Transcript: TIPS Procedure Techniques: East vs. West

With Dr. Peter Bream and Dr. Peder Horner

Dr. Peter Bream and Dr. Peder Horner discuss their Colapinto vs. Uchida needle preference, advantages of the ICE catheter, and other great pearls and pitfalls for the TIPS Procedure. You can read the full transcript here or listen to this episode on BackTable.com.

Transcript: TIPS Procedure Techniques: East vs. West

Table of Contents

(1) Radiation Protection for TIPS Procedure

(2) TIPS Overview and Alternative Procedures

(3) TIPS Patient Workup

(4) Routine Steps for TIPS Procedure

(5) TIPS Pressure Measurements

(6) TIPS Adjunctive Techniques

Introduction

[Michael Barraza]
Welcome to the BackTable Podcast, your source for all things IR. You can find all previous episodes of our podcast on iTunes, our app, or Spotify. This is Michael Barraza, returning as your host. Today's episode is sponsored by RadPad. RadPad was developed by physicians, for physicians, providing clinically proven radiation protection during SNA and digital subtraction in geography. Don't bet your career or your health on anything less. Trust RadPad radiation protection shields for all your fluoro guided interventions. See radpad.com for more information. Contact info at radpad.com for free radiation evaluation, and a no brainer radiation protection cap. Let them know you heard about it on the BackTable Podcast.

[Michael Barraza]
I'm honored to welcome back two guests who've enlightened us before on previous episodes of the BackTable Podcast. Dr. Peter Bream from the University of North Carolina, and Dr. Peder Horner from Interventional Radiology of Colorado at Denver. The Peters are joining us from 1600 miles apart, and two hours time difference. Huge thanks to both of you for joining us.

(1) Radiation Protection for TIPS Procedure

[Michael Barraza]
Before we kick things off, just a question I had for you, we're talking about TIPS today, which as we know, can be some longer cases. Do you guys do anything special for radiation protection other than glasses and white aprons?

[Peter Bream]
I wear booties.

[Michael Barraza]
Booties?

[Peter Bream]
Yeah, you got to make sure that you have booties, because you're going to get blood all over your feet.

[Peder Horner]
That's a good point, Pete. I totally agree with that.

[Michael Barraza]
Not me.

[Peder Horner]
I definitely use the shield. My techs know to prep the shield on every case.

[Michael Barraza]
I need to get better using the shield. We got the little skirts at the bottom, but you know, that's one of the things I need to work on. My second year out in practice, I've had some hefty doses over these first couple years.

[Michael Barraza]
One of the best things about IR, is the way that different people practice at different institutions, and different private practice versus academic. I think we'll see a little bit of that tonight in our podcast. I've recently moved institutions, and we were really good about putting the leaded shield, prepping it out, we used Phillips equipment at my previous institution, and there was a remote control that allowed you to go back and see still images, and go back and see previous runs, and that was attached to the shield.

[Michael Barraza]
There was an incentive to have that shield right there in front of your face. I thought that was a really good way to remind you to use the shield. In my current practice, we're using Siemens equipment, there's no remote control, and there's not a whole lot of incentive, and to be quite honest with you, I forget. I really need to be better about bringing that extra shield and to really get the scatter off the patient. That's what that's for.

[Peter Bream]
Right.

[Peder Horner]
Yeah, you're right, Peter. We have a Phillips machine, and we use that remote as well. It's on our shield, so we got to have it. It's a nice reminder. I love that.

[Michael Barraza]
Actually, how many have you thrown away?

[Peder Horner]
Not personally.

[Peter Bream]
Well, those things cost about $1200 a piece. Probably once a quarter, someone would have to go dumpster diving to go find the remote that was on the table, that was picked up and threw it away.

(2) TIPS Overview and Alternative Procedures

[Michael Barraza]
That's great. I actually got my Rad Pad, no brainer protection caps in the mail last week. They're going to actually come in and do an evaluation at Centennial for us, but I'd encourage you guys to do the same. We're going to talk about TIPS today, and it's obviously an expansive topic. I'll try to focus on some of the more practical elements and skip over some of the basics. I'm definitely looking forward to, as Peter said, I'm going to call you McBreemie, so we can distinguish the two of you. McBreemie said you learn different ways to do different things at different institutions, so it will be interesting to hear how you guys are doing this. I'd like to start maybe by having you each tell us what your TIPS practice looks like.

[Michael Barraza]
For me, it seems to come in waves, but overall, I'm mostly treating patients with acute or recent variceal bleeding. It's a little bit harder, I've had to really go out and get the ones with refractory ascites, and usually have a dozen paras. Why don't you start, McBreemie, tell us what you're mainly doing these for, and where you're getting most of your patients.

