Tools and Technical Tips for TIPS
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Tools and Technical Tips for TIPS

Updated: Jul 11

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure requiring thorough evaluation of the patient’s hemodynamics. As such, approaches to TIPS can evolve based on changes that occur in the interventional suite. Interventional radiologists Dr. Peter Bream and Dr. Peder Horner discuss imaging work-up prior to elective TIPS procedure, preferred tools for executing TIPS, and TIPS technique.


We’ve provided the highlight reel below, but you can listen to the full podcast here.


The BackTable Brief

  • Dr. Bream emphasizes the importance of obtaining imaging prior to TIPS. Abdominal MRI or CT can illustrate portal vein patency, which affects the approach to the procedure. Both Dr. Horner and Dr. Bream recommend echocardiogram as part of TIPS work-up.

  • Preferred tools for TIPS include the Rosch-Uchida set as well as the Colapinto needle and Ring set. Both Dr. Horner and Dr. Bream find using the Terumo Glide Advantage wire to be helpful in these cases.

  • Dr. Horner and Dr. Bream are proponents of using balloon catheters for measuring transjugular and wedge pressures. Both agree on the importance of obtaining a right atrial pressure and main portal vein pressure after stent placement.

  • Dr. Bream notes that his number of “one-stick” TIPS procedures has increased since he started using biplane. Dr. Horner advocates for the ICE catheter, which has helped reduce the number of sticks and needle passes. This benefits coagulopathic patients undergoing TIPS.



Disclaimer: The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.


Elective TIPS Procedure Work-Up


Dr. Bream and Dr. Horner discuss the importance of echocardiogram and abdominal CT or MRI prior to TIPS.


[Michael Barraza]

Let's talk about a work-up, maybe starting with elective TIPS, where you have a luxury of time to really get what you want. Let's say the patient is in your office for the first time, cirrhosis, refractory ascites, but nothing else to work with other than a full slate of labs, no imaging, no new cardiac history. Walk me through how you determine if your patients are a candidate for TIPS.


[Peter Bream]

There's a checklist we look at, have they had an echocardiogram, are they are in right heart failure—


[Michael Barraza]

So no known cardiac issues or pulmonary hypertension in an elective TIPS patient, do you require an EKG or an Echo? If they don't have any known cardiac history?


[Peter Bream]

Yes. I would get an Echo before I'm going to do a TIPS. I think that's just too easy to do, and it can uncover things where people are asymptomatic.


[Michael Barraza]

What about imaging? If I can get it, I love a CT before TIPS.


[Peder Horner]

Absolutely. You can use the osseous landmarks on the CT to really help you know where your going to be and all those things.


[Peter Bream]

We had a TIPS recently that failed where the veins were just really, really parallel, they came to like a 90 degree angle, they were small. They tried for several hours to get this. One of the hepatic veins, the main right hepatic vein was an accessory right hepatic vein, which actually came off below the level of the portal vein. There was no way to stick. However, if you carefully looked at the MRI, there was actually a juicy middle hepatic vein which came off of the left. They never interrogated the left to see if you could try it from the left, or they could find this vein, which was the best one. One, you need to know if the portal vein is patent, because you're going to do other things that are very different if that's not the case. Two, I plan the entire case out in my head before I go in there. I have a plan.



Preferred Tools for TIPS


The Rosch-Uchida is Dr. Horner’s preferred TIPS set. In contrast, Dr. Bream prefers to use the Colapinto needle and Ring set. Both Dr. Horner and Dr. Bream like using the Terumo Glide Advantage wire. For pressure measurements, Dr. Bream has been using a Compass device that provides a digital readout of the mean arterial pressure.


[Michael Barraza]

What's your preferred TIPS set and why?


[Peder Horner]

Well, I did train in Oregon, so I am a Rosch-Uchida guy. That's my set, that's my go-to. It's very rare that I can't get the job done with that set.


[Peter Bream]

Yeah. So I'm a Ring guy, I was trained using the Ring, and I've trained all of my fellows over the years of doing a Ring. I have tried a couple of times to do the Uchida, and my main issue with that is two things. One, I think it can be hard to get through the liver parenchyma, it'll bounce back, it'll bounce you out, because it's a lot more flexible of a needle. Two, I've actually seen portal vein dissections.


[Michael Barraza]

I do like the big Colapinto Needle, but it's still taking some getting used to, the Ring set.


