Podcast Transcript: TIPS Procedure Techniques: East vs. West

[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.