Technique for the Transjugular Intrahepatic Portosystemic Shunt Procedure

Chapter 13: Technique for the Transjugular Intrahepatic Portosystemic Shunt Procedure

John A. Kaufman, Frederick S. Keller, and Josef Rösch

Historical Note

The origin of transjugular intrahepatic portosystemic shunt (TIPS) can be traced to inadvertent entries into intrahepatic portal branches during transjugular cholangiography done in the late 1960s to define biliary obstructions. This ability to access the portal vein from the transjugular approach led to the development of this technique in animal experiments for visualization of the portal venous system. Enlarging the tract in the liver between the hepatic and portal venous systems using dilatation catheters and maintaining patency by inserting Teflon tubing was the next step ( Fig. 13.1). These experimental shunts in canines, however, stayed patent for only 2 weeks and then thrombosed because of their small (4 to 6 mm) diameters and slow portal flow caused by a lack of portal hypertension (PHT). In a final report in 1971, the conclusion was that TIPS was a feasible technique. Even though one of the authors was able to demonstrate TIPS in human liver specimens and cadavers, technology at that time was not sufficiently advanced for TIPS to be clinically applicable.¹ Progress in technology has helped to advance TIPS from an experimental to a clinical procedure. Introduction of dilatation balloon catheters allowed Ronald Colapinto to perform the first clinical TIPS in the early 1980s.² However, even continuous 12-hour dilatation of the liver puncture tract offered only temporary results. Introduction of expandable metallic stents in the mid 1980s finally made TIPS a clinical reality. Palmaz explored using his balloon-expandable stents to create TIPS in dogs and achieved long-term primary patency.³ The first clinical TIPS procedure using stents was performed in January 1988 in Freiburg, Germany, by Goetz Richter and associates using Palmaz stents.⁴ Their success inspired many interventionalists to introduce TIPS procedures at their hospitals and contributed to a rapid expansion of this new technique. Introduction of a stent graft for TIPS in the late 1990s then brought further progress and significantly improved the long-term results of TIPS.

Present Status

Presently, 24 years after its clinical introduction, TIPS has become widely disseminated throughout the world and has been accepted as a minimally invasive treatment of the complications of PHT. More than 2300 citations on PubMed for “transjugular intrahepatic portosystemic shunt” speak for popularity and scientific interest in TIPS.

TIPS is a challenging procedure. Clinically, it requires detailed knowledge of patient’s general condition and anatomy of his or her hepatic and portal venous systems. Technically, it calls for a skillful interventionalist experienced with jugular vein access, catheterization of hepatic veins, intrahepatic access to main portal branches, dilatation of the intrahepatic tract, and placement of the expandable stent or stent graft. Procedural success and freedom from complications were reported to be closely related to the experience of the operator. The average technical success rate of TIPS was reported at 97.3% with failure rate higher in those institutions having performed fewer than 100 procedures.⁵ Similarly, the rate of fatal procedural complication was reported at 1.4% at institutions with more than 150 procedures and at 3% with fewer than 150 TIPS.⁵ In current practice, the majority (80%–90%) of TIPS procedures are performed on an elective basis.^6–9 The main indications for TIPS are prevention of recurrent bleeding from gastroesophageal or ectopic varices and management of refractory ascites or recurrent hepatic hydrothorax. An emergency “rescue” TIPS for acute uncontrollable variceal bleeding, which used to be a common indication for TIPS in earlier years, should be done only in patients with a reasonable chance of survival (see Chapter 21).

Procedure Planning

To facilitate the TIPS procedure, the interventionalist needs to become familiar with the anatomy of the liver and its venous and portal vasculature, which are often distorted by processes leading to PHT.^10,11 Abdominal ultrasonography, including duplex evaluation of the portal and hepatic veins, has been often used for pre-TIPS evaluation. We prefer the cross-sectional liver imaging by computed tomography because it provides a detailed view of the liver anatomy and pathology ( Fig. 13.2).

Fig. 13.1 The first successful experimental transjugular intrahepatic portosystemic shunt created in a canine in November 1968 with use of Teflon tubing. Reprinted from Rösch J, Hanafee WN, Snow H. Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology 1969;92:1112–1114; with permission from RSNA.

Fig. 13.2 Reformatted liver computed tomography scan demonstrating anatomic relation of hepatic veins and portal vein bifurcation.

In particular, the anatomic relationship between the hepatic and portal veins can be determined and the optimal site for intrahepatic portal vein entry selected.

Before the procedure, ascites is often drained. This lowers the position of the liver and thus facilitates catheterization of hepatic veins and introduction of the portal vein access set. Hepatic hydrothorax is not evacuated. All patients receive antibiotics before the procedure (1 g of cefazolin). In patients with significant penicillin allergy, vancomycin is used as an alternative.12

The Procedure

Some interventionalists perform TIPS with conscious sedation using a combination of fentanyl and midazolam. In patients with alcohol dependence, they augment sedation with droperidol.¹² Presently, we now perform TIPS with our patients under general anesthesia. General anesthesia is easier and safer in uncooperative patients and in all cases permits the interventionalist to concentrate completely on the procedure. The anesthesiologist can provide apnea during parts of the procedure such as intrahepatic puncture and filming. Electrocardiographic monitoring is required, especially during passing catheters across the right atrium.

