ARRS 2022 Abstracts

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E1536. Tips on TIPS: Techniques for Portal Vein Targeting During TIPS Creation
Authors
  1. Dan Laney; Louisiana State University Health Sciences Center
  2. Alexandra Fairchild; Louisiana State University Health Sciences Center
  3. Hector Ferral; Louisiana State University Health Sciences Center
  4. Bahri Ustunsoz; Louisiana State University Health Sciences Center
Background
Transjugular intrahepatic portosystemic shunt (TIPS) is one of the hallmark procedures performed by the modern interventional radiologist. It involves creating a shunt between the portal and hepatic venous systems by deploying a covered stent between the two, allowing blood to bypass the cirrhotic liver resulting in decreased portal venous pressure. Puncturing the portal vein from the hepatic vein is the critical step in successful TIPS creation; however, even when performed by an experienced interventionist, success is not guaranteed as portal venous anatomy can be highly variable. Further, as the number of attempted punctures of the portal vein increases so does the likelihood of a complication, such as hepatic arterial puncture, non-target organ puncture, biliary system puncture, and iatrogenic fistula formation. Prior studies have demonstrated the efficacy of various assistive techniques for puncturing the portal vein during TIPS, leading to an increased rate of technical success and optimizing the safety of the procedure. This educational exhibit aims to demonstrate a variety of techniques for increasing the likelihood of a safe and successful portal vein puncture during TIPS creation.

Educational Goals / Teaching Points
Hepatic venous and portal venous anatomy can be variable, creating challenges during TIPS creation. There are numerous techniques for portal vein access during TIPS creation. Each portal vein access technique carries a unique set of risks and benefits. A patient's anatomy will help guide the technique selected.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Techniques for portal vein targeting during TIPS include: percutaneous portal access; indirect portogram; fiducial marker under CT; CO2 portogram (hepatic vein wedge portogram, direct parenchymal injection of CO2); ultrasound technique (transabdominal, transvenous); and overlay techniques (MRI/CT overlay, needle guidance).

Conclusion
There are multiple techniques spanning multiple imaging modalities that can assist in the portal venous puncture during a TIPS creation. Employing these techniques during TIPS creation increases the chance of technical success and optimizes patient outcomes by increasing the ease of portal vein puncture, allowing for a more optimally placed puncture, and decreasing the number of attempted punctures necessary. As each technique has its own set of advantages and disadvantages, the patient's venous anatomy should guide the interventionist in deciding which technique is best suited for any given case.