Tips for Creating TIPS with Intravascular Ultrasound Guidance: An Illustrative Guide of Hepatic Vascular Anatomy and Procedure Techniques

Introduction: Portal hypertension and its associated sequelae can have devastating effects on patients and result in significant morbidity and mortality. Transjugular intrahepatic portosystemic shunts (TIPS) have been performed in these patients to decrease the hepatic venous pressure gradient and to primarily address esophageal variceal bleeding or ascites. Traditionally, wedged hepatic venography with CO₂ has been used to delineate portal venous anatomy and to gain access to the portal system. Recently, intravascular ultrasound (IVUS) has been described as a method to better visualize the three-dimensional anatomy of the hepatic vasculature for use in shunt creation, although experience and expertise with IVUS are limited.

Content Organization: We will review the hepatic and portal venous anatomy as well as important anatomic variations to consider that could affect TIPS creation. Various approaches to achieving a portosystemic anastomosis will be discussed, and the role of IVUS in creating these anastomoses will be highlighted. Technical aspects of using the IVUS probe will be reviewed along with an emphasis on how to achieve the desired portosystemic shunt. We will briefly discuss advantages of IVUS TIPS compared with conventional TIPS based on our published experience.

Learning Points: The addition of IVUS to the interventional radiology armamentarium allows for better visualization of hepatic and portal venous anatomy during TIPS creation. A thorough understanding of hepatic vascular anatomy and the various portosystemic shunts that can be created is important for both the diagnostic and interventional radiologist. Increased familiarity with IVUS will allow interventional radiologists to provide the best possible care to patients suffering from portal hypertension

 

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No conflict of interest has been declared by the author(s).