[Peter Bream]

Right. One thing I don't like is the new Gore set. I have found that needle to be very flimsy and very hard to direct. It doesn't torque well. The best part about the Colapinto is that you can really torque, and a lot of these times when you're really close, you just need to come back a little bit, torque a little bit, and then go back in. You really need to have a needle that will hold its shape for that. One thing with the Colapinto that I do is, after each pass and while aspirating, you get a little syringe of saline, and you just flush a little bit to make sure that it's patent. You've made your pass, you think you're in the portal vein, before you hook up the contrast and try and aspirate, you just take some saline...if you do contrast, you start getting blobs of contrast everywhere. You just do saline, make sure you can flush forward just a little bit with saline, and then hook up your 10CC contract syringe and start backing up while you're aspirating.


[Michael Barraza]

With the ring set I've found more frequently, it's harder to get the sheath to make the turn sometimes. Do you guys have any tricks to get it across a tight angle?


[Peder Horner]

For me, my typical go-to wire in these cases now is actually a Terumo Glide Advantage. I love that wire because all of a sudden you've got a stiff, working wire, with a hydrophilic durable tip. That has dramatically changed access in TIPS, for me at least.


[Peter Bream]

I have gone to getting across with a stiff Glide, and then once the Glide's down, putting down the catheter for the pressure measurement and for the injection. Then, I swap over to the super stiff Amplatz. I even have gone to Lunderquist wires for that and just don't mess around. You have a rail to be able to hold everything in place, so that when you're placing your stent, you've got a steady platform. If we had the Glidewire Advantage, I probably would be using that. It's an expensive wire.


[Michael Barraza]

Let's talk about pressure measurements.


[Peter Bream]

We've been using that Compass device, the digital readout device. I started using it in children when I was doing opening pressures on LPs, especially on these patients with really high pressures and you're sitting there and you're waiting for the little fluid to go all the way up your 60 centimeter pipette. You hook this digital readout device in-line with your catheter with a stopcock on the back, you flush it, you turn the stopcock off, and now you have a direct pressure measurement in millimeters of mercury. Disadvantage with this is it just does mean pressure. It does not do your systolic and diastolic, so if you're really wanting to know, tease out things, you need to use the pressure monitor that you can hook up. But these digital readouts are nice, and they speed things up.


Some Tips for TIPS


Dr. Horner and Dr. Bream emphasize the importance of performing TIPS under general anesthesia and taking transjugular and wedge pressures with a balloon catheter. They also discuss the advantages of using the ICE catheter, biplane, and CO2 injection.


[Michael Barraza]

Let's get into the procedural steps for a routine TIPS. Do you guys do all of yours with general anesthesia?


[Peder Horner]

Yes. But I’ve seen them done with moderate sedation, and I kind of got to say, it's probably barbaric.


[Peter Bream]

Absolutely. One is just the general comfort of the procedure. Two, if you paralyze them, you can slow down the breathing so that there's not as much diaphragmatic excursions. Your measurements are better when you're trying to lay your TIPS down, especially if you need to extend the TIPS. It's not moving up and down…much better control over the movement of the liver that way.


[Michael Barraza]

Do you guys think there's any role for the borderline patients for doing transjugular wedge pressure measurements prior to setting them up for actual TIPS?


[Peder Horner]

I measure pressures before on every case. I've been in the situation actually where we had a young patient who had refractory ascites, and we went in, we had the clinic consult and the work up. When we got in and did the pressures, there was no gradient. It was a normal gradient, so we had to just back out. It's not great to put a patient through a procedure, but at the same time, you can always, before the needle is thrown, back out and really think about it. TIPS is really an exercise in physiology and hemodynamics, right? We really have to be constantly evaluating those during the procedure, and not just having a preset notion of yes, this is what I'm going to do, etc. I think it can be a dynamic situation that you find yourself in, and you have to be willing to back out and sort of change plans if the data's not supporting your hypothesis.


[Peter Bream]

I have a little bit of a different take on that. I don't do a transjugular pressure or a wedge pressure before I start a TIPS because I feel like you need a direct measurement. You need a direct portosystemic gradient. I changed my practice probably about eight or nine years ago to exclusively using balloon catheters for measuring those pressures. This change came from an article that said fibrosis and cirrhosis can be segmental, and you can drop a catheter into a completely normal part of the liver, get that one wedge pressure from that one little area, and miss hypertension. Whereas, if you put the balloon in there, and get a larger segment, you have less sampling error. I feel like you get in, you get your pressures, and then at that point, you only have a five French catheter across the parenchyma. You can always stop at that point.


