A frank and opinionated discussion and argument between two “Professors of TIPS”

Episode Transcript

Recorded live from the Cook booth at SIR and featuring leading experts in the field of interventional radiology discussing a wide range of IR-related topics, this is the Cook@ SIR Podcast Series.

Well, hello everyone, and welcome to the Cook Podcast booth. This is the third year of interventional radiology podcasts from within the SIR Exhibit Hall. My name is Ziv Haskal, and I’m joined by:

And I’m Mike Darcy.

We are super excited to kick this off. We are coming from a red booth with boxing gloves between us over here, and that topic is two old guys talk about TIPS, but I hope it’s going to be a little bit better than that. It’s really exciting. We’re really grateful to Cook for giving this opportunity and want to remind you that there are going to be a whole lot of podcasts that are going to be recorded this week and available. But we’ve been tasked to talk about TIPS, which is, I think it’s fair to say, has been a major aspect of our career. When, Mike, did you do your first TIPS?

I did my first TIPS in 1991. So it was just two years after the invention of TIPS. How about you?

Well, I had the luck of being a fellow in 1991, 1992 with Ernie Ring, with Jeanne LaBerge, with Roy Gordon, and that was—in fact, supposedly, we had a number 1-800-VARICES because there were so few places in the US. And in retrospect, it probably should have been 1-900 so they’d get money on every call.

So when you were there working with Ernie, did they really have it figured out or were they still figuring out how to do TIPS?

There was such drama about these cases that it always looked easy when he was doing something in these cases. But there actually was a live broadcast because there was such a gap in knowledge and understanding what the thing was that I remember a live case at the Fairmont Hotel in San Francisco, top of the hill, broadcast live. And I was scrubbed behind Ernie. Bright lights, he’s operating on a patient who was actually a nun, but no one in the audience knew that she was a nun. So at some point she got a little too sleepy and Ernie keeps tapping her and said, “Hey, Sister, Sister. Hey, Sister.” And we finally get this report back from the Fairmont that say they’re all getting really anxious that he keeps calling her—

Well, I can imagine Ernie doing that. It sounds typical Ernie. But it’s interesting how I think things have changed from the standpoint of back in those days, they wouldn’t send you a patient for TIPS unless they were on death’s doorstep. They’d either been through multiple, multiple endoscopic approaches to try to stop the bleeding or they had been tapped 10 zillion times, and now TIPS has become an integral part of the management of portal hypertension. And I’m just curious as to your perspective on how things have changed.

I think we both lived through that transition. I was lucky enough that in November of our fellowship year, we actually had a party at a Mexican restaurant for the 100th TIPS created at UCSF, which was probably 100 times more than most places. So they had got it together. But when I went as a junior professor to Penn, they’d hang black crepe outside of the rooms because nobody wanted to do this thing that would take five hours. And I came skilled, so I said, “This is interesting to me. I’ll take this on.” And all we got were patients that were essentially dead from intubated ARDS, multi-organ failure. And you’d decompress them, they’d stop bleeding, but they would still all die and they would say, “Haskal, you killed another patient with TIPS.” And what was it that Ernie said that if the patient looks like they’re not going to survive having their toenails clipped, then TIPS is not going to be the thing that’s going to let them live long. How did you bridge that transition from those patients to, “Give us a break and let us show you what we can do for selection?”

Well, I think that’s really tough. There were a lot of patients who you simply didn’t really have many choices. There were a lot of papers a number of years back where people tried to define specific criteria and say, okay, if the patient’s MELD score or bilirubin, whatever, is above this level, you shouldn’t do a TIPS. And yet you just sometimes are in a situation where the patient has no options and it’s either do something and hope they survive or just let them die. And I distinctly remember this one patient I had who he had a horrendous MELD. He was bleeding to death. He had a Sengstaken-Blakemore tube in. It was not stopping the bleeding. And by all objective criteria, we should not have even done it to this guy.

But you did.

But we did.

And?

We followed him for eight years afterwards. He survived, his bleeding stopped, and he ultimately died from a heart attack unrelated to his liver. So I think that’s why, when you look at the recent consensus, well, it’s not so recent anymore, there was an ALTA Consensus Conference about two years ago, and one of the questions that was posed was, should there be an absolute cutoff above which you shouldn’t do a TIPS on a patient? And the overall consensus was no, there is no one number you can look at. It really comes down to be a decision between you as the IR and the referring clinicians and the patient. And the patient really becomes an important decision-maker when you start talking about TIPS for ascites because there are—

It’s a quality-of-life procedure—

It’s a quality-of-life—

And it’s got to be clear that you’re going to get them to a QOL improvement.

Exactly.

Yeah, that’s right.

Because I’ve had a bunch of patients who they really were not great candidates and there were high risks. And when you sit down and talk with them in the clinic, they would say, “Doc, I don’t care. I can’t live like this.”

There’s so many things that I hear when you bring up this great topic. I hear futility. I hear shunt diameter. I hear calibrating to individual patients. And maybe we should— Let’s touch on that point of futility, because as we’ve become more recognized for being primary clinicians— For years, I admitted, and I admit, my own TIPS patients to hospital. There is no other doctor who takes care of them for elective patients. And I know that it’s been the same for you forever as well. But it’s equally hard if you’re not in a busy practice to know when to say no, when it is futile and you need to see another— the bilirubin’s 40, the patient is deeply acidotic, blood is no longer blood, it’s red water. And there is a point where you’re just not going to impact survival even if they— and sometimes it’s hard to say no. But the fact that you can engage in those conversations as an advocate with expertise is what you’re talking about.

