Hemoperitoneum &#40;2&#41;Encephalopathy &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Reference review of TIPS in children&#46;</p>"
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                            0 => "J&#46;C&#46; Garcia-Pagan"
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2012.01.002

The statistics are updated each day

Year/Month	Html	Pdf	Total

2018 May	0	1	1
2018 April	20	0	20
2018 March	2	0	2
2018 February	6	2	8
2018 January	9	2	11
2017 December	12	4	16
2017 November	9	5	14
2017 October	7	2	9
2017 September	8	1	9
2017 August	16	9	25
2017 July	10	7	17
2017 June	21	12	33
2017 May	22	1	23
2017 April	19	3	22
2017 March	19	54	73
2017 February	7	4	11
2017 January	18	1	19
2016 December	14	3	17
2016 November	20	5	25
2016 October	20	2	22
2016 September	9	8	17
2016 August	14	4	18
2016 July	9	1	10
2016 June	19	10	29
2016 May	12	5	17
2016 April	15	8	23
2016 March	18	4	22
2016 February	25	13	38
2016 January	22	12	34
2015 December	15	5	20
2015 November	19	16	35
2015 October	30	16	46
2015 September	24	12	36
2015 August	31	10	41
2015 July	32	9	41
2015 June	27	10	37
2015 May	29	25	54
2015 April	34	16	50
2015 March	22	13	35
2015 February	16	16	32
2015 January	25	12	37
2014 December	5	1	6

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