Intravascular Ultrasound Guidance for TIPS Procedures: A Review

Meta-analysis of transjugular intrahepatic portosystemic shunt creation with or without intravascular ultrasound guidance

OBJECTIVE

To conduct a meta-analysis to assess the efficacy of intravascular ultrasound (IVUS) during transjugular intrahepatic portosystemic shunt (TIPS) creation.

METHODS

MEDLINE and Embase databases were queried until July 2022 for comparative studies reporting procedure metrics for TIPS creation with or without IVUS guidance. Meta-analysis was performed with random-effects modelling for total procedural time, time to portal venous access, fluoroscopy time, iodinated contrast volume use, air kerma, dose area product, and number of needle passes. Intraoperative procedure-related complications were also reviewed.

RESULTS

Of 95 unique records initially identified, 6 were eligible for inclusion. A total of 194 and 240 patients underwent TIPS with and without IVUS guidance. Pooled analyses indicated that IVUS guidance was associated with reduced total procedure time (SMD -0.76 [95% CI -1.02, -0.50] P < .001), time to portal venous access (SMD -0.41 [95% CI -0.67, -0.15] P = .002), fluoroscopy time (SMD, -0.54 [95% CI -1.02, -0.07]; P = .002), contrast volume use (SMD, -0.89 [95% CI -1.16, -0.63]; P < .001), air kerma (SMD, -0.75 [95% CI -1.11, -0.38]; P < .001) and dose area product (SMD, -0.98 [95% CI -1.77, -0.20]; P = .013). A total of 4.2 and 7.8 needle passes were required in the IVUS and non-IVUS group, respectively (SMD, -0.60 [95% CI -1.42, 0.21]; P = .134). Pooled complication rates were 15.2% (12/79) and 21.4% (28/131), respectively.

CONCLUSION

IVUS guidance during TIPS creation improves procedural metrics including procedural time, contrast usage, and radiation exposure.

ADVANCES IN KNOWLEDGE

(1) The use of IVUS during TIPS is associated with shorter procedural time, lower contrast usage, and radiation exposure. (2)The use of IVUS is not associated with higher complication rates.

Variceal and Nonvariceal Upper Gastrointestinal Bleeding Refractory to Endoscopic Management: Indications and Role of Interventional Radiology

For over 60 years, diagnostic and interventional radiology have been heavily involved in the evaluation and treatment of patients presenting with gastrointestinal bleeding. For patients who present with upper GI bleeding and have a contraindication to endoscopy or have an unsuccessful attempt at endoscopy for identifying or controlling the bleeding, interventional radiology is often consulted for evaluation and consideration of catheter-based intervention.

Role of Interventional Radiology (IR) in vascular emergencies among cirrhotic patients

Gastrointestinal hemorrhage remains one of the most common causes of morbidity and mortality among patients with liver cirrhosis. Mostly, these patients bleed from the gastroesophageal varices. However, nonvariceal bleeding is also more likely to occur in these patients. Because of frequent co-existing coagulopathy, cirrhotics are more prone to bleed from a minor vascular injury while performing percutaneous interventions. Ultrasound-guided bedside vascular access is an essential procedure in liver critical care units. Transjugular portosystemic shunts (TIPS) with/without variceal embolization is a life-saving measure in patients with refractory variceal bleeding. Whenever feasible, balloon-assisted retrograde transvenous obliteration (BRTO) is an alternative to TIPS in managing gastric variceal bleeding, but without a risk of hepatic encephalopathy. In cases of failed or unfeasible endotherapy, transarterial embolization using various embolic agents remains the cornerstone therapy in patients with nonvariceal bleeding such as ruptured hepatocellular carcinoma, gastroduodenal ulcer bleeding, and procedure-related hemorrhagic complications. Among various embolic agents, N-butyl cyanoacrylate (NBCA) enables better vascular occlusion in cirrhotics, even in coagulopathy, making it a more suitable embolic agent in an expert hand. This article briefly entails the different interventional radiological procedures in vascular emergencies among patients with liver cirrhosis.

Safety and Effectiveness of a Novel Tips Access Set with Steerable Cannula in a Swine Model

PURPOSE

This study aimed to assess the safety, effectiveness, and feasibility of the Liverty™ transjugular intrahepatic portosystemic shunt (TIPS) access set, which has an ergonomic handle that allows for in situ cannula tip deflection and a distal steerable cannula angle, versus the COOK® Rosch-Uchida Transjugular Liver Access Set (RUPS-100) in healthy pigs.

METHODS

Twelve pigs randomly underwent TIPS with the Liverty™ set or the RUPS-100 set. Three interventionalists performed 4 TIPS procedures, 2 with each set. The primary outcome was procedural success, defined as successful establishment of the intrahepatic portosystemic shunt and stent placement.

RESULTS

The shunt was successfully established in 11 pigs. The procedural success was achieved in all 6 pigs in the Liverty™ group and 5 out of 6 pigs for the RUPS-100 group (Fisher exact test, P > 0.999). The mean duration of puncture was shorter in the Liverty™ group versus the RUPS-100 group (12.3 ± 4.5 min vs. 16.2 ± 8.5 min), but without significant statistical difference (two sample t test, P = 0.359). The cannula angle was adjusted 69% of passes in the Liverty™ group, which was significantly higher than that in the RUPS-100 group (12%, P = 0.004). Overall, the TIPS procedural performance was comparable between the groups. Both sets were safe. No intraabdominal hemorrhage, vascular injuries, tissue or organ injuries, porto-biliary fistula, biliary peritonitis, and infection or abscess occurred in either group.

CONCLUSION

The Liverty™ set is safe and has similar procedural metrics to the COOK® RUPS-100 set. It allows in situ adjustment of the angle of the stiffening cannula without increasing procedure time and lessens the occurrences of periprocedural complications.

The Use of Intracardiac Echocardiography in Transjugular Intrahepatic Portosystemic Shunt Procedure

Transjugular intrahepatic portosystemic shunt (TIPS) is a complex intervention with a steep learning curve that requires centers of expertise to improve technical success and reduce complications. Portal venous access is the most challenging step of the procedure and requires planning and image guidance strategies to prevent vascular or bile duct injury and further complications. Intracardiac echocardiography (ICE) has been reported to be a safe and accurate tool that provides images of the portal vein anatomy in real time. The use of ICE has become the standard of care in several centers. It is now frequently used to target the portal vein in complex TIPS procedures. This review article describes some technical aspects and indications of ICE-guided TIPS.