Intravascular Ultrasound for Transjugular Intrahepatic Portosystemic Shunt Creation: “TIPS” and Tricks

 

 Buy Article Permissions and Reprints

Cirrhosis affects 4.5 million people in the United States.[1] Sequela of cirrhosis and portal hypertension include varices, which occur in up to 60 to 80% of cirrhotic patients and pose a bleeding risk of 25 to 35%[2]; refractory ascites, which occurs in 5 to 10% of patients[3]; recurrent hepatic hydrothorax, which occurs in 5 to 10% of cirrhotic patients[4]; and hepatic encephalopathy, which occurs in up to 45% of patients with cirrhosis.[5] Transjugular intrahepatic portosystemic shunt (TIPS) creation results in portal venous decompression and reduces mortality and morbidity associated with these portal hypertensive sequelae. There is a clear survival benefit with TIPS creation in patients at risk of variceal hemorrhage, including those who fail endoscopic banding, who are at high risk of pharmacologic or endoscopic treatment failure,[6] and who undergo early TIPS creation for secondary prophylaxis against bleeding.[7] [8] For those with refractory ascites and hepatic hydrothorax, resolution of fluid accumulation can be expected in 85%[9] and 82%, respectively.[10]

First developed by Josef Rosch in 1969, TIPS has undergone multiple iterations that have improved the technical and clinical success rates, including incorporation of the bare metal stent and introduction of the Viatorr (GORE, Flagstaff, AZ) stent graft.[11] Despite such improvements, traditional fluoroscopic-guided TIPS still has limitations. Most notable are the operator's dependence on a two-dimensional (2D) understanding of the relationship between hepatic veins (HVs) and portal veins (PVs) as visualized by wedged hepatic venography, and the lack of real-time PV visualization during PV puncture. This fluoroscopic technique potentiates risks associated with multiple errant punctures, including hepatic artery pseudoaneurysm and thrombosis, biliary injury, and transcapsular perforation. Although rare, wedge venography also carries the risk of capsular rupture, which can lead to fatal bleeding and the need for additional interventions.[8] Multiple modifications have been explored to address this specific issue of PV access, including transhepatic or trans-splenic access with placement of a marker wire and use of transabdominal ultrasound guidance.[12] Because all these techniques have their own risks and shortcomings, their attempts to address the remaining challenges with fluoroscopic TIPS have led to the innovative use of intravascular ultrasound (IVUS). IVUS guidance during TIPS creation allows direct, real-time visualization of PV puncture. Additionally, it facilitates accurate determination of stent size and precise stent deployment. Finally, IVUS aids in more challenging cases, such as in the setting of challenging venous anatomy (accessory right HV or small PV branches), liver masses, Budd-Chiari, and PV thrombosis.[13] [14]

The application of IVUS was first reported in 1967 for intracardiac imaging. The original IVUS probe was a 5.5-Fr, over-the-wire catheter with a high frequency (20 MHz), which was a rotational transducer that provided high-resolution 360-degree cross-sectional images of the coronary arteries.[15] Subsequently, a lower frequency, phased array intracardiac echocardiography (ICE) catheter was developed to provide high resolution, real-time visualization of cardiac structures during guidance of percutaneous cardiac interventions and electrophysiology procedures. The creation of this side firing catheter opened the door for use in TIPS. When positioned in the IVC at the level of caudate lobe, the ICE catheter generates high-resolution 90-degree longitudinal sector images of the hepatic parenchyma, bile ducts, arteries, and veins, thus allowing real-time visualization of the entire needle trajectory as it traverses the hepatic parenchyma from HV to PV. This review aims to provide an evidence-based overview of the benefits of IVUS guidance during TIPS, to highlight the rotational IVUS atlas through correlation with computed tomographic (CT) and fluoroscopic anatomy, and to provide a case-based tutorial on the techniques and benefits of IVUS guidance.

