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Review
. 2020 Oct;37(4):405-413.
doi: 10.1055/s-0040-1715875. Epub 2020 Oct 1.

Intracardiac Echocardiography-Guided TIPS: A Primer for New Operators

Matthew C Grimsbo  1 , Matthew A Brown  2 , Jonathan D Lindquist  2 , Kristofer M Schramm  2 , Daniel L Kirkpatrick  2 , Robert K Ryu  2 , Premal S Trivedi  2
Affiliations
Review

Intracardiac Echocardiography-Guided TIPS: A Primer for New Operators

Matthew C Grimsbo et al. Semin Intervent Radiol. 2020 Oct.
No abstract available

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest None declared.

Figures

Fig. 1
Fig. 1
The intracardiac echo probe is equipped with a linear phase array multifrequency transducer at its tip. The white and black arrows represent the angulation controls of the intracardiac echocardiography catheter in the anterior-posterior and left-right directions, respectively; however, we opt for manual rotation of the entire probe for finer control.
Fig. 2
Fig. 2
( a ) A depiction of the working field with intravascular access provided through tandem puncture of the jugular vein. ( b ) A depiction of the working field with the ICE probe draped outside of the immediate working field and inserted through the lateral access site. ICE, intracardiac echocardiography; TIPS, transjugular intrahepatic portosystemic shunt.
Fig. 3
Fig. 3
The intracardiac echocardiography probe (arrow) position within the intrahepatic inferior vena cava at the level of the main portal vein, noted fluoroscopically. This position facilitates clear visualization of the main, right, and left portal veins. 5 Fr catheter access into the main portal vein has been achieved; gentle contrast injection confirms tip within the splenic vein.
Fig. 4
Fig. 4
( a , b ) The venous phase CT image through the level of the hepatic veins is intentionally flipped left/right to provide anatomic orientation for the intracardiac echocardiography (ICE) images in Figs. 5 and 6 . The probe fires in an axial fashion from the inferior vena cava, along the axis of the hepatic veins which makes it useful for initial orientation. The letters in this figure correlate to the ultrasound images listed in Fig. 6 ; B+C indicates the right hepatic vein; F indicates the middle hepatic vein. D+E shows portions of the right portal vein (PV), G shows the main portal vein, which is well oriented for ICE imaging in this patient. In general, the portal veins tend to run orthogonal to the ultrasound beam making orientation more difficult.
Fig. 5
Fig. 5
An illustration depicting the direction of the intracardiac echocardiography (ICE) catheter's probe from the operator's point of view, when in-line with the tandem jugular vein access. ( a ) The initial orientation of the ICE probe at ∼30 degrees or 5 o'clock. ( b ) The orientation of the ICE probe after an anterior sweep of the ICE catheter in the counterclockwise direction. ( c ) The approximate orientation of the main portal vein. The labeling in this illustration corresponds with Figs. 4 and 5.
Fig. 6
Fig. 6
A counterclockwise sweep of the intracardiac echocardiography catheter while positioned at the hepatic vein confluence from a jugular vein approach. ( a ) The peritoneal space or lung, which is characterized by an absence of vascular structures on ultrasound and shadowing. See the corresponding plane of imaging noted in Fig. 4 . ( b ) The right hepatic vein containing an echogenic catheter. ( c ) The right hepatic vein and posterior branch of the right portal vein. ( d ) The posterior and anterior branches of the right hepatic vein. ( e ) The confluence of the posterior and anterior branches of the right portal vein. ( f ) The middle hepatic vein and right portal vein. ( g ) The main portal vein.
Fig. 7
Fig. 7
( a ) The needle tip (arrowhead) can be seen in the liver parenchyma directed anteriorly and inferiorly toward the right portal vein (arrow). ( b ) The dashed arrow depicts the 0.035-inch guide wire within the confluence of the anterior and posterior right portal vein.
Fig. 8
Fig. 8
A representation of simultaneous portal vein (catheter) and hepatic vein (sheath) injections used for stent sizing. Normal portal vein anatomy is demonstrated with antegrade flow of contrast. The intracardiac echocardiography catheter (black arrow) is positioned at the level of the main right portal vein. A Blakemore tube is noted in the background (star).
Fig. 9
Fig. 9
Baseline sonographic evaluation with the intracardiac echocardiography catheter reveals a favorable transhepatic trajectory from the middle hepatic vein (MHV) to the right portal vein (RPV). Consequently, the MHV was intentionally chosen for TIPS access.
Fig. 10
Fig. 10
A nonocclusive eccentric thrombus (arrow) occluding the main portal vein as seen by intracardiac echocardiography catheter. Ultrasound confirmation of needle tip position within the thrombosed vein was used in lieu of contrast injection to obtain portal vein access.
Fig. 11
Fig. 11
The intracardiac echocardiography (ICE) probe is used as a mark for stent placement and length determination. The ICE probe (arrow) is located at ( a ) the level of the portal vein puncture as assessed by ultrasound imaging and ( b ) subsequently moved to the hepatic vein–inferior vena cava (HV–IVC) confluence. Distance between these two probe positions is measured fluoroscopically via the marker pigtail. As there was PV thrombosis, injected contrast did not delineate the level of the PV puncture well, but ICE directly visualizes the site of puncture. Depending on the acuity of the thrombosis, pull back of the uncovered portion of the Viatorr may also be unreliable.
Fig. 12
Fig. 12
( a ) Portal venography demonstrating the cavernous collateral (arrow) as well as additional smaller cavernous collaterals (arrowheads). ( b ) Intracardiac echocardiography (ICE) image demonstrating multiple cavernous collaterals in the porta hepatis (arrows). ( c ) ICE image demonstrating the needle tip (arrowheads) directed anteriorly and inferiorly toward the dominant cavernous collateral (arrow). ( d ) Completion venography demonstrating placement of the transjugular intrahepatic portosystemic shunt from the right hepatic vein to the dominant cavernous collateral (arrow). The cardinal vein has also been embolized with coils (star).
See this image and copyright information in PMC

References

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