Exactly. And that’s precisely what they were talking about today in the plenary session, about how IR has become a specialty of clinicians who help manage these patients. While I said there are a lot of cases that we’ve done that were really bad candidates and we’ve gotten through it, there are cases we have declined because there was just no hope of getting them through that. And that’s where you as a clinician has to look at the patient, have your own assessment of their ability to survive, and you have to have the discussions with the family and the patient.

I distinctly remember one of our fellows left and was relating to me how she was in her practice, it was a private practice, and she went in to look at this patient who was on the table for TIPS. And she was starting to look at the patient and one of her partners came in and said, “Are you going to do this TIPS or not?” And she said, “Well, I have to look in and see whether it’s indicated.” And his response was, “Well, they sent the patient to us for it. It must must’ve been indicated.” And so that, to me, is a prime example of how we have transitioned from being the person that gets referred patients to do something versus clinicians who are recognized for being able to make their own decisions and help them.

So it speaks to the spectrum of TIPS practice, if you will, which is on one end is the full belt-and-suspender clinician, which I think both of us inhabit, and many of us as well, which is: this is an important part of our patient care. We follow these patients. I see all my patients within two weeks. I don’t care if anyone else is seeing them. I manage their encephalopathy, their medications, their diuretics. I tell them if somebody else tells them to stop them, don’t, not until you talk to me. And it’s part because I practice in places where that wasn’t cohesive.

So I just picked up the role and there’s a pleasure in seeing people at follow up. There’s the far end, the other end, where we’ll do it because you ask, but we don’t want to because it’s still difficult or my experience level is not 50 cases or whatever that step is. And then there’s the middle where you pull and you grow the practice, but you bring expertise to the table. And I think if we can move people to that middle, even that, they don’t have to make it the central part, then we really, we’ve made different offers to patients.

One of the things you just said that I thought that brought up a funny story, the pleasure of seeing these patients back. So in St. Louis, we had this little neighborhood called The Hill, which is so Italian that some people only speak Italian there. And I did a guy from The Hill, variceal bleeding, bleeding to death, that kind of scenario. And when I saw him back in clinic, he’s flanked by these two big guys. And I thought, “Oh my God, I did something wrong. He’s here to break my knee caps or something,” and—

Let me guess, they work in construction.

No, I can’t remember what they did, but—

Waste management.

But the guy, the patient, he goes, “Boys, this is Dr. Darcy. This is the guy that saved my life.” It was his son. It just gives you such a great feeling.

It’s a stunning thing. It’s a stunning thing.

But the other thing I was going to say about follow-up was, I don’t know if you saw this at your practices, but for a while, TIPS was really going strong. And then when a lot of people started seeing these stenoses develop in TIPS, there was a big drop in referrals in a lot of practices. We did not see that at our practice because we followed the patients. We oftentimes managed those stenoses before the hepatologist even realized there was an issue. And so they never really lost confidence in TIPS.

And you’re talking about the ’90s where every chapter and lecture on TIPS included the phrase, “clouded by patency issues.” And everybody would just use those words and it was just terrifying or just enough already. And I probably that sentence endless times, but it was actually a fundamental aspect of what was my early research, writing a paper on the midterm results of follow-up, which is one of my more highly cited papers, and then writing a lot of stratification papers like that bilirubin paper and things like that. And ultimately, it pushed me into animal research, on trying to design things where I went through five different types of materials from polyurethanes to porous, non-porous to—

Yeah, I remember those papers of yours.

I had 60 or 70 pigs. They were all named alphabetically. There was one for Roman Caesar, an Augustus, and Brutus wasn’t a Caesar, but— Claudius. And then there were ones that were biblical characters and other things, and they would just be the pigs in the series, including the ones that I had to chase into the hallway because we didn’t lock the door. Penn was one of the most locked-down places for animal experiments because of PETA. So it was a combination and then a locked door and then the animal work, and we’d sedate these animals, stick them with an intramuscular injection in a cage, pin them against the back with the floor rack. I’d always have the biggest fellow with me, and this was at 8:00 at night because that’s when you have to use the human labs.

And the pig would fall asleep, we’d drag it out of the cage. We’d intubate it, and then we’d put it in the cafeteria truck and roll it three buildings past the med school portraits where we’d put it into the animal lab, and I’d then implant these devices. And one night, big fellow with me, we injected, the pig leaps over for us and it runs out of the facility. We haven’t closed the door. And in a millisecond, I see my career is over. This is going to be on the front page of Philadelphia Enquirer. There’s a pig and two guys chasing a pig down the hallway in front of the med school portraits. He fell asleep halfway down that hallway and we dragged him back with one leg leaving a wet stain on the floor. We cleaned up. It was rough.

So that does bring up the interesting topic of evolution of devices and things for TIPS. One of the things that has always been of interest is the individual sets that people like to use. And let’s hear your thoughts on why you prefer the set that you use.

Well, it’s your favorite axe, right? And across the world, for the longest time it was the Rösch-Uchida set and then the Colapinto set, which has had various names on it, the Ring set and for a time, a Haskal set. And again, the Ring set or variations in China, which is, what is it, the 15 gage needle and the outer sheath, and you’re making a puncture directly. If you make a lot of passes, you’re making basically a 9 French hole in the liver. You wouldn’t drain a bile duct by putting in a 9 French sheath and making blind punctures. The Rösch-Uchida set has its own aspects of chores of moving in and out. Now we’ve got other sets and before we talk about where we’re at, what’s your favorite axe or has it shifted?

