Abstract
Creation of a transjugular intrahepatic portosystemic shunt (TIPS) is known to be a technically challenging procedure due to difficulty in maintining right hepatic vein (RHV) access and achieving portal vein (PV) access. Here we describe a modification of the standard technique aimed at improving operator ease and procedure time. The proposed technique begins with the same steps as the standard technique. After a 10 Fr TIPS sheath is navigated into the RHV, a 4 Fr stiff anchor/CO2 injectable catheter (anchor) is advanced through the sheath. Wedge CO2 portal venography is performed. A TIPS needle is advanced through the sheath without its protective catheter, alongside the anchor, into the RHV. The sheath is retracted and the TIPS needle is positioned within the RHV and advanced into PV. Often, multiple passes are required to achieve PV access. The operator is also faced with the challenges of determining PV position and losing RHV access. The anchor allows easily re-advancement of the sheath when needed, saving the time and effort of RHV reselection. The anchor also affords easy repetition of CO2 venography when the TIPS needle is in the liver parenchyma. The stiff anchor minimizes risk of kinking and perforation. The remainder of the procedure, including placement of the endoprosthesis, follows the standard technique. This technique has been performed safely in 35 cases at our institution. An analysis of uncomplicated cases, defined as those without PV thrombus, compared to 46 traditional cases, revealed a near 50% reduction in time from CO2 venography to portal access with the new technique (17.8 ± 1.9 min vs. 34.5 ± 6.3 min, P <0.05). The new technique was also associated with a 21% reduction in FT (25.5 ± 1.6 min vs. 32.2 ± 3.2 min, P <0.05). There were no cases of sheath perforation. The proposed new TIPS technique offers multiple advantages including operator ease and faster PV access, with significant demonstrated reduction in PV access time and FT.
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