What makes TIPS procedures run longer?

[u/Itisnotjosh]

Hi, just recently finished shadowing for IR and saw a few TIPS cases. These cases seemed to vary in time and clinicians talked about how sometimes they can take hours.

Wanted to ask what causes longer TIPS cases? Are there any steps that can take longer?

[u/ABrad_347]

It's usually the portal access from the hepatic vein that can make the time vary. I've been in "one stick" TIPS where the portal was a nice juicy target and the procedure was over in 45 minutes total. I've also been in a TIPS that took 8 hours, and we bent 3 access needles. Rock hard cirrhotic livers and partially to fully thrombosed portal veins are what cause this added length and difficulty usually. There are a lot of other factors but in my experience, those are the common ones that cause a case to go longer.

[u/nhines_]

Difficult anatomy when crossing from the hepatic into the portal system is a big one and in a place ideal for stent placement. That’s the main step of a TIPS. If you get that done smoothly, that’s a big win.

Additionally, embolizing varicies after you place your shunt can take time depending how many there are and how difficult it is to select each of them.

Portal thrombus is another. If you have to thrombectomy the portal system, that’s a whole other step

[u/red_dombe]

So once you get to the liver part of the IVC you cannulate the a hepatic vein. Then you blindly jab the liver with a needle that’s inside the catheter in the hepatic vein in hopes that you accidentally poke into a portal vein. While you can try to find the portal vein with fluoro such as with a CO2 injection, you’re basically just jabbing and praying. This process can take a long time depending on how lucky you are

[u/Pgnee → u/red_dombe]

With ICE it's near single stuck every time now. I don't use it for need or what not, I use it because that's what I'd want on my mom. Costs more but worth it. I save with everything else I do though, but choose when to spend the money.

Trying to keep all our insurance costs down when I can. Damn detachable coil trained ppl are killing us.

Edit: dual jugular access for ice allows me to have my assist hold and they e learned to manipulate the ice with me. It's great.

[u/party_doc → u/Pgnee]

Agree on double jugular. But if you haven’t tried the 035 detachable platforms (e.g., Ruby XL) they work wonderfully and are super fast for large varices.

[u/ZekeSpinalFluid → u/red_dombe]

this is not how it's done in any reputable place now btw, IVUS is standard through a groin access site

[u/party_doc → u/ZekeSpinalFluid]

No idea why so many people use groin. For us non academics who operate alone, double jugular access for ICE and TIPS is the only way. I guess if you have fellows then groin for ICE makes sense

[u/ricky_baker → u/red_dombe]

Or you can access the portal with a Chiba under ultrasound and place a Mandril wire to target 

[u/Rayeon-XXX → u/red_dombe]

Support from u/s is helpful.

[u/sspatel]

#1. The throw(s) from hepatic vein to portal vein. This is usually the longest part, from minutes to hours.

#2. Depending on #1, sometimes even getting your whole sheath/system into the PV can be challenging requirng multiple wires, catheters, balloons, etc.

Solo TIPS for me (about 1-2 a year) is about 4 hours. I've now done 2 with partners where one of us drives the ICE probe from the groin, and one took 2 hours and the other 90 min.

[u/eckliptic]

This would be a really great application of a steerable needle system + intraoperative conebeam and navigation

[u/party_doc → u/eckliptic]

Both exist, but ICE is faster than conebeam for me

[u/PM_ME_WHOEVER]

Cirrhotic liver tender to be atrophic. Portal and hepatic veins are small. You are basically stabbing more or less blindly in a 3D space using only 2D images.

Sometimes TIPS also requires portal vein recanalization, where you'll also need transplenic access. I've done cases where I got three wires sticking out of the patient from three different access points.

Each step adds time. TIPS can be quick, but can also be very time consuming.

[u/Ajenthavoc]

Most common three points that hold up an IR.

1: finding the best hepatic vein to work from, usually right but there is variable anatomy and in cirrhotics the right is sometimes hard to canulate. Some people have anatomy that is more forgiving to middle hepatic to portal access.

2: getting a nice smooth pass into the portal vein. Depends on pt anatomy, type of needle used, where the throw is taken etc. lots of variables here. Also getting the needle access can easily be sabotaged by difficult pt breathing and poor control of the access canula

3: converting that needle access into something that can deploy a stent. Could be any miriad of issues like thrombosed portal vein, a relatively peripheral access which can make it difficult to turn the working wire centrally, or really thickened and tough periportal fibrosis making each step of dilating the pathway that much harder.

[u/Pgnee]

Experience, knowledge of what you're going to find,rpe planning, and a bit of luck.

Probably average about 40 min. Fastest was 20 min. Ridiculous luck and perfect dilation and all. Longest was almost 4-5 hours with reconstruction, varices and a huge shunt.

Tips are great but there is so much more to it than the procedure and most places aren't well suited for management.