Well, I basically have always used just a standard Rösch-Uchida set, the Colapinto needle with an outer sheath. To me, that was always the most flexible because if I was close but not quite there, I could just instantly re-advance the needle itself a little bit and be where I wanted to be. The other thing I like about it is, although you said the set itself is fairly large caliber, if you wanted to make some smaller passes, you could put a long Chiba through it.

But you’re also making passes with a sheathed 5 French needle, which is in contrast to the 9 French pass. So you have the tiresome aspect of pulling out a stylet, aspirating, putting the stylet back in after each pass. You don’t have that with the Colapinto set, but you’re making a smaller problem.

I guess we’re talking about different– I use Colapinto needle basically without a stylet in it. But yeah, the one thing that I never quite got used to was the set with the little catheter and the stylet in it, which I think is called the— isn’t that the Rösch-Uchida or Colapinto?

That is the RUPS set.

That’s the RUPS set, yeah. Yeah.

Yes. The RUPS set was the 5 French rocket needle or sheath needle, which Barry Uchida and Josef Rösch developed, which for a while was at least 55 or 60% in China, were RUPS sets. So they’re strong. Where does this come from? It’s what you trained on, right?

Right.

I trained on a Colapinto named after Ron Colapinto from 1992 who did TIPS before stents and reported angioplasty for nearly 12 hours trying to keep these things open. Now we know that that balloon is the most painful thing that you can do to a patient, right? Blow up a balloon. And yet allegedly in this paper, they had balloons inflated overnight. I think there’s a little bit of maybe—

Yeah, the one thing in the paper—

Not quite true reporting.

In the paper, they didn’t say if they were keeping the patients sedated that whole time too. It was interesting.

Research is noisy. Yeah.

Yes. But it is interesting that he was able to at least lead to a proof of concept that getting this pathway, this new pathway open, even though it closed again quickly, at least temporarily, it relieved the bleeding symptoms.

Let’s take it further back, 1969. 1969 was Professor Rösch’s animal experiment, that eureka moment when they were trying to do transvenous cholangiography, hit the portal vein, and they had, “Aha, maybe we can.” Right? And what was it, almost 20 years, 19 years of cyroprobes and cutting and trying to do something to keep these open in an ’82 Colapinto. And what happened in ’88?

So in ’88, well, I guess that’s when Palmaz came out with his stents that allowed them to hold these things open. And then he and Goetz Richter did the first human case with a stent.

I think they published it in German in ’88 and in English, the same patient in ’89.

’89, right. Right.

Now do you know that Professor Palmaz, Julio, had done experiments in dogs with the Palmaz stent?

Right.

So here’s a trivia question. Do you know what Julio’s TIPS dog’s name was for his stainless steel stent?

I did hear that at one point from my—

Rusty.

Rusty. Yeah, yeah.

Rusty. And he kept the dog afterwards. It’s— God love—

What kind of dog was it? Do you know?

I seem to remember something looked like a Weimaraner or a retriever, but I remember a picture of Julio sitting next to the dog. Of course, now Julio has a magnificent winery and a Porsche collection that has to be seen in Napa.

But it is amazing how just that one change of adding a stent there totally revolutionized TIPS. And then the addition of stent grafts, you yourself did a lot of that work with various types of materials and saw that you had to be pretty specific, having a PTFE coating to keep it open. But that has made such a huge difference in patency, increased confidence in the procedure. And so it really was game changing, I think, in terms of the whole ability to promote TIPS to referring clinicians.

We suddenly began to be able to talk about outcomes and not just have to talk about maintaining patency and writing papers and focusing. But we could start talking about diameters and pressures and results and things like that that made that disappear. So the inspiration for that was the paper that Nishimine and Saxon had published on the Spiral Z® stent covered with ePTFE. I went from company to company to trying to convince people to get involved in TIPS and GORE, for their vision, were the only ones, “So what is this TIPS?” And then engaged. And I was responsible for all that animal experiment for the GORE devices and led the US trial. It was a really exciting time to get involved with. And those kinds of industry collaborations are really— you feel like you’re part of a big enterprise.

And these are some of the themes that the Professor Machan was giving in his Dotter lectured just earlier. We recommend that you catch this on video. But this was a 20-year timespan from the idea of TIPS to the first human case. You think about Hans Wallstén who wrote the Wallstén patent in 1982 for the Wallstent. And in that Swedish patent, he actually described the use of the stent for treating aortic aneurysms. This is a bare stent. He logged in his patent. He saw it in ’82. And you know how long it took Juan Parodi’s development of that, that wasn’t even a Wallstent. It was a graft hanging off of a Palmaz stent. What does it mean that you future inventors, you can come up with your own ideas but you can also look back and say, “Where has the technical device or innovation or tool or intelligence come up that allows me to look back and solve the problem that has lay fallow because of that lack?”

Yeah. Well, the interesting thing, though, it’s not just a jump and all of a sudden going from 0 to 60, there were a lot of incremental changes over the way. First you had the development of stents to keep it open. Then it was covered stents and then it became controlled expansion stents. So each one of these little incremental changes has altered how we perceive the procedure itself. When you look at some of the talk about stent diameter and people say, “Well, you can dilate to 8, but that doesn’t really make that much difference.” Well, that’s because most of those papers are looking at older stents that self-dilated on their own anyways. And so they really weren’t comparing encephalopathy rates in an 8 versus a 10.

Notwithstanding that people didn’t actually record encephalopathy in any methodical fashion.

Well, true.

