ARRS 2022 Abstracts

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E2038. Ice Ice Baby! Intravascular Ultrasound-Guided TIPS: A-Z, From Setup to Portal Access
Authors
  1. Chadi Diab; University of Kentucky
  2. Mohamed Issa; University of Kentucky
  3. Andrew Shabila; University of Kentucky
  4. Roberto Galuppo Monticelli; University of Kentucky
  5. Gaby Gabriel; University of Kentucky
  6. Merve Ozen; University of Kentucky
  7. Driss Raissi; University of Kentucky
Background
The technique and devices utilized for the creation of a transjugular intrahepatic portosystemic shunt (TIPS) have significantly evolved since its introduction in the 1980s. Portal venous access is still primarily done under fluoroscopic guidance after obtaining a roadmap portal venogram or by marking the portal vein with a percutaneously inserted microwire. Multiple needle passes might be needed, which can increase the procedure time, radiation exposure, and or complication rate. Using intravascular ultrasound (IVUS) guidance is a novel and safe technique, where an intracardiac echocardiogram probe (ICE) is introduced to the level of the retrohepatic IVC to provide direct guidance for portal venous access. Nonetheless, it has a steep learning curve and despite increasing intraprocedural safety, it can raise costs and procedural time if the operator has a limited experience in the intravascular 3D landmarks for guidance.

Educational Goals / Teaching Points
The goal of the presentation is to present step-by-step instructions on how to setup one of the commonly used ICE probes. The image characteristic as well as the different functions of the catheter will be described including the rotational tip. The cons and pros of the different ICE approaches will be discussed with focus on the benefit of having two accesses in the internal jugular vein. In preparation for portal venous access, intravascular sonographic hepatic anatomy will be described in correlation with reconstructed multiplanar CT images. Finally, we will share some tips and tricks on optimal hepatic vein catheterization, ICE guided needle angle adjustment and tracking.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
There are significant anatomical variants involving the hepatic and portal venous anatomy. These reflect into different 3D anatomical relationships. The common teaching is to angulate the TIPS needle anteriorly from the right hepatic vein, and posteriorly from the middle hepatic vein, when targeting the right portal vein; however, there are many variables that play a role. These includes the choice of the optimal hepatic vein, the hepatic vein needle advancement starting point, the correct needle angle, and the length of parenchymal tract. All these variables have been resolved conventionally by a combination of estimation, experience, and recurrent attempts. A good understanding of IVUS images will define these variables precisely, providing more accurate answers based on real-time images.

Conclusion
IVUS guidance offers real-time anatomical orientation in TIPS creation. Additionally, it has been shown to decrease the procedure time, radiation exposure, and complication rates, especially in complex cases. Hence, it is advised for the interventional radiologist to be familiar with this novel device.