The Anchor-Rail TIPS Technique: An Update

The Anchor-Rail (AR) technique begins with the same steps as the standard technique, obtaining jugular vein access and ultimately navigating a 10 Fr TIPS sheath into the right hepatic vein. Next, a 4 Fr stiffened CO2 injectable catheter, the anchor, is advanced through the sheath and wedged, where CO2 portal venography is performed. The anchor is then kept in place (unlike in the conventional technique where it would be removed at this point) , and a TIPS needle is advanced through the sheath “unprotected,” i.e. without its protective catheter, alongside the anchor, into the hepatic vein. The TIPS sheath is retracted so as to expose the TIPS needle, and the needle is advanced through the hepatic parenchyma into the portal vein. By leaving the anchor in place, it saves time and effort of hepatic vein reselection, as it allows for easy readvancement of the sheath over the anchor into the hepatic vein, if multiple portal passes are needed. Additionally, it affords easy repetition of CO2 portovenography. The stiffness of the anchor is also essential as it prevents kinking and perforation of the sheath. Once portal access is obtained, the anchor is removed and the remainder of the procedure follows the standard technique.
TIPS procedures performed at our institution from November 1, 2016 until June 30, 2023 were retrospectively reviewed. Fluoroscopic images and clips were reviewed, marking specific time points of CO2 portovenography prior to portal access and successful achievement of portal access with the guidewire.

Results: 138 cases met inclusion criteria. 100 cases were performed using the AR technique and 38 cases were performed using the conventional technique. The mean time from portovenogram to portal vein access for the AR technique was 22.9 minutes, as compared to 34.5 minutes for the conventional technique (p< 0.05).  There was no incidence of sheath perforation or cardiac injury using the AR technique.

Conclusion:

Our study demonstrates the AR technique to be safe and effective with a significant reduction in portal vein access time when compared to the conventional TIPS technique.