PROCEDURE:

  1. TIPSS Check and Balloon Dilatation
  2. Thoracentesis

CLINICAL HISTORY: 

OPERATOR: 

ACCESS SITE: Right internal jugular vein with ultrasound guidance

MEDICATION: Zosyn 3.375 grams IV, 1 mg IV Versed and 100 mcg IV fentanyl

CONTRAST: 80 ml nonionic contrast

FLUOROSCOPY TIME: 5.1 minutes

COMPLICATIONS: None

 

PROCEDURE:

After written informed consent was obtained, the patient was placed supine on the procedure table.  The right lateral chest was prepped and draped in standard sterile fashion.  The right lateral thorax was evaluated with ultrasound and an appropriate skin entry site was infiltrated with local. Under direct ultrasound guidance, a 21 gauge puncture needle was advanced into

the right pleural space. An 0.018″microwire was advanced into the right posterior pleural space and needle was exchanged for the 5 French micropuncture sheath. Wire and inner dilator were removed and a short 0.035″ wire was advanced.  Sheath was then exchanged for a 6 French skater catheter was attached to a Pleur-evac at -20 mm of Hg low suction. 3.1 liters of fluid were removed.  The catheter was withdrawn and a sterile occlusive dressing was applied.  The patient tolerated the procedure well without immediate complications.

Ultrasound examination of the right abdomen was performed. Small amount of perihepatic ascites was demonstrated. There was insufficient ascites to warrant a therapeutic paracentesis.

The right neck was also prepped and draped in standard sterile fashion.  The right neck was evaluated with ultrasound. The skin overlying the right internal jugular vein was anesthetized with local, and a small dermatotomy was made. Under ultrasound guidance a 21-gauge needle was advanced into the right internal jugular vein. A 0.018″ guidewire was advanced through the micropuncture needle. The needle was exchanged for a 5 French transitional catheter. The 0.018″ wire and inner dilator were removed, and a 0.035″ Amplatz wire was advanced into the inferior vena cava.  The transitional catheter was exchanged for a 10F CHECK FLO sheath.

A 5 French angled catheter was placed over a Rosen wire and used to select the existing TIPS shunt. The Rosen wire was exchanged for an Amplatz and a marking pigtail catheter was advanced to the portal venous confluence. Portogram was obtained.  Prior to intervention, pressures measured 21 mmHg in the portal system and 7 mmHg in the right atrium.  This corresponds to a portosystemic gradient of 14 mm Hg.  Pigtail catheter was removed and a 10 mm x 4 cm conquest balloon was advanced beyond the Viatorr stent. Balloon was dilated to nominal pressure sequentially from distal to proximal along the Viatorr stent. Follow-up portogram demonstrated good flow through the TIPS shunt with no filling of collaterals. The pressure within the portal system after shunt dilatation measured 13 mm Hg, and the right atrial pressure measured 6 mmHg. This corresponds to a portosystemic gradient of 7 mm Hg.  At the end of the procedure the sheath was removed over a guidewire and hemostasis was obtained with manual compression and placement of a Vpad.

The patient tolerated the procedure well and there were no immediate complications.

 

FINDINGS: 

  1. Large right pleural effusion on ultrasound.
  2. Post thoracentesis single shot image demonstrates significant decrease in size of right pleural effusion.
  3. Right internal jugular vein is ultrasonographically patent and compresses. Needle entry was documented.
  4. Prior to intervention, portogram demonstrates widely patent TIPS shunt with smooth course.  There is no significant collateral filling, however there is some filling of the left and right portal veins.
  5. The initial portosystemic gradient is 14 mmHg.
  6. Sequential balloon dilatation of the TIPS shunt was performed with waist demonstrated at the superior aspect of the stent which resolved with dilatation to nominal pressure.
  7. Following balloon dilatation of the existing TIPS shunt to 10 mm, the portosystemic gradient is 7 mmHg.
  8. There is good flow through the shunt at the conclusion of the procedure.

 

IMPRESSION:

Successful balloon dilatation of existing 10 mm x 6 cm x 2 cm Viatorr stent with 8 mm x 4 cm conquest balloon. The portosystemic gradient was reduced from 14 mm Hg to 7 mmHg.

Large volume thoracentesis with removal of 3.1 L straw colored fluid.