[Peter Bream]
I'm not sure how far we're going to go into alternatives to TIPS, but I know that BRTOs have become a huge part of our practice, and cases where we might have done TIPS in the past, we're now doing BRTOs.

[Michael Barraza]
Really?

[Peter Bream]
Yeah. We can throw that in as well. We're a transplant center at UNC, so we have a large liver failure population, a large cirrhosis population. We work very closely with the hepatologists and the transplant surgeons here. That's where most of our patients come from. We do a fair amount of TIPS for both of the main indications, for ascites, and for variceal bleeding. Mainly esophageal variceal bleeding, that's refractory to GI management, but also for gastric varices as well, although it's not as robust. We usually end up doing an antegrade obliteration of the varices, along with the TIPS, if we're dealing with gastric varices that do not have a splenorenal shunt.

[Peter Bream]
In my previous practice, we rarely ever did an emergent TIPS in the middle of the night, so I'd be interested to hear Peter's experience, and maybe yours, Mike's, as well. We had a pretty strong former colleague that felt like the mortality on those were so high that you needed to get the patient stabilized, maybe put in a Minnesota tube, or a Blakemore tube, transfuse them, do the full work up with the echo looking at the right heart, and making sure that the TIPS is going to be safe, rather than just barrel in there with somebody that's bleeding out in the middle of the night.

[Peter Bream]
I have learned that there are some attendings in my practice now that will barrel in at 2:00 in the morning, and do a TIPS, much to my chagrin. I have not had that face, that's my wooden table that I'm knocking on, but I feel pretty strongly about that as well. We'll try to do whatever I can to stabilize the patient before sending them into the depths of IR to exsanguinate.

[Michael Barraza]
What about you, western Peter?

[Peder Horner]
Yeah, that's good, Pete, thanks for sharing those. We're a private practice, and we've got a different situation than you do. My scenario is more community based hospital, so we got some big ones and some smaller ones. It really depends on where we are, and the indications, because some of the more ascites, refractory ascites cases I can do at one hospital where's there a big liver population, in terms of non-alcoholic steatohepatitis, cirrhosis, or your cryptogenics, and then you've got your peripheral folks in the smaller hospital, sometimes very high acuity, high alcoholic livers with variceal hemorrhages and what not, so we have a very dynamic, varied practice, depending on where I happen to be and where the call is coming from.

[Peder Horner]
We try not to TIPS in the middle of the night either, I don't think anyone likes to do that, but I think it does come up sometimes when all other situations and options have been exhausted. For us, again, it really depends on where we are. It's fun being in a private practice, I don't know, Michael, what your experience is, but each place is different. Each place, even though we try to standardize our equipment, each place is going to have a completely different set up and experience with technologists and what not, which is kind of a bigger issue. I'll try to touch on it later.

[Michael Barraza]
I think it is a big issue, and it's really affected how and where I do these. I'm privileged to do TIPS at I believe nine hospitals in the region, and some of these hospitals are just not prepared for that. I learned a hard lesson early on, where I got a call at one of these ancillary hospitals asking me to do a TIPS, and they insisted that I do it there. They had one TIPS set, they didn't have any backup equipment, the techs had probably seen one or two of these.

[Michael Barraza]
What I ended up doing was, I transferred the patient to myself at a different hospital where I have techs that are much better at these, and I got an angry call from somebody in administration, like you're sending these patients out? They worried we're not getting paid for this. They were demanding that this patient, and actually I forgot to share this step, this patient was getting sent from another hospital to this one, to get the TIPS. So instead of sending them there, I said no, just send them to this other hospital and I'll do it there.

[Michael Barraza]
They were insisting on having this done there. Well, of course I worked the patient up when I got them to my own hospital after the angry phone calls, and the patient was a terrible candidate for TIPS, and was a perfect candidate for BRTO, so I did the BRTO, I couldn't have done at this hospital. So now, I really, of all those non hospitals will only do TIPS at two or three of them. I just ship them to wherever I'm going to go, they're all the same hospital system, and I'm good with that.

[Peder Horner]
That certainly helps. I agree, and Pete touched on this earlier, myself and my colleagues in my practice have switched to almost like a BRTO first, in sort of approach to hemorrhage, so if they've got gastric varices, if you've got a big shunt, we'll BRTO first. We don't even talk about TIPS. I really think that that approach has been very helpful in our practice, and it's been pretty cool getting to share that with some of the GI docs. Some of them are, again, smaller community hospitals and sometimes they're not aware of the other options out there besides TIPS.