It was not. When I ran the randomized trial of TIPS versus the Wallstent, it was clear to me that they all opened because we had follow-up venographs as part of the trial. But it was often balanced by this 1 mm of tissue that would develop half a millimeter around the lumen, it would just gradually narrow it. So you’re balancing the thing open versus variably developing a pseudoendothelium that Jeanne LaBerge had characterized. But that wasn’t something you’d predict. You were just hoping that biology would be in your favor. And that’s probably why we all saw patients that might slowly get less encephalopathic after their first procedure because they were probably developing that lining, and now that goes away. What’s the oldest TIPS patient in terms of one that you still follow?

Well, there’s one that I can remember that I have pictures that I show in lectures. It’s a fifteen-year-old TIPS. And it’s still widely patent, stent graft and no varices.

So I’m going to blow your mind because I have a patient who is now 24 years, Budd-Chiari, stays open. It told her, “You can never have kids. You can never do this thing.” She has four kids. She’s lived her life without any issues. There’s never the word “transplant.” She’s doing fine. I thought that was amazing. I keep in touch with her, but two weeks ago, a woman shows up in my clinic to talk to me about something and my nurse says, “You remember this name?” And I said, “Holy cow, I remember that name.” 31 years.

Wow.

TIPS is patent. I treated her for basically fulminant Budd-Chiari syndrome.

And this was a bare metal stent?

Bare metal stent, Budd-Chiari, she was in ICU. She was dying from liver failure. We both remember that the time to treat Budd-Chiari, people would say you’re going to kill the patient. Last thing we do. They do a surgical shunt, but they couldn’t conceive that this was equal and better. But I got along with a transplant surgeon at Penn, and we did this procedure. 31 years later, the shunt is patent.

Wow.

She comes in with a different problem that we’re going to try to help her with with oncologic, but 31 years. Talk about satisfaction and how you can have a meaningful impact in people’s lives.

That is amazing. Unfortunately, some of the patients have so many other problems going on that you don’t get to have that kind of long-term follow up. But that is pretty amazing, 31.

So we touched on a little bit about kits. And, of course, the major kits are made by Cook and there are two systems, and you go with what you’re used to. We want to acknowledge that there’s some difference guidance systems, that Argon has a kit, Scorpion, that has some rotatory ability to move the needle to perhaps direct it toward something. There’s a BD kit that has a deflectable cannula so you can adjust the angle of firing a thin stylet. It spans a bit of the difference between the two Cook and RUPS set. And it’s important just to be aware and excited that people are still innovating even now, this many decades into trying to provide people more options and ways to make these punctures, which really gets to this issue of guidance and why it’s hard for people. So why don’t we spend a little bit of time talking about it because I remember, and I still quote your paper from, what was it? Just last week, you published it, right? Maybe it was 21 years ago.

It was about 20 years ago.

And remind everybody what that paper was.

Well, so basically, one of my fellows and I, we just looked at bony landmarks because sometimes you didn’t really have a good way of opacifying the portal system and so you had to make blind passes. Throughout my career, I almost always used wedged CO² venography because the CO² goes through sinusoids easily. I could almost always opacify the portal system. And if I did it in two projections, I had a pretty darn good idea where the portal vein was and could usually hit it in one or two passes. But occasionally, for one reason or another, you still didn’t see where the portal vein was. And so we thought, “Well, where should you at least be making blind passes?” And this was long before ICE came on the scene. We just looked at bony landmarks and we found that if you looked, took the vertebral body as a gauge or a measure that 90-some percent of the right portal trunks were between 1/2 and 1 1/2 vertebral bodies widths lateral to the spine. So if you–

But around T10, 11 interface, right?

Yeah. Yeah.

And those were in bleeding patients, so these were normal-sized livers. They weren’t the shrunken ascites livers.

Right.

Different, but for those patients, that was the target zone, right?

Yeah. Yeah. Yeah. Yeah.

I still use that target zone. I use the Darcy target zone on that scatter plot that you published, which is, shoot in this area as a starting point. If I don’t find a portal vein in one of those patients within three passes, I’m thinking I’m in the wrong vein or I need to curve the needle, or I’m almost always too posterior. What are the things that go through your mind if you’re making those passes and you’re not landing?

Well, one of the first questions is, am I starting from where I think I’m starting? I’ve seen at least one case where one of my partners thought he was in a right hepatic vein and he turned anteriorly.

It was the middle.

And he was in the middle and he got into anterior branches of the left. And usually when you recognize that, it’s–

It’s a little harder to get down there.

You say, “Okay, well, I’m going to pull back.” Well, I saw one case where this person was bound and determined to still create it, and the TIPS ended up being like a pig’s curly-Q tail. And, of course, you would expect it’s shut down that day.

I have one day that I call the rollercoaster TIPS, which actually makes a loop. It is open, it stays open. But you do that once, you’re never going to do it again.

And most of the time I think you know that if you have a really, really curved track, it’s going to close down pretty quickly compared to otherwise.

We may get the boxing gloves out for that.

But this was also pre-stent graft era too.

Yes, I’ll give you that. But you’ve also described the classic situation used to happen where you’re making punctures and you can’t get in and you call your partner in, and they come in. And that’s the good thing about having partners. And they come in, they make some punctures. I’m sure our listeners have been in this situation and they hit it on the first pass and you say, “Yeah, not so hard.” And whether they or you didn’t realize you were in the middle and they were in the right, and sometimes those veins look exactly the same, right?

Yeah. So how do you distinguish middle from right?

I don’t use the Darcy trick of turning the thing over because I think that doesn’t speak to me, but I will window and level the vein to see whether it comes off from a more anterior aspect of the cava. And I also look for the marginal vein. I learned that trick from Jeanne LaBerge, if the right hepatic vein shares that little guy that goes over the diaphragm–

The diaphragm.

