Intracardiac Echocardiography–Guided TIPS: A Primer for New Operators

Transjugular intrahepatic portosystemic shunt (TIPS) creation is an effective intervention to address complications of decompensated portal hypertension, most commonly variceal hemorrhage and refractory ascites. While TIPS is considered challenging, reported technical success rate is high at 95%.[1] [2] Variant anatomy and relative contraindications such as portal vein thrombosis pose additional challenges and can reduce likelihood of success.[3] [4] Most operators consider puncture of the portal vein to be the technically difficult part of TIPS creation, which frequently requires multiple needle passes. Existing methods for the guidance of a needle pass into the portal vein do not provide real-time feedback and multiple needle passes are not without risk. Indirect portal venogram via injection of contrast or CO₂ increases risk of hepatic laceration and air embolus, respectively. Direct venogram via percutaneous needle puncture of the portal system carries a heightened risk of hemorrhage.[3] [5] [6] Needle passes without real-time imaging guidance can lead to complications such as extrahepatic portal vein puncture, extracapsular puncture, hemoperitoneum, and hemobilia.[3] [4]

Intracardiac echocardiography is a recent advancement in TIPS guidance and has been associated with reduced fluoroscopy time, overall procedure time, contrast agent use, and rate of extracapsular puncture.[7] [8] The added real-time visualization of intracardiac echocardiography (ICE) also allows for novel approaches to cases that were once relative contraindications for TIPS. For example, Hedge et al[9] described successfully positioning a TIPS shunt between hepatic cysts in a patient with polycystic liver disease (PCLD). Moreover, anatomical variations that once complicated TIPS procedures can be routinely accomplished with ICE guidance. In light of this recent technical advancement, we have written this article as a primer for adoption of ICE guidance during TIPS creation.

Financial Disclosures

P.S.T.: Grant funding—AUR (GERRAF).

K.M.S.: Investor—Exact Sciences.

J.D.L.: Consultant/Advisory board—Avantec.

R.K.R.: Advisory board—Argon Medical, consultant—Cook Medical, consultant—B. Braun.

Publikationsverlauf

Artikel online veröffentlicht:
01. Oktober 2020

• References

• 1 Dariushnia SR, Haskal ZJ, Midia M. , et al. Society of Interventional Radiology Standards of Practice Committee. Quality improvement guidelines for transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 2016; 27 (01) 1-7
• 2 Haskal ZJ, Martin L, Cardella JF. , et al. Society of Interventional Radiology Standards of Practice Committee. Quality improvement guidelines for transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 2003; 14 (09) , Pt 2 S265-S270
• 3 Mauro M, Murphy K, Thomson K, Venbrux A, Morgan R. Image-Guided Interventions: Expert Radiology Series. Saunders; 2013
• 4 Wang L, He F, Yue Z. , et al. Techniques and long-term effects of transjugular intrahepatic portosystemic shunt on liver cirrhosis-related thrombotic total occlusion of main portal vein. Sci Rep 2017; 7 (01) 10868
• 5 Farsad K, Fuss C, Kolbeck KJ. , et al. Transjugular intrahepatic portosystemic shunt creation using intravascular ultrasound guidance. J Vasc Interv Radiol 2012; 23 (12) 1594-1602
• 6 Darcy M. Transjugular intrahepatic portosystemic shunt: techniques for portal localization. Tech Vasc Interv Radiol 2000; 3: 147-157
• 7 Gipson MG, Smith MT, Durham JD. , et al. Intravascular US-guided portal vein access: improved procedural metrics during TIPS creation. J Vasc Interv Radiol 2016; 27 (08) 1140-1147
• 8 Kao SD, Morshedi MM, Narsinh KH. , et al. Intravascular ultrasound in the creation of transhepatic portosystemic shunts reduces needle passes, radiation dose, and procedure time: a retrospective study of a single-institution experience. J Vasc Interv Radiol 2016; 27 (08) 1148-1153
• 9 Hedge JC, Foulke E, Farsad K. Intravascular US guidance for direct intrahepatic portosystemic shunt creation in the setting of polycystic liver disease. J Vasc Interv Radiol 2018; 29 (10) 1476-1477
• 10 Montgomery A, Ferral H, Vasan R, Postoak DW. MELD score as a predictor of early death in patients undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) procedures. Cardiovasc Intervent Radiol 2005; 28 (03) 307-312
• 11 Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L. , et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40 (04) 793-801
• 12 García-Pagán JC, Caca K, Bureau C. , et al. Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362 (25) 2370-2379
• 13 Ren JF, Marchlinski FE, Callans DJ, Herrmann HC. Clinical use of AcuNav diagnostic ultrasound catheter imaging during left heart radiofrequency ablation and transcatheter closure procedures. J Am Soc Echocardiogr 2002; 15 (10) , Pt 2 1301-1308
• 14 Pillai, AK Andring B, Faulconer N. , et al. Utility of intravascular US-guided portal vein access during transjugular intrahepatic portosystemic shunt creation: retrospective comparison with conventional technique in 109 patients. J Vasc Interv Radiol 2016; 27: 1154-1159