[Peder Horner]

I do use balloon catheter for wedging.


[Peter Bream]

Smart guy. I think we're in the minority though.


[Peder Horner]

I've heard of people just sticking a five French catheter in and wedging it.


[Michael Barraza]

When you're getting your sheath down, what is your method for distinguishing between the right and the middle hepatic veins? It's not always simple, sometimes the arrow doesn't really fall the way you want. How do you distinguish it?


[Peter Bream]

I think that the arrow does work well. When it doesn't work well is when you have ascites… Our algorithm, when somebody's getting it for ascites, is we put an eight French catheter in and start draining the ascites while we're doing the procedure. Again, if you've looked at the imaging beforehand and have a 3D map in your mind before you even go in, you can figure out that this is coming off a little more anterior. It may be going straight to the right, but it is coming off a little bit more anterior, you're certainly going posterior, so that's middle hepatic versus right. I think it's hard to tell when you are in there without the TIPS needle set, and you're just in there with your NPA, or it can be whatever catheter. But you can also figure that out by just angling the beam. Something that has totally changed my practice and my number of sticks and everything is using biplane. My number of one-stick TIPS has gone way up since I started using biplane.


[Peder Horner]

I do a CO2 injection for my right hepatic vein before I start TIPSing. If I'm not using the ICE, I'll do that. I've started using ICE, and it's very nice, I got to say. It really cuts down on the number of needle passes and you really can be confident where you are, where the needle is, and it just makes beautiful pictures. The advent of using ICE catheter, reducing the number of sticks and passes with your needle, is super important. Gone are the days when you have to stick until you get the portal vein, because that's where you might get into trouble, right?


[Peter Bream]

Yeah. If I can't get it, I basically just take the MPA and dig it down in, and then do a good CO2 reflux. If I can't see it there, then I may go to an occlusion balloon and do that. If I can't get it there, then I get the needle out, and I dig the needle into the parenchyma and do a CO2 run through the needle.


[Michael Barraza]

Let's talk about pressure measurements. Once you've got across, how do they affect your stent selection and dilatation, and what values might cause you to pull everything out and call it a day?


[Peter Bream]

Some of my colleagues will get a right atrial pressure before they start, and that's their right atrial pressure for the case. I tend to not do that. I get a right atrial pressure after I'm through, take a pressure in the portal vein, just in the main portal vein, and then pull the TIPS sheath back and do it in the right atrium.


[Peder Horner]

Yes, same.


[Michael Barraza]

Do you use the same target gradient for every case, or do you change it up based on the indication?


[Peter Bream]

Lower for bleeding, higher for ascites. One of the issues, especially in the bleeding situation, is their right atrial pressure may be very high from being resuscitated, so you've got to understand you may not get the gradient you want initially. But, they will be diuresed, and those pressures will drop once they've gotten over their acute event, especially with a functioning right heart.


[Peder Horner]

TIPS is a really high stakes procedure for us…Really knowing your stock at your hospitals, having your techs be actively engaged in the teaching process, really helps them understand what you're going to need next and allows that procedure to move along quicker. A lot of times, these can be long cases, nowadays they're not usually, but when they go long I think a lot of it can sometimes be unfamiliarity with staff with what you're doing and needing.


[Peter Bream]

One thing I've noticed from some of my colleagues and some of the fellows this year is not doing that final run of the TIPS. This is when you put the catheter all the way out to the splenic vein and get a good image of the entire splenic vein from the splenic hilum all the way to the TIPS to identify any short gastrics or any feeders that are feeding any types of varices that you may not even do anything about now, but you'll know about in the future.


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Podcast Participants:

Dr. Peder Horner is a practicing interventional radiologist with Diversified Radiology in the Denver, CO area.

Dr. Peter Bream is a practicing interventional radiologist and professor with the University of North Carolina at Chapel Hill School of Medicine.

Host Dr. Michael Barraza is a practicing interventional radiologist with Radiology Alliance in Nashville.


Cite this podcast:

BackTable, LLC (Producer). (2019, June 16). Ep. 44 – TIPS Procedure Techniques: East vs. West [Audio podcast]. Retrieved from http://www.backtable.com/podcasts


Medical Disclaimer:

The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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