I’m still using things I learned from her.

So the thing you referred to that I usually do is if I just go to an RAO projection, the middle is almost always pretty vertically oriented and the right–

It’s where your wire gets stuck when you’re putting in a dialysis catheter that drops down and hits the bottom?

Yeah.

That’s the middle hepatic vein, right?

Yes, exactly. The one thing also problematic about that middle is, aside from the problem of knowing which way to make your needle passes, which direction to turn, the other problem with middle hepatic is that little curve right up at the top where it joins the IVC, because multiple papers have looked at the whole process of should you leave your stent in the hepatic vein or stent to the IVC? And you and I both know that if you leave even just like a couple millimeters of hepatic vein uncovered, you’ll develop a stenosis there. And we’ve seen cases where people were in the middle hepatic, they just didn’t make that last low curve and boom, they get a stenosis, right?

Yeah. So Mike and I are talking about how difficult it is when you’re working from the middle, which is, left is really the middle because it’s proximal puncture that you have to place your stent graft sometimes in a near lateral and mess up the drapes, the arm goes up. Nobody wants to do it, and it is really easy to be short at the top, in that middle. But maybe we should jump to ICE and where we’re going, which is the intracardiac ultrasound long distance. It’s what I call the AWACS radar of TIPS.

As you can see, 5, 6 centimeters, it’s everything that IVIS isn’t. We both know, this literature, which is in skilled hands, and of course, all the papers are here are all the people who do it the old way, and here is the one or two people in the practice who use ICE. So those guys are the pro they compare to everybody else. There’s always a little bit of bias. But still, there’s no question that with skills, fewer passes, lower flouro rate, and in some way, needle passes, endless versus fewer and less fluoro, has got to translate to potentially better outcomes or certainly confidence.

Yeah. I remember Bob Ryu at a meeting, one of the early talks about ICE describing it as a game changer. And when we looked at our own data, again, it was comparing Dan Picus and I, the experienced guys, versus the newbies. We could get into the portal vein just as quickly with just as few passes as the guy who is using ICE. But I think what ICE really does is it levels the playing field a little bit. For the people that don’t have tons of experience, it does sometimes allow them to access portal veins more quickly with fewer potential complications than if they just keep stabbing the liver multiple times. Having said that, I think you do have to be a little careful with ICE because I’ve seen one or two cases where the person using it clearly had what I refer to as ICE blinders. They’re so focused–

The frozen landscape.

Yeah, they’re so focused on the ICE image that they fail to look fluoroscopically to see where they’re at. And one of these cases I looked at and I thought, “My God, I would never let my needle go that far below the lower margin liver fluoroscopically.” And sure enough, they’d punctured the main portal vein because they couldn’t see the branches and they were just looking with their ICE image. So I think ICE does have some pitfalls probably most people would get over that pretty quickly and be able to recognize right. But I think the other thing that is important, and the reason why a lot of my fellows have wanted to do cases with me or Dan Picus is because you can’t always count on ICE being available. You should have a fallback position of what if your ICE machine breaks? You need to know how to be able to do it.

How are you going to tailgate without an ice machine?

Yeah, I hear you.

So you touched on something that I touched on a lot, spoke a lot about yesterday in the Extreme IR session, which is tunnel vision, where we get into these points where we don’t realize that we’ve lost situational awareness. But the impact of this, I think right now, of trying to solve a 3D procedure with 2D tools, is that the way that you and I train people and do it ourselves is an apprenticeship model. We have to train people one-to-one. It’s completely inefficient. Only the people that you’ve trained go out there with those skills, and there is no force multiplier in terms of expanding knowledge. So right now, ICE is not on label, which means everybody who uses it is using it on their own in some fashion. They can’t be trained except in seminars and courses. We’ve got an SIR fall meeting that last year had had some hands-on training, but again, it’s limited.

So if and when that becomes regulatory approved for TIPS, and I think it’s our duty to push people to pursue that, then that means that people will be able to be taught. And to give you just the local perspective on it, I have multiple partners, senior and otherwise, and the senior people can do TIPS blind. And the junior people, a number of them, I trained them how to do TIPS. They’re all faculty. All of them have switched to ICE. I’m the guy who’s not because I still average 15 minutes of fluoro. But I recognize that in that sense, it’s a bit of a dinosaur play when you have it available to keep doing it. So I think we need to get people towards some solution like that they can use because that’s going to blow it open to the next step when people are comfortable and say, “I want to grow this in my practice and offer this to more patients, not fear it.”

And I think that makes sense. Dinosaurs like myself, who instead of using a laser cutter still prefer a stone axe, I guess.

Laser axe, give yourself a little credit.

Yeah, it works and I can do it as quickly as, in fact, probably quicker than the guys using ICE. But you’re right. Just because I’m comfortable doing it that way doesn’t mean we shouldn’t push.

So you remember the skills that we have with wires and catheters to get up a diseased iliac artery?

Oh, yeah.

You’d advance, you’d turn, you’d advance a Bentson, you’d move to the side, and there were pictures and all these old textbooks on how to get up the iliac artery to get into the aorta. One wire made all of that disappear and leveled the playing field. You open up that hydrophilic wire, everybody’s up, that whole thing disappears. That’s a transformative opportunity of great tech that levels the field. You hit on it.

It is. But I do think that we’ve lost a little bit of the skill set that people can use. You know yourself, even with–

I don’t argue. I’m still doing it the way I do it.

Even with directional catheters and hydrophilic wires, you still sometimes just can’t get quite where you need to get unless you have the skills to maneuver these things. I’m always sounding like the old guy that walked 20 miles uphill in the snow to go to school.

