PROCEDURE:

1. Right hepatic venogram

2. Transjugular liver biopsy

3. Wedged hepatic, free hepatic, and right atrial pressure measurement

CLINICAL HISTORY:

FLUOROSCOPY TIME: minutes

CONTRAST: Omnipaque 300

ACCESS SITE: Right internal jugular vein with ultrasound

SPECIMENS: 18-gauge cores biopsies in formalin

COMPLICATIONS: None immediate

The risks, benefits, and alternatives to the procedure and sedation were explained to the patient. The specific risk of hepatic damage and hemorrhage were detailed and accepted. Written informed consent was obtained.

The right neck was prepped and draped in sterile fashion. Using local anesthetic and ultrasound guidance, the right internal jugular vein was punctured with a 21 gauge needle. An image documenting vein patency and needle entry was stored and transferred to PACS. A 0.018″ guidewire was advanced through the needle. The needle was exchanged for a 5 French transitional catheter. The inner dilator and 0.018″ guidewire were removed and a 0.035″ guidewire was advanced into the IVC. The transitional catheter was exchanged for a 9 French sheath. Through the sheath and over the guidewire a 5 French MPA catheter was used to select the right hepatic vein. Digital subtraction hepatic venography was then performed.

The MPA catheter was exchanged for a Fogarty balloon occlusion catheter. Wedged right hepatic and free right hepatic pressure measurements were obtained. The Fogarty was exchanged for the 7-French sheath preloaded with a 5 French catheter. The wire and catheter were removed, and passes were made through the sheath with the 18 gauge coaxial needle. The specimen was placed in formalin and delivered to the laboratory.

The sheath was pulled back into the right atrium and a pressure measurement was obtained. The sheath was then removed and hemostasis achieved with manual compression. No immediate complication occurred, and the patient was discharged from the angiography suite in satisfactory condition.

Findings:

1. The right hepatic vein is normal in caliber and appearance.

2. The specimen appeared adequate.

3. The right internal jugular vein is ultrasonographically patent and compresses. Needle entry was documented.

4. Mean wedged right hepatic pressure measured mmHg. Mean free right hepatic venous pressure measured mmHg. The corrected sinusoidal pressure is mmHg.

Impression:

1. Normal right hepatic venogram.

2. No evidence of portal hypertension.

3. Uneventful image guided transjugular liver biopsy as described.