Intravascular Ultrasound in the Creation of Transjugular Intrahepatic Portosystemic Shunts: Review of the Literature and Future Directions

Purpose of Review: Transjugular intrahepatic portosystemic shunt (TIPS) placement is a well-established interventional radiology procedure for treating sequelae of portal hypertension involving shunting portal blood flow to the hepatic vein bypassing the liver through a stent graft. Creating a TIPS can be a complex and radiation-intensive procedure due to the technically challenging step of cannulating the portal vein from the hepatic vein. As this is the most unpredictable step in TIPS creation, multiple techniques have been described for visualizing the portal vein to facilitate its access. The use of intravascular ultrasound (IVUS) has gained significant interest over the last few years due to reports of improved procedural metrics such as shortened procedural time and radiation dose. The purpose of this article is to review the literature and detail technical advances utilizing IVUS in TIPS creation. Recent Findings: Intravascular ultrasound has been shown to be a safe and reproducible means of real-time image guidance for TIPS creation. The use of IVUS has been associated with improved procedural metrics including a decreased number of intrahepatic needle passes, shorter portal vein access times, decreased contrast usage, and a decrease in radiation dose. Summary: Due to technical advances and real-time portal vein visualization using IVUS, TIPS creation at our institution has dramatically changed. Our institutional practice has nearly completed shifted to the sole use of IVUS for portal vein access in TIPS creation due to significantly improved procedural metrics including radiation dose and contrast usage.