Portal Vein Access Set

Presently, there are four commercially available transjugular access sets for TIPS in the United States. The Ring set, the Rösch-Uchida set (RUPS), and the Haskal set are all from Cook Medical (Bloomington, IN), and the fine-needle access set is from Angio-Dynamics (Lantham, NY). There are only minor differences among these sets, and the choice is mostly based on personal preference. We use the RUPS ( Fig. 13.3). With this equipment, the hepatic vein and portal vein puncture is done with a sharp 0.038 trocar stylet inside a well-tapered 5-Fr catheter. A curved 14-gauge stiffening cannula inside a curved 10-Fr catheter and a 10-Fr Flexor introducer sheath ensures stable position for the trocar puncture. The curved tip of the cannula can be manually adjusted depending on the anatomy of the hepatic veins.

Fig. 13.3 The portal vein access set (Rösch-Uchida set [RUPS], Cook Medical). (1) 0.038-in trocar stylet; (2) Tapered 5-Fr catheter; (3) 14-gauge cannula; (4) 10-Fr catheter; (5) 10-Fr flexor sheath; (6) Assembled RUPS.

Hepatic Vein Catheterization

The right internal jugular venous approach is most commonly used for TIPS because of its straight course to the inferior vena cava (IVC). The left internal jugular vein is used when the right vein is occluded and often in patients with high position of the liver. The left-sided approach gives the portal vein access set a more oblique orientation that favors catheterization of horizontally directed hepatic veins.

Jugular vein access is performed with a micropuncture (21-gauge) needle under ultrasonic guidance. The midportion of the neck is usually selected for access. After sterile skin preparation, a small skin incision with a scalpel that is dilated with a hemostat, the jugular vein is accessed. The access site is then dilated with the micropuncture catheter, and a 0.038-J guidewire is introduced and advanced through the right atrium into the IVC. The skin and subcutaneous tissue of the neck are then dilated with an 11-Fr dilator, and the RUPS access set without the trocar stylet is introduced. The hepatic vein is catheterized. This is accomplished using the curve of the metal cannula with the leading guidewire. If the guidewire will not exit the right atrium, it is withdrawn into the superior vena cava, and the curve of the metal cannula is used to orient the guidewire through the right atrium into the IVC and hepatic vein.

Selection of the correct hepatic vein for access to the portal vein is critical for successful TIPS because it determines the anterior or posterior orientation of the metal cannula for portal vein access. The right hepatic vein, when of sufficient size, is best suited for TIPS because of its location and relation to the portal vein. It lies superiorly, posteriorly, and slightly laterally to the right portal vein. If the right hepatic vein in a cirrhotic liver is small or cannot be safely be catheterized, then either the middle hepatic or left hepatic vein can be used to create TIPS. The middle hepatic vein lies superiorly and anteriorly and sometimes slightly medially to the right portal vein. The left hepatic vein is anterior, superior, and lateral to the left portal vein.10,11

Wedged Hepatic Venogram

Wedged hepatic venography gives useful information about the portal venous anatomy, particularly the position of the portal vein. We perform it using an occlusion balloon catheter and CO₂ as contrast material ( Fig. 13.4). When the 10-Fr sheath of the RUPS set is securely located in the preselected hepatic vein, the inner 5-Fr catheter, metal stiffening cannula, and 10-Fr Teflon catheter are removed. A 5-Fr occlusion balloon catheter is introduced into the sheath, and the balloon inflated with dilute contrast material sufficiently to wedge the catheter in the midportion of the catheterized hepatic vein. Thirty to 50 mL of sterile CO₂ is rapidly injected while digital subtraction images are obtained. We prefer the “balloon occlusion” technique to wedging an end-hole catheter peripherally in a small hepatic vein because it is more effective and safer.

Portal Vein Access

Portal vein access is initiated in the proximal 2 to 3 cm of the hepatic vein cephalad to the expected location of the target portal vein main branch. Visualization of the portal vein during hepatic wedged venography serves as guidance for orientation of the puncture.¹³ The locked access set is rotated anteriorly in the right hepatic vein or posteriorly in the middle or left hepatic veins. The tip of the 10-Fr catheter is then wedged inferiorly against the hepatic vein wall. This step of wedging is essential for successful liver puncture because if the tip of the 10-Fr catheter is free in hepatic vein, the needle slides along the vein wall rather than piercing it. Portal vein access should be about 2 cm lateral to the portal bifurcation. In this position, the liver parenchymal tract and the TIPS are almost a continuation of the portal vein, thus having optimal flow. Also, the superior portal vein wall is intraparenchymal with no risk of extraparenchymal portal access. The puncture is performed with a sharp thrust of the locked trocar and 5-Fr catheter into the hepatic parenchyma for a distance of 3 to 5 cm. The trocar stylet is removed, and a 10-mL syringe containing contrast material is attached to the 5-Fr catheter. During its slow withdrawal, suction is applied. When blood is aspirated, contrast material is injected to confirm catheter position in the portal system ( Fig. 13.5).