Intravascular Ultrasound for Creation of Portosystemic Shunts: An Illustrative Guide of Hepatic Vascular Anatomy and Procedure Techniques

Introduction Portal hypertension and its associated sequelae can have devastating effects on patients and can result in significant morbidity and mortality. Transjugular intrahepatic portosystemic shunts (TIPS) have been performed in these patients to decrease portal pressures, although the procedure can be technically challenging due to altered hepatic anatomy in cirrhotic patients. Traditionally, wedged hepatic venography with carbon dioxide (CO₂) has been used to delineate portal venous anatomy and to gain access to the portal system. Recently, intravascular ultrasound (IVUS) has been described as a tool to better visualize the three-dimensional anatomy of the hepatic vasculature for use in shunt creation, although experience and expertise with IVUS is limited.

Content Organization We will review hepatic and portal venous anatomy using color illustrations and correlative IVUS images. The various TIPS anastomotic possibilities will be discussed including right hepatic vein to right portal vein, middle hepatic vein to the right or left portal vein, and inferior vena cava to main portal vein (DIPS) using case examples. Emphasis will be placed on technical use of the IVUS probe and how to maneuver the probe to successfully create the desired shunt. This will be accomplished via rich illustrations and corresponding IVUS, computed tomography (CT), and fluoroscopic images. We will also briefly review our published experience with IVUS TIPS in 109 patients.

Learning Points IVUS assistance in the creation of portosystemic shunts has been recently advocated as a means of achieving shorter procedure times, fewer complications, decreased contrast medium usage, and less radiation dose. It provides the operator the ability to choose the optimal portosystemic shunt route via direct visualization. Increased familiarity with IVUS techniques will allow interventional radiologists to provide the best possible care to patients suffering from portal hypertension.