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OBJECTIVE. Transjugular intrahepatic portosystemic shunt (TIPS) creation increases the risk of hepatic encephalopathy due to overshunting. Techniques exist to secondarily reduce the shunt for refractory encephalopathy. The purpose of this article is to describe a technique for primary TIPS restriction using a balloon-expandable stent within the transvenous hepatic track followed by deployment of a self-expanding polytetrafluoroethylene–lined stent-graft within the balloon-expandable stent to create the TIPS. CONCLUSION. This technique enables control over the degree of portosystemic shunting in elective TIPS creation.

OBJECTIVE. The purpose of this article is to highlight the clinical and radiologic evaluation of patients referred for transjugular intrahepatic portosystemic shunt (TIPS) creation. CONCLUSION. TIPS creation is an effective procedure for portal diversion in the setting of recurrent variceal bleeding or diuretic refractory ascites secondary to portal hypertension. Close collaboration between hepatologists and interventional radiologists is important for appropriate patient selection. Pre-procedural clinical and radiologic evaluation is fundamental for successful management of these patients.

OBJECTIVE. The purpose of this article is to present our experience in treating patients with hepatic metastases from a neuroendocrine primary malignancy. CONCLUSION. The tumor and patient characteristics, vascular access, and features of treatment all play a role in the long-term management of patients with metatastic neuroendocrine tumors. Routine prophylactic measures are recommended to reduce the frequency and severity of crisis events related to hormone release in patients with neuroendocrine tumors.

AJR 2015; 204:W733 0361–803X/15/2046–W733 © American Roentgen Ray Society Reply to “Laser Ablation for Hepatic Metastases From Neuroendocrine Tumors” We appreciate the interest in our article, “Catheter-Based Treatments for Hepatic Metastases from Neuroendocrine Tumors” [1] and welcome the comments and suggestions provided by Tombesi et al. [2]. We wholeheartedly agree that cytoreductive techniques are a growing component of the treatment algorithm for oligometastatic neuroendocrine tumors. However, there is significant institutional variation in the techniques. Many institutions approach liver metastases with nonanatomic resections and rely on “wedge” or “melon-ball” techniques to resect lesions with limited hepatic parenchymal margins. In fact, recently at our institution a total of 73 “lesions” (most less than 1 cm in size) were removed from one patient in a single open procedure. We tend to use percutaneous ablative techniques for metastases that are larger in size but fewer in number. These percutaneous techniques include radiofrequency ablation, microwave ablation, cryoablation, and irreversible electroporation. The laser ablation techniques described by Tombesi et al. [2] are intriguing; however, they are not readily available in the United States. These noncatheter-based liver-directed therapies introduce an entirely different set of treatment strategies and may well be worth a dedicated study. Kenneth J. Kolbeck Khashayar Farsad Dotter Interventional Institute, Oregon Health & Science University, Portland, OR DOI:10.2214/AJR.15.14379 WEB—This is a web exclusive article.