PROCEDURE: 

  1. Primary TIPS
  2. Middle hepatic venogram
  3. Direct portogram
  4. Transjugular liver biopsy
  5. Triple lumen central venous catheter placement with ultrasound and fluoroscopic guidance

 

CLINICAL HISTORY: __-year-old Female/Male with history of colon cancer status post chemotherapy and subsequent hepatic steatosis/cirrhosis with portal hypertension, partial portal vein thrombosis and esophageal variceal bleed.   now presenting for TIPS placement

OPERATOR: 

ACCESS SITE: Right Internal Jugular vein with ultrasound guidance

ANESTHESIA: General Anesthesia

MEDICATION: Zosyn 3.375 grams IV

CONTRAST: 75 ml Omnipaque

FLUOROSCOPY TIME: 40.9 minutes

IMPLANTABLE DEVICES: 10 mm x 8 cm x 2 cm Viatorr stent

COMPLICATIONS: None 

 

PROCEDURE:

Following written informed consent, the patient was placed supine on the procedure table. After induction of general anesthesia, the right neck and abdomen were prepped and draped in standard sterile fashion. 

The right neck was then 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 12F TIPS sheath. Right atrial pressures were obtained through the sheath.

A 5 French MPA catheter was  placed over a Glidewire and used to select the middle hepatic vein. A middle hepatic digital subtraction venogram was obtained. The catheter was removed over a Lunderquist wire .  Alongside the existing wire and through the sheath a Fogarty balloon catheter was advanced into the hepatic vein. Wedged and free right hepatic pressure measurements were obtained but given the presence of hepatic vein to IVC shunting the wedged pressures are not reliable.  Subsequently the 7-French angled biopsy sheath was advanced into the  right hepatic vein over the guidewire.  The wire was removed, and two passes were made through the sheath with the 18 gauge coaxial needle.  The specimens were placed in formalin.  The biopsy sheath was removed and finally, digital subtraction CO2 portography was obtained however given the veno-veno collaterals the portal vein was not visualized. 

At this time attention was turned to obtaining transhepatic portal access.The abdomen was evaluated with ultrasound. An appropriate skin entry site was chosen and anesthetized with local. Under ultrasound guidance, a micropuncture needle and 0.018′ wire was advanced into a branch of the right portal vein and down into the main portal vein. The needle was removed and the inner 3 French of a Aprima transitional catheter was advanced into the portal vein.  Digital subtraction CO2 portography was then performed.

The Fogarty balloon catheter was removed over the guidewire and the 12F sheath exchanged for a 10 French TIPS sheath and advanced into the middle hepatic vein.  Using the Rosch-Uchida TIPS set, the middle portal vein was accessed. A stiff Glidewire was placed through the catheter into the portal system, and the TIPS sheaths were advanced over the wire into the portal vein. The inner sheath was removed and a marking pigtail catheter was advanced over the guidewire and used to measure the parenchymal tract and measure portal venous pressure. Digital subtraction portography was then obtained by injecting both the pigtail catheter and sheath simultaneously.  The marking pigtail catheter was removed and plasty the tract was performed with a 6 mm x 4 cm conquest balloon and subsequently sheath was advanced through the tract into the portal vein. Subsequently a 10 mm x 8 cm x 2 cm Viatorr stent was deployed within the TIPS shunt. The shunt was dilated to 10 mm. Follow-up digital subtraction portogram demonstrated good flow through the TIPS shunt with no filling of collaterals. 

The pressure within the portal system after shunt placement measured 13 mm Hg, and the right atrial pressure measured 10 mmHg. This corresponds to a portosystemic gradient of 3 mm Hg. At the end of the procedure the sheath was removed over a guidewire and a 12 French x 15 cm triple lumen catheter was placed.  The catheter was flushed and heparinized per protocol. The catheter was sutured to the skin with 2-0 Prolene and a biodisc and sterile dressing were applied. The patient tolerated the procedure well and there were no immediate complications. 

 

FINDINGS: 

  1. Right internal jugular vein is ultrasonographically patent and compresses.  Needle entry was documented.
  2. Scout image of the chest demonstrates satisfactory location of the endotracheal tube
  3. Middle hepatic digital subtraction venogram confirms vein patency.
  4. Wedged hepatic venogram demonstrates extensive hepatic vein to systemic venous collaterals without visualization of the portal vein
  5. Direct portogram demonstrates patency of the main portal vein with at least partial thrombosis of the main portal vein. There are bilateral right greater than left portal venous cavernous transformation. Satisfactory anatomy for TIPS placement with patent portal vein.
  6. The initial portosystemic gradient is 14 mmHg.
  7. Post-TIPS portosystemic gradient is 3 mmHg.
  8. The TIPS shunt has a smooth course and extends from the middle hepatic vein to the right portal vein.
  9. There is good flow through the shunt at the conclusion of the procedure and without filling of varices .

 

IMPRESSION:

Successful creation of TIPS from right hepatic vein to right portal vein with a 10 mm x 8 cm x 2 cm Viatorr stent. The portosystemic gradient was reduced from 14 mm Hg to 3 mmHg.

 

PLAN: The patient will be admitted to the ICU for post-procedure monitoring.  After discharge He/She will follow-up in one month in performing doctors s clinic and the TIPS shunt will be evaluated with ultrasound.