TIPS with ICE Guidance

Dr. Ozen begins by discussing the challenges she faced when introducing this new technique into her practice at the University of Kentucky. She faced pushback from administration about procedure time and anesthesia time. She now does all her TIPS with intracardiac echocardiography (ICE) guidance, but she keeps CO2 available in case of device malfunction, which would cause her to revert to the traditional method of CO2 angiography.

It takes time to learn how to navigate the ICE probe, also called intravascular ultrasound (IVUS), but it helps with complicated cases like thrombosed portal veins and Budd-Chiari syndrome. She uses the “vampire stick” technique, which is a side by side internal jugular access technique for the TIPS needle and the US probe. She puts her TIPS access more medial, which makes it more stable, and places her ICE access more lateral.

After getting access, she spends time understanding the anatomy in the liver. Prior CT is useful for getting information about patient specific anatomy. She then uses ICE to view the portal vein and hepatic vein on the same plane, then she advances the needle with one stick. Dr. Ozen prefers a Rösch-Uchida needle versus a Colapinto because she feels she can better visualize it with ICE. One thing she recommends spending time on is understanding where to start introducing your needle. If there is clot or liver stuck in the needle and preventing blood return, she recommends flushing the needle, or advancing it and then pulling back gently. She ends by stating that learning how to operate the ICE probe is a steep learning curve, but one that every IR should invest time in. It cuts down on anesthesia and fluoroscopy time, and provides a level of safety that is simply not achievable with traditional methods.