Abstract
Purpose of Review
Transjugular intrahepatic portosystemic shunt (TIPS) placement is a well-established interventional radiology procedure for treating sequelae of portal hypertension involving shunting portal blood flow to the hepatic vein bypassing the liver through a stent graft. Creating a TIPS can be a complex and radiation-intensive procedure due to the technically challenging step of cannulating the portal vein from the hepatic vein. As this is the most unpredictable step in TIPS creation, multiple techniques have been described for visualizing the portal vein to facilitate its access. The use of intravascular ultrasound (IVUS) has gained significant interest over the last few years due to reports of improved procedural metrics such as shortened procedural time and radiation dose. The purpose of this article is to review the literature and detail technical advances utilizing IVUS in TIPS creation.
Recent Findings
Intravascular ultrasound has been shown to be a safe and reproducible means of real-time image guidance for TIPS creation. The use of IVUS has been associated with improved procedural metrics including a decreased number of intrahepatic needle passes, shorter portal vein access times, decreased contrast usage, and a decrease in radiation dose.
Summary
Due to technical advances and real-time portal vein visualization using IVUS, TIPS creation at our institution has dramatically changed. Our institutional practice has nearly completed shifted to the sole use of IVUS for portal vein access in TIPS creation due to significantly improved procedural metrics including radiation dose and contrast usage.
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References
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Rosch J, Hanafee WN, Snow H. Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology. 1969;92(5):1112–4.
Coldwell DM, Ring EJ, Rees CR, et al. Multicenter investigation of the role of transjugular intrahepatic portosystemic shunt in management of portal hypertension. Radiology. 1995;196(2):335–40.
LaBerge JM, Ring EJ, Gordon RL, et al. Creation of transjugular intrahepatic portosystemic shunts with the wallstent endoprosthesis: results in 100 patients. Radiology. 1993;187(2):413–20.
Dariushnia SR, Haskal ZJ, Midia M, et al. Quality improvement guidelines for transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol. 2016;27(1):1–7.
Marquardt S, Rodt T, Rosenthal H, Wacker F, Meyer BC. Impact of anatomical, procedural, and operator skill factors on the success and duration of fluoroscopy-guided transjugular intrahepatic portosystemic shunt. Cardiovasc Intervent Radiol. 2015;38(4):903–12.
Rossle M, Siegerstetter V, Huber M, Ochs A. The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art. Liver. 1998;18(2):73–89.
Gaba RC, Khiatani VL, Knuttinen MG, et al. Comprehensive review of TIPS technical complications and how to avoid them. AJR Am J Roentgenol. 2011;196(3):675–85.
Miller DL, Balter S, Cole PE, et al. Radiation doses in interventional radiology procedures: the RAD-IR study: part I: overall measures of dose. J Vasc Interv Radiol. 2003;14(6):711–27.
Miraglia R, Maruzzelli L, Cortis K, et al. Radiation exposure in transjugular intrahepatic portosystemic shunt creation. Cardiovasc Intervent Radiol. 2016;39(2):210–7.
Farsad K, Fuss C, Kolbeck KJ, et al. Transjugular intrahepatic portosystemic shunt creation using intravascular ultrasound guidance. J Vasc Interv Radiol. 2012;23(12):1594–602.
•• 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(8):1148–53. First study to demonstrate improved procedural metrics when using IVUS including fewer intrahepatic needle passes, decreased contrast usage, decreased radiation dose, and shortened procedural time.
•• 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(8):1140–47. Study found that IVUS guidance facilitates successful TIPS creation in patients with challenging anatomy along with a reduction in procedural metrics including radiation dose, contrast, and procedural time.
•• 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(8):1154–59. Study concluded that IVUS TIPS is associated with shorter portal vein acces times, decreased needle pass-related capsular perforations, and reduced radiation dose.
Ripamonti R, Ferral H, Alonzo M, Patel NH. Transjugular intrahepatic portosystemic shunt-related complications and practical solutions. Semin Intervent Radiol. 2006;23(2):165–76.
Ali F, Mangi MA, Rehman H, Kaluski E. Use of carbon dioxide as an intravascular contrast agent: a review of current literature. World J Cardiol. 2017;9(9):715–22.
Yamagami T, Tanaka O, Yoshimatsu R, et al. Hepatic artery-targeting guidewire technique during transjugular intrahepatic portosystemic shunt. Br J Radiol. 2011;84(1000):315–8.
Zabicki B, Ricke J, Dudeck O, Pech M. CT-assisted transfemoral intrahepatic portosystemic shunt in a long duration follow-up: a case report. Pol J Radiol. 2014;79:39–41.
Gazzra C, Fonio P, Gallesio C, et al. Ultrasound-guided transhepatic puncture of the hepatic veins for TIPS placement. Radiol Med. 2013;118(3):379–85.
Haskal ZJ, Duszak R Jr, Furth EE. Transjugular intrahepatic transcaval portosystemic shunt: the gun-sight approach. J Vasc Interv Radiol. 1996;7(1):139–42.
Piliere G, Van Horn MH, Dixon R, Stavas J, Aylward S, Bullitt E. Vessel target location estimation during the TIPS procedure. Med Image Anal. 2009;13(3):519–29.
Tavare AN, Wigham A, Hadjivassilou A, et al. Use of transabdominal ultrasound-guided transjugular portal vein puncture on radiation dose in transjugular intrahepatic portosystemic shunt formation. Diagn Interv Radiol. 2017;23(3):206–10.
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):187–93.
Kew J, Davies RP. Intravascular ultrasound guidance for transjugular intrahepatic portosystemic shunt procedure in a swine model. Cardiovasc Intervent Radiol. 2004;27(1):38–41.
Saxon RR, Keller FS. Technical aspects of accessing the portal vein during the TIPS procedure. J Vasc Interv Radiol. 1997;8(5):733–44.
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Raja S. Ramaswamy, Tatulya Tiwari, Olaguoke Akinwande, and Christopher D. Malone each declare no potential conflicts of interest.
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Ramaswamy, R.S., Tiwari, T., Akinwande, O. et al. Intravascular Ultrasound in the Creation of Transjugular Intrahepatic Portosystemic Shunts: Review of the Literature and Future Directions. Curr Radiol Rep 7, 4 (2019). https://doi.org/10.1007/s40134-019-0314-z
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DOI: https://doi.org/10.1007/s40134-019-0314-z