A Meta-analysis on Interventional Metrics of Transjugular Intrahepatic Portosystemic Shunt Placement With Cone-beam Computed Tomography Guidance and Fluoroscopy Guidance

Background/Aim: To integrate the results of studies on interventional metrics of cone-beam computed-tomography (CBCT) guidance and fluoroscopy guidance in transjugular intrahepatic portosystemic shunt (TIPS) placement in a meta-analysis. Materials and Methods: A systemic literature search was conducted in PubMed, Ovid/Medline, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Google Scholar. Inclusion criteria were original research articles in English, comparison of CBCT and fluoroscopy guided TIPS placements and reporting of outcome parameters (procedure time, fluorotime, radiation exposure). Study quality was assessed by modified Downs-and-Black checklist. Heterogeneity was evaluated using forest plots, I2, and considering study differences. A meta-analysis was conducted to combine the outcome effect using mean difference (MD) between CBCT and fluoroscopy guided TIPS placements. Results: In this meta-analysis, five studies with 218 patients and TIPS placements were included. Study quality was limited with 12±0 points for procedure time, fluorotime and dose area product (DAP). Heterogeneity was indicated in procedure time (I2=48.7%), fluorotime (I2=44.2%) and DAP (I2=55.4%). By application of random-effects model, procedure time and fluorotime of TIPS placements were not significantly different between CBCT and fluoroscopy guidance with an overall MD of −14.43min [95% confidence interval (CI)=−38.82 to 9.97 min; p=0.16] and −6.23 min (95% CI=−22.27 to 9.80 min; p=0.24). DAP was not significant between TIPS placement under CBCT and fluoroscopy guidance with a MD of 27.44 Gy*cm2 (95% CI=−10.47 to 65.34 Gy*cm2; p=0.11). Conclusion: CBCT guidance tends to accelerate fluoroscopy and procedure times with slightly elevated DAP compared to fluoroscopy guidance in TIPS placements. Evidence is limited by the small number of feasibility studies. Further investigations need standardized reporting, especially for procedural complications and shunt patency.