Transabdominal Ultrasound-Guided Transjugular Intrahepatic Portosystemic Shunt Placement between Left Hepatic Vein and Left Portal Vein: A Technical Note

Abstract

The conventional approach for transjugular intrahepatic portosystemic shunt (TIPS) involves creating a communication between the right hepatic vein and the right branch of the portal vein. However, some studies suggest that TIPS placement between the left hepatic vein and the left portal vein branch may reduce the risk of hepatic encephalopathy. This left-to-left TIPS technique can also be beneficial for patients with an attenuated or thrombosed right portal vein, an atrophied right lobe, or those who have undergone a right hepatectomy or liver transplant with a left lobe graft. Here, we present our technique for performing left-to-left TIPS using transabdominal ultrasound guidance.

Keywords

streamline - encephalopathy - stent

Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) placement has become a well-established procedure for alleviating symptoms of portal hypertension refractory to standard medical therapy in patients who are not liver transplant candidates. Conventional TIPS procedures are performed by creating an intraparenchymal tract between the right hepatic vein and the right portal vein. However, some studies have reported that placement of a stent between the left hepatic vein and left branch of the portal vein is more desirable due to the decreased risk of hepatic encephalopathy and reduced incidence of stent dysfunction and liver failure.[1] [2] [3] Herein, we describe our technique of accessing the left portal vein from the left hepatic vein for TIPS stent placement using transabdominal ultrasound guidance.

Technique

Using standard technique, the right internal jugular vein is accessed and a 10-Fr, 11-cm vascular access sheath placed (Avanti, Cordis, Miami, FL, United States). The left hepatic vein is then cannulated using a combination of 5-Fr, 65-cm multipurpose catheter (MPA, Cook Inc., Bloomington, IN, United States) and 0.035-inch, 150-cm hydrophilic guidewire (Radifocus, Terumo Corporation, Japan). The hydrophilic guidewire is then exchanged for a 260-cm, 0.035-inch Amplatz Ultrastiff guidewire (Cook Inc.) and the MPA catheter removed. The position of the wire within the left hepatic vein is confirmed with transabdominal ultrasound at this point. Under fluoroscopic guidance, the 10-Fr, 11-cm vascular access sheath is now exchanged for the 10-Fr, 40-cm flexor Check-Flo introducer sheath and dilator from Rösch-Uchida Transjugular Liver Access set (RUPS-100, Cook Inc.) over the Ultrastiff guidewire. The dilator is now removed while keeping the guidewire in place. The 14-gauge stiffening cannula from the RUPS-100 set is now threaded within the 10-Fr introducer sheath over the Ultrastiff guidewire and placed with its tip just beyond the tip of the introducer sheath. This is followed by the introduction of the trocar stylet and catheter set with its tip flush with the tip of the stiffening cannula. At this point, the second operator uses transabdominal ultrasound to guide the portal puncture. The curvilinear ultrasound probe is kept in the epigastric region in the midline in the sagittal plane in such a way that the left hepatic vein is seen in its entire length, while the left branch of portal vein is seen in the cross-sectional plane as a circle ([Fig. 1]). The entire RUPS-100 set assembly lying within the left hepatic vein is now withdrawn as a unit under ultrasound guidance till the point where it comes in the same coronal plane as the left portal vein branch to be punctured. Now, the stiffening cannula is rotated anteriorly so that it wedges against the left hepatic venous wall and gets directed toward the portal vein target. This anterior rotation could be clockwise or anticlockwise depending on the initial direction of the cannula, which in turn is decided by the orientation of left hepatic vein within the liver. Stiffening cannula is now adjusted subtly so that it comes in the same sagittal plane as the ultrasound probe. The trocar stylet-catheter set is now advanced under ultrasound guidance to puncture the portal vein ([Fig. 2]). After portal puncture, the trocar stylet is unscrewed and removed while keeping the 5-Fr catheter in place. A 0.035-inch, 260-cm hydrophilic guidewire (Radifocus, Terumo) is then passed through the 5-Fr catheter into the portal vein and parked in the superior mesenteric vein or splenic vein. The rest of the steps are the same as those of the standard TIPS procedure. The TIPS stent (Niti, Taewoong, South Korea) is finally placed between the left hepatic vein and the left portal vein ([Fig. 3]).

Fig. 1 (A, B) Images depicting how the ultrasound probe needs to be positioned in the epigastric region and oriented in the sagittal plane to get a (C) sonographic image of the left lobe of the liver in which the left hepatic vein is seen in its length (solid arrow) and the left portal vein branch is seen in cross-section as a circle (dashed arrow). (D) The corresponding computed tomography (CT) image, which is oriented to match with the ultrasound image.

