yeah

steps in a tips

work in progress, might be missing s$$$

VS style

 

a good indication:  failure of endoscopic management of varices 

Get anesthesia on board

Haskel set preferred stock, check to make sure viotorrs are stocked with multiple lengths

prep r abd and R neck wide

first get portal vein access with greb sheath

use greb needle (long 21 gauge trocar needle) to access peripheral right portal vein using US

exchange for greb sheath and park in MPV, can do portography 

obtain pressure measurements and record on table (off to patient, open to air to zero, then off to air and on to patient to record waveform)

attach flush IV tubing to portal vein catheter and KVO

now attention to RHV access

Access RIJ using micropuncture

Advance bentson down to RHV

if cannot find RHV with bentson, can try glidewire with glide berenstein, had good success once using glide berenstein over amplatz

once in RHV, can do short dsa through cath to prove RHV access

all i do is record my consciousness and that is enough-sg

exchange for amplatz into RHV and then advance 10F sheath dilator to RHV

at this point will attempt to access RPV using colapinto needle

sometimes i feel like i'm behind the curve, but what is reality?- sg

colapinto needle comes in a sheath like device

keep it sheathed until ready to access RPV

once you hub the device outside patient, needle is exposed

if in RHV, aim forward, if in MHV, aim posterior (Middle->posterior, MP)

once you thrust forward, attach 10 cc syringe with dilute contrast, infuse to remove parenchyma from needle and then withdraw needle with aspiration to find blood

if aspirate blood, infuse contrast to identify hopefully identify portal vein

if in RPV, advance slippy wire AKA roadrunner AKA woadfinder (or Glidewire or even Bentson)

ideally wire travels to RPV and then MPV indicating portal access

then can advance MPA catheter over wire to prove portal access with contrast infusion

then can remove wire and advance stiff wire (Lunderquist vire or superstiff amplatz) to connect RHV and RPV and smooth out curve

at this point usu VS takes 5-10 min break (intermission)

now goal is to dilate parenchymal tract, measure for stent length and deploy stent

using conquest balloons (conquest 40, 8mm x 4cm and 10mm x 4cm)

use inflation device (blowy-uppy) to dilate parenchymal tract, save images of waist, VS doesn't keep balloon up too long, on order of seconds, start 8 then go 10

in order to deploy stent have to get 10F angled sheath down into portal vein so this should happy now with the dilation, can use dilator to facilitate

use sizing catheter to get stent length

proximal aspect of stent should terminate in IVC

stent is always 2 cm uncovered (going in PV) and then 4-8 cm covered, 8 -10 mm (AM prefers 10 mm)

forgot to mention, measure pressures in RA and RHV 

to deploy stent

get stent on table

be careful advancing into sheath as can get kinked up

make sure sheath is in portal vein 

to deploy noncovered portion, unsheath (pull sheath back)

then pull stent back until it "catches" in the parenchymal tract (CT trick)

then deploy the covered portion with rip cord

now can use baloons to "touch up" internal aspects of stent

do final decent TIPSoGRAM using sheath or long catheter

measure pressures

remove all wires and catheters

hold pressure at RIJ site 5-10 min

sterile dressings

fin

​

Things to pull for TIPS:

Haskal Set- will have most shit

10F sheath

12F sheath - if doing Yamada style safety wire thing

MPA catheter

Glidewire

Stiff angled glidewire- poss exch length

Bentson

Super Stiff Amplatz

Lunderquist wire - long

4F angled glidecath 100 cm length (important, for portal access)

5.5F 80 cm fogarty balloon catheter- for Co2 venogram

Need Co2 for injection

6 mm x 4 cm balloon

10 mm x 4 cm balloon

Viatorr stents

Rosch Uchida access set

Marker pig catheter 100 cm (65 may work)

pressure measurement stuff

12F central venous catheter (if leaving one)

​

I thik thats it

​

 

 

how to do a Transjugular Liver Biopsy

 

AM style

 

There are a few different kits

the difficulty is in getting access to the RHV

there are at least two kits, AM prefers the Cook set

the biopsy instrument is a sidecut needle with specimen trough, similar to the Tenmo Evolution

Goal of procedure is to get periportal tissue biopsied as well as measure portal and systemic pressures

 

Start procedure by prepping and draping R neck

Access RIJ using micopuncture technique

Using multipurpose angled catheter and Bentson (or Amplatz) access the RHV and shoot a short venogram to prove it

Once have a wire in the RHV, can advance sheath to this level

AM prefers the 10F sheath from the TIPS kit or at least I saw this used

Can measure RA / RHV pressure through sheath- zero out to the air, then measure pressure.

Can wedge sheath or wedge multipurpose angled catheter through sheath in order to measure wedged HV/ PV pressure

Now to biopsy liver, goal is 3 core specimens

The biopsy instrument goes down the sheath

You hub the device to the sheath and then poke out the tray into the liver

Once you have the tray in the liver, fire the device to get the core

You have to recock the device to retreive the core

roll core off the tray and then place in formalin

Repeat x3

After finished, remove all instruments and hold pressure at the neck for 5-10 Minutes

​

How to cath the RHV or HV in general, DK style

Use a MPA / hockey stick cath

go down past the HV and then form catheter

use 10 cc syringe with contrast

start fishing

start looking right but if dont see it, try front back side to side, sometimes the takeoff is anterior

once you fish it, keep advancing the cath while injecting contrast, spin the hockey stick to stay off small branches and tuck it deep in the RHV

switch over for amplatz and then complete rest of procedure

​

​

​

--

​

BRTO

stands for balloon occluded retrograde transvenous obliteration

per JM is an easy procedure in theory

though sounds like big deal

​

need isolated gastric varices for this to be successful

did a case where i literally saw the UGIB at a CT scanner, blood in the plastic container

pt came back down intubated

check previous imaging for splenorenal shunt

if no splenorenal shunt, can't do

​

procedure:

