Intravascular Ultrasound in the Creation of Transjugular Intrahepatic Portosystemic Shunts: Review of the Literature and Future Directions
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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.
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.
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.
KeywordsTransjugular intrahepatic portosystemic shunt TIPS Intracardiac echocardiography Intravascular ultrasound Portal hypertension
Compliance with Ethical Guidelines
Conflict of interest
Raja S. Ramaswamy, Tatulya Tiwari, Olaguoke Akinwande, and Christopher D. Malone each declare no potential conflicts of interest.
Research Involving Human and Animal Rights
All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki Declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).
Recently published papers of particular interest have been highlighted as: •• Of major importance
- 11.•• 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.Google Scholar
- 12.•• 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.Google Scholar
- 13.•• 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.Google Scholar