[Peder Horner]
There have been a lot of times where I've left articles from the Japanese literature, in the ICU, in the chart. You know what I mean?

[Michael Barraza]
Well, so are you guys approaching BRTO like the Japanese do, or are you doing it strictly for gastric varices in the setting of a splenorenal shunt?

[Peter Bream]
I would say mainly for us, if they have a splenorenal shunt, we're doing exactly what Peter said, which is we're considering a sclerosing type of procedure to start with. There are two camps. There's the western camp of diversion or decompression, and then you have the eastern camp, mainly the Japanese and the Asian, that have the sclerosant, or the obliteration side. As I've thought about this over the years, I start to think of these gastric varices being very similar to an arteriovenous malformation, where if you do not get rid of the actual varix, then it's going to, let's say you just coiling a couple of the inflows, it will recruit other vessels, there's so many vessels in this area that could be potentially recruited. If you can't get directly into the varix and at least reflux sclerosant up into the varix, then you may really be treating it now, but you're not treating it down the road.

[Michael Barraza]
I'm sure, Peter probably, has that occurred as well, right?

[Peter Bream]
I remember doing this 15 years ago, when we really weren't considering doing anything like that, and TIPS was first the TIPS, and then the second was coiling all the varices, and it was a six hour procedure. We'll probably get into techniques later, but 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, where 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. This identifies 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 them in the future.

[Peter Bream]
Do you do that, Peter, is your final run, or are you just--I think a lot of people forget because it's just been such a long hard road.

[Michael Barraza]
I think for me it depends on the scenario, and how badly the guy was bleeding. How many sticks it took.

[Peder Horner]
Right. That's right. It depends on what, if the techs are completely bored, and they're tired and ready to go home. No, but I do, I usually do a final run from the splenic, as you say. If I can, if I remember, I like seeing those and knowing where those are.

[Michael Barraza]
One last question about that, BRTO, are you guys strictly doing them for gastric varices, or are you occasionally doing them for patients with esophageal varices?

[Peder Horner]
Mine are usually for gastric varices. I just don't see the splenorenal shunt in the esophageal camp, I really don't. I don't know if you're different, Pete, but I look for it, but I don't see it.

[Michael Barraza]
I never have, I'm just curious.

[Peter Bream]
No, the anatomy is a little different with that. With a coronary vein, left gastric vein, versus the short gastrics, causing the splenorenal shunt. I've done it before for small valve varices, so you have another root where it's going up through the duodenum, and actually have done more of an antegrade approach to those, and actually trying to sclerose the varix that may be in the duodenum. I've only had to do that a couple of times, though. That's kind of unusual.

[Peder Horner]
Yeah, and we're going to get totally derailed here, Michael, I'm so sorry, but I've had a couple patients over the last year where they've had stomal varices where they're very high functioning people, did not want any kind of risk of HE, hepatic encephalopathy. So, we actually did transhepatic portal vein access, and then went down to the varices and sclerosed them just like a BRTO, antegrade stomal variceal embolization, whatever you want to call it. Those have worked really, really well so far. I've been out for about a year now.

[Peter Bream]
I did a ton of those at my previous institution where we would either stick them directly, or we would go transhepatic. I can tell you that my practices varied on that. When I first started doing those we were just coiling, and then as I got more facile with Sotradecol, I was doing more obliteration. I can't tell you whether, I didn't follow anybody or anything like that--I can't tell you which is better. I can tell you, though, that just blocking the portal venous flow and getting that main channel that's coming from the portal vein is dramatic for these patients.

[Peter Bream]
Like you said, they're highly functioning patients, they've unfortunately had their peritoneum disrupted, so they have a way for this to create this varix in their stoma, and it can be devastating. They can just bleed like crazy. I agree with you, that's something that all IRs need to have in their armamentarium, and not be afraid to go after.

[Michael Barraza]
For the less high functioning patients, the Peder Horner special, the Denver Shunt, the hometown shunt.

[Peder Horner]
That's right, my hometown shunted. I like that.

(3) TIPS Patient Workup

[Michael Barraza]
Yeah, hometown shunts, that's what it is. Back to TIPS, I think we can skip over indications for TIPS. 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.

[Peder Horner]
You want to take this one, Pete?

[Michael Barraza]
Sure, Pete.