R groin CFV access

can work thru 7-9F sheath, ansel sheath

use glide and angled catheter (JM prefer angled glidecath) to access splenorenal shunt after cannulating L renal vein

get wire up through into shunt

can perform exchanges to amplatz to drive sheath up to inferior aspect of varix

goal is exchange for 5.5F fogarty occlusion balloon for infusing sclerosant

can use microcatheter for more selective injection

in this case, used sclerosant of gelfoam and STS foam mix, lipiiodol for radiopacity

infuse until appears filled, check for nontarget which could go to the lungs (PE)

once have endpoint remove all devices and hold pressure at groin

​

​

​

some more BRTO tips from SD

had a case where i started off

used 4F glide cobra into L renal

tons of flow and couldn't see anthing

was recommended using 4-5F glide Sim-1 (huge reverse curve cath)

sat very nicely in L renal

then advance amplatz deep into gonadal i bleeive

then tracked sheath up (12F sheath)

then did angiography and could see the gastrorenal shunt

form there used cobra to catherize the shunt

this stuff aint straighforward- i didn't know where to go 12.18.2016

--

​

TJ LB (argon kit, CL method)

​

Start off with micropunc RIJ

advance long amplatz into IVC
advance 9-10F vascular sheath into RA

use MPA (included in kit) and glide or amplatz to cannulate RHV or MHV (or LHV)

once have acess, advance cath deep into vein

can perform venography

advance amplatz deep into vein.  in fact according to some, can put back end of amplatz first for more stiffness

Now will advance the sheath with dilator into the vein, to get purchase

now remove dilator and advance the 7F metal cannula and sheath (biopsy sheath) over wire and thru sheath

if in RHV, aim forward, if in MHV aim backward

can pull sheath back slighty to expose biopsy sheath

now advance needle into biopsy sheath

want to make sure needle never crosses capsule.  this is what causes bleeding

to obtain core, cock needle

advance needle thru, may get hung up in the cannula curve

use back end of needle to "poke" needle out a bit

then push all the way to core it

save image

do 2-3 cores

thats it

--

​

TJ LB tips

​

use the MPA catheter

spin the catheter

use a reg glidewire and spin and prolapse down the large portion of the RHV

make sure your not in the renal

look for the liver shadow to know your in the region of hepatis

you should really be right under the right atrium

use the 10F flexor sheath- 35 cm so you can stay in the RHV

25 cm sheaths are not long enough

do pressures after the biopsy - like LGM

​

Portal Vein Embolization- DK

exactly how the shits done

​

for RPVE

​

acess R oprtal vein posterior peripherally using US sorta like ptc

use 22G chiba and jeff set / pcn / biliary access set

get amplatz to roll into splenic V

upsize to 7F sheath

advance pigtail to splenic vein

do splenoportogram with breath hold ideally lay out the portal

can do addt'l oblique

figure out where to put occlusion balloon ususlaly RPV base

use 7F over wire fogarty balloon cath

blow up balloon and occlude

do occlusion portogram - thru sheath and then thru catheter

dont want occlusion balloon to move or you are f'd

once have baloon up and proof of occlusion infuse sclerosant

321 mixture of air/sotra/lipiodol foam use metal stopcock

infuse sclerosant in this case 10-20 cc

let sit for like 30-45 min

do some still images

when done, do some portography, prove that RPV is thrombosed

then pull out carefully

shoot some gelfoam plegets thru the sheath prior to pull out

hold pressure done

PVE - as it is

this is literally exactly how its done - so dun forget

​

​

--

​

TIPS tips:

the point of succesis when the sheath tracks into the portal vein

until then you got nothing

to get the sheath to track through the tract

can use long 8mm balloons as a dilator

inflate baloon, then deflate and push sheath over balloon

use a stiff wire like lunderquist to help straighten out the curves of the tract

often you will lose pushability in the right atrium

​

TIPS Check (check of patency and Portosystemic gradient)

​

RIJ access

use amplatz or glide to catheterize tips stent and advance wire into portal infow

use pigtail catheter to measure pressures- make sure to measure direct portal and RA

can use pigtail to push through stent without going through sideholes

do flush portogram to eval tips patency

may need to extend stent

may need to perform pharm-mech thrombolysis

thats it

​

for difficult TIPS Access for TIPS Check:  use reverse curve catheter.  For ex:  use Sim1 Glidecath- it worked 6/2017

also think about using 10F curved sheath for addt'l support

or coem from groin

​

​

BRTO take 2

done w/ JR in 2018, Oct

​

indication - refractory bleeding gastric varices req 6U PRBC, CTA showing splenorenal shunt anatomy

​

R groin access

use cobra or Sim cath to cath renal

if use SIm, use pullback trick to engage superior aspect of L renal vein, engage shunt

do some shunt venography

get wire up into shunt, try exch length rosen to switch into 7F 50 cm sheath up into shunt

now in good shape for rest of case

through sheath, use 6F fogarty balloon cath

do occlusion of shunt and then perform shunt venogram to demonstrate gastric varices

eval for possible inflows of concern - connection to heart, lungs, portal

figure out how much contrast needed to opacify majority of gastric varix

then mix up scleroasant - 123 mix of STS, lipiodol, air and infuse slowly into varix under fluoro control

make sure balloon is occlusive or else sclerosant will go systemic - bad

after sclerosant sets for several minutes, occlude the shunt outflow

easiest way is to advance micro through 6F fogarty- then place large microcoils

can use 15-20 mm long microcoils x2-3

carefully let down baloon, can do some repeat venography to demonstrate closure

pull caths and done

​

​

​

​

​