13th Annual Global Embolization Symposium & Technologies
Purpose : Creation of a transjugular intrahepatic portosystemic shunt (TIPS) is widely known to be a technically challenging procedure associated with high complication rates and radiation exposure. Here we describe a modification of the standard technique aimed at improving operator ease and procedure time.
Material and Methods : The proposed technique begins with the same steps as the standard technique, including obtaining jugular vein access and using a series of wire and catheter exchanges to navigate a TIPS sheath into the right hepatic vein. Here, a Fogarty balloon is inflated to facilitate CO2 portal venography. The balloon is then deflated but kept in place over a stiff wire. An "unprotected" or bare TIPS needle is advanced through the sheath, parallel to the balloon, into the right hepatic vein. The vascular sheath is retracted and the TIPS needle is advanced into portal vein. Once portal access is obtained, the remainder of the procedure, including placement of the endoprosthesis, follows the standard technique.
Results : A key element of the new technique is placement of a TIPS needle in parallel with a stiffened Fogarty balloon through a TIPS sheath. Often, multiple passes are required to achieve portal vein access and the operator is faced with the challenge of losing right hepatic vein access. The stiffened balloon catheter serves as a rail to easily re-advance the sheath when needed, saving the time and effort involved in reselecting the right hepatic vein. The balloon also affords the ability to easily repeat CO2 venography as needed. Because of spatial constraints within the sheath, the TIPS needle is advanced without its dilator. To prevent sheath puncture, the Gore TIPS Set is used in particular as its sheath is relatively kink resistant and is therefore less likely to perforate compared to other options.
This technique has been performed safely in over 30 cases at our institution. An analysis of uncomplicated cases, defined as those without portal vein thrombus, revealed a near 50% reduction in time from CO2 venography to successful portal access. For the standard technique, this time was 34.5±6.3 min, compared to 17.8±1.9 min for the new technique (p<0.05). The new technique was also associated with a 21% reduction in fluoroscopy time (p<0.05).
Conclusions : The proposed new TIPS technique offers multiple advantages including operator ease and faster portal vein access. This technique has demonstrated significant reduction in time required to access portal vein as well as fluoroscopy time.