[Peter Bream]
Sure, Pete. I am very fortunate in that I do have some great dedicated clinic time now, with a beautiful new clinic in my operation. I will say that most of my patients come pretty worked up. I don't have to do much once I see them in the clinic. There's not a whole test to order, not a whole lot of things to be doing. I get them from hepatologists who have a pretty good algorithm, and they've already worked these patients up. I do like the opportunity to talk to these patients and sit them down and draw pictures. It is a very hard concept for patients to understand, and taking the time to draw a picture, explain to them what you're trying to do--you're offloading the pressure of this blood flow that can't get back to their heart any other way.

[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.

[Michael Barraza]
Western Peter?

[Peder Horner]
Yes, for sure. I agree. We do.

[Peter Bream]
I think that's just too easy to do, too ubiquitous of an exam, 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.

[Peter Bream]
Absolutely. 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. 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.

[Michael Barraza]
That is brutal.

[Peder Horner]
That's unfair.

[Peter Bream]
It is, but you know what, 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.

[Peder Horner]
Right. Exactly. You can use the osseous landmarks on the CT to really help you know where you're canvas] is going to be, and all those things.

[Peter Bream]
Surgical clips from gall bladders, all that sort of stuff.

[Peder Horner]
Exactly.

[Michael Barraza]
My favorite. Aim an inch left to the clip, and go.

[Peter Bream]
I had one two weeks with a biliary stent, and it was the greatest work I've ever had, it was amazing.

[Michael Barraza]
So talking about elective TIPS, say for ascites or anything like that, do you have an age cut off? That's something that's come up for me recently, and it's like uh. I know literature says age greater than 65 is a known risk for encephalopathy after a TIPS, but a healthy 68 year old with bad ascites, I don't know. I didn't really have an answer.

[Peter Bream]
I don't think I've been referred somebody who the hepatologist felt would be too old for a TIPS. They wouldn't refer them, if their functional status was so low.

[Peter Bream]
I haven't had that problem. I don't know, Peter, have you?

[Peder Horner]
I haven't had that, but I think the oldest I've done is 80. Encephalopathy is an issue with those older people for sure. You look at the meta analysis, like Selarno, etc., and all those from, are in the 2000s, you'll see that age over 60 is known, I think, to be an independent risk factor for worse HE.

[Peter Bream]
I don't think today's 68 year-olds are the same as 20 years ago. I really don't.

[Michael Barraza]
I did 84 recently. And the lady, she was a really, really young 84.

[Michael Barraza]
She did fine, and I just counseled her on increased risk. She'd had a pretty bad bleed and she was going to bleed again, and so it was pretty straightforward. What about for patients with mild intermittent encephalopathy? How do you approach those patients? I guess for ascites it's more complicated, but for bleeding risk, that just seems like a challenge.

[Peter Bream]
I think it's definitely a challenge, this is the opportunity during your clinic appointment to talk about these things, and talk about the risks. And then weigh the risk benefit ratio from weekly paras, or weekly thoras. You can always reverse a TIPS, you can always occlude it or narrow it. You just have to have a frank discussion with the referring clinician and the patient and talk about these things so if they do occur, you have a plan B.

[Michael Barraza]
Just a couple more questions regarding a work up. One, you see every now and then somebody with coagulopathy or thrombocytopenia, and I know what our SIR guidelines say about correcting or not doing it above or below a certain number, but a lot of these patients just have chronic coagulopathy. How do you guys approach that?

[Peder Horner]
That's a good question. I think, certainly, if you're in the heat of the moment, we prefer not to do the middle of the night TIPS for sure, but they do happen. Even the middle of the night TIPS happens during the day too, every once in a while.

[Michael Barraza]
This is true. Right.

[Peder Horner]
Like guns ablaze, they're barreling in.

[Peter Bream]
And they're coming from the GI lab, where they picked a scab.

[Michael Barraza]
We've had a rash of those recently, and it just makes me sweat.

[Peder Horner]
Right. Because you want your iron and your platelets to be tuned up as best you can, certainly given some platelets before or during the procedure is fine, if they're on the low side, or even some FFP. I think, honestly, the advent of using ICE catheter, reducing the number of sticks and passes with your needle is super important, especially in those coagulopathic patients. 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?

[Michael Barraza]
Correct.

[Peter Bream]
What's the number you use for platelets, Peter, before you'll do a platelet transfusion?

[Peder Horner]
You know, usually around 50.

[Michael Barraza]
I usually use 40.

[Peder Horner]
All right, 35.

[Michael Barraza]
I don't believe in platelets.

[Peter Bream]
I don't believe in platelets.

[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 in every case.

[Michael Barraza]
Do you?

