PROCEDURE:

  1. TIPS check
  2. Hemodynamic pressure measurements 

DATE OF PROCEDURE: 

INDICATION:  Patient with history of alcoholic cirrhosis and hepatitis C status post TIPS creation for refractory ascites. Routine duplex ultrasound demonstrates turbulent flow at the hepatic venous end, and presents for TIPS evaluation with hemodynamic pressure measurements.

OPERATING PHYSICIAN: 

MEDICATIONS:  1.5 milligrams Versed IV; 150 mcg fentanyl IV

CONTRAST:  45 cc Omnipaque 350

FLUOROSCOPY TIME:  4.7 minutes

ACCESS SITE:  Right internal jugular vein with ultrasound guidance.

 

PROCEDURE:

The risks, benefits and alternatives of the procedure and sedation were explained to the patient. Written informed consent was obtained. A timeout was performed.

The patient was positioned supine on the angiography table. The right neck was prepped and draped in sterile fashion. The skin and subcutaneous tissues overlying the right internal jugular vein were locally anesthetized with 2% lidocaine without epinephrine. Using ultrasound guidance, a 21 gauge micropuncture needle was advanced into the right internal jugular vein. A 0.018 guidewire was advanced through the micropuncture needle. The micropuncture needle was removed and exchanged for a 5 French transitional dilator. The 0.018 wire and inner dilator were removed, and an 0.035 Amplatz wire was advanced into the IVC. The transitional dilator was removed, the tract dilated and a 10 French Checkflo sheath was advanced over the wire into the right atrium. Right atrial pressure was obtained.

A 5 French MPA catheter and 0.035 glidewire were used to select the right hepatic vein. The wire and catheter were passed through the existing TIPS into the splenic vein. The Glidewire was then removed, and replaced for a 0.035-in. Amplatz guidewire. The MPA catheter was then removed over wire and exchanged for a 5 French marker pigtail catheter.  Pressures were obtained within the portal venous system at the portal confluence. Digital subtraction portography was performed.  Images were reviewed. The Glidewire was then advanced fluoroscopically through the pigtail catheter and the pigtail catheter removed under fluoroscopic guidance.

The sheath was removed and hemostasis was achieved with manual compression. A sterile dressing was applied. The procedures were well tolerated. The patient left the interventional suite in satisfactory condition.

 

FINDINGS:

  1. Patent right internal jugular vein.
  2. Initial direct portography demonstrates a patent TIPS without in-stent stenosis (specifically at the portal or hepatic venous ends) and normal caliber of the main portal vein. There is mild intrahepatic portal venous flow within the hepatic parenchymal branches, without opacifiation of any varices.
  3. Initial pressures: right atrial =  11 mmHg; direct portal/SMV = 20 mmHg; gradient across the TIPS = 9 mmHg

 

IMPRESSION:

Uneventful TIPS evaluation with hemodynamic pressure measurements, as described above. The TIPS is patent with a portosystemic gradient of 9mmHg.