New Techniques and Devices in Transjugular Intrahepatic Portosystemic Shunt Placement

Abstract

Recently, new techniques and devices in transjugular intrahepatic portosystemic shunt (TIPS) placement have emerged that can improve upon the standard procedure. Ultrasound guidance during TIPS with intracardiac echocardiography (ICE), placement of controlled expansion (CX) stents, and portal vein recanalization (PVR) via transsplenic access are three techniques with new data supporting their implementation. ICE guidance can improve the technical success of difficult cases, decrease procedure time, and decrease complications such as capsular puncture, hemobilia, and hepatic artery injury. CX stents offer the operator better control over the final portosystemic gradient, which is particularly useful in patients with a high risk of post-TIPS hepatic encephalopathy. Finally, transsplenic access provides a stable, antegrade route for PVR, which can be used to optimize transplant candidacy as well as treat the sequelae of portal hypertension in patients with portal vein thrombosis. This article will describe the benefits, technical parameters, and patient selection criteria for each of these new techniques.

Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt to reduce hepatic encephalopathy

“…In early TIPS technology, it was easier to use the right than left branch of the portal vein for puncture target[24]. Currently, experienced interventional radiologists can choose the left or right branch as a puncture target, with no technical difficulty and a near 100% success rate[25]. Further consideration is how to improve the clinical success rate and reduce the incidence of HE and liver failure.…”

EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis

“…These imaging techniques reduced TIPS procedure duration and reduced the number of passes required to reach the portal vein and their use is therefore recommended despite a lack of evidence that they reduce bleeding complications. 208…”

Transjugular Intrahepatic Portosystemic Shunt

“…22 iTIPS uses a 90-degree side fire ICE transducer catheter to provide direct sonographic visualization during critical steps such as hepatic vein cannulation, PVP, and stent deployment. 22,23 The ICE catheter is introduced through vascular access at either a second IJV site or through a common femoral vein approach. 23 Instead of relying on single-plane, indirect image guidance with wedged hepatic venogram during PVP, ICE allows operators to visualize the precise location of their needle tip in relation to the targeted portal vein and hepatic parenchyma (Figure 1).…”

“…22,23 The ICE catheter is introduced through vascular access at either a second IJV site or through a common femoral vein approach. 23 Instead of relying on single-plane, indirect image guidance with wedged hepatic venogram during PVP, ICE allows operators to visualize the precise location of their needle tip in relation to the targeted portal vein and hepatic parenchyma (Figure 1). iTIPS has been associated with fewer needle passes and capsular perforations during this step, and overall decreased procedure time and radiation exposure compared with conventional TIPS.…”