[Peder Horner]
Absolutely, because I've been in the situation actually, when I was in training in Oregon, where we had a patient. It was actually a young patient, who had refractory ascites, and we went in and had the clinic consult and the work up. We got in and did the pressures, and there was no gradient, really. 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, before the needle is thrown, you've got some time to back out and really think about it.

[Peder Horner]
I think 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. 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 would start a TIPS. I feel like you need a direct measurement. You need a direct portosystemic gradient, especially with a wedge catheter. One of the other topics that we were going to talk about at one point was transjugular liver biopsies, which I think is a whole topic in itself. After reading the literature, I changed my practice probably about eight or nine years ago, to exclusively using balloon catheters for measuring those pressures.

[Peter Bream]
It 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, and 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 use a balloon catheter for wedging.

[Peter Bream]
Smart guy.

[Michael Barraza]
Me too, me too, okay.

[Peter Bream]
I think we're in the minority, though, guys.

[Michael Barraza]
Really?

[Peter Bream]
Oh yes. I don't know.

[Peder Horner]
That's interesting. I've heard of people just sticking a five French catheter in and wedging it, right? Is that what people do?

[Peter Bream]
That's what the majority of my partners, and the majority of the partners at my previous institution did.

[Peder Horner]
Wow. It is an interesting thought, right? I've seen, rarely, random liver biopsies come back discordant with really what you think is going on. Maybe there's segmental fibrosis or-

[Peter Bream]
Exactly. Yeah.

[Peder Horner]
It's a good point.

[Michael Barraza]
As long as it doesn't come back with renal tissue. One last question on work up.

[Peter Bream]
More bang for your buck.

[Peder Horner]
That's right.

[Michael Barraza]
In the setting of life threatening, acute variceal bleeding, you don't always have time to get your full work up. What if anything in these patients is a deal breaker? Do you have a MELD limit for acute bleeding? It's a loaded question, isn't it?

[Peter Bream]
You know, you just have to take every single one of these cases on a case by case basis, and look at the full picture. Again, throw in, is there a possibility to do an obliteration instead of a decompression. I think the literature's pretty clear on this, that MELDs greater than 15 to 17 or 18, are problematic. Again, it goes in with the whole discussion about encephalopathy, and things like that. You've got to weigh all these risks, because they can go into fulminant liver failure pretty damn quick.

[Peder Horner]
Absolutely. You also have to take into account the discussion with the family and their values, and where they are with the whole process. A lot of the people I see in this situation where urgent TIPS for variceal hemorrhages, you're looking at 30 or 40 year olds, and they still have families. I think to say no, I'm not going to do this because your MELD is too high. Most families that I've come across, they want something more, even it's-

[Michael Barraza]
They won't accept that.

[Peder Horner]
Yeah. They wanted to have everything done. If it was like a 60, 70, 80, 90, 100...Whatever, you know me, people have had a full life. People have a lot different sort of approach to that situation than the younger alcoholics that I tend to see at some of the smaller hospitals.

[Peter Bream]
Right.

(4) Routine Steps for TIPS Procedure

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

[Peter Bream]
Absolutely.

[Peder Horner]
Yes. I've seen them done with moderate sedation, and I kind of got to say, it's probably barbaric.

[Peter Bream]
I agree 100%. I have seen it done. There are still attendings at my institution that will attempt them, mainly because sometimes it's hard to get anesthesia, but I think that's always a bargaining chip when you've got somebody that needs this procedure done. I do think that it's very important for a couple of reasons. One is, just the general comfort of the procedure. Two is, especially if you paralyze them, you can slow down the breathing so that there's not as much diaphragmatic excursions, so your measurements are better when you're trying to lay your TIPS down--especially you need to extend the TIPS, it's not moving up and down.

[Peter Bream]
Same reason why I do all my PTCs with general anesthesia. Especially if it's a non-dilated system. Much better control over the movement of the liver that way.

[Michael Barraza]
Plus I don't want my patients to hear me cursing.

[Peter Bream]
Right.

[Michael Barraza]
Western Peter. 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.

[Michael Barraza]
Me too, and I don't have it here.

[Peder Horner]
Oh man.

[Peder Horner]
This is a good point to mention that there are a lot of places that will have a ring set with a nine French sheath. You don't want to get into, get across, get everything set up, and then find out you've got a nine French sheath.

[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 with a Ushida where, instead of getting right into the vein, it actually created a flap on the side. I guess you could get that with any TIPS set, but it just seemed to me that I had never seen it before in my practice, and then some new attendings came in who were using the Ushida set, and I actually saw a dissection. I could tell exactly where it came from and everything. It was directly, I think, attributable to the fact that the Uchida just went down the side of the vein and just dissected it as it went down. I'm not completely against Uchida, I actually used one in a sharp recanalization in an SVC last week, so there you go.