That’s because you’re from the Midwest.

Yeah.

It’s actually true.

Yeah. But when I was a fellow, we didn’t even have 5 French catheters. We had 6.5 French blue Torcon catheters, and you had to do your mesenteric angios and embolizations, all that stuff.

Well, that was Professor Ring’s favorite, the 7 French Cobra. You do the visceral angiography, and then you’d still send people home that same day after manual pressure.

Sure.

And they would just–

Yeah. Right. But it did force you to learn how to turn and manipulate catheters.

Because your attending would take it away from you if you weren’t fast.

Yeah. I watch some of the fellows now. They’ll try for two seconds with a catheter, and if they don’t get it, they immediately want to go to microcatheter or something fancy. And there is a certain benefit to knowing how to really get the most out of the tools you have.

There is a pleasure in manipulating tools. There are technical satisfactions that we have from our daily work.

This is G-rated podcast. You probably need to watch where you go with that.

So since you mentioned it, when we’re talking about favorite axe, what is your favorite go-to wire on entry into the portal vein?

Well, to be honest, I still mostly use a Bentson because the very flexible floppy tip allows me to, if it doesn’t go straight down, it allows me to buckle pretty easily because–

Buckle peripherally and then still bend–

Yeah. Yeah.

toward the center.

Yeah. So if it goes out a little bit peripheral, then you just push a little bit more and it’ll almost always buckle straight down. Also, I’ll say I’ll also use the needle itself to help steer that.

The bevel.

So I’ll turn the needle to maybe force the wire a little further one direction or another. Do I avoid glide wires? No, I’ll use a glide wire, but you just have to be a little careful with that because you can shear the coating off a glide wire.

Which is non-radiopaque.

Yes, and so that’s a potential problem.

So I use a long taper, stiff, hydrophilic wire. And whether it’s the Terumo long taper stiff shaft or the Roadrunner, for some of the same principles, the Bentson of glide wires, my goal is any portal vein that I enter 2 mm to a big branch, I’m going to convert it. The ICE approach is, I can pick the vein and move toward it and target it. So there are just different kinds of approaches that you deal with.

And there definitely is some benefit to having that more targeted approach that you mentioned, because I’ve definitely seen people get into a more peripheral branch on the right. And after struggling to find their way into a portal vein, they say, “Okay, I’m just going to take it.” And then you end up with a C-shaped curve tract, which at least in my experience, they don’t remain patent as long as a straighter tract, but they’re also much harder to–

I’ll disagree, but that’s okay.

Okay. That’s good.

With stent grafts. What about skinny needles and skinny wires? Is that part of your kit or not?

Well, like I said, when I was talking earlier about the Colapinto needle, you can put it a long Chiba through there. The one time where I have found that extremely useful is there have been times where I knew exactly where the portal vein was, because although some of the traditional teaching is you make your pass and then you draw back and look for aspiration of blood. In my hands, that doesn’t always work. Sometimes you’re in a vein and you’re still not able to aspirate blood. So what I always did was I would always inject a little bit of contrast, almost like I do in a PTC, as I would draw my needle back. And if one or two passes I had not gotten in, sometimes you would actually outline the portal branch a little bit.

Yeah, I always love that. Do you remember that somebody actually reported that as a sign?

Right. But I’ve had a few cases where, okay, I can see it. It’s right there outlined by contrast and the needle will not penetrate because there’s so much periportal fibrosis. In that setting, I found that if you then take that Chiba, it’ll just pop through very easily.

It may be the only thing, actually, that can get through from all the different kits. I have cycled through all the kits that we’ve talked about, and Chiba was the only one. But that paper that you’re talking about that came out I think in the late ’90s was basically. I made a complete mess by injecting contrast everywhere, such that the only thing that isn’t full of contrast is the absence, and that’s the portal vein. So I’m going to write a paper out and describe it, and that’s what those authors did. I still laugh at how you convert the misadventure into adventure and you publish.

You definitely–

The LPU is the least publishable unit.

You definitely can make a mess of things if you inject too much. But now the downside to using that Chiba that we both are apparently used occasionally is then you’re stuck with an .018 wire through it. But what I found is once I get the wire down, then I’ll just actually advance the Chiba like a catheter over that wire, and then I just advance the Colapinto needle over the Chiba.

If the tract is straight, you’ll just drive over them.

I’ll drive everything, even if it’s not all that straight, with curving I can drive it down.

I use those needles a fair bit. Every Budd-Chiari case for a transcaval puncture or a extensive portal vein thrombosis where I may have to do just what you said, which is do those blind punctures if I can’t see it with ICE, or that super hard portal vein, doesn’t have to be schisto where you’re puncturing. 180 nitinol wire, so it doesn’t bend. And for years, I used to make these long transitional dilators until I accidentally got smart and looked through the Cook catalog.

There’s a 60 cm long micropuncture set, which we have now stocked for years, which when you get that .018 wire down, you push all your equipment forward to a reasonable degree. You take it out and you put a, as we used to say in Boston, a wicked long micropuncture set. The thing goes all the way down tracts, take out the center, and it’s .035, baby. It’s a good kit. So for those of you haven’t tried it, get that 60 Chiba, get your 180 nitinol wire, and make sure you’ve got that. It might even be MPI-60 for all I know, but somebody at Cook’ll put it into it. We’ll fix that in post. Yeah.

One trick that I learned early on, one of the early cases I did, I finally got into the portal vein and I thought, “Okay, great.” I pulled everything out and went to put my balloon down and I could not get a balloon to go past that portal fibrosis. So basically, once I’m in, I always make sure I have that outer sheath of whatever set I’m using into the portal vein so I can pass a balloon through that.

