Intracardiac Echocardiography–Guided TIPS: A Primer for New Operators

Transjugular intrahepatic portosystemic shunt (TIPS) creation is an effective intervention to address complications of decompensated portal hypertension, most commonly variceal hemorrhage and refractory ascites. While TIPS is considered challenging, reported technical success rate is high at 95%.[1] [2] Variant anatomy and relative contraindications such as portal vein thrombosis pose additional challenges and can reduce likelihood of success.[3] [4] Most operators consider puncture of the portal vein to be the technically difficult part of TIPS creation, which frequently requires multiple needle passes. Existing methods for the guidance of a needle pass into the portal vein do not provide real-time feedback and multiple needle passes are not without risk. Indirect portal venogram via injection of contrast or CO₂ increases risk of hepatic laceration and air embolus, respectively. Direct venogram via percutaneous needle puncture of the portal system carries a heightened risk of hemorrhage.[3] [5] [6] Needle passes without real-time imaging guidance can lead to complications such as extrahepatic portal vein puncture, extracapsular puncture, hemoperitoneum, and hemobilia.[3] [4]

Intracardiac echocardiography is a recent advancement in TIPS guidance and has been associated with reduced fluoroscopy time, overall procedure time, contrast agent use, and rate of extracapsular puncture.[7] [8] The added real-time visualization of intracardiac echocardiography (ICE) also allows for novel approaches to cases that were once relative contraindications for TIPS. For example, Hedge et al[9] described successfully positioning a TIPS shunt between hepatic cysts in a patient with polycystic liver disease (PCLD). Moreover, anatomical variations that once complicated TIPS procedures can be routinely accomplished with ICE guidance. In light of this recent technical advancement, we have written this article as a primer for adoption of ICE guidance during TIPS creation.

Financial Disclosures

P.S.T.: Grant funding—AUR (GERRAF).

K.M.S.: Investor—Exact Sciences.

J.D.L.: Consultant/Advisory board—Avantec.

R.K.R.: Advisory board—Argon Medical, consultant—Cook Medical, consultant—B. Braun.

Publication History

Article published online:
01 October 2020

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