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

[Peter Bream]
Right. One thing I don't like is the new GORE set. They have it here, and I have tried at least three times to use it, when they have already opened it because they thought another attending was going to use it. 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.

[Michael Barraza]
I don't know about the GORE set. The first time I used it, I had gone three or four passes, and I was like, God, how am I not in there? I nailed this thing. I took the set out and when I flushed it, this big chunk of meat came out, just it can clog really easily. And it's just not something I usually think about with those needles.

[Peter Bream]
One thing with the Colapinto that I do, is once you've made your pass, you get a little syringe of saline, and you just flush a little bit to make sure that it's patent.

[Michael Barraza]
After each pass?

[Peter Bream]
After each pass.

[Michael Barraza]
Do you take the needle out with each pass?

[Peter Bream]
No, you're flushing it. 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, just make sure you can flush forward just a little bit with saline, and then hook up your 10 cc contract syringe and start backing up while you're aspirating.

[Michael Barraza]
While you're aspirating.

[Peter Bream]
Right. Because otherwise, you may be aspirating and not getting anything, and the needle is plugged. That may be an advantage to the Uchida.

[Peder Horner]
Yeah. With the Ushida, it's usually just one pass, you don't have to flush any cell stuff.

[Michael Barraza]
Maybe that's just an operator thing. Maybe it's you.

[Peder Horner]
I know, right. You guys should understand, just for full disclosure here, I'm kind of old school in a few ways. I drive a 44 year old car, and I like my TIPS set about as old.

[Michael Barraza]
I'm going to ask a basic question, and that's 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? I found a couple tricks that have worked for me, but I'd like to hear what you guys have to say.

[Peter Bream]
I think that the arrow does work well,, and when it doesn't work well is when you have ascites. You've got a big ascites there and it's torqued the liver around. I've also found that that can create some acute angles in the liver as well. 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.

[Peder Horner]
Yeah, we do too.

[Michael Barraza]
I do that before I get access.

[Peder Horner]
And you want to monitor for bloody ascites.

[Peter Bream]
Absolutely. Or not.

[Peder Horner]
It never happens.

[Michael Barraza]
The nurse is freaking out over there, you're like, no, it's okay.

[Peter Bream]
But I think that if you just, you've really only got two options. 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. It’s certainly going posterior, so that's middle hepatic versus right.

[Peter Bream]
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. I haven't said this yet, but one practice that has totally changed my practice and my number of sticks and everything is using biplane.

[Michael Barraza]
I can't wait to ask you why. We're going to get into that in a bit, but that's one of the main things I want to ask you about.

[Peter Bream]
My number of one stick TIPS has gone way up since I started using biplane.

[Michael Barraza]
With a Colapinto Needle.

[Peder Horner]
You've got to use every trick you can get.

[Michael Barraza]
It'd be hard to improve it 100%. For me, if I can't tell for sure, it's obliquing the tube and seeing something go toward the spine, if something's leaning to the right. Do you guys do a portogram with an occlusion balloon?

[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. Yeah, for sure. That really helps.

[Michael Barraza]
Peter, do you?

[Peter Bream]
Absolutely. Yeah. If I can't get, I basically just take the NPA and dig it down in and then do a good CO2 reflux. If I can't see if 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]
Interesting.

[Peter Bream]
It's kind of a graduated way of doing it.

[Peder Horner]
I usually do mine right after my balloon wedge pressures. I'll just do a 60 cc CO2 and just overlay that as a road map.

[Peter Bream]
Right.

[Michael Barraza]
I'm in the minority, I don't routinely do portogram.

[Peter Bream]
Then how do you know what you're aiming for?

[Michael Barraza]
Get a good CT beforehand, if I can.

[Peter Bream]
Now, do you have technology to be able to fuse that?

[Michael Barraza]
No. Well, maybe I do. I don't know how to work it.

[Peter Bream]
Right. I've seen that work pretty well too.

[Michael Barraza]
Yeah, I just use my extraordinary skills, and that usually gets me through. Let's see. What else. 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]
One thing that I might mention with the Uchida, I always put a bigger curve on my Uchida.

[Michael Barraza]
On the needle or the sheath?

[Peder Horner]
The cannula for the sheath, and also for transjugular liver biopsies, I don't know what you guys see. It's almost like the angle that it comes from the factory is just not quite right. I got to add a little bit bigger, sort of radius, curve to it.