Or if not just bumped up against it and have somebody pressing on it, right?

Right.

Just for that, those 3 mm can be the millimeters of non– I remember I was doing a live case in New Delhi some time ago, and we’re against the portal vein. I learned later the family is watching on closed-circuit TV. It was a horror. And they hand me the balloon and the balloon had been, this is a long time ago, re-sterilized. And it wouldn’t fit through the Colapinto sheath, just like you said. So I had to take this thing out and the thing wouldn’t pass, and adventure ensued. The needle goes back in, you work the tract a little bit and things of that sort. So that pressure up against it is a really important tip that you’ve emphasized there.

Let’s talk about shunt diameters, because there was a long time ago, and we were just early, early on the early TIPS for ascites trial that GORE had sponsored, which was, let’s not just treat truly refractive ascites with people with some baseline encephalopathy, but let’s treat people with severe and annoying ascites who do better. Those are the ones that improve their nutritional status. They put on weight. They live for 20 years. And we just couldn’t recruit to a trial because we were just 10 years too early. But I remember that we had vigorous arguments about shunt diameter, and I was saying, “It’s got to be an 8,” Even with devices dilating, and you were more in the camp of 10 at the time, but how did you evolve?

And the rationale for that was I had seen cases where we tried to underdilate to 8, but we were using a 10 millimeter diameter stent. And then with self-expansion, you sometimes get into trouble because with self-expansion, it may for foreshorten a little bit, and then the top of the stent instead of being where you want is poking against the wall.

You’re talking about Wallstents.

Stents. Yeah, it’s a while ago.

Agreed.

And then when it’s poking against the upper wall of the cava, your hosed. We’d actually have to do percutaneous punctures to feed a wire through the TIPS backwards.

I used to call that the T-bar TIPS or to mess with your partner TIPS because they’ve got to come in and fix it.

Right. Exactly. So I would always just go ahead and dilate up to 10. And the literature looking at shunt diameter versus encephalopathy was all over the map. Some studies said it made a big difference. Some said it made no difference. But I think some of the more recent literature with stent grafts do show potential benefits to using smaller–

So where do you start now? You’ve got a patient for ascites and what are your end points?

Well, I think, so first of all, question is are you going to use clinical versus pressures and that–

What do you do? Come on.

That’s an important thing.

Put it on the table, dude.

So for bleeding, it’s pretty well established.

I don’t want bleeding. I want ascites.

Okay.

Come on.

So for ascites, the current recommendations that came out of that ALTA Conference are dilate to 8 and see how they do, because there you’ve got a little bit of leeway. Now they’re having said that you can come back and dilate larger if they don’t respond. That is not the way the GORE device is approved. So if you actually talk to GORE, they say it’s approved for dilating to a larger diameter at the time, not down the road.

That’s just what we did for the labeling. I was at that FDA meeting.

So the current recommendations that came out of the ALTA Conference is dilate to 8 and leave it. And if they don’t respond in a month, come back and dilate them larger.

So I will tell you that with perhaps an exception of one, I haven’t dilated a GORE device more than 8 in 16 to 17 years, I felt like I was out on an island where everybody said, you got to make them bigger. And I just dilate to 8 because I saw everybody two weeks later.

But are you talking even with their legacy device?

Oh, absolutely. In fact, from the original legacy device, I photoshopped an image that showed it narrow that was squeezed. And I started to try to convince GORE within the first two years of that that we need to think of a device that has a mechanism. It took a long time.

Yeah. But unfortunately, like the study that Ron Gaba did up in Chicago showing that the legacy devices did self-dilate on their own, ultimately.

But they also narrowed down with a variable degree of pseudomonas. And how do I know that? Because I had all those venograms at six months from the original TIPS, so I knew that they trimmed by 0.5 mm.

His CT data, though, showed–

But he didn’t have intimal lining. It just had stent diameter-

Yeah.

And there’s a millimeter of tissue reduction. It’s fun to argue about, but I think the message that we both want to get out however we got here is that everybody now understands that we can do more with smaller shunt diameters at the outset that we have a duty to see these patients early. And if you start at that 8 and maybe you ignore pressures completely on these ascites patients, you drop it in, you’ve thrown a rock into the water, you let it ripple for two weeks, that there’s far more effect than we realize.

Yeah, and I think the problem with ascites is we don’t know what the optimal pressure gradient is. There’s a lot of anecdotal evidence indicating that sometimes you need lower pressure gradients to get rid of ascites than you do to stop bleeding. Having said that, there are a number of papers that show pretty definitively that if you drive your pressure gradient too low, that leads to increased mortality. So there was one paper that, excuse me, did ROC curves looking at pressure gradients and effect on complications, what they call low-pressure complications, either death or intractable encephalopathy. And in that setting, they found that if they looked at people with a pressure gradient of five or less, there was 100% sensitivity with low-pressure complications. So sometimes you need to go low, but you had to be cautious about going too low.

Too low is a no-go. I think that’s our message over here. I will tell you that I have moved to do 7 mm shunts commonly as starting points. I ignore the gradient. I lead a transnational trial now on a TIPS device that is finished enrolling. They’re now collecting data, but we have the ability to make smaller caliber shots even down to 6. I don’t really believe that 6 is the number of there, but I land on 7 and then just see. And one of the end points is not below a pressure gradient, but a percent reduction from the absolute starting numbers. And that was designed to not force interventionists to chase a number that might push them to do something rather than perhaps wait and see and do that secondary intervention. And I think that two-step ability, that freedom to do that and have your clinicians understand that they should ask you for that special small-caliber TIPS because they’re starting to call for that as if it’s something new when we’ve all been doing it. I think this is a refresher and a renewer for us in the TIPS place.

