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

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.

Publikationsverlauf

Artikel online veröffentlicht:
16. Juni 2023

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