[Michael Barraza]
Agreed.

[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 steerable tip. That has dramatically changed access in TIPS, for me at least.

[Michael Barraza]
I use it through my needle too.

[Peter Bream]
Yeah. It's interesting, I don't have that needle. I don't have that wire here at my institution. I used it at my previous institution. It was my go to dialysis access, dialysis interventions wire, for the very same reason that you're saying. You can cross the lesion, then you have a working wire. I have gone to getting across with a Glide, a stiff Glide, and then once the Glide's down, putting down the catheter for the pressure measurement and for the injection, and then swapping over to the super stiff Amplatz.

[Peter Bream]
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]
So is Viatorr, so, you know.

[Peter Bream]
This is true. Very true.

[Peder Horner]
I'm not really thinking about cost when it comes to TIPS, especially.

(5) TIPS Pressure Measurements

[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?

[Peder Horner]
Never quit TIPS.

[Peter Bream]
Yeah. One thing that's really interesting is that you learn from your fellows what your other attendings do. Scrub in with other people. I learned that 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.

[Peter Bream]
We've been using that compass device, the digital readout device, for the pressure.

[Michael Barraza]
I don't even know what that is.

[Peder Horner]
I've seen that. Tell us about it.

[Peter Bream]
It's a pretty slick device. I started using it on 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. But basically what is it, it's a little box, plastic box, it has a digital readout. You hit a button on the side and that zeroes it, and then you hook this in-line with your catheter with a stopcock on the back, flush it, and turn the stopcock off. Now you have a direct pressure measurement, in millimeters of mercury.

[Peter Bream]
You do that, then you just take that off, put it on the sheath, and get the same thing. A disadvantage with this is it just does mean. 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 to the monitor. But these are nice, and they speed things up.

[Michael Barraza]
I was going to say, does that cost less in time and frustration than trying to relearn your nurses how to hook up the pressure monitor and zero?

[Peter Bream]
That's where you make up the cost. Absolutely.

[Michael Barraza]
When I started my job, having come from Penn where the techs knew how to work that so well, that was my biggest level of stress, with the TIPS or transjugular liver biopsy. It was just not screwing up the pressure measurement.

[Peter Bream]
Right. Getting back to CO2, Peter, what do you guys use for your CO2? You've got the big tank-

[Peder Horner]
Yeah, we have a big tank, and just kind of do it old school with some three ways and 60 cc syringes and a flow switch. It works fast, and we actually have that set up pretty quickly.

[Peter Bream]
Do you have that Nablis set which has the bag and the three-

[Peder Horner]
No.

[Peter Bream]
Syringes, and all that stuff.

[Peder Horner]
We don’t. Again, just hook up directly to the CO2 tank and flush it out a few times, and do a wet hook up with some saline, and go.

[Michael Barraza]
We actually don't have CO2, so I just blow into the catheter. No, we really don't, that's part of the reason I'm not doing portograms.

[Peter Bream]
Yeah. You can do them with contrast, but it's much harder to do. We had the Commander system also before I left my previous institution, we don't have it at my new place, but we actually got it because the vascular surgeons were using it for their CO2 PAD cases. I don't know if you've heard of this, but it's basically a tabletop--have you heard about it?

[Michael Barraza]
No, I've heard about it, I've heard it's great.

[Peter Bream]
Yeah. It's wonderful. It takes all of the guesswork out of this. You can wrap the whole thing in sterile, you hook up a catheter to it, and you have a little button you press, and you just go pfft, and fill up your 60 cc syringe, and go. You can do it as many times as you want. It's really, really nice. The actual device is the size of a VCR or something, or even smaller than that--a 10 inch by 3 inch box, basically.

[Michael Barraza]
That's great. None of the trainees know of VCRs anymore.

[Peter Bream]
That's true, I forgot about that.

[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.

[Peder Horner]
Right.

[Peter Bream]
Less than 8 for me for bleeding, and less than 12 for me for ascites.

[Peder Horner]
Right. I try not to get below 8 on ascites.

[Peter Bream]
Correct.

[Peder Horner]
Because you're really starting to get into HE territory.

[Peter Bream]
Correct.

[Peder Horner]
Yeah. I agree. You really got to be aggressive, at least below 10, if not eight.

[Michael Barraza]
Okay.

[Peter Bream]
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.

(6) TIPS Adjunctive Techniques

[Michael Barraza]
One thing I wanted to cover, really quickly, I know we're just about out of time. Alternative and adjunctive techniques that you use during a TIPS, one, when, if ever, are you guys embolizing varices in addition to placing the TIPS?

