A new alternative for a transjugular intrahepatic portosystemic shunt: EUS-guided creation of an intrahepatic portosystemic shunt (with video)

Background: Transjugular intrahepatic portosystemic shunt (TIPSS) is an effective treatment for portal hypertension and its associated complications. EUS-guided creation of an intrahepatic portosystemic shunt (IPSS) may become a useful alternative to conventional TIPSS. Objective: To assess the feasibility of EUS-guided IPSS creation in a live porcine model. Setting: Acute and survival experiments in 50-kg pigs. Design and Interventions: Under linear-array EUS guidance, the hepatic vein (HV) and then the portal vein (PV) were punctured with a 19-gauge FNA needle. A 0.035-inch guidewire was advanced through the needle into the PV lumen. The needle was exchanged over the wire, a metal stent was deployed under EUS and fluoroscopic guidance, and the distal end of the stent was positioned inside the PV and the proximal end within the HV. Eight animals were euthanized after the procedure, and 2 animals were kept alive for 2 weeks. Main Outcome Measurements: Successful EUS-guided IPSS creation. Results: Portosystemic shunt placement was successful in all animals. Intrahepatic vascular puncture and stent deployment were technically easy. Portosystemic flow through the shunt was documented by portal venogram and EUS Doppler. Necropsy performed after acute and survival experiments revealed no evidence of bleeding or damage to any intraperitoneal organs. There were no complications during the follow-up period in the 2 animals that were kept alive. Limitations: Experiments were preformed in healthy animals with normal PV pressure. Conclusions: EUS-guided IPSS creation is technically feasible and may become an alternative to the currently used method of TIPSS placement.