Publication History

Article published online:
16 June 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

• References

• 1 Summary Health Statistics Tables for U.S. Adults: National Health Interview Survey;. 2018 ; Table A-4b A 4c
  PubMedGoogle Scholar
• 2 D'Amico G, Morabito A. Noninvasive markers of esophageal varices: another round, not the last. Hepatology 2004; 39 (01) 30-34
  CrossrefPubMedGoogle Scholar
• 3 Zhao R, Lu J, Shi Y, Zhao H, Xu K, Sheng J. Current management of refractory ascites in patients with cirrhosis. J Int Med Res 2018; 46 (03) 1138-1145
  CrossrefPubMedGoogle Scholar
• 4 Garbuzenko DV, Arefyev NO. Hepatic hydrothorax: an update and review of the literature. World J Hepatol 2017; 9 (31) 1197-1204
  CrossrefPubMedGoogle Scholar
• 5 Bleibel W, Al-Osaimi AM. Hepatic encephalopathy. Saudi J Gastroenterol 2012; 18 (05) 301-309
  CrossrefPubMedGoogle Scholar
• 6 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
  CrossrefPubMedGoogle Scholar
• 7 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
  CrossrefPubMedGoogle Scholar
• 8 Zaman A, Chalasani N. Bleeding caused by portal hypertension. Gastroenterol Clin North Am 2005; 34 (04) 623-642
  CrossrefPubMedGoogle Scholar
• 9 Gaba RC, Parvinian A. How quickly does ascites respond to TIPS? Clinical follow-up of a cohort of eighty patients. Diagn Interv Radiol 2014; 20 (04) 364-364
  CrossrefPubMedGoogle Scholar
• 10 Siegerstetter V, Deibert P, Ochs A, Olschewski M, Blum HE, Rössle M. Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: long-term results in 40 patients. Eur J Gastroenterol Hepatol 2001; 13 (05) 529-534
  CrossrefPubMedGoogle Scholar
• 11 Fanelli F. The evolution of transjugular intrahepatic portosystemic shunt: tips. ISRN Hepatol 2014; 2014: 762096
  CrossrefPubMedGoogle Scholar
• 12 Thornburg B, Desai K, Hickey R. et al. Portal vein recanalization and transjugular intrahepatic portosystemic shunt creation for chronic portal vein thrombosis: technical considerations. Tech Vasc Interv Radiol 2016; 19 (01) 52-60
  CrossrefPubMedGoogle Scholar
• 13 Englesbe MJ, Kubus J, Muhammad W. et al. Portal vein thrombosis and survival in patients with cirrhosis. Liver Transpl 2010; 16 (01) 83-90
  CrossrefPubMedGoogle Scholar
• 14 Mancuso A, Fung K, Mela M. et al. TIPS for acute and chronic Budd-Chiari syndrome: a single-centre experience. J Hepatol 2003; 38 (06) 751-754
  CrossrefPubMedGoogle Scholar
• 15 Hodgson JM, Graham SP, Savakus AD. et al. Clinical percutaneous imaging of coronary anatomy using an over-the-wire ultrasound catheter system. Int J Card Imaging 1989; 4 (2-4): 187-193
  CrossrefPubMedGoogle Scholar
• 16 Farsad K, Kaufman JA. Novel image guidance techniques for portal vein targeting during transjugular intrahepatic portosystemic shunt creation. Tech Vasc Interv Radiol 2016; 19 (01) 10-20
  CrossrefPubMedGoogle Scholar
• 17 RiChard J, Thornburg B. New techniques and devices in transjugular intrahepatic portosystemic shunt placement. Semin Intervent Radiol 2018; 35 (03) 206-214
  Article in Thieme ConnectPubMedGoogle Scholar
• 18 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
  CrossrefPubMedGoogle Scholar
• 19 Luo SH, Chu JG, Huang H, Yao KC. Effect of initial stent position on patency of transjugular intrahepatic portosystemic shunt. World J Gastroenterol 2017; 23 (26) 4779-4787
  CrossrefPubMedGoogle Scholar
• 20 Maleux G, Pirenne J, Vaninbroukx J, Aerts R, Nevens F. Are TIPS stent-grafts a contraindication for future liver transplantation?. Cardiovasc Intervent Radiol 2004; 27 (02) 140-142
  CrossrefPubMedGoogle Scholar
• 21 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
  CrossrefPubMedGoogle Scholar
• 22 Ramaswamy RS, Charalel R, Guevara CJ. et al. Propensity-matched comparison of transjugular intrahepatic portosystemic shunt placement techniques: Intracardiac echocardiography (ICE) versus fluoroscopic guidance. Clin Imaging 2019; 57: 40-44
  CrossrefPubMedGoogle Scholar
• 23 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 (08) 1154-1159
  CrossrefPubMedGoogle Scholar