Abstract No. 278 Transjugular Intrahepatic Portosystemic Shunt Creation Using Intravascular Ultrasound versus Fluoroscopic Guidance: A Dual-Institution Retrospective Comparative Study

Portal vein cannulation is one of the most technically challenging steps in the creation of a transjugular intrahepatic portosystemic shunt (TIPS). Intracardiac echocardiography (ICE) allows for direct visualization of the portal vein using ultrasound, thereby reducing radiation exposure and potentially procedure time. The purpose of this study was to evaluate procedural metrics, shunt patency, and mortality of patients who underwent TIPS creation using ICE versus conventional fluoroscopic guidance. The study sample included 66 patients who underwent TIPS creation using ICE ("iTIPS group") and 135 patients who underwent TIPS creation using conventional fluoroscopic guidance ("cTIPS group") at 2 tertiary academic medical centers from 2015-2019 by experienced operators. TIPS that required variceal embolization or portal vein thrombectomy/recanalization were excluded. Data regarding baseline clinical characteristics, procedural metrics including radiation exposure, shunt patency, and mortality were analyzed. The two groups were balanced with respect to age, sex, TIPS indication, and MELD-Na scores (p= 0.25-0.87). The iTIPS group had a higher prevalence of Latino patients (p< 0.0001) and higher proportion of patients with cirrhosis due to viral etiology (p = 0.003). TIPS was technically successful in 66 patients in the iTIPS group and 130 patients in the cTIPS group (100% vs. 96%, p = 0.17). Air kerma (266 ± 254 mGy vs. 1235 ± 1049 mGy, p < 0.00001), Dose area product (5728 ± 6518 uGy*m2 vs. 28969 ± 19067 uGy*m2, P < 0.00001), fluoroscopy time (18.7 ± 9.6 min vs. 32.3 ± 19.0 min, p < 0.00001), and total procedure time (93 ± 40 min vs. 110 ± 51 min, p = 0.01) were lower in the iTIPS group compared to the cTIPS group. Intraprocedural complications were similar between the iTIPS group and cTIPS group (1.5% vs. 3.7%, p = 0.67). In a median follow up of 26 months (IQR 6-61 months), thrombosis-free survival (p = 0.23), intervention-free survival (p = 0.29) and patient mortality (p = 0.61) did not differ between the two groups. Compared with conventional fluoroscopic guidance, the use of intravascular ultrasound during TIPS creation results in decreased radiation exposure and procedure time, and may confer a greater chance of technical success. However, imaging guidance modality does not appear to affect shunt patency or mortality in intermediate-term follow up.