Tools and Technical Tips for 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.

[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.