Can IVUS-Guided TIPS be more than just “Fancy TIPS”?
Intravascular ultrasound guided access to a portal vein during TIPS creation is an alternate technique to the conventional method of fluoroscopically guided access following hepatoportal venography. This retrospective study was performed to compare three parameters: mean time to PV access, radiation dose, and capsular perforation, between the intravascular US guided access (n=55) and conventional fluoroscopically guided access (n=54) groups. Further, the results were stratified by operator experience (10 total operators; 5 with <20, and 5 with > 20 conventional TIPS procedures before this study, classified as inexperienced, and experienced, respectively). There was no significant difference in the sex, age, BMI, etiology of cirrhosis, or indication for TIPS, in the two study populations. The study found that parameter mean time to PV access was significantly lower for the intravascular US guided access group overall, but showed no difference when comparing experienced operators only. Further, parameter mean time to PV access continued to decrease over the course of the study in the US guided access group. In measuring radiation dose and capsular perforation, both were statistically lower in the intravascular US guided group than the conventional group.
Alternate techniques to gaining portal vein access during TIPS include three dimensional navigation using fusion, prior percutaneous PV marking, utilization of cone beam CT, transabdominal ultrasound, and intravascular ultrasound. While there have been studies comparing the conventional vs. intravascular US guided PV access techniques in the past, this is the first one to take operator experience into account, and has a slightly higher number of patients (109 vs. 100). This study also does not compare the number of needle passes performed to access the PV, as this was felt to be a subjective measurement. Further, time for femoral vein access and IVUS set-up was not included in this study nor was the added cost associated with the device. As technology progresses, cost, operator preference, and quality control will dictate whether such ancillary techniques will contribute in regularly to TIPS creation.
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Pillai, Anil K., et al. Utility of Intravascular US–Guided Portal Vein Access during Transjugular Intrahepatic Portosystemic Shunt Creation: Retrospective Comparison with Conventional Technique in 109 Patients. Article in press. doi: 10.1016/j.jvir.2016.05.010
Nabeel Mecci, MD
University of Virginia
PGY-2 Radiology Resident