[Peder Horner]
That's a good question, because I've always embolized varices if I see them. That's just how I was trained. Someone told me recently that you can't bill for embolization. So, I don't really care, but if I see big varices, I usually still embolize them with coils.

[Michael Barraza]
Coils? Okay.

[Peter Bream]
I was taught in my fellowship that, once you were done and you had a good gradient, you had the gradient you want now--remember this is when we were still putting wall stents in--so I'll put that caveat out there...

[Michael Barraza]
Wow.

[Peter Bream]
Yeah, I'm that old. We would say do a hand injection of 10 cc’s of contrast with the catheter in the splenic vein, and if you did not see any varices, you wouldn't embolize them. If you did a power injection, you're going to reflux up anyway, and you get false. We felt like that was enough to prove they were not filing anymore, but you did see them filling, you would embolize them at that time. I've kind of used that. That's not very scientific, but it works.

[Michael Barraza]
Western Peter, when are you using ICE?

[Peter Bream]
Yeah, tell me about ICE, we don't have it and-

[Peder Horner]
It's interesting, because I actually trained with Brian Peterson, who invented the DIPS procedure. So it's like an early, 1.0 version of ICE. At the time, we were accessing femoral and jugular, we were doing it that way for the DIPS. But with the ICE, I've started using it, 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. I think it really is a good idea when you're talking about those people who have low reserve, they're coagulopathic, thrombocytopenic--those sorts of cases. I don't have it at every hospital, though. You really have to be trained in the old way, using fluoro, I think for sure.

[Peder Horner]
I'm not using it every case...go ahead.

[Peter Bream]
I'm not familiar with technology at all. It's a side firing, over the wire, intravascular ultrasound, is that correct?

[Peder Horner]
What it is is side firing, it's not over the wire.

[Peder Horner]
You put it through a different sheath. I usually use a second IJ access sheathing, like a nine French. You kind of steer it. You get it into the entropatic portion of the IVC, and then you localize your right portal vein, and then you can lock it in place, and sit it. Then, once you're in plane, you don't have to really futz with the ultrasound transfuser that much.

[Peder Horner]
I've been doing it now, just by myself. I've got a tech that's scrubbing, handing me things for the actual wires and what not, but actually once I set it where I want it, then I can just do it myself. It works really well.

[Peter Bream]
Interesting. I mentioned this earlier, my previous institution had the Phillips system. Phillips biplane, at least the ones that we had, doesn't have the ability to stand at the neck and angle the C arm, the APC arm, off of the head. It has to stay directly in front, and then you have your biplane coming in from the sides. That made it nearly impossible to stand there and try and throw a needle, because you really need to be at the top of the head to do that--you can't stand at the side. Siemens system has a way of parking it so that you bring it up, straight up in front of the head, and then you slide the biplane in, and then swing that back out 45 degrees so that you can stand at the head.

[Peter Bream]
It doesn't work for all patients because we can't penetrate through the abdomen in some of these patients. I've learned that in my IVC filters because I've used this technique for IVC filter removal as well. You literally cannot see anything through these people sometimes. But, when you do this, you do a single CO2 run, and you do AP and lateral at the same time. You start, and you pick where you're going to leave with the vein on the AP, you switch to lateral, you point it towards that vein, and you pop. It is really amazing how accurate you can be with a good CO2 run using the biplane. That's really been wonderful in getting single stick TIPS that way.

[Peder Horner]
That's a great idea, Pete. Again, I cover six different hospitals, and one of them has a biplane unit, but no ICE.

[Peder Horner]
It's good to have all these tools and techniques in your back pocket.

[Peter Bream]
Absolutely.

[Peder Horner]
It really is. One last thing I was going to say is, with TIPS, it is a really high stakes procedure for us. I was alluding to this earlier, but any chance you can get to really teach your staff what you're doing ahead of time can really help. I've learned that the hard way when going to some smaller hospitals. The techs are great, but they don't see TIPS very often, they're going to be a little confused by what you're needing and wanting.

[Peder Horner]
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 unfamiliar with staff with what you're doing and needing.

[Michael Barraza]
Right on.

[Peder Horner]
It's been fun guys.

[Michael Barraza]
It has been fun. Thank you both for joining us, it was awesome.

Podcast Participants

Dr. Peter Bream

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

Dr. Peder Horner

Dr. Peder Horner

Dr. Michael Barraza

Host Dr. Michael Barraza is a practicing interventional radiologist (and all around great guy) with Radiology Associates in Baton Rouge, LA.

Cite This Podcast

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

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