Advanced portal venous access techniques for transjugular intrahepatic portosystemic shunt placement

Abstract

IntroductionTransjugular intrahepatic portosystemic shunt (TIPS) placement is a well-established but technically challenging procedure for the management of sequelae of end-stage liver disease. Performed essentially blindly, traditional fluoroscopically guided TIPS placement requires multiple needle passes and prolonged radiation exposure to achieve successful portal venous access, thus increasing procedure time and the risk of periprocedural complications. Several advanced image-guided portal access techniques, including intracardiac echocardiography (ICE)-guided access, cone-beam CT (CBCT)-guided access and wire-targeting access techniques, can serve as alternatives to traditional CO2 portography-based TIPS creation.MethodsA literature search was performed on the electronic databases including MEDLINE and Embase, from 2000 to the present to identify all relevant studies. The reference list also included studies identified manually, and studies referenced for other purposes.FindingsThe main benefit of these advanced access techniques is that they allow the operator to avoid essentially blind portal punctures, and the ability to visualise the target, thus reducing the number of required needle passes. Research has shown that ICE-guided access can decrease the radiation exposure, procedure time and complication rate in patients undergoing TIPS placement. This technique is particularly useful in patients with challenging portal venous anatomy. However, ICE-guided access requires additional equipment and possibly a second operator. Other studies have shown that CBCT-guided access, when compared with traditional fluoroscopy-guided access, provides superior visualisation of the anatomy with similar amount of radiation exposure and procedure time. The wire-targeting technique, on the other hand, appears to offer reductions in procedure time and radiation exposure by enabling real-time guidance. However, this technique necessitates percutaneous injury to the liver parenchyma in order to place the target wire.ConclusionAdvanced portal access techniques have certain advantages over the traditional fluoroscopically guided TIPS access. To date, few studies have compared these advanced guided access options, and further research is required.

TIPS and Interventional Radiology Management of Portal Hypertensive Complications in Pediatric Population

“…4 ). 21 Alternatively, transabdominal ultrasound guidance can be used for real-time visualization of the transparenchymal puncture. CBCT is conducted during an inspiratory breath hold after intravenous injection of diluted iodine-containing contrast agent.…”

Advanced Techniques for Accessing the Portal Vein during Transjugular Intrahepatic Portosystemic Shunt Creation

“…4 It is important to note that misregistration, most commonly due to difference in respiration or volume of ascites, is a significant limitation of this second method. 5…”

“…Advancement of the TIPS needle may be aided by placing a catheter, platinum-tipped wire, vascular snare, or contrast-filled balloon at the portal target. 5 TIPS is then performed in standard fashion. Tract embolization of the transhepatic access may be performed with absorbable gelatin sponge slurry and/or pushable coils.…”

“…4 It is important to note that misregistration, most commonly due to difference in respiration or volume of ascites, is a significant limitation of this second method. 5 Regardless of approach, the three-dimensional images can be used to plan the trajectory to avoid damage to critical structures and provide a virtual navigation path on fluoroscopy. Tacher et al described their experience using fusion of preoperative portal venous phase CT with intraoperative noncontrast cone-beam CT to provide real-time tri-planar navigation for portal branch cannulation, which was demonstrated to be safe and effective in addition to resulting in a lower procedural time, contrast dose, and radiation exposure compared with reported values for standard TIPS.…”

High volume retrograde portography for better discrimination of the portal vein during TIPS procedure

“… 5 – 7 Percutaneous wire placement or Cone-Beam CT as guiding methods for portal vein delineation are also possible. 8 , 9 With this prospective study, we examined to what extent the quality of retrograde portography with contrast media can be influenced by optimizing individual parameters.…”