Fig. 2 (A) Ultrasound images depicting the advancement of the trocar stylet and catheter set through the liver parenchyma to puncture the portal vein (arrows). The dashed arrow denotes the stretched-out far end of the portal venous wall by the trocar stylet. (B) The guidewire (arrows) within the portal vein.

Fig. 3 Digital subtraction image shows the transjugular intrahepatic portosystemic shunt (TIPS) stent (solid arrow) between the left hepatic vein and the left portal vein. Coils used to occlude the coronary vein can also be seen (dashed arrow).

Discussion

Owing to the streamline flow in the portal venous system, there is incomplete mixing of blood coming from the superior mesenteric vein and splenic vein into the main portal vein, resulting in the mesenteric blood going predominantly into the right portal vein and splenic blood preferentially going into the left portal vein.[4] As a result, it has been hypothesized that toxins (mainly ammonia) coming from the mesenteric venous blood preferentially reach the right lobe of the liver through the right portal vein.[1] [2] [3] This has been cited as a potential reason for the lower incidence of hepatic encephalopathy after left-sided TIPS. In addition, since the left lobe of the liver is often smaller in size compared with the right lobe, the extent of hepatic parenchymal hypoperfusion would theoretically be less in left-sided TIPS, leading to reduced incidence of liver dysfunction after the shunting.[1] Moreover, the straighter and shorter stent in left-to-left TIPS might reduce the rates of stent dysfunction. Overall, left-sided TIPS seems to create a better balance between the reduction of portal hypertension and the maintenance of hepatic perfusion.[1]

Left-to-left TIPS could also be useful in patients who have chronically thrombosed or severely attenuated right portal vein, post liver transplant recipients with a left lobe graft, post right hepatectomy patients, and those with severely atrophied and dysmorphic right lobe.[5] In patients who experience inadequate portal pressure reduction or a recurrence of portal hypertensive symptoms after a conventional TIPS, a parallel left-sided TIPS may be considered as an alternative. Likewise, for patients with an occluded conventional TIPS, where transjugular access fails to cannulate the stent and percutaneous access is contraindicated, a parallel left-to-left TIPS could be a viable option.

Studies reporting the efficacy and results of left-to-left TIPS have all described the use of fluoroscopic guidance for portal vein access.[1] [2] [3] [5] Some of these studies have mentioned difficulty in accessing the left portal vein under fluoroscopic guidance and the need for increasing the curvature of the stiffening cannula to achieve the same.[1] However, with the use of additional transabdominal ultrasound guidance, we have not felt the need to bend the cannula in any of the cases since a suitable plane for puncture could always be found with dynamic ultrasound imaging. While the technique to puncture the right portal vein during TIPS has been well described in the literature, we could not find any reference for left-sided TIPS under ultrasound guidance. The essential difference between the two techniques is the position and orientation of the ultrasound probe and the need for clockwise or anticlockwise rotation of the cannula, as the case may be. The only issue with left-sided TIPS under ultrasound guidance in our experience has been the poor visibility of the left lobe of the liver on ultrasound in some patients with cirrhosis, particularly those with an atrophied left lobe. Also, when the peripheral branch of the left portal vein is accessed, chances of acute angulation of stent would be higher compared with the conventional TIPS leading to inadequate reduction in portal pressure.

Transabdominal ultrasound guidance for portal puncture also has the potential to reduce the procedure times, contrast usage, radiation exposure, and risk of inadvertent hepatic capsular transgressions.[6] Since ultrasound machines are widely available and relatively cheap, utilizing them during TIPS could be a feasible and cost-effective measure as well.

Conflict of Interest

None declared.

• References

• 1 Chen L, Xiao T, Chen W. et al. Outcomes of transjugular intrahepatic portosystemic shunt through the left branch vs. the right branch of the portal vein in advanced cirrhosis: a randomized trial. Liver Int 2009; 29 (07) 1101-1109
• 2 Luo SH, Chu JG, Huang H, Zhao GR, Yao KC. Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt to reduce hepatic encephalopathy. World J Gastroenterol 2019; 25 (09) 1088-1099
• 3 Zuo K, Wang C, Wang J, Xia FF, Song T. Transjugular intrahepatic portosystemic shunt through left branch versus right branch of portal vein: a meta-analysis. Abdom Radiol (NY) 2021; 46 (04) 1718-1725
• 4 de Araujo EM, Torres US, Racy DJ, Torres LR, Chojniak R, D'Ippolito G. The “streamline phenomenon” of the portal vein flow and its influence on liver involvement by gastrointestinal diseases: current concepts and imaging-based review. Abdom Radiol (NY) 2020; 45 (02) 403-415
• 5 Maleux G. Transjugular intrahepatic portosystemic shunt via left hepatic - left portal veins. Ann Gastroenterol 2019; 32 (06) 656
• 6 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 (03) 206-210

Publikationsverlauf

Artikel online veröffentlicht:
28. März 2025