And I would like to correct one thing you said.

Go for it.

You’re referring docs because we are clinicians, and I hate it when the residents differentiate us from the clinicians.

Point taken. Point taken. Absolutely. These patients will be referred to you not to create a TIPS but to consider them. And we just have to get everybody on board with saying it’s great that they’ve called and asked or ordered, horrible word, but now we’ll go see and render our opinion. That’s really what you’re saying.

And the thing that made me really understand that we had reached that level as consulting clinicians at Wash U was the head of transplant would call me one time when he had a difficult patient. He wouldn’t say, “Mike, I want you to do a TIPS on this person.” He would say, “Hey, I’ve got Mr. Jones. I’d like you to go see him,” just like he would talk to a gastroenterologist or anybody else. And so I think that ability or willingness to go up on the floors and see patients consult on them is critical to cementing your role as a fellow clinician.

I have an internal role that’s held well for me for a very long time, which is a referral for TIPS for ascites from an inpatient, I’ll never do it. I’ll see them, I’ll evaluate them, and then I’ll see them again as an outpatient. Because I can’t prove it to you, but there’s something somewhat artificial about a patient who’s hospitalized with refractory ascites and you get called. There’s a decompensation, there’s an infection or something. So I view that as the consult, and then I’m going to see them, check them for encephalopathy as an outpatient and talk to them in my office. And some of that is just that point that you said, which is, you are the consultant. And when you tell them, “I’ll see them, I’ll manage it, I’m on it,” that’s the script, right?

Okay. And that’s clarifying, you’re talking about ascites patients?

Yeah, hydrothorax in the hospital, they’re getting TIPS if there’s any possible means. And of course, bleeding, we no longer call it early TIPS. We call it preemptive TIPS. This is in the ASLD guidelines. It’s all over the place. We still have a duty to overcome the tribal aspect of, yes, we understand that preemptive TIPS is important. It reduces mortality, hospitalization, death, re-bleeding. But this is the first time that we’ve seen him, so let’s see how endoscopy goes. And the answer is no. The data is, I do the TIPS in this patient who omits the profile within the next 24 to maximum 72 hours. We don’t have to keep reinventing data. Right?

Yeah. The thing that is interesting about that whole preemptive TIPS concept is when you look at the paper is that proved that preemptive TIPS was beneficial, they were all done with older technology. You didn’t really have the ability to fine-tune shunt diameters and all that kind of stuff. And as well as I do, even bleeding patients, sometimes if you just put in your standard TIPS size, sometimes you drop the pressure too low. So I think in this modern era where you really can fine tune your shunt diameter and maybe target specific pressures, it might change. It might make it even better.

I think we have as the interventionalists, clinicians, as you say, a duty to remind and to advocate in our respective hospitals that preemptive TIPS is something that has to be done. And if you’re an academic hospital, you have to keep reminding people in ICUs constantly that this is aspect, whether it’s medical grand rounds, whether it’s data, whether it’s building a constant collective reminder, so it’s just embedded. Or if you’re in certain large hospitals in China, you have a Green Pass program where you land into the hospital with that, you get this Green Pass, and basically it means that you just move quickly toward TIPS. Everybody’s on board. They’ve put a name on the program, which basically is the same as having a clinical care pathway. It’s the TIPS equivalent of the PERT call. It’s not the immediacy because why– there’s a GI bleed and who used to get consulted, right? Surgery. When’s the last time you saw a surgeon operate on a GI bleed, do a Billroth II?

Never.

So why are you consulted on day four of that bleed when in fact you have the definitive intervention? There’s still places that struggle with that. We need to be at the top of the food chain, back to your point.

And unfortunately, I think some practices still have not totally adapted the clinical model. To me, the fact that most have, and we’re teaching most of our trainees how to be true clinicians, that is one of the greatest changes that we’ve made. That’s why those four people got the Leader in Innovation Award because it has totally changed the paradigm of how we are training people and what kind of people we are producing. I think the reason why we lost some of the stuff previously was just the old model of sitting in a lab waiting for somebody to send you a patient then send–

The trap door, right?

Yes.

Where the patient falls on the table, you do a procedure, trap door open, the next one falls on top, right?

And then you send it back to “the doctor” to take care of the patient.

Yeah. They think that doctor did it for them. I think that’s the important message. We’re in a new era and portal hypertension is, again, in resurgence. It’s one of the more attended sessions at the SIR meeting. There are going to be a lot of people in the rooms. And I think as we wrap up, perhaps remind people that there’s a fall meeting for the SIR. It’s called the EDGE meeting. It’s going to be October and it’s in San Diego. And there’s going to be a whole course, again, portal hypertension where there’s going to be intensive training and hands-on models and a lot of interesting tech because we’ve got generations of people who are embedded and see this as our identity. And hopefully they will propagate this the same to their trainees and to their partners as well.

Yeah, I remember when I was training, Amplatz and Castaneda would say, “Oh, interventional is not even going to be around in a few years because everybody’s going to take it.” I am so optimistic that we’re just going to keep growing.

Through all those peaks and valleys, you and I have never stopped coming to work and having a great time doing amazing things for people, regardless of people proclaiming our early demise. And I think we’re going to wrap up this TIPS, portal hypertension, dinosauric podcast between Dr. Darcy and I.

And I think we both would like to thank Cook very much for inviting us to do this.

Thank you very much.