- Selective visceral arteriography
- Calcium stimulation test
- Hepatic venography and hepatic venous sampling
Indication: High insulin levels. .
Access site:Right common femoral artery with ultrasoundRight internal jugular vein with ultrasound
Complications: None immediate.
SEDATION: Monitored by the IR registered nurse or surrogate, an independent trained observer providing Moderate Sedation with fentanyl.
CONSENT: Following discussion procedure its risks benefits (including bleeding and vessel damage) and alternatives, review of readily available relevant imaging prior to the procedure informed consent was obtained witnessed and documented upon the chart. Standard presurgical timeout confirming patient procedure and when relevant side and site was performed. Any discrepancies were resolved via consultation with appropriate readily available data sources. The patient was prepared and draped in standard sterile fashion.
The risks, benefits, and alternatives to the procedure and sedation were explained to the patient. The specific risks of vascular damage and thromboembolic phenomena were detailed and accepted. Written informed consent was obtained. A time out/call to order was performed prior to procedure initiation.
The patient was assessed for conscious sedation and found to be an adequate candidate. A dedicated nurse monitored heart rate, blood pressure, and oxygen saturation throughout the procedure.
The right jugular region was ultrasonographically evaluated. Using local anesthetic and ultrasound guidance, the right internal jugular vein was accessed with a 21 gauge needle. Needle entry was documented, and images sent to PACS. A 0.018” wire was placed centrally, and a needle exchanged for a transitional dilator. A 5 French sheath was placed at the neck and flushed.
An angled catheter and guidewire were used to select the hepatic vein. Right hepatic venography was performed using nonionic contrast. The catheter was capped and flushed.
The right groin was prepped and draped in sterile fashion. The common femoral artery was accessed via Seldinger technique and a French sheath placed. Over a 0.035” wire, a 5 French catheter was reformed in the .
The SMA was selected and DSA images performed with imaging into the venous phase.
The celiac axis was selected and images obtained.
A microcatheter was introduced coaxially and placed selectively in the splenic artery. Splenic arteriography was performed. mEq calcium gluconate were injected into the proximal splenic artery with hepatic venous blood samples obtained in the hepatic vein at times T=0 seconds, 30 seconds, 60 seconds, 90 seconds, and 120 seconds.
The catheter was positioned in the distal splenic artery. mEq calcium gluconate were injected with hepatic venous blood samples obtained in the hepatic vein at times T=0 seconds, 30 seconds, 60 seconds, 90 seconds, and 120 seconds.
The proper hepatic artery was selectively catheterized with the microcatheter. Arteriography was performed. 0.375 mEq calcium gluconate were injected into the proper hepatic artery. Venous samples were again obtained in the right hepatic vein at times of 0, 30, 60, 90, and 120 seconds post injection.
The gastroduodenal branch was selectively catheterized. Arteriography was performed. 0.375 mEq calcium gluconate were injected into the gastroduodenal branch. Venous samples were obtained in the right hepatic vein at T = 0 seconds, 30 seconds, 60 seconds, 90 seconds, and 120 seconds. The microcatheter was removed.
The catheter was replaced in the SMA. Position was confirmed with contrast injection. mEq calcium gluconate were injected, and right hepatic venous samples obtained as above.
femoral arterial hemostasis method. The right internal jugular sheath was removed and hemostasis achieved with compression.No immediate complication occurred.
Branching anatomy is standard. There are no accessory or replaced hepatic branches.
The portal vein is widely patent.
interpret each selected branch. is there tumor blush?
The right jugular vein is patent and compresses. Needle entry wasstored to PACS.
Normal right hepatic venogram.
Uneventful visceral arteriogram with arterial calcium gluconateinfusion and simultaneous right hepatic venous sampling as described.vessels/sites were sampled.