Intravascular Ultrasound Guidance for TIPS Procedures: A Review

The most challenging and time-consuming step of TIPS procedures is obtaining appropriate portal vein (PV) access. Given the lack of real-time direct target visualization, conventional fluoroscopic guidance requires multiple passes, contributing to complications. In comparison, intravascular ultrasound (IVUS) guidance during TIPS procedures provides direct visualization of hepatic structures and real-time guidance for PV puncture. IVUS guidance during TIPS creation improves procedural metrics such as radiation dose, contrast agent volume, procedure time, and technical success rate and is particularly beneficial in technically challenging cases (e.g., in patients portal vein thrombosis, small or variant portal vein anatomy, Budd-Chiari syndrome, or liver masses). The purpose of this review is to summarize current IVUS technology, describe the technical aspects of IVUS-guided TIPS creation, and discuss the clinical indications for and benefits of using IVUS for TIPS creation, while presenting available evidence supporting the technique's use. Given the improved safety profile and overall success rate in comparison with conventional guidance methods, IVUS guidance has the future potential to become the standard practice for TIPS placement.